Ankle sprain: pathophysiology, predisposing factors, and management strategies

Ligamentous ankle injuries in relation to the morphology of the incisura fibularis: A systematic review

IMPORTANCE

Ligamentous ankle lesions are among the most frequent sports injuries. One of the key intrinsic stabilizers of the ankle joint is the incisura fibularis (IF), as it interlocks the distal tibia and fibula. Despite an abundant amount of studies related to ligamentous ankle injuries, scant attention has been given to the specific role of the IF morphology.

OBJECTIVE

We systematically reviewed all literature focused on the relation between ligamentous ankle lesions and IF morphology.

EVIDENCE REVIEW

A systematic literature search was conducted on PubMed, Embase, and Web of Science according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021282862). In general, search terms were related to ankle and syndesmosis trauma/instability in combination with morphology parameters of the IF. Studies categorizable as original research (randomized controlled trial or observational) were included. Studies concerning degenerative ankle disease and cadavers were excluded.

FINDINGS

Thirteen studies were confirmed eligible and consisted of a prospective cohort (n ​= ​1), retrospective comparative (n ​= ​10), and observational (n ​= ​2) study design. Several studies have found an increased number of ankle ligament injuries and a higher incidence of chronic ankle instability in association with a shallow IF depth. In addition, statistically significant differences in incisura height and angle were also noted: a shorter incisura and more obtuse angle were more present in patients with ankle ligament injuries.

CONCLUSION AND RELEVANCE

Most studies found distinct characteristics of the IF morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. However, not all studies could identify this association and presented a heterogeneous methodological quality. Therefore, further prospective studies are warranted to clarify the relationship between the IF morphology and ligamentous ankle injuries.

LEVER OF EVIDENCE

Level III, systematic review.

Effects of Acute Lateral Ankle Sprain on Spinal Reflex Excitability and Time-to-Boundary Postural Control in Single-Leg Stance

Background/Objectives: Acute lateral ankle sprain (ALAS) affects balance, often assessed by changes in traditional center of pressure (COP) parameters. Spatiotemporal measures of COP and time-to-boundary (TTB) analysis may offer improved sensitivity in detecting postural deviations associated with ALAS. However, the neurophysiological mechanism underlying these changes remains unknown. This study aimed to explore the effects of ALAS on spinal reflex excitability in the fibularis longus (FL) during single-leg balance and TTB parameters following ALAS. Methods: Fourteen participants with and without ALAS were recruited within 14 days from the onset of the injury. We assessed FL spinal reflex excitability and postural control during a single-leg stance. The primary outcomes included the H/M ratio, H-latency, and TTB parameters. For H-reflex testing, the peripheral electrical stimulation was delivered at the sciatic nerve before bifurcating into the tibial and common fibular nerve while participants maintained a single-leg balance position with the involved side of the limb. The TTB parameters of the medial-lateral (ML) and anterior-posterior (AP) directions of the mean, SD, and minimum were assessed, which indicate postural correction and strategies. Results: Patients with ALAS had a significantly lower AP-TTB minimum compared with healthy uninjured controls, with a moderate effect size (p = 0.039; d = -0.83). However, there was no significant difference in the H/M ratio (ALAS: 0.29 ± 0.16 vs. CON: 0.24 ± 0.10; p = 0.258) and H-reflex latency (ALAS: 34.6 ± 1.92 vs. CON: 33.8 ± 1.75 ms; p = 0.277); Conclusions: These results indicate that reflex control at the spinal level may have a minimal role in response to balance deficits following ALAS.

Recent advances in the management of chronic ankle instability

Ankle sprains are the most common lesion of the ankle joint which might result in chronic ankle instability (CAI). Significant strides have been taken to enhance our comprehension of the underlying mechanisms of CAI, as the exploration of novel surgical techniques and the identification of previously unrecognized anatomical components. The present review aims to provide an extensive overview of CAI, encompassing its pathophysiology, epidemiology, clinical assessment, treatment, and rehabilitation. Treatment of CAI requires a multifaceted algorithm, involving historical analysis, clinical evaluations, and diagnostic imaging. Surgical interventions for CAI primarily involve the anatomical and/or non-anatomical reconstruction and/or repair of the anterior talofibular ligament. Anatomical repair has exhibited superior functional outcomes and a reduced risk of secondary osteoarthritis compared to non-anatomical repair. Non-anatomical approaches fall short of replicating the normal biomechanics of the anterior talofibular ligament, potentially leading to postoperative stiffness. This review seeks to academically review and up-to-date literature on this issue, tailored for clinical practice, with the intent of aiding surgeons in staying abreast of this critical subject matter.

