Reliability and smallest real difference of the ankle lunge test post ankle fracture

Relationship between ankle dorsiflexion range of motion and sprinting and jumping ability in young athletes

OBJECTIVES

To investigate the relationship between predicted risk of injury based on the dichotomous classification of the weight-bearing lunge (WBL) test scores and variables related to jumping and sprinting ability in young athletes. Furthermore, to compare the impact of the classical dichotomous classification versus a more specific quartile subdivision of the WBL test scores on the explored variables.

DESIGN

Cross-sectional study.

PARTICIPANTS

125 healthy athletes (mean age 10.38 (SD = 2.28) years) were recruited.

MAIN OUTCOME MEASURES

Ankle dorsiflexion was evaluated with the WBL test, jumping distance with the standing long jump (SLJ) test, and maximal running speed with the 14-m and 28-m sprint test.

RESULTS

Athletes with WBL test scores lower than 10 cm exhibited significantly poorer results for the SLJ test as well as lower 14-m and 28-m sprint times than those with WBL test scores higher than 10 cm (p < 0.05). Likewise, when WBL test scores were subdivided by quartiles, a positive trend between range of motion and improved performance was shown.

CONCLUSIONS

Reduced ankle dorsiflexion mobility may affect sprinting and jumping ability in young athletes. In addition, a more detailed classification of ankle restriction by quartiles is proposed in this study in order to prevent injury and enhance athletic performance.

Recovery and Return to Activity 1 Year After Ankle Fracture Managed With Open Reduction and Internal Fixation: A Prospective Longitudinal Cohort Study

Background:

Ankle fractures are common and frequently managed with open reduction and internal fixation (ORIF). Although these fractures can occur at any age, they are most common in younger individuals with high-energy trauma or older adults with lower-energy trauma. Our investigation focused on those aged 65 years or younger. Our primary objective was to describe recovery over the first postfracture year in (1) functional dorsiflexion using the weightbearing lunge test (WBLT), (2) patient-reported functional outcomes using the Olerud Molander Ankle Score (OMAS), (3) return to prefracture activity levels, and (4) return to work. Secondarily, we examined patient and clinical factors (including the WBLT and OMAS) associated with return to prefracture activities, including sports.

Methods:

Using a prospective inception cohort of 142 patients between 18 and 65 years old who underwent ORIF after ankle fracture and attended follow-up visits, we collected information from participants and their medical charts. We assessed functional dorsiflexion (using side-to-side difference in WBLT), patient-reported functional outcome (OMAS), and self-reported return to prefracture activity levels and work at 6 weeks, 6 months and 1 year postoperatively.

Results:

The WBLT, OMAS, and return to prefracture activity and work improved significantly over time ( P < .001). However, at 1 year postoperation, the mean side-to-side difference in the WBLT was 3.22±2.68 cm, 69 (72%) reported ankle stiffness, and only 49 (52%) had returned to prefracture activity levels. Of those who were working, 97% had returned to work by 1 year postoperation. Only the OMAS ( P < .001) and side-to-side difference in WBLT ( P = .011) were significantly associated with return to prefracture activity levels.

Conclusion:

Although participants improved significantly over the first postoperative year in all outcomes, many reported limitations in functional dorsiflexion and return to prefracture activities. Those with higher OMAS scores and smaller side-to-side difference in WBLT were more likely to return to prefracture activity levels by 1 year postoperatively. Level of Evidence: Level II, prognostic study.

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

OBJECTIVES

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

DESIGN

Cross-sectional.

SETTING

Preseason.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

How Much Does the Talocrural Joint Contribute to Ankle Dorsiflexion Range of Motion During the Weight-Bearing Lunge Test? A Cross-sectional Radiographic Validity Study

BACKGROUND

Ankle dorsiflexion range of motion is commonly measured during the weight-bearing lunge test (WBLT) as the horizontal knee distance traveled or tibial inclination. These measures are assumed to represent talocrural dorsiflexion, yet have not been validated against radiographic images.

OBJECTIVES

To determine the (1) contribution of the talocrural joint to tibial inclination during the WBLT, (2) validity of inclinometer and photographic measures of tibial inclination compared to radiographic images, and (3) the association between tibial inclination and horizontal distance measures.

