Chronic Ankle Instability in Sporting Populations

Delayed functional therapy after acute lateral ankle sprain increases subjective ankle instability - the later, the worse: a retrospective analysis

Background

The lateral ankle sprain (LAS) is one of the most common injuries in everyday and sports activities. Approximately 20–40 % of patients with LAS develop a chronic ankle instability (CAI). The underlying mechanisms for CAI have not yet been clearly clarified. An inadequate rehabilitation after LAS can be speculated, since the LAS is often handled as a minor injury demanding less treatment. Therefore, the aims of this retrospective study were to determine the CAI rate depending on age and sex and to identify possible determinants for developing CAI.

Methods

Between 2015 and 2018 we applied the diagnostic code “sprain of ankle” (ICD S93.4) to identify relevant cases from the database of the BG Klinikum Duisburg, Germany. Patients received a questionnaire containing the Tegner-Score, the Cumberland Ankle Instability Tool (CAIT) and the Foot and Ankle Disability Index. Additionally, there were questions about the modality and beginning of therapy following LAS and the number of recurrent sprains. There was a total of 647 completed datasets. These were divided into a CAI and non-CAI group according to a CAIT cut-off-score with CAI ≤ 24 and non-CAI > 24 points, representing one out of three criteria for having CAI based on international consensus.

Results

The overall CAI rate was 17.3 %. We identified a higher CAI rate in females and within the age segment of 41 to 55 years. A later start of therapy (> 4 weeks) after acute LAS significantly increases ankle instability in CAIT (p < .05). There was a significantly higher CAIT score in patients having no recurrent sprain compared to patients having 1–3 recurrent sprains or 4–5 recurrent sprains (p < .001).

Conclusions

Females over 41 years show a higher CAI rate which implies to perform specific prevention programs improving ankle function following acute LAS. A delayed start of therapy seems to be an important determinant associated with the development of CAI. Another contributing factor may be a frequent number of recurrent sprains that are also linked to greater levels of subjective ankle instability. Therefore, we would recommend an early start of functional therapy after acute LAS in the future to minimize the development of CAI.

Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain

OBJECTIVE

Distal fibular mobilization with movement (MWM), with and without a posterior gliding fibular tape, and anteroposterior mobilization of the talus (MOB) are widely used to treat acute lateral ankle sprains. The purpose of this study was to investigate the short-term and long-term relative effectiveness of these techniques.

METHODS

In this double-blind randomized controlled trial, 45 amateur soccer players with acute (<72 hours) lateral ankle sprain were randomly allocated to 6 sessions (3/wk within the first 2 weeks) of either MWM, MWM with tape (MWMtape), or MOB. All participants also received general advice, transcutaneous electrical nerve stimulation, edema draining massage, and a program of proprioception exercises. Participant ratings of function on the Foot and Ankle Ability Measure and Patient Global Impression of Improvement Scale were the primary outcomes measured over 52 weeks. Secondary outcomes were ankle pain, pressure pain threshold, range of motion, volume, and strength.

RESULTS

MWM and MWMtape were equally effective and participants demonstrated greater function on the Foot and Ankle Ability Measure at 12 and 52 weeks when compared with those receiving MOB; however, the latter demonstrated superior function at 2 weeks. No differences between groups were observed for Patient Global Impression of Improvement Scale or any of the secondary outcomes.

CONCLUSION

There are limited differences in the short term among techniques, with the exception of better sport function with MOB. Over the longer term, the distal fibular MWM is most effective to achieve activities of daily living and sport function when added to usual physical therapy care. The addition of a posterior gliding fibular tape provides no additional benefit.

IMPACT

Distal fibular mobilization with movement may be the most appropriate choice of treatment for acute lateral ankle sprain to achieve long-term activities of daily living and sport function. In the short term, anteroposterior mobilization of the talus offers greater improvement in sport function. The use of fibular tape provides no added benefit as an adjunct to a treatment that includes distal fibular mobilization with movement.

Tensiomyographic Neuromuscular Response of the Peroneus Longus and Tibialis Anterior with Chronic Ankle Instability

This study aimed to investigate the muscle contractile response of the peroneus longus (PL) and tibialis anterior (TA) in groups with and without chronic ankle instability (CAI) using tensiomyography. Twenty-three adults, 12 with CAI and 11 healthy participants, participated in this study. All subjects underwent a tensiomyographic assessment of the PL and TA to measure delay time, contraction time and maximal displacement. The ankle evertor and invertor normalized peak torques, maximum work done and muscle thickness of the PL and TA were calculated. The delay time and contraction time of the PL in the CAI side were significantly higher than those in the healthy group (p < 0.05); however, no significant difference could be detected in the TA between groups. Furthermore, there was no significant difference in the normalized peak torques, maximum work done and muscle thickness of the PL and TA between groups. The CAI side demonstrated a delayed muscle contractile response of the PL when compared with the healthy group although there was no difference in muscle strength and muscle size. Clinicians should consider the muscle contractile response of the PL for rehabilitation of the ankle evertor with CAI.

The epidemiology of chronic ankle instability with perceived ankle instability- a systematic review

Background

Chronic ankle instability, developing from ankle sprain, is one of the most common sports injuries. Besides it being an ankle issue, chronic ankle instability can also cause additional injuries. Investigating the epidemiology of chronic ankle instability is an essential step to develop an adequate injury prevention strategy. However, the epidemiology of chronic ankle instability remains unknown. Therefore, the purpose of this study was to investigate the epidemiology of chronic ankle instability through valid and reliable self-reported tools in active populations.

Methods

An electronic search was performed on PubMed and Web of Science in July 2020. The inclusion criteria for articles were peer-reviewed, published between 2006 and 2020, using one of the valid and reliable tools to evaluate ankle instability, determining chronic ankle instability based on the criteria of the International Ankle Consortium, and including the outcome of epidemiology of chronic ankle instability. The risk of bias of the included studies was evaluated with an adapted tool for the sports injury review method.

Results

After removing duplicated studies, 593 articles were screened for eligibility. Twenty full-texts were screened and finally nine studies were included, assessing 3804 participants in total. The participants were between 15 and 32 years old and represented soldiers, students, athletes and active individuals with a history of ankle sprain. The prevalence of chronic ankle instability was 25%, ranging between 7 and 53%. The prevalence of chronic ankle instability within participants with a history of ankle sprains was 46%, ranging between 9 and 76%. Five included studies identified chronic ankle instability based on the standard criteria, and four studies applied adapted exclusion criteria to conduct the study. Five out of nine included studies showed a low risk of bias.

Conclusions

The prevalence of chronic ankle instability shows a wide range. This could be due to the different exclusion criteria, age, sports discipline, or other factors among the included studies. For future studies, standardized criteria to investigate the epidemiology of chronic ankle instability are required. The epidemiology of CAI should be prospective. Factors affecting the prevalence of chronic ankle instability should be investigated and clearly described.

Kinesiology tape length and ankle inversion proprioception at step-down landing in individuals with chronic ankle instability

OBJECTIVES

To determine the effect of different lengths of kinesiology tape (KT) on ankle inversion proprioceptive performance in individuals with or without chronic ankle instability (CAI).

DESIGN

A repeated measures study.

METHODS

Fifteen participants with unilateral CAI and fifteen participants with no CAI volunteered. The Ankle Inversion Discrimination Apparatus for Landing (AIDAL) was used to measure ankle proprioceptive acuity. All participants were tested under four KT conditions: no tape (baseline), short tape length (only foot and ankle complex involved), mid length (below the knee) and long length (above the knee) taping. After the baseline test, participants underwent the 3 different taping tests in a random order.

RESULTS

Repeated measures ANOVA indicated that, compared to those without CAI, individuals with CAI performed significantly worse across the 4 different conditions (F = 8.196, p = 0.008). There was a significant KT main effect (F = 7.489, p < 0.001) and a significant linear effect (F = 17.083, p < 0.001), suggesting that KT significantly improved ankle proprioceptive performance in landing, and with longer tape length there was greater proprioceptive enhancement. Post-hoc analysis showed that for the CAI group, both mid length (p = 0.013, 95%CI = -0.063, -0.009) and long length (p = 0.010, 95%CI = -0.067, -0.011) taping can significantly improve ankle proprioceptive performance compared to no tape, whereas for the non-CAI group, ankle proprioceptive acuity was significantly improved only with long length taping (p = 0.007, 95%CI = -0.080, -0.015).

