Understanding acute ankle ligamentous sprain injury in sports

Effects of chronic ankle instability after grade I ankle sprain on the post-traumatic osteoarthritis

BACKGROUND

Untreated acute ankle sprains often result in chronic ankle instability (CAI) and can ultimately lead to the development of post-traumatic osteoarthritis (PTOA). At present, a typical animal model of ankle instability in mice is established by transecting the ligaments around the ankle joint. This study aimed to establish a grade I acute ankle sprain animal model by rapid stretching of peri-ankle joint ligaments. Furthermore, we tried to explore the pathophysiological mechanism of ankle osteoarthritis.

METHODS

In all, 18 male C57BL/6 J mice (7 weeks) were randomly divided into three groups: calcaneofibular ligament (CFL) laxity group, deltoid ligament (DL) laxity group, and SHAM group. One week after the surgical procedure, all mice were trained to run in the mouse rotation fatigue machine daily. The mice were tested on the balance beam before surgery and three days, 4 weeks, 8 weeks, and 12 weeks after surgery. Footprint analyses were performed on each mouse before surgery and 12 weeks after surgery. Micro-CT scanning was then performed to evaluate the degeneration of ankle joints and histological staining was performed to analyze and evaluate PTOA caused by ankle joint instability.

RESULTS

After surgery, the mice in the CFL and DL laxity groups took longer to cross the balance beam and slipped more often than those in the SHAM group (p < 0.05). The step length and width in the CFL and DL laxity groups were significantly shorter and smaller than those in the SHAM group 12 weeks after surgery (p < 0.05). There was a significant increase in the bone volume fraction (BV/TV) in the CFL and DL laxity groups compared with the SHAM group (p < 0.05). Histological staining results suggested obvious signs of PTOA in the CFL and DL laxity groups.

CONCLUSIONS

Based on CFL and DL laxity in a mouse ankle instability model, this study suggests that grade I ankle sprain can contribute to chronic ankle instability, impair motor coordination and balance, and eventually lead to PTOA of ankle with significant degeneration of its adjacent joints.

Construction and validation of a nomogram model for predicting different sites of ankle pain in runners with chronic ankle instability

This study aimed to establish a risk prediction nomogram model for anterolateral, mediolateral, and posterolateral ankle pain in runners with chronic ankle instability (CAI) and analyse the potential risk factors for pain at different ankle sites. Thirty recreational runners with CAI who reported ankle pain in the anterolateral, mediolateral, or posterolateral regions were recruited for this study. Kinematic, kinetic, and electromyographic data during running were collected using motion capture system, 3-D force platform, and surface electromyography system. These data were used to generate a dynamic nomogram. The results showed that anterolateral ankle pain in runners with CAI may be caused by insufficient gastrocnemius muscle strength (OR 0.85, 95% CI 0.73-0.97), excessive ground reaction force (GRF, OR 2.64, 95% CI 1.25-6.22), and an increased percentage of ankle energy absorption (OR 9.11, 95% CI 1.50-77.79). Mediolateral ankle pain might be contributed by greater ankle inversion angle (OR 1.08, 95% CI 1.01-1.00) and GRF (OR 2.13, 95% CI 1.17-4.31). Moreover, posterolateral ankle pain was predicted by increased ankle adduction angle (OR 1.06, 95% CI 1.00-1.12), increased GRF (OR 2.16, 95% CI 1.07-4.80), and decreased dynamic stability (OR 0.20, 95% CI 0.05-0.68). To prevent ankle pain, runners with CAI should be encouraged to focus on improving the neuroreceptor sensitivity of the gastrocnemius muscles, and retraining their energy absorption patterns.

Analysing lower limb motion and muscle activation in athletes with ankle instability during dual-task drop-jump

This study investigates the impact of chronic ankle instability (CAI) on athletes' lower extremity mechanics during bounce drop-jump landings with divided attention. Thirty Division I physical education voluntarily participated in the study. They performed two sets of bounce drop jumps: one set with a divided attention task and the other without. The obtained data were analysed using a paired t-test to compare the outcomes between the divided attention (DA) and non-divided attention (NDA) tasks. Athletes with CAI, during the DA task, displayed higher vertical landing forces, increased ankle inversion velocity, and greater range of motion of the ankle, knee, and hip in the frontal and transverse planes. They also exhibited insufficient neuromuscular preparation of the rectus femoris muscle. Notably, distinct kinematic alterations were observed in the ankle, knee, and hip joints regarding frontal and transverse lower-extremity kinematics. The findings suggest that athletes with CAI experience decreased activation of the rectus femoris muscle, which may impact their dynamic postural stability from pre-landing to ascending phases. Furthermore, the results indicate that individuals with CAI closely replicate the injury mechanisms encountered during a drop-jump landing task with divided attention. These insights offer valuable information about the real-time challenges faced by athletes with CAI.

Effect of a semirigid ankle brace on the in vivo kinematics and muscle activity of patients with functional ankle instability during simulated ankle sprain

INTRODUCTION

Ankle braces can effectively decrease the incidence of recurrent ankle sprain; however, whether the brace can decrease the severity of sprain and its related mechanism during sprain remain unknown.

METHODS

Twenty-two patients with functional ankle instability (FAI) (12 males and 10 females) and 16 healthy subjects (8 males and 8 females) were enrolled in this study. All of the subjects walked on a custom-built tilting platform that offered a 30° inversion (IV) to mimic the IV of ankle sprain. We collected the kinematic and surface electromyography data of patients with FAI with or without ankle brace and normal controls 6 times.

RESULTS

The FAI without brace group showed significantly higher maximum IV angles and average IV velocities than the control group (P < .001). The FAI with brace group revealed significantly lower maximum IV angles and average IV velocities than the FAI without brace group (P < .001); this group also showed significantly higher maximum external rotation (ER) angle and average ER velocities than the FAI with brace (P < .001) and control (P < .001) groups. The FAI with brace group indicated significantly lower average EMGPrep (P = .047), EMGTilt (P = .037), and EMGafterTilt (P = .004) of the peroneus longus than the FAI without brace group.

CONCLUSIONS

The ankle brace could effectively decrease IV angles and their velocities and increase ER angles and their corresponding velocities during ankle sprain in patients with FAI. It could also decrease the activity of the peroneus longus muscle during ankle sprain.

Evidence-based clinical practice guidelines for the management of acute ankle injuries according to: a PRISMA systematic review and quality appraisal with AGREE II

BACKGROUND

Acute ankle injuries are commonly seen in emergency rooms, with significant social impact and potentially devastating consequences. While several clinical practice guidelines (CPGs) related to ankle injuries have been developed by various organizations, there is a lack of critical appraisal of them. The purpose of this systematic review is to identify and critically appraise evidence-based clinical practice guidelines (EB-CPGs) related to acute ankle injuries in adults.

METHOD

We conducted searches in the Cochrane Library, MEDLINE, EMBASE databases, WHO, and reviewed 98 worldwide orthopedic association websites up until early 2023. Two authors independently applied the inclusion and exclusion criteria, and each evidence-based clinical practice guideline (EB-CPG) underwent independent critical appraisal of its content by all four authors using the Appraisal of Guidelines for REsearch and Evaluation (AGREE II) instrument. AGREE II scores for each domain were then calculated.

RESULTS

This review included five evidence-based clinical practice guidelines. The mean scores for all six domains were as follows: Scope and Purpose (87.8%), Stakeholder Involvement (69.2%), Rigour of Development (72.5%), Clarity of Presentation (86.9%), Applicability (45.6%), and Editorial Independence (53.3%).

CONCLUSION

The number of EB-CPGs related to ankle injuries are limited and the overall quality of the existing evidence-based clinical practice guidelines (EB-CPGs) for ankle injuries is not strong, with three of them being outdated. However, valuable guidance related to Ottawa rules, manual therapy, cryotherapy, functional supports, early ambulation, and rehabilitation has been highlighted. Challenges remain in areas such as monitoring and/or auditing criteria, consideration of the target population's views and preferences, and ensuring editorial independence. Future guidelines should prioritize improvements in these domains to enhance the quality and relevance of ankle injury management.

SYSTEMATIC REVIEW

Systematic review.

A Rehabilitation Algorithm After Lateral Ankle Sprains in Professional Football (Soccer): An Approach Based on Clinical Practice Guidelines

Lateral ankle sprain (LAS) is one of the most common types of injury in professional football (soccer) players with high risk of recurrence. The rehabilitation after LAS in professional football players is often still time-based and relies on anecdotal experience of clinicans. There is still a lack of utilization of criteria-based rehabilitation concepts after LAS in professional football. The aims of this clinical commentary are (1) to critically discuss the need for criteria-based rehabilitation concepts after LAS in professional football players, (2) to highlight the current lack of these approaches and (3) to present a novel clinical guideline-based rehabilitation algorithm. Short time-loss (15 days) and high recurrence rate (17%) raise the question of trivialization of LAS in professional football. Despite consequences for many stakeholders involved (players, teams, clubs, insurers), there is still a lack of of criteria-based, step-by-step approaches. The use of a criteria-based rehabilitation approach might reduce the high recurrence rate after LAS in professional football players and will lead, in turn, to increased long-term player availability. Practical experiences of he authors demonstrate the feasibility of such an approach. The effectiveness of this novel rehabilitation algorithm remains to be evaluated in future studies. Level of Evidence: 5.

