The Cumberland ankle instability tool: a report of validity and reliability testing

Ultrasonography assessments of talar cartilage and ATFL after running in chronically unstable, coper, and healthy ankles: a case-control study

BACKGROUND

Comparisons of talar cartilage and the anterior talofibular ligament (ATFL) profiles in individuals with different levels of chronic ankle instability (CAI) provide insight into early adaptation of tissue morphology.

PURPOSE

This study compared morphologic response and recovery of the talar cartilage and ATFL before and after 30-min of self-paced treadmill running between individuals with CAI, coper (full recovery from a first-time ankle sprain), and healthy controls.

METHODS

Sixty young males (24.8 years, 176.9 cm, 75.7 kg) were allocated into the CAI, coper, and healthy control group by their number of ankle sprains and scores on the self-reported ankle instability questionnaires (Cumberland Ankle Instability Tool, and Foot and Ankle Ability Measure-Activities of Daily Living). Ultrasonographic images in the cross-sectional area (CSA; overall, lateral, and medial) and ATFL length (unstressed and stressed and position) before and after treadmill running were recorded and analyzed.

RESULTS

There were no group by time interactions in the talar cartilage CSA (F14,399 <1.09, p > .36 for all tests) and ATFL length (F14,399< .69, p > .79 for all tests). Regardless of time, CAIs had the largest overall (F2,399 = 42.68, p < .001), lateral (F2,399 = 37.16, p < .001), and medial (F2,399 = 36.57, p < .001) CSA of talar cartilage and the longest stressed-ATFL length (F2,399 = 54.42, p < .001), followed by copers and healthy controls.

CONCLUSION

Morphologic features of the talar cartilage and ATFL appear to depend on the level of ankle instability (e.g. a history of recurrent ankle sprain).

A novel method of assessing proprioception in the foot-ankle joint complex after lateral ankle sprain

OBJECTIVES

To investigate the validity of a novel method for assessing intra-foot proprioception impaired by chronic ankle instability (CAI) and its association with perceived ankle instability, and to include a conventional joint position reproduction (JPR).

DESIGN

Case-control study.

SETTING

University laboratory.

PARTICIPANTS

Eleven controls and 19 individuals with CAI.

MAIN OUTCOME MEASURES

A circumduction reproduction test was developed to evaluate proprioception by measuring absolute errors between eyes-opened and closed conditions during ankle circumduction movement, consisting of inversion and eversion phases. Errors in hallux marker trajectory and intra-foot joint relative angles were analyzed. Additionally, the JPR was administered to comparison with the novel method.

RESULTS

During the eversion phase, the CAI group had significantly more errors in the X and Y component than the control group. The Pearson's r between the X component and IdFAI was 0.354 (p = 0.054). The X component correlated with the movement of the rearfoot, midfoot and forefoot, with correlations of r > 0.4. However, the JPR did not detect differences between two groups (p > 0.05).

CONCLUSIONS

The circumduction reproduction test has discriminant validity for distinguishing between two groups and may provide an advantage over JPR.

The relationship between chronic ankle instability and sleep behaviour

Chronic Ankle Instability (CAI) is a condition characterized by giving-way episodes, instability and recurrent ankle sprains. Poor sleep can increase the risk of musculoskeletal injury and sleep is known to be an important aspect of injury recovery. However, the effect sleep has on those with CAI as well as its risk for recurrent episodes of giving-way remains unclear. The purpose of this study was to examine the relationship between sleep behaviour and giving-way episodes associated with CAI. Twenty-five participants with CAI (11 M/14 F, age = 22.9 ± 2.7 years, height = 171.9 ± 8.9 cm, mass = 76.7 ± 15.9 kg) were included in this study. All participants completed baseline patient-reported outcome measures and wore a fitness tracker that measured sleep for 1 month. Seven participants had a giving-way (GW, no-giving way = NWG) episode. Those with a giving-way episode spent significantly less time asleep (GW = 325.3 ± 63.2 min, NGW = 413.9 ± 49.5 min, p < 0.001, d = 1.659), less time in bed (GW = 384.9 ± 79.0 min, NGW = 473.1 ± 55.0 min, p = 0.002, d = 1.419), less minutes in REM (GW = 59.9 ± 19.9 min, NGW = 93.5 ± 25.4 min, p = 0.002, d = 1.400) and less minutes in light sleep (GW = 197.6 ± 51.5 min, NGW = 250.2 ± 34.4 min, p = 0.003, d = 1.328) compared to those without. In conclusion, this study shows that individuals with CAI who suffered a giving-way episode had poorer sleep behaviour the night before an episode.

The effects and optimal dosage of traditional Chinese exercises on patients with chronic ankle instability: A systematic review and meta-analysis

BACKGROUND

The effectiveness of Traditional Chinese exercises in promoting functional recovery in patients with chronic ankle instability, as well as the potential impact of variables such as intervention type, duration, frequency, and cycle on treatment outcomes, still requires further investigation.

METHODS

Literature searches were conducted in multiple databases including China National Knowledge Infrastructure (CNKI), VIP, Wanfang, China Biomedical Literature Database (CBM), PubMed, EBSCO(Medline、CINAHL、SPORTDiscus), Embase, Cochrane Library, ProQuest, and Web of Science for randomized controlled trials assessing the effects of Traditional Chinese Exercises interventions on patients with Chronic Ankle Instability. The publication timeframe spanned from the inception of each database until January 20, 2025. Meta-analysis was performed using STATA 15 software on the included studies.

RESULTS

Twelve randomized controlled trials (RCTs) involving 323 patients were included in this analysis. Compared with the control group, Traditional Chinese exercises showed the following improvements: CAIT: WMD = 4.02, 95 % CI [3.22, 4.81], z = 9.90, P < 0.001.Balance: ANT: SMD = 0.38, 95 % CI [0.18, 0.59], z = 3.71, P = 0.003.PM: SMD = 0.49, 95 % CI [0.26, 0.70], z = 4.73, P < 0.001.PL: SMD = 0.67, 95 % CI [0.46, 0.88], z = 6.35, P < 0.001.C: SMD = 0.80, 95 % CI [0.35, 1.25], z = 3.51, P < 0.001.JPS:Plantarflexion: SMD = -0.58, 95 % CI [-0.94, -0.21], z = 3.09, P = 0.002.Inversion: SMD = -0.46, 95 % CI [-0.86, -0.06], z = 2.23, P = 0.025.Muscle Strength: Plantarflexion: SMD = 0.81, 95 % CI [0.43, 1.18], z = 4.25, P < 0.001.Inversion: SMD = 0.66, 95 % CI [0.25, 1.07], z = 3.16, P = 0.002.Eversion: SMD = 1.04, 95 % CI [0.62, 1.46], z = 4.82, P < 0.001.Subgroup Analysis: Tai Chi training conducted twice weekly for a 12-week intervention period, with 60-minute sessions, demonstrated the most effective improvements.

LEVEL OF EVIDENCE

The evidence level for the effects of Traditional Chinese exercises on Balance-ANT, Balance-PM, and Balance-PL balance directions in CAI patients is rated as "moderate."

CONCLUSION

Traditional Chinese exercise has been shown to significantly improve balance, muscle strength, and joint position sense in CAI patients. Based on the current findings, Tai Chi training appears to provide greater benefits for CAI patients. It is recommended that CAI patients participate in Tai Chi training twice a week, with each session lasting 60 minutes, over a 12-week period.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO database, CRD42024613359.

Future risk of falls induced by ankle-foot sprains history: An observational and mendelian randomization study

Background

Ankle-foot sprains are the most common musculoskeletal injuries, which can impair balance and theoretically increase the risk of falls, but still, there is a lack of evidence supporting the direct association between ankle-foot sprains and the future risk of falls.

Methods

UK Biobank cohort was utilized to measure the association between ankle-foot sprains and fall risk with covariates adjusted. Then, the two-sample Mendelian randomization (MR) analysis was applied based on the genetically predicated ankle-foot sprains from FinnGen to validate causal relationship. Finally, genetically predicated cerebellar neuroimaging features were used to explore the mediating role of maladaptive neuroplasticity between ankle-foot sprains and falls by two-step MR analyses.

Results

Patients with ankle-foot sprains history exhibited a slightly increased risk of falls than the matched controls before and after adjustment for covariates (odd ratio [OR] ranged from 1.632 to 1.658). Two-sample MR analysis showed that ankle-foot sprains led to a higher risk of falls (OR ​= ​1.036) and a lower fractional anisotropy of superior cerebellar peduncle (SCP) (left, β ​= ​-0.052; right, β ​= ​-0.053). A trend of mediating effect was observed for the fractional anisotropy of right SCP in the causal effects of ankle-foot sprains on falls (β ​= ​0.003).

Conclusion

The history of ankle-foot sprains is associated with a slightly increased risk of falls. These findings improve our understanding of the clinical consequences of ankle-foot sprains in terms of fall risk and suggest the importance of adopting more efficient strategies for managing residual functional deficits after the injuries.

A cross-sectional study on peroneal muscle echogenicity changes and their effects on balance functions in individuals with chronic ankle instability

This study investigated the relationship between peroneal muscle echogenicity and balance function in individuals with chronic ankle instability (CAI). While prior research has examined peroneal muscle activity, reaction time, and balance, the impact of echogenicity-an indicator of myosteatosis/fibrosis-remained underexplored. Cross-sectional study. Sixty-two adults with CAI were included. Peroneal muscle size, echogenicity, and stiffness were assessed using ultrasound. Dynamic balance was evaluated via the Y balance test (YBT), and static postural control was evaluated during lateral step-down (LSDT) and single-leg stance test (SLST). Eversion strength was assessed with a dynamometer. The relationship between muscle characteristics and balance was assessed using canonical correlation and stepwise linear regression. Individuals with increased peroneal muscle echogenicity had reduced muscle size, poorer eversion strength, and poorer balance. Eversion strength is positively associated with YBT scores across all echogenicity levels and negatively associated with posture parameters during the LSDT in moderate echogenicity. Peroneal longus stiffness was positively associated with YBT in severe echogenicity and posture parameters during the SLST. Increased peroneal muscle echogenicity is associated with poorer eversion strength and stiffness, resulting in poorer balance performance. Improving the peroneal muscle quality may enhance functions in the CAI condition.

Hop Stabilization Training Improves Functional Movement Patterns and Quality of Life in Female Athletes With Chronic Ankle Instability

CONTEXT

Chronic ankle instability (CAI) is a common consequence of a lateral ankle sprain. Sex differences in functional outcomes exist, but there is a lack of female-specific intervention studies. Hop stabilization training is effective in male athletes with CAI but has not been investigated in female athletes. Therefore, the purpose of this investigation was to describe the effect of hop stabilization exercises on functional movement patterns and patient-reported outcomes in female athletes with CAI. We also compared the current effect sizes with those observed in an all-male cohort following an identical intervention.

DESIGN

Randomized controlled trial.

