Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains

Gait kinematics and kinetics in patients with chronic ankle instability and healthy controls: A statistical parametric mapping analysis

BACKGROUND

Chronic ankle instability (CAI) is associated with changes in gait biomechanics which may be related to chronic dysfunction. Traditional statistical models may be limited in their ability to assess the complex 3D movement of the lower extremity during gait. Multivariate analysis of the lower extremity kinematics may reveal unique biomechanical differences associated with CAI.

RESEARCH QUESTION

Do patients with CAI differ from healthy controls in their lower extremity biomechanics and GRF when comparing 3D biomechanics?

METHODS

Thirty-nine young, active adults participated in this study. Data was collected using a 3D motion analysis system while patients walked and jogged. Statistical parametric mapping (SPM) was used to explore 3D GRF, kinematics and kinetics of the of the lower extremity of CAI and healthy patients.

RESULTS

During walking, patients with CAI had greater inversion from 68-100% of gait cycle (p < 0.001, mean difference=3.2°). During jogging, patients with CAI had greater inversion from 20-92% (p < 0.001, mean difference=4.6°). Greater plantar flexion moments were found from 65-71% (p = 0.05, mean difference=347.4Nm/kg) and greater eversion moments were found from 95-100% (p = 0.03, mean difference=74.6Nm/kg) in the CAI group. No differences in GRF were found.

SIGNIFICANCE

Greater inversion may present a potentially injurious position. A faulty position of the rearfoot may require greater muscle function in order to correct the position of the joint resulting in greater eversion moments at the ankle. However, this kinetic change does not appear to correct the ankle position.

Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments

PURPOSE

Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations.

METHODS

A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods.

RESULTS

A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available.

CONCLUSION

There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications.

LEVEL OF EVIDENCE

Level IV.

Validity and reliability of the Modified Four Square Step Test in individuals with ankle sprain

BACKGROUND

Postural instability and gait abnormalities are frequently observed after an ankle sprain. A modified Four Square Step Test (mFSST) was developed to assess dynamic balance during gait. The aim of this study was to evaluate the reliability and validity of the mFSST in individuals with ankle sprains.

METHODS

The study included 39 individuals with grade 1 and 2 ankle sprains with a mean age of 30.36 ± 6.21 years. The dynamic balance of the participants was assessed with the mFSST and Timed Up & Go test (TUG). To determine the test-retest reliability of the mFSST, the test was repeated approximately 1 h apart.

RESULTS

The test-retest reliability of the mFSST was excellent (ICC = 0.85). Furthermore, when the concurrent validity of the mFSST was examined, a high correlation was found between with the TUG (r = 0.78, p < 0.001).

CONCLUSION

The mFSST is a valid and reliable clinical assessment method for evaluating dynamic balance during walking in individuals with ankle sprains. We think that the mFSST is preferable in clinical evaluations because its platform is easy to prepare and requires very little equipment.

Injury severity at the time of sport-related ankle sprain is associated with symptoms and quality of life in young adults after 3-15 years

BACKGROUND

Ankle sprains are the most common sports-related injuries. Individuals with time-loss ankle sprains often experience residual symptoms and chronic ankle instability years after injury. Up to 90% of post-traumatic ankle osteoarthritis cases are associated with severe ankle sprain. This study aimed to examine whether ankle injury severity sustained during youth sports participation is associated with ankle symptoms and function.

MATERIALS AND METHODS

Cohort study included 50 young adults (mean age, 23 years) with a 3-to 15-year history of a youth-sport related 'significant ankle sprain' (SAS). The primary independent variable was injury severity, which was captured in the index SAS injury details through interviews. SAS was defined as ligament and other intra/extra-articular structure injuries that disrupted youth sport participation, at least 3 days of time loss, and required medical consultation. Severe SAS was defined as SAS involving >28 days of time loss, and non-severe SAS only involved ankle ligaments and/or with ≤28 days of time loss. The Foot and Ankle Outcome Score questionnaire was used to assess ankle symptoms and function. Descriptive statistics and multivariable linear regression models were used to examine the association between SAS severity and outcomes, with sex and time since injury as covariates.

RESULTS

Compared to participants with non-severe SAS, participants with a history of severe SAS demonstrated significantly poorer outcomes in symptoms [-18.4 (99% CI: -32.2 to -4.6)], pain [-10.1 (99% CI: -19.2 to -1.1)] and QoL [-17.1 (99% CI: -33.1 to -1.1)] in multivariable linear regression models.

CONCLUSIONS

Severe ankle sprain with a loss of > 4 weeks from sports participation at the time of injury is independently associated with poorer ankle symptoms, pain, and ankle-related quality of life after 3-15 years. Secondary prevention measures are needed in individuals with a history of severe ankle sprains to mitigate the potential health consequences.

Age of Adolescent Female Soccer Players at First Ankle Sprain and Menarche

Objectives

: To provide targeted interventions for the prevention of first ankle sprains, this study determined the prevalence of ankle sprains in female adolescent soccer players and analyzed the correlation between the age at the first occurrence of ankle sprain and the age at menarche.

Methods

: The study included 131 female participants from three club teams. The mean age was 13.37 ± 0.96 years. A survey was conducted using a questionnaire that requested information regarding the age at which the first ankle sprain occurred, age at menarche, status of ankle problems, extent to which the ankle joint problem affected playing ability, use of medical facilities or other healthcare facilities for the first or recurrent ankle sprains, and methods used to care for their ankle.

Results

Ankle sprains most commonly occurred for the first time at 12 years, followed by the ages of 13, 10, and 11 years. About 25% of participants experienced their first ankle sprain at the age of menarche, 20% at 1 year after menarche, and 16% a year before menarche. The incidence of the first ankle sprain was high in the second and fifth years after starting to play soccer. Medical treatment was rarely received for the second or subsequent injury, although 36% had some sequelae.

Conclusions

Adolescent female soccer players were not injured early in their soccer careers. Most players experienced their first ankle sprain at the age of 12 years, which was at or close to the age of menarche.

Cone-Beam Weight-Bearing Computed Tomography of Ankle Arthritis and Total Ankle Arthroplasty

Weight-bearing computed tomography has multiple advantages in evaluating the hindfoot and ankle. It can assess hindfoot and ankle alignment, pathology in ankle arthritis, and complications related to total ankle replacements. It is an essential tool in ankle osteoarthritis diagnostic, preoperative planning, and total ankle replacement outcomes. It allows for better accuracy and reproducibility of alignment and implant size. In addition, it has the potential to more assertively detect complications related to weight bearing.

Conservative Functional Treatment of Acute Fibular Ligament Rupture of the Ankle

BACKGROUND

Acute rupture of the fibular ligament complex is one of the commonest injuries in sports. Prospective randomized trials in the 1980s led to a paradigm shift from primary surgical repair to conservative functional treatment.

METHODS

This review is based on publications retrieved by a selective search in PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) and meta-analyses on surgical versus conservative treatment from the years 1983 to 2023.

RESULTS

10 of 11 prospective randomized trials of surgical versus conservative treatment conducted between 1984 and 2017 did not reveal any significant difference in the overall outcome. These findings were confirmed in two meta-analyses and two systematic reviews that were published between 2007 and 2019. Isolated benefits in the surgical group were outweighed by a variety of postoperative complications. The anterior fibulotalar ligament (AFTL) was ruptured in 58% to 100% of cases, followed by the fibulocalcaneal ligament combined with the LFTA in 58% to 85%, and the posterior fibulotalar ligament (mostly incomplete ruptures) in 1.9% to 3%.

