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PURPOSE: To test the hypothesis that ankles with functional instability will demonstrate slower muscular reaction times than their contralateral stable ankle (SA) and stable healthy controls to a simulated nonpathological ankle sprain mechanism.
METHODS: Nineteen male volunteers with a history of unilateral ankle sprain and functional ankle instability (FAI) and 19 healthy male controls performed reaction time tests on a purpose-built platform that simulated a nonpathological combined inversion/plantarflexion ankle sprain mechanism. Participants provided informed written consent. Reaction time and muscle activity magnitude data were reported for the FAI group's unstable (UA) and stable ankles (SA) and the control group's dominant (DA) and nondominant ankles (NDA) to unilateral simulated ankle sprain (USAS).
RESULTS: The reaction times of the peroneus longus (PL), peroneus brevis (PB), and tibialis anterior (TA) in the UA were significantly slower (P < 0.025) than the SA and control group's DA in the limb experiencing USAS. The reaction times of the support limb PL, TA, and extensor digitorum longus (EDL) muscles of the UA were slower than the DA (P < 0.025). The magnitude of EMG response was not different between the SA and UA (P > 0.025).
CONCLUSIONS: Results demonstrate a deficit (slower reaction time) in ankles with FAI when acting in support and when exposed to a simulated sprain compared to stable healthy controls. As a result of slower reaction times, acting to support the UA may put the contralateral SA at an increased risk of ankle sprain. This suggests that rehabilitation of a lateral ankle sprain should include strengthening the evertors (peroneals and EDL) at the subtalar joint and the dorsiflexors (TA and EDL) at the talocrural joint.
Purpose: To test the hypothesis that ankles with functional instability will demonstrate greater single-limb postural sway (PS) than their contralateral stable joint and stable healthy controls and to examine the relationship between single-limb postural sway and muscular reaction time to a simulated ankle sprain mechanism.
Methods: Nineteen male volunteers with a history of unilateral ankle sprain and functional ankle instability (FAI) and 19 healthy male controls performed 12 single-limb PS tests, 3 on each leg with and without vision. Participants provided informed consent. Postural sway data are reported on the FAI group's unstable (UA) and stable ankles (SA), and the control group's dominant (DA) and nondominant ankles (NDA).
Results: With vision, the UA and SA revealed similar postural control; however, the UA showed greater (P < 0.05) anteroposterior PS than the DA (0.46 cm) and the NDA (0.51 cm). Without vision, the UA showed greater (P < 0.05) medial (2.41 cm) and lateral (2.59 cm) PS than the SA and also showed greater (P < 0.05) medial (2.05 and 2.10 cm, respectively) and lateral (2.28 and 2.26 cm, respectively) than the DA and NDA. The relationship between PS and muscle reaction times, derived from the previous article was calculated. Significant correlations (P < 0.05) were found between the unstable ankle peroneus longus (PL) and peroneus brevis (PB) reaction time and lateral (r = 0.63 and r = 0.81, respectively), medial (r = 0.74 and r = 0.76, respectively), and anterior PS (r = 0.56 and r = 0.55, respectively; P < 0.01).
Conclusions: Results reveal postural sway deficits in ankles with FAI. They also demonstrate a significant relationship between PL and PB reaction times and postural sway in UA. Individuals who sustain an acute ankle sprain and those with FAI require rehabilitation that improves proprioception, strengthens the evertors and dorsiflexors, and restores peroneal reaction time.
HYPOTHESIS: Subtalar instability is thought to be one of the possible causes for chronic functional instability of the foot and ankle. The purpose of this study was to determine the extent of ligament injury that is followed by subtalar instability and to depict consecutive pathologic joint motion.
METHODS: Twelve fresh human cadaver lower legs were investigated with respect to pathologic motion and mobility of the subtalar joint in a modified spinal column simulator after arthrodesis of the talocrural articulation and selective sectioning of the lateral ligaments of the subtalar joint. In order to simulate several injury mechanisms, ligaments were dissected starting anteriorly in group one (n = 6) and posteriorly in group two (n = 6).
RESULTS: Dissection of the bifurcate ligament in group one resulted in a significant increase in plantar- and dorsiflexion, dissection of the inferior extensor retinaculum resulted in a significant increase in eversion and inversion. Additional dissection of the lateral talocalcaneal ligament resulted in a significant increase in internal and external rotation. Dissection of the calcaneofibular ligament in group two was followed by significant kinematic changes regarding all degrees of motion in the subtalar joint.
CONCLUSIONS: The calcaneofibular ligament plays a key role in lateral stabilisation of the subtalar joint. Therefore, ligaments of the subtalar joint should be included in surgical repair.