METHODS

Fourteen female CAI participants completed hop stabilization training (age = 25.29 [5.86] y), and 14 female CAI participants were in the control group (age = 24.73 [6.97] y). Inclusion criteria were consistent with the International Ankle Consortium recommendations. The hop stabilization program consisted of three 20-minute sessions per week for 6 weeks. Sessions consisted of increasing foot-to-ground contacts each week until a taper in the final week. Exercise difficulty was also modified throughout the program. Functional movement patterns via the Functional Movement Screen and Fusionetics Scores, dorsiflexion range of motion, and select region-specific patient-reported outcomes were captured.

RESULTS

The hop training group (pre: 12.68 [1.32] cm, post: 13.42 [1.35] cm) had a significant improvement (P< .001) in dorsiflexion range of motion relative to the control group (pre: 13.62 [1.22] cm, post: 13.68 [1.16] cm). Hop training also significantly improved (P,<0.01) functional movement patterns and all patient-reported outcomes. Relative to an all-male cohort who previously underwent the same hop stabilization program, the current female cohort demonstrated larger effect sizes, but all 95% CIs overlapped.

CONCLUSIONS

A 6-week hop training program significantly improves patient-reported outcomes, dorsiflexion range of motion, and functional movement patterns in female athletes with CAI .

Development of the Foot and Ankle Activity Level Scale (FAALS) Instrument

BACKGROUND

Activity level is a benchmark to document patient recovery; however, there is a lack of instrumentation to measure activity level specific to the foot and ankle. The purpose of this study was to develop a foot and ankle activity level scale (FAALS) instrument that will serve as an effective clinical tool for practitioners by assigning an activity level to patients.

METHODS

This was a 4-phase study with 3 rounds of data collection (n = 1432). Phase 1 was item generation using an expert panel to determine content validity (101 items). In phase 2, all items from phase 1 were piloted (n = 100) to remove poorly performing items (77 items). In phase 3 (n = 505), item reduction, reliability, and validity Rasch analyses were conducted, leaving a total of 22 items. Validity was assessed using outfit mean-square (MNSQ) and infit MNSQ statistics, with acceptable values between 0.5 and 1.5. An additional round of data collection was completed to serve as a validation data set to confirm FAALS instrument structure and psychometric analytics (n = 827). Correlation analysis was performed to assess convergent and divergent validity. Multiple linear regression analysis was conducted to determine whether the FAALS could detect differences in scores between groups with previously proven factors that affect functional status.

RESULTS

Person reliability was 0.92 and item reliability was 1.00, demonstrating excellent reliability. There was excellent evidence of validity, with mean-square values between 0.5 and 1.5. The 22 FAALS items are summed for a total score that corresponds to one of 4 activity levels. The FAALS instrument demonstrated sensitivity in the ability to discern between groups with expected foot and ankle functional differences for previous ankle surgery status, t(502) = -7.69, P < .001, and body mass index, t(502) = -3.41, P < .001.

CONCLUSION

The FAALS instrument is a short, clinically useful tool to measure activity level specific to the foot and ankle. FAALS normative values provide valuable information for physician-patient communication, which may serve to facilitate shared decision-making, improve postoperative care, and allow physicians to track recovery progress.

Predictors of Chronic Ankle Instability Among Soccer Players

Background and Objectives: Chronic ankle instability (CAI) is prevalent among soccer players, often resulting from recurrent ankle injuries (RAIs). Despite its impact on performance and long-term joint health, the associated risk factors remain insufficiently explored. This study aimed to identify the key risk factors for CAI among soccer players. Materials and Methods: A cross-sectional study was conducted among 310 soccer players from different professional sports clubs. The Arabic version of the Cumberland Ankle Instability Tool (Ar-CAIT) was used to assess ankle instability. Spearman's rho correlation and multiple linear regression were used to identify significant predictors of CAI. Additionally, structural equation modeling (SEM) was used to conduct mediation analysis and evaluate potential indirect effects. Results: Spearman's correlation analysis revealed significant negative associations between Ar-CAIT scores and both BMI (r = -0.158, p < 0.05) and RAI (r = -0.273, p < 0.01), while training hours were positively correlated with Ar-CAIT scores (r = 0.169, p < 0.05). Multiple regression analysis confirmed that higher BMI (β = -0.133, p = 0.017) and a greater number of ankle injuries (β = -0.285, p < 0.001) were associated with lower Ar-CAIT scores, whereas increased training hours (β = 0.140, p = 0.010) were predictive of better ankle stability. Mediation analysis revealed that BMI and training hours partially mediate the relationship between RAI and Ar-CAIT scores. Conclusions: RAI, elevated BMI, and reduced training hours were significant predictors of CAI in soccer players. These findings emphasize the importance of implementing targeted injury prevention and rehabilitation strategies, particularly focusing on weight management and structured training programs to reduce CAI risk. Future longitudinal studies are required to explore the underlying mechanisms contributing to CAI development.

The Porto Ankle Testing Device is reliable to measure ankle laxity with concurrent magnetic resonance imaging

OBJECTIVES

The purpose of this study was to assess the reliability of a new arthrometer - the Porto Ankle Testing Device (PATD) - that is compatible with magnetic resonance imaging (MRI) assessment to measure ankle joint laxity.

METHODS

This cross-sectional study enrolled 33 ankles without a history of sprain or symptoms of instability. All ankles underwent ankle instrumented stress testing with the PATD with concurrent MRI. The PATD protocol compares the ankle rest position against the ankle stress under the anterolateral drawer or the talar tilt test. Tibiotalar and subtalar laxity measurements were calculated as the difference in joint position before and after stress testing. Tibiotalar laxity measurements included the anterior talus translation (ATT) and the talar tilt (TT). The ATT was measured in the anterior, diagonal, and inferior directions. Subtalar laxity measurements included anterior calcaneus translation (ACT), the subtalar tilt (STT), the subtalar opening distance, and the subtalar rotation. The intraclass correlation coefficient (ICC) was computed to evaluate the inter and intra-rater reliability, and the standard error measurement (SEM) to estimate the amount of random error associated with laxity measurements.

RESULTS

All tibiotalar and subtalar laxity measurements were classified as excellent reliability for inter (ICC, 0.77-0.98) and intra-rater (ICC, 0.87-0.99). Only the ATT in the inferior direction showed suboptimal inter-rater reliability (ICC, 0.59-0.70). The SEM values showed a low risk of associated random error from measurement and were higher for inter-rater than for repeated measures, suggesting that repeated measures result in a lower risk of random error.

CONCLUSION

The measurement of tibiotalar and subtalar laxity with the PATD provides excellent reliability between different assessors and after repeated measures. The PATD can overcome the limitations of previous devices while offering the correlation of structural integrity with a reliable assessment of functional competence of ankle ligaments (joint laxity) within the same exam.

LEVEL OF EVIDENCE

Level IV.

Participant demographics and research questions from 10-years of chronic ankle instability studies: A scoping review

OBJECTIVES

To determine 'who' and 'what' were studied over the previous 10-years as it relates to individuals with chronic ankle instability.

DESIGN

Scoping review.

METHODS

Web of Science™ was used to identify all studies that referenced the International Ankle Consortium selection criteria guidelines. Original research reports which cited adherence to the guidelines were included. Data related to demographic information and outcome measures were synthesized to form a descriptive analysis.

RESULTS

A total of 377 studies were included which equated to 11,604 participants with chronic ankle instability. The combined average age of participants was 23.9 years. For measures related to ankle sprain history, participants averaged 4.3 ± 3.7 sprains and 6.2 ± 5.9 years since their first ankle sprain. Across the studies, the number of ankle sprains was reported in 42.7 % of studies and time since first ankle sprain was reported in 10.9 % of studies. Nearly 80 % of studies reported information from at least one validated questionnaire related to ankle instability or ankle function. The primary aim of most studies (44 %) was to determine differences in motor-behavioral impairments between individuals with and without chronic ankle instability.

CONCLUSIONS

Although many studies indicated that they adhered to the International Ankle Consortium selection criteria for chronic ankle instability, variables related to demographic information were inconsistently reported, which may inhibit the external validity of studies related to chronic ankle instability. In addition, much of the research related to chronic ankle instability pertained to young-adults and aimed to identify various motor-behavioral impairments.

Effects of semaglutide in patients with chronic ankle instability: evidence from a prospective cohort

BACKGROUND

Whether patients with chronic ankle instability (CAI) can benefit from weight loss yielded by using glucagon-like peptide-1 receptor agonists (GLP1-RAs) has remained unclear.

METHODS

In this observational study, we recruited more than 2000 adults with CAI according to the selection criteria proposed by International Ankle Consortium with at least two-year follow up from three medical centers. The primary endpoint was the change from baseline of the Foot and Ankle Ability Measure (FAAM) sports subscale at the last follow up. Secondary endpoints included the change from baseline of Foot and Ankle Outcome Score (FAOS)/ Cumberland Ankle Instability Tool (CAIT)/ FAAM activities of daily living (ADL) subscale, number of ankle sprains during study period, incident ankle surgery in treatment of CAI.

RESULTS

In this study, 71 out of 2018 patients who received semaglutide in purpose of treating type 2 diabetes (T2DM) and/or weight loss during the study period. After controlling baseline characteristics, the adjusted mean difference in change from baseline was 16.3 for FAAM sports subscale and 9.3 for FAAM ADL subscale. Likewise, the adjusted analysis of five subscales of FAOS showed similar results, all consistently favoring semaglutide group. For CAIT, patients in the semaglutide group had achieved statistically significant improvement compared with control group. The association of semaglutide exposure with improvement in FAAM sports and ADL subscales was mediated by the weight loss measured by BMI (mediation proportion: FAAM sports subscale, 31.2% [22.2-41.2%]; FHSQ ADL subscale, 34.1% [24.4-44.8%]). We also observed statistically significant decreases in number of recurrent ankle sprains during study period. For incident ankle surgery, 1 out of 71 patients (1.4%) and 151 out of 1947 patients (7.8%) received ankle surgeries in semaglutide and control groups, respectively (P = 0.047).

CONCLUSIONS

Semaglutide may show potential benefits as a supplementary intervention in treatment of CAI by improving patient-reported outcomes and preventing recurrent ankle sprains. Further randomized trial is warranted by the current study to further confirm our findings.

TRIAL REGISTRATION

researchregistry10716.

Postural control strategies in individuals with and without chronic ankle instability during the reach phase of the posteromedial direction of the star excursion balance test

OBJECTIVE

To compare center of mass (COM) and center of pressure (COP) displacement, joint angles, and muscle activity for the ankle, knee, and hip during the posteromedial (PM) reach direction of the Star Excursion Balance Test between individuals with chronic ankle instability (CAI) and healthy individuals.

DESIGN

Cross-sectional Study.

SETTING

Biomechanics laboratory.

PARTICIPANTS

Fifteen individuals with CAI (age: 20.0 ± 1.2 y) and 20 healthy individuals (age: 20.6 ± 0.8 y).

MAIN OUTCOME MEASURES

The maximum reach distance (MRD). The COM and COP displacement, and ankle, knee, and hip joint angles of the stance limb during the PM reach task measured via a 3D motion analysis system. Electromyography (EMG) was also recorded during the task from the tibialis anterior (TA), soleus, peroneus longus, vastus medialis (VM), biceps femoris, and gluteus medius muscles.

