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

OBJECTIVES

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

DESIGN

Descriptive epidemiology study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Validity and Reliability of Hindi version of Foot and Ankle Disability Index in patients with chronic recurrent lateral ankle sprain

BACKGROUND

Lateral Ankle Sprain (LAS) is a recurrent musculoskeletal injury commonly noticed in primary care, podiatry, orthopaedics, and physical therapy centers. The Foot and Ankle Disability Index (FADI) is a self-reported and region-specific tool with no previous literature available on the translation of the FADI scale into Hindi language.

AIM

The study aims to translate and evaluate each translated domain of FADI to see its cross-cultural adaptation, content validity and reliability for patients with chronic recurrent LAS.

STUDY DESIGN

A Cross-Sectional Study.

METHODS

The scale was translated from the reference language to the target language, Hindi, using the instructions provided in the literature. Delphi survey was conducted for content validation followed by recruitment of 51 participants with a history of long lasting repetitive lateral sprain of ankle to evaluate test-retest reliability of Hindi version of FADI.

RESULT

The S-CVI/Ave and S-CVI/UA came out to be 0.988 and 0.884, respectively and I-CVI for all items of Hindi version of FADI were more than 0.90. The ICC (Intra-class Correlation Coefficient) and internal consistency was evaluated, which came out to 0.961 and 0.980, respectively for Hindi version of FADI.

CONCLUSION

Hindi version of FADI is a valid and reliable scale that has been translated and adapted to be implemented among Indian population suffering from long lasting repetitive LAS.

FADI EVALUATION OF THE EFFECTS OF KINESITHERAPY AFTER ANKLE FRACTURE

The aim of the study was to analyze the values of Foot and Ankle Disability Index (FADI) after kinesitherapy in subjects with bimalleolar or trimalleolar fracture of the ankle after surgery treatment and the obtained values of manual muscle test (MMT) and range of motion (ROM) after rehabilitation, compared with the obtained values of FADI index and on that basis evaluate its possibility in assessing the functionality of the respondents after surgery for bimalleolar or trimalleolar fracture of the ankle. The sample included 60 subjects over the age of 18 who underwent surgery for osteosynthesis due to bimalleolar or trimalleolar fracture of the ankle. All subjects were treated with kinesitherapy as part of the postoperative rehabilitation program. The research was conducted from 2013 to 2018 at the Department of Orthopedics of Dr. Safet MujiÊ Cantonal Hospital in Mostar and Mostar University Clinical Hospital. A statistically significant correlation was found between FADI index values per group and average percentage recovery per MMT (p<0.05), as well as a statistically significant correlation between FADI score values per group and mean percentage ROM value (p<0.05). A statistically significant association was found between mean percentage recovery per ROM and MMT (p<0.05). The conducted research confirmed the working hypothesis of the conducted study. The effects of kinesitherapy after ankle surgery can be evaluated using the FADI index, as well as by manual muscle test and ROM measurement.

[Physical rehabilitation for ankle joint injuries in elderly and elderly people (Stage 2).]

The main part of the injuries of elderly and senile patients as a result of physical activity falls on the lower limbs, due to the increased load during movement. Ankle injuries have a multifactorial etiology involving the interaction of compensatory spinal and leg biomechanics, environmental factors, and shoe selection. In this regard, it is necessary to prepare a complex of rehabilitation measures, including physical therapy, with the possibility of implementing the recovery process not only on an outpatient basis, but also at home, thereby improving the quality of life and preventing disability. The patients of the comparison group received standard complex therapy, including orthopedic methods of treatment, drug therapy, myostimulation, and massage. For patients of the main group, in addition to the traditional complex, the exercise therapy technique according to the claimed method was added. The study revealed no significant complications and side effects when using this technique, which allows us to recommend it as a means of secondary prevention and injuries of the ankle joint, especially when conservative and targeted therapy is contraindicated. A significant difference was found in goniometry parameters after the recovery period in patients in the main and comparison groups.

[Physical rehabilitation for ankle joint injuries in elderly and elderly people (Stage 1).]

A multidisciplinary approach to recovery after injuries of the ankle joint in elderly and senile people by specialists of various profiles using drug and non-drug methods is especially relevant today. It is required to develop and put into practice various options for the combined use of physical rehabilitation means at different stages of the rehabilitation treatment of elderly and senile patients with this pathology. The study revealed no significant complications and side effects when using this technique, which allows us to recommend it as a means of secondary prevention and injuries of the ankle joint, especially with contraindications to the use of non-steroidal anti-inflammatory drugs and glucocorticosteroids. A significant difference was found in goniometry parameters after the recovery period in patients in the main and comparison groups. Despite the fact that in both groups the difference in values was probably significant, but in the main group it was much larger (almost 1,5 times). The technique can be recommended for use in fitness centers, athletic halls and medical and physical education dispensaries.

Kinetic Effects of 6 Weeks' Pilates or Balance Training in College Soccer Players with Chronic Ankle Instability

Lateral ankle sprain (LAS) is a common sports injury that frequently occurs in active individuals. LAS is characterized by a high recurrence rate, with a large proportion of patients progressing to chronic ankle instability (CAI). Pilates exercises have provided positive results in health care and in rehabilitation. This study compared Pilates training (PT) with traditional balance training (BT) in patients with CAI. Fifty-one college football players with CAI, divided into PT (n = 26) and BT (n = 25) groups, were included in the study. The groups performed PT or BT training as assigned, three times per week for 6 weeks. Isokinetic ankle strength, one-leg hop tests, Y-balance test (YBT), and foot and ankle outcome score (FAOS) were evaluated before and after training. There were considerable improvements in both the PT and BT groups after training. Group and time comparisons revealed that the PT group achieved better triple hop test results than the BT group, whereas the BT group exhibited a greater improvement in YBT posteromedial and posterolateral reach distances. In athletes with CAI, both PT and BT effectively improved symptoms and function. These findings suggest that ankle strength, balance, and core stability should be comprehensively evaluated and targeted in CAI rehabilitation programs.

Tertiary rehabilitation in acute ankle sprain caused by sports training

BACKGROUND

An ankle sprain is a common joint sprain in sports injury, which is closely related to its physiological position and anatomical characteristics, and may progress into chronic ankle instability after improper early treatment or premature exercise.

OBJECTIVE

To analyze the tertiary rehabilitation effect of acute lateral ankle sprain caused by sports training.

METHOD

Ninety-six athletes with acute lateral ankle sprain diagnosed from January 2019 to June 2020 were included and divided into the control group and the rehabilitation group using the random number table grouping method, with 48 cases in each group. The two groups received standardized treatment, and the rehabilitation group additionally received tertiary rehabilitation. The American Orthopedic Foot and Ankle Society (AOFAS ) scores, degree of ankle swelling, pain, and re-injury rate were compared between the two groups.

