Intrinsic Predictive Factors of Noncontact Lateral Ankle Sprain in Collegiate Athletes: A Case-Control Study

Relationship of Chronic Ankle Instability With Foot Alignment and Dynamic Postural Stability in Adolescent Competitive Athletes

Background

Competitive adolescent athletes should be aware of the early signs of chronic ankle instability (CAI) and the connection between the condition and performance.

Purpose

To investigate whether CAI is related to foot alignment and morphology as well as dynamic postural stability after a jump landing among adolescent competitive athletes with and without a history of a lateral ankle sprain and CAI.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Between July 2020 and August 2021, adolescent competitive athletes (N = 85; n = 49 boys; n = 36 girls) were classified into 3 groups using Cumberland Ankle Instability Tool (CAIT) scores: healthy athletes (n = 55), coper athletes (n = 19), and athletes with CAI (n = 11). Results of foot alignment assessments involving the leg-heel angle (LHA) and navicular height, intrinsic foot muscle morphology, dynamic postural stability index (DPSI), and other parameters were compared among the 3 groups. The relationship between the CAIT score and the LHA and dynamic postural stability and instability were examined using multiple linear regression.

Results

Compared with the healthy group, the CAI group had a significantly greater LHA (8.73°± 3.22° vs 6.09°± 3.26°; P < .05), higher DPSI (0.336 ± 0.046 vs 0.298 ± 0.035), and higher vertical stability index (0.303 ± 0.048 vs 0.264 ± 0.037; P < .05 for all). Multiple regression analysis showed that the LHA (β = -0.228; P = .033) and DPSI (β = -0.240; P = .025) were significantly associated with the CAIT score .

Conclusion

Valgus rearfoot alignment and poorer dynamic postural control were associated with CAI among adolescent athletes.

Landing Technique and Ankle-dorsiflexion Range of Motion are not Associated with the History of Lower Limb Injuries among Youth Basketball Athletes

Background

Lower limb injuries generate a significant health burden in basketball. Landing technique and ankle-dorsiflexion range of motion have been suggested as risk factors for lower limb injuries among youth athletes, but studies conducted specifically with basketball athletes are lacking.

Hypothesis/Purpose

To describe the period prevalence of basketball-related injuries and to examine the association of the history of lower limb injuries with landing technique and ankle-dorsiflexion range of motion asymmetry among youth basketball athletes.

Study Design

Cross-Sectional Survey.

Methods

Youth basketball athletes were asked to complete a paper-based survey to investigate personal characteristics, training characteristics and their three-month history of basketball-related injuries. The Landing Error Scoring System and the Weight-Bearing Lunge Test were used to evaluate landing technique and ankle-dorsiflexion range of motion. Binary logistic regression was utilized to examine the association of the investigated variables with the presence of history of lower limb injuries among the athletes.

Results

A total of 534 athletes participated. The three-month prevalence of basketball-related injuries was 23.2% (95% CI 19.7 - 27), and the majority of the reported injuries affected the lower limbs (69.7%; n=110). Sprains were the most frequent type of injury (29.1%; n=46), and the ankle (30.4%; n=48) and knee (21.5%; n=34) were the most affected anatomic locations. Landing technique (p = 0.105) and ankle-dorsiflexion range of motion asymmetry (p = 0.529) were not associated with the history of lower limb injuries.

Conclusion

The three-month prevalence of basketball-related injuries was 23.2%. Although ankle sprains were the most frequent injury, landing technique and ankle-dorsiflexion range of motion asymmetry were not associated with the history of lower limb injuries among youth basketball athletes.

Level of Evidence

3.

Effectiveness of the Rehabilitation Training Combined with Maitland Mobilization for the Treatment of Chronic Ankle Instability: A Randomized Controlled Trial

The study aims to determine whether routine rehabilitation training combined with the Maitland mobilization is more effective than routine rehabilitation training alone in patients with chronic ankle instability, intending to provide a novel rehabilitation strategy for chronic ankle instability. A total of 48 subjects were divided into three groups: EG (Maitland mobilization and routine rehabilitation), CG (routine rehabilitation), and SG (sham mobilization and routine rehabilitation). The intervention was performed three times each week for 4 weeks, for a total of 12 sessions. Before and after the intervention, the muscle strength, star excursion balance test (SEBT), weight-bearing dorsiflexion range of motion (WB-DFROM), ankle range of movement, Cumberland ankle instability tool (CAIT), self-comfort visual analog scale (SCS-VAS), and self-induced stability scale (SISS-VAS) were assessed. The results showed that the improvement of SEBT, WB-DFROM, and active ankle range of movement without the pain in EG was more obvious than CG and SG, but the improvement of the self-report of ankle severity and muscle strength was not. Compared with routine rehabilitation training alone, routine rehabilitation training combined with Maitland mobilization for patients with chronic ankle instability may provide more benefit in terms of balance and ankle range of movement than routine rehabilitation alone, but the improvement in muscle strength was not evident enough.

