Rehabilitation of ankle and foot injuries in athletes

From injury to rehabilitation: How kinesiology taping helps patients with first metatarsophalangeal joint sprain (turf toe) in pain reduction, gait parameters and functional ability improvement. A randomized clinical trial

Objective

Turf toe is a common sports injury that may affect mobility and functional ability. For complete recovery, rehabilitation modalities are required to overcome these issues. This study investigated whether kinesio taping (KT) would reduce pain, improve gait performance, and enhance the functional capacity of turf toe patients undergoing physical therapy.

Methods

sixty patients with grade II turf toe (age; 25-30 years) assigned randomly into three treatment groups; KT applied alongside an exercise program conducted three times/week for 12 successive weeks. (KT group; n = 20), placebo taping plus exercise (Placebo group; n = 20), or exercise only (Control group; n = 20). Pain, gait parameters, and functional ability assessed using VAS, 3D gait analysis, and 6MWT respectively pre- and post-treatment.

Results

There was a significant post-treatment decrease in VAS score in the KT group lower than the control or placebo group and a significant increase in 6MWT distance in the KT group higher than the control or placebo group (p < 0.001). Additionally, there was a significant post-treatment increase in step length, stride length, cadence and velocity of KT group higher than control and placebo group (p < 0.05). There was no significant difference in gait parameters between control and placebo groups post treatment (p > 0.05).

Conclusions

The findings of the study demonstrated that KT is a useful complementary modality to exercise in patients with turf toe, as it may result in more favorable improvements to pain, gait characteristics, and functional abilities. Further studies should be conducted to assess the long-term effects, different KT application methods, and tailored treatment protocols on turf toe.

Plantar pressure analysis of different orthoses in patients after first metatarsophalangeal joint arthrodesis

BACKGROUND

There is no gold standard for a walking orthosis after first metatarsophalangeal joint (MTPJ) arthrodesis surgery. Evaluation of plantar pressure measures and patient perceptions for different orthoses may assist surgeons to choose a postsurgery orthotic. The purpose of this study was to measure plantar pressure under the distal first ray during walking and patient perceptions of comfort, stability, and preference with 4 different orthoses in patients with a history of first MTPJ arthrodesis.

METHODS

Crossover study in a university laboratory. Eleven patients volunteered (8 female, 3 male, age = 59.4 ± 9.1 years, 21.9 ± 17.5 months since surgery) who had a unilateral first MTPJ arthrodesis procedure more than 6 months before study participation. Four orthosis conditions were evaluated in all participants: patient's shoe, carbon fiber insert, OrthoWedge, and Post-Op Shoe. We analyzed peak plantar pressure and pressure-time integral under the whole foot and the distal first ray as well as recorded subjective rating for comfort and stability. Rank ordered for preferred orthosis.

RESULTS

OrthoWedge had significantly lower whole-foot and distal first ray peak pressure than the other conditions. The pressure-time integral for the OrthoWedge was significantly less than the Carbon Fiber Insert and Post-Op Shoe. For stability, comfort, and condition preference, the OrthoWedge was ranked lowest among the 4 conditions.

CONCLUSIONS

The OrthoWedge generated the lowest peak plantar pressure but was subjectively ranked as the least preferred orthosis. This discrepancy between objective biomechanical and subjective comfort measures must be weighed as surgeons prescribe an orthosis to patients after first MTPJ arthrodesis.

Intramedullary Kirschner Wire Fixation for Metatarsal Fractures: A Comprehensive Review of Treatment Outcomes

Metatarsal fractures pose significant challenges in orthopedic practice, necessitating effective treatment methods to ensure optimal patient outcomes. This comprehensive review focuses on intramedullary Kirschner wire fixation as a promising intervention for metatarsal fractures. Beginning with an overview of metatarsal fractures and the imperative for effective treatments, the review delves into intramedullary fixation's definition, historical background, advantages, and disadvantages. Indications for its use in metatarsal fractures are discussed, providing a foundation for understanding its application. The surgical technique section outlines critical aspects, including patient selection criteria and preoperative planning. Before presenting a detailed step-by-step procedure for intramedullary Kirschner wire fixation, anesthesia considerations are explored. Emphasizing precision, fluoroscopic guidance, and meticulous postoperative care, this section provides insights for surgeons and healthcare practitioners. Considerations for rehabilitation follow, addressing postoperative care, expected recovery timelines, and physical therapy recommendations. Early mobilization, weight-bearing guidelines, and a structured rehabilitation program play pivotal roles in recovery. In the conclusion, key findings are summarized, highlighting the efficacy of intramedullary Kirschner wire fixation, its advantages, and recommendations for clinical practice. Additionally, areas for future research are identified, guiding further exploration and refinement of this surgical approach. This review is valuable for clinicians, researchers, and healthcare practitioners involved in metatarsal fracture management, contributing to the evolution of treatment strategies and improving patient care.

Lateral Ankle Ligaments: An Insight Into Their Functional Anatomy, Variations, and Surgical Importance

BACKGROUND

Ankle sprains are prevalent injuries leading to functional impairment. The lateral ankle ligament complex (LLC), comprising the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), and calcaneofibular ligament (CFL), is weak and prone to injury. The morphometric data of these ligaments are essential for orthopedic practices, including techniques like direct repair or ATFL reconstruction with autograft/allograft, which are limited in the literature. The present study aims to document the anatomy and morphometry of the LLC.

METHODS

Fifteen adult Indian-origin embalmed cadavers were selected for the study. Ankles with antemortem or postmortem injuries or previous surgical interventions were excluded from the study. After precise dissection of the ankle's anterior and lateral aspects as per Cunningham's dissection manual, ligaments were exposed. Length and width were measured using a digital vernier caliper. Morphological attributes such as shape, orientation, and inter-fiber angles were documented.

RESULTS

The most common shape in ATFL was a single band (53.33%). Inner ATFL fibers merged with the ankle joint capsule in 73.33%. ATFL mean length and width were 14 ± 2.4 mm and 7.6 ± 2.0 mm. The angle between the fibula's long axis and ATFL fibers was 107 ± 22°, and the angle between tibiotalar joint lines and parallel ATFL fibers was 30 ± 9.5°. A single band of CFL was predominant (73.33%). The mean length and width of CFL were 18.4 ± 3.9 mm and 5.2 ± 1.3 mm; the angle between the anterior fibula border's long axes and parallel CFL line was 131°. PTFL length was 20.9 ± 3.3 mm and width was 6.2 ± 1.4 mm. The mean length and width of the anterior inferior talofibular ligament (AiTFL) were 11.7 ± 2.6 mm and 9.5 ± 1.6 mm, and of the posterior inferior talofibular ligament (PiTFL) were 12.8 ± 2.1 mm and 10.4 ± 2 mm.

