Individuals with chronic ankle instability compensate for their ankle deficits using proximal musculature to maintain reduced postural sway while kicking a ball

Isometric and isokinetic hip strength in males with chronic ankle instability and its relationship with dynamic balance and self-reported instability

OBJECTIVES

To investigate isometric and isokinetic hip strength as well as dynamic balance in males with chronic ankle instability (CAI) and explore potential associations between hip strength, dynamic balance, and self-reported instability.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Fifty male participants (25 with CAI and 25 healthy controls).

MAIN OUTCOME MEASURES

Hip isometric and isokinetic torque normalized to body weight, Lower Quarter Y-balance Test (YBT-LQ), the Polish version of The Cumberland Ankle Instability Tool (CAIT-PL).

RESULTS

Significant differences were observed only in the hip isometric abductors/adductors strength ratio (p = 0.034, ES = 0.65), which was lower in the CAI group. CAI participants showed reduced dynamic balance in posterolateral reach (p = 0.006, ES = 0.92) and composite score of YBT-LQ (p = 0.012, ES = 0.91). There was a moderate positive correlation between dynamic balance and hip abductors strength during posteromedial (r = 0.40, p = 0.049) and posterolateral (r = 0.40, p = 0.048) YBT-LQ reaches, and isometric hip abductors strength moderately positively correlated with self-reported instability (r = 0.46, p = 0.021) in the CAI group.

CONCLUSION

Males with CAI exhibit deficits in frontal plane hip isometric strength, specifically in the hip abductor/adductor ratio, while no deficits were observed in isokinetic strength. The relationships between hip abductors strength, dynamic balance, and self-reported ankle instability may suggest the importance of hip abductors isometric strength for functional outcomes in CAI-patients.

Comparing the Effects of Progressive Balance and Hip Strengthening Rehabilitation in Individuals With Chronic Ankle Instability

CONTEXT

Chronic ankle instability (CAI) is associated with motor-behavioral and sensory-perceptual impairments, including reduced balance performance, hip strength, and ankle function, and increased disablement, and injury-related fear. Progressive balance training (BAL) and hip strengthening (HIP) can both improve balance and function, but their comparative effects are unknown. Our objective was to compare the effects of progressive BAL and HIP on balance, hip strength, and patient-reported outcomes in those with CAI.

METHODS

Forty-five individuals with CAI volunteered for this randomized control study. Participants were randomly allocated to BAL, HIP, and control (CON) groups (n = 15 per group). BAL and HIP each participated in 8-week interventions while CON did not. Participants' involved limbs underwent testing of patient-reported outcomes (Foot and Ankle Ability Measure [FAAM-ADL, FAAM-S], modified Disablement in the Physically Active Scale [mDPA], Tampa Scale of Kinesiophobia-11 [TSK-11], Fear-Avoidance Beliefs Questionnaire [FABQ], and Self-Efficacy of Balance Scale [SEBS]), Star Excursion Balance Test (SEBT), and isometric hip strength (extension [EXT], abduction [ABD], and external rotation [ER]) before and after the intervention. Multiple imputation was used for missing data. Multivariate repeated-measures analyses of variance analyzed effects of the interventions.

RESULTS

A significant group × time interaction existed for psychosocial outcomes (P = .008), but not for balance (P = .159), strength (P = .492), or ankle function and disability (P = .128). Time main effects existed for balance (P = .003), strength (P < .001), function and disability (P < .001), and psychosocial outcomes (P = .006). BAL significantly improved in SEBT, EXT, ABD, and all patient-reported outcomes. HIP significantly improved in EXT, ABD, ER, FAAM-S, mDPA, FABQ, and SEBS.

CONCLUSIONS

Balance training and hip strengthening can both improve motor-behavioral and sensory-perceptual impairments in individuals with CAI; however, balance training remains the most effective option for clinicians.

Comparing virtual reality and balance training effects on postural strategies during ball kicking in soccer players with chronic ankle instability

The study aimed to determine if virtual reality (VR) games could enhance neuromuscular control and improve anticipatory and compensatory strategies in ball-kicking for soccer players. It was a single-blind randomized clinical trial involving 32 male soccer players with chronic ankle instability. Participants were divided into two groups: VR games and balance training. The primary outcomes measured were the amplitude and onset time of muscle activities in the peroneus longus (PL), tibialis anterior (TA), soleus (SOL), rectus femoris (RF), biceps femoris (BF), and gluteus medius (GM) in three phases: anticipatory (APA), compensatory 1 (CPA1), and compensatory 2 (CPA2). Secondary outcomes included the Y-balance test and perceived ankle instability. Evaluations were done before and after treatment. Both groups underwent 12 sessions, three times a week, each lasting 60 min. In the VR games group, there was a significant decrease in SOL muscle activity amplitude during CPA2 after treatment (P = 0.033), and the BF muscle activated earlier (P = 0.043). The balance training group showed a significant increase in GM muscle activity amplitude during APA (P = 0.037) and earlier activation of the GM muscle post-treatment (P = 0.050). Additionally, this group demonstrated significant decreases in RF activity during CPA1 and PL activity in CPA1 and CPA2 (P = 0.048, P = 0.030, and P = 0.050, respectively). Between-group comparisons indicated a significant increase in GM muscle activity amplitude during APA and a reduction during CPA1 for the balance training group compared to the VR games group (P = 0.050 and P = 0.012, respectively). Both groups showed significant reductions in perceived ankle instability (VR group: P = 0.002, balance training group: P < 0.001) and improvements on the Y-balance test (VR group: P < 0.021, balance training group: P < 0.033), although neither group showed significant improvement in the anterior direction. Overall, both VR games and balance training effectively enhanced perceived ankle stability and dynamic postural control, with neither approach showing clear superiority. Both groups exhibited improvements in muscle activation timing, though neither outperformed the other. While both interventions led to increased muscle activity amplitude during the anticipatory and compensatory phases, the balance training group achieved somewhat greater improvements. These results suggest that both VR games and balance training are effective rehabilitation approaches for chronic ankle instability, providing comparable benefits for enhancing ankle stability and neuromuscular control, without a distinct advantage of one over the other.RCT Registration: On the Iranian Registry of Clinical Trials (IRCT20230124057197N1). Registration date: 30/06/2023.

Balance in obese and normal weight pregnant women: A longitudinal study

INTRODUCTION

Pregnancy's physiological changes and weight gain can decrease balance control, increasing the risk of falls and impacting quality of life. The effect of obesity on balance control in pregnant women needs further investigation.

OBJECTIVE

Investigate the effect of obesity during pregnancy on center of pressure (COP) control under sensory disturbances at different gestational age.

METHODS

The COP (95% ellipse area, mean velocity and total length) of 23 pregnant women classified as normal weight (CG: n = 12) and obese (OG: n = 11) was evaluated at three gestational-age week times (T1 = 16th, T2 = 24th, T3 = 32nd week) on a force platform on standing position (SP) and under three disturbances: 1) visual disturbance (eyes closed), 2) proprioceptive disturbance (over an unstable surface) and, 3) vestibular disturbance (head movement). A mixed ANOVA (3 repeated measures vs. 2 groups) and LSD post-hoc was applied to examine main effects and interactions. Effect sizes were assessed using generalized eta squared (η2).

RESULTS

As main effect, in SP, COP area increased from T2 to T3 for both groups (P = 0.021, η2 = 0.193). One interaction was observed, under visual disturbance, the area increased from T2 to T3 only in the CG group (P = 0.020, η2 = 0.195).

CONCLUSION

The progression of pregnancy negatively impacts postural stability throughout its course. Visual disturbance only affected the balance of the CG. Hence, obesity combined with pregnancy does not appear to alter COP variables.

