Assessment tools for identifying functional limitations associated with functional ankle instability

A clinical guide to the medial ligaments of the ankle: Anatomy, function, diagnosis of injuries and treatment of instability-a narrative review

BACKGROUND

The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability.

METHODS

Literature search on PubMed.

RESULTS

Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse.

CONCLUSION

There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.

Effect of Low-Load Blood Flow Restriction Training on Patients With Functional Ankle Instability: A Randomized Controlled Trial

CONTEXT

Decreased muscle strength and balance in patients with functional ankle instability (FAI) can be effectively improved by ankle strength training. Low-load blood flow restriction (LL-BFR) training increases muscle size and strength, but there is limited evidence from studies on muscle strength and balance in FAI patients.

OBJECTIVE

To study the effects of LL-BFR training versus high-load training (HLT) on muscle strength and balance in FAI patients.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Forty-six young adults with a history of FAI.

INTERVENTIONS

Participants in the LL-BFR and HLT groups performed 4 sets (30 × 15 × 15 × 15) of ankle training at 20% to 40% of the one-repetition maximum and 70% to 85% one-repetition maximum, respectively, twice a week for 6 weeks.

MAIN OUTCOME MEASURE(S)

Plantar flexion, dorsiflexion, inversion, and eversion muscle strength, and the Y-balance test scores were assessed at baseline and after 3 and 6 weeks; the thickness of the tibialis anterior, triceps surae, and peroneus longus muscles were assessed at baseline and after 6 weeks.

RESULTS

Inversion, eversion, dorsiflexion, and plantar flexion muscle strength; tibialis anterior, triceps surae, and peroneus longus thickness; and Y-balance test scores were significantly increased in the LL-BFR group after 3 and 6 weeks compared with baseline (P < .05), with no significant difference between the LL-BFR and HLT groups after 6 weeks (P > .05). However, at the end of 3 weeks, eversion muscle strength and Y-balance test scores were significantly higher in the LL-BFR group than in the HLT group (P < .05).

CONCLUSIONS

Over 6 weeks, LL-BFR training was as effective as HLT in improving ankle muscle strength, muscle thickness, and balance in FAI patients, but LL-BFR training improved the ankle eversion muscle strength and dynamic balance more than HLT did in the early stages of the intervention. This finding will provide a new intervention strategy for the clinical rehabilitation of FAI patients.

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

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

Lower Extremity Muscle Activation during the Star Excursion Balance Test in Patients with Chronic Ankle Instability and Copers

Background and Objectives: The aim of this study was to assess the impact of ankle muscles on performance of the Star Excursion Balance Test (SEBT) among individuals with stable ankles, a history of ankle sprain, and chronic ankle instability (CAI). Materials and Methods: Sixty subjects (twenty per group) performed the SEBT in each of the anterior (A), posteromedial (PM), and posterolateral (PL) directions. Normalized maximum reach distance (NMRD) and normalized mean amplitude of the tibialis anterior (NMA_TA), fibularis longus (NMA_FL), and medial gastrocnemius (NMA_MG) were measured during performance of the SEBT. Results: Copers have greater NMRD than subjects with stable ankles and those with CAI, and subjects with stable ankles also have greater NMRD than those with CAI in only the PL direction. Subjects with stable ankles and those with CAI showed greater NMA_TA than copers. The A direction showed greater NMA_TA than the PM and PL directions. Copers showed greater NMA_FL than subjects with stable ankles. Subjects with CAI showed greater NMA_MG than copers and subjects with stable ankles. The A and PL directions showed greater NMA_MG than the PM direction. Conclusions: Overall, copers and/or subjects with CAI demonstrated altered neuromuscular function by compensating for their ankle muscles when compared to subjects with stable ankles due to a history of ankle sprain.

Cross-cultural adaptation and validation of the Chinese version of the ankle joint functional assessment tool (AJFAT) questionnaire

BACKGROUND

Ankle joint functional assessment tool (AJFAT) is gradually becoming a popular tool for diagnosing functional ankle instability (FAI). However, due to the lack of standard Chinese versions of AJFAT and reliability and validity tests, the use of AJFAT in the Chinese population is limited. This study aimed to translate and cross-culturally adapt the AJFAT from English into Chinese, and evaluate the reliability and validity of the Chinese version of AJFAT and to investigate its psychometric properties.

METHODS

The translation and cross-cultural adaptation of AJFAT was performed according to guidelines for cross-cultural adaptation of self-report measures. 126 participants with a history of ankle sprain completed the AJFAT-C twice within 14 days and completed the Cumberland ankle instability tool (CAIT-C) once. Test-retest reliability, internal consistency, ceiling and floor effects, convergent and structure validity and discriminative ability were investigated.

RESULTS

The test-retest reliability (ICC = 0.91, 95%CI = 0.87-0.94) and internal consistency (Cronbach's alpha = 0.87) of the AJFAT-C were excellent. No ceiling or floor effects were detected. A moderate correlation between the AJFAT-C and the CAIT-C suggested a moderate convergent validity. The AJFAT-C had a two-factor structure: 1. function of the unstable side of the ankle joint (9 items) and 2. symptoms of the unstable side of the ankle (2 items). The ideal cut-off point of the AJFAT-C was calculated as 26 points.

CONCLUSION

The Chinese version of AJFAT can be considered as a valid and reliable ankle joint function evaluation tool that can be applied in clinical and research work.

Validity and Reliability of Kinvent Plates for Assessing Single Leg Static and Dynamic Balance in the Field

The objective of this study was to validate PLATES for assessing unipodal balance in the field, for example, to monitor ankle instabilities in athletes or patients. PLATES is a pair of lightweight, connected force platforms that measure only vertical forces. In 14 healthy women, we measured ground reaction forces during Single Leg Balance and Single Leg Landing tests, first under laboratory conditions (with PLATES and with a 6-DOF reference force platform), then during a second test session in the field (with PLATES). We found that for these simple unipodal balance tests, PLATES was reliable in the laboratory and in the field: PLATES gives results comparable with those of a reference force platform with 6-DOF for the key variables in the tests (i.e., Mean Velocity of the Center of Pressure and Time to Stabilization). We conclude that health professionals, physical trainers, and researchers can use PLATES to conduct Single Leg Balance and Single Leg Landing tests in the laboratory and in the field.

Effects of visual deprivation on the injury of lower extremities among functional ankle instability patients during drop landing: A kinetics perspective

Background: The ankle is prone to injury during drop landing with usual residual symptoms, and functional ankle instability (FAI) is the most common. Vision guarantees the postural stability of patients with FAI, and visual deprivation (VD) increases their risk of injury when completing various movements. This study explored injury risk during drop landing in patients with FAI under VD through the kinetics of lower extremities. Methods: A total of 12 males with FAI participated in the study (age, 23.0 ± 0.8 years; height, 1.68 ± 0.06 m; weight, and 62.2 ± 10.4 kg) completed single-leg drop landings under visual presence (VP) and VD conditions. Ground reaction force (GRF), time to peak GRF, joint torque, and vertical length variation (ΔL) were measured. Results: Significant effects were detected in the group for time to peak lateral GRF (p = 0.004), hip extensor torque (p = 0.022), ankle plantarflexion torque (p < 0.001), ankle varus torque (p = 0.021), lower extremity stiffness (p = 0.035), and ankle stiffness (p < 0.001). Significant effects of conditions were detected for vertical GRF, time to peak vertical and lateral GRF, loading rate, hip extensor torque, knee extensor torque, hip varus torque, knee varus torque, lower extremity stiffness, and ankle stiffness (p < 0.05). ΔL was affected by VD with a significant difference (p < 0.001). Conclusion: In patients with FAI, an unstable extremity has a higher injury risk than a stable extremity, and VD increases such risk. However, because the influence of the central nervous system on hip strategy is also affected, the effect on the unstable extremity is more significant and more likely to result in injury. Deepening the squat range may be an effective preventive measure for reducing injury risk of unstable extremities during drop landing.

Effects of Conservative Interventions on Static and Dynamic Balance in Individuals With Chronic Ankle Instability: A Systematic Review and Meta-analysis

OBJECTIVE

To determine which conservative interventions are effective for static and dynamic balance in patients with chronic ankle instability (CAI).