The Impact of Ankle Mobilization Techniques on Static Stability in Individuals With Acute Inversion Ankle Sprain: A Randomized Clinical Trial

Objective

The purpose of the study was to compare the impact of the mobilization techniques and mobilization with movement techniques on static balance in individuals with acute inversion ankle sprain.

Methods

Volunteers with acute inversion ankle sprain (N = 40) were equally and randomly assigned to 2 groups. Participants in intervention group I received the Mulligan mobilization with movement techniques, whereas participants in intervention group II underwent the Maitland mobilization techniques. Each participant received the intervention every other day for 2 consecutive weeks. To assess static balance, participants assumed a single-leg stance on the affected leg at the center of a force plate with eyes open or closed plate for 20 seconds. The displacement, velocity, and area of the center of pressure were recorded 1 day before and after the intervention.

Results

The velocity of the center of pressure in the anterior-posterior direction was significantly reduced only in group I during eyes open (P = .043) and closed (P = .004). However, the displacement of the center of pressure in the anterior-posterior direction was significantly decreased in both group I (P = .024) and group II (P = .028) with eyes open. No significant changes were found in the area of the center of pressure in either group during eyes open or closed (P > .053).

Conclusions

Both Mulligan's and Maitland's approaches significantly improved sway displacement. For the individuals with acute inversion ankle sprain who were included in this study, the Mulligan technique were more effective in improving static balance indicators compared to the Maitland technique.

Clinical Trial

The study was then registered in the Iranian Registry of Clinical Trials (17/02/2019) (IRCT20190108042292N2).

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Point of Care Ultrasound Guided Management of Lateral Ankle Sprains: A Case Series

Background

Lateral ankle sprain (LAS) is a common injury with incidence rates reported at 7.2 per 1000 person-years. Physical examination strategies provide limited information to guide rehabilitation that can maximize clinical outcomes. Early and accurate diagnostic information using ultrasound imaging enables individualized care and the ability to monitor healing along with its response to activity and rehabilitation.

Purpose

The purpose of this study was to describe and observe the outcomes associated with Point of Care Ultrasound (POCUS) guided early management of acute and sub-acute lateral ankle sprains.

Study Design

Case series.

Methods

Individuals with a LAS within the prior 28 days underwent a clinical evaluation to include a POCUS exam to assess ligamentous integrity. Objective and POCUS findings were integrated to classify each LAS into one of four categories. Each grade of ankle sprain corresponded to levels of bracing for the protection of injured structures with each patient receiving physical therapy care based on rehabilitation guidelines. Participants completed the Foot and Ankle Ability Measure (FAAM) activities of daily living and Sports subscale, the Foot and Ankle Outcome Score (FAOS), Patient Reported Outcomes Measurement Information Systems Global Health, Tampa Scale of Kinesiophobia (TSK-11), Cumberland Ankle Instability Tool (CAIT), and the Numeric Pain Rating Scale as well as the Ankle Lunge Test and Figure 8 measurements at baseline, 4 weeks, 8 weeks and 12 weeks post enrollment. The FAAM Sport subscale, all FAOS subscales, and the TSK-11 were also collected at 24 weeks while the CAIT was collected at baseline and 24 weeks.

Results

Fourteen participants were enrolled with 11 participants completing all data collection. FAAM Sport scores significantly improved at 4, 8, 12 and 24 weeks. All components of the FAOS significantly increased except for Sport scores at four weeks and Quality of Life scores at four and eight weeks.

Conclusion

POCUS guided early management and ligamentous protection of LASs resulted in significant short and long-term improvement in function and return to sporting activity. This case series highlights the feasibility of using ultrasound imaging to assess the severity of ligamentous injury and align bracing strategies for ligamentous protection. The observations from this case series suggest that functional bracing strategies focused on ligamentous protection to promote healing and reduce re-injury rates does not delay improvement in functional outcomes.

Level of Evidence

Level IV, Case Series.

The Specific Anatomical Morphology of Lateral Ankle Ligament: Qualitative and Quantitative Cadaveric based Study

OBJECTIVE

The accurate understanding in morphological features of the lateral ankle ligaments is necessary for the diagnosis and management of ankle instability and other ankle problems. The purpose of this study was to evaluate the anatomical morphology and the attachment areas of lateral ligament complex of ankle joint based on the cadaveric study.

METHODS

Fifty-four fresh frozen cadaveric ankles were dissected to evaluate the lateral ankle ligaments. Each ligament was separated into two or three small bundles. In the investigated footprint areas, acrylic colors were used as a marker point to locate specific areas of ligament bundle attached to the bone. The Image J software was used to measure and analyze the sizes of the specific footprint areas to achieve descriptive statistical analysis.