RESULTS

The AOFAS scores of the two groups increased after treatment (P< 0.05). The degree of swelling in both groups after treatment was improved (P< 0.05). The Visual Analogue Scale (VAS) scores in both groups declined two weeks after treatment, with lower results observed in the rehabilitation group The two groups showed similar results of the follow-up visit (P< 0.05).

CONCLUSION

Rehabilitation exercise on acute lateral ankle sprain effectively relieves ankle swelling and pain.

Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis

Research questions

1) Do exercise-based rehabilitation programs reduce re-injury following acute ankle sprain?; 2) Is rehabilitation effectiveness moderated by the exercise’s therapeutic quality, content and volume?

Methods

This systematic review with meta-analysis (PROSPERO: CRD42020210858) included randomized controlled trials in which adults who sustained an acute ankle sprain received exercise-based rehabilitation as an intervention. Databases CINAHL, Web of Science, SPORTDiscus, Cochrane Central Register of Controlled Trials, PEDro and Google Scholar were searched for eligible articles (last search: March 2021). ROB II screening tool by Cochrane was used to assess risk of bias and the i-CONTENT tool was used to assess quality of interventions. Both qualitative analysis and quantitative data synthesis were performed.

Results

Fourteen randomized controlled trials comprising 2182 participants were included. Five studies were judged overall low risk of bias and i-CONTENT assessment showed poor to moderate therapeutic quality of exercise across all included articles. Pooled data found significant reductions in re-injury prevalence at 12 months, in favour of the exercise-based rehabilitation group vs usual care (OR: 0.60; 95%CI: 0.36 to 0.99). Pooled data for re-injury incidence showed not-significant results (MD: 0.027; 95%CI: -2.14 to 2.19). Meta-regression displayed no statistically significant association between training volume and odds of re-injury (r = -0.00086; SD: 0.00057; 95%CI: -0.00197 to 0.00025). Results from patient-reported outcomes and clinical outcomes were inconclusive at 1 month, 3–6 months and 7–12 months of follow up.

Conclusion

Exercise-based rehabilitation reduces the risk of recurrent ankle sprain compared to usual care, but there is insufficient data to determine the optimal content of exercise-based interventions. Training volume varied considerably across studies but did not affect the odds of sustaining a re-injury. Effects on patient-reported outcomes and clinical outcomes are equivocal. Future research should compare different exercise contents, training volumes and intensities after ankle sprain.

Passive Exercise Adaptation for Ankle Rehabilitation Based on Learning Control Framework

Ankle injuries are among the most common injuries in sport and daily life. However, for their recovery, it is important for patients to perform rehabilitation exercises. These exercises are usually done with a therapist's guidance to help strengthen the patient's ankle joint and restore its range of motion. However, in order to share the load with therapists so that they can offer assistance to more patients, and to provide an efficient and safe way for patients to perform ankle rehabilitation exercises, we propose a framework that integrates learning techniques with a 3-PRS parallel robot, acting together as an ankle rehabilitation device. In this paper, we propose to use passive rehabilitation exercises for dorsiflexion/plantar flexion and inversion/eversion ankle movements. The therapist is needed in the first stage to design the exercise with the patient by teaching the robot intuitively through learning from demonstration. We then propose a learning control scheme based on dynamic movement primitives and iterative learning control, which takes the designed exercise trajectory as a demonstration (an input) together with the recorded forces in order to reproduce the exercise with the patient for a number of repetitions defined by the therapist. During the execution, our approach monitors the sensed forces and adapts the trajectory by adding the necessary offsets to the original trajectory to reduce its range without modifying the original trajectory and subsequently reducing the measured forces. After a predefined number of repetitions, the algorithm restores the range gradually, until the patient is able to perform the originally designed exercise. We validate the proposed framework with both real experiments and simulation using a Simulink model of the rehabilitation parallel robot that has been developed in our lab.

A New Trajectory Determination Method for Robot-Assisted Ankle Ligament Rehabilitation

Keeping ligament strain at an appropriate range is beneficial for avoiding unexpected injuries and enhancing treatment efficacy. This study proposes a new trajectory determination method specifically for the robot-assisted ankle ligament rehabilitation. The input of this method is a set of strain constraints of certain ligaments and the output is the detailed training trajectory. Simulations were conducted with two cases (one-ligament injury and three-ligaments injury). While this method has not been experimentally tested, on condition of an accurate ligament kinematics assessment, ligament strain can be guaranteed to be within the specified range following the derived trajectory. This method can help design injury-specific treatment protocols and has potential in improving the effectiveness of robot-assisted ankle rehabilitation. Future work will verify the validity and the practicality, and consider the improvement of the method.

Cast versus functional brace in the rehabilitation of patients treated for an ankle fracture: protocol for the UK study of ankle injury rehabilitation (AIR) multicentre randomised trial

INTRODUCTION

Each year in the UK over 120 000 people fracture their ankle. It is not known what the best rehabilitation strategy is for these people. Traditionally standard care has involved immobilisation in a plaster cast but an alternative is a functional brace, which can be removed to allow early movement. This paper details the protocol for a multicentre randomised trial of plaster cast immobilisation versus functional bracing for patients with an ankle fracture.

METHODS AND ANALYSIS

We will recruit adults with a fractured ankle, for which the treating clinician would consider plaster cast to be a reasonable management option. Randomisation will be on a 1:1 basis, stratified by centre, operative or non-operative management and age. Participants will be allocated to either plaster cast or a functional brace, both treatments are widely used. To have 90% power to detect a difference of 10 points on the primary outcome (Olerud and Molander Ankle Score) at the primary outcome time point (16 weeks), we need to randomise a minimum of 478 people. Quality of life and resource use will be collected at 6, 10, 16, 24 weeks and 12, 18, 24 months. The differences between treatment groups will be assessed on an intention-to-treat basis. The economic evaluation will adhere to the recommendations of the National Institute for Health and Care Excellence reference case.

ETHICS, REGISTRATION AND DISSEMINATION

National Research Ethic Committee approved this study on 4 July 2017 (17/WM/0239). The first site opened to recruitment 9 October 2017. The results of this trial will be submitted to a peer-reviewed journal and will inform clinical practice.

TRIAL REGISTRATION NUMBER

ISRCTN15537280; Pre-results.

Effects of two proprioceptive training programs on ankle range of motion, pain, functional and balance performance in individuals with ankle sprain

BACKGROUND

Following ankle sprain, residual symptoms are often apparent, and proprioceptive training is a treatment approach. Evidence, however, is limited and the optimal program has to be identified.

OBJECTIVE

To investigate the effects of two post-acute supervised proprioceptive training programs in individuals with ankle sprain.