RESULTS

MRD of the CAI group was shorter than the healthy group (P = 0.005). The CAI group showed higher COM positioning (P = 0.007), less knee flexion (P = 0.009), and lower muscle activity in TA (P = 0.04), and VM (P = 0.007) during performance of the PM reach as compared to the healthy group.

CONCLUSIONS

These findings suggest that individuals with CAI demonstrate altered postural control strategies during PM reach performance, likely contributing to a shorter MRD.

The effect of combined compression and tactile stimulation on ankle somatosensation in a lunar gravity lower limb load analog

Ankle somatosensation appears to be negatively affected when in simulated hypogravity (gravity, 1 > g < 0). Developing countermeasures to reduce this negative effect is necessary for sensorimotor control as astronauts prepare to explore the Moon. Head-elevated supine lying has been found to be an effective method in simulating the physiological impact of hypogravity by reducing the weight-bearing capacity through the lower limbs. This study investigated whether wearing a combined compression sock with plantar textured sole (compression-tactile sock) is associated with enhanced somatosensory acuity of the lower limbs in a simulated hypogravity environment. Ankle somatosensory acuity was assessed on 55 healthy participants between the ages of 18 and 65 years (female subjects 28, male subjects 27; mean age 41 years ±14). The active movement extent discrimination assessment (AMEDA) was used to assess somatosensory acuity on participants' non-dominant foot under four conditions: (1) upright standing in barefoot; (2) upright standing wearing compression-tactile socks; (3) simulated hypogravity (head-elevated supine position) in barefoot; and (4) simulated hypogravity (head-elevated supine position) wearing compression-tactile socks. Analysis was conducted for (i) the whole participant group, (ii) high (above-average) performers, (iii) medium (average) performers, and (iv) low (below average) performers. It was hypothesized that low performers would experience the greatest gains when wearing the sock, compared to those in barefoot. When assessing the group as a whole, AMEDA scores were significantly reduced in the simulated hypogravity (head-elevated supine) conditions when compared to upright standing conditions (p < 0.001; 3% decline when barefoot; 2.9% decline when wearing the socks). Wearing compression-tactile socks had no effect on AMEDA scores when compared to barefoot (p = 0.173). When analyzed by the performance group, somatosensory acuity was enhanced in the compression-tactile sock condition, when compared to barefoot (upright, p = 0.009, 4.7% increase; head-elevated supine, p = 0.022, 3% increase) in the low performers only. In the medium and high-performer groups, there was no difference between the compression-tactile sock conditions and barefoot conditions (p > 0.05 for all). Compression-tactile socks may be associated with enhanced somatosensory acuity in upright standing and simulated hypogravity for individuals with below-average somatosensory acuity. Further research is warranted to assess the effect of compression-tactile socks in an actual hypogravity environment to determine whether the compression-tactile socks can maintain one's somatosensory acuity.

Toe-out landing reduces anterior talofibular ligament strain while maintains calcaneofibular ligament strain in people with chronic ankle instability

BACKGROUND

The anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) are vulnerable to be torn or ruptured during lateral ankle sprain (LAS), especially in people with chronic ankle instability (CAI). This study aims to determine whether landing with a larger toe-out angle would influence ATFL and CFL strains in people with CAI, aiming to contribute to the development of effective landing strategies to reduce LAS risk.

METHODS

Thirty participants with CAI (22 males and 8 females, age: 21.6 ± 1.5 years, height: 175.3 ± 7.1 cm, body mass: 70.8 ± 7.1 kg, mean ± SD) were recruited. Each participant landed on a specialized trap-door device with their unaffected limbs on a support platform and their affected limbs on a movable platform, which could be flipped 24° inward and 15° forward to mimic LAS conditions. Two landing conditions were tested-i.e., natural landing (NL, with natural toe-out angle at landing) and toe-out landing (TL, with toe-out angle increased to over 150% of that under the NL conditions). Kinematic data were captured using a 12-camera motion analysis system, and ATFL and CFL strains were calculated using a 3D rigid-body foot model. Paired sample t tests and Pearson's correlations were used to analyze data.

RESULTS

Compared to NL conditions, ATFL strain decreased (p < 0.001, d = 2.42) while CFL strain remained unchanged (p = 0.229, d = 0.09) under TL conditions. The toe-out angle was negatively and strongly correlated with ATFL strain (r = -0.743, p < 0.001) but not with CFL strain (r = 0.153, p = 0.251). Compared to NL conditions, participants exhibit a lower ankle inversion angle (p < 0.001, d = 0.494), a higher plantarflexion angle (p < 0.001, d = 1.101), and no significant difference in external rotation angle (p = 0.571, d = 0.133) under TL conditions.

CONCLUSION

Toe-out landing may reduce ATFL strain while maintaining CFL strain in people with CAI, thereby reducing the risk of LAS.

Correlates of gait speed changes during uneven terrain walking in older adults: differential roles of cognitive and sensorimotor function

Many studies of walking function and aging have measured walking on flat surfaces with and without dual-tasking (i.e., performing a concurrent cognitive task). Walking in the community increases the complexity with surface undulations and varying surface types. We hypothesized that changes in walking resulting from increasing terrain unevenness would be better predicted by sensorimotor function than cognitive function. Sixty-three community-dwelling older adults (65-93 yrs old; 32 males) performed overground walking under four uneven terrain conditions (Flat, Low, Medium, and High unevenness). Cognitive (cognitive flexibility, working memory, inhibition) and sensorimotor assessments (grip strength, 2-pt discrimination, pressure pain threshold) were measured as the primary predictors of walking performance. We found that walking speed decreased linearly with more elevated uneven terrain conditions across all participants; this was accentuated in older adults with lower mobility function. Greater rates of decline in walking speed from flat to uneven terrain were associated with worse attention and inhibitory function as well as lower 2-point tactile discrimination. Findings suggest that greater rates of decline with elevated terrain walking are associated with lower mobility function, lower executive functions and less somatosensation.

Clinical outcomes of all-inside arthroscopic lateral ankle ligament reconstruction for chronic lateral ankle instability: A prospective series with minimum 12 month outcomes

BACKGROUND

Chronic lateral ankle instability (CAI) is a common condition that can be effectively treated with lateral ankle ligament reconstruction to restore ankle stability and function. The aim was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the Manchester-Oxford Foot Questionnaire (MOXFQ), Visual Analog Score (VAS) and Euroqol-5D-5L (EQ-5D) patient-reported outcome measures (PROMs).

METHODS

This prospective series included 36 consecutive patients who underwent isolated arthroscopic lateral ligament reconstruction for CAI between November 2020 and November 2022 with minimum 12-month follow up. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, and a minimum of 12 months postoperatively. The MOXFQ is a foot and ankle-specific PROM that assesses foot and ankle function, the VAS measures pain and the EQ5D evaluates general health-related quality of life.

RESULTS

Patients were followed up for 12-25 months. In all patients, there was significant improvement in all postoperative PROMs (p < 0.05). The MOXFQ index decreased from 59.1 ± 19.2-13.5 ± 18.1 (p < 0.01), EQ-5D index increased from 0.607 ± 0.224-0.854 ± 0.175 (p < 0.01) and VAS pain decreased from 36.6 ± 22.3-13.6 ± 18.4 (p < 0.01).A total of 6 patients(16.3 %) were lost to follow up and mean follow-up time was 1.63 ± 0.54 years.

CONCLUSION

Arthroscopic lateral ankle ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes.

LEVEL OF EVIDENCE

IV.

Ankle Scientific Knowledge and Physiotherapy Practice: A Thematic Analysis of Clinical Behaviors of French-Speaking Physiotherapists

CONTEXT

Chronic ankle instability (CAI) is prevalent among individuals who sustain a lateral ankle sprain (LAS) injury. The persistence of the characteristic long-standing clinical symptoms of CAI may be attributable to the lack of adoption by physiotherapists of evidence-informed clinical guidelines.

OBJECTIVE

To investigate the extent to which French-speaking physiotherapists implement the International Ankle Consortium rehabilitation-oriented assessment (ROAST) framework when providing clinical care for individuals with an acute LAS injury.

DESIGN

Cross-sectional study.

SETTING

Online survey informed by a Delphi process of foot-ankle experts.

PATIENTS OR OTHER PARTICIPANTS

A total of 426 French-speaking physiotherapists completed the online survey.

MAIN OUTCOME MEASURE(S)

The survey was disseminated to French-speaking physiotherapists in France; Switzerland; Quebec, Canada; Luxembourg; and Belgium. It comprised closed and open-ended questions organized in 5 sections: (1) participant demographics, (2) participant self-assessment of expertise, (3) clinical diagnostic assessment of the ankle (bones and ligaments), (4) clinical evaluation after an acute LAS injury (ROAST framework), and (5) CAI. The qualitative data from the open-ended questions were analyzed using best-practice thematic-analysis guidelines.

RESULTS

Only 6.3% (n = 27) of the respondents could name all Ottawa Ankle Rules criteria. Only 25.6% (n = 109) of the respondents cited or described criterion standard tests from the literature to assess the integrity of the lateral ankle ligaments. Less than 25% (n = 71) of the respondents reported using clinical evaluation outcome metrics (ROAST) recommended by the International Ankle Consortium to inform their clinical care for individuals with an acute LAS injury. In general, the respondents had a greater knowledge of the functional than the mechanical insufficiencies associated with CAI.

CONCLUSION

A minority of French-speaking physiotherapist survey respondents use the International Ankle Consortium ROAST to inform their clinical care for individuals with an acute LAS injury. This highlights the responsibility of the scientific community to better disseminate evidence-informed research to clinicians.

Muscle mechanics and energetics in chronic ankle instability and copers during landing: Strategies for adaptive adjustments in locomotion pattern

Individuals with chronic ankle instability (CAI) and copers typically exhibited aberrant landing kinematics. Altered kinematics might lead to changes in muscle loading, potentially affecting the energy demand of locomotion. Understanding alterations in muscle mechanics and energetics during landing could enhance the rehabilitation program design. Therefore, the objective of this study was to explore the muscle mechanics and energetics of individuals with CAI, copers, and healthy controls during single leg jump landing. Three groups, CAI, copers, and healthy individuals (total n = 66), performed the landing task, and data on 3D motion capture, ground reaction force (GRF), and muscle activation were simultaneously collected. A musculoskeletal model was applied to estimate muscle force and mechanical power. Compared to healthy groups, individuals with CAI showed increased peak muscle forces in the gluteus maximus (p < 0.001), gluteus medius (p < 0.001), vastus lateralis (p < 0.001), and peroneus longus (p < 0.001) during landing. Whereas copers exhibited higher peak muscle forces in the vastus lateralis (p < 0.05), medial gastrocnemius (p < 0.05), soleus (p < 0.05), and peroneus longus (p < 0.001). Additionally, negative mechanical power redistribution in CAI shifted from the ankle to the hip (p < 0.001), while copers exhibited a similar redistribution from the ankle to the knee (p < 0.05). This study suggested that both CAI and copers exhibit biomechanical modifications in proximal joints. Copers showed a novel landing strategy aimed for enhancing landing stability, but with the risk of ACL injury. The identified energy redistribution observed in both CAI and copers could potentially contribute to the recurrent ankle sprains. This research facilitates a better understanding of how muscle mechanics and energy demands influence the landing pattern in individuals with CAI and copers.

