The peroneal strength deficits in patients with chronic ankle instability compared to ankle sprain copers and normal individuals

In vivo ankle kinetics after surgical management of concurrent chronic ankle instability and osteochondral lesions of the talus

BACKGROUND

Ankle joint moment and reaction force alteration after surgical treatment of chronic ankle instability (CAI) and osteochondral lesions of the talus (OLT) remains unknown.

RESEARCH QUESTION

The current study aimed to investigate the in vivo kinetic effects of surgical management on patients with CAI and OLT and conduct a comparison with healthy subjects.

METHODS

Eight patients with concurrent CAI and OLT were assessed in a stair descent setting prior to surgical management and one-year postoperatively. For inverse dynamic analysis, ground reaction forces and trajectories of skin markers were imported to AnyBody Modelling System to calculate the ankle joint reaction force and external ankle moment. One-dimensional statistical parametric mapping was performed for the comparison of ankle kinetic curves during gait cycle among healthy subjects, patients before surgery and patients after surgery.

RESULTS

Preoperative patients displayed increased dorsiflexion moment compared with healthy subjects during 38.2 %-40.9 % of the gait cycle and during 38.1 %-41.1 % of the gait cycle with postoperative patients. Preoperative patients showed an increased anterior shear force compared with healthy subjects during 42.2 %-43.7 % of the gait cycle, and 42.8 %-43.2 % of the gait cycle with postoperative patients. Patients exhibited an increased maximal medial force preoperatively and postoperatively compared with healthy subjects (p < 0.001).

SIGNIFICANCE

One-stage surgical treatment of CAI and OLT can decrease the excessive dorsiflexion moment and anterior force of the ankle joint. Excessive medial force of the ankle joint was partially decreased postoperatively, but it still significantly increased compared with that of healthy subjects. Such a finding may be attributed to impaired peroneal activation and requires additional rehabilitative treatment.

Application of Smart Insoles in Assessing Dynamic Stability in Patients with Chronic Ankle Instability: A Comparative Study

Chronic ankle instability (CAI), due to its chronic nature and biomechanical complexity, is well-suited for continuous monitoring and tele-rehabilitation using wearable sensor technology. This study assessed whether a smart insole system, equipped with 4 force-sensing resistor sensors and an inertial measurement unit, combined with functional tests and biomechanical indices, could distinguish CAI patients from healthy controls. A total of 21 CAI patients (23.8 ± 5.1 years) and 16 controls (22.62 ± 2.60 years) completed a battery of functional performance tests while wearing the smart insole system. The results showed an increased medial-lateral pressure ratio in the CAI during heel raise (p = 0.031, effect size = 0.82) and hop tests, suggesting an everted foot position. Significant deviations in center-of-pressure trajectory during double-leg heel raises (p = 0.005, effect size = 1.10) suggested asymmetric motion coordination, while compensatory fluctuations of the lifted limb during single-leg balance tests (p = 0.011, effect size = 1.03) were greater in CAI patients. These findings facilitated the development of features to characterize CAI-specific movement patterns. Together, this system shows promise as a quantitative assessment tool for CAI, supporting improved treatment outcomes through tele-rehabilitation.

High-Density Surface Electromyography Feedback Enhances Fibularis Longus Recruitment in Chronic Ankle Instability

PURPOSE

This study aimed to determine whether individuals with chronic ankle instability (CAI) can activate the fibularis longus compartments with high-density surface electromyography (HD-sEMG) biofeedback to the same extent as those without CAI, and to analyze the effect of ankle position on compartment activation in individuals with CAI using HD-sEMG feedback.

METHODS

There were 16 volunteers per group (CAI and No-CAI). The sEMG amplitude at each compartment (anterior and posterior) and the barycenter of the spatial sEMG amplitude distribution of the fibularis longus were recorded during eversion in neutral and plantar flexion positions at 30% and 70% of maximum voluntary contraction force, both with and without visual feedback on the spatial sEMG amplitude distribution.

RESULTS

sEMG amplitude of the posterior compartment of the fibularis longus in the CAI group trained with HD-sEMG feedback during eversion at 70% maximum voluntary contraction (in plantar flexion) was significantly higher than without HD-sEMG feedback (95% CI = 3.75-34.50% root mean square) and was similar to the activation of the No-CAI group (95% CI = -14.34% to 34.20% root mean square). Furthermore, individuals with CAI who underwent training with HD-sEMG feedback in plantar flexion exhibited a posterior displacement of the barycenter (95% CI = 0.56-2.84 mm).

CONCLUSIONS

Utilizing HD-sEMG feedback during eversion in plantar flexion position increases activation of the fibularis longus posterior compartment in individuals with CAI to the same extent as healthy people. HD-sEMG-based topographic maps can serve as effective feedback training to restore motor control of the ankle. Long-term efficacy for improving motor function requires investigation through longitudinal studies.

The clinical effects of pulsed electromagnetic field therapy for the management of chronic ankle instability: a study protocol for a double-blind randomized controlled trial

BACKGROUND

Chronic ankle instability is associated with long-term neuromuscular deficits involving poor postural control and peroneal muscular impairment. Symptoms of chronic ankle instability hinder engagement in physical activity and undermine the patient's quality of life. Despite the existence of various treatment modalities, none has conclusively provided evidence of clinical effectiveness in counteracting neuromuscular deficits, such as arthrogenic muscle inhibition of the peroneal longus (PL). Pulse electromagnetic field therapy employed as an adjunct biophysical therapy can potentially improve stability by mitigating peroneal muscle weakness and by activating the peroneal muscle. We postulate that by combining standard care (muscle strengthening, balance training, and range of motion exercise) with pulse electromagnetic field therapy, postural control stability and peroneal muscle weakness will significantly improve.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled trial. A total of 48 adults with chronic ankle instability will be recruited and randomly allocated into either the intervention or control groups. The intervention group (n = 24) will receive active pulse electromagnetic field therapy and standard exercise training, while the control group (n = 24) will receive sham pulse electromagnetic field therapy and standard exercise training for 8 weeks. Primary and secondary outcomes will be evaluated at baseline, week 4, 8 as well as at 3-, 6-, and 12-month follow-up visits.