METHODS

Participants were recruited from a physiotherapy center for ankle sprain rehabilitation. In a pre-post treatment, blinded-assessor design, 22 individuals were randomly allocated to a balance or a proprioceptive neuromuscular facilitation (PNF) group. Both groups received 10 rehabilitation sessions, within a six-week period. Dorsiflexion range of motion (ROM), pain, functional and balance performance were assessed at baseline, at the end of training and eight weeks after training.

RESULTS

Follow-up data were provided for 20 individuals. Eight weeks after training, statistically significant (p< 0.017) improvements were found in dorsiflexion ROM and most functional performance measures for both balance and PNF groups. Eight weeks after training, significant (p< 0.017) improvements in the frontal plane balance test and pain were observed for the balance group.

CONCLUSIONS

Balance and PNF programs are recommended in clinical practice for improving ankle ROM and functional performance in individuals with sprain. Balance programs are also recommended for pain relief.

The effect of sensory-targeted ankle rehabilitation strategies on single-leg center of pressure elements in those with chronic ankle instability: A randomized clinical trial

OBJECTIVES

To determine the effects of sensory-targeted ankle rehabilitation strategies on laboratory-oriented measures of single-leg balance in those with chronic ankle instability.

DESIGN

Non-inferiority randomized controlled trial.

METHODS

Seventy-seven participants with self-reported chronic ankle instability were randomized into 4 treatment groups: Ankle joint mobilization, plantar massage, triceps surae stretching, and a control group. All participants performed 3 trials of single-leg balance on a force plate with eyes open and closed at 3 time points (baseline, immediately after the first treatment, and following 6 treatments over 2 weeks). The spatial (standard deviation), temporal (velocity), and spatiotemporal (time-to-boundary) elements of center of pressure excursions in single-leg balance were evaluated with eyes open and eyes closed at each time point. Immediate and final change scores were calculated for each group from the baseline values on these variables.

RESULTS

Joint mobilization produced immediate improvements in the temporal elements with eyes open and closed that exceeded the minimum detectable changes for these measures. Plantar massage and triceps surae stretching also enhanced the temporal element after a single treatment, but only with eyes closed. No substantial benefit of any of the interventions were found after 2-weeks of treatment, regardless of treatment group.

CONCLUSIONS

Sensory-targeted ankle rehabilitation strategies substantially improve single-leg postural control after one treatment, but these changes are short-lived. Future research is needed to determine whether combinations of sensory-targeted ankle rehabilitation strategies with other therapeutic interventions potentially improve single-leg balance stability in those with CAI compared to use in isolation.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01541657.

Advanced conservative treatment of complete acute rupture of the lateral ankle ligaments: Verifying by stabilometry

BACKGROUND

The aim of this study was to investigate the result of the specific conservative treatment of acute lateral ankle ligaments rupture and verify the effect of this therapy by stabilometry.

METHODS

17 young athletes were examined after acute lateral ankle sprain (grade III). Diagnosis was based on musculoskeletal ultrasound examinations. Pressure plate evaluated postural stability after conservative treatment at regular intervals during 1year.

RESULTS

There were no significant differences in postural stability in double-leg stance between limbs. In single-leg stance, COP confidence ellipse (p=0,011) and COP excursion in sagittal plane (p=0,000) were significantly higher for the injured leg when compared with the uninjured leg only one week after removing the cast.

CONCLUSIONS

After conservative treatment of grade III injuries with STABHA, immobilization with full weight bearing on the injured leg for 6 weeks and rehabilitation, stabilometry results showed that none of the patients had impaired postural stability or were at risk of functional ankle instability in the monitored period.

A Case of Rhabdomyolysis Caused by Blood Flow-Restricted Resistance Training

Blood flow-restricted resistance (BFRR) training is effective as a means to improve muscle strength and size while enduring less mechanical stress. It is generally safe but can have adverse effects. We present a case of an active duty Soldier who developed rhabdomyolysis as a result of a single course of BFRR training. He was presented to the emergency department with bilateral lower extremity pain, was admitted for electrolyte monitoring and rehydration, and had an uncomplicated hospital course and full recovery. This is an increasingly common mode of rehabilitation in the military, and practitioners and providers should be aware of it and its possible adverse effects.

Bilateral Posterior Tibial Tendon and Flexor Digitorum Longus Dislocations

The authors present a case of a previously healthy and athletic 17-year-old female who presented with a 3.5-year history of medial left ankle pain after sustaining an inversion injury while playing basketball. Prior to presentation, she had failed prior immobilization and physical therapy for a presumed ankles sprain. Physical examination revealed a dislocated posterior tibial tendon (PTT) that was temporarily reducible, but would spontaneously dislocate immediately after reduction. She had pain and snapping of the PTT with resisted ankle plantar flexion and resisted inversion as well as 4/5 strength in ankle inversion. The diagnosis of dislocated PTT was confirmed on magnetic resonance imaging (MRI). The patient underwent suture anchor repair of the medial retinaculum of the left ankle. At the time of surgery both the PTT and flexor digitorum longus (FDL) were dislocated. Three months postoperatively, the patient represented with PTT dislocation of the right (nonoperative) ankle confirmed by MRI. After failure of immobilization, physical therapy, and oral anti-inflammatory medications, the patient underwent suture anchor repair of the medial retinaculum of the right ankle. At 6 months postoperatively, the patient has 5/5 strength inversion bilaterally, no subluxation of either PTT, and has returned to all activities without limitation. The authors present this unique case of bilateral PTT dislocation and concurrent PTT/FDL dislocation along with review of the literature for PTT dislocation. The authors highlight the common misdaiganosis of this injury and highlight the successful results of surgical intervention.

LEVELS OF EVIDENCE

Level V: Case report.

Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial

OBJECTIVE

 To assess the efficacy of a programme of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains.

DESIGN

 A randomised controlled trial of 503 participants followed for six months.

SETTING

 Participants were recruited from two tertiary acute care settings in Kingston, ON, Canada.

PARTICIPANTS

 The broad inclusion criteria were patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain. Exclusions were patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilisation and those unable to accommodate the time intensive study protocol.

INTERVENTION

 Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised programme of physiotherapy.

MAIN OUTCOME MEASURES

 The primary outcome of efficacy was the proportion of participants reporting excellent recovery assessed with the foot and ankle outcome score (FAOS). Excellent recovery was defined as a score ≥450/500 at three months. A difference of at least 15% increase in the absolute proportion of participants with excellent recovery was deemed clinically important. Secondary analyses included the assessment of excellent recovery at one and six months; change from baseline using continuous scores at one, three, and six months; and clinical and biomechanical measures of ankle function, assessed at one, three, and six months.

RESULTS

 The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval -3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analysed as a continuous change score.

CONCLUSIONS

 In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol.Trial registration ISRCTN 74033088 (www.isrctn.com/ISRCTN74033088).

