Lack of Consensus on Return-to-Sport Criteria Following Lateral Ankle Sprain: A Systematic Review of Expert Opinions

Effect of aquatic versus conventional physical therapy program on ankle sprain grade III in elite athletes: randomized controlled trial

INTRODUCTION

Ankle sprains are the second most common sports injury after knee injuries, with about 85% of them affecting the lateral ankle ligaments. These injuries are particularly prevalent in sports like basketball and volleyball.

PURPOSE

To investigate the effect of Aquatic therapy as an early rehabilitation protocol for elite athletes with acute lateral ankle sprain grade III on back-to-sport time, dynamic balance, pain, Athletic performance, and muscle power compared to land-based exercise training.

METHODS

Thirty elite athletes have ankle sprain grade III with sprain onset from 1 to 7 days, their age ranges from 18-30 years old were recruited. All participants are professional athletes; mainly participating in above-head sports such as volleyball and basketball. The patients were randomly allocated into two treatment groups: Group I (control group): 15 patients received a conventional physical therapy program of structured therapeutic exercise program, manual therapy and land-based exercises, in addition to external support, and Group II (Aquatic therapy group): 15 patients received aquatic training. Visual Analog Scale (VAS) was used to measure the pain intensity, while the dynamic balance was measured by the Star Excursion Balance Test. Athletic performance was measured by HOP Tests (Single, Triple, 6-m, and Cross-over hops) aided by the Agility T-Test (ATT) and Illinois Agility Test (IAT). Muscle power was tested by a Single Leg Press. Finally, back to sports time was recorded for each participant in both groups.

RESULTS

There was a significant interaction effect of Aquatic therapy and time for VAS (p < 0.001), single hop (p < 0.001), triple hop (p < 0.001), cross-over hop (p < 0.001), IAT (p = 0.019) and ATT (p < 0.001) of both affected and nonaffected. There was no significant interaction effect of Aquatic therapy and time for 6-MHT of affected (p = 0.923), and nonaffected (p = 0.140). There was a significant main effect of time for all dependent variables (p < 0.001) except for 6-MHT of affected (p = 0.939), nonaffected (p = 0.109), and IAT (p = 0.099). The Star excursion dynamic balance test (SEBT) and Single leg press revealed a significant difference between groups on affected and non-affected sides (p < 0.001*). Lastly and most importantly the back-to-sport time revealed a significant difference in the return-to-sport time in favor of the Aquatic therapy group who returned faster than the control group (p < 0.001*).

CONCLUSION

Aquatic therapy is more effective than traditional protocols regarding early rehabilitation of acute ankle sprain grade III in Elite professional athletes for reducing pain intensity, improving dynamic balance and athletic performance and power and accelerating their return to sports time. Because aquatic therapy produces better outcomes, it is advised to be included in the rehabilitation programs of athletic patients with acute ankle sprains grade III.

A Rehabilitation Algorithm After Lateral Ankle Sprains in Professional Football (Soccer): An Approach Based on Clinical Practice Guidelines

Lateral ankle sprain (LAS) is one of the most common types of injury in professional football (soccer) players with high risk of recurrence. The rehabilitation after LAS in professional football players is often still time-based and relies on anecdotal experience of clinicans. There is still a lack of utilization of criteria-based rehabilitation concepts after LAS in professional football. The aims of this clinical commentary are (1) to critically discuss the need for criteria-based rehabilitation concepts after LAS in professional football players, (2) to highlight the current lack of these approaches and (3) to present a novel clinical guideline-based rehabilitation algorithm. Short time-loss (15 days) and high recurrence rate (17%) raise the question of trivialization of LAS in professional football. Despite consequences for many stakeholders involved (players, teams, clubs, insurers), there is still a lack of of criteria-based, step-by-step approaches. The use of a criteria-based rehabilitation approach might reduce the high recurrence rate after LAS in professional football players and will lead, in turn, to increased long-term player availability. Practical experiences of he authors demonstrate the feasibility of such an approach. The effectiveness of this novel rehabilitation algorithm remains to be evaluated in future studies. Level of Evidence: 5.

Ankle ligament reconstruction-return to sport after injury scale and return to sports after ankle ligament reconstruction or repair-A systematic review

Purpose

To systematically review existing literature regarding the ankle ligament reconstruction-return to sport after injury (ALR-RSI) scale and to assess its correlation with Return to sport and functional outcomes as well as feasibility, reliability and consistency.

Methods

A systematic review of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) was conducted using PubMed, Embase and Cochrane Library. Studies that evaluated psychological readiness to return to sport after ankle ligament reconstruction or repair for the treatment of chronic lateral ankle instability using the ALR-RSI scale were included. The results from each study were pooled, and weighted means and overall rates were calculated.

Results

In total, 157 patients (53.2% male, mean age: 34.2 years) from three articles were included. Overall, 85.0% of patients reported successful return to sport, but only 48.9% of patients returned to the preoperative sporting level. All studies reported a significant difference in psychological scores between patients who returned to sport and those who did not. Pooled mean patient-reported outcome measures, reported as the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS, three studies) Score and Karlsson-Peterson Score (three studies), were 82.7 (range: 29-100) and 81.7 (range: 25-100), respectively. The ALR-RSI scale demonstrated strong correlations with the AOFAS Score and Karlsson-Peterson Score.

