1
|
Yokoe T, Yang F, Tajima T, Chosa E. The evaluation of rotational lateral ankle laxity in gravity stress position by ultrasonography: normative value in uninjured ankles. BMC Musculoskelet Disord 2024; 25:764. [PMID: 39354465 DOI: 10.1186/s12891-024-07881-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Accepted: 09/19/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND The evaluation of lateral ankle laxity remains challenging when diagnosing chronic lateral ankle instability (CLAI). Several studies have reported that internal rotation of the talus as an indicator of rotational lateral ankle laxity (RLAL) increases in patients with CLAI. However, there is no established method for detecting and evaluating the RLAL. This study aimed to report a novel method for evaluating the RLAL in the gravity stress position by measuring the talofibular distance (TFD) using ultrasonography (US) and show the normative value of the TFD. METHODS The TFDs in the subjects with healthy ankles were prospectively measured 10 mm distal to the ankle joint in the neutral ankle position and gravity stress position using US. The differences in the TFD between the two ankle positions were evaluated. The differences in the TFD by gender and ankle laterality were also evaluated. RESULTS A total of 52 healthy ankles of 28 subjects (mean age, 24.0 ± 1.6; male/female, 12/16) were finally included. There was a significant difference in the TFD between the neutral ankle position (6.9 ± 0.9 mm) and gravity stress position (9.0 ± 0.9 mm) (p < 0.001). The mean difference in the TFD between the two ankle positions was 2.1 ± 0.6 mm. There were no significant differences in the TFD by gender and ankle laterality. CONCLUSIONS The present study reported a novel US method for evaluating RLAL by applying gravity stress and the normative value of the TFD.
Collapse
Affiliation(s)
- Takuji Yokoe
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Kihara, Kiyotake, 5200, 889-1692, Miyazaki, Japan.
| | - Fan Yang
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Kihara, Kiyotake, 5200, 889-1692, Miyazaki, Japan
| | - Takuya Tajima
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Kihara, Kiyotake, 5200, 889-1692, Miyazaki, Japan
| | - Etsuo Chosa
- Division of Orthopaedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, Kihara, Kiyotake, 5200, 889-1692, Miyazaki, Japan
| |
Collapse
|
2
|
Chen Y, Cao S, Wang C, Zhang C, Huang J, Wang X, Ma X. Diagnostic Evaluation of Mechanical Ankle Instability by Comparing Injured and Uninjured Contralateral Ankles Using Arthrometry. J Athl Train 2023; 58:934-940. [PMID: 36827611 PMCID: PMC10784880 DOI: 10.4085/1062-6050-0494.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
CONTEXT Individuals with mechanical ankle instability (MAI) have obvious lateral ligament laxity and excessive ankle joint motion beyond the physiological range. Arthrometry has been introduced to quantitatively measure the laxity of the ankle joint. However, the diagnostic accuracy of arthrometry in MAI is still debatable. OBJECTIVES To (1) evaluate the difference in laxity between bilateral ankles in patients with and those without MAI and (2) calculate the diagnostic accuracy of ankle arthrometry using bilateral comparisons. DESIGN Cross-sectional study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 38 individuals with unilateral MAI (age = 31.24 ± 7.90 years, height = 168.93 ± 7.69 cm, mass = 65.72 ± 10.47 kg) and 38 individuals without MAI (control group; age = 32.10 ± 7.10 years, height = 166.59 ± 7.89 cm, mass = 62.93 ± 10.72 kg). MAIN OUTCOME MEASURE(S) Bilateral ankle laxity in each participant was quantitatively measured by performing the arthrometric anterior drawer test. Continuous data of loading force and joint displacement were recorded. Data from both ankles were compared for the ankle joint displacement at a loading force of 75 N (D75) and load-displacement ratio from 10 to 40 N (LDR 10-40). RESULTS The D75 between injured and uninjured ankles in patients with MAI was different (t37 = 9.78, P < .001). The mean LDR 10-40 in injured ankles was higher than that in uninjured ankles (t37 = 9.80, P < .001). In the control group, no differences were found between the left and right ankles. The MAI group had larger bilateral differences than the control group (t37 range = 7.33-8.18; P < .001). When LDR 10-40 was used to diagnose MAI, the arthrometer showed sensitivity and specificity of 0.900 and 0.933, respectively, with a cutoff value of 0.0351 mm/N. CONCLUSIONS An ankle arthrometer can be used to quantitatively measure the difference in bilateral ankle laxity in patients with MAI. Arthrometer-measured LDR 10-40 can be used to diagnose MAI with high diagnostic accuracy.
