Prevention and treatment of ankle sprain in athletes

The Consistency of Primary, Secondary and Tertiary Prevention Definitions in the Context of Musculoskeletal Sports Injuries: A Rapid Review and Critical Exploration of Common Terms of Usage

BACKGROUND

Formal statements articulating the meaning of primary, secondary and tertiary prevention concepts are commonly used in the musculoskeletal sports injuries literature, but appear to be employed inconsistently and incorrectly. Standard definitions, appropriate to athletic health and performance practice, are required to systematically develop the state-of-the-art. To accomplish this, we summarized prevention definitions with the aim of improving conceptual clarity across the musculoskeletal sports injuries literature.

MAIN BODY

We used a rapid literature review method, searching Scopus, PubMed/Medline, Cochrane Library reviews/trials, Web of Science, Sports Medicine and Education Index, SPORTDiscus and CINAHL databases for titles/abstracts for available literature, published in English from database-inception to November 2023. Our search terms were: sport/athlete, injury, primary prevention, secondary prevention, and/or tertiary prevention. Definitions were extracted to create categories illustrating overlap and variation. We extracted definitions from 144 included studies (n). Primary prevention appears focused on mitigating injury risk (n = 52) and preventing initial injuries (n = 42). Secondary prevention appears to address five distinct concepts: preventing recurrences (n = 42), preventing sequelae (n = 41), preventing index injury worsening (n = 27), mitigating injury risk (n = 15), and restoring function (n = 12). Tertiary prevention appears focused on preventing sequelae (n = 17) and restoring function (n = 9).

CONCLUSIONS

From a definition viewpoint, the aim of primary prevention is narrowly conceptualized and consistent in the musculoskeletal sports injury research literature. However, secondary prevention definitions vary substantially, with at least three distinct conceptual aims observable. Tertiary prevention definitions appear infrequently in the literature and when observed tend to overlap with secondary prevention. Currently, researchers are likely to struggle with the formulation of clearly-defined and transferrable research questions relating to the aims of secondary prevention.

Effect of Foot Position on Ankle Muscle Activity During Wobble Board Training in Individuals With Chronic Ankle Instability

OBJECTIVE

The purpose of this study was to compare the effects of foot positioning on muscle activities of the peroneus longus (PL), medial gastrocnemius (MG), and tibialis anterior (TA)/PL ratio in individuals with chronic ankle instabilities (CAI) during wobble board training.

METHODS

Thirty individuals with CAI were included, and statistical significance of PL and MG muscle activities was determined using 1-way repeated measures analysis of variance alongside TA/PL activity ratio at the university research laboratory. The participants performed the wobble board training in 3 different foot positions: medial from the centerline of the wobble board (WBT-M), middle from the centerline of the wobble board, and lateral from the centerline of the wobble board (WBT-L). Peroneus longus, MG, and TA muscle activities were measured using surface electromyography.

RESULTS

Peroneus longus activity was significantly higher in the WBT-L position than in the other 2 positions, and it was significantly higher in the middle from the centerline of the wobble board than in the WBT-M position. Medial gastrocnemius activity was significantly greater in the WBT-L position than in the other 2 positions. Tibialis anterior/PL ratio was higher in the WBT-M position than in the other 2 positions.

CONCLUSION

The findings of this study showed that WBT-L increased PL muscle activity by >70% of the maximal voluntary isometric contraction without increasing TA/PL ratio in individuals with CAI.

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Characterization of pain-related behaviors and gene expression profiling of peripheral sensory ganglia in a mouse model of acute ankle sprain

Introduction

Lateral ankle sprain (LAS) is a very common type of joint injury. It occurred with high incidence among general population and especially among individuals participating sports and outdoor activities. A certain proportion of individuals who once developed LAS may suffer persistent ankle pain that affects daily activities. However, the mechanisms underlying LAS-induced pain still remained largely unknown.

Methods

We established a LAS mouse model and systematically evaluated the pain-related behaviors in this mouse model. RNA sequencing (RNA-Seq), combined with bioinformatics analysis, was undertaken to explore gene expression profiles. Immunostaining was used to study glial cell and neuron activation in ipsilateral spinal cord dorsal horn (SCDH) of LAS model mice. Ibuprofen was used to treat LAS model mice.

Results

The LAS model mice developed obvious signs of mechanical and heat hypersensitivities as well as gait impairments in ipsilateral hind paws. Besides, LAS model mice developed signs of pain-related emotional disorder, including pain-induced aversion. By RNA-Seq, we were able to identify certain differentially expressed genes and signaling pathways that might contribute to pain mechanisms of LAS mouse model. In addition, LAS model mice showed increased c-Fos and p-ERK immunoreactivity as well as astrocyte and microglia overactivation in ipsilateral spinal cord dorsal horn, indicating central sensitization might occur. Finally, LAS model mice respond to ibuprofen, a drug clinically used to treat ankle sprain pain.