Effect of Foot Orthotics on Single- and Double-Limb Dynamic Balance Tasks in Patients With Chronic Ankle Instability
Amelia R. Sesma, Carl G. Mattacola, Tim L. Uhl, Arthur J. Nitz, Patrick O. McKeon Foot & Ankle Specialist, Vol. 1, No. 6, 390-397 (2008)
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Deficits have been observed in patients with chronic ankle instability while performing dynamic balance tasks. Foot orthotic intervention has demonstrated improvements in static balance following lateral ankle sprain, but the effect is unknown in patients with chronic ankle instability during dynamic balance tasks. Twenty patients with self-reported unilateral chronic ankle instability volunteered for participation. They completed a familiarization session and 2 test sessions separated by 4 weeks. The familiarization session consisted of practice trials of the Star Excursion Balance Test (SEBT) and Limits of Stability (LOS) test, orthotic fitting, and the Cumberland Ankle Instability Tool (CAIT) questionnaire. Patients were instructed to wear the custom-fitted orthotics for at least 4 hours a day to a preferred 8 hours a day for the 4 weeks between sessions. There was an increase in distance reached in the posterolateral direction over the 4-week period in the orthotic condition. There was an increase in distance reached in the medial direction, demonstrating an improvement on the injured side in the orthotic condition after 4 weeks of orthotic intervention. No consistent, meaningful results were observed in the LOS. The involved leg had a significantly lower CAIT score than the uninvolved leg during both sessions, but the involved leg CAIT scores significantly improved over 4 weeks compared with the baseline measure. Orthotic intervention may prove beneficial for improving dynamic balance as measured by the SEBT in individuals with chronic ankle instability and may be a useful adjunct to clinical and sport interventions.
To investigate the effects induced by wearing an orthosis during the rehabilitation process, 23 ankle sprain patients (degrees I and II) were evaluated in three conditions (reference, with an elastic compression stocking and with an orthosis), 14 h, 10 and 30 days on average after their injury and compared with those of 30 age-matched healthy individuals. The patients were tested with separate measurements of the reaction forces under each limb to highlight the possible compensatory mechanisms between the sound and the injured legs. Their postural stability was enhanced during unilateral orthosis wear, explained by a bilateral effect involving both feet. Wearing a compression stocking induced comparably mild intermediate effects compared with the effects observed with the orthosis. These effects were constant throughout the next month. Following lateral ankle sprain, wearing an orthosis allows patients to improve postural function a few hours after the injury to 1 month later. Only cutaneous pressure intervening without mechanical maintenance induced mild effects, indicating that orthosis effects on postural control could partly result from its sensorial stimulation. It, therefore, seems relevant to prescribe orthosis wear for at least 1 month.
Effects of Taping and Exercise on Ankle Joint Movement in Subjects With Chronic Ankle Instability: A Preliminary Investigation.
Delahunt E, O'Driscoll J, Moran K. Arch Phys Med Rehabil. 2009 Aug;90(8):1418-1422
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OBJECTIVE: To examine the effects of ankle joint taping and exercise on ankle joint sagittal plane and rear-foot frontal plane movement in subjects with chronic ankle instability.
DESIGN: Laboratory-based, repeated-measures study. SETTING: University biomechanics laboratory. PARTICIPANTS: Subjects with chronic ankle instability (N=11) as defined by the Cumberland Ankle Instability Tool. INTERVENTIONS: Each participant performed 3 single-leg drop landings onto a forceplate under 3 different conditions. These conditions were: condition 1 (no tape), condition 2 (taped), and condition 3 (postexercise taped). MAIN OUTCOME MEASURES: Kinematic data were used to identify ankle joint sagittal plane and rear-foot frontal plane positions at 50ms before initial contact (IC) and at IC, under each of the conditions.
RESULTS: There was a significant effect on the angle of ankle joint plantar flexion, both at 50ms before IC (F(2,18)=29.4, P<.001) and at IC (F(2,18)=16.1, P<.001), as a result of the application of tape. Post hoc analysis revealed that condition 1 (no tape) resulted in significantly greater plantar flexion angle at 50ms before IC than condition 2 (taped) (7.7+/-3.0 degrees ; P=.002) and condition 3 (postexercise taped) (8.3+/-4.8 degrees ; P=.01). Similarly, condition 1 (no tape) resulted in significantly greater plantar flexion at IC than both condition 2 (taped) (5.3+/-3.2 degrees ; P<.001) and condition 3 (postexercise taped) (5.3+/-4.4 degrees ; P=.001). No significant differences were evident between condition 2 (taped) and condition 3 (postexercise taped) (P>.05).
CONCLUSIONS: These results indicate that taping acted to reduce the degree of plantar flexion at both 50ms before and at IC with the ground, and that these reductions were retained even after exercise.
Altered ankle kinematics and shank-rear-foot coupling in those with chronic ankle instability.
Drewes LK, McKeon PO, Paolini G, Riley P, Kerrigan DC, Ingersoll CD, Hertel J. J Sport Rehabil. 2009 Aug;18(3):375-88.
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CONTEXT: Kinematic patterns during gait have not been extensively studied in relation to chronic ankle instability (CAI).
OBJECTIVE: To determine whether individuals with CAI demonstrate altered ankle kinematics and shank-rear-foot coupling compared with controls during walking and jogging. DESIGN: Case control. SETTING: Motion-analysis laboratory. PARTICIPANTS: 7 participants (3 men, 4 women) suffering from CAI (age 24.6 +/- 4.2 y, height 172.6 +/- 9.4 cm, mass 70.9 +/- 8.1 kg) and 7 (3 men, 4 women) healthy, matched controls (age 24.7 +/- 4.5 y, height 168.2 +/- 5.9 cm, mass 66.5 +/- 9.8 kg).
INTERVENTIONS: Subjects walked and jogged on a treadmill while 3-dimensional kinematics of the lower extremities were captured. MAIN OUTCOME MEASURES: The positions of rear-foot inversion-eversion and shank rotation were calculated throughout the gait cycle. Continuous relative-phase angles between these segments were calculated to assess coupling.
RESULTS: The CAI group demonstrated more rear-foot inversion and shank external rotation during walking and jogging. There were differences between groups in shank-rear-foot coupling during terminal swing at both speeds.