Postural stability measures as diagnostic tools for chronic ankle instability: a comprehensive assessment

BACKGROUND

Chronic ankle instability (CAI) is characterized by recurrent sprains and persistent symptoms, which impair postural control. This study evaluates the diagnostic utility of various linear and nonlinear postural stability measures in distinguishing individuals with CAI from healthy controls.

METHODS

Postural stability was assessed in 24 participants (12 with CAI and 12 healthy controls) using a force platform under four conditions: hard surface with eyes open, hard surface with eyes closed, soft surface with eyes open, and soft surface with eyes closed. Linear measures of center of pressure (COP) included range in the anteroposterior (Rfa) and mediolateral (Rsw) directions, mean velocity (MV), and sway area. Nonlinear measures included approximate entropy (ApEn), the largest Lyapunov exponent, and correlation dimension (CD) with its standard deviation. Diagnostic accuracy was evaluated using receiver operating characteristic (ROC) analysis to determine cutoff scores, allowing effective differentiation between CAI and healthy participants.

RESULT

AI individuals exhibited increased mediolateral COP sway and higher mean velocity on hard surfaces with both eyes open and closed. On soft surfaces with eyes closed, they showed significant deficits in sway area and mean velocity, reflecting challenges in postural control. ROC analysis revealed that certain linear and nonlinear measures showed strong diagnostic accuracy in distinguishing individuals with CAI from healthy controls. Nonlinear analysis revealed elevated ApEn and reduced CD in CAI participants, indicating greater postural irregularity and reduced dynamic stability. On a hard surface with eyes open both Rsw (cutoff: 1.18 cm, OR: 4.55) and ApEn (cutoff: 0.07, OR: 4.0) were particularly strong diagnostic indicators.

CONCLUSION

Linear and nonlinear postural stability measures effectively differentiate individuals with CAI from healthy controls. Key metrics, including Rsw, MV, ApEn, and CD, offer strong diagnostic value for early detection and personalized rehabilitation. Incorporating these measures into clinical practice may improve CAI management and patient outcomes.

ETHICAL CODE

IR.TUMS.FNM.REC.1400.236. March 14, 2022.

Comparative analysis of land-based vs. water-based balance training on quality of life and physical and psychological deficits in athletes with chronic ankle instability: a randomized controlled trial

BACKGROUND

Aquatic training is known for its effective and gentle rehabilitation benefits, but its impact on athletes with chronic ankle instability (CAI) remains underexplored. This study compares the effects of water-based and land-based balance training on functional performance, dynamic balance, fear of reinjury, and quality of life in athletes with CAI.

METHODS

Forty-one athletes with chronic ankle instability (CAI) were randomly assigned to water-based (WBBE, n = 21) or land-based (LBBE, n = 20) balance exercise groups, completing 24 sessions of 30-45 min over 8 weeks. Assessments before and after the interventions included functional ankle instability (CAIT), kinesiophobia (TSK-17), quality of life (SF-36), dynamic postural control (Y Balance Test), and functional performance (Figure-8 hop and single-limb side-hop tests). Perceived treatment effects were measured using the Global Rating of Change (GROC) post-intervention. Data were analyzed using mixed-design ANOVA (P ≤ 0.05).

RESULTS

The statistical analysis of the study revealed no significant time × group interaction effects for CAIT scores, kinesiophobia scores, the Psychological Quality of Life (QoL) Component, or SEBT scores (p > 0.05). The LBBE group showed significant improvements in functional tasks, specifically in F8H and SLSH scores, compared to the WBBE group (p < 0.05), while the WBBE group had better outcomes in overall Quality of Life and the Physical QoL Component than the LBBE group (p < 0.05).

CONCLUSION

Both land-based and water-based balance exercises benefit athletes with CAI, with land-based exercises improving functional performance and water-based exercises enhancing physical and overall Quality of Life. A flexible rehabilitation program combining both approaches can optimize recovery, addressing specific needs, even though no significant differences were found in ankle stability, kinesiophobia, psychological Quality of Life, and dynamic balance between the two methods.

TRIAL REGISTRATION

This study was prospectively registered with the University Hospital Medical Information Network Clinical Trial Registry under Clinical Trials UMIN000051746 on July 29, 2023.

Kinematics of balance controls in people with chronic ankle instability during unilateral stance on a moving platform

Balance control deficits resulting from ankle sprains are central to chronic ankle instability (CAI) and its persistent symptoms. This study aimed to identify differences in balance control between individuals with CAI and healthy controls (HC) using challenging single-leg balance tasks. Twenty-three CAI and 23 HC participants performed balance tasks on a force plate that either remained static or moved mediolaterally. Force and kinematic data were recorded to measure balance and joint movements. The CAI group showed significantly shorter time-to-boundary during static conditions but no significant differences during moving conditions compared to HC. During moving conditions, CAIs exhibited greater proximal compensations, with greater range of motion and higher angular velocity in the knee, hip, and torso. while no significant differences were observed in these parameters during static conditions. Principal component analysis indicated specific kinetic chain in CAI during one-leg balance under both static and moving conditions compared to HC. These findings suggest an altered movement strategy in CAI, that ankle injuries impair the ability to stabilize both distal and proximal joints, and an altered kinetic chain from ankle to torso. Rehabilitation programs for CAI might benefit from considering the integration of the entire kinetic chain, addressing both distal and proximal joint dynamics to support effective recovery and prevent secondary injuries.

Exploring low- and high-order functional connectivity in chronic ankle instability through resting-state fMRI

BACKGROUND

The functional connectivity (FC) has emerged as a valuable tool for comprehending the cerebral operational mechanism. Understanding the FC changes in patients with chronic ankle instability (CAI) helps reveal the underlying central nervous system mechanisms of the disease and provides clues for developing personalized treatment plans.

OBJECTIVES

To explore differences between low- and high-order FC in patients with CAI and healthy controls, as well as the correlation among the feature connections and clinical data.

METHODS

In our study, we recruited 40 patients with CAI and 42 healthy individuals who had not experienced ankle injuries. All participants underwent clinical assessments of ankle joints, collected the number of ankle sprains within the past 6 months, and performed resting-state functional magnetic resonance imaging (rs-fMRI) scans. Pearson correlation and matrix variate normal distribution (MVND) were used to construct low-order and high-order FC networks, respectively. Feature selections between groups were performed by two-sample t-tests, and a multi-kernel support vector machine (MK-SVM) was subsequently applied to combine the multiple connection patterns for the classification. Using leave-one-out cross-validation (LOOCV) to assess classification performance and identify the consensus connections contributing most to classification.

RESULTS

FC was reduced in certain brain regions of CAI patients. More consensus connections were recognized in low-order FC network than in high-order FC network. The highest classification accuracy of 91.30% was achieved by combining three connection patterns. The most discriminating functional connections were primarily centered on the default mode network and spanned the visual network, sensorimotor network, ventral attention network, and central executive network. In addition, FC strength in the left cingulate and paracingulate gyrus (DCG.L) and right superior temporal gyrus (STG.R) was negatively correlated with the number of ankle sprains in the past 6 months in all FC networks (p < 0.05).

CONCLUSIONS

Abnormalities in connectivity in patients with CAI were observed in both low- and high-order FC networks. The adaptive changes in the brain related to CAI may extend beyond the sensorimotor networks, primarily involving higher-level default mode networks associated with attention. Moreover, the FC strength between DCG.L and STG.R may predict the risk of ankle re-sprains and help clinicians develop personalized treatment plans.

Bilateral alterations in sensorimotor function and altered sensory strategy in individuals with unilateral chronic ankle instability

Objective

This study aimed to evaluate bilateral sensorimotor function in patients with unilateral CAI. Furthermore, sensory reweighting ability and vestibular modulation were assessed.

Methods

Twenty individuals with unilateral CAI and twenty healthy controls participated in this study. All participants executed ankle proprioception, plantar sensation, unilateral stance, Y balance, motor control test (MCT) and sensory organisation test (SOT) assessments. Proprioception assessment included joint position sense and force sense (FS), and plantar sensation evaluation consisted of light-touch, vibration and two-point discrimination (TPD) thresholds at the heel, head of the first metatarsal (1 MF), base of the fifth metatarsal (5 MF), centre of foot and forefoot. MCT and SOT tests were conducted using NeuroCom Balance Manager System. Except for SOT, all tests evaluated bilateral limbs, and the order of limbs was randomly selected. 2 (group) × 2 (limb) mixed model analyses of variance were performed for outcome measures of unilateral stance, Y balance and MCT, and independent t-test was used to analyse the outcomes of SOT between two groups. Mann-Whitney U and Wilcoxon test were applied to examine the differences in plantar sensation between groups and limbs.

Results

For plantar sensation, increased light-touch threshold at heel and 1 MF and the TPD threshold at 1 MF were observed bilaterally in CAI group (p < 0.05). No differences were observed in joint position sense (JPS), but bilateral deficit was found in plantarflexor FS with moderate effect size (uninjured side: ES = 0.67; injured side: ES = 0.61) in CAI group. For unilateral stance with eyes closed, moderate postural instability was displayed bilaterally in the anteroposterior direction (uninjured side: ES = 0.71; injured side: ES = 0.86). The delayed latency of MCT with medium-backward translation was also observed in both sides of unilateral CAI (uninjured: ES = 0.74; injured: ES = 0.92). Compared with healthy controls, higher visual reliance was shown moderately in the injured and uninjured sides of unilateral CAI (uninjured: ES = 0.78; injured: ES = 0.91). Sensory analysis of SOT displayed decreased use of visual (p = 0.001) and vestibular information (p < 0.000) in CAI group.

Conclusion

Unilateral CAI presented impaired plantar sensation and ankle proprioception on both sides. Higher visual reliance, delayed motor response and postural instability under unreliable visual clues were also displayed bilaterally. Except for bilateral sensorimotor alterations, reduced ability of sensory reweighting and fixed sensory strategy also presented in CAI group, but the somatosensory clue still served as the main sensory source in CAI.

Effects of Tai Chi training on functionality, dynamic balance, kinesiophobia, and quality of life in athletes with functional ankle instability

This study investigated the effects of Tai Chi training on functionality, dynamic balance, kinesiophobia, and quality of life in athletes with Functional Ankle Instability (FAI). Forty-three athletes with FAI were randomly assigned to either a Tai Chi group (n = 21) or a control group (n = 22). The Tai Chi group followed a tailored exercise protocol addressing ankle instability through a three-phase progression, while the control group had no intervention but continued their usual activities. Measurements, including Cumberland Ankle Instability Tool (CAIT), Star Excursion Balance Test (SEBT), Tampa Scale for Kinesiophobia (TSK), Short Form-12 (SF-12), figure-8 hop test, and perceived treatment effect were assessed before and after the intervention. The Tai Chi group showed significant improvements in CAIT score and SEBT reach distance compared to the control group (p < 0.001). Tai Chi exercises also reduced TSK, improved figure-8 hop score, and enhanced the physical component of SF-12 (p < 0.005), with no significant effect on the mental component of SF-12 (p = 0.7). The findings imply that Tai Chi may be a valuable consideration for athletic trainers and sports medicine professionals working with athletes with FAI.

