Generalized joint hypermobility and risk of lower limb joint injury during sport: a systematic review with meta-analysis

Development, validation, and psychometric analysis of Foot and Ankle Flexibility Index (FAFI)

AIM

To develop a new tool for identifying joint hypermobility of the paediatric foot and ankle, based on a dichotomous scoring system utilising the Lower Limb Assessment Score (LLAS), to separate the foot and ankle items.

MATERIAL AND METHODS

A total of 205 children, aged between 5 and 10 years, participated in a cross-sectional study. The new tool Foot and Ankle Flexibility Index (FAFI) was predicated upon the last 7 items of LLAS, which are specific to the foot and ankle. The internal consistency was measured with Cronbach's test. Kappa statistics with 95% CI were calculated to verify the level of inter-rater and intra-rater agreement for the FAFI.

RESULTS

Cronbach's alpha returned 0.82. The correlations between items returned a mean of 0.59 (range: 0.43-0.74). The discrimination score on the ROC curve (4 points) showed that the model can be used to identify children with joint hypermobility of the foot and ankle. Inter-rater reliability was largely good (ICC = 0.89). Excellent intra-rater reliability was found (ICC = 0.96) CONCLUSIONS: This study identified high reliability between evaluators, and high sensitivity and specificity, for a new reliable and valid tool for the identification of foot and ankle joint hypermobility.

Single-Leg Heel Raise Capacity is Lower, and Perceived Ankle Instability is Greater, in Dancers and Athletes With Posterior Ankle Impingement Syndrome

OBJECTIVE

To compare clinical assessment findings between elite athletic populations with and without a clinical diagnosis of posterior ankle impingement syndrome (PAIS).

DESIGN

Cross-sectional case-control study.

SETTING

Elite ballet and sport.

PARTICIPANTS

Ten male and female professional ballet dancers and athletes with a clinical diagnosis of PAIS and were matched for age, sex, and activity to 10 professional ballet dancers and athletes without PAIS.

INDEPENDENT VARIABLES

Posterior ankle pain on body chart and a positive ankle plantarflexion pain provocation test.

MAIN OUTCOME MEASURES

Single-leg heel raise (SLHR) endurance test, range of motion testing for weight-bearing ankle dorsiflexion, passive ankle plantarflexion, and first metatarsophalangeal joint dorsiflexion, and Beighton score for generalized joint hypermobility. Participants also completed the Cumberland Ankle Instability Tool (CAIT) questionnaire.

RESULTS

The group with PAIS achieved significantly fewer repetitions on SLHR capacity testing ( P = 0.02) and were more symptomatic for perceived ankle instability according to CAIT scores ( P = 0.004).

CONCLUSIONS

Single-leg heel raise endurance capacity was lower, and perceived ankle instability was greater in participants with PAIS. The management of this presentation in elite dancers and athletes should include the assessment and management of functional deficits.

Effect of 6-Week Instrument-Assisted Soft Tissue Mobilization on Joint Flexibility and Musculotendinous Properties

Instrument-assisted soft tissue mobilization (IASTM) stimulates soft subcutaneous tissues by applying pressure to the skin with a specialized bar or spurtle-like instrument. No studies have verified whether several weeks of continuous IASTM alone can alter joint flexibility and musculotendinous properties in healthy participants. We examined the effect of a 6-week IASTM program on joint flexibility and the musculotendinous properties of the lower limbs. Fourteen healthy men (aged 19-35 years) who participated in a 6-week IASTM program (3 days weekly) for the soft tissue of the posterior aspect of one lower leg were included. The other leg served as the control. Before and after the intervention, we measured the maximal ankle joint dorsiflexion angle (dorsiflexion range of motion: DFROM) and maximal passive torque (MPT), a measure of stretch tolerance. We measured muscle and tendon stiffness using shear wave elastography on the gastrocnemius and Achilles tendon. IASTM significantly increased the DFROM and MPT (p < 0.05 for both). However, no significant changes were observed in muscle and tendon stiffness. None of the parameters changed significantly in the control group. The 6-week IASTM program increased stretch tolerance and joint flexibility but did not change muscle and tendon stiffness.

Lower rates of return to sport in patients with generalised joint hypermobility two years after ACL reconstruction: a prospective cohort study

BACKGROUND

Generalised joint hypermobility (GJH) has been associated with an increased risk of suffering an anterior cruciate ligament (ACL) injury. Patients with GJH exhibit lower muscle strength and poorer scores for patient-reported outcomes after ACL reconstruction, compared with patients without GJH. The aim of this study was to examine differences in the percentages of patients who return to sport (RTS) or pre-injury level of activity (RTP), muscle function and patient-reported outcomes at the time of RTS or RTP, as well as the time of RTS or RTP in patients with GJH compared with patients without GJH in the first two years after ACL reconstruction.

METHODS

This prospective study used data from an ACL- and rehabilitation-specific register located in Gothenburg, Sweden. Patients aged between 16 and 50, who had a primary ACL injury treated with reconstruction, were included. Data up to two years after ACL reconstruction were used and consisted of achieving RTS and RTP, results from isokinetic muscle function tests for knee extension and flexion and patient-reported outcomes (Knee Self-Efficacy Scale, Knee injury and Osteoarthritis Outcome Score and ACL-Return to Sport after Injury scale) at the time of RTS, as well as the time of RTP. A Beighton Score of ≥ 5/9 was used to define GJH. A Tegner Activity Scale of ≥ 6 was used to define RTS, while a Tegner equal to or above pre-injury level was used to define RTP.

RESULTS

A total of 1,198 patients (54.7% women) with a mean age of 28.5 ± 8.6 years were included. A smaller proportion of patients with GJH achieved RTS compared with patients without GJH (49.2% vs. 57.3%, Odds ratio: 0.720, p = 0.041). Furthermore, patients with GJH were marginally less symmetrical on the knee extension strength test, expressed as a Limb Symmetry Index, at the time of RTP compared with patients without GJH (87.3 ± 13.5 vs. 91.7 ± 14.3, Cohen's d = 0.142, p = 0.022). No further differences were found between groups regarding any muscle function tests or patient-reported outcomes.

CONCLUSION

A smaller proportion of patients with GJH achieved RTS compared with patients without GJH. Patients with GJH displayed less symmetrical knee extension strength at the time of RTP compared with patients without GJH.

Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction

OBJECTIVES

To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R).

METHODS

Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS.

RESULTS

A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures.

CONCLUSION

Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.

The impact of the menstrual cycle on orthopaedic sports injuries in female athletes

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Injury Risk in Collegiate Football Players With Generalized Joint Hypermobility: A Prospective Cohort Study Over 2 Years

Background

Generalized joint hypermobility (GJH) has been identified as a risk factor for injury in various athletic patient populations.

Purpose

To evaluate GJH as a predisposing risk factor for injury in a population of National Collegiate Athletic Association (NCAA) Division I football players.

Study Design

Cohort study; Level of evidence, 2.

Methods

The Beighton score was collected for 73 athletes during their preseason physical examinations in 2019. GJH was defined as a Beighton score ≥4. Athlete descriptive characteristics, including age, height, weight, and playing position, were recorded. The cohort was evaluated prospectively for 2 years, and the number of musculoskeletal issues, injuries, treatment episodes, days unavailable, and surgical procedures for each athlete during this period were recorded. These measures were compared between the GJH and no-GJH groups.

Results

The mean Beighton score was 1.4 ± 1.5 for the 73 players; 7 players (9.6%) had a Beighton score indicating GJH. During the 2-year evaluation, there were 438 musculoskeletal issues, including 289 injuries. The mean number of treatment episodes per athlete was 77 ± 71 (range, 0-340), and the mean number of days unavailable was 67 ± 92 days (range, 0-432 days). There were 23 athletes who required 25 operations, the most common procedure being arthroscopic shoulder stabilization (n = 6). The number of injuries per athlete was not significantly different between the GJH and no-GJH groups (3.0 ± 2.1 vs 4.1 ± 3.0; P = .13), nor were there any between-group differences in the number of treatments received (74.6 ± 81.9 vs 77.2 ± 71.5; P = .47), days unavailable (79.6 ± 124.5 vs 65.3 ± 89.3; P = .61), or rates of surgery (43% vs 30%; P = .67).

Conclusion

A preseason diagnosis of GJH did not place NCAA football players at a greater risk for injury during the 2-year study period. Based on the findings of this study, no specific preparticipation risk counseling or intervention is warranted for football players who are diagnosed with GJH as defined by the Beighton score.

Musculoskeletal Injury in American Football: A Bibliometric Analysis of the Most Cited Articles

Background

Textbook knowledge and clinical dogma are often insufficient for effective evidence-based decision making when treating musculoskeletal injuries in American football players, given the variability in presentation and outcomes across different sports and different levels of competition. Key evidence can be drawn directly from high-quality published articles to make the appropriate decisions and recommendations for each athlete's unique situation.

Purpose

To identify and analyze the 50 most cited articles related to football-related musculoskeletal injury to provide an efficient tool in the arsenal of trainees, researchers, and evidence-based practitioners alike.