New Insights Optimize Landing Strategies to Reduce Lower Limb Injury Risk

Single-leg landing (SL) is often associated with a high injury risk, especially anterior cruciate ligament (ACL) injuries and lateral ankle sprain. This work investigates the relationship between ankle motion patterns (ankle initial contact angle [AICA] and ankle range of motion [AROM]) and the lower limb injury risk during SL, and proposes an optimized landing strategy that can reduce the injury risk. To more realistically revert and simulate the ACL injury mechanics, we developed a knee musculoskeletal model that reverts the ACL ligament to a nonlinear short-term viscoelastic mechanical mechanism (strain rate-dependent) generated by the dense connective tissue as a function of strain. Sixty healthy male subjects were recruited to collect biomechanics data during SL. The correlation analysis was conducted to explore the relationship between AICA, AROM, and peak vertical ground reaction force (PVGRF), joint total energy dissipation (TED), peak ankle knee hip sagittal moment, peak ankle inversion angle (PAIA), and peak ACL force (PAF). AICA exhibits a negative correlation with PVGRF (r = -0.591) and PAF (r = -0.554), and a positive correlation with TED (r = 0.490) and PAIA (r = 0.502). AROM exhibits a positive correlation with TED (r = 0.687) and PAIA (r = 0.600). The results suggested that the appropriate increases in AICA (30° to 40°) and AROM (50° to 70°) may reduce the lower limb injury risk. This study has the potential to offer novel perspectives on the optimized application of landing strategies, thus giving the crucial theoretical basis for decreasing injury risk.

The relationship between ankle landing kinematics, isokinetic strength, muscle activity, and the prevalence of lower extremity injuries in university-level netball players during a single season

Background

Safe landing in netball is fundamental. Research on the biomechanics of multidirectional landings is lacking, especially among netball players. Furthermore, few studies reporting the associations between ankle kinematics, isokinetic ankle muscle strength, muscle activities, and injury prevalence in South African netball have been undertaken.

Objectives

To determine the relationships between ankle kinematics, kinetics, isokinetic strength, and muscle activity during jump-landing tasks, as well as the prevalence of lower extremity injuries in university-level netball players during a single season.

Methods

This cross-sectional repeated-measure study consisted of ten university-level female netball players. The injury prevalence data was collected during the 2022 netball season. The ankle muscle activity, kinematic, and kinetic data were collected during multidirectional single-leg landing and muscle strength was collected from plantar- and dorsiflexion trials.

Results

Netball players' ankle strength was generally below average. There was evidence of negative correlations between the ankle range of motion (ROM), isokinetic strength, and muscle activity amplitudes. A lack of evidence prevented the conclusion that lower extremity dominance predisposed players to injury, and that any specific body part was more likely to be injured among netball players.

Conclusion

Landing forces and muscle activity are direction-dependent, especially for the dominant limb. Lower extremity strength and neuromuscular control (NMC) across multiple jump-landing directions should be an area of focus for female netball players.

Postoperative Long-Term Monitoring of Mechanical Characteristics in Reconstructed Soft Tissues Using Biocompatible, Immune-Tolerant, and Wireless Electronic Sutures

Accurate postoperative assessment of varying mechanical properties is crucial for customizing patient-specific treatments and optimizing rehabilitation strategies following Achilles tendon (AT) rupture and reconstruction surgery. This study introduces a wireless, chip-less, and immune-tolerant in vivo strain-sensing suture designed to continuously monitor mechanical stiffness variations in the reconstructed AT throughout the healing process. This innovative sensing suture integrates a standard medical suturing thread with a wireless fiber strain-sensing system, which incorporates a fiber strain sensor and a double-layered inductive coil for wireless readout. The winding design of Au nanoparticle-based fiber electrodes and a hollow core contribute to the fiber strain sensor's high sensitivity (factor of 6.2 and 15.1 pF for revised sensitivity), negligible hysteresis, and durability over 10,000 stretching cycles. To ensure biocompatibility and immune tolerance during extended in vivo periods, an antibiofouling lubricant layer was applied to the sensing suture. Using this sensing system, we successfully monitored the strain responses of the reconstructed AT in an in vivo porcine model. This facilitated the postoperative assessment of mechanical stiffness variations through a well-established analytical model during the healing period.

Impact of specialized fatigue and backhand smash on the ankle biomechanics of female badminton players

During fatigued conditions, badminton players may experience adverse effects on their ankle joints during smash landings. In addition, the risk of ankle injury may vary with different landing strategies. This study aimed to investigate the influence of sport-specific fatigue factors and two backhand smash actions on ankle biomechanical indices. Thirteen female badminton players (age: 21.2 ± 1.9 years; height: 167.1 ± 4.1 cm; weight: 57.3 ± 5.1 kg; BMI: 20.54 ± 1.57 kg/m2) participated in this study. An 8-camera Vicon motion capture system and three Kistler force platforms were used to collect kinematic and kinetic data before and after fatigue for backhand rear-court jump smash (BRJS) and backhand lateral jump smash (BLJS). A 2 × 2 repeated measures analysis of variance was employed to analyze the effects of these smash landing actions and fatigue factors on ankle biomechanical parameters. Fatigue significantly affected the ankle-joint plantarflexion and inversion angles at the initial contact (IC) phase (p < 0.05), with both angles increasing substantially post-fatigue. From a kinetic perspective, fatigue considerably influenced the peak plantarflexion and peak inversion moments at the ankle joint, which resulted in a decrease the former and an increase in the latter after fatigue. The two smash landing actions demonstrated different landing strategies, and significant main effects were observed on the ankle plantarflexion angle, inversion angle, peak dorsiflexion/plantarflexion moment, peak inversion/eversion moment, and peak internal rotation moment (p < 0.05). The BLJS landing had a much greater landing inversion angle, peak inversion moment, and peak internal rotation moment compared with BRJS landing. The interaction effects of fatigue and smash actions significantly affected the muscle force of the peroneus longus (PL), with a more pronounced decrease in the force of the PL muscle post-fatigue in the BLJS action(post-hoc < 0.05). This study demonstrated that fatigue and smash actions, specifically BRJS and BLJS, significantly affect ankle biomechanical parameters. After fatigue, both actions showed a notable increase in IC plantarflexion and inversion angles and peak inversion moments, which may elevate the risk of lateral ankle sprains. Compared with BRJS, BLJS poses a higher risk of lateral ankle sprains after fatigue.

Lateral Ankle Joint Injuries in Indoor and Court Sports: A Systematic Video Analysis of 445 Nonconsecutive Case Series

BACKGROUND

Lateral ankle sprains are one of the most common injuries in indoor and court sports. Self-reports and case studies have indicated that these injuries occur via both contact and noncontact injury mechanisms typically because of excessive inversion in combination with plantarflexion and adduction of the foot. Video-based documentation of the injury mechanism exists, but the number of cases reported in the literature is limited.

PURPOSE

To retrieve and systematically analyze a large number of video-recorded lateral ankle injuries from indoor and court sports, as well as describe the injury mechanism, injury motion, and injury pattern across different sports.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 445 unique video-recorded lateral ankle sprain injuries were retrieved from indoor and court sports of broadcasted levels of competition. The videos were independently analyzed by 2 different reviewers. Outcomes included classification of the injury mechanism according to the International Olympic Committee consensus guidelines, primary and secondary motions of ankle joint distortion, and documentation of the fixation point (fulcrum) around which the foot rotates.

RESULTS

Overall, 298 (67%) injuries were direct contact, 113 (25%) were noncontact, and 32 (7%) were indirect contact incidents. Direct contact injuries were especially prevalent in basketball (76%), handball (80%), and volleyball (85%), while noncontact injuries dominated in tennis and badminton (96% vs 95% across both). Inversion (65%) and internal rotation (33%) were the primary distortion motions, with the lateral forefoot (53%) and lateral midfoot (40%) serving as the main fulcrums. Landing on another player's foot was the leading cause of injury (n = 246; 55%), primarily characterized by inversion (79%) around a midfoot fulcrum (54%). The noncontact and indirect landings on floor (n = 144; 33%) were primarily characterized by a distortion around a forefoot fulcrum (69%).

CONCLUSION

Two of 3 ankle sprains from online video platforms were direct contact injuries, with most involving landing on another player's foot. The distortion motion seems to be related to the injury mechanism and the fixation point between the foot and the floor. The injury mechanisms varied greatly between sports, and future studies should clearly differentiate and investigate the specific injury mechanisms.

Exploring influences and risk of bias of studies on return to sport and work after lateral ankle sprain: A systematic review and meta-analysis

BACKGROUND

Lateral ankle sprains are the most common traumatic musculoskeletal injuries of the lower extremity, with an incidence rate of 15%-20%. The high incidence and prevalence highlights the economic impact of this injury. Ankle sprains lead to a high socioeconomic burden due to the combination of the high injury incidence and high medical expenses. Up to 40% of patients who suffer from an ankle sprain develop chronic ankle instability. Chronic instability can lead to prolonged periods of pain, immobility and injury recurrence. Identification of factors that influence return to work (RTW) and return to sports (RTS) after a lateral ankle sprain (LAS) may help seriously reduce healthcare costs.

AIM

To explore which factors may potentially affect RTW and RTS after sustaining an LAS.