Foot and Ankle Injuries in Elite Taekwondo Athletes: A 4-Year Descriptive Analysis

Background:

Foot and ankle injuries are a common but underestimated problem in taekwondo. Detailed data on injury incidence rates (IIRs), patterns, and injury mechanism are missing.

Purpose:

The primary aims were to evaluate the prevalence of foot and ankle injuries and the exposure-adjusted IIR of elite taekwondo athletes during matches while training (ie, sparring) and in competitions. The secondary aims were to evaluate injury site, type, sport-specific mechanism, and time loss.

Study Design:

Descriptive epidemiology study.

Methods:

Athletes from a single national Olympic taekwondo training center were assessed prospectively for foot and ankle injuries over 4 years (between January 1, 2016, and December 31, 2019). Data were collected regarding number and type of injuries, anatomic location, and total exposure time during training and competition for each athlete. Injury mechanism and dominant foot were assessed via personal interview. Time loss from sport was analyzed retrospectively. The injury prevalence and IIR were calculated. Correlation between mechanism and injury type, location, and dominant foot was evaluated. Time loss according to location and injury type was assessed. The chi-square test and Fisher exact test were used to test for differences in sex, age, and taekwondo experience and for comparison of injury location and type, injury mechanism, and side dominance, respectively. Training and competition IIRs and prevalence were calculated with 95% CIs (for Poisson rates).

Results:

From an initial 107 athletes, 79 (73.8%) were included in the final data set. Of these athletes, 38 were injured (n = 112 injuries) for a prevalence of 48.1% (95% CI, 43%-52%). The overall IIR of the ankle joint was 13.14 injuries per 1000 athletes (95% CI, 1.5-25.9) and was significantly higher during competition versus training (P < .001). Ankle joint injuries were most common (n = 71; 63%). Significantly more noncontact versus contact ankle ligament injuries (n = 46; 83%) occurred (P < .001). The forefoot (n = 18; 66%) was mainly affected by contact injuries (P < .001). Time loss was the highest for midfoot fractures (mean ± SD, 23.0 ± 0.6 days; range, 23-24 days).

Conclusion:

Noncontact ligamentous ankle injuries were most common, with a higher incidence during competition. Improvement of strength, endurance, and postural stability under strain is recommended for prevention.

Serial Within-Session Improvements in Ankle Dorsiflexion During Clinical Interventions Including Mobilization-With-Movement and A Novel Manipulation Intervention - A Case Series

BACKGROUND

Persisting reductions in ankle dorsiflexion range of motion are commonly encountered clinically and seen to be associated with adverse outcomes after ankle and other lower extremity injuries. Accordingly improving identified deficits is a common goal for rehabilitation; however, little data exists documenting any improvement related to interventions in these patients.

PURPOSE

To document the change in dorsiflexion range of motion after stretching and mobilization-with-movement and exercise and a novel manipulation intervention in a population of injured athletes.

DESIGN

Case series in 38 consecutive injured athletes with persisting reductions in ankle dorsiflexion range of motion (42 "stiff" ankles, 34 uninjured) in an outpatient sports physiotherapy clinic.

METHOD

During a single treatment session, two baseline measurements of weight-bearing dorsiflexion were taken at the start of the session to establish reliability and minimum detectable change, and then the same measures were performed after stretching and a mobilization-with-movement intervention, and again after clinical exercise and a novel manipulation which was applied on both ankles.

RESULTS

Excellent reliability was demonstrated (ICC2,1>0.93, MDC=3.5°) for the dorsiflexion measure. Statistically significant (p<0.01), but clinically meaningless improvements were seen after stretching and the mobilization-with-movement intervention on the injured and uninjured legs (1.9° and 1.4° respectively) with greater improvements seen after exercise and the subsequent manipulation (6.9° and 4.7°).

