Comparison of the Effect of the Combined Mechanism Ankle Support on Static and Dynamic Postural Control of Chronic Ankle Instability Patients

Immediate Effects of Wearing an Ankle Bandage on Fine Coordination, Proprioception, Balance and Gait in the Subacute Phase of Ankle Sprains

Ankle sprains are the most frequently occurring musculoskeletal injuries among recreational athletes. Ankle support through bandages following the initial orthotic treatment might be beneficial for rehabilitation purposes. However, the literature is sparse regarding the use of an ankle support directly after the acute phase of an ankle sprain. Therefore, this study investigates the hypothesis that wearing an ankle bandage immediately after an acute ankle sprain improves motor performance, stability and reduces pain. In total, 70 subjects with acute unilateral supination trauma were tested. Subjects were tested five weeks post-injury to assess immediate effects of the ankle bandage. On the testing day, subjects completed rating questionnaires and underwent comprehensive biomechanical assessments. Biomechanical investigations included fine coordination and proprioception tests, single leg stances, the Y-Balance test, and gait analysis. All biomechanical investigations were conducted for the subject's injured leg with and without a bandage (MalleoTrain® Bauerfeind AG, Zeulenroda-Triebes, Germany) and the healthy leg. Results indicated moderate to strong improvements in ankle stability and pain relief while wearing the bandage. Wearing the bandage significantly normalized single leg stance performance (p < 0.001), stance phase duration (p < 0.001), and vertical ground reaction forces during walking (p < 0.05). However, the bandage did not have a clear effect on fine coordination and proprioception. The findings of our study suggest that ankle bandages may play a crucial role in early-stage rehabilitation by enhancing motor performance and reducing pain.

Postural Control Deficits During Static Single-leg Stance in Chronic Ankle Instability: A Systematic Review and Meta-Analysis

CONTEXT

Postural control deficits arising from injured ankles are central to chronic ankle instability (CAI) and its persistent symptoms. This is usually measured by recording the center of pressure (CoP) trajectory during static single-leg stance using a stable force plate. However, existing studies have produced conflicting results on whether this mode of measurement adequately reveals the postural deficits in CAI.

OBJECTIVE

To determine whether postural control during static single-leg stance is impaired in CAI patients when compared with uninjured healthy controls.

DATA SOURCES

Literature databases, PubMed, Embase, Web of Science, Cochrane Library, Scopus, CINAHL, and SPORTDiscus, were searched from inception to April 1, 2022, using ankle-, injury-, and posture-related terms.

STUDY SELECTION

Two authors independently performed the step-by-step screening of article titles, abstracts, and full texts to select peer-reviewed studies investigating CoP trajectory during static single-leg stance using a stable force plate in CAI patients and healthy controls. A total of 13,637 studies were reviewed, and 38 studies (0.003%) met the selection criteria.

STUDY DESIGN

Meta-analyses of descriptive epidemiological study.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

CoP parameters, sway directions, visual condition, and numerical data (means and standard deviations) were extracted.

RESULTS

The injured ankles of CAI patients had higher standard deviations of sway amplitude in both anterior-posterior and medial-lateral directions (standardized mean difference [SMD] = 0.36 and 0.31, respectively) under conditions of open eyes than controls. Higher mean sway velocity in anterior-posterior, medial-lateral, and total directions (SMD = 0.41, 0.37, and 0.45, respectively) with closed eyes was also found.

CONCLUSION

CAI patients had deficits of postural control during static single-leg stance, and these deficits were identified by the CoP trajectory. Further methodological explorations of CoP parameters and corresponding test conditions are required to enhance the sensitivity and reliability of postural deficit assessments in CAI using force plates.