Gluteus Medius for Individuals with Chronic Ankle Instability: Assessing Muscle Activity

Emerging evidence has suggested that gluteus medius (GM) muscle activity may be critical for functional performance in individuals with chronic ankle instability (CAI). This study aimed to systematically review the literature to determine whether there are differences in GM muscle activity between individuals with and without CAI. A comprehensive search in PubMed, Embase, Cochrane Library, Web of Science, EBSCO, and PEDro databases was undertaken from the year of inception to 10 June 2024. Studies that investigated GM muscle activity during physical activities in healthy controls or copers and individuals with CAI were included. The quality assessment was conducted using the Newcastle-Ottawa Quality scale (NOS). After review, forty studies (1840 participants) were included; NOS scoring for the included studies ranged from 5/9 to 9/9 stars. GM activity was reported for seven activities: walking (14 studies), stance-transition (four studies), jump-landing (13 studies), perturbation (six studies), balance (four studies), cutting (three studies), and other functional exercises (seven studies). The outcome measures selected to examine each task varied across studies, and electromyography (EMG) results were inconsistent. Overall, although the quality of the available studies was generally high, there were substantial methodological differences, and the activity of GM muscles in CAI participants compared to controls was equivocal. A consensus on standardization of GM muscle activity assessment reporting should be established to guide future studies.

Cross-education effects of balance training in individuals with chronic ankle instability

BACKGROUND

Individuals with chronic ankle instability (CAI) often experience deficits in balance, hip strength, and lumbopelvic stability. Unilateral balance training can lead to improved balance in the contralateral limb, but it is unknown if similar cross-education effects occur for hip strength and lumbopelvic stability. Our purpose was to determine if unilateral balance training improved balance, hip strength, and lumbopelvic stability of the contralateral limbs in individuals with CAI.

METHODS

Using a randomized-controlled trial, 30 individuals with CAI were separated into control (CON) and balance (BAL). Uninvolved limbs underwent testing at baseline and post-intervention. We tested balance with the star excursion balance test in anterior (SEBT-ANT), posterolateral (SEBT-PL), and posteromedial (SEBT-PM) directions. We tested hip strength with a handheld dynamometer in extension (EXT), abduction (ABD), and external rotation (ER). We tested lumbopelvic stability with a unilateral hip bridge. After baseline, BAL completed an 8-week balance training program on the involved limb. CON did not participate in the intervention. Two-way repeated measures ANOVAs analyzed effects of group and time on each outcome. Cohen's d effect sizes analyzed each group's changes from baseline to post-intervention.

RESULTS

Eleven participants discontinued the study (5 CON, 6 BAL) before completion. There were significant group-by-time interactions for SEBT-PL (P = 0.03) and hip bridge (P = 0.03). BAL had moderate to large effect sizes for SEBT-PM (d = 0.69 [-0.06,1.41]), SEBT-PL (d = 0.87 [0.10,1.60]), EXT (d = 0.73 [-0.02,1.45]), ABD (d = 0.79 [0.03,1.51]), and hip bridge (d = 0.83 [0.07,1.55]).

CONCLUSION

A balance training program for limbs with CAI led to contralateral improvements in balance, hip strength, and lumbopelvic stability.

Evaluation of Trunk Muscle Strength and Endurance: A Comparison of Women With and Without Chronic Ankle Instability

Objective

The purpose of this study was to compare the strength and endurance of the trunk muscles in women with chronic ankle instability (CAI) compared with those who do not have CAI.

Methods

Sixty-two women were assigned into 2 equal groups of 31; group A included women with CAI and group B included healthy women. Peak torques per body weight of the trunk extensors and flexors were measured using a Biodex System 3 Isokinetic Dynamometer. McGill core endurance tests (prone bridge, right side bridge, left side bridge, trunk flexion, and horizontal back extension) were administered to assess trunk muscle endurance. Statistical analysis using 1-way between-subjects multivariate analysis of variance was performed.

Results

No significant differences in peak torques per body weight strength ratios of trunk extensors and flexors between the 2 tested groups (P > .05) were found. Similarly, no significant difference was found in the trunk muscle endurance between the 2 tested groups (P > .05).

Conclusion

No statistically significant differences were observed in the strength and endurance of the trunk muscle between women with CAI and healthy women.

Biomechanical and Physiological Variables in Dynamic and Functional Balance Control during Single-Leg Loading in Individuals with Chronic Ankle Instability: A Scoping Review

BACKGROUND

This scoping review summarizes the tasks and outcomes in dynamic and functional balance assessments of individuals with chronic ankle instability, focusing on the physiological and biomechanical characteristics.

METHOD

A comprehensive literature search was conducted in PubMed, Scopus, Web of Science, and MEDLINE databases in September 2023 and revised in April 2024. Studies evaluating dynamic and functional balance in chronic ankle instability using clinical tests, as well as biomechanical and physiological outcomes, were included.

RESULTS

Out of 536 publications, 31 met the screening criteria. A history of ankle sprain was the main focus of the inclusion criteria (28 articles, 90%). The star excursion balance test, emphasizing maximum reach distance, was the most common quantitative task (12 articles, 66%). Physiological data mainly came from electromyography studies (7 articles, 23%), while biomechanical variables were often assessed through center of pressure studies using force plates (17 articles, 55%).

CONCLUSIONS

The preferred quantitative clinical assessment was the star excursion balance test, focusing on normalized reach outcomes. Qualitative functional balance assessments emphasize landing activities and center of pressure displacement. Electromyography is commonly used to analyze the tibialis anterior and peroneus longus muscles. However, there is a lack of qualitative data on dynamic balance control, including morphological characteristics and the center of mass adaptation.

Analysis of stress response distribution in patients with lateral ankle ligament injuries: a study of neural control strategies utilizing predictive computing models

BACKGROUND

Ankle sprains are prevalent in sports, often causing complex injuries to the lateral ligaments. Among these, anterior talofibular ligament (ATFL) injuries constitute 85%, and calcaneofibular ligament (CFL) injuries comprise 35%. Despite conservative treatment, some ankle sprain patients develop chronic lateral ankle instability (CLAI). Thus, this study aimed to investigate stress response and neural control alterations during landing in lateral ankle ligament injury patients.

METHOD

This study recruited twenty individuals from a Healthy group and twenty CLAI patients performed a landing task using relevant instruments to collect biomechanical data. The study constructed a finite element (FE) foot model to examine stress responses in the presence of laxity of the lateral ankle ligaments. The lateral ankle ligament was modeled as a hyperelastic composite structure with a refined representation of collagen bundles and ligament laxity was simulated by adjusting material parameters. Finally, the validity of the finite element model is verified by a high-speed dual fluoroscopic imaging system (DFIS).

RESULT

CLAI patients exhibited earlier Vastus medialis (p < 0.001) and tibialis anterior (p < 0.001) muscle activation during landing. The FE analysis revealed that with laxity in the ATFL, the peak von Mises stress in the fifth metatarsal was 20.74 MPa, while with laxity in the CFL, it was 17.52 MPa. However, when both ligaments were relaxed simultaneously, the peak von Mises stress surged to 21.93 MPa. When the ATFL exhibits laxity, the CFL is subjected to a higher stress of 3.84 MPa. Conversely, when the CFL displays laxity, the ATFL experiences a peak von Mises stress of 2.34 MPa.

CONCLUSION

This study found that changes in the laxity of the ATFL and the CFL are linked to shifts in metatarsal stress levels, potentially affecting ankle joint stability. These alterations may contribute to the progression towards CLAI in individuals with posterolateral ankle ligament injuries. Additionally, significant muscle activation pattern changes were observed in CLAI patients, suggesting altered neural control strategies post-ankle ligament injury.

Lower limb squat biomechanics and select clinical measures in chronic ankle instability

BACKGROUND

Individuals with chronic ankle instability often present with clinical and biomechanical abnormalities, however squat biomechanics have not been investigated. The purpose of this study was to compare select clinical assessments and squat biomechanics between individuals with and without chronic ankle instability.

METHODS

Fifteen individuals with chronic ankle instability and a matched control group were studied. A weight-bearing dorsiflexion lunge test, foot posture, and an in-line half-kneeling motor control test for core stability were assessed. Lower limb 3D bilateral and unilateral squat biomechanics were captured. Groups, limbs and squat tasks were compared using an alpha of 0.05.

FINDINGS

Individuals with chronic ankle instability had less static weight-bearing dorsiflexion and failed the core stability test more frequently, but did not differ in foot morphology compared to the controls. When squatting, those with chronic ankle instability demonstrated reduced peak ankle dorsiflexion angles and moments in the involved limb (p < 0.04) during single limb squats and had interlimb differences in ankle dorsiflexion angle as well as hip and knee kinetics (p < 0.04) during double limb squats. In those with chronic ankle instability, there was less overall motion, but higher kinetic demands in single limb versus double leg squatting (p < 0.03).

