The Cost-Effectiveness of Measures to Prevent Recurrent Ankle Sprains: Results of a 3-Arm Randomized Controlled Trial

Orthotic Devices for the Foot and Ankle

Millions of Americans wear ankle-foot orthotic devices for protection, pain relief, and deformity correction. Inquiries about off-the-shelf and custom devices are a common reason for evaluation with a foot and ankle surgeon or general orthopaedic surgeon. Despite limited high-quality evidence for their use, these devices can have a notable clinical impact on physical function. An up-to-date understanding of orthotic device options and their appropriate use in managing musculoskeletal pathologies applies to all orthopaedic providers. This review aims to categorize orthosis types and provide specific device recommendations for common adult conditions such as flatfoot, cavovarus foot, and ankle instability. Collaboration with a certified orthotist can help patients achieve functional and recreational goals with the use of appropriately designed and applied orthoses.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Burden of the "Simple Ankle Sprains": A Review of the Epidemiology and Long-Term Impact

Lateral ankle sprain (LAS) is not as simple as it was believed to be as it has substantial negative impacts on the active sporting population. The negative impact on physical function, quality of life (QoL) and economic burden is significant with increased risk of reinjury, development of chronic lateral ankle instability and posttraumatic ankle osteoarthritis resulting in functional deficits, decreased QoL and chronic disabilities. Economic burden from a societal perspective demonstrated notably higher indirect costs from productivity loss. Preventative interventions with early surgery for a selective cohort of active sporting population may be considered to mitigate morbidities associated with LAS.

Does prevention pay off? Economic aspects of sports injury prevention: a systematic review

OBJECTIVE

To identify, summarise and critically assess economic evaluation studies on sports injury prevention strategies.

DESIGN

Systematic review.

DATA SOURCES

PubMed, SportDiscuss.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

The current literature was searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Economic analyses published since 2010 were checked for inclusion. The methodological quality of the studies was assessed using the Oxford Level of Evidence for economic and decision analysis; underlying randomised controlled trials (RCTs) were rated according to the Physiotherapy Evidence Database (PEDro) Scale, and risk of bias was assessed using the Revised Cochrane risk-of-bias tool.

RESULTS

Ten studies fulfilled the inclusion criteria. The quality assessment revealed limited data quality. For trial-based analysis, underlying RCTs were of good quality and had a low risk of bias. Prevention concepts for general injury reduction showed effectiveness and cost savings. Regarding specific injury types, the analysis of the studies showed that the best data are available for ankle, hamstring and anterior cruciate ligament injuries. Measures using specific training interventions were the predominant form of prevention concepts; studies investigating these concepts showed cost-effectiveness with total cost savings between €24.82 and €462 per athlete.

CONCLUSION

Injury prevention strategies that were studied are cost-effective. However, estimates and outcomes vary throughout the included studies, and precluded pooling of existing data. Knowledge about the cost-effectiveness of evaluated prevention measures will help improve the acceptance and application of prevention initiatives.

A systematic review of health economic evaluation in orthotics and prosthetics: Part 2-orthotics

BACKGROUND

Health economic evaluations (HEEs) in orthotics are in their infancy. Identification of evidence gaps and method design issues will inform the design of future HEEs that advance knowledge and contributes to policy and investment decisions.

OBJECTIVES

The aim of this systematic review was to critically appraise the existing orthotic/prosthetic health economic evaluation literature and therefore determine evidence gaps, critical method design issues, and the extent to which the literature informs orthotic policy and investment decisions.

STUDY DESIGN

Systematic review.

METHODS

A range of databases were searched using intervention- and HEE-related terms. The Consolidated Health Economic Checklist-Extended and the Checklist for Health Economic Evaluation Reporting Standards were used to identify issues with method design and reporting.

RESULTS

Nine orthotic HEEs were narrowly focused on the cost-effectiveness of low-cost orthotic devices (eg, ankle orthoses for ankle sprains). Method design (eg, cost identification and valuation) and reporting issues (eg, lack of detail about the study population) limited the extent to which this literature can inform policy and investment decisions.

CONCLUSIONS

HEEs comparing a wider variety of interventions are required, particularly for commonly used orthoses (eg, ankle-foot orthoses) and clinical presentations (eg, post-stroke). There are opportunities to strengthen future orthotic HEEs by adopting method design features (eg, microcosting and sensitivity analyses) as recommended by HEE appraisal and reporting tools.

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.