Conclusion

Patients who returned to sport after ankle ligament reconstruction or repair exhibited higher psychological readiness compared to those who did not. The ALR-RSI scale showed strong correlations with ankle function. Evaluation of psychological readiness using the ALR-RSI scale may provide an additional tool in the assessment of patients who underwent ankle ligament reconstruction or repair.

Level of Evidence

Level III, systematic review.

Low Ankle-GO Score While Returning to Sport After Lateral Ankle Sprain Leads to a 9-fold Increased Risk of Recurrence: A Two-year Prospective Cohort Study

BACKGROUND

Lateral ankle sprain (LAS) is the most common sports injury, leading to a high rate of recurrence and the development of chronic ankle instability. One possible explanation is the lack of objective, evidence-based criteria to inform return to sport decisions following LAS. The aim of this study was therefore to assess the efficacy of a new functional score to distinguish patients at risk of recurrent LAS within two years after the initial injury.

METHODS

The Ankle-GO score was used in 64 active patients two months after LAS. This composite score includes 2 self-reported questionnaires and 4 functional tests, for a maximum score of 25 points. The rate of reinjury was prospectively recorded 2 years after inclusion. Potential predictive variables for reinjury were tested using the Chi-square and independent t-tests. The area under the receiver operating characteristics curve (AUC) with the optimal cut-off score was determined to assess the predictive value of the Ankle-GO score for the risk of reinjury. Multivariate logistic regression was then used to determine the influence of risk factors of reinjury.

RESULTS

Fifty-four (85%) patients were included (23 men and 31 women, 34.7 ± 13 years old) including 18 (33.3%) with a reinjury. The two-month Ankle-GO score was lower in patients with a recurrent LAS (5.4 ± 2.8 points vs. 9.1 ± 4.5, p = 0.002) and predicted the risk of reinjury (AUC = 0.75). Patients with < 8 points were found to have a significantly higher risk of reinjury (OR = 8.6; 95%CI: 2-37.2, p = 0.001). Women also tend to have a higher risk of recurrence (OR = 3.8; 95%CI: 0.9-15.5, p = 0.065).

CONCLUSION

The Ankle-GO score is a new objective criterion for RTS after LAS. Patients with a low score at two months have a 9-fold greater risk of recurrence within two years.

The Perils of Misinterpreting and Misusing "Publication Bias" in Meta-analyses: An Education Review on Funnel Plot-Based Methods

Publication bias refers to a systematic deviation from the truth in the results of a meta-analysis due to the higher likelihood for published studies to be included in meta-analyses than unpublished studies. Publication bias can lead to misleading recommendations for decision and policy making. In this education review, we introduce, explain, and provide solutions to the pervasive misuses and misinterpretations of publication bias that afflict evidence syntheses in sport and exercise medicine, with a focus on the commonly used funnel-plot based methods. Publication bias is more routinely assessed by visually inspecting funnel plot asymmetry, although it has been consistently deemed unreliable, leading to the development of statistical tests to assess publication bias. However, most statistical tests of publication bias (i) cannot rule out alternative explanations for funnel plot asymmetry (e.g., between-study heterogeneity, choice of metric, chance) and (ii) are grossly underpowered, even when using an arbitrary minimum threshold of ten or more studies. We performed a cross-sectional meta-research investigation of how publication bias was assessed in systematic reviews with meta-analyses published in the top two sport and exercise medicine journals throughout 2021. This analysis highlights that publication bias is frequently misused and misinterpreted, even in top tier journals. Because of conceptual and methodological problems when assessing and interpreting publication bias, preventive strategies (e.g., pre-registration, registered reports, disclosing protocol deviations, and reporting all study findings regardless of direction or magnitude) offer the best and most efficient solution to mitigate the misuse and misinterpretation of publication bias. Because true publication bias is very difficult to determine, we recommend that future publications use the term "risk of publication bias".

Assessments Used by Athletic Trainers to Decide Return-to-Activity Readiness in Patients With an Ankle Sprain

CONTEXT

Athletic trainers (ATs) often care for patients with ankle sprains. Expert consensus has been established for rehabilitation-oriented assessments (ROASTs) that should be included in ankle-sprain evaluations. However, the methods ATs use to determine return-to-activity readiness after an ankle sprain are unknown.

OBJECTIVES

To identify ATs' methods for determining patients' return-to-activity readiness after an ankle sprain and demographic characteristics of the ATs and their methods.

SETTING

Online survey.

DESIGN

Cross-sectional study.

PATIENTS OR OTHER PARTICIPANTS

We recruited 10 000 clinically practicing ATs. A total of 676 accessed the survey, 574 submitted responses (85% completion rate), and 541 respondents met the inclusion criteria.

MAIN OUTCOME MEASURE(S)

We distributed an online survey to ATs that asked about their assessment of pain, swelling, range of motion, arthrokinematics, strength, balance, gait, functional capacity, physical activity level, and patient-reported outcomes in deciding return to activity. Descriptive statistics were used to characterize participant demographics and frequencies of the assessment measures used by ATs. Chi-square analysis was conducted to identify relationships between the demographics and assessment selection.

RESULTS

Pain, swelling, range of motion, strength, balance, gait, and functional capacity were assessed by 76.2% to 96.7% of ATs. Arthrokinematics, physical activity level, and patient-reported outcomes were assessed by 25.3% to 35.1% of participants. When selecting specific assessment methods, ATs often did not use recommended ROASTs. Athletic trainers with higher degrees, completion of more advanced educational programs, employment in nontraditional settings, more clinical experience, and familiarity with expert consensus recommendations were more likely to use ROASTs.

