Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains

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.

Does Neuromuscular Electrical Stimulation Improve Recovery Following Acute Ankle Sprain? A Pilot Randomised Controlled Trial

Aim:

Following soft tissue ankle injury, patients are often referred for out-patient physiotherapy and present symptoms including pain, reduced range of movement and function, and oedema. In this study, we assess the use of a neuromuscular electrical stimulation (NMES) device as an adjunctive therapy to reduce oedema in patients recovering from grade I and II ankle sprains.

Methods:

This was a single-centre, pilot randomised controlled study, recruiting patients referred to physiotherapy following an ankle sprain. Participants presenting with oedema were randomised to one of two treatment groups: (1) the current standard of care and (2) the current standard of care plus NMES use. Participants were identified in an emergency department and referred to a physiotherapy department for treatment 1 to 5 days following the injury and returned to clinic 7 days later.

Results:

Twenty-two participants completed the study and had full data sets for analysis (11 in each group). Mean volumetric displacement was reduced in the intervention group in comparison to the standard care group (P = .011); however, there were no between-group differences in figure of eight measurements, function or pain scores. The device was well tolerated, with no device-related adverse events recorded.

Conclusions:

In this pilot, randomised controlled trial, NMES was well tolerated by patients following ankle sprain and demonstrated statistically significant improvements in oedema reduction as measured by fluid displacement. No other changes were observed. Further work will need to confirm the clinical significance and effect on longer term recovery post-ankle sprain.

Hindfoot Arthrodesis Screw Position and Trajectory Effect on Talus Subsidence When Performed With Total Ankle Arthroplasty

BACKGROUND:

Total ankle arthroplasty (TAA) is increasingly being recognized as an effective surgical option for end-stage ankle arthritis. Associated hindfoot arthrodesis procedures are at times needed to correct malalignment or to address adjacent joint arthritis. Results following TAA and associated hindfoot arthrodesis have at times been underwhelming and the devascularization of the talar blood supply has been postulated as a potential cause. This study explored the association between hindfoot arthrodesis fixation and talar component subsidence.

METHODS:

The study included 81 consecutive patients who underwent a TAA with either an isolated subtalar arthrodesis or combined subtalar and talonavicular arthrodesis with a minimum of 2 years of follow-up. Radiographic and clinical evaluations including patient-reported outcomes were performed at each postoperative visit. The primary outcome measure was the presence of talar component subsidence while patient-reported outcomes were the secondary outcome measure.

RESULTS:

30.9% of patients had evidence of talar component subsidence. Subsidence was seen in 55.5% of patients with dorsal to plantar subtalar fixation compared to 11.1% of patients with plantar to dorsal screws ( P < .001) and in 44.4% of patients with screws violating the sinus tarsi compared to 3.7% of patients without screws in the sinus tarsi ( P < .001). Screws that were placed from dorsal to plantar were more likely to violate the sinus tarsi ( P < .001). Patients with evidence of talar subsidence reported higher pain scores and lower functional scores. There were 8 TAA failures, and the presence of dorsal to plantar screws was associated with failure ( P < .01).

CONCLUSION:

Screws that are placed across the subtalar joint from a dorsal to plantar approach are more likely to violate the sinus tarsi, contributing to a significantly higher rate of talar component subsidence when associated with TAA.

LEVEL OF EVIDENCE:

Level II, prospective comparative series.

Factors influencing return to play following conservatively treated ankle sprain: a systematic review

BACKGROUND

Ankle sprain is a very common injury, yet uncertainty exists in what is appropriate time to return to play (RTP). Such guidance may inform treatment pathways and effective practice.

OBJECTIVES

To determine if consensus exist about potential influencing factors for time to RTP in conservatively treated ankle sprain.

METHODS

We searched AMED, CINAHL Plus, Cochrane library, EMBASE, MEDLINE (EBSCO), SPOERDiscus, PsycINFO, PEDro, Scopus, unpublished literature and ongoing trials and Google Scholar from inception until April 2017. The quality of the eligible papers was assessed using the Downs and Black tool for randomized controlled trials (RCTs) and Critical Appraisal Skills Program (CASP) for observational studies.

RESULTS

The initial search identified 1885 articles. After screening, 14 articles were included. Of these, 11 were RCTs and 3 were prospective observational studies. Individual treatment methods that resulted in a shorter time to RTP were functional treatment, compression stockings, anteroposterior joint mobilization, hyaluronic acid injection (HA), Jump Stretch Flex Band programme (JSFB) and diclofenac medication. Prognostic factors for determining time to RTP in the included prospective observational studies were measures of Global function, SF 36PF, athlete's ambulation status, weight-bearing activity scores and self-reported athletic ability.

CONCLUSION

To our knowledge, this is the first review to report influencing factors for time to RTP following conservatively treated ankle sprain. Findings from this review identified factors that influence time to RTP. However, caution should be taken in generalizing these results due to the heterogeneity of studies and inability to clearly define and list the criteria for safe RTP. The inclusion of factors such as age, sex, BMI, level of sport, injury related factors in future studies might help to understand the course of injury and therefore assist in constructing safer criteria.

A Narrative Review on Avulsion Fractures of the Upper and Lower Limbs

Avulsion fractures compromise function and movement at the affected joint. If left untreated, it can lead to deformity, nonunion, malunion, pain, and disability. The purpose of this review was to identify and describe the epidemiology and available treatment options for common avulsion fractures of the upper and lower extremities. Current evidence suggests that optimal treatment is dependent on the severity of the fracture. Conservative efforts generally include casting or splinting with a period of immobilization. Surgery is typically indicated for more severe cases or if nonoperative treatments fail; patient demographics or preferences and surgeon experience may also play a role in decision making. Some avulsion fractures can be surgically managed with any one of various techniques, each with their own pros and cons, and often there is no clear consensus on choosing one technique over another; however, there is some research suggesting that screw fixation, when possible, may offer the best stability and compression at the fracture site and earlier mobilization and return to function. Physicians should be mindful of the potential complications associated with each intervention.

