Inclusion criteria when investigating insufficiencies in chronic ankle instability

Joint mobilization acutely improves landing kinematics in chronic ankle instability

PURPOSE

The objective of this study is to examine the acute effect of ankle joint mobilizations akin to those performed in everyday clinical practice on sagittal plane ankle joint kinematics during a single-leg drop landing in participants with chronic ankle instability (CAI).

METHODS

Fifteen participants with self-reported CAI (defined as <24 on the Cumberland Ankle Instability Tool) performed three single-leg drop landings under two different conditions: 1) premobilization and, 2) immediately, postmobilization. The mobilizations performed included Mulligan talocrural joint dorsiflexion mobilization with movement, Mulligan inferior tibiofibular joint mobilization, and Maitland anteroposterior talocrural joint mobilization. Three CODA cx1 units (Charnwood Dynamics Ltd., Leicestershire, UK) were used to provide information on ankle joint sagittal plane angular displacement. The dependent variable under investigation was the angle of ankle joint plantarflexion at the point of initial contact during the drop landing.

RESULTS

There was a statistically significant acute decrease in the angle of ankle joint plantarflexion from premobilization (34.89° ± 4.18°) to postmobilization (31.90° ± 5.89°), t(14) = 2.62, P < 0.05 (two-tailed). The mean decrease in the angle of ankle joint plantarflexion as a result of the ankle joint mobilization was 2.98° with a 95% confidence interval ranging from 0.54 to 5.43. The eta squared statistic (0.32) indicated a large effect size.

CONCLUSION

These results indicate that mobilization acted to acutely reduce the angle of ankle joint plantarflexion at initial contact during a single-leg drop landing. Mobilization applied to participants with CAI has a mechanical effect on the ankle joint, thus facilitating a more favorable positioning of the ankle joint when landing from a jump.

Double-leg stance and dynamic balance in individuals with functional ankle instability

To investigate whether double-leg stance could reveal balance deficits in subjects with functional ankle instability (FAI) and whether such an assessment of static balance would be correlated with measures of dynamic instability, 16 individuals with FAI and 16 healthy controls participated in this study. Static postural control was tested using double-leg stance (either with the eyes open (EO) or closed (EC)) on a dual-plate force platform. Dynamic balance was evaluated using the Multiple Hop Test (MHT) and a weight-shifting task. FAI subjects were significantly less stable in the anteroposterior direction during double-leg stance (as assessed by velocity of centre of pressure, VCP), both for the EO and EC condition. In the mediolateral direction the VCP values were also higher in FAI, but significance was only found for the EC condition (p=.02). FAI subjects made significantly more balance errors compared to healthy controls (p<.001) on both the affected and less affected leg during MHT. There were no significant differences between FAI and healthy subjects during the weight-shifting task. No relationship was found between double-leg stance and MHT measures (all correlations (rs) less than .30). This study suggests that static postural control during double-leg stance is impaired in FAI subjects. Although dynamic balance during MHT is also affected, no significant relationship was found between static and dynamic measurements, which indicate that they are most probably related to different aspects of postural control.

Chronic ankle instability affects learning rate during repeated proprioception testing

OBJECTIVES

1. To determine whether individuals with chronic ankle instability (CAI) have lower proprioception sensitivity scores from a test on the Active Movement Extent Discrimination Apparatus (AMEDA). 2. To determine whether individuals with CAI can improve proprioception sensitivity scores with repeated active movement testing using the AMEDA. 3. To assess the test-retest reliability of the AMEDA.

DESIGN

A cohort study comparing those with CAI or healthy ankles.

SETTING

University clinical laboratory.

PARTICIPANTS

61 healthy university students, 36 with CAI, 25 with stable ankles.

MAIN OUTCOME MEASURES

A 2-way ANOVA was conducted to compare performance of CAI and stable ankle groups, over 3 test repetitions on the AMEDA. The reliability intra-class correlation coefficient (ICC) was obtained for test repetitions.