CONCLUSIONS

KT can be used to improve ankle inversion proprioceptive performance during landing in both individuals with and without CAI and increasing tape length may achieve greater proprioceptive improvement.

Multi-axis destabilisation device influences plantar pressure distribution in adults with chronic ankle instability

Patients with chronic ankle instability (CAI) walk with increased lateral plantar pressure, precipitating future injuries. Gait retraining to medially shift plantar pressure may prevent recurrent injury. We assessed if a multi-axis destabilisation device changed plantar pressure and muscle activity in patients with CAI during walking. Twelve adults with CAI (age: 23.6 ± 5.0 years; body mass index: 26.7 ± 4.5 kg/m2) participated. Insole plantar pressure and electro-myography were collected synchronously during treadmill walking. The destabilisation device had a half-sphere under both the rearfoot and forefoot. Two 30s walking trials were recorded at baseline, first without and second with the destabilisation device. After 20 min of walking with the destabilisation device, two 30s post-walking trials were collected, first with and second without the destabilisation device. The middle 10 steps of each trial were extracted, plantar pressure quantified, and data averaged across steps for repeated measures ANOVA analysis. Electromyographic data wereextracted from 50 ms pre- through 200 ms post-initial contact. The centre of pressure shifted medially during destabilisation device use (P < 0.002) versus baseline. This shift was notretained upon device removal. Thus, the device capably shifts plantar pressure while worn. Its effects beyond a single sessionare unknown.

Eyes-Open Versus Eyes-Closed Somatosensory Motor Balance in Professional Soccer Players With Chronic Ankle Instability: A Case-Control Study

Background:

Chronic ankle instability (CAI) is a condition defined by certain structural and functional deficits in the ankle joint complex after acute ankle injury. These deficits include pathological joint laxity, impaired postural control, and decreased strength and neuromuscular control.

Purpose:

To compare an eyes-open versus an eyes-closed balance training protocol in professional soccer players with CAI.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

For this study, we evaluated 19 players from 2 professional soccer teams in Madrid, Spain, all of whom had CAI. Participants from both teams were randomly assigned to an eyes-open group (n = 9) or eyes-closed group (n = 10). All participants completed 4 weeks of a supervised exercise protocol consisting of 3 sessions per week. Members of both the eyes-open and eyes-closed groups performed the same exercise protocol in the same order of execution. At the end of the protocol, the participants were assessed for pain (visual analog scale), ankle dorsiflexion range of motion (weightbearing lunge test), dynamic stability (Star Excursion Balance Test), and fear of movement and reinjury (Tampa Scale for Kinesiophobia). We compared results both before and after balance training and between the eyes-open and eyes-closed balance training groups.

Results:

Statistically significant differences were found for all of the assessed variables before and after balance training. No statistically significant differences were found between the eyes-closed and eyes-open groups on any variable.

Conclusion:

In the current study, eyes-closed balance training was not more effective than eyes-open balance training for CAI in professional soccer players.

Effects of Dry Needling on Neuromuscular Control of Ankle Stabilizer Muscles and Center of Pressure Displacement in Basketball Players with Chronic Ankle Instability: A Single-Blinded Randomized Controlled Trial

This study aimed to compare the effects of dry needling (DN) versus placebo DN applied to the peroneus longus (PL) and tibialis anterior (TA) on neuromuscular control and static postural control in basketball players with chronic ankle instability (CAI). A single-blinded randomized controlled trial was conducted. Thirty-two male and female basketball players with CAI were randomly assigned to receive either DN (n = 16) or placebo DN (n = 16). Pre-activation amplitudes of PL and TA were assessed with surface electromyography (EMG) during a dynamic landing test. Center of pressure (CoP) displacement and sway variability in anterior-posterior (AP) and medio-lateral (ML) directions were measured with a force platform during a single leg balance test (SLBT). Measures were obtained prior to a single DN intervention, immediately after, at 48 h, and 1 month after. The DN group displayed a significant increase in PL and TA pre-activation values, which were maintained 1 month later. Significant reductions in the ML and AP displacements and sway variability of CoP were found for the DN group. These results showed improvements in feedback/feed-forward strategies following DN, including enhanced neuromuscular control and static postural control, with the potential to become a convenient and accessible preventive treatment in CAI subjects.

Health-Related Quality of Life Among Middle-Aged Adults With Chronic Ankle Instability, Copers, and Uninjured Controls

CONTEXT

People with chronic ankle instability (CAI) display a lower regional and global health-related quality of life (HRQoL). Examinations of HRQoL outcomes associated with CAI have addressed younger adults, restricting our understanding of the long-term consequences of CAI.

OBJECTIVE

To compare ankle regional and global HRQoL in middle-aged participants with and those without CAI.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 59 middle-aged volunteers, consisting of 18 with CAI (age = 50.2 ± 9.3 years), 17 who were ankle-sprain copers (age = 54.5 ± 8.7 years), and 24 uninjured controls (age = 56.7 ± 10.0 years).

MAIN OUTCOME MEASURE(S)

Participants completed the Foot and Ankle Disability Index (FADI) and the Patient-Reported Outcomes Measurement Information System Adult Profile. Regional HRQoL was assessed using the FADI Activities of Daily Living and Sport subscales. Global HRQoL was measured using the 43-item Patient-Reported Outcomes Measurement Information System Adult Profile, which contains 7 short forms-Physical Function, Pain Interference, Fatigue, Depression, Sleep Disturbance, Anxiety, and Ability to Participate in Social Roles and Activities. Separate Kruskal-Wallis tests were used to determine between-groups differences.

RESULTS

Middle-aged participants with CAI had lower scores on both subscales of the FADI than the coper and control groups (all P values <.001). Participants with CAI scored lower on the Physical Function (U = 116.0, z = -2.78, P = .005) and Ability to Participate in Social Roles and Activities (U = 96.0, z = -3.09, P = .002) subscales but higher on the Pain Interference (U = 144.0, z = -2.36, P = .02), Fatigue (U = 110.0, z = -2.72, P = .006), and Depression (U = 110.5, z = -2.91, P = .004) subscales than the control group. Participants with CAI also scored lower on the Physical Function (U = 74.5, z = -2.79, P = .005) and Ability to Participate in Social Roles and Activities (U = 55.0, z = -3.29, P = .001) subscales but higher on the Fatigue (U = 90.0, z = -2.09, P = .04) and Depression (U = 96.5, z = -1.97, P = .048) subscales than the coper group.

CONCLUSIONS

Middle-aged participants with CAI displayed worse ankle regional and global HRQoL than their age-matched healthy counterparts and copers. These results demonstrated that CAI can affect HRQoL outcomes in middle-aged adults.

Neuromuscular control of the ankle during pre-landing in athletes with chronic ankle instability: Insights from statistical parametric mapping and muscle co-contraction analysis

OBJECTIVE

The present study aimed to compare the neuromuscular control of the muscles around the ankle between athletes with CAI and without history of any ankle sprain (Non-CAI) by using statistic parametric mapping (SPM) and co-contraction analyses.

DESIGN

Cross-sectional study; Setting: Laboratory; Participants: 40 athletes (20 CAI, 20 Non-CAI) were pair-matched for age and gender.

MAIN OUTCOME MEASURES

Neuromuscular control was examined using surface electromyography (EMG) amplitude and muscle co-contraction 200 ms before foot-contact with the ground during a jump-landing task.

RESULTS

The EMG amplitude of tibialis anterior, peroneus longus, and gastrocnemius medialis were analyzed using statistic parametric mapping. The CAI group exhibited decreased EMG amplitude of peroneus longus during preparation for foot-contact. There were no significant co-contraction differences between groups.

CONCLUSIONS

Our findings demonstrate that SPM combined with the co-contraction provides a comprehensive EMG analysis to detect the differences of neuromuscular control between athletes with and without chronic ankle instability. Additionally, this finding indicates that CAI contributed to altered neuromuscular control during the pre-landing phase, which may contribute to re-injury mechanisms.