Development of a medical device compatible with MRI/CT to measure ankle joint laxity: the Porto Ankle Testing Device

Ankle sprains are common and often develop into chronic ankle instability. Ankle laxity is usually assessed by manual testing followed by magnetic resonance imaging to confirm the diagnosis. Manual testing however provides a subjective measure and is limited to the assessor sensibility. Current available technologies incorporate arthrometers to objectively measuring ankle laxity, but are not capable to assess the structural integrity of the capsuloligamentous structures. To overcome these limitations, we developed a novel medical device to assist in the diagnosis of ankle ligament injuries—the Porto Ankle Testing Device. With this device, it is possible to combine and correlate the assessment of the capsuloligamentous’ structural integrity with the joint functional competence (ie, joint multiplanar laxity). The main purpose of this work is to present the fundamental aspects and step-by-step development of the Porto Ankle Testing Device. We discuss the design specifications and technical requirements with the purpose to design and develop this medical device, described the features of the different components and explained the mechanical systems that are incorporated emulate manual testing and to measure the multiplanar ankle laxity. The preliminary findings are presented with the purpose to display the assessment protocol, the method of laxity measurement and the obtained results. We propose a unique and reliable medical device to safety and effectively assess ankle ligament injuries and contribute to enhance diagnosis, refine treatment indications and allow objective measurement of ligament laxity before and/or after stabilization surgery.

A systematic review of health economic evaluations in orthotics and prosthetics: Part 1 - prosthetics

BACKGROUND

The extent to which current prosthetic health economic evaluations inform healthcare policy and investment decisions is unclear. To further the knowledge in this area, existing evidence gaps and method design issues must be identified, thereby informing the design of future research.

OBJECTIVES

The aim of this systematic review was to identify evidence gaps, critical method design and reporting issues and determine the extent to which the literature informs a wide range of policy and investment decisions.

STUDY DESIGN

Systematic review.

METHODS

A range of databases were searched using intervention- and health economic evaluation-related terms. Issues with methodological design and reporting were evaluated using the Consolidated Health Economic Checklist - Extended and the Checklist for Health Economic Evaluation Reporting Standards.

RESULTS

The existing health economic evaluation literature was narrowly focused on informing within-participant component decisions. There were common method design (e.g. time horizon too short) and reporting issues (e.g. competing intervention descriptions) that limit the extent to which this literature can inform policy and investment decisions.

CONCLUSION

There are opportunities to conduct a wider variety of health economic evaluations to support within- and across-sector policy and investment decisions. Changes to aspects of the method design and reporting are encouraged for future research in order to improve the rigour of the health economic evaluation evidence.

CLINICAL RELEVANCE

This systematic review will inform the clinical focus and method design of future prosthetic health economic evaluations. It will also guide readers and policy-makers in their interpretation of the current literature and their understanding of the extent to which the current literature can be used to inform policy and investment decisions.

Acute ankle sprain in athletes: Clinical aspects and algorithmic approach

Acute ankle sprain is the most common lower limb injury in athletes and accounts for 16%-40% of all sports-related injuries. It is especially common in basketball, American football, and soccer. The majority of sprains affect the lateral ligaments, particularly the anterior talofibular ligament. Despite its high prevalence, a high proportion of patients experience persistent residual symptoms and injury recurrence. A detailed history and proper physical examination are diagnostic cornerstones. Imaging is not indicated for the majority of ankle sprain cases and should be requested according to the Ottawa ankle rules. Several interventions have been recommended in the management of acute ankle sprains including rest, ice, compression, and elevation, analgesic and anti-inflammatory medications, bracing and immobilization, early weight-bearing and walking aids, foot orthoses, manual therapy, exercise therapy, electrophysical modalities and surgery (only in selected refractory cases). Among these interventions, exercise and bracing have been recommended with a higher level of evidence and should be incorporated in the rehabilitation process. An exercise program should be comprehensive and progressive including the range of motion, stretching, strengthening, neuromuscular, proprioceptive, and sport-specific exercises. Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables, manual tests for stability, and functional performance testing. There are some common myths and mistakes in the management of ankle sprains, which all clinicians should be aware of and avoid. These include excessive imaging, unwarranted non-weight-bearing, unjustified immobilization, delay in functional movements, and inadequate rehabilitation. The application of an evidence-based algorithmic approach considering the individual characteristics is helpful and should be recommended.

The predictive value of the multiple hop test for first-time noncontact lateral ankle sprains

The predictive value of the multiple hop test for first-time noncontact lateral ankle sprains.

BACKGROUND

Lateral ankle sprains (LAS) are very common sports injuries, cause high health care costs and are associated with postural control deficits. From a preventive point of view, clinicians should dispose valid field tests to identify athletes at risk for a LAS. The aim of this study is to evaluate the predictive value of the multiple hop test (MHT) for first-time noncontact LAS.