RESULTS

The scores improved in both groups when the AMEDA test was repeated (p = <0.001). The rates of improvement in proprioception test scores differed, with the CAI group showing a slower learning rate than the stable ankle group (p = 0.047). The ICC for the whole group across the three trials was 0.80 (95% CI = 0.69 to 0.87, p = <0.001).

CONCLUSIONS

CAI participants improve their proprioception scores more slowly upon repeated AMEDA testing, suggesting differences in learning strategies.

Clinical examination results in individuals with functional ankle instability and ankle-sprain copers

CONTEXT

Why some individuals with ankle sprains develop functional ankle instability and others do not (ie, copers) is unknown. Current understanding of the clinical profile of copers is limited.

OBJECTIVE

To contrast individuals with functional ankle instability (FAI), copers, and uninjured individuals on both self-reported variables and clinical examination findings.

DESIGN

Cross-sectional study.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Participants consisted of 23 individuals with a history of 1 or more ankle sprains and at least 2 episodes of giving way in the past year (FAI: Cumberland Ankle Instability Tool [CAIT] score = 20.52 ± 2.94, episodes of giving way = 5.8 ± 8.4 per month), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers: CAIT score = 27.74 ± 1.69), and 23 individuals with no history of ankle sprain and no instability (uninjured: CAIT score = 28.78 ± 1.78).

INTERVENTION(S)

Self-reported disability was recorded using the CAIT and Foot and Ankle Ability Measure for Activities of Daily Living and for Sports. On clinical examination, ligamentous laxity and tenderness, range of motion (ROM), and pain at end ROM were recorded.

MAIN OUTCOME MEASURE(S)

Questionnaire scores for the CAIT, Foot and Ankle Ability Measure for Activities of Daily Living and for Sports, ankle inversion and anterior drawer laxity scores, pain with palpation of the lateral ligaments, ankle ROM, and pain at end ROM.

RESULTS

Individuals with FAI had greater self-reported disability for all measures (P < .05). On clinical examination, individuals with FAI were more likely to have greater talar tilt laxity, pain with inversion, and limited sagittal-plane ROM than copers (P < .05).

CONCLUSIONS

Differences in both self-reported disability and clinical examination variables distinguished individuals with FAI from copers at least 1 year after injury. Whether the deficits could be detected immediately postinjury to prospectively identify potential copers is unknown.

Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium

The International Ankle Consortium is an international community of researchers and clinicians whose primary scholastic purpose is to promote scholarship and dissemination of research-informed knowledge related to pathologies of the ankle complex. The constituents of the International Ankle Consortium and other similar organizations have yet to properly define the clinical phenomenon known as chronic ankle instability (CAI) and its related characteristics for consistent patient recruitment and advancement of research in this area. Although research on CAI and awareness of its impact on society and healthcare systems have grown substantially in the last 2 decades, the inconsistency in participant/patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalize this evidence to the target patient population. Therefore, there is a need to provide standards for patient/participant selection criteria in research focused on CAI, with justifications using the best available evidence.

National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes

OBJECTIVE

To present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes.

BACKGROUND

Because ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented.

RECOMMENDATIONS

The recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.

The eccentric torque production capacity of the ankle, knee, and hip muscle groups in patients with unilateral chronic ankle instability

Purpose

The aim of this study was to investigate eccentric torque production capacity of the ankle, knee and hip muscle groups in patients with unilateral chronic ankle instability (CAI) as compared to healthy matched controls.

Methods

In this case-control study, 40 participants (20 with CAI and 20 controls) were recruited based on convenient non-probability sampling. The average peak torque to body weight (APT/BW) ratio of reciprocal eccentric contraction of ankle dorsi flexor/plantar flexor, ankle evertor/invertor, knee flexor/extensor, hip flexor/extensor and hip abductor/adductor was determined using an isokinetic dynamometer. All subjects participated in two separate sessions with a rest interval of 48 to 72 hours. In each testing session, the torque production capacity of the ankle, knee, and hip muscle groups of only one lower limb was measured. At first, 3 repetitions of maximal eccentric-eccentric contraction were performed for the reciprocal muscles of a joint in a given movement direction. Then, the same procedure of practice and testing trials was repeated for the next randomly-ordered muscle group or joint of the same limb.

