Validity and Responsiveness of a Modified Balance Error Scoring System Assessment Using a Mobile Device Application in Patients Recovering from Ankle Sprain

Background

Static balance is often impaired in patients after ankle sprains. The ability to identify static balance impairments is dependent on an effective balance assessment tool. The Sway Balance Mobile Application (SWAY App) (Sway Medical, Tulsa, OK) uses a smart phone or tablet to assess postural sway during a modified Balance Error Scoring System (mBESS) assessment and shows promise as an accessible method to quantify changes in static balance after injury.

Purpose

The primary purposes of this study were to determine the ability to differentiate between those with ankle sprain versus controls (construct validity) and ability to detect change over time (responsiveness) of a mBESS assessment using a mobile device application to evaluate static balance after an acute ankle sprain.

Study Design

Case-control study.

Methods

Twenty-two military academy Cadets with an acute ankle sprain and 20 healthy Cadets were enrolled in the study. All participants completed an assessment measuring self-reported function, ankle dorsiflexion range of motion (via the weightbearing lunge), dynamic balance, and static balance. Static balance measured with the mBESS using the SWAY App was validated against laboratory-based measures. Cadets with ankle sprains completed their assessment twice: once within two weeks of injury (baseline) and again after four weeks of rehabilitation that included balance training. Independent and paired t-tests were utilized to analyze differences over time and between groups. Effect sizes were calculated and relationships explored using Pearson's correlation coefficients.

Results

The mBESS scores measured by the SWAY App were lower in participants with acute ankle sprains than healthy Cadets (t = 3.15, p = 0.004). Injured participants improved their mBESS score measured by SWAY at four weeks following their initial assessments (t = 3.31, p = 0.004; Baseline: 74.2 +/- 16.1, 4-weeks: 82.7 +/- 9.5). The mBESS measured by the SWAY App demonstrated moderate to good correlation with a laboratory measure of static balance (r = -0.59, p \< 0.001).

Conclusion

The mBESS assessed with a mobile device application is a valid and responsive clinical tool for evaluating static balance. The tool demonstrated construct (known groups) validity detecting balance differences between a healthy and injured group, concurrent validity demonstrating moderate to good correlation with established laboratory measures, and responsiveness to changes in static balance in military Cadets during recovery from an acute ankle sprain.

Level of Evidence

Level 3.

IMPLEMENTATION OF OTTAWA ANKLE RULES IN UNIVERSITY HOSPITAL EMERGENCY ROOM: PILOT STUDY

Ankle injuries are the most common musculoskeletal injuries in emergency rooms and are associated with a great social and economic impact. The need to request additional tests for ankle sprains is based on suspicion of fracture. The Ottawa Ankle Rules (OAR) establish criteria for ordering radiographs to avoid performing unnecessary examinations.

OBJECTIVE

To evaluate the implementation of the Ottawa Rules as a protocol for treating ankle sprains in the emergency department of a university hospital.

METHODS

This is a retrospective observational study, conducted over a period of three months before and three months after implementation of the protocol.

RESULTS

In the first phase, all patients complaining of ankle sprain underwent radiographs. In the second phase, after the application of the OAR, out of 85 patients evaluated, only 58 underwent complementary exams, showing a reduction of 31.8% in the request for imaging exams. There was no significant difference in fracture detection between the two groups (p=0.476).

CONCLUSION

The OAR can be used as a tool in diagnosing ankle sprains, and their implementation reduced the request for imaging exams. Level of Evidence III, Retrospective Comparative Study.

Effects of gait training with auditory biofeedback on biomechanics and talar cartilage characteristics in individuals with chronic ankle instability: A randomized controlled trial

BACKGROUND

Altered walking gait is a typical impairment following ankle sprains which may increase susceptibility to recurring injuries and development of posttraumatic osteoarthritis at the ankle. There is a lack of targeted gait training interventions focusing on specific modifications in individuals with chronic ankle instability (CAI). Additionally, there is a need to focus on cartilage health changes following gait training to mitigate osteoarthritis progression.

RESEARCH QUESTION

To determine the immediate and retention effects of gait training using auditory biofeedback (AudFB) in patients with chronic ankle instability (CAI) on biomechanics and talar cartilage characteristics.

