A systematic review on ankle injury and ankle sprain in sports

Effect of a 6-week dynamic neuromuscular training programme on ankle joint function: A Case report

Background

Ankle joint sprain and the subsequent development of chronic ankle instability (CAI) are commonly encountered by clinicians involved in the treatment and rehabilitation of musculoskeletal injuries. It has recently been advocated that ankle joint post-sprain rehabilitation protocols should incorporate dynamic neuromuscular training to enhance ankle joint sensorimotor capabilities. To date no studies have reported on the effects of dynamic neuromuscular training on ankle joint positioning during landing from a jump, which has been reported as one of the primary injury mechanisms for ankle joint sprain. This case report details the effects of a 6-week dynamic neuromuscular training programme on ankle joint function in an athlete with CAI.

Methods

The athlete took part in a progressive 6-week dynamic neuromuscular training programme which incorporated postural stability, strengthening, plyometric, and speed/agility drills. The outcome measures chosen to assess for interventional efficacy were: [1] Cumberland Ankle Instability Tool (CAIT) scores, [2] Star Excursion Balance Test (SEBT) reach distances, [3] ankle joint plantar flexion during drop landing and drop vertical jumping, and [4] ground reaction forces (GRFs) during walking.

Results

CAIT and SEBT scores improved following participation in the programme. The angle of ankle joint plantar flexion decreased at the point of initial contact during the drop landing and drop vertical jumping tasks, indicating that the ankle joint was in a less vulnerable position upon landing following participation in the programme. Furthermore, GRFs were reduced whilst walking post-intervention.

Conclusions

The 6-week dynamic neuromuscular training programme improved parameters of ankle joint sensorimotor control in an athlete with CAI. Further research is now required in a larger cohort of subjects to determine the effects of neuromuscular training on ankle joint injury risk factors.

INVERSE DYNAMICS OF THE LOWER EXTREMITIES: NOVEL APPROACH CONSIDERING TALOCRURAL AND SUBTALAR JOINT AXIS

A recent survey of epidemiological studies lists ankle injuries as one common sport injury. However, the details of the injury mechanisms of ankle sprains — the majority of ankle injuries — remain not well understood.

The purpose of the presented study is twofold. The first aim is to introduce a new, widely applicable method to calculate ankle joint torques during movement using inverse dynamics. The subtalar and talocrural joint are modeled as anatomically based revolute joints. The kinematics of the lower extremities and ground reaction force are used as input data. Second, a comparison of two calculation approaches (dynamic versus static) is reported, aimed at verifying and simplifying the introduced method to have a more convenient tool at hand for applications in the field. For one first movement measurement (hopping), the calculated joint torques show a good match for the two calculation approaches.

After further application, the evaluation of the resulting joint torques will provide further insights into the joint mechanics and can contribute to a better understanding of the respective injury mechanisms.

Hence, this approach is interesting for researchers to be used in order to understand ankle injuries and to determine the influence of landing grounds and shoes on ankle joint torques.

The Epidemiology of Ankle Sprain during Hiking in Uniformed Groups

Purpose

To determine the prevalence of ankle sprain during hiking training in uniformed groups and identify the risk factors of ankle sprain and the risk factors associated with residual problems after ankle sprain.

Methods

A retrospective cross-sectional study involved 590 members of a uniformed group from secondary schools and their leaders by means of a self-administered anonymous questionnaire.

Results

The prevalence of ankle sprain was 9.15%. Most of them were lateral sprains (70.4%) and occurred in scree ground (51.9%) and downhill slope (50.0%). Subjects who are “older” aged, are overweight, are leaders in uniformed groups, have a past history of ankle sprain or problem, have a long-term lower limb injury, wear inadequate sized or tight shoes, and use hiking poles, have significant risks. The prevalence of having residual problems after ankle sprains was 48.14%, and the most common one was residual ankle pain (25.0%).

Conclusion

Uniformed group leaders and members should be aware of the risk factors of ankle sprain during hiking training in the countryside. They should also be aware of the importance of proper treatment and rehabilitation to prevent residual ankle problem.

Level of Evidence

Level II prognostic study.

Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition

BACKGROUND

Syndesmotic and medial ankle sprains constitute up to 15% of all ankle sprains in athletic populations and can result in significant time lost to injury and long-term disability.

PURPOSE

The objective of this study was to estimate the rate of syndesmotic and medial ankle sprain injuries and identify risk factors associated with these injuries within the physically active cadet population at the United States Military Academy (USMA).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The Cadet Illness and Injury Tracking System (CIITS) database at USMA was queried for all ankle injuries between 2005 and 2009. Sex, level of competition, and exposure to sport were among risk factors analyzed.

RESULTS

Among 20 336 person-years, 1206 cadets sustained ankle sprain. Syndesmotic (6.7%) and medial (5.1%) ankle sprains had an incidence rate (IR) of 4.8 and 3.5 per 1000 person-years, respectively. Compared with women, men were 3 times more likely to experience medial ankle sprain (IR ratio [IRR] 3.37; 95% confidence interval [CI]: 1.05, 10.74], but there was no difference in rate of syndesmotic sprains by sex (IRR 1.06; 95% CI: 0.58, 1.95). Athletics accounted for 81% of syndesmotic sprains and 64% of medial sprains. Sprint football (52.3), team handball (men's, 34.7), soccer (men's, 30.5; women's, 6.5), and basketball (men's, 24.8; women's, 6.7) had the highest syndesmotic IR per 100 000 athlete-exposures. Medial sprain IR was highest in men's rugby (16.6) and gymnastics (14.0). When analyzed by athlete-exposure, male intercollegiate athletes had a greater risk of syndesmotic sprain than their female counterparts (3.53; 95% CI: 1.26, 9.83). Furthermore, intercollegiate level of competition had an increased risk of syndesmotic sprain when compared with intramural level (IRR 2.41; 95% CI: 1.03, 5.65).

CONCLUSION

Male athletes have an over threefold greater risk of medial ankle sprain. Male sex and higher level of competition are risk factors for syndesmotic ankle sprain during athletics.