CONCLUSION

Conservative functional treatment is now the standard treatment in acute fibular ligament rupture of the ankle because it is low-risk, low-cost, and safe. Primary surgery is indicated in only 0.5% to 4% of cases. Physical examination for tenderness to palpation and for stability, as well as stress ultrasonography, can be used to differentiate sprains from ligamentous tears. MRI is superior only for the detection of additional injuries. Stable sprains can be successfully treated with an elastic ankle support for a few days, and unstable ligamentous ruptures with an orthosis for 5 to 6 weeks. Subsequent physiotherapy with proprioceptive exercises is the best way to prevent recurrent injury.

Acute Ankle Sprain in Elite Athletes: How to Get Them Back to the Game?

Despite the high frequency of ankle sprains, the ideal management is controversial, and a significant percentage of patients sustaining an ankle sprain never fully recover. There is strong evidence that residual disability of ankle joint injury is often caused by an inadequate rehabilitation and training program and early return to sports. Therefore, the athlete should start their criteria-based rehabilitation and gradually progress through the programmed activities, including cryotherapy, edema relief, optimal weight-bearing management, range of motion exercises for ankle dorsiflexion improvement, triceps surae stretching, isometric exercises and peroneus muscles strengthening, balance and proprioception training, and bracing/taping.

Preventive interventions for lateral ankle sprains: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of preventive interventions for lateral ankle sprain in the general population.

DATA SOURCES

A search of PubMed, EMBASE, Cochrane CENTRAL, Medline, CINAHL, and ClinicalTrials.gov was conducted up to August 2022.

REVIEW METHODS

Randomized controlled trials and prospective cohort studies that evaluated any interventions for preventing lateral ankle sprain were included. Two reviewers independently conducted the search, screening, and data extraction. The methodological quality of each study was assessed using the revised Cochrane risk-of-bias tool for randomized trials or using the Cochrane Risk Of Bias In Non-Randomized Studies tool for prospective cohort studies.

RESULTS

Seventeen studies met the inclusion criteria. Proprioceptive training exhibited better effects on preventing future lateral ankle sprain compared with the control group (risk ratio = 0.59, p < 0.001), and a stronger preventive effect was observed in participants with a history of lateral ankle sprain in the subgroup analysis (risk ratio = 0.49, p = 0.02). Compared with no bracing, ankle bracing had no significant better effect in preventing lateral ankle sprain (risk ratio = 0.43, p = 0.05). Proprioceptive training and ankle bracing had similar preventive effects (risk ratio = 0.98, p = 0.97). Limited evidence hindered the synthesis of data on pain, swelling, costs, and time loss.

CONCLUSION

Proprioceptive training is recommended for preventing lateral ankle sprain, especially for people with a history of lateral ankle sprain. Bracing seems to have an ambiguous preventive effect and requires more further investigation.

[Radiographic diagnosis of distal fibula avulsion fractures: Comparison of ankle X-ray and three-dimensional reconstruction of CT]

OBJECTIVE

To investigate the difference in sensitivity between X-ray and three-dimensional reconstruction of computed tomography (3D-CT) for the diagnosis of distal fibular avulsion fracture, and the radiographic presentation of the ossicle.

METHODS

From January to October 2018, 92 patients with distal fibular avulsion fracture were visited for surgical treatment in Department of Sports Medicine, Peking University Third Hospital, and 60 cases were finally enrolled according to the inclusion and exclusion criteria. Intraoperative detection was regarded as the gold standard, and the diagnostic sensitivity of preoperative ankle X-ray and 3D-CT for the distal fibular avulsion fractures was statistically determined. The ossicle maximum diameter as well as the degree of its displacement were also measured. On 3D-CT, the distance from the ossicle center point to the anterior fibular tuberosity (a), the distance to the fibular tip (b), and the a/b value was used to present the ossicle displacement.

RESULTS

Among the 60 patients, 36 and the 52 patients were correctly detected by X-ray and 3D-CT, respectively, and the sensitivities was 60.0% and 86.7%, respectively (P=0.004). The mean diameter of the ossicle on X-ray and 3D-CT was (9.2±3.9) mm and (10.5±3.2) mm, respectively. The mean distance from the ossicle center to the anterior fibular tuberosity (a) was (17.5±3.6) mm and the mean distance to the fibular tip (b) was (17.4±4.8) mm, with mean a/b values of 1.1±0.7. The intraclass correlation coefficients (ICC) for each measurement ranged from 0.891-0.998 with a high degree of consistency.

CONCLUSION

Compared with X-ray, 3D-CT has higher sensitivity in diagnosing distal fibular avulsion fractures, can help clinicians evaluate ossicle's location and choose surgical methods, and is recommended to be performed in patients with suspected distal fibula avulsion fractures in clinical practice.

Isolated, periosteal stripping injuries of the Flexor Retinaculum: Case series of 3 patients with clinico-radiological review

Isolated periosteal avulsion injuries of the flexor retinaculum on the medial side of the ankle are rare and may mimic osseous injuries or deltoid ligament tears. We describe a case series of 3 individuals with isolated, stripping injuries of the tibial attachment of the flexor retinaculum without underlying fracture or deltoid ligament disruption. A new classification system of flexor retinaculum periosteal stripping injuries of the ankle is proposed with clinico-radiological features.

The incidence of musculoskeletal injuries: a systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Methods

PubMed (National Library of Medicine) and Scopus (Elsevier) databases were searched. Articles were eligible for inclusion if they reported incidence rate (or count with population at risk), contained data on adult population, and were written in English language. The number of cases and population at risk were collected, and the pooled incidence rates (per 100,000 person-years) with 95% confidence intervals (CIs) were calculated by using either a fixed or random effects model.

Results

The screening of titles yielded 206 articles eligible for inclusion in the study. Of these, 173 (84%) articles provided sufficient information to be included in the pooled incidence rates. Incidences of fractures were investigated in 154 studies, and the most common fractures in the whole adult population based on the pooled incidence rates were distal radius fractures (212.0, 95% CI 178.1 to 252.4 per 100,000 person-years), finger fractures (117.1, 95% CI 105.3 to 130.2 per 100,000 person-years), and hip fractures (112.9, 95% CI 82.2 to 154.9 per 100,000 person-years). The most common sprains and dislocations were ankle sprains (429.4, 95% CI 243.0 to 759.0 per 100,000 person-years) and first-time patellar dislocations (32.8, 95% CI 21.6 to 49.7 per 100,000 person-years). The most common injuries were anterior cruciate ligament (17.5, 95% CI 6.0 to 50.2 per 100,000 person-years) and Achilles (13.7, 95% CI 9.6 to 19.5 per 100,000 person-years) ruptures.

Conclusion

The presented pooled incidence estimates serve as important references in assessing the global economic and social burden of musculoskeletal injuries. Cite this article: Bone Joint Res 2022;11(11):814–825.

Validity and reliability of the French translation of the Identification of Functional Ankle Instability (IdFAI)

PURPOSE

To translate and validate the Identification of Functional Ankle Instability (IdFAI) into French.

METHODS

The IdFAI was translated according to international recommendations. Discriminative power, floor and ceiling effects, construct validity (including confirmatory factorial analysis (CFA)), internal consistency and test-retest reliability were measured. Standard Error of Measurement (SEM) and Smallest Detectable Change (SDC) were also calculated.

RESULTS

160 participants were included. The IdFAI-F showed a very good test-retest reliability (ICC = 0.95). The SEM was 1.37 and the MDC was 3.79. The internal consistency was moderate (Cronbach's alpha coefficient = 0.68). The correlation between the IdFAI and the Cumberland Ankle Instability Tool (CAIT) was high (r = -0.75, p < 0.001). No floor, nor ceiling effects were observed. The CFA analyses did not confirm the factor structure proposed by the authors of the original English version.