METHODS

EMBASE and PubMed were systematically searched for relevant studies published until June 2023. Inclusion criteria were as follows: (1) Injury including LAS or chronic ankle instability; (2) Described any form of treatment; (3) Assessment of RTW or RTS; (4) Studies published in English; and (5) Study designs including randomized controlled clinical trials, clinical trials or cohort studies. Exclusion criteria were: (1) Studies involving children (age < 16 year); or (2) Patients with concomitant ankle injury besides lateral ankle ligament damage. A quality assessment was performed for each of the included studies using established risk of bias tools. Additionally quality of evidence was assessed using the GRADEpro tool in cases where outcomes were included in the quantitative analysis. A best evidence synthesis was performed in cases of qualitative outcome analysis. For all studied outcomes suitable for quantitative analysis a forest plot was created to calculate the effect on RTW and RTS.

RESULTS

A total of 8904 patients were included in 21 studies, 10 randomized controlled trials, 7 retrospective cohort studies and 4 prospective cohort studies. Fifteen studies were eligible for meta-analysis. The overall RTS rate ranged were 80% and 83% in the all treatments pool and surgical treatments pool, respectively. The pooled mean days to RTS ranged from 23-93 d. The overall RTW rate was 89%. The pooled mean time to RTW ranged from 5.8-8.1 d. For patients with chronic ankle instability, higher preoperative motivation was the sole factor significantly and independently (P = 0.001) associated with the rate of and time to RTS following ligament repair or reconstruction. Higher body mass index was identified as a significant factor (P = 0.04) linked to not resuming sports or returning at a lower level (median 24, range 20-37), compared to those who resumed at the same or higher level (median 23, range 17-38). Patients with a history of psychological illness or brain injury, experienced a delay in their rehabilitation process for sprains with fractures and unspecified sprains. The extent of the delayed rehabilitation was directly proportional to the increased likelihood of experiencing a recurrence of the ankle sprain and the number of ankle-related medical visits. We also observed that 10% of athletes who did return to sport after lateral ankle sprain without fractures described non-ankle-related reasons for not returning.

CONCLUSION

All treatments yielded comparable results, with each treatment potentially offering unique advantages or benefits. Preoperative motivation may influence rehabilitation after LAS. Grading which factor had a greater impact was not possible due to the lack of comparability among the included patients.

A biomechanical report of an acute lateral ankle sprain during a handball-specific cutting movement

Biomechanical measurements of accidental ankle sprain injuries are rare but make important contributions to a more detailed understanding of the injury mechanism. In this case study, we present the kinematics and kinetics of a lateral ankle sprain of a female athlete performing handball-specific fake-and-cut manoeuvres. Three-dimensional kinematics and kinetics were recorded and six previously performed trials were used as reference. Plantarflexion, inversion, and internal rotation angles were substantially larger than the reference trials and peaked between 190 and 200 ms after initial ground contact. We observed a highly increased inversion and internal rotation moment. However, compared to the non-injury trials the data also revealed a reduction in the second dorsiflexion moment peak. Ground reaction forces were lower throughout the injury trial. Other parameters at initial ground contact including ankle and hip position, step length, and the traction coefficient indicate that a preparatory maladjustment occurred. This study adds valuable contributions to the understanding of lateral ankle sprains by building upon previously published reports and considering the shoe-surface interaction as an important factor for injury.

Epidemiology and management of ankle sprain injuries over seven seasons in an elite professional ballet company

OBJECTIVES

To investigate the epidemiology and management of ankle ligament sprains over seven seasons in a professional ballet company.

DESIGN

Descriptive epidemiology study.

METHODS

Medical attention injury, time-loss injury, and exposure data pertaining to 140 professional ballet dancers were prospectively recorded by Chartered Physiotherapists over seven seasons (2015/16-2021/22); a period including the COVID-19 global pandemic.

RESULTS

Sixty-nine ankle sprains (46 time-loss) in 45 dancers (32 %) were recorded: 51 sprains were classified as grade I, 15 were classified as grade II, and three were classified as grade III; 53 sprains affected only one ligament, whilst 16 were multi-ligament sprains. For time-loss injuries, median time-loss durations varied by grading (I - 31 days, II - 54 days, and III - 147 days) and the number of ligaments affected (one - 31 days, two - 54 days, three - 134 days, four - 137 days), with time-loss ranging from 1 to 188 days. Of the 46 time-loss ankle sprains, eight were mild, nine were moderate, and 29 were severe. The incidence rate (injuries·1000 h-1) of medical attention ankle sprains was 0.073 (95 % CI: 0.046 to 0.117) in male dancers and 0.101 (95 % CI: 0.069 to 0.148) in female dancers, and the incidence of time-loss ankle sprains was 0.044 (95 % CI: 0.024 to 0.080) in male dancers and 0.064 (95 % CI: 0.040 to 0.103) in female dancers. No significant effect of sex was observed on either medical attention (p = .304) or time-loss (p = .327) ankle sprain incidence rates. Ten percent of dancers sustained multiple sprains across the seven seasons. Fifty and 39 % of ankle sprains in female and male dancers, respectively, were preceded by a history of ankle sprains. Jumping and landing (30 sprains) and non-dance movements (16 sprains) were the most common inciting movements. Bone bruising and synovitis were the most common concurrent pathologies.

CONCLUSIONS

Ankle sprains placed a considerable burden on the ballet company studied. These time-loss durations specified by number and grade of ligament sprain, injury history, and secondary pathologies can guide return-to-dance rehabilitation pathways.

Description of the lateral fibulotalocalcaneal ligament in fetal specimens and its potential clinical implications

PURPOSE

The increase in ankle sprains in children is a reflection of the greater inclusion of this population in sports. This places the calcaneofibular (CFL) and the anterior talofibular (ATFL) ligaments in focus for study. In adults, the presence of arcuate fibers extending between these two ligaments suggests the existence of a new anatomical and functional complex called the lateral fibulotalocalcaneal ligament of the ankle (LFTCL), which can be associated with the persistence of instability of the talocrural joint in ankle sprains. This study aimed to verify the presence of arciform fibers between the CFL and ATFL in human fetuses and to study the topography of the lateral ankle region.

METHODS

Forty matched fetal ankles aged between 28 and 38 weeks, fixed in 4% formalin, were macroscopically, chemically and mesoscopically dissected and analyzed in stereoscope.

RESULTS

The ATFL was characterized as a capsular ligament consisting of two fascicles (proximal and distal). The CFL was characterized as an extracapsular ligament. The LFTCL complex was verified in all specimens, characterized by the arcuate fibers between the ATFL and the CFL.

CONCLUSION

Such results suggest that this functional unit is congenital and that it should be taken into consideration in the treatment of persistent ankle instabilities in the pediatric population.

Classification of chronic ankle instability using machine learning technique based on ankle kinematics during heel rise in delivery workers

Objective

Ankle injuries in delivery workers (DWs) are often caused by trips, and high recurrence rates of ankle sprains are related to chronic ankle instability (CAI). Heel rise requires joint angles and moments similar to those of the terminal stance phase of walking that the foot supinates. Thus, our study aimed to develop, determine, and compare the predictive performance of statistical machine learning models to classify DWs with and without CAI using ankle kinematics during heel rise.

Methods

In total, 203 DWs were screened for eligibility. Seven predictors were included in our study (age, work duration, body mass index, calcaneal stance position angle [CSPA] in the initial and terminal positions during heel rise, calcaneal movement during heel rise [CMHR], and plantar flexion angle during heel rise). Six machine learning algorithms, including logistic regression, decision tree, AdaBoost, Extreme Gradient boosting machines, random forest, and support vector machine, were trained.

Results

The random forest model (area under the curve [AUC], 0.967 [excellent]; F1, 0.889; accuracy, 0.925) confirmed the best predictive performance in the test datasets among the six machine learning models. For Shapley Additive Explanations, old age, low CMHR, high CSPA in the initial position, high PFA, long work duration, low CSPA in the terminal position, and high body mass index were the most important predictors of CAI in the random forest model.

Conclusion

Ankle kinematics during heel rise can be considered in the classification of DWs with and without CAI.

Effects of Kinesio taping on lower limb biomechanical characteristics during unexpected jumping in patients with chronic ankle instability

PURPOSE

The current biomechanical research on the application of Kinesio taping (KT) to patients with chronic ankle instability (CAI) has focused on testing the expected movements. However, unexpected movements are more common in actual sports. Therefore, the present study aimed to investigate the effects of KT on the biomechanical characteristics of the knee and ankle joints during unexpected jumping movements.

METHODS

Twenty-one patients with unilateral CAI were recruited to capture the biomechanical parameters during unexpected jumping movements under different interventions: no taping (NT), placebo taping (PT), and KT. A one-way repeated measures analysis of variance was used to compare the differences in knee and ankle biomechanical characteristics among patients with CAI between the three intervention conditions.

RESULTS

At initial contact, the KT group demonstrated a significant decrease in ankle plantarflexion and knee flexion angles compared to the NT group (p < 0.05). At the early landing phase, the KT group had a significant increase in peak ankle dorsiflexion angle, peak ankle eversion angle, peak ankle dorsiflexion moment, and peak ankle eversion moment compared to the NT and PT groups (p < 0.05). Furthermore, the KT group had a significantly reduced peak knee flexion angle, peak knee eversion angle, and peak vertical ground reaction force (p < 0.05) compared to the NT and PT groups.