Study Design

Cross-sectional study.

Methods

The ISI Web of Science and SCOPUS databases were queried for articles pertaining to musculoskeletal injury in American football. For each of the top 50 most cited articles, bibliometric elements were evaluated: citation count and density, decade of publication, journal, country, multiple publications by the same first author or senior author, article content (topic, injury area), and level of evidence (LOE).

Results

The mean ± SD number of citations was 102.76 ± 37.11; the most cited article, with 227 citations, was "Syndesmotic Ankle Sprains" published in 1991 by Boytim et al. Several authors served as a first or senior author on >1 publication, including J.S. Torg (n = 6), J.P. Bradley (n = 4), and J.W. Powell (n = 4). The American Journal of Sports Medicine published the majority of the 50 most cited articles (n = 31). A total of 29 articles discussed lower extremity injuries, while only 4 discussed upper extremity injuries. The majority of the articles (n = 28) had an LOE of 4, with only 1 article having an LOE of 1. The articles with an LOE of 3 had the highest mean citation number (133.67 ± 55.23; F = 4.02; P = .05).

Conclusion

The results of this study highlight the need for more prospective research surrounding the management of football-related injury. The low overall number of articles on upper extremity injury (n = 4) also highlights an area for further research.

Hypermobility spectrum disorders: A review

It remains a clinical challenge identifying when joint hypermobility (JH) is responsible for pain. Previous nomenclature utilized terms such as (benign) joint hypermobility syndrome (JHS) but this was updated in 2017 as advances in genetics provide a basis for nearly all variants of Ehlers-Danlos syndrome (EDS) with the exception of hypermobile EDS (hEDS). New terminology describes hypermobility spectrum disorders (HSDs) as the updated term for JHS. Diagnosis of a subtype of HSDs should be considered in patients who have JH coupled with the presence of secondary musculo-skeletal manifestations (trauma, chronic pain, disturbed proprioception, and other manifestations) and at the exclusion of hEDS. Extra-articular manifestations are common. Treatment relies on management strategies for other chronic pain syndromes with a multidisciplinary approach likely optimal. Lifestyle modifications focus on weight loss and exercise. Physical therapy helps strengthen periarticular muscles, improving mobility. Pharmacologic therapies focus on judicious use of non-steroidal anti-inflammatory drugs and acetaminophen. Serotonin and norepinephrine reuptake inhibitor may help widespread pain. Avoidance of opioids remains prudent. The purpose of this review is to provide clinicians the rationale for the update in nomenclature, understand the musculoskeletal and extra-articular manifestations of the subtypes of HSDs, considerations when making the diagnosis, and treatment.

Untangling risk factors including discipline-specific exposure for injuries in preprofessional and professional circus artists in the USA

Objective

This prospective cohort study quantified injury patterns related to specific circus discipline exposure in preprofessional and professional circus artists.

Methods

Circus artists (n=201; ages 13-69; 172 female, 29 male assigned sex at birth) were enrolled in 10 cities across the USA. Participants were followed for 1 year from enrolment, completing a weekly training log and undergoing a physical therapist evaluation for injuries. The circus-specific extension of the International Olympic Committee 2020 consensus on recording injury and illness in sports was used to analyse injury patterns.

Results

The study completion rate was 77% (n=155). Data were analysed by participant subgroup (age, professional status, sex at birth). The highest injury rates in participant subgroups were for males (5.69/1000 exposures) and related to discipline subgroups, were in aerial with ground elements (5.93/1000 exposures) and aerial (4.26/1000 exposures). Adults had more injuries related to aerial, whereas adolescents had more related to ground disciplines (χ² (2)=10.62, p=0.005) and non-time loss injuries (χ² (1)=5.45, p=0.02). Females had a higher proportion of repetitive injuries (70% vs 55%) than males (χ² (1) = 4.43, p=0.035). Individuals with an eating disorder history had more (p<0.004) injuries (mean 2.27±2.29) than those without (mean=1.48±0.96).

Conclusions

This study showed that intrinsic factors (age, sex at birth and history of eating disorder) and extrinsic factors (circus discipline exposure) affect injury risk. We need to account for the intersectionality of these factors to address risk management at an individual and group level.

Krafttraining bei Frauen mit generalisierter Hypermobilität: Machbarkeit, Beschwerden und Effekte

Hintergrund Eine generalisierte Hypermobilität liegt vor, wenn die Beweglichkeit in mehreren Gelenken das übliche Maß übersteigt. Bis zu 30 % der Frauen und 10 % der Männer sind davon betroffen. Hypermobilität ist keine Pathologie, wenn sie jedoch mit Schmerzen und weiteren Symptomen einhergeht, kann sie die Gesundheit und Alltagsfunktionen beeinträchtigen. Zur physiotherapeutischen Behandlung gibt es wenige Studien, wobei Krafttraining eine mögliche Intervention sein könnte.

Ziel Erfassung der Machbarkeit und des Effekts eines Krafttrainings für Frauen mit generalisierter Hypermobilität.

Methode Pre-post-Studie, in der hypermobile Frauen (Beighton-Score > 5) zwischen 20 und 40 Jahren während 12 Wochen ein Krafttraining an Geräten, fokussiert auf Beine und Rücken, absolvierten. Mithilfe eines Protokolls und wöchentlicher Fragebogen wurden das Training und dadurch ausgelöste Beschwerden analysiert. Vor und nach dem Training wurde die Kraft der Knieflexoren und -extensoren sowie der Muskelquerschnitt am Oberschenkel gemessen. Die Analyse erfolgte primär deskriptiv, zusätzlich erfolgte ein Vergleich von 2 Subgruppen mittels Mann-Whitney-U und Chi2-Test.

Ergebnisse 46 Teilnehmerinnen (26,3 ± 4,3 Jahre) absolvierten das Training. 6 davon brachen die Studie vorzeitig ab, davon eine wegen Rückenschmerzen aufgrund einer Diskushernie. 72,5 % der verbleibenden 40 Teilnehmerinnen absolvierten 20 oder mehr Trainings. In 34 % der Trainingswochen wurden geringe Beschwerden angegeben, mehrheitlich an Knie und Rücken. Der Einsatz der verwendeten Gewichte war oft tief, so wurde auf der Legpress mit durchschnittlich 44,8 % des Körpergewichts begonnen, nach 12 Wochen lag das Trainingsgewicht im Mittel bei 52,2 kg, was 85,7 % des Körpergewichts entspricht. Bei der Kraft und beim Muskelquerschnitt wurden keine signifikanten Verbesserungen erreicht, wobei bis zu 17 Teilnehmerinnen (42,5 %) eine Verbesserung von mehr als 10 % erreichten.

Schlussfolgerung Das Krafttraining war für die meisten Teilnehmerinnen machbar und gut verträglich. Das mehrheitlich selbstgesteuerte Training war zu wenig intensiv, um eindeutige Auswirkungen auf Kraft oder Muskelmasse zu erreichen, obwohl einzelne Teilnehmerinnen durchaus davon profitierten. In weiteren Studien sollten individuellere und enger begleitete Trainingsprogramme untersucht werden.

Age and Sex Comparisons in Pediatric Track and Field Hurdle Injuries Seen in Emergency Departments of the US

There is limited literature analyzing pediatric hurdle injuries based on sex and age. This study compares hurdle-related injury types, injured body parts, and injury mechanisms by age and sex in pediatrics. Hurdle-related injury data from the National Electronic Injury Surveillance System were used to retrospectively review the injuries of hurdlers 18 years and under. Differences in injured body parts, injury types, and mechanisms were analyzed by age (pre-high school vs. high school) and sex (male vs. female). A total of 749 cases were extracted. Fractures were more common in pre-high schoolers (34.1% vs. 21.5%, p = 0.001), while more sprains were identified in high schoolers (29.6%) than pre-high schoolers (22.8%, p = 0.036). Males suffered more fractures than females (35.1% vs. 24.3%, p = 0.001). Females sustained more joint sprains (29.1% vs. 21.0%, p = 0.012) and contusions/hematomas (12.7% vs. 7.5%, p = 0.020). Ankle injuries were more common in females (24.0%) than males (12.0%, p = 0.001), while wrist injuries were more prevalent in males (11.7% vs. 7.2%, p = 0.034). The most common injury mechanism was apparatus-related, with no differences based on age or sex. Injury types and injured body parts differed depending on age and sex in pediatric hurdle injuries seen in emergency departments. These findings may be helpful for injury prevention and medical care for pediatric hurdlers.

Generalized joint hypermobility subjects without knee hyperextension have greater walking anterior tibial translation and flexion angle than those with knee hyperextension

BACKGROUND

The walking knee kinematic results of generalized joint hypermobility (GJH) subjects were controversial in previous studies. We proposed that this could be related to the knee statuses of GJH subjects with/without knee hyperextension (KH) and assumed that there are significant sagittal knee kinematic differences between GJH subjects with/without KH during gait.

