A systematic review on ankle injury and ankle sprain in sports

The eccentric torque production capacity of the ankle, knee, and hip muscle groups in patients with unilateral chronic ankle instability

Purpose

The aim of this study was to investigate eccentric torque production capacity of the ankle, knee and hip muscle groups in patients with unilateral chronic ankle instability (CAI) as compared to healthy matched controls.

Methods

In this case-control study, 40 participants (20 with CAI and 20 controls) were recruited based on convenient non-probability sampling. The average peak torque to body weight (APT/BW) ratio of reciprocal eccentric contraction of ankle dorsi flexor/plantar flexor, ankle evertor/invertor, knee flexor/extensor, hip flexor/extensor and hip abductor/adductor was determined using an isokinetic dynamometer. All subjects participated in two separate sessions with a rest interval of 48 to 72 hours. In each testing session, the torque production capacity of the ankle, knee, and hip muscle groups of only one lower limb was measured. At first, 3 repetitions of maximal eccentric-eccentric contraction were performed for the reciprocal muscles of a joint in a given movement direction. Then, the same procedure of practice and testing trials was repeated for the next randomly-ordered muscle group or joint of the same limb.

Results

There was no significant interaction of group (CAI and healthy controls) by limb (injured and non-injured) for any muscle groups. Main effect of limb was not significant. Main effect of group was only significant for eccentric torque production capacity of ankle dorsi flexor and hip flexor muscle groups. The APT/BW ratio of these muscles was significantly lower in the CAI group than the healthy controls (P<0.05).

Conclusion

CAI is associated with eccentric strength deficit of ankle dorsi flexor and hip flexor muscles as indicated by reduction in torque production capacity of these muscles compared to healthy controls. This strength deficit appeared to exist in both the injured and non-injured limbs of the patients.

Fatigue-induced alterations of static and dynamic postural control in athletes with a history of ankle sprain

CONTEXT

Sensorimotor control is impaired after ankle injury and in fatigued conditions. However, little is known about fatigue-induced alterations of postural control in athletes who have experienced an ankle sprain in the past.

OBJECTIVE

To investigate the effect of fatiguing exercise on static and dynamic balance abilities in athletes who have successfully returned to preinjury levels of sport activity after an ankle sprain.

DESIGN

Cohort study.

SETTING

University sport science research laboratory.

PATIENTS OR OTHER PARTICIPANTS

30 active athletes, 14 with a previous severe ankle sprain (return to sport activity 6-36 months before study entry; no residual symptoms or subjective instability) and 16 uninjured controls.

INTERVENTION(S)

Fatiguing treadmill running in 2 experimental sessions to assess dependent measures.

MAIN OUTCOME MEASURE(S)

Center-of-pressure sway velocity in single-legged stance and time to stabilization (TTS) after a unilateral jump-landing task (session 1) and maximum reach distance in the Star Excursion Balance Test (SEBT) (session 2) were assessed before and immediately after a fatiguing treadmill exercise. A 2-factorial linear mixed model was specified for each of the main outcomes, and effect sizes (ESs) were calculated as Cohen d.

RESULTS

In the unfatigued condition, between-groups differences existed only for the anterior-posterior TTS (P = .05, ES = 0.39). Group-by-fatigue interactions were found for mean SEBT (P = .03, ES = 0.43) and anterior-posterior TTS (P = .02, ES = 0.48). Prefatigue versus postfatigue SEBT and TTS differences were greater in previously injured athletes, whereas static sway velocity increased similarly in both groups.

CONCLUSIONS

Fatiguing running significantly affected static and dynamic postural control in participants with a history of ankle sprain. Fatigue-induced alterations of dynamic postural control were greater in athletes with a previous ankle sprain. Thus, even after successful return to competition, ongoing deficits in sensorimotor control may contribute to the enhanced ankle reinjury risk.

Evaluation of joint position recognition measurement variables associated with chronic ankle instability: a meta-analysis

OBJECTIVE

To identify the most precise and consistent variables using joint repositioning for identifying joint position recognition (JPR) deficits in individuals with chronic ankle instability (CAI).

DATA SOURCES

We conducted a computerized search of the relevant scientific literature from January 1, 1965, to July 31, 2010, using PubMed Central, CINAHL, MEDLINE, SPORTDiscus, and Web of Science. We also conducted hand searches of all retrieved studies to identify relevant citations. Included studies were written in English, involved human participants, and were published in peer-reviewed journals.

STUDY SELECTION

Studies were included in the analysis if the authors (1) had examined JPR deficits in patients with CAI using active or passive repositioning techniques, (2) had made comparisons with a group or contralateral limb without CAI, and (3) had provided means and standard deviations for the calculation of effect sizes.

DATA EXTRACTION

Studies were selected and coded independently and assessed for quality by the investigators. We evaluated 6 JPR variables: (1) study comparisons, (2) starting foot position, (3) repositioning method, (4) testing range of motion, (5) testing velocity, and (6) data-reduction method. The independent variable was group (CAI, control group or side without CAI). The dependent variable was errors committed during joint repositioning. Means and standard deviations for errors committed were extracted from each included study.

DATA SYNTHESIS

Effect sizes and 95% confidence intervals were calculated to make comparisons across studies. Separate meta-analyses were calculated to determine the most precise and consistent method within each variable. Between-groups comparisons that involved active repositioning starting from a neutral position and moving into plantar flexion or inversion at a rate of less than 5°/s as measured by the mean absolute error committed appeared to be the most sensitive and precise variables for detecting JPR deficits in people with CAI.

Hip kinematics during a stop-jump task in patients with chronic ankle instability

CONTEXT

Chronic ankle instability (CAI) commonly develops after lateral ankle sprain. Movement pattern differences at proximal joints may play a role in instability.

OBJECTIVE

To determine whether people with mechanical ankle instability (MAI) or functional ankle instability (FAI) exhibited different hip kinematics and kinetics during a stop-jump task compared with "copers."

DESIGN

Cross-sectional study.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Sixty-three recreational athletes, 21 (11 men, 10 women) per group, matched for sex, age, height, mass, and limb dominance. All participants reported a history of a moderate to severe ankle sprain. The participants with MAI and FAI reported 2 or more episodes of giving way at the ankle in the last year and decreased functional ability; copers did not. The MAI group demonstrated clinically positive anterior drawer and talar tilt tests, whereas the FAI group and copers did not.

INTERVENTION(S)

Participants performed a maximum-speed approach run and a 2-legged stop jump followed by a maximum vertical jump.

MAIN OUTCOME MEASURE(S)

An electromagnetic tracking device synchronized with a force plate collected data during the stance phase of a 2-legged stop jump. Hip motion was measured from initial contact to takeoff into the vertical jump. Group differences in hip kinematics and kinetics were assessed.