CONCLUSIONS

Before approving return to activity for patients with ankle sprains, ATs did not use some recommended outcomes and assessment methods. Practice in nontraditional settings, more advanced degrees, more clinical experience, and familiarity with expert consensus guidelines appeared to facilitate the use of ROASTs.

Development and Validation of the Ankle-GO Score for Discriminating and Predicting Return-to-Sport Outcomes After Lateral Ankle Sprain

BACKGROUND

Lateral ankle sprain (LAS) is the most common sports-related injury. However, there are currently no published evidence-based criteria to guide the patient's return to sport (RTS) and this decision is generally time-based. The aim of this study was to assess the psychometric properties of a new score (Ankle-GO) and its predictive ability for RTS at the same level of play after LAS.

HYPOTHESIS

The Ankle-GO is robust for discriminating and predicting RTS outcomes.

STUDY DESIGN

Prospective diagnostic study.

LEVEL OF EVIDENCE

Level 2.

METHODS

The Ankle-GO was administered to 30 healthy participants and 64 patients at 2 and 4 months after LAS. The score was calculated as the sum of 6 tests for a maximum of 25 points. Construct validity, internal consistency, discriminant validity, and test-retest reliability were used to validate the score. The predictive value for the RTS was also validated based on the receiver operating characteristic (ROC) curve.

RESULTS

The internal consistency of the score was good (Cronbach's alpha coefficient of 0.79) with no ceiling or floor effect. Test-retest reliability was excellent (intraclass coefficient correlation = 0.99) with a minimum detectable change of 1.2 points. The 2-month scores were significantly lower than 4-month and control group scores (7.7 ± 4, 13.9 ± 4.6, and 19.6 ± 3.4 points, respectively, P < 0.01). Ankle-GO values were also significantly higher in patients who returned to their preinjury level at 4 months compared with those who did not (P < 0.01). The predictive value of the 2-month Ankle-GO score was fair for a RTS at the same or higher than preinjury level at 4 months (area under ROC curve, 0.77; 95% CI, 0.65-0.89; P < 0.01).

CONCLUSION

The Ankle-GO appears to be a valid and robust score for clinicians to predict and discriminate RTS in patients after LAS.

CLINICAL RELEVANCE

Ankle-GO is the first objective score to help in the decision-making of the RTS after LAS. At 2 months, patients with an Ankle-GO score <8 points are unlikely to RTS at the same preinjury level.

Immediate effects of local muscle vibration on static and dynamic balance control in individuals with chronic ankle instability

OBJECTIVES

To investigate the immediate effects of local muscle vibration (LMV) on static and dynamic balance control in individuals with and without chronic ankle instability (CAI).

DESIGN

Quasi-experimental study.

SETTING

Research laboratory.

PARTICIPANTS

Twenty-six individuals with CAI and 26 healthy controls.

MAIN OUTCOME MEASURES

Center of pressure variables (mean total velocity and displacement in anteroposterior (AP) and mediolateral (ML) directions) during single-leg standing with eyes open and eyes closed and also reach distances in anterior (ANT), posteromedial (PM), and posterolateral (PL) directions of the modified star excursion balance test (MSEBT) were assessed before and after LMV.

RESULTS

Statistical analyses showed a significant decrease in mean total velocity and displacement in AP direction from before to after LMV in eyes open condition for both individuals with CAI (p = 0.025, p = 0.041, respectively) and healthy controls (p = 0.001, p = 0.003, respectively). Similar results were observed in eyes closed condition for both individuals with CAI (p < 0.001, p < 0.001, respectively) and healthy controls (p = 0.040, p = 0.014, respectively). The results also showed increased reach distances in ANT (p < 0.001), PM (p < 0.001), and PL directions (p < 0.001) in all participants after LMV.

CONCLUSION

Our results suggest that LMV may be a useful tool in rehabilitation of static and dynamic balance deficits in individuals with CAI.

Evaluating Functional Performance Tests in those with Non-arthritic Intra-articular Hip Pain: An International Consensus Statement

Background

Non-arthritic intra-articular hip pain, caused by various pathologies, leads to impairments in range of motion, strength, balance, and neuromuscular control. Although functional performance tests offer valuable insights in evaluating these patients, no clear consensus exists regarding the optimal tests for this patient population.

Purpose

This study aimed to establish expert consensus on the application and selection of functional performance tests in individuals presenting with non-arthritic intra-articular hip pain.

Study Design

A modified Delphi technique was used with fourteen physical therapy experts, all members of the International Society for Hip Arthroscopy (ISHA). The panelists participated in three rounds of questions and related discussions to reach full consensus on the application and selection of functional performance tests.

Results

The panel agreed that functional performance tests should be utilized at initial evaluation, re-evaluations, and discharge, as well as criterion for assessing readiness for returning to sports. Tests should be as part of a multimodal assessment of neuromuscular control, strength, range of motion, and balance, applied in a graded fashion depending on the patient's characteristics. Clinicians should select functional performance tests with objective scoring criteria and prioritize the use of tests with supporting psychometric evidence. A list of recommended functional performance tests with varying intensity levels is provided. Low-intensity functional performance tests encompass controlled speed in a single plane with no impact. Medium-intensity functional performance tests involve controlled speed in multiple planes with low impact. High-intensity functional performance tests include higher speeds in multiple planes with higher impact and agility requirements. Sport-specific movement tests should mimic the patient's particular activity or sport.