RESEARCH QUESTION

Do GJH subjects with KH exhibit significantly different kinematic characteristics than those without KH during walking?

METHODS

35 GJH subjects without KH, 34 GJH subjects with KH, and 30 healthy controls were recruited in this study. A three-dimensional gait analysis system was used to record and compare the knee kinematics of the participants.

RESULTS

Significant walking knee kinematics differences were found between GJH subjects with/without KH during walking. GJH subjects without KH had greater flexion angles (4.7-6.0°, 24-53 % gait cycle (GC), p < 0.001; 5.1-6.1°, 65-77 % GC, p = 0.008) and anterior tibial translation (ATT) (3.3-4.1 mm, 0-4 % GC, p = 0.015; 3.8-4.3 mm, 91-100 % GC, p = 0.01) than those with KH. Compared to controls, GJH without KH exhibited increased ATT (4.0-5.7 mm, 0-26 % GC, p < 0.001; 5.1-6.7 mm, 78-100 % GC, p < 0.001), and range of motion of ATT (3.3 mm, p = 0.028) whereas GJH with KH only exhibited increased extension angle (6.9-7.3°, 62-66 % GC, p = 0.015) during walking.

SIGNIFICANCE

The findings confirmed the hypothesis and suggested that GJH subjects without KH had more walking ATT and flexion angle asymmetries than those with KH. This may raise concerns about the differences in knee health and risk of knee diseases between GJH subjects with/without KH. However, further investigations should be done to explore the exact influence of walking ATT and flexion angle asymmetries in GJH subjects without KH.

Upslope walking increases anterior tibial translation deficiency in patients with generalized joint hypermobility

BACKGROUND

Generalized joint hypermobility (GJH) is a highly prevalent disease that frequently affects the knee joint. The current literature has conflicting results about whether patients with GJH had knee kinematics deficiency during gait. This could be because most of the testing environment (level walking) was gentle and low-demanding for patients when studying their knee kinematics. With a high-demanding knee function and sagittal firm structure requirement, upslope walking was thought to stimulate sagittal knee kinematics deficiency in patients with GJH.

RESEARCH QUESTIONS

However, only little investigation reported whether upslope walking could stimulate knee kinematic deficiency or not. We hypothesize that upslope walking can increase sagittal knee kinematic deficiency between GJH subjects and healthy controls.

METHODS

A three-dimensional motion analysis was conducted to explore whether upslope walking could stimulate sagittal knee kinematic deficiency in patients with GJH. A total of 44 patients with GJH and 44 healthy controls were recruited. Subjects walked on both level and upslope (15%) conditions when the kinematic data were collected. SPM1D analysis was taken to explore the differences between groups.

RESULTS

Our results showed that upslope walking could significantly increase knee flexion angle and anterior tibial translation in both GJH patients and healthy controls (p < 0.05). The increments of anterior tibial translation (values in upslope walking minus values in level walking) of GJH patients were greater than those of healthy controls (magnitude varying from 2.5 to 2.9 mm during 0-3% gait cycles (GC), p = 0.034; 1.4-2.9 mm during 93-100%GC, p = 0.012).

SIGNIFICANCES

The findings partially confirmed our hypothesis and suggested that upslope walking could increase anterior tibial translation deficiency in patients with GJH. Upslope walking may be a practical motion task in studying the weakness of knee kinematics of GJH subjects for researchers and scholars. Patients with GJH may face a more challenging knee kinematic environment than healthy controls in up-sloped activities.

Kinematic alterations of the ankle in subjects with generalized joint hypermobility compared with the controls: A cross-sectional study

INTRODUCTION

Generalized joint hypermobility (GJH) is a hereditary connective tissue disease in which the range of motion (ROM) of multiple joints exceeds the normal range, and the ROM varies with age, gender, and ethnicity. At present, the six-degree-of-freedom (6-DOF) of ankle kinematics among people with GJH have not been studied. To investigate the kinematic characteristics in the ankle during treadmill gait of university students with generalized joint hypermobility compared to normal participants. We hypothesized that compared to the participants in the control group, those with GJH would exhibit kinematic characteristics of poorer active motion stability in the ankle during treadmill gait.

METHODS

Healthy university student volunteers aged 18-24 (excluding those with a history of ankle trauma, etc.) were recruited and divided into a control group (50 volunteers) and a GJH group (Beighton score ≥4, 50 volunteers). Data of the 6-DOF kinematics of ankle was collected using a 3D gait analysis system. Variables were evaluated using independent t-tests and Wilcoxon signed-rank tests.

RESULTS

In the proximal/distal parameter, proximal displacement was significantly increased in the GJH group compared with the control group during 4-9% and 96-97% of the gait phase (loading response and terminal swing phase), with an increase of (0.1-0.2 cm, p < .05). Regarding the proximal/distal, internal/external, plantarflexion/dorsiflexion, and anterior/posterior parameters, the participants with GJH exhibited greater ROM than those in the control group throughout the gait cycle (0.24 ± 0.22 cm vs. 0.19 ± 0.15 cm, p = 0.047, 5.56 ± 2.90° vs. 4.48 ± 3.30°, p = .020, 23.05 ± 5.75° vs. 20.36 ± 4.91°, p < .001, 0.65 ± 0.30 cm vs. 0.55 ± 0.27 cm, p = .018). However, ROM of inversion/eversion translation was found to be decreased in the GJH group compared to the control group (8.92 ± 1.59° vs. 9.47 ± 1.37°, p = .009). In addition, there was no statistical difference between the GJH group and the control group in ROM of medial/lateral translation (0.05 ± 0.06 cm vs. 0.04 ± 0.05 cm, p = .131).

CONCLUSION

Our results confirm that our hypothesis is not valid. Although there were a few differences in each gait parameter of the ankle between the GJH group and the control group, the difference was not significant. These results indicate that the presence of GJH has less effect on ankle kinematics and enhance our knowledge of the relationship between GJH and 6-DOF of ankle kinematics.

International Perspectives on Joint Hypermobility: A Synthesis of Current Science to Guide Clinical and Research Directions

ABSTRACT

There is exponential clinical and research interest in joint hypermobility due to recognition of the complexity of identification, assessment, and its appropriate referral pathways, ultimately impacting management. This state-of-the-science review provides an international, multidisciplinary perspective on the presentation, etiology, and assessment of joint hypermobility, as it presents in those with and without a systemic condition. We synthesize the literature, propose standardizing the use of terminology and outcome measures, and suggest potential management directions. The major topics covered are (i) historical perspectives; (ii) current definitions of hypermobility, laxity, and instability; (iii) inheritance and acquisition of hypermobility; (iv) traditional and novel assessments; (v) strengths and limitations of current assessment tools; (vi) age, sex, and racial considerations; (vii) phenotypic presentations; (viii) generalized hypermobility spectrum disorder and hypermobility Ehlers-Danlos syndrome; and (ix) clinical implications and research directions. A thorough understanding of these topics will equip the reader seeking to manage individuals presenting with joint hypermobility, while mindful of its etiology. Management of generalized joint hypermobility in the context of a complex, multisystem condition will differ from that of acquired hypermobility commonly seen in performing artists, specific athletic populations, posttrauma, and so on. In addition, people with symptomatic hypermobility present predominantly with musculoskeletal symptoms and sometimes systemic symptoms including fatigue, orthostatic intolerance, and gastrointestinal or genitourinary issues. Some also display skeletal deformities, tissue and skin fragility, and structural vascular or cardiac differences, and these warrant further medical follow-up. This comprehensive review on the full spectrum of joint hypermobility will assist clinicians, coaches/sports trainers, educators, and/or researchers in this area.

Patients With Generalized Joint Hypermobility Have Thinner Superior Hip Capsules and Greater Hip Internal Rotation on Physical Examination

Purpose

To compare preoperative hip range of motion (ROM), hip capsular thickness on magnetic resonance imaging (MRI), and bony morphology on radiographs and computed tomography (CT) between patients with and without joint hypermobility as measured by the Beighton Test score (BTS), with subanalysis based on sex and age.

Methods

Consecutive patients who underwent hip arthroscopy for a diagnosis of femoroacetabular impingement syndrome with or without dysplasia were retrospectively reviewed. Patient BTS, hip ROM, demographics, surgical data, morphologic measures on radiographs and CT, and MRI findings including hip capsule thickness at various locations were compiled. Multiple statistical tests were performed, including multivariable linear or logistic regression models, while controlling for BTS, age, and sex.

Results

In total, 99 patients were included with a mean age of 29 ± 9.9 years; 62 (62.6%), were female. Forty patients (40.4%) had a BTS ≥4. Female patients (P < .001) and younger patients (26.7 vs 30.9 years, P = .030) were more likely to have a BTS ≥4. Male patients had significantly thicker superior capsules (3.4 mm vs. 2.8 mm, P = .034). BTS was not associated with capsular thickness when controlling for sex. On CT, femoral version (18.9° vs 11.4°, P < .001), and McKibben index (37.8° vs. 28.2°, P < .001) were significantly greater in those with a BTS ≥4. Patients with a BTS ≥4 had more hip internal rotation at 90° of flexion (15.0° vs 10.0°, P < .001), when prone (30.0° vs 20.0°, P = .004), and in extension (10.0° vs. 5.0°, P < .001).

