The benefit of a single-leg strength training program for the muscles around the untrained ankle

Exercise prescription and strategies to promote the cross-education of strength: a scoping review

The cross-education of strength is moderated by exercise design and prescription in clinical and non-clinical populations. This review synthesizes the available evidence regarding exercise design strategies for unilateral resistance training and provides evidence-based recommendations for the prescription of unilateral training to maximize the cross-education of strength. Greater insights regarding the timing and effectiveness of cross-education interventions in clinical scenarios will strengthen the use of unilateral resistance training for individuals who may benefit from its use.

Bilateral Improvements Following Unilateral Home-Based Training in Plantar Flexors: A Potential for Cross-Education in Rehabilitation

CONTEXT

Cross-education (CE) refers to neuromuscular gains in the untrained limb upon contralateral limb training. To date, only laboratory-based exercise programs have demonstrated CE. Home-based exercise prescription eliciting CE could have greater clinical applicability.

OBJECTIVE

To determine the effect of an 8-week, home-based unilateral strength training intervention on isokinetic muscle strength, muscular excitation, and power in trained and untrained plantar flexors.

DESIGN

Randomized controlled trial.

METHODS

Thirty-four healthy participants were randomized to intervention (n = 20) or control (n = 14). The intervention group completed 3 sets of 12 repetitions of progressively loaded unilateral calf raises 3 days per week. Concentric and eccentric peak torque were measured using isokinetic dynamometry at 30°/s and 120°/s. Maximal electromyogram amplitude was simultaneously measured. Power was measured using a jump mat. All variables were measured at preintervention, midintervention, and postintervention.

RESULTS

Strength significantly increased bilaterally pre-post at both velocities concentrically and eccentrically in intervention group participants. Maximal electromyogram amplitude significantly increased pre-post bilaterally at both velocities in the medial gastrocnemii of the intervention group. Power significantly increased bilaterally pre-post in the intervention group, with a dose-response effect demonstrated in the untrained plantar flexors. The CE effects of strength, power, and electromyogram activation were 23.4%, 14.6%, and 25.3%, respectively. All control group values were unchanged pre-post.

CONCLUSION

This study shows that a simple at-home unilateral plantar flexor exercise protocol induces significant increases in contralateral strength, muscular excitation, and power. These results suggest the applicability of CE in home rehabilitation programs aiming to restore or maintain neuromuscular function in inactive individuals or immobilized ankles.

A randomized controlled trial comparing rehabilitation with isokinetic exercises and Thera-Band strength training in patients with functional ankle instability

BACKGROUND

Although muscle strength training is a prevalent treatment for patients with functional ankle instability (FAI), previous investigations on the efficacy have yielded conflicting results.

OBJECTIVE

This study aims to compare the efficacy of 6-week isokinetic strength training and Thera-Band strength training on improving ankle strength, dynamic balance ability, and function in individuals with FAI.

METHODS

Fifty-two FAI patients were randomized into two treatment groups: an isokinetic strength training (IST, n = 26) group and a Thera-Band resistance training (TBT, n = 26) group. The IST group engaged in isokinetic concentric strength training with inversion, eversion, dorsiflexion, and plantar flexion, whereas the TBT group engaged in progressive resistance training with Thera-Band three times per week for six weeks. Before and after the training, an isokinetic concentric strength test of the involved ankle joint, Star Excursion Balance Test (SEBT), and Cumberland Ankle Instability Tool (CAIT) function assessment were performed.

RESULTS

After six weeks of intervention, the strength of inversion and eversion was significantly improved in both the IST and TBT groups (p < 0.05), with the IST group exhibiting a significant (p < 0.05) improvement when compared to the TBT group. The SEBT and CAIT results were significantly (p < 0.05) improved in the IST group compared to the TBT group.

CONCLUSIONS

The six-week of isokinetic strength training is more effective than the Thera-Band progressive resistance training in improving the physical function of FAI patients.

CLINICAL TRIAL REGISTRATION NUMBER

This randomized controlled clinical trial has been registered in the China Clinical Trial Registry (ChiCTR2100044444) https://www.google.com/search?client=firefox-b-d&q=ChiCTR2100044444.

Effect of Functional Rehabilitation on Performance of the Star Excursion Balance Test Among Recreational Athletes With Chronic Ankle Instability: A Systematic Review

OBJECTIVE

To determine (1) the effectiveness of rehabilitation for chronic ankle instability as measured by the Star Excursion Balance Test (SEBT) and (2) the relative efficacy and the long-term effects of these rehabilitation interventions.

DATA SOURCES

Ten electronic databases were searched (2009-2019).

STUDY SELECTION

Included articles were randomized controlled trials in English investigating recreational athletes aged ≥18 years with chronic ankle instability. At least 1 functional rehabilitation intervention had to be included and the SEBT test (or the modified version) used as an outcome measure.

DATA EXTRACTION

Two researchers (L.A., O.N.) extracted data regarding participant demographics; intervention characteristics; trial size; and results at baseline, postintervention, and at follow-up, where appropriate.

DATA SYNTHESIS

A systematic review and narrative synthesis was conducted. Methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool and the van Tulder scale. The review was registered with PROSPERO (ID: 164468). Ten studies (n=368), 2 high-quality, 1 moderate-quality, and 7 low-quality, were included in the review. Interventions included balance training, strength training, vibration training, and mixed training. Results suggest that rehabilitation of chronic ankle instability that includes wobble board exercises (average percentage change: 14.3%) and hip strengthening exercises (average percentage change: 12.8%) are most effective. Few studies compared different types of rehabilitation for chronic ankle instability. However, improvements on the SEBT suggest that a rehabilitation program focusing on wobble board training and hip strengthening performed 3 times weekly for 4-6 weeks is the optimal rehabilitation program to improve dynamic postural control in recreational athletes with chronic ankle instability.