The Effect of Fibular Reposition Taping on Postural Control in Individuals With Chronic Ankle Instability: A Critically Appraised Topic

Clinical Scenario: History of acute ankle sprains can result in chronic ankle instability (CAI). Arthrokinematic changes resulting from CAI may restrict range of motion and contribute to postural control deficits. Mulligan or fibular reposition taping (FRT) has been suggested as a means to realign fibular positional faults and may be an effective way to improve postural control and balance in patients with CAI. Clinical Question: Is there evidence to suggest that FRT will improve postural control for patients with CAI in the affected limb compared with no taping? Summary of Key Findings: Three of the 4 included studies found no significant difference in postural control in patients receiving FRT compared with sham or no tape. Clinical Bottom Line: There is moderate evidence refuting the use of FRT to improve postural control in patients with CAI. Strength of Recommendation: There is grade B evidence to support that FRT does not improve postural control in people with CAI.

The Role of the Accessory Malleolar Ossicles and Malleolar Avulsion Fractures in Lateral Ankle Ligament Reconstruction

While it is well known that ankle sprains are one of the most common injuries in the United States, predictive factors regarding failure of conservative treatment are not well known. There are many biomechanical and epidemiological factors that play a role in recurrence and failure of conservative treatment, but most cases are able to be treated with immobilization and/or rest, ice, elevation, physical therapy, and bracing. We propose that one important risk factor is often overlooked simply due to the fact that a vast majority of these cases resolve without the need for surgery. Accessory ossicles and avulsion fractures of the malleoli or talus may represent a predisposition or marker for ligamentous damage that may lead to the need for lateral ankle ligament repair or reconstruction in the future. We have identified 61 consecutive patients who underwent lateral ankle ligament repair or reconstruction by the primary surgeon from the years 2007 to 2017. Out of those patients who met our inclusion and exclusion criteria, 66% had the presence of osseous pathology consisting of accessory ossicles or avulsion fractures of the medial or lateral malleolus or talus. The proportion of osseous pathology seen with lateral ankle ligament repair or reconstruction was higher than what has been previously reported in both operative and nonoperative settings. This may help identify a risk factor for failure of conservative treatment in patients presenting with acute ankle sprains or ankle instability especially in the active cohort.

LEVELS OF EVIDENCE

Level IV: Case series.

Postoperative Imaging of the Ankle

OBJECTIVE

The purpose of this article is to review imaging after commonly encountered surgical interventions of the ligaments, tendons, and soft tissues around the ankle. Intraoperative images, when available, are provided to improve conceptual understanding of these complex procedures.

CONCLUSION

Surgical interventions in the ankle are becoming more prevalent with increasing athletic demands and emerging focus on techniques for prevention of joint injury. Knowledge of the surgical techniques, imaging appearances, and complications in the postoperative ankle is necessary for the accurate diagnosis of postoperative complications and for optimal patient care.

Characteristics of patients with ankle sprain presenting to an emergency department in the south of England (UK): A seven-month review

INTRODUCTION

There is lack of evidence about ankle sprain patients presenting to emergency department (ED) in the UK. The study aim was to determine prevalence, demographic and clinical characteristics of patients attending to one ED. Knowing those characteristics may help setting prevention strategies and inform effective clinical practice.

METHODS

A retrospective review of records from patients' database system was conducted between May and November 2015 (inclusive).

RESULTS

909 new patients with ankle sprain were recorded during the study period. Patients had a median age of 27 years (IQR 20). Men aged between 14 and 37 years had higher percentage of injuries compared to women of a similar age. Overall prevalence of injury was equally distributed between men and women. Most patients were sent to radiography department for ankle/foot X-ray (89%). Over half of patients (58%) were sent home with no follow-up treatment. A subsample (n = 106) from the original sample (n = 909) showed a variety of causes of injury such as tripping (29%), non-specific injury (26.4%), sports (26%), walking (12.2%) and other accidental causes (6%). Football was the most prevalent sport (13%).

CONCLUSIONS

Prevention strategies, appropriate assessment tools and tailored rehabilitation programs are warranted to reduce number of patients and potential chronic symptoms.

Foot and ankle kinematics in chronic ankle instability subjects using a midfoot strike pattern when running, including influence of taping

BACKGROUND

Investigate differences in multi-segment foot kinematics between controls and participants with chronic ankle instability during running with a midfoot striking pattern and to evaluate the effect of Low-Dye and High-Dye taping.

METHODS

Three-dimensional multi-segment foot kinematics of 12 controls and 15 participants with chronic ankle instability were collected while running barefoot, and in both taping conditions. Ranges of motion occurring at each joint, each sub phase of stance, were compared between groups and between taping conditions (0-dimensional inference). Kinematic data were also compared using one-dimensional statistical parametric mapping.

FINDINGS

The symptomatic group demonstrated while barefoot running a significantly decreased rearfoot dorsiflexion range of motion during the peak impact phase as well as a less dorsiflexed position from 6 to 12% of the running cycle. During the absorption and generation phase, the symptomatic group also showed a significantly increased rearfoot dorsiflexion and adduction motion as well as an increased midfoot inversion motion. In the peak impact phase of both taping conditions, a decreased midfoot inversion motion was found. The High-Dye taping resulted in a decreased rearfoot plantarflexion motion whereas the Low-Dye caused a decreased midfoot inversion motion.

INTERPRETATION

Persons with chronic ankle instability seem to have altered rearfoot and midfoot kinematics while running with a midfoot striking index. High-Dye taping seems to have better therapeutic features than Low-Dye taping.

Effects of Dangguixu-san on acute lateral ankle sprain: study protocol for a randomized controlled trial

BACKGROUND

Ankle sprain is a common musculoskeletal injury. In Korean medicine, blood stasis is thought to be the main cause of pain and swelling in patients with ankle sprain. Dangguixu-san (DS), a herbal extract, is widely used in Korean medicine for the treatment of traumatic ecchymosis and pain by promoting blood circulation and relieving blood stasis. However, the effects of DS on ankle sprain have not been evaluated in a randomized clinical trial. Here, we describe the protocol for a randomized controlled trial that will evaluate the efficacy and safety of DS for the treatment of ankle sprain.