METHODS

Non-elite athletes (n = 232) performed the MHT at baseline. During a 12-month follow-up period, all noncontact LAS related to health care costs were recorded. Outcomes of the MHT (completion time, balance errors and perceived difficulty) between the injured and uninjured group were compared and odds ratios (OR) and relative risks (RR) were calculated using a logistic regression analysis.

RESULTS

Ten first-time noncontact LAS were recorded (4.3%). Injured athletes made significantly more change-in-support strategy (CSS) errors when compared to uninjured athletes (p = .04). The OR of the number of CSS errors was 1.14 (p = .03), the RR 4.1 (p = .04).

CONCLUSIONS

Athletes scoring > 12 CSS errors, have a four times increased risk for a first-time noncontact LAS. The MHT is a valid field test to identify athletes at risk for a first-time noncontact LAS.

Ankle Sprains: Evaluation, Rehabilitation, and Prevention

Ankle sprains affect athletic populations at high rates. Athletes who suffer an ankle sprain frequently go on to develop persistent symptoms, resulting in significant resources spent toward treatment, rehabilitation, and prevention. A thorough clinical evaluation is necessary to ensure an accurate diagnosis and appropriate treatment prescription. This narrative review aims to present an approach to evaluation of high and low ankle sprains for athletes of all levels. The authors review the current evidence for ankle sprain treatment and rehabilitation. Strategies for prevention of recurrent sprains and return to play considerations also are discussed.

Lower Signal Intensity of the Anterior Talofibular Ligament is Associated with a Higher Rate of Return to Sport After ATFL Repair for Chronic Lateral Ankle Instability

BACKGROUND

The treatment strategy for anterior talofibular ligament (ATFL) injury is usually determined by the ATFL remnant condition during surgery. Preoperative magnetic resonance imaging (MRI)-based signal intensity of the ATFL remnant, represented by the signal/noise ratio (SNR) value, can reveal the ATFL remnant condition. Thus far, there is a lack of evidence regarding the relationship between the ATFL remnant condition and functional outcomes.

PURPOSE/HYPOTHESIS

The purpose was to quantitatively evaluate whether the MRI-based ATFL ligament SNR value is related to functional outcomes after ATFL repair for ankles with chronic lateral ankle instability. The hypothesis was that a lower preoperative SNR is related to a better clinical outcome, particularly a higher rate of return to sport.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

First, a preliminary study was performed to measure the ATFL SNR in preoperative MRI, the results of which suggested that a preoperative SNR >10.4 was indicative of a poor ATFL condition. Then, a cohort study was retrospectively performed with consecutive patients who underwent open repair of ATFL injuries between January 2009 and August 2014. Accordingly, the patients were divided into 2 groups: high SNR (HSNR; ≥10.4) and low SNR (LSNR; <10.4). Functional outcomes based on the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner Activity Scale were then compared between the HSNR group and the LSNR group.

RESULTS

Ultimately, 70 patients were available for the final follow-up: 37 in the HSNR group and 33 in the LSNR group. No significant difference was detected between the HSNR group and the LSNR group in terms of the AOFAS score, KAFS, or Tegner Activity Scale (P > .05 for all) preoperatively. At the final follow-up, the mean ± SD AOFAS score in the LSNR group (92 ± 6) was higher than that in the HSNR group (87 ± 12), although no significant difference was detected postoperatively (P = .16). The mean KAFS in the LSNR group (94 ± 7) was significantly higher than that in the HSNR group (88 ± 11) postoperatively (P = .03). At follow-up, the mean Tegner score in the LSNR group (6; range, 3-7) was significantly higher than that in the HSNR group (5; range, 1-8) postoperatively (P = .03). Patients in the LSNR group had a significantly higher percentage of sports participation than those in the HSNR group (91% vs 65%, P = .02) postoperatively.

CONCLUSION

A lower signal intensity in the ATFL ligament based on preoperative MRI is associated with a better clinical outcome, particularly a higher rate of return to sport.

