Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

Health-seeking behaviors, management practices, and return to play decisions after an ankle sprain in netball: An international cross-sectional survey of 1592 non-elite netballers

OBJECTIVES

Evaluate if non-elite netballers sought health care, treatments received, and return-to-play decisions after an ankle sprain, including intercountry differences.

DESIGN

Cross-sectional survey.

METHODS

Non-elite netballers aged >14 years were recruited from Australia, United Kingdom, and New Zealand. Participants completed an online survey regarding their last ankle sprain and were queried regarding health care sought, health professionals consulted, treatments received, time missed, and return-to-play clearance. Data were described using number (proportion) for the overall cohort and countries. Between-country differences in health care use were compared using chi-square tests. Descriptive statistics were presented for management practices.

RESULTS

We received 1592 responses from Australian (n = 846), United Kingdom (n = 454), and New Zealand (n = 292) netballers. Three in five (n = 951, 60 %) sought health care. Of those, most consulted a physiotherapist (n = 728, 76 %), received strengthening exercises (n = 771, 81 %), balance exercises (N = 665, 70 %) and taping (n = 636, 67 %). Few received return-to-play clearance (n = 362, 23 %). Comparing countries, fewer United Kingdom netballers sought health care than Australian and New Zealand netballers (Australia: 60 % vs United Kingdom: 53 % vs New Zealand: 68 %, p < 0.001), consulted a physiotherapist (Australia: 79 %, United Kingdom: 63 %, New Zealand: 87 %), received strengthening (Australia: 84 %, United Kingdom: 73 %, New Zealand: 84 %) or balance exercises (Australia: 71 %, United Kingdom: 60 %, New Zealand: 80 %) or taping (Australia: 74 %, United Kingdom: 39 %, New Zealand: 82 %). More Australian netballers returned to play within 1-7 days (Australia: 25 %, United Kingdom: 15 %, New Zealand: 21 %) and fewer United Kingdom netballers received return-to-play clearance (Australia: 28 %, United Kingdom: 10 %, New Zealand: 28 %).

CONCLUSIONS

Health-seeking behaviours are adopted by some, but not all netballers after an ankle sprain. For those who sought care, most consulted a physiotherapist and were prescribed exercise-based interventions and external ankle support, but few received return-to-play clearance. Comparing countries, United Kingdom netballers had lower health-seeking behaviours and received less best-practice management than Australian and New Zealand netballers.

Effects of whole-body vibration on sensorimotor deficits and brain plasticity among people with chronic ankle instability: a study protocol for a single-blind randomized controlled trial

BACKGROUND

Chronic ankle instability (CAI) is a form of musculoskeletal disease that can occur after a lateral ankle sprain, and it is characterized by pain, recurrent ankle sprains, a feeling of "giving way" at the ankle joint, and sensorimotor deficits. There has been increasing evidence to suggest that plastic changes in the brain after the initial injury play an important role in CAI. As one modality to treat CAI, whole-body vibration (WBV) has been found to be beneficial for treating the sensorimotor deficits accompanying CAI, but whether these benefits are associated with brain plasticity remains unknown. Therefore, the current study aims to investigate the effect of WBV on sensorimotor deficits and determine its correlation with plastic changes in the brain.

METHODS

The present study is a single-blind randomized controlled trial. A total of 80 participants with CAI recruited from the university and local communities will be divided into 4 groups: whole-body vibration and balance training (WBVBT), balance training (BT), whole-body vibration (WBV), and control group. Participants will be given the WBV intervention (25-38 Hz, 1.3-2 mm, 3-time per week, 6-week) supervised by a professional therapist. Primary outcome measures are sensorimotor function including strength, balance, proprioception and functional performance. Brain plasticity will be evaluated by corticomotor excitability, inhibition, and representation of muscles, as measured by transcranial magnetic stimulation. Activation of brain areas will be assessed through functional near-infrared spectroscopy. Secondary outcome measures are self-reported functional outcomes involving the Cumberland Ankle Instability Tool and the Foot and Ankle Ability Measure. All tests will be conducted before and after the WBV intervention, and at 2-week follow-up. Per‑protocol and intention-to-treat analysis will be applied if any participants withdraw.

DISCUSSION

This is the first trial to investigate the role of brain plasticity in sensorimotor changes brought by WBV for individuals with CAI. As plastic changes in the brain have been an increasingly important aspect in CAI, the results of the current study can provide insight into the treatment of CAI from the perspective of brain plasticity.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2300068972); registered on 02 March 2023.

Inertial sensors-based assessment to detect hallmarks of chronic ankle instability during single-leg standing: Is the healthy limb "healthy"?

BACKGROUND

Chronic ankle instability can be common in sportsmen and can increase the risk of damaging the articular surfaces and result in negative consequences to joint health. Balance assessment is often used to evaluate ankle instability characteristics and guide rehabilitation protocols. This study aims to investigate balance-related parameters in people with chronic ankle instability and healthy-matched controls, using inertial sensors.

METHODS

Ten young adults with a history of multiple ankle sprains (30 y, 25-34, 5 females) and ten matched healthy controls (30 y, 23-39, 5 females) were invited to participate in the study. Inertial sensors were placed on the head of the astragalus and on the chest to collect kinematic parameters during a 20-s single-leg stance performed on the leg with ankle instability (and corresponding for the healthy controls) and on the contralateral leg, randomly. Outcomes were calculated with MATLAB and subsequently analyzed.

FINDINGS

A significant group effect was found only for the inversion angle (F_1,15 = 12.514, p = 0.003, pη² = 0.455), consisting of individuals with ankle instability being characterized by higher inversion angles (4.999 degrees, 95% CI: 1.987-8.011, p = 0.003) without significant side differences. No significant side x group effects were found for the assessed parameters.

INTERPRETATION

Results from this study suggest that young adults with chronic ankle instability might be characterized by worse single-stance control in terms of inversion angle, and such worse performance could also be found in the contralateral leg. As such, inertial sensors could be used to assess kinematic parameters during balance tasks in people with chronic ankle instability.

The Tampa Scale of Kinesiophobia: A Systematic Review of Its Psychometric Properties in People With Musculoskeletal Pain

OBJECTIVE

The aims of this systematic review were to identify the different versions of the Tampa Scale of kinesiophobia (TSK) and to report on the psychometric evidence relating to these different versions for people experiencing musculoskeletal pain.