An ankle joint model-based image-matching motion analysis technique

This study presented a model-based image-matching (MBIM) motion analysis technique for ankle joint kinematic measurement. Five cadaveric below-hip specimens were manipulated through a full range of ankle joint motions in bare-foot and shoed conditions. The ankle motions were analyzed by bone-pin marker-based motion analysis and MBIM motion analysis techniques respectively. The root mean square errors of all angles of motion were less than 3°. The average Intraclass Correlation Coefficients (ICCs) for the intra-rater reliability were greater than 0.928 and the average ICCs for the inter-rater reliability were greater than 0.948 for all angles of motion. Excellent validity, intra-rater reliability and inter-rater reliability were achieved for the MBIM technique in both bare-foot and shoed conditions. The MBIM technique can therefore provide good estimates of ankle joint kinematics.

Effects of kinesio tape compared with nonelastic sports tape and the untaped ankle during a sudden inversion perturbation in male athletes

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To examine the effect of 2 adhesive tape conditions compared to a no-tape condition on muscle activity of the fibularis longus during a sudden inversion perturbation in male athletes (soccer, team handball, basketball).

BACKGROUND

Ankle sprains are common in sports, and the fibularis muscles play a role in providing functional stability of the ankle. Prophylactic ankle taping with nonelastic sports tape has been used to restrict ankle inversion. Kinesio Tape, an elastic sports tape, has not been studied for that purpose.

METHODS

Fifty-one male premier-league athletes were tested for functional stability of both ankles with the Star Excursion Balance Test. Based on the results, those with the 15 highest and those with the 15 lowest stability scores were selected for further testing. Muscle activity of the fibularis longus was recorded with surface electromyography during a sudden inversion perturbation. Each participant was tested under 3 conditions: ankle taped with nonelastic white sports tape, ankle taped with Kinesio Tape, and no ankle taping. Differences in mean muscle activity were evaluated with a 3-way mixed-model analysis of variance (ANOVA) for the 3 conditions, across four 500-millisecond time frames, and between the 2 groups of stable versus unstable participants. Differences in peak muscle activity and in the time to peak muscle activity were evaluated with a 2-way mixed-model ANOVA.

RESULTS

Significantly greater mean muscle activity was found when ankles were taped with nonelastic tape compared to no tape, while Kinesio Tape had no significant effect on mean or maximum muscle activity compared to the no-tape condition. Neither stability level nor taping condition had a significant effect on the amount of time from perturbation to maximum activity of the fibularis longus muscle.

CONCLUSION

Nonelastic sports tape may enhance dynamic muscle support of the ankle. The efficacy of Kinesio Tape in preventing ankle sprains via the same mechanism is unlikely, as it had no effect on muscle activation of the fibularis longus.

Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique

The goal of this study was to retrospectively evaluate the clinical outcomes of arthroscopic repair for chronic ankle instability using a bioabsorbable anchor with 2 sutures. We evaluated the results of 28 ankles treated with arthroscopic anterior talofibular ligament repair using bioabsorbable anchors with a FiberWire and TigerWire suture (Arthrex, Inc, Naples, Florida) placed on the fibula from March 2008 to January 2009. Average follow-up was 15.9 months (range, 13-25 months). Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot ankle score and stress radiographs. Mean AOFAS hindfoot ankle score was 92.48 ± 6.14 at last follow-up compared to the mean preoperative score of 60.78 ± 16.38 (P=.041). Mean postoperative anterior draw test score difference between 2 ankles was 0.61 ± 0.75 compared to the mean preoperative score difference of 3.59 ± 0.68 (P=.00). There was a 14% complication rate, including 3 cases of portal site irritation and 1 case of superficial infection. Stress radiographs revealed 3 cases of anterior displacement >3 mm compared to the other side. All patients returned to their previous activity level.Arthroscopic ligament reconstruction for chronic lateral ankle instability using suture anchors is effective in returning patients to their preinjury function levels. Good clinical results were obtained with some minor complications. This minimally invasive technique is a reasonable alternative to other open surgical procedures for chronic ankle instability.

Chronic ankle instability: evolution of the model

CONTEXT

The Hertel model of chronic ankle instability (CAI) is commonly used in research but may not be sufficiently comprehensive. Mechanical instability and functional instability are considered part of a continuum, and recurrent sprain occurs when both conditions are present. A modification of the Hertel model is proposed whereby these 3 components can exist independently or in combination.

OBJECTIVE

To examine the fit of data from people with CAI to 2 CAI models and to explore whether the different subgroups display impairments when compared with a control group.

DESIGN

Cross-sectional study.

PATIENTS OR OTHER PARTICIPANTS

Community-dwelling adults and adolescent dancers were recruited: 137 ankles with ankle sprain for objective 1 and 81 with CAI and 43 controls for objective 2.

INTERVENTION(S)

Two balance tasks and time to recover from an inversion perturbation were assessed to determine if the subgroups demonstrated impairments when compared with a control group (objective 2).

MAIN OUTCOME MEASURE(S)

For objective 1 (fit to the 2 models), outcomes were Cumberland Ankle Instability Tool score, anterior drawer test results, and number of sprains. For objective 2, outcomes were 2 balance tasks (number of foot lifts in 30 seconds, ability to balance on the ball of the foot) and time to recover from an inversion perturbation. The Cohen d was calculated to compare each subgroup with the control group.

RESULTS

A total of 56.5% of ankles (n = 61) fit the Hertel model, whereas all ankles (n = 108) fit the proposed model. In the proposed model, 42.6% of ankles were classified as perceived instability, 30.5% as recurrent sprain and perceived instability, and 26.9% as among the remaining groups. All CAI subgroups performed more poorly on the balance and inversion-perturbation tasks than the control group. Subgroups with perceived instability had greater impairment in single-leg stance, whereas participants with recurrent sprain performed more poorly than the other subgroups when balancing on the ball of the foot. Only individuals with hypomobility appeared unimpaired when recovering from an inversion perturbation.

CONCLUSIONS

The new model of CAI is supported by the available data. Perceived instability alone and in combination characterized the majority of participants. Several impairments distinguished the sprain groups from the control group.

Diclofenac epolamine plus heparin plaster versus diclofenac epolamine plaster in mild to moderate ankle sprain: a randomized, double-blind, parallel-group, placebo-controlled, multicentre, phase III trial

BACKGROUND

In general sports, ankle sprain is the most frequently reported ankle injury and can cause chronic lateral ankle pain and tenderness. Treatment with NSAIDs is preferred, and several topical NSAID formulations are now available, helping to avoid the systemic adverse events typically associated with oral preparations.