DATA SOURCES

PubMed, Cochrane Library, Web of Sciences, and CINAHL databases were searched up to March 20, 2022.

STUDY SELECTION

Randomized controlled trials investigating the effects of conservative interventions on static and/or dynamic balance in patients with CAI compared with those of different conservative interventions or controls were included.

DATA EXTRACTION

Two independent reviewers extracted the data. Certainty of the evidence was assessed using the GRADE approach.

DATA SYNTHESIS

Forty-eight studies (1906 participants) were included. Whole-body vibration training (WBVT) was significantly more effective than controls for both static (standardized mean difference, 1.13; 95% confidence interval [CI], 0.58-1.68; moderate-certainty evidence) and dynamic balance (0.56; CI, 0.24-0.88; low-certainty evidence). Balance training (BT) and joint mobilization were significantly more effective than controls for dynamic balance (0.77; CI, 0.41-1.14; and 0.75; CI, 0.35-1.14, respectively), but not for static balance (very low to low-certainty evidence). Adding other interventions to BT had no significant effect on either type of balance compared with that of BT alone (moderate to low-certainty evidence). Strength training (ST) and taping had no significant effect on either type of balance (very low- to low-certainty evidence). Multimodal interventions were significantly effective in improving dynamic balance (0.76; CI, 0.32-1.20; low-certainty evidence). Adding transcranial direct current stimulation to ST was significantly more effective for dynamic balance than ST (0.81; CI, 0.08-1.53; moderate-certainty evidence). The effects on balance were not significantly different among BT, ST, and WBVT (very low- to low-certainty evidence).

CONCLUSIONS

The significantly effective interventions reviewed may be treatment options for balance impairments associated with CAI. However, interventions should be chosen carefully, as much of the certainty of evidence is very low to low.

Can stabilization analysis following a single leg drop jump be compared between young and middle-aged adults

We aimed to verify whether the computational approaches previously proposed to analyze stability after a single-leg drop-jump (SLDJ) could be applied to a population of middle-aged adults. Fifteen middle-aged (56.4 ± 4.6 years) and 15 young adults (26.7 ± 3.9 years) performed five SLDJs. Stabilization measurements included (1) time to stabilization (TTS) based on vertical ground reaction force (GRF) (TTSv) and a fixed stabilization threshold; (2) TTS based on medio-lateral GRF (TTSml) using five different methods to preprocess the signal and stabilization threshold; (3) early medio-lateral stabilization- the averaged absolute values of the GRF in 0.2-1.4 s post-landing; (4) late medio-lateral stabilization - the averaged absolute values of the GRF at 1 s-5 s after landing. TTSv showed longer TTS values in middle-aged participants. In addition, middle-aged adults showed greater sway in late stabilization. However, TTSml values varied considerably between calculation methods, and early stabilization showed no significant differences between groups except in the first 0.2 s after landing. The results of the current study suggest that TTS calculations are sensitive to signal and threshold selection, and to the processing method. Calculations based on a fixed threshold are more appropriate for studying dynamic postural stability in middle age. With appropriate method selection, a decreased stabilizing performance can be demonstrated in middle-aged adults compared to young adults.

Impact of Sub-Clinical and Clinical Compression Socks on Postural Stability Tasks among Individuals with Ankle Instability

Compression socks are used by a very diverse group of individuals and may potentially have a greater impact on physically diminished or impaired individuals as opposed to healthy individuals. The purpose of this study was to compare the effects of sub-clinical (SC) and clinical (CL) compression socks among healthy (CON), copers (COP), and individuals with chronic ankle instability (CAI). Postural stability was evaluated in 20 participants (11 males and 9 females) using Balance Tracking System Balance platform (BTrackS™) during the modified clinical test of sensory integration in balance (mCTSIB) and limits of stability (LOS) tests. Postural sway parameters were analyzed using a mixed model repeated measures analysis of variance 3 (group: CON, COP, and CAI) by 3 (compression condition: BF, SC, and CL) × 4 (balance condition: EO, EC, EOF, and ECF) for mCTSIB and a 3 (group: CON, COP, and CAI) by 3 (compression condition: BF, SC, CL) × 4 (balance condition: FL, BL, BR, FR) for LOS. Results revealed significantly greater postural stability with both SC and CL compression socks when compared to barefoot conditions. However, no significant differences were observed among groups for compression socks grades. Both SC and CL compression socks may be effective in increasing postural stability.

Effect of Combined Balance Exercises and Kinesio Taping on Balance, Postural Stability, and Severity of Ankle Instability in Female Athletes with Functional Ankle Instability

Ankle sprain is a common musculoskeletal injury, and recurrent ankle sprains often lead to ankle instability. This study aimed to examine whether a 6-week balance training on a wobble board (WB) combined with kinesio taping (KT) is effective in improving balance, postural stability, and ankle stability among female athletes with functional ankle instability (FAI). Twenty-four female athletes with FAI were randomly assigned to study (SG) or control groups (CG). SG attended a 6-week training protocol of combined balance training on the wobble board with KT applied to ankles during exercise. CG only went through a 6-week balance training procedure that was the same as the SG. Before and after the training program, balance and postural stability and the severity of ankle instability were assessed by single-leg Biodex Balance system and Cumberland Ankle Instability Tool (CAIT), respectively. The analysis revealed that the scores of balance and postural stability decreased after the 6-week training for CG (p = 0.002) and SG (p = 0.001), which indicates an improvement for these variables, and the score of CAIT increased, which means the severity of instability reduced (p = 0.001 for both groups). Significant between-group differences were found for balance and postural stability (t = 2.79, p = 0.011, g = −1.99) and the severity of instability (t = 2.082, p = 0.049, g = 1.36), favoring SG compared with CG. This study showed that the addition of KT to balance training is more effective than balance training alone in improving balance, postural stability, and severity of ankle instability in female athletes with FAI. Our findings could provide a preliminary reference for designing combined balance and KT programs for delivering health benefits to females with FAI.

Diagnostic Accuracy of Clinical Tests Assessing Ligamentous Injury of the Talocrural and Subtalar Joints: A Systematic Review With Meta-Analysis

Context:

Ankle sprains are the most common acute musculoskeletal injury. Clinical tests represent the first opportunity to assess the sprain’s severity, but no systematic review has compared these tests to contemporary reference standards.

Objective:

To determine the diagnostic accuracy of clinical tests assessing the talocrural and subtalar joint ligaments after ankle sprain.

Data Sources:

CINAHL, EMBASE, MEDLINE, hand-searching, and PubMed-related article searches (inception to November 18, 2020).

Study Selection:

Eligible diagnostic studies compared clinical examination (palpation, joint laxity) against imaging or surgery. Studies at a high risk of bias or with high concerns regarding applicability on Quality Assessment of Diagnostic Accuracy Studies-2 were excluded from the meta-analysis.

Study Design:

Systematic review and meta-analysis.

Level of Evidence:

Level 3a.

Data Extraction:

True-positive, false-negative, false-positive, and true-negative findings were extracted to calculate sensitivity, specificity, and likelihood ratios. If ordinal data were reported, these were extracted to calculate Cohen’s kappa.

Results:

A total of 14 studies met the inclusion criteria (6302 observations; 9 clinical tests). No test had both sensitivity and specificity exceeding 90%. Palpation of the anterior talofibular ligament is highly sensitive (sensitivity 95%-100%; specificity 0%-32%; min-max; n = 6) but less so for the calcaneofibular ligament (sensitivity 49%-100%; specificity 26%-79%; min-max; n = 6). Pooled data from 6 studies (885 observations) found a low sensitivity (54%; 95% CI 35%-71%) but high specificity (87%; 95% CI 63%-96%) for the anterior drawer test.

Conclusion:

The anterior talofibular ligament is best assessed using a cluster of palpation (rule out), and anterior drawer testing (rule in). The talar tilt test can rule in injury to the calcaneofibular ligament, but a sensitive clinical test for the ligament is lacking. It is unclear if ligamentous injury grading can be done beyond the binary (injured vs uninjured), and clinical tests of the subtalar joint ligaments are not well researched. The generalizability of our findings is limited by insufficient reporting on blinding and poor study quality.