METHODS

Medline [Ovid] CINAHL and Embase databases were searched for publications reporting on the psychometric properties of the TSK in populations with musculoskeletal pain. Risks of bias were evaluated using the COSMIN risk of the bias assessment tool.

RESULTS

Forty-one studies were included, mainly with a low risk of bias. Five versions of the TSK were identified: TSK-17, TSK-13, TSK-11, TSK-4, and TSK-TMD (for temporomandibular disorders). Most TSK versions showed good to excellent test-retest reliability (intraclass coefficient correlation 0.77 to 0.99) and good internal consistency (ɑ=0.68 to 0.91), except for the TSK-4 as its reliability has yet to be defined. The minimal detectable change was lower for the TSK-17 (11% to 13% of total score) and the TSK-13 (8% of total score) compared with the TSK-11 (16% of total score). Most TSK versions showed good construct validity, although TSK-11 validity was inconsistent between studies. Finally, the TSK-17, -13, and -11 were highly responsive to change, while responsiveness has yet to be defined for the TSK-4 and TSK-TMD.

DISCUSSION

Clinical guidelines now recommend that clinicians identify the presence of kinesiophobia among patients as it may contribute to persistent pain and disability. The TSK is a self-report questionnaire widely used, but 5 different versions exist. Based on these results, the use of TSK-13 and TSK-17 is encouraged as they are valid, reliable, and responsive.

Effects of foot intensive rehabilitation (FIRE) on clinical outcomes for patients with chronic ankle instability: a randomized controlled trial protocol

BACKGROUND

Lateral ankle sprains account for a large proportion of musculoskeletal injuries among civilians and military service members, with up to 40% of patients developing chronic ankle instability (CAI). Although foot function is compromised in patients with CAI, these impairments are not routinely addressed by current standard of care (SOC) rehabilitation protocols, potentially limiting their effectiveness. The purpose of this randomized controlled trial is to determine if a Foot Intensive REhabilitation (FIRE) protocol is more effective compared to SOC rehabilitation for patients with CAI.

METHODS

This study will use a three-site, single-blind, randomized controlled trial design with data collected over four data collection points (baseline and post-intervention with 6-, 12-, and 24-month follow-ups) to assess variables related to recurrent injury, sensorimotor function, and self-reported function. A total of 150 CAI patients (50 per site) will be randomly assigned to one of two rehabilitation groups (FIRE or SOC). Rehabilitation will consist of a 6-week intervention composed of supervised and home exercises. Patients assigned to SOC will complete exercises focused on ankle strengthening, balance training, and range of motion, while patients assigned to FIRE will complete a modified SOC program along with additional exercises focused on intrinsic foot muscle activation, dynamic foot stability, and plantar cutaneous stimulation.

DISCUSSION

The overall goal of this trial is to compare the effectiveness of a FIRE program versus a SOC program on near- and long-term functional outcomes in patients with CAI. We hypothesize the FIRE program will reduce the occurrence of future ankle sprains and ankle giving way episodes while creating clinically relevant improvements in sensorimotor function and self-reported disability beyond the SOC program alone. This study will also provide longitudinal outcome findings for both FIRE and SOC for up to two years. Enhancing the current SOC for CAI will improve the ability of rehabilitation to reduce subsequent ankle injuries, diminish CAI-related impairments, and improve patient-oriented measures of health, which are critical for the immediate and long-term health of civilians and service members with this condition. Trial Registration Clinicaltrials.gov Registry: NCT #NCT04493645 (7/29/20).

Rehabilitation strategies for lateral ankle sprain do not reflect established mechanisms of re-injury: A systematic review

OBJECTIVES

1) determine the primary impairment addressed by each exercise included in exercise-based rehabilitation programs for patients with an acute ankle sprain; 2) Determine whether prescribed exercises incorporate complex tasks associated with ankle sprain injury mechanisms?

METHODS

We searched databases CINAHL, Web of Science, SPORTDiscus, Cochrane Register of Controlled Trials, PEDro, Google Scholar for RCT's including patients with acute ankle sprains, managed through exercise-based rehabilitation. Risk of bias was assessed by the Risk of Bias 2 tool. Exercises were analysed based on: the primary impairment(s) addressed; direction of movement; base of support; weightbearing status; flight phase. (PROSPERO: CRD42020210858) RESULTS: We included fourteen RCT's comprising 177 exercises. Neuromuscular function was addressed in 44% of exercises, followed by performance tasks (23%), and muscle strengthening (20%). Exercises were limited to movements across the sagittal plane (48%), with 31% incorporating multiplanar movements. Weight bearing exercises were almost divided equally between single-limb (59/122) and double leg stance exercises (61/122). Eighteen percent of all exercises incorporated a flight phase.

CONCLUSIONS

Rehabilitation after LAS comprises simple exercises in the sagittal plane that do not reflect mechanisms of re-injury. Future interventions should incorporate more open chain joint position sense training, multiplanar single limb challenges, and jumping and landing exercises.

Effect of Braces on Performance in the Context of Chronic Ankle Instability

Ankle braces are commonly recommended for prevention of ankle sprains, especially secondary sprains, rehabilitation, and return to normal activity or sport after injury. One common resistance to use is the feeling that braces will impede functional performance. For people with chronic ankle instability, the limited research indicates that the use of semirigid, lace-up, or soft-shell braces will not affect, and in some cases, may enhance performance. Activities that could be enhanced are jumping, hopping, and dynamic balance.

Inertial Sensor-Based Assessment of Static Balance in Athletes with Chronic Ankle Instability

The Balance Error Scoring System (BESS), a subjective examiner-based assessment, is often employed to assess postural balance in individuals with chronic ankle instability (CAI); however, inertial sensors may enhance the detection of balance deficits. This study aimed to compare the BESS results between the CAI and healthy groups using conventional BESS scores and inertial sensor data. The BESS test (six conditions: double-leg, single-leg, and tandem stances on firm and foam surfaces, respectively) was performed for the CAI (n = 16) and healthy control (n = 16) groups with inertial sensors mounted on the sacrum and anterior shank. The BESS score was calculated visually by the examiner by counting postural sway as an error based on the recorded video. The root mean square for resultant acceleration (RMS_acc) in the anteroposterior, mediolateral, and vertical directions was calculated from each inertial sensor affixed to the sacral and shank surfaces during the BESS test. The mixed-effects analysis of variance and unpaired t-test were used to assess the effects of group and condition on the BESS scores and RMS_acc. No significant between-group differences were found in the RMS_acc of the sacral and shank surfaces, and the BESS scores (P > 0.05), except for the total BESS score in the foam condition (CAI: 14.4 ± 3.7, control: 11.7 ± 3.4; P = 0.039). Significant main effects of the conditions were found with respect to the BESS scores and RMS_acc for the sacral and anterior shank (P < 0.05). The BESS test with inertial sensors can detect differences in the BESS conditions for athletes with CAI. However, our method could not detect any differences between the CAI and healthy groups.