OBJECTIVE

To compare the efficacy and tolerability of a newly developed fixed-dose diclofenac epolamine (diclofenac hydroxyethylpyrrolidine, DHEP)/heparin plaster (Flectoparin® Tissugel) with that of a DHEP (Flector EP Tissugel®) or placebo plaster in the treatment of mild to moderate ankle sprain in adults.

METHODS

This was a randomized, double-blind, parallel-group, placebo-controlled, multicentre, phase III study conducted in the emergency medical centres of hospitals or private clinics in Europe. Outpatients aged 18-65 years who had suffered an acute ankle sprain (O'Donoghue grade I or II in severity, with external lateral ligament involvement) within the previous 48 hours and had peri-malleolar oedema were eligible for inclusion. A total of 430 patients were randomized to receive a DHEP/heparin 1.3%/5600 IU (n = 142), DHEP 1.3% (n = 146) or placebo (n = 142) plaster, applied once daily to the injured ankle for a total of 7 days. The primary endpoint was the mean change from baseline in pain on movement on day 3, as measured by a visual analogue scale (VAS).

RESULTS

The DHEP/heparin plaster was associated with a significantly (p = 0.002) greater mean reduction from baseline in pain on movement after 3 days of treatment than the DHEP plaster (-24.2 vs -18.8 mm VAS), with each active treatment providing significantly (p ≤ 0.005) greater pain relief than placebo (-13.7 mm VAS). Both DHEP/heparin and DHEP were also effective in relieving other measures of pain, with DHEP/heparin recipients experiencing significantly less daily pain while leaning on the injured limb than DHEP recipients (p < 0.001). In addition, oedema was reduced to a significantly greater extent with DHEP/heparin than with placebo (day 7 only; p = 0.012). The DHEP/heparin plaster and DHEP plaster were both well tolerated, with adverse event profiles similar to that of placebo. Local adverse events were infrequent and generally mild in severity and there were no systemic adverse effects.

CONCLUSION

The fixed-dose DHEP/heparin plaster is effective and has advantages over the DHEP plaster in relieving pain, and possibly also swelling, associated with mild to moderate acute ankle sprains with oedema in adults.

Inclusion criteria when investigating insufficiencies in chronic ankle instability

INTRODUCTION

The development of chronic ankle instability (CAI) is the primary residual deficit after ankle joint sprain. It has been proposed that CAI is characterized by two entities, namely, mechanical instability and functional instability. Each of these entities in turn is composed of various insufficiencies. Research of functional insufficiencies to date has shown large variances in results. One particular reason for this could be discrepancies in inclusion criteria and definitions between CAI, mechanical instability, and functional instability used in the literature. Thus, we endeavored to undertake a systematic investigation of those studies published in the area of CAI to identify if there is a large discrepancy in inclusion criteria across studies.

METHODS

A systematic search of the following databases was undertaken to identify relevant studies: Cochrane Central Register of Controlled Trials, PubMed, CINAHL, SportDiscus, PEDro, and AMED.

RESULTS

The results of this study indicate that there is a lack of consensus across studies regarding what actually constitutes ankle instability. Furthermore, it is evident that the majority of studies use very different inclusion criteria, which leads to a nonhomogenous population and to difficulties when comparing results across studies.

CONCLUSIONS

Future studies should endeavor to be specific with regard to the exact inclusion criteria being used. Particular emphasis should be given to issues such as the number of previous ankle sprains reported by each subject and how often and during which activities episodes of "giving way" occur as well as the presence of concomitant symptoms such as pain and weakness. We recommend that authors use one of the validated tools for discriminating the severity of CAI. Furthermore, we have provided a list of operational definitions and key criteria to be specified when reporting on studies with CAI subjects.

The effects of carrying extra weight on ankle stability in adolescent basketball players

PURPOSE

The purpose of this study was to investigate the effects of weight on ankle stability in adolescent basketball players.

METHODS

20 non-injured subjects (age=11.05+/-1.5 years) were included in this study. Each subject performed a 15min warm-up by running or riding a stationary bike. The Star Excursion Balance Test (SEBT), single-leg balance test (performed with eyes open and eyes closed) and vertical jump test were performed with dominant lower extremity. 1 week later, same tests were performed with a schoolbag. The schoolbag contained weight bars as 20% of the players own body weight.

RESULTS

Only posteromedial component of SEBT had significant difference between non-weight measurement and weighted measurement (p=0.004). Single-leg stance test performed with eyes open (p=0.006) and closed (p=0.001) had significant difference between non-weight measurement and weighted measurement. Also the vertical jump test had significant difference between non-weight measurement and weighted measurement (p=0.001).

CONCLUSIONS

These findings indicate that 20% weight of their own body weight does not affect dynamic ankle stability and postural limitations, which are magnified by advancing weight. We are confident in our conclusions because of the three-way interaction noted with posterior/medial with weight in SEBT. Furthermore, Star Excursion Balance test is more effective both weight and non-weight in measuring functional stability of the ankle.

Potential savings of a program to prevent ankle sprain recurrence: economic evaluation of a randomized controlled trial

BACKGROUND

The most common ankle injury is the lateral ankle sprain. Dutch annual sports-related ankle sprain costs can roughly be estimated at €187,200,000. Research has shown that proprioceptive training accounts for an approximated overall 50% reduction in ankle sprain recurrence rate.

HYPOTHESIS

An unsupervised proprioceptive training program to reduce the recurrence of lateral ankle sprains will reduce overall health care costs.

DESIGN

Cohort study (economic analysis); Level of evidence, 2.

METHODS

The study included 522 male and female athletes: 256 athletes (120 female and 136 male) in the intervention group, and 266 athletes (128 female and 138 male) in the control group. Both groups received treatment according to usual care. Athletes allocated to the intervention group received an 8-week proprioceptive training program in addition to usual care. Costs per athlete and costs per injured athlete were calculated. Costs related to ankle sprain recurrences were measured from a societal perspective using cost diaries. Bootstrapping was used to analyze the cost-effectiveness data. Follow-up was 1 year.