METHODS

Eighteen participants with CAI were randomly assigned into Control (n = 7) or AudFB (n = 11) groups. Each group completed 8-sessions of 30-minute treadmill walking. The AudFB group received biofeedback through a pressure sensor fashioned to the lateral foot and instructions to walk while avoiding noise from the sensor. The Control group did not receive instructions during sessions. An in-shoe insole system measured peak pressure, maximum force, and center of the pressure gait line (COP) during walking. Ultrasonography captured talar cartilage thickness and echo intensity before and after walking. Biomechanics and ultrasound were measured at baseline, immediately, and 1-week after the intervention. Repeated measures mixed-methods analysis of variance assessed changes within groups across time.

RESULTS

The AudFB group significantly reduced pressure and force in the lateral foot and medially shifted their COP at Immediate and 1-week Post. There were no observed changes in the Control group. In addition, neither group demonstrated changes in ultrasound measures at follow-up.

SIGNIFICANCE

Implementation of auditory biofeedback during gait training can be a valuable tool for clinicians treating patients with CAI.

Plantar pressure profile during walking is associated with talar cartilage characteristics in individuals with chronic ankle instability

BACKGROUND

Individuals with chronic ankle instability typically present with abnormal gait patterns favoring the lateral foot. This gait pattern may alter cartilage stress potentially increasing the risk of osteoarthritis development, thus exploring this relationship may provide insights for early interventions. The purpose of this study was to examine the relationship gait biomechanics and talar articular cartilage characteristics.

METHODS

Talar articular cartilage was assessed with ultrasound at rest and after walking for 30-min in twenty-five adults (14 females, 22.6 ± 3.12 years, 168.12 ± 9.83 cm, 76.00 ± 15.47 kg) with chronic ankle instability. Cartilage was segmented into Total, Medial, and Lateral regions. During the 30-min walking period, plantar pressure of the entire foot was recorded every 5-min and condensed to create a biomechanical loading pattern and center of pressure gait line. Relationships between resting cartilage thickness and echo intensity, changes in thickness and echo intensity, and plantar pressure profiles were assessed with correlation coefficients.

FINDINGS

There was a significant relationship between plantar pressure in the lateral forefoot and medial talar cartilage deformation (r = 0.408, p < .05). Early stance center of pressure was correlated with deformation in the total (r = 0.439-0.524) and lateral (r = 0.443-0.550) regions (p < .05). There were no significant correlations between echo intensity and biomechanics.

INTERPRETATION

This study contributes to the growing evidence that talar cartilage strain patterns are associated with biomechanics during walking. Further validation is needed to determine a causal relationship between biomechanics and ultrasound cartilage characteristics after ankle sprains. In addition, research should continue determining the utility of ultrasound to monitor joint health after musculoskeletal injuries.

Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain

OBJECTIVE

Distal fibular mobilization with movement (MWM), with and without a posterior gliding fibular tape, and anteroposterior mobilization of the talus (MOB) are widely used to treat acute lateral ankle sprains. The purpose of this study was to investigate the short-term and long-term relative effectiveness of these techniques.

METHODS

In this double-blind randomized controlled trial, 45 amateur soccer players with acute (<72 hours) lateral ankle sprain were randomly allocated to 6 sessions (3/wk within the first 2 weeks) of either MWM, MWM with tape (MWMtape), or MOB. All participants also received general advice, transcutaneous electrical nerve stimulation, edema draining massage, and a program of proprioception exercises. Participant ratings of function on the Foot and Ankle Ability Measure and Patient Global Impression of Improvement Scale were the primary outcomes measured over 52 weeks. Secondary outcomes were ankle pain, pressure pain threshold, range of motion, volume, and strength.

RESULTS

MWM and MWMtape were equally effective and participants demonstrated greater function on the Foot and Ankle Ability Measure at 12 and 52 weeks when compared with those receiving MOB; however, the latter demonstrated superior function at 2 weeks. No differences between groups were observed for Patient Global Impression of Improvement Scale or any of the secondary outcomes.

CONCLUSION

There are limited differences in the short term among techniques, with the exception of better sport function with MOB. Over the longer term, the distal fibular MWM is most effective to achieve activities of daily living and sport function when added to usual physical therapy care. The addition of a posterior gliding fibular tape provides no additional benefit.

IMPACT

Distal fibular mobilization with movement may be the most appropriate choice of treatment for acute lateral ankle sprain to achieve long-term activities of daily living and sport function. In the short term, anteroposterior mobilization of the talus offers greater improvement in sport function. The use of fibular tape provides no added benefit as an adjunct to a treatment that includes distal fibular mobilization with movement.