Health economic evaluation in orthotics and prosthetics: a systematic review protocol

BACKGROUND

Health economic evaluations are essential to support health care policy and investment decisions. To date, health economic evaluations in orthotics and prosthetics have focused on discrete components of an orthosis/prosthesis (e.g. a microprocessor controlled prosthetic knee joint) rather than the broader service provided by orthotist/prosthetists. As such, the contribution to orthotic/prosthetic policy and investment decisions is unclear. Whilst there are opportunities to conduct more informative health economic evaluations that describe the costs and benefits of the orthotic/prosthetic service, it is important that prospective research is informed by a critical review of the method design challenges and an understanding of how this research can be improved. The aim of this systematic review is to critically appraise the existing orthotic/prosthetic health economic evaluation literature and therefore determine evidence gaps, critical method design issues and the extent to which the literature informs orthotic/prosthetic policy and investment decisions.

METHODS

A comprehensive range of databases-AMED, EMBASE, MEDLINE and PsychINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Nursing and Allied Health, Web of Science, Cochrane Database of Systematic Reviews (CDSR) and specialty health economic databases-will be searched using National Library of Medicine Medical Subject Headings (MeSH) terms as well as the title, abstract, and keyword terms. Search terms related to the intervention (e.g. orthosis), including variants used by varying professional disciplines (e.g. brace), will be used in preference to defining the populations that use orthotic and prosthetic services (e.g. people living with rheumatoid arthritis). Search terms related to health economic evaluations will be guided by previously developed and tested search strings and align with recommendations by the Canadian Agency for Drugs and Technologies in Health. Articles meeting the inclusion criteria will be hand-searched for relevant citations, and a forward citation search using Google Scholar will also be conducted to identify early online articles not yet indexed in traditional databases. Original research published in the English language and after 1 January 2000 will be included. The Checklist for Health Economic Evaluation Reporting Standards (CHEERS) and the Consensus on Health Economic Criteria (CHEC)-Extended list will be used to appraise the methodological quality and identify sources of bias. Data extraction and appraisal will be conducted by one reviewer independently using appraisal instrument guidelines and a content specific decision aid with exemplars. A subsequent review by a second researcher will be undertaken to confirm the accuracy of the extraction and appraisal, and a final review by a third where consensus cannot be reached. The data will be extracted to a purpose-built data extraction template with decision-making guidelines to support consistency. Where possible, the findings of the review will be reported as a meta-analysis, although the heterogeneity of the literature will likely mean a narrative review that illuminates method design issues that contribute to imprecision and variation will be more appropriate.

DISCUSSION

This protocol has been purposefully designed to summarise the existing evidence and appraise the methodological approaches used and the quality of the health economic evaluations in orthotics and prosthetics. What we learn from this review will be used to guide further work in this area and design more rigorous health economic evaluations into the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018116910.

Comparison of the '11+ Kids' injury prevention programme and a regular warmup in children's football (soccer): a cost effectiveness analysis

OBJECTIVE

To evaluate a potential reduction in injury related healthcare costs when using the '11+ Kids' injury prevention programme compared with a usual warmup in children's football.

METHODS

This cost effectiveness analysis was based on data collected in a cluster randomised controlled trial over one season from football teams (under-9 to under-13 age groups) in Switzerland. The intervention group (INT) replaced their usual warmup with '11+ Kids', while the control group (CON) warmed up as usual. Injuries, healthcare resource use and football exposure (in hours) were collected prospectively. We calculated the mean injury related costs in Swiss Francs (CHF) per 1000 hours of football. We calculated the cost effectiveness (the direct net healthcare costs divided by the net health effects of the '11+ Kids' intervention) based on the actual data in our study (trial based) and for a countrywide implementation scenario (model based).

RESULTS

Costs per 1000 hours of exposure were CHF228.34 (95% CI 137.45, 335.77) in the INT group and CHF469.00 (95% CI 273.30, 691.11) in the CON group. The cost difference per 1000 hours of exposure was CHF-240.66 (95%CI -406.89, -74.32). A countrywide implementation would reduce healthcare costs in Switzerland by CHF1.48 million per year. 1002 players with a mean age of 10.9 (SD 1.2) years participated. During 76 373 hours of football, 99 injuries occurred.

CONCLUSION

The '11+ Kids' programme reduced the healthcare costs by 51% and was dominant (ie, the INT group had lower costs and a lower injury risk) compared with a usual warmup. This provides a compelling case for widespread implementation.

The effectiveness of proprioceptive and neuromuscular training compared to bracing in reducing the recurrence rate of ankle sprains in athletes: A systematic review and meta-analysis

BACKGROUND

Ankle sprains are common musculoskeletal injuries in which the ligaments of the ankle partially or completely tear due to sudden stretching.

OBJECTIVES

To critically appraise, evaluate and establish the best available evidence to determine the effectiveness of proprioceptive and neuromuscular training (PNT) compared to bracing in reducing the recurrence rate of ankle sprains in athletes.