What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain?

OBJECTIVE

To investigate the incidence of subsequent lumbar spine, hip, and ankle-foot injuries after a diagnosis of patellofemoral pain.

DESIGN

Retrospective cohort study.

SETTING

Military Health System.

PARTICIPANTS

Individuals (n = 92,319) ages 17-60 diagnosed with patellofemoral pain between 2010-2011.

INTERVENTIONS

Therapeutic exercise.

MAIN OUTCOME MEASURES

Frequency of adjacent joint injuries in the 2-year period after initial patellofemoral pain injury, and hazard ratios (HR) with 95% confidence interval (CI) and Kaplan-Meier survival curves for risk of adjacent joint injury based on receiving therapeutic exercise for the initial injury.

RESULTS

After initial patellofemoral pain diagnosis, 42,983 (46.6%) individuals sought care for an adjacent joint injury. Of these, 19,587 (21.2%) were subsequently diagnosed with a lumbar injury, 2837 (3.1%) a hip injury, and 10,166 (11.0%) an ankle-foot injury. One in five (19.5%; n = 17,966) received therapeutic exercise which reduced the risk of having a subsequent lumbar (HR = 0.78, 95% CI 0.76-0.81), hip (HR = 0.93, 95% CI 0.87-0.98) or ankle-foot (HR = 0.86, 95% CI 0.83-0.90) injury.

CONCLUSION

The results suggest that a high number of individuals with patellofemoral pain will sustain an adjacent joint injury within 2 years although causal relationships cannot be determined. Receiving therapeutic exercise for the initial knee injury reduced the risk of sustaining an adjacent joint injury. This study helps provide normative data for subsequent injury rates in this population and guide development of future studies designed to understand causal factors.

A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy

Symptom modification techniques have been recently dichotomously labeled as either passive or active therapies. Active therapy such as exercise has been rightfully advocated for while "passive" therapies, mainly manual therapy have been regarded as low value within the physical therapy treatment spectrum. In sporting environments where physical activity and exercise are inherent to the athletic experience, the utilization of exercise-only strategies to manage pain and injury can be challenging when considering the demands and qualities of a sporting career which include chronically high internal and external workloads. Participation may be impacted by pain and its influence on related factors such as training and competition performance, career length, financial earning potential, educational opportunity, social pressures, influence of family, friends, and other key stakeholders of their athletic activity. Though highly polarizing viewpoints regarding different therapies create black and white "sides," a pragmatic gray area regarding manual therapy exists in which proper clinical reasoning can serve to improve athlete pain and injury management. This gray area includes both historic positive reported short-term outcomes and negative historical biomechanical underpinnings that have created unfounded dogma and inappropriate overutilization. Applying symptom modification strategies to safely allow the continuation of sport and exercise requires critical thinking utilizing not only the evidence-base, but also the multi-factorial nature of sports participation and pain management. Given the risks associated with pharmacological pain management, the cost of passive modalities like biophysical agents (electrical stimulation, photobiomodulation, ultrasound, etc), and the indications from the evidence-base when combined with active therapies, manual therapy can be a safe and effective treatment strategy to keep athletes active.

Level of Evidence

5.

The Influence of Therapeutic Exercise after Ankle Sprain on the Incidence of Subsequent Knee, Hip, and Lumbar Spine Injury

PURPOSE

This study aimed to investigate the burden of knee, hip, and lumbar spine disorders occurring in the year after an ankle sprain and the influence therapeutic exercise (TE) has on this burden.

METHODS

A total of 33,361 individuals diagnosed with ankle sprain in the Military Health System between 2010 and 2011 were followed for 1 yr. The prevalence of knee, hip, and lumbar care-seeking injuries sustained after sprain was identified. Relationships between demographic groups, ankle sprain type, and use of TE with rate of proximal injuries were evaluated using Cox proportional hazard models to determine hazard rate effect modification by attribute. The observed effect of TE for ankle sprain on rate of injury to proximal joints was evaluated using Kaplan-Meier survival analyses.

RESULTS

Of the total cohort, 20.5% ( n = 6848) of patients sustained a proximal injury. Specifically, 10.1% of the cohort sustained a knee ( n = 3356), 2.9% a hip ( n = 973), and 10.3% a lumbar injury ( n = 3452). Less than half of the cohort received TE after initial sprain. Patients that did were less likely to have subsequent knee (HR = 0.87, 95% confidence interval [CI] = 0.80-0.94), hip (HR = 0.68, 95% CI = 0.58-0.79), or lumbar (HR = 0.82, 95% CI = 0.76-0.89) injuries.

CONCLUSIONS

One in five individuals that sought care for an ankle sprain experienced a proximal joint injury in the following year. TE for the management of the initial ankle sprain reduced the likelihood of proximal injury diagnosis and should be considered in treatment plans for return to work and sport protocols after ankle sprains.

Effect of Q-angle, lateral distal tibial angle and hip muscle torques on ankle injury

BACKGROUND

The ankle sprain is the most common ankle injury. Although the factors that increase the risk of ankle injury are included in the literature, the definitive evidence is controversial.

OBJECTIVE

The aim of our study was to examine whether Q-angle, lateral distal tibial angle (LDTA), and hip muscle torque are associated with ankle sprain.

METHODS

Thirty-six individuals who underwent an axial X-ray examination of the lower extremity following ankle sprain were included. The Q-angle and LDTA were measured on the axial knee X-rays on both sides. The isometric muscle strength was measured with a digital handheld dynamometer for the quadriceps femoris muscle, the gluteus medius muscle and the gluteus maximus muscle. Muscle torques were calculated by multiplying isometric muscle strength values with the distance to the joint center.