RESULTS

The double bands of anterior talofibular ligament (ATFL) were found as a major type in the present study with 57.41% (31 of 54 ankles) while the single band of ATFL was observed in 42.59% (23 of 54 ankles). The attachment sizes of the ATFL, posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL) were evaluated into two areas; proximal and distal attachments. The average of proximal or fibular part of ATFL, PTFL and CFL were 85.06, 134.27, 93.91 mm2 respectively. The average of distal part of ATFL, PTFL and CFL were 100.07, 277.61, 249.39 mm2 respectively.

CONCLUSION

Considering the lateral ankle ligament repaired or reconstruction especially using arthroscopy, the precise understanding in specific detail of the lateral ankle ligament may help both diagnose and select the appropriate treatment for solving the ankle problems. These observations may help the surgeon to perform the surgical procedure for determining the appropriate techniques and avoid complication to patients.

Do visual and step height factors cause imbalance during bipedal and unipedal stances? A plantar pressure perspective

Objective: The plantar pressure analysis technique was used to explore the static balance ability and stability of healthy adult males under the influence of visual and step height factors during bipedal and unipedal stances. Methods: Thirty healthy adult males volunteered for the study. Experiments used the F-scan plantar pressure analysis insoles to carry out with eyes open (EO) and eyes closed (EC) at four different step heights. The plantar pressure data were recorded for 10 s and pre-processed to derive kinematic and dynamic parameters. Results: For unipedal stance, most of kinematic parameters of the subjects' right and left feet were significantly greater when the eyes were closed compared to the EO condition and increased with step height. The differences in toe load between right and left feet, open and closed eyes were extremely statistically significant (p < 0.001). The differences in midfoot load between the EO and EC conditions were statistically significant (p = 0.024) and extremely statistically significant between the right and left feet (p < 0.001). The difference in rearfoot load between EO and EC conditions was extremely statistically significant (p < 0.001) and statistically significant (p = 0.002) between the right and left feet. For bipedal stance, most of kinematic parameters of the subjects' EO and EC conditions were statistically significant between the right and left feet and increased with step height. The overall load's difference between EO and EC states was statistically significant (p = 0.003) for both feet. The overall load's difference between the right and left feet was extremely statistically significant (p < 0.001) in the EC state. The differences between the right and left feet of the forefoot and rearfoot load with EO and EC suggested that the right foot had a smaller forefoot load, but a larger rearfoot load than the left foot (p < 0.001). The differences between the forefoot and rearfoot load of the subjects' both feet with EO and EC were extremely statistically significant (p < 0.001). Conclusion: Both visual input and step height factors, even the dominant foot, act on kinematic and dynamic parameters that affect the maintenance of static balance ability.

Unexpected inversion perturbation during a single-leg landing in patients with chronic ankle instability

It remains unclear how unexpected perturbations during single-leg landings affect lower extremity kinematics and muscle activations in patients with chronic ankle instability (CAI). The purpose of this study was to identify the differences in lower extremity movement patterns among CAI subjects, copers, and healthy controls. Sixty-six people including 22 CAI subjects, 22 copers, and 22 healthy controls volunteered to participate in the study. Lower extremity joint kinematics and EMG activations from 200-ms pre to 200-ms post the initial contact during unexpected tilted landings were measured. Functional data analysis was used to evaluate between-group differences for outcome measures. Relative to copers and healthy controls, CAI subjects showed more inversion from 40-ms to 200-ms after initial contact. Relative to healthy controls, CAI subjects and copers showed more dorsiflexion. Relative to healthy controls, CAI subjects and copers showed more muscle activation in tibialis anterior and peroneus longus, respectively. In conclusion, CAI subjects demonstrated greater inversion angles and muscle activation before initial contact compared to LAS copers and healthy controls. This suggests that CAI subjects and copers prepare for their landing with protective movements, but the prepared movements shown by CAI subjects may be insufficient to reduce risk of recurrent injury.

Influence of neoprene ankle orthoses on dynamic balance during a vertical jump in healthy individuals and with sprain history: A cross-sectional study

INTRODUCTION

A sprain describes an excessive amount of force or strain on a ligament, which may or may not lead to its rupture. Orthoses are among the most common modalities prescribed as a conservative treatment for ankle instability and sprain.

OBJECTIVE

We aimed to analyse the effect of neoprene orthosis on the balance and functionality of healthy individuals and volunteers with lateral ankle sprains METHODS: We evaluated 12 healthy volunteers (control group) and 12 volunteers diagnosed with a sprain and/or instability (patient group). A total of 14 men and 10 women participated in the study, with an average age of 26.15 (± 4.40) years. The volunteers' tasks consisted of performing vertical bipodal and unipodal jumps on a force platform, which were recorded in a video from the lateral view of the lower limb for posterior evaluation of the knee and ankle angles. Mann-Whitney and Wilcoxon tests were used for comparisons, considering p < 0.05 level of significance.