RESULTS

The MAI group demonstrated greater hip flexion at initial contact and at maximum (P = .029 and P = .017, respectively) and greater hip external rotation at maximum (P = .035) than the coper group. The MAI group also demonstrated greater hip flexion displacement than both the FAI (P = .050) and coper groups (P = .006). No differences were noted between the FAI and coper groups in hip kinematic variables or among any of the groups in ground reaction force variables.

CONCLUSIONS

The MAI group demonstrated different hip kinematics than the FAI and coper groups. Proximal joint motion may be affected by ankle joint function and laxity, and clinicians may need to assess proximal joints after repeated ankle sprains.

Isokinetic testing of evertor and invertor muscles in patients with chronic ankle instability

Ankle sprains are among the most common sport-related injuries and can lead to chronic ankle instability. Impaired sensorimotor function of the ankle musculature is often suggested as a cause. The current study sought to assess and compare the isokinetic performance and electromyographic patterns of evertor and invertor muscles in patients with chronic ankle instability and in a control group. Twelve patients with chronic ankle instability and twelve healthy subjects were included. Isokinetic eccentric and concentric testing at various angular velocities was performed for eversion and inversion movements. The corresponding myoelectric activities of the fibularis longus and tibialis anterior muscles were quantified from surface electromyographic recordings by computing average root mean square values. Patients had lower myoelectric activity of the evertor and invertor muscles than controls did; this difference could account for the eccentric weakness associated with ankle instability. Functional strength ratios revealed a dynamic strength imbalance in unstable ankle patients and that may contribute to recurrent injury. Our findings suggest that rehabilitation programs for unstable ankle patients must be focused on the motor control of eccentric contractions of the ankle evertors and invertors, to boost these muscles' contribution to ankle stabilization.

Functional ankle instability and health-related quality of life

CONTEXT

To our knowledge, no authors have assessed health-related quality of life (HR-QOL) in participants with functional ankle instability (FAI). Furthermore, the relationships between measures of ankle functional limitation and HR-QOL are unknown.

OBJECTIVE

To use the Short Form-36v2 Health Survey (SF-36) to compare HR-QOL in participants with or without FAI and to determine whether HR-QOL was related to functional limitation.

DESIGN

Cross-sectional study.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Sixty-eight participants with FAI (defined as at least 1 lateral ankle sprain and 1 episode of giveway per month) or without FAI were recruited (FAI group: n = 34, age = 25 ± 5 years, height = 1.71 ± 0.08 m, mass = 74.39 ± 12.78 kg, Cumberland Ankle Instability Tool score = 19.3 ± 4; uninjured [UI] group: n = 34, age = 23 ± 4 years, height = 1.69 ± 0.08 m, mass = 67.94 ± 11.27 kg, Cumberland Ankle Instability Tool score = 29.4 ± 1).

MAIN OUTCOME MEASURE(S)

All participants completed the SF-36 as a measure of HR-QOL and the Foot and Ankle Ability Measure (FAAM) and the FAAM Sport version (FAAMS) as assessments of functional limitation. To compare the FAI and UI groups, we calculated multiple analyses of variance followed by univariate tests. Additionally, we correlated the SF-36 summary component scale and domain scales with the FAAM and FAAMS scores.

RESULTS

Participants with FAI had lower scores on the SF-36 physical component summary (FAI = 54.4 ± 5.1, UI = 57.8 ± 3.7, P = .005), physical function domain scale (FAI = 54.5 ± 3.8, UI = 56.6 ± 1.2, P = .004), and bodily pain domain scale (FAI = 52.0 ± 6.7, UI = 58.5 ± 5.3, P < .005). Similarly, participants with FAI had lower scores on the FAAM (FAI = 93.7 ± 8.4, UI = 99.5 ± 1.4, P < .005) and FAAMS (FAI = 84.5 ± 8.4, UI = 99.8 ± 0.72, P < .005) than did the UI group. The FAAM score was correlated with the physical component summary scale (r = 0.42, P = .001) and the physical function domain scale (r = 0.61, P < .005). The FAAMS score was correlated with the physical function domain scale (r = 0.47, P < .005) and the vitality domain scale (r = 0.36, P = .002).

CONCLUSIONS

Compared with UI participants, those with FAI had less HR-QOL and more functional limitations. Furthermore, positive correlations were found between HR-QOL and functional limitation measures. This suggests that ankle impairment may reduce overall HR-QOL.

Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review

OBJECTIVES

To determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury.

DESIGN

Systematic review.

DATA SOURCES

An electronic database search was conducted (to 6 August 2012) of databases such as: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information.

STUDY SELECTION

Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies included participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard.

RESULTS

The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies investigated diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR-1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83-100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was found for other tests.

CONCLUSIONS

This is the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. Few studies were identified and our findings show that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. Additional diagnostic tests, such as MRI, should be considered before making a final diagnosis of syndesmosis injury.

Prevalência de dor nos nadadores de São Vaetano do Sul

OBJECTIVE: A natação é um esporte que vem se destacando nos últimos anos, sendo reconhecido que requer um elevado nível de treinamento e que gera sobrecarga musculoesquelética, a qual predispõe os nadadores a lesões. OBJETIVO: Verificar a prevalência e as regiões corporais com dor, correlacionando com o estilo principal e o tempo de prática nos nadadores do SERC em São Caetano do Sul. Método: Aplicação de um questionário com 19 perguntas em 71 atletas, sendo 30 do sexo feminino e 41 do masculino, nas categorias petiz (10 a 12 anos), infantil (12 a 14 anos), juvenil (14 a 16 anos), júnior (16 a 18 anos) e sênior (a partir dos 18 anos). As variáveis foram analisadas pelo teste de igualdade de duas proporções e Mann-Whitney. RESULTADOS: A prevalência de dor foi de 74,6% (n = 53; p < 0,001), sendo 39,6% (n = 21) no ombro e 22,6% (n = 12; p = 0,059) na coxa e o nado costas foi o único estilo que não apresentou correlação com a dor (p = 1,000), bem como com o tempo de prática (p = 0,075). CONCLUSION: Na população estudada houve alta prevalência de dor, sendo as regiões do ombro e da coxa as mais acometidas, não tendo correlação nem com o nado costas e tampouco com o tempo de prática esportiva.

The impact of knee surface alignment on ankle sprain occurrence

BACKGROUND

Knee position provides useful information for the anatomical alignment of the lower extremity. Analyzing the geometric components of this alignment should yield useful information about how these factors affect the occurrence of an ankle sprain. The aim of this study is to investigate the correlation among these anthropometric characteristics and the possible future occurrence of ankle sprain injuries.