Conclusion

This international consensus statement provides recommendations for clinicians regarding selection and utilization of functional performance tests for those with non-arthritic intra-articular hip pain. These recommendations will encourage greater consistency and standardization among clinicians during a physical therapy assessment.

Health-seeking behaviors, management practices, and return to play decisions after an ankle sprain in netball: An international cross-sectional survey of 1592 non-elite netballers

OBJECTIVES

Evaluate if non-elite netballers sought health care, treatments received, and return-to-play decisions after an ankle sprain, including intercountry differences.

DESIGN

Cross-sectional survey.

METHODS

Non-elite netballers aged >14 years were recruited from Australia, United Kingdom, and New Zealand. Participants completed an online survey regarding their last ankle sprain and were queried regarding health care sought, health professionals consulted, treatments received, time missed, and return-to-play clearance. Data were described using number (proportion) for the overall cohort and countries. Between-country differences in health care use were compared using chi-square tests. Descriptive statistics were presented for management practices.

RESULTS

We received 1592 responses from Australian (n = 846), United Kingdom (n = 454), and New Zealand (n = 292) netballers. Three in five (n = 951, 60 %) sought health care. Of those, most consulted a physiotherapist (n = 728, 76 %), received strengthening exercises (n = 771, 81 %), balance exercises (N = 665, 70 %) and taping (n = 636, 67 %). Few received return-to-play clearance (n = 362, 23 %). Comparing countries, fewer United Kingdom netballers sought health care than Australian and New Zealand netballers (Australia: 60 % vs United Kingdom: 53 % vs New Zealand: 68 %, p < 0.001), consulted a physiotherapist (Australia: 79 %, United Kingdom: 63 %, New Zealand: 87 %), received strengthening (Australia: 84 %, United Kingdom: 73 %, New Zealand: 84 %) or balance exercises (Australia: 71 %, United Kingdom: 60 %, New Zealand: 80 %) or taping (Australia: 74 %, United Kingdom: 39 %, New Zealand: 82 %). More Australian netballers returned to play within 1-7 days (Australia: 25 %, United Kingdom: 15 %, New Zealand: 21 %) and fewer United Kingdom netballers received return-to-play clearance (Australia: 28 %, United Kingdom: 10 %, New Zealand: 28 %).

CONCLUSIONS

Health-seeking behaviours are adopted by some, but not all netballers after an ankle sprain. For those who sought care, most consulted a physiotherapist and were prescribed exercise-based interventions and external ankle support, but few received return-to-play clearance. Comparing countries, United Kingdom netballers had lower health-seeking behaviours and received less best-practice management than Australian and New Zealand netballers.

Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Limited evidence exists regarding the assessment of single-item patient-reported outcomes when patients are medically cleared to return to sport after a lateral ankle sprain (LAS) injury.

OBJECTIVE

To evaluate self-reports of improvement in health status, pain, function, and disability at return to sport after an LAS.

DESIGN

Descriptive study.

SETTING

Sixty-nine athletic training facilities across 24 states.

PATIENTS OR OTHER PARTICIPANTS

A total of 637 patients (males = 53.2%) who were diagnosed with an LAS, restricted from sport after injury, and subsequently medically cleared to return to sport within 60 days were included.

MAIN OUTCOME MEASURE(S)

Descriptive statistics were used to summarize scores for health status (Global Rating of Change), pain (Numeric Pain Rating Scale), function (Global Rating of Function), and disability (Global Rating of Disability). Mann-Whitney U tests were used to compare score differences between sexes. A Kaplan-Meier analysis was performed to provide a visual depiction of sex differences in the time to return to sport.

RESULTS

Most patients sustained an LAS injury while participating in basketball, football, or soccer and were cleared to return to sport 8 days after injury. More than two-thirds of patients reported a meaningful improvement in health status between the time of injury and return to sport. However, many noted deficits related to pain (65.1%), function (86.2%), or disability (35.8%) at return to sport. No differences were seen between males and females for pain (P = .90), function (P = .68), change in health status (P = .45), or disability (P = .21) at return to sport, although males returned to sport slightly sooner than females (P = .025).

CONCLUSIONS

Despite self-perceived improvements in health status since the time of injury, patients typically returned to sport with deficits in pain, function, and disability after an LAS. Patients may be returning to unrestricted sport participation before they feel their bodies have fully recovered from the injury.

Inertial sensors-based assessment to detect hallmarks of chronic ankle instability during single-leg standing: Is the healthy limb "healthy"?

BACKGROUND

Chronic ankle instability can be common in sportsmen and can increase the risk of damaging the articular surfaces and result in negative consequences to joint health. Balance assessment is often used to evaluate ankle instability characteristics and guide rehabilitation protocols. This study aims to investigate balance-related parameters in people with chronic ankle instability and healthy-matched controls, using inertial sensors.

METHODS

Ten young adults with a history of multiple ankle sprains (30 y, 25-34, 5 females) and ten matched healthy controls (30 y, 23-39, 5 females) were invited to participate in the study. Inertial sensors were placed on the head of the astragalus and on the chest to collect kinematic parameters during a 20-s single-leg stance performed on the leg with ankle instability (and corresponding for the healthy controls) and on the contralateral leg, randomly. Outcomes were calculated with MATLAB and subsequently analyzed.