Conclusion

Our study found LAS model mice may be used as a preclinical animal model for screening novel targets or therapies for ankle sprain. Thus, the study may further help to understand molecular mechanisms contributing to ankle sprain-induced pain.

Hindi translation, cross-culture adaptation, validation and relaibility of foot and ankle disability index instrument in patients with chronic recurrent lateral ankle sprain-A study protocol

BACKGROUND

Ankle sprains are one of the most common musculoskeletal injuries. English and Italian versions of the Foot and Ankle Disability Index (FADI) questionnaire are available for assessment, but no Hindi version of the FADI questionnaire is yet available for the population who only communicate and understand the Hindi language.

AIM

This study aims to translate and culturally adapt the Hindi version of the FADI questionnaire and to evaluate its validity.

STUDY DESIGN

A Cross-Sectional Study.

METHOD

In accordance with Beaton guidelines, the FADI questionnaire will be translated into Hindi by two translators with medical and non-medical backgrounds, respectively. The recording observer will then take a seat to create a T1-2 version of the translated questionnaire. A Delphi survey with 6-10 experts will be conducted. The pre-final form will be fully tested on 51 patients, and the scale validity will be reported. Finally, the translated questionnaire version will be analyzed by the ethics committee.

RESULT

Statistical analysis will be done using the Scale-level Content Validity Index (S-CVI). An individual item of the questionnaire will be validated and documented in the context of the Item-level Content Validity Index (I-CVI). This will be achieved with the help of the Averaging method (S-CVI/Ave) and the Universal Agreement calculation method (S-CVI/UA). Both absolute and relative reliability will be calculated. For absolute reliability, Bland and Altman agreement will be used. Intra-class correlation coefficient (ICC) and Cronbach's alpha (internal consistency), along with Spearman Rank rho and Pearson product, will be analysed for relative reliability.

CONCLUSION

The study will determine the content validity and reliability of the Hindi version of the FADI questionnaire in patients with a chronic recurrent lateral ankle sprain.

Adaptation of the Signal Noise Quotient MRI classification for graft ligamentization analysis following ATFL and CFL anatomical reconstruction: Validation of the SNQA

BACKGROUND

Chronic ankle instability is the most frequent clinical sign of an antero tibiofibular (ATFL) and/or calcaneo fibular ligament (CFL) tear. One common surgical technique is to use the distal tendon of the gracilis muscle to reconstruct both the ATFL and CFL. In the knee, the hamstring tendons used in anterior cruciate ligament (ACL) reconstruction may go through structural modifications called "ligamentization ". A noninvasive MRI technique has been developed using the Signal/Noise Quotient to compare the signal of the graft following reconstruction to that of the posterior cruciate ligament. To our knowledge no studies have ever evaluated radiographic changes in the graft over time. The main goal of this study was to develop a specific MRI protocol to evaluate graft remodeling following ATFL and CFL reconstruction over time.

METHODS

A prospective study of the changes in the MRI signal of the ATFL-CFL graft 3-months postoperatively was performed in 20 patients. The main outcome was a comparison of the graft signal to that of the peroneal fibular tendon and the surrounding noise to determine the Ankle SNQ (SNQA). MRI images were evaluated by two senior radiologists to assess inter-rater reliability and then 2 weeks later for the intra-rater reproducibility.

RESULTS

The intraclass correlation (ICC) showed excellent inter- and intra rater reliability for the ATFL SNQA (0.96 and 0.91, respectively); and for the CFL SNQA, the ICC was 0.97 and 0.99, respectively. Bland-Altman analysis showed very limited bias in the interpretation of SNQA.

CONCLUSION

This preliminary study confirmed the inter- and intra- rater reliability of a new tool using the SNQA.