Neuromuscular Mechanosensitivity in Subjects with Chronic Ankle Sprain: A Cross-Sectional Study

BACKGROUND

Ankle sprain is one of the most common musculoskeletal injuries in sports, at work, and at home. Subjects who suffer from this injury may develop ankle instability. Functional instability has been associated with a high rate of resprain and impaired neuromuscular control in patients with ankle instability.

OBJECTIVE

Measurement of neural and muscular mechanosensitivity after ankle sprain injury and establishment of the relationship between these variables.

METHODS

A cross-sectional case-control study was performed with a sample of 58 students from Alcalá de Henares University (21 males and 37 females, mean age ± SD = 21 ± 3.7 years). Subjects were divided into two groups: a case group (N = 29, subjects with unstable ankle) and a control group (N = 29, healthy subjects). The pressure pain threshold (PPT) of the tibialis anterior, peroneus longus, and peroneus brevis muscles and mechanosensitivity of the common peroneus and tibial nerves were evaluated in all subjects through a manual mechanical algometer.

RESULTS

Neuromuscular PPTs showed significant differences (P < 0.05) between both groups, such that, compared with the control group, the case group exhibited significantly lower PPT levels. In the case group, a strong positive correlation was observed between neural and muscular homolateral mechanosensitivity in both lower limbs.

CONCLUSIONS

Participants with chronic ankle instability showed higher neuromuscular mechanosensitivity in muscles and nerves surrounding the ankle joint than healthy subjects. These findings indicate that low PPT values may be associated with symptoms that characterize this disease.

Intervention Strategies Used in Sport Injury Prevention Studies: A Systematic Review Identifying Studies Applying the Haddon Matrix

BACKGROUND

Prevention of sport injuries is crucial to maximise the health and societal benefits of a physically active lifestyle. To strengthen the translation and implementation of the available evidence base on effective preventive measures, a range of potentially relevant strategies should be considered.

OBJECTIVE

Our aim was to identify and categorise intervention strategies for the prevention of acute sport injuries evaluated in the scientific literature, applying the Haddon matrix, and identify potential knowledge gaps.

METHODS

Five electronic databases were searched (PubMed, EMBASE, SPORTDiscus, CINAHL, Cochrane) for studies that evaluated the effect of interventions on the occurrence of acute sport injuries. Studies were required to include a control group/condition, prospective data collection, and a quantitative injury outcome measure.

RESULTS

A total of 155 studies were included, mostly randomised controlled trials (43%). The majority of studies (55%) focussed on strategies requiring a behavioural change on the part of athletes. Studies predominantly evaluated the preventive effect of various training programmes targeted at the 'pre-event' phase (n = 73) and the use of equipment to avoid injury in the 'event phase' (n = 29). A limited number of studies evaluated the preventive effect of strategies geared at rules and regulations (n = 14), and contextual modifications (n = 18). Studies specifically aimed at preventing re-injuries were a minority (n = 8), and were mostly related to ankle sprains (n = 5).

CONCLUSIONS

Valuable insight into the extent of the evidence base of sport injury prevention studies was obtained for 20 potential intervention strategies. This approach can be used to monitor potential gaps in the knowledge base on sport injury prevention.

Exercise-Based Interventions for Injury Prevention in Tackle Collision Ball Sports: A Systematic Review

BACKGROUND

The injury burden in collision sports is relatively high compared to other team sports. Therefore, participants in these sports would benefit by having effective injury prevention programs. Exercise-based interventions have successfully reduced injuries in soccer, but evidence on exercise-based interventions in tackle collision sports is limited.

OBJECTIVE

The objective of this review is to systematically examine the evidence of exercise-based intervention programs reducing injuries in tackle collision sports.

DATA SOURCES

PubMed, EBSCOHost, and Web of Science were searched for articles published between January 1995 and December 2015. The methodological quality was assessed using an adapted Cochrane Bone Joint and Muscle Trauma Group quality assessment tool.

STUDY SELECTION

The inclusion criteria were (1) (randomized) control trials and observational studies; (2) sporting codes: American, Australian and Gaelic Football, rugby union, and rugby league; (3) participants of any age or sex; (4) exercise-based, prehabilitative intervention; and (5) primary outcome was injury rate or incidence (injury risk). The exclusion criteria were (1) unavailability of full-text; and (2) article unavailable in English.

RESULTS

Nine studies with a total of 3517 participants were included in this review. Seven of these studies showed a significant decrease in injury risk. These studies included three sporting codes and various age groups, making it difficult to make inferences. The two highest methodological quality studies found no effect of an exercise-based intervention on injury risk.