INTERPRETATION

Individuals with chronic ankle instability had impaired weight-bearing dorsiflexion and showed impaired core stability more often, which accompanied altered squatting mechanics in both variations. Within the limbs with chronic ankle instability, single limb squats showed lesser kinematic demands but higher kinetic demands than double limb squatting.

Anticipatory postural control in adaptation of goal-directed lower extremity movements

Skilled football players can adapt their kicking movements depending on external environments. Predictive postural control movements, known as anticipatory postural adjustments (APAs), are needed preceding kicking movements to precisely control them while maintaining a standing posture only with the support leg. We aimed to clarify APAs of the support leg in the process of adaptation of goal-directed movements with the lower limb. Participants replicated ball-kicking movements such that they reached a cursor, representing a kicking-foot position towards a forward target while standing with the support leg. APAs were observed as the centre of pressure of the support leg shifted approximately 300 ms in advance of the onset of movement of the kicking foot. When the cursor trajectory of the kicking foot was visually rotated during the task, the kicking-foot movement was gradually modified to reach the target, indicating adaptation to the novel visuomotor environment. Interestingly, APAs in the mediolateral direction were also altered following the change in kicking-foot movements. Additionally, the APAs modified more slowly than the kicking-foot movements. These results suggest that flexible changes in predictive postural control might support the adaptation of goal-directed movements of the lower limb.

Three-dimensional ankle kinematics of the full gait cycle in patients with chronic ankle instability: A case-control study

Objectives

The ankle kinematic characteristics of chronic ankle instability (CAI) at different gait phases and dimensions were not directly and overall explained. These characteristics have yet to be established. This study aimed to observe ankle kinematic changes of CAI, and explore their mechanisms, at different gait phases and dimensions in full gait cycle.

Methods

A three-dimensional (3D) motion capture system measured the 3D ankle movements of 53 individuals with CAI (meanage = 25.11 ± 6.01years, meanheight = 170.77 ± 7.80 cm, meanmass = 64.28 ± 9.28 kg) and 53 healthy controls (meanage = 24.66 ± 6.32 years, meanheight = 169.98 ± 9.00 cm, meanmass = 63.11 ± 9.62 kg) during barefoot walking overground at a self-selected speed. Once the acquisition results were processed with visual 3D software, the kinematics data were exported, and the eight phases of the gait cycle were identified.

Results

As compared with the control group, individuals with CAI displayed a significantly smaller plantarflexion in toe off (P = 0.049, Cohen's d = 0.387), a significantly increased inversion in heel strike (P = 0.007, Cohen's d = 0.271) and initial swing (P = 0.035, Cohen's d = 0.233), mid-swing (P = 0.019, Cohen's d = 0.232) and end-swing (P = 0.021, Cohen's d = 0.214), and significantly smaller eversion in mid stance（P = 0.010, Cohen's d = 0.288）and heel off (P = 0.033, Cohen's d = 0.089). Significant between-group differences in ankle kinematics were observed in the sagittal and frontal planes, but not in the horizontal plane, during walking.

Conclusion

When walking, patients with CAI have altered sagittal- and frontal-plane kinematics during different stance and swing phases. These kinematic changes require multi-dimensional, dynamic, continuous functional assessment and specialized rehabilitation intervention.

Effects of 12 weeks of Tai Chi Chuan intervention on the postural stability and self-reported instability in subjects with functional ankle instability: Study protocol for a randomized controlled trial

Background

Tai Chi Chuan (TCC) is a physical activity modality that originated in China and is now widely popular around the world. Although there are a series of articles reporting that TCC can improve balance and other functional symptoms in a variety of populations, including the elderly, patients with stroke, and patients with Parkinson's disease, its efficiency has not been scientifically and methodically evaluated in subjects with functional ankle instability (FAI). Moreover, there is no literature directly comparing TCC and conventional balance training (CBT) interventions for FAI. The objective of this study is to investigate the comparative effects of TCC intervention and CBT protocols in improving postural balance and subjective instability feelings in patients with FAI.

Methods

This study will be a single-center, parallel group, randomized controlled trial. Sixty-eight patients with FAI will be included and randomly assigned in a 1:1 ratio to either an intervention group (n =34) or a control group (n = 34). The participants in the intervention group will complete 12 weeks of TCC intervention (40 min/time, 3 times/week for 12 weeks) on the basis of health education treatment. The control group will receive health education and 36 CBT sessions during a 12-week period. Outcome measures include postural stability and self-reported feelings of instability at baseline, after the end of the intervention, and 3-month follow-up. The postural stability assessment of patients with FAI will be detected by performing static and dynamic postural tests, which will be carried out through a specific balance platform (TecnoBody ProKin). Self-reported feelings of instability will be assessed by Cumberland Ankle Instability Tool (CAIT), American Orthopedics Foot and Ankle Society's Ankle–Hindfoot Evaluation Scale (AOFAS-AHES), and the MOS item Short Form Health Survey (SF-36).

Discussion

This trial will demonstrate whether a 12-week TCC intervention positively affects postural stability and self-reported outcomes in patients with FAI. At the same time, the superiority of its clinical efficacy will also be compared with that of CBT. This study may also help to redefine the value of traditional Chinese exercises in the treatment of chronic ankle instability.

Clinical trial registration

Chinese Clinical Trial Registry: ChiCTR2100041790. Registration date: 22 March 2021. http://www.chictr.org.cn/edit.aspx?pid=119501&htm=4.

Can therapeutic exercises improve proprioception in chronic ankle instability? a systematic review and network meta-analysis

OBJECTIVE

To assess exercise therapies that aim to enhance proprioception in individuals with chronic ankle instability (CAI).

DATA SOURCES

Five databases (PubMed, Embase, Cochrane Library, Web of Science, and EBSCO) were searched in October 2021.

STUDY SELECTION

Randomized controlled trials involving exercise therapy conducted on individuals with CAI were included.

DATA EXTRACTION

Data were extracted by two independent reviewers using a standardized form. Methodological quality and risk of bias were assessed with the PEDro scale.

DATA SYNTHESIS

The end-trial weighted mean difference and standard deviations were analyzed, and the synthetic value for the improvement in error scores of ankle joint position sense (JPS) in multiple directions was evaluated.

RESULTS

Eleven trials with 333 participants were eligible for inclusion in this systematic review and were included in the Network Meta-Analysis. Foot and ankle muscle strengthening exercise showed the highest probability of being among the best treatments (surface under the cumulative ranking (SUCRA)=74.6%). The next two were static balance exercise only (SUCRA=67.9%) and corrective exercise (SUCRA=56.1%). The SUCRA values of proprioceptive exercise, dynamic balance exercise only, aquatic exercise, rehabilitation exercise with brace, mixed static/dynamic balance exercise, and control were at relatively low levels, and scored at 49.6%, 48.8%, 47.8%, 47.7%, 44.0%, and 13.5%, respectively.

CONCLUSIONS

Foot and ankle muscle strengthening exercise may have a good effect when used to improve JPS in individuals with CAI. Probably, the more complex balance exercise intervention becomes, the less effective the proprioceptive outcome.

PROSPERO REGISTRATION NUMBER

CRD42021240331.

Corticospinal activity during a single-leg stance in people with chronic ankle instability

PURPOSE

The aim of the study was to determine whether corticospinal excitability and inhibition of the tibialis anterior during single-leg standing differs among individuals with chronic ankle instability (CAI), lateral ankle sprain copers, and healthy controls.

METHODS

Twenty-three participants with CAI, 23 lateral ankle sprain copers, and 24 healthy control participants volunteered. Active motor threshold (AMT), normalized motor-evoked potential (MEP), and cortical silent period (CSP) were evaluated by transcranial magnetic stimulation while participants performed a single-leg standing task.

RESULTS

Participants with CAI had significantly longer CSP at 100% of AMT and lower normalized MEP at 120% of AMT compared to lateral ankle sprain copers (CSP_100%: p = 0.003; MEP_120%: p = 0.044) and controls (CSP_100%: p = 0.041; MEP_120%: p = 0.006).

CONCLUSION

This investigation demonstrate altered corticospinal excitability and inhibition of the tibialis anterior during single-leg standing in participants with CAI. Further research is needed to examine the effects of corticospinal maladaptations to motor control of the tibial anterior on postural control performance in those with CAI.