Acute ankle sprain in athletes: Clinical aspects and algorithmic approach

Acute ankle sprain is the most common lower limb injury in athletes and accounts for 16%-40% of all sports-related injuries. It is especially common in basketball, American football, and soccer. The majority of sprains affect the lateral ligaments, particularly the anterior talofibular ligament. Despite its high prevalence, a high proportion of patients experience persistent residual symptoms and injury recurrence. A detailed history and proper physical examination are diagnostic cornerstones. Imaging is not indicated for the majority of ankle sprain cases and should be requested according to the Ottawa ankle rules. Several interventions have been recommended in the management of acute ankle sprains including rest, ice, compression, and elevation, analgesic and anti-inflammatory medications, bracing and immobilization, early weight-bearing and walking aids, foot orthoses, manual therapy, exercise therapy, electrophysical modalities and surgery (only in selected refractory cases). Among these interventions, exercise and bracing have been recommended with a higher level of evidence and should be incorporated in the rehabilitation process. An exercise program should be comprehensive and progressive including the range of motion, stretching, strengthening, neuromuscular, proprioceptive, and sport-specific exercises. Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables, manual tests for stability, and functional performance testing. There are some common myths and mistakes in the management of ankle sprains, which all clinicians should be aware of and avoid. These include excessive imaging, unwarranted non-weight-bearing, unjustified immobilization, delay in functional movements, and inadequate rehabilitation. The application of an evidence-based algorithmic approach considering the individual characteristics is helpful and should be recommended.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 1: Overview and critical appraisal

BACKGROUND

Ankle and foot sprains and fractures are common injuries affecting many individuals, often requiring considerable and costly medical interventions. The objectives of this systematic review are to collect, assess, and critically appraise the published literature on the health economics of ankle and foot injury (sprain and fracture) treatment.

METHODS

A systematic literature review of Ovid MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, AMED, Ovid Healthstar, and CINAHL was conducted for English-language studies on the costs of treating ankle and foot sprains and fractures published from January 1980 to December 2014. Two reviewers assessed the articles for study quality and abstracted data.

RESULTS

The literature search identified 2047 studies of which 32 were analyzed. A majority of the studies were published in the last decade. A number of the studies did not report full economic information, including the sources of the direct and indirect costs, as suggested in the guidelines. The perspective used in the analysis was missing in numerous studies, as was the follow-up time period of participants. Only five of the studies undertook a sensitivity analysis which is required whenever there are uncertainties regarding cost data.

CONCLUSION

This systematic review found that publications do not consistently report on the components of health economics methodology, which in turn limits the quality of information. Future studies undertaking economic evaluations should ensure that their methods are transparent and understandable so as to yield accurate interpretation for assistance in forthcoming economic evaluations and policy decision-making.

Effects of sudden unexpected mechanical perturbation training aimed at the primary prevention of inversion ankle sprain on reactiveness of ankle movement and cortical activity in normal young adults

[Purpose] To determine the effects of sudden unexpected mechanical perturbation training aimed at the primary prevention of inversion ankle sprain on the reactiveness of ankle eversion movement and cortical activity. [Participants and Methods] Sixty healthy participants were randomly allocated equally into 1) the sudden unexpected mechanical perturbation training group, 2) self-paced training group, or 3) control group. The first two groups performed each course of training 3 days per week for 4 weeks. During pre-training and post-training, the latency to peak amplitude on the surface electromyography of the peroneus longus and the time to reposition the plate back to its initial position under the right foot after sudden unexpected mechanical perturbation were measured. Functional near-infrared spectroscopy was used to measure the changes in the concentration of oxygenated hemoglobin. [Results] The latency to peak amplitude was significantly shorter in group 1 than in group 2; time to reposition the plate was the shortest among the 3 groups during post-training. The changes in the concentration of oxygenated hemoglobin were significantly increased in the supplementary motor and pre-motor areas during post-training than during pre-training in group 1. [Conclusion] Sudden unexpected mechanical perturbation training may facilitate the primary prevention of inversion ankle sprain via the positive effects on the reactiveness of ankle eversion movement and cortical activity.

Current and Potential Roles in Sports Pharmacy: A Systematic Review

(1) Background: The objective of this systematic review was to evaluate current and potential roles for pharmacists in sports medicine and to identify key themes in outcomes reported in studies. (2) Methods: EMBASE, MEDLINE, CINAHL, Scopus and the Cochrane Library were searched in January 2019. Peer-reviewed, original research articles were considered for inclusion. Articles published in a language other than English were excluded. Quality appraisal was performed independently by two authors. (3) Results: Findings of 11 eligible articles (10 observational and 1 experimental study design) were grouped into three themes: (i) doping prevention and control, (ii) injury management and first aid, and (iii) educational and curricular needs. Pharmacists were perceived as a good potential source of information about doping and are enthusiastic about counseling athletes, but lack knowledge and confidence in this area. While pharmacists were frequently consulted for advice on managing sprains and strains, their advice was not always guided by current evidence. Pharmacists and pharmacy students recalled limited opportunity for education in sports pharmacy. (4) Conclusion: Pharmacists showed a willingness and an aptitude to counsel athletes. However, lack of knowledge and confidence, and limited educational opportunities, were key barriers. More research is necessary to support pharmacists in this role.