METHODOLOGY

The following seven databases were searched in June 2017: PubMed, Cochrane Library, PEDro, ScienceDirect, Scopus, SPORTDiscus, EBSCO Host: CINAHL. The main search terms used were "ankle sprains", "proprioceptive training", "neuromuscular training" and "bracing". The quality of the trials were critically appraised according to the PEDro scale. The RevMan 5© software was used to pool results.

RESULTS

Three studies met the inclusion criteria and the quality according to the PEDro scale ranged from 4/10-7/10. The pooled data showed no difference between PNT and bracing in reducing the recurrence rate of ankle sprains in athletes at 12 months after initiation of the study.

CONCLUSION

This systematic review of the overall effect suggested that current evidence (Level II) does not favour the use of PNT over bracing in reducing the recurrence rate of ankle sprains. Physiotherapists are advised to use either PNT or bracing according to the patients preference and their own expertise.

Health and Economic Burden of Running-Related Injuries in Dutch Trailrunners: A Prospective Cohort Study

Background

Trailrunning is becoming very popular. However, the risk and burden of running-related injuries (RRI) in trailrunning is not well established.

Objective

To investigate the prevalence, injury rate, severity, nature, and economic burden of RRIs in Dutch trailrunners.

Methods

This prospective cohort study included 228 trailrunners aged 18 years or over (range 23–67), and was conducted between October 2013 and December 2014. After completing the baseline questionnaire, the Oslo Sports Trauma Research Center Questionnaire on Health Problems was administered every 2 weeks to collect data on RRIs. Participants who reported RRIs were asked about healthcare utilization (direct costs) and absenteeism from paid work (indirect costs). RRI was defined as disorders of the musculoskeletal system or concussions experienced or sustained during participation in running.

Results

The mean prevalence of RRIs measured over time was 22.4 % [95 % confidence interval (CI) 20.9–24.0], and the injury rate was 10.7 RRIs per 1000 h of running (95 % CI 9.4–12.1). The prevalence was higher for overuse (17.7 %; 95 % CI 15.9–19.5) than for acute (4.1 %; 95 % CI 3.3–5.0) RRIs. Also, the injury rate was higher for overuse (8.1; 95 % CI 6.9–9.3) than for acute (2.7; 95 % CI 2.0–3.4) RRIs. The median of the severity score was 35.0 [25–75 %, interquartile range (IQR) 22.0–55.7], and the median of the duration of RRIs was 2.0 weeks (IQR 2.0–6.0) during the study. The total economic burden of RRIs was estimated at €172.22 (95 % CI 117.10–271.74) per RRI, and €1849.49 (95 % CI 1180.62–3058.91) per 1000 h of running. An RRI was estimated to have a direct cost of €60.92 (95 % CI 45.11–94.90) and an indirect cost of €111.30 (95 % CI 61.02–192.75).

Conclusions

The health and economic burden of RRIs presented in this study are significant for trailrunners and for society. Therefore, efforts should be made in order to prevent RRIs in trailrunners.

Electronic supplementary material

The online version of this article (doi:10.1007/s40279-016-0551-8) contains supplementary material, which is available to authorized users.

Considerations and Interpretation of Sports Injury Prevention Studies

Promoting sports participation for health is part of the public health agenda worldwide. The same holds true for preventing sports injury, an unfavorable consequence of sports. In order to transfer research findings to practice, however, clinicians should consider the particulars of design, outcome measures, and data analyses of sports injury prevention studies. This article provides a summary of approaches used to assess the effect of injury prevention strategy in sports. This summary is intended to support clinicians on the decision-making process to apply research findings in the area of sports injury prevention in their practice.

Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4-5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option.

Quantitative magnetic resonance imaging (MRI) analysis of anterior talofibular ligament in lateral chronic ankle instability ankles pre- and postoperatively

BACKGROUND

The aim of this study was to quantitatively evaluate and characterize the dimension and signal intensity of anterior talofibular ligament (ATFL) using 3.0 T MRI in the mechanical ankle instability group pre- and postoperatively.

METHODS

A total of 97 participants were recruited retrospectively in this study, including 56 with mechanical chronic ankle instability (CAI group) and 41 without ankle instability (Control group). All the subjects accepted MRI preoperatively. Among the 56 CAI patients, 25 patients, who accepted modified Broström repair of ATFL, underwent a MRI scan at follow-up. The ATFL dimension (length and width) and signal/noise ratio (SNR) were measured based on MRI images. The results of the MRI studies were then compared between groups.