MATERIAL AND METHODS

A total of 60 elite athletes (25.2 ± 3.2 years) participated in the current study. The data used for measuring knee surface alignment were the following: anatomical alignment angle (AA), condylar hip angle (CH), tibial plateau angle (PA), and joint surface (condylar plateau) angle (CP). Standardized radiography was used in all measurements. All knee alignment measurements were made on digital radiographs. The study lasted for 18 months. A logistic regression (probit) was used for the statistical analysis of the outcomes. A significance level of P = .05 was considered.

RESULTS

The knee angle factors (AA, CH, PA, and CP) proved to be statistically nonsignificant (P > .05).

CONCLUSIONS

The geometric knee surface alignment factors do not seem to be a decisive factor that would increase the probability of spraining an ankle.

LEVELS OF EVIDENCE

PROGNOSTIC LEVEL IV: Case Series.

Kinematics analysis of ankle inversion ligamentous sprain injuries in sports: five cases from televised tennis competitions

BACKGROUND

Ankle ligamentous sprain is common in sports. The most direct way to study the mechanism quantitatively is to study real injury cases; however, it is unethical and impractical to produce an injury in the laboratory. A recently developed, model-based image-matching motion analysis technique allows quantitative analysis of real injury incidents captured in televised events and gives important knowledge for the development of injury prevention protocols and equipment. To date, there have been only 4 reported cases, and there is a need to conduct more studies for a better understanding of the mechanism of ankle ligamentous sprain injury.

PURPOSE

This study presents 5 cases in tennis and a comparison with 4 previous cases for a better understanding of the mechanism of ankle ligamentous sprain injury.

STUDY DESIGN

Case series; level of evidence, 4.

METHODS

Five sets of videos showing ankle sprain injuries in televised tennis competition with 2 camera views were collected. The videos were transformed, synchronized, and rendered to a 3-dimensional animation software. The dimensions of the tennis court in each case were obtained to build a virtual environment, and a skeleton model scaled to the injured athlete's height was used for the skeleton matching. Foot strike was determined visually, and the profiles of the ankle joint kinematics were individually presented.

RESULTS

There was a pattern of sudden inversion and internal rotation at the ankle joint, with the peak values ranging from 48°-126° and 35°-99°, respectively. In the sagittal plane, the ankle joint fluctuated between plantar flexion and dorsiflexion within the first 0.50 seconds after foot strike. The peak inversion velocity ranged from 509 to 1488 deg/sec.

CONCLUSION

Internal rotation at the ankle joint could be one of the causes of ankle inversion sprain injury, with a slightly inverted ankle joint orientation at landing as the inciting event. To prevent the foot from rolling over the edge to cause a sprain injury, tennis players who do lots of sideward cutting motions should try to land with a neutral ankle orientation and keep the center of pressure from shifting laterally.

Return to play in athletes following ankle injuries

BACKGROUND

The decision to return to play following an ankle injury is a multifactorial process involving both physical and psychological parameters. The current body of literature lacks evidence-based guidelines to assist in the decision.

OBJECTIVE

THIS ARTICLE REVIEWS THE EVIDENCE TO SUPPORT SUCH TESTING: the dorsiflexion lunge test, star excursion balance test, agility T-test, and sargent/vertical jump test. The importance of psychological factors is also highlighted.

EVIDENCE ACQUISITION

The primary literature search was conducted using PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) with the search terms "ankle AND injury" and the following limits activated: English language. A secondary search was then conducted with the search terms "return to play" and "sport injuries and return to play."

RESULTS

Various functional tests have been used to determine whether a patient is able to return to play following an ankle injury. This study documented four tests that have been used to assess range of motion, balance and proprioception, agility and strength and the reasoning as to why these tests are used.

CONCLUSIONS

Functional testing provides objective measures for gauging an athlete's progression through the rehabilitation process. Testing balance and proprioception, strength, range of motion, and agility coupled with psychological assessment evaluates readiness for return to play.

The Use of Model Matching Video Analysis and Computational Simulation to Study the Ankle Sprain Injury Mechanism

Lateral ankle sprains continue to be the most common injury sustained by athletes and create an annual healthcare burden of over $4 billion in the U.S. alone. Foot inversion is suspected in these cases, but the mechanism of injury remains unclear. While kinematics and kinetics data are crucial in understanding the injury mechanisms, ligament behaviour measures – such as ligament strains – are viewed as the potential causal factors of ankle sprains. This review article demonstrates a novel methodology that integrates model matching video analyses with computational simulations in order to investigate injury-producing events for a better understanding of such injury mechanisms. In particular, ankle joint kinematics from actual injury incidents were deduced by model matching video analyses and then input into a generic computational model based on rigid bone surfaces and deformable ligaments of the ankle so as to investigate the ligament strains that accompany these sprain injuries. These techniques may have the potential for guiding ankle sprain prevention strategies and targeted rehabilitation therapies.

Development of the Identification of Functional Ankle Instability (IdFAI)

BACKGROUND

Self-reported questionnaires are a common method used in identifying individuals with ankle instability. Recently a study illustrated the singular use of any of the most frequently utilized questionnaires failed to significantly predict ankle stability status. Therefore, the purpose of this article was to present information related to the development of the Identification of Functional Ankle Instability (IdFAI).

METHODS

Volunteers (n = 278; 125 males, 153 females, 19.8 ± 1.4 years) completed the IdFAI on one occasion. An exploratory factor analysis was conducted with principal axis factoring as the extraction method with varimax rotation. Additionally, a discriminant function analysis was conducted to identify a discrimination score and to evaluate the accuracy of the questionnaire.

RESULTS

The factor analysis revealed: factor 1 (four questions) explained 53.7% of the variance, factor 2 (four questions) with an additional 17.4%, and factor 3 (two questions) an additional 6.3%. Overall, these factors accounted for 77.4% of the variance. There was a distinct discrimination score of 10.3 to identify people who have the minimally accepted criteria for FAI. Overall, the IdFAI has an accuracy of 89.6%.

CONCLUSION

This investigation showed that the IdFAI was a feasible and appropriate way to identify individuals with FAI.

CLINICAL RELEVANCE

We suggest clinicians and researchers utilize the IdFAI to identify individuals with functional ankle instability since it is a short, simple, easy questionnaire to administer and take, and has been shown to have excellent accuracy.