Registration:

Prospero ID: CRD42020187848.

Data Availability:

Data are available in a public, open access repository on publication, including our RevMan file and the CSV file used for meta-analysis: http://doi.org/10.5281/zenodo.4917138

Validity and Reliability of the Malay Version of the Identification of Functional Ankle Instability (IdFAI-M) Questionnaire among Malaysian University Athletes

Introduction:

This study was designed to produce a validated and reliable Malay version of the Identification of Functional Ankle Instability (IdFAI-M) questionnaire.

Materials and method:

The cross-cultural adaptation was conducted based on standard guidelines to produce the Malay version of the Identification of Functional Ankle Instability (IdFAI-M) questionnaire. The reliability and validity testing were then performed among one hundred and twenty-three physically active University of Malaya students. Among them, twenty-two students also participated in the second return of the questionnaire over a two-week interval, which was then evaluated for test-retest reliability testing.

Results:

The content validity for item-level (I-CVI) and Kappa values for all items were more than 0.7, respectively and the all scales-level (S-CVI) values were 0.983 (consistency), 0.967 (representativeness), 1.00 (relevance) and 0.983 (clarity). The questionnaire also demonstrated excellent reliability with an intraclass correlation coefficient (ICC2.1) above 0.850 for all items. It was observed that outer loading of most items were more than the minimum acceptable value (0.7). Fornell-Larcker criterion demonstrate all values for each reflective construct was larger than the correlations with other constructs, indicating discriminant. The cross-loading values of each item has shown a weak correlation with all other constructs, except for the one to which it was theoretically associated.

Conclusions:

The Malay version of the IdFAI (IdFAI-M) is a reliable and valid instrument that can be readily utilised to subjectively assess ankle instability.

The Effects of Therapeutic Exercise With and Without Mobilization in Participants With Chronic Ankle Instability: A Randomized Controlled Trial

Context: Manual therapy (MT) is reported to increase range of motion (ROM), improve balance, and decrease pain in individuals with chronic ankle instability (CAI). Additional literature is needed to examine the effectiveness of the addition of MT to a therapeutic exercise regimen in individuals with CAI. Objective: To examine the combined effects of thrust joint manipulation (TJM) and exercise on function in participants reporting CAI. Design: Randomized controlled trial. Setting: Research laboratory. Participants: A convenience sample of 30 participants (mean age 23.7 [3.65] y; mean height 169.50 [9.50] cm; mean mass 66.48 [10.64] kg). Intervention: Participants were randomly allocated to the exercise (n = 15) or exercise + TJM group (n = 20) and completed an exercise program. The exercise + TJM group also received MT at the talocrural, proximal, and distal tibiofibular joints in the first 3 sessions. Main Outcome Measures: Self-reported outcomes were recorded at baseline and follow-up using the Foot and Ankle Ability Measure (FAAM), the FAAM-Sport (FAAM-S) subscale, and the Ankle Joint Functional Assessment Tool (AJFAT). The side-hop test, figure-of-8 hop test, 3 directions of the Star Excursion Balance Test, and dorsiflexion ROM were also assessed at baseline and follow-up. Results: Only the exercise + TJM group demonstrated an improvement in weight-bearing dorsiflexion with the knee flexed following treatment (P = .02). For all outcome measures, except ROM, subjects improved significantly at follow-up regardless of group assignment (P ≤ .01). Conclusions: Our data suggest that rehabilitation of patients with CAI is related to improved ROM, function, and self-reported outcomes. This provides evidence that the addition of MT to exercise may enhance improvements in ROM as compared with exercise alone. Additional research is needed to identify optimal parameters to maximize therapeutic benefit.

Ultrasound Imaging of Crural Fascia and Epimysial Fascia Thicknesses in Basketball Players with Previous Ankle Sprains Versus Healthy Subjects

Background: Fascial layers may play an important role in locomotor mechanics. Recent researches have revealed an association between increases of fascia thickness and reduced joint flexibility in patients with chronic pain. The purpose of this study was to measure and compare, through the use of ultrasound imaging, the thickness of the deep/crural fascia in different points of the leg as well as the epimysial fascia thickness at level 2 of anterior compartment of leg, in male basketball players with history of recurrent ankle sprain and in healthy participants. Methods: A cross-sectional study has been performed using ultrasound imaging to measure deep/crural fascia thickness of anterior, lateral and posterior compartment of the leg at different levels with a new protocol in a sample of 30 subjects, 15 basketball players and 15 healthy participants. Results: Findings of fascial thickness revealed statistically significant differences (p < 0.01) in epimysial fascia thickness and in deep/crural fascia thickness between levels/compartments of the same group and between two groups. Moreover, Post 3 deep/crural fascia thicknesses (p < 0.001) were decreased showing statistically significant difference for the basketball players group respect the healthy participants group. Conclusions: These findings suggested that the posterior compartment was thicker than anterior compartment, probably due to a postural reason in both groups. Moreover, they showed an increase of thickness of the epimysial fascia in basketball players with previous ankle sprains. This variability underlines the importance to assess the fasciae and to make results comparable.

Single-Legged Hop and Single-Legged Squat Balance Performance in Recreational Athletes With a History of Concussion

CONTEXT

Researchers have suggested that balance deficiencies may linger during functional activities after concussion recovery.

OBJECTIVE

To determine whether participants with a history of concussion demonstrated dynamic balance deficits as compared with control participants during single-legged hops and single-legged squats.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 15 previously concussed participants (6 men, 9 women; age = 19.7 ± 0.9 years, height = 169.2 ± 9.4 cm, mass = 66.0 ± 12.8 kg, median time since concussion = 126 days [range = 28-432 days]) were matched with 15 control participants (6 men, 9 women; age = 19.7 ± 1.6 years, height = 172.3 ± 10.8 cm, mass = 71.0 ± 10.4 kg).

INTERVENTION(S)

During single-legged hops, participants jumped off a 30-cm box placed at 50% of their height behind a force plate, landed on a single limb, and attempted to achieve a stable position as quickly as possible. Participants performed single-legged squats while standing on a force plate.

MAIN OUTCOME MEASURE(S)

Time to stabilization (TTS; time for the normalized ground reaction force to stabilize after landing) was calculated during the single-legged hop, and center-of-pressure path and speed were calculated during single-legged squats. Groups were compared using analysis of covariance, controlling for average days since concussion.

RESULTS

The concussion group demonstrated a longer TTS than the control group during the single-legged hop on the nondominant leg (mean difference = 0.35 seconds [95% confidence interval = 0.04, 0.64]; F_2,27 = 5.69, P = .02). No TTS differences were observed for the dominant leg (F_2,27 = 0.64, P = .43). No group differences were present for the single-legged squat on either leg (P ≥ .11).

CONCLUSIONS

Dynamic balance-control deficits after concussion may contribute to an increased musculoskeletal injury risk. Given our findings, we suggest that neuromuscular deficits currently not assessed after concussion may linger. Time to stabilization is a clinically applicable measure that has been used to distinguish patients with various pathologic conditions, such as chronic ankle instability and anterior cruciate ligament reconstruction, from healthy control participants. Whereas the single-legged squat may not sufficiently challenge balance control, future study of the more dynamic single-legged hop is needed to determine its potential diagnostic and prognostic value after concussion.

Relationship between chronic ankle sprain instability and ultrasonographic evaluation of the peroneus during a single-leg standing task

[Purpose] This study aimed to examine the relationship between chronic ankle sprain instability and ultrasonography of the peroneus muscles during a single-leg standing task. [Participants and Methods] We examined nine college-aged students with a history of lateral ankle joint sprain with chronic ankle sprain instability scores less than 24. Participants underwent ultrasonographic measurement of the pennation angle and muscle thickness of the peroneal and gastrocnemius muscle groups of both legs. In addition, participants were evaluated for fluctuation by the root mean square calculated from accelerations in the anteroposterior, lateral-horizontal, and vertical directions during the single-leg standing position by affixing the accelerometer to their waist. Measurement results were compared between sprain and non-sprain sides. [Results] Ultrasonography revealed a significant reduction in the feathered pennation angle of the long peroneal muscle on the side of the sprain, but no other significant differences. Also, significant extension was observed on the side of the sprain in the anteroposterior and vertical directions during single-leg standing; however, no significant differences were found in the lateral-horizontal direction. [Conclusion] Participants with chronic ankle sprain instability exhibited greater fluctuation in the anteroposterior and vertical directions. Such fluctuations are believed to be compensatory in nature because the feathered horn of the long peroneal muscle is decreased, and pronation of the forefoot is difficult during one-leg standing.