CONCLUSION

KT significantly improves the sprain-prone touchdown posture of patients with CAI. And reducing the risk of ankle sprains during the early landing phase by promoting ankle dorsiflexion and eversion angles and moments.

The immediate effect of synergistic muscles kinesio taping on function and balance of volleyball players with functional ankle instability: A randomized controlled trial

OBJECTIVES

To determine the immediate effect of synergistic muscles Kinesio taping (KT) on the function and balance of volleyball players with functional ankle instability (FAI).

DESIGN

Parallel, superiority randomized controlled trial.

METHODS

Twenty-six semi-professional volleyball players with FAI were randomly assigned to either the intervention or control group. All participants received KT of fibularis longus, gastrocnemius, and gluteus maximus muscles for one session. The intervention group received KT with 35 % tension, while the control group received KT without tension. The function was assessed using the side hop and single hop distance tests. Dynamic balance was assessed with the Y Balance test. The outcomes were measured at baseline, 20 min after KT, and 24 h after KT. Statistical analyses were performed using Mixed-model repeated measures analysis of variance (ANOVA) and one-way ANOVA.

RESULTS

The interactions of time*group for the outcomes of function using the single hop test and stability in the anterior direction of the Y Balance test were significant (p < 0.05). Within-group comparisons showed after KT, both groups experienced significant improvements in all outcomes compared to the baseline. Results of between-group comparisons revealed that the application of KT with tension compared to no tension significantly improved function and balance in the anterior of the Y Balance test.

CONCLUSIONS

Kinesio taping can be an effective treatment option to improve function and balance in FAI. Additionally, Kinesio taping with tension compared to KT without tension had superiority.

Preparing to Land: Hamstring Preactivation Is Higher in Females and Is Inhibited by Fatigue

The hamstring plays an important role in reducing loads born by the anterior cruciate ligament. As anterior cruciate ligament injuries occur rapidly after ground contact, how the hamstring is activated prior to landing can influence injury risk. The purpose was to determine sex-related differences in hamstring activation immediately before landing and the effect of fatigue on "preactivation." Twenty-four participants (13 males and 11 females, age = 24.3 [6.5] y, mass = 72.2 [19.3] kg, height = 169 [9.7] cm) participated in this study. Participants completed a drop-vertical jump protocol before and after a lower body fatigue protocol. Hamstring electromyography (EMG) amplitude at 5 periods prior to landing, peak vertical ground reactions forces (in newtons/body weight), rate of loading (in body weight/second), and landing error scoring system were measured. Females had higher EMG amplitude before and after fatigue (P < .024), with decreased EMG amplitude for both sexes after fatigue (P = .025). There was no change on vertical ground reaction force, rate of loading, or landing error scoring system. Males and females demonstrated similar landing performance before and after fatigue but have different hamstring neuromuscular coordination strategies. The acute reduction in hamstring EMG amplitude following fatigue may increase loading on the anterior cruciate ligament.

Deep Learning Approach for MRI in the Classification of Anterior Talofibular Ligament Injuries

BACKGROUND

Diagnosing anterior talofibular ligament (ATFL) injuries differs among radiologists. Further assessment of ATFL tears is valuable for clinical decision-making.

PURPOSE

To establish a deep learning method for classifying ATFL injuries based on magnetic resonance imaging (MRI).

STUDY TYPE

Retrospective.

POPULATION

One thousand seventy-three patients from a single center with ankle MRI within 1 month of reference standard arthroscopy (in-group dataset), were divided into training, validation, and test sets in a ratio of 8:1:1. Additionally, 167 patients from another center were used as an independent out-group dataset.

FIELD STRENGTH/SEQUENCE

Fat-saturation proton density-weighted fast spin-echo sequence at 1.5/3.0 T.

ASSESSMENT

Patients were divided into normal, strain and degeneration, partial tear and complete tear groups (groups 0-3). The complete tear group was divided into five sub-groups by location and the potential avulsion fracture (groups 3.1-3.5). All images were input into AlexNet, VGG11, Small-Sample-Attention Net (SSA-Net), and SSA-Net + Weight Loss for classification. The results were compared with four radiologists with 5-30 years of experience.

STATISTICAL TESTS

Model performance was evaluated by the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), and so on. McNemar's test was used to compare performance among the different models, and between the radiologists and models. The intraclass correlation coefficient (ICC) was used to assess the reliability of the radiologists. P < 0.05 was considered statistically significant.

RESULTS

The average AUC of AlexNet, VGG11, SAA-Net, and SSA-Net + Weight Loss was 0.95, 0.99, 0.99, 0.99 in groups 0-3 and 0.96, 0.99, 0.99, 0.99 in groups 3.1-3.5. The effect of SSA-Net + Weight Loss was similar to SSA-Net but better than AlexNet and VGG11. In the out-group test set, the AUC of SSA-Net + Weight Loss ranged from 0.89 to 0.99. The ICC of radiologists was 0.97-1.00. The effect of SSA-Net + Weight Loss was better than each radiologist in the in-group and out-group test sets.

DATA CONCLUSION

Deep learning has potential to be used for classifying ATFL injuries. SSA-Net + Weight Loss has a better diagnostic effect than radiologists with different experience levels.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.

Effects of A Single Balance Training Session on Neural Excitability in Individuals With Chronic Ankle Instability

CONTEXT

Individuals with chronic ankle instability (CAI) demonstrate reduced spinal reflex modulation and corticospinal excitability of the soleus, which may contribute to decreased balance performance.

OBJECTIVE

To determine the effects of a single session of balance training on Spinal-reflexive excitability modulation and corticospinal excitability in those with CAI.

DESIGN

Randomized controlled trials.

SETTING

Research laboratory.

PARTICIPANTS

Thirty participants with CAI were randomly assigned to the balance training (BAL) or control (CON) group.

MAIN OUTCOME MEASURES

Modulation of soleus spinal-reflexive excitability was measured by calculating relative change in normalized Hoffmann reflexes (ratio of the H-reflex to the M-wave) from prone to single-leg standing. Corticospinal excitability was assessed during single-leg stance using transcranial magnetic stimulation, outcomes of which included active motor threshold (AMT), motor evoked potential, and cortical silent period (CSP). Balance performance was measured with center of pressure velocity in anterior to posterior and medial to lateral directions. Separate 2 × 2 repeated-measures analyses of variance were employed to determine the effect of group (BAL and CON) and time (baseline and posttraining) on each dependent variable.

RESULTS

There were significant group by time interactions in the modulation of soleus spinal-reflexive excitability (F1,27 = 4.763, P = .04); CSP at 100% AMT (F1,27 = 4.727, P = .04); and CSP at 120% AMT (F1,27 = 16.057, P < .01). A large effect size suggests increased modulation of spinal-reflexive excitability (d = 0.81 [0.03 to 1.54]) of the soleus in BAL compared with CON at posttest, while CSP at 100% (d = 0.95 [0.17 to 1.70]) and 120% AMT (d = 1.10 [0.29 to 1.84]) was reduced in BAL when compared with CON at posttest.

CONCLUSION

After a single session of balance training, individuals with CAI initiated increases in spinal reflex modulation and corticospinal excitability of the soleus. Thus, individuals with CAI who undergo balance training exhibit positive neural adaptations that are linked to improvements in balance performance.

Effects of accelerated rehabilitation exercise on quadriceps femoris and postural stability after anterior versus posterior cruciate ligament reconstruction

This study aimed to investigate the effect of a 12-week accelerated rehabilitation exercise program on isokinetic strength and dynamic balance ability of thighs in 20 adult men who underwent anterior cruciate ligament reconstruction (ACLR) or posterior cruciate ligament reconstruction (PCLR) and to analyze intergroup differences in recovery patterns. In this study, we examined 10 patients who underwent ACLR and 10 who underwent PCLR. These patients participated in an accelerated rehabilitation exercise program 5 times weekly for 12 weeks. The participants' isokinetic strength, muscular endurance, and dynamic balance ability of the femoral muscles were measured before and 12 weeks after reconstruction surgery. Isokinetic knee muscle function showed no significant difference between the ACLR and PCLR groups at 60°/sec. Both the groups demonstrated significant increases in muscle strength between the flexors and extensors. However, a between-group difference was noted in knee muscular endurance at 180°/sec, with ACLR patients showing significant differences between extensors and flexors, unlike PCLR patients. Assessment of the dynamic balance ability revealed that overall knee stability did not significantly differ between groups, and both the ACLR and PCLR groups exhibited improved dynamic balance ability. However, significant differences were found in anteroposterior and left-right stabilities. Patients who underwent ACLR had significantly improved anteroposterior and left-right stability, wherever patients who underwent PCLR showed no significant difference. This accelerated rehabilitation exercise program improved the muscle strength and muscular endurance of patients who underwent ACLR and PCLR, suggesting its potential efficacy in recovering dynamic balance ability, particularly after ACLR.

