Eccentric reinforcement of the ankle evertor muscles after lateral ankle sprain

Acute Neuromuscular Alterations of Ankle Evertors Induced by Short Trail Running: Sex-Related Considerations

Ravier, G, Dury, J, Grevillot, J, Girard, B, Bouzigon, R, and Michel, F. Acute neuromuscular alterations of ankle evertors induced by short trail running: sex-related considerations. J Strength Cond Res 37(10): 2008–2015, 2023—This study investigated the exercise-induced effects on the neuromuscular function of ankle evertors, balance control associated with trail running, and sex-related interactions. Fourteen male and 14 female medium-level runners completed a 16-km (400 D+) course. At rest and immediately after running, maximal voluntary isometric contraction (MVC) and rate of force development (RFD) for knee extension and ankle eversion, electromyographic (EMG) activity of peroneus muscles during MVC plateau (EMG) and the first 200 ms (EMG200), ankle angular velocity ( INV) during 20 weight-bearing inversion movements, and balance control during destabilizing single-leg task were evaluated. Repeated measures ANOVA-revealed changes in knee and ankle MVC (ankle: P = 0.0004, −12%) and RFD (ankle: P < 0.0001, −19%), EMG (P < 0.0001, −17%), EMG200 (P < 0.0001, −19%), and ankle INV (P < 0.0001, +35%) in response to trail running. Single-leg balance was not impaired. Sex-related differences were observed in EMG and EMG200 with higher values in men than in women. MVC and RFD were greater in men when expressed in absolute values, but not different relative to body mass. Single-leg balance and ankle INV did not differ between men and women. Finally, none of these variables showed any sex-related difference when considering pre-exercise to postexercise changes. This study demonstrated impairment in neuromuscular function of evertor muscles and ability in braking inversion in response to trail running. Sex-related differences were observed in neuromuscular activity but not in fatigability. These data suggest that coaches might implement strength exercises specifically designed for ankle lateral stability into their training program.

Which Functional Tests and Self-Reported Questionnaires Can Help Clinicians Make Valid Return to Sport Decisions in Patients With Chronic Ankle Instability? A Narrative Review and Expert Opinion

Lateral ankle sprain is the most common injury in sports, with up to 40% of patients developing chronic ankle instability (CAI). One possible cause underlying this high rate of recurrence or feeling of giving way may be a premature return to sport (RTS). Indeed, except for time-based parameters, there are no specific criteria to guide clinicians in their RTS decisions in patients with CAI. A recent international consensus highlighted the relevance and importance of including patient-reported ankle function questionnaires combined with functional tests targeting ankle impairments in this population. Thus, the aim of this narrative review and expert opinion was to identify the most relevant functional performance tests and self-reported questionnaires to help clinicians in their RTS decision-making process following recurrent ankle sprains or surgical ankle stabilization. The PubMed (MEDLINE), PEDro, Cochrane Library and ScienceDirect databases were searched to identify published articles. Results showed that the single leg stance test on firm surfaces, the modified version of the star excursion balance test, the side hop test and the figure-of-8 test appeared to be the most relevant functional performance tests to target ankle impairments in patients with CAI. A combination of the Foot and Ankle Ability Measure (FAAM) and the Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) questionnaires were the most relevant self-reported questionnaires to assess patient function in the context of CAI. Although these functional tests and questionnaires provide a solid foundation for clinicians to validate their RTS decisions in patient with CAI, objective scientific criteria with cut-off scores are still lacking. In addition to the proposed test cluster, an analysis of the context, in particular characteristics related to sports (e.g., fatigue, cognitive constraints), to obtain more information about the patient's risk of recurrent injury could be of added value when making a RTS decision in patients with CAI. In order to evaluate the strength of evertors under ecological conditions, it would also be interesting to assess the ability to control weight-bearing ankle inversion in a unipodal stance. Further studies are needed to assess the relevance of this proposed test cluster in RTS decision-making following lateral ankle sprain injury and CAI.