RESULTS

Mean total costs in the intervention group were €81 (standard deviation, €134) per athlete and €114 (€325) per injured athlete. Mean overall costs in the control group were €149 (€836) per athlete and €447 (€1403) per injured athlete. Statistically significant differences in total costs were found per athlete (mean difference, -€69; 95% confidence interval, -€200 to -€2) and per injured athlete (-€332; -€741 to -€62) in favor of the intervention group. A cost-effectiveness plane showed the effect of the intervention was larger and the costs were lower in the intervention group than the control group.

CONCLUSION

The use of a proprioceptive training program after usual care of an ankle sprain is cost-effective for the prevention of ankle sprain recurrences in comparison with usual care alone. In the Netherlands, an estimated annual €35.9 million in medical and lost productivity costs can be saved solely by advocating a proprioceptive training program as in the present study.

Effectiveness of additional supervised exercises compared with conventional treatment alone in patients with acute lateral ankle sprains: systematic review

OBJECTIVE

To summarise the effectiveness of adding supervised exercises to conventional treatment compared with conventional treatment alone in patients with acute lateral ankle sprains.

DESIGN

Systematic review. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, Cinahl, and reference screening.

STUDY SELECTION

Included studies were randomised controlled trials, quasi-randomised controlled trials, or clinical trials. Patients were adolescents or adults with an acute lateral ankle sprain. The treatment options were conventional treatment alone or conventional treatment combined with supervised exercises. Two reviewers independently assessed the risk of bias, and one reviewer extracted data. Because of clinical heterogeneity we analysed the data using a best evidence synthesis. Follow-up was classified as short term (up to two weeks), intermediate (two weeks to three months), and long term (more than three months).

RESULTS

11 studies were included. There was limited to moderate evidence to suggest that the addition of supervised exercises to conventional treatment leads to faster and better recovery and a faster return to sport at short term follow-up than conventional treatment alone. In specific populations (athletes, soldiers, and patients with severe injuries) this evidence was restricted to a faster return to work and sport only. There was no strong evidence of effectiveness for any of the outcome measures. Most of the included studies had a high risk of bias, with few having adequate statistical power to detect clinically relevant differences.

CONCLUSION

Additional supervised exercises compared with conventional treatment alone have some benefit for recovery and return to sport in patients with ankle sprain, though the evidence is limited or moderate and many studies are subject to bias.

Ankle manual therapy for individuals with post-acute ankle sprains: description of a randomized, placebo-controlled clinical trial

BACKGROUND

Ankle sprains are common within the general population and can result in prolonged disablement. Limited talocrural dorsiflexion range of motion (DF ROM) is a common consequence of ankle sprain. Limited talocrural DF ROM may contribute to persistent symptoms, disability, and an elevated risk for re-injury. As a result, many health care practitioners use hands-on passive procedures with the intention of improving talocrural joint DF ROM in individuals following ankle sprains. Dosage of passive hands-on procedures involves a continuum of treatment speeds. Recent evidence suggests both slow- and fast-speed treatments may be effective to address disablement following ankle sprains. However, these interventions have yet to be longitudinally compared against a placebo study condition.

METHODS/DESIGN

We developed a randomized, placebo-controlled clinical trial designed to test the hypotheses that hands-on treatment procedures administered to individuals following ankle sprains during the post-acute injury period can improve short-, intermediate-, and long-term disablement, as well as reduce the risk for re-injury.

DISCUSSION

This study is designed to measure the clinical effects of hands-on passive stretching treatment procedures directed to the talocrural joint that vary in treatment speed during the post-acute injury period, compared to hands-on placebo control intervention.

TRIAL REGISTRATION

http://www.clinicaltrials.gov identifier NCT00888498.

The epidemiology of ankle sprains in the United States

BACKGROUND

Ankle sprain has been studied in athletic cohorts, but little is known of its epidemiology in the general population. A longitudinal, prospective epidemiological database was used to determine the incidence and demographic risk factors for ankle sprains presenting to emergency departments in the United States. It was our hypothesis that ankle sprain is influenced by sex, race, age, and involvement in athletics.

METHODS

The National Electronic Injury Surveillance System (NEISS) was queried for all ankle sprain injuries presenting to emergency departments between 2002 and 2006. Incidence rate ratios were then calculated with respect to age, sex, and race.

RESULTS

During the study period, an estimated 3,140,132 ankle sprains occurred among an at-risk population of 1,461,379,599 person-years for an incidence rate of 2.15 per 1000 person-years in the United States. The peak incidence of ankle sprain occurred between fifteen and nineteen years of age (7.2 per 1000 person-years). Males, compared with females, did not demonstrate an overall increased incidence rate ratio for ankle sprain (incidence rate ratio, 1.04; 95% confidence interval, 1.00 to 1.09). However, males between fifteen and twenty-four years old had a substantially higher incidence of ankle sprain than their female counterparts (incidence rate ratio, 1.53; 95% confidence interval, 1.41 to 1.66), whereas females over thirty years old had a higher incidence compared with their male counterparts (incidence rate ratio, 2.03; 95% confidence interval, 1.65 to 2.65). Compared with the Hispanic race, the black and white races were associated with substantially higher rates of ankle sprain (incidence rate ratio, 3.55 [95% confidence interval, 1.01 to 6.09] and 2.49 [95% confidence interval, 1.01 to 3.97], respectively). Nearly half of all ankle sprains (49.3%) occurred during athletic activity, with basketball (41.1%), football (9.3%), and soccer (7.9%) being associated with the highest percentage of ankle sprains during athletics.

CONCLUSIONS

An age of ten to nineteen years old is associated with higher rates of ankle sprain. Males between fifteen and twenty-four years old have higher rates of ankle sprain than their female counterparts, whereas females over thirty years old have higher rates than their male counterparts. Half of all ankle sprains occur during athletic activity.

Effect of taping on actual and perceived dynamic postural stability in persons with chronic ankle instability

OBJECTIVE

To investigate whether 2 different mechanisms of ankle joint taping ([1] lateral subtalar sling or [2] fibular repositioning) can enhance actual and perceived dynamic postural stability in participants with chronic ankle instability (CAI).

DESIGN

Laboratory-based repeated-measures study.

SETTING

University biomechanics laboratory.

PARTICIPANTS

Participants (n=16) with CAI.

INTERVENTIONS

Participants performed the Star Excursion Balance Test (SEBT) under 3 different conditions: (1) no tape, (2) lateral subtalar sling taping and (3) fibular repositioning taping.