Clinical versus Functional Reaction Time: Implications for Postconcussion Management

PURPOSE

This study aimed to examine the association between clinical and functional reaction time (RT) assessments with and without simultaneous cognitive tasks among healthy individuals.

METHODS

Participants (n = 41, 49% female; 22.5 ± 2.1 yr; 172.5 ± 11.9 cm; 71.0 ± 13.7 kg) completed clinical (drop stick, Stroop) and functional (gait, jump landing, single-leg hop, anticipated cut, unanticipated cut) RT assessments in random order. All RT assessments, except Stroop and unanticipated cut, were completed under single- (movement only) and dual-task conditions (movement and subtracting by 6s or 7s). Drop stick involved catching a randomly dropped rod embedded in a weighted disk. Stroop assessed RT via computerized neurocognitive testing. An instrumented walkway measured gait RT when center-of-pressure moved after random stimulus. All other functional RT assessments involved participants jumping forward and performing a vertical jump (jump landing), balancing on one leg (single-leg hop), or a 45° cut in a known (anticipated cut) or unknown (unanticipated cut) direction. RT was determined when the sacrum moved following random visual stimulus. Pearson correlation coefficients and a 5 × 2 repeated-measures ANOVA compared RT assessments and cognitive conditions.

RESULTS

Stroop RT outcomes did not significantly correlate with functional RT assessments (r range = -0.10 to 0.24). A significant assessment by cognitive task interaction (F4,160 = 14.01; P < 0.001) revealed faster single-task RT among all assessments compared with dual-task (mean differences, -0.11 to -0.09 s; P < 0.001), except drop stick (P = 0.195). Single-leg hop (0.58 ± 0.11 s) was significantly slower compared with jump landing (0.53 ± 0.10 s), anticipated cut (0.49 ± 0.09 s), gait (0.29 ± 0.07 s), and drop stick (0.21 ± 0.03 s; P values ≤ 0.001). Dual-task assessments were significantly slower than single-task assessments (mean difference, 0.08 s; P < 0.001).

CONCLUSIONS

Clinical and functional RT assessments were not correlated with each other, suggesting that sport-like RT is not being assessed after concussion. Functional and dual-task RT assessments may add clinical value and warrant further exploration after concussion.

Cross cultural adaptation, reliability, and validity of the Greek version of the Cumberland Ankle Instability Tool

Objectives: This study's objective was to translate and cross-culturally adapt the Cumberland Ankle Instability Tool (CAIT) into the Greek language and to evaluate its psychometric properties.Methods: CAIT was translated and adapted into Greek according to official cross-cultural adaptation guidelines of self-reported measures. The Greek version of the CAIT (CAIT-GR) was tested for reliability (internal consistency, test-retest reliability), validity (discriminative and convergent validity) and floor-ceiling effects. Additionally, a cut-off value discriminating between stable and unstable ankles across healthy participants and participants with ankle complaints was calculated. A convenience sample of 123 Greek individuals was recruited, 43 of which had a history of at least one ankle sprain. All participants completed the final version of the CAIT-GR twice within 7-10 days. Participants with a history of ankle sprain also completed the Greek version of the Lower Extremity Functional Scale (LEFS) and the Visual Analogue Scale (VAS).Results: CAIT-GR mean scores were 26.9 ± 3.16 for participants without a history of ankle sprain and 20.6 ± 4.62 for the instability group. The cut-off value was at 24.5 points of the total CAIT score (range 0-30). CAIT-GR had a moderate correlation with VAS (0.54) and a high correlation with LEFS (0.735). Results indicated good discriminative validity, high internal consistency (Cronbach's alpha of 0.97) and excellent test-retest reliability (ICC_2,1 = 0.97, 95%CI = 0.97-0.98). Neither a floor nor a ceiling effect was observed.Conclusions: The CAIT-GR questionnaire was found to be a reliable and valid measure for chronic ankle instability. It is therefore, available for use in future clinical research and practice.

A Review of Field-Based Assessments of Neuromuscular Control and Their Utility in Male Youth Soccer Players

Read, PJ, Oliver, JL, Croix, MS, Myer, GD, and Lloyd, RS. A review of field-based assessments of neuromuscular control and their utility in male youth soccer players. J Strength Cond Res 33(1): 283-299, 2019-Lower-extremity injuries in male youth soccer are common and equate to a substantial time loss from training and competitions during the course of a season. Extended periods of absence will impact player involvement in skill and physical development activities, as well as participation in competitive match play. Neuromuscular risk factors for lower-extremity injury in male youth soccer players can be categorized into quadriceps dominance, leg dominance, ligament dominance, trunk dominance, and reduced dynamic stability. Valid screening methods to identify risk factors that are practically viable are needed for youth athletes who may be at a greater risk of injury in soccer. Although field-based tests of neuromuscular control provide a reliable option for the assessment of injury risk in adults and females, less data are available in male youth soccer players, and further research is required to examine their ability to predict injury risk. This article provides a review of the current literature pertaining to field-based screening tests and critically appraises their suitability for use with male youth soccer players. Currently, the only method that has been validated in male youth soccer players is the landing error scoring system. Asymmetrical anterior reach measured during the Y-Balance test may also be considered because of its strong predictive ability in male youth basketball players; however, further research is required to fully support its use with soccer players.

Translation, cross-cultural adaptation and factor analysis of the Persian version of ankle instability instrument

Background: Ankle Instability Instrument (AII) is a questionnaire for determination of ankle stability status. The aim of this study is to cross-culturally translate and investigate the reliability and validity of AII in a sample of Persian-speaking Iranians, suffering from ankle sprain.

Methods: One hundred twenty persons with a history of ankle sprain were recruited in the study. All participants completed the Persian version of Ankle Instability Instrument, Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM) and Foot and Ankle Outcome Score (FAOS) at the baseline. Out of them, 60 randomly selected subjects completed the questionnaires once more, one week later. Face validity, Test–retest reliability, internal consistency, standard error of measurement, minimal metric detectable change, spearman’s correlation coefficient and confirmatory factor analysis of AII measured. We used Lisrel v 8.80 software with significant level of p<0.05.

Results: Persian version of AII is clear and unambiguous and its qualitative face validity was confirmed in the pilot study on the 20 subjects with a lateral ankle sprain. The interclass correlation coefficient, Cronbach’s alpha, standard error of measurement and minimal metric detectable change were 0.93, 0.87, 0.81 and 2.25 (95% confidence interval, 0.85-0.96). The Spearman correlations coefficients between AII, and CAIT, FAAM and FAOS measures were 0.91, 0.71 and 0.69 respectively. The original three factor structure of AII was replicated based on the confirmatory factor analysis. Which showed an adequate fit of the model to the data and goodness-of-various fit indices.

Conclusion: The Ankle Instability Instrument Persian Version (AII-PV) is a reliable and valid measure for assessing the ankle stability status.

A comparison of foot kinetic parameters between pronated and normal foot structures during forward jump landing

BACKGROUND

Pronated foot is one of the most important factors that may lead to musculoskeletal injuries of the lower extremities. It is known that in a pronated foot, excessive mechanical loads are applied to the lower limb structures, which result in the altered foot biomechanics, including vertical ground reaction forces (VGRFs) and rate of loading (ROL). Therefore, the aim of this study was to determine the changes in foot kinetic parameters in the pronated compared to the normal foot structures.

METHODS

In this cross-sectional study, 15 individuals (mean age of 23.27 ± 3.28 years) with asymptomatic pronated feet and 15 normal subjects (mean age of 23.40 ± 3.11 years) were recruited from both genders by using a simple non-random sampling method. VGRF, ROL, and the resultant vector of time to stabilization (RVTTS) were evaluated during the forward jump landing task by using a force plate.