Effects of Combining High-Definition Transcranial Direct Current Stimulation with Short-Foot Exercise on Chronic Ankle Instability: A Pilot Randomized and Double-Blinded Study

(1) Background: Balance decline is highly prevalent in people suffering from chronic ankle instability (CAI). The control of balance depends upon multiple neurophysiologic systems including the activation of cortical brain regions (e.g., the primary sensorimotor cortex). The excitability of this region, however, is diminished in people with CAI. In this pilot double-blinded randomized controlled trial, we tested the effects of high-definition transcranial direct current stimulation (HD-tDCS) designed to facilitate the excitability of M1 and S1 in combination with short-foot exercise (SFE) training on proprioception and dynamic balance performance in individuals with CAI. (2) Methods: Thirty young adults completed baseline assessments including the Active Movement Extent Discrimination Apparatus (AMEDA), Joint Position Reproduction (JPR) test, Y-balance test, and the Sensory Organization Test (SOT). They were then randomized to receive a four-week intervention of SFE in combination with tDCS (i.e., HD-tDCS+SFE) or sham (i.e., control) stimulation. Baseline assessments were repeated once-weekly throughout the intervention and during a two-week follow-up period. (3) Results: Twenty-eight participants completed this study. Blinding procedures were successful and no adverse events were reported. As compared to the control group, the HD-tDCS+SFE group exhibited significant improvements in the JPR test, the Y balance test, and the SOT at different time points. No group by time interaction was observed in AMEDA test performance. (4) Conclusions: HD-tDCS combined with SFE may improve dynamic balance and proprioception in CAI. Larger, more definitive trials with extended follow-up are warranted.

The prevalence of chronic ankle instability and its relationship to foot arch characteristics in female collegiate athletes

OBJECTIVE

To determine the prevalence of chronic ankle instability (CAI) and to investigate its relationship to the foot arch in collegiate female athletes by each sports event.

DESIGN

Cross-sectional study.

SETTING

University setting.

PARTICIPANTS

138 collegiate female athletes.

MAIN OUTCOME MEASURES

All subjects were asked about previous ankle sprains, and the arch height index (AHI) was calculated. Athletes with a previous sprain history were evaluated based on the criteria by the International Ankle Consortium (IAC), the severity of ankle instability (CAIT), and foot and ankle function (FAAM). The prevalence of CAI and the relationship between the AHI and ankle instability were analyzed by each sports event.

RESULTS

Of 106 athletes with a previous ankle sprain, 10 (9.4%) met the IAC criteria below the cut-off value of the CAIT, and only 1 athlete (0.9%) was below the FAAM cut-off value. The AHI was not significantly different in athletes with CAI. The AHI was significantly lower in swimmers than in track and field (sprint) athletes.

CONCLUSION

Most female athletes with CAI were aware of the severity of ankle instability, but they did not feel dysfunction of the ankle during sports. Additionally, the AHI may depend on the characteristics of sports events.

[Ligamentous ankle injury: an underestimated trauma?]

Ligamentous injuries of the ankle joint are among the most common injuries in sports, with landing on the opponent's foot or direct contact counting among the most common injury mechanisms. Initial measures most notably include a clinical examination, supplemented by X-rays, sonography or MRI as required. In most cases, conservative treatment is the treatment of choice. At the beginning, pain and swelling have to be reduced. Then function must be regained before patients may return to sports after a return-to-play test. Some injury patterns are more complex with concomitant injuries, and despite all the success of conservative treatment, certain cases remain the preserve of surgery. Not only the downtime of athletes, the severity of long-term damage and chronic functional limitations, but also the associated costs for treatment suggest the recommendation that ankle joint injuries should not be underestimated and adequate treatment should be selected.

Sport Concussion Assessment Tool: baseline and clinical reference limits for concussion diagnosis and management in elite Rugby Union

OBJECTIVES

Rugby Union has adapted the Sports Concussion Assessment Tool (SCAT) into an abridged off-field concussion screen and the complete SCAT is used during diagnostic screens performed after head impact events. No firm guidelines exist as to what should be considered "abnormal" and warrant further evaluation. This study evaluates SCAT performances in 13,479 baseline SCAT assessments, and proposes clear reference limits for each sub-component of the SCAT5. Baseline reference limits are proposed to guide management of baseline testing by identifying abnormal sub-tests, enhancing the clinical validity of baseline screens, while clinical reference limits are identified to support concussion diagnosis when no baseline is available.

DESIGN

Cross sectional census sample.

METHODS

13,479 baseline SCATs from 7565 elite male rugby players were evaluated. Baseline reference limits were identified for each sub-test as the sub-test result achieved by approximately 5% of the population, while clinical references limits corresponded to the sub-test score achieved by as close as possible to 50% of the cohort.

RESULTS

Players reported symptoms 35% (95% CI 1.29-1.42) more frequently during SCAT5 than SCAT3 baseline assessments (mean 1.4±2.7 vs 1.0±2.4). Ceiling effects were identified for many cognitive sub-tests within the SCAT. Baseline and Clinical reference limits corresponding to the worst performing 5th percentile and 50th percentile were described.

CONCLUSIONS

Targeted baseline re-testing should be repeated when abnormal sub-tests are identified according to proposed baseline reference limits, while a more conservative clinical reference limit supports concussion diagnosis during screens in diagnostic settings.

Cross-cultural adaptation, reliability, and validation of the Taiwan-Chinese version of Cumberland Ankle Instability Tool

Purpose: To cross-cultural translate the Cumberland Ankle Instability Tool (CAIT) to Taiwan-Chinese version (CAIT-TW), and to evaluate the validity, reliability and cutoff score of CAIT-TW for Taiwan-Chinese athletic population.Materials and methods: The English version of CAIT was translated to CAIT-TW based on a guideline of cross-cultural adaptation. 77 and 58 Taiwanese collegial athletes with and without chronic ankle instability filled out CAIT-TW, Taiwan-Chinese version of Lower Extremity Functional Score (LEFS-TW) and Numeric Rating Scale (NRS). The construct validity, test-retest reliability, internal consistency and cutoff score of CAIT-TW were evaluated.Results: In construct validity, the Spearman's correlation coefficients were moderate (CAIT-TW vs LEFS-TW: Rho = 0.39, p < 0.001) and strong (CAIT-TW vs NRS: Rho= 0.76, p < 0.001). The test retest reliability was excellent (ICC_2.1 = 0.91, 95% confidential interval = 0.87-0.94, p < 0.001) with a good internal consistency (Cronbach's α: 0.87). Receiver operating characteristic curve showed a cutoff score of 21.5 (Youden index: 0.73, sensitivity: 0.87, specificity 0.85).Conclusions: The CAIT-TW is a valid and reliable tool to differentiate between stable and instable ankles in athletes and may further apply for research or daily practice in Taiwan.Implications for rehabilitationFor athletes, chronic ankle instability is prevalent and causes negative sequela, such as lowered quality of daily life, affected functional performance, and may cause post traumatic osteoarthritis.The psychometric properties of the Taiwan-Chinese version of the Cumberland Ankle Instability Tool showed moderate to strong construct validity, excellent test retest reliability, a good internal consistency and a cutoff score of 21.5.The validity and reliability of the Taiwan-Chinese version of the Cumberland Ankle Instability Tool are to enable clinicians to evaluate and manage ankle instability in Taiwanese who speaks Mandarin Chinese.

Prevalence and characteristics of chronic ankle instability and copers identified by the criteria for research and clinical practice in collegiate athletes

OBJECTIVES

To investigate the prevalence and characteristics of chronic ankle instability (CAI) and copers among collegiate athletes as identified by criteria for research (CAI-R and copers-R) and for clinical practice (CAI-C and copers-C).

DESIGN

Cross-sectional study.

SETTING

University.

PARTICIPANTS

Collegiate athletes (n = 507).

MAIN OUTCOME MEASURES

Participants were assessed by questionnaires based on the International Ankle Consortium guidelines. The percentages of participants with CAI-R, CAI-C, copers-R and copers-C were calculated, respectively. Demographic and injury data were statistically compared between CAI-R and copers-R groups.

RESULTS

The data of 470 participants was retained after exclusions. Of these, the prevalence of CAI-R (10.0%) was only half of that of CAI-C (19.8%), and that of copers-R and copers-C was about 5%. Seventy percent of unclassifiable participants had recurrent ankle sprains. CAI was most common in basketball, while copers were less prevalent in basketball, judo, rugby and gymnastics. The age at the initial injury was significantly younger in the CAI-R participants than in the copers-R.