Effects of the application of ankle functional rehabilitation exercise on the ankle joint functional movement screen and isokinetic muscular function in patients with chronic ankle sprain

[Purpose] This study was conducted to investigate the effects of ankle functional rehabilitation exercise on ankle joint functional movement screen results and isokinetic muscular function in patients with chronic ankle sprain patients. [Subjects and Methods] In this study, 16 patients with chronic ankle sprain were randomized to an ankle functional rehabilitation exercise group (n=8) and a control group (n=8). The ankle functional rehabilitation exercise centered on a proprioceptive sense exercise program, which was applied 12 times for 2 weeks. To verify changes after the application, ankle joint functional movement screen scores and isokinetic muscular function were measured and analyzed. [Results] The ankle functional rehabilitation exercise group showed significant improvements in all items of the ankle joint functional movement screen and in isokinetic muscular function after the exercise, whereas the control group showed no difference after the application. [Conclusion] The ankle functional rehabilitation exercise program can be effectively applied in patients with chronic ankle sprain for the improvement of ankle joint functional movement screen score and isokinetic muscular function.

Joint stability characteristics of the ankle complex in female athletes with histories of lateral ankle sprain, part II: clinical experience using arthrometric measurement

CONTEXT

This is part II of a 2-part series discussing stability characteristics of the ankle complex. In part I, we used a cadaver model to examine the effects of sectioning the lateral ankle ligaments on anterior and inversion motion and stiffness of the ankle complex. In part II, we wanted to build on and apply these findings to the clinical assessment of ankle-complex motion and stiffness in a group of athletes with a history of unilateral ankle sprain.

OBJECTIVE

To examine ankle-complex motion and stiffness in a group of athletes with reported history of lateral ankle sprain.

DESIGN

Cross-sectional study.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-five female college athletes (age = 19.4 ± 1.4 years, height = 170.2 ± 7.4 cm, mass = 67.3 ± 10.0 kg) with histories of unilateral ankle sprain.

INTERVENTION(S)

All ankles underwent loading with an ankle arthrometer. Ankles were tested bilaterally.

MAIN OUTCOME MEASURE(S)

The dependent variables were anterior displacement, anterior end-range stiffness, inversion rotation, and inversion end-range stiffness.

RESULTS

Anterior displacement of the ankle complex did not differ between the uninjured and sprained ankles (P = .37), whereas ankle-complex rotation was greater for the sprained ankles (P = .03). The sprained ankles had less anterior and inversion end-range stiffness than the uninjured ankles (P < .01).

CONCLUSIONS

Changes in ankle-complex laxity and end-range stiffness were detected in ankles with histories of sprain. These results indicate the presence of altered mechanical characteristics in the soft tissues of the sprained ankles.

Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability.

BACKGROUND

Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function.

METHODS

Forty-three participants (mean ± SD age, 25.6 ± 7.6 years; height, 174.3 ± 10.2 cm; mass, 74.6 ± 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21).

RESULTS

There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P<.001) in dorsiflexion at each postintervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores.

CONCLUSIONS

The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing.

LEVEL OF EVIDENCE

Therapy, level 2b-.

Incidência de lesões e desvios posturais em atletas de taekwondo

Com o objetivo de analisar a incidência de lesões e desvios posturais no taekwondo foram avaliados 10 atletas do sexo masculino da seleção catarinense. O histórico de lesões relacionadas à prática desta modalidade foi obtido por aplicação de questionário. A postura foi analisada por meio do protocolo do software SAPO. Os resultados indicaram lesões mais frequentes nos membros inferiores (7/10), principalmente no pé, por fratura e entorse. Houve diferença significativa entre os hemicorpos no ângulo Q (p = 0,037), ângulo perna/retropé (p = 0,001), alinhamento horizontal da pelve (p = 0,016) e comprimento entre membros (p = 0,02). Sugere-se a implementação de treinamento preventivo e exercícios compensatórios para prevenir lesões e desvios posturais em atletas de taekwondo.

Pediatric volleyball-related injuries treated in US emergency departments, 1990-2009

This study describes the epidemiology of pediatric volleyball-related injuries treated in US hospital emergency departments. Data for children younger than 18 years obtained from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission from 1990 through 2009 were analyzed. An estimated 692 024 volleyball-related injuries to children younger than 18 years occurred during the study period. The annual number of injuries declined significantly by 23% during the study period; however, the annual injury rate remained unchanged, and the number of volleyball-related concussions/closed head injuries increased significantly. Upper (48%) and lower (39%) extremity injuries occurred most frequently, as did strains/sprains (54%). Contact with the net/pole was associated with concussions/closed head injury our findings indicate opportunities for making volleyball an even safer sport for children. Protective padding, complying with US volleyball standards, should cover all volleyball poles and protruding hardware to prevent impact-related injuries.