CONCLUSIONS

Few studies directly compared different rehabilitation interventions, and there was limited long-term follow-up; therefore, the relative efficacy of different rehabilitation programs remains unclear. However, it seems that rehabilitation of chronic ankle instability should include proprioceptive and strengthening exercises of relatively short duration.

Combined Effects of Strengthening and Proprioceptive Training on Stability, Balance, and Proprioception Among Subjects with Chronic Ankle Instability in Different Age Groups: Evaluation of Clinical Outcome Measures

BACKGROUND

Lateral ankle sprains are among the common injuries in the physically active population in different age groups and progress to chronic ankle instability (CAI). Accordingly, the current study assesses the effectiveness of strengthening and proprioceptive training programs on proprioception and balance in those suffering from CAI.

DESIGN

Quasi-experimental design.

METHODS

Thirty-six individuals with self-reported CAI were assigned into three groups based on age: group 1 (23 ± 1.84), group 2 (35.80 ± 1.68), group 3 (44.25 ± 4.86), then performed strength and balance exercises for 6 weeks. The study furthermore measured pre- and post-training of joint position sense (JPS), static balance, dynamic balance, chronic ankle instability tool (CAIT) and lower extremity functional scale (LEFS).

RESULTS

Statistical analysis showed significant improvement (P < 0.01) on all outcome measures among all groups. In group 1, mainly the plantar flexion JPS improved to 3.7°, while in group 2 and group 3 the eversion JPS improved to 3.1° and 1.78° (P < 0.01). With reference to static balance with one's eyes closed and eyes open, the improvement in group 1 was 4.46, 11.05 s, group 2 was 2.23, 7.85 s and group 3 was 1.69, 4.68 s. In relation to dynamic balance, the development in group 1 was 5.85 cm, while group 2 was 4.71 cm and group 3 was 2.49 cm. Moreover, both CAIT and LEFS showed significant differences (P < 0.01) after training.

CONCLUSION

This study found that combined strengthening and proprioceptive training effectively improves stability, proprioception, balance, and self-reported functional outcomes.

Effectiveness of Low-Frequency Stimulation in Proprioceptive Neuromuscular Facilitation Techniques for Post Ankle Sprain Balance and Proprioception in Adults: A Randomized Controlled Trial

Stretching is an important part of post ankle sprain rehabilitation, as well as an effective exercise for improving general ankle-joint performance. But the combination of stretching alongside low-frequency stimulation has not yet been extensively studied. Therefore, the purpose of the present randomized controlled trial was to compare the combined effects of low-frequency transcutaneous electrical nerve stimulation (TENS) with proprioceptive neuromuscular facilitation (PNF) on strength, balance, and proprioception among individuals with post ankle sprain. Sixty male subjects with lateral ankle sprain were selected and randomly allocated to three groups: group 1, group 2, and the control group (CG). Subjects in group 1 received the PNF stretching technique combined with TENS. TENS stimulation was provided using two electrodes placed 5 cm apart directly on the triceps sural muscle of the affected leg and a biphasic current with a symmetrical waveform at 50 Hz for 15 seconds, tuned for a 3-second ramp up time and a 30-second rest time with a 250-microsecond pulse duration was given with PNF stretching. Subjects in group 2 received the PNF stretching technique alone. Both group 1 and group 2 received these treatments for 4 weeks (4 days/week); follow-up assessments were administered in the third and fifth weeks. CG received no treatment; outcome measures alone were assessed. Outcome measures comprised pain, balance, flexibility, proprioception, range of motion, muscle strength, and functional limitation. A mixed-model ANOVA showed significant interaction (time and group) and the time effect for all the outcome measures (p ≤ 0.05). Group 1 (PNF-TENS) showed significant improvement for all the outcome variables compared to the other groups. The present study showed PNF stretching combined with TENS for the triceps sural muscle to trigger muscle contraction during the muscle contraction phase of the PNF stretch, compared against PNF stretching alone, produced significant improvements in ankle function for post ankle sprain subjects.

Access to Physical Therapy for Pediatric and Adolescent Patients Following Orthopedic Surgery

The objective of this study was to evaluate the relationship between insurance status and access to physical therapy (PT). Masked telephone interviews with PT facilities in a major metropolitan area were conducted with researchers posing as parents of children. Each facility was called twice: once with a private insurer and once with a government insurer. Earliest available appointment, if the facility accepted insurance, and amount of time required to return a call were recorded. Fifty-four PT clinics responded. Clinics that accepted private insurance were significantly greater than the proportion that accepted government insurance (85.2% vs 14.8%, P < .001). There was no significant difference in time between initial call and first offered appointment, in the 2 insurance conditions (private: 8.09 days, government: 8.67 days, P = .33). There were no significant differences in appointment delays between both insurance conditions. Our study found there was a significantly lower rate of children with government-funded insurance that had access to postsurgical rehabilitation.

Effects of the standard physiotherapy programme on pain and isokinetic ankle strength in individuals with grade I ankle sprain

Objectives

The isokinetic evaluation of the ankle joint is important in determining the effectiveness of the rehabilitation programme for the management of ankle sprains. This study aimed to determine the effects of physiotherapy programme on isokinetic variables in individuals with grade I ankle sprains.

Methods

Seven patients with acute grade 1 ankle sprain (15 days of ankle sprain) were recruited. They were provided with 7 days of protection, optimal loading, ice, compression, and elevation (POLICE) treatment, and the standard physiotherapy programme consisted of towel stretching and balancing exercises on one leg. Pain scale score was recorded daily during the physiotherapy programme. The isokinetic ankle strengths of the patient's injured and uninjured legs were compared before and after the physiotherapy programme. Isokinetic tests were conducted in painless range of motion for the injured leg.