Development of a 3D active movement extent discrimination apparatus for testing proprioception at the ankle joint with inversion movements made in plantarflexion

Proprioception plays an important role in joint stability, and ankle sprains usually happen involving plantarflexion, internal rotation, and inversion. However, ankle 3D movement proprioception has never been measured in weight-bearing. Accordingly, the active 3-dimensional movement extent discrimination apparatus (AMEDA-3D) was developed and its reliability and validity were investigated. A total of 58 subjects volunteered for this trial, with 12 subjects with chronic ankle instability (CAI) and 12 healthy controls in the test-retest reliability study. There were 17 subjects with CAI and 17 healthy controls in the validity study. An intraclass correlation coefficient (ICC) and Minimum Detectable Change at the 90% confidence interval (MDC90) were computed. AMEDA-3D scores were analysed by independent samples t-tests, and Youden's index was used to calculate the optimal AMEDA-3D cut-off for discriminating individuals with CAI. Pearson's correlation analysis was used to explore the relationship between AMEDA-3D scores and Y Balance Test (YBT), Time In Balance Test (TIB), and Cumberland Ankle Instability Tool (CAIT) scores. The main results were as follows: (1) The ICC(3,1) value of AMEDA-3D scores was 0.817 (95% CI = 0.452-0.945) in CAI subjects. (2) The AMEDA-3D proprioceptive area under the curve score used to discriminate CAI subjects from healthy controls was 0.778, with a sensitivity of 94% and a specificity of 82%. (3) AMEDA-3D proprioceptive scores were moderately correlated with CAIT scores (r = 0.58 and p < 0.001), YBT (r = 0.47 and p = 0.005), and TIB (r = 0.68 and p < 0.001). Our findings suggest that the AMEDA-3D tool shows good reliability and validity for clinical assessment of proprioceptive deficits associated with CAI. Improved ankle 3D motor proprioception may positively impact subjects' balance control, self-rated symptoms, and function.

The clinical effects of pulsed electromagnetic field therapy for the management of chronic ankle instability: a study protocol for a double-blind randomized controlled trial

BACKGROUND

Chronic ankle instability is associated with long-term neuromuscular deficits involving poor postural control and peroneal muscular impairment. Symptoms of chronic ankle instability hinder engagement in physical activity and undermine the patient's quality of life. Despite the existence of various treatment modalities, none has conclusively provided evidence of clinical effectiveness in counteracting neuromuscular deficits, such as arthrogenic muscle inhibition of the peroneal longus (PL). Pulse electromagnetic field therapy employed as an adjunct biophysical therapy can potentially improve stability by mitigating peroneal muscle weakness and by activating the peroneal muscle. We postulate that by combining standard care (muscle strengthening, balance training, and range of motion exercise) with pulse electromagnetic field therapy, postural control stability and peroneal muscle weakness will significantly improve.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled trial. A total of 48 adults with chronic ankle instability will be recruited and randomly allocated into either the intervention or control groups. The intervention group (n = 24) will receive active pulse electromagnetic field therapy and standard exercise training, while the control group (n = 24) will receive sham pulse electromagnetic field therapy and standard exercise training for 8 weeks. Primary and secondary outcomes will be evaluated at baseline, week 4, 8 as well as at 3-, 6-, and 12-month follow-up visits.

DISCUSSION

Chronic ankle instability is a common debilitating condition without a curative conservative treatment. Investigating different treatment modalities will be essential for improving rehabilitation outcomes in this clinical population. This study will investigate the effectiveness of pulsed electromagnetic field therapy on the functional and clinical outcomes in the chronic ankle instability population. This trial may demonstrate this non-invasive biophysical therapy to be an effective measure to help patients with CAI.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05500885. Registered on August 13, 2022.

Neurophysiologic inhibitory factors influencing subsequent ankle sprain in collegiate male athletes: a prospective cohort study

Many athletes with recurrent ankle sprains complain of neurophysiological deficits related to chronic ankle instability (CAI). However, it remains unclear how changes in the corticospinal pathway affect the potential risk of subsequent ankle sprains. The purpose of this study was to investigate whether the corticospinal excitability (input-output properties) and silent period (SP) could be related to the risk of subsequent ankle sprains among athletes. Forty-three male collegiate basketball athletes were enrolled, and 82 ankles were finally sorted into four ankle groups based on symptoms (CAI, sub-CAI, copers, and normal). The neurophysiological data was recorded in both ankles using transcranial magnetic stimulation (TMS) as baseline assessments. Subsequently, we prospectively followed the occurrence of subsequent ankle sprain injuries for 24 months (SG, subsequent ankle sprain group; NSG, non-sprain group). In the baseline assessment, we confirmed that the threshold of the input-output properties in the CAI group was higher than those in the normal group. After the follow-up, 22 ankles sustained subsequent ankle sprains (SGs). We also found that SGs exhibited a significantly longer SP at the middle and high stimulus intensities of TMS compared to NSGs (60 ankles) (middle: p = 0.012, Cohen's d = 0.644, and high: p = 0.020, Cohen's d = 0.590). These findings suggest that a prolonged SP could be a crucial factor affecting subsequent ankle sprains in athletes. To prevent further recurrent sports injuries, neurophysiologic probes, particularly a longer SP, might be a potential assessment tool to return to the field.

Copers exhibit altered ankle and trunk kinematics compared to the individuals with chronic ankle instability during single-leg landing

Copers are individuals who have had a lateral ankle sprain but have no history of recurrent lateral ankle sprain, residual symptoms, or functional disability. Copers have shown no significant difference in lower limb kinematics in landing for proactive conditions compared with a control (CTR) group. However, the copers (CPR) group has shown differences compared to CTR and chronic ankle instability (CAI) groups for dynamic balance conditions, suggesting that the trunk may compensate for foot instability during shock absorption. This study aimed to examine the differences in the kinematics and kinetics among CPR, CAI and CTR groups in reactive and proactive single-leg landing tasks. Participants were physically active adults with CAI (n = 14), CPR (n = 14), and CTR (n = 14), who performed proactive and reactive single-leg landings. The lower limb, trunk kinematics, vertical ground reaction force (vGRF) peak value, and the time to minimum peak vGRF were analysed. It might be conceivable that the CPR group could absorb vGRF efficiently by increasing the trunk flexion angle and increasing the time to reach the minimum peak vGRF regardless of landing condition. The results suggest that evaluating the movements of the entire body, including the ankle and trunk, is essential.

Neuromuscular Electrical Stimulation of Peroneal Longus Improve Balance Control Ability in Young Adults With Chronic Ankle Instability: A Randomized Controlled Trial

OBJECTIVE

This study aimed to investigate the effects of 6 wks of peroneal longus neuromuscular electrical stimulation on the balance control ability in young adults with chronic ankle instability.

DESIGN

This study is a double-blind randomized controlled trial. Six weeks of neuromuscular electrical stimulation and placebo intervention were conducted in the neuromuscular electrical stimulation and control groups for 20 mins, three times a week, respectively. Thirty-eight participants successfully completed the whole intervention and single-leg standing tests. The kinetics data of the center of pressure trajectory during static single-leg stance were measured using a Kistler force platform. Two-way repeated measures analysis of variance was used to analyze the electrical stimulation effects.

RESULTS

Significant interactions were detected in Cumberland Ankle Instability Tool scores and all balance parameters including displacement X, displacement Y, 95% confidence ellipse area, root-mean-square, and center of pressure mean displacement velocity ( P < 0.05, 0.103 ≤ η 2 ≤ 0.201). Significant between-group differences were found in Cumberland Ankle Instability Tool scores ( P = 0.003, Cohen's d = 0.215), displacement X ( P = 0.045, Cohen's d = 0.107), root-mean-square ml ( P = 0.019, Cohen's d = 0.143), and 95% confidence ellipse area ( P = 0.031, Cohen's d = 0.123) after the 6-wk interventions.

CONCLUSIONS

Six weeks of neuromuscular electrical stimulation on the peroneus longus can improve static balance control ability in young adults with chronic ankle instability, especially the stability of ankle frontal plane.

Effects of dual-task paradigm on the injury potential during landing among individuals with chronic ankle instability

Purpose

Chronic ankle instability (CAI) causes maladaptive neuroplastic changes in the central nervous system, which may lead to high injury potential under dual-task conditions. This study aims to explore the effects of dual-task paradigm on the injury potential during landing among individuals with CAI.

Methods

Twenty participants with CAI (4 female and 16 male, 12 were affected with their right limbs and 8 were affected with their left limbs, 20.4 ± 1.7 years, 176.9 ± 5.0 cm, and 72.0 ± 11.1 kg) and eighteen without CAI (6 female and 12 male, 20.2 ± 1.5 years, 173.5 ± 7.0 cm, and 70.3 ± 10.8 kg) were recruited. They drop-landed on a trap-door device, with their affected or matched limbs on a flippable platform, under single- (drop-landing only) and dual-task (drop-landing while subtracting of serial threes) conditions. A twelve-camera motion capture system was used to capture the kinematic data. Two-way ANOVA with mixed design (CAI vs non-CAI groups by single-vs dual-task conditions) was used to analyze the data.

Results

Significant group-by-condition interactions were detected in the ankle inversion angle (P = 0.040, η 2 p = 0.012) and ankle inversion angular velocity (P = 0.038, η 2 p = 0.114). Both indicators decreased among individuals without CAI from single-to dual-task conditions, while remained unchanged among those with CAI; and they were higher among individuals with CAI under both single- and dual-task conditions, compared to those without CAI.

Conclusion

Individuals with CAI have a reduced ability to limit ankle inversion compared to those without CAI. Under dual-task conditions, individuals without CAI limited their ankle inversion, while those with CAI did not. Drop-landing, especially under dual-task conditions, poses a high risk of excessive ankle inversion for individuals with CAI.

Correlations of strength, proprioception, and dynamic balance to the Cumberland Ankle Instability Tool Score among patients with chronic ankle instability: a cross-sectional study

BACKGROUND

The Cumberland Ankle Instability Tool (CAIT) is used to screen patients with chronic ankle instability (CAI) and to quantify the severity of ankle instability. Neuromuscular deficits are common in CAI, including proprioception, strength, and balance issues. The relationship between CAIT scores and neuromuscular factors is unclear. The purpose of this study was to investigate the correlation between ankle instability and ankle muscle strength, proprioception, and dynamic balance.