CONCLUSIONS

The IdFAI-F is a valid and reliable tool to accurately identify and measure chronic ankle instability in research and clinical settings for French-speaking individuals.

Cross-cultural adaptation and validation of the Arabic version of the foot function index in patients with chronic lateral ankle instability

Background

The English version of the Foot Function Index (FFI) is a reliable and valid tool for measuring pain and functional instability due to chronic lateral ankle instability (CLAI). However, its use among Arabic speakers with CLAI is limited because of the unavailability of the Arabic version of the FFI (FFI-Arb). This study aimed to translate, cross-culturally adapt and validate the FFI from the original English version into Arabic.

Methods

The FFI questionnaire was translated using the Beaton guidelines. Two-hundred-and-thirty native Arabic-speaking participants with CLAI were recruited from different physiotherapy clinics in Saudi Arabia. The convergent validity of the FFI-Arb was tested using the Spearman correlation with the Arabic version Cumberland ankle instability tool (CAIT-Arab). Test-retest reliability was tested among 92 participants who completed the form again after seven days.

Results

Two-hundred-and-thirty participants were enrolled (mean age = 32.09, Standard deviation (SD) = 8.64 years old). There was excellent internal consistency for the three subscales of FFI: pain (0.95), disability (0.97), and activity limitation (0.86), as for the total score (0.98). Convergent validity was analyzed by Spearman rank correlation between the new translated versions of FFI-Arb and CAIT-Arab. The total FFI-Arb and CAIT-Arab scores were moderately correlated (rho = − 0.569; p < 0.001). Subscales of FFI-Arb, such as pain, disability, and activity limitation, were also moderately correlated with CAIT-Arab (rho = − 0.565, rho = − 0.561, rho = − 0.512; p < 0.001). The construct validity was confirmed by principal component analysis (factor analysis) showing a three-factor structure (eigenvalue 1) of FFI-Arb with a total variance of 77.3%. Test-retest reliability was excellent for the total score of the FFI-Arb and all its subscales (interclass correlation coefficient = 0.984–0.999).

Conclusions

The FFI-Arb is a reliable and valid tool for Arabic-speaking patients with CLAI. The FFI-Arb can be utilized in hospitals and clinics in Arabic speaking countries.

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.

Digital Rehabilitation for Acute Ankle Sprains: Prospective Longitudinal Cohort Study

Background

Ankle sprains are one of the most prevalent soft-tissue injuries worldwide. Physical therapy, especially progressive exercise, has proven effective in improving function, while preventing recurrence.

Objective

We aim to present the results of a fully remote and digitally guided rehabilitation program for acute ankle sprains.

Methods

We performed a prospective longitudinal cohort study of individuals eligible for workers’ compensation, who were referred for digital rehabilitation therapy for a sprained ankle. Therapeutic exercise sessions were to be performed independently by the patient at home using the biofeedback device provided by SWORD Health. Primary endpoints were the change in self-reported Numerical Pain Rating Scale (NPRS) and Foot and Ankle Ability Measure–activities of daily living (FAAM–ADL) and FAAM–Sports scores. Participants were assessed at baseline, end of the program, and 6 months after program completion. Secondary outcomes included digital therapy dosage, pain and fatigue during sessions, and satisfaction.

Results

In total, 93 (89.4%) patients completed the program and 79 (76.0%) were available for follow-up. Changes in the primary outcomes between baseline and the 6-month follow-up were both significant (P<.001) and clinically meaningful: mean difference of –2.72 points (95% CI –3.31 to –2.13) on the NPRS (49.8% reduction), 21.7 points (95% CI 17.13-26.27) on the FAAM–ADL (41.1% increase), and 37.8 points (95% CI 30.45-45.15) on the FAAM-Sports (151.8% increase). Longer waiting periods between the accident date and treatment initiation were found to negatively impact functional status at baseline and at the end of the program, triggering an extension in the program duration. The total training volume (12.5 hours, SD 10.5 hours) was similar to that of other interventions for ankle sprains, but the dosage per week was much higher (2.4 hours per week, SD 0.87 hours per week). The mean patient satisfaction score was 8.8 (SD 1.57) out of 10. Among program completers, 83.9% attained full recovery and were discharged with no residual disability.

Conclusions

Being far less demanding in terms of human resources, the digital program presented constituted a viable, clinically effective, and convenient solution for ankle sprain rehabilitation, particularly during the pandemic. This is the first study presenting a fully remote home-based rehabilitation program for acute ankle sprains, with patients achieving sustained long-term results. This was a prospective cohort study and, as such, did not include a control group, but the results appear comparable to those published for face-to-face interventions.

Trial Registration

ClinicalTrials.gov NCT04819022; https://clinicaltrials.gov/ct2/show/NCT04819022

[Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department]

Hintergrund

Sprunggelenk- und Fußverletzungen gehören zu den häufigsten Krankheitsbildern in der Traumatologie. Ziel dieser Studie war es, die demografischen Veränderungen von Patienten mit Fuß- und Sprunggelenkverletzungen, das zeitliche Auftreten und die Entwicklung über die Jahre in einer Notaufnahme zu untersuchen.

Material und Methoden

Retrospektive Datenauswertung von Patienten, welche aufgrund einer Fuß- und Sprunggelenkverletzung in der Notaufnahme im Zeitraum von 2010 bis 2017 behandelt wurden. Die Patienten wurden mittels ICD-Codes identifiziert und die demografischen Veränderungen, das zeitliche Auftreten und die Entwicklung über die Jahre analysiert. Mittels Quantil-Quantil-Diagramm wurden kontinuierliche Variablen auf Normalverteilung getestet und, falls zutreffend, mittels t‑Test oder nichtparametrischem Mann-Whitney-U-Test auf Signifikanz überprüft.

Ergebnisse

Insgesamt wurden 6581 Fuß- und Sprunggelenkverletzungen in die Analyse eingeschlossen. Das mittlere Alter von Patienten mit einer Fußfraktur war 39 ± 17,4 Jahre und mit einer Sprunggelenkfraktur 47 ± 19,2 Jahre (p < 0,001). Ligamentäre Verletzungen des Sprunggelenks traten insbesondere bei jüngeren Patienten in den Sommermonaten auf. Die Altersverteilung bei Sprunggelenkfrakturen zeigte für Männer einen Häufigkeitsgipfel zwischen dem 30. und 39. Lebensjahr und bei Frauen ein vermehrtes Auftreten ab dem 50. Lebensjahr. In der Altersgruppe zwischen 65 und 75 Jahren stellten Trimalleolarfrakturen die zweithäufigste Sprunggelenkfraktur dar. Frakturen des Fußes betrafen am häufigsten Patienten im Alter von 20 bis 29 Jahren, wobei bei Frauen ein 2. Häufigkeitsgipfel zwischen dem 50. und 59. Lebensjahr zu beobachten war.

Schlussfolgerung

Ligamentäre Verletzungen des Sprunggelenks sind häufige Krankheitsbilder in der Notaufnahme und betreffen v. a. jüngere Patienten. Sprunggelenkfrakturen zeigten für Frauen eine bimodale Altersverteilung, und insbesondere Bi- und Trimalleolarfrakturen waren vermehrt bei Frauen ab dem 65. Lebensjahr zu beobachten. Aufgrund der erhöhten Prävalenz von Fuß- und Sprunggelenkfrakturen bei älteren Frauen sollte in diesem Patientenkollektiv eine weitere Osteoporoseabklärung veranlasst werden.

