Simple advice for a simple ankle sprain? The not so benign ankle injury

Ankle joint contact force profiles differ between those with and without chronic ankle instability during walking

BACKGROUND

Individuals with chronic ankle instability (CAI) exhibit aberrant gait biomechanics relative to uninjured controls. Altered gait biomechanics likely contribute aberrant joint loading and subsequent early onset ankle joint degeneration. Joint (i.e. cartilage) loading cannot be directly measured without invasive procedures but can be estimated via joint contact forces (JCF) generated from musculoskeletal modeling. However, no investigation has quantified JCF in those with CAI during walking despite the link between ligamentous injury and ankle post-traumatic ankle osteoarthritis.

RESEARCH QUESTION

Do patients with CAI exhibit altered ankle compressive and shear JCF profiles during the stance phase of walking compared to those without CAI?

METHODS

Ten individuals with CAI and 10 individuals without a history of ankle sprain completed a gait assessment at their self-selected speed on an instrumented treadmill. Musculoskeletal modeling was applied to estimate ankle JCF variables within a generic model. Variables included the peak, impulse, and loading rates for compressive, anteroposterior shear, and mediolateral shear JCF.

RESULTS

Those with CAI had significantly different JCF forces, relative to uninjured controls, in all directions. More specifically, lower compressive peak and impulse values were noted while higher anteroposterior shearing forces (1 st peak, impulse, loading late) were observed in those with CAI. Those with CAI also demonstrated higher mediolateral shearing forces (1 st peak and impulse).

SIGNIFICANCE

Our finding suggests that those with CAI exhibit different ankle joint loading patterns than uninjured controls. Directionality of the identified differences depends on the axis of movement.

Prevalence of and factors associated with osteoarthritis and pain in retired Olympians, with comparison to the general population: part 1 – the lower limb

Objectives

This study aims (1) to determine the prevalence of lower limb osteoarthritis (OA) and pain in retired Olympians; (2) to identify factors associated with their occurrence and (3) to compare with a sample of the general population.

Methods

3357 retired Olympians (median 44.7 years) and 1735 general population controls (40.5 years) completed a cross-sectional survey. The survey captured demographics, general health, self-reported physician-diagnosed OA, current joint/region pain and injury history (lasting >1 month). Adjusted OR (aOR) compared retired Olympians with the general population.

Results

The prevalence of (any joint) OA in retired Olympians was 23.2% with the knee most affected (7.4%). Injury was associated with increased odds (aOR, 95% CI) of OA and pain in retired Olympians at the knee (OA=9.40, 6.90 to 12.79; pain=7.32, 5.77 to 9.28), hip (OA=14.30, 8.25 to 24.79; pain=9.76, 6.39 to 14.93) and ankle (OA=9.90, 5.05 to 19.41; pain=5.99, 3.84 to 9.34). Increasing age and obesity were also associated with knee OA and pain. While the odds of OA did not differ between Olympians and the general population, Olympians with prior knee and prior hip injury were more likely than controls with prior injury to experience knee (1.51, 1.03 to 2.21 (Olympians 22.0% vs controls 14.5%)) and hip OA (4.03, 1.10 to 14.85 (Olympians 19.1% vs Controls 11.5%)), respectively.

Conclusions

One in four retired Olympians reported physician-diagnosed OA, with injury associated with knee, hip and ankle OA and pain. Although overall OA odds did not differ, after adjustment for recognised risk factors Olympians were more likely to have knee and hip OA after injury than the general population, suggesting injury is an occupational risk factor for retired Olympians.

Maximal lateral ligament strain and loading during functional activities: Model-based insights for ankle sprain prevention and rehabilitation

BACKGROUND

Although it is generally accepted that sports activities present a high risk of lateral ligament injury, the extent to which ligaments are loaded during functional activities is less explored. This is relevant when considering ankle sprain prevention and staged rehabilitation following ligament sprain or reinforcing surgery. Therefore, anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament strain and loading were evaluated, based on a newly developed loading index, during movements executed during daily life and rehabilitation.

METHODS

Three-dimensional motion analysis data was acquired in 10 healthy volunteers during eleven different movements and processed using musculoskeletal modelling. Maximal lateral ligament strain and ligament loading, based on an new index accounting for the ankle and subtalar moment magnitude, ligament strain magnitude and duration, were calculated and statistically compared to ligament strain and loading during walking and a reference clinical (talar tilt) test.