Kinematic real-time feedback is more effective than traditional teaching method in learning ankle joint mobilisation: a randomised controlled trial

BACKGROUND

To analyse the effect of real-time kinematic feedback (KRTF) when learning two ankle joint mobilisation techniques comparing the results with the traditional teaching method.

METHODS

Double-blind randomized trial.

SETTINGS

Faculty of Health Sciences.

PARTICIPANTS

undergraduate students with no experience in manual therapy. Each student practised intensely for 90 min (45 min for each mobilisation) according to the random methodology assigned (G1: traditional method group and G2: KRTF group). G1: an expert professor supervising the student's practice, the professorstudent ratio was 1:8. G2: placed in front of a station where, while they performed the manoeuvre, they received a KRTF on a laptop.

OUTCOME MEASURES

total time of mobilisation, time to reach maximum amplitude, maximum angular displacement in the three axes, maximum and average velocity to reach the maximum angular displacement, average velocity during the mobilisation.

RESULTS

Among the pre-post intervention measurements, there were significant differences within the two groups for all outcome variables, however, G2 (KRTF) achieved significantly greater improvements in kinematic parameters for the two mobilisations (significant increase in displacement, velocity and significant reduction in the mobilisations runtime) than G1. Ankle plantar flexion: G1's measurement stability (post-intervention) ranged between 0.491 and 0.687, while G2's measurement stability ranged between 0.899 and 0.984. Ankle dorsal flexion mobilisation: G1 the measurement stability (post-intervention) ranged from 0.543 and 0.684 while G2 ranged between 0.899 and 0.974.

CONCLUSION

KRTF was proven to be more effective tool than traditional teaching method in the teaching - learning process of two joint mobilisation techniques.

TRIAL REGISTRATION

NCT02504710.

The ability of the Biodex Stability System to distinguish level of function in subjects with a second-degree ankle sprain

Objective: To assess the capacity of the Biodex Stability System using a one-leg stance protocol to differentiate between injured and non-injured limbs and between level of disabilities.

Design: Cross-sectional study.

Setting: Military and civilian clinic.

Subjects: Thirty-four individuals with a second-degree lateral ankle sprain and 36 healthy subjects.

Methods and measures: Subjects were tested on the Stability System 30 days after injury using a one-leg stance protocol in the dynamic limit-of-stability mode. All subjects also filled out a disability questionnaire (Lower Extremity Functional Scale). The groups were compared based on the overall dynamic limit-of-stability score and its relationship with the score on the disability questionnaire was also examined.

Results: The overall dynamic limit-of-stability scores (subjects with a lateral ankle sprain: 13.0% (5.5)-26.0% (9.2); healthy subjects: 16.9% (7.9)-27.9% (9.6)) clustered in the lower end of the theoretical range of 0–100%. Statistically significant differences in the overall dynamic limit-of-stability scores were found between the injured and non-injured limbs but group differences were small and clinically not relevant. No significant relationships were found between the overall dynamic limit-of-stability scores and the Lower Extremity Functional Scale scores (58.2 (11.8)) of the subjects with a lateral ankle sprain.

Conclusions: The one-leg stance protocol carried out in the dynamic limit-of-stability mode is very challenging and offers a very limited capacity to differentiate between injured and non-injured limbs. The main outcome of the Stability System does not appear to be a good indicator of the functional capacity of people with a lateral ankle sprain.

Reliability and Validity Study of the Chamorro Assisted Gait Scale for People with Sprained Ankles, Walking with Forearm Crutches

Objective

The aim of this study was to design and validate a functional assessment scale for assisted gait with forearm crutches (Chamorro Assisted Gait Scale—CHAGS) and to assess its reliability in people with sprained ankles.

Design

Thirty subjects who suffered from sprained ankle (anterior talofibular ligament first and second degree) were included in the study. A modified Delphi technique was used to obtain the content validity. The selected items were: pelvic and scapular girdle dissociation(1), deviation of Center of Gravity(2), crutch inclination(3), steps rhythm(4), symmetry of step length(5), cross support(6), simultaneous support of foot and crutch(7), forearm off(8), facing forward(9) and fluency(10). Two raters twice visualized the gait of the sample subjects which were recorded. The criterion-related validity was determined by correlation between CHAGS and Coding of eight criteria of qualitative gait analysis (Viel Coding). Internal consistency and inter and intra-rater reliability were also tested.

Results

CHAGS obtained a high and negative correlation with Viel Coding. We obtained a good internal consistency and the intra-class correlation coefficients oscillated between 0.97 and 0.99, while the minimal detectable changes were acceptable.

Conclusion

CHAGS scale is a valid and reliable tool for assessing assisted gait with crutches in people with sprained ankles to perform partial relief of lower limbs.

Foot and Ankle Injuries in American Football

Physicians need to be aware of a variety of foot and ankle injuries that commonly occur in American football, including turf toe, Jones fractures, Lisfranc injuries, syndesmotic and deltoid disruption, and Achilles ruptures. These injuries are often complex and require early individual tailoring of treatment and rehabilitation protocols. Successful management and return to play requires early diagnosis, a thorough work-up, and prompt surgical intervention when warranted with meticulous attention to restoration of normal foot and ankle anatomy. Physicians should have a high suspicion for subtle injuries and variants that can occur via both contact and noncontact mechanisms.

An in-vivo lateral ankle ligament strain behavior assessment technique for potential use in robot-assisted therapy

Ankle sprains are very common, especially in sports activities. Accurate assessment of ankle ligament strain behavior is crucial in understanding ankle function and optimizing ankle rehabilitation programs. This study proposed an in-vivo lateral ankle ligament strain assessment technique for potential use in robot-assisted therapy. It consists of two phases: real-time identification of ankle joint and subtalar joint orientations and simulation of lateral ankle ligament strain behavior. A healthy participant conducted robot-assisted rehabilitation exercises and the results compared to a kinematic model. The model was found to be realistic, leading to the conclusion that this method may be appropriate for determining lateral ankle ligament strain in robot-assisted therapy.

[Foot and ankle ability measure: cross-cultural translation and validation of the Italian version of the ADL module (FAAM-I/ADL)]

BACKGROUND

Valid and reliable outcome measures are fundamental for evaluating and comparing the effects of rehabilitation. Among the different tools used for the assessment of musculoskeletal disorders of the lower limb, the Foot and Ankle Ability Measure (FAAM) has been shown to have good psychometric properties. However, it has not yet been translated into Italian. The module regarding the performance of daily living activities (FAAM/ADL), in particular, can be applied also in an occupational setting.

OBJECTIVE

To obtain an Italian version of the FAAM, and to validate the FAAM-I/ADL.