RESULTS

The findings showed that the following parameters were significantly higher in the group of pronated feet than in the normal subjects: VGRF (3.30 ± 0.17 vs. 2.81 ± 0.15, p = .042), ROL (0.10 ± 0.01 vs. 0.07 ± 0.006, p = .020), and RVTTS (2592.80 ± 141.24 vs. 2114.00 ± 154.77, p = .030).

CONCLUSION

All the measured foot kinetic parameters were higher in the pronated foot subjects than in the normal participants. An impaired movement control and greater forces imposed on the foot region of the pronated foot, compared to the normal foot individuals, were discovered indicating the former group's possible increase of susceptibility to various musculoskeletal injuries.

Isometric Hip Strength and Dynamic Stability of Individuals With Chronic Ankle Instability

CONTEXT

  Compared with individuals who have a history of lateral ankle sprain (LAS) without markers of chronic ankle instability (CAI; LAS copers) and healthy people, those with CAI often exhibit neuromuscular impairments and dynamic-stability deficits at the hip. However, the influence of hip-strength deficits on dynamic stability remains unknown.

OBJECTIVE

  To compare isometric hip strength and dynamic stability in individuals with or without CAI and examine the degree of dynamic-stability variance explained by isometric hip strength.

DESIGN

  Case-control study.

SETTING

  Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Sixty individuals (47 women, 13 men; age = 23.7 ± 4.6 years, height = 166.6 ± 7.7 cm, mass = 70.8 ± 15.7 kg) separated into CAI, LAS coper, and control groups based on previously established criteria.

MAIN OUTCOME MEASURE(S)

  Group differences in resultant vector time to stabilization (RVTTS) and isometric hip-extension, -abduction, and external-rotation strength were determined using 1-way analyses of covariance that controlled for sex and limb (dominant or nondominant) tested and Cohen d effect sizes (95% confidence intervals). Backward linear regressions and Cohen f² effect sizes (95% confidence intervals) determined the amount of RVTTS variance explained by isometric hip strength. Significance was set a priori at P < .05.

RESULTS

  The CAI group had less isometric hip-extension strength than LAS copers ( P = .02, d = 0.72 [0.06, 1.34]) and controls ( P = .01, d = 1.19 [0.50, 1.84]) and less external-rotation strength than LAS copers ( P = .03, d = 0.78 [0.13, 1.41]) and controls ( P = .01, d = 1.02 [0.34, 1.65]). No group differences existed for RVTTS ( F_2,57 = 1.16, P = .32) or abduction strength ( F_2,57 = 2.84, P = .07). Resultant vector time to stabilization was explained by isometric hip strength for LAS copers ( R² = 0.21, f² = 0.27 [0.22, 0.32], P = .04) but not for the CAI ( R² = 0.12, f² = 0.14 [0.06, 0.22], P = .22) or control ( R² = 0.10, f² = 0.11 [0.03, 0.19], P = .18) groups.

CONCLUSIONS

  Participants with CAI had decreased isometric hip strength, but that did not equate to dynamic-stability deficits. Clinicians should include hip-muscle strengthening in rehabilitation protocols for patients with CAI, yet these gains may not enhance dynamic stability when landing from a jump.

The Cumberland Ankle Instability Tool (CAIT) in the Dutch population with and without complaints of ankle instability

PURPOSE

To develop a translated Dutch version of the Cumberland Ankle Instability Tool (CAIT) and test its psychometric properties in a Dutch population with foot and ankle complaints.

METHODS

The CAIT was translated into the Dutch language using a forward-backward translation design. Of the 130 subsequent patients visiting the outpatient clinic for foot and ankle complaints who were asked to fill out a questionnaire containing the CAIT, the Foot and Ankle Outcome Score (FAOS), and the numeric rating scale (NRS) pain, 98 completed the questionnaire. After a 1-week period, patients were asked to fill out a second questionnaire online containing the CAIT and NRS pain. This second questionnaire was completed by 70 patients. With these data, the construct validity, test-retest reliability, internal consistency, measurement error, and ceiling and floor effects were assessed. Additionally, a cut-off value to discriminate between stable and unstable ankles, in patients with ankle complaints, was calculated.

RESULTS

Construct validity showed moderate correlations between the CAIT and FAOS subscales (Spearman's correlation coefficient (SCC) = 0.36-0.43), and the NRS pain (SCC = -0.55). The cut-off value was found at 11.5 points of the total CAIT score (range 0-30). Test-retest reliability showed to be excellent with an intraclass correlation coefficient of 0.94. Internal consistency was high (Cronbach's α = 0.86). No ceiling or floor effects were detected.

CONCLUSION

Based on the results, the Dutch version of the CAIT is a valid and reliable questionnaire to assess ankle instability in the Dutch population and is able to differentiate between a functionally unstable and stable ankle. The tool is the first suitable tool to objectify the severity of ankle instability specific complaints and assess change in the Dutch population. Level of evidence II.

Energy dissipation differs between females with and without chronic ankle instability

Chronic ankle instability (CAI) is associated with altered energy dissipation patterns, but comparisons to lateral ankle sprain (LAS) copers have not been explored. The purpose of this study was to examine differences in relative sagittal plane energy dissipation during a single-leg landing between female CAI and LAS coper participants. We separated 33 females (23.6 ± 4.6 years, 164.3 ± 6.2 cm, 69.4 ± 13.7 kg) into CAI (n = 17) and LAS coper (n = 16) groups. Participants completed 5 single-leg landings followed by a 5-second stabilization. We collected sagittal plane kinematics and joint moments at the ankle, knee, hip, and proximal joints (knee and hip) combined then calculated each joint's energy dissipation at 50, 100, 150, and 200 ms post-landing. We compared the percentage of total energy dissipated by the ankle, knee, hip, and proximal joints during each interval utilizing independent t tests and Cohen's d effect sizes. Statistical significance was set a priori at P < .05. The CAI group had lower relative energy dissipation from the ankle at 50 (24.7 ± 11.5% vs 39.2 ± 11.8%, P < .01, d = 1.25 [0.47, 1.95]), 100 (66.9 ± 19.4% vs 77.7 ± 6.5%, P = .04, d = 0.74 [0.01, 1.42]), and 150 ms (70.7 ± 17.8% vs 81.0 ± 5.7%, P = .03, d = 0.77 [0.04, 1.46]) compared to LAS copers. The CAI group had a greater hip contribution through 150 ms (17.9 ± 10.7% vs 11.7 ± 4.4%, P = .04, d =-0.75 [-1.44, -0.03]) and the proximal joints at 50 (75.3 ± 11.5% vs 60.8 ± 11.8%, P < .01, d = -1.25 [-1.96, -0.47]), 100 (33.1 ± 19.4% vs 22.3 ± 6.5%, P = .04, d = -0.74 [-1.42, -0.01]), and 150 ms (29.3 ± 17.8 vs 19.0 ± 5.7%, P = .03, d =-0.77 [-1.46, -0.04]) compared to LAS copers. Females with CAI may benefit from therapeutic exercises designed to correct a single-leg energy dissipation strategy that relies less on the ankle joint.

Neuromuscular Risk Factors for Knee and Ankle Ligament Injuries in Male Youth Soccer Players

Injuries reported in male youth soccer players most commonly occur in the lower extremities, and include a high proportion of ligament sprains at the ankle and knee with a lower proportion of overuse injuries. There is currently a paucity of available literature that examines age- and sex-specific injury risk factors for such injuries within youth soccer players. Epidemiological data have reported movements that lead to non-contact ligament injury include running, twisting and turning, over-reaching and landing. Altered neuromuscular control during these actions has been suggested as a key mechanism in females and adult populations; however, data available in male soccer players is sparse. The focus of this article is to review the available literature and elucidate prevalent risk factors pertaining to male youth soccer players which may contribute to their relative risk of injury.