DISCUSSION

Chronic ankle instability is a common debilitating condition without a curative conservative treatment. Investigating different treatment modalities will be essential for improving rehabilitation outcomes in this clinical population. This study will investigate the effectiveness of pulsed electromagnetic field therapy on the functional and clinical outcomes in the chronic ankle instability population. This trial may demonstrate this non-invasive biophysical therapy to be an effective measure to help patients with CAI.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05500885. Registered on August 13, 2022.

Can Arthrogenic Muscle Inhibition Exist in Peroneal Muscles Among People with Chronic Ankle Instability? A Cross-sectional Study

BACKGROUND

Ankle sprains lead to an unexplained reduction of ankle eversion strength, and arthrogenic muscle inhibition (AMI) in peroneal muscles is considered one of the underlying causes. This study aimed to observe the presence of AMI in peroneal muscles among people with chronic ankle instability (CAI).

METHODS

Sixty-three people with CAI and another sixty-three without CAI conducted maximal voluntary isometric contraction (MVIC) and superimposed burst (SIB) tests during ankle eversion, then fifteen people with CAI and fifteen without CAI were randomly invited to repeat the same tests to calculate the test-retest reliability. Electrical stimulation was applied to the peroneal muscles while the participants were performing MVIC, and the central activation ratio (CAR) was obtained by dividing MVIC torque by the sum of MVIC and SIB torques, representing the degree of AMI.

RESULTS

The intra-class correlation coefficients were 0.77 (0.45-0.92) and 0.92 (0.79-0.97) for the affected and unaffected limbs among people with CAI, and 0.97 (0.91-0.99) and 0.93 (0.82-0.97) for the controlled affected and unaffected limbs among people without CAI; Significant group × limb interaction was detected in the peroneal CAR (p = 0.008). The CARs were lower among people with CAI in the affected and unaffected limbs, compared with those without CAI (affected limb = 82.54 ± 9.46%, controlled affected limb = 94.64 ± 6.37%, p < 0.001; unaffected limb = 89.21 ± 8.04%, controlled unaffected limb = 94.93 ± 6.01%, p = 0.016). The CARs in the affected limbs were lower than those in the unaffected limbs among people with CAI (p = 0.023). No differences between limbs were found for CAR in the people without CAI (p = 0.10).

CONCLUSIONS

Bilateral AMI of peroneal muscles is observed among people with CAI. Their affected limbs have higher levels of AMI than the unaffected limbs.

Individuals With Chronic Ankle Instability Show Abnormalities in Maximal and Submaximal Isometric Strength of the Knee Extensor and Flexor Muscles

BACKGROUND

It has been shown that chronic ankle instability (CAI) leads to abnormalities in neuromuscular control of more proximal joints than the ankle. Although strength of the hip and the ankle muscles has been largely investigated providing concordant results, limited evidence with contrasting results has been reported regarding knee extensor and flexor muscles.

PURPOSE

To investigate maximal and submaximal isometric muscle strength in individuals with CAI.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifteen participants with unilateral CAI and 15 healthy matched controls were recruited. To quantify maximal strength, peak forces were recorded during a maximal isometric voluntary contraction of knee extensor and flexor muscles at 30° and 90° of knee flexion and normalized by the body weight of each participant. At both angles, submaximal isometric contractions at 20%, 50%, and 80% of the maximal voluntary isometric contraction were performed to analyze strength steadiness, in terms of coefficient of variation, and strength accuracy, in terms of absolute error. During all the assessments, knee extensor and flexor muscle activation was recorded by means of surface electromyography.

RESULTS

Knee flexor maximal isometric strength was significantly lower in the injured limb of individuals with CAI in comparison with healthy controls at both 30° (0.15 ± 0.05 vs 0.20 ± 0.05; P < .05) and 90° (0.14 ± 0.04 vs 0.18 ± 0.05; P < .05). Knee extensor and flexor steadiness was significantly lower (higher coefficient of variation) in both the injured and the noninjured limbs of individuals with CAI in comparison with healthy individuals at 90° and at 30° for knee flexor steadiness of the injured limb. Knee extensor and flexor accuracy was lower (higher absolute error) in both the injured and noninjured limbs of individuals with CAI in comparison with healthy individuals, mainly at 30°, while at 90° it was lower only in the injured limb. No differences between the 2 groups were found for maximal isometric strength of knee extensor muscles, as well as for muscle activations.

CONCLUSION

Individuals with CAI show abnormalities in maximal and submaximal isometric strength of knee flexor muscles, and submaximal strength of the knee extensor muscles. Further studies should deeply investigate mechanisms leading to these abnormalities.

CLINICAL RELEVANCE

Rehabilitation interventions should consider abnormalities of neuromuscular control affecting joints more proximal than the ankle in individuals with CAI.

REGISTRATION

NCT05273177 (ClinicalTrials.gov identifier).