Results

Pain was significantly reduced after the patients underwent the standard physiotherapy programme. No significant differences were observed in terms of the ankle peak torque, time to peak torque, and ankle plantar flexion-to-dorsiflexion ratio of the injured and uninjured legs. The injured leg showed significant improvement in terms of ankle eversion-to-inversion ratio (E:I) after 7 days of performing the standard physiotherapy programme.

Conclusion

Performing the standard physiotherapy programme for 1 week reduces pain and improves the ankle E:I in patients with grade 1 ankle sprain.

Eccentric cross-exercise after anterior cruciate ligament reconstruction: Novel case series to enhance neuroplasticity

OBJECTIVES

Substantial changes in neural function are historically present after anterior cruciate ligament reconstruction (ACLR), and are not rectified with traditional rehabilitation. Cross-exercise is a potential means to enhance neural excitability and improve recovery after ACLR. Hence our purpose, was to detail changes in brain activation, neural excitability and patient-reported outcomes in a cohort that completed an 8-week quadriceps-focused eccentric cross-exercise training program immediately following ACLR.

DESIGN

Case series.

SETTING

University.

PARTICPANTS

Five patients participated in an 8-week (24-session) eccentric cross-exercise intervention after ACLR.

MAIN OUTCOME MEASURES

Brain activation, neural activity and patient-reported outcomes were evaluated within 2 weeks post-ACLR and again at 10-weeks post-ACLR after the intervention. Each cross-exercise session consisted of 4 sets of 10 isokinetic eccentric contractions at 60 deg/sec with the noninvolved limb.

RESULTS

Following the intervention, patients demonstrated a facilitated spinal reflexive and muscle activity response from the motor cortex during a time when these measures are known to be depressed. Patients also demonstrated a reduce dependence on frontal cortex activity to generate quadriceps contractions. Further patients reported significant reductions in pain and symptoms and greater knee function.

CONCLUSIONS

Eccentric cross-exercise after ACLR helps to facilitate positive adaptations in neural function and patient reported outcomes.

Neurophysiological adaptations in the untrained side in conjunction with cross-education of muscle strength: a systematic review and meta-analysis

We reviewed the evidence from randomized controlled trials (RCTs) focusing on the neurophysiological adaptations in the untrained side associated with cross-education of strength (CE) and pooled data into definite effect estimates for neurophysiological variables assessed in chronic CE studies. Furthermore, scoping directions for future research were provided to enhance the homogeneity and comparability of studies investigating the neural responses to CE. The magnitude of CE was 21.1 ± 18.2% (mean ± SD; P < 0.0001) in 22 RCTs ( n = 467 subjects) that measured at least 1 neurophysiological variable in the untrained side, including the following: electromyography (EMG; 14 studies); motor evoked potential (MEP; 8 studies); short-interval intracortical inhibition (SICI), recruitment curve, and M wave (6 studies); cortical silent period (cSP; 5 studies); interhemispheric inhibition, intracortical facilitation (ICF), and H reflex (2 studies); and V wave, short-interval ICF, short-latency afferent inhibition, and long-latency afferent inhibition (1 study). Only EMG, MEP, ICF, cSP, and SICI could be included in the meta-analysis (18 studies, n = 387). EMG ( P = 0.26, n = 235) and MEP amplitude ( P = 0.11, n = 145) did not change in the untrained limb after CE. cSP duration ( P = 0.02, n = 114) and SICI ( P = 0.001, n = 95) decreased in the untrained hemisphere according to body region and type and intensity of training. The magnitude of CE did not correlate with changes in these transcranial magnetic stimulation (TMS) measures. The design of this meta-analytical study and the lack of correlations prevented the ability to link mechanistically the observed neurophysiological changes to CE. Notwithstanding the limited amount of data available for pooling, the use of TMS to assess the ipsilateral neurophysiological responses to unilateral training still confirms the central neural origin hypothesis of chronic CE induced by strength training. However, how these neural adaptations contribute to CE remains unclear.

Cross-education of muscular strength following unilateral resistance training: a meta-analysis

PURPOSE

Cross-education (CE) of strength is a well-known phenomenon whereby exercise of one limb can induce strength gains in the contralateral untrained limb. The only available meta-analyses on CE, which date back to a decade ago, estimated a modest 7.8% increase in contralateral strength following unilateral training. However, in recent years new evidences have outlined larger contralateral gains, which deserve to be systematically evaluated. Therefore, the aim of this meta-analysis was to appraise current data on CE and determine its overall magnitude of effect.

METHODS

Five databases were searched from inception to December 2016. All randomized controlled trials focusing on unilateral resistance training were carefully checked by two reviewers who also assessed the eligibility of the identified trials and extracted data independently. The risk of bias was assessed using the Cochrane Risk-of-Bias tool.

RESULTS

Thirty-one studies entered the meta-analysis. Data from 785 subjects were pooled and subgroup analyses by body region (upper/lower limb) and type of training (isometric/concentric/eccentric/isotonic-dynamic) were performed. The pooled estimate of CE was a significant 11.9% contralateral increase (95% CI 9.1-14.8; p < 0.00001; upper limb: + 9.4%, p < 0.00001; lower limb: + 16.4%, p < 0.00001). Significant CE effects were induced by isometric (8.2%; p = 0.0003), concentric (11.3%; p < 0.00001), eccentric (17.7%; p = 0.003) and isotonic-dynamic training (15.9%; p < 0.00001), although a high risk of bias was detected across the studies.