Efficacy and Safety of an Etofenamate Medicated Plaster for Acute Ankle Sprain: A Randomized Controlled Trial

Background:

The favorable benefit-risk profile of topical nonsteroidal anti-inflammatory drugs (NSAIDs) makes them a preferred treatment for pain relief in soft tissue injuries.

Purpose:

To assess the efficacy and safety of a novel etofenamate 70-mg medicated plaster in patients with acute uncomplicated ankle sprain.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Patients with grade 1 or 2 ankle sprain of recent onset were randomized to etofenamate or placebo plasters (1:1) applied twice daily for 7 days. Clinical assessments, including ankle pain on movement (POM) in mm on a 100-mm visual analog scale (VAS), were made at predefined intervals during the treatment period.

Results:

In total, 156 male or female adult patients (mean age, 35.3 ± 11.8 years) were enrolled. The fall in VAS values for POM from baseline to 72 hours was markedly in favor of the etofenamate plaster, with respective reductions of 52.7% and 24.0% for active and placebo plasters (least squares mean treatment difference, 22.1 mm; P value for analysis of covariance < .0001). Similar clinically relevant differences between etofenamate and placebo were seen for POM at the 48-, 96-, and 168-hour visits (P < .0001). These differences between etofenamate and placebo plasters were reflected in area under the curve for POM, pain at rest, and ankle swelling measured at various time points during the 7 days. Time taken to achieve a meaningful (30%) and optimal (50%) reduction of POM was significantly shorter in the etofenamate group. The responder rate (proportion of patients with at least 50% pain reduction at 72 hours) was 52.5% for the etofenamate plaster and 7.7% for the placebo. A significantly greater proportion of patients randomized to etofenamate rated their progress and/or the treatment as “good” or “very good.” The medicated plasters adhered well over the 12-hour dosing period and were very well-tolerated.

Conclusion:

With respect to the investigated indication, uncomplicated ankle sprain, the etofenamate plaster has therapeutic efficacy that is similar to that for the best available topical NSAID formulations.

Registration:

2016-000252-99 (EudraCT number).

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

Diagnostic Accuracy of Clinical Tests Assessing Ligamentous Injury of the Talocrural and Subtalar Joints: A Systematic Review With Meta-Analysis

Context:

Ankle sprains are the most common acute musculoskeletal injury. Clinical tests represent the first opportunity to assess the sprain’s severity, but no systematic review has compared these tests to contemporary reference standards.

Objective:

To determine the diagnostic accuracy of clinical tests assessing the talocrural and subtalar joint ligaments after ankle sprain.

Data Sources:

CINAHL, EMBASE, MEDLINE, hand-searching, and PubMed-related article searches (inception to November 18, 2020).

Study Selection:

Eligible diagnostic studies compared clinical examination (palpation, joint laxity) against imaging or surgery. Studies at a high risk of bias or with high concerns regarding applicability on Quality Assessment of Diagnostic Accuracy Studies-2 were excluded from the meta-analysis.

Study Design:

Systematic review and meta-analysis.

Level of Evidence:

Level 3a.

Data Extraction:

True-positive, false-negative, false-positive, and true-negative findings were extracted to calculate sensitivity, specificity, and likelihood ratios. If ordinal data were reported, these were extracted to calculate Cohen’s kappa.

Results:

A total of 14 studies met the inclusion criteria (6302 observations; 9 clinical tests). No test had both sensitivity and specificity exceeding 90%. Palpation of the anterior talofibular ligament is highly sensitive (sensitivity 95%-100%; specificity 0%-32%; min-max; n = 6) but less so for the calcaneofibular ligament (sensitivity 49%-100%; specificity 26%-79%; min-max; n = 6). Pooled data from 6 studies (885 observations) found a low sensitivity (54%; 95% CI 35%-71%) but high specificity (87%; 95% CI 63%-96%) for the anterior drawer test.

Conclusion:

The anterior talofibular ligament is best assessed using a cluster of palpation (rule out), and anterior drawer testing (rule in). The talar tilt test can rule in injury to the calcaneofibular ligament, but a sensitive clinical test for the ligament is lacking. It is unclear if ligamentous injury grading can be done beyond the binary (injured vs uninjured), and clinical tests of the subtalar joint ligaments are not well researched. The generalizability of our findings is limited by insufficient reporting on blinding and poor study quality.

Registration:

Prospero ID: CRD42020187848.

Data Availability:

Data are available in a public, open access repository on publication, including our RevMan file and the CSV file used for meta-analysis: http://doi.org/10.5281/zenodo.4917138

A systematic review of health economic evaluation in orthotics and prosthetics: Part 2-orthotics

BACKGROUND

Health economic evaluations (HEEs) in orthotics are in their infancy. Identification of evidence gaps and method design issues will inform the design of future HEEs that advance knowledge and contributes to policy and investment decisions.

OBJECTIVES

The aim of this systematic review was to critically appraise the existing orthotic/prosthetic health economic evaluation literature and therefore determine evidence gaps, critical method design issues, and the extent to which the literature informs orthotic policy and investment decisions.

STUDY DESIGN

Systematic review.

METHODS

A range of databases were searched using intervention- and HEE-related terms. The Consolidated Health Economic Checklist-Extended and the Checklist for Health Economic Evaluation Reporting Standards were used to identify issues with method design and reporting.

RESULTS

Nine orthotic HEEs were narrowly focused on the cost-effectiveness of low-cost orthotic devices (eg, ankle orthoses for ankle sprains). Method design (eg, cost identification and valuation) and reporting issues (eg, lack of detail about the study population) limited the extent to which this literature can inform policy and investment decisions.

CONCLUSIONS

HEEs comparing a wider variety of interventions are required, particularly for commonly used orthoses (eg, ankle-foot orthoses) and clinical presentations (eg, post-stroke). There are opportunities to strengthen future orthotic HEEs by adopting method design features (eg, microcosting and sensitivity analyses) as recommended by HEE appraisal and reporting tools.

Short-Term Effects of Balance Training with Stroboscopic Vision for Patients with Chronic Ankle Instability: A Single-Blinded Randomized Controlled Trial

Chronic Ankle Instability (CAI) is one of the most common musculoskeletal dysfunctions. Stroboscopic vision (SV) training has been deemed to enhance somatosensorial pathways in this population group; nevertheless, until recently no studies have addressed the additional effects of this treatment option to the traditional therapeutic approach.

METHODS

To evaluate the effectiveness of a partial visual deprivation training protocol in patients with CAI, a randomized controlled trial was carried out. Patients with CAI (n = 73) were randomized into either a balance training, SV training, or a control (no training) group. For participants assigned into training groups, they received 18 training sessions over 6 weeks. The primary outcome was dynamic balance as measured by the Star Excursion Balance Test assessed at baseline and after 6 weeks of intervention. Secondary outcome measures included ankle dorsiflexion range of motion, self-reported instability feeling, and ankle functional status.

RESULTS

Better scores in stroboscopic training and balance training groups in all outcome measures were observed in comparison with the control group with moderate to large effect sizes. Stroboscopic training was more effective than neuromuscular training in self-reported instability feeling (cohen's d = 0.71; p = 0.042) and anterior reach distance of the star excursion balance test (cohen's d = 1.23; p = 0.001).

CONCLUSIONS

Preliminary findings from the effects of SV Stroboscopic training in patients with CAI, suggest that SV may be beneficial in CAI rehabilitation.

Consistency and Reliability of Ankle Stress Radiography in Patients With Chronic Lateral Ankle Instability

Background:

Ankle stress radiographs are important tools for evaluating chronic lateral ankle instability. The consistency of a patient’s ankle condition as it affects the reliability of ankle stress radiographs has never been evaluated.