METHODS/DESIGN

In this randomized, double-blinded, placebo-controlled, parallel-arm clinical trial with a 1:1 allocation ratio, participants (n = 48) with acute lateral ankle sprain (ALAS) that occurred within 72 h before enrollment will be randomly assigned to a DS (n = 24) or a placebo (n = 24) group. Both groups will receive acupuncture treatment once a day for 5 days a week (excluding Saturday and Sunday) and the trial medication (DS/placebo capsule) three times a day for seven consecutive days. The primary outcome measure will be pain relief evaluated using a Visual Analog Scale (VAS). Secondary outcome measures will include Foot and Ankle Outcome Scores (FAOS), edema, European Quality of Life Five-Dimension-Five-Level Scale (EQ-5D-5 L) scores, and the number of recurrent ankle sprains. VAS, FAOS, edema, and EQ-5D-5 L scores will be recorded before, at the end of, and at 4 weeks after treatment completion. EQ-5D-5 L scores will be additionally recorded at 26 weeks after treatment completion. The number of recurrent ankle sprains will be recorded at 4, 8, 12, and 26 weeks after treatment completion.

DISCUSSION

This study is expected to provide evidence regarding the efficacy, safety, and usefulness of DS for the treatment of ALAS.

TRIAL REGISTRATION

cris.nih.go.kr, registration number: KCT 0002374 . Registered on 11 July, 2017 and approved by the Ministry of Food and Drug Safety (registration number, 31244).

Integrating electronic healthcare records of armed forces personnel: Developing a framework for evaluating health outcomes in England, Scotland and Wales

•

A framework which integration national Electronic Healthcare Record datasets from England, Scotland and Wales is proposed.

•

Variable similarity is used to develop a schema which allows for variables to be linked and combined across the nations.

•

Evaluation of integration shows that it is possibly to perform data linkage across the nations.

Background

Electronic Healthcare Records (EHRs) are created to capture summaries of care and contact made to healthcare services. EHRs offer a means to analyse admissions to hospitals for epidemiological research. In the United Kingdom (UK), England, Scotland and Wales maintain separate data stores, which are administered and managed exclusively by devolved Government. This independence results in harmonisation challenges, not least lack of uniformity, making it difficult to evaluate care, diagnoses and treatment across the UK. To overcome this lack of uniformity, it is important to develop methods to integrate EHRs to provide a multi-nation dataset of health.

Objective

To develop and describe a method which integrates the EHRs of Armed Forces personnel in England, Scotland and Wales based on variable commonality to produce a multi-nation dataset of secondary health care.

Methods

An Armed Forces cohort was used to extract and integrate three EHR datasets, using commonality as the linkage point. This was achieved by evaluating and combining variables which shared the same characteristics. EHRs representing Accident and Emergency (A&E), Admitted Patient Care (APC) and Outpatient care were combined to create a patient-level history spanning three nations. Patient-level EHRs were examined to ascertain admission differences, common diagnoses and record completeness.

Results

A total of 6,336 Armed Forces personnel were matched, of which 5,460 personnel had 7,510 A&E visits, 9,316 APC episodes and 45,005 Outpatient appointments. We observed full completeness for diagnoses in APC, whereas Outpatient admissions were sparsely coded; with 88% of diagnoses coded as “Unknown/unspecified cause of morbidity”. In addition, A&E records were sporadically coded; we found five coding systems for identifying reason for admission.

Conclusion

At present, EHRs are designed to monitor the cost of treatment, enable administrative oversight, and are not currently suited to epidemiological research. However, only small changes may be needed to take advantage of what should be a highly cost-effective means of delivering important research for the benefit of the NHS.

The effects of Kinesiotape on acute lateral ankle sprain: study protocol for a randomized controlled trial

Background

Ankle sprains are some of the most frequent injuries of the musculoskeletal system. However, there is no substantive evidence supporting which treatment strategy is superior. Taping with Kinesiotape (KT) is a new method that is used as an alternative to the more established taping and bracing techniques used for the prophylaxis and treatment of ankle sprains. The aim of this study is to examine the efficacy of KT on ankle sprain by comparing acupuncture combined with KT (AcuKT) with acupuncture alone in patients with acute lateral ankle sprains.

Methods/design

This study is a prospective, multi-center (DongShin University Gwangju Oriental Hospital, DongShin University Mokpo Oriental Hospital, and KyungHee Korean Medicine Hospital), outcome assessor-blinded, randomized controlled clinical trial with a 1:1 allocation ratio. Participants (n = 60) with a lateral ankle sprain occurring within 1 week of the study will be randomly assigned to either an acupuncture group (n = 10 at each center (total n = 30)) or an AcuKT group (n = 10 at each center (total n = 30)). The acupuncture group will receive acupuncture treatment at ST36, ST41, BL60, BL62, KI3, KI6, GB39, and GB40 once per day, 5 days per week (excluding Saturday and Sunday) for 1 week. The AcuKT group will receive acupuncture treatment at ST36, ST41, BL60, BL62, KI3, KI6, GB39, and GB40 and the ankle meridian tendino-musculature and a figure-of-eight shape form of KT treatment once per day, 5 days per week (excluding Saturday and Sunday) for 1 week. The primary outcome will be pain evaluation assessed according to a Visual Analogue Scale (VAS), while Foot and Ankle Outcome Score (FAOS), edema, European Quality of Life Five Dimension-Five Level Scale (EQ-5D-5 L) score, and number of recurrent ankle sprains will be considered as secondary outcome measures. VAS, FAOS, and edema measurements will be performed at baseline (before intervention), 5 days after the first intervention (i.e., at the end of the intervention), and 4 weeks after the completion of intervention. EQ-5D-5 L measurements will be conducted at baseline, 5 days after the first intervention, 4 weeks after the completion of intervention, and 26 weeks after the completion of intervention. The number of recurrent ankle sprains will be determined at 4, 8, 12, and 26 weeks after the completion of the intervention.

Discussion

This study will provide data regarding the efficacy of KT for the treatment of acute lateral ankle sprain. The results may lead to insights into the usefulness of KT in the treatment of acute lateral ankle sprain.

Trial registration

cris.nih.go.kr, ID: KCT0002257. Registered on 27 February 2017, and approved by the Ministry of Food and Drug Safety (Medical Device Clinical Trial Plan Approval #737).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2527-5) contains supplementary material, which is available to authorized users.