CONCLUSIONS: Altered ankle kinematics and joint coupling during the terminal-swing phase of gait may predispose a population with CAI to ankle-inversion injuries. Less coordinated movement during gait may be an indication of altered neuromuscular recruitment of the musculature surrounding the ankle as the foot is being positioned for initial contact.
Modified Evans technique improves plantar pressure distribution in lateral ankle instability.
Ateşalp S, Demiralp B, Ozkal UB, Uğurlu M, Bozkurt M, Başbozkurt M. Eklem Hastalik Cerrahisi. 2009;20(1):41-6.
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OBJECTIVES: Efficiency of the modified Evans technique based on clinical and radiological evaluations was determined by plantar pressure measurement.
PATIENTS AND METHODS: Eleven patients (2 females, 9 males; mean age 29 years; range 19 to 39 years) with chronic lateral ankle instability were surgically treated using the modified Evans technique. Plantar pressures of nine patients were measured pre- and post-operatively.
RESULTS: Plantar pressure below the first metatarsal head decreased in seven of the patients after surgery. Furthermore, in all of the patients, the time of initial contact decreased significantly and the pathology returned to normal limits in the postoperative period.
CONCLUSION: Modified Evans technique, despite its controversial long-term outcomes in lateral ankle instability, decreases first metatarsal head pressure and initial contact time significantly.
The influence of Mulligan ankle taping during balance performance in subjects with unilateral chronic ankle instability.
Hopper D, Samsson K, Hulenik T, Ng C, Hall T, Robinson K. Phys Ther Sport. 2009 Nov;10(4):125-30
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OBJECTIVE: To determine whether Mulligan ankle tape influenced the performance in subjects with unilateral chronic ankle instability (CAI) during static balance; postural sway recovery patterns after hopping and dynamic tracking balance tasks.
DESIGN: A cross-sectional, within-subjects experimental study design between 4 ankle conditions (taped; untaped: injured and uninjured).
PARTICIPANTS: 20 volunteer recreational athletes with unilateral CAI were recruited. Means and standard deviations highlighted the athletes' characteristics: age =23+/-1 years; height=173.1+/-2.4 cm; weight=69.3+/-3 kg; Functional Ankle Disability Index (FADI)=93.5+/-5.1% and FADI Sport=84.2+/-9.4%. INTERVENTIONS: Mulligan ankle taping. MAIN OUTCOME MEASUREMENTS: Static balance (10s); postural sway recovery patterns after a 30s functional hop test (immediately, 30 and 60s); dynamic tracking balance tasks (wandering, target overshoot and reaction-time).
RESULTS: Between the four conditions, static balance showed no significant differences (p=0.792); significant changes occurred in postural sway over time (p<0.001); no significant changes were reported for the dynamic tracking tasks. Wandering was highly correlated with reaction-time and overshooting (p<0.01).
CONCLUSION: Under resting and fatigued conditions, Mulligan ankle taping did not impact on the neuromuscular control during static and dynamic balance in subjects with healthy and unstable ankles.
This paper purpose is to suggest an in-depth approach to diagnose the causes and lesions associated with and consecutive to chronic ankle instability due to ankle collateral ligament laxity. The different therapeutic and medicosurgical options adapted to this diagnostic approach are identified. The diagnostic aim is to precisely locate the ligamentous injuries of the tibiofibular, subtalar, talar and calcanean system, to identify the predisposing factors such as the hindfoot morphology, and any lesions associated with chronicity: anterolateral impingement, fibular injury, osteochondral lesions of the talus dome and early osteoarthritis. Clinical tools are used in particular to identify areas of pain and for comparative analysis of mobility and laxity (ligament testing). There are also radiological tests, weight-bearing plain X-ray (stress X-ray), (alignment of the hind foot, with a Meary view [metal wire circling the heel], arthrosis), dynamic images to confirm and quantify laxity (manually, with a Telos device, with patient-controlled varus) and also more sophisticated techniques (ultrasound, CT arthrogramm, gadolinium enhanced MRI, MR arthrogramm) to identify ligament, tendon and cartilage damages. They are adapted to the lesions which have been identified in the diagnostic work-up: conservative first, to treat proprioceptive deficits (a new neuromuscular reprogramming technique which emphasizes muscle preactivation) and any static disorders (plantar orthotics); then surgical, to repair any collateral ligament (or sometimes subtalar) injury with three types of procedures: tightening the capsuloligamentous structures, ligament reconstruction with reinforcement (using the fibrous periosteum, the frondiform ligament (of Retzius) or tendinous reconstruction with the plantaris muscle, the peroneus tertius or even the calcanean tendon) and tendon tansfer procedures using all or part of the peroneus brevis (whole peroneus brevis and half peroneus brevis procedures). Any additional surgical procedures which may be indicated based on the results of the diagnostic work-up are performed at the same time as primary surgery when possible as needed (medial complex repair, calcaneal realignment osteotomies, talus osteochondral injuries debridment or fixation, anterior and posterior impingement suppression, tendon tears repair). The goal of this diagnostic and therapeutic approach is to stop the progression of laxity and to protect the ankle against degenerative arthritis, which is the main risk in these chronic conditions
Chronic ankle instability: Biomechanics and pathomechanics of ligaments injury and associated lesions.
Bonnel F, Toullec E, Mabit C, Tourné Y; et la Sofcot.