Purpose:

To investigate the consistency and reliability of ankle stress radiographs in patients with chronic lateral ankle instability without an ankle injury during the study period.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

Included were patients with chronic lateral ankle instability who underwent 2 repeated ankle stress radiographs between January 2014 and July 2019; those with an ankle injury during the study period were excluded. The tibiotalar tilt angle on varus stress radiographs and anterior translation of the talus on anterior drawer stress radiographs were measured at initial presentation and final follow-up examination. Interobserver reliability and consistency of ankle stress radiographs were analyzed using the intraclass correlation coefficient (ICC).

Results:

A total of 45 patients (mean ± standard deviation age, 36.4 ± 13.4 years; 18 men and 27 women; follow-up duration, 9.1 ± 3.2 months) were included. The mean ± standard deviation tibiotalar tilt angle and anterior talar translation at initial presentation were 10.8° ± 5.2° and 6.9 ± 2.7 mm, respectively. The interobserver reliabilities of the tibiotalar tilt angle and anterior talar translation were excellent (ICC = 0.926 [95% CI, 0.874-0.959] and 0.911 [95% CI, 0.766-0.961], respectively). The consistency between the initial and final radiographs was good for tibiotalar tilt angle (ICC = 0.763 [95% CI, 0.607-0.862]) and poor for anterior talar translation (ICC = 0.456 [95% CI, 0.187-0.660]).

Conclusion:

Although the interobserver reliability of the radiographic measurements was excellent, the consistency of the ankle stress radiographs was not as acceptable. Surgeons need to be cautious when deciding whether to operate on a patient with chronic lateral ankle instability based on a single ankle stress radiograph.

Incidence and risk factors for poor ankle functional recovery, and the development and progression of posttraumatic ankle osteoarthritis after significant ankle ligament injury (SALI): the SALI cohort study protocol

Background

Ankle sprains are one of the most common musculoskeletal injuries, accounting for up to 5% of all Emergency Department visits in the United Kingdom. Ankle injury may be associated with future ankle osteoarthritis. Up to 70% of ankle osteoarthritis cases may be associated with previous ankle injury. There is limited research regarding the association between ankle sprain and ankle osteoarthritis development. The current study aims to phenotype those who suffer significant ankle ligament injuries, identify potential risk factors for ankle injuries and subsequent poor recovery, examine why individuals may develop osteoarthritis, and what factors influence this chance.

Methods

In this multicentre cohort study participants were recruited from nine Emergency Departments and two Urgent Care Centres in the United Kingdom. Participants (aged 18–70 years old) were defined as those who had suffered an isolated acute ankle sprain, which was Ottawa Ankle Rules positive, but negative for a significant ankle fracture on x-ray. Age and sex matched controls were also recruited. The controls were individuals who had not suffered a significant ankle injury, including ankle pain, function affected for more than 7 days, or the ankle caused them to report to an Emergency Department. Data is collected through a series of seven questionnaires (at baseline, 3 months, 1 year, 3 years, 5 years, 10 years, and 15 years later). The questionnaires include four sections (demographic questions; index injury, and injury history questions; functional assessment questions; and quality of life questions) and are designed to collect detailed information about the individual, their injury, potential risk factors for ankle sprains and ankle osteoarthritis, plus their medical history and any medication consumed.

Discussion

The Significant Ankle Ligament Injury (SALI) study aims to add to the limited knowledge regarding which factors can predict ankle sprains, complaints, and osteoarthritis. This is important because despite ankle sprains being regarded as a benign injury that resolves quickly, residual symptoms are not uncommon months and years after the injury.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04230-8.

Trends in operative ankle ligament surgery in Finland between 1986 and 2018

BACKGROUND

Ankle sprains are common musculoskeletal injuries. Until the 1990s, ankle ligament injuries were often treated operatively. The aim of this registry study was to determine how the change in treatment practice has affected the number of acute and elective ankle ligament surgeries in Finland.

MATERIAL

The data of ankle ligament injury patients operated between 1 January 1986 and 31 December 2018 was collected from the Finnish National Hospital Discharge Register.

RESULTS

A total of 33,770 ankle ligament injuries were repaired. The incidence of acute ankle ligament injury repair surgery has decreased nearly 80% over the last three decades. No increase in the number of late-stage ankle ligament injury repairs was found.

CONCLUSION

The number of acute and elective ankle ligament surgeries has remained low in the 2000s. This suggests that the occurrence of clinical instability after ankle sprains has not increased, even though acute-phase treatment has become conservative.

European Resuscitation Council Guidelines 2021: First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Hip and knee muscle torque and its relationship with dynamic balance in chronic ankle instability, copers and controls

OBJECTIVES

We compared hip and knee isometric muscle torque between individuals with chronic ankle instability (CAI), those who have sustained one ankle sprain with no ongoing problems (copers) and healthy controls. Our secondary objective was to compare balance between groups and investigate the relationship between muscle torque and balance.

DESIGN

Cross-sectional study.

METHODS

22 CAI, 20 copers and 22 uninjured participants were tested. Isometric torque (normalised to body mass (Nm/kg)) was measured using a rigidly-fixated hand-held dynamometer. Balance was assessed with the Y-balance test.

RESULTS

Knee and hip flexor and extensor, and hip adductor and abductor muscle torque was less in individuals with CAI compared to controls (standardised mean difference (SMD) >1.2). Hip and knee flexor and extensor muscle torque was less in CAI participants than copers (SMD: 0.69-1.1). Hip external and internal rotator torque did not differ between groups. There was no difference in hip or knee muscle torque between controls and copers (SMD: 0.01-0. 54). Balance was impaired in CAI participants compared to copers and controls in all directions. There was a strong positive correlation between posterolateral Y-balance test performance and torque of the hip adductors (r=0.53), flexors (r=0.52) and extensors (r=0.50).

CONCLUSIONS

Individuals with CAI have weak knee and hip muscles compared to copers and controls. Hip strength was shown to be related to posterolateral balance performance. Future studies may investigate the effect of hip and knee strengthening exercise on ongoing ankle problems, such as episodic giving way in individuals with CAI.

Compression Wrapping for Acute Closed Extremity Joint Injuries: A Systematic Review

OBJECTIVE

Current prehospital recommendations for an acute closed extremity joint injury (ACEJI) are to apply compression in some manner. However, the effectiveness of compression is unclear. We performed a systematic review to summarize and synthesize the evidence for the use of a compression bandage for ACEJI in the prehospital setting.

DATA SOURCES

Cochrane Library, PubMed, and Embase were searched for relevant literature in November 2019.

STUDY SELECTION

Controlled trials involving adults in the prehospital setting with a recent ACEJI were included when compressive, nonimmobilizing interventions, feasible in a first aid setting, were applied and compared with no compression or any noncompressive intervention, such as braces, splints, or noncompressive stockings. Articles in all languages were included if an English abstract was available.

DATA EXTRACTION

Data on study design, study population, intervention, outcome measures, and methodologic quality were extracted from each included article.

DATA SYNTHESIS

Eight studies out of 1193 possibly relevant articles were included. All authors examined compression in the treatment of acute ankle sprains; no studies involved compression for the treatment of other ACEJIs. No difference in the major outcomes of pain reduction or swelling, ankle-joint function, or range of motion could be demonstrated. For the outcome of recovery time, no benefit was shown when comparing compression with no compression. Evidence was insufficient to inform a conclusion about the outcomes of time to return to work or sport. All evidence was of low to very low certainty.