CONCLUSIONS

The type of sport and the age at the initial injury may be associated with developing CAI. The standard criteria may not capture the entire clinical CAI population, therefore, care should be taken when applying the research to clinical practice.

The Effect of Divided Attention with Bounce Drop Jump on Dynamic Postural Stability

This study determined the effect of divided attention on controlling postural stability during a drop vertical jump task. In total, 30 participants were tested for drop vertical jumps from a 30-cm high platform and landing on a single leg with or without divided attention tasks. Three-dimensional marker trajectories and ground reaction forces were collected simultaneously. Vertical ground reaction force, loading rate, and dynamic postural stability index were analyzed with or without divided attention tasks. The paired sample t test indicated a significantly low knee flexion angle, high vertical ground reaction force, and increased loading rate in the divided attention task. Moreover, participants showed an increased vertical stability index and dynamic postural stability index in the divided attention task than in the nondivided attention task. Thus, results demonstrated that the divided attention task could affect posture control, leading to poor dynamic posture stability and possibly increasing lower extremity injury risk. The influence of the divided attention task on movement quality likely indicates that an athlete can no longer focus his attention on the bounce drop jump maneuver. Therefore, the bounce drop jump combined with dynamic postural stability index could be used in posture stability screening.

Outcome of a neuromuscular training program on recurrent ankle sprains. Does the initial type of healthcare matter?

OBJECTIVES

To study the impact of initial healthcare for a lateral ankle sprain on the outcome of neuromuscular training (NMT) on recurrent sprains and describe athlete characteristics receiving different types of healthcare.

DESIGN

Secondary analysis of three randomized trials.

METHOD

From three previous trials evaluating NMT, data on athlete characteristics, type of initial healthcare and a recurrent sprain during one-year follow-up were collected (N = 705). Multilevel logistic regression analyses were used to test the impact of initial healthcare on the outcome of NMT on recurrent sprains. Potential differences in athlete characteristics between different types of healthcare were examined using one-way analysis of variance and Pearson chi-square test.

RESULTS

After NMT, 39.7% of the athletes visiting paramedical care reported a recurrent sprain, 21.8% of secondary and 34.0% of primary care. Athletes who visited a physiotherapist reported more recurrent sprains, than those not visiting a physiotherapist (adjusted OR 3.15;95%CI 1.88-5.23). Athletes visiting paramedical (49.7%) and primary care (48.4%) used more braces and/or tape during sport than those not visiting any care (34.2%).

CONCLUSIONS

The initial type of healthcare of athletes with an ankle sprain, that consecutively received NMT, seems to impact the occurrence of recurrent sprains. Physiotherapists may be visited by athletes with a poorer prognosis, which may be explained by different athlete characteristics.

Musculoskeletal injuries in athletes from five modalities: a cross-sectional study

Background

Musculoskeletal injuries (MSK-I) are a serious problem in sports medicine. Modifiable and non-modifiable factors are associated with susceptibility to these injuries. Thus, the aim of this study was to describe the prevalence of and identify the factors associated with MSK-I, including tendinopathy and joint and muscle injuries, in athletes.

Methods

In this cross-sectional observational study, 627 athletes from rugby (n = 225), soccer (n = 172), combat sports (n = 86), handball (n = 82) and water polo (n = 62) were recruited at different sports training centres and competitions. Athlete profiles and the prevalence of MSK-I were assessed using a self-reported questionnaire. Only previous MSK-I with imaging confirmation and/or a positive physical exam by a specialized orthopaedist were considered. The association of the epidemiological, clinical and sports profiles of athletes with MSK-I was evaluated by a logistic regression model.

Results

The mean age was 25 ± 6 years, and 60% of the athletes were male. The epidemiological, clinical and sports profiles of the athletes were different for the five sport groups. The MSK-I prevalence among all athletes was 76%, with 55% of MSK-I occurring in a joint, 48% occurring in a muscle and 30% being tendinopathy, and 19% of athletes had three investigated injuries. The MSK-I prevalence and injury locations were significantly different among sport groups. There was a predominance of joint injury in combat sports athletes (77%), muscle injury in handball athletes (67%) and tendinopathy in water polo athletes (52%). Age (≥30 years) was positively associated with joint (OR = 5.2 and 95% CI = 2.6–10.7) and muscle (OR = 4.9 and 95% CI = 2.4–10.1) injuries and tendinopathy (OR = 4.1 and 95% CI = 1.9–9.3).

Conclusion

There is a high prevalence of tendinopathy and joint and muscle injuries among rugby, soccer, combat sports, handball and water polo athletes. The analysis of associated factors (epidemiological, clinical and sports profiles) and the presence of MSK-I in athletes suggests an approximately 4–5-fold increased risk for athletes ≥30 years of age. The identification of modifiable and non-modifiable factors can contribute to implementing surveillance programmes for MSK-I prevention.

Prevalence and Impact of Chronic Ankle Instability in Adolescent Athletes

Background:

The prevalence and impact of chronic ankle instability (CAI) in adolescent athletes are unknown. To better develop and justify prevention strategies of lateral ankle sprains and CAI, it is important to understand the origin and associated long-term impact of CAI within populations other than adults.

Purpose/Hypothesis:

The purpose of this study was to determine the prevalence and impact of CAI on ankle function, health-related quality of life (HRQoL), and physical activity in adolescent athletes. The hypothesis was that the presence of CAI will be commonly reported among adolescent athletes and that participants with CAI will have lower self-reported ankle function, HRQoL, and physical activity when compared with participants without CAI.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A cohort of 1002 healthy (able to fully participate) adolescent athletes (50.4% female; mean age, 15.6 ± 1.6 years) across 8 club sport facilities and high schools completed paper-and-pencil surveys to establish the presence of CAI (Identification of Functional Ankle Instability [IdFAI]) and estimate perceived ankle function (Foot and Ankle Ability Measure [FAAM]–Activities of Daily Living and FAAM-Sport), HRQoL (Pediatric Quality of Life Inventory 4.0 [PedsQL]), and physical activity (Hospital for Special Surgery Pediatric Functional Activity Brief Scale [HSS Pedi-FABS]).

Results:

The overall prevalence of CAI was 20.0%. Participants with unilateral CAI reported significantly lower (P < .001) ankle function (FAAM-Sport: 87.0 ± 14.8) and HRQoL (total PedsQL: 89.8 ± 9.8) than participants who did not have CAI (FAAM-Sport: 97.7 ± 6.0; total PedsQL: 93.5 ± 9.1). Physical activity was not different between participants with and without CAI.

Conclusion:

The prevalence of CAI was high among adolescent athletes. The presence of CAI negatively affected ankle function and HRQoL in adolescent athletes. Given the high prevalence and negative impact of CAI in an adolescent population, strategies to prevent ankle injuries and maintain physical activity are needed to alleviate future long-term consequences associated with developing CAI. These strategies should be implemented as soon as sport participation begins, as it appears that the origin of CAI may occur before adulthood.

Baseline Assessments of Strength and Balance Performance and Bilateral Asymmetries in Collegiate Athletes

Dai, B, Layer, J, Vertz, C, Hinshaw, T, Cook, R, Li, Y, and Sha, Z. Baseline assessments of strength and balance performance and bilateral asymmetries in collegiate athletes. J Strength Cond Res 33(11): 3015-3029, 2019-Injuries to upper and lower extremities comprise more than 70% of the total injuries in collegiate athletes. Establishing normative data of upper and lower extremity strength and balance may help guide postinjury rehabilitation and return-to-play decisions. The purposes of the current study were to develop the normative data of performance and bilateral asymmetries during 4 upper and lower extremity strength and balance tests in collegiate athletes and to quantify the correlations between strength and balance performance and bilateral asymmetries. A total of 304 male and 195 female Division I athletes from 14 sports performed a maximum push-up test to assess upper extremity strength, a countermovement jump test to assess lower extremity strength, an upper extremity reaching test to assess upper extremity balance, and a lower extremity reaching test to assess lower extremity balance. Bilateral ground reaction forces were collected for the push-up and jump tests. Reaching distances were measured for the 2 balance tests. Bilateral asymmetries were generally less than 10%. Significant sports effects were observed for all 5 performance variables (p < 0.001) but not for asymmetry variables (p ≥ 0.36). Weak correlations were found between strength and balance performance and asymmetries (r < 0.3). Normative data are sex and sports specific in collegiate athletes. Increased asymmetries could be more individualized rather than sex and sports specific. When return-to-play decisions are made, athletes following injuries need to demonstrate less than 10% of asymmetries to be consistent with the normative data. Strength and balance should be evaluated and improved with specific focuses.