FINDINGS

A significant group effect was found only for the inversion angle (F_1,15 = 12.514, p = 0.003, pη² = 0.455), consisting of individuals with ankle instability being characterized by higher inversion angles (4.999 degrees, 95% CI: 1.987-8.011, p = 0.003) without significant side differences. No significant side x group effects were found for the assessed parameters.

INTERPRETATION

Results from this study suggest that young adults with chronic ankle instability might be characterized by worse single-stance control in terms of inversion angle, and such worse performance could also be found in the contralateral leg. As such, inertial sensors could be used to assess kinematic parameters during balance tasks in people with chronic ankle instability.

Rehabilitation of a lateral ankle reconstruction in a male professional football player - A narrative case report

OBJECTIVES

Lateral ankle sprains involving the ATFL and CFL are common injuries in football with a high recurrence rate. There is a lack of research to guide post-operative rehabilitation of football players following lateral ligament ankle reconstructive surgery. This narrative case report discusses the management of a lateral ligament reconstruction in a male professional football player.

METHODS

A 25-year-old professional footballer underwent a lateral ankle reconstruction following recurrent lateral ankle sprains leading to an unstable ankle.

RESULTS

Following 11-weeks of rehabilitation the player was cleared to return to full-contact training. The player competed in his first competitive match 13-weeks post-injury and completed a 6-month full-training block, without episodes of pain or instability.

CONCLUSION

This case report illustrates the rehabilitation process of a football player following a lateral ankle ligament reconstruction within a timeframe expected in elite sport.

Inertial Sensor-Based Assessment of Static Balance in Athletes with Chronic Ankle Instability

The Balance Error Scoring System (BESS), a subjective examiner-based assessment, is often employed to assess postural balance in individuals with chronic ankle instability (CAI); however, inertial sensors may enhance the detection of balance deficits. This study aimed to compare the BESS results between the CAI and healthy groups using conventional BESS scores and inertial sensor data. The BESS test (six conditions: double-leg, single-leg, and tandem stances on firm and foam surfaces, respectively) was performed for the CAI (n = 16) and healthy control (n = 16) groups with inertial sensors mounted on the sacrum and anterior shank. The BESS score was calculated visually by the examiner by counting postural sway as an error based on the recorded video. The root mean square for resultant acceleration (RMS_acc) in the anteroposterior, mediolateral, and vertical directions was calculated from each inertial sensor affixed to the sacral and shank surfaces during the BESS test. The mixed-effects analysis of variance and unpaired t-test were used to assess the effects of group and condition on the BESS scores and RMS_acc. No significant between-group differences were found in the RMS_acc of the sacral and shank surfaces, and the BESS scores (P > 0.05), except for the total BESS score in the foam condition (CAI: 14.4 ± 3.7, control: 11.7 ± 3.4; P = 0.039). Significant main effects of the conditions were found with respect to the BESS scores and RMS_acc for the sacral and anterior shank (P < 0.05). The BESS test with inertial sensors can detect differences in the BESS conditions for athletes with CAI. However, our method could not detect any differences between the CAI and healthy groups.

Patients Experience Significant and Meaningful Changes in Self-Report of Function During the First 2 Weeks After an Ankle Sprain Injury: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Ankle sprains are common during sport participation and associated with long-term deficits in self-report of function. However, little is known of short-term changes in self-report of function following injury. The authors aimed to assess statistical and clinically meaningful changes in self-report of function, as measured by the Foot and Ankle Ability Measure (FAAM), during the first 2 weeks after an ankle sprain injury.

DESIGN

A retrospective analysis of electronic medical records.

METHODS

Eighty-eight patients, who were diagnosed with an ankle sprain injury by an athletic trainer, received usual care from an athletic trainer, and completed the FAAM during treatment at weeks 1 and 2 postinjury. The authors calculated the percentage of patients who reported clinically meaningful changes and used Wilcoxon signed-rank tests to compare differences in FAAM scores between time points.

RESULTS

Between weeks 1 and 2, significant differences were noted for the FAAM Activities of Daily Living (FAAM-ADL) (P < .001) and FAAM Sport (FAAM-Sport) (P < .001). At the patient level, 86.5% (64/74) and 85.2% (69/81) of patients reported changes that exceeded the minimal clinically important difference value for the FAAM-ADL and FAAM-Sport, respectively, between weeks 1 and 2. At week 2, 31.8% (28/88) and 47.7% (42/88) of patients reported a score below 90% on the FAAM-ADL and below 80% on the FAAM-Sport subscale, respectively. Also, 36.4% (32/88) and 25.0% (22/88) of patients reported a score of 100% on the FAAM-ADL and FAAM-Sport subscales, respectively, at week 2.

CONCLUSIONS

Patients report statistically significant and meaningful improvements in self-report of function during the first 2 weeks following ankle sprain injury. However, almost half of patients still report deficits in sport function at 2 weeks postinjury. Patient-reported outcome measures such as the FAAM, can help capture the patient's perception of function and inform patient care decisions. Research efforts should explore individual response patterns to treatment.