Epidemiology of strain/sprain injuries among cheerleaders in the United States

OBJECTIVE

The aim of this study is to describe the epidemiology of cheerleading-related strain/sprain injuries by type of cheerleading team and type of event.

METHODS

Athlete exposure (AE) and injury data were collected from 412 United States cheerleading teams via the Cheerleading Reporting Information Online surveillance tool, and injury rates were calculated.

RESULTS

Strains/Sprains were the most common injury (53%; 0.5 injuries per 1000 AEs) sustained by cheerleaders during our 1-year study. The lower extremities (42%), particularly the ankles (28%), were injured most often. Most injuries occurred during practice (82%); however, the rate of injury was higher during competition (0.8 injuries per 1000 AEs; 95% confidence interval [CI], 0.6-1.0) than during practice (0.6 injuries per 1000 AEs; 95% CI, 0.5-0.6) for all team types. Injuries were sustained most frequently by high school cheerleaders (51%), although college cheerleaders had the highest injury rate (1.2 injuries per 1000 AEs). Strains/Sprains occurred most frequently while attempting a stunt (34%) or while tumbling (32%). Spotting/Basing other cheerleaders (19%) was the most common mechanism of injury and was more likely to result in a lower back strain/sprain than other mechanisms of injury (odds ratio, 3.38; 95% CI, 1.41-8.09; P < .01).

CONCLUSIONS

Cheerleaders should increase their focus on conditioning and strength-building training, which may help to prevent strain/sprain injuries. Spotters and bases should additionally focus on proper lifting technique to help avoid back injury. Guidelines may need to be developed for return-to-play after cheerleading-related strain/sprain injuries.

Recommendations of community pharmacists for the treatment of sprains and strains

Objective

To determine the recommendations that community pharmacists make when treating ankle sprains and strains, in particular regarding the use of non-steroidal anti-inflammatory drugs (NSAIDs). The current debate about this issue is whether to initiate NSAIDs immediately post-injury, or withhold for the first 48 hours to allow inflammation to occur. The opposing viewpoints are that ‘inflammation is a barrier to healing’ and that ‘inflammation is vital for healing’

Method

In August 2005, a structured questionnaire was mailed to 493 community pharmacies throughout New Zealand and addressed to the pharmacist. Questions covered the advice and interventions (both pharmacological and non-pharmacological) that would be given to a patient presenting with a strain or sprain, beliefs about different analgesics and their role in treatment, and information relating to their postgraduate qualifications and prevalence of sprains and strain seen in their pharmacy.

Key findings

The response rate was 46.5% (229), the mean number of sprains reported in a month was nine. Ninety-six per cent (219) of pharmacists recommended RICE (rest, ice, compression, elevation) as the mainstay of treatment in these types of injuries, and analgesics were recommended frequently, 89% (201). Almost half, 46% (104) of the pharmacists thought that NSAIDs should be withheld for 24–48 h post-injury, and almost half, 46% (104) did not; the remainder, 8% (17) were unsure.

Conclusion

Current evidence is moving away from using NSAIDs immediately post-injury to treat strains and sprains. While many pharmacists are aware of this, there are still others who are either unaware of this new research or who disagree. Most pharmacists were treating these injuries well, but pharmacists need to be aware of current recommendations to make sure that they follow ‘best practice’ and minimise further harm to their patients.

Understanding acute ankle ligamentous sprain injury in sports

This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.

Prophylactic ankle taping: elastic versus inelastic taping

BACKGROUND

The ankle is frequently injured in sporting activities, and therefore it is frequently protected with prophylactic ankle taping. This study aimed first, to compare the mechanical fatigue of two types of prophylactic ankle taping after 30 minutes of intense exercise, one made with elastic tape (ET) and the other with inelastic tape (IT), and second, to investigate the subjects' perception on the tape restriction and comfort.

MATERIALS AND METHODS

Twenty-seven active women (mean age, 20.6 +/- 4.1 years), without previous ankle injuries volunteered for the study. The participants were tested on three different conditions: with elastic ankle taping, with inelastic taping, and without taping, before and after 30 minutes of intense exercise. The ankle passive ranges of movement (ROMs) were measured before and after exercise, and a subjective scale on taping comfort and restriction was completed by the subjects.

RESULTS

Both types of ankle taping showed less ROM restriction after 30 minutes of exercise in inversion (IT = 27% and ET = 21%), and plantarflexion (IT = 8% and ET = 6%). The IT showed more loss of restriction than the ET, with significant differences in inversion (p < 0.05). The participants perceived the ET as more comfortable and less restrictive.