Fatigue of hip abductor muscles implies neuromuscular and kinematic adaptations of the ankle during dynamic balance

OBJECTIVE

Determine whether hip abductor muscle fatigue influenced ankle kinematic and muscle activity during ankle-destabilized tasks.

DESIGN

Cross-sectional study.

METHODS

Twenty-six healthy, active participants performed two tests (Star Excursion Balance Test, SEBT; Weight Bearing Inversion Test, WBIT) for assessment of dynamic balance and ability to control inversion. Participants were equipped with an ankle-destabilizing sandal in inversion and eversion to perform both tests, which were completed before and after a fatiguing exercise of hip abductor muscles (up to 50% reduction in strength). Electromyographic activity of peroneus longus (PL) and brevis (PB), tibialis anterior, gastrocnemius lateralis (GastL) and gluteus medius (GlutM) muscles were recorded. In addition, ankle kinematics were recorded using an inertial measurement unit.

RESULTS

Hip abductor fatigue induced a significant decrease in SEBT scores in three directions (p < 0.01). During SEBT, ankle supination decreased by 3.2° in the anterior and posteromedial directions (p < 0.01). Muscle activity of GastL increased during achievement of three directions (p < 0.05) in response to hip abductor fatigue. In posteromedial direction, PL (p < 0.001) and GlutM (p < 0.01) activity increased with fatigue. During WBIT, inversion angular velocity was not impacted by fatigue while, PB and GastL activity increased after fatiguing exercise (p < 0.005).

CONCLUSION

A decrease in SEBT performance and EMG adaptations with proximal fatigue attest to the importance of the hip abductor muscle in dynamic postural control. This could have important implications in building injury prevention programs. Changes in ankle supination may reflect a protective strategy of the joint in response to hip fatigue.

The effectiveness of different ankle strengthening training programs on performance

BACKGROUND

The purpose of this study was to investigate the effectiveness of different ankle strengthening training programs: eccentric, concentric, and resistance bands, on performance of university level sedentary males.

METHODS

Sixty-three males between the ages of 18 and 26 years were randomized to either eccentric isokinetic (n=21), concentric isokinetic (n=21), and resistance bands ankle strengthening groups (n=21). Training was performed three days a week, for eight weeks for both sides of ankle. Each program was made progressively harder by increasing the number of repetitions or sets. Measurements evaluating strength, balance and jumping performance were repeated pre, post and at one month (follow-up) after training.

RESULTS

Statistical significance was observed for concentric evertor strength for both sides of the ankle for all groups after training (p<0.05). In addition, statistically significant increases were seen in jumping performance for all groups and dynamic balance for eccentric and concentric groups (p<0.05), with the concentric being statistically higher compared to the resistance bands group for all parameters (p<0.05).

CONCLUSIONS

Ankle isokinetic strength (eccentric, concentric) training is more effective than resistance bands regarding improvement on strength, explosive strength, and dynamic balance. Ankle isokinetic strength training, which includes evertor and invertor muscles, improves performance, especially when applied concentrically. Therefore, the proper strengthening of ankle muscles will prevent the re-injury of ankles with individuals returning to activities.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

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

SETTING

College athletic training clinic.

PATIENTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Surgical management of chronic lateral ankle instability: a meta-analysis

Background

A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. The purpose of this meta-analysis was to compare different surgical techniques for management of chronic lateral ankle instability.

Methods

We searched the Cochrane Library, MEDLINE, and EMBASE. All identified randomized and quasi-randomized controlled trials of operative treatment for chronic lateral ankle instability were included. Two review authors independently extracted data from each study and assessed risk of bias. Where appropriate, results of comparable studies were pooled.

Results

Seven randomized controlled trials were included for analysis. They fell in five clearly distinct groups.

One study comparing two different kinds of non-anatomic reconstruction procedures (dynamic and static tenodesis) found two clinical outcomes favoring static tenodesis: better clinical satisfaction and fewer subsequent sprains.