Conclusions

All female patients, regardless of Beighton score, and all patients with a BTS ≥4 indicated for primary hip arthroscopy for femoroacetabular impingement syndrome with or without dysplasia were more likely to have thinner superior hip capsules on MRI and greater hip internal rotation on exam. Bony morphologic differences exist between sexes and between patients with and without hypermobility, likely contributing to differences in ROM.

Level of Evidence

III, retrospective cohort study.

Does Ligamentous Laxity Protect Against Chondral and Osteochondral Injuries in Patients With Patellofemoral Instability?

Background:

Many patients undergoing medial patellofemoral ligament (MPFL) reconstruction for patellofemoral instability have chondral or osteochondral injuries requiring treatment.

Hypothesis:

In patients undergoing MPFL reconstruction for patellofemoral instability, those with ligamentous laxity (LAX) would be less likely to have chondral or osteochondral defects requiring surgical intervention compared with those with no laxity (NLX).

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Included were 171 patients with patellofemoral instability (32 men, 139 women; mean age, 22 years [range, 11-57 years]) who underwent MPFL reconstruction between 2005 and 2015. Patients with a Beighton-Horan score ≥5 were considered LAX (n = 96), while patients with scores <5 were considered NLX (n = 75). Preoperative magnetic resonance images were evaluated to determine the presence, size, and location of chondral or osteochondral injury as well as the grade according to the Outerbridge classification. Documented anatomic measurements included tibial tubercle–trochlear groove (TT-TG) distance, Caton-Deschamps Index (CDI) for patellar height, and the Dejour classification for trochlear dysplasia.

Results:

Of the 171 patients, 58 (34%) required a surgical intervention for a chondral or osteochondral defect: chondroplasty (29/58; 50%), particulated juvenile cartilage implantation (18/58; 31%), microfracture (16/58; 28%), osteochondral fracture fixation (2/58; 3.4%), and osteochondral allograft (2/58; 3.4%). While there was no statistical difference in the proportion of patellar chondral or osteochondral injuries between patients with NLX (58%) versus LAX (67%) (P = .271), there was a significantly higher rate of patellar grade 3 or 4 injuries in the NLX (74%) versus LAX (45%) group (P = .004). Similarly, there was no difference in femoral chondral or osteochondral injury rates between groups (P = .132); however, femoral grade 3 or 4 injuries were significantly higher in the NLX (67%) versus the LAX (13%) group (P = .050). After adjusting for age, sex, radiographic parameters (TT-TG distance and CDI), and trochlear morphology, patients with LAX were 75% less likely to have had a grade 3 or 4 patellar cartilage injury compared with patients with NLX (P = .006).

Conclusion:

For patients who sustained patellar or femoral chondral or osteochondral injuries, compared with their counterparts with NLX, patients with LAX were less likely to have severe (grade 3 or 4) injuries requiring surgical intervention.

Association between the Beighton Score and Stress Ultrasonographic Findings of the Anterior Talofibular Ligament in Healthy Young Women: A Cross-Sectional Study

The Beighton score (BS) is widely used to evaluate generalized joint laxity. However, the association between the BS and lateral ankle laxity is unclear. This study compared the ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) between high- (≥6) and low- (≤3) BS groups of healthy young women. The ATFL lengths of healthy young women were measured in the stress and nonstress positions using the previously reported technique from March 2021 to January 2022. The ATFL ratio (ratio of stress to nonstress ATFL length) was used as an indicator of lateral ankle laxity. The anterior drawer test (ADT) was performed. The correlation between the BS and US findings was also examined. A total of 20 (high-BS group) and 61 (low-BS group) subjects with a mean age of 23.8 ± 1.0 years were included. The high-BS group showed a higher grade of ADT than the low-BS group. No significant differences were found in the nonstress and stress ATFL lengths and ATFL ratio (1.10 ± 0.05 vs. 1.09 ± 0.05, p = 0.19) between the groups. No correlation was found between the BS and US findings. In conclusion, this study did not detect significant differences in the US findings of the ATFL between the high- and low-BS groups.

Female Athlete Hip Injuries: A Narrative Review

OBJECTIVE

In this narrative review, we highlight sex-specific anatomic and biomechanical features of the hip region in female athletes, as well as the potential impact of these characteristics on observed disparities in both intra-articular and extra-articular injury patterns between female and male athletes. It is our goal to broaden the scope of knowledge related to hip pathology in active female athletes among sports medicine providers with the hope of better optimizing sport participation and performance in female athletes.

DATA SOURCES

A literature review was conducted using PubMed database and Google Scholar search engine. Search terms included sport, female, athlete, sex differences, injury, hip, and all diagnoses discussed in this review. Cross-reference of these articles identified additional resources.

MAIN RESULTS

Sex-specific differences in both static design and dynamic function contribute to disparities in hip injury patterns between female and male athletes. Intra-articular injuries, including labral and ligamentum teres pathology, as well as extra-articular injuries, including iliopsoas tendon dysfunction, gluteal and proximal hamstring tendinopathy, ischiofemoral impingement, bone stress injuries, and certain nerve entrapment syndromes, seem to affect female athletes more commonly than male counterparts.

CONCLUSIONS

Given unique anatomic and functional considerations, the growing population of female athletes worldwide warrants specialized care and consideration. Potential predisposition to specific hip injuries should be taken into consideration during diagnostic evaluation of hip pain in the female athlete.

Risk Factors Influencing the Incidence of Ankle Sprain Among Elite Football and Basketball Players: A Prospective Study

Introduction. The objective of the present study was to investigate whether certain intrinsic factors (foot hyperpronation, generalized joint laxity) and clinical tests (anterior drawer and talar tilt tests, single-leg balance test and star excursion balance test, ankle and first metatarsophalangeal range of motion) could predict the incidence of lateral ankle sprains among elite football and basketball players during a full year. Method. In a prospective cohort study, 106 elite basketball and football players were recruited. During the preseason period, players underwent baseline measurements. Team physicians in following year reported occurrence of new ankle sprains. Results. Ankle sprain was more frequent among basketball players (P = .01). The history of recurrent (P = .001) and acute ankle sprain (P = .01) and each 5-year increase in age (P = .039) were predictive factors for ankle sprain. No evidence for relationship between other risk factors and occurrence of ankle sprain were achieved. Conclusion. In our study, the history of recurrent and acute ankle sprain was the strongest predictor for ankle injuries. Considering the limitations of this study, it seems mandatory to conduct more prospective studies with a larger sample size and longer follow-up period.Levels of Evidence: Level II: Prognostic.

Effectiveness of physiotherapy interventions for injury in ballet dancers: A systematic review

Background

The unique repetitive nature of ballet dancing, which often involves transgressing endurance limits of anatomical structures, makes dancers prone to injury. The following systematic review aims to assess the effectiveness of physiotherapy interventions in the treatment of injuries in ballet dancers.

Methods

The review was performed in line with the PRISMA statement on preferred reporting items for systematic reviews and meta-analyses. Six electronic databases (PubMed, Ovid Embase, Cochrane, Medline, PEDro, Google Scholar) were queried. The study populations comprised active ballet dancers and/or ballet school attendees with acute and chronic injuries and those with persistent pain. There were no restrictions regarding age, sex, ethnicity or nationality. The Modified McMaster Critical Review Form for quantitative studies was used to assess the methodological quality of the studies reviewed in accordance with the relevant guidelines.

Results

Out of the total of 687 articles subjected to the review, 10 met the inclusion criteria. Diverse physiotherapeutic interventions were described and effectiveness was assessed using different parameters and measurements. Overall, the results indicate that physiotherapy interventions in ballet dancers exert a positive effect on a number of indices, including pain, ROM and functional status.

Conclusions

Due to the small amount of evidence confirming the effectiveness of physiotherapeutic interventions in ballet dancers after injuries and methodological uncertainties, it is recommended to improve the quality of prospective studies.

Injury risk profile of amateur Irish women soccer players and players' opinions on risk factors and prevention strategies

OBJECTIVE

To explore injury profile, opinions on risk factors and injury prevention, among Irish amateur women soccer players.

DESIGN

A cross-sectional online survey.

SETTING

Irish amateur winter league.

PARTICIPANTS

Active players ≤18 years of age.

MAIN OUTCOMES

Differences were found between injured and uninjured groups, and risk factors that significantly predict soccer injury were identified.

RESULTS

168 injuries were reported by 83 respondents during the winter season. An increased prevalence of competition anxiety was observed in (53.8%:n = 85 of respondents) compared to other risk factors. There was a negative association between injuries and players' general health state (OR = 0.820, 95% CI 0.7-0.9, p = 0.007). Players' knowledge about some risk factors including playing position, joint hypermobility, and playing during menses contradicts current evidence. 50%; n = 67 of the respondents had not received any education on injury risk or prevention.