CONCLUSIONS

The relatively simple clinical exercise and manipulation intervention program was associated improvement in dorsiflexion range of motion in this cohort with persisting ankle stiffness. The interventions described largely restored range of motion consistent with baseline levels of the uninjured ankles. Improvements were also seen in the uninjured ankles following intervention.

Effects of Combination Movement Patterns Quality and Physical Performance on Injuries in Young Athletes

Identifying the factors associated with the injuries is crucial to prevention, enabling apply effective methods to reduce injuries frequency. This is especially important for young athletes for whom an injury may impair development or prematurely end a sports career. Therefore, the objective of this study is to examine if the movement patterns quality and physical performance simultaneously affected injury occurrence in young athletes. The participants were 176 athletes aged 22.44 ± 1.64. The injury data were collected from the 12 months retrospective period. The functional movement screen test was conducted to assess the quality of movement patterns, and the physical performance tests were done for assessing strength, power, flexibility, and balance. Results showed relationships between movement patterns quality and flexibility with injuries. The receiver operating characteristic curve demonstrated growing injury frequency for 14 ≥ FMS and 21 cm ≥ Sit-and-reach test. Rank Transform ANOVA revealed a simultaneous effect of movement quality (F = 11.5361; p = 0.0008) and flexibility (F = 8.0514; p = 0.0050) on an injury. Post-hoc tests indicated that the group with low-quality movement patterns combined with a low level of flexibility is the most frequently injured (p < 0.05). It is recommended to include in training, routine exercises improving movement patterns and flexibility to prevent injuries.

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.

Lateral Ankle Sprains and Their Association with Physical Function in Young Soccer Players

Purpose

Lateral ankle sprain (LAS) in childhood can result in lateral malleolus avulsion fractures; additionally, bone nonunion may occur. Physical maturity relates to the development of bone morphology and physical functionality. It is unknown how changes in physical functionality attributable to physical maturity affect young soccer players with abnormal lateral malleolus (ALM) morphology. Hence, the present study aimed to investigate the bone morphology of the lateral malleolus in young soccer players and to examine its relationship with physical functionality at different maturity levels.

Subjects and Methods

Two hundred and ninety young soccer players aged 6–15 years were included. The presence of ALM was assessed using ultrasonography. The subjects were allocated to three groups based on physical maturity (Pre-, Mid-, and Post-peak height velocity age [PHVA]). The prevalence of ALM and the relationship between ALM and physical maturity were examined for body composition, foot pressure distribution, foot alignment, ankle mobility, and single-leg balance.

Results

The prevalence of ALM was 17.6%. For physical maturity, the post-PHVA group showed a decrease in ankle dorsiflexion and eversion and an increase in one-leg hop distance compared to the Pre-PHVA group (P < 0.05). In the ALM group, the center of pressure during heel raising was distributed laterally in the Post-PHVA (P < 0.01), and the weight-bearing dorsiflexion angle was decreased in the Mid- and Post-PHVA (P < 0.05).

Conclusion

In the Post-PHVA young soccer players, decreased ankle dorsiflexion and eversion and increased one-leg hop distance were observed. The ALM group exhibited lateral loading during heel raising in the Post-PHVA group and decreased weight-bearing ankle dorsiflexion angle in the Mid- and Post-PHVA groups. The findings indicate the importance of secondary prevention of LAS and ultrasonography. Prospective studies of LAS in young athletes are required in the future.

Criteria-Based Return to Sport Decision-Making Following Lateral Ankle Sprain Injury: a Systematic Review and Narrative Synthesis

OBJECTIVE

The aim of this systematic review was to identify prospective studies that used a criteria-based return to sport (RTS) decision-making process for patients with lateral ankle sprain (LAS) injury.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

The PubMed (MEDLINE), Web of Science, PEDro, Cochrane Library, SPORTDiscus (EBSCO), ScienceDirect, and Scopus databases were searched to 23 November 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they prospectively applied a criteria-based RTS decision-making process for patients with LAS injury, but were excluded if they merely gathered outcome measures at the RTS time point. Studies were also excluded if patients were recovering from ankle fracture, high ankle sprain, medial ankle sprain, chronic ankle instability or complex ankle injury.

RESULTS

No studies were identified that used a criteria-based RTS decision-making process for patients with LAS injury. We were unable to conduct a quantitative synthesis or meta-analysis, therefore we provide a narrative synthesis of relevant questionnaires, as well as clinical and functional assessments commonly used in studies retrieved in the search.