CONCLUSIONS

The evidence for the use of a compression wrap was limited to patients with closed ankle injuries. In this systematic review, we could not demonstrate either a beneficial or harmful effect from the application of a compression or elastic bandage compared with no compression or a noncompressive stocking, splint, or brace as a first aid treatment in the prehospital environment.

Comparison of Regularly Scheduled Ibuprofen Versus "Pro Re Nata" for Ankle Sprains in Children Treated in the Emergency Department: A Randomized Controlled Trial

OBJECTIVE

We compared pain and degree of disability in patients with acute ankle sprains receiving regular scheduled ibuprofen versus pro re nata (PRN).

METHODS

This study is a randomized single-blinded controlled trial of children aged 7 to 17 years presenting with acute ankle sprain to an emergency department. Patients were randomized to receive 10 mg/kg of ibuprofen per dose (maximum 600 mg) every 6 hours regular scheduled versus PRN. Outcome measures included a 100-mm visual analog scale pain and degree of disability at day 4. A sample size of 72 children had a power of 80% to detect a clinically meaningful difference of 20 mm between the regular and PRN group.

RESULTS

We randomly assigned 99 patients to receive regular scheduled (n = 50) or PRN (n = 49) ibuprofen. Pain scores and degree of disability at day 4 showed no significant differences between groups. The rate of reported adverse effects was higher in the regular scheduled group (11.4% vs 9.5%) versus the PRN group.

CONCLUSIONS

Our study suggests that there is little benefit from routinely using a regular scheduled ibuprofen regimen for acute pediatric ankle sprains.

Chronic Lateral Ankle Instability: Topical Review

Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Failure after strict rehabilitation may be an indication for surgery. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion.

French translation and validation of the Cumberland Ankle Instability Tool, an instrument for measuring functional ankle instability

BACKGROUND

Ankle sprains are one of the most common musculoskeletal injuries, and can lead to chronic ankle instability (CAI). The Cumberland Ankle Instability Tool (CAIT) measures a subset of CAI, functional ankle instability (FAI). Because no French version existed, we set out to translate and validate the CAIT in French.

METHODS

The CAIT was translated using a forward-backward methodology. We examined its psychometric properties and calculated a cut-off score for FAI in a sample of 102 subjects (median age 22 years).

RESULTS

The CAIT was translated without significant problems. The CAIT-F can discriminate between those with and without FAI (p < 0.001), with a cut-off score of ≤ 23 points. The test-retest reliability is excellent (ICC = 0.960), as is the internal consistency (α = 0.885). Construct validity was confirmed. No floor or ceiling effects were detected among subjects with FAI.

CONCLUSIONS

The CAIT is now available in French, and is a valid and reliable instrument.

Pain Level, Range of Motion, and Foot Volume Do Not Differ in Recurrent and First-Time Ankle Sprains

Objective. This study aims to describe the clinical features in terms of pain perception, ankle range of motion, and foot volume in participants with recurrent ankle sprains compared with first-time sprains. Methods. Individuals with grade I and II ankle sprains were referred to physiotherapy care for further rehabilitation by their general practitioner. Primary outcome measures were range of movement, pain, and foot volume. Recurrences were described according to engagement in sport. Results. A total of 115 participants were recruited (age = 22.2 ± 6.9 years; female, 84). Neither pain level (P = .822), nor range of motion (dorsiflexion P = .452; plantar flexion P = .436; inversion P = .383; eversion P = .657), nor foot volume (P = .654) were significantly different between the groups: individuals with first-time sprain or with recurrences. Conclusion. Pain and high existence of other lower-limb injuries were reported disregarding the presence of a recurrence. Clinically, it is difficult to differentiate recurrent sprain from a first-time ankle sprain by means of foot volume, range of movement, or pain intensity.

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.

Chronic ankle instability patients exhibit higher variability in lower extremity joint-coupling variability during drop vertical jumps

Chronic ankle instability (CAI) has been associated with biomechanical alterations during landing tasks. While joint coupling differences have been reported during gait in patients with CAI, there is no known research assessing joint coupling during a drop-vertical jumping (DVJ). Joint coupling variability measure may provide information on the sensorimotor health of these patients. The purpose of this study was to compare lower extremity joint coupling variability during a DVJ between patients with CAI and controls. Twenty-eight young, active individuals (CAI:n = 14, Control:n = 14) participated in the study. A 3D motion capture system was used to collect kinematics during 15 drop-vertical jump trials. A vector coding analysis was used to assess the variability in the following joint couples: knee sagittal-ankle frontal, knee sagittal-ankle sagittal, hip frontal-ankle frontal, and hip frontal-ankle sagittal. The CAI group had higher joint coupling variability in hip frontal-ankle sagittal, knee sagittal-ankle frontal and knee sagittal-ankle sagittal planes both prior to and following ground contact during the drop vertical jumps. These changes indicate potential adaptations to the constraint of CAI and the task of the DVJ. Higher variability may reflect an attempt by the subjects to explore alternate movement strategies or reflect poor sensorimotor control strategies. Clinicians should consider the challenges of DVJ during rehabilitation as they create a unique task constraint.

Extremity CT and ultrasound in the assessment of ankle injuries: occult fractures and ligament injuries

OBJECTIVE

To assess the rates of fractures and ligament injuries in patients with an acute ankle injury and a normal radiographic examination, and to consider the most appropriate examination protocol.

METHODS

Patients with an acute ankle injury who presented to the John Radcliffe Hospital Emergency Department with a normal radiographic examination were eligible for the study. They were invited to receive a cone beam CT and ultrasound examination at a local radiology department within 5 days of their ankle injury.

RESULTS

Of the 100 patients recruited to the study, 19 patients were found to have major fractures and 42 patients had small avulsion fractures. Additionally, 42 patients had ankle effusions and there were a large number of soft tissue injuries. There were 83 acute injuries of the anterior talofibular ligament, 19 of the anterior tibiofibular ligaments, 26 of the calcaneofibular ligament, 39 of the deltoid ligament complex, 21 of the talonavicular ligament, 14 of the spring ligament and 3 of the calcaneocuboid ligament.

CONCLUSION

Conventional radiographic examination misses significant fractures of the foot and ankle and the presence of an ankle effusion does not relate to the severity of injury. Ultrasound is a useful imaging technique that can supplement clinical practice, but it is unlikely to replace current protocols alone. Cone beam CT is an appropriate alternative to plain radiography, being more sensitive in detecting fractures and delivering a similar dose of radiation. However, neither CT or ultrasound examination can detect all avulsion fractures. Simple anterior process fractures of the calcaneus are associated with talonavicular ligament injuries and the medial ligaments are injured in almost 50% of cases when there is a lateral ligament injury.

ADVANCES IN KNOWLEDGE

Fractures in the foot and ankle are detected more precisely with cone beam CT compared to radiographs. Cone beam CT delivers similar doses of to conventional radiographs which is around 10% of that resulting from conventional CT. Ultrasound examination is an effective assessment tool to detect ligamentous injuries. The absence of an ankle effusion does not exclude a major fracture.

Weight, BMI and stability are risk factors associated with lateral ankle sprains and chronic ankle instability: a meta-analysis

IMPORTANCE

Lateral ankle sprains (LAS) are common in the general population and may lead to chronic ankle instability (CAI). If patients at risk could be identified, they could receive adequate and on-time treatment.

OBJECTIVE

The purpose of the current review was to identify all reported intrinsic factors associated with sustaining a LAS or progressing to CAI after an initial sprain.