CONCLUSION

Comprehensive knowledge of these ligaments' anatomy and relationships is vital for clinical examination and ultrasonography. Understanding LLC details aids radiologists and orthopedic surgeons in graft selection, sizing, and precise anatomical structure placement during surgical reconstruction.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Physiotherapy Management Post-operative to Total Extensor Hallucis Longus Rupture: A Case Report

Due to the contracture or degeneration of the ruptured tendon, using primary suturing to treat chronic extensor hallucis longus (EHL) tendon ruptures is challenging. The most common cause of EHL rupture is a laceration when a sharp object drops over the dorsum of the foot. EHL injuries are rare cases. In this report, we present a case of a 23-year-old female who was operated on for EHL rupture; she visited the Physiotherapy department with complaints of pain swelling over the left dorsum of the foot and was unable to perform great toe movements for six weeks. After three weeks of patient-tailored rehabilitation protocol that included interventions like faradic stimulation, strengthening exercises, gripping exercises, proprioception training, etc., we assessed the patient's primary outcomes like pain intensity, muscle strength, and range of motion and functional outcome measures that included lower extremity functional scale score at the end. Improvement in all the outcomes was seen. Our case report concludes that physiotherapy intervention has improved the primary and secondary outcomes and has helped patients to perform functional activities efficiently, such as maintaining balance while standing, walking, and bearing equal weight. This case report portrays that early physiotherapy treatment post-operatively in EHL rupture cases proves to be very beneficial.

Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes

PURPOSE OF REVIEW

First metatarsophalangeal joint sprains or turf toe (TT) injuries occur secondary to forceful hyperextension of the great toe. TT injuries are common among athletes, especially those participating in football, soccer, basketball, dancing, and wrestling. This review summarizes the current treatment modalities, rehabilitation protocols, and return-to-play criteria, as well as performance outcomes of patients who have sustained TT injuries.

RECENT FINDINGS

Less than 2% of TT injuries require surgery, but those that do are typically grade III injuries with damage to the MTP joint, evidence of bony injury, or severe instability. Rehabilitation protocols following non-operative management consist of 3 phases lasting up to 10 weeks, whereas protocols following operative management consist of 4 phases lasting up 20 weeks. Athletes with low-grade injuries typically achieve their prior level of performance. However, among athletes with higher grade injuries, treated both non-operatively and operatively, about 70% are expected to maintain their level of performance. The treatment protocol, return-to-play criteria, and overall performance outcomes for TT injuries depend on the severity and classification of the initial sprain. For grade I injuries, players may return to play once they experience minimal to no pain with normal weightbearing, traditionally after 3-5 days. For grade II injuries, or partial tears, players typically lose 2-4 weeks of play and may need additional support with taping when returning to play. For grade III injuries, or complete disruption of the plantar plate, athletes lose 4-6 weeks or more depending upon treatment strategy.

Conservative Management of Acute Lateral Ligaments of the Ankle Injuries: An Analytical Literature Review

Injuries to the lateral ligaments of the ankle are among the most frequent sporting injuries. These injuries constitute a significant portion of all sports-related injuries. Nearly all cases involve damage to either the anterior talofibular ligament (ATFL) or the calcaneofibular ligament (CFL). While they are generally considered to be mild injuries, without adequate rehabilitation and treatment, these injuries often result in lingering symptoms for many patients for a period ranging from 6 weeks to 18 months. Subsequently, this analysis seeks to assess the non-surgical, conservative approaches currently employed in managing lateral ligament injuries of the ankle. Therefore, this assessment explores the variations and effectiveness of conservative treatment approaches based on the injury's severity and the mechanisms of trauma. The study conducted an analytical literature review that relied on diverse sources, including orthopedic books, e-books, articles, journals, and internet databases, to accomplish this. The main sources were obtained from reputable databases such as UpToDate, NCBI, and PubMed. Collectively, these sources provide definitions, outlines, evaluations, and discussions related to the topic. As such, they facilitated the formulation of an informed conclusion on the approach to treating lateral ligament injuries of the ankle complex. The reviewed literature shows that early and effective initial treatment involving pain management, prompt resumption of weight-bearing activities, limited immobilisation, and targeted physical therapy yields favorable outcomes for minor-grade sprains and is an effective preventive measure against recurrent injuries. Accordingly, athletes who experience regular ankle sprains should consider prophylactic bracing or taping to lower the risk of re-injury while enhancing their functionality. Notably, the existing functional and conservative management methods demonstrate and yield positive post-treatment outcomes. Nonetheless, the efficiency and effectiveness of these treatments depend on the specific nature of the injury and the unique traits of the individuals who sustain it. Consequently, these factors must be considered for when determining the appropriate treatment approach.

A Novel Intrinsic Foot Muscle Strength Dynamometer Demonstrates Moderate-To-Excellent Reliability and Validity

Background

Intrinsic foot muscle (IFM) weakness can result in reduced foot function, making it crucial for clinicians to track IFM strength changes accurately. However, assessing IFM strength can be challenging for clinicians, as there is no clinically applicable direct measure of IFM strength that has been shown to be reliable and valid with the foot on the ground.

Purpose

The purpose was to investigate the intra-rater and inter-rater reliability of a novel, budget-friendly IFM dynamometer and determine its agreement with a handheld dynamometer (HHD). The researchers also examined correlations of foot morphology and activity level to IFM strength.

Study design

Descriptive Laboratory Study.

Methods

Two assessors measured IFM strength of 34 healthy volunteers (4 male, 30 female; age=21.14±2.57, height=164.66 ±7.62 cm, mass=64.45±11.93 kg) on two occasions 6.62±0.78 days apart with the novel dynamometer to assess intra- and inter-rater reliability. The HHD was used to measure IFM in the first session in order to assess validity.

Results

For the novel dynamometer, intra- and inter-rater reliability was moderate-to-excellent (ICC = 0.73 - 0.95), and the majority of the strength tests were within the 95% limits of agreement with the HHD. Wider foot morphology and a higher number of days walking over the prior seven days had small but significant correlations with IFM strength (dominant foot r = 0.34, non-dominant foot r = 0.39; r = -0.33, -0.39 respectively).