Orthop Traumatol Surg Res. 2010 May 19. [Epub ahead of print]
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The objective of this study was to evaluate the conditions of ankle stability and the morphological and/or lesional factors in sprains that determine when instability becomes chronic. It is based on a review of the literature and the data from the 2008 Sofcot symposium. The biomechanics of the ankle cannot be reduced to a simple flexion-extension movement with one degree of freedom as characterized by the talocrural joint: its function cannot be dissociated from the subtalar joint, allowing the foot to adapt to the ground surface. Functional stability is related to the combination of the particular biometry of the joint surfaces and a multiaxial ligament system. The bone morphology of the talus, shaped like a truncated cone, explains the potential instability in plantar flexion; the radii of curvature of the talar dome have a variable mediolateral distribution: most often the medial radius of curvature is inferior to the lateral radius of curvature (66%), sometimes equal (19%), or inverted (15%). Joint kinematics, combining rotation and slide, can therefore be modulated by the talar morphology, explaining the occurrence of at-risk ankles. Ligament stability relies on the organization in three parts of the lateral collateral ligament and the specific subtalar ligaments: the cervical and the talocalcaneal interosseous ligament. The different injury mechanisms are largely responsible for the sequence of ligament lesions: the most frequent is inversion. The first ligament stabilizers correspond to the cervical and anterior talofibular ligaments; the talocalcaneal ligament, by its oblique orientation, is solicited when there is a dorsal varus-flexion component. In chronic instability, these mechanisms explain the onset of associated lesions (impingement, osteochondral lesions, fibular tendon pathology), which can play a role in instability syndrome. Ligament lesions determine laxity, characteristic of mechanical instability. Functional instability goes along with proprioceptive deficiency. There are postural factors such as varus of the hindfoot that favor instability. Knowledge of all these factors, often associated, will provide a precise lesional assessment and treatment adapted to the instability
BACKGROUND: Chronic ankle instability alters spinal level sensorimotor function and is hypothesized to alter supraspinal motor control mechanisms. Gait initiation is a functional task modulated by supraspinal pathways, but the effect of chronic ankle instability, a peripheral musculoskeletal impairment, on gait initiation and thus supraspinal motor control mechanisms remains unknown.
PURPOSE: This study was conducted to determine if supraspinal aspects of motor control are altered in subjects with chronic ankle instability.
STUDY DESIGN: Controlled laboratory study.
METHODS: Subjects with chronic ankle instability (5 males, 15 females; age, 20.5 +/- 1.0 years; height, 169.8 +/- 9.8 cm; weight, 74.2 +/- 20.2 kg) and uninjured controls (4 males, 16 females; age, 20.85 +/- 1.6 years; height, 164.3 +/- 7.9 cm; weight, 64.2 +/- 10.62 kg) completed 5 gait initiation trials for each leg at a self-selected pace. The resulting trajectory of the center of pressure trace was investigated and peak center of pressure excursions in the anteroposterior and mediolateral directions, peak resultant center of pressure excursions, and average direction-specific velocities were calculated.
RESULTS: Significant group x limb interactions were noted during the first (resultant center of pressure displacement [F(1,37) = 4.60, P = .04]) and second (mediolateral center of pressure displacement [F(1,37) = 3.82, P = .05]) period of gait initiation. Center of pressure displacement was reduced (impaired) in the involved limb of the chronic ankle instability group (resultant, 0.29 +/- 0.02; mediolateral, 0.72 +/- 0.02) relative to the uninvolved limb of the chronic ankle instability group (resultant, 0.32 +/- 0.02; mediolateral, 0.76 +/- 0.02) and both limbs of the control group (resultant, 0.32 +/- 0.02; mediolateral, 0.74 +/- 0.02) when the involved limb of the chronic ankle instability group served as the initial stance limb.
CONCLUSION: These interactions suggest that supraspinal motor control mechanisms are altered in subjects with chronic ankle instability to place a greater emphasis on reducing the postural demands on the involved limb.
CLINICAL RELEVANCE: These changes suggest that supraspinal adaptations to motor control may be an important contributor to the underlying neurophysiologic mechanism of chronic ankle instability. The presence of supraspinal adaptations in subjects with chronic ankle instability also indicates that health care providers and rehabilitation specialists treat chronic ankle instability as a global/central and not just a local/peripheral injury.
Characteristics of people with recurrent ankle sprains: a systematic review with meta-analysis.
Hiller CE, Nightingale EJ, Christine Lin CW, Coughlan GF, Caulfield B, Delahunt E. Br J Sports Med. 2011 Jan 21. [Epub ahead of print]
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Objective To examine whether people with recurrent ankle sprain, have specific physical and sensorimotor deficits. Design A systematic review of journal articles in English using electronic databases to September 2009. Included articles compared physical or sensorimotor measures in people with recurrent (≥2) ankle sprains and uninjured controls.
Main outcome groups Outcome measures were grouped into: physical characteristics, strength, postural stability, proprioception, response to perturbation, biomechanics and functional tests. A meta-analysis was undertaken where comparable results within an outcome group were inconsistent.
Results Fifty-five articles met the inclusion criteria. Compared with healthy controls, people with recurrent sprains demonstrated radiographic changes in the talus, changes in foot position during gait and prolonged time to stabilisation after a jump. There were no differences in ankle range of motion or functional test performance. Pooled results showed greater postural sway when standing with eyes closed (SMD=0.9, 95% CI 0.4 to 1.4) or on unstable surfaces (0.5, 0.1 to 1.0) and decreased concentric inversion strength (1.1, 0.2 to 2.1) but no difference in evertor strength, inversion joint position sense or peroneal latency in response to a perturbation.