METHODS

Tibial inclination using an inclinometer, horizontal distance via a ruler, and radiographic and photographic images were recorded in 20 participants in standing and during the end-range WBLT. Two assessors used computer software to measure talar rotation and tibial inclination from digital radiographs and photographs. The limits of agreement between photographic and inclinometer measures compared to radiographic measures, as well as correlations between measures, were calculated.

RESULTS

In the end-range WBLT, 91.8% of motion occurred at the talocrural joint, with 8.2% occurring distally. There were very strong correlations (all, r 0.88, P<.001) between end-range radiographic and photographic measures, radiographic and inclinometer measures, and radiographic, inclinometer, and photographic measures of tibial inclination and horizontal lunge distance. Calculation of the limits of agreement indicated unacceptable agreement between inclinometer and radiographic measures (-7.84°, 5.92°) and acceptable agreement between photographic and radiographic measures (-2.17°, 2.49°).

CONCLUSION

Tibial inclination during the WBLT primarily occurs at the talocrural joint. While inclinometer and photographic measures of tibial inclination can reliably be used clinically to measure dorsiflexion range of motion during the WBLT, inclinometer results differ slightly from those obtained via radiographs. J Orthop Sports Phys Ther 2019;49(12):934-941. Epub 23 Jul 2019. doi:10.2519/jospt.2019.8697.

MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: A DESCRIPTIVE CASE SERIES

Background and Purpose

Lateral ankle sprain the most common injury in physically active populations. Individuals who sustain an acute lateral ankle sprain may not receive timely formal rehabilitation and are at an increased risk to have subsequent sprains which can lead to chronic pain and instability. Attention to essential factors for ligament protection and healing while preserving ankle movement, may result in a more stable yet mobile ankle offering improved outcomes. The purpose of this case series was to describe the methods and observe the outcomes associated with a comprehensive strategy for managing acute first episode grade II lateral ankle sprains.

Study design

Prospective case series.

Case Descriptions and Interventions

Ten patients (mean age 26.7 years, range 16-51 years, mean 2.3 days from injury) with acute grade II lateral ankle sprain were treated with an approach to protect the injured ligament, prevent impairments to movement, restore strength and proprioception, and progress to full function. Patient outcomes were assessed at four, eight and 12 weeks. Follow-up interviews at six and 12 months assessed injury recurrence.

Outcomes

Patients were treated for an average of eight sessions over a mean of seven weeks. Rapid change in self-reported function, ankle ROM, and pain were observed in the first four weeks of care. Clinically meaningful improvements in function and ankle ROM were also noted at eight weeks and maintained at 12-week follow-ups. All patients returned to desired physical activity with only a single re-sprain event within one year after injury.

Conclusion

The results of this prospective case series suggest that a treatment approach designed to protect the injured ligament, maintain and restore normal ankle motion, and provide a tailored functional pathway to return to run and sport demonstrated resolution of symptoms and improvement in reported functional outcomes in a group of patients following grade II acute primary ankle sprain.

Level of Evidence

Level IV, Case Series.

Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial

BACKGROUND

Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients.

OBJECTIVES

To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture.

METHODS

In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling.

RESULTS

There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (-47.9 N/m; 95% confidence interval: -86.1, -9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%.

CONCLUSION

A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation.

LEVEL OF EVIDENCE

Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):310-319. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8864.

Ankle dorsiflexion: what is normal? Development of a decision pathway for diagnosing impaired ankle dorsiflexion and M. gastrocnemius tightness

INTRODUCTION

Impaired ankle dorsiflexion (ADF) is known to increase forefoot pressure, which is associated to various pathologies affecting the foot and ankle. M. gastrocnemius tightness (MGT) is its most common cause. Up to date we are missing a standardized examination procedure, norm values, and a valid decision pathway to diagnose impaired ADF and MGT. The aim of this study was to define norm values for ADF using a standardized examination procedure. These were used to define a decision pathway to diagnose impaired ADF and MGT.