Medial compressible forefoot sole elements reduce ankle inversion in lateral SSC jumps

Sideward movements are associated with high incidences of lateral ankle sprains. Special shoe constructions might be able to reduce these injuries during lateral movements. The purpose of this study was to investigate whether medial compressible forefoot sole elements can reduce ankle inversion in a reactive lateral movement, and to evaluate those elements' influence on neuromuscular and mechanical adjustments in lower extremities. Foot placement and frontal plane ankle joint kinematics and kinetics were analyzed by 3-dimensional motion analysis. Electromyographic data of triceps surae, peroneus longus, and tibialis anterior were collected. This modified shoe reduced ankle inversion in comparison with a shoe with a standard sole construction. No differences in ankle inversion moments were found. With the modified shoe, foot placement occurred more internally rotated, and muscle activity of the lateral shank muscles was reduced. Hence, lateral ankle joint stability during reactive sideward movements can be improved by these compressible elements, and therefore lower lateral shank muscle activity is required. As those elements limit inversion, the strategy to control inversion angles via a high external foot rotation does not need to be used.

Establishing proof of concept: Platelet-rich plasma and bone marrow aspirate concentrate may improve cartilage repair following surgical treatment for osteochondral lesions of the talus

Osteochondral lesions of the talus are common injuries in the athletic patient. They present a challenging clinical problem as cartilage has a poor potential for healing. Current surgical treatments consist of reparative (microfracture) or replacement (autologous osteochondral graft) strategies and demonstrate good clinical outcomes at the short and medium term follow-up. Radiological findings and second-look arthroscopy however, indicate possible poor cartilage repair with evidence of fibrous infill and fissuring of the regenerative tissue following microfracture. Longer-term follow-up echoes these findings as it demonstrates a decline in clinical outcome. The nature of the cartilage repair that occurs for an osteochondral graft to become integrated with the native surround tissue is also of concern. Studies have shown evidence of poor cartilage integration, with chondrocyte death at the periphery of the graft, possibly causing cyst formation due to synovial fluid ingress. Biological adjuncts, in the form of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have been investigated with regard to their potential in improving cartilage repair in both in vitro and in vitro settings. The in vitro literature indicates that these biological adjuncts may increase chondrocyte proliferation as well as synthetic capability, while limiting the catabolic effects of an inflammatory joint environment. These findings have been extrapolated to in vitro animal models, with results showing that both PRP and BMAC improve cartilage repair. The basic science literature therefore establishes the proof of concept that biological adjuncts may improve cartilage repair when used in conjunction with reparative and replacement treatment strategies for osteochondral lesions of the talus.

Magnetic resonance imaging features of osteochondral lesions of the talus

BACKGROUND

Osteochondral lesions of the talus (OLT) traditionally have been thought to occur anterolaterally or posteromedially. Recent studies utilizing magnetic resonance imaging (MRI) have questioned this teaching. The purpose of this study was to use MRI to describe the location, frequency, and morphology of OLT and determine if any correlations exist between lesion location and other data points.

METHODS

The location, frequency, and size of OLT based on a nine-zone grid were recorded on 77 MRI examinations. Lateral ligaments were inspected for evidence of injury. Stability of the lesions was assessed based on four MRI criteria: presence or absence of cartilage defects, edema-like signal abnormality, T2 bright rim, and/or subchondral cysts. Demographic data including patient age, injury mechanism, and chronicity were recorded. An ANOVA model was used to determine if statistical differences existed between lesion size and location. Pearson correlation coefficients were used to examine any association between lesion location and demographic data.

RESULTS

Most of the lesions were located medially and centrally on the talar dome (54.5%), with the second highest frequency found laterally and centrally (31.2%). With the numbers available there was no statistical difference between the size of the lesions based on location. No strong correlations were found between lesion location and demographic data.

CONCLUSION

This study refutes traditional teachings regarding the location of OLT and supports recent studies showing that most lesions are located medially and centrally on the talar dome.

Is the inverted surface landing more suitable in evaluating ankle braces and ankle inversion perturbation?

OBJECTIVE

To investigate biomechanical (kinematic) differences between 2 ankle brace testing protocols: landing on an inverted surface (IS) and inversion drop on an inversion platform.

DESIGN

Five trials in each of 4 dynamic movement conditions were performed: inversion drop and drop landing from 0.45 m onto an IS without and with an ankle brace. A 7-camera motion analysis system was used to obtain the 3-dimensional kinematics. A 2 × 2 (brace × movement) repeated measures analysis of variance was used to evaluate selected variables for inversion drop and IS landing.

SETTING

Research laboratory.

PATIENTS

Eleven healthy subjects participated in the study.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Maximum ankle frontal plane and sagittal plane joint angles, range of motion, and maximum angular velocity.

RESULTS

The IS landing resulted in significantly earlier maximum inversion, inversion velocities, dorsiflexion range of motion (ROM), contact dorsiflexion velocity, and maximum dorsiflexion velocity compared with the inversion drop. The ankle brace application during the IS landing reduced the contact plantarflexion angle, dorsiflexion ROM and maximum dorsiflexion velocity, and maximum inversion.

CONCLUSIONS

The results from this study showed that the IS landing protocol produced significantly earlier maximum inversion angle and velocity and inversion velocities compared with the inversion drop protocol. These results showed that the IS landing is more demanding and should be considered in future investigations of ankle braces and lateral ankle performance/injury mechanisms.

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

OBJECTIVE

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

DESIGN

Blinded case-control study.

SETTING

: University research laboratory.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

BIOMECHANICS AND POTENTIAL INJURY MECHANISMS OF WRESTLING

Wrestling is one of the oldest and most popular competitive sports in the world, however, knowledge of the biomechanics of wrestling is not well established and the biomechanical risk factors of injuries unclear. The purpose of this study was to investigate the joint kinematics of the lower limbs and the center of pressure (COP) movements in Greco-Roman style (GR) and free style (FS) wrestlers during tackle defense. Eighteen male college wrestlers participated in the current study: 10 majored in GR (height: 171.1 ± 8.0 cm; weight: 73.9 ± 11.5, kg) and 8 in FS (height: 169.0 ± 5.2 cm; weight: 71.8 ± 11.4 kg). The wrestlers received tackle attacks from three different directions while their kinematic data measured by a 3D motion capture system and ground reaction forces from two AMTI forceplates. The wrestlers who majored in GR style tended to resist tackle attacks longer than the FS group. Compared to the GR group, the FS wrestlers tended to have greater A/P excursions of the COP with significant greater knee flexion. This flexed knee strategy may be related to the rule of the game and the training the FS wrestlers received. Significantly increased joint angles in the transverse and frontal planes at the knee and ankle found in the current study may be related to the risk of knee and ankle injuries commonly observed in wrestlers. Strengthening of the muscles of the lower extremity may be helpful for reducing these injuries during competitions.