Results

There was no significant interaction of group (CAI and healthy controls) by limb (injured and non-injured) for any muscle groups. Main effect of limb was not significant. Main effect of group was only significant for eccentric torque production capacity of ankle dorsi flexor and hip flexor muscle groups. The APT/BW ratio of these muscles was significantly lower in the CAI group than the healthy controls (P<0.05).

Conclusion

CAI is associated with eccentric strength deficit of ankle dorsi flexor and hip flexor muscles as indicated by reduction in torque production capacity of these muscles compared to healthy controls. This strength deficit appeared to exist in both the injured and non-injured limbs of the patients.

Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review

CONTEXT

A dynamic postural-control task that has gained notoriety in the clinical and research settings is the Star Excursion Balance Test (SEBT). Researchers have suggested that, with appropriate instruction and practice by the individual and normalization of the reaching distances, the SEBT can be used to provide objective measures to differentiate deficits and improvements in dynamic postural-control related to lower extremity injury and induced fatigue, and it has the potential to predict lower extremity injury. However, no one has reviewed this body of literature to determine the usefulness of the SEBT in clinical applications.

OBJECTIVE

To provide a narrative review of the SEBT and its implementation and the known contributions to task performance and to systematically review the associated literature to address the SEBT's usefulness as a clinical tool for the quantification of dynamic postural-control deficits from lower extremity impairment.

DATA SOURCES

Databases used to locate peer-reviewed articles published from 1980 and 2010 included Derwent Innovations Index, BIOSIS Previews, Journal Citation Reports, and MEDLINE.

STUDY SELECTION

The criteria for article selection were (1) The study was original research. (2) The study was written in English. (3) The SEBT was used as a measurement tool.

DATA EXTRACTION

Specific data extracted from the articles included the ability of the SEBT to differentiate pathologic conditions of the lower extremity, the effects of external influences and interventions, and outcomes from exercise intervention and to predict lower extremity injury.

DATA SYNTHESIS

More than a decade of research findings has established a comprehensive portfolio of validity for the SEBT, and it should be considered a highly representative, noninstrumented dynamic balance test for physically active individuals. The SEBT has been shown to be a reliable measure and has validity as a dynamic test to predict risk of lower extremity injury, to identify dynamic balance deficits in patients with a variety of lower extremity conditions, and to be responsive to training programs in both healthy people and people with injuries to the lower extremity. Clinicians and researchers should be confident in employing the SEBT as a lower extremity functional test.

Hip kinematics during a stop-jump task in patients with chronic ankle instability

CONTEXT

Chronic ankle instability (CAI) commonly develops after lateral ankle sprain. Movement pattern differences at proximal joints may play a role in instability.

OBJECTIVE

To determine whether people with mechanical ankle instability (MAI) or functional ankle instability (FAI) exhibited different hip kinematics and kinetics during a stop-jump task compared with "copers."

DESIGN

Cross-sectional study.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Sixty-three recreational athletes, 21 (11 men, 10 women) per group, matched for sex, age, height, mass, and limb dominance. All participants reported a history of a moderate to severe ankle sprain. The participants with MAI and FAI reported 2 or more episodes of giving way at the ankle in the last year and decreased functional ability; copers did not. The MAI group demonstrated clinically positive anterior drawer and talar tilt tests, whereas the FAI group and copers did not.

INTERVENTION(S)

Participants performed a maximum-speed approach run and a 2-legged stop jump followed by a maximum vertical jump.

MAIN OUTCOME MEASURE(S)

An electromagnetic tracking device synchronized with a force plate collected data during the stance phase of a 2-legged stop jump. Hip motion was measured from initial contact to takeoff into the vertical jump. Group differences in hip kinematics and kinetics were assessed.