RESULTS

The control group presented a decrease in ground reaction force when using Orthosis during the bipodal jump (p < 0.05). A decrease in anteroposterior force displacement was also observed in the left unipodal jump (p < 0.01). The patient group presented an increase in force and moment of medial-lateral displacement for both bipodal (p < 0.02) and left unipodal jumps with Orthosis (p < 0.02). A kinematic analysis showed that the control group presented the smallest knee flexion angle (p < 0.01), while the patient group presented the smallest dorsiflexion ankle angle in the bipodal jump when using orthosis (p < 0.01).

CONCLUSION

We concluded that orthosis had influence on individuals' balance and joint angles. In healthy individuals presented better balance with and without orthosis and greater flexion with orthosis in the bipodal jump, regarding to the patient group presented smaller oscillations in the unipodal jump with orthosis and showed smaller knee flexion and ankle dorsiflexion.

What Does Provide Better Effects on Balance, Strength, and Lower Extremity Muscle Function in Professional Male Soccer Players with Chronic Ankle Instability? Hopping or a Balance Plus Strength Intervention? A Randomized Control Study

Chronic ankle instability (CAI) has a higher frequency in soccer due to the rapid changes in body movement. Thus, this study compared the effects of eight weeks of a hopping protocol and a combined protocol of balance plus strength in a within-between group analysis. Thirty-six male professional soccer players participated in this study and were randomly allocated in three groups: control group (CG, n = 12), hopping group (HG, n = 12), and balance plus strength group (BSG, n = 12). Strength, static and dynamic balance, and function were assessed at baseline and eight weeks post intervention. First, Foot and Ankle Ability Measure (FAAM) and FAAM sport scales were applied. Then, a dynamometer was used to measure strength of the muscles around the hip, knee, and ankle joints. The Bass stick measured static balance and the Y balance test measured dynamic balance. Additionally, functional tests were carried out by Triple Hop, the Figure 8 hop, and vertical jump. A repeated measures ANOVA [(3 groups) × 2 moments] was used to compare the within and between group differences. In general, all tests improved after eight weeks of training with both protocols. Specifically, the BSG improved with large ES for all tests, while the HG improved all test with small to large effect sizes (ES). Furthermore, HG showed higher values for vertical jump (p < 0.01, ES = 1.88) and FAAMSPORT (p < 0.05, ES = 0.15) than BSG. BSG showed higher values for hip abduction (p < 0.05, ES = 2.77), hip adduction (p < 0.05, ES = 0.87), and ankle inversion (p < 0.001, ES = 1.50) strength tests, while HG showed higher values for knee flexion [ES = 0.86, (0.02, 1.69)] and ankle plantarflexion [ES = 0.52, (−0.29, 1.33)]. Balance plus strength protocol showed more positive effects than the hopping protocol alone for soccer players with CAI.

How Common is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury?

Posterior tibial tendon dysfunction (PTTD) and tarsal tunnel syndrome (TTS) are debilitating conditions reported to occur after ankle sprain due to their proximity to the ankle complex. The objective of this study was to investigate the incidence of PTTD and TTS in the 2 years following an ankle sprain and which variables are associated with its onset. In total, 22,966 individuals in the Military Health System diagnosed with ankle sprain between 2010 and 2011 were followed for 2 years. The incidence of PTTD and TTS after ankle sprain was identified. Binary logistic regression was used to identify potential demographic or medical history factors associated with PTTD or TTS. In total, 617 (2.7%) received a PTTD diagnosis and 127 (0.6%) received a TTS diagnosis. Active-duty status (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.70-2.79), increasing age (OR 1.03, 95% CI 1.02-1.04), female sex (OR 1.58, 95% CI 1.28-1.95), and if the sprain location was specified by the diagnosis (versus unspecified location) and did not include a fracture contributed to significantly higher (p < 0.001) risk of developing PTTD. Greater age (OR 1.06, 95% CI 1.03-1.09), female sex (OR 2.73, 95% CI 1.74-4.29), history of metabolic syndrome (OR 1.73, 95% CI 1.03-2.89), and active-duty status (OR 2.28, 95% CI 1.38-3.77) also significantly increased the odds of developing TTS, while sustaining a concurrent ankle fracture with the initial ankle sprain (OR 0.45, 95% CI 0.28-0.70) significantly decreased the odds. PTTD and TTS were not common after ankle sprain. However, they still merit consideration as postinjury sequelae, especially in patients with persistent symptoms. Increasing age, type of sprain, female sex, metabolic syndrome, and active-duty status were all significantly associated with the development of one or both subsequent injuries. This work provides normative data for incidence rates of these subsequent injuries and can help increase awareness of these conditions, leading to improved management of refractory ankle sprain injuries.