RESULTS

Discrimination analysis shows that the gluteus maximus (0.90), gluteus medius (0.49), quadriceps femoris muscle torques (0.34), and lateral distal tibial angle (0.43) were the factors that most contributed to ankle sprain. No significant relationship was found between the Q-angle and ankle sprain (p = 0.603). A strong relationship was found between LDTA, quadriceps femoris, gluteus medius and gluteus maximus muscle torques and ankle sprain (p = 0.014, p < 0.001, p = 0.011, p = 0.002, respectively).

CONCLUSIONS

In conclusion, the torques of the proximal muscle may be more related than the Q-angle to lateral ankle sprain injury. Individuals with high LDTA should also be carefully examined for the risk of ankle sprain.

Effects of Conservative Interventions on Static and Dynamic Balance in Individuals With Chronic Ankle Instability: A Systematic Review and Meta-analysis

OBJECTIVE

To determine which conservative interventions are effective for static and dynamic balance in patients with chronic ankle instability (CAI).

DATA SOURCES

PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to March 20, 2022.

STUDY SELECTION

Randomized controlled trials investigating the effects of conservative interventions on static and/or dynamic balance in patients with CAI compared with those of different conservative interventions or controls were included.

DATA EXTRACTION

Two independent reviewers extracted the data. Certainty of the evidence was assessed using the GRADE approach.

DATA SYNTHESIS

Forty-eight studies (1906 participants) were included. Whole-body vibration training (WBVT) was significantly more effective than controls for both static (standardized mean difference, 1.13; 95% confidence interval [CI], 0.58-1.68; moderate-certainty evidence) and dynamic balance (0.56; CI, 0.24-0.88; low-certainty evidence). Balance training (BT) and joint mobilization were significantly more effective than controls for dynamic balance (0.77; CI, 0.41-1.14; and 0.75; CI, 0.35-1.14, respectively), but not for static balance (very low to low-certainty evidence). Adding other interventions to BT had no significant effect on either type of balance compared with that of BT alone (moderate to low-certainty evidence). Strength training (ST) and taping had no significant effect on either type of balance (very low- to low-certainty evidence). Multimodal interventions were significantly effective in improving dynamic balance (0.76; CI, 0.32-1.20; low-certainty evidence). Adding transcranial direct current stimulation to ST was significantly more effective for dynamic balance than ST (0.81; CI, 0.08-1.53; moderate-certainty evidence). The effects on balance were not significantly different among BT, ST, and WBVT (very low- to low-certainty evidence).

CONCLUSIONS

The significantly effective interventions reviewed may be treatment options for balance impairments associated with CAI. However, interventions should be chosen carefully, as much of the certainty of evidence is very low to low.

Physiotherapists' knowledge of and adherence to evidence-based practice guidelines and recommendations for ankle sprains management: a cross-sectional study

BACKGROUND

Lateral ankle sprain (LAS) is a common and burdensome injury. However, the quality of its management is scant. Nowadays, physiotherapy management of musculoskeletal diseases seems to be generally not based on research evidence. Studies that investigated the knowledge-to-practice gap in LAS management are yet to be carried out. Therefore, this research investigated physiotherapists' knowledge of and adherence to LAS Clinical Practice Guidelines (CPGs) and recommendations.

METHODS

A cross-sectional study based on an online survey structured in three sections. The first section collected demographic data. The second section showed two clinical cases (with positive and negative Ottawa Ankle Rules (OAR), respectively). The participants indicated which treatments they would adopt to manage them. Participants were classified as 'following', 'partially following', 'partially not following' and 'not following' the CPGs and recommendations. In the third section, participants expressed their agreement with different CPG and recommendation statements through a 1-5 Likert scale.

RESULTS

In total, 483 physiotherapists (age: 34 ± 10; female 38%, male 61.5%, other 0.5%) answered the survey: 85% completed the first two sections, 76% completed all three sections. In a case of acute LAS with negative OAR, 4% of the participants were considered as 'following' recommended treatments, 68% as 'partially following', 23% as 'partially not following', and 5% as 'not following'. In a case of acute LAS with positive OAR, 37% were considered 'following' recommended treatments, 35% as 'partially following', and 28% as 'not following'. In the third section, the consensus was achieved for 73% of the statements.

CONCLUSION

This study showed that although there is a good knowledge about first-line recommended treatments, a better use of CPGs and recommendations should be fostered among physiotherapists. Our results identify an evidence-to-practice gap in LAS management, which may lead to non-evidence-based practice behaviors.

Effect of Joint Mobilization in Individuals with Chronic Ankle Instability: A Systematic Review and Meta-Analysis

Sensorimotor and range of motion deficits due to chronic ankle instability (CAI) are abnormalities of the movement system that make postural control difficult. This review aimed to quantify the effect of joint mobilization on the range of motion, dynamic balance, and function in individuals with CAI. Randomized controlled trials in which joint mobilization was performed in individuals with CAI were searched for in five international databases (CENTRAL, CINAHL, Embase, MEDLINE, PEDro). Qualitative and quantitative analyses were performed using the risk of bias tool and RevMan 5.4 provided by the Cochrane Library. Nine studies with 364 individuals with CAI were included in this study. This meta-analysis reported that joint mobilization showed significant improvement in the dorsiflexion range of motion (standardized mean difference [SMD] = 1.02, 95% confidence interval [CI]: 0.41 to 1.63) and dynamic balance (SMD = 0.49, 95% CI: 0.06 to 0.78) in individuals with CAI. However, there was no significant improvement in function (patient-oriented outcomes) (SMD = 0.76, 95% CI: -0.00 to 1.52). For individuals with CAI, joint mobilization has limited function but has positive benefits for the dorsiflexion range of motion and dynamic balance.