RESULTS

The CAI group had a significantly higher ATFL length (p = 0.03) or ATFL width (p < 0.001) compared with the control group. The mean SNR value of the CAI group was significantly higher than that of the control group (p = 0.006). Furthermore, the mean SNR value of the ATFL after repair surgery (8.4 ± 2.4) was significantly lower than that of the ATFL before surgery (11.2 ± 3.4) (p < 0.001). However, no significant change of ATFL length or ATFL width were observed after repair surgery.

CONCLUSIONS

CAI ankles had a higher ATFL length or width as well as higher signal intensity compared with stable ankles. After repair surgery, the mean SNR value of the ATFL decreased, indicating the relaxed ATFL becomes tight postoperatively.

User Survey of 3 Ankle Braces in Soccer, Volleyball, and Running: Which Brace Fits Best?

CONTEXT

  Recurrence rates for ankle sprains are high. Therefore, preventive measures such as ankle bracing during sports are recommended.

OBJECTIVE

  To systematically evaluate the perceived ease of use, quality, comfort, stability, and hindrance of and the overall satisfaction with 3 contemporary brace types in 3 types of sports.

DESIGN

  Randomized comparative user survey.

SETTING

  Recreational sports: soccer, volleyball, and running.

PATIENTS OR OTHER PARTICIPANTS

  Young adult recreational athletes (29 soccer players, 26 volleyball players, and 31 runners).

INTERVENTION(S)

  Compression brace (CB), lace-up brace (LB), and semirigid brace (SB).

MAIN OUTCOME MEASURE(S)

  Rating of perceived ease of use, quality, comfort, stability, and hindrance of and overall satisfaction with the brace types during sports on a 5-point Likert scale. The secondary outcome measure was participants' willingness to buy the tested brace.

RESULTS

  Overall, the 3 brace types received high mean scores for ease of use and quality. Soccer players preferred the CB over both alternatives, considering the higher scores for comfort (CB = 4.0, LB = 3.5, SB = 2.8), hindrance (CB = 3.7, LB = 2.9, SB = 2.8), overall satisfaction (CB = 3.6, LB = 3.0, SB = 2.5), and greatest willingness to buy this brace. Volleyball players preferred the LB over both alternatives, considering the higher scores for stability (LB = 4.2, CB = 3.2, SB = 3.3), overall satisfaction (LB = 3.8, CB = 3.0, SB = 3.0), and greatest willingness to buy this brace. Runners preferred the CB over both alternatives considering the better score for hindrance (CB = 3.6, LB = 2.8, SB = 2.9) and greatest willingness to buy this brace.

CONCLUSIONS

  All 3 ankle-brace types scored high on perceived ease of use and quality. Regarding the brace types, soccer players, volleyball players, and runners differed in their assessments of subjective evaluation of comfort, stability, hindrance, overall satisfaction, and willingness to buy the brace. Soccer players and runners preferred the CB, whereas volleyball players preferred the LB.

Preventing recurrent ankle sprains: Is the use of an App more cost-effective than a printed Booklet? Results of a RCT

Recurrent ankle sprains can be reduced by following a neuromuscular training (NMT) program via a printed Booklet or a mobile application. Regarding the high incidence of ankle sprains, cost-effectiveness regarding implementation can have a large effect on total societal costs. In this economic analysis, we evaluated whether the method of implementing a proven effective NMT program using an App or a Booklet resulted in differences in injury incidence rates leading to costs and hence to differences in cost-effectiveness. In total, 220 athletes with a previous ankle sprain were recruited for this randomized controlled trial with a follow-up of 12 months. Half of the athletes used the freely available "Strengthen your ankle" App and the other half received a printed Booklet. After the 8-week program, athletes were questioned monthly on their recurrent injuries. Primary outcome measures were incidence density of ankle injury and incremental cost-effectiveness ratio (ICER). During follow-up, 31 athletes suffered from a recurrent ankle sprain that led to costs resulting in a hazard ratio of 1.13 (95% CI: 0.56-2.27). The incremental cost-effectiveness ratio of the App group in comparison with the Booklet group was €361.52. The CE plane shows that there was neither a difference in effects nor in costs between both intervention methods. This study showed that the method of implementing the NMT program using an App or a Booklet led to similar cost-effectiveness ratios and the same occurrence of recurrent injuries leading to costs. Both the App and the Booklet can be used to prevent recurrent ankle injuries, showing no differences in (cost-) effectiveness at 12-month follow-up.

Current Trends in the Management of Lateral Ankle Sprain in the United States

OBJECTIVE

To characterize trends in the acute management (within 30 days) after lateral ankle sprain (LAS) in the United States.

