Fibular malalignment in individuals with chronic ankle instability

Characteristics of the static muscle stiffness of ankle plantar flexors in individuals with chronic ankle instability

PURPOSE

Individuals with chronic ankle instability (CAI) have deficits in closed kinetic chain dorsiflexion that may perpetuate injury. Determining the characteristics of muscle stiffness in the plantar flexors of individuals with CAI may help in developing appropriate treatments. We aimed to highlight the characteristics of static muscle stiffness in ankle plantar flexor muscles during the passive dorsiflexion of the ankle joint in individuals with CAI.

METHODS

A total of 30 patients were included in the study based on the International Ankle Consortium criteria. The patients were categorized evenly into healthy, coper, and CAI groups (i.e., 10 patients in each group). After measuring the dorsiflexion range of motion (non-weight-bearing/weight-bearing) of the ankle joint, the static muscle stiffness measurements of the medial gastrocnemius, lateral gastrocnemius, soleus, and peroneus longus were obtained. The measurements were performed during the knee joint's extension and 50° flexion and passive dorsiflexion between the range of 40° plantar flexion and 20° dorsiflexion.

RESULTS

The dorsiflexion range of motion of the CAI group was significantly smaller than that of the healthy and coper groups in the weight-bearing position. No interaction was observed for muscle stiffness in both the knee flexion and extension positions, and no significant differences were identified among the three groups. The shear modulus of the soleus at 20° ankle dorsiflexion with knee flexion had a significant negative correlation with the weight-bearing range of motion of the ankle.

CONCLUSION

The limitation in the weight-bearing dorsiflexion range of motion in CAI was largely due to factors other than the increased elasticity of the ankle plantar flexor muscles.

Current concepts in the surgical management of chronic ankle lateral ligament instability

Background/aims

Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI).

Methods

The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI.

Results

Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes.

Conclusion

Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Abnormalities of foot and ankle alignment in individuals with chronic ankle instability: a systematic review

Background

To prevent recurrent ankle sprain, it is important to clarify the pathology of chronic ankle instability (CAI). An association has been reported between CAI and abnormalities of foot posture and ankle alignment. There is no consensus on the types of these abnormalities that occur in individuals with CAI. The objective of this systematic review is to clarify the relevance of abnormality of foot posture and ankle alignment for CAI.

Methods

A systematic computerized literature search was performed of the PubMed, CINAHL, SPORTDiscus, Web of Science, and the Cochrane Register of Clinical Trials databases. The selected studies either compared CAI patients with a control group or CAI ankles with contralateral healthy ankles and specifically reported foot posture and alignment of the ankle in the outcomes. They were written in English and published prior to June 2021. The methodological quality of the included studies was evaluated using a 16-question index. Data were extracted independently by two reviewers, and the certainty of evidence was assessed using GRADE approach.

Results

Sixteen studies including 872 patients of high to low methodological quality were included. These showed there was significant anterior displacement and internal rotation of the talus in CAI ankles (low evidence), but there was no consensus on fibular alignment or foot posture.

Conclusions

This review showed there was significant anterior displacement and internal rotation of the talus in CAI ankles but found no consensus on the characteristics of fibular and foot alignment. Further investigations are required to clarify the characteristic foot and ankle malalignment in CAI to facilitate the development of efficient interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04537-6.

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.

Is subtle cavus foot a risk factor for chronic ankle instability? Comparison of prevalence of subtle cavus foot between chronic ankle instability and control group on the standing lateral radiograph

BACKGROUND

Subtle cavus foot (SCF) is an entity characterized by mild cavus. However, few studies have examined whether a SCF may be a risk factor for chronic ankle instability (CAI).

METHODS

This study included 116 patients who underwent lateral ankle ligament repair (modified Broström operation) for CAI and 105 controls. We used the standing lateral radiograph, so compared calcaneal pitch angle, Meary's angle, heights of the first and fifth metatarsal bases, and fibular positions between groups. Additionally, two observers subjectively rated the standing lateral radiographs for the presence of SCF.

RESULTS

There were no significant intergroup differences in any of the radiographic angles. The prevalence of SCF was 20.7% in the CAI group and 18.1% in the control group according to observer 1 versus 21.6% and 28.6% (CAI group and control group, respectively) according to observer 2. There were no significant intergroup differences in the proportion of SCF between the two observers (p=0.105 and 0.211, respectively).

CONCLUSION

SCF was not a significant risk factor for CAI when judging by standing lateral radiograph, and the detection of SCF seems to require considerable experience. Thus, care should be taken when determining whether to perform corrective osteotomies when treating CAI patients with SCF.

LEVEL OF EVIDENCE

III, case control.