METHODS

The cultural adaptation was performed according to international guidelines for forward/backward translation. The activities of daily living (ADL) module of the FAAM-I (FAAM-I/ADL) was validated with classical test theory methods in a convenience sample of 57 patients. Different parameters were calculated: internal consistency (Cronbach's α and item-to-total correlation); criterion validity, through Pearson's correlation (r) with the Lower Extremity Functional Scale (LEFS); test-retest reliability (ICC2,1); Standard Error of Measurement (SEM); and Minimal Detectable Change (MDC95).

RESULTS

The statistical analysis showed good internal consistency (Cronbach's α=.96, item-to-total correlation ranged between .51 and .85), high criterion validity (r=.66, p&lt;0.01) and excellent test-retest reliability (ICC2, 1=.98, CI95%=.97-.99). The SEM was 2.7 points, with a MDC95 of 7.5 points.

CONCLUSIONS

FAAM-I/ADL shows good psychometric properties, together with speed and ease of administration and scoring. Its use will facilitate the comparison of Italian data with international studies, ensuring greater uniformity of assessment.

A prospective study on time to recovery in 254 injured novice runners

OBJECTIVES

Describe the diagnoses and the time to recovery of running-related injuries in novice runners.

DESIGN

Prospective cohort study on injured runners.

METHOD

This paper is a secondary data analysis of a 933-person cohort study (DANO-RUN) aimed at characterizing risk factors for injury in novice runners. Among those sustaining running-related injuries, the types of injuries and time to recovery is described in the present paper. All injured runners were diagnosed after a thorough clinical examination and then followed prospectively during their recovery. If they recovered completely from injury, time to recovery of each injury was registered.

RESULTS

A total of 254 runners were injured. The proportion of runners diagnosed with medial tibial stress syndrome was 15%, 10% for patellofemoral pain, 9% for medial meniscal injury, 7% for Achilles tendinopathy and 5% for plantar fasciitis. Among the 220 runners (87%) recovering from their injury, the median time to recovery was 71 days (minimum  = 9 days, maximum  = 617 days).

CONCLUSIONS

Medial tibial stress syndrome was the most common injury followed by patellofemoral pain, medial meniscal injury and Achilles tendinopathy. Half of the injured runners were unable to run 2×500 meters without pain after 10 weeks. Almost 5% of the injured runners received surgical treatment.

Multi-segment foot mobility in a hinged ankle-foot orthosis: the effect of rotation axis position

Hinged ankle-foot orthoses are prescribed routinely for the treatment of ankle joint deficits, despite the conflicting outcomes and the little evidence on their functional efficacy. In particular, the axis of rotation of the hinge is positioned disregarding the physiological position and orientation. A multi-segment model was utilized to assess in vivo the effect of different positions for this axis on the kinematics of foot joints. A special custom-made hinged orthosis was manufactured via standard procedures for a young healthy volunteer. Four locations for the mechanical axis were obtained by a number of holes where two nuts and bolts were inserted to form the hinge: a standard position well above the malleoli, at the level of the medial malleolus, at the level of the lateral malleolus, and the physiological between the two malleoli. The shank and foot were instrumented with 15 reflective markers according to a standard protocol, and level walking was collected barefoot and with the orthosis in the four mechanical conditions. The spatio-temporal parameters observed in the physiological axis condition were the closest to normal barefoot walking. As expected, ankle joint rotation was limited to the sagittal plane. When the physiological axis was in place, rotations of the ankle out-of-sagittal planes, and of all other foot joints in the three anatomical planes, were found to be those most similar to the natural barefoot condition. These preliminary measures of intersegmental kinematics in a foot within an ankle-foot orthosis showed that only a physiological location for the ankle mechanical hinge can result in natural motion at the remaining joints and planes.

Predicting functional recovery after acute ankle sprain

Introduction

Ankle sprains are among the most common acute musculoskeletal conditions presenting to primary care. Their clinical course is variable but there are limited recommendations on prognostic factors. Our primary aim was to identify clinical predictors of short and medium term functional recovery after ankle sprain.

Methods

A secondary analysis of data from adult participants (N = 85) with an acute ankle sprain, enrolled in a randomized controlled trial was undertaken. The predictive value of variables (age, BMI, gender, injury mechanism, previous injury, weight-bearing status, medial joint line pain, pain during weight-bearing dorsiflexion and lateral hop test) recorded at baseline and at 4 weeks post injury were investigated for their prognostic ability. Recovery was determined from measures of subjective ankle function at short (4 weeks) and medium term (4 months) follow ups. Multivariate stepwise linear regression analyses were undertaken to evaluate the association between the aforementioned variables and functional recovery.

Results

Greater age, greater injury grade and weight-bearing status at baseline were associated with lower function at 4 weeks post injury (p<0.01; adjusted R square=0.34). Greater age, weight-bearing status at baseline and non-inversion injury mechanisms were associated with lower function at 4 months (p<0.01; adjusted R square=0.20). Pain on medial palpation and pain on dorsiflexion at 4 weeks were the most valuable prognostic indicators of function at 4 months (p< 0.01; adjusted R square=0.49).

Conclusion

The results of the present study provide further evidence that ankle sprains have a variable clinical course. Age, injury grade, mechanism and weight-bearing status at baseline provide some prognostic information for short and medium term recovery. Clinical assessment variables at 4 weeks were the strongest predictors of recovery, explaining 50% of the variance in ankle function at 4 months. Further prospective research is required to highlight the factors that best inform the expected convalescent period, and risk of recurrence.

Effectiveness of robot-assisted therapy on ankle rehabilitation--a systematic review

OBJECTIVE

The aim of this study was to provide a systematic review of studies that investigated the effectiveness of robot-assisted therapy on ankle motor and function recovery from musculoskeletal or neurologic ankle injuries.

METHODS

Thirteen electronic databases of articles published from January, 1980 to June, 2012 were searched using keywords 'ankle*', 'robot*', 'rehabilitat*' or 'treat*' and a free search in Google Scholar based on effects of ankle rehabilitation robots was also conducted. References listed in relevant publications were further screened. Eventually, twenty-nine articles were selected for review and they focused on effects of robot-assisted ankle rehabilitation.

RESULTS

Twenty-nine studies met the inclusion criteria and a total of 164 patients and 24 healthy subjects participated in these trials. Ankle performance and gait function were the main outcome measures used to assess the therapeutic effects of robot-assisted ankle rehabilitation. The protocols and therapy treatments were varied, which made comparison among different studies difficult or impossible. Few comparative trials were conducted among different devices or control strategies. Moreover, the majority of study designs met levels of evidence that were no higher than American Academy for Cerebral Palsy (CP) and Developmental Medicine (AACPDM) level IV. Only one study used a Randomized Control Trial (RCT) approach with the evidence level being II.