Decreased perceived ankle and knee joint health in individuals with perceived chronic ankle instability

PURPOSE

Abnormal movement patterns and neuromuscular impairments at the ankle are thought to contribute to ankle joint degeneration in those with chronic ankle instability. However, these impairments are not confided to the ankle; rather, proximal neuromuscular deficiencies at the knee and aberrant movement patterns, thought to be responsible for reductions in knee joint health, have also been identified. While neuromuscular impairments and self-reported functional limitations have been examined in those with chronic ankle instability, patient-generated symptoms associated with joint health of the ankle and knee have not been investigated. Therefore, the purpose was to compare perceived ankle and knee joint health in individuals with and without chronic ankle instability.

METHODS

The Ankle Osteoarthritis Scale and the Knee Injury and Osteoarthritis Outcome Score assessed region-specific ankle and knee joint health.

RESULTS

Participants with chronic ankle instability reported more ankle pain (P < 0.001) and disability (P < 0.001) than the control group. Chronic ankle instability individuals also reported worse knee joint health (P < 0.05).

CONCLUSIONS

The increased symptomology associated with decreased ankle joint health further supports information demonstrating joint degeneration in young adults with chronic ankle instability. The decreased perceived knee joint health provides preliminary evidence of the negative impact proximal neuromuscular impairments associated with chronic ankle instability that may have on joints other than the ankle. Assessing subjective ankle and knee joint function can guide clinicians in developing individualized rehabilitation by providing them with an understanding if a patient presenting with chronic ankle instability suffers from symptoms arising from more than just the ankle.

LEVEL OF EVIDENCE

Case-control, Level III.

Do Grade II Ankle Sprains Have Chronic Effects on the Functional Ability of Ballet Dancers Performing Single-Leg Flat-Foot Stance? An Observational Cross-Sectional Study

Ballet dancers have a higher risk than the general population of ankle sprains. Ankle proprioception is of the utmost importance for executing static and dynamic positions typical of ballet dancing. Ankle sprains can create changes in functional ability that may affect ballet performance. The aim of this cross-sectional observational study is to evaluate if non-professional ballet dancers that were previously injured with a grade II ankle sprain carry a long-term stability deficit in ballet specific positions (passé, arabesque) and in single-leg flat-foot stance, thereby affecting ballet performance. We enrolled 22 amateur female ballet dancers, 11 who previously had a grade II ankle injury and 11 who had no history of ankle injury. Stabilometric data (Center of Pressure Speed and Elipse Area) were assessed with the postural electronic multisensory baropodometer in normal, arabesque, and passè positions with both open and closed eyes. Using an unpaired t-test, we compared healthy and pathological feet of the ankle injury group for a standard monopodalic position and two ballet-specific positions. No difference between pathological and healthy feet of non-professional ballet dancers who suffered grade II ankle injury was detected. According to the parameters considered in this study, grade II ankle sprains seem to have a favorable prognosis in the sample that we evaluated.

Pressure pain sensitivity over nerve trunk areas and physical performance in amateur male soccer players with and without chronic ankle instability

OBJECTIVE

Chronic ankle instability (CAI) is reported after ankle sprain. Our aim was to assess differences in mechanical pain sensitivity of lower extremity nerve trunks and physical performance between amateur soccer players with and without CAI.

DESIGN

A cross-sectional case-control study.

SETTING

Amateur soccer teams.

PARTICIPANTS

Fifty-five male soccer players, 28 with and 27 without CAI participated.

MAIN OUTCOME MEASURES

The perceived instability was assessed with the Cumberland Ankle Instability Tool (CAIT). Pressure pain thresholds (PPTs) on the common peroneal and tibialis nerve trunks, vertical jump, lateral step-down test and joint position sense of the knee were assessed by a blinded assessor.

RESULTS

Soccer players with CAI showed lower PPTs over the common peroneal nerve than those without CAI (between-groups mean difference: 1.0 ± 0.8 kg/cm², P < 0.001). No differences for PPT over the tibialis posterior (P = 0.078) or any physical performance outcome (knee joint positioning sense [P = 0.798], lateral step-down test [P = 0.580] and vertical jump variables [all, P > 0.310]) were found. PPT over the common peroneal nerve exhibited a significant moderate correlation with the CAIT score (r = 0.528, P < 0.001).

CONCLUSION

Amateur soccer players with CAI have higher pressure pain sensitivity over the common peroneal nerve but exhibit similar physical performance to amateur soccer players without CAI.

The effects of wearing an Ankle Stabilizing Orthosis (ASO) Ankle Brace on ankle joints kinetics and kinematics during a basketball rebounding task

Following an ankle injury, athletes sometimes brace the injured ankle in hopes of minimizing the likelihood of suffering a recurring injury. This study aims to evaluate the effects of wearing an Ankle Stabilizing Orthosis (ASO) ankle brace unilaterally on the dominant side on bilateral ankle joint kinetics and kinematics and peroneus longus EMG activity. Since a significant proportion of ankle injuries in basketball occur during rebounding, data was collected during a simulated rebounding task. Rebounding is defined as the act of retrieving a missed shot attempt. Subjects oftentimes jump vertically to acquire the basketball as it rebounds from the backboard or rim. Sixteen subjects participated in the study (11 males, 5 females; mean age = 26.94 years, SD = 5.32; mean height 1.72 m, SD = 0.08; mean weight 73.95 kg, SD = 13.68). Participants completed the rebounding task in braced (ASO) and unbraced (UB) conditions. Ankle and foot inversion angles, ankle inversion moments and peroneus longus EMG activity were recorded and analysed to determine the effects of wearing an ankle brace unilaterally. In the dominant limb, when compared to UB, ASO reduced ankle and foot inversion, and increased ankle inversion moments. No significant differences were observed in peroneus longus EMG activity. In the non-dominant limb, no significant differences were observed for any of the parameters. These results suggest that wearing an ASO ankle brace on the dominant ankle reduces maximum ankle and foot inversion angles without posing an increased risk to the unbraced leg. However, the increased ankle inversion moments in the braced ankle suggest that there are adjustments regarding force distribution, perhaps due to the restricted range of motion.

Changes in Spinal and Corticospinal Excitability in Patients with Chronic Ankle Instability: A Systematic Review with Meta-Analysis

The objective of this systematic review with meta-analysis was to determine alterations in spinal and corticospinal excitability of ankle muscles in patients with chronic ankle instability (CAI) compared to uninjured controls. Independent researchers performed comprehensive literature searches of electronic databases and included studies that compared groups with and without CAI and investigated neural excitability with Hoffmann reflex (H-reflex) and/or transcranial magnetic stimulation (TMS). A fixed-effect meta-analysis was conducted to determine group differences for (1) soleus and fibularis maximal H-reflex (Hmax)/maximal M-wave (Mmax)-ratios, and (2) soleus and fibularis longus cortical motor thresholds (CMTs). Seventeen studies were included in the current meta-analysis. They showed that the Hmax/Mmax-ratios of the soleus and the fibularis longus in the CAI group were significantly lower than those in the uninjured control group (soleus: d = −0.41, p < 0.001; fibularis longus: d = −0.27, p = 0.04). There was no evidence for changes in the CMT. This systematic review is the first to demonstrate evidence that patients with CAI present decreased spinal reflex excitability in the soleus and fibularis longus. However, there is no evidence of changes in supraspinal excitability when considering only the CMT. The latter result needs to be interpreted with caution as all except one study demonstrate some changes at the supraspinal level with CAI.

Cross-cultural adaptation and psychometric properties' evaluation of the modern standard Arabic version of Cumberland Ankle Instability Tool (CAIT) in professional athletes

Purpose

To cross-culturally adapt the Cumberland Ankle Instability Tool into modern standard Arabic and to assess its psychometric properties.