Is the fibula positioned anteriorly in weight-bearing in individuals with chronic ankle instability? A case control study

Background: Clinically, a discrepancy of fibular position in relation to the tibia has been proposed as a factor in the persistence of chronic ankle instability (CAI). Previous studies have produced conflicting findings, perhaps due to varying radiological methods and measurement of participants in non-weight-bearing positions.Objectives: To compare normalized-fibular position in weight-bearing in individuals with CAI with healthy controls.Design: A weight-bearing lateral X-ray was taken of the affected ankle of 33 adults with CAI and 33 matched controls. The distance between the anterior edges of the distal fibula and tibia was recorded, and then normalized as a proportion of maximal tibial width. Normalized-fibular position was compared between groups using independent t-tests. Intra-class correlation coefficients (ICC_2,1) were calculated to determine reliability of measurements. A receiver-operating characteristic (ROC) curve was used to determine sensitivity, specificity, and a cutoff score to differentiate individuals with CAI from controls using normalized-fibular position.Results: Normalized fibular position was significantly different (CAI, 29.7 (6.6)%; healthy, 26.7 (4.8)%) between the groups. Measurement of intra-rater (0.99, 95%CI = 0.98 to 1.00) and inter-rater (0.98, 95%CI = 0.96 to 0.99) reliability were both excellent. The threshold normalized-fibular position was 27%, with a score more than 27% indicating a greater chance of being in the CAI group. Sensitivity was 69.7% and specificity was 54.5% for this threshold.Conclusion: A slightly anteriorly positioned fibula in relation to the tibia was observed in people with CAI. Specificity/sensitivity scores for normalized-fibular position indicate that it has little ability to predict CAI alone.

Radiologic Evaluation of the Effect of Distal Tibiofibular Joint Anatomy on Arthroscopically Proven Ankle Instability

BACKGROUND

Ankle sprains occur frequently in both athletes and the general population. The social and economic consequences can be significant. In an effort to understand the injury, dynamic and static structures around the ankle have been investigated in detail, but anatomical factors predisposing to lateral ankle instability have not been fully clarified. The aim of this study was to radiologically investigate the relationship between bony variations of the distal tibiofibular joint and arthroscopically proven ankle instability.

METHODS

Fifty patients with arthroscopically proven ankle instability and 50 patients without instability were included in this study. Measurements were obtained from a magnetic resonance imaging (MRI) section 1 cm proximal to the tibiotalar joint; distal tibiofibular joint anterior facet length (a), posterior facet length (b), angle between the anterior and posterior facets (c), fibular notch depth (d), tibia thickness (e), and fibula thickness (f) was measured.

RESULTS

It was found that instability was more frequent when the length of a (P < .001) and e (P < .001) were shorter. In addition, when value of a/b and e/f were evaluated, it was observed that the number of individuals who had instability increased as the ratio became smaller (P < .016-.020, respectively). Pearson correlation analysis indicated strong negative correlation between the values of a-e and instability (r = -0.348, P < .001, and r = -0.328, P = .001; respectively).

CONCLUSION

Lateral ankle sprains are common, and a clear understanding of the relevant structures and clinical function of the ankle complex should extend beyond the talocrural joint. This study demonstrated that the presence of narrow anterior facet (a) and thinner tibia (e) were strongly correlated with lateral ankle instability.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Weight, BMI and stability are risk factors associated with lateral ankle sprains and chronic ankle instability: a meta-analysis

IMPORTANCE

Lateral ankle sprains (LAS) are common in the general population and may lead to chronic ankle instability (CAI). If patients at risk could be identified, they could receive adequate and on-time treatment.

OBJECTIVE

The purpose of the current review was to identify all reported intrinsic factors associated with sustaining a LAS or progressing to CAI after an initial sprain.

EVIDENCE REVIEW

PubMed, Embase, MEDline, Cochrane and PEDro were searched for studies published until July 2019. Articles were selected if they included intrinsic factors related to LAS or CAI, subjects of at least 16 years old, and contained a minimum of 10 patients and 10 controls. Studies were excluded if they concerned reviews or case reports, included patients with previous surgical interventions, concomitant injuries or joint pathology other than ankle instability. Quality of included studies was assessed using the Quality in Prognostic Studies tool and quality of evidence was assessed using the GRADEpro tool. In case outcomes were described by at least three studies, data were pooled and assessed by performing a meta-analysis. Based on the pooled data, either a fixed-effects model or random-effects model was selected to correct for the degree of heterogeneity.

FINDINGS

The search resulted in a total of 4154 studies. After title and abstract screening and subsequent full-text screening, 80 relevant studies were included. Results of the meta-analyses indicated that, compared with healthy controls, patients with LAS had a higher mean body mass index (BMI). In patients with CAI, a higher weight and a longer time to stabilise after performing a task (eg, jumping) were found compared with healthy controls. Other outcomes could not be compared using a meta-analysis due to heterogeneity in outcome measurement and the great number of different outcomes reported. Identification of the risk factors when patients present themselves after a LAS may help to determine which patients are at risk of recurrent sprains or developing CAI.

CONCLUSIONS AND RELEVANCE

Based on the findings in this review, a higher BMI, and a higher weight and neuromuscular stability deficits may be regarded risk factors for sustaining a LAS or developing CAI, respectively.

LEVEL OF EVIDENCE

III.

Pediatric and adolescent ankle instability: diagnosis and treatment options

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Effect of mobilization with movement on lateral knee pain due to proximal tibiofibular joint hypomobility

This case report describes a 45-year-old female who presented with lateral knee pain over the right proximal tibiofibular joint (PTFJ) managed unsuccessfully with rest, medications, bracing, injection, and physiotherapy. Clinical diagnosis of PTFJ hypomobility was based on concordant symptom reproduction with palpatory tenderness, accessory motion testing, and restricted anterior glide of the fibula. Intervention consisted of Mulligan's mobilization with movement and taping over the right PTFJ with immediate improvements noticed in pain, range of motion, and function. The patient was seen twice a week and was discharged after four treatment sessions. A follow-up after 6 months revealed that the patient was pain free and fully functional.