Electromiographic activity during single leg jump in adolescent athletes with chronic ankle instability: A pilot study

Chronic ankle instability (CAI) is a common condition in athletes, which can alter the muscular activity of lower limb during jump. The objective of the study was to verify the magnitude of activation, onset timing and order of recruitment of the proximal and local muscles to the ankle of young athletes with CAI during a single leg vertical jump. Thirty-seven athletes were selected and divided into: 1) CAI group and 2) control group. An electromyographic evaluation was performed during the jump on force plate. The muscles evaluated were the proximal muscles - gluteus medius (GMed), rectus femoris (RF) and local ankle muscles - tibialis anterior (TA), peroneus longus (PL) and lateral gastrocnemius (LG). In propulsion, the CAI group showed early activation of all evaluated muscles, when compared to control group (p = 0.05). No diferences were found between groups concerning magnitude of electromyographic signal and order of muscle recruitment. During landing, an increase in magnitude of the electromyographic signal of TA in the CAI group was observed and no diferences were found between groups for onset activation and order of muscle recruitment. The results can be applied to athletes' rehabilitation through specific neuromuscular control exercises, such as reaction time and local and proximal joint stabilization to optimize muscle performance and injury incidence. Therefore, in the single leg vertical jump athletes with CAI presented higher activation of the TA in the landing and an early activation of the GMed, RF, TA, PL and LG in propulsion in relation to control group.

Disrupted somatosensory input alters postural control strategies during the Star Excursion Balance Test (SEBT) in healthy people

BACKGROUND

Chronic adaptations, including persistent sensorimotor deficits, remain in individuals with a history of ankle instability, resulting in altered postural control strategies during functional tasks such as gait, running, or landing. However, we do not know the contribution of the altered somatosensory input on postural control strategies during a dynamic balance task such as the Star Excursion Balance Test (SEBT).

RESEARCH QUESTION

The purpose of this study was to characterize postural control strategies with and without disrupted somatosensory input during a dynamic balance task in people without chronic ankle sprain.

METHODS

This study was a crossover study design. Twenty healthy young adults (10 men, 10 women; age = 23.9 ± 3.0 years, height = 174.2 ± 7.4 cm, mass = 71.2 ± 16.7 kg) performed the posteromedial reach test during the SEBT while standing on the ground and on foam. We measured the maximum reach distance (MRD); joint angles of the ankle, knee, hip, and trunk in the sagittal, frontal, and transverse planes; and position and displacement of the center of mass (COM) and center of pressure (COP) during the posteromedial reach task.

RESULTS

The MRD was shorter when standing on the foam than on the ground (p < 0.001). There was a condition by phase interaction for ankle dorsiflexion; tibia internal rotation; and trunk flexion (p < 0.001; p = 0.03; p = 0.01, respectively). The COM and COP were positioned more laterally on the foam (p < 0.001). The COM and COP anterior-posterior displacements were more anterior during the foam condition (p = 0.017).

SIGNIFICANCE

By using a foam pad to disrupt somatosensory information, participants demonstrated altered strategies to control the joint kinematics, COM, and COP, as a function of posteromedial distance. Ankle and trunk movement strategies may influence the posteromedial reach distance. This model may simulate changes that occur with chronic ankle instability.

Muscle activations during functional tasks in individuals with chronic ankle instability: a systematic review of electromyographical studies

BACKGROUND

It has been reported that individuals with chronic ankle instability (CAI) show motor control abnormalities. The study of muscle activations by means of surface electromyography (sEMG) plays a key role in understanding some of the features of movement abnormalities.

RESEARCH QUESTION

Do common sEMG activation abnormalities and strategies exists across different functional movements?

METHODS

Literature review was conducted on PubMed, Web-of-Science and Cochrane databases. Studies published between 2000 and 2020 that assessed muscle activations by means of sEMG during any type of functional task in individuals with CAI, and used healthy individuals as controls, were included. Methodological quality was assessed using the modified Downs&Black checklist. Since the methodologies of different studies were heterogeneous, no meta-analysis was conducted.

RESULTS

A total of 63 articles investigating muscle activations during gait, running, responses to perturbations, landing and hopping, cutting and turning; single-limb stance, star excursion balance task, forward lunges, ball-kicking, y-balance test and single-limb squatting were considered. Individuals with CAI showed a delayed activation of the peroneus longus in response to sudden inversion perturbations, in transitions between double- and single-limb stance, and in landing on unstable surfaces. Apparently, while walking on ground there are no differences between CAI and controls, walking on a treadmill increases the variability of muscles activations, probably as a "safety strategy" to avoid ankle inversion. An abnormal activation of the tibialis anterior was observed during a number of tasks. Finally, hip/spine muscles were activated before ankle muscles in CAI compared to controls.

CONCLUSION

Though the methodology of the studies herein considered is heterogeneous, this review shows that the peroneal and tibialis anterior muscles have an abnormal activation in CAI individuals. These individuals also show a proximal muscle activation strategy during the performance of balance challenging tasks. Future studies should investigate whole-body muscle activation abnormalities in CAI individuals.

Effect of Functional Rehabilitation on Performance of the Star Excursion Balance Test Among Recreational Athletes With Chronic Ankle Instability: A Systematic Review

OBJECTIVE

To determine (1) the effectiveness of rehabilitation for chronic ankle instability as measured by the Star Excursion Balance Test (SEBT) and (2) the relative efficacy and the long-term effects of these rehabilitation interventions.

DATA SOURCES

Ten electronic databases were searched (2009-2019).

STUDY SELECTION

Included articles were randomized controlled trials in English investigating recreational athletes aged ≥18 years with chronic ankle instability. At least 1 functional rehabilitation intervention had to be included and the SEBT test (or the modified version) used as an outcome measure.

DATA EXTRACTION

Two researchers (L.A., O.N.) extracted data regarding participant demographics; intervention characteristics; trial size; and results at baseline, postintervention, and at follow-up, where appropriate.

DATA SYNTHESIS

A systematic review and narrative synthesis was conducted. Methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool and the van Tulder scale. The review was registered with PROSPERO (ID: 164468). Ten studies (n=368), 2 high-quality, 1 moderate-quality, and 7 low-quality, were included in the review. Interventions included balance training, strength training, vibration training, and mixed training. Results suggest that rehabilitation of chronic ankle instability that includes wobble board exercises (average percentage change: 14.3%) and hip strengthening exercises (average percentage change: 12.8%) are most effective. Few studies compared different types of rehabilitation for chronic ankle instability. However, improvements on the SEBT suggest that a rehabilitation program focusing on wobble board training and hip strengthening performed 3 times weekly for 4-6 weeks is the optimal rehabilitation program to improve dynamic postural control in recreational athletes with chronic ankle instability.

CONCLUSIONS

Few studies directly compared different rehabilitation interventions, and there was limited long-term follow-up; therefore, the relative efficacy of different rehabilitation programs remains unclear. However, it seems that rehabilitation of chronic ankle instability should include proprioceptive and strengthening exercises of relatively short duration.

Differences in the locomotion biomechanics and dynamic postural control between individuals with chronic ankle instability and copers: a systematic review

An empirical consensus of differences between chronic ankle instability (CAI) individuals and copers (individuals who sprained ankle once and without recurrent symptoms or injury) has not been reported. This study aimed to review the locomotion biomechanics and dynamic postural control between these two populations. Database of ScienceDirect, PubMed and Web of Science was used to search ('chronic ankle instability' OR 'ankle instability') AND ('ankle sprain' OR 'coper*') until 30 November 2020. Articles that made a comparison about changes in biomechanical parameters between Copers and CAI individuals during locomotor or functional tasks were included in this review. Twenty-three articles met the inclusion criteria. CAI individuals exhibited an increased hip flexion to maintain stability, suggesting the adopted hip strategy compared to copers during landing. Dorsiflexion angle and ankle frontal displacement increased considerably compared to copers, which might increase risks of lateral ankle sprain injury. CAI individuals reduced the ankle displacements in the sagittal plane and indicated worse performance of Star Excursion Balance Test in the posterior-lateral direction compared to copers. Identified motion deficits or altered motion strategies provide opportunities for targeted intervention and scheme after index sprain or in CAI individuals.