Three-dimensional matrix-induced autologous chondrocytes implantation for osteochondral lesions of the talus: midterm results

Introduction. We evaluate the midterm results of thirty patients who underwent autologous chondrocytes implantation for talus osteochondral lesions treatment. Materials and Methods. From 2002 to 2009, 30 ankles with a mean lesion size of 2,36 cm(2) were treated. We evaluated patients using American Orthopaedic Foot and Ankle Surgery and Coughlin score, Van Dijk scale, recovering time, and Musculoskeletal Outcomes Data Evaluation and Management System. Results. The mean AOFAS score varied from 36.9 to 83.9 at follow-up. Average of Van Dijk scale was 141.1. Coughlin score was excellent/good in 24 patients. MOCART score varied from 6.3 to 3.8. Discussion. This matrix is easy to handle conformable to the lesion and apply by arthroscopy. No correlation between MRI imaging and clinical results is found. Conclusions. Our results, compared with those reported in literature with other surgical procedures, show no superiority evidence for our technique compared to the others regarding the size of the lesions.

The effect of ankle taping or bracing on proprioception in functional ankle instability: a systematic review and meta-analysis

OBJECTIVES

To determine if wearing an ankle brace or taping the ankle, compared to no brace or tape, improves proprioceptive acuity in people with a history of ankle sprain or functional ankle instability.

DESIGN

Systematic review and meta-analysis.

METHODS

Studies using controlled, cross-over designs whereby participants who had sprained their ankle at least once or had functional ankle instability, underwent some form of proprioceptive sensation testing with and without ankle brace or tape, were included. Proprioceptive acuity was reported for the ankle tape/brace condition and the condition where no tape or brace was worn. Meta-analysis was employed to compare proprioceptive acuity with and without ankle tape/brace.

RESULTS

Eight studies were included in the review. Studies measured either sense of movement or sense of joint position. The mean differences in 19 of 32 comparisons were not significant. Of the remaining mean differences, 10 were positive, indicating better proprioceptive acuity in the taped/braced condition and 3 were negative, indicating poorer proprioceptive acuity. Overall, there was no significant effect with ankle tape/brace compared to the no tape/brace condition (mean difference: 0.08°, 95% CI: -0.39 to 0.55). This finding was consistent when the two aspects of proprioception (sense of movement or joint position) were considered separately.

CONCLUSIONS

The pooled evidence suggests that using an ankle brace or ankle tape has no effect on proprioceptive acuity in participants with recurrent ankle sprain or who have functional ankle instability.

A mechanical jig for measuring ankle supination and pronation torque in vitro and in vivo

This study presents the design of a mechanical jig for evaluating the ankle joint torque on both cadaver and human ankles. Previous study showed that ankle sprain motion was a combination of plantarflexion and inversion. The device allows measurement of ankle supination and pronation torque with one simple axis in a single step motion. More importantly, the ankle orientation allows rotation starting from an anatomical position. Six cadaveric specimens and six human subjects were tested with simulated and voluntary rotation respectively. The presented mechanical jig makes possible the determination of supination torque for studying ankle sprain injury and the estimation of pronation torque for examining peroneal muscle response.

Rotational Stiffness of Football Shoes Influences Talus Motion during External Rotation of the Foot

Shoe-surface interface characteristics have been implicated in the high incidence of ankle injuries suffered by athletes. Yet, the differences in rotational stiffness among shoes may also influence injury risk. It was hypothesized that shoes with different rotational stiffness will generate different patterns of ankle ligament strain. Four football shoe designs were tested and compared in terms of rotational stiffness. Twelve (six pairs) male cadaveric lower extremity limbs were externally rotated 30 deg using two selected football shoe designs, i.e., a flexible shoe and a rigid shoe. Motion capture was performed to track the movement of the talus with a reflective marker array screwed into the bone. A computational ankle model was utilized to input talus motions for the estimation of ankle ligament strains. At 30 deg of rotation, the rigid shoe generated higher ankle joint torque at 46.2 ± 9.3 Nm than the flexible shoe at 35.4 ± 5.7 Nm. While talus rotation was greater in the rigid shoe (15.9 ± 1.6 deg versus 12.1 ± 1.0 deg), the flexible shoe generated more talus eversion (5.6 ± 1.5 deg versus 1.2± 0.8 deg). While these talus motions resulted in the same level of anterior deltoid ligament strain (approxiamtely 5%) between shoes, there was a significant increase of anterior tibiofibular ligament strain (4.5± 0.4% versus 2.3 ± 0.3%) for the flexible versus more rigid shoe design. The flexible shoe may provide less restraint to the subtalar and transverse tarsal joints, resulting in more eversion but less axial rotation of the talus during foot/shoe rotation. The increase of strain in the anterior tibiofibular ligament may have been largely due to the increased level of talus eversion documented for the flexible shoe. There may be a direct correlation of ankle joint torque with axial talus rotation, and an inverse relationship between torque and talus eversion. The study may provide some insight into relationships between shoe design and ankle ligament strain patterns. In future studies, these data may be useful in characterizing shoe design parameters and balancing potential ankle injury risks with player performance.

Sports activity after osteochondral transplantation of the talus

BACKGROUND

There are limited data regarding activity after osteochondral transplantation of the talus in orthopaedic publications.

HYPOTHESIS

Osteochondral transplantation of the talus is a clinically successful treatment and enables patients to pursue regular and ongoing recreational sporting activities.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

One hundred thirty-one patients were retrospectively analyzed to determine their sporting and recreational activities at an average of 60 ± 28.4 months postoperatively (range, 24-141 months). The clinical evaluation included the Tegner activity scale, the Activity Rating Scale (ARS), and a visual analog scale (VAS) for pain.

RESULTS

The VAS illustrated significant preoperative to postoperative improvements (6.3 to 2.7; P < .001). Regarding sporting activity, 96.9% of the patients were engaged in sports during their lifetimes compared with 83.8% the year before surgery and 89.3% at the time of survey. The Tegner score dropped from 5.9 preoperatively to 5.0 after surgery (P = .001), and the ARS decreased from 8.9 preoperatively to 6.8 postoperatively (P = .003). The sports frequency and the duration of activities did not significantly change after surgery: 1.7 ± 2.0 (range, 0-8; P = .053) and 4.2 ± 3.8 hours (range, 0-30 hours; P = .052), respectively. The number of actual reported different sports disciplines was unchanged in comparison to the year before surgery (3.7 ± 2.9; range, 0-12). The top 10 cited sports activities did not change for the lifetime, preoperative, and postoperative periods but illustrated an altered order. Although the overall satisfaction with the surgery was good, 15% of our patients were only partially satisfied, and 14% were not satisfied with the procedure.