CONCLUSIONS

Unilateral resistance training induces significant contraction type-dependent gains in the contralateral untrained limb. Methodological issues in the included studies are outlined to provide guidance for a reliable quantification of CE in future studies.

Dynamic plantar pressure distribution, strength capacity and postural control after Lisfranc fracture-dislocation

Substantial progress has been made in the operative treatment of Lisfranc fractures, however, the prognosis remains poor. We hypothesized that Lisfranc injuries change the postural control and muscle strength of the lower limb. Both are suggested to correlate with the clinical outcome and quality of life. 17 consecutive patients suffering from a Lisfranc fracture dislocation were registered, underwent open reduction and internal fixation and were followed-up for 50.5±25.7months (Mean±SDM). Biomechanical analysis of muscle strength capacities, postural control and plantar pressure distribution was assessed >6 month postoperatively. Results were correlated to clinical outcome (AOFAS, FFI, Pain, SF-36). The isokinetic assessment revealed a significant reduction in plantar flexor and dorsal extensor peak torque of the injured limb compared to the uninjured limb. The dorsal extensor peak torque thereby correlated well with clinical outcome. Altered postural control was evident by a significant reduction in unilateral stance time, from which we calculated a strong correlation between stance time and the isokinetic strength measurement. Plantar pressure measurements revealed a significant reduction in peak pressure under the midfoot and of Force-Time Integral beneath the second metatarsal. Sufficient rehabilitation is crucial to the clinical outcome following anatomical open reduction of Lisfranc fracture-dislocation. The present study supports a rehabilitation approach focussing on restoring proprioception and calf muscular strength including isometric exercises of the dorsal extensors.

Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis

BACKGROUND

Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI)), with a coinciding proliferation of review articles summarising these reports.

OBJECTIVE

To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI.

DESIGN

Overview of intervention systematic reviews.

PARTICIPANTS

Individuals with acute ankle sprain/CAI.

MAIN OUTCOME MEASUREMENTS

The primary outcomes were injury/reinjury incidence and function.

RESULTS

46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains.

CONCLUSIONS

For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI.

Multiarticular isokinetic high-load eccentric training induces large increases in eccentric and concentric strength and jumping performance

This study investigated the effects of short-term eccentric exercise training using a custom-made isokinetic leg press device, on concentric and eccentric strength and explosiveness as well as jumping performance. Nineteen healthy males were divided into an eccentric (ECC, n = 10) and a control group (CG, n = 9). The ECC group trained twice per week for 8 weeks using an isokinetic hydraulic leg press machine against progressively increasing resistance ranging from 70 to 90% of maximal eccentric force. Jumping performance and maximal force generating capacity were measured before and after eccentric training. In the ECC group, drop jump (DJ) height and maximal power were increased by 13.6 ± 3.2% (p < 0.01) and 25.8 ± 1.2% (p < 0.01), whereas ground contact time was decreased by 17.6 ± 2.6% (p < 0.01). Changes in ankle, knee, and hip joint angles were also reduced by 33.9 ± 1.1%, 31.1 ± 1.0%, and 32.4 ± 1.6% (all p < 0.01), respectively, indicating an increase in muscle stiffness during the DJ. Maximal eccentric and concentric leg press force was increased by 64.9 ± 5.5% (p < 0.01) and 32.2 ± 8.8% (p < 0.01), respectively, and explosiveness, measured as force attained in the first 300 milliseconds, was increased by 49.1 ± 4.8% (p < 0.01) and 77.1 ± 7.7% (p < 0.01), respectively. The CG did not show any statistically significant changes in all parameters measured. The main findings of this study were that maximal concentric and eccentric force, explosiveness, and DJ performance were markedly increased after only 16 training sessions, possibly because of the high eccentric load attained during the bilateral eccentric leg press exercise performed on this custom-made device.

The Effects of Tai Chi on Peripheral Somatosensation, Balance, and Fitness in Hispanic Older Adults with Type 2 Diabetes: A Pilot and Feasibility Study

Peripheral neuropathy and loss of somatosensation in older adults with type 2 diabetes can increase risk of falls and disability. In nondiabetic older adult population Tai Chi has been shown to enhance balance and fitness through improvements in somatosensation and neuromuscular control, and it is unclear if Tai Chi would elicit similar benefits in older adults with diabetes. Therefore, the purpose of this study was to investigate the effects of an 8-week, three-hour-per-week Tai Chi intervention on peripheral somatosensation in older adults with type 2 diabetes. Participants were eight Hispanic older adults with type 2 diabetes who participated in the Tai Chi intervention and a convenience sample of Hispanic older adults as a referent group. Baseline and postintervention assessments included ankle proprioception, foot tactile sense, plantar pressure distribution, balance, and fitness. After intervention, older adults with type 2 diabetes showed significant improvements in ankle proprioception and fitness and decreased plantar pressure in the forefoot, with no statistical effect noted in balance or tactile sensation. Study results suggest that Tai Chi may be beneficial for older adults with diabetes as it improves ankle proprioception; however, study findings need to be confirmed in a larger sample size randomized controlled trial.

A comprehensive assessment of the cross-training effect in ankle dorsiflexors of healthy subjects: A randomized controlled study

PURPOSE

To investigate the cross-training effect, induced on ankle dorsiflexors (AD) by unilateral strength-training of the contralateral muscles, as transfer of peak torque (PT) and muscle work (MW) and their relative contributions to muscle performance.

METHODS

Thirty healthy volunteers were randomly assigned to a training or control group. The trained group sustained a 4-week maximal isokinetic training of the stronger AD at 90 and 45°/s. At both angular velocities, PT, MW and MW/PT ratio were measured from both legs at baseline and after intervention (trained group) or no-intervention (controls). The familiarization/learning-effect was calculated and subtracted by PT and MW measures to obtain their net changes.