Effects of Ankle Orthoses, Taping, and Insoles on Postural Stability of Individuals with Chronic Ankle Instability: A Systematic Review

Chronic ankle instability (CAI) is a prevalent condition characterized by recurring instances of the ankle giving way and persistent symptoms, including pain and diminished function. Foot and ankle external supports are commonly used in clinical practice and research for treating CAI. This systematic review aimed to assess the effects of foot and ankle external supports on the postural stability of individuals with CAI to guide clinical practice and inform future research. A comprehensive search was conducted in PubMed, Web of Science, Scopus, and Google Scholar databases from 1 January 2012 to 1 November 2022. Eighteen studies involving individuals with CAI were chosen in this systematic review. The quality of the included studies and risk of bias were assessed using Cochrane Collaboration's tool for randomized controlled trials, the Newcastle-Ottawa Scale for case-control studies, and the DELPHl-list for crossover trial studies. The external supports included in this review were ankle orthoses (elastic, semi-rigid, and active orthoses), taping (kinesiotaping and fibular reposition taping), and insoles (textured and supportive insoles). The outcome measures included static and dynamic postural stability tests, such as the single-leg stance test, star excursion balance test, Y-balance test, single-leg landing test, lateral jump test, walking test, and running test. The results showed that elastic orthoses, Kinesiotaping, and textured insoles demonstrated potential benefits in improving postural stability in individuals with CAI. Elastic orthoses decreased ankle joint motion variability, kinesiotaping facilitated cutaneous receptors and proprioceptive feedback, while textured insoles increased tactile stimulation and foot position awareness. However, the effects of semi-rigid orthoses, fibular reposition taping, and arch support insoles were inconsistent across studies. Future research should explore the long-term effects of these external supports, analyze the effects of different characteristics and combinations of supports, and employ standardized outcome measures and testing protocols for assessing postural stability.

Effects of textured insoles and elastic braces on dynamic stability in patients with functional ankle instability

BACKGROUND

Functional ankle instability (FAI) is a common condition that affects individuals who have experienced previous ankle sprains. Textured insoles and elastic ankle braces have been previously used as interventions to improve stability in FAI patients. However, the optimal combination of these interventions has not been fully explored. The objective of this study was to investigate the effects of different types of textured insoles and elastic ankle braces on the dynamic stability of individuals diagnosed with FAI.

METHODS

The study involved 18 FAI patients who performed single-leg landing tasks with and without wearing an eight-band elastic ankle brace while wearing textured insoles with protrusion heights of 0 mm, 1 mm, and 2 mm. The dynamic posture stability index (DPSI) and its components in the anterior-posterior (APSI), mediolateral (MLSI) and vertical (VSI) directions were calculated from the ground reaction force collected from the Kistler force plate during the first three seconds of the landing tasks.

RESULTS

A significant interaction was found between textured insole type and ankle brace for DPSI (P = 0.026), APSI (P = 0.001), and VSI (P = 0.021). However, no significant interaction was observed for MLSI (P = 0.555). With elastic ankle braces, textured insoles with 1-mm protrusions significantly enhanced anterior-posterior, mediolateral, vertical, and overall stability compared to textured insoles with no and 2 mm protrusions (P < 0.05). Without elastic ankle braces, textured insoles with 1-mm protrusions significantly improved the anterior-posterior (P = 0.012) and overall stability (P = 0.014) of FAI patients compared to smooth insoles.

CONCLUSIONS

The combination of textured insoles with 1-mm protrusion heights and an elastic ankle brace could enhance the dynamic stability of individuals with FAI, potentially mitigating the risk of ankle sprains.

Role of interventions targeting plantar cutaneous receptors in improving postural control in chronic ankle instability: A systematic review with meta-analysis

INTRODUCTION

Chronic ankle instability (CAI) is a disorder that occurs after one or more acute ankle sprains and is characterised by persistent symptoms which include episodes of ''giving way'' a sensation of instability, recurrent ankle sprains, and functional deficits. Despite of effective treatment strategies a comprehensive approach is needed that can break this continuum of disability and improve the postural control. A systematic review with meta-analysis assessing the effectiveness of interventions targeting plantar cutaneous receptors for improving postural control in individuals with chronic ankle instability.

METHODS

The systematic review with meta-analysis was performed following PRISMA guidelines. Outcome measure used to evaluate the improvement in which static postural control was assessed on SLBT (Single limb balance test) and COP (Centre of pressure) whereas dynamic postural control was assessed on SEBT (star excursion balance test) and scores expressed as mean ± SD and random-effects model were performed, and heterogeneity between the studies was calculated using the I2 statistic.