Conclusion There are specific impairments in people with recurrent ankle sprain but not necessarily in areas commonly investigated.
Press Release: Foot positioning during walking and running may influence ankle sprains
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Athens, Ga. – The position of the foot just before ground contact during running and walking may put people at risk for ankle sprains, according to a new study published by a University of Georgia kinesiology researcher.
The results of the study, which appear in the June online edition of the American Journal of Sports Medicine, found that people who have a history of repetitive ankle sprains demonstrated lower clearance heights between their feet and the floor during running, and pointed their toes down more during walking. Ankle sprains are the most common sports-related injury, and many who experience a sprain will go on to develop chronic instability, suffering repeated sprains during their lifetime.
“Almost everyone who is physically active will suffer an ankle sprain at some point,” said the study’s lead author, Cathleen Brown Crowell, an assistant professor in the UGA College of Education’s department of kinesiology. “Many people develop repetitive ankle injuries that are painful, can decrease performance and increase the risk of ankle osteoarthritis. We were able to identify factors in foot positioning prior to contact with the ground that may pre-dispose some people to these repetitive injuries. These findings can help clinicians develop rehabilitation programs that address movements that may have been ignored in the past.”
The study collected data on more than 30 male recreational athletes, some with a history of repetitive ankle sprains and some without. Motion capture equipment analyzed joint movements and forces in the participants during walking and running. This study was unique in that it analyzed all three possible motions of the ankle, and included participants who had different types of ankle instability, explained Brown Crowell.
While such motion capture equipment may not be available for analysis of patients in rehabilitation clinics, the findings can be applied to physically active individuals at any level who sprain their ankles.
“We can apply our findings to clinical practice,” said Brown Crowell. “Our study demonstrates there are differences in movements at the foot and ankle in an injured population, which may respond to rehabilitation interventions beyond typical stretching and strengthening. The next step is to see if targeted interventions, trying to influence how people run and walk, can treat and even prevent ankle sprains.”
A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types.
Kemler E, van de Port I, Backx F, van Dijk CN. Sports Med. 2011 Mar 1;41(3):185-97.
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Ankle injuries, especially ankle sprains, are a common problem in sports and medical care. Ankle sprains result in pain and absenteeism from work and/or sports participation, and can lead to physical restrictions such as ankle instability. Nowadays, treatment of ankle injury basically consists of taping the ankle. The purpose of this review is to evaluate the effectiveness of ankle braces as a treatment for acute ankle sprains compared with other types of functional treatments such as ankle tape and elastic bandages. A computerized literature search was conducted using PubMed, EMBASE, CINAHL and the Cochrane Clinical Trial Register. This review includes randomized controlled trials in English, German and Dutch, published between 1990 and April 2009 that compared ankle braces as a treatment for lateral ankle sprains with other functional treatments. The inclusion criteria for this systematic review were (i) individuals (sports participants as well as non-sports participants) with an acute injury of the ankle (acute ankle sprains); (ii) use of an ankle brace as primary treatment for acute ankle sprains; (iii) control interventions including any other type of functional treatment (e.g. Tubigrip™, elastic wrap or ankle tape); and (iv) one of the following reported outcome measures: re-injuries, symptoms (pain, swelling, instability), functional outcomes and/or time to resumption of sports, daily activities and/or work. Eight studies met all inclusion criteria. Differences in outcome measures, intervention types and patient characteristics precluded pooling of the results, so best evidence syntheses were conducted. A few individual studies reported positive outcomes after treatment with an ankle brace compared with other functional methods, but our best evidence syntheses only demonstrated a better treatment result in terms of functional outcome. Other studies have suggested that ankle brace treatment is a more cost-effective method, so the use of braces after acute ankle sprains should be considered. Further research should focus on economic evaluation and on different types of ankle brace, to examine the strengths and weaknesses of ankle braces for the treatment of acute ankle sprains.
Is there much evidence to support valgus forefoot posting to increase lateral ankle stability?
I've got theories and observations, but no studies. Ankle instability can have multiple causes and I'm not sure that it is well defined. A tendency toward inversion ankle sprains is something different than lax lateral collateral ankle ligaments is different from inhibited or weak peroneal muscles.
Some studies of sinus tarsi syndrome and lateal ankle instability have demonstrated increased latency to activation of peroneal muscles in response to a sudden inversion movement, and this could explain why they have an increased number of ankle sprains. An increased latency probably would not be helped by a forefoot valgus wedge. On the other hand, peroneal weakness might be helped by a forefoot valgus wedge because there would be increased pronation moment from the ground when there was decreased pronation moment from muscles.
Eric
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I guess it would depend on the forefoot plantar pressures too, as to whether it could be approp. treated with ff valgus wedging. An excessively supinated gait ( that predisposes patient to lateral landing and lat ankle sprains) with ++ px under the 5 th would not respond well to extra valgus wedging.
I guess it would depend on the forefoot plantar pressures too, as to whether it could be approp. treated with ff valgus wedging. An excessively supinated gait ( that predisposes patient to lateral landing and lat ankle sprains) with ++ px under the 5 th would not respond well to extra valgus wedging.