RESULTS

Net PT increased in both legs (untrained: +27.5% at 90°/s and +17.9% at 45°/s; trained: +15% at 90°/s and +16.3% at 45°/s). Similarly, net MW increased in both the untrained (90°/s: +29.6%; 45°/s: +37%) and trained (90°/s: +23.4%; 45°/s: +18.3%) legs. PT and MW gains were larger in the untrained than trained AD (p<0.0005), with MW improving more than PT at 45°/s (p=0.04). The MW/PT ratio increased bilaterally only in the trained group (p<0.05), depending on the angular velocity.

CONCLUSIONS

The cross-training effect occurred in AD muscles in terms of both PT and MW, with MW adding valuable information to PT-analysis in describing muscle performance. Moreover, the MW/PT ratio allowed estimating the contributions of these parameters to muscle capability and may represent a novel index in isokinetic testing. The greater improvements in the untrained than trained limb raises interesting clinical implications in asymmetric conditions.

Assessment of functional treatment versus plaster of Paris in the treatment of grade 1 and 2 lateral ankle sprains

Background

Despite the common occurrence of ankle sprains, no treatment is considered to be the gold standard for the management of such sprains. We assessed functional treatment versus plaster of Paris (POP) for the treatment of lateral ankle sprains, with pain and function employed as the outcome measures.

Materials and methods

126 Patients were eligible for inclusion. They were assigned to either the functional treatment Tubigrip (TG) group or the POP group after applying block randomization. Characteristics such as age, dominant ankle, and gender were assessed at baseline. Pain and functional assessments were done using the visual analog scale (VAS) and the Karlsson score (KS) at baseline (at the start of the study) and during the 2nd and 6th weeks, respectively. Data on other subjective parameters, such as the number of painkillers used, the number of days taken off work, and the number of sleepless nights, were requested from the patients at the end of the study. SPSS version 16 was used for analysis, and p < 0.05 was taken to indicate significance.

Results

60 Patients completed the trial in each group. The mean ages were 28.77 ± 6.72 in the TG group and 29.83 ± 6.30 in the POP group (p = 0.034). There was a slight female predominance. Right and left ankles were equally involved in the TG group, while left ankles were mainly involved in the POP group. Mean differences in VAS and KS between the two groups were statistically significant at the end of the study. The mean number of painkillers used by the patients in the TG group was higher than the number used in the POP group (p < 0.001). The mean number of days taken off work was 4.18 ± 1.73 days in the TG group, and 6.25 ± 2.73 days in the POP group (p < 0.001). The mean number of sleepless nights was higher in the POP group.

Conclusion

The results of our study indicate that functional treatment provides better functional support and pain reduction than a below-knee POP cast.

Level of evidence

Level I.

Ankle strength and force sense after a progressive, 6-week strength-training program in people with functional ankle instability

CONTEXT

Although strength training is commonly used to rehabilitate ankle injuries, studies investigating the effects of strength training on proprioception have shown conflicting results.

OBJECTIVE

To determine the effects of a 6-week strength-training protocol on force sense and strength development in participants with functional ankle instability.

DESIGN

Randomized controlled clinical trial.

SETTING

University athletic training research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 40 participants with functional ankle instability were recruited. They were randomly placed into a training group (10 men, 10 women: age = 20.9 ± 2.2 years, height = 76.4 ± 16.1 cm, mass = 173.0 ± 7.9 kg) or control group (10 men, 10 women: age = 20.2 ± 2.1 years, height = 78.8 ± 24.5 cm, mass = 173.7 ± 8.2 kg).

INTERVENTION(S)

Participants in the training group performed strength exercises with the injured ankle 3 times per week for 6 weeks. The protocol consisted of a combination of rubber exercise bands and the Multiaxial Ankle Exerciser, both clinically accepted strengthening methods for ankle rehabilitation. The progression of this protocol provided increasingly resistive exercise as participants changed either the number of sets or resistance of the Thera-Band or Multiaxial Ankle Exerciser. Main Outcome Measure(s): A load cell was used to measure strength and force sense. Inversion and eversion strength was recorded to the nearest 0.01 N. Force-sense reproduction was measured at 2 loads: 20% and 30% of maximal voluntary isometric contraction.

RESULTS

Increases in inversion (F(1,38) = 11.59, P < 0.01, η(p)(2) = 0.23, power = 0.91) and eversion (F(1,38) = 57.68, P < .01, η(p)(2) = 0.60, power = 0.99) strength were found in the training group at the posttest when compared with the control group. No significant improvements were noted in force-sense reproduction for either group.

CONCLUSIONS

Strength training at the ankle increased strength but did not improve force sense.

WITHDRAWN: Interventions for preventing ankle ligament injuries

BACKGROUND

Some sports, for example basketball and soccer, have a very high incidence of ankle injuries, mainly sprains. Consequently, ankle sprains are one of the most commonly treated injuries in acute care.

OBJECTIVES

To assess the effects of interventions used for the prevention of ankle ligament injuries or sprains in physically active individuals from adolescence to middle age.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauam Group's specialised register, MEDLINE, PubMed, EMBASE, CINAHL, the National Research Register and bibliographies of study reports. We also contacted colleagues and some trialists. The most recent search was conducted in July 2000.

SELECTION CRITERIA

Randomised or quasi-randomised trials of interventions for the prevention of ankle sprains in physically active individuals from adolescence to middle age were included provided that ankle sprains were recorded. Interventions included use of modified footwear, external ankle supports, co-ordination training and health education. These could be applied as a supplement to treatment provided that prevention of re-injury was the primary objective.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed methodological quality and extracted data. Wherever possible, results of outcome measures were pooled and sub-grouped by history of previous sprain. Relative risks (RR) and 95% confidence intervals (95% CI) are reported for individual and pooled data.