Current concepts in the surgical management of chronic ankle lateral ligament instability

Background/aims

Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI).

Methods

The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI.

Results

Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes.

Conclusion

Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Outcome of retroarticular drilling for osteochondritis dissecans of the talus in a pediatric population

BACKGROUND

Outcomes of bone marrow stimulation for osteochondritis dissecans (OCD) of the talus in pediatric patients is not optimal. The objective was to evaluate the retroarticular drilling technique for talar OCD.

METHODS

A retrospective case-series study of pediatric cases treated for talar OCD with retroarticular drilling was done. Clinical and radiological outcome scores were recorded as follows: the percentage of patients who had a successful treatment, the percentage for every category of the Berndt and Harty treatment result grading and the percentage for every radiographical outcome score were computed.

RESULTS

Nineteen patients (18 girls; mean age: 14.6 ± 2.1 years) were included. The mean follow-up was 14.8 (±11.7) months. 26.3% required revision surgery. The Berndt and Harty scores were: 57.9% good, 10.5% fair, 31.6% poor. Radiological outcomes were: 21% healed, 47.4% partially healed, 31.6% no healing. The radiological outcome score was better for younger patients (P = 0.01) and those with an open physis (P = 0.001).

CONCLUSION

26.3% of patients needed revision surgery after talar OCD retroarticular drilling and 21% were healed radiographically. Skeletal immaturity and a younger age were associated to a better radiological outcome.

Spinal Reflex Excitability of Lower Leg Muscles Following Acute Lateral Ankle Sprain: Bilateral Inhibition of Soleus Spinal Reflex Excitability

Neural changes in the ankle stabilizing muscles following ankle sprains are thought to be one contributing factor to persistent ankle dysfunction. However, empirical evidence is limited. Therefore, we aimed to examine spinal reflex excitability of lower leg muscles following acute ankle sprains (AAS). We performed a case-control study with 2 groups consisting of 30 young adults with AAS and 30 aged-matched uninjured controls. Hoffmann reflex (H-reflex) testing was performed to estimate spinal reflex excitability of lower leg muscles: soleus, fibularis longus (FL), tibialis anterior (TA). Maximal H-reflex (H_max) and motor responses (M_max) were determined by delivering a series of electrical stimuli at the sciatic nerve. H_max/M_max ratios were calculated to represent normalized spinal reflex excitability. Separate group-by-limb analyses of variance (ANOVA) with repeated measures found there were no significant interactions for any of the muscles (SL: F_1,56 = 0.95, p = 0.33, FL: F_1,51 = 0.65, p = 0.42, TA: F_1,51 = 1.87, p = 0.18), but there was a significant main effect of group in the soleus (F_1,56 = 6.56, p = 0.013), indicating the H_max/M_max ratio of soleus in the AAS group was significantly lower bilaterally (AAS = 0.56 ± 0.19, control = 0.68 ± 0.17, p = 0.013), with no significant group differences in the other muscles (FL: F_1,51 = 0.26, p = 0.61, TA: F_1,51 = 0.93, p = 0.34). The bilateral inhibition of the soleus spinal reflex excitability following AAS may be significant in that it may explain bilateral sensorimotor deficits (postural control deficits) following unilateral injury, and provide insights into additional therapies aimed at the neural change.

Perception of stability correlates with objective performance of dynamic stability for people with chronic ankle instability

Purpose

Lateral ankle sprains are one of the most prevalent musculoskeletal injuries, with one of the highest recurrence rates. One in five people develops chronic ankle instability (CAI) after a lateral ankle sprain. CAI is mainly described as a subjective phenomenon, but is associated with recurrent symptoms, reduced dynamic stability, and reduced physical activity and quality of life. Understanding the relationship between perception of stability and effect on performance for people with CAI could inform rehabilitative strategies in clinical practice. This study aimed to investigate the relationship between the perception of stability and objective performance of dynamic stability this population.

Methods

This study is a sub-analysis of data from four separate studies in Australia and the United Kingdom. Participants were screened and categorised as a CAI, coper, or healthy participant. Each participant completed the Star Excursion Balance Test (SEBT) and Cumberland ankle instability tool (CAIT). Distances reached in the anterior, posterior-medial, and posterior-lateral directions, and average, of the SEBT were analysed.

Results

Data from 95 participants with CAI, 45 copers, and 101 healthy participants was analysed. There was a significant moderate correlation between CAIT score and SEBT reach distance in all directions for the CAI group (p < 0.001). For copers, there was small significant correlation in the posterior-lateral direction (p < 0.05).