Predicting poor outcome from simple ankle injuries: a prospective cohort study

BACKGROUND

Sprained ankles are common and when there are no signs or evidence of a fracture, conventional management is conservative. At present, there are no clinical markers to identify those that may develop persisting instability and disability that would require rehabilitation or surgery.

OBJECTIVES

To investigate the nature and extent of soft tissue ankle injuries, and to consider whether the anatomical severity of injury can predict functional outcome.

METHODS

Patients attending a local Accident and Emergency Department in Oxford with an acute ankle injury with no clinical requirement for radiographs, or where radiographs were normal, were invited into the study. Within 5 days, patients underwent a diagnostic ultrasound examination, a cone beam CT study and a disability assessment. Ultrasound and physiotherapy assessments were repeated at 3 and 6 months.

RESULTS

100 patients were recruited and grouped based upon injuries. 58 had simple ankle injuries, 21 complex, 19 had significant fractures and 2 were excluded from further follow up analysis. There were no clinically significant differences in pain, disability or functional outcomes between the groups at all points of the study.

CONCLUSION

Medium to long term clinical outcomes were not solely determined by the severity of injury. Some patients with simple injuries were seen to have ongoing problems, whereas some with complex injuries recovered completely in a shorter period. Advances in knowledge: The severity of an ankle injury determined by radiological imaging does not necessarily dictate the severity of a patient's symptoms and the trajectory of their recovery.

Epidemiology of Joint Dislocations and Ligamentous/Tendinous Injuries among 2,700 Patients: Five-year Trend of a Tertiary Center in Iran

BACKGROUND

The epidemiology of traumatic dislocations and ligamentous/tendinous injuries is poorly understood. In this study, we aimed to evaluate the prevalence and distribution of various dislocations and ligamentous/tendinous injuries in a tertiary orthopedic hospital in Iran.

METHODS

Musculoskeletal injuries in an academic tertiary health care center in Tehran February 2005 to October 2010 were recorded. The demographic details of patients with pure dislocations and ligamentous/tendinous injuries were extracted and the type and site of injuries were classified according to their specific age/gender groups.

RESULTS

Among 18,890 admitted patients, 628 (3.3%) were diagnosed with dislocations and 2.081 (11%) with ligamentous/tendinous injuries. The total male/female ratio was 4.2:1 in patients with dislocations and 1.7:1 in patients with ligamentous/tendinous injuries. Shoulder was the most prevalent site of dislocation (50.6%), followed by fingers (10.1%), toes (7.6%), hip (7.3%), and elbow (6.5%). Ankle was the most common site of ligamentous/tendinous injury (53.5%), followed by midfoot (12.3%), knee (8.3%), hand (7%), and shoulder (5%). The mean ages of the patients in dislocations and ligamentous/tendinous injuries were 35.0±18.2 and 31.3± 15.1, respectively. There was no seasonal variation.

CONCLUSION

Shoulder dislocation and ankle ligamentous injury are the most frequent injuries especially in younger population and have different distribution patterns in specific age and sex groups. Epidemiologic studies can help develop and evaluate the injury prevention strategies, resource allocation, and training priorities.

Lower extremity joint coupling variability during gait in young adults with and without chronic ankle instability

Chronic ankle instability (CAI) is a condition resulting from a lateral ankle sprain. Shank-rearfoot joint-coupling variability differences have been found in CAI patients; however, joint-coupling variability (VCV) of the ankle and proximal joints has not been explored. Our purpose was to analyse VCV in adults with and without CAI during gait. Four joint-coupling pairs were analysed: knee sagittal-ankle sagittal, knee sagittal-ankle frontal, hip frontal-ankle sagittal and hip frontal-ankle frontal. Twenty-seven adults participated (CAI:n = 13, Control:n = 14). Lower extremity kinematics were collected during walking (4.83 km/h) and jogging (9.66 km/h). Vector-coding was used to assess the stride-to-stride variability of four coupling pairs. During walking, CAI patients exhibited higher VCV than healthy controls for knee sagittal-ankle frontal in latter parts of stance thru mid-swing. When jogging, CAI patients demonstrated lower VCV with specific differences occurring across various intervals of gait. The increased knee sagittal-ankle frontal VCV in CAI patients during walking may indicate an adaptation to deal with the previously identified decrease in variability in transverse plane shank and frontal plane rearfoot coupling during walking; while the decreased ankle-knee and ankle-hip VCV identified in CAI patients during jogging may represent a more rigid, less adaptable sensorimotor system ambulating at a faster speed.

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.

Acute ankle sprain: conservative or surgical approach?

Ankle sprains fall into two main categories: acute ankle sprains and chronic ankle instability, which are among the most common recurrent injuries during occupational activities, athletic events, training and army service.

Acute ankle sprain is usually managed conservatively and functional rehabilitation failure by conservative treatment leads to development of chronic ankle instability, which most often requires surgical intervention.

Enhancing the in-depth knowledge of the ankle anatomy, biomechanics and pathology helps greatly in deciding the management options.

Cite this article: Al-Mohrej OA, Al-Kenani NS. Acute ankle sprain: conservative or surgical approach? EFORT Open Rev 2016;1:34-44. DOI: 10.1302/2058-5241.1.000010.

The Relation of Q Angle and Anthropometric Measures with Ankle Sprain; a Case-control study

INTRODUCTION

Since most studies on ankle sprain are medical and sports-related and not much epidemiologic and etiologic data from the general population exist in this field, the present study evaluates the relationship between Q angle and anthropometric measures with ankle sprain in the general population.

METHODS

In the present case-control study, all of the patients over 18 years age presenting to emergency departments (ED) of two educational Hospitals, complaining from ankle sprain, were evaluated during more than 1 year. A checklist consisting of demographic data, height, weight, body mass index (BMI), and history of ankle sprain, as well as degree of Q angle was filled for all participants. The correlation of mentioned variables with incidence of ankle sprain was calculated using SPSS 22.