Do people with musculoskeletal pain differ from healthy cohorts in terms of global measures of strength? A systematic review and meta-analysis

OBJECTIVE

It is currently unknown if people with musculoskeletal pain display different multi-joint strength capacities than healthy cohorts. The aim was to investigate whether people with musculoskeletal pain show differences in global measures of strength in comparison to healthy cohorts.

DATA SOURCES

A systematic review was conducted using three databases (Medline, CINAHL and SPORTDiscus) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

REVIEW METHODS

Studies involving participants with painful musculoskeletal conditions and multi-joint strength assessment measured at baseline were included. A meta-analysis was also performed to compute standardized mean differences (± 95% confidence intervals), using Hedge's g, and examined the differences in multi-joint strength at baseline between participants with painful musculoskeletal conditions and healthy participants.

RESULTS

In total, 5043 articles were identified, of which 20 articles met the inclusion criteria and were included in the qualitative analysis. The available evidence revealed that multi-joint strength values were limited to knee osteoarthritis, fibromyalgia, chronic low back pain, and rheumatoid arthritis. Only four studies were included in the quantitative synthesis and revealed that only small differences in both chest press (g = -0.34, 95% CI [-0.64, -0.03]) and leg press (g = -0.25, 95% CI [-0.49, -0.02]) existed between adult women with fibromyalgia and active community women.

CONCLUSION

There is a paucity of multi-joint strength values in participants with musculoskeletal pain. Quantitative comparison with healthy cohorts was limited, except for those with fibromyalgia. Adult women with fibromyalgia displayed reduced multi-joint strength values in comparison to active community women.

Time-loss and recurrence of lateral ligament ankle sprains in male elite football: A systematic review and meta-analysis

A literature search was conducted to systematically review and meta-analyze time-loss and recurrence rate of lateral ankle sprains (LAS) in male professional football players. Six electronic databases (PubMed, Scopus, Web of Science, PEDRO, CINAHL, and Cochrane) were searched independently, separately both for time-loss and recurrence from inception until April 30, 2021. In addition, reference lists were screened manually to find additional literature. Cohort studies, case reports, case-control studies and RCT in English language of male professional football players (aged more than 16 years) for which data on time-loss or recurrence rates of LAS were available were included. A total of 13 (recurrence) and 12 (time-loss) studies met the inclusion criteria. The total sample size of the recurrence studies was 36,201 participants (44,404 overall initial injuries; 7944 initial ankle sprain [AS] injuries, 1193 recurrent AS injuries). 16,442 professional football players (4893 initial AS injuries; 748 recurrent AS injuries) were meta-analyzed. A recurrence rate of 17.11% (95% CI: 13.31-20.92%; df = 12; Q = 19.53; I² = 38.57%) based on the random-effects model was determined. A total of 7736 participants were part of the time-loss studies (35,888 total injuries; 4848 total ankle injuries; 3370 AS injuries). Out of the 7736 participants, 7337 participants met the inclusion criteria with a total of 3346 AS injuries. The average time-loss was 15 days (weighted mean: 15.92; median: 14.95; min: 9.55; max: 52.9). We determined a priori considerable heterogeneity (CI: 18.15-22.08; df = 11; Q = 158; I² = 93%), so that the data on time-loss are only presented descriptively. There is an average time-loss of 15 days per LAS and a recurrence rate of 17%. LAS is one of the most common types of injury with higher recurrence rates than ACL injuries (9%-12%) in professional football players. Nevertheless, the focus of research in recent years has been mostly on ACL injuries. However, the high recurrence rates and long-term consequences show the necessity for research in the field of LAS in elite football. Yet, heterogeneous data lead to difficulties concerning the aspect of comparability.

Effects of Conservative Interventions on Static and Dynamic Balance in Individuals With Chronic Ankle Instability: A Systematic Review and Meta-analysis

OBJECTIVE

To determine which conservative interventions are effective for static and dynamic balance in patients with chronic ankle instability (CAI).

DATA SOURCES

PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to March 20, 2022.

STUDY SELECTION

Randomized controlled trials investigating the effects of conservative interventions on static and/or dynamic balance in patients with CAI compared with those of different conservative interventions or controls were included.

DATA EXTRACTION

Two independent reviewers extracted the data. Certainty of the evidence was assessed using the GRADE approach.

DATA SYNTHESIS

Forty-eight studies (1906 participants) were included. Whole-body vibration training (WBVT) was significantly more effective than controls for both static (standardized mean difference, 1.13; 95% confidence interval [CI], 0.58-1.68; moderate-certainty evidence) and dynamic balance (0.56; CI, 0.24-0.88; low-certainty evidence). Balance training (BT) and joint mobilization were significantly more effective than controls for dynamic balance (0.77; CI, 0.41-1.14; and 0.75; CI, 0.35-1.14, respectively), but not for static balance (very low to low-certainty evidence). Adding other interventions to BT had no significant effect on either type of balance compared with that of BT alone (moderate to low-certainty evidence). Strength training (ST) and taping had no significant effect on either type of balance (very low- to low-certainty evidence). Multimodal interventions were significantly effective in improving dynamic balance (0.76; CI, 0.32-1.20; low-certainty evidence). Adding transcranial direct current stimulation to ST was significantly more effective for dynamic balance than ST (0.81; CI, 0.08-1.53; moderate-certainty evidence). The effects on balance were not significantly different among BT, ST, and WBVT (very low- to low-certainty evidence).