RESULTS

The MAI group demonstrated greater hip flexion at initial contact and at maximum (P = .029 and P = .017, respectively) and greater hip external rotation at maximum (P = .035) than the coper group. The MAI group also demonstrated greater hip flexion displacement than both the FAI (P = .050) and coper groups (P = .006). No differences were noted between the FAI and coper groups in hip kinematic variables or among any of the groups in ground reaction force variables.

CONCLUSIONS

The MAI group demonstrated different hip kinematics than the FAI and coper groups. Proximal joint motion may be affected by ankle joint function and laxity, and clinicians may need to assess proximal joints after repeated ankle sprains.

Isokinetic testing of evertor and invertor muscles in patients with chronic ankle instability

Ankle sprains are among the most common sport-related injuries and can lead to chronic ankle instability. Impaired sensorimotor function of the ankle musculature is often suggested as a cause. The current study sought to assess and compare the isokinetic performance and electromyographic patterns of evertor and invertor muscles in patients with chronic ankle instability and in a control group. Twelve patients with chronic ankle instability and twelve healthy subjects were included. Isokinetic eccentric and concentric testing at various angular velocities was performed for eversion and inversion movements. The corresponding myoelectric activities of the fibularis longus and tibialis anterior muscles were quantified from surface electromyographic recordings by computing average root mean square values. Patients had lower myoelectric activity of the evertor and invertor muscles than controls did; this difference could account for the eccentric weakness associated with ankle instability. Functional strength ratios revealed a dynamic strength imbalance in unstable ankle patients and that may contribute to recurrent injury. Our findings suggest that rehabilitation programs for unstable ankle patients must be focused on the motor control of eccentric contractions of the ankle evertors and invertors, to boost these muscles' contribution to ankle stabilization.

A new paradigm for rehabilitation of patients with chronic ankle instability

Lateral ankle sprains have been shown to be one of the most common musculoskeletal injuries in both athletes and the recreationally active population. Moreover, it is estimated that approximately 30% of people who incur a lateral ankle sprain will sustain recurrent ankle sprains and experience symptoms of pain and instability that last > 1 year. Chronic ankle instability (CAI) is the term used to describe cases involving repetitive ankle sprains, multiple episodes of the ankle "giving way," persistent symptoms, and diminished self-reported function for > 1 year after the initial ankle sprain. The optimal conservative treatment for CAI is yet to be determined; however, comparison between patients with CAI and individuals showing no history of ankle sprain has revealed several characteristic features of CAI. These include diminished range of motion, decreased strength, impaired neuromuscular control, and altered functional movement patterns. We propose a new treatment paradigm for conservative management of CAI with the aim of assessing and treating specific deficits exhibited by individual patients with CAI.

Development of the Identification of Functional Ankle Instability (IdFAI)

BACKGROUND

Self-reported questionnaires are a common method used in identifying individuals with ankle instability. Recently a study illustrated the singular use of any of the most frequently utilized questionnaires failed to significantly predict ankle stability status. Therefore, the purpose of this article was to present information related to the development of the Identification of Functional Ankle Instability (IdFAI).

METHODS

Volunteers (n = 278; 125 males, 153 females, 19.8 ± 1.4 years) completed the IdFAI on one occasion. An exploratory factor analysis was conducted with principal axis factoring as the extraction method with varimax rotation. Additionally, a discriminant function analysis was conducted to identify a discrimination score and to evaluate the accuracy of the questionnaire.

RESULTS

The factor analysis revealed: factor 1 (four questions) explained 53.7% of the variance, factor 2 (four questions) with an additional 17.4%, and factor 3 (two questions) an additional 6.3%. Overall, these factors accounted for 77.4% of the variance. There was a distinct discrimination score of 10.3 to identify people who have the minimally accepted criteria for FAI. Overall, the IdFAI has an accuracy of 89.6%.

CONCLUSION

This investigation showed that the IdFAI was a feasible and appropriate way to identify individuals with FAI.

CLINICAL RELEVANCE

We suggest clinicians and researchers utilize the IdFAI to identify individuals with functional ankle instability since it is a short, simple, easy questionnaire to administer and take, and has been shown to have excellent accuracy.