CONCLUSION

Patients engage in fewer, less frequent sporting activities when a symptomatic osteochondral lesion (OCL) at the talus is present. Talar osteochondral transplantation shows good clinical midterm results and allows patients to return to sporting activity. However, we found patients modify their postoperative sporting activities, and we noted a reduction of participation in high-impact and contact sports.

Intrinsic predictive factors for ankle sprain in active university students: a prospective study

The ankle is the joint most affected among the sports-related injuries. The current study investigated whether certain intrinsic factors could predict ankle sprains in active students. The 125 participants were submitted to a baseline assessment in a single session were then followed-up for 52 weeks regarding the occurrence of sprain. The baseline assessment were performed in both ankles and included the questionnaire Cumberland ankle instability tool - Portuguese, the foot lift test, dorsiflexion range of motion, Star Excursion Balance Test (SEBT), the side recognition task, body mass index, and history of previous sprain. Two groups were used for analysis: one with those who suffered an ankle sprain and the other with those who did not suffer an ankle sprain. After Cox regression analysis, participants with history of previous sprain were twice as likely to suffer subsequent sprains [hazard ratio (HR) 2.21 and 95% confidence interval (CI) 1.07-4.57] and people with better performance on the SEBT in the postero-lateral (PL) direction were less likely to suffer a sprain (HR 0.96 and 95% CI 0.92-0.99). History of previous sprain was the strongest predictive factor and a weak performance on SEBT PL was also considered a predictive factor for ankle sprains.

Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm

Acute ankle injuries are among the most common injuries in emergency departments. However, there are still no standardized examination procedures or evidence-based treatment. Therefore, the aim of this study was to systematically search the current literature, classify the evidence, and develop an algorithm for the diagnosis and treatment of acute ankle injuries. We systematically searched PubMed and the Cochrane Database for randomized controlled trials, meta-analyses, systematic reviews or, if applicable, observational studies and classified them according to their level of evidence. According to the currently available literature, the following recommendations have been formulated: i) the Ottawa Ankle/Foot Rule should be applied in order to rule out fractures; ii) physical examination is sufficient for diagnosing injuries to the lateral ligament complex; iii) classification into stable and unstable injuries is applicable and of clinical importance; iv) the squeeze-, crossed leg- and external rotation test are indicative for injuries of the syndesmosis; v) magnetic resonance imaging is recommended to verify injuries of the syndesmosis; vi) stable ankle sprains have a good prognosis while for unstable ankle sprains, conservative treatment is at least as effective as operative treatment without the related possible complications; vii) early functional treatment leads to the fastest recovery and the least rate of reinjury; viii) supervised rehabilitation reduces residual symptoms and re-injuries. Taken these recommendations into account, we present an applicable and evidence-based, step by step, decision pathway for the diagnosis and treatment of acute ankle injuries, which can be implemented in any emergency department or doctor's practice. It provides quality assurance for the patient and promotes confidence in the attending physician.

Movement variability during single leg jump landings in individuals with and without chronic ankle instability

BACKGROUND

Repeated episodes of giving way at the ankle may be related to alterations in movement variability.

METHODS

Eighty-eight recreational athletes (39 males, 49 females) were placed in 4 groups: mechanically unstable, functionally unstable, copers, and controls based on ankle injury history, episodes of giving way, and joint laxity. Lower extremity kinematics and ground reaction forces were measured during single leg landings from a 50% maximum vertical jump in the anterior, lateral, and medial directions. Ensemble curves of 10 trials were averaged and coefficients of variation were identified for ankle, knee, hip, and trunk motion in 3 planes. A log(e) (ln) transformation was performed on the data. Mixed model analyses of variance (ANOVAs) with Tukey post-hoc tests were utilized with Bonferroni corrections to α ≤ 0.008.

FINDINGS

At the knee, controls were more variable than functionally unstable and copers for knee rotation before initial contact, and were more variable during stance than functionally unstable in knee rotation (P ≤ 0.008). Interactions during stance revealed controls were more variable than functionally unstable in lateral jumps for hip flexion, and than mechanically and functionally unstable in hip abduction in the anterior direction (P≤0.008). Controls were more variable than all other groups in hip flexion and than mechanically unstable in hip abduction (P ≤0 .008).

INTERPRETATION

Individuals with ankle instability demonstrated less variability at the hip and knee compared to controls during single leg jump landings. Inability to effectively utilize proximal joints to perform landing strategies may influence episodes of instability.

Modified Watson-Jones technique for chronic lateral ankle instability in athletes: clinical and radiological mid- to long-term follow-up

BACKGROUND

We clinically and radiologically assessed mid- to long-term follow-up of a group of patients treated with a modified Watson-Jones technique for chronic ankle instability.

METHODS

Fourteen athletes were retrospectively evaluated with physical examination, and Tegner, Good and AOFAS scales; moreover, a 2-view stress, side-to-side X-ray, was performed.

RESULTS

All patients were followed-up at a mean of 10.8 years. No one reported further ankle sprains. Mean Good scale value decreased from 3.7 to 1.6, while the Tegner scale decreased from 6.8 to 5.1; the mean AOFAS score was 92.2. Mean sagittal-plane ROM was 62.3° (4.9° S/S difference), while mean coronal-plane ROM was 25.5° (3.8° S/S difference). Mean X-ray talar tilt angle was 4.5° (0.1° S/S difference), while mean anterior drawer test angle was 5.4 mm (0.5 mm S/S difference).

CONCLUSIONS

The modified Watson-Jones procedure seems to be a reliable technique in providing satisfactory mid- to long-term clinical and radiological results.

Epidemiological survey of orthopedic joint dislocations based on nationwide insurance data in Taiwan, 2000-2005

BACKGROUND

The epidemiology of acute orthopedic dislocations is poorly understood. A nationwide database provides a valuable resource for examining this issue in the Taiwanese population.

METHODS

A 6-year retrospective cohort study of 1,000,000 randomly-sampled beneficiaries from the year 2005 was used as the original population. Based on the hospitalized and ambulatory data, the concomitant ICD9-CM diagnosis codes and treatment codes were evaluated and classified into 8 and 3 major categories, respectively. The cases matching both inclusive criteria of dislocation-related diagnosis codes and treatment codes were defined as incident cases.