Effects of shoe collar types on ankle and knee biomechanics characteristics when performing the side-step cutting task

This study aimed to examine the effect of football shoes with different collar types on ankle and knee kinematic and kinetics features during 45° and 135° side-step cutting tasks. Fifteen healthy college football players volunteered for the study. Each participant was instructed to perform side-step cutting tasks with high, low, and no collar football shoes. The kinematic and ground reaction force data were measured using a Vicon motion capture system and a Kistler force plate, respectively. Two-way MANOVAs with repeated measures were used to examine the effect of shoe collar type and task conditions. There were no interaction effects. The high collar football shoe showed decreased ankle range of motion in the sagittal plane (p = 0.010) and peak ankle external rotation moment (p = 0.009) compared to the no collar football shoe. The high (p = 0.025) and low (p = 0.029) collar football shoes presented greater peak ankle external rotation angles than the no collar football shoe. These results imply that football shoes with high collars made of high intensity knitted fabric could be used to restrict ankle joint movement, with potential implications for decreasing the risk of ankle sprain injuries in football players.

Brace for Impact: A Retrospective Analysis of the Modified Broström-Gould Procedure With and Without Internal Brace Augmentation

Background Chronic lateral ankle instability (CLAI) is caused by lateral ankle ligament weakness or rupture secondary to recurrent sprains. The surgical management has traditionally involved a modified Broström-Gould (MBG) procedure with or without internal brace (IB) augmentation. This study aims to demonstrate the improved outcomes for patients undergoing an MBG procedure with IB augmentation for CLAI. Methodology A retrospective analysis was performed among 40 patients undergoing an MBG procedure with or without IB for CLAI at a large teaching hospital between January 2012 and June 2019. Functional outcomes were measured using the Manchester-Oxford Foot Questionnaire (MOxFQ). Clinic letters were reviewed to assess additional outcomes including postoperative complications, revision surgery rate, time in a plaster cast, and time to full weight-bearing. Results A total of 23 patients were included in the study, with seven undergoing both MBG and IB procedures and 16 undergoing MBG intervention alone. The average age was 37.1 years in the IB group and 35.7 years in the MBG group. The mean MOxFQ overall raw scores (10.9 vs. 33.6, p < 0.016), standing and walking MOxFQ subscale (4 vs. 15.2, p < 0.012), pain MOxFQ subscale (4.86 vs. 10.9, p < 0.042), and social interaction subscale (2 vs. 7.5 p < 0.023) all showed significantly better results for the IB group versus the MBG group. Patients in the IB group had significantly less number of weeks in plaster than the MBG group and were able to fully weight bear sooner (4.14 vs. 6, p < 0.01). The MBG group suffered a postoperative complication in seven patients compared to zero in the IB group (p < 0.057). There were three re-ruptures in the MBG group requiring further revision surgery compared to zero in the IB group (3 vs. 0, p < 0.53). Conclusions MBG surgery with IB augmentation for CLAI appears to have better outcomes in terms of overall function and may have fewer overall complications. The IB group displayed a lower recurrence of pain, less time in a plaster cast, and a quicker return to walking.

Incidence of Injuries Associated With Anterior Talofibular Ligament Injury Based on the Reporting of Magnetic Resonance Imaging

Introduction This paper aims to report the incidence of ligamentous, tendon, and other structural injuries associated with an anterior talofibular ligament (ATFL) injury based on magnetic resonance imaging (MRI) findings. Methods The reports of all patients who underwent surgical treatment for ATFL injury between 2021 and 2022 at Changi General Hospital and had preoperative MRI ankle scans performed were analyzed in this retrospective study. Patients who had a preoperative MRI ankle scan performed with specific reporting of the ATFL, calcaneofibular ligament (CFL), deltoid ligaments, peroneal tendons, and the presence of an osteochondral defect (OCD) were included in this study. Patients who underwent surgery but did not have a preoperative MRI ankle scan done or had ankle fractures or systemic conditions affecting the same ankle were excluded. Results Eighty-six patients were included in this study, of which 59 were males and 27 were females. About 73.3% (63 of 86) of patients had sustained injuries in association with ATFL injury, and 58.1% (50 of 86) of patients suffered an associated injury to the calcaneofibular ligament (CFL). There were injuries to the superficial and deep deltoid ligaments in 29.1% (25 of 86) and 44.2% (38 of 86) of patients, respectively. The peroneal tendons were also injured in 17.4% (15 of 86) of patients. Lastly, there were also associated OCDs found in 19.8% (17 of 86) of patients. Conclusion There is a high incidence of injuries associated with an ATFL injury. The CFL and deltoid ligament complex are the most commonly injured structures in association with the ATFL. One in five patients will also have an associated OCD. The ATFL tends to be the only structure that is commonly addressed during surgery. Repair of the ATFL only may thus lead to poorer outcomes and persistent pain, if the underlying cause is due to the other concurrent injuries. Clinical evaluation of the other structures should thus be thoroughly performed to allow the addressing of any concurrent injuries in the same surgical setting to achieve better outcomes.

Imaging of Acute Ankle and Foot Sprains

Ankle and foot injuries are very common injuries in the general population, and more so in athletes. MR imaging is the optimal modality to evaluate for ligamentous injuries of the ankle and associated conditions after ankle sprain. In this article, the authors discuss the epidemiology, biomechanics, normal anatomy, and pathology of the ankle as well as injuries of the hindfoot and midfoot that are often associated with ankle injuries.

Hindi translation, cross-culture adaptation, validation and relaibility of foot and ankle disability index instrument in patients with chronic recurrent lateral ankle sprain-A study protocol

BACKGROUND

Ankle sprains are one of the most common musculoskeletal injuries. English and Italian versions of the Foot and Ankle Disability Index (FADI) questionnaire are available for assessment, but no Hindi version of the FADI questionnaire is yet available for the population who only communicate and understand the Hindi language.

AIM

This study aims to translate and culturally adapt the Hindi version of the FADI questionnaire and to evaluate its validity.

STUDY DESIGN

A Cross-Sectional Study.

METHOD

In accordance with Beaton guidelines, the FADI questionnaire will be translated into Hindi by two translators with medical and non-medical backgrounds, respectively. The recording observer will then take a seat to create a T1-2 version of the translated questionnaire. A Delphi survey with 6-10 experts will be conducted. The pre-final form will be fully tested on 51 patients, and the scale validity will be reported. Finally, the translated questionnaire version will be analyzed by the ethics committee.

RESULT

Statistical analysis will be done using the Scale-level Content Validity Index (S-CVI). An individual item of the questionnaire will be validated and documented in the context of the Item-level Content Validity Index (I-CVI). This will be achieved with the help of the Averaging method (S-CVI/Ave) and the Universal Agreement calculation method (S-CVI/UA). Both absolute and relative reliability will be calculated. For absolute reliability, Bland and Altman agreement will be used. Intra-class correlation coefficient (ICC) and Cronbach's alpha (internal consistency), along with Spearman Rank rho and Pearson product, will be analysed for relative reliability.

CONCLUSION

The study will determine the content validity and reliability of the Hindi version of the FADI questionnaire in patients with a chronic recurrent lateral ankle sprain.

Clinical significance of the anteromedial talus osteophyte in anteromedial ankle impingement in chronic lateral ankle instability

PURPOSE

The aim of this study was to evaluate the relation between anteromedial ankle osteophytes (AMAO) and anteromedial ankle impingement (AMAI) in chronic lateral ankle instability (CLAI) through visualization and quantification.

METHODS

Forty-three patients with unilateral CLAI between September 2018 and March 2020 accepted arthroscopic repair of an anterior talofibular ligament (ATFL) and were split into two groups: AMAI (AMAI including intraoperative AMAO resection) and pure CLAI (with AMAO but without AMAI, no AMAO resection). The AMAO protrusion lengths in each direction were measured and compared after all of the ankles were reconstructed. All patients were assessed preoperatively and at 2-year follow-up with ankle dorsiflexion, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and visual analog scale (VAS) score.

RESULTS

Intelligent analysis showed that a large extent of osteophytes was found at the dorsomedial surface of the talar neck in AMAI group. The upper and inner bound protrusion distances of AMAO in AMAI group were greater than in the pure CLAI group. There was no significant difference in anterior bound protrusion distance of AMAO between the two groups. Preoperatively, the ankle dorsiflexion of AMAI group (7.6 ± 1.4°) was considerably lower than that of pure CLAI group (22.4 ± 1.9°) (p < 0.001). When compared to the pure CLAI group, the AMAI group had a substantially worse AOFAS score (62.2 ± 6.7 vs 71.1 ± 9.1; p < 0.001) and VAS score (6.0 ± 1.0 vs 4.9 ± 0.8; p < 0.05). However, there was no significant difference in postoperative ankle dorsiflexion, AOFAS score, or VAS score between the two groups.

CONCLUSION

AMAO is formed mostly on the dorsomedial surface of the talar neck in CLAI with AMAI, and the upper and inner bound protrusion lengths of AMAO were shown to be significantly correlated with the existence of AMAI in CLAI.