MAIN OUTCOME MEASURES

Reach distances in the anterior, posteromedial, and posterolateral directions on the SEBT. Participants' perceptions of stability, confidence, and reassurance when performing the SEBT under 2 different taping conditions.

RESULTS

Taping did not improve reach distance on the SEBT (P>.05). Feelings of confidence increased for 56% of participants (P=.002) under both tape conditions. Feelings of stability increased for 87.5% of participants (P<.001) using condition 2 (lateral subtalar sling taping) and 75% of participants (P=.001) using condition 3 (fibular repositioning taping). Feelings of reassurance increased for 68.75% of participants (P=.001) using condition 2 (lateral subtalar sling taping) and 50% of participants (P=.005) using condition 3 (fibular repositioning taping).

CONCLUSIONS

No significant change in dynamic postural stability was observed after application of either taping mechanism; however, participants' perceptions of confidence, stability, and reassurance were significantly improved. Further research is necessary to fully elucidate the exact mechanisms by which taping may help reduce the incidence of repeated injury in subjects with CAI.

Epidemiology of strain/sprain injuries among cheerleaders in the United States

OBJECTIVE

The aim of this study is to describe the epidemiology of cheerleading-related strain/sprain injuries by type of cheerleading team and type of event.

METHODS

Athlete exposure (AE) and injury data were collected from 412 United States cheerleading teams via the Cheerleading Reporting Information Online surveillance tool, and injury rates were calculated.

RESULTS

Strains/Sprains were the most common injury (53%; 0.5 injuries per 1000 AEs) sustained by cheerleaders during our 1-year study. The lower extremities (42%), particularly the ankles (28%), were injured most often. Most injuries occurred during practice (82%); however, the rate of injury was higher during competition (0.8 injuries per 1000 AEs; 95% confidence interval [CI], 0.6-1.0) than during practice (0.6 injuries per 1000 AEs; 95% CI, 0.5-0.6) for all team types. Injuries were sustained most frequently by high school cheerleaders (51%), although college cheerleaders had the highest injury rate (1.2 injuries per 1000 AEs). Strains/Sprains occurred most frequently while attempting a stunt (34%) or while tumbling (32%). Spotting/Basing other cheerleaders (19%) was the most common mechanism of injury and was more likely to result in a lower back strain/sprain than other mechanisms of injury (odds ratio, 3.38; 95% CI, 1.41-8.09; P < .01).

CONCLUSIONS

Cheerleaders should increase their focus on conditioning and strength-building training, which may help to prevent strain/sprain injuries. Spotters and bases should additionally focus on proper lifting technique to help avoid back injury. Guidelines may need to be developed for return-to-play after cheerleading-related strain/sprain injuries.

Severe open ankle sprain (SOAS): a lesion presenting as a penetrating soft tissue injury

The objective of this retrospective case study was to describe the incidence and clinical features of severe open ankle sprain (SOAS), defined as a tear of the lateral or medial collateral ligaments with an associated transverse tear of the skin over the corresponding malleolus. To this end, we reviewed the medical records of patients with SOAS managed between January 2005 and January 2009, using the databases of 3 different orthopedic trauma centers. Our review revealed 9 patients with SOAS, 7 (77.77%) of which involved the lateral ligaments and 2 (22.22%) of which involved the medial ligaments. The median age was 32 (range 21 to 45) years, and the injury occurred as a result of a motor vehicle accident in 6 (66.67%) patients, and as a result of a fall from a height in 3 (33.33%) patients. Two tendons were damaged in 2 (22.22%) patients, the deep fibular nerve (deep peroneal nerve) in 2 (22.22%) patients, and the anterior tibial artery in 1 (11.11%) patient. The only abnormality on plain radiographs was pneumarthrosis, which was present in 5 (55.56%) patients. The incidence of SOAS is rare, accounting for 0.002% (9/438,000) of all trauma cases and 0.22% (9/4142) of all cases of ankle trauma. The diagnosis was confirmed by intraoperative stress-maneuvers in all 9 patients. In conclusion, SOAS should be suspected in patients who present with a traumatic skin wound over the malleolus.

Identification of ankle sprain motion from common sporting activities by dorsal foot kinematics data

This study presented a method to identify ankle sprain motion from common sporting activities by dorsal foot kinematics data. Six male subjects performed 300 simulated supination sprain trials and 300 non-sprain trials in a laboratory. Eight motion sensors were attached to the right dorsal foot to collect three-dimensional linear acceleration and angular velocity kinematics data, which were used to train up a support vector machine (SVM) model for the identification purpose. Results suggested that the best identification method required only one motion sensor located at the medial calcaneus, and the method was verified on another group of six subjects performing 300 simulated supination sprain trials and 300 non-sprain trials. The accuracy of this method was 91.3%, and the method could help developing a mobile motion sensor system for ankle sprain detection.

Epidemiology of ankle sprain at the United States Military Academy

BACKGROUND

Ankle sprain is a common injury in athletic populations that results in significant time lost to injury.

HYPOTHESIS

The incidence rates (IRs) of ankle ligament sprains are influenced by gender, height, weight, body mass index (BMI), physical conditioning, level of competition, type of sport, and athlete exposure to sport.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A longitudinal cohort study was performed to determine the effect of risk factors for ankle sprain at the United States Military Academy between 2005 and 2007.

RESULTS

A total 614 cadets sustained new ankle sprains during 10 511 person-years at risk, resulting in an overall IR of 58.4 per 1000 person-years. Women (96.4), compared with men (52.7), had a significantly increased rate ratio (IRR) for ankle sprain of 1.83 (95% confidence interval [CI], 1.52-2.20). Men with ankle sprains had higher mean height, weight, and BMI than uninjured men (P <.001). Men with ankle sprains had higher average scores in push-ups, sit-ups, and run time than uninjured men (P <.001). Ankle sprain occurred most commonly during athletics (64.1%). Ankle sprain IR did not significantly differ between intercollegiate and intramural athletic competition after controlling for athlete-exposure (IRR, 1.05; 95% CI, 0.81-1.37). The ankle sprain IRR of female compared with male intercollegiate athletes was 0.93 (95% CI, 0.67-1.32) per 1000 person-years and 1.04 (95% CI, 0.74-1.47) per 1000 athlete-exposures. The intercollegiate sports of men's rugby, women's cheerleading, and men's/women's basketball, soccer, and lacrosse had the highest ankle sprain IR.