METHODS

Thirty-four individuals with chronic ankle instability were included in this study. The participants' CAIT scores, muscle strength (isokinetic) and proprioception in plantarflexion (PF), dorsiflexion (DF), inversion (IV), and eversion (EV), and dynamic balance (Star Excursion Balance Test in anterior, posteromedial, and posterolateral directions) were assessed. Bivariate correlations were used to determine the relationship between CAIT scores and ankle muscle strength, proprioception, and dynamic balance.

RESULTS

In terms of muscle strength, ankle PF (r = 0.378, 95%CI: 0.046-0.635, P = 0.027) and IV (r = 0.527, 95%CI: 0.233-0.736, P = 0.001) strength were positively correlated with CAIT Score, whereas ankle DF and EV strength had no significant correlation with CAIT Score. In terms of proprioception, ankle IV proprioception (r = -0.340, 95%CI: -0.608-0.002, P = 0.027) was negatively correlated with CAIT Score, while ankle PF, DF, and EV proprioception had no significant correlation with CAIT Score. In terms of dynamic balance, the SEBT posteromedial (r = 0.444, 95%CI: 0.124-0.680, P = 0.001) was positively correlated with CAIT Score. The SEBT anterior and posterolateral were not significantly correlated with the CAIT Score.

CONCLUSION

This study found that increasing ankle plantarflexion and inversion muscle strength, improving dynamic balance in the posteromedial direction, and decreasing ankle inversion proprioceptive thresholds may help improve the subjective stability of CAI. This provides data support for targeted ankle neuromuscular function rehabilitation training for patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100044089. Registered on 10 March 2021.

Comparison of the distance between the talus and lateral malleolus during the stance phase with and without chronic ankle instability

The level of dynamic mechanical instability between the bony parts of the ankle joint provides important information on biomechanical function. However, the dynamics of the distance between the talus and lateral malleolus during gait remain unclear. This study aimed to compare the distance between the talus and lateral malleolus and the ankle joint angles during the stance phase of gait between individuals with chronic ankle instability (CAI) and healthy adults. The comparison was conducted using a synchronized ultrasound (US) imaging with a three-dimensional motion analysis (MA) system. This cross-sectional study included 12 participants (5 males, 7 females; age, 20.5 ± 1.8 years; height, 166.6 ± 9.4 cm; body weight, 60.2 ± 5.3 kg; body mass index, 21.7 ± 2.0 kg/m2; 16 feet) with CAI and 10 healthy controls (4 males, 6 females; age, 21.2 ± 1.6 years; height, 164.6 ± 10.5 cm; body weight, 56.8 ± 11.3 kg; body mass index, 20.8 ± 2.6 kg/m2; 20 feet). The distance between the talus and lateral malleolus during gait was significantly increased in the CAI group compared with that in the control group throughout the stance phase. The ankle dorsiflexion angle was smaller in the CAI group during the middle and terminal stance phases. Additionally, the ankle inversion angle was greater in the CAI group than in the control group. Our findings show the application of the synchronized US and MA system in the assessment of mechanical instability in CAI group, which may be used to determine treatment efficacy.

Smartphone Proprioception for Ankle Navigation (SPAN): Reliability and Effect of Position Exposure Time

This study investigated ankle discriminative acuity and performance and measurement consistency for tests undertaken with different joint position exposure times (PETs). Twenty-four participants were tested using a novel Smartphone Proprioception for Ankle Navigation (SPAN) under four PETs, i.e., 0.25s, 0.5s, 0.75s and 1s, delivered in a random sequence, and then re-tested within one week. The results indicated a PET main effect (F = 10.12, p = 0.004, partial ƞ2 = 0.14), and limb preference main effect (F = 5.39, p = 0.03, partial ƞ2 = 0.19), without significant interactions (p > 0.05). Ankle proprioception improved with prolonged PET, with the non-dominant side outperforming the dominant side. A PET of 0.25s showed good to excellent reliability, with intraclass correlation coefficients (ICCs) of 0.897 (95%CI: 0.761, 0.955) and 0.885 (95%CI: 0.736, 0.951), with standard errors of measurements (SEM) between 0.030 and 0.035, and minimum detectable change at 90% (MDC90) between 0.070 and 0.082, compared to poor to moderate reliability at the other three longer PETs (ICCs =0.352-0.736). The findings suggested the prolongation of PET can improve ankle proprioceptive performance but can amplify the inter-occasion variability, likely due to increased cognitive analysis with longer stimulus sampling. SPAN may thus be a cost-effective and accessible apparatus for clinical practice.

Influence of Anterior Talofibular Ligament Injury and Ankle Anterior Displacement on Symptoms in Individuals With Chronic Ankle Instability

CONTEXT

Repeated ankle sprains can lead to injuries, including those of the anterior talofibular ligament (ATFL); however, the extent to which these ligament injuries are associated with symptoms of chronic ankle instability (CAI) remains unclear.

OBJECTIVE

To examine the influence of ATFL injury and ankle anterior displacement on symptoms of CAI.

DESIGN

Case-control study.

SETTING

University laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 122 of 426 college students who completed a questionnaire on the history of ankle sprain were enrolled in healthy (n = 34; 24 men, 10 women; age = 20.6 ± 0.5 years), coper (n = 49; 38 men, 11 women; age = 20.2 ± 1.2 years), and CAI groups (n = 39; 24 men, 15 women; age = 20.1 ± 1.1 years).

MAIN OUTCOME MEASURE(S)

One examiner measured the ATFL delineation using ultrasound and anterior ankle displacement using a capacitance-type sensor device. The Cumberland Ankle Instability Tool was applied to assess pain and perceived instability.

RESULTS

The ATFL was normal more frequently in the healthy group and abnormal more frequently in the CAI group (χ2 = 18.45, P < .001). Anterior ankle displacement was greater in the coper and CAI groups than in the healthy group (both, P < .001), but no difference was observed between the coper and CAI groups (P = .16). We observed no correlation between the anterior ankle displacement and Cumberland Ankle Instability Tool scores (r = -0.004, P = .71) in participants with previous ankle sprains.

CONCLUSIONS

Observation of an abnormal ATFL on ultrasonography was associated with anterior displacement of the ankle joint. However, the influence of anterior ankle displacement due to damage to the ATFL on the pain and perceived instability in CAI was assumed to be small.

Decreased proprioception is associated with inferior postural control during unplanned landing in individuals with chronic ankle instability

Poor postural control during jump landing may increase ankle sprain incidences among people with chronic ankle instability (CAI). The effects of anticipation on it and its relationship with proprioception need further examination. Fifteen participants with CAI and 15 healthy controls were recruited to perform single-leg jump landings when knowing the landing side before (planned) or after (unplanned) take-off respectively, along with a step-down proprioception test differentiating four inclination platforms (inverted 12°, 14°, 16° and 18°). Ground reaction force data (peak force, loading rate and time of stabilisation) during landings and proprioception scores were collected and analysed. The CAI group exhibited a higher loading rate (59.6 ± 7.6 vs 49.4 ± 6.7 N/kg*seconds, p = 0.011) and longer medial-lateral time to stabilisation (4.82 ± 0.69 vs 4.11 ± 0.47 seconds, p = 0.023) compared to the control group during an unplanned landing. Furthermore, the above variables were negatively correlated with the step-down proprioception score only in the unplanned condition but not in the planned condition. CAI participants had inferior medial-lateral time-to-stabilisation and loading attenuation during unplanned jump landing than healthy controls, which were associated with decreased proprioception, highlighting the importance of addressing proprioception to improve balance control during unpredictable landing situations.

The evolution of patient-reported outcome measures after a first lateral ankle sprain: A prospective study

PURPOSE

A lateral ankle sprain is the most common musculoskeletal injury in the physically active population. However, it is unclear how the clinical condition evolves during the period after the injury and what proportion of patients develops chronic symptoms. Therefore, the purpose of this study is to assess the evolution of patient-reported outcome measures after a first time lateral ankle sprain.

METHODS

A prospective clinical study assessed the patient-reported outcome measures (PROMs) of a consecutive group of 100 patients during 1 year after a first lateral ankle sprain. The Karlsson score and Foot and Ankle Outcome Score (FAOS) were assessed at 6 weeks, 3 months, 6 months, 9 months and 1 year. The Cumberland Ankle Instability Tool (CAIT)-score was assessed at 6 months, 9 months and 1 year. The difference between the time points of all scores was analysed using the positive change over time (binomial test versus 50%) and the difference in score (signed rank test). The time to sustained excellent level was also assessed overall and in several subgroups: age, gender, degree of injury (2 or 3), avulsion fracture, use of crutches, use of cast. Differences between subgroups were assessed by a generalized log-rank test.

RESULTS

All clinical scores demonstrated an improvement up to 12 months after the sprain. The median Karlsson score (interquartile range) improved from 62 (50-80) at 6 weeks to 90 (72-100) at 3 months, to 97 (82-100) at 6 months to 100 (90-100) at 9 months, to 100 (100-100) at 1 year. The analysis of positive change over time demonstrated a significant positive change (P-value <.0005) between all time points except between 6 weeks and 12 weeks when using the FAOS quality score. The difference in score demonstrated a significant change (P-value <.01) between all time points except between 36 weeks and 48 weeks when using the FAOS pain and FAOS sports score. Age and presence of an avulsion fracture were correlated with a slower recovery and worse results. At 1 year, in total 13 patients (13%) had a worse outcome corresponding to a Karlsson score < 81 or CAIT score < 24.

CONCLUSION

The clinical condition after a first ankle sprain demonstrated a significant improvement in PROMs between the different time points in the first year. Twelve months after a first lateral ankle sprain 13% had a fair or poor outcome. Higher age and presence of an avulsion fracture were correlated with a slower recovery and worse results. This information is useful in clinical practice to predict further progression and inform patients. Moreover, it is valuable to improve treatment strategies.

LEVEL OF EVIDENCE

Level II (prospective cohort study).

Effects of short- or long-term use of orthotic interventions on functional performance in individuals with chronic ankle instability: A systematic review

BACKGROUND

Individuals with chronic ankle instability (CAI) have problems in function. The purpose of this study was to systematically investigate the short- or long-term effects of various orthoses on function of these people.

METHODS

Randomized controlled trial (RCT) studies reporting on the short- or long-term effects of orthotic intervention on functional performance in individuals with CAI were identified through PubMed, Cochrane Library, PEDro, MEDLINE via Ovid, and Scopus databases from inception to July 2022. Two reviewers independently extracted data and assessed the risk of bias and quality of the studies using ROB tool and PEDro scale, respectively.

RESULTS

Eleven RCTs published from 2012 to 2022 were included in this review. The studies were of a fair or good quality. The risk of bias was low in 50 percent and high in 16.7 percent of the studies. The mSEBT in the posterolateral and posteromedial directions were improved both in the short- and long-term application of orthoses. Single leg hop did not change but single leg stance was improved more in the experimental group who used orthoses for 4 weeks.

CONCLUSION

Various tapes can improve dynamic balance immediately after application and their effects would last up to 2 months. Therefore, they can be used during training. Athletes with CAI who want to perform better should use the tape at least two weeks before competing to take advantage of its long-term effects. The timing of application of orthotic appliances, needs to be adjusted according to the relevant function.