LEVEL OF EVIDENCE IV

The effects of ankle dorsiflexor fatigue on lower limb biomechanics during badminton forward forehand and backhand lunge

Background: Local muscle fatigue may have an adverse effect on the biomechanics of the lunge movement and athletic performance. This study analyzed the biomechanical indicators of the forward lunge in badminton players before and after fatigue of the ankle dorsiflexors. Methods: Using the isometric muscular strength testing system, 15 badminton players underwent an ankle dorsiflexor fatigue test. Before and after the fatigue experiment, five lunges were done in both the forehand forward (FH) and backhand forward (BH) directions, five in each direction. A Vicon motion capture system and an AMTI force measuring station were used to record lower limb kinematic and ground reaction force (GRF). Pre-fatigue and post-fatigue variability were determined using paired-samples t-tests, Wilcoxon signed rank test, and Statistical Non-parametric Mapping (SNPM). Result: The results showed that after fatigue, the peak angle of ankle dorsiflexion was significantly reduced (p = 0.034), the range of motion (ROM) of the ankle sagittal plane (p = 0.000) and peak angle of ankle plantarflexion (p = 0.001) was significantly increased after forehand landing. After fatigue, ankle inversion was significantly increased after forehand and backhand landings (FH: p = 0.033; BH: p = 0.015). After fatigue, peak knee flexion angles increased significantly (FH: Max: p = 0.000, Min: p = 0.000; BH: Max: p = 0.017, Min: p = 0.037) during forehand and backhand landings and ROM in knee flexion and extension increased (p = 0.009) during forehand landings. Knee inversion range of motion was significantly increased after fatigue (p = 0.024) during forehand landings. Peak hip flexion angle (p = 0.000) and range of motion (p = 0.000) were significantly reduced in forehand landings after fatigue. The mean loading rate (p = 0.005) and the maximum loading rate (p = 0.001) increased significantly during backhand landings after fatigue. Post-fatigue, the center of pressure (COP) frontal offset increased significantly (FH: p = 0.000; BH: p = 0.000) in the forehand and backhand landings. Conclusion: These results indicate that when the ankle dorsiflexors are fatigued, the performance of the forehand is significantly negatively affected, and the impact force of the backhand is greater.

Current Concept Review: State of Acute Lateral Ankle Injury Classification Systems

Acute lateral ankle sprain (ALAS) is one of the most frequent musculoskeletal injuries, with a great impact on health and socioeconomic factors. There are few consensuses on this subject and multiple therapeutic options that are difficult to compare due to the lack of a universally adopted classification system. The objective of this study is to is to report the actual knowledge on how ALAS are classified and reported and not to make any therapeutic recommendation. A comprehensive literature review of the literature was carried out through a search in the MEDLINE, Cochrane Library and Google Scholar databases, with identification of articles that describe ways to classify lateral ankle sprains or with relevant content for their classification. Twenty-five different classification systems were identified. The majority of articles referring to ALAS use an unspecific classification. Most classification systems divide sprains into 3 degrees. The most used parameters are the anatomy of the injury, clinical parameters, functional loss and the presence of instability. No articles were found to verify the validity of the systems used, namely regarding their association with therapeutic proposals or prognostic predictions. Based on the available evidence, recommendations cannot be made regarding the most appropriate classification system. The considerable heterogeneity of the existing literature makes it difficult to compare studies and to optimize the treatment and follow-up of these injuries. Future research in this area is necessary to define a practical and rigorous system that can be used universally.

Platelet-rich plasma, a biomaterial, for the treatment of anterior talofibular ligament in lateral ankle sprain

Background: Because of the rising prevalence of anterior talofibular ligament (ATFL) damage, there is a considerable interest in developing innovative techniques to improve the biological healing response of ATFL. Platelet-rich plasma (PRP) includes several growth factors linked to a favorable healing response, however none of the studies involved both quality evaluation and clinical results to evaluate this treatment. Purpose: To determine the clinical results of PRP injections into the ATFL in lateral ankle sprain (LAS) patients, as well as the quality of the ATFL based on radiographic outcomes. Methods: Patients with clinically confirmed grade II LAS for the first time (n = 83) were examined. The clinical outcomes of three types of injection methods were evaluated: none, once within 48 h after the sprain, and once more 4 weeks later after first injection. PRP was injected into the tear site of the ATFL using ultrasound guidance, and all ankles were immobilized for 2 weeks. The American Orthopedic Foot and Ankle Score (AOFAS) ankle-hindfoot scale and the Visual Analogue Scale (VAS) were used to assess the results at 2, 6, 8, 24, and 48 weeks of follow-up. The signal/noise ratio (SNR) value of Magnetic Resonance Imaging (MRI)-based ATFL signal intensity can disclose ATFL quality. The ATFL SNR results were then assessed 8, 24 and 48 weeks following the first injection to compare ATFL quality. Results: The PRP injection groups outperformed the control group in terms of clinical outcomes, and the two injections group outperformed other groups in terms of pain reduction and functional outcome at 8 weeks. The clinical results of all groups were comparable at 6 and 12 months follow-up. ATFL SNR findings improved significantly across all groups over time. At the same follow-up time, the PRP injection groups outperformed the control group, and the best SNR result showed in the two injections group at the final follow-up. Conclusion: PRP injection helped relieve early symptoms of LAS, although all patients saw a similar development after 6 months. The two PRP injections group produced considerably better clinical results and quality of the ATFL in short-term follow-up.

Time-loss and recurrence of lateral ligament ankle sprains in male elite football: A systematic review and meta-analysis

A literature search was conducted to systematically review and meta-analyze time-loss and recurrence rate of lateral ankle sprains (LAS) in male professional football players. Six electronic databases (PubMed, Scopus, Web of Science, PEDRO, CINAHL, and Cochrane) were searched independently, separately both for time-loss and recurrence from inception until April 30, 2021. In addition, reference lists were screened manually to find additional literature. Cohort studies, case reports, case-control studies and RCT in English language of male professional football players (aged more than 16 years) for which data on time-loss or recurrence rates of LAS were available were included. A total of 13 (recurrence) and 12 (time-loss) studies met the inclusion criteria. The total sample size of the recurrence studies was 36,201 participants (44,404 overall initial injuries; 7944 initial ankle sprain [AS] injuries, 1193 recurrent AS injuries). 16,442 professional football players (4893 initial AS injuries; 748 recurrent AS injuries) were meta-analyzed. A recurrence rate of 17.11% (95% CI: 13.31-20.92%; df = 12; Q = 19.53; I² = 38.57%) based on the random-effects model was determined. A total of 7736 participants were part of the time-loss studies (35,888 total injuries; 4848 total ankle injuries; 3370 AS injuries). Out of the 7736 participants, 7337 participants met the inclusion criteria with a total of 3346 AS injuries. The average time-loss was 15 days (weighted mean: 15.92; median: 14.95; min: 9.55; max: 52.9). We determined a priori considerable heterogeneity (CI: 18.15-22.08; df = 11; Q = 158; I² = 93%), so that the data on time-loss are only presented descriptively. There is an average time-loss of 15 days per LAS and a recurrence rate of 17%. LAS is one of the most common types of injury with higher recurrence rates than ACL injuries (9%-12%) in professional football players. Nevertheless, the focus of research in recent years has been mostly on ACL injuries. However, the high recurrence rates and long-term consequences show the necessity for research in the field of LAS in elite football. Yet, heterogeneous data lead to difficulties concerning the aspect of comparability.

Kinesio taping for ankle sprain in youth athlete: A protocol for systematic review and meta-analysis

BACKGROUND

Ankle sprain is considered a major problem that may hinder youth athletes' athletic development because it will lead to ongoing dysfunction, reoccurrence of ankle sprain, chronic ankle instability, and posttraumatic osteoarthritis. Kinesio taping (KT) is a therapeutic taping technique that has been widely used in the treatment of various ankle issues including sprained ankles and in the prevention of ankle sprains. It can not only provide the injured ankle with support during the rehabilitation phase, but also enhance the ankle stability during activity. However, the available evidence regarding its effectiveness in the treatment and prevention of ankle sprain is inconsistent. Therefore, a systematic review will help clinicians and coaches better understand the application of KT in clinical and training practices. This study is to systematically review the literature on the use of KT to improve outcomes including ankle function, proprioception, and pain and to evaluate the effectiveness of KT in the treatment and prevention of ankle sprain injuries.

METHODS

A comprehensive electronic search of the literature will be undertaken in the following databases: PubMed, CINAHL, SPORTDiscus, Cochrane library, Web of Science and Scopus from 1979 to August 2022. The Physiotherapy Evidence Database scale will be used to assess the methodological quality of all included studies and RevMan 5.3 (Copenhagen, The Nordic Cochrane Centre) for the data analysis.

RESULTS

This study will provide a standardized evaluation and comparison for effects of KT on the treatment and prevention of ankle sprains in youth athletes.

CONCLUSION

This review will provide the evidence of the effectiveness of KT used in the treatment and prevention of ankle sprain in youth athletes. This review will also provide directions and recommendations for future research and clinical practices targeting treatment and prevention of ankle sprains in youth athletes.

Effects of lateral instability on ankle coupled motions in vivo using 3D fluoroscopy

Lateral ankle instability (LAI) compromises the normal kinematics of the ankle, affecting activities of daily living. In vitro kinematics of ankles with LAI during single-plane motions are available, but the active control stability of these motions remains unclear. The current study measured the 3D ankle kinematics during unresisted single-plane motion tests using a bi-plane fluoroscope with a CT model-based 2D/3D registration method in 12 patients with LAI and 14 healthy peers. The coupling of the kinematic components at the talocrural and subtalar joints was quantified by the path difference between the forward and return paths of the coupled motion. Significantly increased path differences were found in the subtalar dorsiflexion/plantarflexion and inversion/eversion components during internal/external rotation tests (p < 0.05). During inversion/eversion, significantly reduced tibiocalcaneal ranges of motion and the path differences in the talocrural and subtalar dorsiflexion/plantarflexion components were noted (p < 0.05). The current results suggest that chronic LAI had compromised control stability at the subtalar joint during internal/external rotation tests and a conservative motion control strategy with significantly reduced ranges of motion to maintain good control of out-of-plane motion components in response to direct challenges of the anterior talofibular ligament during inversion/eversion tests. The current results also suggest that, compared to kinematic patterns of individual components, the path difference of the coupled motion may serve as a better measure of the motion control stability of the ankle in differentiating LAI from healthy controls.