RESULTS

300 patients with ankle sprain were evaluated (53.5% male). Mean age of the patients was 37.03 ± 14.20 years. Mean weight, height, and BMI were 71.71 ± 11.26 (43 - 114), 168.74 ± 8.63 (143 - 190) and 25.14 ± 3.19 (18.41 - 38.95), respectively. Mean Q angle of the patients was 12.78 ± 3.19 degrees (5 - 23). There was a significant correlation between weight (p < 0.001), BMI (p = 0.001), history of sprain (r: 0.26, p < 0.001) and Q angle (p = 0.002) with incidence of ankle sprain. In addition, there was a significant statistical correlation between weight (p = 0.031), BMI (p = 0.020) and Q angle (p = 0.004) with history of ankle sprain. In patients with a history of ankle sprain, Q angle was wider by about 2 degrees.

CONCLUSION

It seems that the prevalence of ankle sprain directly correlates with high weight, BMI, and Q angle and is more prevalent in those with a history of sprain. Although the findings of the present study show a statistically significant correlation between these factors and ankle sprain, the correlation is not clinically significant.

Long-term prognosis of acute lateral ankle ligamentous sprains: high incidence of recurrences and residual symptoms

BACKGROUND

Acute lateral ankle ligamentous sprains (ALALS) are common injuries. This injury does not always have a favourable long-term outcome. Studies reporting the prognosis of ALALS after functional treatment are scarce.

OBJECTIVE

To determine the prognosis of functionally treated ALALS, in terms of recurrent ALALS and residual symptoms.

STUDY DESIGN

Retrospective cohort study.

SETTING

Patients were recruited from 20 family practices, nine physical therapy practices, the emergency departments of a regional hospital and a university hospital.

PATIENTS

Adult patients with an ALALS caused by an inversion trauma were invited to participate in this study 2.5-5 years after their initial injury.

INDEPENDENT VARIABLES

Functional treatment of the initial ALALS.

MAIN OUTCOME MEASURES

Acute lateral ankle ligamentous sprain recurrences and residual symptoms.

RESULTS

A total of 44 patients were included, with an average follow-up period after the initial ankle sprain of 204 weeks (range 150-274 weeks). Eight patients (18.1%) had reinjured their ankle. Explicit pain around the ankle joint at physical examination was experienced by 45.5%. Clinical symptoms of anterior ankle impingement were present in 25% (all athletes), with radiologically confirmed tibiotalar osteophyte bone formation in 82% of them.

CONCLUSIONS

A large proportion of patients with ALALS experience recurrences and persistent symptoms after their initial ankle injury. The high percentage of patients with anterior ankle impingement syndromes illustrates the need for early assessment of this impairment in patients with persistent complaints.

Supervised physiotherapy for mild or moderate ankle sprain

Clinical benefit might depend on the nature, intensity, and duration of treatment

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial

OBJECTIVE

 To assess the efficacy of a programme of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains.

DESIGN

 A randomised controlled trial of 503 participants followed for six months.

SETTING

 Participants were recruited from two tertiary acute care settings in Kingston, ON, Canada.

PARTICIPANTS

 The broad inclusion criteria were patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain. Exclusions were patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilisation and those unable to accommodate the time intensive study protocol.

INTERVENTION

 Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised programme of physiotherapy.

MAIN OUTCOME MEASURES

 The primary outcome of efficacy was the proportion of participants reporting excellent recovery assessed with the foot and ankle outcome score (FAOS). Excellent recovery was defined as a score ≥450/500 at three months. A difference of at least 15% increase in the absolute proportion of participants with excellent recovery was deemed clinically important. Secondary analyses included the assessment of excellent recovery at one and six months; change from baseline using continuous scores at one, three, and six months; and clinical and biomechanical measures of ankle function, assessed at one, three, and six months.

RESULTS

 The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval -3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analysed as a continuous change score.

CONCLUSIONS

 In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol.Trial registration ISRCTN 74033088 (www.isrctn.com/ISRCTN74033088).

Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis

BACKGROUND

Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI)), with a coinciding proliferation of review articles summarising these reports.

OBJECTIVE

To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI.

DESIGN

Overview of intervention systematic reviews.

PARTICIPANTS

Individuals with acute ankle sprain/CAI.

MAIN OUTCOME MEASUREMENTS

The primary outcomes were injury/reinjury incidence and function.

RESULTS

46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains.

CONCLUSIONS

For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI.

Contrast Therapy and Heat Therapy in Subacute Stage of Grade I and II Lateral Ankle Sprains

Objective This study was conducted to determine the most effective thermal modality; heat or contrast therapy-in reducing pain, reducing swelling, and increasing range of movement (ROM) of the grade I and II lateral ankle sprain in the prechronic stage of the subacute phase. Design Randomized control trail. Methods One hundred and fifteen participants of both genders who were diagnosed as having grade I or II lateral ankle sprain were randomly assigned to the study on the fifth day of injury. Pain, volume, and ROM were recorded before and after treatment continuously for 3 days. Results Effects were evaluated as "Immediately after application" and "3 days after continuous application." Immediately after application, there was no difference between the 2 modalities on ankle ROM; heat reduced pain over contrast therapy, and both modalities increased swelling. When considering the effects after continuous application for 3 days, no difference was found between the 2 modalities on ROM and the reduction of pain. Contrast therapy reduced swelling while heat caused increased swelling even after 3 days. Conclusion The use of different thermal modalities during the transition from the acute to chronic phase of injury can be suggested as effective treatment options according to the objectives of injury management: pain reduction, improve ROM, and swelling management.

LEVELS OF EVIDENCE

Therapeutic, Level II: Randomized clinical trial.

Incidence and Cost of Ankle Sprains in United States Emergency Departments

BACKGROUND

Ankle sprains represent a common injury in emergency departments, but little is known about common complications, procedures, and charges associated with ankle sprains in emergency departments.

HYPOTHESIS

There will be a higher incidence of ankle sprains among younger populations (≤25 years old) and in female patients. Complications and procedures will differ between ankle sprain types. Lateral ankle sprains will have lower health care charges relative to medial and high ankle sprains.

STUDY DESIGN

Descriptive epidemiological study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A cross-sectional study of the 2010 Nationwide Emergency Department Sample was conducted. Outcomes such as charges, complications, and procedures were compared using propensity score matching between lateral and medial as well as lateral and high ankle sprains.

