**5.3 Improve strength**

*Essentials in Hip and Ankle*

**5.2 Improve range of motion (ROM)**

*5.2.1 Range of motion exercises*

exercising.

the athlete.

*5.2.2 Manual therapy*

more times with a rest of 10 s taken in between.

achieved by both adhesive and nonadhesive tapes, but it is important to renew them timely as the compression wears off with time. Normally a nonadhesive tape should be renewed after 3 days, and an adhesive tape should be renewed after 5 days [10]. This prevents swelling and immobilizes the injured area which prevents further injury and thus promotes healing. Passive exercises can be started in stage 3 which is the local numbness stage in which the athlete experiences less discomfort when

Range of motion exercises include both active and passive exercises. Achilles tendon stretching should be started within 48–72 h in a pain-free range irrespective of weight-bearing status of the athlete to avoid the tissue from contracting. Self-passive stretches can also be given with the help of a towel. Next, the stretches should be extended to weight-bearing position, which can be done by standing on an inclined surface and asking the athlete to shift his/her weight forward. The stretches should be maintained 15–30 s, repeated 10 times, and should be done 3–5 times per day. Passive exercises are followed by active ROM exercises whereby the athlete can do alphabet letter exercises, i.e., drawing letters in the air both in upper and lower cases. The exercises should be done 2–3 times per hour, 4–5 times per day. Stationary biking can also be included to improve dorsiflexion and plantar flexion motion in a controlled environment while providing a cardiovascular workout for

Manual therapy is started within 48 h after the injury when ankle dorsiflexion is restricted. To improve range, a gentle oscillating passive joint mobilization is given. Here the talus is moved posteriorly. By the convex concave rule, when the talus is moved posteriorly, the convex talus rolls upward and slides posteriorly on the concave surface of the crux, thus improving the dorsiflexion range. In a technique described by Maitland [11], with the athlete in supine position, the affected foot is taken in the available pain-free ROM in dorsiflexion. Gentle oscillations are then given to the joint to avoid pain and spasm. The oscillations are given for 60 s, 2 or

Mobilization with movement is another technique of manual therapy suggested by Mulligan [12] which helps with increasing the ROM actively. In this technique the athlete position is high kneeling with weight-bearing on the

affected limb or standing with the affected foot placed forward. In both positions the ankle is in neutral position. A padded belt is used for mobilization and is placed in such a way that the bottom of the belt is leveled with the inferior margin of the medial malleolus. The position of the mobilization belt allows the examiner to fix the talus and calcaneus with his/her hands and draws the tibia forward on the talus, thereby creating a relative posterior talar glide. Once the glide is given, the athlete actively dorsiflexes the ankle in a pain-free range. The glide should be maintained throughout the movement. Two sets of 10 repetitions, separated by a 2-min rest, are performed. Once ROM is achieved and swelling and pain are controlled, the athlete is ready to proceed to the strengthening phase of rehabilitation. Guidelines suggest that a normal ROM should be achieved within 2 weeks

**104**

after injury [13].

Strengthening of weakened muscles is essential for a quick recovery and thus helps in preventing re-injury. An eversion to inversion strength ratio >1.0 is an important indicator of ankle sprain injury [14, 15]. Exercises should focus on strengthening the peroneal muscles because insufficient strength in this group of muscles has been associated with CAI and recurrent injury. However, all muscles of the ankle should be targeted, and all exercises should be performed bilaterally. When the training is performed bilaterally, we can expect substantial strength gains in both extremities. Strengthening begins with isometric exercises performed against an immovable object in four directions of ankle movement and is progressed to dynamic resistive exercises (isotonic exercises) using ankle weights, surgical tubing, or resistance bands.

With a structured rehabilitation program, the athlete can create continuous goals and more easily appreciate improvements. A daily adjustable progressive resistance exercise (DAPRE) strength progression, originally described by Knight [16] and later modified by Perrin and Gieck [17], can be used to create a structured progression of exercises for the athletes. The strengthening exercises should be performed with an emphasis on the eccentric component. Athletes should be instructed to pause 1 s between the concentric and eccentric phases of exercise and perform the eccentric component over a 4-s period. Concentric contraction refers to the active shortening of the muscle with resultant lengthening of the resistance band, while eccentric contraction involves the passive lengthening of the muscle by the elastic pull of the band. Resistive exercises should be performed (2–3 sets of 10–12 repetitions) in all four directions twice a day. As weight-bearing strengthening exercises, toe raises, heel walks, and toe walks should be incorporated to regain strength and coordination. Toe curling exercises with paper or towel and marble picking should also be included for strengthening of the foot musculature (**Table 2**).