Conclusion

This novel IFM dynamometer is a budget-friendly ($75) tool that was shown to be reliable and valid in a healthy population.

Levels of evidence

Level 3©The Author(s).

Effects of Attrition Shoes on Balance Control Ability and Postural Stability Following a Single-Leg Drop Jump Landing

The purpose of the study is to determine the influence of lateral-heel-worn shoes (LHWS) on balance control ability through the single-leg drop jump test. The results could be beneficial by preventing lower limb injuries. Eighteen healthy participants performed the single-leg drop jump test. Times to stabilization for ground reaction forces (TTSG) in the anterior/posterior, medial/lateral, and vertical directions were calculated to quantify dynamic balance control ability. Outcome variables of the center of pressure (COP) were used to examine the main effect of LHWS during the static phase. The postural control ability was assessed through time to stabilization for the center of mass (TTSC) in the three directions. TTSG and TTSC for the LHWS group were found to be longer than those for the new shoes (NS) group in the M/L direction (p < 0.05). An increase in the TTS revealed an increased risk of falls during physical activities. However, no significant effects for both TTSG and TTSC were found in the other two directions between LHWS and NS groups. A static phase was cropped using TTSG for each trial, which indicated a phase after participants obtained balance. Outcome measures derived from COP showed no significant effects in the static phase. In conclusion, LHWS weakened balance control ability and postural stability in the M/L direction when compared to the NS group. During the static phase, no significant differences were found between the LHWS group and the NS group in balance control ability and postural stability. Consequently, lateral-worn shoes might increase the risk of fall injuries. The results could serve as an evaluation of shoe degradation for individuals with the aim of avoiding the risk of falls.

Low-dye taping may enhance physical performance and muscle activation in basketball players with overpronated feet

BACKGROUND

Low-dye taping (LTD) is widely used by athletes and medical practitioners but the research regarding its impacts on athletic performance is lacking. This study investigated the effects of using low-dye taping on plyometric performance and muscle activities in recreational basketball players with overpronated feet.

METHODS

Twelve collegiate males with at least three years basketball training experience and navicular drop (ND) value ≥10 mm performed the navicular drop, drop jump and countermovement jump tests. Surface electromyography of selected lower limb muscles were observed during bilateral free squat. All tests in non-taped (NT) and taped (TAP) conditions were counterbalanced using repeated crossover study design. Paired t-test with an alpha level of 0.05 and non-clinical magnitude-based decision (MBD) with standardized effects were used to analyze data.

RESULTS

Contact time and reactive strength index (RSI) in the TAP condition were significantly shorter (p = 0.041) and higher (p<0.01) than the NT condition respectively. No significant difference in CMJ performance between NT and TAP was observed. MBD demonstrated clear effects on both ND (standardized effect: -1.54±0.24), flight time (standardized effect: 0.24±0.30), contact time (standardized effect: -0.27±0.21), RSI (standardized effect: 0.69±0.35) and eccentric activities of inferior gluteus maximus (standardized effect: 0.23±0.35), gluteus medius (standardized effect: 0.26±0.29) and tibialis anterior (standardized effect: 0.22±0.06).

CONCLUSIONS

LDT is effective in correcting overpronated feet by increasing ND height. Meanwhile, it provides a small increase in RSI and gluteal muscle activity during the eccentric (down) phase of the bilateral squat, and without affecting CMJ performance. Conditioning coaches or therapists may use LDT to enhance gluteal activation for reducing injury occurrence and reactive strength performance in drop jump tasks.

Control Design for CABLEankle, a Cable Driven Manipulator for Ankle Motion Assistance

A control design is presented for a cable driven parallel manipulator for performing a controlled motion assistance of a human ankle. Requirements are discussed for a portable, comfortable, and light-weight solution of a wearable device with an overall design with low-cost features and user-oriented operation. The control system utilizes various operational and monitoring sensors to drive the system and also obtain continuous feedback during motion to ensure an effective recovery. This control system for CABLEankle device is designed for both active and passive rehabilitation to facilitate the improvement in both joint mobility and surrounding muscle strength.

Recognizing Continuous Multiple Degrees of Freedom Foot Movements with Inertial Sensors

Recognition of continuous foot motions is important in robot-assisted lower limb rehabilitation, especially in prosthesis and exoskeleton design. For instance, perceiving foot motion is essential feedback for the robot controller. However, few studies have focused on perceiving multiple-degree of freedom (DOF) foot movements. This paper proposes a novel human-machine interaction (HMI) recognition wearable system for continuous multiple-DOF ankle-foot movements. The proposed system uses solely kinematic signals from inertial measurement units and multiclass support vector machines by creating error-correcting output codes. We conducted a study with multiple participants to validate the performance of the system using two strategies, a general model and a subject-specific model. The experimental results demonstrated satisfactory performance. The subject-specific approach achieved 98.45% ± 1.17% (mean ± SD) overall accuracy within a prediction time of 10.9 ms ± 1.7 ms, and the general approach achieved 85.3% ± 7.89% overall accuracy within a prediction time of 14.1 ms ± 4.5 ms. The results prove that the proposed system can more effectively recognize multiple continuous DOF foot movements than existing strategies. It can be applied to ankle-foot rehabilitation and fills the HMI high-level control demand for multiple-DOF wearable lower-limb robotics.

Comparison of the Effect of Resistance and Balance Training on Isokinetic Eversion Strength, Dynamic Balance, Hop Test, and Ankle Score in Ankle Sprain

Ankle sprain is a commonly recurring sports injury. This study aimed to compare the rehabilitation effects of resistance and balance training programs in patients with recurrent ankle sprain. Patients with recurrent lateral ankle sprain completed a home-based rehabilitation program comprising resistance training (RT; n = 27) or balance training (BT; n = 27). RT consisted of exercises using elastic tube bands, and BT consisted mainly of exercises performed using a variety of balance tools. Exercises were performed for 6 weeks, twice a day for 20 min, 5 days per week. Isokinetic eversion strength, Y-Balance test and hop tests, and foot and ankle outcome score (FAOS) were evaluated. Both RT and BT significantly improved strength and dynamic balance (p < 0.05). Compared to RT, BT also significantly improved the outcome of the crossover hop test (p = 0.008). The changes reflected group and time in pain (p = 0.022), sports (p = 0.027), and quality of life (p = 0.033) of FAOS were significantly greater in BT than RT.