CONCLUSIONS

The significantly effective interventions reviewed may be treatment options for balance impairments associated with CAI. However, interventions should be chosen carefully, as much of the certainty of evidence is very low to low.

The Effect of Manual Therapy Plus Exercise in Patients with Lateral Ankle Sprains: A Critically Appraised Topic with a Meta-Analysis

A high percentage of patients with lateral ankle sprains report poor outcomes and persistent neuromuscular impairment leading to chronic ankle instability and re-injury. Several interventions have been proposed and investigated, but the evidence on manual therapy combined with therapeutic exercise for pain reduction and functional improvement is still uncertain. The purpose was to study the effectiveness of adding manual therapy to therapeutic exercise in patients with lateral ankle sprains through a critically appraised topic. The literature search was performed in PubMed, PEDro, EMBASE and CINAHL databases, and only randomized clinical trials were included according to following criteria: (1) subjects with acute episodes of lateral ankle sprains, (2) administered manual therapy plus therapeutic exercise, (3) comparisons with therapeutic exercise alone and (4) reported outcomes for pain and function. Three randomized clinical trials (for a total of 180 patients) were included in the research. Meta-analyses revealed that manual therapy plus exercise was more effective than only exercises in improving dorsal (MD = 8.79, 95% CI: 6.81, 10.77) and plantar flexion (MD = 8.85, 95% CI 7.07, 10.63), lower limb function (MD = 1.20, 95% CI 0.63, 1.77) and pain (MD = -1.23; 95% IC -1.73, -0.72). Manual therapy can be used with therapeutic exercise to improve clinical outcome in patients with lateral ankle sprains.

Ballet Rehabilitation: A Novel Return to Sport Protocol

Dance injuries and re-injuries are common but can be difficult to rehabilitate because of the unique demands and motor skills required. During tissue healing, pain resolves prior to tissue maturation and re-injury often occurs if the original injury is not properly rehabilitated.

The purpose of this narrative review is to analyze the existing literature addressing ballet injury, re-injury, and recovery, and to provide clinicians with timing guidelines for entering and implementing a Return to Sport (RTS) ballet rehabilitation protocol designed to prevent re-injury by progressive, sport-specific tissue loading. Thus far, a literature-based ballet-specific and body region-specific late-stage rehabilitation RTS protocol has not been established. The authors sought to address this literature gap by combining this comprehensive narrative review with our extensive clinical expertise to develop a late-stage rehabilitation RTS protocol to help guide medical clinicians treating injured ballet dancers.

Acute Ankle Sprain Management: An Umbrella Review of Systematic Reviews

Even though ankle sprains are among the most frequent musculoskeletal injuries seen in emergency departments, management of these injuries continues to lack standardization. Our objective was to carry out an umbrella review of systematic reviews to collect the most effective evidence-based treatments and to point out the state-of-the-art management for this injury. PubMed, Scopus, Web of Science, and the Cochrane library were searched from January 2000 to September 2020. After removing duplicates and applying the eligibility criteria, based on titles and abstracts, 32 studies were screened. At the end of the process, 24 articles were included in this umbrella review with a mean score of 7.7/11 on the AMSTAR quality assessment tool. We found evidence supporting the effectiveness of non-surgical treatment in managing acute ankle sprain; moreover, functional treatment seems to be preferable to immobilization. We also found evidence supporting the use of paracetamol or opioids as effective alternatives to non-steroidal anti-inflammatory drugs to reduce pain. Furthermore, we found evidence supporting the effectiveness of manipulative and supervised exercise therapy to prevent re-injury and restore ankle dorsiflexion.

Which Functional Tests and Self-Reported Questionnaires Can Help Clinicians Make Valid Return to Sport Decisions in Patients With Chronic Ankle Instability? A Narrative Review and Expert Opinion

Lateral ankle sprain is the most common injury in sports, with up to 40% of patients developing chronic ankle instability (CAI). One possible cause underlying this high rate of recurrence or feeling of giving way may be a premature return to sport (RTS). Indeed, except for time-based parameters, there are no specific criteria to guide clinicians in their RTS decisions in patients with CAI. A recent international consensus highlighted the relevance and importance of including patient-reported ankle function questionnaires combined with functional tests targeting ankle impairments in this population. Thus, the aim of this narrative review and expert opinion was to identify the most relevant functional performance tests and self-reported questionnaires to help clinicians in their RTS decision-making process following recurrent ankle sprains or surgical ankle stabilization. The PubMed (MEDLINE), PEDro, Cochrane Library and ScienceDirect databases were searched to identify published articles. Results showed that the single leg stance test on firm surfaces, the modified version of the star excursion balance test, the side hop test and the figure-of-8 test appeared to be the most relevant functional performance tests to target ankle impairments in patients with CAI. A combination of the Foot and Ankle Ability Measure (FAAM) and the Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) questionnaires were the most relevant self-reported questionnaires to assess patient function in the context of CAI. Although these functional tests and questionnaires provide a solid foundation for clinicians to validate their RTS decisions in patient with CAI, objective scientific criteria with cut-off scores are still lacking. In addition to the proposed test cluster, an analysis of the context, in particular characteristics related to sports (e.g., fatigue, cognitive constraints), to obtain more information about the patient's risk of recurrent injury could be of added value when making a RTS decision in patients with CAI. In order to evaluate the strength of evertors under ecological conditions, it would also be interesting to assess the ability to control weight-bearing ankle inversion in a unipodal stance. Further studies are needed to assess the relevance of this proposed test cluster in RTS decision-making following lateral ankle sprain injury and CAI.

Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes

Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.

Perception of stability correlates with objective performance of dynamic stability for people with chronic ankle instability

Purpose

Lateral ankle sprains are one of the most prevalent musculoskeletal injuries, with one of the highest recurrence rates. One in five people develops chronic ankle instability (CAI) after a lateral ankle sprain. CAI is mainly described as a subjective phenomenon, but is associated with recurrent symptoms, reduced dynamic stability, and reduced physical activity and quality of life. Understanding the relationship between perception of stability and effect on performance for people with CAI could inform rehabilitative strategies in clinical practice. This study aimed to investigate the relationship between the perception of stability and objective performance of dynamic stability this population.

Methods

This study is a sub-analysis of data from four separate studies in Australia and the United Kingdom. Participants were screened and categorised as a CAI, coper, or healthy participant. Each participant completed the Star Excursion Balance Test (SEBT) and Cumberland ankle instability tool (CAIT). Distances reached in the anterior, posterior-medial, and posterior-lateral directions, and average, of the SEBT were analysed.

Results

Data from 95 participants with CAI, 45 copers, and 101 healthy participants was analysed. There was a significant moderate correlation between CAIT score and SEBT reach distance in all directions for the CAI group (p < 0.001). For copers, there was small significant correlation in the posterior-lateral direction (p < 0.05).

Conclusion

This study highlights the discrepancies between the perception of stability and objective dynamic stability, and reinforces the importance of using both types of measures for continual assessment in practice to optimise selecting rehabilitative strategies.

Current ankle sprain prevention and management strategies of netball athletes: a scoping review of the literature and comparison with best-practice recommendations

Background

Ankle sprains are the most commonly reported injury in netball. Approximately four in five netball athletes will sustain an ankle sprain, up to half will go on to sustain recurrent ankle sprains, and nine in ten report perceived ankle instability. Historically, prevention and management strategies of ankle sprains and injuries have been investigated for a variety of sports, however, no literature reviews have investigated these in netball athletes, or compared these with current best-practice within the literature. Therefore, this scoping review aims to understand how netball athletes currently prevent and manage ankle sprains and to compare these approaches with best-practice recommendations.

Methods

A literature search was conducted using MEDLINE, CINAHL, and SPORTDiscus databases using keywords to capture studies with data or information related to the prevention and management of ankle sprains and injuries in netball.

Results

The search strategy captured 982 studies across all databases, with 30 netball studies included in this scoping review. Studies suggest netball athletes are not commonly referred to health professionals, do not undertake adequate rehabilitation, and almost immediately return to court following an ankle sprain or injury. Current best-practices suggest injury prevention programs and external ankle support effectively reduce ankle sprains and injuries; however, poor compliance and implementation may be a significant barrier. Currently, there is a lack of evidence that netball-specific footwear reduces the risk of ankle sprains.

Conclusion

The findings suggest netball athletes do not implement current best-practice prevention and management strategies following an ankle sprain. This is despite evidence of the effectiveness of injury prevention programs, external ankle support, and adequate rehabilitation in reducing ankle sprain rates. Current-best practice prevention and management of ankle sprains should be considered by clinicians, coaches, and athletes to reduce the prevalence and chronicity of ankle sprains in netball.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00342-9.

The current clinical practice of general orthopaedic surgeons in the treatment of lateral ankle sprain: a questionnaire survey in Miyazaki, Japan

BACKGROUND

Lateral ankle sprain (LAS) is one of the most common musculoskeletal injuries. Numerous studies regarding LAS have been performed. However, there are few studies evaluating the current clinical practice of orthopaedic surgeons regarding LAS. The purpose of this study was to evaluate the current clinical practice of general orthopaedic surgeons in the treatment of LAS.

METHODS

A questionnaire survey was conducted from September 2020 to December 2020 in Miyazaki, Japan, to evaluate the clinical practice of general orthopaedic surgeons in the treatment of LAS. The survey was composed of 12 questions that were developed with consideration of the recommendations in the current clinical practice guidelines (CPGs) published by the Dutch orthopaedic society. The questions in this study were focused on the diagnosis, conservative treatment, rehabilitation, and the criteria for return to sports (RTS).

RESULTS

The survey response rate was 82.7% (129/156). Among the respondents, 95.3% did not consider the Ottawa Ankle Rules in the decision to perform plain radiography for patients. Rehabilitation following LAS was performed in 58.9% of patients. Eighty-five (65.9%) of the surgeons used only one factor as the criterion for RTS. The absence of pain was the most frequently used criterion (45.7%). No objective criteria were used for the RTS decision in athletes with LAS.

CONCLUSIONS

The present study suggested that most general orthopaedic surgeons do not provide the care for patients with LAS recommended by the current CPGs. No objective criteria for the RTS decision are used for athletes with LAS.

Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework-an international multidisciplinary consensus

BACKGROUND

Despite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap.

METHODS

We used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses.

RESULTS

Sixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement-PAASS: Pain (during sport participation and over the last 24 hours), Ankle impairments (range of motion; muscle strength, endurance and power), Athlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), Sensorimotor control (proprioception; dynamic postural control/balance), Sport/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session).

CONCLUSION

Expert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury.

TRIAL REGISTRATION NUMBER

ACTRN12619000522112.

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.