Conclusion

This study highlights the discrepancies between the perception of stability and objective dynamic stability, and reinforces the importance of using both types of measures for continual assessment in practice to optimise selecting rehabilitative strategies.

Effect of Four Weeks of Home-Based Balance Training on the Performance in Individuals with Functional Ankle Instability: A Remote Online Study

The purpose of the current study is to evaluate the effect of 4 weeks of home-based balance training (HBBT) on the performance of individuals with functional ankle instability (FAI) in daily activities and sports. Thirty college students diagnosed with FAI and with a mean weight of 79.8 ± 3.4 kg, height of 182.5 ± 5.1 cm, age of 23.5 ± 1.2 years, and instability score of 20 ± 2.3 were selected to participate in this study and were randomly divided by computer-generated methods into two groups: the HBBT group and the control group (CG), each consisting of 15 subjects. The HBBT group performed the program at home for 4 weeks, while the CG was non-exercise. Before and after the 4 weeks of exercise program, a form containing the foot and ankle ability measure for daily activities and sports was completed by the individuals. For data analysis, intra- and inter-group comparisons were performed using paired and independent sample t-tests, respectively, at a significance level of p ≤ 0.05. The results showed that 4 weeks of progressive HBBT were sufficient to significantly improve the measurement of the ability of ankle and foot function in individuals with FAI, even with a total volume of only 60 min per week. Accordingly, it is suggested that individuals with FAI can benefit from short-term HBBT programs, which are simple yet powerful enough to promote improvements in daily activities.

Painful legs and moving toes

A 40-year-old woman reported involuntary and irregular movements of her left toes accompanied by pain. This arose following arthroscopy after a sprained left ankle. She had involuntary flexion-extension and abduction and adduction movements of the hallux and the other toes, with reduced pinprick sensation on the skin web between the left hallux and the second toe. Nerve conduction studies confirmed a deep peroneal nerve axonal injury. We diagnosed the syndrome of painful legs and moving toes, provoked by a peripheral nerve injury. Her symptoms have persisted despite pregabalin, gabapentin and amitriptyline.

Time-frequency analysis of muscle activation patterns in people with chronic ankle instability during Landing and cutting tasks

BACKGROUND

People with chronic ankle instability (CAI) exhibit neuromuscular deficits. Previous studies, however, only investigated magnitudes of muscle activation and not the time-frequency domain.

RESEARCH QUESTION

Do people with CAI exhibit differences in muscle activation patterns in the time-frequency domain during landing, anticipated cutting, and unanticipated cutting compared to matched controls?

METHODS

Eleven people with CAI and eleven healthy matched controls (CON) performed landing, anticipated cutting, and unanticipated cutting as surface EMG of the lateral gastrocnemius, medial gastrocnemius, fibularis longus, soleus, and tibialis anterior were recorded. The time-frequency domain of surface EMG data was analyzed with wavelet transformations and principal component analysis (PCA), PC scores were compared across group, task, and muscle with three-way ANOVAs.

RESULTS

The PCA extracted two PCs that captured the overall magnitude (PC1) of wavelet intensities across the time-frequency domain and a shift among the range of frequencies (PC2) where wavelet intensities were most prominent. A main effect for group indicated that people with CAI demonstrated smaller (p = 0.009) PC1 scores than people in the CON group across all muscles and tasks. An interaction between group and task indicated that people in the CAI group exhibited smaller (p = 0.041) PC2 scores than people in the CON group during only anticipated cutting.

SIGNIFICANCE

People with CAI exhibited neuromuscular deficits in the time-frequency domain of EMG during dynamic tasks. These deficits appear to reflect a neuromuscular strategy characterized by the recruitment of fewer motor units in ankle muscles regardless of task, and an inability to scale the recruitment of motor units in the frequency domain in response to different task demands. Rehabilitation for people with CAI should consider that this population exhibits differences in neuromuscular control that exist not only in the overall magnitudes, but also in the time-frequency domain, of muscle activation patterns.

The effects of shoe collar height on ankle sprain mechanics in athletes: A review of literature

Background:

Our aim was to conduct a review to summarize the existing information regarding the effects of shoe collar height in altering ankle sprain mechanics in athletes.

Methods:

A systematic literature search of PubMed, Embase, MEDLINE, and SPORTDiscus was conducted in September 2019.

Results:

There were 10 studies published from 1993 to 2019 that were included. Most studies showed high-top shoes limited ankle sprain kinematics and increased resistance to inversion moment in static but not dynamic testing. High-top shoes were associated with delayed pre-landing ankle evertor muscle activation and smaller electromyography amplitudes.