RESULTS

A total of 168 CAI populations were included among the 8 selected studies in the meta-analysis. In which,5 studies using Plantar massage and 3 studies using foot insole were assessed, with moderate to high quality on the Pedro scale (range 4-7). For single and six-sessions of plantar massage showed insignificant effect on SLBT COP and for the single session of custom moulded FO showed insignificant effect on SEBT.

CONCLUSION

The meta-analysis showed non-significant pooled results for plantar massage and foot orthotics on static and dynamic postural control when assessed on postural outcome measures. Further high-quality evidence-based trials would be required to highlight the importance of sensory targeted approaches to treat the postural instability in CAI patients.

Dynamic reach deficits in those with chronic ankle instability: A systematic review and meta-analysis

OBJECTIVE

The purpose of this review with meta-analyses was to determine the dynamic reach differences 1) between chronic ankle instability (CAI) and uninjured individuals, 2) between the limbs of an individual with CAI, and 3) between the uninvolved CAI limb and the healthy control limb across all possible reach directions of the Star Excursion Balance Test (SEBT).

METHODS

PubMed, CINAHL, SPORTDiscus, and Scopus databases were searched up to October 2021. Data were extracted from the retained studies and underwent methodological quality assessment and meta-analysis using random-effect models.

RESULTS

After screening, 33 articles were included for the analyses. In all possible SEBT reach directions, the CAI group demonstrated significantly decreased normalized dynamic reach distances relative to the uninjured control group (SMDs: -0.66 to -0.48, p ≤ 0.05). Similarly, the involved CAI limb demonstrated significantly decreased normalized dynamic reach distances relative to the uninvolved CAI limb (SMDs: -0.61 to -0.33, p ≤ 0.05). However, no differences were noted between the uninvolved CAI limb and the healthy control limb (SMDs: -0.22 to 0.09, p ≥ 0.13).

CONCLUSIONS

Our findings were that the involved limb of those with CAI has dynamic postural deficits relative to (i) an uninjured control group and (ii) relative to their uninvolved limb. However, the uninvolved limb of the CAI group does not differ from an uninjured control group in any reach direction.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Dynamic Balance Measures in Healthy and Chronic Ankle Instability Participants While Wearing Ankle Braces: Systematic Review With Meta-Analysis

CONTEXT

Ankle braces have been theorized to augment dynamic balance.

OBJECTIVES

To complete a systematic review with meta-analysis of the available literature assessing the effect of ankle braces on dynamic balance in individuals with and without chronic ankle instability (CAI).

EVIDENCE ACQUISITION

Electronic databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus) were searched from inception to October 2019 using combinations of keywords related to dynamic balance, ankle braces, Star Excursion Balance Test (SEBT), Y-Balance Test (YBT), and Time to Stabilization. Inclusion criteria required that studies examined the effects of ankle braces on dynamic balance. Studies were excluded if they evaluated other conditions besides CAI, did not access dynamic balance, or did not use an ankle brace. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The level of evidence was assessed using the Strength of Recommendation Taxonomy. The magnitude of brace effects on dynamic balance was examined using Hedges g effect sizes (ESs) and 95% confidence intervals (CIs). Random-effects meta-analysis was performed to synthesize SEBT/YBT and Time to Stabilization data separately.

DATA SYNTHESIS

Seven studies were included with a median Physiotherapy Evidence Database score of 60% (range 50%-60%), and 4 were classified as high quality. Overall meta-analysis indicated a weak to no effect of braces on SEBT/YBT (ES = 0.117; 95% CI, -0.080 to 0.433; P = .177) and Time to Stabilization (ES = -0.064; 95% CI, -0.211 to 0.083, P = .083). Subanalysis of SEBT/YBT measures indicated a weak negative effect in healthy participants (ES = -0.116; 95% CI, -0.209 to -0.022, P = .015) and a strong positive effect in individuals with CAI (ES = 0.777; 95% CI, 0.418 to 1.136; P < .001).