CONCLUSION

There are currently no published evidence-based criteria to inform RTS decisions for patients with an LAS injury. Based on our narrative synthesis, we propose a number of variables that could be used to develop a criteria-based RTS decision paradigm. Future research should aim to reach consensus on these variables and apply them to actual RTS decisions within prospective study designs. Furthermore, we suggest that complex systems theory and the RTS continuum could be used to inform the development of an RTS decision-making paradigm for athletes with LAS injury.

Jogging and Practical-Duration Foam-Rolling Exercises and Range of Motion, Proprioception, and Vertical Jump in Athletes

CONTEXT

Foam-rolling exercises are frequently included in warmups due to their benefits for increasing range of motion (ROM). However, their effects on proprioception and vertical jump have not been analyzed and therefore remain unclear. Moreover, the effects of performing practical-duration foam-rolling exercises after typical warmup exercises such as jogging are unknown.

OBJECTIVE

To analyze the effects of jogging and practical-duration foam-rolling exercises on the ROM, knee proprioception, and vertical jump of athletes.

DESIGN

Randomized controlled study.

SETTING

Sports laboratory and university track.

PATIENTS OR OTHER PARTICIPANTS

Thirty athletes were randomly classified into an experimental group (EG) or control group (CG).

INTERVENTION(S)

The EG performed 8-minute jogging and foam-rolling exercises. The CG performed 8-minute jogging.

MAIN OUTCOME MEASURE(S)

Knee flexion, hip extension, active knee extension, ankle dorsiflexion (ADF), knee-joint position sense, and countermovement jump (CMJ) were evaluated before the intervention (baseline), after (post 0 min), and 10 minutes later.

RESULTS

The EG exhibited higher values for ADF and CMJ at post 0 min (ADF: P < .001, d = 0.88; CMJ: P < .001, d = 0.52) and 10 minutes later (ADF: P = .014, d = 0.41; CMJ: P = .006, d = 0.22) compared with baseline. Although the CG also showed increased CMJ at post 0 min (P = .044, d = 0.21), the EG demonstrated a greater increase (P = .021, d = 0.97). No differences were found in the remaining ROM variables (knee flexion, hip extension, active knee extension: P values > .05). For knee-joint position sense, no differences were found (P > .05).

CONCLUSIONS

Combining jogging and practical-duration foam rolling may increase ADF and CMJ without affecting knee proprioception and hip or knee ROM. Jogging by itself may slightly increase ADF and CMJ, but the results were better and were maintained after 10 minutes when foam rolling was added.

Athletes at late stage rehabilitation have persisting deficits in plantar- and dorsiflexion, and inversion (but not eversion) after ankle sprain

OBJECTIVES

Document reliability and normative data for a novel device measuring weight-bearing ankle range of motion after ankle injury.

DESIGN

Cross-sectional Cohort, two occasions one day apart.

SETTING

Sports medicine hospital.

PARTICIPANTS

87 ankle-injured male athletes at a late stage of their rehabilitation and 25 uninjured subjects. The injured athletes had met all criteria to return to functional, on-field rehabilitation.

MAIN OUTCOME MEASURES

Reliability (Intra-Class correlation Coefficient (ICC), and Minimum Detectable Change as a percent of the grand mean), weight-bearing range of motion (degrees) of dorsiflexion, plantarflexion, inversion, and eversion.

RESULTS

Good (dorsiflexion = 0.82[0.76-0.87] and inversion = 0.81[0.75-0.86]) and excellent (plantarflexion = 0.93[0.90-0.95]) reliability was documented, however reliability for the eversion measure showed only fair reliability (0.61[0.49-0.70]). Reduced range of motion in the injured leg was seen in all 4 directions, however with different magnitudes: Large differences were plantarflexion (-8.5°, ES = 0.80), medium for dorsiflexion (-5.2°, 0.57), small for inversion (-4.8°, 0.36), and trivial for eversion (-1.7°, 0.15).

CONCLUSION

The device demonstrated clinically useful reliability for measuring these ranges of motion in a functional, weight-bearing position. PF ROM showed the greatest reduction in range in these athletes at a late stage of their rehabilitation.

THE EFFECT OF NOVEL ANKLE-REALIGNING SOCKS ON DYNAMIC POSTURAL STABILITY IN INDIVIDUALS WITH CHRONIC ANKLE INSTABILITY

BACKGROUND

A dynamic postural stability deficit has been suggested to be present in individuals with chronic ankle instability (CAI). Interventions to improve postural control in individuals with CAI have been reported, but they required a long period of and compliance with interventions.