The Effect of Manual Therapy Plus Exercise in Patients with Lateral Ankle Sprains: A Critically Appraised Topic with a Meta-Analysis

A high percentage of patients with lateral ankle sprains report poor outcomes and persistent neuromuscular impairment leading to chronic ankle instability and re-injury. Several interventions have been proposed and investigated, but the evidence on manual therapy combined with therapeutic exercise for pain reduction and functional improvement is still uncertain. The purpose was to study the effectiveness of adding manual therapy to therapeutic exercise in patients with lateral ankle sprains through a critically appraised topic. The literature search was performed in PubMed, PEDro, EMBASE and CINAHL databases, and only randomized clinical trials were included according to following criteria: (1) subjects with acute episodes of lateral ankle sprains, (2) administered manual therapy plus therapeutic exercise, (3) comparisons with therapeutic exercise alone and (4) reported outcomes for pain and function. Three randomized clinical trials (for a total of 180 patients) were included in the research. Meta-analyses revealed that manual therapy plus exercise was more effective than only exercises in improving dorsal (MD = 8.79, 95% CI: 6.81, 10.77) and plantar flexion (MD = 8.85, 95% CI 7.07, 10.63), lower limb function (MD = 1.20, 95% CI 0.63, 1.77) and pain (MD = -1.23; 95% IC -1.73, -0.72). Manual therapy can be used with therapeutic exercise to improve clinical outcome in patients with lateral ankle sprains.

Predicting the success of multimodal rehabilitation in chronic ankle instability based on patient-reported outcomes

Background

The aim of this study was to identify potential indicators to predict the success of multimodal rehabilitation in chronic ankle instability (CAI) patients based on patient-reported outcomes.

Methods

Sixty patients with self-reported CAI participated. Their demographic information, injury history, and symptoms were recorded. Physical examinations and dynamic posture control tests were performed. The participants underwent sixteen 30-min treatment sessions of multimodal rehabilitation over 8 weeks. Fifty-one patients (85.0%) were available for follow-up after 8 weeks of the intervention. Treatment success was defined based on the participants’ perceived recovery using the global rating of change (GRC). Potential predictor variables were entered into a stepwise logistic regression model to identify variables for the prediction of treatment success.

Results

Forty of 51 participants (78.4%) were considered to have a successful outcome. Of the variables assessed, time since last sprain ≤ 8 months was a predictor of treatment success (p < 0.05). If a patient met the criteria, there was an 88.03% probability of successful multimodal rehabilitation.

Conclusion

A time since the last sprain ≤ 8 months may predict successful patient-reported outcomes after multimodal rehabilitation in CAI patients.

Level of evidence

Prospective study, Level 2.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05676-0.

Comparative Effects of Neuromuscular- and Strength-Training Protocols on Pathomechanical, Sensory-Perceptual, and Motor-Behavioral Impairments in Patients with Chronic Ankle Instability: Randomized Controlled Trial

(1) Background: Chronic ankle instability (CAI) is a complex condition that includes limited mobility, perceived instability, and recurrent ankle sprains are common characteristics that reduce the quality of life in subjects who suffer from CAI. Neuromuscular training and strength training have been recommended in CAI management interventions. However, there are contradictory findings on results when comparing neuromuscular training, strength training, and the control group. The objective of this study was to compare the effectiveness of 8 weeks of neuromuscular intervention training, strength training, and no intervention in a sporting population with reported CAI. (2) Methods: Sixty-seven athletes with CAI were randomly assigned to a neuromuscular training group (NG), strength training group (SG), or control group (CG). Participants completed 8 weeks of neuromuscular training (a combination of static and dynamic exercises), strength training (resistance band exercises), or no training. Outcome measures were assessed at baseline and after 8 weeks and included selfs-reported instability feeling (CAIT), dynamic balance (SEBT), ankle dorsiflexion range of motion (WBLT), and functional status (FAAM and FAAM-SPORT). (3) Results: There were significant differences between strength and control groups in the posteromedial direction of SEBT, FAAM, and FAAM-SPORT after 8 weeks of intervention. (4) Conclusions: Neuromuscular training and strength training based on resistance bands exercises showed significant improvements in ankle dorsiflexion, subjective feeling of instability, functional status, and dynamic balance in patients with CAI.

What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment

BACKGROUND

Patient expectations related to physical therapy outcomes are commonly collected through surveys and close-ended questionnaires. These methods may not optimally capture patients' expectations for physical therapy, especially in the patients' own words. Louis Gifford identified four questions attempting to guide clinicians' understanding of patients' expectations for physical therapy. However, a qualitative assessment mapping the expectations that patients have prior to starting physical therapy appears to be undocumented.

OBJECTIVES

The aim of this study was to determine patient expectations prior to beginning physical therapy for individuals with musculoskeletal conditions.

DESIGN

Qualitative analysis with structured interviews and open-ended participant responses.

METHODS

Twenty-five people (18 female, 7 male; mean age: 47.04 years) were interviewed prior to their initial physical therapy evaluation using a pragmatic approach rooted in phenomenology. Data were transcribed, coded, and thematized using qualitative data analysis software.

RESULTS

Outcome, education, exercise, evaluation, and cause of pain were key themes expressed by participants. Participants appear to want to better understand their symptoms, how they can improve symptoms, what the clinician will do, and how long they will attend physical therapy. Many participants were not certain where physical therapy fit within their overall healthcare plan, and perceptions of manual therapy were vague.

CONCLUSIONS

These identified themes highlight what patients may expect from a physical therapy experience and clinicians should work to identify and satisfy each patient's individual expectations to optimize outcomes.

Which Functional Tests and Self-Reported Questionnaires Can Help Clinicians Make Valid Return to Sport Decisions in Patients With Chronic Ankle Instability? A Narrative Review and Expert Opinion

Lateral ankle sprain is the most common injury in sports, with up to 40% of patients developing chronic ankle instability (CAI). One possible cause underlying this high rate of recurrence or feeling of giving way may be a premature return to sport (RTS). Indeed, except for time-based parameters, there are no specific criteria to guide clinicians in their RTS decisions in patients with CAI. A recent international consensus highlighted the relevance and importance of including patient-reported ankle function questionnaires combined with functional tests targeting ankle impairments in this population. Thus, the aim of this narrative review and expert opinion was to identify the most relevant functional performance tests and self-reported questionnaires to help clinicians in their RTS decision-making process following recurrent ankle sprains or surgical ankle stabilization. The PubMed (MEDLINE), PEDro, Cochrane Library and ScienceDirect databases were searched to identify published articles. Results showed that the single leg stance test on firm surfaces, the modified version of the star excursion balance test, the side hop test and the figure-of-8 test appeared to be the most relevant functional performance tests to target ankle impairments in patients with CAI. A combination of the Foot and Ankle Ability Measure (FAAM) and the Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) questionnaires were the most relevant self-reported questionnaires to assess patient function in the context of CAI. Although these functional tests and questionnaires provide a solid foundation for clinicians to validate their RTS decisions in patient with CAI, objective scientific criteria with cut-off scores are still lacking. In addition to the proposed test cluster, an analysis of the context, in particular characteristics related to sports (e.g., fatigue, cognitive constraints), to obtain more information about the patient's risk of recurrent injury could be of added value when making a RTS decision in patients with CAI. In order to evaluate the strength of evertors under ecological conditions, it would also be interesting to assess the ability to control weight-bearing ankle inversion in a unipodal stance. Further studies are needed to assess the relevance of this proposed test cluster in RTS decision-making following lateral ankle sprain injury and CAI.