Short-term and long-term effects of ankle joint taping and bandaging on balance, proprioception and vertical jump among volleyball players with chronic ankle instability

OBJECTIVE

This study hypothesized that the prolonged use of taping during athletic activities produces more significant increases in proprioception, balance, and vertical jump among volleyball players with CAI.

DESIGN

A randomized controlled study.

PARTICIPANTS

One-hundred participants with chronic ankle instability (CAI) participated in this study. Participants were distributed into 3-groups: taping group, bandaging group, and control group.

PRIMARY OUTCOME MEASURES

Proprioception (ankle range of motion absolute error), balance(Y-balance test), and vertical jump (vertical jump tester).

INTERVENTIONS

Three interventions were performed: ankle rigid taping, ankle bandaging, and placebo taping. The measurements were performed at baseline, immediately, 2-weeks and 2-months after support.

RESULTS

Immediately after supports, there were non-significant differences between all groups for proprioception, balance (P < .05). There was a significant difference between banding and control groups, and taping and control groups for the vertical jump (P < .05). After 2-weeks and 2-months, there were significant differences between bandaging and control groups, and taping and control groups for proprioception, balance, and vertical jump (P < .05). There were non-significant differences between taping and bandaging groups (P < .05) during all assessments.

CONCLUSION

This study indicated that ankle taping and bandaging immediately improve vertical jump only; while they improve proprioception, balance, and vertical jump after 2-weeks and 2-months.

Closing the Wearable Gap-Part VII: A Retrospective of Stretch Sensor Tool Kit Development for Benchmark Testing

This paper presents a retrospective of the benchmark testing methodologies developed and accumulated into the stretch sensor tool kit (SSTK) by the research team during the Closing the Wearable Gap series of studies. The techniques developed to validate stretchable soft robotic sensors (SRS) as a means for collecting human kinetic and kinematic data at the foot-ankle complex and at the wrist are reviewed. Lessons learned from past experiments are addressed, as well as what comprises the current SSTK based on what the researchers learned over the course of multiple studies. Three core components of the SSTK are featured: (a) material testing tools, (b) data analysis software, and (c) data collection devices. Results collected indicate that the stretch sensors are a viable means for predicting kinematic data based on the most recent gait analysis study conducted by the researchers (average root mean squared error or RMSE = 3.63°). With the aid of SSTK defined in this study summary and shared with the academic community on GitHub, researchers will be able to undergo more rigorous validation methodologies of SRS validation. A summary of the current state of the SSTK is detailed and includes insight into upcoming experiments that will utilize more sophisticated techniques for fatigue testing and gait analysis, utilizing SRS as the data collection solution.

Functional Outcomes and Psychological Benefits of Active Video Games in the Rehabilitation of Lateral Ankle Sprains: A Case Report

CONTEXT

The use of active video games (AVG) as a treatment modality in the rehabilitation context is increasing. However, little is known about the functional outcomes and psychological benefits of such rehabilitation in college athletes with lateral ankle sprains (LASs).

OBJECTIVE

To examine functional outcomes and psychological benefits of AVG-aided rehabilitation program for LAS.

DESIGN

A mixed-methods, single-subject case series design.

SETTING

College athletic training clinic.

PATIENTS

Two female college soccer players who sustained LAS (grades I and II) during sport participation.

INTERVENTION

A 4-week balance training program. One patient completed balance exercises using AVG, whereas the other patient completed traditional balance exercises.

MAIN OUTCOME MEASURES

Several validated instruments were used to evaluate different functional outcomes and psychological factors: balance (Balance Error Scoring System, Star Excursion Balance Test), rehabilitation adherence (Rehabilitation Adherence Measure for Athletic Training), foot and ankle function (Foot and Ankle Ability Measure), perceptions of pain (Visual Analog Scale for pain), perceived readiness to return to sport (Injury-Psychological Readiness to Return to Sport Scale), and mood (Brunel Mood Scale).

RESULTS

It appears that the balance training protocols (AVG and traditional balance exercises) were equally effective in restoring patient's balance to functional levels. Despite very individualistic processes of rehabilitation, the participants' perceived pain, perceived readiness to return to sport, and mood states were closely linked with objective and subjective functional measures of progress.

CONCLUSIONS

Based on the results, AVG has the potential to provide more versatility into the static and dynamic postural control exercises typically used following acute LAS. Moreover, the current results support the existing psychological and biopsychosocial theoretical conceptualizations of athletes' responses to injuries and rehabilitation process.

Effect of Kinesio Taping and balance exercises on postural control in amateur soccer players: A randomised control trial

The objective of this study was to determine the effect of Kinesio Taping (KT), alone or together with balance exercises (BE), on parameters related to postural control, such as dynamic balance, static balance and flexibility. Forty-four male amateur soccer players (mean age 24.45 (4.79) years) were randomly allocated to 3 groups: KT+BE that received KT and BE (n = 16); KT_p+BE, in which the KT was used as a placebo (n = 15) and KT alone (n = 13). The intervention period lasted 4 weeks. Star Excursion Balance Test (SEBT), Unipedal Stance Test (UST) and the Toe Touch Test (TTT) were assessed at baseline (pre), two weeks after beginning the treatment (mid) and after the intervention (post). We observed a significant improvement on the SEBT (mid and post-treatment) and the UST (post-treatment), but not on the TTT in either KT+BE or KT_p+BE groups post treatment. No differences were found either in KT group at any time point or between groups in any variable studied. In conclusion, KT functional correction technique does not improve static and dynamic balance when applied alone, whereas BE alone or combined with KT significantly improves these variables. None of these techniques has any effect on flexibility. Abbreviation: KT: Kinesiotaping; BE: Balance exercises; KTp: Placebo Kinesiotaping; UST: Unipedal Stance Test; SEBT: Star Excursion Balance Test; TTT: Toe Touch Test.

Robust Longitudinal Ankle Edema Assessment Using Wearable Bioimpedance Spectroscopy

OBJECTIVE

We present a robust methodology for tracking ankle edema longitudinally based on bioimpedance spectroscopy (BIS).

METHODS

We designed a miniaturized BIS measurement system and employed a novel calibration method that enables accurate, high-resolution measurements with substantially lower power consumption than conventional approaches. Using this state-of-the-art wearable BIS measurement system, we developed a differential measurement technique for robust assessment of ankle edema. This technique addresses many of the major challenges in longitudinal BIS-based edema assessment, including day-to-day variability in electrode placement, positional/postural variability, and intersubject variability.