CONCLUSION

This study identified that Irish amateur women soccer players that responded have different characteristics, prevalence of risk factors and injury profiles to women players from different levels and countries. The findings suggest that some players may not be aware of the existing evidence base pertaining to common risk factors for injury. Further research is required to confirm the findings and explore the implementation of injury prevention strategies.

Joint hypermobility in athletes is associated with shoulder injuries: a systematic review and meta-analysis

BACKGROUND

Joint hypermobility in athletes is associated with increased risk of knee injuries, but its role in relation to shoulder injuries has not been scrutinized. Therefore, our aim was to synthesize the evidence on the association between joint hypermobility and shoulder injuries in athletes.

METHODS

Data sources were MEDLINE, CINAHL, EMBASE, and SPORTDiscus from inception to 27th February 2021. Eligibility criteria were observational studies of athletes (including military personnel), mean age ≥ 16 years, and with a transparent grouping of those with and without joint hypermobility. A broad definition of joint hypermobility as the exposure was accepted (i.e., generalised joint hypermobility (GJH), shoulder joint hypermobility including joint instability). Shoulder injuries included acute and overuse injuries, and self-reported pain was accepted as a proxy for shoulder injuries. The Odds Ratios (OR) for having shoulder injuries in exposed compared with non-exposed athletes were estimated using a random effects meta-analysis. Subgroup analyses were performed to explore the effect of sex, activity type, sports level, study type, risk of bias, and exposure definition. Risk of bias and the overall quality of evidence were assessed using, respectively, the Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Among 6207 records, six studies were included with 2335 (range 118-718) participants (34.1% females; athlete mean age 19.9 years). Athletes with joint hypermobility were more likely to have shoulder injuries compared with athletes without joint hypermobility (OR = 3.25, 95% CI 1.64, 6.43, I2 = 75.3%; p = 0.001). Exposure definition (GJH, OR = 1.97, 95% CI 1.32, 2.94; shoulder joint hypermobility, OR = 8.23, 95% CI 3.63, 18.66; p = 0.002) and risk of bias (low, OR = 5.25, 95% CI 2.56, 10.8; high, OR = 1.6, 95% CI 0.78, 3.29; p = 0.024) had large impacts on estimates, while the remaining subgroup analyses showed no differences. The overall quality of evidence was low.

CONCLUSION

Joint hypermobility in athletes is associated with a threefold higher odds of having shoulder injuries, highlighting the need for prevention strategies in this population. However, due to low quality of evidence, future research will likely change the estimated strength of the association.

PROTOCOL REGISTRATION

Open Science Framework registration osf.io/3wrn9.

The Case for Retiring Flexibility as a Major Component of Physical Fitness

Flexibility refers to the intrinsic properties of body tissues that determine maximal joint range of motion without causing injury. For many years, flexibility has been classified by the American College of Sports Medicine as a major component of physical fitness. The notion flexibility is important for fitness has also led to the idea static stretching should be prescribed to improve flexibility. The current paper proposes flexibility be retired as a major component of physical fitness, and consequently, stretching be de-emphasized as a standard component of exercise prescriptions for most populations. First, I show flexibility has little predictive or concurrent validity with health and performance outcomes (e.g., mortality, falls, occupational performance) in apparently healthy individuals, particularly when viewed in light of the other major components of fitness (i.e., body composition, cardiovascular endurance, muscle endurance, muscle strength). Second, I explain that if flexibility requires improvement, this does not necessitate a prescription of stretching in most populations. Flexibility can be maintained or improved by exercise modalities that cause more robust health benefits than stretching (e.g., resistance training). Retirement of flexibility as a major component of physical fitness will simplify fitness batteries; save time and resources dedicated to flexibility instruction, measurement, and evaluation; and prevent erroneous conclusions about fitness status when interpreting flexibility scores. De-emphasis of stretching in exercise prescriptions will ensure stretching does not negatively impact other exercise and does not take away from time that could be allocated to training activities that have more robust health and performance benefits.

Hypermobile Disorders and Their Effects on the Hip Joint

Hypermobility, or joint hyperlaxity, can result from inherited connective tissue disorders or from micro- or macrotrauma to a joint. The supraphysiologic motion of the hip joint results in capsuloligamentous damage, and these patients have a propensity to develop femoroacetabular impingement syndrome (FAIS) and labral injury. In this review, the recent literature evaluating the definitions, history, incidence, genetics, and histology of hypermobile disorders is investigated. We then review the clinical evaluation, natural history, and resulting instability for patients presenting with a hypermobile hip. Lastly, treatment options and outcomes will be highlighted.

Joint hypermobility and musculoskeletal injuries in a university-aged population

OBJECTIVE

To explore the correlation between joint hypermobility and risk of musculoskeletal injuries in a university-aged population.

DESIGN

Cross-sectional study using an anonymous survey.

SETTING

Anatomy & Physiology lab.

PARTICIPANTS

816 undergraduate Anatomy & Physiology students at a university in the United States.

MAIN OUTCOME MEASURES

Beighton score, self-reported musculoskeletal injuries.

RESULTS

Athletically active study respondents reported more musculoskeletal injuries than respondents who indicated not being athletically active. Female respondents had lower rates of self-reported injuries than male respondents (55.4% vs. 65.5%; p = 0.0099; odds ratio: 1.53). The most commonly reported injury type for both women and men were quadriceps, groin and hamstring injuries. Neither male nor female respondents with generalized joint hypermobility (GJH) or localized joint hypermobility (LJH) reported higher rates of musculoskeletal injuries.

CONCLUSIONS

Athletically active young adults are at greater risk for sustaining musculoskeletal injuries; however, there is no additional increase in injury risk for young people with GJH or LJH.

The Influence of Asymptomatic Hypermobility on Unanticipated Cutting Biomechanics

BACKGROUND

Generalized joint hypermobility is an important risk factor for knee injuries, including to the anterior cruciate ligament (ACL). Examining movement patterns specific to hypermobile individuals during sport-specific movements could facilitate development of targeted recommendations and injury prevention programs for this population.

HYPOTHESIS

Asymptomatic hypermobile participants will present kinematics measures suggestive of a greater risk of noncontact knee or ACL injuries.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Forty-two (15 asymptomatic hypermobile and 27 nonhypermobile) individuals performed unanticipated side-step cutting on their dominant and nondominant legs. Ankle, knee, hip, pelvis, and trunk angles in all planes of motion were collected during the first 100 ms after initial contact using a 3-dimensional infrared system. Precontact foot-ground angles were also extracted. Data from hypermobile and nonhypermobile groups were compared using multiple regression models with sex as a confounder. When nonsignificant, the confounder was removed from the model. Effect sizes (Hedge g) were calculated in the presence of significant between-group differences.

RESULTS

Hypermobile individuals presented with lower minimum knee valgus angles with a mean difference of 3.5° (P = 0.03, Hedge g = 0.69) and greater peak knee external rotation angles with a mean difference of -4.5° (P = 0.04, Hedge g = 0.70) during dominant leg cutting, and lower peak ankle plantarflexion angles with a mean difference of 4.5° (P = 0.03, Hedge g = 0.73) during nondominant leg cutting compared with nonhypermobile individuals.

CONCLUSIONS

Based on current scientific evidence, however, the identified differences are not crucial biomechanical injury risk factors that could predispose asymptomatic hypermobile individuals to noncontact knee or ACL injuries.

CLINICAL RELEVANCE

Further research is needed to highlight differences between hypermobility groups. Knowledge of the differences between these groups may change the physical activity recommendations, prevention of injury, and rehabilitation approaches.

Recognition of Failure Modes of Lateral Ankle Ligament Reconstruction: Revision and Salvage Options

Primary lateral ankle ligament reconstruction has a high success rate, but failures may lead to recurrent instability. In patients with recurrent lateral ankle instability, it is important to determine the mode of failure. Underlying cavovarus deformity and joint hypermobility must be identified and addressed at the time of revision surgical stabilization. The modified Brostrom-Gould procedure is typically performed for primary lateral ankle ligament reconstruction, but it may be used in revision stabilization procedures utilizing suture-tape augmentation. Revision lateral ankle stabilization surgery can also be addressed with anatomic allograft reconstruction of the ATFL and CFL, and is the authors'preferred technique.

Generalized joint hypermobility, scoliosis, patellofemoral pain, and physical abilities in young dancers

Background

Many young girls with generalized joint hypermobility (GJH) choose to participate in dance because their bodies are suited for this activity. Scoliosis tends to occur often in thin girls, who also are more likely to choose dance. Both anomalies (GJH and scoliosis) may be related to reduced abilities such as diminished strength and insufficient postural balance, with increased risk for musculoskeletal conditions. The main objectives of the present study were to determine the prevalence of dancers with GJH, the prevalence of dancers with scoliosis, and the prevalence of dancers with these two anomalies; and, to determine differences in physical abilities and the presence of patellofemoral pain (PFP) between young female dancers with and without such anomalies.