It Would Take Combat Relevance to Put a Chiropractor in Khakis— This Is Why That Has Not Happened

The purpose of this article is to challenge the premise of a recent commentary suggesting that chiropractors should become commissioned officers. An overview of the early practice guidelines and current scientific evidence for the use of spine and peripheral manipulation is provided. The Military Health System is designed to support military operations and currently includes a large contingent of active duty musculoskeletal healthcare experts to include sports medicine–trained family physicians, orthopedic surgeons, physician assistants/associates, doctors of physical therapy/physical therapists, occupational therapists, and podiatrists. The evidence is clear that it is not in the best interest of our military services to commission alternative practitioners whose practices are out of step with the rest of medicine.

Uneven treadmill training for rehabilitation of lateral ankle sprains and chronic ankle instability: a pragmatic randomized controlled trial (Preprint)

Background

Lateral ankle sprains (LASs) are common injuries among military service members. Approximately 40% of individuals with an LAS progress to develop chronic ankle instability (CAI), a condition that results in substantial mechanical and neurophysiological impairment and activity limitation. Since proprioceptive and balance training improve functional outcomes and prevent secondary injury following LAS, they are recommended in clinical practice. Uneven treadmills are an innovative modality that challenge the sensorimotor system while performing an ecologically valid task simulating environments frequently encountered by service members with LAS and CAI.

Objective

The aim of this study is to evaluate whether the inclusion of uneven treadmill training in standard rehabilitation can improve clinical, functional, biomechanical, and patient-reported outcomes compared with the standard of care alone in service members with LAS and CAI. The prophylactic effects of treatment on secondary injury and identification of any contributing or mediating factors that influence outcomes following treatment will also be evaluated. We hypothesize that service members receiving uneven treadmill training will demonstrate greater improvements in clinical and instrumented measures of impairment, patient-reported function, and lower risk of injury recurrence than the control group immediately post and 18 months following treatment.

Methods

A multisite, parallel randomized clinical trial will be performed among service members aged 18-49 years being treated for LAS and CAI in military treatment facilities in the United States. Participants randomly assigned and allocated to receive the experimental intervention will be provided up to 12 sessions of training on an uneven terrain treadmill over a 6-week treatment course to supplement standard rehabilitation care. Treatment intensity of the rehabilitation exercises and treadmill training will be progressed on the basis of patient-perceived intensity and treatment responses. Outcome measures will include patient-reported outcomes, functional assessments, performance measures, and biomechanical measures. Investigators collecting outcome measures will be blinded to treatment allocation. Reinjury rates and patient-reported outcomes of function will be tracked over 18 months following treatment.

Results

The project was funded in September 2020. Patient recruitment began in November 2021, with 3 participants enrolled as of February 2022. Dissemination of the main study findings is anticipated in 2024.

Conclusions

This study will assess the impact of an innovative uneven-terrain treadmill on treatment outcomes in the rehabilitation of service members with LAS and CAI. The results of this study will be used to inform rehabilitation practices and to potentially improve functional outcomes and secondary prevention in this patient population.

Trial Registration

ClinicalTrials.gov NCT04999904; https://clinicaltrials.gov/ct2/show/NCT04999904?term=NCT04999904

International Registered Report Identifier (IRRID)

DERR1-10.2196/38442

Effects of Midfoot Joint Mobilization on Perceived Ankle–Foot Function in Chronic Ankle Instability: A Crossover Clinical Trial

Context: To investigate the effects of midfoot joint mobilization and a 1-week home exercise program, compared with a sham intervention, and home exercise program on pain, patient-reported outcomes, ankle–foot joint mobility, and neuromotor function in young adults with chronic ankle instability. Design: Crossover clinical trial. Methods: Twenty participants with chronic ankle instability were instructed in a stretching, strengthening, and balance home exercise program and were randomized a priori to receive either midfoot joint mobilizations (forefoot supination, cuboid glide, and plantar first tarsometatarsal) or a sham laying of hands on the initial visit. Changes in foot morphology, joint mobility, strength, dynamic balance, and patient-reported outcomes assessing pain, physical, and psychological function were assessed pre to post treatment and 1 week following post treatment. Participants crossed over to receive the alternate treatment and were assessed pre to post treatment and 1 week following. Linear modeling was used to assess changes in outcomes. Results: Participants demonstrated significantly greater perceived improvement immediately following midfoot mobilization in the single assessment numeric evaluation (sham: 5.0% [10.2%]; mobilization: 43.9% [26.2%]; β: 6.8; P < .001; adj R2: .17; Hedge g: 2.09), and global rating of change (sham: −0.1 [1.1]; mobilization: 1.1 [3.0]; β: 1.8; P = .01; adj R2: .12; Hedge g: 0.54), and greater improved 1-week outcomes in rearfoot inversion mobility (sham: 4.4° [8.4°]; mobilization: −1.6° [6.1°]; β: −6.37; P = .01; adj R2: .19; Hedge g: 0.81), plantar flexion mobility (sham: 2.7° [6.4°]; mobilization: −1.7° [4.3°]; β: −4.36; P = .02; adj R2: .07; Hedge g: 0.80), and posteromedial dynamic balance (sham: 2.4% [5.9%]; mobilization: 6.0% [5.4%]; β: 3.88; P = .04; adj R2: .10; Hedge g: 0.59) compared to the sham intervention. Conclusion: Greater perceived improvement and physical signs were observed following midfoot joint mobilization.