Collapse
Affiliation(s)
- Yungu Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, Jingan District, Shanghai, China
| | - Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Jingan District, Shanghai, China
| | - Chen Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Jingan District, Shanghai, China
| | - Chao Zhang
- Department of Orthopedics, Huashan Hospital, Fudan University, Jingan District, Shanghai, China
| | - Jiazhang Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Jingan District, Shanghai, China
| | - Xu Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Jingan District, Shanghai, China
| | - Xin Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Jingan District, Shanghai, China
| |
Collapse
|
3
|
Wenning M, Schmal H. Chronic Ankle Instability - Mechanical vs. Functional. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:552-562. [PMID: 35158394 DOI: 10.1055/a-1696-2503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Chronic ankle instability arises from three interacting contributing factors: mechanical ankle instability, functional ankle instability, and perceived ankle instability. To decide on the most appropriate individual recommendation for therapeutic options, it is necessary to assess which of the two main aetiologies - functional vs. mechanical - is dominant in causing the perceived impairment. It is essential to perform a thorough analysis and diagnosis, even though quantifying mechanical ankle instability is still a challenge in the clinical approach to this common pathology. When diagnosing mechanical instability, the most established procedure is physical examination, although this unfortunately does not allow the deficit to be quantified. Additional options include stress-ultrasound, 3D stress-MRI (3SAM), ankle arthrometry, marker-based 3D motion analysis, and diagnostic ankle arthroscopy. Of these the latter is considered the gold standard, even though it is an invasive procedure, it may not be performed for diagnostic reasons only, and it also does not allow the mechanical instability to be quantified. For diagnosing functional instability there are non-instrumented tests such as the Star Excursion Balance Test or Y-Balance Test, posturography/stabilometry, and gait and running analysis, possibly combined with EMG acquisition and isokinetic strength testing.To date, the standard of care is conservative management of ankle instability, and the therapy should include sensorimotor training, strength training of the periarticular muscles, balance training, and gait and running exercises on different surfaces. However, it is increasingly clear that a certain degree of mechanical instability cannot be compensated for by functional training. Thus, it is the goal of differential diagnostics to identify those patients and guide them to mechanical therapy, including ankle bracing, taping, and surgical ligament reconstruction.
Collapse
Affiliation(s)
- Markus Wenning
- Department of Orthopedic and Trauma Surgery, Albert-Ludwigs-Universität Freiburg Medizinische Fakultät, Freiburg, Deutschland
| | - Hagen Schmal
- Department of Orthopedic and Trauma Surgery, Albert-Ludwigs-Universitat Freiburg Medizinische Fakultat, Freiburg, Deutschland
- Department of Orthopedic Surgery, Odense University Hospital Department of Orthopaedic Surgery, Odense, Denmark
| |
Collapse
|
4
|
Chen Y, Cao S, Wang C, Ma X, Wang X. Quantitative analysis with load–displacement ratio measured via digital arthrometer in the diagnostic evaluation of chronic ankle instability: a cross-sectional study. J Orthop Surg Res 2022; 17:287. [PMID: 35606774 PMCID: PMC9125832 DOI: 10.1186/s13018-022-03177-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/17/2022] [Indexed: 12/26/2022] Open
Abstract
Background Arthrometry has been introduced to evaluate the laxity of ankle joint in recent years. However, its role in the diagnosis of chronic ankle instability is still debatable. Therefore, we assessed the diagnostic accuracy of a digital arthrometer in terms of sensitivity and specificity. Methods According to the inclusion and exclusion criteria proposed by the International Ankle Consortium, we recruited 160 uninjured ankles (control group) and 153 ankles with chronic ankle instability (CAI group). Ankle laxity was quantitively measured by a validated digital arthrometer. Data of loading force and joint displacement were recorded in a continuous manner. Differences between the control and CAI groups were compared using 2-tailed independent t test. A receiver operating characteristic curve analysis was used to calculate area under a curve, sensitivity and specificity. Results Load–displacement curves of the two groups were depicted. Differences of joint displacement between the control and CAI groups were compared at 30, 45, 60, 75, 90, 105 and 120 N, which were all of statistical significance (all p < 0.001) with the largest effect size at 90 N. Statistical significance was found in the differences between the two groups in load–displacement ratio at 10–120 N, 10–40 N, 40–80 N and 80–120 N (all p < 0.001), with the largest effect size at 10–40 N. Load–displacement ratio at the interval of 10–40 N had the highest area under a curve (0.9226), with sensitivity and specificity of 0.804 and 0.863, respectively, when the cutoff point was 0.1582 mm/N. Conclusion The digital arthrometer measurement could quantitively analyze the ankle laxity with high diagnostic accuracy. The load–displacement ratio would be a reliable and promising approach for chronic ankle instability diagnosis. Level of evidence level II.