RESULTS

During 2000-2005, the estimated annual incidence (per 100,000 population) of total orthopedic dislocations in Taiwan was 42.1 (95%CI: 38.1-46.1). The major cause of these orthopedic dislocations was traffic accidents (57.4%), followed by accident falls (27.5%). The annual incidence dislocation by location was shoulder, 15.3; elbow, 7.7; wrist, 3.5; finger, 4.6; hip, 5.2; knee, 1.4; ankle, 2.0; and foot, 2.4. Approximately 16% of shoulder dislocations occurred with other concomitant fractures, compared with 17%, 53%, 16%, 76% and 52%, respectively, of dislocated elbow, wrist, hip, knee, and ankle cases. Including both simple and complex dislocated cases, the mean medical cost was US$612 for treatment of a shoulder dislocation, $504 for the elbow, $1,232 for the wrist, $1,103 for the hip, $1,888 for the knee, and $1,248 for the ankle.

CONCLUSIONS

In Taiwan, three-quarters of all orthopedic dislocations were of the upper limbs. The most common complex fracture-dislocation was of the knee, followed by the wrist and the ankle. Those usually needed a treatment combined with open reduction of fractures and resulted in a higher direct medical expenditure.

Neuromuscular training to enhance sensorimotor and functional deficits in subjects with chronic ankle instability: A systematic review and best evidence synthesis

Objective

To summarise the available evidence for the efficacy of neuromuscular training in enhancing sensorimotor and functional deficits in subjects with chronic ankle instability (CAI).

Design

Systematic review with best evidence synthesis.

Data Sources

An electronic search was conducted through December 2009, limited to studies published in the English language, using the Pubmed, CINAHL, Embase, and SPORTDiscus databases. Reference screening of all included articles was also undertaken.

Methods

Studies were selected if the design was a RCT, quasi RCT, or a CCT; the patients were adolescents or adults with confirmed CAI; and one of the treatment options consisted of a neuromuscular training programme. The primary investigator independently assessed the risk of study bias and extracted relevant data. Due to clinical heterogeneity, data was analysed using a best-evidence synthesis.

Results

Fourteen studies were included in the review. Meta-analysis with statistical pooling of data was not possible, as the studies were considered too heterogeneous. Instead a best evidence synthesis was undertaken. There is limited to moderate evidence to support improvements in dynamic postural stability, and patient perceived functional stability through neuromuscular training in subjects with CAI. There is limited evidence of effectiveness for neuromuscular training for improving static postural stability, active and passive joint position sense (JPS), isometric strength, muscle onset latencies, shank/rearfoot coupling, and a reduction in injury recurrence rates. There is limited evidence of no effectiveness for improvements in muscle fatigue following neuromuscular intervention.

Conclusion

There is limited to moderate evidence of effectiveness in favour of neuromuscular training for various measures of static and dynamic postural stability, active and passive JPS, isometric strength, muscle onset latencies, shank/rearfoot coupling and injury recurrence rates. Strong evidence of effectiveness was lacking for all outcome measures. All but one of the studies included in the review were deemed to have a high risk of bias, and most studies were lacking sufficient power. Therefore, in future we recommend conducting higher quality RCTs using appropriate outcomes to assess for the effectiveness of neuromuscular training in overcoming sensorimotor deficits in subjects with CAI.

Ankle arthroscopy in children

INTRODUCTION

Arthroscopy of the ankle has gained acceptance as a procedure for diagnosing and treating chronic and post-traumatic ankle problems. The senior author's perception is that magnetic resonance imaging (MRI) under-diagnoses anterior soft tissue impingement lesions in children. The purpose of this study was retrospectively to analyse the outcome of ankle arthroscopy in the paediatric age group.

PATIENTS AND METHODS

Between March 2005 and September 2007, 23 children underwent ankle arthroscopy for post-traumatic pathology. The indications for arthroscopy were failure of non-operative treatment for at least 12 weeks or a grade 3 or 4 osteochondral defect (OCD) on imaging.

RESULTS

At arthroscopy, OCDs were visualised in 12 cases and impingement lesions were seen in 17 ankles. MRI was performed in 8 of these 12 cases and only 1 suggested the possibility of an impingement lesion. Of the 17 cases of impingement seen on arthroscopy, 12 reported mechanical symptoms preoperatively and 4 were unstable on examination under anaesthetic. Eighteen of the twenty-three patients had complete relief of symptoms at 3 months. Eighteen children who were evaluated at one-year follow up had a mean American Orthopaedic Foot and Ankle Society score of 87. 5 (range: 49-100).

CONCLUSIONS

Ankle arthroscopy has a successful outcome in paediatric patients and the results are comparable with those reported in adult series. MRI was found to be insensitive for the diagnosis of soft tissue impingement of the ankle.

Foot clearance in walking and running in individuals with ankle instability

BACKGROUND

Foot positioning before heel strike has been attributed to chronic ankle instability injury mechanics, and may play a role in developing and perpetuating chronic ankle instability.

PURPOSE

This study was undertaken to determine if a group of individuals with mechanical instability (MI) or a group with functional instability (FI) of the ankle joint demonstrate less foot-floor clearance and a more inverted and plantar flexed position of the foot during the terminal swing phase of the running and walking cycles when compared with a group of ankle sprain copers who had an injury but no residual instability.

STUDY DESIGN

Controlled laboratory study.

METHODS

Three-dimensional motion analysis was performed on 3 groups (n = 11 male athletes each) differentiated based on ankle injury history and ligamentous laxity during walking and running on a raised platform.

RESULTS

The MI group (14.8° ± 12.0°) demonstrated greater maximum foot external rotation than the FI (3.2° ± 6.0°) and coper groups (2.9° ± 11.0°) (P = .01; η(p) (2) = .25) during running and greater rotation than the coper group during walking (3.3° ± 6.1° vs -4.5° ± 4.1°; P = .03; η(p) (2) = .21). The FI group (6.1° ± 3.2°) had greater plantar flexion at minimum than the MI group (0.1° ± 3.5°) during walking (P = .02; η(p) (2) = .25). Other group differences demonstrated large effect sizes, but not statistical significance, including unstable groups having lower minimum metatarsal height than copers during running.

CONCLUSION

Differences in foot and leg position during terminal swing were observed between MI and FI groups and copers. Greater plantar flexion and lower minimum metatarsal height may increase risk for inadvertent contact and thus episodes of instability.

CLINICAL RELEVANCE

Rehabilitation programs may need to address terminal swing to improve mechanics and avoid potential episodes of giving way at the ankle.

The influence of playing level on functional ankle stability in soccer players

OBJECTIVE

The aim of this study was to compare the functional ankle stability between professional and amateur soccer players as well as controls.

MATERIALS AND METHODS

Thirty professional soccer players, 30 amateur soccer players and 30 controls were evaluated. All participants completed a questionnaire. Range of motion (ROM), peroneal reaction time (PRT) and ankle position sense were measured. Balance control was investigated with the Biodex Stability System, measuring the stable level 8 and the unstable level 2.