Sway activity and muscle recruitment order during transition from double to single-leg stance in subjects with chronic ankle instability

Subjects with CAI (chronic ankle instability) are slower in activating their leg muscles when shifting weight (from double to single leg stance; DLS and SLS). We examined if these delays are associated with longer transition/stabilization times. This was tested by analyzing the center of pressure (COP) trajectory data (1) in the DLS phase before onset of transition, (2) in the quasi-stable phase of the SLS, immediately after the transition phase but before time to stabilization (TTS) and (3) in the SLS phase after TTS. Data were recorded from 20 subjects with CAI and 20 controls. The TTS was longer for the CAIs than for controls (3.25 vs. 2.28 s in EO and 3.41 vs. 2.51 s in EC; p<0.001). Similarly, the time of transition (TTR) was prolonged in CAIs (1.48 vs. 1.14 s in EO and 1.53 vs. 1.20 s in EC; p<0.05). These prolonged periods came in parallel with an increase in the ML sway in the quasi-stable phase (mean displacement 2.20 vs. 1.75 cm in EO; 3.37 vs. 2.62 cm in EC; significant for EC p<0.05). The TTR in CAIs was positively correlated with time onsets of the adductor longus muscle during transitions with EC (R=0.51, p=0.03). The findings support the use of a weight-shifting paradigm for the evaluation of balance control in CAI. Specifically, we underscore the transition phase and quasi-stable phase of the SLS as promising time windows for documenting balance control deficits in CAI.

The effect of ankle taping or bracing on proprioception in functional ankle instability: a systematic review and meta-analysis

OBJECTIVES

To determine if wearing an ankle brace or taping the ankle, compared to no brace or tape, improves proprioceptive acuity in people with a history of ankle sprain or functional ankle instability.

DESIGN

Systematic review and meta-analysis.

METHODS

Studies using controlled, cross-over designs whereby participants who had sprained their ankle at least once or had functional ankle instability, underwent some form of proprioceptive sensation testing with and without ankle brace or tape, were included. Proprioceptive acuity was reported for the ankle tape/brace condition and the condition where no tape or brace was worn. Meta-analysis was employed to compare proprioceptive acuity with and without ankle tape/brace.

RESULTS

Eight studies were included in the review. Studies measured either sense of movement or sense of joint position. The mean differences in 19 of 32 comparisons were not significant. Of the remaining mean differences, 10 were positive, indicating better proprioceptive acuity in the taped/braced condition and 3 were negative, indicating poorer proprioceptive acuity. Overall, there was no significant effect with ankle tape/brace compared to the no tape/brace condition (mean difference: 0.08°, 95% CI: -0.39 to 0.55). This finding was consistent when the two aspects of proprioception (sense of movement or joint position) were considered separately.

CONCLUSIONS

The pooled evidence suggests that using an ankle brace or ankle tape has no effect on proprioceptive acuity in participants with recurrent ankle sprain or who have functional ankle instability.

Chronic ankle instability: diagnosis and treatment

BACKGROUND

Chronic ankle instability (CAI) is a very common injury but still remains an area of debate.

QUESTIONS

This review aims to define the current diagnosis and treatment of persons with CAI.

METHODS

A PubMed (MEDLINE) search of the years 2010 and 2011 (1 January 2010 to 15 July 2011) was performed using three keywords: ankle and chronic and instability. The number of articles in English language that was identified was 57.

RESULTS

Low reliability has been found in effectively testing CAI in a clinical setting. No single force-plate measure is very effective in predicting if an individual had CAI or not. Availability of a nonradiographic device (ankle arthrometer) to measure ankle instability could improve diagnostic accuracy and facilitate decision making in patients with CAI. The sensitivity of magnetic resonance imaging (MRI) may not be adequate to detect lesions in these patients before surgery. In a symptomatic patient, negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment. Conservative treatment (rehabilitation, taping, brace) may reduce the occurrence of recurrent ankle sprains and may be effective in managing CAI. In patients with CAI, strengthening of the muscles around the ankle with well-planned proprioceptive exercises helped the patients return to normal living and sports activities, and prevents unnecessary surgery, especially in cases with functional instability. There is no consensus regarding optimum surgical treatment for CAI, but all of them often have good results.