FINDINGS

Anterior talofibular, calcaneofibular and posterior talofibular lateral ligament loading were highest during vertical drop jumps, medio-lateral single leg hops and running. Additionally, anterior talofibular loading was high during stair descending, calcaneofibular loading during single leg stance without visual feedback and posterior talofibular loading during anterior single leg hops. During the clinical test, anterior talofibular and calcaneofibular ligament strain were substantially lower than the maximal strain during different movements.

INTERPRETATION

Our results allow classification of exercises according to the ligament loading index and maximal strain, thereby providing objective data to progressively stage ligament loading during rehabilitation.

Impact of hip abductor and adductor strength on dynamic balance and ankle biomechanics in young elite female basketball players

This study aimed to evaluate, in an isolated and relative manner, hip abductor (ABD) and adductor (AD) strength and to study the extent to which these factors are related to balance and ankle dorsiflexion mobility in young elite female basketball players. Sixty trainee-level elite female basketball players (13–18 years old), who voluntarily agreed to participate in the study, were divided into three subgroups based on competition age divisions (U14, U16, U18). Isometric hip ABD and AD strength in each leg was evaluated using the ForceFrame Strength Testing System, also calculating the strength ratio and imbalance between legs. Y Balance Test (YBT) and ankle dorsiflexion mobility were also assessed. ANOVA was used for between-group differences analysis. Likewise, the impact of hip strength on balance and ankle mobility was analyzed using Pearson's correlation coefficient. A linear regression model for dependent variables was created with all variables that exhibited significant correlations. A between-group comparison analysis for the three competition age subgroups (U14, U16, U18) revealed non-significant differences (p > 0.005) for the hip strength variables except for hip ABD strength. The correlation study showed low-moderate effect sizes for hip ABD (in both the contralateral and homolateral limb) and AD strength (only the homolateral limb) with YBT and ankle dorsiflexion. However, when performing a regression model, only right hip ABD significantly predicted right limb YBT scores (β = 0.592, p = 0.048). The present study indicated that, although both hip ABD and AD strength correlate with balance and ankle mobility with low-moderate effect sizes, only hip ABD strength was found to significantly predict YBT scores. Therefore, the potential role of hip ABD strength in particular, but also hip AD strength, for monitoring and enhancing balance and ankle mobility outcomes, should be taken into consideration when designing and implementing preventive strategies for lower-limb injuries.

Health-Related Outcomes 3-15 Years Following Ankle Sprain Injury in Youth Sport: What Does the Future Hold?

BACKGROUND

This study examined the association between youth sport-related ankle sprain injury and health-related outcomes, 3-15 years postinjury.

METHODS

A historical cohort study in which uninjured controls were cluster-matched with injured cases. The primary outcome was self-reported Foot and Ankle Outcome Score (FAOS). Secondary outcomes included measures of adiposity, validated questionnaires for physical activity, athletic identity, fear of pain, and tests of strength, balance, and function.

RESULTS

We recruited 86 participants (median age of 23 years; 77% female); 50 with a time-loss ankle sprain, median of 8 years postinjury, and 36 uninjured controls cluster-matched by sex and sport. Based on mixed effects multivariable regression models, previously injured participants demonstrated poorer outcomes than controls on all 5 FAOS subscales regardless of sex and time since injury, with the largest differences observed in symptoms (-20.9, 99% CI: -29.5 to -12.3) and ankle-related quality of life (-25.3, 99% CI: -34.7 to -15.9) subscales. Injured participants also had poorer unipedal dynamic balance (-1.9, 99% CI: 3.5 to -0.2) and greater fear of pain (7.2, 99% CI: 0.9-13.4) compared with controls. No statistically significant differences were found for other secondary outcomes.

CONCLUSION

At 3-15 years following time-loss ankle sprain injury in youth sport, previously injured participants had more pain and symptoms, poorer self-reported function, ankle-related quality of life, reduced sport participation, balance, and greater fear of pain than controls. This underlines the need to promote the primary prevention of ankle sprains and secondary prevention of potential health consequences, including posttraumatic osteoarthritis.

LEVEL OF EVIDENCE

Level III, historical cohort study.