Exercise combined with electrical stimulation for the treatment of chronic ankle instability - A randomized controlled trial

PURPOSE

To compare the short, medium, and long-term effects of balance exercises combined with either peroneal neuromuscular electrical stimulation (NMES) or peroneal transcutaneous electrical nerve stimulation (TENS) on dynamic postural control and patient reported outcome measures (PROMs) in patients with chronic ankle instability (CAI).

METHODS

Thirty-four participants with CAI were randomly assigned to a 12-session home based exercise program combined with NMES (Ex-NMES) or TENS (Ex- TENS). Baseline postural control was tested with the modified Star Excursion Balance Test (mSEBT) and time to stabilization (TTS) after a single-leg drop-jump. The self-reported function was measured using the Cumberland Ankle Instability Tool (CAIT), the Identification of Functional Ankle Instability (IdFAI), and the Sports subscale of the Foot and Ankle Ability Measure (FAAMSport).

RESULTS

Both groups showed significant improvements in all self-reported outcome measures at the 12-month follow-up. Subjects in the Ex-NMES group had significantly better IdFAI (-4.2 [95% CI -8.1, -0.2]) and FAAMSport (13.7 [95% CI 2.2, 25.2]) scores at 6- and 12-month follow-up, respectively, compared to the Ex-TENS group. Medium to large between-group effect sizes were observed in self-reported functional outcomes and the mSEBT.

CONCLUSION

The consistent trend of improvement in self-reported functional outcomes when training is combined with NMES compared with training with TENS may indicate a potential benefit that should be further investigated as a treatment for patients with CAI.

Balance, strength and physical activity after ankle sprain: Comparison between children with chronic ankle instability and copers

OBJECTIVE

The aim of this study was to compare muscle strength, balance, and physical activity between children with chronic ankle instability and copers.

DESIGN

Cross-sectional study.

SETTING

Pediatric Physical Therapy laboratory.

PARTICIPANTS

Children aged between 7 and 12 years old from regular schools who had a history of unilateral ankle sprain.

MAIN OUTCOME MEASURES

Lower extremity strength, Static and dynamic standing balance, and Level of physical activity.

RESULTS

Fifteen children with chronic ankle instability and 15 copers were recruited. Demographic data showed no differences between group except for sex and the Cumberland Ankle Instability Tool-Youth (CAITY) score. Children with CAI had a significantly lower score during the standing long jump test (p < 0.05), poorer performance of single leg stance test (p < 0.001) and Y-Balance test in the anterior, posteromedial, and posterolateral directions (p < 0.05) when compared to copers. Total METs per week was significantly higher in the copers (p < 0.05).

CONCLUSION

Children with chronic ankle instability exhibited weaker lower limb strength, poorer static and dynamic standing balance, and participate in less physical activity compared to those in a coper group which may have future negative health consequences. Knowledge about the differences between the two groups may provide guidance for physical educators and physical therapists. (200 words).

Individuals with chronic ankle instability show altered regional activation of the peroneus longus muscle during ankle eversion

Individuals with chronic ankle instability (CAI) present muscular weakness and potential changes in the activation of the peroneus longus muscle, which likely explains the high recurrence of ankle sprains in this population. However, there is conflicting evidence regarding the role of the peroneus longus activity in CAI, possibly due to the limited spatial resolution of the surface electromyography (sEMG) methods (i.e., bipolar sEMG). Recent studies employing high-density sEMG (HD-sEMG) have shown that the peroneus longus presents differences in regional activation, however, it is unknown whether this regional activation is maintained under pathological conditions such as CAI. This study aimed to compare the myoelectric activity, using HD-sEMG, of each peroneus longus compartment (anterior and posterior) between individuals with and without CAI. Eighteen healthy individuals (No-CAI group) and 18 individuals with CAI were recruited. In both groups, the center of mass (COM) and the sEMG amplitude at each compartment were recorded during ankle eversion at different force levels. For the posterior compartment, the sEMG amplitude of CAI group was significantly lower than the No-CAI group (mean difference = 5.6% RMS; 95% CI = 3.4-7.6; p = 0.0001). In addition, it was observed a significant main effect for group (F1,32  = 9.608; p = 0.0040) with an anterior displacement of COM for the CAI group. These findings suggest that CAI alters the regional distribution of muscle activity of the peroneus longus during ankle eversion. In practice, altered regional activation may impact strengthening programs, prevention, and rehabilitation of CAI.

Advances in Diagnosis and Management of Lateral Ankle Instability: A Review of Current Literature

Lateral ankle sprains and instability are an increasingly identified pain point for patients, accounting for 20 to 25% of musculoskeletal injuries. Lateral ankle injuries are especially concerning given the propensity for patients to develop chronic lateral ankle instability and for the high risk of reinjury on an unstable ankle. With the complex articulation of the tibiofibular syndesmosis, subtalar, and talocrural joints, pinpointing ankle dysfunction remains difficult. Multiple reviews have evaluated management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Although multiple surgical options exist, many nonsurgical functional options have also been developed for patients that may help patients prevent the development of chronic lateral ankle instability. In recent times, many new options have come up, including in-office needle arthroscopy and continual advancements in diagnosis and our understanding of this difficult topic. Multiple reviews have evaluated the management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Given this, this review will help to highlight new diagnostic and nonsurgical therapeutic options for the management of lateral ankle instability.

Efficacy of resistance training with elastic bands compared to proprioceptive training on balance and self-report measures in patients with chronic ankle instability: A systematic review and meta-analysis

BACKGROUND

Proprioceptive training and resistance training are physiotherapy treatment methods for Chronic Ankle Instability (CAI).