RESULTS

The sample contained 225,114 ankle sprains. Female patients sustained more lateral ankle sprains (57%). After propensity score adjustment, lateral sprains incurred greater charges than medial ankle sprains (median [interquartile range], $1008 [$702-$1408] vs $914 [$741-$1108]; P < 0.01). Among complications, pain in the limb (1.92% vs 0.52%, P = 0.03), sprain of the foot (2.96% vs 0.70%, P < 0.01), and abrasion of the hip/leg (1.57% vs 0.35%, P = 0.03) were more common in lateral than medial ankle sprain events. Among procedures, medial ankle sprains were more likely to include diagnostic radiology (97.91% vs 83.62%, P < 0.01) and less likely to include medications than lateral ankle sprains (0.87% vs 2.79%, P < 0.01). Hospitalizations were more common following high ankle sprains than lateral ankle sprains (24 [6.06%] vs 1 [0.25%], P < 0.01).

CONCLUSION

Ankle sprain emergency department visits account for significant health care charges in the United States. Age- and sex-related differences persist among the types of ankle sprains.

CLINICAL RELEVANCE

The health care charges associated with ankle sprains indicate the need for additional preventive measures. There are age- and sex-related differences in the prevalence of ankle sprains that suggest these demographics may be risk factors for ankle sprains.

Incidence and Cost of Ankle Sprains in United States Emergency Departments

Background:

Ankle sprains represent a common injury in emergency departments, but little is known about common complications, procedures, and charges associated with ankle sprains in emergency departments.

Hypothesis:

There will be a higher incidence of ankle sprains among younger populations (≤25 years old) and in female patients. Complications and procedures will differ between ankle sprain types. Lateral ankle sprains will have lower health care charges relative to medial and high ankle sprains.

Study Design:

Descriptive epidemiological study.

Level of Evidence:

Level 3.

Methods:

A cross-sectional study of the 2010 Nationwide Emergency Department Sample was conducted. Outcomes such as charges, complications, and procedures were compared using propensity score matching between lateral and medial as well as lateral and high ankle sprains.

Results:

The sample contained 225,114 ankle sprains. Female patients sustained more lateral ankle sprains (57%). After propensity score adjustment, lateral sprains incurred greater charges than medial ankle sprains (median [interquartile range], $1008 [$702-$1408] vs $914 [$741-$1108]; P < 0.01). Among complications, pain in the limb (1.92% vs 0.52%, P = 0.03), sprain of the foot (2.96% vs 0.70%, P < 0.01), and abrasion of the hip/leg (1.57% vs 0.35%, P = 0.03) were more common in lateral than medial ankle sprain events. Among procedures, medial ankle sprains were more likely to include diagnostic radiology (97.91% vs 83.62%, P < 0.01) and less likely to include medications than lateral ankle sprains (0.87% vs 2.79%, P < 0.01). Hospitalizations were more common following high ankle sprains than lateral ankle sprains (24 [6.06%] vs 1 [0.25%], P < 0.01).

Conclusion:

Ankle sprain emergency department visits account for significant health care charges in the United States. Age- and sex-related differences persist among the types of ankle sprains.

Clinical Relevance:

The health care charges associated with ankle sprains indicate the need for additional preventive measures. There are age- and sex-related differences in the prevalence of ankle sprains that suggest these demographics may be risk factors for ankle sprains.

Atypical Chronic Ankle Instability in a Pediatric Population Secondary to Distal Fibula Avulsion Fracture Nonunion

Chronic ankle instability is a disabling condition, often occurring as a result of traumatic ankle injury. A paucity of published data is available documenting chronic ankle instability in the pediatric population. Much of the data has been confined to the adult population. We present 2 cases of chronic ankle instability, 1 in a 12-year-old and 1 in a 9-year-old patient. Unlike the typical adult etiology, the cause of instability was a dysfunctional lateral ligamentous complex as a consequence of bony avulsion of the tip of the fibula. Both patients had sustained a twisting injury to the ankle. The fractures failed to unite. The nonunion resulted in dysfunction of the anterior talofibular ligament with consequent chronic ankle instability. At the initial clinical assessment, magnetic resonance imaging was requested for both patients. In patient 1 (12 years old), the fracture was fixed with 2 headless screws and was immobilized in a plaster cast for 6 weeks. In patient 2 (9 years old), because of the small size of the avulsed fragment, fixation was not possible. A modified Gould-Broström procedure was undertaken, facilitating repair of the avulsed fragment using anchor sutures.

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.

Effects of Nintendo Wii Fit Plus training on ankle strength with functional ankle instability

[Purpose] The objective of this study was to examine the effects of a training program using the Nintendo Wii Fit Plus on the ankle muscle strengths of subjects with functional ankle instability. [Subjects and Methods] This study was conducted using subjects in their 20s who had functional ankle instability. They were randomized to a strengthening training group and a balance training group with 10 subjects in each, and they performed an exercise using Nintendo Wii Fit Plus for 20 minutes. In addition, every participant completed preparation and finishing exercises for 5 minutes, respectively. [Results] The muscle strengths after conducting plantar flexion and dorsiflexion significantly increased at the angular velocities of 60° and 120° in the strengthening training group. Furthermore, the muscle strengths after conducting plantar flexion, dorsiflexion, eversion, and inversion significantly increased at the angular velocities of 60° and 120° in the balance training group. [Conclusion] The balance training group using Nintendo Wii Fit Plus showed better results than the strengthening training group. Consequently, it is recommended to add the balance training program of the Nintendo Wii Fit Plus to conventional exercise programs to improve ankle muscle strength in functional ankle instability at a low cost.

Ankle muscle strength influence on muscle activation during dynamic and static ankle training modalities

Muscle weakness is considered a risk factor for ankle injury. Balance training and barefoot running have been used in an attempt to strengthen the muscles crossing the ankle. It is expected that training tasks that successfully strengthen the ankle would elicit increased muscular activity. However, it is unknown how an individual's ankle strength will influence the muscle activity used during a given task. Twenty-six participants performed dynamic (shod, barefoot running) and static tasks (squat on ground, squat on ®Bosu Ball) believed to strengthen the muscles surrounding the ankle. Electromyographic signals of the tibialis anterior, peroneus longus, gastrocnemius lateralis (GL) and gastrocnemius medialis (GM) were recorded and analysed using a non-linearly scaled wavelet analysis. Participants were divided into a strong group and a weak group according to their isometric plantar-flexion torque. The weak group required more relative GL and GM muscle activity during each training task compared to the strong group. No difference was observed between shod and barefoot running. There was a significant effect of training task on muscle activation level for the weak group. Differences in ankle strength had a significant impact on muscle activation.