CONCLUSION

All the selected studies showed improvements in terms of ankle performance or gait function after a period of robot-assisted ankle rehabilitation training. The most effective robot-assisted intervention cannot be determined due to the lack of universal evaluation criteria for various devices and control strategies. Future research into the effects of robot-assisted ankle rehabilitation should be carried out based on universal evaluation criteria, which could determine the most effective method of intervention. It is also essential to conduct trials to analyse the differences among different devices or control strategies.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults.

SEARCH METHODS

We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy.

AUTHORS' CONCLUSIONS

There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

[On the forensic medical estimation of the harm to health in the case of the ankle joint injury]

This paper is focused on the forensic medical evaluation of the severity of the harm to health of the subjects suffering an ankle joint (AJ) injury. The retrospective data pertinent to the forensic medical evaluation of ankle joint injuries are presented in conjunction with the methods for their clinical diagnostics currently applied in traumatology and orthopedics and by the specialists in socio-medical expertise for the assessment of the efficacy of the surgical treatment, prognosis, and rehabilitation of the affected patients.

Update on acute ankle sprains

Ankle sprains are a common problem seen by primary care physicians, especially among teenagers and young adults. Most ankle sprains are inversion injuries to the lateral ankle ligaments, although high sprains representing damage to the tibiofibular syndesmosis are becoming increasingly recognized. Physicians should apply the Ottawa ankle rules to determine whether radiography is needed. According to the Ottawa criteria, radiography is indicated if there is pain in the malleolar or midfoot zone, and either bone tenderness over an area of potential fracture (i.e., lateral malleolus, medial malleolus, base of fifth metatarsal, or navicular bone) or an inability to bear weight for four steps immediately after the injury and in the emergency department or physician's office. Patients with ankle sprain should use cryotherapy for the first three to seven days to reduce pain and improve recovery time. Patients should wear a lace-up ankle support or an air stirrup brace combined with an elastic compression wrap to reduce swelling and pain, speed recovery, and protect the injured ligaments as they become more mobile. Early mobilization speeds healing and reduces pain more effectively than prolonged rest. Pain control options for patients with ankle sprain include nonsteroidal anti-inflammatory drugs, acetaminophen, and mild opioids. Because a previous ankle sprain is the greatest risk factor for an acute ankle sprain, recovering patients should be counseled on prevention strategies. Ankle braces and supports, ankle taping, a focused neuromuscular training program, and regular sport-specific warm-up exercises can protect against ankle injuries, and should be considered for patients returning to sports or other high-risk activities.

Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair

PURPOSE

Recently, a new suture-button fixation device has emerged for the treatment of acute distal tibiofibular syndesmotic injuries and its use is rapidly increasing. The current systematic review was undertaken to compare the biomechanical properties, functional outcome, need for implant removal, and the complication rate of syndesmotic disruptions treated with a suture-button device with the current 'gold standard', i.e. the syndesmotic screw.

METHOD

A literature search in the electronic databases of the Cochrane Library, EMbase, Pubmed Medline, and Google Scholar, between January 1st 2000 to December 1st 2011, was conducted to identify studies in which unstable ankle fractures with concomitant distal tibiofibular syndesmotic injury were treated with either a syndesmotic screw or a suture-button device.

RESULTS

A total of six biomechanical studies, seven clinical full-text studies and four abstracts on the TightRope system, and 27 studies on syndesmotic screw or bolt fixation were identified. The AOFAS of 133 patients treated with TightRope was 89.1 points, with an average study follow-up of 19 months. The AOFAS score in studies with 253 patients treated with syndesmotic screws (metallic and absorbable) or bolts was 86.3 points, with an average study follow-up of 42 months. Two studies reported an earlier return to work in the TightRope group. Implant removal was reported in 22 (10%) of 220 patients treated with a TightRope (range, 0-25%), in the screw or bolt group the average was 51.9% of 866 patients (range, 5.8-100%).

CONCLUSION

The TightRope system has a similar outcome compared with the syndesmotic screw or bolt fixation, but might lead to a quicker return to work. The rate of implant removal is lower than in the syndesmotic screw group. There is currently insufficient evidence on the long-term effects of the TightRope and more uniform outcome reporting is desirable. In addition, there is a need for studies on cost-effectiveness of the treatment of acute distal tibiofibular syndesmotic disruption treated with a suture-button device.

Physiotherapists' compliance with ankle injury guidelines is different for patients with acute injuries and patients with functional instability: an observational study

QUESTIONS

What are the characteristics of patients with acute ankle injuries or functional instability of the ankle? Do physiotherapists treat these patients according to evidence-based guidelines? What are the determinants of adherence to the guidelines?

DESIGN

Observational study using multi-level analyses of data from the National Information Service for Allied Health Care in the Netherlands. This network continuously collects healthcare-related information on characteristics of patients and their referral, health problem, and treatment plan.

PARTICIPANTS

1413 patients treated for ankle injuries.

OUTCOME MEASURES

Adherence to the guidelines was measured using three quality indicators: number of sessions, interventions, and accomplished treatment goals.

RESULTS

Interventions and treatment goals were often aimed at the improvement of body functions, especially in patients with functional instability. Although not advised in the guidelines, manual manipulation was applied during treatment in 21% of the patients with functional instability. On average, patients with acute ankle injuries have a 38% chance of being treated according to the guidelines. Adherence can be explained partly by the duration of the complaint, whether the complaint is recurrent, the patient's age and the experience of the therapist, but it depends substantially on the therapist.

CONCLUSION

There is some discrepancy between the guidelines and practice, especially regarding the interventions applied to patients with functional instability. However, there is large variation between therapists. The sooner a patient presents for treatment and the greater the experience of the physiotherapist with ankle injuries, the greater the likelihood that treatment will follow the guidelines.

Physical therapy and rehabilitation of the foot and ankle in the athlete

Foot and ankle injuries in athletes are common. Physical therapy plays a fundamental role in the management of sports injuries. The purpose of this article is to (1) raise awareness for using physical therapy for treatment of foot and ankle injuries in athletes, (2) discuss considerations specific to athletes during the rehabilitation process, and (3) increase the reader's knowledge about the in-depth role of physical therapy in the management of foot and ankle injuries in athletes.

Can an ankle-foot orthosis change hearts and minds?

The current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting the extremities. While many injuries have resulted in amputation, surgical advances have allowed the orthopaedic surgeon to pursue limb salvage in the face of injuries once considered unsalvageable. The military limb salvage patient is frequently highly active and motivated and expresses significant frustration with the slow nature of limb salvage rehabilitation and continued functional deficits. Inspired by these patients, efforts at this institution began to provide them with a more dynamic orthosis. Utilizing techniques and technology resulting from cerebral palsy, stroke, and amputation research, the Intrepid Dynamic Exoskeletal Orthosis was created. To date, this device has significantly improved the functional capabilities of the limb salvage wounded warrior population when combined with a high-intensity rehabilitation program. Clinical and biomechanical research is currently underway at this institution in order to fully characterize the device, its effect on patients, and what can be done to modify future generations of the device to best serve the combat-wounded limb salvage population.