CONCLUSION

We would recommend the use of ET as the first choice for prophylactic ankle taping because it produces the same restriction in the ROM as the IT with less taping fatigue, and is perceived as more comfortable and less restrictive by the users.

Prophylactic ankle braces and star excursion balance measures in healthy volunteers

CONTEXT

The effects of prophylactic ankle braces on lower extremity functional performance in healthy participants have not been studied extensively.

OBJECTIVE

To determine if prophylactic ankle braces affected multidirectional reach distances during a test of dynamic balance.

DESIGN

Crossover.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty-six healthy, physically active volunteers (18 men, 18 women; age = 23.6 +/- 2.7 years, height = 173.8 +/- 9.3 cm, mass = 74.4 +/- 12.7 kg, reach-leg length = 91.9 +/- 5.1 cm).

INTERVENTION(S)

Volunteers performed balance testing in 3 conditions: unbraced, while wearing a semirigid ankle brace, and while wearing a lace-up ankle brace.

MAIN OUTCOME MEASURE(S)

We used the Star Excursion Balance Test, calculating the mean of 3 attempts in 8 directions (anterior, anterior-medial, medial, posterior-medial, posterior, posterior-lateral, lateral, and anterior-lateral), normalized by the participant's reach-leg length. Data were collected after 6 practice attempts for each of the conditions according to a balanced Latin square.

RESULTS

Bracing condition had no effect (P > .05) on any of the Star Excursion Balance Test directional measures. The largest mean difference due to bracing was 2.5% between the lace-up brace condition and the control in the posterior reach direction. This indicates that the actual reach differences due to bracing were less than 5.08 cm (2 inches) in length.

CONCLUSIONS

Clinicians can be confident that the prophylactic use of ankle braces does not disrupt lower extremity dynamic balance during a reaching task in healthy participants.

The role of shoe design in ankle sprain rates among collegiate basketball players

CONTEXT

Much of the recent focus in shoe design and engineering has been on improving athletic performance. Currently, this improvement has been in the form of "cushioned column systems," which are spring-like in design and located under the heel of the shoe in place of a conventional heel counter. Concerns have been raised about whether this design alteration has increased the incidence of ankle sprains.

OBJECTIVE

To examine the incidence of lateral ankle sprains in collegiate basketball players with regard to shoe design.

DESIGN

Prospective cohort study.

SETTING

Certified athletic trainers at 1014 National Collegiate Athletic Association (NCAA)-affiliated schools sponsoring basketball during the 2005-2006 regular season were notified of an online questionnaire. Athletic trainers at 22 of the 1014 schools participated.

PATIENTS OR OTHER PARTICIPANTS

A total of 230 basketball players (141 males, 89 females; age = 20.2 +/- 1.5 years) from NCAA Division I-III basketball programs sustained lateral ankle sprains.

MAIN OUTCOME MEASURE(S)

Ankle sprain information and type of shoe worn (cushioned column or noncushioned column) were collected via online survey. The incidence of lateral ankle sprains and type of shoes worn were compared using a chi-square analysis.

RESULTS

No difference was noted in ankle sprain incidence between groups (chi(2) = 2.44, P = .20, relative risk = 1.47, 95% confidence interval [CI] = 0.32, 6.86). The incidence of ankle sprains was 1.33 per 1000 exposures in the cushioned column group (95% CI = 0.62, 3.51) and 1.96 per 1000 exposures in the noncushioned column group (95% CI = 0.51, 4.22).

CONCLUSIONS

No increased incidence of ankle sprains was associated with shoe design.

Mudanças no padrão temporal da EMG de músculos do tornozelo e pé pré e pós-aterrissagem em jogadores de voleibol com instabilidade funcional