Methods

One hundred thirty-two female dancers, aged 12–14 years, were assessed for anthropometric parameters, GJH, scoliosis, knee muscle strength, postural balance, proprioception ability, and PFP.

Results

GJH was identified in 54 dancers (40.9%) and scoliosis in 38 dancers (28.8%). Significant differences were found in the proportion of dancers with no anomalies (74 dancers, 56.1%) and dancers with both anomalies (34 dancers, 25.8%) (p < .001). Dancers with both anomalies had reduced dynamic postural balance in the anterior direction (p = .023), reduced proprioception ability (p < .001), and weaker knee extensors (p = .036) and flexors (p = .040) compared with dancers with no anomalies. Among dancers with both anomalies, 73.5% suffered bilateral PFP, 17.6% suffered unilateral PFP, and 8.8% had no PFP (p < .001).

Conclusions

A high prevalence of young girls participating in dance classes had GJH, as the increased joint flexibility probably provides them with some esthetic advantages. The high prevalence of scoliosis found in these young dancers might be attributed to their relatively low body mass, their delayed maturation, and the selection process of dancers. Dancers with both GJH and scoliosis had decreased muscle strength, reduced postural balance, reduced proprioception, with higher risk of PFP. The main clinical implications are the need to reduce the risk of PFP among dancers by developing appropriate strength and stabilizing exercises combined with proprioceptive and postural balance training, to improve the correct alignment of the hyperextended and hypermobile joints, and to improve their supporting muscle strength.

Effect of resistance training on muscle properties and function in women with generalized joint hypermobility: a single-blind pragmatic randomized controlled trial

Background

Generalized joint hypermobility is defined as an excessive range of motion in several joints. Having joint hypermobility is not a pathology, but when associated with pain and other symptoms, it might affect health and function. Evidence for physiotherapy management is sparse and resistance training might be a possible intervention. Thus, the effects of 12-week resistance-training on muscle properties and function in women with generalized joint hypermobility were evaluated.

Methods

In this single-blind randomized controlled trial women between 20 and 40 years with generalized joint hypermobility (Beighton score at least 6/9) were included. Participants were randomly allocated to 12-week resistance training twice weekly (experimental) or no lifestyle change (control). Resistance training focused on leg and trunk muscles. Primary outcome was muscle strength; additional outcomes included muscle properties, like muscle mass and density, functional activities, pain and disability. Training adherence and adverse events were recorded.

Results

Of 51 participating women 27 were randomised to training and 24 into the control group. In each group 11 women had joint hypermobility syndrome, fulfilling the Brighton criteria, while 24 (89%) in the training group and 21 (88%) in the control group mentioned any pain. The mean strength of knee extensors varied in the training group from 0.63 (sd 0.16) N/bm before training to 0.64 (sd 0.17) N/bm after training and in the control group from 0.53 (sd 0.14) N/bm to 0.54 (sd 0.15) N/bm. For this and all other outcome measures, no significant differences between the groups due to the intervention were found, with many variables showing high standard deviations. Adherence to the training was good with 63% of participants performing more than 80% of sessions. One adverse event occurred during training, which was not clearly associated to the training. Four participants had to stop the training early.

Conclusions

No improvement in strength or muscle mass by self-guided resistance training was found. Low resistance levels, as well as the choice of outcome measures were possible reasons. A more individualized and better guided training might be important. However, program adherence was good with few side effects or problems triggered by the resistance training.

Trial registration

This trial was prospectively registered in the ISRCTN registry (www.isrctn.com, BMC, Springer Nature) on July 16, 2013 as ISRCTN90224545. The first participant was enrolled at October 25, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00238-8.

Is there a relationship between sagittal cervical spine mobility and generalised joint hypermobility? A cross-sectional study of 1000 healthy Australians

OBJECTIVES

The primary aim was to determine the association between sagittal cervical mobility and the presence and extent of GJH across the lifespan. Secondary aims were to determine which features explain variability in cervical range of motion (CROM) and to establish the sagittal cervical hypermobile range in both genders across the lifespan.

DESIGN

Cross-sectional observational study. Spearman's rho determined the relationship between presence and extent of GJH and CROM, age, gender and ethnicity. Multiple regression identified the factors explaining variability in CROM. The hypermobile CROM was identified as the upper 5% of flexion, extension and combined ranges for age and gender.

SETTING

University laboratory in Sydney Australia.

PARTICIPANTS

One thousand healthy individuals, aged 3-101 years.

OUTCOME MEASURES

Cervical active range of motion was assessed using an inclinometer, extent of and presence of generalised joint hypermobility were assessed using the Beighton scoring system and age- and gender-specific criteria respectively.

RESULTS

CROM correlated positively with GJH (Beighton score as a continuous or dichotomous age and gender specific variable) (rho=0.12-0.50; p < 0.001) and negatively with age (rho=0.54; p < 0.001). Age, gender and extent of GJH (Beighton as a continuous score) accounted for 19 to 51% of variability in CROM. Cut-offs for cervical hypermobility were calculated across the lifespan.

CONCLUSIONS

Increased sagittal CROM was observed in individuals identified with GJH. Extension CROM decreased with age more than flexion; the greatest loss in the second and third decades. CROM screening is warranted for patients identified with GJH and for rehabilitation goal-setting.

Rehabilitation of Watson-Jones proximal tibial avulsion injury in elite academy level football: A report of two separate cases in one season

OBJECTIVES

Watson-Jones proximal tibial avulsion injuries occur more frequently in athletic and muscular adolescent males. However, they are rare and therefore infrequently described in the medical literature. Two of these injuries occurred in a Category 1 football academy in the same season within a six-month period. We have described the cases with the hope of better informing other clinicians should they encounter this injury.

METHODS

This case report describes the injury mechanism, surgical management and rehabilitation for the two cases [Players A and B]. Outcomes measures including player speed, agility and power were compared with scores from players of the same age group at the time of injury in the Premier League academies. Risk factors are also discussed.

RESULTS

Both players were managed surgically, initially. Player B had the surgical fixation removed during rehabilitation. Player A still has the fixation in situ. Post-surgery, player A returned to full play at thirty-two weeks and thirty-eight weeks for player B. No critical incidents occurred during rehabilitation.

CONCLUSION

Watson-Jones avulsion fractures, although rare, can be managed successfully. Athletes can achieve a successful return to play at their previous level.

Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain

OBJECTIVES

A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability.

CONTENT

Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability.

SUMMARY AND OUTLOOK

It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.

Risk of Injury in Physically Active Students: Associated Factors and Quality of Life Aspects

Background: The aim of this study was to assess the potential factors of hypermobility and pain threshold on the risk of injury in physically active students and to verify which domains of quality of life are rated lower by young people with a history of injuries. Methods: The study included 278 students (138 women and 140 men) who regularly undertake physical activity. Anthropometric measurements, body composition, pain threshold, incidence of hypermobility syndrome, information on the history of injuries to the locomotor system, and the quality of life of the study participants were collected. Results: In the group studied, hypermobility and pain threshold had a statistically significant related on the risk of injury. Participants with a history of injuries had lower scores for an individual’s overall perception of their own health and the physical domain. There were also significant differences in the psychological domain of the quality of life between males and females with a history of injuries. Conclusion: In the studied group, the risk of injuries was related to diagnosed hypermobility and pain threshold measured on the lower limbs. The study also showed that people with a history of injuries had statistically significantly lower scores in the individual general perception of their own health and in the physical domain. Gender had a significant impact on the quality of life of people with injuries.

Generalized joint hypermobility in siblings with anterior cruciate ligament injuries and matched unrelated healthy siblings

BACKGROUND AND PURPOSE

Anterior cruciate ligament (ACL) ruptures are common knee injuries, and siblings of individuals with an ACL injury may be at higher risk of ACL injury. Generalized hypermobility may be a familial factor predisposing siblings to ACL injury and may also relate to faulty lower limb alignment. There is a need to determine whether the interaction between hypermobility, family history, and faulty alignment makes siblings with hypermobility at higher risk for ACL injury so that appropriate preventative measures can be taken. This study therefore aimed to (a) compare the prevalence of generalized hypermobility and faulty limb alignment in siblings with and without injury and (b) assess the relationship between generalized hypermobility and lower limb alignment.

METHODS

In this case-controlled study, 24 siblings with ACL injuries from 10 families were matched with 24 healthy uninjured siblings from 10 unrelated families. Generalized hypermobility was assessed using Beighton's criteria. Chi-square analyses compared generalized hypermobility and lower limb alignment between siblings and sibling pairs with and without injuries. Spearman's rho was used to assess correlations between generalized hypermobility and lower limb alignment.

RESULTS

There were significant differences between the number of injured and uninjured siblings demonstrating generalized hypermobility when tallied individually (p = .003) and in same-family sibling pairs (p = .019). Significant (or close) differences were found between siblings for knee hyperextension (p < .001), knee valgus (p = .01), and foot pronation (p = .002) and for sibling pairs sharing knee hyperextension (p < .001), knee valgus (p = .06), and foot pronation (p = .06). Generalized hypermobility correlated with knee hyperextension (r_s = .722; p < .001), knee valgus (r_s = .385; p = .007), and foot pronation (r_s = .328; p = .023).