RESULTS

We first evaluated the hardware in bench-top testing, and determined the error of the bioimpedance measurements to be 0.4 Ω for the real components and 0.54 Ω for the imaginary components with a resolution of 0.2 Ω. We then validated the hardware and differential measurement technique in: 1) an ex vivo, fresh-frozen, cadaveric limb model, and 2) a cohort of 11 human subjects for proof of concept (eight healthy controls and five subjects with recently acquired acute unilateral ankle injury).

CONCLUSION

The hardware design, with novel calibration methodology, and differential measurement technique can potentially enable long-term quantification of ankle edema throughout the course of rehabilitation following acute ankle injuries.

SIGNIFICANCE

This could lead to better-informed decision making regarding readiness to return to activities and/or tailoring of rehabilitation activities to an individual's changing needs.

Questionnaires and scales for assessment of ankle function: a systematic review of instruments translated and validated for Brazilian Portuguese

PURPOSE

Several questionnaires have been used for functional evaluation. They must be translated and adapted transculturally, these instruments need to be valid, reliable, and sensitive according to the population. This review identified the questionnaires which were adapted transculturally in Brazilian Portuguese, to verify the methodological quality.

METHODS

A search was performed in the PubMed, BIREME, SportDiscus, SciELO, Scopus, Science Direct, and Web of Science. The methodological quality was evaluated by the COnsensus-based Standards for Health Measurement INstruments (COSMIN) Risk of Bias checklist. For cross-cultural translation and adaptation studies, the properties of measurement of structural validity, internal consistency (IC), cross-cultural validity, reliability, measurement error, and criterion validity were analyzed.

RESULTS

A total of 4564 articles were found; 10 fulfilled the inclusion criteria. The psychometrics properties verified were IC; criterion validity; reproducibility; floor/ceiling effect and responsiveness. Criterion validity was the best criterion evaluated. The main failures were related to sample size, and the most deficient properties were IC, reliability, and error of measure.

CONCLUSIONS

The studies verified presented "inadequate" final score using COSMIN. Although specific questionnaires for ankle evaluation have been cross culturally validated in Brazilian Portuguese, their methodological quality was generally low, as verified through the analysis of their psychometric properties. IMPLICATIONS FOR REHABILITATION The questionnaires which were cross culturally adapted to Brazilian Portuguese were shown to be of low methodological quality. In using them careful consideration needs to be given to the psychometrics of each measure. Caution should be exercised in making clinical decisions drawn from the results.

Antimicrobial susceptibility pattern of aerobes in diabetic foot ulcers in a South-Indian tertiary care hospital

PURPOSE

Diabetic foot infections (DFIs) are major public health concerns. In the view of the ever increasing burden of multidrug-resistant (MDR) organisms, improving the use of antimicrobial agents (AMAs) is a national priority. Objective of the study was to determine antimicrobial susceptibility (AMS) pattern of aerobes in DFIs.

METHODS

A cross-sectional study was conducted for a period of 3 years at Department of Surgery, Kasturba hospital, Manipal, India during which, 260 diabetic foot ulcer (DFU) patients admitted in the general surgery wards were enrolled for the study. These patients' culture specimens were observed as Gram-stained smears and cultured aerobically on blood agar and MacConkey agar plates. AMS test was performed by disc diffusion technique according to Clinical and Laboratory Standards Institute (CLSI) guidelines.

RESULTS

A total of 354 microbes were isolated from the ulcer wounds of 213 diabetic foot patients, with an average of 1.7 organisms per lesion. Monomicrobial infections were less common (n=81; 31.2%) than polymicrobial infections (n=132; 50.7%). Gram-negative bacteria were the most common among the isolates (n=192; 54.2%). Aerobic Gram-positive Cocci accounted for 162 (45.8%) of all isolates. On the other hand, Staphylococcus aureus was the most frequently isolated aerobe (n=106; 29.9%) followed by Pseudomonas aeruginosa (n=91; 25.7%).

CONCLUSION

AMS data from our study recommends that doxycycline would be the appropriate choice as single drug for empirical coverage for Gram-positive organisms. The most appropriate antibiotic for Gram-negative organisms is meropenem. One of the critical observations is the presence of Acinetobacter, an MDR isolated from DFIs, which is either relatively or totally resistant to all the AMAs tested.

Return to Sport in Athletes with Midportion Achilles Tendinopathy: A Qualitative Systematic Review Regarding Definitions and Criteria

Background

Midportion Achilles tendinopathy (AT) can cause long-term absence from sports participation, and shows high recurrence rates. It is important that the decision to return to sport (RTS) is made carefully, based on sharply delimited criteria. Lack of a well-defined definition and criteria hampers the decision to RTS among athletes with AT, and impedes comparison of RTS rates between different studies.

Objective

The aim of this study was to systematically review the literature for definitions of, and criteria for, RTS in AT research.

Study Design

Qualitative systematic review.

Methods

The PubMed, EMBASE, Cochrane, CINAHL, PEDro, and Scopus electronic databases were searched for articles that reported on the effect of a physiotherapeutic intervention for midportion AT. Article selection was independently performed by two researchers. Qualitative content analysis was used to analyze the included studies and extract definitions of, and criteria for, RTS.

Results

Thirty-five studies were included in the content analysis, showing large variety in both the definitions and criteria. Thirty-two studies reported a definition of RTS, but only 19 studies described the criteria for RTS. The content analysis revealed that ‘reaching pre-injury activity/sports level, with the ability to perform training and matches without limitations’, ‘absence of pain’, and ‘recovery’ were the main content categories used to define RTS. Regarding the criteria for RTS, eight different content categories were defined: (1) ‘level of pain’; (2) ‘level of functional recovery’; (3) ‘recovery of muscle strength’; (4) ‘recovery of range of motion’; (5) ‘level of endurance of the involved limb’; (6) ‘medical advice’; (7) ‘psychosocial factors’; and (8) ‘anatomical/physiological properties of the musculotendinous complex’. Many criteria were not clearly operationalized and lacked specific information.

Conclusions

This systematic review shows that RTS may be defined according to the pre-injury level of sports (including both training and matches), but also with terms related to the absence of pain and recovery. Multiple criteria for RTS were found, which were all related to level of pain, level of functional recovery, muscular strength, range of motion, endurance, medical advice, psychosocial factors, or anatomical/physiological properties of the Achilles tendon. For most of the criteria we identified, no clear operationalization was given, which limits their validity and practical usability. Further research on how RTS after midportion AT should be defined, and which criteria should be used, is warranted.