Two studies compared non-anatomic reconstruction versus anatomic repairment. In one study, nerve damage was more frequent in non-anatomic reconstruction group; the other one reported that radiological measurement of ankle laxity showed that non-anatomic reconstruction provided higher reduction of talar tilt angle.

Two studies comparing two anatomic repairment surgical techniques (transosseous suture versus imbrication) showed no significant difference in any clinical outcome at the follow-up except operation time.

One study compared two different anatomic repairment techniques. They found that the double anchor technique was superior with respect to the reduction of talar tilt than single anchor technique.

One study compared an anatomic reconstruction procedure with a modified Brostrom technique. Primary reconstruction combined with ligament advanced reinforcement system results in better patient-scored clinical outcome, at 2 years post-surgery, than the modified Brostrom procedure.

Conclusions

There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still get some conclusions: (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains. (2) Non-anatomic reconstruction abnormally increased inversion stiffness at the subtalar level as compare with anatomic repairment. (3) Multiple types of modified Brostrom procedures could acquire good clinical results. (4) Anatomic reconstruction is a better procedure for some specific patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0870-6) contains supplementary material, which is available to authorized users.

Reliability of Ankle⁻Foot Complex Isokinetic Strength Assessment Using the Isomed 2000 Dynamometer

For quantifying muscle strength in clinical and research practice, establishing the reliability of measurements, specifically to the procedures used, is essential for credible findings. The objective was to establish the reliability of isokinetic measurement of ankle plantar and dorsal flexors (PF/DF) and invertors and evertors (INV/EV) on an IsoMed 2000 dynamometer. Twenty healthy subjects (10 males, 10 females, mean age: 23.1 ± 3.1 years) completed an isokinetic measurement session. The intraclass correlation coefficient (ICC) and standard error of measurement were assessed for peak torque and work of ankle PF/DF (concentric and eccentric) and INV/EV (concentric) for the preferred and nonpreferred limb. Standardized isokinetic measurements of reciprocal PF/DF and INV/EV muscle actions were associated with ICC ranging from 0.77 to 0.98 for the majority of observed parameters. The exception was work in the eccentric mode in the ankle DF and peak torque in the concentric mode in the ankle INV on the preferred limb, where ICC ranged from 0.64 to 0.71. The IsoMed 2000 isokinetic dynamometer can be reliably employed in future studies for reciprocal ankle PF/DF and INV/EV assessment in healthy adult subjects after implementation of a familiarization session.

The influence of foot position on lower leg muscle activity during a heel raise exercise measured with fine-wire and surface EMG

OBJECTIVE

Exercises for lower leg muscles are important to improve function. To examine the influence of foot position on lower leg muscle activity during heel raises.

DESIGN

Cross-sectional laboratory study.

SETTING

Laboratory.

PARTICIPANTS

Fourteen healthy men participated in this study.

MAIN OUTCOME MEASURES

The muscle activity levels of the tibialis posterior (TP), peroneus longus (PL), flexor digitorum longus (FDL) and medial gastrocnemius (MG) were measured. The heel raises consisted of three foot positions: 1) neutral, 2) 30° abduction, and 3) 30° adduction. The EMG data for five repetitions of each foot position were normalized to maximum voluntary contraction. One-way repeated measure ANOVA was employed for statistical analysis.

RESULTS

The muscle activity level of TP, PL and FDL was significantly different between the three foot positions during the heel raises. TP and FDL showed the highest activity level in 30° foot adduction while PL demonstrated the highest activity level in 30° foot abduction.

CONCLUSIONS

Heel raises with 30° foot adduction and abduction positions can change lower leg muscle activity; These findings suggest that altering foot posture during the heel raise exercise may benefit patients with impaired TP, PL or FDL function.

Assessment of evertor weakness in patients with chronic ankle instability: Functional versus isokinetic testing

BACKGROUND

Ankle sprain is the most common sport-related injury and eccentric weakness of ankle evertors is regarded as a significant muscular deficit related to chronic ankle instability. However, the eccentric performance of the evertors is rarely assessed by clinicians because procedures used for research purposes (i.e. isokinetic tests) are not easily applicable in daily practice.