CONCLUSIONS

There is evidence that exercise-based injury preventions can be beneficial in reducing injury risk in collision sports, but more studies of high methodological quality are required.

The Prevalence of Selected Intrinsic Risk Factors for Ankle Sprain Among Elite Football and Basketball Players

BACKGROUND

Lateral ankle sprains (LAS) are among the most common sports- related injuries and the reinjury rate is very high.

OBJECTIVES

This study aimed to evaluate the prevalence of some intrinsic risk factors among professional football and basketball players with or without history of acute or recurrent ankle sprain.

PATIENTS AND METHODS

One hundred and six professional football and basketball players who were referred for pre-participation examinations were recruited in this study. Prepared checklist was completed for each participant. Athletes were asked for any history of previous ankle sprain and the severity (based of self-description of signs and symptoms by the athlete), level and number of injuries in the last two years. All players were assessed for measures of foot posture index- 6, foot length and width, Beighton generalized joint laxity score, anterior drawer and talar tilt tests, star excursion and single leg balance tests and goniometric assessment of ankle plantarflexion, ankle dorsiflexion and first metatarsophalangeal dorsiflexion.

RESULTS

Forty eight basketball players (45.3%) and 58 football players (54.7%) with mean (SD) age of 19.8 (4.5) years participated. About 58.5% and 14.2% of athletes had a history of ankle sprain and recurrent sprain in at least one extremity, respectively. Sprains were more prevalent in basketball players and in dominant leg. There was no significant difference in assessed risk factors between athletes with and without history of ankle sprain, except for positive single leg balance test which was more prevalent in athletes with history of ankle sprain and also for positive talar tilt test and decreased ankle plantarflexion range of motion in acute and recurrent injury of left ankle.

CONCLUSIONS

Some intrinsic risk factors including lateral ankle ligaments laxity, balance and ankle plantarflexion seem to be related to acute or recurrent LAS in athletes. Further research is needed to reveal the role of different arthrokinematics following lateral ankle sprain.

Intraarticular Entrapment of Os Subfibulare Following a Severe Inversion Injury of the Ankle: A Case Report

INTRODUCTION

Anterior Talofibular Ligament (ATFL) rupture is the most commonly injured anatomic structure in lateral ankle sprain. In some cases, ATFL avulsion fracture from the lateral malleolus may occur instead of purely ligamentous injuries. The ATFL avulsion fracture is detected as a small ossicle at the tip of lateral malleolus on direct radiographs, which is called os subfibulare in chronic cases.

CASE PRESENTATION

Severe displacement of this ossicle to the tibiotalar joint space is an extremely rare injury. Herein, a case of intra-articular entrapment of os subfibulare following a severe inversion injury of the ankle, which caused a diagnostic challenge was presented.

CONCLUSIONS

To the best of our knowledge, this is the first case of entrapment of os subfibulare in the talotibial joint space. Fixation of the os subfibulare to lateral malleolus resulted in union and excellent functional results.

Naproxen Twice Daily Versus as Needed (PRN) Dosing: Efficacy and Tolerability for Treatment of Acute Ankle Sprain, a Randomized Clinical Trial

Purpose

This study was conducted to compare the efficacy and safety of naproxen 500 mg twice daily (BID) versus naproxen 500 mg as needed (PRN) for treatment of ankle sprain.

Methods

In this seven-day, randomized, parallel group trial, 135 patients with ankle sprain occurring less than 48 hours prior to the first dose of study medication were randomized to receive naproxen 500 mg BID (67 patients) and naproxen 500 mg as needed (PRN) (68 patients). The ankle pain was assessed at rest and on full weight bearing using Numeric Rating Scale (NRS) from 0 (no pain) to 10 (the worst imaginable pain). Ankle swelling was assessed as a 4-point scale ranging from 0 (no swelling) to 3 (severe swelling) rated by the investigator. The primary efficacy end point was the patient's assessment of ankle pain via NRS and the degree of swelling on day seven.

Results

Results showed a significant decrease in pain on weight bearing, pain at rest and the extent of swelling (P<0.001) in both groups, but there was no substantial difference between the two groups (P>0.05) after seven days. Assessing the safety profile of the two different dosing, 13.3% of the naproxen BID group and 6.7% of the as needed group had adverse events, showing that the as needed regimen was safer (P<0.001).

Conclusion

Results showed that naproxen as needed may reduce the pain and edema of the sprained ankle with no significant difference compared to the BID regimen, while it possesses better safety profile and lower total drug use.