Does Strength Training for Chronic Ankle Instability Improve Balance and Patient-Reported Outcomes and by Clinically Detectable Amounts? A Systematic Review and Meta-Analysis

OBJECTIVE

Strength training as a form of exercise therapy has long been used to maintain or promote strength, but its effectiveness as a treatment intervention in chronic ankle instability (CAI) is not fully understood. The purpose of this study was to evaluate the effects of strength training compared with no exercise and neuromuscular control training on balance and self-reported function in people with CAI.

METHODS

Eight databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, CNKI, and WanFang) were searched in June 2020. Randomized controlled trials (RCTs) involving strength training conducted on individuals with CAI were included. Data were extracted by 2 independent reviewers using a standardized form. Methodological quality and risk of bias were assessed by using the PEDro Scale. In addition, the GRADE evaluation system (Grading of Recommendations Assessment, Development and Evaluation) was used to determine the strength of evidence. A total of 554 studies were initially screened, resulting in a final selection of 11 RCTs involving 428 participants, and 8 RCTs were included in the final meta-analysis. Compared with no exercise, strength training demonstrated some benefits in the Star Excursion Balance Test (anterior: weighted mean difference [WMD] = 2.39, 95% CI = 0.60-4.18; posteromedial: WMD = 3.30, 95% CI = 0.24-6.35; posterolateral: WMD = 2.97, 95% CI = 0.37-5.57), but these intervention results did not reach the minimal detectable change values.

CONCLUSION

Available evidence showed that, compared with controls, strength training did not produce any minimal detectable changes on Star Excursion Balance Test or Foot and Ankle Ability Measure scores in individuals with CAI. Clinicians should use strength training cautiously for improving balance and symptoms in CAI.

IMPACT

The results of this study may have an impact on selecting effective physical therapy interventions for managing symptoms associated with CAI.

Transient characteristics of body sway during single-leg stance in athletes with a history of ankle sprain

BACKGROUND

The role of the measurements of postural stability in the context of screening for ankle sprain risk is still equivocal. Transient characteristics of body sway have been suggested as an alternative or an improvement to traditional whole-trial analyses.

RESEARCH QUESTION

Are transient characteristics of body sway sensitive to the history of ankle sprain?.

METHODS

The assessment of 30-s single-leg body sway was performed on a group of 93 athletes from basketball, soccer, tennis and running who reported at least 1 ankle sprain in the last 12 months, while a group of 244 athletes from the same disciplines served as a control group without an ankle sprain reported for the same time period. We considered the mean center-of-pressure (CoP) velocity, CoP amplitude and CoP frequency. In addition to traditional whole-trial variables, we calculated the relative differences between the 1 st and the 2nd (DIF_21) and 1 st and 3rd (DIF_31) 10-s time intervals within the whole trial.

RESULTS

The indexes of transient characteristics of body sway (i.e., the DIF_21 and DIF_31) were in trivial or weak correlations with whole-trial variables (all r ≤ 0.29). Athletes with ankle sprain history exhibited smaller CoP ML velocity (p = 0.002) and larger CoP ML frequency (p = 0.001). In the injured group, the injured leg exhibited lower total and medial-lateral (ML) CoP velocity (p = 0.005-0.040), as well as lower CoP ML amplitude (p = 0.002) and higher CoP ML frequency (p = 0.010). The transient characteristics of body sway (DIF_21 and DIF_31) were very similar between the groups and between the injured and uninjured legs.

SIGNIFICANCE

Transient characteristics of body sway do not appear to differentiate the athletes with and without a history of ankle sprain. Further research is needed to confirm if the transient characteristics of body sway could be used for detection of risk of falls in older adults or assessment of athletic performance.

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 effect of chronic ankle instability on muscle activations in lower extremities

BACKGROUND/PURPOSE

Muscular reflex responses of the lower extremities to sudden gait disturbances are related to postural stability and injury risk. Chronic ankle instability (CAI) has shown to affect activities related to the distal leg muscles while walking. Its effects on proximal muscle activities of the leg, both for the injured- (IN) and uninjured-side (NON), remain unclear. Therefore, the aim was to compare the difference of the motor control strategy in ipsilateral and contralateral proximal joints while unperturbed walking and perturbed walking between individuals with CAI and matched controls.

MATERIALS AND METHODS

In a cross-sectional study, 13 participants with unilateral CAI and 13 controls (CON) walked on a split-belt treadmill with and without random left- and right-sided perturbations. EMG amplitudes of muscles at lower extremities were analyzed 200 ms after perturbations, 200 ms before, and 100 ms after (Post100) heel contact while walking. Onset latencies were analyzed at heel contacts and after perturbations. Statistical significance was set at alpha≤0.05 and 95% confidence intervals were applied to determine group differences. Cohen's d effect sizes were calculated to evaluate the extent of differences.

RESULTS

Participants with CAI showed increased EMG amplitudes for NON-rectus abdominus at Post100 and shorter latencies for IN-gluteus maximus after heel contact compared to CON (p<0.05). Overall, leg muscles (rectus femoris, biceps femoris, and gluteus medius) activated earlier and less bilaterally (d = 0.30-0.88) and trunk muscles (bilateral rectus abdominus and NON-erector spinae) activated earlier and more for the CAI group than CON group (d = 0.33-1.09).

CONCLUSION

Unilateral CAI alters the pattern of the motor control strategy around proximal joints bilaterally. Neuromuscular training for the muscles, which alters motor control strategy because of CAI, could be taken into consideration when planning rehabilitation for CAI.

Peak Forces and Force Generating Capacities of Lower Extremity Muscles During Dynamic Tasks in People With and Without Chronic Ankle Instability

People with chronic ankle instability (CAI) exhibit neuromuscular deficits. However, no study has investigated deficits in forces or force-generating capacities of individual muscles in people with CAI during dynamic tasks. Therefore, the purpose of this study was to estimate and compare peak forces and force-generating capacities of individual muscles during dynamic tasks in people with CAI and healthy controls (CON). Eleven people with CAI and eleven CON performed landing, anticipated cutting, and unanticipated cutting as motion capture, force plate, and electromyography data were recorded. A musculoskeletal model was used to estimate the force and force-generating capacity of lower extremity muscles. People with CAI exhibited greater gluteus maximus force and force-generating capacity than CON during all tasks. In addition, people with CAI exhibited greater force-generating capacity of the vastii muscles than CON during the unanticipated cutting task. These findings suggest that, during dynamic tasks, people with CAI exhibit a neuromuscular control strategy that is characterised by differences in peak forces and force-generating capacities of proximal muscles, which may allow them to compensate for previously described deficits in distal muscles.

Effects of a lower limb muscular fatigue on posture-movement interaction during a lower limb pointing task

PURPOSE

The aim of the present study was to investigate the effects of muscular fatigue on the interaction between posture and movement during a lower limb pointing task.

METHODS

Participants (n = 16), aged 18-30 years, kicked a ball toward a target in four conditions of fatigue: No muscular fatigue (NF), fatigue in the kicking (FM) or postural limb (FP) alone, and fatigue in both limbs (FMP). The mean amplitude and speed of the centre of foot pressure (CoP) and centre of mass (CoM) displacements were estimated through a force platform and an optoelectronic system, respectively. In addition, surface electromyography (EMG) of the biceps femoris, rectus femoris, medial gastrocnemius, and peroneus longus was recorded to investigate the anticipatory postural adjustments (APAs).

RESULTS

Muscular fatigue yielded a decreased kicking accuracy (p < 0.001) and an increased time to perform the movement (p < 0.001), mainly during the backswing motion. In addition, significant increases in the mean amplitude and speed of the CoP and CoM displacement were found in the anteroposterior (AP) and mediolateral (ML) axes (ps < 0.001), especially when both limbs were fatigued. The EMG analysis confirmed that fatigue modified the way APAs were generated. During fatigue, postural muscle activity increased, but was delayed with respect to movement onset (ps < 0.001). This pattern of response was more consistent when both limbs were fatigued (p < 0.001).

CONCLUSION

The present results suggested an additive effect of fatigue and a functional adaptation and subsequent decrease in the overall variability of APAs, indicating that postural and motor processes are interdependent.