I disagree. A foot with a laterally positioned STJ axis could be considered as a foot with an excessively supinated gait. Whether or not to add a forefoot valgus wedge would be dependent on the eversion range of motion of the forefoot in stance. If the person has a lot of eversion range of motoin available and is "oversupinated" or has a problem like peroneal tendonitis, then adding a forefoot valgus wedge would be quite beneficial. A foot with a laterally deviated STJ axis can have high pressures under lateral forefoot and have a large range of eversion range of motion available. Although a foot with a partially compensated varus will also tend to have high pressure sub 5th met. You can tell the difference between these feet with the Coleman block test or assessing maximum eversion height.
Eric
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I disagree. A foot with a laterally positioned STJ axis could be considered as a foot with an excessively supinated gait. Whether or not to add a forefoot valgus wedge would be dependent on the eversion range of motion of the forefoot in stance. If the person has a lot of eversion range of motoin available and is "oversupinated" or has a problem like peroneal tendonitis, then adding a forefoot valgus wedge would be quite beneficial. A foot with a laterally deviated STJ axis can have high pressures under lateral forefoot and have a large range of eversion range of motion available. Although a foot with a partially compensated varus will also tend to have high pressure sub 5th met. You can tell the difference between these feet with the Coleman block test or assessing maximum eversion height.
Eric
You could add a FF Valg Wdg, but that is often TOO late (LMS to Toe-Off Phase of Gait) to "catch" the rearfoot from inverting, rolling, or spraining; in order to prevent the RF from chronically inverting all too easily, especially in the laterally placed STJ-A, place a laterally based wedge of 2, 4, or 6mm, depending on the severity of the instability and the size of the patient.
"Intrinsic STJ-Instability (STJ-I) is eval'd by putting the STJ thru a ROM, and then one will feel either a smooth arc (normal), little to no motion (suspect coalition, either caritilaginous or ossseous), or as though there is a sharp "dell of the arc of ROM" and the ankle 'gives way laterally' (=STJ-I)...
Now, this is the rearfoot (ankle) that rolls/inverts/sprains--EVEN when sub 5th MT head is loaded and one places their other index finger sub proximal medial heel!! Yes, in heel contact to rearfoot loading phase of gait, one should [needs] to place a medial wedge in to ALL shoe gear and/or onto their Functional Foot Orthotics.
Any questions. Do this and your patients will luv you.
Also, place your patients into a Bioskin Biolok (low profile, ultra-breathable) ankle brace, with the straps reefed up/locked in place while the ankle/rearfoot is dorsiflexed & everted into the position of maximal stability. This is for work, play, exercise, and uneven terrain such as for military et al.
How do you like it know. The total package. Stability from the ground up and all around the ankle.
You could add a FF Valg Wdg, but that is often TOO late (LMS to Toe-Off Phase of Gait) to "catch" the rearfoot from inverting, rolling, or spraining; in order to prevent the RF from chronically inverting all too easily, especially in the laterally placed STJ-A, place a laterally based wedge of 2, 4, or 6mm, depending on the severity of the instability and the size of the patient.
I would agree that a valgus heel wedge would work sooner than a forefoot wedge in heel to toe gait. I don't understand why a forefoot valgus wedge working later is a problem. The effect of the forefoot wedge would be seen as soon as the forefoot hits the ground. If there is range of motion of the STJ available the forefoot valgus wedge will tend to put the STJ in a more pronated position and this will be accompanied by more internal leg rotation which will move the STJ axis to a more medial position. With the axis and the foot in that position the ground will be less likely to cause the STJ to invert and "roll". So, there is no reason not to use the forefoot valgus wedge if there is STJ range of motion available.
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Originally Posted by WillTrekker
"Intrinsic STJ-Instability (STJ-I) is eval'd by putting the STJ thru a ROM, and then one will feel either a smooth arc (normal), little to no motion (suspect coalition, either caritilaginous or ossseous), or as though there is a sharp "dell of the arc of ROM" and the ankle 'gives way laterally' (=STJ-I)...
The "dell of the arc" was something taught to me back in podiatry school. I looked at it a fair amount around that time, but I don't recall correlating that with the complaint of ankle instability in gait. We've had a couple of discussions about what causes the examiner to experience the "sharp" sensation. Having looked at a fair number of cadaver specimens, I haven't seen anything anatomical that could explain that sensation. My explanation is that when you move the STJ when holding the fifth metatarsal the position of the applied force changes more quickly than in feet without the sharp sensation. You also don't get the sharp sensation when you move the STJ when grasping the calcaneus.
What do you think causes the sharp sensation? Why do you think the sharp sensation would correlate with ankle instability?
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Originally Posted by WillTrekker
Now, this is the rearfoot (ankle) that rolls/inverts/sprains--EVEN when sub 5th MT head is loaded and one places their other index finger sub proximal medial heel!! Yes, in heel contact to rearfoot loading phase of gait, one should [needs] to place a medial wedge in to ALL shoe gear and/or onto their Functional Foot Orthotics.
Did you really mean to say medial wedge? In a foot with an extreme laterally positioned axis, the 5th met head may sit medial to the axis and force here will still cause supination. A valgus heel and forefoot wedge can help by decreasing supination moent from the ground by shifting the center of pressure more laterally. If there is range of motion, the valgus (lateral) wedge can move the axis more medial as explained above.
Of course, as you mentioned you can work use an ankle brace to apply moments to the STJ from something other than changing the location of ground reaction force.
This is a very interesting thread that I have monitored until now.
There seems to be agreement that there is a laterally deviated STJ Axis in play.
I am not sure if the forefoot position that is being discussed here is equally in agreement. Is it pronated or supinated?