Development of an efficient rehabilitation exercise program for functional recovery in chronic ankle instability

[Purpose] The aim of the present study was to construct an integrated rehabilitation exercise program to prevent chronic pain and improve motor ability in cases of ankle injury and re-injury. [Subjects and Methods] Twenty-six male soccer players who required functional strength exercises due to repeated ankle injury were the subjects. A 12-week rehabilitation exercise program was constructed with the aim of improving muscle strength in the ankle and dynamic coordination of the lower limb. Muscle strength and dynamic coordination were evaluated using the Y Balance Test, and isokinetic muscle strength of ankle dorsiflexion, plantarflexion, inversion, and eversion were measured before and after the 12-week program. [Results] Following 12 weeks of rehabilitation exercise, there were statistically significant improvements in the ratios of dorsiflexor strength to plantarflexor strength, eversion strength, and inversion strength on the left side. The other variables showed no significant changes. [Conclusion] The rehabilitation exercise program for chronic ankle instability helped to reduce pain, and to restore normal joint range of motion, muscle strength and endurance, and functional ability. Active protocols to improve complex functions need to be developed to complement these results.

Strength-Duration Curves of the Common Fibular Nerve Show Hypoexcitability in People With Functional Ankle Instability

BACKGROUND

Some motor impairments, such as decreased reaction of peroneal muscles, altered kinematics, or poor postural control, have been described in people with functional ankle instability. Evidence shows a possible relationship between fibular nerve impairments and functional ankle instability.

OBJECTIVE

To investigate the electrophysiologic excitability of the common fibular nerve, as measured by strength-duration curves, in subjects with functional ankle instability compared with a control group without ankle impairment.

DESIGN

A cross-sectional study.

SETTING

University Research laboratory.

PARTICIPANTS

Fifty subjects with functional ankle instability (35 men, 15 women; ages 24.36 ± 5.01 years) and 63 uninjured control patients (44 men, 19 women; ages 22.67 ± 4.85 years) were recruited by convenience sampling.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Strength-duration curves of the common fibular nerve were made in all participants. Rheobase, chronaxie, Bawen index, accommodation index, galvano-tetanic threshold, and intensity thresholds for different pulse durations were obtained and compared between the 2 groups.

RESULTS

Subjects with functional ankle instability show increased values of chronaxie (0.58 ± 0.24 ms versus 0.47 ± 0.16 ms; P = .004), Bawen index (1.53 ± 0.24 versus 1.39 ± 0.21; P = .002), and intensity thresholds for pulse durations ≤2 ms both for rectangular and triangular pulse wave forms. The accommodation index was smaller in subjects with functional ankle instability than controls (3.7 ± 0.72 versus 4.05 ± 0.98; P = .036). The remaining parameters did not show significant differences between groups.

CONCLUSIONS

These findings suggest that subjects with functional ankle instability show a decreased excitability in their common fibular nerve when compared with subjects without ankle injuries.

Patient-Reported Outcome Measures in Individuals With Chronic Ankle Instability: A Systematic Review

CONTEXT

A comprehensive systematic literature review of the health-related quality-of-life (HRQOL) differences among individuals with chronic ankle instability (CAI), ankle-sprain copers, and healthy control participants has not been conducted. It could provide a better indication of the self-reported deficits that may be present in individuals with CAI.

OBJECTIVE

To systematically summarize the extent to which HRQOL deficits are present in individuals with CAI.

DATA SOURCES

We searched for articles in the electronic databases of EBSCO Host and PubMed Central using key words chronic, functional, mechanical, coper, instability, sprains, and patient-assessed. We also performed a hand search of reference lists, authors, and patient-reported outcomes (PROs) of the articles screened for inclusion.

STUDY SELECTION

Studies were included if they (1) incorporated a PRO as a participant descriptor or as a study outcome to compare adults with CAI to ankle-sprain copers or healthy controls, (2) were written in English, and (3) were published in peer-reviewed journals.

DATA EXTRACTION

Two authors independently assessed methodologic quality using the modified Downs and Black Index. Articles were filtered into 3 categories based on between-groups comparisons: CAI and copers, CAI and healthy control participants, copers and healthy participants. We calculated Hedges g effect sizes and 95% confidence intervals to examine PRO group differences.

DATA SYNTHESIS

Of the 124 studies assessed for eligibility, 27 were included. A total of 24 articles compared PROs in individuals with CAI and healthy controls, 7 compared individuals with CAI and copers, and 4 compared copers and healthy controls. Quality scores on the modified Downs and Black Index ranged from 52.9% to 88.2%, with 8 high-, 16 moderate-, and 3 low-quality studies. Overall, we observed moderate to strong evidence that individuals with CAI displayed deficits on generic and region-specific PROs compared with copers and healthy controls. However, evidence that differences exist between copers and healthy controls was conflicting. In addition, for dimension-specific outcomes, evidence to suggest that fear of reinjury is heightened in individuals with CAI was limited.

CONCLUSIONS

The evidence suggested that CAI is associated with functional and HRQOL deficits, particularly when examined with region-specific PROs. However, PROs do not appear to differ between copers and healthy controls.

Altered visual focus on sensorimotor control in people with chronic ankle instability

The purpose of this investigation was to examine the effects of the combination of chronic ankle instability (CAI) and altered visual focus on strategies for dynamic stability during a drop-jump task. Nineteen participants with self-reported CAI and 19 healthy participants performed a drop-jump task in looking-up and looking-down conditions. For the looking-up condition, participants looked up and read a random number that flashed on a computer monitor. For the looking-down condition, participants focused their vision on the force plate. Sagittal- and frontal-plane kinematics in the hip, knee and ankle were calculated at the time points of 100 ms pre-initial foot contact to ground and at IC. The resultant vector time to stabilisation was calculated with ground reaction force data. The CAI group demonstrated less hip flexion at the point of 100 ms pre-initial contact (P < 0.01), and less hip flexion (P = 0.03) and knee flexion at initial contact (P = 0.047) compared to controls. No differences in kinematics or dynamic stability were observed in either looking-up or looking-down conditions (P > 0.05). Altered visual focus did not influence movement patterns during the drop-jump task, but the presence of CAI did. The current data suggests that centrally mediated changes associated with CAI may lead to global alterations in the sensorimotor control.

Time to stabilization in single leg drop jump landings: an examination of calculation methods and assessment of differences in sample rate, filter settings and trial length on outcome values

Time to stabilization (TTS) is the time it takes for an individual to return to a baseline or stable state following a jump or hop landing. A large variety exists in methods to calculate the TTS. These methods can be described based on four aspects: (1) the input signal used (vertical, anteroposterior, or mediolateral ground reaction force) (2) signal processing (smoothed by sequential averaging, a moving root-mean-square window, or fitting an unbounded third order polynomial), (3) the stable state (threshold), and (4) the definition of when the (processed) signal is considered stable. Furthermore, differences exist with regard to the sample rate, filter settings and trial length. Twenty-five healthy volunteers performed ten 'single leg drop jump landing' trials. For each trial, TTS was calculated according to 18 previously reported methods. Additionally, the effects of sample rate (1000, 500, 200 and 100 samples/s), filter settings (no filter, 40, 15 and 10 Hz), and trial length (20, 14, 10, 7, 5 and 3s) were assessed. The TTS values varied considerably across the calculation methods. The maximum effect of alterations in the processing settings, averaged over calculation methods, were 2.8% (SD 3.3%) for sample rate, 8.8% (SD 7.7%) for filter settings, and 100.5% (SD 100.9%) for trial length. Differences in TTS calculation methods are affected differently by sample rate, filter settings and trial length. The effects of differences in sample rate and filter settings are generally small, while trial length has a large effect on TTS values.

Longer reaction time of the fibularis longus muscle and reduced postural control in basketball players with functional ankle instability: A pilot study

BACKGROUND

Motor control evaluation in subjects with functional ankle instability is questionable when both ankles of the same subject are compared (affected vs non-affected).

OBJECTIVE

To compare the postural control and reaction time of ankle muscles among: basketball players with FAI (instability group), basketball players without FAI (non-instability group) and healthy non-basketball-playing participants (control group).

DESIGN

Case-control study.

SETTING

Laboratory.

PARTICIPANTS

Instability (n = 10), non-instability (n = 10), and control groups (n = 11).

MAIN OUTCOME MEASURES

Centre of pressure variables (area, velocity and sway) were measured with a force platform. Reaction time of ankle muscles was measured via electromyography.