CONCLUSIONS

Generalized hypermobility and faulty limb alignment occur significantly more frequently in injured than uninjured families. Screening for both features would assist in identifying at-risk siblings. Prevention programmes reduce ACL injuries by 50-70% and should target hypermobile siblings of the ACL injured.

Generalised joint hypermobility increases ACL injury risk and is associated with inferior outcome after ACL reconstruction: a systematic review

Objectives

To investigate the association between generalised joint hypermobility (GJH) and ACL injury risk. Secondary aims involved evaluating associations between GJH and postoperative outcome (including graft-failure risk, knee laxity and patient-reported outcome). Furthermore, we aimed to compare the performance of different grafts in patients with GJH.

Methods

Databases MEDLINE/PubMed, EMBASE and the Cochrane Library were searched, including 2760 studies. Two reviewers independently screened studies for eligibility. A modified version of the MINORS score was applied for quality appraisal. Studies assessing GJH while reporting the risk of ACL injury and/or postoperative outcome were included.

Results

Twenty studies were included, using several different methods to determine GJH. There was consistent evidence showing that GJH is a risk factor for unilateral ACL injury in males, while in females, the results were conflicting. There was limited evidence associating GJH with increased knee laxity 5 years postoperatively. There was consistent evidence of inferior postoperative patient-reported outcome in patients with GJH. Moreover, there was limited yet consistent evidence indicating that patellar-tendon autografts are superior to hamstring-tendon autografts in patients with GJH in terms of knee laxity and patient-reported outcome. There was insufficient evidence to draw conclusions regarding the outcomes of bilateral ACL injury and graft failure.

Conclusions

In men, GJH was associated with an increased risk of unilateral ACL injury. Moreover, GJH was associated with greater postoperative knee laxity and inferior patient-reported outcome. Based on the available evidence, a patellar-tendon autograft appears to be superior to a hamstring-tendon autograft in patients with GJH. However, the included studies were heterogeneous and there is a need for consensus in the assessment of GJH within sports medicine.

Generalized joint hypermobility does not influence clinical outcomes following isolated MPFL reconstruction for patellofemoral instability

PURPOSE

Generalized joint hypermobility (GJH) has frequently been described as a risk factor for patellofemoral instability; however, only a few primary research studies have demonstrated any evidence of a relationship. The primary purpose of this study was to determine if isolated proximal soft tissue stabilization for patellofemoral instability is as successful in patients with GJH compared those without, as measured by disease-specific quality-of-life (QOL), symptom scores and functional outcomes. The secondary purpose was to determine if clinical and patient-reported outcomes were influenced by patient demographic factors in the presence of joint hypermobility.

METHODS

Between 2009 and 2014, data were collected on 174/193 knees (92% follow-up) following an isolated medial patellofemoral ligament reconstruction (MPFL-R). Patients with a Beighton score of 4 or greater were classified as positive for GJH, and any score of 3 or less was classified as negative. Pre- and post-operative Banff Patella Instability Instrument (BPII) scores were compared using a two-sample t test to determine the influence of GJH on QOL. The relationship between the Beighton score, and demographic and clinical factors was explored using correlational analysis. Functional testing including balance and single-leg hop testing was conducted 1 and 2 years post-operatively. Limb symmetry and mean limb-to-limb performance differences were calculated.

RESULTS

In this cohort of isolated MPFL reconstructions, 55.1% had a positive Beighton score. There were seven surgical failures (3.6%). There was no evidence of a relationship between a positive Beighton score and pre-operative BPII scores, post-operative BPII scores or post-operative symptom scores. GJH did not correlate significantly with any post-operative functional testing measures. A positive Beighton score was inversely related to patient age and more prevalent in females.

CONCLUSIONS

This study determined that the presence of GJH did not influence disease-specific quality of life, physical symptom score or functional outcomes following MPFL reconstruction.

LEVEL OF EVIDENCE

III.

Prevalence of generalized joint hypermobility, musculoskeletal injuries, and chronic musculoskeletal pain among American university students

The objective of this study was to investigate the prevalence of generalized joint hypermobility (GJH) in a university-aged population, whether young adults (aged 18–25 years) with GJH are prone to sustain more musculoskeletal injuries, and are more likely to suffer from chronic musculoskeletal pain. The study used an interactive survey to gather data; GJH was assessed using a cut-off Beighton score of ≥5 in accordance with the 2017 International Classification of EDS criteria. The analyzed sample consisted of 482 female and 172 male participants from Florida Gulf Coast University (USA). The prevalence of GJH in a university-aged population can be estimated at 12.5%. Women did not have higher rates of GJH than men. However, female participants showed significantly higher rates of hypermobility of the spine as well as the right knee and elbow joints. The Beighton scores did not differ by ethnicity/race. Female participants had a lower rate of self-reported injuries than male participants, although this difference was not significant. There was no difference in the proportion of all participants classified within different categories (0; 1–4; 5–9) of Beighton scores and whether or not they reported having been injured. Male and female participants reported chronic pain of joints and neck or back at the same rates across the Beighton score categories. Female participants, however, reported higher pain intensity for chronic neck and back pain. This study increases knowledge about a correlation between GJH, musculoskeletal injuries, and chronic pain of joints, neck, and back in a university-aged population.

Recognizing and Effectively Managing Hypermobility-Related Conditions

Hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) can cause widespread or chronic pain, fatigue, and proprioceptive and coordination deficits resulting in functional restrictions. These conditions are common and often unrecognized, and patients are likely to present in physical therapy for musculoskeletal injuries, pain, or coordination deficits. Although physical therapy is considered central to managing these conditions, many patients report pain and iatrogenic injuries due to inappropriate interventions. The diagnostic classification for these conditions was revised in 2017 to supersede previous diagnostic categories of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome-hypermobility type/type III. It is now known that these conditions affect multiple body systems and not just joints and that patients require a holistic approach. This Perspective article will describe the 2017 diagnostic classification system, clinical presentation, examination, evaluation, and management of patients with HSD/hEDS. Both adult and pediatric cases are presented to illustrate the patient management concepts discussed. This knowledge can lead to more effective management of this patient population.

Generalized hypermobility syndrome (GHS) alters dynamic plantar pressure characteristics

BACKGROUND

In the relevant literature generalized hypermobility syndrome (GHS) has been shown to alter the kinetic and kinematic patterns of the human movement system. Although GHS affects the general body biomechanics of individuals, the body of knowledge in plantar pressure distribution in GHS is far from sufficient.

OBJECTIVE

The aim of this study was to determine whether individuals with joint hypermobility syndrome have abnormal plantar pressure distribution during normal gait compared to healthy individuals.

METHODS

A total of 37 participants (mean age: 22.16 ± 2.58 years) diagnosed with GHS and 37 aged-matched participants (mean age: 23.35 ± 2.85 years) without GHS were included in the study. Dynamic plantar pressure distribution was obtained as each participant walked in barefoot at a self-selected pace over EMED-m system (Novel GmbH, Munich, Germany). Correlations between hypermobility score (HS) (Beighton score) and plantar pressure variables, and between group differences in peak pressure (PP), pressure-time integral (PTI), average pressure (AP) and maximum force (MxF) were computed for 10 regions under the sole.

RESULTS

HS was significantly correlated with peak pressure under the mid-foot (MF) (r= 0.24, p= 0.043), 5th metatarsal head (MH5) (r= 0.33, p= 0.001), big toe (BT) (r= 0.44, p< 0.001), and second toe (ST) (r= 0.38, p= 0.001). A similar trend was observed for pressure-time integrals under hindfoot (HF) (r= 0.24, p= 0.04), MF (r= 0.30, p= 0.009), MH5 (r= 0.25, p= 0.033), BT (r= 0.37, p= 0.001) and ST (r= 0.34, p= 0.003). The only significant MxF detected was under the ST (r= 0.23, p= 0.048), and AP was determined to be significantly higher as HS increases indicated by APs under MH5 (r= 0.24, p= 0.042), BT (r= 0.32, p= 0.005) and ST (r= 0.40, p< 0.001). Peak pressure values under HF were significantly higher in the hypermobile group (p= 0.023), MH5 (p= 0.001), BT (p< 0.001) and ST (p= 0.003). AP and PTI were also found to be significantly higher in the hypermobile group under MH5 (p= 0.009), BT (p= 0.037), and ST (p= 0.003). MxF was higher only under MF5 (p= 0.029) and SF (p= 0.041) in the hypermobile group.

CONCLUSION

The forefoot regions received a higher load in GHS during gait. This could be useful in clinical evaluation of the foot in GHS, preventing potential injuries of lower extremity, and also in processes related to decision making for foot orthotics and/or rehabilitation protocols.

Is femoral trochlear dysplasia related to global joint hypermobility?

BACKGROUND

Hypermobility is a known risk factor for patellar instability. In this study, we hypothesized that a significant relationship exists between global joint hypermobility and trochlear dysplasia.