Rehabilitation of ankle and foot injuries in athletes

Foot and ankle injuries are extremely common among athletes and other physically active individuals. Rehabilitation programs that emphasize the use of therapeutic exercise to restore joint range of motion, muscle strength, neuromuscular coordination, and gait mechanics have been shown to have clinical success for patients suffering various foot and ankle pathologies. Rehabilitation programs are discussed for ankle sprains, plantar fasciitis, Achilles tendonitis, and turf toe.

Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial

OBJECTIVE

To compare an accelerated intervention incorporating early therapeutic exercise after acute ankle sprains with a standard protection, rest, ice, compression, and elevation intervention.

DESIGN

Randomised controlled trial with blinded outcome assessor.

SETTING

Accident and emergency department and university based sports injury clinic.

PARTICIPANTS

101 patients with an acute grade 1 or 2 ankle sprain.

INTERVENTIONS

Participants were randomised to an accelerated intervention with early therapeutic exercise (exercise group) or a standard protection, rest, ice, compression, and elevation intervention (standard group).

MAIN OUTCOME MEASURES

The primary outcome was subjective ankle function (lower extremity functional scale). Secondary outcomes were pain at rest and on activity, swelling, and physical activity at baseline and at one, two, three, and four weeks after injury. Ankle function and rate of reinjury were assessed at 16 weeks.

RESULTS

An overall treatment effect was in favour of the exercise group (P=0.0077); this was significant at both week 1 (baseline adjusted difference in treatment 5.28, 98.75% confidence interval 0.31 to 10.26; P=0.008) and week 2 (4.92, 0.27 to 9.57; P=0.0083). Activity level was significantly higher in the exercise group as measured by time spent walking (1.2 hours, 95% confidence interval 0.9 to 1.4 v 1.6, 1.3 to 1.9), step count (5621 steps, 95% confidence interval 4399 to 6843 v 7886, 6357 to 9416), and time spent in light intensity activity (53 minutes, 95% confidence interval 44 to 60 v 76, 58 to 95). The groups did not differ at any other time point for pain at rest, pain on activity, or swelling. The reinjury rate was 4% (two in each group).

CONCLUSION

An accelerated exercise protocol during the first week after ankle sprain improved ankle function; the group receiving this intervention was more active during that week than the group receiving standard care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13903946.

Early functional outcome of a modified Brostrom-Gould surgery using bioabsorbable suture anchor for chronic lateral ankle instability

INTRODUCTION

The purpose of this study was to evaluate the early functional outcome following the use of a bioabsorbable suture anchor to simplify the repair of injured lateral ankle structures as a variation of an established technique known as the Brostrom-Gould procedure.

METHODS

This was a prospective study of 30 ankles with chronic lateral instability that underwent a modified Brostrom-Gould surgery using a bioabsorbable suture anchor, performed by a single surgeon. A total of 29 patients, aged 15 to 52 (mean is 33) years, were enrolled in the study. The follow-up period ranged from three to six (mean is four) months. The function of the patients' ankles was scored using the Kaikkonen Functional Scale, both preoperatively and postoperatively.

RESULTS

Preoperatively, all ankles had poor scores (less than 50). Postoperatively, 28 ankles showed excellent scores and two ankles showed good scores, while none obtained a fair or poor score. The difference in the overall means between the postoperative and preoperative scores was statistically significant (p-value is 0.001). Post surgery, 24 ankles had no symptoms, while six had only mild ankle tightness with extreme inversion movement at the last review. All patients were able to walk normally, and 29 ankles regained their normal running capability. There was marked improvement in the ability to descend stairs, to rise on heels and toes, to perform a single-limb stance, and in range of motions of the ankle dorsiflexion as well as in ankle laxity.

CONCLUSION

The modified Brostrom-Gould procedure using a bioabsorbable suture anchor allowed for early ankle rehabilitation and offered a reproducible and excellent early functional outcome with minimal complications.

Acute ankle sprain in dancers

Ankle sprain is a common injury in dancers. Because of the relative frequency of this injury and its wide acceptance as a likely part of an active lifestyle, in many individuals it may not receive the careful attention it deserves. An extreme ankle range of motion and excellent ankle stability are fundamental to success in dance. Hence, following a proper treatment protocol is crucial for allowing a dancer who suffers an ankle sprain to return to dance as soon as possible without impaired function. This article reviews the basic principles of the etiology and management of ankle sprain in dancers. Key concepts are on-site examination and treatment, early restoration, dance-specific rehabilitation, and a carefully administered safe return to dance. Additionally, injuries that may occur in conjunction with ankle sprain are highlighted, and practical, clinically relevant summary concepts for dance healthcare professionals, dance scientists, dance teachers, and dancers are provided.

Sports ankle injuries - assessment and management

BACKGROUND

Sports ankle injuries present commonly in the general practice setting. The majority of these injuries are inversion and plantar flexion injuries that result in damage to the lateral ligament complex.

OBJECTIVE

The aim of this article is to review the assessment and management of sports ankle injuries in the general practice setting.

DISCUSSION

Assessment of an ankle injury begins with a detailed history to determine the severity, mechanism and velocity of the injury, what happened immediately after and whether there is a past history of inadequately rehabilitated ankle injury. Examination involves assessment of weight bearing, inspection, palpation, movement, and application of special examination tests. Plain X-rays may be helpful to exclude a fracture. If the diagnosis is uncertain, consider second line investigations including bone scan, computerised tomography or magnetic resonance imaging, and referral to a sports physician. Manage all lateral ligament complex ankle sprains with ice, compression, elevation where possible and analgesia. Severe ligament sprains or rupture benefit from a brief period of immobilisation. After initial management, the athlete should complete a 6 week guided rehabilitation program. Athletes with moderate to severe lateral ankle ligament sprains should wear a semirigid or rigid ankle orthosis for at least 6 months following injury.

One- or two-legged standing: what is the more suitable protocol to assess the postural effects of the rigid ankle orthosis?

To highlight the capacity of one- and two-legged standing protocols when assessing postural behavior induced by a rigid ankle orthosis, 14 healthy individuals stood upright barefoot and wore either an elastic stocking on the preferred leg or a rigid orthosis with or without additional taping in one- or two-legged (TL) conditions. Traditional center-of pressure (CP) measures were evaluated for the total two-feet resultant CP and under the feet (plantar CP). Focusing on the plantar CP displacements under the leg fitted with the various orthoses demonstrated particular postural behaviors for traditional parameters with main effects along the mediolateral axis. Only the TL protocol showed the limiting effects of the rigid shells on the inversion-eversion movements in healthy individuals.