Collapse
|
5
|
Kataoka K, Hoshino Y, Nagamune K, Nukuto K, Yamamoto T, Yamashita T, Kanzaki N, Kakutani K, Matsushita T, Kuroda R. The quantitative evaluation of anterior drawer test using an electromagnetic measurement system. Sports Biomech 2021; 21:550-561. [PMID: 34016026 DOI: 10.1080/14763141.2021.1918754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The anterior drawer test (ADT) is the gold standard examination for the diagnosis of anterior talofibular ligamentinsufficiency,although there is noquantitative evaluation of ADT that is generally usable and reliable.An electromagnetic sensor (EMS)has been used to quantitatively evaluate joint kinematics, and has a high potential to be applied to the ankle joint. The aim of this study was to validatethe EMS measurement of the ADTin comparison to the fluoroscopic evaluationand to evaluate the reproducibility of the EMS measurement.Six feet were included,and an examinerperformed the ADT5 times for each foot while the anterior translation of the ankle jointwas quantitative evaluatedusing EMS and fluoroscope simultaneously. The anterior translation of the ankle joint during the ADT in EMS and in fluoroscope was 8.1 ± 5.7 mm and 3.6 ± 2.4 mm.Astrong correlation was observed between the measurements using EMS and fluoroscope (p < 0.01, the correlation coefficient = 0.91). Another 20 feet were included, and three examiners performed the ADT five times for each foot with the EMS measurement. The intra and inter-examiner reliability was 0.99 and 0.89.The EMS could quantify the anterior translation during the ADT which corresponds to fluoroscopic evaluation.
Collapse
Affiliation(s)
- Kiminari Kataoka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kouki Nagamune
- Department of Human and Artificial Intelligent Systems, University of Fukui
| | - Koji Nukuto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tetsuya Yamamoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takahiro Yamashita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| |
Collapse
|
6
|
Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther 2021; 51:CPG1-CPG80. [PMID: 33789434 DOI: 10.2519/jospt.2021.0302] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.
Collapse
|
7
|
Wenning M, Gehring D, Lange T, Fuerst-Meroth D, Streicher P, Schmal H, Gollhofer A. Clinical evaluation of manual stress testing, stress ultrasound and 3D stress MRI in chronic mechanical ankle instability. BMC Musculoskelet Disord 2021; 22:198. [PMID: 33596891 PMCID: PMC7890850 DOI: 10.1186/s12891-021-03998-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/15/2021] [Indexed: 12/26/2022] Open
Abstract
Background Chronic ankle instability (CAI) arises from the two etiological factors of functional (FAI) and mechanical ankle instability (MAI). To distinguish the contributions of the two etiologies, it is necessary to quantitively assess functional and mechanical deficits. Validated and reproducible assessment of mechanical instability remains a challenge in current research and practice. Physical examination, stress sonography and a novel 3D stress MRI have been used, while stress radiography has been called into question and arthrometry is limited to research purposes. The interaction of these primarily mechanical measurements with the functional and subjective components of CAI are subject to debate. The aim of this study was the evaluation of the clinical and biomechanical preferences of the three different methods in the diagnosis of MAI. Methods In this cross-sectional diagnostic study, we compared three different diagnostic approaches to mechanical ankle instability: (1) manual stress testing (anterior drawer test [ADT] and talar tilt test [TTT]), (2) stress sonography and (3) 3D stress MRI (3SAM) The latter includes quantification of 3D cartilage contact area (CCA) in plantarflexion-supination compared to neutral-null position. We applied these measurements to a cohort of patients suffering from chronic mechanical ankle instability (n = 25) to a matched cohort of healthy controls (n = 25). Perceived instability was assessed using the Cumberland Ankle Instability Tool (CAIT) and Forgotten Joint Score (FJS). Functional deficits were measured using postural sway and the y-Balance test. Results Significant differences between the two groups (single-factor “group” ANOVA, p < 0.05) were found in all of the mechanical assessments with strong effect sizes. Spearman’s correlations were strong for CAIT and manual stress testing (TTT rho = − 0.83, ADT rho = − 0.81), 3D stress MRI (rho = − 0.53) and stress sonography (TTT rho = − 0.48, ADT rho = − 0.44). Furthermore, the correlation between manual stress testing and CCA in the fibulotalar articulation (CCAFT) was strong (rho = 0.54) and the correlations to stress sonography were moderate (ADT rho = 0.47 and TTT rho = 0.43). The calculation of cutoff values revealed a distance of > 5.4 mm increase in ligament length during stress sonography (sensitivity 0.92, specificity 0.6) and > 43% loss of articulating surface in the fibulotalar joint (CCAFT in supination-plantarflexion using 3SAM, sensitivity 0.71, specificity 0.8) as potential cutoff values for diagnosing MAI. Conclusions Manual stress testing showed to be a valuable method of identifying mechanical ankle instability. However, due to is subjective character it may overvalue patient-reported instability as a factor which explains the high correlation to the CAIT-score, but this may also reduce its value in diagnosing the isolated mechanical quality of the joint. Thus, there is a persisting need for objective and reproducible alternatives focusing on MAI. According to our results, 3D stress MRI and stress sonography represent valuable alternatives and may be used to quantitively assess mechanical ankle instability in research and practice. Trial registration German Registry of Clinical Trials # DRKS00016356, registered on 05/11/2019.