Conclusions:

There is currently weak evidence to support that high-top shoes can limit ankle sprain kinematics in dynamic testing. Further studies with more consistent study interventions and outcome variables are needed to definitively establish the effects of shoe collar height on ankle sprain mechanics in athletes.

The Translational Potential of this Article:

Multiple studies on the effects of shoe collar height and ankle sprain mechanics have been performed but there is a lack of consistency in terms of study design, intervention, and outcome measures. A formal systematic review and meta-analysis were not applicable due to the heterogeneity of studies, and mixed results from these studies can be confusing to interpret, making further research on this topic difficult as a result of lack of future direction. We summarized the existing literature on this topic to provide a clearer picture and guide future research on this controversial matter.

Effect of Leg Length–Evening Device on Perceived Balance in Patients Wearing a Controlled Ankle Motion Boot

Background:

Patients are often made weightbearing as tolerated (WBAT) in a controlled ankle motion (CAM) boot for the management of various foot and ankle conditions. The CAM boot causes a leg length discrepancy (LLD) between the booted (longer) and contralateral (shorter) lower extremities. This discrepancy can potentially cause balance problems, undue strain on joints, and discomfort in patients. We hypothesized that a leg length–evening orthotic placed on the plantar aspect of the contralateral shoe improves balance among patients who are WBAT in a CAM boot.

Methods:

Patients made WBAT in a CAM boot were randomized to either the leg length–evening orthotic intervention group or to a control group in which patients wore a normal shoe of their choice. Patients were followed for 2 weeks and asked a series of questions pertaining to balance and pain experienced at their knees, hips, and back. Balance was the primary outcome and was scored from 0 (no difficulty with balance) to 10 (great difficulty with balance). Of 107 subjects enrolled and randomized, 95 (88.8%) completed the study, satisfying the a priori sample size requirement of 94 patients. There were no differences in baseline characteristics between groups (P > .05 for each).

Results:

Intervention patients reported less difficulty with balance than control patients (intention-to-treat analysis: 2.0±1.5 vs 3.2±1.8, P = .001; as-treated analysis: 2.1±1.7 vs 3.0±1.7, P = .009). Intervention and control patients did not differ with respect to pain experienced at their knees, hips, or back, or in a composite total pain score (P > .05 for each).

Conclusion:

This multicenter randomized controlled trial found that adding a limb length–evening orthotic to the plantar aspect of the contralateral shoe in a patient that is WBAT in a CAM boot improved patient-reported self-assessment of balance. The trial was powered to identify a difference in the primary outcome measure of balance and may have been insufficiently powered to identify differences in knee, hip, back, or total pain.

Level of Evidence:

Level II, prospective comparative study.

The comprehensive review of the neurovascular supply of the ankle joint: clinical implications

The rupture of ligament in the lateral part of ankle joint is a common injury and can lead to chronic ankle instability and lead to ankle osteoarthritis. Ankle arthroscopy is considered as a standard option to treat various ankle problems due to the need for only minimal incisions and fewer complications when compared to open surgery. However, there are complications associated with arthroscopic surgery e.g. damage to the anatomical structures around the portal placement areas. The present review provides anatomical knowledge of the superficial and deep neurovascular structures in the ankle region. These structures are important when ankle surgery is performed in order to avoid any intraoperative injury and prevent any complication following surgery.

Criteria-Based Return to Sport Decision-Making Following Lateral Ankle Sprain Injury: a Systematic Review and Narrative Synthesis

OBJECTIVE

The aim of this systematic review was to identify prospective studies that used a criteria-based return to sport (RTS) decision-making process for patients with lateral ankle sprain (LAS) injury.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

The PubMed (MEDLINE), Web of Science, PEDro, Cochrane Library, SPORTDiscus (EBSCO), ScienceDirect, and Scopus databases were searched to 23 November 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they prospectively applied a criteria-based RTS decision-making process for patients with LAS injury, but were excluded if they merely gathered outcome measures at the RTS time point. Studies were also excluded if patients were recovering from ankle fracture, high ankle sprain, medial ankle sprain, chronic ankle instability or complex ankle injury.

RESULTS

No studies were identified that used a criteria-based RTS decision-making process for patients with LAS injury. We were unable to conduct a quantitative synthesis or meta-analysis, therefore we provide a narrative synthesis of relevant questionnaires, as well as clinical and functional assessments commonly used in studies retrieved in the search.

CONCLUSION

There are currently no published evidence-based criteria to inform RTS decisions for patients with an LAS injury. Based on our narrative synthesis, we propose a number of variables that could be used to develop a criteria-based RTS decision paradigm. Future research should aim to reach consensus on these variables and apply them to actual RTS decisions within prospective study designs. Furthermore, we suggest that complex systems theory and the RTS continuum could be used to inform the development of an RTS decision-making paradigm for athletes with LAS injury.