Effects of 12 Weeks of Tai Chi Intervention in Patients With Chronic Ankle Instability: A Randomized Controlled Trial

CONTEXT

Tai Chi is a physical activity modality which is widely practiced over the world. The effectiveness of Tai Chi on postural control and balance has been described in older population, but until recently there are no studies that include patients with chronic ankle instability.

OBJECTIVES

The aim of this study was to evaluate the effectiveness of 12 weeks of Tai Chi intervention on dynamic balance and self-reported instability in patients with chronic ankle instability.

STUDY DESIGN

A randomized controlled trial was carried out.

SETTING

University physical therapy facility.

PARTICIPANTS

Fifty-two participants were allocated to an intervention group (n = 26) based on Tai Chi training or a control group (n = 26) who received no intervention.

INTERVENTION

The participants completed 12 weeks of Tai Chi intervention (1 h session/2 times per week) or no intervention in the control group.

MAIN OUTCOME MEASURES

Outcome measures included postural control and self-reported instability feeling assessed by the Star Excursion Balance Test and the Cumberland Ankle Instability Tool, respectively.

RESULTS

There was observed significant improvement in all Star Excursion Balance Test reach distances (anterior [F = 6.26, P < .01]; posteromedial [F = 9.58, P < .01], and posterolateral [F = 8.42, P < .01]) in the Tai Chi group with no change in the control group (P < .01). The intervention group demonstrated significant improvement on self-reported instability feeling assessed by the Cumberland Ankle Instability Tool questionnaire (F = 21.36, P < .01).

CONCLUSION

The obtained results suggested that 12 weeks of Tai Chi intervention have positive effects on postural control and self-reported instability feeling in patients with chronic ankle instability.

Altered movement strategy of chronic ankle instability individuals with postural instability classified based on Nyquist and Bode analyses

BACKGROUND

The aim of the current study was to assess movement strategies during a single leg balance in chronic ankle instability individuals with unstable postural control strategy identified by Nyquist and Bode analyses in conjunction with sample entropy.

METHODS

Thirty-three participants with self-reported chronic ankle instability and 22 healthy controls performed single-leg eyes closed static balance trials. The sagittal and frontal plane kinematics in the lower extremity and trunk as well as center of pressure trajectories were recorded during three, 20-second trials. The Nyquist and Bode stability analyses, which classify center of pressure waveforms as stable based on the resulting gain and phase margins, were performed to identify the presence of postural control deficits. Sample entropy was implemented to analyze movement strategies during the task.

FINDINGS

Based on the Nyquist and Bode stability analyses, we included 19 out of 33 chronic ankle instability participants with unstable postural control strategy and 16 out of 22 controls with stable postural control strategy in the final analyses. Chronic ankle instability participants demonstrated a significantly lower sample entropy value in sagittal and frontal plane trunk kinematics and sagittal plane hip kinematics compared to the controls. No between-group differences existed in other kinematic measures.

INTERPRETATION

The lower sample entropy values in participants with chronic ankle instability indicates that those with postural control deficits may increase reliance on the trunk and hip joint contributions to the maintenance of postural control, reflecting changes in the sensorimotor constraints on movement patterns during the task.

Changes in Spinal and Corticospinal Excitability in Patients with Chronic Ankle Instability: A Systematic Review with Meta-Analysis

The objective of this systematic review with meta-analysis was to determine alterations in spinal and corticospinal excitability of ankle muscles in patients with chronic ankle instability (CAI) compared to uninjured controls. Independent researchers performed comprehensive literature searches of electronic databases and included studies that compared groups with and without CAI and investigated neural excitability with Hoffmann reflex (H-reflex) and/or transcranial magnetic stimulation (TMS). A fixed-effect meta-analysis was conducted to determine group differences for (1) soleus and fibularis maximal H-reflex (Hmax)/maximal M-wave (Mmax)-ratios, and (2) soleus and fibularis longus cortical motor thresholds (CMTs). Seventeen studies were included in the current meta-analysis. They showed that the Hmax/Mmax-ratios of the soleus and the fibularis longus in the CAI group were significantly lower than those in the uninjured control group (soleus: d = −0.41, p < 0.001; fibularis longus: d = −0.27, p = 0.04). There was no evidence for changes in the CMT. This systematic review is the first to demonstrate evidence that patients with CAI present decreased spinal reflex excitability in the soleus and fibularis longus. However, there is no evidence of changes in supraspinal excitability when considering only the CMT. The latter result needs to be interpreted with caution as all except one study demonstrate some changes at the supraspinal level with CAI.

Bilateral spatiotemporal postural control impairments are present in participants with chronic ankle instability

OBJECTIVES

This study evaluated center-of-pressure (COP) and time-to-boundary (TTB) measures of postural control during a Lateral Step-Down Test in participants with chronic ankle instability (CAI).

DESIGN

Cohort study.

SETTING

Biomechanics laboratory.

PARTICIPANTS

Physically active adults with CAI (n = 15) and matched controls (n = 15).

MAIN OUTCOME MEASURES

Traditional COP and TTB measures of postural control were computed in the medial/lateral (ML) and anterior/posterior (AP) directions.

RESULTS

No significant results were found for the traditional COP measures (p > 0.05). The CAI group exhibited a lower TTB ML absolute minimum on their affected limb compared to the matched limb of the control group (p < 0.001). Additionally, on average the CAI group displayed significantly lower TTB ML mean of minima (p = 0.004) and TTB standard deviation of minima in the ML (p < 0.001) and AP directions (p = 0.002) regardless of limb.

CONCLUSIONS

Sensorimotor impairments associated with CAI negatively alter spatiotemporal postural control and may cause a maladaptive reorganization of centrally mediated motor control strategies that results in bilateral postural control deficits during the Lateral Step-Down Test. In addition, traditional COP measures did not reveal any postural control deficits suggesting that a spatiotemporal analysis should be used when assessing postural control in participants with CAI.

Postoperative Treatment of Distal Radius Fractures Using Sensorimotor Rehabilitation

Background  Sensorimotor and specifically proprioception sense has been used in rehabilitation to treat neurological and joint injuries. These feedback loops are not well understood or implemented in wrist treatment. We observed a temporary sensorimotor loss, following distal radius fractures (DRF) that should be addressed postsurgery. Purpose  The purpose of this prospective therapeutic study was to compare the outcomes of patients following surgery for DRF treated using a sensorimotor treatment protocol with those patients treated according to the postoperative standard of care. Patients and Methods  Patients following surgery for DRF sent for hand therapy were eligible for the study. Both the evaluation and treatment protocols included a comprehensive sensorimotor panel. Patients were randomized into standard and standard plus sensorimotor postoperative therapy and were evaluated a few days following surgery, at 6 weeks, and 3 months postsurgery. Results  Sixty patients following surgery were randomized into the two treatment regimens. The initial evaluation was similar for both groups and both demonstrated significant sensorimotor deficits, following surgery for DRF. There was documented sensorimotor and functional improvement in both groups with treatment. The clinical results were better in the group treated with the sensorimotor-proprioception protocol mostly in the wrist; however, not all of the differences were significant. Conclusion  Patients after surgery for DRF demonstrate significant sensorimotor deficits which may improve faster when utilizing a comprehensive sensorimotor treatment protocol. However, we did not demonstrate efficacy of the protocol in treating proprioceptive deficits. Further study should include refinement of functional outcome evaluation, studying of the treatment protocol, and establishment of sensorimotor therapeutic guidelines for other conditions. Level of Evidence This is a level II, therapeutic study.

Kinetic Compensations due to Chronic Ankle Instability during Landing and Jumping

INTRODUCTION

Skeletal muscles absorb and transfer kinetic energy during landing and jumping, which are common requirements of various forms of physical activity. Chronic ankle instability (CAI) is associated with impaired neuromuscular control and dynamic stability of the lower extremity. Little is known regarding an intralimb, lower-extremity joint coordination of kinetics during landing and jumping for CAI patients. We investigated the effect of CAI on lower-extremity joint stiffness and kinetic and energetic patterns across the ground contact phase of landing and jumping.

METHODS

One hundred CAI patients and 100 matched able-bodied controls performed five trials of a landing and jumping task (a maximal vertical forward jump, landing on a force plate with the test leg only, and immediate lateral jump toward the contralateral side). Functional analyses of variance and independent t-tests were used to evaluate between-group differences for lower-extremity net internal joint moment, power, and stiffness throughout the entire ground contact phase of landing and jumping.