DESIGN

Descriptive epidemiology study.

PATIENTS

Of note, 825 718 ankle sprain patients were identified; 96.2% were patients with LAS. Seven percent had an associated fracture and were excluded from the remaining analysis.

SETTING

Primary and tertiary care settings.

INTERVENTIONS

We queried a database of national health insurance records for 2007 to 2011 by ICD-9 codes for patients with LAS while excluding medial and syndesmotic sprains and any LAS with an associated foot or ankle fracture.

MAIN OUTCOME MEASURES

The percentage of patients to receive specific diagnostic imaging, orthopedic devices, or physical therapy treatments within 30 days of the LAS diagnosis and the associated costs.

RESULTS

Over two-thirds of patients with LAS without an associated fracture received radiographs, 9% received an ankle brace, 8.1% received a walking boot, 6.5% were splinted, and 4.8% were prescribed crutches. Only 6.8% received physical therapy within 30 days of their LAS diagnosis, 94.1% of which performed therapeutic exercise, 52.3% received manual therapy, and 50.2% received modalities. The annual cost associated with physician visits, diagnostic imaging, orthopedic devices, and physical therapy was 152 million USD, 81.5% was from physician evaluations, 7.9% from physical therapy, 7.2% from diagnostic imaging, and 3.4% from orthopedic devices.

CONCLUSIONS

Most patients with LAS do not receive supervised rehabilitation. The small proportion of patients with LAS to receive physical therapy get rehabilitation prescribed in accordance with clinical practice guidelines. The majority (>80%) of the LAS financial burden is associated with physician evaluations.

The Epidemiology of Lateral Ligament Complex Ankle Sprains in National Collegiate Athletic Association Sports

BACKGROUND

Ankle sprains are a common injury in collegiate sports. Few studies have examined the epidemiology of individual ligament injuries, specifically the lateral ligament complex (LLC) of the ankle.

PURPOSE

To describe the epidemiology, including the estimated yearly national incidence, of LLC sprains among National Collegiate Athletic Association (NCAA) athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Injury surveillance data for 25 sports from the NCAA Injury Surveillance Program (NCAA-ISP) for the academic years 2009-2010 to 2014-2015 were used for analysis. All injuries included for analysis had a diagnosis of an LLC sprain. LLC sprain rates and rate ratios (RRs) with 95% CIs were calculated. From the sample, national estimates of the annual incidence of LLC sprains across the entire student-athlete body from these 25 sports were also calculated.

RESULTS

During the 2009-2010 to 2014-2015 academic years, 2429 LLC sprains were reported, for a rate of 4.95 per 10,000 athlete-exposures (AEs). LLC sprains comprised 7.3% of all reported collegiate sports injuries in the NCAA-ISP. Also, an estimated 16,022 LLC sprains occurred annually among the 25 sports. The sports with the highest LLC sprain rates were men's basketball (11.96/10,000 AEs) and women's basketball (9.50/10,000 AEs). Most LLC sprains occurred during practices (57.3%); however, the LLC sprain rate was higher in competitions than in practices (RR, 3.29; 95% CI, 3.03-3.56). Also, 11.9% of LLC sprains were identified as recurrent injuries, with the largest proportions of recurrent LLC sprains being found within women's basketball (21.1%), women's outdoor track (21.1%), women's field hockey (20.0%), and men's basketball (19.1%). In 44.4% of LLC sprains, the athlete returned to play in less than 24 hours; in 3.6%, the athlete required more than 21 days before returning to play (including those who did not return to play at all).

CONCLUSION

LLC sprains were the most commonly reported injury diagnosis among United States collegiate student-athletes. Continued examination of interventions that aim to reduce the incidence, severity, and recurrence of LLC sprains, specifically in women, is warranted.

Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains

Lateral ankle sprains (LASs) are the most prevalent musculoskeletal injury in physically active populations. They also have a high prevalence in the general population and pose a substantial healthcare burden. The recurrence rates of LASs are high, leading to a large percentage of patients with LAS developing chronic ankle instability. This chronicity is associated with decreased physical activity levels and quality of life and associates with increasing rates of post-traumatic ankle osteoarthritis, all of which generate financial costs that are larger than many have realised. The literature review that follows expands this paradigm and introduces emerging areas that should be prioritised for continued research, supporting a companion position statement paper that proposes recommendations for using this summary of information, and needs for specific future research.