METHODS

The present study assessed the ability of two different testing procedures to distinguish between groups of 12 healthy subjects or 12 patients suffering from chronic ankle instability. On the one hand, the strength of evertors was assessed with a goldstandard isokinetic procedure. On the other hand, we assessed the ability of the subjects to control ankle inversion during weight bearing (functional standing test).

FINDINGS

Data showed no significant difference between groups for isokinetic peak torque values normalized to body weight. Conversely, the functional test revealed a significantly impaired ability to control ankle inversion during weight bearing in subjects with chronic ankle instability.

INTERPRETATION

This suggests that this easy-to-apply functional test is better suited compared to isokinetic testing procedures to assess weakness of evertors in patients suffering from chronic ankle instability. Moreover, this test may also be used to objectively monitor improvements during rehabilitation or progression in prevention protocols.

Rehabilitation after anatomical ankle ligament repair or reconstruction

The selection, implementation of and adherence to a post-operative regimen are all essential in order to achieve the best outcomes after ankle ligament surgery. The purpose of this paper is to present a best-evidence approach to this, with grounding in basic science and a consensus opinion from the members of the ESSKA-AFAS Ankle Instability Group. Basic science and clinical evidence surrounding tissue healing after surgical repair or reconstruction of the ligaments as well as around the re-establishment of sensorimotor control are reviewed. A consensus opinion based on this evidence as to the recommended rehabilitation protocol after ankle ligament surgery was then obtained from the members of the ESSKA-AFAS Ankle Instability Group. Rehabilitation recommendations are presented for the initial post-operative period, the early recovery phase and a goal-orientated late rehabilitation and return-to-sport phase. This paper presents practical, evidenced-based guidelines for rehabilitation and return to activity after lateral ankle ligament surgery.

Rehabilitation after anatomical ankle ligament repair or reconstruction

The selection, implementation of and adherence to a post-operative regimen are all essential in order to achieve the best outcomes after ankle ligament surgery. The purpose of this paper is to present a best-evidence approach to this, with grounding in basic science and a consensus opinion from the members of the ESSKA-AFAS Ankle Instability Group. Basic science and clinical evidence surrounding tissue healing after surgical repair or reconstruction of the ligaments as well as around the re-establishment of sensorimotor control are reviewed. A consensus opinion based on this evidence as to the recommended rehabilitation protocol after ankle ligament surgery was then obtained from the members of the ESSKA-AFAS Ankle Instability Group. Rehabilitation recommendations are presented for the initial post-operative period, the early recovery phase and a goal-orientated late rehabilitation and return-to-sport phase. This paper presents practical, evidenced-based guidelines for rehabilitation and return to activity after lateral ankle ligament surgery.

Impaired control of weight bearing ankle inversion in subjects with chronic ankle instability

BACKGROUND

Previous studies have proposed that evertor muscle weakness represents an important factor affecting chronic ankle instability. For research purposes, ankle evertor strength is assessed by means of isokinetic evaluations. However, this methodology is constraining for daily clinical use. The present study proposes to assess ankle evertor muscle weakness using a new procedure, one that is easily accessible for rehabilitation specialists. To do so, we compared weight bearing ankle inversion control between patients suffering from chronic ankle instability and healthy subjects.

METHODS

12 healthy subjects and 11 patients suffering from chronic ankle instability conducted repetitions of one leg weight bearing ankle inversion on a specific ankle destabilization device equipped with a gyroscope. Ankle inversion control was performed by means of an eccentric recruitment of evertor muscles. Instructions were to perform, as slow as possible, the ankle inversion while resisting against full body weight applied on the tested ankle.

RESULTS

Data clearly showed higher angular inversion velocity peaks in patients suffering from chronic ankle instability. This illustrates an impaired control of weight bearing ankle inversion and, by extension, an eccentric weakness of evertor muscles.

INTERPRETATION

The present study supports the hypothesis of a link between the decrease of ankle joint stability and evertor muscle weakness. Moreover, it appears that the new parameter is of use in a clinical setting.