I read that it is everted but I'm looking more for the sagittal plane component, as I'm not so sure that inversion forefoot moments are the real culprit.
In addition, there seems to be a greater supinatory moment produced in the UA compared to the its mate with the same injurious force. Perhaps this is indicative of an assymetry of the limbs where the short side is more inverted and therefore is more apt to sprain when challenged with supinatory moments.
Perhaps a lift on the UA might help or LLD should be considered as culpatory? After all, a 1/2" valgus wedge in the rearfoot with have a 1/4" lift effect.
Foot pressure and center of pressure in athletes with ankle instability during lateral shuffling and running gait.
Huang PY, Lin CF, Kuo LC, Liao JC. Scand J Med Sci Sports. 2011 Aug 18.
Quote:
This study evaluates foot pressure and center of pressure (COP) patterns in individuals with ankle instability during running and lateral shuffling. Eleven participants with ankle instability (AI) and 11 normal subjects (Normal) performed running and lateral shuffling tasks. The outcome measures were foot progression angle, peak pressure, and displacement of COP during stance phase. During running, the foot progression angle, that is, the angle of foot abduction, was lower in the AI group (Normal: 13.46° ± 4.45°; AI: 8.78° ± 3.91°), and the 1st metatarsal contact pressure (Normal: 0.76 ± 0.47 N/cm(2) ·kg; AI: 1.05 ± 0.70 N/cm(2) ·kg) and the 3rd metatarsal peak pressure were higher in the AI (Normal: 0.96 ± 0.60 N/cm(2) ·kg; AI: 1.54 ± 0.68 N/cm(2) ·kg). The medial-lateral (M-L) COP in the late-stance phase of running for the AI group transferred faster from lateral to medial foot than the Normal group. For lateral shuffling, the AI group had greater peak pressure at the 1st (Normal: 0.76 ± 0.67 N/cm(2) ·kg; AI: 1.49 ± 1.04 N/cm(2) ·kg), 2nd (Normal: 0.57 ± 0.39 N/cm(2) ·kg; AI: 0.87 ± 0.68 N/cm(2) ·kg), 3rd (Normal: 0.70 ± 0.54 N/cm(2) ·kg; AI: 1.42 ± 0.87 N/cm(2) ·kg), and 4th (Normal: 0.52 ± 0.38 N/cm(2) ·kg; AI: 1.12 ± 0.78 N/cm(2) ·kg) metatarsal areas than the Normal group. The M-L COP located more laterally from the early to mid-stance phase in the AI compared with the Normal group. The findings suggest that COP displacement during lateral shuffle may be a factor in ankle instability while the foot progression angle during running may be a compensatory strategy.
Foot pressure and center of pressure in athletes with ankle instability during lateral shuffling and running gait.
Huang PY, Lin CF, Kuo LC, Liao JC. Scand J Med Sci Sports. 2011 Aug 18.
Quote:
This study evaluates foot pressure and center of pressure (COP) patterns in individuals with ankle instability during running and lateral shuffling. Eleven participants with ankle instability (AI) and 11 normal subjects (Normal) performed running and lateral shuffling tasks. The outcome measures were foot progression angle, peak pressure, and displacement of COP during stance phase. During running, the foot progression angle, that is, the angle of foot abduction, was lower in the AI group (Normal: 13.46° ± 4.45°; AI: 8.78° ± 3.91°), and the 1st metatarsal contact pressure (Normal: 0.76 ± 0.47 N/cm(2) ·kg; AI: 1.05 ± 0.70 N/cm(2) ·kg) and the 3rd metatarsal peak pressure were higher in the AI (Normal: 0.96 ± 0.60 N/cm(2) ·kg; AI: 1.54 ± 0.68 N/cm(2) ·kg). The medial-lateral (M-L) COP in the late-stance phase of running for the AI group transferred faster from lateral to medial foot than the Normal group. For lateral shuffling, the AI group had greater peak pressure at the 1st (Normal: 0.76 ± 0.67 N/cm(2) ·kg; AI: 1.49 ± 1.04 N/cm(2) ·kg), 2nd (Normal: 0.57 ± 0.39 N/cm(2) ·kg; AI: 0.87 ± 0.68 N/cm(2) ·kg), 3rd (Normal: 0.70 ± 0.54 N/cm(2) ·kg; AI: 1.42 ± 0.87 N/cm(2) ·kg), and 4th (Normal: 0.52 ± 0.38 N/cm(2) ·kg; AI: 1.12 ± 0.78 N/cm(2) ·kg) metatarsal areas than the Normal group. The M-L COP located more laterally from the early to mid-stance phase in the AI compared with the Normal group. The findings suggest that COP displacement during lateral shuffle may be a factor in ankle instability while the foot progression angle during running may be a compensatory
It would be very interesting to combine this with peroneal EMG recordings. The reason that there may be a more rapid shift of the COP from lateral to medial may be that the peroneals are acting more in the ankle instability group. They might be acting more because this group has a laterally positioned STJ axis.
Context: To our knowledge, no authors have assessed health-related quality of life (HR-QOL) in participants with functional ankle instability (FAI). Furthermore, the relationships between measures of ankle functional limitation and HR-QOL are unknown.
Objective: To use the Short Form-36v2 Health Survey (SF-36) to compare HR-QOL in participants with or without FAI and to determine whether HR-QOL was related to functional limitation.
Design: Cross-sectional study.
Setting: Sports medicine research laboratory.