OBJECTIVE

To compare the efficacy of proprioceptive training to resistance training with elastic bands for treating CAI as measured by the Star Excursion Balance Test (SEBT), the Foot and Ankle Ability Measure (FAAM), and the Cumberland Ankle Instability Tool (CAIT).

METHOD

Our systematic study and meta-analysis was based on the PICOS and PRISMA protocols. The PubMed, PEDro, and ScienceDirect databases were searched for randomized clinical trials on proprioceptive and resistance training. Risk of bias was assessed according to Cochrane guidelines and quality of evidence was reported using the Grading of Recommendations Assessment, Development, and Evaluation approach (GRADE).

RESULTS

Five studies involving 259 patients were included in the review. According to the findings of the meta-analysis, proprioceptive training was similarly effective with resistance training in SEBT and FAAM measures. Compared with resistance exercise, proprioceptive training demonstrated some benefits in CAIT scores (weighted mean difference [WMD] = -2.21, 95% CI = -4.05-0.36), but these intervention results were not clinically significant (MDC, MCID score >3 points).

CONCLUSION

Low-quality evidence from studies showed that neither of the interventions was superior on the SEBT or the FAAM scores in individuals with CAI because no clinically significant differences were found. More high-quality studies comparing the two interventions are needed to draw firm conclusions.

Ankle biomechanics of the three-step layup in a basketball player with chronic ankle instability

At present, the effects of chronic ankle instability (CAI) on the biomechanics of the ankle joint in the three-step layup of basketball players are not clear. This work aims to thoroughly investigate the impact of CAI on the biomechanical characteristics of the ankle during the execution of a three-step layup in basketball players. Thirty male basketball players were stratified into distinct groups-namely, a CAI group and a non-CAI group-comprising 15 individuals each, based on the presence or absence of CAI. Demographic attributes, including age, weight, height, and the Cumberland Ankle Instability Tool (CAIT) score, were subjected to rigorous statistical examination within both athlete cohorts. The research employed four Whistler 9281CA 3D force measuring platforms (Switzerland), recording at 1000 Hz, in conjunction with eight camera motion analysis systems (USA), functioning at a frequency of 200 Hz. The study recorded maximal plantarflexion angle, inversion angle, dorsiflexion angle, and peak ankle dorsiflexion moment across the subjects during the distinct phases of push-off, landing, and the ensuing landing period. The findings notably exhibited that within the context of the one-foot push-off phase, the maximum ankle inversion angle was notably diminished in the CAI group as contrasted with the non-CAI group, demonstrating statistical significance (t = - 3.006, P < 0.01). The CAI group exhibited a lesser alteration in ankle inversion angle compared to the non-CAI group. Notably, during the one-foot landing period, the CAI group demonstrated a significantly greater maximum ankle inversion angle in contrast to the non-CAI group (t = 8.802, P < 0.001). Furthermore, the CAI group displayed a substantially larger maximum dorsiflexion angle at the ankle joint compared to the non-CAI group (t = 2.265, P < 0.05). Additionally, the CAI group exhibited a prolonged peak time for ankle dorsiflexion moment as compared to the non-CAI group (t = - 2.428, P < 0.05). Collectively, the findings elucidated a reduction in the maximum ankle joint inversion angle during the one-foot push-off phase in individuals with CAI. Furthermore, increased maximum inversion angle and maximum dorsiflexion angle of the ankle joint were observed during the one-foot landing period, alongside a lengthening of the peak time of ankle dorsiflexion moment. These results contribute valuable insights into the selection of training methodologies for basketball players afflicted by CAI.

Decreased rate of torque development in ankle evertors for individuals with chronic ankle instability

BACKGROUND

Individuals with chronic ankle instability have decreased peak torque during maximum voluntary contraction in ankle evertors/invertors, and hip abductors. However, it is unclear whether individuals with chronic ankle instability and/or copers demonstrate decreased rate of torque development in ankle evertors/invertors, and hip abductors.

METHODS

54 university-aged participants (18 chronic ankle instability, 18 copers, and 18 controls) performed three maximal isometric contractions for ankle evertors and invertors, and hip abductors. Rate of torque development was defined as the linear slope of the torque-time curve during the first 200 ms of each contraction and compared between the three groups using a one-way analysis of variance (α = 0.05).

FINDINGS

The chronic ankle instability group showed 38.1% less rate of torque development than the coper (P = 0.03 and d = 0.84) and 37.1% than the control groups (P = 0.03 and d = 1.03) in the ankle evertors. For the hip abductors, there were moderate effects between the chronic ankle instability group and the copers (P = 0.06 and d = 0.70), and control groups (P = 0.06 and d = 0.75).

INTERPRETATIONS

The observed between-groups differences in rate of torque development indicate that restoring rate of torque development after lateral ankle sprain may be important to reduce risk of reinjury and development of chronic ankle instability. Clinicians should consider the rate of torque development in the ankle evertors and hip abductors during rehabilitation chronic ankle instability patients.

Functional effects of arthroscopic modified Broström procedure on lateral ankle instability: A pilot study

BACKGROUND

This study aims to assess the mechanical and functional effects of the arthroscopic modified Broström procedure (AMBP) on patients with lateral ankle instability.

METHODS

Eight patients with unilateral ankle instability treated with AMBP and eight healthy subjects were recruited. Healthy subjects, preoperative and one-year postoperative patients were assessed using outcome scales and the Star Excursion Balance Test (SEBT) for dynamic postural control. One-dimensional statistical parametric mapping was performed to compare ankle angle and muscle activation curve during stair descent.