Incidence and risk factors for poor ankle functional recovery, and the development and progression of posttraumatic ankle osteoarthritis after significant ankle ligament injury (SALI): the SALI cohort study protocol

Background

Ankle sprains are one of the most common musculoskeletal injuries, accounting for up to 5% of all Emergency Department visits in the United Kingdom. Ankle injury may be associated with future ankle osteoarthritis. Up to 70% of ankle osteoarthritis cases may be associated with previous ankle injury. There is limited research regarding the association between ankle sprain and ankle osteoarthritis development. The current study aims to phenotype those who suffer significant ankle ligament injuries, identify potential risk factors for ankle injuries and subsequent poor recovery, examine why individuals may develop osteoarthritis, and what factors influence this chance.

Methods

In this multicentre cohort study participants were recruited from nine Emergency Departments and two Urgent Care Centres in the United Kingdom. Participants (aged 18–70 years old) were defined as those who had suffered an isolated acute ankle sprain, which was Ottawa Ankle Rules positive, but negative for a significant ankle fracture on x-ray. Age and sex matched controls were also recruited. The controls were individuals who had not suffered a significant ankle injury, including ankle pain, function affected for more than 7 days, or the ankle caused them to report to an Emergency Department. Data is collected through a series of seven questionnaires (at baseline, 3 months, 1 year, 3 years, 5 years, 10 years, and 15 years later). The questionnaires include four sections (demographic questions; index injury, and injury history questions; functional assessment questions; and quality of life questions) and are designed to collect detailed information about the individual, their injury, potential risk factors for ankle sprains and ankle osteoarthritis, plus their medical history and any medication consumed.

Discussion

The Significant Ankle Ligament Injury (SALI) study aims to add to the limited knowledge regarding which factors can predict ankle sprains, complaints, and osteoarthritis. This is important because despite ankle sprains being regarded as a benign injury that resolves quickly, residual symptoms are not uncommon months and years after the injury.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04230-8.

Self-reported sports injuries and later-life health status in 3357 retired Olympians from 131 countries: a cross-sectional survey among those competing in the games between London 1948 and PyeongChang 2018

Objective

Describe the self-reported prevalence and nature of Olympic-career injury and general health and current residual symptoms in a self-selected sample of retired Olympians.

Methods

3357 retired Olympians from 131 countries completed a cross-sectional online survey, distributed by direct email through World Olympians Association and National Olympian Associations databases. The survey captured Olympic sport exposure, significant training and competition injury history (lasting >1 month), general health (eg, depression) during the athlete’s career, and current musculoskeletal pain and functional limitations.

Results

55% were men (44% women, 1% unknown), representing 57 sports (42 Summer, 15 Winter), aged 44.7 years (range 16–97). A total of 3746 injuries were self-reported by 2116 Olympians. This equated, 63.0% (women 68.1%, men 59.2%) reporting at least one significant injury during their Olympic career. Injury prevalence was highest in handball (82.2%) and lowest in shooting (40.0%) for Summer Olympians; and highest in alpine skiing (82.4%) and lowest in biathlon (40.0%) for Winter Olympians. The knee was the most frequently injured anatomical region (20.6%, 120 median days severity), followed by the lumbar spine (13.1%, 100 days) and shoulder/clavicle (12.9%, 92 days). 6.6% of Olympians said they had experienced depression during their career. One-third of retired Olympians reported current pain (32.4%) and functional limitations (35.9%).

Conclusions

Almost two-thirds of Olympians who completed the survey reported at least one Olympic-career significant injury. The knee, lumbar spine and shoulder/clavicle were the most commonly injured anatomical locations. One-third of this sample of Olympians attributed current pain and functional limitations to Olympic-career injury.

Risk Factors for Osteochondral Lesions and Osteophytes in Chronic Lateral Ankle Instability: A Case Series of 1169 Patients

Background:

Osteochondral lesions (OCLs) and bony impingement are common secondary lesions of chronic lateral ankle instability (CLAI), but the risk factors that predict OCLs and bony impingement are unknown.