Method

Cross-cultural adaptation followed a combination of guidelines and for psychometric evaluation a sample of 107 athletes as recruited. All recommended measurement properties by the Consensus-based Standards for the selection of health status Measurement Instruments were evaluated, including face, structural, convergent, and discriminant validity; reproducibility; distribution-based responsiveness, and interpretability. We also used a structured content analytic method to evaluate content validity.

Results

The tool presented excellent internal consistency (α = 0.92) and reliability (ICC 0.75–0.98), and good convergent validity compared with Lower Extremity Functional Scale (ρ = 0.67). For reproducibility testing: Minimal detectable change ranged from 0.41 to 6.0 points; for responsiveness assessment: the effect sizes were large (Glass’Δ range 2.03–2.08, Cohen’s d range 2.22 to 2.53) and the Area under the Curve was 0.869. Its unidimensionality was proved by a 1-factor solution explaining 63.8% of the variance.

Conclusion

The Arabic version of Cumberland Ankle Instability Tool presented acceptable psychometric properties comparable to the original version. The questionnaire is understood across most of the Arabic speaking world and can be used in research and clinical practice to assess patients suffering from chronic ankle instability.

Comparison of 3 ankle braces in reducing ankle inversion in a basketball rebounding task

Lateral ankle injury incidence rates are very high in the sport of basketball, with a significant proportion occurring during rebounding. Ankle braces are often used as preventative and rehabilitative techniques in the hope of minimizing the likelihood of experiencing excessive ankle inversion. This study aims to evaluate the effect of different ankle braces in preventing ankle inversion during a basketball rebounding task. Sixteen subjects participated in the study (11 males, 5 females; mean age = 26.94 years, SD = 5.32; mean height 1.72 m, SD = 0.08; mean weight 73.95 kg, SD = 13.68). Participants performed a simulated rebounding task in multiple braced conditions: unbraced (UB), Ossur Formfit (OF), Talarmade Ankleguard Air/Gel Stirrup (TAG) and Bauerfeind Malleoloc (BF). Ankle and foot inversion angles, ankle inversion moments and peroneus longus EMG activity were recorded and analysed to determine the effectiveness of each condition to resist inversion. All braced conditions reduced ankle and foot inversion angles compared to UB. In the non-dominant limb, OF showed reduced maximum ankle inversion compared to BF (non-dominant mean difference = 0.630°, p < 0.001) and reduced foot inversion compared to TAG (non-dominant mean difference = 0.966°, p = 0.035). Compared to UB, OF and TAG increased ankle inversion moments in the dominant ankle and showed decreases in the non-dominant ankle. BF reduced mean peak peroneus longus EMG activity compared to all other trials. Whilst statistically significant differences that were demonstrated between several braced conditions are relatively small, they are clinically significant knowing that the maximum barefoot inversion whilst standing is less than 17 degrees.

Epidemiology of Ankle Sprains and Chronic Ankle Instability

OBJECTIVE

To provide a focused overview of the existing literature on the epidemiology of acute ankle sprains (lateral, medial, and high/syndesmotic) with an emphasis on incidence studies from the United States. In addition, we provide a brief overview of chronic ankle instability (CAI), posttraumatic osteoarthritis, and injury prevention to contribute to our understanding of the epidemiology of these injuries and the current state of the science on ankle sprains and ankle instability in sports medicine.

BACKGROUND

Acute ankle sprains are one of the most common musculoskeletal injuries, with a high incidence among physically active individuals. Additionally, acute ankle sprains have a high recurrence rate, which is associated with the development of CAI. Understanding the epidemiology of these injuries is important for improving patients' musculoskeletal health and reducing the burden of lower limb musculoskeletal conditions.

DESCRIPTION

Acute ankle-sprain incidence rates are summarized among the general population, as well as among physically active populations, including organized athletics and military personnel, with a focus on incidence in the United States. The link between a prior ankle sprain and a future acute ankle sprain is described. We also discuss the association between the incident ankle sprain and adverse, long-term outcomes such as CAI and posttraumatic osteoarthritis. Finally, we summarize injury-prevention successes and future directions for research and prevention.

CLINICAL APPLICATIONS

This information is useful for health care providers to understand the expected incidence rates of acute ankle sprains, be aware of the association between ankle sprains and negative short- and long-term outcomes, and be familiar with existing injury-prevention programs.

A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift

Lateral ankle sprains are the most common injuries sustained during physical activity. The epidemiologic trends associated with chronic ankle instability (CAI) suggest that current rehabilitation approaches may be inadequate. We sought to synthesize best-practices evidence for the rehabilitation of patients with acute ankle sprains and CAI through the integration of emerging paradigms in perception, the dynamics of skill acquisition, and the biopsychosocial model of function, disability, and health. From the best available evidence, 4 key factors emerged for effective treatment and rehabilitation strategies: pain reduction, external ankle support for up to 1 year, progressive return to motion, and coordination training. We combined these factors into a meta-theoretical framework that centers on the perceptual interdependence of the cellular, local, and global functioning levels by linking insights from the body-self neuromatrix, the dynamics of skill acquisition, and the biopsychosocial model. Based on the best-practice recommendations from systematic reviews, ankle-sprain rehabilitation represents a multidimensional phenomenon governed by perception. The impairments, activity limitations, and participation restrictions associated with CAI may be linked to perceptual-interdependence alterations. Pain and edema reduction, the use of external ankle support for up to 1 year, progressive return to motion, and coordination training foster enhanced perceptual interdependence from cells to society. Using the perceptual-interdependence framework for ankle-sprain rehabilitation, we offer new insights for charting the course of effective strategies for enhancing function, reducing disability, and preventing the long-term sequelae associated with CAI.

Epidemiology of Ankle Sprains and Chronic Ankle Instability

OBJECTIVE

To provide a focused overview of the existing literature on the epidemiology of acute ankle sprains (lateral, medial, and high/syndesmotic) with an emphasis on incidence studies from the United States. In addition, we provide a brief overview of chronic ankle instability (CAI), posttraumatic osteoarthritis, and injury prevention to contribute to our understanding of the epidemiology of these injuries and the current state of the science on ankle sprains and ankle instability in sports medicine.

BACKGROUND

Acute ankle sprains are one of the most common musculoskeletal injuries, with a high incidence among physically active individuals. Additionally, acute ankle sprains have a high recurrence rate, which is associated with the development of CAI. Understanding the epidemiology of these injuries is important for improving patients' musculoskeletal health and reducing the burden of lower limb musculoskeletal conditions.

DESCRIPTION

Acute ankle-sprain incidence rates are summarized among the general population, as well as among physically active populations, including organized athletics and military personnel, with a focus on incidence in the United States. The link between a prior ankle sprain and a future acute ankle sprain is described. We also discuss the association between the incident ankle sprain and adverse, long-term outcomes such as CAI and posttraumatic osteoarthritis. Finally, we summarize injury-prevention successes and future directions for research and prevention.

CLINICAL APPLICATIONS

This information is useful for health care providers to understand the expected incidence rates of acute ankle sprains, be aware of the association between ankle sprains and negative short- and long-term outcomes, and be familiar with existing injury-prevention programs.

The Effect of Ankle Bracing on Kinematics in Simulated Sprain and Drop Landings: A Double-Blind, Placebo-Controlled Study

BACKGROUND

The efficacy of external ankle braces to protect against sudden inversion sprain has yet to be determined while taking into account the possible placebo effect of brace application.

PURPOSE

To assess the protective effect of an external ankle brace on ankle kinematics during simulated inversion sprain and single-legged drop landings among individuals with a history of unilateral lateral ankle sprain.

HYPOTHESIS

The primary hypothesis was that active and placebo external braces would reduce inversion angle during simulated inversion sprain.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixteen participants with ankle instability and previous sprain performed single-legged drop landings and sudden inversion tilt perturbations. Kinematics of the affected limb were assessed in 3 conditions (active bracing, passive placebo bracing, and unbraced) across 2 measurement days. Participators and investigators were blinded to the brace type tested. The effect of bracing on kinematics was assessed with repeated measures analysis of variance with statistical parametric mapping, with post hoc tests performed for significant interactions.

RESULTS

Only active bracing reduced inversion angles during a sudden ankle inversion when compared with the unbraced condition. This reduction was apparent between 65 and 140 milliseconds after the initial fall. No significant differences in inversion angle were found between the passive placebo brace and unbraced conditions during sudden ankle inversion. Furthermore, no significant differences were found among all tested conditions in the sagittal plane kinematics at the knee and ankle.