Wii Fit™ exercise therapy for the rehabilitation of ankle sprains: Its effect compared with physical therapy or no functional exercises at all

Lateral ankle sprains represent the most common sports-related injuries. The Nintendo Wii Fit™ could be useful in the treatment of ankle sprains. The aim of this study was to compare the effectiveness of exercise training using the Wii Fit™ in ankle sprain patients: (a) with physical therapy; and (b) a control group not receiving any treatment. Ninety lateral ankle sprain patients were randomized to a Wii Fit™, physical therapy, or control group. We assessed the following outcome measures before, and 6 weeks after starting the allocated treatment: Foot and Ankle Ability Measure, pain during rest and walking, delay before return to sport, patient satisfaction, and effectiveness of the allocated treatment. Six weeks after the baseline measures, foot and ankle ability scores had improved in all groups, and pain had decreased during walking (P < 0.050). No between-group differences were detected between Wii Fit™ treatment, and both other groups (P > 0.050). In conclusion, the Wii Fit™ could be used as an exercise therapy to treat ankle sprain patients. However, Wii Fit™ was not more effective than only physical therapy, or no exercise therapy at all. Patients who did not receive treatment showed similar results as people who got any kind of exercise therapy.

Effects of soft bracing or taping on a lateral ankle sprain: a non-randomised controlled trial evaluating recurrence rates and residual symptoms at one year

Background

After sustaining an ankle sprain, taping is often the standard treatment in primary care. Ankle braces are sometimes used as an alternative. This study aimed to compare the effects of four weeks of soft bracing or taping following acute lateral ankle ligamentous sprain (ALALS) on sprain recurrence rates and residual symptoms at one year.

Methods

In this pragmatic, non-randomised controlled trial, 157 adult participants with an ALALS caused by an inversion trauma were alternately allocated to a four week treatment with a soft brace (intervention group) or a four week treatment with ankle tape (control group) in order of presentation. The primary outcome was the 1-year incidence of the self-reported recurrence of ALALS. The secondary outcome was the occurrence of residual symptoms.

Results

Baseline characteristics did not differ appreciably between the treatment groups. Thirteen patients (17%) in the brace group reported a re-injury versus 11 patients (14%) treated with tape, corresponding to a risk difference of 3.1% (relative risk 1.2, 95% CI 0.6 to 2.6). Cox regression analysis showed a hazard ratio of self-reported ankle sprain recurrence within 52 weeks in the brace group compared to the tape group of 0.9 (95% CI 0.4 to 1.9). After one year, patients in the brace group had poorer scores on the manual anterior ankle test, corresponding to a risk difference of 15.4% (RR 2.4, 95% CI 1.1 to 5.0).

Conclusion

ALALS recurrences and residual symptoms appear to be similar at one year when an ALALS is treated with four weeks of soft bracing or taping.

Trial registration

ISRCTN92030205

Minimally invasive reconstruction of the lateral ankle ligaments using semitendinosus autograft or tendon allograft

BACKGROUND

The purpose of the study was to retrospectively compare the therapeutic effect between semitendinosus autograft and tendon allograft for lateral ankle ligaments reconstruction.

METHODS

From September 2006 to June 2011, 68 patients (41 males, 27 females) with chronic ankle instability underwent anatomical reconstruction of the lateral ligaments using semitendinosus autograft (autograft group, 32 patients) or tendon allograft (allograft group, 36 patients) via a minimally invasive approach. All patients were followed up for at least 12 months. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and stress tests were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded.

RESULTS

Compared with allograft group, the average operation time was significantly increased (85.5 ± 11.5 minutes vs 58.1 ± 10.2 minutes, P < .0001), but the mean time to heal was significantly shorter (11.2 ± 4.1 months vs 13.5 ± 5.2 months, P = .0458) in the autograft group. Although the mean AOFAS score was significantly increased at the final follow-up in the autograft group (95.1 ± 7.5 vs 62.3 ± 8.2, P = .0001) and allograft group (94.8 ± 5.5 vs 60.2 ± 8.4, P < .0001), no significant difference in AOFAS was found between these 2 groups. Similarly, there was no significant difference in talar tilt or shift between autograft and allograft groups. In addition, no patients complained of weakness or disability at the donor site in the autograft group, while incisional swelling was observed in 4 patients in the allograft group, which was resolved via dressing change, oral use of indomethacin or dexamethasone.

CONCLUSION

Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach was safe and effective for ankle instability with a relatively short time for healing and minimal donor site problems.

LEVEL OF EVIDENCE

Level III, comparative case series.

A large-scale study on epidemiology and risk factors for chronic ankle instability in young adults

Up to 40% of ankle sprains can result in chronic ankle instability (CAI). The prevalence of CAI and its association with body mass index (BMI) and height in the general young adult population has not been reported. The database records of young adults before recruitment into mandatory military service were studied. Information on the disability codes associated with CAI was retrieved. Logistic regression models were used to assess the association between the BMI and body height with various grades of CAI severity. The study cohort included 829,791 subjects (470,125 males and 359,666 females). The prevalence was 0.7% for mild CAI and 0.4% for severe instability in males and 0.3% and 0.4%, respectively, for females (p < .001). An increased BMI was associated with ankle instability in males (overweight, odds ratio [OR] 1.249, p < .001; obese, OR 1.418, p < .001) and females (overweight, OR 1.989 p < .001; obese, OR 2.754, p < .001). The body height was associated with an increased risk of CAI when the highest height quintile was compared with the lowest height quintile in both males (OR 2.443, p < .001) and females (OR 1.436, p < .001) for all levels of instability severity. The present study has shown a greater prevalence of CAI among males than females in a general healthy young adult population. CAI was associated with an increased BMI and greater body height for all grades of instability severity.