PROSPERO Registration Number

CRD42017062518.

Electronic supplementary material

The online version of this article (10.1007/s40279-017-0833-9) contains supplementary material, which is available to authorized users.

Turf toe: A clinical update

Turf toe is a condition that describes injury to the plantar metatarsophalangeal-sesamoid complex of the great toe.

It is a relatively rare and debilitating condition, particularly seen in American footballers after the introduction of harder, artificial ‘turf’ surfaces.

Turf toe represents a significant injury to the hallux and requires a high index of suspicion.

If unrecognized, it can lead to chronic problems including reduced push-off strength, persistent pain, progressive deformity and eventual joint degeneration.

Patients with chronic injuries may have worse outcomes, and therefore early, accurate diagnosis and initiation of treatment play a vital role.

A multidisciplinary team approach is key for successful return to sport.

Cite this article: EFORT Open Rev 2018;3:501-506. DOI: 10.1302/2058-5241.3.180012

Effects of Taping on Achilles Tendon Protection and Kendo Performance

Context:It has been reported that there is a high rate of Achilles tendon injury among kendo athletes. For protection and to support the area, kendo athletes habitually use taping during practice or games.Objective:To investigate the effect of various taping techniques on injury prevention and functional performance in kendo athletes.Design:Case-control study.Setting:Laboratory.Participants:15 University Kendo Team athletes with at least 2 y kendo experience.Main Outcome Measures:Athletes completed 5 stepping backwards and striking cycles under 4 taping conditions: no taping, athletic taping of ankle joint (AT-Ankle), athletic taping of Achilles tendon (AT-Achilles), and Kinesio-Tex taping of Achilles tendon (KT-Achilles). Jump distance, lower limb angular motion, left foot-ground contact time, Achilles tendon force (ATF), and soleus and medial gastrocnemius muscle activities were measured.Results:Lowest peak ATF was found in AT-Achilles during heel-down phase, with statistically significant difference from KT-Achilles peak force. Significant decline of soleus muscle electromyography amplitude was also found when compared to no taping during heel-down phase and other conditions during pushing phase. Conversely, KT-Achilles showed significant decrease in foot-ground contact time compared with no taping and greater ankle range of motion than in AT-Ankle.Conclusion:To protect the Achilles tendon, AT-Achilles taping is recommended since it tends to decrease ATF. Conversely, to enhance athlete performance, we recommend KT-Achilles taping to speed up kendo striking motion. However, the Achilles tendon must withstand greatest forces concurrently. This finding implies that AT-Achilles taping can protect the injured Achilles tendon and KT-Achilles taping can enhance performance on the kendo striking motion.

Evaluating Postural Control and Ankle Laxity Between Taping and High-Top Cleats in High School Football Players

CONTEXT

Lateral ankle sprains are the most common injuries in high school sports. While ankle taping is a preferred method of external prophylactic support, its restrictive properties decline during exercise. The Under Armour^® Highlight cleat is marketed on the premise that it provides added support without the need for additional ankle taping.

OBJECTIVE

To determine if differences in ankle joint laxity and postural control exist between football players wearing the Under Armour^® Highlight cleat (Under Armour Inc, Baltimore, MD) as compared to a low/mid-top cleat with ankle tape.

DESIGN

Crossover trial.

SETTING

Athletic training room and football practice field sideline.

PATIENTS

32 interscholastic football players (15.8 ± 1.0 y; 178.9 ± 7.4 cm; 87.1 ± 21.4 kg).

INTERVENTIONS

Ankle laxity was assessed using an instrumented ankle arthrometer (Blue Bay Research Inc, Milton, FL), while postural control testing was performed on the Tekscan MobileMat™ Balanced Error Scoring System (BESS; South Boston, MA). The 2 treatments included Under Armour^® Highlight cleats and a low/mid-top cleat with ankle tape applied to the nondominant ankle only. Measurements were taken before and immediately after practice.

MAIN OUTCOME MEASURES

The independent variable was treatment (Highlight vs low/mid-top cleat with ankle tape). Dependent variables included ankle arthrometry measures of anterior displacement (mm), inversion/eversion rotation (deg), and the modified BESS error scores. A linear mixed-effects model was used for analysis.

RESULTS

The low/mid-top cleat with tape condition had significantly higher inversion range-of-motion (ROM) and inversion/eversion rotation postexercise when compared to the Highlight cleat (P < 0.05).

CONCLUSIONS

The results of this study provide some evidence that the Under Armour^® Highlight cleat restricts ankle ROM following a training session better than the taped low/mid-top cleat. Further study is warranted to determine if this high-top style of football cleat can reduce the incidence of ankle sprains and how it might compare to spat taping.

Control of vertical posture while standing on a sliding board and pushing an object

Voluntary pushing or translation perturbation of the support surface each induces a body perturbation that affects postural control. The objective of the study was to investigate anticipatory (APA) and compensatory (CPA) postural adjustments when pushing an object (that induces self-initiated perturbation) and standing on a sliding board (that induces translational perturbation). Thirteen healthy young participants were instructed to push a handle with both hands while standing on a sliding board that was either free to move in the anterior-posterior direction or stationary. Electromyographic activity (EMG) of trunk and lower extremity muscles, center of pressure (COP) displacements, and the forces exerted by the hand were recorded and analyzed during the APA and CPA phases. When the sliding board was free to move during pushing (translation perturbation), onsets of activity of ventral leg muscles and COP displacement were delayed as compared to pushing when standing on a stationary board. Moreover, magnitudes of shank muscle activity and the COP displacement were decreased. When pushing heavier weight, magnitudes of muscle activity, COP displacement, and pushing force increased. The magnitude of activity of the shank muscles during the APA and CPA phases in conditions with translational perturbation varied with the magnitude of the pushing weight. The outcome of the study suggests that the central nervous system prioritizes the pushing task while attenuates the source of additional perturbation induced by translation perturbation. These results could be used in the development of balance re-training paradigms involving pushing weight while standing on a sliding surface.

Measuring the 3D motion space of the human ankle

BACKGROUND

The 3D motion space of the human ankle is an important area of study in medicine. The 3D motion space can provide significant information for establishing more reasonable rehabilitation procedures and standards of ankle injury care.

OBJECTIVE

This study aims to measure the 3D motion space of the human ankle and to use mathematical methods to quantify it.