RESULTS

A one-way ANOVA demonstrated that there were significant differences between the instability and non-instability groups in the fibularis longus (p < 0.001), fibularis brevis (p = 0.031) and tibialis anterior (p = 0.049) muscles. Repeated-measures ANOVA and post hoc analysis determined significant differences for the area between the instability and non-instability groups (p = 0.001).

CONCLUSION

Basketball players with FAI have reduced postural control and longer reaction time of the fibularis and tibialis anterior muscles.

Prevalence of chronic ankle instability in high school and division I athletes

OBJECTIVE

The purpose of this study was to determine the prevalence of chronic ankle instability among high school and collegiate athletes.

DESIGN

Descriptive epidemiological survey.

METHODS

Athletes from four high schools and a division I university were contacted to participate. For collegiate athletes, a questionnaire packet was distributed during preparticipation physicals. For high school athletes, parental consent was obtained and then questionnaires were distributed during preparticipation physicals, parent meetings, or individual team meetings. All athletes completed the Cumberland Ankle Instability Tool for both their left and right ankles. Subjects also provided general demographic data and completed the Ankle Instability Instrument regarding history of lateral ankle sprains and giving way. Athletes were identified as having chronic ankle instability if they scored less than 24 on the Cumberland Ankle Instability Tool.

RESULTS

Of the 512 athletes who completed and returned surveys, 23.4% were identified as having chronic ankle instability. High school athletes were more likely to have chronic ankle instability than their collegiate counterparts (P < .001). Chronic ankle instability was more prevalent among women than among men in both high school (P = .01) and collegiate settings (P = .01).

CONCLUSIONS

Findings of this study revealed differences in the distribution of chronic ankle instability that warrant further study.

Physiological and performance responses to the FIFA 11+ (part 2): a randomised controlled trial on the training effects

The aim of this study was to examine the training effects of an injury prevention programme on neuromuscular control, strength and performance in male amateur football players. Eighty-one players were allocated to the "FIFA 11+" (n = 42) or a control group (CON, n = 39). The "FIFA 11+" group performed the programme 3 times a week for 9 weeks; the control group completed the usual warm-up. Primary outcomes were: time-to-stabilisation test and eccentric/concentric flexors strength. Secondary outcomes were: eccentric/concentric extensors strength, star excursion balance test, core-stability test, vertical jump, sprint, and agility. After controlling for covariates, significant between-group differences after the intervention (in favour of the "FIFA 11+" players) were found for time-to-stabilisation (-2.8%, 90% confidence interval [CI] -4.4 to -1.2%) and core-stability (-8.9%, -14.6 to -3.1%). Differences were also found for eccentric (3.8%, 1.4 to 6.2%) and concentric flexors strength (3.2%, 0.6 to 5.9%) at 60° · s(-1) but this difference was only possibly meaningful (62.4%) from a practical point of view. No substantial and/or significant differences were found for the other outcomes. Performing "FIFA 11+" for 9 weeks can improve neuromuscular control. Possible worthwhile differences were found for flexors strength but there were no substantial effects in the other performance measures.

A systematic review and meta-analysis of dynamic tests and related force plate parameters used to evaluate neuromusculoskeletal function in foot and ankle pathology

BACKGROUND

Force plates are commonly used to register ground reaction forces in order to assess neuromusculoskeletal function of the ankle joint. There exists a great variety in dynamic tests on force plates and in parameters calculated from ground reaction forces in order to evaluate neuromusculoskeletal function of the ankle. The purpose of this study was to evaluate which dynamic tests and force plate parameters are most sensitive to differences between and within groups with regard to foot and ankle pathology.

METHODS

A systematic review and meta-analysis was performed evaluating studies that compared force plate parameters of dynamic tests between patients with foot and ankle pathology, and healthy controls. Data were pooled per parameter and test category. Given the clinical heterogeneity, we constructed comprehensive recommendation criteria to indicate a 'proven relevant parameter' or 'candidate relevant parameter'.

RESULTS

A total of 34 studies were included, and 58 relevant comparisons were identified. Results were subdivided by test category: walking, running, landing (in anteroposterior direction), sideways (movement in mediolateral direction) and termination (movement in anteroposterior direction). The 'walking' test showed significant differences in a great variety of pathologies, with the magnitude and timing of the 'second peak vertical force' as proven relevant parameters. The 'landing' test detected differences due to ankle instability, with 'time to stabilization in anteroposterior direction' as proven relevant parameter.

INTERPRETATION

This study provides recommendations concerning the potential of various dynamic tests and force plate parameters as a tool to compare neuromusculoskeletal function between patients with foot and ankle pathology and healthy controls.

Customized noise-stimulation intensity for bipedal stability and unipedal balance deficits associated with functional ankle instability

CONTEXT

Stochastic resonance stimulation (SRS) administered at an optimal intensity could maximize the effects of treatment on balance.

OBJECTIVE

To determine if a customized optimal SRS intensity is better than a traditional SRS protocol (applying the same percentage sensory threshold intensity for all participants) for improving double- and single-legged balance in participants with or without functional ankle instability (FAI).

DESIGN

Case-control study with an embedded crossover design.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twelve healthy participants (6 men, 6 women; age = 22 ± 2 years, height = 170 ± 7 cm, mass = 64 ± 10 kg) and 12 participants (6 men, 6 women; age = 23 ± 3 years, height = 174 ± 8 cm, mass = 69 ± 10 kg) with FAI.

INTERVENTION(S)

The SRS optimal intensity level was determined by finding the intensity from 4 experimental intensities at the percentage sensory threshold (25% [SRS₂₅], 50% [SRS₅₀], 75% [SRS₇₅], 90% [SRS₉₀]) that produced the greatest improvement in resultant center-of-pressure velocity (R-COPV) over a control condition (SRS₀) during double-legged balance. We examined double- and single-legged balance tests, comparing optimal SRS (SRS(opt1)) and SRS₀ using a battery of center-of-pressure measures in the frontal and sagittal planes.

MAIN OUTCOME MEASURE(S)

Anterior-posterior (A-P) and medial-lateral (M-L) center-of-pressure velocity (COPV) and center-of-pressure excursion (COPE), R-COPV, and 95th percentile center-of-pressure area ellipse (COPA-95).

RESULTS

Data were organized into bins that represented optimal (SRS(opt1)), second (SRS(opt2)), third (SRS(opt3)), and fourth (SRS(opt4)) improvement over SRS₀. The SRS(opt1) enhanced R-COPV (P ≤ .05) over SRS₀ and other SRS conditions (SRS₀ = 0.94 ± 0.32 cm/s, SRS(opt1) = 0.80 ± 0.19 cm/s, SRS(opt2) = 0.88 ± 0.24 cm/s, SRS(opt3) = 0.94 ± 0.25 cm/s, SRS(opt4) = 1.00 ± 0.28 cm/s). However, SRS did not improve R-COPV over SRS₀ when data were categorized by sensory threshold. Furthermore, SRS(opt1) improved double-legged balance over SRS₀ from 11% to 25% in all participants for the center-of-pressure frontal- and sagittal-plane assessments (P ≤ .05). The SRS(opt1) also improved single-legged balance over SRS₀ from 10% to 17% in participants with FAI for the center-of-pressure frontal- and sagittal-plane assessments (P ≤ .05). The SRS(opt1) did not improve single-legged balance in participants with stable ankles.

CONCLUSIONS

The SRS(opt1) improved double-legged balance and transfers to enhancing single-legged balance deficits associated with FAI.

Musculoskeletal conditions of the foot and ankle: assessments and treatment options

Musculoskeletal conditions of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients' quality of life. Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle. This review provides a summary of the assessments and non-invasive treatment options based upon available evidence. Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance that may be evident in static and/or dynamic tasks. In addition, both clinical and epidemiological studies support the inter-dependence between the foot and proximal joints. For instance, aberrant foot structure has been linked to foot osteoarthritis (OA), as well as OA and pain at the knee and hip. Most recently, advances in motion capture technology and plantar load distribution measurement offer opportunities for precise dynamic assessments of the foot and ankle. In individuals with musculoskeletal conditions of the foot and ankle, the chief objectives of treatment are to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Given that most patients present with multiple impairments, combinational therapies that target foot-specific as well as global impairments have shown promising results. In particular, in individuals with rheumatoid arthritis and other rheumatic diseases, comprehensive rehabilitation strategies including early detection, foot-based interventions (such as orthoses) and wellness-based approaches for physical activity and self-management have been successful. While significant improvements have been made in the last decade to the assessment and treatment of foot and ankle conditions, few randomised clinical trials specifically have investigated patients with foot or ankle conditions to provide global insights into this area. Consequently, current recommendations vary based upon the scope of studies presented in this review as well as the strength of studies. This review indicates a need for more in-depth investigations into the components of assessment and treatment options for foot and ankle musculoskeletal conditions.