CONCLUSIONS

Conservative treatment of patients with CAI must be the first-line therapy. Surgical treatment must be indicated only when conservative treatment fails.

Intrinsic predictive factors for ankle sprain in active university students: a prospective study

The ankle is the joint most affected among the sports-related injuries. The current study investigated whether certain intrinsic factors could predict ankle sprains in active students. The 125 participants were submitted to a baseline assessment in a single session were then followed-up for 52 weeks regarding the occurrence of sprain. The baseline assessment were performed in both ankles and included the questionnaire Cumberland ankle instability tool - Portuguese, the foot lift test, dorsiflexion range of motion, Star Excursion Balance Test (SEBT), the side recognition task, body mass index, and history of previous sprain. Two groups were used for analysis: one with those who suffered an ankle sprain and the other with those who did not suffer an ankle sprain. After Cox regression analysis, participants with history of previous sprain were twice as likely to suffer subsequent sprains [hazard ratio (HR) 2.21 and 95% confidence interval (CI) 1.07-4.57] and people with better performance on the SEBT in the postero-lateral (PL) direction were less likely to suffer a sprain (HR 0.96 and 95% CI 0.92-0.99). History of previous sprain was the strongest predictive factor and a weak performance on SEBT PL was also considered a predictive factor for ankle sprains.

Movement variability during single leg jump landings in individuals with and without chronic ankle instability

BACKGROUND

Repeated episodes of giving way at the ankle may be related to alterations in movement variability.

METHODS

Eighty-eight recreational athletes (39 males, 49 females) were placed in 4 groups: mechanically unstable, functionally unstable, copers, and controls based on ankle injury history, episodes of giving way, and joint laxity. Lower extremity kinematics and ground reaction forces were measured during single leg landings from a 50% maximum vertical jump in the anterior, lateral, and medial directions. Ensemble curves of 10 trials were averaged and coefficients of variation were identified for ankle, knee, hip, and trunk motion in 3 planes. A log(e) (ln) transformation was performed on the data. Mixed model analyses of variance (ANOVAs) with Tukey post-hoc tests were utilized with Bonferroni corrections to α ≤ 0.008.

FINDINGS

At the knee, controls were more variable than functionally unstable and copers for knee rotation before initial contact, and were more variable during stance than functionally unstable in knee rotation (P ≤ 0.008). Interactions during stance revealed controls were more variable than functionally unstable in lateral jumps for hip flexion, and than mechanically and functionally unstable in hip abduction in the anterior direction (P≤0.008). Controls were more variable than all other groups in hip flexion and than mechanically unstable in hip abduction (P ≤0 .008).

INTERPRETATION

Individuals with ankle instability demonstrated less variability at the hip and knee compared to controls during single leg jump landings. Inability to effectively utilize proximal joints to perform landing strategies may influence episodes of instability.

Critical review of self-reported functional ankle instability measures

BACKGROUND

Since functional ankle instability (FAI) lacks a "gold standard'' measure, a variety of self-reported ankle instability measures have been created. The purpose of this study was to determine which ankle instability measure identifies individuals who meet a minimum acceptable criterion for FAI.

METHODS

Participants volunteered from a large university population which included 242 participants (104 males, 138 females; 21.4 ± 1.4 years). The predictor variables were seven ankle instability questionnaires: Ankle Instability Instrument (AII), Ankle Joint Functional Assessment Tool (AJFAT), Chronic Ankle Instability Scale (CAIS), Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM), Foot and Ankle Instability Questionnaire (FAIQ), and Foot and Ankle Outcome Score (FAOS). The outcome variable (MC_FAI) was created based on the minimum acceptable criteria for FAI. This was established as at least one ankle sprain and an episode of giving way. Data were modeled using chi-square and multinomial logistic regression.