METHODS

A motion capturing system was used to simultaneously capture the 3D coordinates of points marked on the foot, and convert these coordinate values into rotation angles through trigonometric functions and vectors. The mathematical expression of the ankle's motion space was obtained by screening, arranging, and fitting the converted data.

RESULTS

The mathematical expression of the 3D motion space of the participants was obtained. We statistically analyzed the data and learned that, in terms of 3D motion space, the right foot is more flexible than the left foot and the female foot is more flexible than the male foot.

CONCLUSIONS

The adduction and abduction rotation ranges are affected by the plantar flexion or dorsal flexure rotation angles. This relationship can be expressed mathematically, which is significant in the study of the ankle joint.

Dynamic plantar pressure distribution, strength capacity and postural control after Lisfranc fracture-dislocation

Substantial progress has been made in the operative treatment of Lisfranc fractures, however, the prognosis remains poor. We hypothesized that Lisfranc injuries change the postural control and muscle strength of the lower limb. Both are suggested to correlate with the clinical outcome and quality of life. 17 consecutive patients suffering from a Lisfranc fracture dislocation were registered, underwent open reduction and internal fixation and were followed-up for 50.5±25.7months (Mean±SDM). Biomechanical analysis of muscle strength capacities, postural control and plantar pressure distribution was assessed >6 month postoperatively. Results were correlated to clinical outcome (AOFAS, FFI, Pain, SF-36). The isokinetic assessment revealed a significant reduction in plantar flexor and dorsal extensor peak torque of the injured limb compared to the uninjured limb. The dorsal extensor peak torque thereby correlated well with clinical outcome. Altered postural control was evident by a significant reduction in unilateral stance time, from which we calculated a strong correlation between stance time and the isokinetic strength measurement. Plantar pressure measurements revealed a significant reduction in peak pressure under the midfoot and of Force-Time Integral beneath the second metatarsal. Sufficient rehabilitation is crucial to the clinical outcome following anatomical open reduction of Lisfranc fracture-dislocation. The present study supports a rehabilitation approach focussing on restoring proprioception and calf muscular strength including isometric exercises of the dorsal extensors.

The Influence of Plantar Short Foot Muscle Exercises on Foot Posture and Fundamental Movement Patterns in Long-Distance Runners, a Non-Randomized, Non-Blinded Clinical Trial

Background

The objective of this study was to evaluate the influence of two kinds of plantar short foot muscles exercise on foot posture and fundamental movement patterns in long-distance runners.

Design

A parallel group non-blinded trial with 6-week follow-up.

Methods

Twenty five long-distance runners aged 22–35 years. They were divided into two groups. In group 1 (n = 13) subjects performed the exercise “Vele’s Forward Lean” and “Reverse Tandem Gait” and in Group 2 (n = 12) the “Short Foot Exercise.” The runners performed the exercises daily for 6 weeks. The Foot Posture Index (FPI-6) and The Functional Movement Screen (FMS) tests were performed twice: at baseline and after 6 weeks of the exercise.

Results

A significant improvement was observed in FPI -6 (talar head palpation in Group 1, and inversion/eversion of the calcaneus in Group 2). Also in Group 1 a significant improvement was noted in FMS tests: deep squat, active straight leg raise and in total score.

Conclusions

Short foot muscles strengthening exercises have beneficial effect on functional movement patterns and on foot posture, therefore they should be included as a part of daily training program of runners.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12615001200572

Dynamic techniques for clinical assessment of the athlete

Clinical diagnostic tests objectively evaluate lower extremity ailments of the athlete. The positive squeeze test is found to be reproducible for ankle syndesmotic injury but is a poor prognosticator. The anterior drawer and talar tilt tests assess lateral ankle sprains. These have limitations secondary to positioning and guarding by the athlete, so comparison with the asymptomatic extremity is recommended. The Ottawa ankle rules assess possible fractures of the ankle and midfoot. The Thompson test evaluates Achilles tendon tears, whereas the windlass technique and the modified Lachman test examine the integrity of the plantar fascia and metatarsophalangeal joint capsule.

Principles of rehabilitation and return to sports following injury

Rehabilitation of an athlete can present its own challenges. Few protocols are available to guide physicians in proper return to sport. Rehabilitation after foot and ankle sport injury can be categorized into 3 different stages but should also be individualized. The focus of this article is to help the treating physician in creating a protocol to safely return an injured athlete back to sport based on current literature and principles.

Analysis of collagen organization in mouse achilles tendon using high-frequency ultrasound imaging

Achilles tendon ruptures are traumatic injuries, and techniques for assessing repair outcomes rely on patient-based measures of pain and function, which do not directly assess tendon healing. Consequently, there is a need for a quantitative, in vivo measure of tendon properties. Therefore, the purpose of this study was to validate ultrasound imaging for evaluating collagen organization in tendons. In this study, we compared our novel, high-frequency ultrasound (HFUS) imaging and analysis method to a standard measure of collagen organization, crossed polarizer (CP) imaging. Eighteen mouse Achilles tendons were harvested and placed into a testing fixture where HFUS and CP imaging could be performed simultaneously in a controlled loading environment. Two experiments were conducted: (1) effect of loading on collagen alignment and (2) effect of an excisional injury on collagen alignment. As expected, it was found that both the HFUS and CP methods could reliably detect an increase in alignment with increasing load, as well as a decrease in alignment with injury. This HFUS method demonstrates that structural measures of collagen organization in tendon can be determined through ultrasound imaging. This experiment also provides a mechanistic evaluation of tissue structure that could potentially be used to develop a targeted approach to aid in rehabilitation or monitor return to activity after tendon injury.

Case series of first metatarsophalangeal joint injuries in division 1 college athletes

Context:

Injuries of the first metatarsophalangeal (hallux MP) joint can be debilitating in the athletic population. Turf toe and plantar plate injuries are typically diagnosed similarly. However, variance in injury mechanism as well as compromised integrity of soft tissue and ligamentous structures make it difficult to accurately diagnose specific hallux MP injuries. Recent literature has supported the use of both radiographic imaging and the Lachman test as reliable indicators of joint instability in the presence of hallux MP injuries. To date, research supporting specific rehabilitation interventions and return-to-play decision making for hallux MP injuries has been limited to case studies and suggested guidelines from literature reviews. There is limited evidence suggesting specific criteria for surgical and nonsurgical decision making in conjunction with rehabilitation progressions to return an athlete to sport when managing hallux MP injuries.

