Gerry, in Kent, England asks:
"I broke my tibia and fibula just above the ankle almost nine months ago. It was fixed with an intermedullary nail. I had some x-rays at six months and my surgeon has given me the OK to return to football. However, I feel like I can’t push off so strongly on the leg that was broken. Could you suggest some exercises to help?"
Marc Bernier, Senior Physical Therapist, Director of Healthsouth Soccer International, replies:
"When devising a program to rehabilitate an injury such as yours, it is important to ensure that the first phase addresses both the loss of mobility and strength that accompanies the injury. The second phase will address balance, proprioceptive, and coordination deficits. Once all of the above components have been normalized, the initiation of football-specific functional training may begin. It is during this phase that an emphasis is placed on footwork, agility and power of the lower extremity. In many instances, the ability to push-off improves to pre-injury levels as the player progresses through his football training; however, this is not always the case, and may require more strict training to address this need.
"One of the deficits I have noticed in athletes that had difficulty in pushing off was an inability to stabilize the ankle while in a dorsiflexed position. Without stability in this position, the ability to efficiently push off into plantarflexion will be significantly diminished. One of my favorite exercises to address this is noted in Figure 1. The athlete is in a single leg stance position on a piece of foam, in a dorsiflexed position. While maintaining this position, the athlete will simulate a push-off from the foot with the heel unweighted, and push into the ball with his hands. To increase the stabilizing effort, the therapist can apply a perturbating force at his pelvis, increasing the need for dynamic stability on behalf of the athlete.
"The next two exercises involve the integration of light plyometrics, with the focus of the movement being on the ankle. "Ankle plyometrics" (Figure 2) are performed with the knees kept in a slightly flexed position, and having the athlete jump repetitively as high as he can by using a forceful plantarflexor force (pushing off using only the calf muscles). "Quick taps" (Figure 3) are performed by quickly alternating feet on top of a step. Start with one foot on the ground and the other on top of the step, and simultaneously switch feet. To make this more challenging, hold onto dumbbells while performing.
" 'Sportscord plyometrics' (Figure 4) are performed to retrain the ability to decelerate body momentum and instantaneously perform a powerful push off manouvre. The athlete starts with significant tension on the sportscord (which is secured around his waist), and standing on the uninvolved leg. The athlete then hops backward onto the involved leg, and instantly pushing off and propelling the body forward back to the starting position. 'Lateral cone plyometrics' (Figure 5) involve jumping laterally over a cone, off one foot onto the other. Emphasis is placed on the height of the jump, progressing from slow (stabilizing for 2 seconds upon each landing) to fast (rapid jumps without pause).
"The final series of exercises are performed on the field. 'Yo-yo runs' are repetitive forward and backward sprints in which an emphasis is placed on the transition from the backwards movement to the forward sprint. This transition requires the ability to decelerate the body at the ankle, and then perform a powerful push off to quickly change direction. This exercise is initially performed over short distances (3 meters) and progressing to longer distances (10-15 meters) which would allow faster speeds and would require more power to change direction. The final exercises in the progression are 'high knee skipping' (emphasizing the push off at the ankle) and 'bounding' (jumping as far as possible from one leg to the other).
"It is important to note that the exercises should be progressed as outlined, to ensure that too much stress is not placed on the site of your fracture, and so the body can become accustomed to the ballistic types of movement. All of this is recommended assuming that you have been cleared for unrestricted athletic activity from your physician."
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