RESULTS

The patients with lateral ankle instability showed good clinical outcomes and increased posterior lateral reach during the SEBT after the AMBP (p = 0.046). The medial gastrocnemius activation after initial contact was reduced (p = 0.049), and the peroneal longus activation after initial contact was promoted (p = 0.014).

CONCLUSION

The AMBP has functional effects of promoting dynamic postural control and peroneal longus activation within one year of follow-up, which can benefit patients with functional ankle instability. However, the medial gastrocnemius activation was unexpectedly reduced post operation.

A randomized controlled trial comparing rehabilitation with isokinetic exercises and Thera-Band strength training in patients with functional ankle instability

BACKGROUND

Although muscle strength training is a prevalent treatment for patients with functional ankle instability (FAI), previous investigations on the efficacy have yielded conflicting results.

OBJECTIVE

This study aims to compare the efficacy of 6-week isokinetic strength training and Thera-Band strength training on improving ankle strength, dynamic balance ability, and function in individuals with FAI.

METHODS

Fifty-two FAI patients were randomized into two treatment groups: an isokinetic strength training (IST, n = 26) group and a Thera-Band resistance training (TBT, n = 26) group. The IST group engaged in isokinetic concentric strength training with inversion, eversion, dorsiflexion, and plantar flexion, whereas the TBT group engaged in progressive resistance training with Thera-Band three times per week for six weeks. Before and after the training, an isokinetic concentric strength test of the involved ankle joint, Star Excursion Balance Test (SEBT), and Cumberland Ankle Instability Tool (CAIT) function assessment were performed.

RESULTS

After six weeks of intervention, the strength of inversion and eversion was significantly improved in both the IST and TBT groups (p < 0.05), with the IST group exhibiting a significant (p < 0.05) improvement when compared to the TBT group. The SEBT and CAIT results were significantly (p < 0.05) improved in the IST group compared to the TBT group.

CONCLUSIONS

The six-week of isokinetic strength training is more effective than the Thera-Band progressive resistance training in improving the physical function of FAI patients.

CLINICAL TRIAL REGISTRATION NUMBER

This randomized controlled clinical trial has been registered in the China Clinical Trial Registry (ChiCTR2100044444) https://www.google.com/search?client=firefox-b-d&q=ChiCTR2100044444.

Surgical management of concurrent lateral ankle instability and osteochondral lesions of the talus increases dynamic sagittal ankle range of motion

PURPOSE

A biomechanical study, in which imaging modalities are used to strictly include patients with concurrent lateral ankle instability (LAI) and osteochondral lesions of the talus (OLT), is needed to demonstrate the static and dynamic ankle range of motion (ROM) restriction in these patients, and determine whether ankle ROM restriction can be corrected postoperatively.

METHODS

Eight patients with concurrent LAI and OLT treated with the arthroscopic modified Broström procedure and microfracture were recruited from June 2019 to January 2020. Patients were assessed using outcome scales, static ankle ROM, and a stair descent gait analysis for dynamic ankle ROM, a day prior to surgery and one year postoperatively. Eight healthy subjects were assessed using the same modalities upon recruitment. Operative outcomes and variables during stair descent were documented and compared among the preoperative, postoperative, and healthy groups. A curve analysis, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalised time series.

RESULTS

The functional outcomes of patients with concurrent LAI and OLT were significantly worse than those of healthy subjects preoperatively, but were partially improved postoperatively. Patients had decreased static and dynamic ROM preoperatively, and static ROM did not significantly increase postoperatively (preoperative, 39.6 ± 11.3; postoperative, 44.9 ± 7.1; healthy, 52.0 ± 4.6; p = 0.021). Patients showed increased dynamic ankle flexion ROM (preoperative, 41.2 ± 11.6; postoperative, 53.6 ± 9.0; healthy, 53.9 ± 3.4; p = 0.012) postoperatively, as well as increased peroneus longus activation (preoperative, 35.8 ± 12.0; postoperative, 55.4 ± 25.1; healthy, 71.9 ± 13.4; p = 0.002) and muscle co-contraction of the tibialis anterior and peroneus longus (preoperative, 69.4 ± 23.4; postoperative, 88.4 ± 9.3; healthy, 66.2 ± 18.1; p = 0.045).

CONCLUSIONS

Patients with concurrent LAI and OLT had decreased static and dynamic sagittal ankle ROM and altered neuromuscular activation patterns. The arthroscopic modified Broström procedure and microfracture did not significantly increase the static sagittal ankle ROM. However, the dynamic sagittal ankle ROM, peroneus longus activation and muscle co-contraction of the tibialis anterior and peroneus longus increased postoperatively.

LEVEL OF EVIDENCE

IV.

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

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

Concomitant osteochondral lesions of the talus affect the stair descent biomechanics of patients with chronic ankle instability: A pilot study

BACKGROUND

Previous studies on the kinematics of patients with chronic ankle instability (CAI) that did not incorporate MRI and arthroscopic assessment could not differentiate between patients with CAI without osteochondral lesion of the talus (OLT) and patients with CAI and OLT and have thus presented contradictory results.

RESEARCH QUESTION

This study aimed to investigate the kinematic and electromyographic differences between patients with and without OLT.

METHODS

Sixteen subjects with CAI (eight without OLT and eight with OLT confirmed through MRI and arthroscopic assessment) and eight healthy subjects underwent gait analysis in a stair descent setting. The three groups' patient-reported outcomes; ankle joint range of motion in flexion, inversion and rotation; and muscle activation of the peroneus, tibialis anterior, and gastrocnemius during a gait cycle were analyzed and compared. A curve analysis, namely, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalized time series.