RESULTS

The regression model revealed all of the questionnaires were more useful at identifying participants who did not meet the minimum criteria for FAI (No MC_FAI = 95.7%, MC_FAI = 55.6%, overall = 84.6%). Based on the Wald criterion, the full model was reduced to the CAIT, AII, and FAAM. The reduced model revealed the CAIT (X(2) = 8.756, p = 0.003) and AII (X(2) = 31.992, p = 0.001) as the only variables that had a significant relationship with the outcome variable.

CONCLUSION

The model illustrates no single measure was able to predict if individuals met the minimally accepted criteria for FAI. However, a significantly accurate prediction of ankle stability status was produced by combining the CAIT and AII.

CLINICAL RELEVANCE

Based on the results we recommend that researchers and clinicians use both the CAIT and AII to determine ankle stability status.

Neuromuscular training to enhance sensorimotor and functional deficits in subjects with chronic ankle instability: A systematic review and best evidence synthesis

Objective

To summarise the available evidence for the efficacy of neuromuscular training in enhancing sensorimotor and functional deficits in subjects with chronic ankle instability (CAI).

Design

Systematic review with best evidence synthesis.

Data Sources

An electronic search was conducted through December 2009, limited to studies published in the English language, using the Pubmed, CINAHL, Embase, and SPORTDiscus databases. Reference screening of all included articles was also undertaken.

Methods

Studies were selected if the design was a RCT, quasi RCT, or a CCT; the patients were adolescents or adults with confirmed CAI; and one of the treatment options consisted of a neuromuscular training programme. The primary investigator independently assessed the risk of study bias and extracted relevant data. Due to clinical heterogeneity, data was analysed using a best-evidence synthesis.

Results

Fourteen studies were included in the review. Meta-analysis with statistical pooling of data was not possible, as the studies were considered too heterogeneous. Instead a best evidence synthesis was undertaken. There is limited to moderate evidence to support improvements in dynamic postural stability, and patient perceived functional stability through neuromuscular training in subjects with CAI. There is limited evidence of effectiveness for neuromuscular training for improving static postural stability, active and passive joint position sense (JPS), isometric strength, muscle onset latencies, shank/rearfoot coupling, and a reduction in injury recurrence rates. There is limited evidence of no effectiveness for improvements in muscle fatigue following neuromuscular intervention.

Conclusion

There is limited to moderate evidence of effectiveness in favour of neuromuscular training for various measures of static and dynamic postural stability, active and passive JPS, isometric strength, muscle onset latencies, shank/rearfoot coupling and injury recurrence rates. Strong evidence of effectiveness was lacking for all outcome measures. All but one of the studies included in the review were deemed to have a high risk of bias, and most studies were lacking sufficient power. Therefore, in future we recommend conducting higher quality RCTs using appropriate outcomes to assess for the effectiveness of neuromuscular training in overcoming sensorimotor deficits in subjects with CAI.

Foot clearance in walking and running in individuals with ankle instability

BACKGROUND

Foot positioning before heel strike has been attributed to chronic ankle instability injury mechanics, and may play a role in developing and perpetuating chronic ankle instability.

PURPOSE

This study was undertaken to determine if a group of individuals with mechanical instability (MI) or a group with functional instability (FI) of the ankle joint demonstrate less foot-floor clearance and a more inverted and plantar flexed position of the foot during the terminal swing phase of the running and walking cycles when compared with a group of ankle sprain copers who had an injury but no residual instability.

STUDY DESIGN

Controlled laboratory study.

METHODS

Three-dimensional motion analysis was performed on 3 groups (n = 11 male athletes each) differentiated based on ankle injury history and ligamentous laxity during walking and running on a raised platform.

RESULTS

The MI group (14.8° ± 12.0°) demonstrated greater maximum foot external rotation than the FI (3.2° ± 6.0°) and coper groups (2.9° ± 11.0°) (P = .01; η(p) (2) = .25) during running and greater rotation than the coper group during walking (3.3° ± 6.1° vs -4.5° ± 4.1°; P = .03; η(p) (2) = .21). The FI group (6.1° ± 3.2°) had greater plantar flexion at minimum than the MI group (0.1° ± 3.5°) during walking (P = .02; η(p) (2) = .25). Other group differences demonstrated large effect sizes, but not statistical significance, including unstable groups having lower minimum metatarsal height than copers during running.