METHODS

Follow-up patients from the shoulder department of our institution with global joint hypermobility (Group 1, n = 42) and healthy volunteers (Group 2, n = 42) without known knee complaints were included in our study. All participants underwent knee magnetic resonance imaging (MRI) for the evaluation of possible trochlear dysplasia, and the measurements included lateral trochlear inclination; trochlear facet asymmetry; the depth of the trochlear groove; condylar asymmetry; lateralization of the patella; sulcus angle; and the lateral, medial and central trochlear height. The Dejour classification was also assessed.

RESULTS

The age and gender distributions of the groups were similar (p > 0.05). The radiological evaluations revealed that the lateral trochlear inclination (p < 0.001), trochlear facet asymmetry (p < 0.001), depth of the trochlear groove (p < 0.001), lateralization of the patella (p < 0.001), sulcus angle (p < 0.001), and central trochlear height (p < 0.001) were significantly different between the two groups. The condylar asymmetry and lateral and femoral condylar height parameters were similar between the groups (p = 0.297, p = 0.890 and p = 0.521, respectively). According to the Dejour classification, 39 patients had dysplasia in Group 1, whereas dysplasia was detected in only 4 of the participants in Group 2.

CONCLUSIONS

Our study revealed that most of the trochlear dysplasia criteria were met in patients with global joint hypermobility. In addition to a clinical patellofemoral examination, the precise radiological evaluation of the joint is beneficial in patellofemoral instability patients with concomitant hypermobility. Patient cohort of this study was consist of patients underwent shoulder surgery.

Joint hypermobility is not positively associated with prevalent multiple joint osteoarthritis: a cross-sectional study of older adults

BACKGROUND

This cross-sectional study evaluated associations of joint hypermobility and multiple joint osteoarthritis (MJOA) in a community-based cohort of adults 45+ years of age.

METHODS

MJOA and joint hypermobility data were from 1677 participants (mean age 69 years, 68% women) who completed research clinic visits during 2003-2010. Prevalent MJOA was defined in four ways. Radiographic OA (rOA) was defined as Kellgren-Lawrence (KL) > 2 at any included study joint; symptomatic OA (sxOA) required both symptoms and rOA in a joint. Joint hypermobility was defined as a Beighton score of > 4. Separate logistic regression models were used to estimate odds ratios (OR) between joint hypermobility and each MJOA definition, adjusting for age, sex, race, body mass index, and baseline visit.

RESULTS

In this cohort, 4% had Beighton score > 4 and 63% met any definition of MJOA. Joint hypermobility was associated with significantly lower odds of radiographic and symptomatic MJOA-1 (multiple joint OA-definition 1: involvement of > 1 IP (interphalangeal) nodes and > 2 sites of hip, knee, and spine; 74 and 58% lower, respectively). However, for the other MJOA definitions (i.e., MJOA-2:involvement of > 2 IP joints, > 1 carpometacarpal [CMC] joints, and knee or hip sites; MJOA-3: involvement of > 5 joint sites from among distal interphalangeal, proximal interphalangeal, CMC, hip, knee, or spine sites; and MJOA-4:involvement of > 2 lower body sites (hip, knee, or spine), there were no statistically significant associations. For associations between site-specific hypermobility and any MJOA definition, most adjusted ORs were less than one, but few were statistically significant.

CONCLUSIONS

Overall, joint hypermobility was not positively associated with any definition of prevalent MJOA in this cohort, and an inverse association existed with one definition of MJOA. Longitudinal studies are needed to determine the contribution of hypermobility to the incidence and progression of MJOA outcomes.

The Lower Limb Assessment Score: A valid measure of hypermobility in elite football?

OBJECTIVE

This study aims to validate the Lower Limb Assessment Score against the current gold standard Beighton Scale within an adult elite footballing population to allow for future research to explore the influence of lower limb specific hypermobility on injury incidence.

DESIGN

Observational cohort study.

SETTING

Thirty-six male, professional footballers aged between 18 and 37 years old.

MAIN OUTCOME MEASURES

The Sensitivity, specificity, positive predictive value, negative predictive value and Spearman's rank correlation between the LLAS and Beighton Scale.

RESULTS

There was significant strong correlation between LLAS and Beighton Scale scores (ρ = 0.732; p < 0.001). The LLAS displayed a sensitivity of 67% and specificity of 94% when a cut off of ≥4/12 was applied to the screening data. This cut off point also yielded moderate Positive Predictive Validity (50%) and excellent Negative Predictive Validity (97%).

CONCLUSIONS

The present study suggests that the LLAS is a valid test for identifying lower limb hypermobility within an adult male footballing population when a cut off of ≥4/12 is used.

Beighton scoring of joint laxity and injury incidence in Middle Eastern male youth athletes: a cohort study

Objectives

To examine the association between generalised joint laxity (GJL) and injury rates in Middle Eastern male youth athletes.

Design

Prospective observational study consisting of GJL screen and injury audit (season 2009/2010).

Setting

Aspire Sports Academy Doha, Qatar.

Participants

A total of 226 adolescent male athletes (mean age: 14.2 years; SD: 1.7; range: 10–18) involved in 15 sporting activities were grouped into contact and non-contact sports. All available athletes were included in this study.

Outcome measures

A seasonal injury audit, athletes’ anthropometric characteristics, for example, weight, height and body mass index and screen for GJL to determine Beighton Score (BS).

Results

The 226 athletes sustained 596 injuries and 75% reported at least one injury over a seasonal injury audit. Players in contact sports were injured more often than players in non-contact sports (more frequent injuries than injury-free time in contact sports; 127 days (95% CI 93 to 160) vs 176 days in non-contact sports (95% CI 118 to 234) (p<0.001). Survival analysis showed that gradient BS was not associated with injury HR=1.004 (95% CI 0.95 to 1.06) in the overall cohort. However, BS was associated with a greater injury risk in contact sports (HR: 1.29; 95% CI 1.05 to 1.59; p=0.015).

Conclusion

Greater GJL, defined by gradient BS, plus involvement in contact sports together influence injury risk in youth athletes. Preseason documentation of GJL scoring should be considered specifically for contact sports as injury pre-emptive measure.

Comparable patient-reported outcomes in females with or without joint hypermobility after hip arthroscopy and capsular plication for femoroacetabular impingement syndrome

Hip arthroscopy is widely utilized to treat femoroacetabular impingement syndrome (FAIS). In order to evaluate the postoperative clinical and functional outcomes at 2-year follow up in patients with and without benign joint hypermobility syndrome following hip arthroscopy with capsular plication for FAIS, consecutive female patients with generalized ligamentous laxity undergoing primary hip arthroscopy with complete T-capsulotomy closure via plication for FAIS were prospectively identified. Patients were matched in a 4:1 ratio based on Beighton-Horan joint mobility index (BHJMI) then classified into no generalized joint laxity (NGJL, Score<4) or generalized joint laxity cohort (GJL, Score=4). Patient and surgical-related factors were analyzed using univariate and paired analysis with statistical significance set at a = 0.05. A total of 125 female patients were included in the study: 25 generalized joint laxity (GJL) patients and 100 matched to age, sex and BMI (NGJL cohort). The results demonstrated that there were no significant differences between demographics, preoperative range of motion, or radiographic analysis on univariate analysis. There was no statistical difference in postoperative range of motion between groups, though both groups demonstrated significant increases in postoperative flexion and postoperative internal rotation following hip arthroscopy. Paired analysis demonstrated no significant difference in HOS-SS, HOS-ADL, mHHS or VAS-pain, while GJL patients reported significantly greater patient satisfaction score at 2-years follow-up (p=0.007). In summary, hip arthroscopy with capsular plication is a highly effective treatment for FAIS in patients with and without generalized joint laxity. In our analysis, patients with and without generalized joint laxity demonstrated statistically similar and significant improvement in outcomes.

Pediatric and adolescent ankle instability: diagnosis and treatment options

PURPOSE OF REVIEW

The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and treatment for lateral ankle instability in pediatric patients.

RECENT FINDINGS

Chronic ankle instability is a common sequela of lateral ankle sprain in young athletes. Incidence is increasing, possibly due in part to inadequate treatment of first-time ankle sprains, as well as increased youth participation in organized and competitive sports. The anterior talofibular ligament (ATFL) is injured in every case, whereas the calcaneofibular ligament (CFL) and syndesmosis may be involved in severe cases. A clinical history, focused physical exam, and appropriate radiographic studies aid in diagnosis, and predisposing factors must be identified. Early treatment of ankle sprains involves bracing or immobilization, followed by a course of physical therapy. Surgery involves anatomic repair of the torn ligaments, and may be required in cases of severe functional and mechanical instability with recurrent sprains refractory to nonsurgical management. Intraarticular disorders should be identified and may be addressed with ankle arthroscopy.

SUMMARY

Prompt treatment of lateral ankle instability in young athletes is important to prevent chronic ankle instability. Many patients are successfully treated without surgery, and those requiring operative intervention improve function postoperatively.