Patients or Other Participants: Sixty-eight participants with FAI (defined as at least 1 lateral ankle sprain and 1 episode of giveway per month) or without FAI were recruited (FAI group: n = 34, age = 25 ± 5 years, height = 1.71 ± 0.08 m, mass = 74.39 ± 12.78 kg, Cumberland Ankle Instability Tool score = 19.3 ± 4; uninjured [UI] group: n = 34, age = 23 ± 4 years, height = 1.69 ± 0.08 m, mass = 67.94 ± 11.27 kg, Cumberland Ankle Instability Tool score = 29.4 ± 1).
Main Outcome Measure(s): All participants completed the SF-36 as a measure of HR-QOL and the Foot and Ankle Ability Measure (FAAM) and the FAAM Sport version (FAAMS) as assessments of functional limitation. To compare the FAI and UI groups, we calculated multiple analyses of variance followed by univariate tests. Additionally, we correlated the SF-36 summary component scale and domain scales with the FAAM and FAAMS scores.
Results: Participants with FAI had lower scores on the SF-36 physical component summary (FAI = 54.4 ± 5.1, UI = 57.8 ± 3.7, P = .005), physical function domain scale (FAI = 54.5 ± 3.8, UI = 56.6 ± 1.2, P = .004), and bodily pain domain scale (FAI = 52.0 ± 6.7, UI = 58.5 ± 5.3, P < .005). Similarly, participants with FAI had lower scores on the FAAM (FAI = 93.7 ± 8.4, UI = 99.5 ± 1.4, P < .005) and FAAMS (FAI = 84.5 ± 8.4, UI = 99.8 ± 0.72, P < .005) than did the UI group. The FAAM score was correlated with the physical component summary scale (r = 0.42, P = .001) and the physical function domain scale (r = 0.61, P < .005). The FAAMS score was correlated with the physical function domain scale (r = 0.47, P < .005) and the vitality domain scale (r = 0.36, P = .002).
Conclusions: Compared with UI participants, those with FAI had less HR-QOL and more functional limitations. Furthermore, positive correlations were found between HR-QOL and functional limitation measures. This suggests that ankle impairment may reduce overall HR-QOL.
Altered plantar-receptor stimulation impairs postural control in those with chronic ankle instability.
McKeon PO, Stein AJ, Ingersoll CD, Hertel J. J Sport Rehabil. 2012 Feb;21(1):1-6.
Quote:
CONTEXT:
Postural control as assessed via time-to-boundary (TTB) measures has been shown to be impaired in those with chronic ankle instability (CAI). Foot orthotics have been shown to improve postural control, although it is not clear if this is via mechanical or sensorimotor mechanisms.
OBJECTIVE:
To assess the effect of textured shoe inserts that provide no mechanical support on postural control as assessed by TTB measures in subjects with CAI.
DESIGN:
A crossover design to examine the effects of a textured insole on postural control in individuals with unilateral CAI. The independent variables were vision (eyes open, eyes closed) and texture (textured insole, sham insole, control).
SETTING:
Laboratory.
PARTICIPANTS:
20 physically active individuals, 12 men, 8 women, age 18-45 y (21.5 ± 5.51) with self-reported CAI.
INTERVENTION:
Each subject balanced in shod single-limb stance with eyes open and eyes closed under 3 conditions (control, sham, and textured insole). The order of testing under the 3 shoe conditions and 2 vision conditions was counterbalanced.
MAIN OUTCOME MEASURES:
The mean of TTB minima and the standard deviation of TTB minima in the mediolateral (ML) and anteroposterior directions.
RESULTS:
There were significant reductions in TTB ML magnitude and variability found in the textured condition compared with the control and sham conditions. In the textured condition, subjects failed significantly more trials than any other condition.
CONCLUSIONS:
Stimulating the plantar surface of the foot, via a textured insole, has an effect in the broad spectrum of postural-control maintenance in individuals with CAI.
Associated intra-articular ankle pathologies in patients with chronic lateral ankle instability: arthroscopic findings at the time of lateral ankle reconstruction.
Lee J, Hamilton G, Ford L. Foot Ankle Spec. 2011 Oct;4(5):284-9
Quote:
Chronic lateral ankle instability (CLAI) can be a debilitating condition. The literature has shown that it is also associated with a number of intra-articular pathologies of the ankle. Some argue that if unaddressed, these intra-articular pathologies can predispose patients to osteoarthritis. Previous studies of patients who underwent prelateral stabilization ankle arthroscopy have shown a high number of pathologies, including osteochondral lesions of the talus.
PURPOSE:
The current study reviewed a consecutive series of patients diagnosed with CLAI who underwent ankle arthroscopy followed by a modified Brostrom-Gould procedure to validate the previous studies.
METHODS:
Intraoperative reports on 28 ankles in 28 consecutive patients were reviewed from 2004 to 2008.
RESULT:
All 28 ankles (100%) demonstrated varying degrees of synovitis. Talar cartilage fibrillation was observed in 7 patients (25%), and talar dome cartilage defect was visualized in 4 patients (14%). Talar dome osteochondral defect was seen in 2 patients (7%), loose bodies were found in 3 patients (11%), Bassett's lesion was seen in 2 patients (7%), and anterolateral impingement was seen in 4 patients (14%). Distal anterior tibial osteophytosis was seen in 4 patients (14%).
CONCLUSION:
This study confirms the high number of intra-articular pathologies in association with CLAI.
Functional ankle instability
Re: Functional ankle instability
Hybrid Mode