RESULTS

Professional soccer players cited significantly more frequent ankle sprains than all other groups (P = 0.002). They showed a significantly decreased dorsiflexion of the right foot (amateur: P = 0.017; controls: P = 0.004), an increased pronation of both feet (amateurs: right: P = 0.0048, left: P = 0.006; controls: right: P = 0.017, left: P = 0.007) and a decreased supination of the left foot in comparison to all other groups (amateurs: P = 0.003; controls: P = 0.004). Balance control showed no significant differences among all groups. Significant differences in angle reproduction were observed between professionals and amateurs for the left ankle joint at the positions of 105° (P = 0.0018) and 140° (P = 0.013). Professionals (P = 0.004) and amateurs (P = 0.001) showed a significantly delayed PRT of the right peroneus longus muscle compared to controls. In addition, the PRT of the right peroneus brevis muscle was significantly increased in professional soccer players in comparison to controls (P = 0.017).

CONCLUSIONS

Professional soccer players have shown more frequent ankle sprains, limited ROM, and delayed PRT of the right leg which reflects the higher risk of functional ankle instability due to intensified work-related use of feet. Therefore, proprioceptive exercises of the ankle in daily training programs are recommended in order to minimize the risk of ankle injuries and improve functional ankle stability.

A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types

Ankle injuries, especially ankle sprains, are a common problem in sports and medical care. Ankle sprains result in pain and absenteeism from work and/or sports participation, and can lead to physical restrictions such as ankle instability. Nowadays, treatment of ankle injury basically consists of taping the ankle. The purpose of this review is to evaluate the effectiveness of ankle braces as a treatment for acute ankle sprains compared with other types of functional treatments such as ankle tape and elastic bandages. A computerized literature search was conducted using PubMed, EMBASE, CINAHL and the Cochrane Clinical Trial Register. This review includes randomized controlled trials in English, German and Dutch, published between 1990 and April 2009 that compared ankle braces as a treatment for lateral ankle sprains with other functional treatments. The inclusion criteria for this systematic review were (i) individuals (sports participants as well as non-sports participants) with an acute injury of the ankle (acute ankle sprains); (ii) use of an ankle brace as primary treatment for acute ankle sprains; (iii) control interventions including any other type of functional treatment (e.g. Tubigrip™, elastic wrap or ankle tape); and (iv) one of the following reported outcome measures: re-injuries, symptoms (pain, swelling, instability), functional outcomes and/or time to resumption of sports, daily activities and/or work. Eight studies met all inclusion criteria. Differences in outcome measures, intervention types and patient characteristics precluded pooling of the results, so best evidence syntheses were conducted. A few individual studies reported positive outcomes after treatment with an ankle brace compared with other functional methods, but our best evidence syntheses only demonstrated a better treatment result in terms of functional outcome. Other studies have suggested that ankle brace treatment is a more cost-effective method, so the use of braces after acute ankle sprains should be considered. Further research should focus on economic evaluation and on different types of ankle brace, to examine the strengths and weaknesses of ankle braces for the treatment of acute ankle sprains.

Evidence-based treatment for ankle injuries: a clinical perspective

The most common ankle injuries are ankle sprain and ankle fracture. This review discusses treatments for ankle sprain (including the management of the acute sprain and chronic instability) and ankle fracture, using evidence from recent systematic reviews and randomized controlled trials. After ankle sprain, there is evidence for the use of functional support and non-steroidal anti-inflammatory drugs. There is weak evidence suggesting that the use of manual therapy may lead to positive short-term effects. Electro-physical agents do not appear to enhance outcomes and are not recommended. Exercise may reduce the occurrence of recurrent ankle sprains and may be effective in managing chronic ankle instability. After surgical fixation for ankle fracture, an early introduction of activity, administered via early weight-bearing or exercise during the immobilization period, may lead to better outcomes. However, the use of a brace or orthosis to enable exercise during the immobilization period may also lead to a higher rate of adverse events, suggesting that this treatment regimen needs to be applied judiciously. After the immobilization period, the focus of treatment for ankle fracture should be on a progressive exercise program.

Pooled analysis of clinical trial data evaluating the safety and effectiveness of diclofenac epolamine topical patch 1.3% for the treatment of acute ankle sprain

This pooled analysis assessed the efficacy and safety of the diclofenac epolamine topical patch 1.3% (DETP) for the treatment of acute mild-to-moderate ankle sprain. Data from 2 randomized, double-blind, placebo-controlled studies enrolling 274 male and female patients aged 18 to 65 years with acute ankle sprain were pooled and evaluated. The primary end point was pain reduction on movement assessed using a 100 mm visual analog scale (VAS). Safety and tolerability were also assessed. Beginning approximately 3 hours after initial treatment, DETP-treated patients experienced statistically significant and sustained lower mean VAS scores in pain intensity on movement (mean ± SD, 54.1 ± 20.0 mm versus 60.3 ± 16.8 mm) compared with placebo-treated patients, representing a 20% versus 13% reduction in VA S pain scores from baseline (P = 0.012). This statistically significant difference in mean VAS score was maintained through day 7 (9.4 ± 14.4 mm versus 18.4 ± 18.2 mm, P < 0.0001). The DETP and placebo patches were well tolerated. These results further confirm the efficacy and safety of DETP for the treatment of acute pain from ankle sprains.

EXACT: exercise or advice after ankle fracture. Design of a randomised controlled trial

Background

Ankle fractures are common. Management of ankle fractures generally involves a period of immobilisation followed by rehabilitation to reduce pain, stiffness, weakness and swelling. The effects of a rehabilitation program are still unclear. However, it has been shown that important components of rehabilitation programs may not confer additional benefits over exercise alone. The primary aim of this trial is to determine the effectiveness and cost-effectiveness of an exercise-based rehabilitation program after ankle fracture, compared to advice alone.

Methods/Design

A pragmatic randomised trial will be conducted. Participants will be 342 adults with stiff, painful ankles after ankle fracture treated with immobilisation. They will be randomly allocated using a concealed randomisation procedure to either an Advice or Rehabilitation group. Participants in the Advice group will receive verbal and written advice about exercise at the time of removal of immobilisation. Participants in the Rehabilitation group will be provided with a 4-week rehabilitation program that is designed, monitored and progressed by a physiotherapist, in addition to verbal and written advice. Outcomes will be measured by a blinded assessor at 1, 3 and 6 months. The primary outcomes will be activity limitation and quality-adjusted life years.

Discussion

This pragmatic trial will determine if a rehabilitation program reduces activity limitation and improves quality of life, compared to advice alone, after immobilisation for ankle fracture.