RESULTS

The patients with and without OLT had no difference in patient-reported outcomes. The maximal ankle plantarflexion of the patients without OLT and the healthy subjects was significantly larger than that of patients with OLT (p = 0.005). The maximal ankle internal rotation of patients without OLT was significantly larger than that of patients with OLT (p = 0.048). The peroneal activation during 0-6% of the gait cycle of patients with OLT was reduced compared with the healthy subjects.

SIGNIFICANCE

Patients with CAI and OLT and patients with CAI without OLT have no difference in patient-reported outcomes, but patients with OLT can be differentiated using the post-initial-contact peroneal activation deficit and the restriction of ankle plantarflexion and internal rotation during stair descent. These variables can be utilized to monitor the function of patients with CAI and their possibility of developing OLT.

Understanding Athletic Trainers' Knowledge, Intervention, and Barriers Toward Arthrogenic Muscle Inhibition

CONTEXT

Arthrogenic muscle inhibition (AMI) is a common neurophysiological response to joint injury. While athletic trainers (ATs) are constantly treating patients with AMI, it is unclear how clinicians are using the available evidence to treat the condition.

OBJECTIVE

To investigate ATs' general knowledge, clinical practice, and barriers for treating AMI.

METHODS

A cross-sectional web-based survey was utilized. The survey was distributed to a random sample of 3000 ATs from the National Athletic Trainers' Association and through social media. 143 board certified ATs (age: 34.6 [10.3] y; experience: 11.7 [9.8] y) from various clinical settings and educational backgrounds were included in the analysis.

RESULTS

One hundred one respondents were able to correctly identify the definition of AMI. The majority of these respondents correctly reported that joint effusion (n = 95, 94.1%) and abnormal activity from joint receptors (n = 91, 90.1%) resulted in AMI. Of the 101 respondents, only 58 (57.4%) reported using disinhibitory interventions to treat AMI. The most frequently used evidence supported interventions were transcutaneous electrical nerve stimulation (n = 38, 65.5%), neuromuscular electrical stimulation (n = 33, 56.9%), and focal joint cooling (n = 25, 43.1%). The interventions used correctly most often based on current evidence were neuromuscular electrical stimulation (n = 29/33, 87.9%) and transcutaneous electrical nerve stimulation (n = 26/38, 68.4%). Overall, difficulty quantifying AMI (n = 62, 61.24%) and lack of education (n = 71, 76.2%) were most frequently perceived as barriers. Respondents that did not use disinhibitory interventions perceived lack of experience treating AMI, understanding the terminology, and access to therapeutic modalities more often than the respondents that reported using disinhibitory interventions.

CONCLUSION

Further education about concepts and treatment about AMI is warranted for ATs. Continued understanding of ATs' clinical practice in regard to AMI may help identify gaps in athletic training clinical education.

Tensiomyographic Neuromuscular Response of the Peroneus Longus and Tibialis Anterior with Chronic Ankle Instability

This study aimed to investigate the muscle contractile response of the peroneus longus (PL) and tibialis anterior (TA) in groups with and without chronic ankle instability (CAI) using tensiomyography. Twenty-three adults, 12 with CAI and 11 healthy participants, participated in this study. All subjects underwent a tensiomyographic assessment of the PL and TA to measure delay time, contraction time and maximal displacement. The ankle evertor and invertor normalized peak torques, maximum work done and muscle thickness of the PL and TA were calculated. The delay time and contraction time of the PL in the CAI side were significantly higher than those in the healthy group (p < 0.05); however, no significant difference could be detected in the TA between groups. Furthermore, there was no significant difference in the normalized peak torques, maximum work done and muscle thickness of the PL and TA between groups. The CAI side demonstrated a delayed muscle contractile response of the PL when compared with the healthy group although there was no difference in muscle strength and muscle size. Clinicians should consider the muscle contractile response of the PL for rehabilitation of the ankle evertor with CAI.

A review of the role of lower-leg strength measurements in ankle sprain and chronic ankle instability populations

Lower-leg strength training has been a cornerstone of ankle sprain and chronic ankle instability (CAI) rehabilitation and an important consideration for return-to-play in athletes with ankle injuries. The purpose of this literature review is to offer a contemporary, evidence-based overview of the role of ankle strength measurements as they relate to acute ankle sprain rehabilitation and those who have developed CAI. A comprehensive 20-year scan of the relevant research was conducted to assist us in providing this important update for clinicians and biomechanists working with patients and subjects with acute and chronic ankle sprains. While variability exists with measurement devices and methodology, strength assessment remains a critical component of ankle sprain and CAI treatment schemes. Helpful tips on obtaining and processing the most accurate strength assessments for lower-leg musculature are presented.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

THE RELATIONSHIP BETWEEN SINGLE LEG BALANCE AND ISOMETRIC ANKLE AND HIP STRENGTH IN A HEALTHY POPULATION

Background

Impaired balance and strength commonly affect athletes with conditions like chronic ankle instability (CAI). Yet, clinical research surrounding the relationship between balance, strength, and CAI is still growing. Deeper investigation of these relationships is warranted to better inform clinical practice patterns when managing athletes with balance deficits.

Purpose

To investigate the relationship between single leg balance, ankle strength, and hip strength in healthy, active adults.

Study Design

Observational study.

Methods

Forty healthy participants (age 23.7 ± 4.9 years) were assessed for static balance, using a modified version of the Balance Error Scoring System (mBESS), as well as isometric strength of ankle and hip musculature via handheld dynamometry. Pearson's correlations were used to analyze relationships between balance and strength measures. Paired t-tests were utilized to compare dominant and non-dominant limb performance.