A new mouse model of ankle instability induced by multiple mechanical sprains with controlled inversion angle and speed

Ankle sprain occurs by a sudden and extreme inversion and plantarflexion at the ankle joint to cause ligamentous injuries. A portion of ankle sprain patients experience recurrent ankle sprains and develop chronic ankle instability (CAI). The present CAI animal models are single events with severe ligamentous injury using surgical transection of ligaments or manually overextending the ankle.

Purpose: To simulate the mechanical and recurrent sprain injuries in CAI patients, we established a new ankle instability model with multiple ankle injuries using a self-designed machine to sprain the ankle with a controlled inversion angle and speed.

Methods: Male C57BL/6J mice were used and respectively subjected to a sham operation, calcaneofibular ligament (CFL) transection, and mechanical ankle sprains. Three mechanical sprains were performed on the 13th and 185th day after the initial mechanical ankle sprain.

Results: The first mechanical sprain and CFL transection induced ankle injury as indicated by an average of a 62% decrease in ankle pressure pain threshold and a 114% increase in the ankle thickness compared with the contralateral untreated ankle. The second and third mechanical sprains induced recurrent ankle injuries. The foot slips during beam tests were increased after mechanical ankle sprains but not after CFL transection, indicating the induction of motor balance deficits. Multiple mechanical ankle sprains induced significant gait changes in longer duration of stance (an average of 194% increase), swing (134%), and step cycle (147%) compared with CFL transection or sham operation, and slower walking speed (78% reduction) and shorter step distance (91%) after the third sprain.

Conclusion: These results elucidate that multiple mechanical sprains, which induce recurrent ankle injuries, balance deficits, and gait changes, are a good model for investigating the mechanisms of CAI induced by recurrent sprain injuries.

An open-source OpenSim® ankle-foot musculoskeletal model for assessment of strains and forces in dense connective tissues

BACKGROUND

The ankle and foot are among the most critical load-bearing joints in the human anatomy. Anatomically accurate human body models are imperative to understanding the mechanics of injury and musculoskeletal disorders. A typical human ankle-foot anatomy consists of 25 DOFs, 112 dense connective tissues (DCTs) (92 ligaments, one capsule and 19 fasciae), 30 tendons, and 65 muscles. Existing models possess less than half of the DOFs and physiological elements. In this work, we have developed an ankle-foot joint complex musculoskeletal model for the OpenSim® platform by incorporating 24 degrees of freedom (DOF) comprising of 66 DCTs (46 ligaments, one 1 capsule and 19 fasciae), 30 tendons, and 65 muscles.

METHODS

Computed tomography (CT) data of human ankle joint-foot complex was segmented using Mimics ® (Version 17.0, Materialise, Belgium) to obtain models of the cartilages and bones of the ankle joint-foot complex. The position and resting lengths of the DCTs were attained from the MRI data and literature. Five joints, namely, tibiotalar, subtalar, chopart, tarsometatarsal (TMT), and metatarsophalangeal (MTP) joints and their joint axes were formulated to yield 24 DOFs. A forward simulation was carried out at each joint of the ankle-foot complex within their respective range of motions. The strains, instantaneous strain rates, and forces developed in the ligaments during the simulation were studied.

RESULTS

During plantar-dorsiflexion of the tibiotalar joint, the anterior tibio-talar ligament (aTTL) yielded the maximum strain compared to all other ligaments. Anterior tibio-fibular ligament (aTFL) experienced extreme strain during subtalar inversion. Hence, the coupled kinematics of subtalar inversion and plantar flexion are failure-prone activities for aTFL. The chopart, TMT, and MTP joints yielded maximum strains or forces for several bundles at the extremes of the range of motion. This signifies that rotations of these joints to their extreme range of motion are prone to failure for the bundles attached to the joint complex.

CONCLUSION

The results illustrate the potential application of the proposed OpenSim® ankle-foot model in understanding the ligament injury mechanism during sports activity and its prevention. Researchers can use the proposed model or customise it to study complex kinematics, understanding injury mechanisms, testing fixtures, orthosis or prosthesis, and many more in the domain of musculoskeletal research.

Prevalence of muscle imbalance and its potential influence on injury among female acrobatic dancers

Objective

The purpose of this study was to determine the prevalence of muscle imbalance among young adolescent acrobats (n=15) and if there was a potential link to injury.

Methods

Isokinetic strength of the lower extremity, isometric strength of the trunk, and flexibility of both the trunk and lower extremity were assessed. Pearson correlation (r) and χ² correlation tests were performed on all explanatory variables.

Results

Significant correlations were found between isokinetic peak torque of the quadriceps and hamstrings (p=0.000) and the plantar flexors and dorsiflexors (p=0.000) on both sides, along with plantar flexor dominance (p=0.000). Non-significant findings were seen when identifying dominance between the quadriceps and hamstrings (p=0.933) as well as when correlating peak torque and flexibility of the lower extremity (right hamstrings: p=0.668, left hamstrings: p=0.338, right quadriceps: p=0.171, left quadriceps: p=0.707, right plantar flexors: p=0.282, left plantar flexors: p=0.382, right dorsiflexors: p=0.297 and left dorsiflexors: p=0.393).

Conclusion

Acrobats demonstrated noticeably high ranges of flexibility, and the most common injury site was found to be the ankle. However, these mentioned injuries were not all due to acrobatic participation. The limited sample size warrants extensive research with a larger sample size to further verify or dispute the results found in this study. Muscle imbalances found within this population could increase the risk of injury.

Central vs. Peripheral Vision during a Singe-Leg Drop Jump: Implications of Dynamics and Patellofemoral Joint Stress

Landing on a single-leg without receiving direct visual information (e.g., not looking at the ground) may increase the risk of injury. We examined whether visual focus contributed to the changing lower-extremity dynamics and patellofemoral joint stress during a single-leg drop jump task. Twenty healthy volunteers visited the laboratory for three separate sessions. During each session, participants randomly performed either of two types of a single-leg drop jump task from a 30 cm high wooden box. Subsequently, participants looked at the landing spot (central vision condition) or kept their heads up (peripheral vision condition) when performing the task. Sagittal and frontal plane lower-extremity joint angles and joint moments (in the ankle, knee, and hip), including the vertical ground reaction force, and patellofemoral joint stress during the first landing phase (from initial contact to peak knee flexion) were compared. Greater ankle inversion and hip adduction were observed when landing with the peripheral vision condition. However, the magnitudes were negligeable (Cohen’s d effect size <0.35). No statistical difference was observed in other comparisons. Landing on a single-leg from a 30 cm height without receiving full visual attention (peripheral vision condition) does not increase the risk of lower-extremity traumatic and overuse injuries.

The Role of Diffusion Weighted MR Imaging in the Diagnosis of Tendon Injuries of the Ankle and Foot

Background and objectives: Our aim is to determine the diagnostic performance and utility of Diffusion Weighted MR Imaging (DWI) against the routine Magnetic Resonance Imaging (MRI) for the evaluation of patients with tendon injuries of the ankle and foot. Materials and Method: After institutional review board approval and informed consent taken from all the patients, ankle and foot MR imaging and DWI-Apparent Diffusion Coefficient (ADC) mapping were performed on the 81 injured tendons of 50 patients. All tendon injuries were named as Rupture (R), Partial tear (PT), and Tenosynovitis (T). Diagnostic interpretation was based on the MRI-DWI and ADC mapping, verified by either open surgery, diagnostic arthroscopy, or conservative procedures-splint application. Statistical analysis of this research was assessed by Fischer’s exact test, variance analysis test between dependent groups, Receiver Operating Characteristics (ROC) curve, and Pearson chi square statistics. Results: MRI depicted all tendon injuries with 70% sensitivity and 100% specificity, and showed a significant statistical relationship to surgical and arthroscopic references with high agreement (p < 0.05, k: 0.609). DWI had 100% sensitivity and 83–90% specificity for the visualization of tendon injuries with certain agreement and a significant statistical relationship to the gold standard (p < 0.05, k: 0.890–0.899). For all those injured tendons, DWI had 100% sensitivity for the diagnosis of R, and 92–97% sensitivity corresponding to PT and T over routine ankle MR imaging. The specificity of DWI to MRI ranged from 75 to 44% for all the injured tendons. DWI had significant statistical superiority over MRI for the visualization of R, PT, and T of all tendons included in this research (p < 0.05). Conclusions: DWI is a good imaging modality for the visualization of ankles with tendon injuries, possibly further improving the sensitivity of the classical ankle and foot MRI, and supplying more beneficial and diagnostic information than routine MR imaging on the basis of R, PT, and T of tendons at the ankle and foot.