RESULTS

Relative to the control group, the CAI group revealed (i) reduced plantarflexion and knee extension and increased hip extension moments; (ii) reduced ankle and knee eccentric and concentric power, and increased hip eccentric and concentric power, and (iii) reduced ankle and knee joint stiffness and increased hip joint stiffness during the task.

CONCLUSIONS

CAI patients seemed to use a hip-dominant strategy by increasing the hip extension moment, stiffness, and eccentric and concentric power during landing and jumping. This apparent compensation may be due to decreased capabilities to produce sufficient joint moment, stiffness, and power at the ankle and knee. These differences might have injury risk and performance implications.

Nonlinear Dynamic Measures for Evaluating Postural Control in Individuals With and Without Chronic Ankle Instability

This study aimed to compare time-to-boundary and sample entropy during a single-leg balance task between individuals with chronic ankle instability (CAI), lateral ankle sprain copers, and healthy controls. Twenty-two participants with CAI, 20 lateral ankle sprain copers, and 24 healthy controls performed a single-leg balance task during an eyes-closed condition. Participants with CAI exhibited lower time-to-boundary values compared with lateral ankle sprain copers and healthy controls. However, we did not find differences in sample entropy variables between cohorts. A decrease in time-to-boundary values in participants with CAI indicated that CAI may constrain the ability of the sensorimotor system to maintain the center of pressure within the boundaries of the base of support. However, the regularity of the center of pressure velocity time series appears not to be altered in the CAI cohort in this study.

Bilateral compensatory postural adjustments to a unilateral perturbation in subjects with chronic ankle instability

BACKGROUND

To evaluate the magnitude of bilateral compensatory postural adjustments in response to a unilateral sudden inversion perturbation in subjects with chronic ankle instability.

METHODS

24 athletes with chronic ankle instability (14 with functional ankle instability, 10 with mechanical ankle instability) and twenty controls participated in this study. The bilateral electromyography of ankle muscles was collected during a unilateral sudden ankle inversion to assess the magnitude of subcortical and voluntary compensatory postural adjustments in both the perturbed and the contralateral limb (support limb).

FINDINGS

In the support position, compared to the control group, the group with functional ankle instability presented decreased compensatory postural adjustments of the tibialis anterior in both the injured and the uninjured limbs in the support position and of the soleus in the uninjured limb. In the side of the perturbation, participants with functional ankle instability presented decreased soleus compensatory postural adjustments in the uninjured limb when compared to the control group. Increased values of soleus and peroneal brevis compensatory postural adjustments were observed in the group with mechanical instability when compared to the control group and to the group with functional ankle instability.

INTERPRETATION

Subjects with functional ankle instability present bilateral impairment of compensatory postural adjustments of the tibialis anterior in a support position and of the soleus of the uninjured limb regardless of the position. Subjects with mechanical instability present bilateral increase of these adjustments in the peroneal brevis regardless of the position and in the soleus muscle in the side of the perturbation.

Effects of Hip Strengthening on Neuromuscular Control, Hip Strength, and Self-Reported Functional Deficits in Individuals With Chronic Ankle Instability

CONTEXT

Deficits in ankle and hip strength and lower-extremity postural control are associated with chronic ankle instability (CAI). Following strength training, muscle groups demonstrate increased strength. This change is partially credited to improved neuromuscular control, and many studies have investigated ankle protocols for subjects with CAI. The effects of isolating hip musculature in strength training protocols in this population are not well understood.

OBJECTIVE

To examine the effects of hip strengthening on clinical and self-reported outcomes in patients with CAI.

DESIGN

Prospective randomized controlled clinical trial.

SETTING

Athletic training facility.

PARTICIPANTS

Twenty-six participants with CAI (12 males and 14 females; age = 20.9 [1.5] y, height = 170.0 [12.7] cm, and mass = 77.5 [17.5] kg) were randomly assigned to training or control groups.

INTERVENTION

Participants completed either 4 weeks of supervised hip strengthening (resistance bands 3 times a week) or no intervention.

MAIN OUTCOME MEASURES

Participants were assessed on 4 clinical measures (Star Excursion Balance Test in the anterior, posteromedial, and posterolateral directions; Balance Error Scoring System; hip external rotation strength; and hip abduction strength) and a patient-reported measure (the Foot and Ankle Ability Measure activities of daily living and sports subscales) before and after the 4-week training period.

RESULTS

The training group displayed significantly improved posttest measures compared with the control group for hip abduction strength (training: 446.3 [77.4] N, control: 314.7 [49.6] N, P < .01); hip external rotation strength (training: 222.1 [48.7] N, control: 169.4 [34.6] N, P < .01); Star Excursion Balance Test reach in the anterior (training: 93.1% [7.4%], control: 90.2% [7.9%], P < .01), posteromedial (training: 96.3% [8.9%], control: 88.0% [8.8%], P < .01), and posterolateral (training: 95.4% [11.1%], control: 86.6% [9.6%], P < .01) directions; Balance Error Scoring System total errors (training: 9.9 [6.3] errors, control: 21.2 [6.3] errors, P < .01); and the Foot and Ankle Ability Measure-sports score (training: 88.0 [12.6], control: 84.8 [10.9], P < .01).

CONCLUSION

Improved clinical and patient-reported outcomes in the training group suggest hip strengthening is beneficial in the management and prevention of recurrent symptoms associated with CAI.

Consecutive postural adjustments (CPAs): A kinetic analysis of variable velocity during a pointing task

AIM

This paper examines the postural adjustments that occur after the end of a voluntary movement (consecutive postural adjustments, CPAs). Its aim is to reinforce the theory that CPAs are necessary to counterbalance the destabilizing effect of a voluntary movement. In addition, we compared the main features of CPAs with those of anticipatory postural adjustments (APAs) in order to gather evidence that could afford new insights into postural programming.

METHODS

Nine healthy adults were invited to adopt a sitting position to perform nine pointing movements at decreasing velocities. The antero-posterior component of the reaction forces was measured. Upper limb kinematics were recorded and the kinetics calculated. The main features under study included linear impulses, peak amplitudes and duration of CPAs and APAs.

RESULTS

Two main results emerged from our study: the impulse produced after the end of a focal movement (CPAI_x) was negative, while the impulse produced before its end (^*ASPI_x) was positive; their absolute values were not significantly different; when movement velocity increased, CPA impulse and peak amplitude (pCPA) increased significantly, contrary to duration (dCPA). Furthermore, APA impulse, peak amplitude and duration were all increased.

CONCLUSIONS

These findings on pointing movements strengthen the hypothesis that CPAs play a role of body stabilization and that the postural chain kinetics is programmed according to focal movement velocity. Evidence on CPA obtained from healthy subjects may contribute to the further specification of the differences associated with motor impairment.

Influence of dual-task constraints on the interaction between posture and movement during a lower limb pointing task

One of the challenges regarding human motor control is making the movement fluid and at a limited cognitive cost. The coordination between posture and movement is a necessary requirement to perform daily life tasks. The present experiment investigated this interaction in 20 adult men, aged 18-30 years. The cognitive costs associated to postural and movement control when kicking towards a target was estimated using a dual-task paradigm (secondary auditory task). Results showed that addition of the attentional demanding cognitive task yielded a decreased kicking accuracy and an increased timing to perform the movement, mainly during the backswing motion. In addition, significant differences between conditions were found for COP and COM displacement (increased amplitude, mean speed) on the anteroposterior axis. However, no significant differences between conditions were found on the mediolateral axis. Finally, EMG analysis showed that dual-task condition modified the way anticipatory postural adjustments (APAs) were generated. More specifically, we observed an increase of the peroneus longus activity, whereas the temporal EMG showed a decrease of its latency with respect to movement onset. These results suggested a functional adaptation resulting in an invariance of overall APAs, emphasizing that cognitive, postural, and motor processes worked dependently.