CONCLUSION

Higher mean height and weight in men, increased BMI in men, greater physical conditioning in men, and athlete exposure to selected sports were all risk factors for ankle sprain.

Osteocartilaginous lesions of the talus in soccer players

OBJECTIVE

The objective of this study is to describe the results of arthroscopic debridement for talar lesions in a population of soccer players.

PATIENTS

Patients were sixteen soccer players with osteochondral talar lesions, treated surgically between 1999 and 2004.

INTERVENTIONS

All patients were diagnosed clinically. Complementary imaging studies included X-ray, scintigraphy, and magnetic resonance imaging. All patients underwent arthroscopic debridement.

MAIN OUTCOME MEASUREMENTS

At 3.56 years of follow up, patient status was assessed using a visual analog scale (VAS) and the Ogilvie-Harris scale. The mean time to return to sports at the same level as that before the start of symptoms was evaluated.

RESULTS

The Ogilvie-Harris score showed 81.75% excellent results and 18.25% good results. The VAS score was 0.26 (0-2.2). Among the total, 93.75% of patients resumed sports activities at the same level as that before surgery.

CONCLUSIONS

Arthroscopic debridement of talar osteochondral lesions in soccer players provides excellent results. We consider this option the treatment of choice in this population.

Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.

Effects of a wobble board-based therapeutic exergaming system for balance training on dynamic postural stability and intrinsic motivation levels

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

To compare the effects of wobble board exercises with and without feedback provided through integrating the wobble board movement into a computer game system, by comparing changes in postural stability and motivation.

BACKGROUND

Therapeutic exergaming systems may offer a solution to poor adherence to postural control exercise regimes by improving motivation levels during exercise performance.

METHODS

Twenty-two healthy adults, randomly assigned to an exergaming group (n = 11) and a control group (n = 11), completed 12 exercise sessions. Dynamic postural stability was quantified at baseline and follow-up using the star excursion balance test and the dynamic postural stability index during a jump-landing task. Intrinsic motivation was measured at baseline using the Self-Motivation Inventory and at follow-up using the Intrinsic Motivation Inventory.

RESULTS

Star excursion balance test scores showed a statistically significant (P<.008) improvement in the posteromedial and posterolateral direction for both groups. No within-group change for the dynamic postural stability index or between-group difference for star excursion balance test or dynamic postural stability index scores were observed. The "interest and enjoyment" category of the Intrinsic Motivation Inventory showed significantly higher scores (P<.001) in the exergaming group at follow-up, which was 1 of the 5 Intrinsic Motivation Inventory categories evaluated.

CONCLUSIONS

The findings suggest that exercising with the therapeutic exergaming system showed similar improvements in dynamic postural stability and showed a greater level of interest and enjoyment when compared to a group doing similar balance training without the game system.

LEVEL OF EVIDENCE

Therapy, level 2b.

Treatment of chronic lateral ankle instability: a modified Broström technique using three suture anchors

Ankle sprains are very common injuries seen in the athletic and young population. Majority of patients will improve with a course of rest and physical therapy. However, with conservative management about twenty percent of all patients will go on to develop chronic lateral ankle instability. This manuscript describes our detailed surgical technique of a modification to the original Broström procedure using three suture anchors to anatomically reconstruct the lateral ankle ligaments to treat high demand patients who have developed chronic lateral ankle instability. The rationale for this modification along with patient selection and workup are discussed. Both the functional outcomes at the two year follow up along with the complications and the detailed postoperative rehabilitation protocol for the high demand athletes are also presented. This modified Broström procedure is shown in both illustrative format and intra-operative photos.

Efficacy of an ankle brace with a subtalar locking system in inversion control in dynamic movements

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To examine effectiveness of an ankle brace with a subtalar locking system in restricting ankle inversion during passive and dynamic movements.

BACKGROUND

Semirigid ankle braces are considered more effective in restricting ankle inversion than other types of brace, but a semirigid brace with a subtalar locking system may be even more effective.

METHODS

Nineteen healthy subjects with no history of major lower extremity injuries were included in the study. Participants performed 5 trials of an ankle inversion drop test and a lateral-cutting movement without wearing a brace and while wearing either the Element (with the subtalar locking system), a Functional ankle brace, or an ASO ankle brace. A 2-way repeated-measures analysis of variance (ANOVA) was used to assess brace differences (P?.05).

RESULTS

All 3 braces significantly reduced total passive ankle frontal plane range of motion (ROM), with the Element ankle brace being the most effective. For the inversion drop the results showed significant reductions in peak ankle inversion angle and inversion ROM for all 3 braces compared to the no brace condition; and the peak inversion velocity was also reduced for the Element brace and the Functional brace. In the lateral-cutting movement, a small but significant reduction of the peak inversion angle in early foot contact and the peak eversion velocity at push-off were seen when wearing the Element and the Functional ankle braces compared to the no brace condition. Peak vertical ground reaction force was reduced for the Element brace compared to the ASO brace and the no brace conditions.

CONCLUSIONS

These results suggest that the tested ankle braces, especially the Element brace, provided effective restriction of ankle inversion during both passive and dynamic movements.

Tibiofemoral angle and its relation to ankle sprain occurrence

The lack of a normal joint orientation generates translational or shear forces across the joint. These forces can put abnormally high strain on the cartilage and the surrounding capsuloligamentous tissues. Ankle joint structure can affect or be affected by bony malformations of the surrounding areas, including the knee and hip. The aim of the current study is to examine the possible relationship between the tibiofemoral (TFA) angle and other factors (anthropometric characteristics, medical history, and age) on the occurrence of ankle sprains because its value provides useful information for the anatomical alignment of the lower extremity. The study sample consisted of 45 high-level athletes, evenly distributed among 3 sports (basketball, soccer, and volleyball). TFA measurements were made on radiographs. The study lasted 2 years. A logistic regression was used to determine the importance of each factor on the probability in question. A significance level of P = .1 was used. The factors contributing more to an ankle sprain were a previous injury of the same type followed by body mass index (BMI) and age. On the contrary, TFA was proven to be statistically nonsignificant. When the BMI variable was substituted with body inertia propensity, a derived variable, the TFA remained statistically nonsignificant. TFA magnitude does not seem to be a determinant factor that could increase the probability of spraining an ankle.