MAIN RESULTS

In this review update, a further nine new trials were included. Overall, 14 randomised trials with data for 8279 participants were included. Twelve trials involved active, predominantly young, adults participating in organised, generally high-risk, activities. The other two trials involved injured patients who had been active in sports before their injury. The prophylactic interventions under test included the application of an external ankle support in the form of a semi-rigid orthosis (three trials), air-cast brace (one trial) or high top shoes (one trial); ankle disk training; taping; muscle stretching; boot inserts; health education programme and controlled rehabilitation.The main finding was a significant reduction in the number of ankle sprains in people allocated external ankle support (RR 0.53, 95% CI 0.40 to 0.69). This reduction was greater for those with a previous history of ankle sprain, but still possible for those without prior sprain. There was no apparent difference in the severity of ankle sprains or any change to the incidence of other leg injuries. The protective effect of 'high-top' shoes remains to be established.There was limited evidence for reduction in ankle sprain for those with previous ankle sprains who did ankle disk training exercises. Various problems with data reporting limited the interpretation of the results for many of the other interventions.

AUTHORS' CONCLUSIONS

This review provides good evidence for the beneficial effect of ankle supports in the form of semi-rigid orthoses or air-cast braces to prevent ankle sprains during high-risk sporting activities (e.g. soccer, basketball). Participants with a history of previous sprain can be advised that wearing such supports may reduce the risk of incurring a future sprain. However, any potential prophylactic effect should be balanced against the baseline risk of the activity, the supply and cost of the particular device, and for some, the possible or perceived loss of performance.Further research is indicated principally to investigate other prophylactic interventions, their cost-effectiveness and general applicability.

Plyometric training versus resistive exercises after acute lateral ankle sprain

BACKGROUND

Plyometric training is a widely used method to improve performance in healthy athletes. It is highly recommended in the late stage of rehabilitation of many lower limb injuries. However, its effects on muscle strength and function in management of lateral ankle sprain have not been reported. Therefore, the objective of the current study was to determine the effects of plyometric training versus resistive exercises on muscle strength and function following acute lateral ankle sprain.

MATERIALS AND METHODS

Twenty-two athletes (aged from 20 to 35 years) of both sexes with grade I or II unilateral inversion ankle sprain participated in the study (at least 3 weeks after acute injury). They were randomly assigned to two groups. The first group received plyometric training, whereas the second one received resistive training for 6 weeks. Isokinetic peak torque/body weight for invertors and evertors at 30 degrees/s and 120 degrees/s and functional tests were assessed before and after training.

RESULTS

Both plyometric and resistive training improve isokinetic evertor and invertor peak torques and functional performance of athletes p < 0.05. There were no significant differences between groups concerning peak torque/body weight for invertors and evertors at both speeds measured p > 0.05. The functional test measures of the plyometric group were significantly higher than that of resistive group.

CONCLUSION

Plyometrics were more effective than resistive exercises in improving functional performance of athletes after lateral ankle sprain.

Effects of a training program after surgically treated ankle fracture: a prospective randomised controlled trial

BACKGROUND

Despite conflicting results after surgically treated ankle fractures few studies have evaluated the effects of different types of training programs performed after plaster removal. The aim of this study was to evaluate the effects of a 12-week standardised but individually suited training program (training group) versus usual care (control group) after plaster removal in adults with surgically treated ankle fractures.

METHODS

In total, 110 men and women, 18-64 years of age, with surgically treated ankle fracture were included and randomised to either a 12-week training program or to a control group. Six and twelve months after the injury the subjects were examined by the same physiotherapist who was blinded to the treatment group. The main outcome measure was the Olerud-Molander Ankle Score (OMAS) which rates symptoms and subjectively scored function. Secondary outcome measures were: quality of life (SF-36), timed walking tests, ankle mobility tests, muscle strength tests and radiological status.

RESULTS

52 patients were randomised to the training group and 58 to the control group. Five patients dropped out before the six-month follow-up resulting in 50 patients in the training group and 55 in the control group. Nine patients dropped out between the six- and twelve-month follow-up resulting in 48 patients in both groups. When analysing the results in a mixed model analysis on repeated measures including interaction between age-group and treatment effect the training group demonstrated significantly improved results compared to the control group in subjects younger than 40 years of age regarding OMAS (p = 0.028), muscle strength in the plantar flexors (p = 0.029) and dorsiflexors (p = 0.030).

CONCLUSION

The results of this study suggest that when adjusting for interaction between age-group and treatment effect the training model employed in this study was superior to usual care in patients under the age of 40. However, as only three out of nine outcome measures showed a difference, the beneficial effect from an additional standardised individually suited training program can be expected to be limited. There is need for further studies to elucidate how a training program should be designed to increase and optimise function in patients middle-aged or older.

TRIAL REGISTRATION

Current Controlled Trials ACTRN12609000327280.

Eccentric plantar-flexor torque deficits in participants with functional ankle instability

CONTEXT

Inversion ankle sprains can lead to a chronic condition called functional ankle instability (FAI). Limited research has been reported regarding isokinetic measures for the plantar flexors and dorsiflexors of the ankle.

OBJECTIVE

To examine the isokinetic eccentric torque measures of the ankle musculature in participants with stable ankles and participants with functionally unstable ankles during inversion, eversion, plantar flexion, and dorsiflexion.

DESIGN

Case-control study.

SETTING

Athletic training research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty participants with a history of "giving way" were included in the FAI group. Inclusion criteria for the FAI group included a history of at least 1 ankle sprain and repeated episodes of giving way. Twenty participants with no prior history of ankle injury were included in the control group.