Results

Negligible to low, negative correlations were found between balance scores and hip extension strength (r = -0.24 to -0.38, p<0.05). High, positive correlations were found between ankle and hip strength measures (r = 0.75 to 0.84, p<0.05). When comparing dominant to non-dominant limbs, only minimal differences were noted in ankle eversion strength (mean difference = 6.0%, p<0.01) and hip extension strength (mean difference = 5.5%, p<0.01).

Conclusions

Minimal relationships were identified between static balance and isometric ankle and hip strength. Comparison of dominant and non-dominant limbs suggests that clinicians should expect relative symmetry in balance and strength in healthy adults. Thus, asymmetries found during clinical examination should raise suspicion of specific impairments that may lead to dysfunction.

Level of Evidence

2c.

Is chronic ankle instability associated with impaired muscle strength? Ankle, knee and hip muscle strength in individuals with chronic ankle instability: a systematic review with meta-analysis

OBJECTIVE

Determine whether impairments in lower limb muscle strength exist in individuals with chronic ankle instability (CAI) compared with uninjured controls.

DESIGN

Systematic review with meta-analysis.

DATA SOURCE

A comprehensive search of PubMed, Cochrane, CINAHL, Web of Science and EMBASE electronic databases from inception to 10 February 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Cross-sectional and case-control studies were included if they objectively measured lower limb muscle strength in individuals with CAI compared with controls. Risk of bias and quality of included studies were assessed. Data of included studies were extracted, and meta-analysis was conducted where appropriate.

RESULTS

12 397 unique studies were identified, of which 20 were included and 16 were eligible for meta-analysis. Reviewed studies clearly described the aim/hypothesis and main outcome measure, but most lacked sample size calculation and assessor blinding. Meta-analyses showed individuals with CAI had lower eccentric and concentric evertor strength (30 and 120°/s; Nm; standardised mean difference (SMD) between -0.73 and -0.95), eccentric invertor strength (60 and 120°/s; both Nm and Nm/kg; SMD between -0.61 and -1.37), concentric invertor strength (60 and 120°/s; Nm; SMD=-0.7) and concentric knee extensor strength (SMD=-0.64) compared with control participants. Ankle eccentric dorsiflexor strength was not different between groups. Although pooling was not possible, data from three separate studies indicated that hip flexor, abductor and external rotator strength, but not hip adductor and extensor strength, was lower in individuals with CAI than in control participants.

CONCLUSION

Individuals with CAI have ankle inversion and eversion strength deficits. Our data also point to differences between individuals with CAI and controls in hip and knee strength. These elements of the kinetic chain should be evaluated by clinicians who rehabilitate individuals with CAI.

PROSPERO REGISTRATION NUMBER

CRD42016037759.

Arthroscopic suture-tape internal bracing is safe as arthroscopic modified Broström repair in the treatment of chronic ankle instability

PURPOSE

The aim of the study was to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients. The hypothesis of the presented study is that suture-tape augmentation technique has comparable clinical and radiological outcomes with arthroscopic Broström repair technique.

METHODS

Sixty-one consecutive patients with chronic ankle instability were operated between 2012 and 2016 randomized to 2 groups. First group was composed of 31 patients whom were operated using an arthroscopic Broström repair technique (ABR) and second group was composed of 30 Patients whom were operated using arthroscopic lateral ligaments augmentation using suture-tape internal bracing (AST). At the end of total follow-up time, all patients were evaluated clinically using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiological evaluation was performed using anterior drawer and varus stress radiographs with standard Telos device in 150 N. Talar tilt angles and anterior talar translation were measured both preoperatively, 1 year postoperatively and at the final follow-up.

RESULTS

Preoperative total FAOS scores for ABR and AST groups were 66.2 ± 12 and 67.1 ± 11, respectively. Postoperative Total FAOS scores for ABR and AST groups were 90.6 ± 5.2 and 91.5 ± 7.7, respectively. There was no statistical difference in between 2 groups both pre- and postoperatively (n.s). According to FAAM, sports activity scores of ABR and AST groups were 84.9 ± 14 and 90.4 ± 12 at the final follow-up, which showed that AST group was significantly superior (p = 0.02). There were no significant differences in preoperative and postoperative stress radiographs between the two groups. Mean operation time for AST and ABR groups were 35.2 min and 48.6 min, respectively, which shows statistically significantly difference (p < 0.05). There was no significant difference in recurrence rate of instability between to operation techniques (n.s).

CONCLUSIONS

Arthroscopic lateral ligament augmentation using suture tape shows comparable clinical outcomes to arthroscopic Broström repair in the treatment of chronic ankle instability at intermediate-term follow-up time. Arthroscopic lateral ligament augmentation using suture tape has a significant superiority in the terms of less operation time and no need for cast or brace immediate after surgery which allows early rehabilitation. It also has a significant superiority in the terms of FAAM scores at sports activity. However, there was no difference during daily life.

LEVEL OF EVIDENCE

II.

Ankle strength is not strongly associated with postural stability in patients awaiting surgery for chronic lateral ankle instability

PURPOSE

(1) To describe ankle strength and postural stability in patients with chronic lateral ankle instability and (2) to analyse the correlation between deficits in ankle strength and postural stability.

METHODS

Results of preoperative isokinetic and balance tests in 203 patients whose contralateral ankle was normal were retrospectively reviewed. Isokinetic peak torque values of eversion and inversion at 2 angular velocities (30°/s and 120°/s) were measured in the injured and normal ankles. In the balance test, the percent differences of 3 actual scores (overall, anterior-posterior, and medial-lateral) between the injured and normal ankles were calculated. Additional statistical analyses were performed to evaluate weakness of ankle strength, postural stability deficits, and their correlation.