Purpose:

To analyze the risk factors for the development of OCLs and osteophytes in patients with CLAI.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Patients diagnosed with CLAI at our institution from June 2007 to May 2018 were enrolled. The assessed potential risk factors were age, sex, postinjury duration, body mass index, injury side, and ligament injury type (isolated anterior talofibular ligament [ATFL] injury, isolated calcaneofibular ligament [CFL] injury, or concomitant ATFL and CFL injuries). Univariate and multivariate logistic regression analyses were performed to evaluate the association between these factors and the presence of OCLs and osteophytes.

Results:

A total of 1169 patients with CLAI were included; 436 patients (37%) had OCLs and 334 (31%) had osteophytes. The presence of OCLs was significantly associated with the presence of osteophytes (P < .001). Male sex and older age were significantly associated with the presence of OCLs in the medial and lateral talus. A postinjury duration of 5 years or longer was significantly associated with the presence of OCLs in the medial talus (odds ratio [OR], 1.532; 95% CI, 1.023-2.293; P = .038) but not in the lateral talus. ATFL and CFL injuries were both significantly associated with the presence of lateral OCLs. Risk factors for the presence of osteophytes were male sex, older age, postinjury duration 5 years or longer, and CFL injury. Patients with concomitant ATFL and CFL injuries were significantly more likely to have osteophytes than were patients with single-ligament injuries (P = .018).

Conclusion:

Risk factors for OCLs and osteophytes were postinjury duration of 5 years or longer, older age, and male sex. ATFL injury was associated with the presence of lateral OCLs, whereas CFL injury was associated with the presence of lateral OCLs and osteophytes. Patients with these risk factors should be closely monitored and treated to reduce the incidence of ankle arthritis.

Supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization for varus ankle osteoarthritis with excessive talar tilt angle

Background

Although supramalleolar osteotomy is the main joint-preserving method for the treatment of varus ankle osteoarthritis, it tends to be ineffective when ankle osteoarthritis presents in combination with an excessive talar tilt angle. The purpose of this study was to present a new surgical technique, supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization, for the treatment of varus ankle osteoarthritis with an excessive talus tilt angle and to evaluate the clinical and radiological results.

Methods

From January 2013 to October 2016, a total of 17 patients with 17 cases of varus ankle arthritis with excessive talar tilt angles (larger than 7.3°) underwent surgical treatment using our new technique. The American Orthopaedic Foot and Ankle Society (AOFAS) clinical ankle-hindfoot scale and a visual analogue scale (VAS) were used to evaluate ankle function and pain before surgery and at the last follow-up. The medial distal tibial angle (MDTA), anterior distal tibial angle (ADTA), talar tilt angle (TTA), and hindfoot moment arm values (HMAVs) were evaluated on weight-bearing radiographs acquired preoperatively and at the last follow-up.

Results

The AOFAS score improved significantly from 45.8 ± 2.1 before surgery to 84.8 ± 1.8 after surgery (p < 0.001), and the VAS score decreased from 4.9 ± 0.4 to 1.1 ± 0.2 (p < 0.001). The MDTA, TTA, and HMAV changed from 80.9° ± 0.4° to 90.1° ± 0.4°, 11.7° ± 0.6° to 1.4° ± 0.3°, and 12.6 mm ± 0.8 mm to 4.2 mm ± 0.6 mm, respectively (each p < 0.001). The ADTA showed no obvious change (p = 0.370). The staging of 11 cases (65%) improved. Intramuscular vein thrombosis of the lower limbs occurred in 1 patient 1 week after surgery, and superficial infection occurred in 1 patient.

Conclusions

Supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization can correct the load of the weight-bearing ankle and effectively improve the ankle function. As the talar tilt angle can be significantly improved after surgery, this technique can be used for the treatment of varus ankle osteoarthritis with an excessive TTA.

Augmented Ligament Reconstruction Partially Restores Hindfoot and Midfoot Kinematics After Lateral Ligament Ruptures

BACKGROUND

Altered kinematics and persisting ankle instability have been associated with degenerative changes and osteochondral lesions.

PURPOSE

To study the effect of ligament reconstruction surgery with suture tape augmentation (isolated anterior talofibular ligament [ATFL] vs combined ATFL and calcaneofibular ligament [CFL]) after lateral ligament ruptures (combined ATFL and CFL) on foot-ankle kinematics during simulated gait.

STUDY DESIGN

Controlled laboratory study.