INTERVENTION(S)

Isokinetic eccentric torque was assessed in each participant.

MAIN OUTCOME MEASURE(S)

Isokinetic eccentric testing was conducted for inversion-eversion and plantar-flexion-dorsiflexion movements. Peak torque values were standardized to each participant's body weight. The average of the 3 trials for each direction was used for statistical analysis.

RESULTS

A significant side-by-group interaction was noted for eccentric plantar flexion torque (P < .01). Follow-up t tests revealed a significant difference between the FAI limb in the FAI group and the matched limb in the control group. Additionally, a significant difference was seen between the sides of the control group (P = .03). No significant interactions were identified for eccentric inversion, eversion, or dorsiflexion torques (P > .05).

CONCLUSIONS

A deficit in plantar flexion torque was identified in the functionally unstable ankles. No deficits were identified for inversion, eversion, or dorsiflexion torque. Therefore, eccentric plantar flexion strength may be an important contributing factor to functional ankle instability.

Management of acute ligament injuries of the ankle

Ligament injuries of the ankle are common and troublesome. Management may seem easy, but residual symptoms ae common. Grade III injuries still generate controversy in terms of the best management available, and more studies are needed when it comes to early mobilization, cast immobilization, or surgery. Even the three Cohrane reviews published to date are not conclusive.

Análise da confiabilidade do método Figura Oito e da volumetria para mensuração do edema de tornozelo

A presença de lesões no tornozelo torna necessária a mensuração do edema como fator diagnóstico e evolutivo. O presente trabalho teve como objetivo analisar a confiabilidade do método Figura Oito e da volumetria para a mensuração do volume do tornozelo, intrateste e interteste. Vinte voluntários, sexo masculino, assintomáticos, idade entre 15 e 30 anos (X= 21,8), foram avaliados aleatoriamente por três examinadores; cada um realizou três mensurações utilizando o método Figura Oito e três, a volumetria. A ordem dos examinadores e da técnica de mensuração foi aleatória. Observou-se excelente confiabilidade nas duas técnicas (ICC = 0,99). O coeficiente de correlação momento-produto de Pearson demonstrou similaridade entre os examinadores; o primeiro apresentou r = 0,91, o segundo, r = 0,95 e o terceiro, r = 0,96. Concluiu-se que os dois métodos são confiáveis, apesar de a maioria dos autores recomendar o método Figura Oito pela sua praticidade, rapidez e baixo custo.

Six Weeks of Strength and Proprioception Training Does Not Affect Muscle Fatigue and Static Balance in Functional Ankle Instability

Context:

The combined effects of strength and proprioception training, especially in individuals with ankle instability, have not been studied extensively.

Objective:

To examine the influence of 6 weeks of strength and proprioception training on measures of muscle fatigue and static balance in those with unilateral functional ankle instability (FAI).

Design:

Pretest–posttest, randomized groups.

Setting:

A climate-controlled sports-medicine research laboratory.

Subjects:

38 subjects with self-reported unilateral FAI.

Measurements:

Muscle fatigue was determined using the median power frequency (fmed) from an electromyographic signal, and static balance was assessed using center-of-pressure values obtained from a triaxial force plate.

Results:

There were no significant effects of the strength or proprioception training on our measures of muscle fatigue and static balance.

Conclusions:

Strength training, proprioception training, and the combination of the 2 failed to improve postural-stability characteristics in a group of subjects with FAI.

Contralateral effects of unilateral resistance training: a meta-analysis

It is often claimed that strength training of one limb increases the strength of the contralateral limb, but this has not been demonstrated consistently, particularly in well-controlled studies. The aim was to quantitatively combine the results of other studies on the effects of unilateral training on contralateral strength in humans to provide an answer to this physiological question. We analyzed all randomized controlled studies of voluntary unilateral resistance training that used training intensities of at least 50% of maximal voluntary strength for a minimum of 2 wk. Studies were identified by computerized and hand searches of the literature. Data on changes in strength of contralateral and control limbs were extracted and statistically pooled in a meta-analysis. This approach allows conclusions to be based on a statistically meaningful sample size, which might be difficult to achieve in other ways. Seventeen studies met the inclusion criteria, and 13 provided enough data for statistical pooling. The contralateral effects of strength training reported in individual studies varied from -2.7 to 21.6% of initial strength. The pooled estimate of the effect of unilateral resistance training on the maximal voluntary strength of the contralateral limb was 7.8% (95% confidence interval: 4.1-11.6%). This was 35.1% (95% confidence interval: 20.9-49.3%) of the effect on the trained limb. Pooling of all available data shows that unilateral strength training produces modest increases in contralateral strength.

Effect of strength and proprioception training on eversion to inversion strength ratios in subjects with unilateral functional ankle instability

OBJECTIVES

To examine the effect of six weeks of strength and proprioception training on eversion to inversion isokinetic strength ratios (E/I ratios) in subjects with unilateral functional ankle instability.

METHODS

Thirty eight subjects were randomly assigned to one of four treatment groups: strength training (S); proprioception training (P); strength + proprioception training (B); control (C). Isokinetic strength was tested before and after training using a Kin Com 125 automatic positioning isokinetic dynamometer. Subtalar joint eversion and inversion motions were tested both concentrically and eccentrically through a range of motion involving 40 degrees. All peak torque and average torque values were normalised for body mass. E/I ratios were calculated from average torque and peak torque measures by taking the concentric eversion value and combining it with the eccentric inversion value. Data were analysed using a mixed model analysis of variance with repeated measures on the test factor. Average torque and peak torque E/I ratios at 30 and 120 degrees/s were analysed separately.