PURPOSE

To examine the effect of novel ankle-realigning socks on dynamic postural stability in individuals with CAI using the star excursion balance test (SEBT).

STUDY DESIGN

Case-control study.

METHODS

Twenty-eight control and 22 subjects with CAI (who were tested in both barefoot and with socks) were enrolled. The weight-bearing ankle dorsiflexion range of motion (DF-ROM) and SEBT were measured in the control group, the barefoot CAI group, and the CAI with socks group. In addition, subjective ankle instability during SEBT was measured using a visual analog scale (0 - 100).

RESULTS

DF-ROM was 48.3 ± 7.4 º in the control group, 43.3 ± 8.0 º in the barefoot CAI group, and 45.7 ± 6.8 º in the CAI with socks group. DF-ROM was significantly less in the barefoot CAI group than in the control group. The SEBT scores were significantly less in the barefoot CAI group than in the control group in all directions. The SEBT score was significantly larger in the CAI with socks group than in the barefoot CAI group in the posteromedial, posterior, and posterolateral directions. In addition, there were no significant differences between the control group and the CAI with socks group in six directions.

CONCLUSION

Wearing the novel ankle-realigning socks immediately improved dynamic postural stability as measured by the SEBT and subjective ankle instability in individuals with CAI.

LEVEL OF EVIDENCE

Level 3b.

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.

Intrinsic Risk Factors of Lateral Ankle Sprain: A Systematic Review and Meta-analysis

Context:

Lateral ankle ligamentous sprain (LAS) is one of the most common injuries in recreational activities and competitive sports. Many studies have attempted to determine whether there are certain intrinsic factors that can predict LAS. However, no consensus has been reached on the predictive intrinsic factors.

Objective:

To identify the intrinsic risk factors of LAS by meta-analysis from data in randomized control trials and prospective cohort studies.

Data Sources:

A systematic computerized literature search of MEDLINE, CINAHL, ScienceDirect, SPORTDiscus, and Cochrane Register of Clinical Trials was performed.

Study Selection:

A computerized literature search from inception to January 2015 resulted in 1133 studies of the LAS intrinsic risk factors written in English.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data Extraction:

The modified quality index was used to assess the quality of the design of the papers and the standardized mean difference was used as an index to pool included study outcomes.

Results:

Eight articles were included in this systematic review. Meta-analysis results showed that body mass index, slow eccentric inversion strength, fast concentric plantar flexion strength, passive inversion joint position sense, and peroneus brevis reaction time correlated with LAS.

Conclusion:

Body mass index, slow eccentric inversion strength, fast concentric plantar flexion strength, passive inversion joint position sense, and the reaction time of the peroneus brevis were associated with significantly increased risk of LAS.

Manual therapy in joint and nerve structures combined with exercises in the treatment of recurrent ankle sprains: A randomized, controlled trial

BACKGROUND

Recurrent ankle sprains often involve residual symptoms for which subjects often perform proprioceptive or/and strengthening exercises. However, the effectiveness of mobilization to influence important nerve structures due to its anatomical distribution like tibial and peroneal nerves is unclear.

OBJETIVES

To analyze the effects of proprioceptive/strengthening exercises versus the same exercises and manual therapy including mobilizations to influence joint and nerve structures in the management of recurrent ankle sprains.

STUDY DESIGN

A randomized single-blind controlled clinical trial.

METHOD

Fifty-six patients with recurrent ankle sprains and regular sports practice were randomly assigned to experimental or control group. The control group performed 4 weeks of proprioceptive/strengthening exercises; the experimental group performed 4 weeks of the same exercises combined with manual therapy (mobilizations to influence joint and nerve structures). Pain, self-reported functional ankle instability, pressure pain threshold (PPT), ankle muscle strength, and active range of motion (ROM) were evaluated in the ankle joint before, just after and one month after the interventions.

RESULTS

The within-group differences revealed improvements in all of the variables in both groups throughout the time. Between-group differences revealed that the experimental group exhibited lower pain levels and self-reported functional ankle instability and higher PPT, ankle muscle strength and ROM values compared to the control group immediately after the interventions and one month later.

CONCLUSIONS

A protocol involving proprioceptive and strengthening exercises and manual therapy (mobilizations to influence joint and nerve structures) resulted in greater improvements in pain, self-reported functional joint stability, strength and ROM compared to exercises alone.