MATERIALS AND METHODS

64 young, asymptomatic subjects were examined. Based on a standardized examination procedure, bilateral ADF, both with the knee extended and flexed, non-weight bearing and weight bearing, was assessed by three investigators. Inter-rater test reliability and norm values for ADF were calculated. Side differences were analyzed. ADF differences between the knee extended and flexed were calculated.

RESULTS

The standardized examination procedure revealed high ICC values (0.876-0.915). ADF values with the knee extended for the left/right limb were 22.7° ± 5.9° [95 % CI 21.2°-24.3°]/23.4° ± 6.5° [95 % CI 21.7°-25.1°] non-weight bearing and 33.3° ± 5.5° [95 % CI 31.9°-34.7°]/33.6° ± 5.6° [95 % CI 32.1°-35.0°] weight bearing. Physiological side differences with the knee extended were <6° (95 % CI). Knee flexion resulted in an approximate ADF increase of 10°.

CONCLUSIONS

Based on an extensive systematic approach, physiological values for ADF were assessed in a large asymptomatic population. This allowed the definition of a decision pathway to diagnose impaired ADF and MGT. Patients presenting with pathologies associated with impaired ADF should be examined according to the herein presented examination protocol. This systematic approach provides a consistent definition of impaired ADF and MGT, which is the prerequisite to study the effectiveness of treatment strategies for MGT.

Diagnosis of Musculus Gastrocnemius Tightness - Key Factors for the Clinical Examination

Common foot and ankle pathologies have been linked to isolated Musculus gastrocnemius tightness (MGT). Various examination techniques have been described to assess MGT. Still, a standardized examination procedure is missing. Literature argues for weightbearing examination but the degree of knee flexion needed to eliminate the restraining effect of the M. gastrocnemius on ankle dorsiflexion (ADF) is unknown. This manuscript investigates the effect of knee flexion on ankle dorsiflexion and provides a detailed description of a standardized examination protocol. Examination on 20 healthy individuals revealed, that 20° of knee flexion is sufficient to fully eliminate the influence of the M. gastrocnemius on ADF. This builds the prerequisite for a standardized examination for MGT. Non-weightbearing and weightbearing examination of ADF has to be conducted with the knee fully extended and at least 20° flexed. Two investigators should conduct non-weightbearing testing with the subject in supine position. In order to obtain reliable results, the axis of the fibula should be marked. One examiner can conduct weightbearing examination with the subject in lunge stance. Isolated MGT is present if ADF is impaired with the knee fully extended and knee flexion results in a significant ADF increase. The herein presented standardized examination is the prerequisite for future studies aiming at establishing norm values.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series

STUDY DESIGN

Case series.

BACKGROUND

Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures.

CASE DESCRIPTION

Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline.

OUTCOMES

Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks.

DISCUSSION

Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population.

LEVEL OF EVIDENCE

Therapy, level 4.

Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review

Ankle dorsiflexion range of motion (DROM) is often a point of emphasis during the rehabilitation of lower extremity pathologies. With the growing popularity of weight-bearing DROM assessments, several versions of the weight-bearing lunge (WBLT) test have been developed and numerous reliability studies have been conducted. The purpose of this systematic review was to critically appraise and synthesize the studies which examined the reliability and responsiveness of the WBLT to assess DROM. A systematic search of PubMed and EBSCO Host databases from inception to September 2014 was conducted to identify studies whose primary aim was assessing the reliability of the WBLT. The Quality Appraisal of Reliability Studies assessment tool was utilized to determine the quality of included studies. Relative reliability was examined through intraclass correlation coefficients (ICC) and responsiveness was evaluated through minimal detectable change (MDC). A total of 12 studies met the eligibility criteria and were included. Nine included studies assessed inter-clinician reliability and 12 included studies assessed intra-clinician reliability. There was strong evidence that inter-clinician reliability (ICC = 0.80-0.99) as well as intra-clinician reliability (ICC = 0.65-0.99) of the WBLT is good. Additionally, average MDC scores of 4.6° or 1.6 cm for inter-clinician and 4.7° or 1.9 cm for intra-clinician were found, indicating the minimal change in DROM needed to be outside the error of the WBLT. This systematic review determined that the WBLT, regardless of method, can be used clinically to assess DROM as it provides consistent results between one or more clinicians and demonstrates reasonable responsiveness.