Sensitivity of a Subject-specific Ankle Sprain Simulation to Extrinsic Versus Intrinsic Biomechanical Factors

Ankle sprains are the most common musculoskeletal injury in sport and military activity, despite existing prophylactic strategies. The purpose of this report was to develop a probabilistic simulation of lateral ankle sprains during single-limb drop landing, towards accelerating innovation in ankle sprain prevention. A deterministic, subject-specific musculoskeletal model was extended with automation and probabilistic distributions on sprain-related biomechanical factors. Probabilistic simulations were generated using traditional Monte Carlo techniques and the advanced mean value method, a more computationally-efficient approach. Predicted distributions of peak ankle joint rotations, velocities, and moments borne by supporting passive structures agreed favorably with the deterministic model and with reports of real sprain biomechanics. Parameter sensitivities identified that predictions were most strongly influenced by drop height, subtalar joint posture at contact, invertor/evertor co-activation, and passive ankle stiffness. The advanced mean value method predicted confidence bounds comparable to a 1000-trial Monte Carlo simulation, and required only 14 model evaluations and 4-min processing time. The extended probabilistic simulation may be useful to virtually test new prophylactic strategies for ankle sprains, and is made available for open-source use (https://simtk.org/projects/sprain-sim).

Delayed Rehabilitation Is Associated With Recurrence and Higher Medical Care Use After Ankle Sprain Injuries in the United States Military Health System

OBJECTIVE

To investigate the influence of time taken to begin musculoskeletal rehabilitation on injury recurrence and ankle-related medical care use at 1 year after ankle sprain.

DESIGN

Retrospective cohort study of all beneficiaries of the US Military Health System seeking care for an ankle sprain over a 4-year period.

METHODS

Individuals were classified according to whether they did or did not receive physical rehabilitation. For those who received rehabilitation (n = 6150), linear relationships (with appropriate covariate controls) were analyzed with generalized linear models and generalized additive models to measure the effects of rehabilitation timing on injury recurrence and injury-related medical care use (costs and visits) at 1 year after injury. The nonlinear effect of rehabilitation timing on the probability of recurrence was assessed.

RESULTS

Approximately 1 in 4 people received rehabilitation. The probability of ankle sprain recurrence increased for each day that rehabilitation was not provided during the first week. The probability of ankle sprain recurrence plateaued until about 2 months after initial injury, then increased again, with 2 times greater odds of recurrence compared to those who received physical rehabilitation within the first month. When rehabilitation care was delayed, recurrence (odds ratio [OR] = 1.28), number of foot/ankle-related visits (OR = 1.22), and foot/ankle-related costs increased (OR = 1.13; up to $1400 per episode).

CONCLUSION

The earlier musculoskeletal rehabilitation care started after an ankle sprain, the lower the likelihood of recurrence and the downstream ankle-related medical costs incurred. J Orthop Sports Phys Ther 2021;51(12):619-627. doi:10.2519/jospt.2021.10730.

Celebrating the Achievements of Yet Another Challenging Year

Editor-in-Chief Clare Ardern and JOSPT's editors thank all of those who contributed to JOSPT in 2021. J Orthop Sports Phys Ther 2021;51(12):552-555. doi:10.2519/jospt.2021.0111.

Chronic ankle instability has no correlation with the number of ruptured ligaments in severe anterolateral sprain: a systematic review and meta-analysis

PURPOSE

Despite being a significant public health problem, ankle sprains' prognostic factors are largely unknown. This review aimed to systematically analyze the literature on acute ankle sprains to compare the prognosis of a combined anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments rupture with an isolated ATFL rupture in terms of progression to chronic ankle instability and other clinical outcomes.

METHODS

The databases for Pubmed, CENTRAL and Web of Science were searched. Clinical studies reporting the prognostic effect of combined ATFL-CFL rupture versus an isolated ATFL rupture in conservatively treated ankle sprains, with a minimum follow-up of 12 months, were eligible for inclusion. Only studies with a reliable diagnostic method for anterolateral ankle ligaments evaluation, namely ultrasonography, magnetic resonance imaging, arthrography or stress tenography, were included. The relative risk (RR), along with the 95% confidence interval (CI), was used to quantitatively analyze the main outcomes.

RESULTS

Nine papers were selected for inclusion, of which five were suitable for quantitative analysis. None of them found a statistically significant correlation between ligament injury severity and progression to chronic instability. Concerning other clinical outcomes, three studies found a statistically significant correlation between a combined ligament injury and a worse clinical prognosis. From the quantitative analysis, the relative risk (RR) of chronic ankle instability in a single versus a combined ligament rupture showed no significant difference.

CONCLUSION

A significant statistical correlation between a combined ATFL-CFL rupture and chronic ankle instability, compared to an isolated ATFL rupture, was not found. There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. The use of reliable and accessible diagnostic methods to determine the number of ruptured ligaments might have a role in managing severe ankle sprains.

LEVEL OF EVIDENCE

Level III.

Responsiveness of the Brazilian IdFAI questionnaire in patients with chronic ankle instability

PURPOSE

This study aimed to determine the responsiveness of the Brazilian version of the Identification of Functional Ankle Instability (IdFAI) questionnaire in students who received an eight-week treatment for chronic ankle instability (CAI).

METHODS

Twenty-five college students (aged 23.12 ± 2.80 years) with CAI, as identified by the IdFAI questionnaire, were recruited. We used distribution and anchor-based methods to assess the responsiveness of the questionnaire, and its ability to determine clinical changes in participants. Eleven anchors were used: Visual Analog Scale for instability (VAS-i); Cumberland Ankle Instability Tool (CAIT); Isometric dorsiflexion, plantar flexion, inversion, and eversion muscle strength measured using a manual dynamometer; Dynamic balance as assessed through the Star Excursion Balance Test (SEBT-Y); Active ankle dorsiflexion range of motion as measured using the weight-bearing lunge test; and Functional performance assessment using three hop tests: single hop, triple crossover hop, and side hop. The distribution-based method used effect size (ES) and standardized response mean (SRM), whereas the anchor-based method used paired t-tests. Both methods allowed the calculation of the minimal important difference (MID).