CONCLUSION

The current literature supports a strong effect of ankle braces on the SEBT/YBT in those with CAI. However, little to no dynamic balance changes were noted in healthy participants. Future research should include consistent ankle brace types, pathologic populations, and the examination of dynamic balance changes contribution to injury risk reduction.

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

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

Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life

The free fibula flap has been one of the most important microvascular grafts for orofacial reconstruction for more than 30 years. The complication rates at the donor-site reported in literature are considered to be low, but the published data vary greatly in some cases. In particular, restrictions in the stability and balance of the involved leg and their effects on the quality of life have been described very inconsistently to date. Therefore, this study mainly focuses on the stability and balance of the affected leg in a split-leg design. Between December 2014 and January 2018, out of 119 subjects who underwent mainly jaw ablative tumor surgery and reconstruction using a fibula flap, 68 subjects were examined for donor site morbidity. Besides reporting general types of complications, two specific test procedures were used. The Star Excursion Balance Test (SEBT) as a practical test for ankle function and the Foot and Ankle Disability Index (FADI) as a questionnaire in order to assess quality of life, depending on the lower leg function. SEBT revealed an average of 55.3 cm with the operated leg as the supporting leg, which corresponds to 95.5% of 57.9 cm achieved with the healthy leg as the supporting leg. An average FADI score of 89.4% was recorded. SEBT and FADI seem to be suitable methods of examination for subjects post fibular transplantation and pointed out minimal limitations of the involved legs in comparison to the unaffected legs. These limitations were clinically not relevant and they had minor influence on the subjects' quality of life and their daily activities.

Effects of Kinesiotape vs Soft and Semirigid Ankle Orthoses on Balance in Patients With Chronic Ankle Instability: A Randomized Controlled Trial

BACKGROUND

Chronic ankle instability (CAI) is a frequent complication of ankle sprain that may be associated with long-term consequences. Although taping and bracing are common interventions that are widely used by clinicians and athletic trainers for patients with CAI, no studies have compared the effects of kinesiotaping and bracing on balance performance in these patients. The present study aimed to compare the effects of ankle kinesiotaping, a soft ankle orthosis, and a semirigid ankle orthosis on balance performance in patients with CAI.

METHODS

Sixty patients with CAI were randomly assigned to 4 groups that received kinesiotaping, a soft orthosis, a semirigid orthosis, or no treatment (control group). Dynamic and static balance were measured with the modified Star Excursion Balance Test, single leg hop test, and single leg stance test before and after a 4-week intervention period.

RESULTS

Significant between-group differences were seen in all evaluated outcomes (P ≤ .003). The lowest reach distances in all directions in the modified Star Excursion Balance Test were found in the control group, and these patients also had a significantly shorter measured distance in the single leg hop test, and more errors in the single leg stance test compared with the 3 intervention groups. No significant differences were found among the 3 intervention groups.

CONCLUSION

Use of kinesiotaping and a soft or a semirigid ankle brace for 4 weeks were all beneficial in improving static and dynamic balance in individuals with CAI. None of the interventions was superior to the other 2.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Quantitative assessments of static and dynamic balance performance in patients with chronic ankle instability

Patients with chronic ankle instability (CAI) have postural-control deficits during center-of-pressure excursions than do healthy individuals. While an external analysis of center-of-pressure excursions in CAI has been performed, a quantitative analysis of center-of-gravity movements, to detect the balance deficits associated with CAI, has yet to be performed. Therefore, the aim of the study is to quantify the balance deficits in patients with unilateral CAI.Forty-four patients with unilateral CAI (24 men; age, 31.7 ± 5.5 years) and 26 uninjured volunteers (12 men; age, 28.6 ± 5.9 years) underwent Neurocom Balance Manager assessments of dynamic and static balance responses in limits of stability, unilateral stance, and forward lunge tests.In the limits of stability test, there were no significant group differences in the forward direction; however, reaction times were longer in the CAI group than in the control group in the backward (P = .037, effect size [ES] = 0.49) and rightward directions (P = .032, ES  = 0.47). Furthermore, the CAI group showed more excursions in the rightward (P = .046, ES = 0.50) and leftward directions (P = .002, ES = 0.80), and less directional control in the leftward direction (P = .036, ES = 0.59). In the unilateral stance test, the center of gravity sway velocity was faster in the CAI group than in the control group, whether eyes were opened or closed (P < .05). There were no significant group differences in forward lunge-test outcomes.Patients with CAI have poor static and dynamic balance performance compared to that in healthy counterparts. Thus, balance retraining should be an essential component of rehabilitation programs for patients with CAI.