EVIDENCE REVIEW

PubMed, Embase, MEDline, Cochrane and PEDro were searched for studies published until July 2019. Articles were selected if they included intrinsic factors related to LAS or CAI, subjects of at least 16 years old, and contained a minimum of 10 patients and 10 controls. Studies were excluded if they concerned reviews or case reports, included patients with previous surgical interventions, concomitant injuries or joint pathology other than ankle instability. Quality of included studies was assessed using the Quality in Prognostic Studies tool and quality of evidence was assessed using the GRADEpro tool. In case outcomes were described by at least three studies, data were pooled and assessed by performing a meta-analysis. Based on the pooled data, either a fixed-effects model or random-effects model was selected to correct for the degree of heterogeneity.

FINDINGS

The search resulted in a total of 4154 studies. After title and abstract screening and subsequent full-text screening, 80 relevant studies were included. Results of the meta-analyses indicated that, compared with healthy controls, patients with LAS had a higher mean body mass index (BMI). In patients with CAI, a higher weight and a longer time to stabilise after performing a task (eg, jumping) were found compared with healthy controls. Other outcomes could not be compared using a meta-analysis due to heterogeneity in outcome measurement and the great number of different outcomes reported. Identification of the risk factors when patients present themselves after a LAS may help to determine which patients are at risk of recurrent sprains or developing CAI.

CONCLUSIONS AND RELEVANCE

Based on the findings in this review, a higher BMI, and a higher weight and neuromuscular stability deficits may be regarded risk factors for sustaining a LAS or developing CAI, respectively.

LEVEL OF EVIDENCE

III.

Cross-cultural adaptation and validation of an ankle instability questionnaire for use in Chinese-speaking population

BACKGROUND

The Identification of Functional Ankle Instability (IdFAI) is a valid and reliable tool to identify chronic ankle instability; however, it was developed in English, thus limiting its usage only to those who can read and write in English. The objectives of our study were to (1) cross-culturally adapt a Chinese (Mandarin) version of the IdFAI and (2) determine the psychometric properties of the Chinese version IdFAI.

METHODS

The cross-cultural adaptation procedures used by the investigators and translators followed previously published guidelines and included 6 stages: (1) initial translation, (2) synthesis of the translations, (3) back translation, (4) developing the pre-final version for field testing, (5) testing the pre-final version, and (6) finalizing the Chinese version of IdFAI (IdFAI-C). Five psychometric properties of the IdFAI-C were assessed from results of 2 participant groups: bilingual (n = 20) and Chinese (n = 625).

RESULTS

A high degree of agreement was found between the English version of IdFAI and IdFAI-C (intra-class correlation_2,1 = 0.995). An excellent internal consistency (Cronbach's α = 0.89), test-retest reliability (intra-class correlation_2,1 = 0.970), and construct validity (r(625) = 0.67) was also found for the IdFAI-C. In addition, the results of exploratory and confirmatory factor analysis indicated that ankle instability was the only construct measured from the IdFAI.

CONCLUSION

The IdFAI-C is a highly reliable and valid self-report questionnaire that can be used to assess ankle instability. Therefore, we suggest that it can be used to effectively and accurately assess chronic ankle instability in clinical settings for Chinese-speaking individuals.

What is the quality of clinical practice guidelines for the treatment of acute lateral ankle ligament sprains in adults? A systematic review

BACKGROUND

Acute lateral ankle ligament sprains (LALS) are a common injury seen by many different clinicians. Knowledge translation advocates that clinicians use Clinical Practice Guidelines (CPGs) to aid clinical decision making and apply evidence-based treatment. The quality and consistency of recommendations from these CPGs are currently unknown. The aims of this systematic review are to find and critically appraise CPGs for the acute treatment of LALS in adults.

METHODS

Several medical databases were searched. Two authors independently applied inclusion and exclusion criteria. The content of each CPG was critically appraised independently, by three authors, using the Appraisal of Guidelines for REsearch and Evaluation (AGREE II) instrument online version called My AGREE PLUS. Data related to recommendations for the treatment of acute LALS were abstracted independently by two reviewers.

RESULTS

This study found CPGs for physicians and physical therapists (Netherlands), physical therapists, athletic trainers, physicians, and nurses (USA) and nurses (Canada and Australia). Seven CPGs underwent a full AGREE II critical appraisal. None of the CPGs scored highly in all domains. The lowest domain score was for domain 5, applicability (discussion of facilitators and barriers to application, provides advice for practical use, consideration of resource implications, and monitoring/auditing criteria) achieving an exceptionally low joint total score of 9% for all CPGs. The five most recent CPGs scored a zero for applicability. Other areas of weakness were in rigour of development and editorial independence.

CONCLUSIONS

The overall quality of the existing LALS CPGs is poor and majority are out of date. The interpretation of the evidence between the CPG development groups is clearly not consistent. Lack of consistent methodology of CPGs is a barrier to implementation.

SYSTEMATIC REVIEW

Systematic review registered with PROSPERO ( CRD42015025478 ).

An Updated Model of Chronic Ankle Instability

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

Risk Factors for Lateral Ankle Sprains and Chronic Ankle Instability

Lateral ankle sprains (LASs) are a common injury sustained by individuals who participate in recreational physical activities and sports. After an LAS, a large proportion of individuals develop long-term symptoms, which contribute to the development of chronic ankle instability (CAI). Due to the prevalence of LASs and the propensity to develop CAI, collective efforts toward reducing the risk of sustaining these injuries should be a priority of the sports medicine and sports physiotherapy communities. The comprehensive injury-causation model was developed to illustrate the interaction of internal and external risk factors in the occurrence of the inciting injury. The ability to mitigate injury risk is contingent on a comprehensive understanding of risk factors for injury. The objective of this current concepts review is to use the comprehensive injury-causation model as a framework to illustrate the risk factors for LAS and CAI based on the literature.

Effect of triage nurse-led application of the Ottawa Ankle Rules on number of radiographic tests and length of stay in selected emergency departments in Oman

AIM

Ankle injuries are commonly seen in the emergency department (ED) and contribute to overcrowding. In Oman, injuries are a leading cause of years of life lost, disability-adjusted life years, and pose a burden to the healthcare system. This study aimed to evaluate the effectiveness of ED triage nurse-led application of the Ottawa Ankle Rules (OARs) toward improving the healthcare outcomes of ankle injury patients.

METHODS

A quasi-experimental design was used to collect data (demographic characteristics, waiting time, length of stay, and number of radiographic tests) from 96 patients. The intervention group (n = 46) received ED triage nurse-led assessment and initiation of radiographic tests based on the OARs. The control group (n = 50) received usual care.

RESULTS

The participants' mean age was 26.4 ± 7.90 years. The main causes of ankle injuries were football (36%), falls (31%) and twisting while walking (24%). There was a significant difference in number of ankle X-rays (t = 6.19; p < .001); length of stay (U = 549; p < .001); and waiting time (U = 167; p < .001) between the control and intervention group. The intervention reduced the mean waiting time and length of stay by 25.09 and 41.01 min, respectively.

CONCLUSION

Application of the OARs by the ED triage nurse can decrease the number of unnecessary radiographic tests, waiting time and length of stay in the ED. Nurses' utilization of evidence-based clinical decision-making tools can improve ED care outcomes of common acute conditions such as ankle injuries.

Epidemiology of Ankle Sprains and Chronic Ankle Instability

OBJECTIVE

To provide a focused overview of the existing literature on the epidemiology of acute ankle sprains (lateral, medial, and high/syndesmotic) with an emphasis on incidence studies from the United States. In addition, we provide a brief overview of chronic ankle instability (CAI), posttraumatic osteoarthritis, and injury prevention to contribute to our understanding of the epidemiology of these injuries and the current state of the science on ankle sprains and ankle instability in sports medicine.