Influence of Landing in Neuromuscular Control and Ground Reaction Force with Ankle Instability: A Narrative Review

Ankle sprains are generally the most common injuries that are frequently experienced by competitive athletes. Ankle sprains, which are the main cause of ankle instability, can impair long-term sports performance and cause chronic ankle instability (CAI). Thus, a comprehensive understanding of the key factors involved in repeated ankle strains is necessary. During jumping and landing, adaptation to the landing force and control of neuromuscular activation is crucial in maintaining ankle stability. Ankle mobility provides a buffer during landing, and peroneus longus activation inhibits ankle inversion; together, they can effectively minimize the risk of ankle inversion injuries. Accordingly, this study recommends that ankle mobility should be enhanced through active and passive stretching and muscle recruitment training of the peroneus longus muscles for landing strategies should be performed to improve proprioception, which would in turn prevent ankle sprain and injury to neighboring joints.

[Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department]

Hintergrund

Sprunggelenk- und Fußverletzungen gehören zu den häufigsten Krankheitsbildern in der Traumatologie. Ziel dieser Studie war es, die demografischen Veränderungen von Patienten mit Fuß- und Sprunggelenkverletzungen, das zeitliche Auftreten und die Entwicklung über die Jahre in einer Notaufnahme zu untersuchen.

Material und Methoden

Retrospektive Datenauswertung von Patienten, welche aufgrund einer Fuß- und Sprunggelenkverletzung in der Notaufnahme im Zeitraum von 2010 bis 2017 behandelt wurden. Die Patienten wurden mittels ICD-Codes identifiziert und die demografischen Veränderungen, das zeitliche Auftreten und die Entwicklung über die Jahre analysiert. Mittels Quantil-Quantil-Diagramm wurden kontinuierliche Variablen auf Normalverteilung getestet und, falls zutreffend, mittels t‑Test oder nichtparametrischem Mann-Whitney-U-Test auf Signifikanz überprüft.

Ergebnisse

Insgesamt wurden 6581 Fuß- und Sprunggelenkverletzungen in die Analyse eingeschlossen. Das mittlere Alter von Patienten mit einer Fußfraktur war 39 ± 17,4 Jahre und mit einer Sprunggelenkfraktur 47 ± 19,2 Jahre (p < 0,001). Ligamentäre Verletzungen des Sprunggelenks traten insbesondere bei jüngeren Patienten in den Sommermonaten auf. Die Altersverteilung bei Sprunggelenkfrakturen zeigte für Männer einen Häufigkeitsgipfel zwischen dem 30. und 39. Lebensjahr und bei Frauen ein vermehrtes Auftreten ab dem 50. Lebensjahr. In der Altersgruppe zwischen 65 und 75 Jahren stellten Trimalleolarfrakturen die zweithäufigste Sprunggelenkfraktur dar. Frakturen des Fußes betrafen am häufigsten Patienten im Alter von 20 bis 29 Jahren, wobei bei Frauen ein 2. Häufigkeitsgipfel zwischen dem 50. und 59. Lebensjahr zu beobachten war.

Schlussfolgerung

Ligamentäre Verletzungen des Sprunggelenks sind häufige Krankheitsbilder in der Notaufnahme und betreffen v. a. jüngere Patienten. Sprunggelenkfrakturen zeigten für Frauen eine bimodale Altersverteilung, und insbesondere Bi- und Trimalleolarfrakturen waren vermehrt bei Frauen ab dem 65. Lebensjahr zu beobachten. Aufgrund der erhöhten Prävalenz von Fuß- und Sprunggelenkfrakturen bei älteren Frauen sollte in diesem Patientenkollektiv eine weitere Osteoporoseabklärung veranlasst werden.

Foot Muscle Strengthening and Lower Limb Injury Prevention

Background and objectives: The active and passive structures of the foot act in unison to not only be compliant enough to assist in ground reaction force attenuation but also resist deformation to provide a stable base of support. A foot that is unable to adjust to the imposed demands during high-intensity sporting activities may alter the moments and forces acting on the joints, increasing the risk of non-contact anterior cruciate ligament ruptures (ACLR) and lateral ankle sprains (LAS). Prophylactic strengthening programs are often used to reduce the risk of these injuries, but at present, very few prophylactic programs include foot-specific strengthening strategies. The aim of this theoretical review is to ascertain the prophylactic role strengthening muscles acting on the foot may have on ACLR and LAS injury risk. Methods: Literature relating to risk factors associated with ACLR and LAS injury and the anatomy and biomechanics of normal foot function was searched. In addition, ACLR and LAS injury prevention programs were also sought. A theoretical, narrative approach was followed to synthesize the information gathered from the articles. Results: The foot segments are governed by the congruity of the articulations and the activity of the foot muscles. As such, there is a coupling effect between shank, calcaneus, midfoot, and hallux movement which play a role in both ACLR and LAS injury risk. Conclusions: Strengthening the muscles acting on the foot may have a significant impact on ACLR and LAS injury risk.

Effect of 8-week treadmill running with peroneal muscle functional electrical stimulation on laterally deviated centre of plantar pressure position and star excursion balance test performance

Introduction

Ankle sprain is a common injury that can have long-term sequelae resulting in pain, swelling and a reduction of physical activity participation. Previous research has shown a laterally deviated centre of pressure (COP) during running gait increases the risk of lateral ankle sprain. As a method of altering COP, electrical stimulation has been considered.

Method

A group of 14 healthy males were randomly allocated to case control groups which were single blinded. The intervention involved an 8-week training programme of functional electrical stimulation to the peroneal muscles during treadmill running, with a sham control group. Outcomes were COP position and star excursion balance test. Statistical analysis was through SPSS using a combination of MANOVA, T-tests and Wilcoxon signed rank.

Results

There was a significant difference in the results post intervention at max pressure for intervention M = 0.7(±0.7) and control M = -6.0 (±4.6) conditions; t(6) = -2.9, p < 0.05.

Conclusion

It has been demonstrated that FES can alter COP during max pressure in running gait after an 8-week training programme, although carry over effect appears limited and further testing is required.

Differences in the locomotion biomechanics and dynamic postural control between individuals with chronic ankle instability and copers: a systematic review

An empirical consensus of differences between chronic ankle instability (CAI) individuals and copers (individuals who sprained ankle once and without recurrent symptoms or injury) has not been reported. This study aimed to review the locomotion biomechanics and dynamic postural control between these two populations. Database of ScienceDirect, PubMed and Web of Science was used to search ('chronic ankle instability' OR 'ankle instability') AND ('ankle sprain' OR 'coper*') until 30 November 2020. Articles that made a comparison about changes in biomechanical parameters between Copers and CAI individuals during locomotor or functional tasks were included in this review. Twenty-three articles met the inclusion criteria. CAI individuals exhibited an increased hip flexion to maintain stability, suggesting the adopted hip strategy compared to copers during landing. Dorsiflexion angle and ankle frontal displacement increased considerably compared to copers, which might increase risks of lateral ankle sprain injury. CAI individuals reduced the ankle displacements in the sagittal plane and indicated worse performance of Star Excursion Balance Test in the posterior-lateral direction compared to copers. Identified motion deficits or altered motion strategies provide opportunities for targeted intervention and scheme after index sprain or in CAI individuals.

In Vivo Foot and Ankle Kinematics During Activities Measured by Using a Dual Fluoroscopic Imaging System: A Narrative Review

Foot and ankle joints are complicated anatomical structures that combine the tibiotalar and subtalar joints. They play an extremely important role in walking, running, jumping and other dynamic activities of the human body. The in vivo kinematic analysis of the foot and ankle helps deeply understand the movement characteristics of these structures, as well as identify abnormal joint movements and treat related diseases. However, the technical deficiencies of traditional medical imaging methods limit studies on in vivo foot and ankle biomechanics. During the last decade, the dual fluoroscopic imaging system (DFIS) has enabled the accurate and noninvasive measurements of the dynamic and static activities in the joints of the body. Thus, this method can be utilised to quantify the movement in the single bones of the foot and ankle and analyse different morphological joints and complex bone positions and movement patterns within these organs. Moreover, it has been widely used in the field of image diagnosis and clinical biomechanics evaluation. The integration of existing single DFIS studies has great methodological reference value for future research on the foot and ankle. Therefore, this review evaluated existing studies that applied DFIS to measure the in vivo kinematics of the foot and ankle during various activities in healthy and pathologic populations. The difference between DFIS and traditional biomechanical measurement methods was shown. The advantages and shortcomings of DFIS in practical application were further elucidated, and effective theoretical support and constructive research direction for future studies on the human foot and ankle were provided.

Active-Sensing Epidermal Stretchable Bioelectronic Patch for Noninvasive, Conformal, and Wireless Tendon Monitoring

Sensors capable of monitoring dynamic mechanics of tendons throughout a body in real time could bring systematic information about a human body's physical condition, which is beneficial for avoiding muscle injury, checking hereditary muscle atrophy, and so on. However, the development of such sensors has been hindered by the requirement of superior portability, high resolution, and superb conformability. Here, we present a wearable and stretchable bioelectronic patch for detecting tendon activities. It is made up of a piezoelectric material, systematically optimized from architectures and mechanics, and exhibits a high resolution of 5.8 × 10⁻⁵ N with a linearity parameter of R² = 0.999. Additionally, a tendon real-time monitoring and healthcare system is established by integrating the patch with a micro controller unit (MCU), which is able to process collected data and deliver feedback for exercise evaluation. Specifically, through the patch on the ankle, we measured the maximum force on the Achilles tendon during jumping which is about 16312 N, which is much higher than that during normal walking (3208 N) and running (5909 N). This work not only provides a strategy for facile monitoring of the variation of the tendon throughout the body but also throws light on the profound comprehension of human activities.