Variability of motion in individuals with mechanical or functional ankle instability during a stop jump maneuver

BACKGROUND

Movement variability may influence episodes of instability following lateral ankle sprain.

METHODS

Sixty-three recreational athletes with a history of moderate-severe ankle sprain were recruited. Mechanically and functionally unstable ankle groups had 2 episodes of instability in the last year. Mechanically unstable had clinically lax lateral ankle ligaments; functionally unstable and copers did not. Copers had a history of sprain but no residual instability. Lower extremity 3-dimensional kinematics and ground reaction forces were measured during a 2-legged stop jump. Average ensemble curves of eight trials normalized to 100% of stance phase were created. The coefficient of variation and average standard deviation of the ensemble curves of each variable were identified. A log(e) (ln) transformation was performed on the data. One-way ANOVAs with Tukey post hoc testing were utilized with alpha=0.05.

FINDINGS

The functionally unstable group demonstrated greater mean (standard deviation) ln coefficient of variation ankle inversion/eversion 3.56 (1.19) than the mechanically unstable 2.77 (0.95) and copers 2.74 (1.05) (P=0.05 and P=0.04; eta(p)(2)=0.12), and greater ln standard deviation ankle inversion/eversion 1.07 (0.78) than copers 0.61 (0.31) (eta(p)(2)=0.13). The mechanically unstable group demonstrated greater ln coefficient of variation anterior-posterior ground reaction force 3.69 (0.27) than functionally unstable 3.43 (0.25) (P=0.02; eta(p)(2)=0.13).

INTERPRETATION

Functionally unstable individuals demonstrated greater ankle frontal plane movement variability during a stop jump, which may increase risk of instability. Mechanically unstable participants demonstrated greater anterior-posterior ground reaction force variability, which may indicate difficulty mitigating landing forces with lax ligaments. Movement variability may influence episodes of ankle instability.

The ability of 4 single-limb hopping tests to detect functional performance deficits in individuals with functional ankle instability

STUDY DESIGN

Experimental laboratory testing using a cross-sectional design.

OBJECTIVES

To determine if functional performance deficits are present in individuals with functional ankle instability (FAI) in 4 single-limb hopping tests, including figure-of-8 hop, side hop, 6-meter crossover hop, and square hop.

BACKGROUND

Conflicting results exist regarding the presence of functional deficits in individuals with FAI. It is important to evaluate whether functional performance deficits are present in this population, as well as if subjective feelings of giving way can assist in identifying these deficits.

METHODS

Sixty college students volunteered for this study. Thirty participants with unilateral ankle instability were placed in the FAI group and 30 participants with no history of ankle injuries were placed in the control group. The FAI group was subsequently further divided to indicate those that reported giving way during the functional test (FAI-GW) and those that did not (FAI-NGW). Time to complete each test was recorded and the mean of 3 trials for each test were used for statistical analysis. To identify performance differences, we used 4 mixed-design 2-way (side-by-group) ANOVAs, 1 for each hop test. A Tukey post hoc test was completed on all significant findings.

RESULTS

We identified a significant side-by-group interaction for all 4 functional performance tests (P<.05). Specifically, for each functional performance test, the FAI limb performed significantly worse than the contralateral uninjured limb in the FAI-GW group. Additionally, the FAI limb in the FAI-GW group performed worse than the FAI limb in the FAI-NGW group, and the matched limb in the control group in 3 of the 4 functional performance tests.

CONCLUSION

We found that functional performance deficits were present in participants with FAI who also experienced instability during the test. This difference was identified when comparing the FAI limb to the contralateral uninjured limb as well as control participants. However, the performance deficits identified in this study were relatively small. Future research in this area is needed to further evaluate the clinical meaningfulness of these findings. Finally, we found that limb dominance did not affect performance.

Severity of functional and mechanical ankle instability in an active population

BACKGROUND

The purpose of this investigation was to evaluate the relationship between the severity of functional and mechanical ankle instability in physically active individuals.

MATERIALS AND METHODS

Eighty college aged physically active individuals from a large university were recruited for this study. All subjects had unilateral functional ankle instability (FAI). FAI was defined as a history of at least two ankle sprains and a score less than or equal to 27 on the Cumberland Ankle Instability Tool (CAIT). The contralateral limb had no history of ankle injury or instability. Anterior displacement (mm) and talar tilt (degrees) were measured using the LigMaster joint arthrometer to identify mechanical ankle instability(MAI). Individuals were tested bilaterally and the maximum value attained during talar tilt and anterior displacement was used for statistical analysis.

RESULTS

First we evaluated side-to-side differences in MAI in all subjects. We found no significant difference between the FAI and the non-FAI ankle for anterior displacement (t(1.79)=1.66, p = 0.10) or talar tilt (t(1.79)=-0.07, p=0.95). Secondly, we evaluated the relationship between the FAI and MAI measures and found no significant correlations between the severity of FAI and magnitude of anterior displacement(r=0.18, p=0.12) or talar tilt (r=0.09, p=0.42).

CONCLUSION

This study demonstrated there was no side-to-side difference in MAI in individuals with unilateral functional ankle instability. Similarly, we also conclude there was no significant relationship between the severity of FAI and MAI. We feel that these findings suggest the symptoms of FAI may not be related to ankle joint laxity, but instead due to other factors associated with FAI.

Pain and dorsiflexion range of motion predict short- and medium-term activity limitation in people receiving physiotherapy intervention after ankle fracture: an observational study

QUESTION

What predicts short - and medium term activity limitation in people after ankle fracture?

DESIGN

Inception cohort observational study.

PARTICIPANT

Adults with ankle fracture recruited within days following cast removal from physiotherapy departments of teaching hospital in Sydney, Australia.

OUTCOME MEASURES

The predictive value of variables that were injury-related (fracture management, fracture severity, angle of the ankle during cast immobilisation, and time from cast removal to baseline) and performance-related (activity limitation, pain, mobility and dorsiflexion range of motion measured soon after cast removal) were examined in one dataset (n = 150) using univariate linear regression. Significant variables (p <or = 0.20) were further examined with a multivariate linear model. A clinical prediction rule was derived then validated using data from an independent dataset (n = 94).