Evidence Acquisition:

A literature search was performed using Medline, PubMed, and Google Scholar to find and review articles from 1970 to 2013 that addressed the basic anatomy of the plantar plate, injuries to this anatomical structure, and the evaluation, diagnosis, surgical and nonsurgical management, and rehabilitation of these injuries, specifically in the athletic population. Medical information for each case was gathered from electronic medical records from the individual athletes cited in this case series, which included imaging reports, rehabilitation documentation, and both evaluation and surgical reports. No statistical analysis was used.

Study Design:

Case series.

Level of Evidence:

Level 4.

Results:

Treatment plans for each case varied depending on surgical and nonsurgical intervention and rehabilitation outcomes. However, each athlete was able to return to sports-specific activities.

Conclusion:

Successful outcomes for hallux MP injuries are contingent on thorough evaluation, appropriate clinical decision making with regard to surgical versus nonsurgical treatment planning, and a multidisciplinary team approach for ensuring a safe return to sport.

Strength-of-Recommendation Taxonomy (SORT):

C.

Imaging of plantar fascia and Achilles injuries undertaken at the London 2012 Olympics

Plantar fascia and distal Achilles injuries are common in elite athletes. Acute athletic injuries of the plantar fascia include acute plantar fasciopathy and partial or complete tears. Underlying most acute injuries is a background of underlying chronic plantar fasciopathy. Injuries may affect the central or less commonly lateral portions of the fascia and acute tears are generally proximal. Athletic Achilles injuries may occur at the mid tendon or the distal insertion, and there may be an underlying chronic tendinopathy. Acute or chronic paratendinopathy may occur as a separate entity or combined with Achilles injury. In this article, the spectrum of athletic injuries of the plantar fascia and Achilles is described, illustrated by imaging findings from the London 2012 Olympic games.

A Comparison of the Foot and Ankle Condition between Elite Athletes and Non-athletes

[Purpose] The purpose of this study was to compare the foot and ankle condition between elite athletes and non-athletes. [Subjects] The elite athletes group included 85 subjects (28 males and 57 females) and the non-athletes group included 85 subjects (38 males and 47 females). [Methods] All subjects were evaluated for pain (visual analogue scale, VAS) and foot and ankle condition (The Foot and Ankle Disability Index, FADI, and The Foot and Ankle Outcome Score, FAOS). [Results] The elite athlete group showed significant differences from the non-athletes group in VAS, FADI (FADI, FADI-Sports), and FAOS (FAOS-symptoms, FAOS-pain, FAOS-ADL, FAOS-sports, FAOS-QoL). In addition, a meaningful difference in VAS, FADI-Sports, and FAOS-symptoms was observed between gymnasts and wrestlers. [Conclusion] The results of this study suggest the necessity prevention of injury to the foot and ankle of elite athletes, and for the development of exercise for the rehabilitation of foot and ankle injuries, because there is a difference in foot and ankle condition between elite athletes and non-athletes.

Conservative management of Achilles Tendinopathy: a case report

OBJECTIVE

To chronicle the conservative treatment and management of a 77-year old female patient presenting with chronic pain of 8 months duration in the midportion of the achilles tendon diagnosed as achilles tendinopathy.

CLINICAL FEATURES

The main clinical feature was pain in the midportion of the achilles tendon, 2 to 6 cm proximal to the calcaneal insertion. Symptom onset was gradual and unrelated to any acute trauma or overt injury mechanism.

INTERVENTION AND OUTCOME

The conservative treatment approach consisted of medical acupuncture with electrical stimulation, Graston Technique®, eccentric calf training, and rehabilitative exercise prescription. Outcome measures included verbal pain rating scale, lower extremity functional scale (LEFS), and a return to activities of daily living (ADLs). The patient attained long-term resolution of her complaint and at 12 month follow-up reported no recurrence of symptoms.

CONCLUSION

A combination of conservative rehabilitation strategies may be used by chiropractors to treat midportion achilles tendinopathy and allow an individual to return to pain free ADLs in a timely manner.

Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability.

BACKGROUND

Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function.

METHODS

Forty-three participants (mean ± SD age, 25.6 ± 7.6 years; height, 174.3 ± 10.2 cm; mass, 74.6 ± 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21).

RESULTS

There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P<.001) in dorsiflexion at each postintervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores.

CONCLUSIONS

The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing.

LEVEL OF EVIDENCE

Therapy, level 2b-.

Overuse injuries in high school runners: lifetime prevalence and prevention strategies

OBJECTIVE

To evaluate lifetime prevalence and risk factors for overuse injuries in high school athletes currently participating in long-distance running and provide recommendations for injury prevention strategies.

DESIGN

Retrospective study design.

SETTING

Twenty-eight high schools in the San Francisco Bay Area.

PARTICIPANTS

A total of 442 female and 306 male athletes, ages 13-18 years, who are on cross-country and track and field teams.

METHODS

Online survey with questions that detailed previous injuries sustained and risk factors for injury.

MAIN OUTCOME MEASUREMENTS

Previous overuse injuries and association of risk factors to injury (including training variables, dietary patterns, and, in girls, menstrual irregularities).

RESULTS

Previous injuries were reported by 68% of female subjects and 59% of male subjects. More injury types were seen in girls (1.2 ± 1.1 versus 1.0 ± 1.0, P < .01). Both genders had similar participation in running (2.5 ± 2.2 versus 2.3 ± 2.1 years), and previous injury prevalence followed a similar pattern: tibial stress injury (girls, 41%; boys, 34%), ankle sprain (girls, 32%; boys, 28%), patellofemoral pain (girls, 21%; boys, 16%), Achilles tendonitis (girls, 9%; boys, 6%), iliotibial band syndrome (girls, 7%; boys, 5%), and plantar fasciitis (girls, 5%; boys, 3%). Higher weekly mileage was associated with previous injuries in boys, (17.1 ± 11.9 versus 14.1 ± 11.5, P < .05) but not in girls (14.4 ± 10.2 versus 12.6 ± 11.8, not significant). A strong association between higher mileage and faster performances was seen in both groups. No association between previous injury and current dietary patterns (including disordered eating and calcium intake) or menstrual irregularities was seen.

CONCLUSIONS

The majority of athletes currently participating in high school cross-country and track and field have a history of sustaining an overuse injury, with girls having a higher prevalence of injury. A modest mileage reduction may represent a modifiable risk factor for injury reduction. Future research is needed to evaluate the effects of incorporating a comprehensive strength training program on the prospective development of overuse injury and performance in this population.