Effects of rehabilitation after ankle fracture: a Cochrane systematic review

BACKGROUND

Ankle fracture is one of the most common lower limb fractures. People experience limitations in activities after ankle fracture.

OBJECTIVES

The aim of this review was to evaluate the effects of rehabilitation interventions after ankle fracture in adults.

METHODS

Electronic databases, reference lists of included studies and relevant systematic reviews, and clinical trials registers were searched for randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture. The primary outcomes were activity limitation and adverse events. Two reviewers independently screened search results, assessed methodological quality, and extracted data.

RESULTS

Thirty-one studies were included. Clinical and statistical heterogeneity, or the low number of studies in the comparison, prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation but also led to a higher rate of adverse events (relative risk 2.61, 95% CI 1.72 to 3.97). Most other rehabilitation interventions did not show an effect in improving activity limitation.

CONCLUSIONS

There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period for improving activity limitation. Because of the potential increased risk, the patient's ability to comply with this treatment regimen is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of an unsupervised proprioceptive training programme on recurrences of ankle sprain after usual care in athletes who had sustained an acute sports related injury to the lateral ankle ligament.

DESIGN

Randomised controlled trial, with one year follow-up.

SETTING

Primary care.

PARTICIPANTS

522 athletes, aged 12-70, who had sustained a lateral ankle sprain up to two months before inclusion; 256 (120 female and 136 male) in the intervention group; 266 (128 female and 138 male) in the control group.

INTERVENTION

Both groups received treatment according to usual care. Athletes allocated to the intervention group additionally received an eight week home based proprioceptive training programme.

MAIN OUTCOME MEASURE

Self reported recurrence of ankle sprain.

RESULTS

During the one year follow-up, 145 athletes reported a recurrent ankle sprain: 56 (22%) in the intervention group and 89 (33%) in the control group. Nine athletes needed to be treated to prevent one recurrence (number needed to treat). The intervention programme was associated with a 35% reduction in risk of recurrence. Cox regression analysis showed significantly fewer recurrent ankle sprains in the intervention than in the control group. This effect was found for self reported recurrent ankle sprains (relative risk 0.63, 95% confidence interval 0.45 to 0.88), recurrent ankle sprains leading to loss of sports time (0.53, 0.32 to 0.88), and recurrent ankle sprains resulting in healthcare costs or lost productivity costs (0.25, 0.12 to 0.50). No significant differences were found between medically treated athletes in the intervention group and medically treated controls. Athletes in the intervention group who were not medically treated had a significantly lower risk of recurrence than controls who were not medically treated.

CONCLUSIONS

The use of a proprioceptive training programme after usual care of an ankle sprain is effective for the prevention of self reported recurrences. This proprioceptive training was specifically beneficial in athletes whose original sprain was not medically treated.

TRIAL REGISTRATION

ISTRCN34177180.

Minocycline-induced pigmentation mimicking persistent ecchymosis

We report an unusual case of minocycline-induced pigmentation mimicking persistent ecchymosis in a patient with persistent (20 months' duration) bluish black discoloration of the medial and lateral aspects of the left ankle following an avulsion fracture. We review the common presentations of minocycline-induced pigmentation as well as some of the more unusual presentations.

Update on proprioception: considerations for dance education

Proprioception is a topic of interest within the larger scope of dance pedagogy, science, and rehabilitation. As the science of proprioception changes, approaches to proprioceptive training also change. Thus, proprioceptive training in dance medicine has expanded to include balance protocols. A key concept within these protocols for treatment of lower extremity injuries is perturbation. Perturbation training is designed to evoke focal neuromuscular control at injured joint sites, as well as more global postural responses for overall balance and coordination. This article provides an update on the science of proprioception within the framework of postural control and balance. Specific practices from rehabilitation that integrate balance exercises into proprioceptive training are considered. Further research is needed to test the efficacy and utility of these exercises within the context of the dance studio.

Reliability of a functional test battery evaluating functionality, proprioception, and strength in recreational athletes with functional ankle instability

AIM

In contrast to the single evaluation methods used in the past, the combination of multiple tests allows one to obtain a global assessment of the ankle joint. The aim of this study was to determine the reliability of the different tests in a functional test battery.

METHODS

Twenty-four male recreational athletes with unilateral functional ankle instability (FAI) were recruited for this study. One component of the test battery included five different functional ability tests. These tests included a single limb hopping course, single-legged and triple-legged hop for distance, and six and cross six meter hop for time. The ankle joint position sense and one leg standing test were used for evaluation of proprioception and sensorimotor control. The isokinetic strengths of the ankle invertor and evertor muscles were evaluated at a velocity of 120 degrees /s. The reliability of the test battery was assessed by calculating the intraclass correlation coefficient (ICC). Each subject was tested two times, with an interval of 3-5 days between the test sessions.

RESULTS

The ICCs for ankle functional and proprioceptive ability showed high reliability (ICCs ranging from 0.94 to 0.98). Additionally, isokinetic ankle joint inversion and eversion strength measurements represented good to high reliability (ICCs between 0.82 and 0.98).

CONCLUSION

The functional test battery investigated in this study proved to be a reliable tool for the assessment of athletes with functional ankle instability. Therefore, clinicians may obtain reliable information from the functional test battery during the assessment of ankle joint performance in patients with functional ankle instability.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation which allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation may start following the period of immobilisation, with physical or manual therapies.

OBJECTIVES

To compare the effectiveness of rehabilitation interventions following ankle fracture in adults.

SEARCH STRATEGY

We searched two Specialised Registers of The Cochrane Collaboration, electronic databases (including MEDLINE, EMBASE and CINAHL), reference lists of included studies and relevant systematic reviews, and clinical trials registers to September 2007.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results, assessed methodological quality, and extracted data. Relative risk and 95% confidence intervals (95% CI) were calculated for dichotomous variables, and weighted or standardised mean difference and 95% CI were calculated for continuous variables. A meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching.

AUTHORS' CONCLUSIONS

There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture. There is also limited evidence for manual therapy after the immobilisation period. Because of the potential increased risk, the patient's ability to comply with the use of a removable type of immobilisation and exercise is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Closed posteromedial dislocation of the ankle without fracture: a case report

Ankle dislocation without fracture is an extremely rare injury. Open dislocations were more common in the previous reports. The authors report a case of closed posteromedial dislocation of the ankle in a 24-year-old basketball player. Closed reduction was performed. The ankle was initially immobilized with the short leg cast before using the functional brace. Details of the rehabilitation program were described. Follow up examination at one-year demonstrated good clinical and functional results confirmed with the inversion stress radiographs. The patient can participate in sports activities at the same level as pre-injury.