RESULTS

Fracture management, fracture severity, baseline activity limitation, pain, mobility and dorsiflexion had significant but weak univariate associations with activity limitation. Only pain and dorsiflexion range of motion contributed independently to the clinical prediction rule. When applied to the validation data, the rule explained 12% of the short-term and 9% of the medium-term variance in activity limitation.

CONCLUSION

Performance-related variables were stronger predictors than injury-related variables. A clinical prediction rule consisting of pain and dorsiflexion range of motion explained a small amount of variance in short- and medium-term activity limitation, suggesting that it may be appropriate to identify people with high levels of pain and restricted dorsiflexion after ankle fracture and target intervention accordingly.

Understanding acute ankle ligamentous sprain injury in sports

This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.

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.

Ankle instability in sports

Ankle stability is integral to normal motion and to minimizing the risk of ankle sprain during participation in sport activities. The ability of the dynamic and static stabilizers of the ankle joint to maintain their structural integrity is a major component of the normal gait cycle. In sports, this quality assumes even greater importance given the range of movement and stresses imposed on the ankle during various sporting disciplines. In the general population, the incidence of ankle sprain is very high. In several studies, injuries to the lateral ankle ligaments have been shown to be the most common sports-related injuries, accounting for approximately 25% of all sports-related injuries. Furthermore, up to 80% of all ankle sprains involve the lateral ligament complex. Other studies have estimated their incidence as approximately 5000 injuries per day in the United Kingdom and 23 000 in the United States. Aggressive treatment of the sprained ankle is essential to maintain foot and ankle mobility and prevent prolonged disability and subsequent overuse injuries among athletes, both professional and "weekend warriors" alike.

Treatment of common deficits associated with chronic ankle instability

Lateral ankle sprains are amongst the most common injuries incurred by athletes, with the high rate of reoccurrence after initial injury becoming of great concern. Chronic ankle instability (CAI) refers to the development of repetitive ankle sprains and persistent residual symptoms post-injury. Some of the initial symptoms that occur in acute sprains may persist for at least 6 months post-injury in the absence of recurrent sprains, despite the athlete having returned to full functional activity. CAI is generally thought to be caused by mechanical instability (MI) or functional instability (FI), or both. Although previously discussed as separate entities, recent research has demonstrated that deficits associated with both MI and FI may co-exist to result in CAI. For clinicians, the main deficits associated with CAI include deficits in proprioception, neuromuscular control, strength and postural control. Based on the literature reviewed, it does seem that subjects with CAI have a deficit in frontal plane ankle joint positional sense. Subjects with CAI do not appear to exhibit any increased latency in the peroneal muscles in response to an external perturbation. Preliminary data suggest that feed-forward neuromuscular control may be more important than feed-back neuromuscular control and interventions are now required to address deficits in feed-forward neuromuscular control. Balance training protocols have consistently been shown to improve postural stability in subjects with CAI. Subjects with CAI do not experience decreased peroneus longus strength, but instead may experience strength deficits in the ankle joint invertor muscles. These findings are of great clinical significance in terms of understanding the mechanisms and deficits associated with CAI. An appreciation of these is vital to allow clinicians to develop effective prevention and treatment programmes in relation to CAI.

Anatomical reconstruction for chronic lateral ankle instability in the high-demand athlete: functional outcomes after the modified Broström repair using suture anchors

BACKGROUND

Modification of the Bröstrom repair with suture anchors has been used to address chronic lateral ankle instability. However, there are few studies in the literature reporting the functional outcomes after this particular procedure in the high-demand athlete.

HYPOTHESIS

Anatomical reconstruction of the lateral ankle ligaments for chronic instability will return the high-demand athlete functionally to his or her previous level of activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Sixty-two patients who had grade III ankle sprain that failed at least a 6-month course of supervised conservative management with a preinjury Tegner score of > or = 6 underwent a variant of the Gould-modified Broström procedure with suture anchors for lateral ankle instability. Each patient was given the Tegner and Karlsson questionnaire at the 6-month, 1-year, and 2-year time points. Range of motion of the operative ankle was also assessed. The mean age was 19.6 years (range, 16-26 years), and 10 patients were lost to follow-up.

RESULTS

The mean follow-up was 29 months (minimum, 24 months) in the remaining 52 patients (84%). Mean Tegner scores at the 1- and 2-year time points were 8.2 (range, 5-9) and 8.6 (range, 5-9), respectively. The mean Karlsson scores were 92 +/- 5.2 and 95 +/- 3.1 at the 1- and 2-year time points, respectively. Range of motion was equal to the contralateral ankle in all but 3 patients at the 2-year follow up. A 6% major complication rate included 3 reruptures.

CONCLUSION

Anatomical ligament reconstruction for chronic lateral ankle instability using a variant of the Gould-modified Broström procedure with suture anchors was effective in returning high-demand athletes to their preinjury functional level.

The effect of Q angle on ankle sprain occurrence

The intersegmental joint forces and the structures that must resist them (articular surfaces, ligaments, and musculature) are related through anatomical alignment of the joints and skeletal system. Ankle joint structure can affect or be affected by bony malformations of the surrounding areas, including the knee and hip. The aim of the current study is to examine the possible relationship between the quadriceps (Q) angle and other factors (anthropometric characteristics, medical history, and age) on the occurrence of ankle sprains, because its value, when assessed correctly, provides useful information for the anatomical alignment of the lower extremity. The study sample consisted of 45 high-level athletes, evenly distributed among 3 sports (basketball, soccer, and volleyball). Q angle measurements were made on radiographs. The study lasted for 2 years. A logistic regression was used to determine the importance of each factor on the probability in question. A significance level of P = .1 was used. The factors contributing more to an ankle sprain were a previous injury of the same type ( P < .01) followed by body mass index (BMI; P < .10) and age (P < .10). On the contrary, Q angle was proven to be statistically nonsignificant (P > .10). The results were valid even when the BMI variable was substituted by body inertia propensity, a derived variable. The Q angle remained statistically nonsignificant ( P > .10). The Q angle magnitude does not seem to be a decisive factor that could increase the probability of spraining an ankle. The most important factors that could affect the probability of sustaining an ankle sprain are the athlete's age, anthropometric characteristics, and prior injuries.