METHODS

Five fresh-frozen cadaveric specimens were tested in a custom-built gait simulator in 5 different conditions: intact, ATFL rupture, ATFL-CFL rupture, ATFL-CFL reconstruction, and ATFL reconstruction. For each condition, range of motion (ROM) and the average angle (AA) in the hindfoot and midfoot joints were calculated during the stance phase of normal and inverted gait.

RESULTS

Ligament ruptures mainly changed ROM in the hindfoot and the AA in the hindfoot and midfoot and influenced the kinematics in all 3 movement directions. Combined ligament reconstruction was able to restore ROM in inversion-eversion in 4 of the 5 joints and ROM in internal-external rotation and dorsiflexion-plantarflexion in 3 of the 5 joints. It was also able to restore the AA in inversion-eversion in 2 of the 5 joints, the AA in internal-external rotation in all joints, and the AA in dorsiflexion-plantarflexion in 1 of the joints. Isolated ATFL reconstruction was able to restore ROM in inversion-eversion and internal-external rotation in 3 of the 5 joints and ROM in dorsiflexion-plantarflexion in 2 of the 5 joints. Isolated reconstruction was also able to restore the AA in inversion-eversion and dorsiflexion-plantarflexion in 2 of the joints and the AA in internal-external rotation in 3 of the joints. Both isolated reconstruction and combined reconstruction were most successful in restoring motion in the tibiocalcaneal and talonavicular joints and least successful in restoring motion in the talocalcaneal joint. However, combined reconstruction was still better at restoring motion in the talocalcaneal joint than isolated reconstruction (1/3 for ROM and 1/3 for the AA with isolated reconstruction compared to 1/3 for ROM and 2/3 for the AA with combined reconstruction).

CONCLUSION

Combined ATFL-CFL reconstruction showed better restored motion immediately after surgery than isolated ATFL reconstruction after a combined ATFL-CFL rupture.

CLINICAL RELEVANCE

This study shows that ligament reconstruction with suture tape augmentation is able to partially restore kinematics in the hindfoot and midfoot at the time of surgery. In clinical applications, where the classic Broström-Gould technique is followed by augmentation with suture tape, this procedure may protect the repaired ligament during healing by limiting excessive ROM after a ligament rupture.

Subgroup characteristics of patients with chronic ankle instability in primary care

OBJECTIVES

To examine clinical and radiological characteristics of participants with an ankle sprain in general practice, classified into subgroups of a previously described chronic ankle instability (CAI) model.

DESIGN

Cross-sectional study.

METHODS

206 participants, who visited their general practitioner with a lateral ankle sprain 6-12 months before inclusion, completed a questionnaire, physical examination, radiography and magnetic resonance imaging. They were classified into three subgroups of the previously described CAI-model: mechanical instability (MI), perceived instability (PI) and recurrent sprains (RS). Regression analyses were applied to evaluate differences in subgroup characteristics.

RESULTS

A total of 192 participants were eligible to be classified into the model. Of these participants, 153 participants were classified into the subgroups and 39 could not be classified. With overlap between the subgroups and patients falling into more than one subgroup, 59 were classified having MI, 145 having PI and 30 having RS. Participants with RS and PI were more often sports participants (OR 6.83;95%CI 1.35-34.56 and OR 4.44;95%CI1.06-18.63 respectively) than participants without RS and PI. Participants with MI more often had a tenderness on palpation of the anterior talofibular ligament (OR 4.09;95%CI 1.91-8.72) and a KL-score≥1 in the talonavicular joint on X-ray (OR 2.24;95%CI 1.09-4.58), compared to participants without MI.

CONCLUSIONS

Sports participation, tenderness on palpation of the anterior talofibular ligament and early signs of osteoarthritis were variables that discriminated between subgroups of CAI. However, further research is mandatory in order to examine the usefulness of the CAI model in relation to prognosis and suitable intervention.

Prevention of Ankle Sprain Injuries in Youth Soccer and Basketball: Effectiveness of a Neuromuscular Training Program and Examining Risk Factors

OBJECTIVES

The primary objective of this study was to examine the effectiveness of a neuromuscular training (NMT) warm-up program in reducing the risk of ankle sprain injury (ASI) in youth soccer and basketball. The secondary objective included the evaluation of risk factors for ASI.

STUDY DESIGN

Secondary analysis of pooled data from 5 studies.