Collapse
Affiliation(s)
- Markus Wenning
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany. .,Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Dominic Gehring
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany
| | - Thomas Lange
- Department of Radiology, Medical Physics, Medical Center - University of Freiburg, Faculty of Medicine, Kilianstrasse 5, 79106, Freiburg, Germany
| | - David Fuerst-Meroth
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Paul Streicher
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany
| | - Hagen Schmal
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetter Str. 55, 79106, Freiburg, Germany.,University Hospital Odense, Department of Orthopaedic Surgery, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - Albert Gollhofer
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany
| |
Collapse
|
8
|
Wenning M, Gehring D, Mauch M, Schmal H, Ritzmann R, Paul J. Functional deficits in chronic mechanical ankle instability. J Orthop Surg Res 2020; 15:304. [PMID: 32762704 PMCID: PMC7412640 DOI: 10.1186/s13018-020-01847-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The interaction of functional and mechanical deficits in chronic ankle instability remains a major issue in current research. After an index sprain, some patients develop sufficient coping strategies, while others require mechanical support. This study aimed to analyze persisting functional deficits in mechanically unstable ankles requiring operative stabilization. METHODS We retrospectively analyzed the functional testing of 43 patients suffering from chronic, unilateral mechanical ankle instability (MAI) and in which long-term conservative treatment had failed. Manual testing and arthroscopy confirmed mechanical instability. The functional testing included balance test, gait analysis, and concentric-concentric, isokinetic strength measurements and was compared between the non-affected and the MAI ankles. RESULTS Plantarflexion, supination, and pronation strength was significantly reduced in MAI ankles. A sub-analysis of the strength measurement revealed that in non-MAI ankles, the peak pronation torque was reached earlier during pronation (maximum peak torque angle at 20° vs. 14° of supination, p < 0.001). Furthermore, active range of motion was reduced in dorsiflexion and supination. In balance testing, patients exhibited a significant increased perimeter for the injured ankle (p < 0.02). During gait analysis, we observed an increased external rotation in MAI (8.7 vs. 6.8°, p<0.02). CONCLUSIONS This study assesses functional deficits existent in a well-defined population of patients suffering from chronic MAI. Impairments of postural sway, gait asymmetries, and asymmetric isokinetic strength can be observed despite long-term functional treatment. The finding that pronation strength is particularly reduced with the foot in a close-to-accident position indicates potential muscular dysfunction in MAI. Possibly, these deficits alongside the underlying mechanical instability characterize patients requiring mechanical stabilization.
Collapse
Affiliation(s)
- Markus Wenning
- Rennbahnklinik, Kriegackerstr 100, CH-4132 Muttenz, Basel, Switzerland.
- Department of Orthopedic and Trauma Surgery, University Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Dominic Gehring
- Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, 79117, Freiburg, Germany
| | - Marlene Mauch
- Rennbahnklinik, Kriegackerstr 100, CH-4132 Muttenz, Basel, Switzerland
| | - Hagen Schmal
- Department of Orthopedic and Trauma Surgery, University Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
- Department of Orthopaedic Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - Ramona Ritzmann
- Rennbahnklinik, Kriegackerstr 100, CH-4132 Muttenz, Basel, Switzerland
| | - Jochen Paul
- Rennbahnklinik, Kriegackerstr 100, CH-4132 Muttenz, Basel, Switzerland
| |
Collapse
|