Cross-cultural adaptation, reliability, and validity of the Sinhala version of the Cumberland Ankle Instability Tool: an instrument for measuring chronic ankle instability in Sri Lanka

PURPOSE

To develop the Sinhala version of the Cumberland Ankle Instability Tool (CAIT-Sin) and evaluate its validity and reliability in native Sinhala speakers.

METHODS

The CAIT was translated and cross-culturally adapted into Sinhala, using a forward-backward translation method. CAIT-Sin, Karlsson score, and visual analog scale (VAS) were filled out by 156 university athletes and students with and without ankle instabilities, in order to test internal consistency, test-retest reliability, criterion validity, floor and ceiling effect, and discriminative ability of the CAIT-Sin. Furthermore, ROC analysis was used to identify the presence of chronic ankle instability (CAI).

RESULTS

The CAIT-Sin was with a high internal consistency (Cronbach's alpha = 0.88) and excellent test-retest reliability (ICC2,1 = 0.95, 95% CI: 0.93-0.96). The CAIT-Sin exhibited strong and positive correlations with the Karlsson score (r = 0.832, p < 0.001) and VAS (r = 0.876, p < 0.001). No ceiling or floor effect was observed in individuals with CAI. A CAIT-Sin score of 26 or lower indicated the presence of CAI.

CONCLUSIONS

The clinicians and researchers in Sri Lanka can use the CAIT-Sin for assessing and measuring CAI because its validity and reliability are confirmed.Implications for RehabilitationFunctional ankle instability is an ongoing chronic condition which presents for rehabilitation therapist.Outcome measurements are crucial in the rehabilitation of ankle sprains and it is important to administer these subjective outcome measures in their native language.The CAIT-Sin was found to have high internal consistency and excellent test-retest reliability.

Investigation of the effect of chronic ankle instability on core stabilization, dynamic balance and agility among basketball players of a university

BACKGROUND

Chronic ankle instability (CAI) is frequently seen in basketball, where ankle sprains are common due to repetitive movements such as jumping, landing, deceleration and acceleration.

OBJECTIVE

This study investigated the effects of CAI on core stabilization, dynamic balance, and agility in university-level basketball players.

MATERIALS AND METHODS

The study included 22 basketball players with CAI (8F, 3M; 20.09 ± 1.04 years) and without CAI (8F, 3M; 21.27 ± 2.24 years), registered as team players in the Yeditepe University basketball teams. Participants divided into two groups: the chronic ankle instability group (CAIG) and the control group (CG). The participants' core stabilization was evaluated using the McGill Core Endurance Test, dynamic balance was evaluated with the Y Balance Test and the T Test was used to evaluate agility.

RESULTS

According to the results of an independent t-test, significant differences were observed between groups including posteromedial (p = 0.03) and posterolateral (p = 0.03) reach distances, trunk flexion (p = 0.04) and trunk extension (p = 0.03) tests. According to the logistic regression analysis, Y Balance Test posteromedial and posterolateral reach distances, trunk flexion and trunk extension tests in the McGill Core Endurance Test were found to be statistically significant on the presence of CAI (p < 0.05).

CONCLUSION

Including core stabilization and dynamic balance exercises in the training program may be beneficial to improve core stabilization and dynamic balance parameters and prevention of CAI in university-level basketball players with CAI.

Ankle sprains in male Israeli infantry soldiers during training: prevalence and risk factors

BACKGROUND

Given the high incidence and heavy burden of ankle sprains in recruits, large-scale, multifactorial investigations into potential risk factors are warranted. This study aimed to identify the incidence of ankle sprains and associated risk factors among new military recruits during their infantry training.

METHODS

The study included 365 infantry recruits (aged 18-21 years), who were inducted into service in March 2022. These recruits were monitored for ankle sprains throughout their basicy and advanced infantry training by a physiotherapist. Preinduction smoking habits, physical fitness preparation and recurrent ankle sprains were recorded. Anthropometric measures, lower-extremity functional movement, Achilles tendon structure, perceived ankle instability, and mechanical ankle instability were assessed at the onset of both training periods.

RESULTS

Ankle sprains were diagnosed in 109 trainees (29.9%) during both the basic and the advanced training periods. Preinduction recurrent ankle sprains were reported by 28.2% of the participants. The relative risk of a recruit with preinduction ankle sprains suffering a subsequent sprain during training was 1.66 (p=0.001). Logistic regression analysis indicated that reduced proprioception ability (OR=0.002), higher body mass index (OR=1.08), preinduction recurrent sprains (OR=1.95) and lack of physical fitness preparation (OR=3.12) were related to ankle sprains throughout the complete basic-and-advanced training period. Preinduction recurrent ankle sprains (OR=3.37) and reduced Achilles tendon quality (OR=1.30) were associated with ankle sprains during the advanced training period.

CONCLUSIONS

Lower-extremity functional movement, body mass index, preinduction recurrent sprains, physical preparation and reduced Achilles tendon quality were associated with the risk of ankle sprains during training. These findings could contribute to developing prevention and intervention programmes for reducing ankle sprains in military trainees.

Effect of 6-week BFRT combined with IASTAM therapy on international standard dancers with chronic ankle instability

Background

In sports dance events, athletes often face the risk of ankle injury and instability, which may have a negative impact on their training and athletic performance, and even hinder their rehabilitation process and increase the likelihood of re-injury.

Objective

This study aims to observe the effects of exercise intervention (low-load ankle muscle strength training with blood flow restriction training (BFRT) equipment and balance training with blood flow restriction training equipment) combined with instrumentation therapy (Instrument-assisted soft tissue mobilization, IASTM) on ankle function, joint range of motion, and strength in sports dancers with chronic ankle instability (CAI). This study aims to provide an evidence-based approach to rehabilitation for athletes by comparing the effects of combination therapy approaches to traditional ankle strength and stability training.

Methods

Forty-two subjects with ankle instability, restriction, or discomfort were selected as observation objects and randomly divided into three groups: the combined group (n = 14, blood flow restriction training combined with IASTM), the simple blood flow restriction training group (n = 15), and the conventional ankle strength and stability training group (n = 13). The intervention lasted for 6 weeks, once a week. The three groups were assessed with the Cumberland ankle instability assessment, Foot and Ankle Ability Measure (FAAM) ankle function assessment score, and ankle range of motion measurement before intervention, after the first intervention, and after 6 weeks of intervention. The ankle strength test was compared and analyzed only before and after intervention.

Result

There was no significant difference in the participant characteristics of the three intervention groups. In terms of Cumberland Ankle Instability Tool (CAIT) scores, within-group comparisons showed that the scores after the first intervention and at the 6-week mark were significantly higher than before the intervention (P < 0.05). Between-group comparisons revealed that the combined intervention group had higher CAIT scores than the other two groups after the 6-week intervention. Regarding the FAAM functional scores, all three interventions significantly improved ankle joint function in patients with chronic ankle instability (P < 0.05), with the BFRT group showing significantly higher FAAM - Activities of Daily Living scale (FAAM-ADL) scores than the control group (P < 0.05). Both the combined and BFRT groups also had significantly higher FAAM-SPORT scores after the first intervention compared to the control (P < 0.05). In terms of ankle range of motion improvement, the combined intervention group showed a significant increase in ankle joint motion after the intervention (P < 0.05), particularly in the improvement of dorsiflexion ability (P < 0.05). As for ankle strength enhancement, all three intervention groups experienced an increase in ankle strength after the intervention (P < 0.05), with the combined intervention group showing a significant improvement in both dorsiflexion and inversion strength compared to the control group (P < 0.05).

Conclusion

BFRT combined with IASTM, isolated BFRT, and conventional ankle strength and stability training significantly improve stability, functionality, and strength in CAI patients. The combined intervention demonstrates superior efficacy in improving ankle range of motion compared to isolated BFRT and conventional approaches.

Peri-ankle muscles architecture and performance changes in patients with chronic ankle instability: A retrospective cross-sectional study

This study aimed to identify changes in the architecture and performance of the peri-ankle muscles in patients with chronic ankle instability (CAI) and investigate the relationship between them. In total, 17 subjects were evaluated retrospectively. Each subject underwent anthropometric and isokinetic test, and peroneus longus (PL) and brevis (PB), medial gastrocnemius (MGCM), and tibialis anterior (TA) ultrasound imaging were performed at rest and maximum voluntary contraction (MVC) conditions. Regarding muscle architectural variables, the pennation angle (PA) of the MGCM at rest and the PA of the TA, MGCM, and PL in MVC were significantly reduced on the injured side compared to the intact side. There were no significant differences in muscle thickness of PL, PB, MGCM, and TA observed between intact and injured side during both rest and MVC. Regarding muscle performance parameters, significant decreased were observed in the muscle strength for both limbs in all four directions under the two different conditions. A secondary finding was that the relative PA ratio of the TA showed moderate correlation with the relative dorsiflexion ratio at 30°/s. These findings can provide opportunities to better understand how injuries in patients with CAI may be related to changes in ankle and foot function.

The Effect of Strength and Balance Training on Kinesiophobia, Ankle Instability, Function, and Performance in Elite Adolescent Soccer Players with Functional Ankle Instability: A Prospective Cluster Randomized Controlled Trial

We aimed to implement strength and balance training for elite adolescent male soccer players with functional ankle instability (FAI) to assess kinesiophobia, ankle instability, ankle function, and performance. This cluster randomized controlled trial comprised 51 elite adolescent male soccer players with FAI recruited from six different teams, divided into strength, balance, and control groups (SG, n = 17; BG, n = 17; and CG, n = 17, respectively). The SG and BG underwent strength and balance training sessions three times per week for 6 weeks. Primary outcomes were the Tampa scale for kinesiophobia-17 (TSK) and Cumberland ankle instability tool (CAIT) scores to assess kinesiophobia and FAI, respectively. Secondary outcomes were ankle strength (four directions), dynamic balance, static balance (ellipse, displacement, velocity), and performance (figure 8 and side-hop tests). A significant interaction effect was observed for both TSK and CAIT post-intervention (both, P < 0.01). In post hoc analyses, the BG had significantly better outcomes in reducing TSK. The SG and BG showed greater improvements in CAIT scores. Regression analysis indicated that CAIT severity correlated significantly with TSK (P = 0.039, R = 0.289). For secondary outcomes, the SG and BG were superior in terms of ankle dorsiflexion/inversion strength, static balance displacement, and figure-8 and side-hop tests (all, P < 0.05). The BG showed significantly better static balance ellipse results (P < 0.05). The 6-week intervention significantly enhanced kinesiophobia management, ankle stability, and performance. Balance training effectively mitigated kinesiophobia and improved balance, compared with strength training alone. Even small variations in CAIT severity can influence kinesiophobia, highlighting the potential benefits of balance training. Integrating balance training into training programs can address both physical and psychological aspects of ankle instability. Research is recommended to explore the longitudinal effects of these interventions and their potential to prevent injury recurrence.