INTRODUÇÃO: A instabilidade funcional (IF) é a complicação mais comum após o entorse de tornozelo; acomete até 52% dos atletas com história de entorse. O entorse de tornozelo é uma das lesões esportivas mais comuns, inclusive no voleibol, em que 90% dos entorses de tornozelo ocorrem durante a aterrissagem, após o movimento de bloqueio. A IF é definida por queixas de falseios e entorses recorrentes, sem que haja evidências clínicas de lesão ligamentar, sendo extremamente prejudicial para a prática do voleibol, pois interfere na realização dos fundamentos envolvidos na modalidade. OBJETIVOS: Comparar os padrões temporais e de magnitude da atividade eletromiográfica dos músculos tibial anterior (TA), fibular longo (FL) e gastrocnêmio lateral (GL) durante a aterrissagem do salto vertical após a execução da habilidade do bloqueio do voleibol entre jogadores com e sem IF de tornozelo. MÉTODOS: Foi adquirida a atividade EMG do tibial anterior, do fibular longo e do gastrocnêmio lateral em 21 atletas com IF (GI) e em 19 atletas controle (GC) - idade média de 20 ± 4 anos. Os envoltórios lineares foram calculados para cada um dos grupos no período de tempo entre 200ms antes e 200ms após o instante do impacto, determinados por meio da componente vertical da FRS. A magnitude e o instante do pico máximo de cada um dos músculos também foram determinados matematicamente. Os grupos foram comparados por meio do teste t (α = 0,05). RESULTADOS: O grupo com instabilidade apresentou instante de pico do TA mais tardio ± (GC = -107,4 ± 29,6ms; GI = -134,0 ± 26,0ms) e FL (GC = -11,0 ± 55,9ms; GI = -41,7 ± 49,8ms) e menor pico de TA (GC = 68,5 ± 17,2%; GI = 81,2 ± 28,8%) e FL (GC = 72,9 ± 27,3%; GI = 59,1 ± 16,0%), CONCLUSÕES: Os resultados mostram um padrão de alteração mais tardio e com menor magnitude nos músculos de atletas com IF que podem predispô-los à condição de instabilidade, mesmo na ausência de lesão anatômica.

Introduction to diagnostic musculoskeletal ultrasound: part 2: examination of the lower limb

This is the second of two articles focusing on ultrasound examination of musculoskeletal components of the upper and lower limbs. Treatment of musculoskeletal injuries is based on establishing an accurate diagnosis. No one would dispute that a good history and physical examination by a competent clinician can help achieve that in the majority of cases. However, musculoskeletal imaging is also an essential adjunct in the work-up of many musculoskeletal disorders. This article describes the ultrasound examination of the lower limb in terms of anatomic structure. Normal and pathologic ultrasound features of these structures, including muscles, tendons, ligaments, bursae, and other soft tissues of the lower limb, will be described by reviewing several representative pathologies commonly seen in musculoskeletal medicine.

A systematic review on ankle injury and ankle sprain in sports

This article systematically reviews epidemiological studies on sports injury from 1977 to 2005 in which ankle injury was included. A total of 227 studies reporting injury pattern in 70 sports from 38 countries were included. A total of 201,600 patients were included, with 32,509 ankle injuries. Ankle injury information was available from 14,098 patients, with 11 847 ankle sprains. Results show that the ankle was the most common injured body site in 24 of 70 included sports, especially in aeroball, wall climbing, indoor volleyball, mountaineering, netball and field events in track and field. Ankle sprain was the major ankle injury in 33 of 43 sports, especially in Australian football, field hockey, handball, orienteering, scooter and squash. In sports injuries throughout the countries studied, the ankle was the second most common injured body site after the knee, and ankle sprain was the most common type of ankle injury. The incidence of ankle injury and ankle sprain was high in court games and team sports, such as rugby, soccer, volleyball, handball and basketball. This systematic review provides a summary of the epidemiology of ankle injury in sports.

A systematic review on ankle injury and ankle sprain in sports

This article systematically reviews epidemiological studies on sports injury from 1977 to 2005 in which ankle injury was included. A total of 227 studies reporting injury pattern in 70 sports from 38 countries were included. A total of 201,600 patients were included, with 32,509 ankle injuries. Ankle injury information was available from 14,098 patients, with 11 847 ankle sprains. Results show that the ankle was the most common injured body site in 24 of 70 included sports, especially in aeroball, wall climbing, indoor volleyball, mountaineering, netball and field events in track and field. Ankle sprain was the major ankle injury in 33 of 43 sports, especially in Australian football, field hockey, handball, orienteering, scooter and squash. In sports injuries throughout the countries studied, the ankle was the second most common injured body site after the knee, and ankle sprain was the most common type of ankle injury. The incidence of ankle injury and ankle sprain was high in court games and team sports, such as rugby, soccer, volleyball, handball and basketball. This systematic review provides a summary of the epidemiology of ankle injury in sports.

Measurement and Evaluation of Dynamic Joint Stability of the Knee and Ankle After Injury

Injuries to the lower extremity, specifically the knee and ankle joints of the human body can occur in any athletic event and are most prevalent in sports requiring cutting and jumping manoeuvres. These joints are forced to rely on the dynamic restraints to maintain joint stability, due to the lack of bony congruence and the inability of the static restraints to handle the forces generated during functional tasks. Numerous variables (proprioception, postural control, electromyography, kinetics/kinematics, dynamic stability protocols) have been measured to better understand how the body maintains joint stability during a wide range of activities from static standing to dynamic cutting or landing from a jump. While the importance of dynamic restraints is not questioned, a recent impetus to conduct more functional or sport-specific testing has emerged and placed a great deal of emphasis on dynamic joint stability and how it is affected by lower extremity injuries. Evidence suggests that surgery and aggressive rehabilitation will not necessarily restore the deficits in dynamic joint stability caused by injury to the anterior cruciate ligament or lateral ankle ligaments. In today's athletic society, there is a major push to return athletes to play as quickly as possible. However, the ramifications of those decisions have not been fully grasped. If an athlete is not fully recovered, a quick return to play could start a vicious cycle of chronic injuries or permanent disability.