RESULTS

There were no significant differences in average torque and peak torque E/I ratios of the functionally unstable ankle for any of the groups after training compared with before.

CONCLUSIONS

Six weeks of strength and proprioception training (either alone or combined) had no effect on isokinetic measures of strength in subjects with self reported unilateral functional instability. Further studies examining this agonist (concentric) to antagonist (eccentric) muscle group strength ratio are needed.

Bracing and rehabilitation—what's new

Based on the recent evidence, ankle bracing and taping do appear to have positive effects on ankle support. For example, both bracing and taping restrict inversion range of motion, with tape and stirrup-style braces providing the best support. Although exercise reduces this restriction, the range remains consistent with levels considered to be within the normal range. Ankle supports also appear to improve the strength of the muscular response to perturbation, potentially providing a stronger muscular contraction. In contrast, ankle supports fail to improve the neuromuscular response time to unexpected perturbations. Thus, it appears that the stronger response may occur too slowly to protect the joint. This slowness of the neuromuscular response, however, may be offset by the support's ability to slow the inversion motion. The slowing of inversion appears to allow the neuromuscular system to respond at or before the point of ligament damage. Finally, ankle supports appear to improve balance only in individuals with previously injured ankles. This suggests that supports may have a selective effect in protecting injured but not uninjured individuals. Despite these positive effects, some cautions should be emphasized. First, most of the studies cited have been performed in the laboratory setting with joint velocities and loads much below what are encountered in the athletic and daily activities. Whether tape and braces can maintain their effectiveness under the more extreme conditions of functional activities remains unclear. Additionally, some evidence suggests that ankle supports may transfer loads to other joints putting them at risk for injury. Thus, further study is needed to determine the risk-to-benefit ratio of ankle supports. Finally, much of the research presented has been done only on uninjured ankles. Based on the current evidence, it seems possible that the effectiveness of ankle supports may differ depending on the population, and it seems clinically important to know whether we can expect the same results for injured and uninjured ankles. Proper and early rehabilitation is important in preventing residual ankle symptoms. Reports indicate that up to 73% of people who sustain a lateral ankle sprain have recurrent sprains, but it is unknown how many of these participants partake in rehabilitation. Proper immobilization and acute care of the injured ankle is imperative. An immobilization boot or strapping that can be removed during early non-weight bearing exercises seems to be most effective. Strength and balance training of the uninjured contralateral limb can be used to assist reaching full recovery in a shorter period of time. Functional exercises can also be performed earlier in the rehabilitation process by reducing the gravitational forces so patients can perform in a pain-free range and still receive the benefits of early activity. Evidence shows that daily ankle disk training assists in preventing ankle sprains, and is a relatively inexpensive and easy alternative to traditional rehabilitation protocols.

Rehabilitation of ligamentous ankle injuries: a review of recent studies

There are many treatment modalities for ankle rehabilitation. These are reviewed, and the most effective training programme for rapid restoration of ankle movement, strength, endurance, and proprioception is selected.

Interventions for preventing ankle ligament injuries

BACKGROUND

Some sports, for example basketball and soccer, have a very high incidence of ankle injuries, mainly sprains. Consequently, ankle sprains are one of the most commonly treated injuries in acute care.

OBJECTIVES

To assess the effects of interventions used for the prevention of ankle ligament injuries or sprains in physically active individuals from adolescence to middle age.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group's specialised register, MEDLINE, PubMed, EMBASE, CINAHL, the National Research Register and bibliographies of study reports. We also contacted colleagues and some trialists. The most recent search was conducted in July 2000.

SELECTION CRITERIA

Randomised or quasi-randomised trials of interventions for the prevention of ankle sprains in physically active individuals from adolescence to middle age were included provided that ankle sprains were recorded. Interventions included use of modified footwear, external ankle supports, co-ordination training and health education. These could be applied as a supplement to treatment provided that prevention of re-injury was the primary objective.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed methodological quality and extracted data. Wherever possible, results of outcome measures were pooled and sub-grouped by history of previous sprain. Relative risks (RR) and 95% confidence intervals (95% CI) are reported for individual and pooled data.

MAIN RESULTS

In this review update, a further nine new trials were included. Overall, 14 randomised trials with data for 8279 participants were included. Twelve trials involved active, predominantly young, adults participating in organised, generally high-risk, activities. The other two trials involved injured patients who had been active in sports before their injury. The prophylactic interventions under test included the application of an external ankle support in the form of a semi-rigid orthosis (three trials), air-cast brace (one trial) or high top shoes (one trial); ankle disk training; taping; muscle stretching; boot inserts; health education programme and controlled rehabilitation. The main finding was a significant reduction in the number of ankle sprains in people allocated external ankle support (RR 0.53, 95% CI 0.40 to 0.69). This reduction was greater for those with a previous history of ankle sprain, but still possible for those without prior sprain. There was no apparent difference in the severity of ankle sprains or any change to the incidence of other leg injuries. The protective effect of 'high-top' shoes remains to be established. There was limited evidence for reduction in ankle sprain for those with previous ankle sprains who did ankle disk training exercises. Various problems with data reporting limited the interpretation of the results for many of the other interventions.

REVIEWER'S CONCLUSIONS

This review provides good evidence for the beneficial effect of ankle supports in the form of semi-rigid orthoses or air-cast braces to prevent ankle sprains during high-risk sporting activities (e.g. soccer, basketball). Participants with a history of previous sprain can be advised that wearing such supports may reduce the risk of incurring a future sprain. However, any potential prophylactic effect should be balanced against the baseline risk of the activity, the supply and cost of the particular device, and for some, the possible or perceived loss of performance. Further research is indicated principally to investigate other prophylactic interventions, their cost-effectiveness and general applicability.