PARTICIPANTS

Male and female youth (11-18 years) soccer and basketball players (n = 2265) in Alberta, Canada.

OUTCOME MEASURES

Ankle sprain injury was the primary outcome and was recorded using a validated prospective injury surveillance system consistent in all studies. The primary exposure of interest was NMT warm-up, which included aerobic, strength, agility, and balance components. Multivariable Poisson regression, controlling for clustering by team and offset for exposure hours, was used to estimate incidence rate ratios (IRRs) with 95% confidence intervals (CIs), with considerations for confounding and effect modification and evaluating all covariates as potential risk factors.

RESULTS

A total of 188 ASIs were reported in 171 players. Neuromuscular training significantly reduced the risk of ASI [IRR = 0.68 (95% CI; 0.46-0.99)]. Independent risk factors for ASI included previous ASI [IRR = 1.98 (95% CI; 1.38-2.81)] and participation in basketball versus soccer [IRR = 1.83 (95% CI; 1.18-2.85)]. Sex, age, body mass index, and previous lower extremity injury (without previous ASI) did not predict ASI (P > 0.05).

CONCLUSIONS

Exposure to an NMT program is significantly protective for ASI in youth soccer and basketball. Risk of ASI in youth basketball is greater than soccer, and players with a history of ASI are at greater risk.

Cross-sectional associations between variations in ankle shape by statistical shape modeling, injury history, and race: the Johnston County Osteoarthritis Project

Background

Injury is an important risk factor for osteoarthritis (OA), a highly prevalent and disabling joint disease. Joint shape is linked to OA, but the interplay of injury and joint shape and their combined role in OA, particularly at the ankle, is not well known. Therefore, we explored cross-sectional associations between ankle shape and injury in a large community-based cohort.

Methods

Ankles without radiographic OA were selected from the current data collection of the Johnston County OA Project. Ankles with self-reported prior injury were included as injury cases (n = 108) along with 1:1 randomly selected non-injured ankles. To define ankle shape, a 68 point model on weight-bearing lateral ankle radiographs was entered into a statistical shape model, producing a mean shape and a set of continuous variables (modes) representing variation in that shape. Nineteen modes, explaining 80% of shape variance, were simultaneously included in a logistic regression model with injury status as the dependent variable, adjusted for intra-person correlation, sex, race, body mass index (BMI), baseline OA radiographic grade, and baseline symptoms.

Results

A total of 194 participants (213 ankles) were included; mean age 71 years, BMI 30 kg/m², 67% white and 71% women. Injured ankles were more often symptomatic and from whites. In a model adjusted only for intra-person correlation, associations were seen between injury status and modes 1, 6, 13, and 19. In a fully adjusted model, race strongly affected the estimate for mode 1 (which was no longer statistically significant).

Conclusions

This study showed variations in ankle shape and history of injury as well as with race. These novel findings may indicate a change in ankle morphology following injury, or that ankle morphology predisposes to injury, and suggest that ankle shape is a potentially important factor in the development of ankle OA.

The Role of Athletic Trainers in Preventing and Managing Posttraumatic Osteoarthritis in Physically Active Populations: a Consensus Statement of the Athletic Trainers' Osteoarthritis Consortium

OBJECTIVE

  To provide athletic trainers with a fundamental understanding of the pathogenesis and risk factors associated with the development of posttraumatic osteoarthritis (PTOA) as well as the best current recommendations for preventing and managing this condition.

BACKGROUND

  Posttraumatic osteoarthritis, or osteoarthritis that develops secondary to joint injury, accounts for approximately 5.5 million US cases annually. A young athlete with a joint injury is at high risk for PTOA before the age of 40, which could lead to the patient living more than half of his or her life with a painful and disabling disorder. Given our frequent contact with physically active people who often sustain traumatic joint injuries, athletic trainers are in a unique position to help prevent and manage PTOA. We can, therefore, regularly monitor joint health in at-risk patients and implement early therapies as necessary.

RECOMMENDATIONS

  The recommendations for preventing and managing PTOA are based on the best available evidence. Primary injury prevention, self-management strategies, maintenance of a healthy body weight, and an appropriate level of physical activity should be encouraged among those at risk for PTOA after acute traumatic joint injury. Education of athletic trainers and patients regarding PTOA is also critical for effective prevention and management of this disease.