Postural adaptations to unilateral knee joint hypomobility induced by orthosis wear during gait initiation

Balance control and whole-body progression during gait initiation (GI) involve knee-joint mobility. Single knee-joint hypomobility often occurs with aging, orthopedics or neurological conditions. The goal of the present study was to investigate the capacity of the CNS to adapt GI organization to single knee-joint hypomobility induced by the wear of an orthosis. Twenty-seven healthy adults performed a GI series on a force-plate in the following conditions: without orthosis ("control"), with knee orthosis over the swing leg ("orth-swing") and with the orthosis over the contralateral stance leg ("orth-stance"). In orth-swing, amplitude of mediolateral anticipatory postural adjustments (APAs) and step width were larger, execution phase duration longer, and anteroposterior APAs smaller than in control. In orth-stance, mediolateral APAs duration was longer, step width larger, and amplitude of anteroposterior APAs smaller than in control. Consequently, step length and progression velocity (which relate to the "motor performance") were reduced whereas stability was enhanced compared to control. Vertical force impact at foot-contact did not change across conditions, despite a smaller step length in orthosis conditions compared to control. These results show that the application of a local mechanical constraint induced profound changes in the global GI organization, altering motor performance but ensuring greater stability.

Energy dissipation differs between females with and without chronic ankle instability

Chronic ankle instability (CAI) is associated with altered energy dissipation patterns, but comparisons to lateral ankle sprain (LAS) copers have not been explored. The purpose of this study was to examine differences in relative sagittal plane energy dissipation during a single-leg landing between female CAI and LAS coper participants. We separated 33 females (23.6 ± 4.6 years, 164.3 ± 6.2 cm, 69.4 ± 13.7 kg) into CAI (n = 17) and LAS coper (n = 16) groups. Participants completed 5 single-leg landings followed by a 5-second stabilization. We collected sagittal plane kinematics and joint moments at the ankle, knee, hip, and proximal joints (knee and hip) combined then calculated each joint's energy dissipation at 50, 100, 150, and 200 ms post-landing. We compared the percentage of total energy dissipated by the ankle, knee, hip, and proximal joints during each interval utilizing independent t tests and Cohen's d effect sizes. Statistical significance was set a priori at P < .05. The CAI group had lower relative energy dissipation from the ankle at 50 (24.7 ± 11.5% vs 39.2 ± 11.8%, P < .01, d = 1.25 [0.47, 1.95]), 100 (66.9 ± 19.4% vs 77.7 ± 6.5%, P = .04, d = 0.74 [0.01, 1.42]), and 150 ms (70.7 ± 17.8% vs 81.0 ± 5.7%, P = .03, d = 0.77 [0.04, 1.46]) compared to LAS copers. The CAI group had a greater hip contribution through 150 ms (17.9 ± 10.7% vs 11.7 ± 4.4%, P = .04, d =-0.75 [-1.44, -0.03]) and the proximal joints at 50 (75.3 ± 11.5% vs 60.8 ± 11.8%, P < .01, d = -1.25 [-1.96, -0.47]), 100 (33.1 ± 19.4% vs 22.3 ± 6.5%, P = .04, d = -0.74 [-1.42, -0.01]), and 150 ms (29.3 ± 17.8 vs 19.0 ± 5.7%, P = .03, d =-0.77 [-1.46, -0.04]) compared to LAS copers. Females with CAI may benefit from therapeutic exercises designed to correct a single-leg energy dissipation strategy that relies less on the ankle joint.

Hip strength and star excursion balance test deficits of patients with chronic ankle instability

OBJECTIVES

To examine isometric hip strength in those with and without CAI, and determine the degree of Star Excursion Balance Test (SEBT) variance explained by isometric hip strength.

DESIGN

Single-blinded, cross-sectional, case-control study.

METHODS

Thirty individuals with CAI, 29 lateral ankle sprain (LAS) copers, and 26 healthy controls participated. We assessed dynamic postural control with the SEBT anterior (SEBT-ANT), posteromedial (SEBT-PM), and posterolateral (SEBT-PL) reaches, and isometric hip extension (EXT), abduction (ABD) and external rotation (ER) strength with hand-held dynamometry. The CAI and LAS coper groups' involved limbs and randomly selected limbs in controls were tested. Separate Kruskal-Wallis tests compared SEBT scores and isometric hip strength between groups. Backwards linear regression models determined the degree of SEBT variance explained by isometric hip strength. Statistical significance was set a priori at P<0.05.

RESULTS

The CAI group had lower SEBT-ANT scores compared to LAS copers (P=0.03) and controls (P=0.03). The CAI group had lower ABD compared to LAS copers (P=0.03) and controls (P=0.02). The CAI group had lower ER compared to LAS copers (P=0.01) and controls (P=0.01). ER (R²=0.25, P=0.01) and ABD (R²=0.25, P=0.01) explained 25% of the CAI group's SEBT-PM and SEBT-PL variances, respectively.

CONCLUSIONS

The CAI group had deficient dynamic postural control and isometric hip strength compared to LAS copers and controls. Additionally, the CAI group's isometric hip strength significantly influenced dynamic postural control performance. Future CAI rehabilitation strategies should consider hip muscular strengthening to facilitate improvements in dynamic postural control.

Muscle Activation During Landing Before and After Fatigue in Individuals With or Without Chronic Ankle Instability

CONTEXT

Ankle instability is a common condition in physically active individuals. It often occurs during a jump landing or lateral motion, particularly when participants are fatigued.

OBJECTIVE

To compare muscle activation during a lateral hop prefatigue and postfatigue in individuals with or without chronic ankle instability (CAI).

DESIGN

Cross-sectional study.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 32 physically active participants volunteered for the study. Sixteen participants with CAI (8 men, 8 women; age = 20.50 ± 2.00 years, height = 172.25 ± 10.87 cm, mass = 69.13 ± 13.31 kg) were matched with 16 control participants without CAI (8 men, 8 women; age = 22.00 ± 3.30 years, height = 170.50 ± 9.94 cm, mass = 69.63 ± 14.82 kg) by age, height, mass, sex, and affected side.

INTERVENTION(S)

Electromyography of the tibialis anterior, peroneus longus, gluteus medius, and gluteus maximus was measured before and after a functional fatigue protocol.

MAIN OUTCOME MEASURE(S)

Activation of 4 lower extremity muscles was measured 200 milliseconds before and after landing from a lateral hop.

RESULTS

We observed no interactions. The group main effects for the peroneus longus demonstrated higher muscle activation in the CAI group (52.89% ± 11.36%) than in the control group (41.12% ± 11.36%) just before landing the lateral hop (F_1,30 = 8.58, P = .01), with a strong effect size (d = 1.01). The gluteus maximus also demonstrated higher muscle activation in the CAI group (45.55% ± 12.08%) than in the control group (36.81% ± 12.08%) just before landing the lateral hop (F_1,30 = 4.19, P = .049), with a moderate effect size (d = 0.71). We observed a main effect for fatigue for the tibialis anterior, with postfatigue activation higher than prefatigue activation (F_1,30 = 7.45, P = .01). No differences were present between groups for the gluteus medius.

CONCLUSIONS

Our results support the presence of a centralized feed-forward neuromuscular alteration in patients with CAI, not only in the ankle-joint muscles but also in the proximal hip muscles. These results may have implications for rehabilitation programs in these patients.

Posterolateral ankle ligament injuries affect ankle stability: a finite element study

BACKGROUND

We have already discovered 23 patients during the work of the outpatient department and operations whose unstable signs on the posterolateral ankle. The anterior drawer test demonstrated normal during the physical examinations while the spaces of the posterior tibiotalar joints increased in stress X-ray plain films. ATFL intact and posterolateral ligaments lax were found during operations too. It is important to make existence claims and illuminate the mechanism of posterolateral ankle instability.

METHODS

A finite element model of the ankle was established for simulating to cut off posterolateral ligaments in turn. Ankle movements with tibia rotation under load on five forefoot positions were simulated as well.

RESULTS

The difference values with tibia external rotation were negative, and the positive results occurred with tibia internal rotation. The tibia-talus difference values in some forefoot positions were 2 ~ 3 mm after PTFL together with CFL or/and PITFL were cut off. The tibula-talus difference values were 2.21 ~ 2.76 mm after both PTFL and CFL were cut off. The tibia-fibula difference values were small. The difference values increased by 2 ~ 5 mm after cutting off the PITFL.

CONCLUSIONS

Posterolateral ankle ligaments, especially CFL and PITFL, play a significant role in maintaining ankle stability. The serious injuries of both CFL and PITFL would affect posterolateral ankle stabilities. PITFL was important to subtalar joint stability.