Discriminating between copers and people with chronic ankle instability

CONTEXT

Differences in various outcome measures have been identified between people who have sprained their ankles but have no residual symptoms (copers) and people with chronic ankle instability (CAI). However, the diagnostic utility of the reported outcome measures has rarely been determined. Identifying outcome measures capable of predicting who is less likely to develop CAI could improve rehabilitation protocols and increase the efficiency of these measures.

OBJECTIVE

To determine the diagnostic utility and cutoff scores of perceptual, mechanical, and sensorimotor outcome measures between copers and people with CAI by using receiver operating characteristic curves.

DESIGN

Case-control study.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-four copers (12 men, 12 women; age = 20.8 ± 1.5 years, height = 173 ± 11 cm, mass = 78 ± 27 kg) and 24 people with CAI (12 men, 12 women; age = 21.7 ± 2.8 years, height = 175 ± 13 cm, mass = 71 ± 13 kg) participated.

INTERVENTION(S)

Self-reported disability questionnaires, radiographic images, and a single-legged hop stabilization test.

MAIN OUTCOME MEASURE(S)

Perceptual outcomes included scores on the Foot and Ankle Disability Index (FADI), FADI-Sport, and a self-report questionnaire of ankle function. Mechanically, talar position was quantified by measuring the distance from the anterior tibia to the anterior talus in the sagittal plane. Sensorimotor outcomes were the dynamic postural stability index and directional indices, which were calculated during a single-legged hop stabilization task.

RESULTS

Perceptual outcomes demonstrated diagnostic accuracy (range, 0.79-0.91), with 95% confidence intervals ranging from 0.65 to 1.00. Sensorimotor outcomes also were able to discriminate between copers and people with CAI but with less accuracy (range, 0.69-0.70), with 95% confidence intervals ranging from 0.37 to 0.86. The mechanical outcome demonstrated poor diagnostic accuracy (0.52).

CONCLUSIONS

The greatest diagnostic utility scores were achieved by the self-assessed disability questionnaires, which indicated that perceptual outcomes had the greatest ability to accurately predict people who became copers after their initial injuries. However, the diversity of outcome measures that discriminated between copers and people with CAI indicated that the causal mechanism of CAI is probably multifactorial.

The multiple hop test: a discriminative or evaluative instrument for chronic ankle instability?

OBJECTIVE

To determine whether the multiple hop test should be used as an evaluative or a discriminative instrument for chronic ankle instability (CAI).

DESIGN

Blinded case-control study.

SETTING

: University research laboratory.

PARTICIPANTS

Twenty-nine healthy subjects (21 men, 8 women, mean age 21.8 years) and 29 patients with CAI (17 men, 12 women, mean age 24.9 years) were selected.

INTERVENTIONS

Subjects performed a multiple hop test and hopped on 10 different tape markers while trying to avoid any postural correction.

MAIN OUTCOME MEASURES

Minimal detectable changes (MDC) of the number of balance errors, the time value, and the visual analog scale (VAS) score (perceived difficulty) were calculated as evaluative measures. For the discriminative properties, a receiver operating characteristic curve was determined and the area under curve (AUC), the sensitivity, specificity, diagnostic accuracy (DA), and likelihood ratios (LR) were calculated whether 1, 2, or 3 outcomes were positive.

RESULTS

Based on their MDC, outcomes should, respectively, change by more than 7 errors (41%), 6 seconds (15%), and 27 mm (55%, VAS score) before considering it as a real change. Area under curves were, respectively, 79% (errors), 77% (time value), and 65% (VAS score). The most optimal cutoff point was, respectively, 13.5 errors, 35 seconds, and 32.5 mm. When 2 of 3 outcomes were positive, the sensitivity was 86%, the specificity was 79%, the DA was 83%, the positive LR was 4.2, and the negative LR was 0.17.

CONCLUSIONS

The multiple hop test seems to be more a discriminative instrument for CAI, and its responsiveness needs to be demonstrated.

Avaliação do torque de resistência passiva em atletas femininas com entorse de tornozelo

INTRODUÇÃO: A entorse de tornozelo é uma das lesões mais comuns em atletas. Uma forma de avaliar a frouxidão ligamentar pode ser através da medida da amplitude passiva dos movimentos de inversão e eversão do pé para estimar a resistência passiva das estruturas capsuloligamentares do tornozelo, o qual pode ser chamado de torque de resistência passiva. Existem poucos estudos que utilizam a avaliação do torque passivo do tornozelo para avaliar a resistência da cápsula e dos ligamentos. OBJETIVO: O objetivo deste estudo foi comparar o torque passivo dos movimentos de inversão e eversão do pé em atletas com e sem história de entorse de tornozelo. MÉTODO: Participaram do estudo 32 atletas de basquetebol e voleibol feminino (16,06 ± 0,8 anos, 67,63 ± 8,17kg, 177,8 ± 6,47cm). Seus tornozelos foram divididos em dois grupos: grupo controle (29), composto por tornozelos sem sintomas, e grupo entorse de tornozelo, composto por tornozelos que sofreram lesão (29). O torque dos movimentos passivos do tornozelo foi registrado por um dinamômetro isocinético, e a atividade dos músculos fibular longo e tibial anterior foi medida por um eletromiógrafo. As atletas realizaram duas repetições do movimento de inversão e eversão, nas velocidades de 5, 10 e 20°/s e, em seguida, o mesmo protocolo foi repetido apenas para o movimento de inversão máxima do pé. RESULTADOS: O torque de resistência passiva durante os movimentos de inversão e eversão do pé foi menor no grupo com entorse do tornozelo. Este grupo também mostrou menor torque durante o movimento de inversão máxima do pé. Não foram observadas diferenças entre o movimento de inversão e eversão. CONCLUSÕES: A entorse de tornozelo leva a um menor torque de resistência passiva, indicando redução da resistência dos ligamentos colaterais do tornozelo e uma frouxidão articular mecânica.

Instrumentos de avaliação para limitações funcionais associadas à instabilidade crônica de tornozelo: uma revisão sistemática da literatura

A instabilidade de tornozelo é definida como a sua tendência para sofrer falseios e entorses de repetição após a ocorrência de entorse lateral. Como a presença de instabilidade é definida por meio das queixas relatadas pelo indivíduo, apresenta caráter subjetivo, sendo importante identificar o melhor instrumento de avaliação para a determinação de sua presença e/ou gravidade. O objetivo deste estudo foi revisar, de forma sistemática, instrumentos de avaliação concebidos para pacientes com instabilidade crônica de tornozelo. Foram realizadas pesquisas bibliográficas nas bases de dados PubMed, Embase, BVS, LILACS e SciELO para identificar os instrumentos elegíveis. No total, seis estudos foram incluídos e apresentaram cinco instrumentos diferentes - Foot and Ankle Disability Index (FADI), Ankle Joint Functional Assessment Tool (AJFAT), Foot and Ankle Ability Measure (FAAM), Ankle Joint Functional Assessment Tool (AII) e Cumberland Ankle Instability Tool (CAIT). Foram encontrados instrumentos com qualidade que detectam limitações funcionais em indivíduos com instabilidade crônica de tornozelo, não sendo instrumentos válidos para diagnóstico de instabilidade. O CAIT mostrou-se a ferramenta mais completa, mas não foi validada em uma população específica de indivíduos com condição de instabilidade do tornozelo. Observa-se a necessidade de mais estudos clinimétricamente válidos a fim de atestar a sua validade para se obter uma ferramenta eficaz e completa da instabilidade funcional do tornozelo.