Ankle joint proprioception and postural control in basketball players with bilateral ankle sprains

BACKGROUND

Deficiencies in ankle proprioception and standing balance in basketball players with multiple ankle sprains have been reported in separate studies. However, the question of how ankle proprioceptive inputs and postural control in stance are related is still unclear.

HYPOTHESIS

Ankle repositioning errors and the amount of postural sway in stance are increased in basketball players with multiple ankle sprains.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty healthy male basketball players and 19 male basketball players who had suffered bilateral ankle sprains within the past 2 years were examined. Both groups were similar in age. Passive ankle joint repositioning errors at 5 degrees of plantar flexion were used to test for ankle joint proprioception. The Sensory Organization Test was applied with dynamic posturography to assess postural sway angle under 6 sensory conditions.

RESULTS

A significant increase in ankle repositioning errors was demonstrated in basketball players with bilateral ankle sprains (P < .05). The mean errors in the right and left ankles were increased from 1.0 degrees (standard deviation, 0.4 degrees ) and 0.8 degrees (standard deviation, 0.2 degrees ), respectively, in the healthy players to 1.4 degrees (standard deviation, 0.7 degrees ) and 1.1 degrees (standard deviation, 0.5 degrees ) in the injured group. A significant increase in the amount of postural sway in the injured subjects was also found in conditions 1, 2, and 5 of the Sensory Organization Test (P < .05). Furthermore, there were positive associations between averaged errors in repositioning both ankles and postural sway angles in conditions 1, 2, and 3 of the Sensory Organization Test (r = 0.39-0.54, P < .05).

CONCLUSIONS

Ankle repositioning errors and postural sway in stance increased in basketball players with multiple ankle sprains. A positive relationship was found between these 2 variables.

CLINICAL RELEVANCE

Such findings highlight the need for the rehabilitation of patients with multiple ankle sprains to include proprioceptive and balance training.

The ankle examination

Ankle injuries are among the most common musculoskeletal complaints a physician will see. A thorough understanding of the bony, ligamentous, and musculotendinous anatomy and an appreciation of the biomechanics of the ankle and mechanisms of injury are important to the accurate assessment of ankle injuries.

The impact of chiropractic manipulative therapy on chronic recurrent lateral ankle sprain syndrome in two young athletes

OBJECTIVE

To describe two cases of abrupt resolution of chronic, recurrent, inversion sprain to ankles in young recreational athletes.

CLINICAL FEATURES

A 13-year-old, female, avid recreational soccer player with ankles that would spontaneously invert during various inconsistent points in the weight bearing gait cycle, sometimes with acute pain or sprain to the ankle. No intervention was attempted prior to her entry to the chiropractic office. A 17-year-old male avid skate- boarder and snowboarder whose left ankle routinely "gave out" into inversion upon mundane weight bearing activity, usually with pain and with dependence on wearing an ankle support when skateboarding to lessen ankle pain. The patient had used an ankle support prior to seeking chiropractic care.

INTERVENTION AND OUTCOME

High velocity, low amplitude chiropractic manipulative therapy applied to the spine, pelvis and extremity joints was the primary intervention in both cases, with particular focus on the ankle. Other procedures used included taping and orthotics, but not before the manipulation effect was noted.

CONCLUSION

High velocity, low amplitude chiropractic manipulative therapy to the spine, pelvis, and extremities, particularly at the ankle, should be considered when managing young recreational athletes with functional chronic, recurrent, ankle inversion sprains.

The incidence of ankle sprains in soccer

This study investigated the relationship between exposure time and ankle sprains in soccer. Forty-one teams (639 players) from four male senior soccer divisions at different levels of skill (divisions I-VI) were followed prospectively for 1 year. The exposure to soccer and the number of injuries per player were higher in higher divisions, but the injury incidence, percentage of ankle injuries and incidence of ankle injuries were the same at different levels of skill. Of all injuries 17 to 20% were ankle sprains and the incidence varied between 1.7 to 2.0 ankle injuries per 1,000 hours of exposure. Since players with previous ankle problems run an increased risk of reinjury we suggest that these players receive preventive advice.