BACKGROUND

Acute ankle sprains are one of the most common musculoskeletal injuries, with a high incidence among physically active individuals. Additionally, acute ankle sprains have a high recurrence rate, which is associated with the development of CAI. Understanding the epidemiology of these injuries is important for improving patients' musculoskeletal health and reducing the burden of lower limb musculoskeletal conditions.

DESCRIPTION

Acute ankle-sprain incidence rates are summarized among the general population, as well as among physically active populations, including organized athletics and military personnel, with a focus on incidence in the United States. The link between a prior ankle sprain and a future acute ankle sprain is described. We also discuss the association between the incident ankle sprain and adverse, long-term outcomes such as CAI and posttraumatic osteoarthritis. Finally, we summarize injury-prevention successes and future directions for research and prevention.

CLINICAL APPLICATIONS

This information is useful for health care providers to understand the expected incidence rates of acute ankle sprains, be aware of the association between ankle sprains and negative short- and long-term outcomes, and be familiar with existing injury-prevention programs.

Epidemiology of Ankle Sprains and Chronic Ankle Instability

OBJECTIVE

To provide a focused overview of the existing literature on the epidemiology of acute ankle sprains (lateral, medial, and high/syndesmotic) with an emphasis on incidence studies from the United States. In addition, we provide a brief overview of chronic ankle instability (CAI), posttraumatic osteoarthritis, and injury prevention to contribute to our understanding of the epidemiology of these injuries and the current state of the science on ankle sprains and ankle instability in sports medicine.

BACKGROUND

Acute ankle sprains are one of the most common musculoskeletal injuries, with a high incidence among physically active individuals. Additionally, acute ankle sprains have a high recurrence rate, which is associated with the development of CAI. Understanding the epidemiology of these injuries is important for improving patients' musculoskeletal health and reducing the burden of lower limb musculoskeletal conditions.

DESCRIPTION

Acute ankle-sprain incidence rates are summarized among the general population, as well as among physically active populations, including organized athletics and military personnel, with a focus on incidence in the United States. The link between a prior ankle sprain and a future acute ankle sprain is described. We also discuss the association between the incident ankle sprain and adverse, long-term outcomes such as CAI and posttraumatic osteoarthritis. Finally, we summarize injury-prevention successes and future directions for research and prevention.

CLINICAL APPLICATIONS

This information is useful for health care providers to understand the expected incidence rates of acute ankle sprains, be aware of the association between ankle sprains and negative short- and long-term outcomes, and be familiar with existing injury-prevention programs.

Does Neuromuscular Electrical Stimulation Improve Recovery Following Acute Ankle Sprain? A Pilot Randomised Controlled Trial

Aim:

Following soft tissue ankle injury, patients are often referred for out-patient physiotherapy and present symptoms including pain, reduced range of movement and function, and oedema. In this study, we assess the use of a neuromuscular electrical stimulation (NMES) device as an adjunctive therapy to reduce oedema in patients recovering from grade I and II ankle sprains.

Methods:

This was a single-centre, pilot randomised controlled study, recruiting patients referred to physiotherapy following an ankle sprain. Participants presenting with oedema were randomised to one of two treatment groups: (1) the current standard of care and (2) the current standard of care plus NMES use. Participants were identified in an emergency department and referred to a physiotherapy department for treatment 1 to 5 days following the injury and returned to clinic 7 days later.

Results:

Twenty-two participants completed the study and had full data sets for analysis (11 in each group). Mean volumetric displacement was reduced in the intervention group in comparison to the standard care group (P = .011); however, there were no between-group differences in figure of eight measurements, function or pain scores. The device was well tolerated, with no device-related adverse events recorded.

Conclusions:

In this pilot, randomised controlled trial, NMES was well tolerated by patients following ankle sprain and demonstrated statistically significant improvements in oedema reduction as measured by fluid displacement. No other changes were observed. Further work will need to confirm the clinical significance and effect on longer term recovery post-ankle sprain.

Hindfoot Arthrodesis Screw Position and Trajectory Effect on Talus Subsidence When Performed With Total Ankle Arthroplasty

BACKGROUND:

Total ankle arthroplasty (TAA) is increasingly being recognized as an effective surgical option for end-stage ankle arthritis. Associated hindfoot arthrodesis procedures are at times needed to correct malalignment or to address adjacent joint arthritis. Results following TAA and associated hindfoot arthrodesis have at times been underwhelming and the devascularization of the talar blood supply has been postulated as a potential cause. This study explored the association between hindfoot arthrodesis fixation and talar component subsidence.

METHODS:

The study included 81 consecutive patients who underwent a TAA with either an isolated subtalar arthrodesis or combined subtalar and talonavicular arthrodesis with a minimum of 2 years of follow-up. Radiographic and clinical evaluations including patient-reported outcomes were performed at each postoperative visit. The primary outcome measure was the presence of talar component subsidence while patient-reported outcomes were the secondary outcome measure.

RESULTS:

30.9% of patients had evidence of talar component subsidence. Subsidence was seen in 55.5% of patients with dorsal to plantar subtalar fixation compared to 11.1% of patients with plantar to dorsal screws ( P < .001) and in 44.4% of patients with screws violating the sinus tarsi compared to 3.7% of patients without screws in the sinus tarsi ( P < .001). Screws that were placed from dorsal to plantar were more likely to violate the sinus tarsi ( P < .001). Patients with evidence of talar subsidence reported higher pain scores and lower functional scores. There were 8 TAA failures, and the presence of dorsal to plantar screws was associated with failure ( P < .01).

CONCLUSION:

Screws that are placed across the subtalar joint from a dorsal to plantar approach are more likely to violate the sinus tarsi, contributing to a significantly higher rate of talar component subsidence when associated with TAA.

LEVEL OF EVIDENCE:

Level II, prospective comparative series.

Factors influencing return to play following conservatively treated ankle sprain: a systematic review

BACKGROUND

Ankle sprain is a very common injury, yet uncertainty exists in what is appropriate time to return to play (RTP). Such guidance may inform treatment pathways and effective practice.

OBJECTIVES

To determine if consensus exist about potential influencing factors for time to RTP in conservatively treated ankle sprain.

METHODS

We searched AMED, CINAHL Plus, Cochrane library, EMBASE, MEDLINE (EBSCO), SPOERDiscus, PsycINFO, PEDro, Scopus, unpublished literature and ongoing trials and Google Scholar from inception until April 2017. The quality of the eligible papers was assessed using the Downs and Black tool for randomized controlled trials (RCTs) and Critical Appraisal Skills Program (CASP) for observational studies.

RESULTS

The initial search identified 1885 articles. After screening, 14 articles were included. Of these, 11 were RCTs and 3 were prospective observational studies. Individual treatment methods that resulted in a shorter time to RTP were functional treatment, compression stockings, anteroposterior joint mobilization, hyaluronic acid injection (HA), Jump Stretch Flex Band programme (JSFB) and diclofenac medication. Prognostic factors for determining time to RTP in the included prospective observational studies were measures of Global function, SF 36PF, athlete's ambulation status, weight-bearing activity scores and self-reported athletic ability.

CONCLUSION

To our knowledge, this is the first review to report influencing factors for time to RTP following conservatively treated ankle sprain. Findings from this review identified factors that influence time to RTP. However, caution should be taken in generalizing these results due to the heterogeneity of studies and inability to clearly define and list the criteria for safe RTP. The inclusion of factors such as age, sex, BMI, level of sport, injury related factors in future studies might help to understand the course of injury and therefore assist in constructing safer criteria.