Do External Supports Improve Dynamic Balance in Patients with Chronic Ankle Instability? A Network Meta-analysis

BACKGROUND

To improve ankle stability in patients who have experienced an ankle sprain with residual symptoms of instability and/or objective joint laxity, external supports (such as taping, bracing, and orthotic insoles) are used sometimes. However, available randomized trials have disagreed on whether restraints improve balance in those individuals. In this situation, a network meta-analysis can help because it allows for comparing multiple treatments simultaneously, taking advantage not only of direct but also indirect evidence synthesis.

QUESTIONS/PURPOSES

The aim of this network meta-analysis was to assess (1) the impact of taping and orthotic devices on dynamic postural control in individuals with ankle instability and (2) the presence of a placebo effect in participants treated with sham taping and complications resulting from the administered treatments.

METHODS

We searched the PubMed, Scopus, and CENTRAL databases up to February 13, 2019 for completed studies. Randomized trials assessing the results of real and/or sham taping, wait-and-see protocols, ankle bracing, and foot orthotics for ankle instability as determined by one or more ankle sprains followed by ongoing subjective symptoms and/or mechanical laxity were included. We evaluated dynamic postural control in terms of the Star Excursion Balance Test in the posteromedial direction (SEBT-PM), which is considered the most representative of balance deficits in patients with ankle instability. Standardized mean differences were re-expressed to percentage differences in SEBT-PM, with higher scores representing possible improvement. Subsequently, those data were checked against the established minimal detectable change of 14% for this scale to make judgements on clinical importance. We also assessed the presence of a placebo effect by comparing the results of sham taping with no treatment and complications resulting from the administered treatments. Additionally, we judged the quality of trials using the Cochrane risk of bias tool and quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. A total of 22 trials met our inclusion criteria, 18 of which were deemed to be at a low risk of bias. A network of treatments consisting of 13 studies was created, and the level of evidence was judged to be high. As far as participants' allocation to treatment arms, 85 patients followed a wait-and-see protocol, 29 received placebo taping, 99 were treated with taping, 16 were treated with bracing, 27 were administered insoles, and six individuals were offered a combination of insoles with bracing. Of note, with statistical power set at 80%, a minimum of 16 patients per treatment group was required to provide sufficient statistical power and detect a SEBT-PM percentage difference of 14%.

RESULTS

A network meta-analysis did not demonstrate a benefit of taping or bracing over no treatment (percentage difference in SEBT-PM between taping and bracing versus control: -2.4 [95% CI -6 to 1.1]; p = 0.18, and -7.5 [95% CI -15.9 to 1]; p = 0.08, respectively). This was also the case for sham taping because the measurement increase failed to exceed the minimal detectable change (percentage difference in SEBT-PM between sham taping and untreated control: -1.1 [95% CI -6.9 to 4.7]; p = 0.72). Importantly, there were no reported adverse events after treatment application.

CONCLUSIONS

Evidence of moderate strength indicated that external supports of any type were no more effective than controls in improving dynamic postural control in patients with at least one ankle sprain and residual functional or mechanical deficits. Therefore, implementing those tools as a standalone treatment does not appear to be a viable strategy for the primary management of ankle instability. It is conceivable that combinations of rehabilitation and external supports could be more effective than external supports alone, and future trials should evaluate the potential of such combinations in enhancing not only clinician-reported but also patient-oriented outcomes using long-term follow-up measurements.

LEVEL OF EVIDENCE

Level I, therapeutic study.