Gait and physical impairments in patients with acute ankle sprains who did not receive physical therapy

OBJECTIVE

To assess ankle function 4 weeks after conservative management and to examine the correlation of function with gait.

DESIGN

A prospective comparison study.

PATIENTS

Thirty patients with grade I or II acute ankle sprains were followed up after 4 weeks of conservative management not involving physical therapy.

METHODS

Participants underwent a clinical assessment and had to walk at a normal self-selected walking speed. Their results were compared with the data of 15 healthy subjects.

MAIN OUTCOME MEASURES

Participants' joint swelling, muscle strength, passive mobility, and pain were assessed. In addition, patients' temporal-spatial, kinematic, and kinetic gait data were measured while walking.

RESULTS

Muscle strength and passive mobility were significantly reduced on the injured side compared with the noninjured side (P < .001). During gait analysis, patients with ankle sprains showed slower walking speed, shorter step length, shorter single support time, reduced and delayed maximum plantar flexion, decreased maximum power, and decreased maximum moment (P < .050) compared with healthy persons. Decreased walking speed was mainly correlated with pain (R = -0.566, P = .001) and deficits in muscle strength of dorsiflexors (R = 0.506, P = .004).

CONCLUSION

Four weeks after an ankle sprain, patients who did not receive physical therapy showed physical impairments of the ankle that were correlated with gait parameters. These findings might help fine-tune rehabilitation protocols.

Ankle injuries in the Netherlands: Trends over 10-25 years

Ankle injuries are a common health problem; data on ankle injury rates and time trends in the population at large are scarce. Our aim was to investigate the incidence of and time trends in population-based and emergency department-treated ankle injuries related to sports activities and other activities related to daily living. Data were obtained from one national survey on accidents and injuries (2000-2010) and one based on emergency department data (1986-2010). Linear regression was used to determine linear trends in ankle injuries per 1000 person-years. The number of ankle injuries related to sports activities and other activities of daily living increased from 19.0 to 26.6 per 1000 person-years (P = 0.002). The number of sports-related ankle injuries treated in emergency departments decreased from 4.2 to 1.5 per 1000 person-years (P < 0.001), and from 3.2 to 2.1 per 1000 person-years (P < 0.001) for other activities of daily living. According to our data, the incidence rates of all ankle injuries are around 5.5 times higher than those registered at emergency departments. The high incidence rates of ankle injuries highlight the need for proper ankle injury treatment and prevention.

Health care consumption and costs due to foot and ankle injuries in the Netherlands, 1986-2010

Background

Foot and ankle injuries account for a large proportion of Emergency Department attendance. The aim of this study was to assess population-based trends in attendances due to foot and ankle injuries in the Netherlands since 1986, and to provide a detailed analysis of health care costs in these patients.

Methods

Age- and gender-standardized emergency attendance rates and incidence rates for hospital admission were calculated for each year of the study. Injury cases and hospital length of stay were extracted from the National Injury Surveillance System (non-hospitalized patients) and the National Medical Registration (hospitalized patients). Data were grouped into osseous and ligamentous injuries for foot and ankle separately. An incidence-based cost model was applied to calculate associated direct health care costs.

Results

Since 1986 the overall emergency attendance rate decreased from 858 to 640 per 100,000 person years. In non-admitted patients (90% of cases), ligamentous injuries approximately halved, whereas osseous injuries increased by 28% (foot) and 25% (ankle). The incidence rate for hospital admission increased by 35%, mainly due to an almost doubling of osseous injuries. Attendance rates showed a peak in adolescents and adults until ~45 years of age in males and (less pronounced) in females. The total number of hospital days decreased to 58,708 days in 2010. Hospital length of stay (HLOS) increased with age and was highest for osseous injuries. HLOS was unaffected by gender, apart for longer stay in elderly females with an osseous ankle injury. Health care costs per case were highest for osseous injuries of the ankle (€ 3,461). Costs were higher for females and increased with age to € 6,023 in elderly males and € 10,949 in elderly females. Main cost determinants were in-hospital care (56% of total costs), rehabilitation/nursing care (15%), and physical therapy (12%).

Conclusions

Since 1986, the emergency attendance rate of foot and ankle injuries in the Netherlands decreased by 25%. Throughout the years, the attendance rate of (relatively simple) ligamentous injuries strongly reduced, whereas osseous injuries nearly doubled. Attendance rates and health care costs were gender- and age-related. Main cost determinants were in-hospital care, rehabilitation/nursing care, and physical therapy.

The Anatomic Pattern of Injuries in Acute Inversion Ankle Sprains: A Magnetic Resonance Imaging Study

Background:

There are little data on the incidence and patterns of injuries seen on magnetic resonance imaging (MRI) in acute inversion ankle sprains. This study may help in the understanding of the pathomechanics, natural history, and outcomes of this common injury.

Study Design:

Case series; Level of evidence, 4.

Methods:

From June 2011 to June 2013, a total of 64 consecutive patients had MRI of the ankle performed for acute inversion injury to the ankle. All injuries/pathologies reported were recorded.

Results:

Only 22% of patients had isolated lateral ligament complex injuries. Twenty-two percent of patients had other pathologies but no lateral ligament injury, and 53% had lateral ligament injuries in combination with other pathologies or injuries. The most common associated finding with lateral ligament injuries was bone bruising (76%) followed by deltoid ligament injury (50%). The overall incidence of bone bruising was 50%. Thirty percent of ankles had tendon pathology, 27% had deltoid ligament injury, and 22% had occult fractures.

Conclusion:

Isolated lateral ligament ankle injury is not as common as is believed. The pattern of injury seems complex, and most patients appear to have more injuries than expected. MRI reveals additional information that may have significance in terms of diagnosis, treatment, and prognosis in this common injury.

Isolated posterior high ankle sprain: a report of three cases

High ankle sprains are difficult to diagnose and account for 10% of all ankle sprains. A high index of suspicion is essential for diagnosis. High ankle sprains are managed symptomatically, with prolonged rehabilitation. The posterior inferior tibiofibular ligament is the strongest syndesmotic ligament; isolated injury of it is rare. We present 3 cases of isolated posterior high ankle sprain and discuss the relevant anatomy, mechanism of injury, and management.