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.

Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review

PURPOSE OF REVIEW

Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options.

RECENT FINDINGS

First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.

Delayed conservative treatment of an acute lateral ankle sprain in a non-athlete female following walking boot immobilisation

Lateral ankle sprains are a common injury with an estimated occurrence rate of 23 000 per day in the USA. Prolonged immobilisation and delayed referral to physical therapy are associated with poorer outcomes. The patient was a 49-year-old woman working as a surgical technologist. She sustained an inversion injury to her left ankle while descending from a stool. Her primary care physician examined her, issued a Controlled Ankle Movement (CAM) walking boot and immobilised her ankle for 6 weeks. Patients with grade I and II lateral ankle sprains who are treated with early mobilisation and referral to physical therapy have demonstrated earlier return to function compared with patients who are treated with prolonged immobilisation and delayed referral. Nevertheless, it remains common for individuals who have sustained a lateral ankle sprain to be immobilised. This case study highlights the importance of early mobilisation and early physical therapy referral for patients with lateral ankle sprains.

Associated Joint Pain With Controlled Ankle Movement Walker Boot Wear

Background:

Controlled ankle movement (CAM) walker boots may cause gait alterations and leg-length discrepancy. This study evaluates secondary site pain relating to immobilization in a CAM walker boot.

Methods:

Patients wearing a CAM walker boot were prospectively enrolled and evaluated for new or worsened secondary site pain. Surveys at four time points were completed to evaluate secondary site pain severity and its effect on function.

Results:

The study included 46 patients (mean age, 49 years). At transition out of the boot (mean, 4.2 weeks), 31 patients (67%) reported pain which was new or worse than at baseline. The sites most susceptible to pain were lower back, contralateral hip, and ipsilateral knee. Most pains (84%) began within the first 2 weeks of boot wear. Secondary site pain was less common after transition out of the boot: 18 patients (39%) at 1 month and 15 patients (33%) at 3 months.

Conclusion:

Secondary site pain after CAM walker boot wear is common. The frequency and severity of pain lessened after transition out of the boot. Yet, one-third of patients still had new or worsened secondary site pain 3 months after cessation of boot wear.

The heterogeneous management of pediatric ankle traumas: A retrospective descriptive study

Frequent misdiagnosis of pediatric ankle traumas leads to inappropriate management, which may result in residual pain, instability, slower return to physical activity, and long-term degenerative changes. The purpose of this study was to evaluate the consistency of diagnosis, management, and the treatment of acute lateral pediatric ankle trauma in a tertiary care pediatric hospital. The hypothesis was that the initial diagnosis is often incorrect, and the treatment varies considerably amongst orthopedic surgeons.We conducted a retrospective study of all cases of ankle sprains and Salter-Harris one (SH1) fractures referred to our orthopedic surgery service between May and August 2014. Exclusion criteria included ankle fractures other than SH1 types, and cases where treatment was initially undertaken elsewhere before referral to our service. Primary outcome was the difference between initial and final diagnosis.Among 3047 cases reviewed, 31 matched our inclusion criteria. Initial diagnosis was 20 SH1 fractures, 8 acute ankle sprains, and 3 uncertain, with a change in diagnosis for 48.5% at follow-up.Accurate diagnosis can be difficult in pediatric ankle trauma, with case management and specific treatments varying considerably. This study reinforces the need to evaluate the safety of a general treatment algorithm for all lateral ankle trauma with normal radiographs.Level of evidence III.

Foot and Ankle Kinematics During Descent From Varying Step Heights

In the general population, one-third of incidences during step negotiation occur during the transition to level walking. Furthermore, falls during curb negotiation are a common cause of injury in older adults. Distal foot kinematics may be an important factor in determining injury risk associated with transition step negotiation. The purpose of this study was to identify foot and ankle kinematics of uninjured individuals during descent from varying step heights. A 7-segment foot model was used to quantify kinematics as participants walked on a level walkway, stepped down a single step (heights: 5 cm, 15 cm, 25 cm), and continued walking. As step height increased, landing strategy transitioned from the rearfoot to the forefoot, and the rearfoot, lateral and medial midfoot, and medial forefoot became more plantar flexed. During weight acceptance, sagittal plane range of motion of the rearfoot, lateral midfoot, and medial and lateral forefoot increased as step height increased. The changes in landing strategy and distal foot function suggest a less stable ankle position at initial contact and increased demand on the distal foot at initial contact and through the weight acceptance phase of transition step negotiation as step height increases.