CONCLUSION

Differences in foot and leg position during terminal swing were observed between MI and FI groups and copers. Greater plantar flexion and lower minimum metatarsal height may increase risk for inadvertent contact and thus episodes of instability.

CLINICAL RELEVANCE

Rehabilitation programs may need to address terminal swing to improve mechanics and avoid potential episodes of giving way at the ankle.

Effect of a 6-week dynamic neuromuscular training programme on ankle joint function: A Case report

Background

Ankle joint sprain and the subsequent development of chronic ankle instability (CAI) are commonly encountered by clinicians involved in the treatment and rehabilitation of musculoskeletal injuries. It has recently been advocated that ankle joint post-sprain rehabilitation protocols should incorporate dynamic neuromuscular training to enhance ankle joint sensorimotor capabilities. To date no studies have reported on the effects of dynamic neuromuscular training on ankle joint positioning during landing from a jump, which has been reported as one of the primary injury mechanisms for ankle joint sprain. This case report details the effects of a 6-week dynamic neuromuscular training programme on ankle joint function in an athlete with CAI.

Methods

The athlete took part in a progressive 6-week dynamic neuromuscular training programme which incorporated postural stability, strengthening, plyometric, and speed/agility drills. The outcome measures chosen to assess for interventional efficacy were: [1] Cumberland Ankle Instability Tool (CAIT) scores, [2] Star Excursion Balance Test (SEBT) reach distances, [3] ankle joint plantar flexion during drop landing and drop vertical jumping, and [4] ground reaction forces (GRFs) during walking.

Results

CAIT and SEBT scores improved following participation in the programme. The angle of ankle joint plantar flexion decreased at the point of initial contact during the drop landing and drop vertical jumping tasks, indicating that the ankle joint was in a less vulnerable position upon landing following participation in the programme. Furthermore, GRFs were reduced whilst walking post-intervention.

Conclusions

The 6-week dynamic neuromuscular training programme improved parameters of ankle joint sensorimotor control in an athlete with CAI. Further research is now required in a larger cohort of subjects to determine the effects of neuromuscular training on ankle joint injury risk factors.

Effect of taping on actual and perceived dynamic postural stability in persons with chronic ankle instability

OBJECTIVE

To investigate whether 2 different mechanisms of ankle joint taping ([1] lateral subtalar sling or [2] fibular repositioning) can enhance actual and perceived dynamic postural stability in participants with chronic ankle instability (CAI).

DESIGN

Laboratory-based repeated-measures study.

SETTING

University biomechanics laboratory.

PARTICIPANTS

Participants (n=16) with CAI.

INTERVENTIONS

Participants performed the Star Excursion Balance Test (SEBT) under 3 different conditions: (1) no tape, (2) lateral subtalar sling taping and (3) fibular repositioning taping.

MAIN OUTCOME MEASURES

Reach distances in the anterior, posteromedial, and posterolateral directions on the SEBT. Participants' perceptions of stability, confidence, and reassurance when performing the SEBT under 2 different taping conditions.

RESULTS

Taping did not improve reach distance on the SEBT (P>.05). Feelings of confidence increased for 56% of participants (P=.002) under both tape conditions. Feelings of stability increased for 87.5% of participants (P<.001) using condition 2 (lateral subtalar sling taping) and 75% of participants (P=.001) using condition 3 (fibular repositioning taping). Feelings of reassurance increased for 68.75% of participants (P=.001) using condition 2 (lateral subtalar sling taping) and 50% of participants (P=.005) using condition 3 (fibular repositioning taping).

CONCLUSIONS

No significant change in dynamic postural stability was observed after application of either taping mechanism; however, participants' perceptions of confidence, stability, and reassurance were significantly improved. Further research is necessary to fully elucidate the exact mechanisms by which taping may help reduce the incidence of repeated injury in subjects with CAI.