RESULTS

The Brazilian IdFAI showed high responsiveness, with a large magnitude of change (ES = 1.34) and a high responsiveness index (SRM = 1.28) when assessed after a treatment for CAI. The IdFAI total score (p < .001) and all the 11 anchors [VAS-i (p < .001); CAIT (p < .001); Isometric dorsiflexion (p < .001), plantar flexion (p < .001), inversion (p < .001), and eversion (p < .001) muscle strength; SEBT-Y (p < .001); Lunge test (p = .002); Single hop (p < .001); triple crossover hop (p < .001); and side hop tests (p < .001)] showed significant differences. The anchor and distribution-based methods demonstrated MID values of 3.72 and 1.49-2.27, respectively.

CONCLUSION

The Brazilian IdFAI questionnaire is a patient-reported outcome measure sensitive to clinical changes in individuals with CAI. It can be used as an identification of patients with CAI, and as a parameter to verify clinical changes of clinical trials or therapeutic interventions in the population with CAI.

Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System

BACKGROUND

Whereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System.

METHODS

This was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed.

RESULTS

Of 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs.

CONCLUSION

Fractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity.

LEVEL OF EVIDENCE

3b.

Short-Term Effect of Manual Therapy &amp; Taping on Subacute Ankle Sprains with Potential Syndesmotic Sprain: A Case Series

STUDY DESIGN

Case Series.

BACKGROUND

Syndesmotic ankle sprains can occur in up to 17% of ankle trauma and can lead to long-term disability. This study describes the management of seven patients with subacute, high-grade ankle sprains with concerns of concurrent syndesmotic strain utilizing manual therapy and rigid sports taping.

METHODS

Seven active duty military members with clinically diagnosed, high-grade ankle sprains and concern for syndesmotic sprain participated in this case series. All patients received multi-modal treatment consisting of manual therapy, rigid sports taping, progressive exercises, and proprioceptive training. Decrease in Numeric Pain Rating Scale (NPRS) following manual therapy and taping treatment, number of sessions before discharge, and the Global Rating of Change (GROC) at discharge were retrospectively reviewed.

RESULTS

All patients demonstrated an immediate decrease in NPRS following treatment on average of 5 points (range, 3-8 points) with a functional asterisk sign. The improvement in pain and function was maintained until the next treatment session with a mean GROC score of +3. The mean time until recovery was 5.4 weeks (range, 1-8 weeks).

DISCUSSION

A multimodal approach for patients diagnosed clinically with high-grade ankle sprains and concern for syndesmotic sprain was useful to immediately reduce pain and improve function, and improvements were maintained throughout the duration of care. This study is the first to assess a combination of manual therapy and rigid sports taping for the treatment of suspected syndesmotic ankle sprains, and more stringent research is needed to validate the findings.

LEVEL OF EVIDENCE

Therapy, 4.

Serial Within-Session Improvements in Ankle Dorsiflexion During Clinical Interventions Including Mobilization-With-Movement and A Novel Manipulation Intervention - A Case Series

BACKGROUND

Persisting reductions in ankle dorsiflexion range of motion are commonly encountered clinically and seen to be associated with adverse outcomes after ankle and other lower extremity injuries. Accordingly improving identified deficits is a common goal for rehabilitation; however, little data exists documenting any improvement related to interventions in these patients.

PURPOSE

To document the change in dorsiflexion range of motion after stretching and mobilization-with-movement and exercise and a novel manipulation intervention in a population of injured athletes.

DESIGN

Case series in 38 consecutive injured athletes with persisting reductions in ankle dorsiflexion range of motion (42 "stiff" ankles, 34 uninjured) in an outpatient sports physiotherapy clinic.

METHOD

During a single treatment session, two baseline measurements of weight-bearing dorsiflexion were taken at the start of the session to establish reliability and minimum detectable change, and then the same measures were performed after stretching and a mobilization-with-movement intervention, and again after clinical exercise and a novel manipulation which was applied on both ankles.

RESULTS

Excellent reliability was demonstrated (ICC2,1>0.93, MDC=3.5°) for the dorsiflexion measure. Statistically significant (p<0.01), but clinically meaningless improvements were seen after stretching and the mobilization-with-movement intervention on the injured and uninjured legs (1.9° and 1.4° respectively) with greater improvements seen after exercise and the subsequent manipulation (6.9° and 4.7°).

CONCLUSIONS

The relatively simple clinical exercise and manipulation intervention program was associated improvement in dorsiflexion range of motion in this cohort with persisting ankle stiffness. The interventions described largely restored range of motion consistent with baseline levels of the uninjured ankles. Improvements were also seen in the uninjured ankles following intervention.

Preseason weight-bearing ankle dorsiflexion in male professional football players with and without a history of severe ankle injury: A novel analysis in an English Premier League club

OBJECTIVES

Ankle injuries are common in professional football and have profound player/team/club consequences. The weight-bearing lunge-test (WBLT) assesses ankle dorsiflexion range-of-motion in football primary/secondary injury prevention and performance contexts. Data for uninjured and previously ankle-injured players in the English Premier League (EPL) is not available. This study analysed WBLT measurements (cm) within and between uninjured and previously severe ankle-injured players (injured-stiff group, injured-lax group) in one EPL club.

DESIGN

Cross-sectional.

SETTING

Preseason.

PARTICIPANTS

Forty-nine players (age 22.9 ± 4.6 yr; height 181.6 ± 5.2 cm; mass 77.7 ± 7.6 kg).

MAIN OUTCOME MEASURES

Prevalence (%) of previous unilateral severe ankle injury (USAI). Side-to-side (right/left, dominant/nondominant, injured/uninjured) WBLT comparisons at group-level (t-test [within-group]; Welch's ANOVA [between-group]; effect sizes [within-/between-group]) and individual-level (limb symmetry index [%]; absolute-asymmetry [%]).

RESULTS

Prevalence of USAI was 38.7%. There were no statistically-significant side-to-side differences for within-/between-group comparisons. Effect sizes: just-below-large (injured-stiff) and extremely-large (injured-lax) for within-group injured-side/uninjured-side comparisons; just-below-medium (injured-lax) to just-above-medium (injured-stiff) for injured-side comparisons to uninjured players. Absolute-asymmetries: uninjured players, 15.4±13.2%; injured-stiff, 21.8±33.6%; injured-lax 20.4±13.6%.

CONCLUSIONS

Over one-third of players had previous USAI. Effect sizes indicate substantial within-group side-to-side differences and less substantial between-group differences. Across groups, some players had absolute-asymmetries that may elicit concern in ankle primary/secondary injury prevention and performance contexts.