CONCLUSION

During an inversion sprain, only the actively protecting ankle brace limited inversion angles among participants. These results do not indicate a placebo effect of external bracing for patients with ankle instability and a history of unilateral ankle sprain. Furthermore, sagittal plane knee kinematics appear to remain unaffected by bracing during single-legged landing, owing to the limited effects of bracing on sagittal ankle kinematics. These results highlight the role of brace design on biomechanical function during sports-related and injury-prone movements.

CLINICAL RELEVANCE

Athletes prone to reinjury after lateral ankle sprain may benefit from brace designs that allow for full sagittal range of motion but restrict only frontal plane motion.

Function of ankle ligaments for subtalar and talocrural joint stability during an inversion movement - an in vitro study

Background

The lateral ankle ligament complex consisting of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL) is known to provide stability against ankle joint inversion. As injuries of the ankle joint have been reported at a wide range of plantarflexion/dorsiflexion angles, the aim of the present study was to evaluate the stabilizing function of these ligaments depending on the sagittal plane positioning of the ankle joint.

Methods

Eight fresh-frozen specimens were tested on a custom-built ankle deflection tester allowing the application of inversion torques in various plantarflexion/dorsiflexion positions. A motion capture system recorded kinematic data from the talus, calcaneus and fibula with bone-pin markers during inversion movements at 10° of dorsiflexion, at neutral position and at plantarflexion 10°. ATFL, CFL and PTFL were separately but sequentially sectioned in order to assess the contribution of the individual ligament with regard to ankle joint stability.

Results

Joint- and position-specific modulations could be observed when the ligaments were cut. Cutting the ATFL did not lead to any observable alterations in ankle inversion angle at a given torque. But subsequently cutting the CFL increased the inversion angle of the talocrural joint in the 10° plantarflexed position, and significantly increased the inversion angle of the subtalar joint in the 10° dorsiflexed position. Sectioning of the PTFL led to minor increases of inversion angles in both joints.

Conclusions

The CFL is the primary ligamentous stabilizer of the ankle joint against a forced inversion. Its functioning depends greatly on the plantar−/dorsiflexion position of the ankle joint complex, as it provides the stability of the talocrural joint primarily during plantarflexion and the stability of the subtalar joint primarily during dorsiflexion.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0330-5) contains supplementary material, which is available to authorized users.

Pediatric and adolescent ankle instability: diagnosis and treatment options

PURPOSE OF REVIEW

The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and treatment for lateral ankle instability in pediatric patients.

RECENT FINDINGS

Chronic ankle instability is a common sequela of lateral ankle sprain in young athletes. Incidence is increasing, possibly due in part to inadequate treatment of first-time ankle sprains, as well as increased youth participation in organized and competitive sports. The anterior talofibular ligament (ATFL) is injured in every case, whereas the calcaneofibular ligament (CFL) and syndesmosis may be involved in severe cases. A clinical history, focused physical exam, and appropriate radiographic studies aid in diagnosis, and predisposing factors must be identified. Early treatment of ankle sprains involves bracing or immobilization, followed by a course of physical therapy. Surgery involves anatomic repair of the torn ligaments, and may be required in cases of severe functional and mechanical instability with recurrent sprains refractory to nonsurgical management. Intraarticular disorders should be identified and may be addressed with ankle arthroscopy.

SUMMARY

Prompt treatment of lateral ankle instability in young athletes is important to prevent chronic ankle instability. Many patients are successfully treated without surgery, and those requiring operative intervention improve function postoperatively.

Chronic Lateral Ankle Instability: Open Surgical Management

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Lateral Ankle Sprain in a Mouse Model: Lifelong Sensorimotor Dysfunction

CONTEXT

  Ankle sprains are the most common orthopaedic injury that occurs during sport and physical activity. Many individuals who sprain their ankles develop chronic ankle instability (CAI), a condition characterized by recurrent injury, decreased physical activity, and decreased quality of life. These residual impairments are believed to persist for the remainder of the patient's life, in part due to the link between CAI and posttraumatic ankle osteoarthritis. However, this belief remains speculative due to the lack of long-term prospective investigations.

OBJECTIVE

  To use a mouse model of mild (MILD) and severe (SEVERE) ankle sprains to quantify balance and locomotor adaptations across the lifespan.

DESIGN

  Cohort study.

SETTING

  University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Fifty male mice (CBA/J) were randomly placed into a control (SHAM), MILD, or SEVERE group and housed individually.

INTERVENTION(S)

  The MILD group underwent surgical transection of a single right hind-limb lateral ankle ligament, and the SEVERE group had 2 of the lateral ligaments transected. The SHAM group underwent a sham surgery during which no lateral ligaments were transected.

MAIN OUTCOME MEASURE(S)

  After surgically inducing the ankle sprain, we measured balance and gait using a balance beam and footprint test before and every 6 weeks for 78 weeks.

RESULTS

  Age-related declines in balance but not stride length were exacerbated by an ankle sprain ( P < .001). Balance and stride lengths changed with age ( P < .001). Foot slips were worse in the SEVERE (4.32 ± 0.98) and MILD (3.53 ± 0.98) groups than in the SHAM group (2.16 ± 0.99; P < .001). Right-limb stride length was shorter in the SEVERE group (6.45 cm ± 0.41 cm) than in the SHAM group (6.87 cm ± 0.40 cm; P = .04).

CONCLUSIONS

  Transecting the lateral ligaments of a mouse hind foot resulted in lifelong sensorimotor dysfunction. Declines starting at 42 weeks postinjury may have represented the onset of posttraumatic osteoarthritis.

Eversion Strength and Surface Electromyography Measures With and Without Chronic Ankle Instability Measured in 2 Positions

BACKGROUND

Individuals with chronic ankle instability (CAI) have demonstrated strength deficits compared to healthy controls; however, the influence of ankle position on force measures and surface electromyography (sEMG) activation of the peroneus longus and brevis has not been investigated. The purpose of this study was to compare sEMG amplitudes of the peroneus longus and brevis and eversion force measures in 2 testing positions, neutral and plantarflexion, in groups with and without CAI.

METHODS

Twenty-eight adults (19 females, 9 males) with CAI and 28 healthy controls (19 females, 9 males) participated. Hand-held dynamometer force measures were assessed during isometric eversion contractions in 2 testing positions (neutral, plantarflexion) while surface sEMG amplitudes of the peroneal muscles were recorded. Force measures were normalized to body mass, and sEMG amplitudes were normalized to a resting period.

RESULTS

The group with CAI demonstrated less force when compared to the control group ( P < .001) in both the neutral and plantarflexion positions: neutral position, CAI: 1.64 Nm/kg and control: 2.10 Nm/kg) and plantarflexion position, CAI: 1.40 Nm/kg and control: 1.73 Nm/kg). There were no differences in sEMG amplitudes between the groups or muscles ( P > .05). Force measures correlated with both muscles' sEMG amplitudes in the healthy group (neutral peroneus longus: r = 0.42, P = .03; plantarflexion peroneus longus: r = 0.56, P = .002; neutral peroneus brevis: r = 0.38, P = .05; plantarflexion peroneus longus: r = 0.40, P = .04), but not in the group with CAI ( P > .05).

CONCLUSIONS

The group with CAI generated less force when compared to the control group during both testing positions. There was no selective activation of the peroneal muscles with testing in both positions, and force output and sEMG activity was only related in the healthy group.

CLINICAL RELEVANCE

Clinicians should assess eversion strength and implement strength training exercises in different sagittal plane positions and evaluate for other pathologies that may contribute to reduced eversion strength in patients with CAI.

LEVEL OF EVIDENCE

Level III, cross-sectional.

Chronic musculoskeletal ankle disorders in Sri Lanka

BACKGROUND

Musculoskeletal disorders of the lower extremities are commonly affected by chronicity and disability. One of the most commonly affected areas is the ankle. Epidemiological information is limited for chronic musculoskeletal ankle disorders in the general community, particularly in the developing world. This study aimed to determine the prevalence and impact of chronic musculoskeletal ankle disorders in the Sri Lankan community.