Measuring sports injuries on the pitch: a guide to use in practice

Sports participation is a major ally for the promotion of physical activity. However, sports injuries are important adverse effects of sports participation and should be monitored in sports populations. The purpose of this paper is to review the basic concepts of injury monitoring and discuss the implementation of these concepts in practice. The aspects discussed are: (1) sports injury definition; (2) classification of sports injuries; (3) population at risk, prevalence, and incidence; (4) severity measures; (5) economic costs; (6) systems developed to monitor sports injuries; and (7) online technology. Only with reliable monitoring systems applied in a continuous and long-term manner will it be possible to identify the burden of injuries, to identify the possible cases at an early stage, to implement early interventions, and to generate data for sports injury prevention. The implementation of sports injuries monitoring systems in practice is strongly recommended.

Interventions preventing ankle sprains; previous injury and high-risk sport participation as predictors of compliance

OBJECTIVES

To describe the association between participants' person-related potential predictor variables and cumulative compliance with interventions for preventing ankle sprains: neuromuscular training, wearing an ankle brace, and a combined training and bracing.

DESIGN

Secondary analysis of compliance data from a randomized controlled trial (RCT) comparing measures preventing ankle ligament injuries.

METHODS

Ordinal regression with a backward selection method was used to obtain a descriptive statistical model linking participants' person-related potential predictor variables with the monthly cumulative compliance measurements for three interventions preventing ankle ligament injuries.

RESULTS

Having had a previous ankle injury was significantly associated with a higher compliance with all of the preventive measures trialed. Overall compliance with bracing and the combined intervention was significantly lower than the compliance with NM training. Per group analysis found that participating in a high-risk sport, like soccer, basketball, and volleyball, was significantly associated with a higher compliance with bracing, or a combined bracing and NM training. In contrast, participating in a high-risk sport was significantly associated with a lower per group compliance with NM training.

CONCLUSIONS

Future studies should include at least registration of previous ankle sprains, sport participation (high- or low-risk), experience in NM training, and hours of sport exposure as possible predictors of compliance with interventions preventing ankle sprains. Practitioners should take into account these variables when prescribing preventive neuromuscular training or bracing.

The preventive effect of the nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial

BACKGROUND

Hamstring injuries are the most common muscle injuries in soccer, and they have a high rate of recurrence. Eccentric hamstrings strength is recognized as an important modifiable risk factor. This led to the development of prevention exercises such as the nordic hamstring exercise (NHE). The effectiveness of the NHE on hamstring injury prevention has never been investigated in amateur soccer.

PURPOSE

To investigate the preventive effect of the NHE on the incidence and severity of hamstring injuries in male amateur soccer players.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Male amateur soccer players (age, mean ± SD, 24.5 ± 3.8 years) from 40 teams were randomly allocated to an intervention (n = 20 teams, 292 players) or control group (n = 20 teams, 287 players). The intervention group was instructed to perform 25 sessions of NHE in a 13-week period. Both the intervention and control groups performed regular soccer training and were followed for hamstring injury incidence and severity during the 2013 calendar year. At baseline, personal characteristics (eg, age, injury history, field position) were gathered from all participants via a questionnaire. Primary outcome was injury incidence. Secondary outcomes were injury severity and compliance with the intervention protocol.

RESULTS

A total of 38 hamstring injuries were recorded, affecting 36 of 579 players (6.2%). The overall injury incidence rate was 0.7 (95% CI, 0.6-0.8) per 1000 player hours, 0.33 (95% CI, 0.25-0.46) in training, and 1.2 (95% CI, 0.82-1.94) in matches. Injury incidence rates were significantly different between the intervention (0.25; 95% CI, 0.19-0.35) and control groups (0.8; 95% CI, 0.61-1.15), χ(2)(1, n = 579) = 7.865; P = .005. The risk for hamstring injuries was reduced in the intervention group compared with the control group (odds ratio, 0.282; 95% CI, 0.110-0.721) and was statistically significant (P = .005). No statistically significant differences were identified between the intervention and control groups regarding injury severity. Compliance with the intervention protocol was 91%.

CONCLUSION

Incorporating the NHE protocol in regular amateur training significantly reduces hamstring injury incidence, but it does not reduce hamstring injury severity. Compliance with the intervention was excellent.

Pediatric ankle sprains and their imitators

Ankle injuries are common in sports, and the ankle sprain is the most common of ankle injuries, but there are many injuries that can mimic a sprain. In the skeletally immature athlete, bone injuries, particularly those that affect the physis, are more likely to occur than a ligamentous injury. Knowledge of relevant anatomy, physical exam, and appropriate imaging can assist the primary care provider in accurately diagnosing the majority of ankle injuries in the young athlete.