RESULTS

Significant differences in 4 peak torque values and 4 relative peak torque values (peak torque/body weight) were found between the injured and normal ankles. All 8 values were significantly lower in the injured ankles. Weakness was severe during inversion and at 30°/s. In the balance test, 49 subjects (24.1%) had significant deficits in postural stability and 109 (53.7%) had favourable results. No strong association was found between weakness of ankle strength and deficits in postural stability.

CONCLUSIONS

Strength measurement alone is insufficient to evaluate preoperative functional deficits, and other functional tests are required to measure postural stability. The results of this study provide further evidence for a rehabilitation programme consisting of proprioceptive training as well as strengthening. The proprioceptive training must be an integral part of the rehabilitation programme in addition to strengthening exercise.

LEVEL OF EVIDENCE

Case series, Level IV.

In vivo kinematics of functional ankle instability patients during the stance phase of walking

BACKGROUND

Previous studies showed functional ankle instability (FAI) patients have morphological ligamentous abnormality, despite having no apparent joint laxity.

RESEARCH QUESTION

Whether tibiotalar and subtalar joints hypermobility exists in FAI patients during stance phase of walking, remains controversial.

METHODS

Ten unilateral FAI patients, ten unilateral lateral ankle sprain (LAS) copers and ten healthy controls were included. A dual fluoroscopy imaging system was utilized to capture the fluoroscopic images of tibiotalar and subtalar joint during the stance phase of walking. Kinematic data from six degrees of freedom were calculated utilizing a solid modeling software. The range of motion and joint excursions about six degrees of freedom were compared among the three groups. The correlations between range of motion and Cumberland Ankle Instability Tool (CAIT) scores were assessed utilizing the Spearman's correlation coefficient (r).

RESULTS

During the stance phase, the FAI patients and LAS copers showed larger tibiotalar anterior/posterior translation than the healthy controls (FAI patients, p = .013; LAS copers, p = .002). The FAI patients also showed significantly larger lateral/medial translation (p = .035) and inversion/eversion rotation (p = .003) of subtalar joints than healthy controls. By contrast, the subtalar joints of the LAS copers were not different from those of the healthy controls in the lateral/medial translation (p = .459) and inversion/eversion rotation (p = .091). CAIT scores were negatively correlated with range of motion.

SIGNIFICANCE

During the stance phase of walking, FAI patients showed significantly larger hypermobility of subtalar joints than healthy controls, contrary to the LAS copers. These findings justify the utilization of dual fluoroscopy imaging system to detect joint hypermobility in FAI patients. Treatment for FAI patients may require stabilization of the subtalar joint.

An Updated Model of Chronic Ankle Instability

Lateral ankle sprains (LASs) are among the most common injuries incurred during participation in sport and physical activity, and it is estimated that up to 40% of individuals who experience a first-time LAS will develop chronic ankle instability (CAI). Chronic ankle instability is characterized by a patient's being more than 12 months removed from the initial LAS and exhibiting a propensity for recurrent ankle sprains, frequent episodes or perceptions of the ankle giving way, and persistent symptoms such as pain, swelling, limited motion, weakness, and diminished self-reported function. We present an updated model of CAI that aims to synthesize the current understanding of its causes and serves as a framework for the clinical assessment and rehabilitation of patients with LASs or CAI. Our goal was to describe how primary injury to the lateral ankle ligaments from an acute LAS may lead to a collection of interrelated pathomechanical, sensory-perceptual, and motor-behavioral impairments that influence a patient's clinical outcome. With an underpinning of the biopsychosocial model, the concepts of self-organization and perception-action cycles derived from dynamic systems theory and a patient-specific neurosignature, stemming from the Melzack neuromatrix of pain theory, are used to describe these interrelationships.

COMPARISON of LOWER QUARTER Y-BALANCE TEST SCORES for FEMALE COLLEGIATE VOLLEYBALL PLAYERS BASED on COMPETITION LEVEL, POSITION, and STARTER STATUS

BACKGROUND

The Lower Quarter Y-Balance Test (YBT-LQ) is used by sports medicine professionals to measure an athlete's dynamic balance. The YBT-LQ is used by clinicians to track recovery during clinical rehabilitation, assess an athlete's readiness to return to sport after injury, and to identify athletes potentially at-risk for a time-loss injury. Normative data for the YBT-LQ are lacking for female collegiate volleyball (VB) players. The purpose of this study was to examine preseason YBT-LQ scores and their relationships to level of competition, starter status, player position, and prior lower quadrant (i.e., low back and lower extremities) injury history.

METHODS

One-hundred thirty-four female collegiate VB players (mean age = 19.3 ± 1.1 years) representing athletes from three levels of competition (D II = 32, D III = 77, NAIA = 25) participated in this study. Athletes reported their prior injury history and performed the YBT-LQ testing protocol.

RESULTS

NAIA and D III athletes demonstrated significantly greater reach measures on the YBT-LQ than D II athletes in several directions. Starters demonstrated significantly greater reach measures in five out of eight reach directions. Liberos/defensive specialists/setters demonstrated significantly greater posterolateral and composite reach measures bilaterally. There was no difference in reach measures based on prior history of lower quadrant (low back and lower extremities) injury.

CONCLUSION

This study provides normative data for YBT-LQ in female collegiate volleyball players. The data presented in this report may be used by coaches and rehabilitation professionals when evaluating dynamic balance in healthy volleyball players and by clinicians to compare an injured athlete's recovery to norms.

LEVEL OF EVIDENCE

3b.