METHODS

A cross-sectional stratified random sample of people (n = 1000) aged 18 to 85 years in Sri Lanka was undertaken by questionnaire in the general community setting. Of those questionnaires, 827 participants provided data. Point prevalence for no history of ankle injury or ankle disorders, history of ankle injuries without chronic ankle disorders, and chronic ankle disorders were obtained. Point prevalence of chronic musculoskeletal disorders and causes for chronicity was evaluated.

RESULTS

There were 448 (54.2%) participants with no ankle disorders, 164 (19.8%) with a history of ankle injury but no chronic disorders, and 215 (26.0%) with chronic ankle disorders. The major component of chronic ankle disorders was musculoskeletal disorders (n = 113, 13.7% of the total sample), most of which were due to ankle injury (n = 80, 9.7% of the total). Sprains were responsible for 17.7% of the total ankle injuries. Arthritis was the other main cause for chronicity of ankle disorders with 4% of total participants (n = 33).

CONCLUSIONS

Almost 14% of the Sri Lankan community was affected by chronic musculoskeletal ankle disorders. The majority were due to a previous ankle injury, and arthritis. Most people had to limit or change their physical activity because of the chronic ankle disorder. A very low utility of physiotherapy services was observed.

The Epidemiology of Lateral Ligament Complex Ankle Sprains in National Collegiate Athletic Association Sports

BACKGROUND

Ankle sprains are a common injury in collegiate sports. Few studies have examined the epidemiology of individual ligament injuries, specifically the lateral ligament complex (LLC) of the ankle.

PURPOSE

To describe the epidemiology, including the estimated yearly national incidence, of LLC sprains among National Collegiate Athletic Association (NCAA) athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Injury surveillance data for 25 sports from the NCAA Injury Surveillance Program (NCAA-ISP) for the academic years 2009-2010 to 2014-2015 were used for analysis. All injuries included for analysis had a diagnosis of an LLC sprain. LLC sprain rates and rate ratios (RRs) with 95% CIs were calculated. From the sample, national estimates of the annual incidence of LLC sprains across the entire student-athlete body from these 25 sports were also calculated.

RESULTS

During the 2009-2010 to 2014-2015 academic years, 2429 LLC sprains were reported, for a rate of 4.95 per 10,000 athlete-exposures (AEs). LLC sprains comprised 7.3% of all reported collegiate sports injuries in the NCAA-ISP. Also, an estimated 16,022 LLC sprains occurred annually among the 25 sports. The sports with the highest LLC sprain rates were men's basketball (11.96/10,000 AEs) and women's basketball (9.50/10,000 AEs). Most LLC sprains occurred during practices (57.3%); however, the LLC sprain rate was higher in competitions than in practices (RR, 3.29; 95% CI, 3.03-3.56). Also, 11.9% of LLC sprains were identified as recurrent injuries, with the largest proportions of recurrent LLC sprains being found within women's basketball (21.1%), women's outdoor track (21.1%), women's field hockey (20.0%), and men's basketball (19.1%). In 44.4% of LLC sprains, the athlete returned to play in less than 24 hours; in 3.6%, the athlete required more than 21 days before returning to play (including those who did not return to play at all).

CONCLUSION

LLC sprains were the most commonly reported injury diagnosis among United States collegiate student-athletes. Continued examination of interventions that aim to reduce the incidence, severity, and recurrence of LLC sprains, specifically in women, is warranted.

Predicting balance improvements following STARS treatments in chronic ankle instability participants

OBJECTIVES

Sensory Targeted Ankle Rehabilitation Strategies that stimulate sensory receptors improve postural control in chronic ankle instability participants. However, not all participants have equal responses. Therefore, identifying predictors of treatment success is needed to improve clinician efficiency when treating chronic ankle instability. Therefore, the purpose was to identify predictors of successfully improving postural control in chronic ankle instability participants.

DESIGN

Secondary data analysis.

METHODS

Fifty-nine participants with self-reported chronic ankle instability participated. The condition was defined as a history of at least two episodes of "giving way" within the past 6 months; and limitations in self-reported function as measured by the Foot and Ankle Ability Measure. Participants were randomized into three treatment groups (plantar massage, ankle joint mobilization, calf stretching) that received 6, 5-min treatment sessions over a 2-week period. The main outcome measure was treatment success, defined as a participant exceeding the minimal detectable change score for a clinician-oriented single limb balance test.

RESULTS

Participants with ≥3 balance test errors had a 73% probability of treatment success following ankle joint mobilizations. Participants with a self-reported function between limb difference <16.07% and who made >2.5 errors had a 99% probability of treatment success following plantar massage. Those who sustained ≥11 ankle sprains had a 94% treatment success probability following calf stretching.

CONCLUSIONS

Self-reported functional deficits, worse single limb balance, and number of previous ankle sprains are important characteristics when determining if chronic ankle instability participants will have an increased probability of treatment success.

The identification of risk factors for ankle sprains sustained during netball participation

OBJECTIVES

Ankle sprains account for a large percentage of injuries sustained in netball. The identification of risk factors for ankle sprain is the preliminary action required to inform future prevention strategies.

DESIGN

Prospective study.

PARTICIPANTS

Ninety-four netball players from club and inter-district teams.

METHODS

Preseason data were collected for; vertical jump height, perceived ankle instability, sprain history, arthrometry inversion-eversion angles, star excursion balance test reach distances, the number of foot lifts during unilateral stance and demi-pointe balance test results. Participants were followed for the duration of one netball season and ankle sprains were recorded.

RESULTS

Eleven sprains were recorded for eleven players using a time-loss definition of injury. Ankle sprains occurred at an incidence rate of 1.74/1000 h of netball exposure. One risk factor was identified to increase the odds of sustaining an ankle sprain during netball participation - a reach distance in the posterior-medial direction of the star excursion balance test of less than or equal to 77.5% of leg length (OR = 4.04, 95% CI = 1.00-16.35).

CONCLUSIONS

The identified risk factor can be easily measured and should be considered for preseason injury risk profiling of netball players. Netball players may benefit from training programs aimed at improving single leg balance.

Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains

Lateral ankle sprains (LASs) are the most prevalent musculoskeletal injury in physically active populations. They also have a high prevalence in the general population and pose a substantial healthcare burden. The recurrence rates of LASs are high, leading to a large percentage of patients with LAS developing chronic ankle instability. This chronicity is associated with decreased physical activity levels and quality of life and associates with increasing rates of post-traumatic ankle osteoarthritis, all of which generate financial costs that are larger than many have realised. The literature review that follows expands this paradigm and introduces emerging areas that should be prioritised for continued research, supporting a companion position statement paper that proposes recommendations for using this summary of information, and needs for specific future research.

Single-leg drop landing movement strategies in participants with chronic ankle instability compared with lateral ankle sprain 'copers'

PURPOSE

To compare the movement patterns and underlying energetics of individuals with chronic ankle instability (CAI) to ankle sprain 'copers' during a landing task.

METHODS

Twenty-eight (age 23.2 ± 4.9 years; body mass 75.5 ± 13.9 kg; height 1.7 ± 0.1 m) participants with CAI and 42 (age 22.7 ± 1.7 years; body mass 73.4 ± 11.3 kg; height 1.7 ± 0.1 m) ankle sprain 'copers' were evaluated 1 year after incurring a first-time lateral ankle sprain injury. Kinematics and kinetics of the hip, knee and ankle joints from 200 ms pre-initial contact (IC) to 200 ms post-IC, in addition to the vertical component of the landing ground reaction force, were acquired during performance of a drop land task.

RESULTS

The CAI group adopted a position of increased hip flexion during the landing descent on their involved limb. This coincided with a reduced post-IC flexor pattern at the hip and increased overall hip joint stiffness compared to copers (-0.01 ± 0.05 vs. 0.02 ± 0.05°/Nm kg(-1), p = 0.03).

CONCLUSIONS

Individuals with CAI display alterations in hip joint kinematics and energetics during a unipodal landing task compared to LAS 'copers'. These alterations may be responsible for the increased risk of injury experienced by individuals with CAI during landing manoeuvres. Thus, clinicians must recognise the potential for joints proximal to the affected ankle to contribute to impaired function following an acute lateral ankle sprain injury and to develop rehabilitation protocols accordingly.

LEVEL OF EVIDENCE

Level III.