Thin and Plain Supplementary Motor Area in Chronic Ankle Instability: A Volume- and Surface-Based Morphometric Study

CONTEXT

The supplementary motor area (SMA) is involved in the functional deficits of chronic ankle instability (CAI), but the structural basis of its abnormalities remains unclear.

OBJECTIVES

To determine the differences in volume- and surface-based morphologic features of the SMA between patients with CAI and healthy controls and the relationship between these features and the clinical features of CAI.

DESIGN

Cross-sectional study.

SETTING

Sports medicine laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 32 patients with CAI (10 women, 22 men; age = 32.46 ± 7.51 years) and 31 healthy controls (12 women, 19 men; age = 29.70 ± 8.07 years) participated.

MAIN OUTCOME MEASURE(S)

We performed T1-weighted structural magnetic resonance imaging of participants and calculated volume- and surface-based morphologic features of SMA subregions. These subregions included anterior and posterior subdivisions of the medial portion of Brodmann area 6 (6 ma and 6 mp, respectively) and supplementary and cingulate eye fields. Between-group comparisons and correlation analysis with clinical features of CAI were performed.

RESULTS

Moderately thinner 6 mp (motor-output site; Cohen d = -0.61; 95% CI = -1.11, -0.10; P = .02) and moderately plainer 6 ma (motor-planning site; Cohen d = -0.70; 95% CI = -1.20, -0.19; P = .01) were observed in the CAI than the control group. A thinner 6 mp was correlated with lower Foot and Ankle Ability Measure Activities of Daily Living subscale scores before (r = 0.400, P = .02) and after (r = 0.449, P = .01) controlling for covariates.

CONCLUSIONS

Patients with CAI had a thinner 6 mp and a plainer 6 ma in the SMA compared with controls. The thin motor-output site of the SMA was associated with ankle dysfunction in patients. This morphologic evidence of maladaptive neuroplasticity in the SMA might promote more targeted rehabilitation of CAI.

Meta-analysis of the dosage of balance training on ankle function and dynamic balance ability in patients with chronic ankle instability

OBJECTIVE

To explore and compare the dosage of balance training on ankle function and dynamic balance ability in patients with chronic ankle instability (CAI).

METHODS

The PubMed, Embase, Web of Science, Medline, and Cochrane databases were searched up to December 2023. Quality assessment was carried out using the risk-of-bias guidelines of the Cochrane Collaboration, and the standardized mean differences (SMD) or mean differences (MD) for each outcome were compute.

RESULTS

Among 20 eligible studies, including 682 participants were analyzed in this meta-analysis. The results of the meta-analysis demonstrated that balance training was effective in enhancing ankle function with self-functional scores (SMD = 1.02; 95% CI, 0.61 to 1.43; p < 0.00001; I2 = 72%) and variables associated with the ability of dynamic balance such as SEBT-A (MD = 5.88; 95% CI, 3.37 to 8.40; p < 0.00001; I2 = 84%), SEBT-PM (MD = 5.47; 95% CI, 3.40 to 7.54; p < 0.00001; I2 = 61%), and SEBT-PL (MD = 6.04; 95% CI, 3.30 to 8.79; p < 0.0001; I2 = 79%) of CAI patients. Meta-regression indicated that the intervention time might be the principal cause of heterogeneity (p = 0.046) in self-functional scores. In subgroup analyses of self-functional score across intervention types, among the intervention time, more than 20 min and less than 30 min had the most favorable effect (MD = 1.21, 95% CI: 0.96 to 1.46, p < 0.00001, I2 = 55%); among the intervention period, 4 weeks (MD = 0.84, 95% CI: 0.50 to 1.19, p < 0.00001, I2 = 78%) and 6 weeks (MD = 1.21, 95% CI: 0.91 to 1.51, p < 0.00001, I2 = 71%) had significant effects; among the intervention frequency, 3 times (MD = 1.14, 95% CI: 0.89 to 1.38), p < 0.00001, I2 = 57%) had significant effects. Secondly, in subgroup analyses of SEBT across intervention types, a 4-week and 6-week intervention with balance training 3 times a week for 20-30 min is the optimal combination of interventions to improve SEBT (dynamic balance) in patients with chronic ankle instability.

CONCLUSION

Balance training proves beneficial for ankle function in patients with CAI. Intervention time constitutes a major factor influencing self-function in patients with CAI. It is recommended that the optimal dosage of balance training for CAI involves intervention three times a week, lasting for 20 to 30 min over a period of 4 to 6 weeks for superior rehabilitation.

Assessing Functional Ankle Instability in Sport: A Critical Review and Bibliometric Analysis

Functional Ankle Instability (FAI) is the subject of extensive research in sports and other environments. Given the importance of accurately measuring this latent construct, it is imperative to carry out a careful assessment of the available tools. In this context, the aim of this review was to take an in-depth look at the six most cited measurement tools to assess FAI, with a specific focus on patient-reported outcome measures related to ankle and foot. Four electronic databases (Web of Science, Scopus, Pubmed, and SportDiscus) were searched (up to November 2022) to identify the six most cited questionnaires for assessing FAI. Our analysis showed that the most cited questionnaires are the following: the Lower Extremity Functional Scale (LEFS), the Foot Function Index (FFI), the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the Olerud and Molander Ankle Score (OMAS), and the Cumberland Ankle Instability Tool (CAIT). Each questionnaire was thoroughly assessed and discussed in three sections: Development, Reliability, and Summaries. In addition, bibliometric data were calculated to analyze the relevance of each questionnaire. Despite variations in terms of validity and reliability, conceptualization, structure, and usefulness, the six questionnaires proved to be robust from a psychometric point of view, being widely supported in the literature. The bibliometric analyses suggested that the FAOS ranks first and the FFI ranks sixth in the weighted average of the impact factors of their original publications.

Biomechanical and Physiological Variables in Dynamic and Functional Balance Control during Single-Leg Loading in Individuals with Chronic Ankle Instability: A Scoping Review

BACKGROUND

This scoping review summarizes the tasks and outcomes in dynamic and functional balance assessments of individuals with chronic ankle instability, focusing on the physiological and biomechanical characteristics.

METHOD

A comprehensive literature search was conducted in PubMed, Scopus, Web of Science, and MEDLINE databases in September 2023 and revised in April 2024. Studies evaluating dynamic and functional balance in chronic ankle instability using clinical tests, as well as biomechanical and physiological outcomes, were included.

RESULTS

Out of 536 publications, 31 met the screening criteria. A history of ankle sprain was the main focus of the inclusion criteria (28 articles, 90%). The star excursion balance test, emphasizing maximum reach distance, was the most common quantitative task (12 articles, 66%). Physiological data mainly came from electromyography studies (7 articles, 23%), while biomechanical variables were often assessed through center of pressure studies using force plates (17 articles, 55%).

CONCLUSIONS

The preferred quantitative clinical assessment was the star excursion balance test, focusing on normalized reach outcomes. Qualitative functional balance assessments emphasize landing activities and center of pressure displacement. Electromyography is commonly used to analyze the tibialis anterior and peroneus longus muscles. However, there is a lack of qualitative data on dynamic balance control, including morphological characteristics and the center of mass adaptation.

Effects of transcranial direct current stimulation combined with Bosu ball training on the injury potential during drop landing in people with chronic ankle instability

Purpose

To investigate the effects of transcranial direct current stimulation (tDCS) combined with Bosu ball training on the injury potential during drop landing in people with chronic ankle instability (CAI).

Methods

A total of 40 participants with CAI were recruited and randomly divided into the tDCS + Bosu and Bosu groups. The people in the tDCS + Bosu group received intervention of tDCS combined with Bosu ball training, and those in the Bosu group received intervention of sham tDCS and Bosu ball training, for 6 weeks with three 20-min sessions per week. Before (week0) and after (week7) the intervention, all participants drop-landed on a trap-door device, with their affected limbs on a moveable platform, which could be flipped 24° inward and 15° forward to mimic an ankle inversion condition. The kinematic data were captured using a twelve-camera motion capture system. Two-way ANOVA with repeated measures was used to analyze data.

Results

Significant group-by-intervention interactions were detected in the peak ankle inversion angular velocity (p = 0.047, η2 p = 0.118), the time to peak ankle inversion (p = 0.030, η2 p = 0.139), and the plantarflexion angle at the moment of peak ankle inversion (p = 0.014, η2 p = 0.173). Post hoc comparisons showed that compared with week0, the peak ankle inversion angular velocity and the plantarflexion angle at the moment of peak ankle inversion were reduced, the time to peak ankle inversion was advanced in both groups at week7, and the changes were greater in the tDCS + Bosu group compared to the Bosu group. And, a significant intervention main effect was detected in the peak ankle inversion angle in the two groups (p < 0.001, η2 p = 0.337).

Conclusion

Compared with the Bosu ball training, the tDCS combined with Bosu ball training was more effective in reducing the injury potential during drop landing in people with CAI.

Point of Care Ultrasound Guided Management of Lateral Ankle Sprains: A Case Series

Background

Lateral ankle sprain (LAS) is a common injury with incidence rates reported at 7.2 per 1000 person-years. Physical examination strategies provide limited information to guide rehabilitation that can maximize clinical outcomes. Early and accurate diagnostic information using ultrasound imaging enables individualized care and the ability to monitor healing along with its response to activity and rehabilitation.

Purpose

The purpose of this study was to describe and observe the outcomes associated with Point of Care Ultrasound (POCUS) guided early management of acute and sub-acute lateral ankle sprains.

Study Design

Case series.

Methods

Individuals with a LAS within the prior 28 days underwent a clinical evaluation to include a POCUS exam to assess ligamentous integrity. Objective and POCUS findings were integrated to classify each LAS into one of four categories. Each grade of ankle sprain corresponded to levels of bracing for the protection of injured structures with each patient receiving physical therapy care based on rehabilitation guidelines. Participants completed the Foot and Ankle Ability Measure (FAAM) activities of daily living and Sports subscale, the Foot and Ankle Outcome Score (FAOS), Patient Reported Outcomes Measurement Information Systems Global Health, Tampa Scale of Kinesiophobia (TSK-11), Cumberland Ankle Instability Tool (CAIT), and the Numeric Pain Rating Scale as well as the Ankle Lunge Test and Figure 8 measurements at baseline, 4 weeks, 8 weeks and 12 weeks post enrollment. The FAAM Sport subscale, all FAOS subscales, and the TSK-11 were also collected at 24 weeks while the CAIT was collected at baseline and 24 weeks.

Results

Fourteen participants were enrolled with 11 participants completing all data collection. FAAM Sport scores significantly improved at 4, 8, 12 and 24 weeks. All components of the FAOS significantly increased except for Sport scores at four weeks and Quality of Life scores at four and eight weeks.

Conclusion

POCUS guided early management and ligamentous protection of LASs resulted in significant short and long-term improvement in function and return to sporting activity. This case series highlights the feasibility of using ultrasound imaging to assess the severity of ligamentous injury and align bracing strategies for ligamentous protection. The observations from this case series suggest that functional bracing strategies focused on ligamentous protection to promote healing and reduce re-injury rates does not delay improvement in functional outcomes.

Level of Evidence

Level IV, Case Series.