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Functional ankle instability

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  #31  
Old 27th April 2012, 08:44 PM
WillTrekker WillTrekker is offline
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Quote:
Originally Posted by efuller View Post
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.
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  #32  
Old 28th April 2012, 10:52 AM
efuller efuller is offline
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Default Re: Functional ankle instability

Quote:
Originally Posted by WillTrekker View Post
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 View Post
"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?


Quote:
Originally Posted by WillTrekker View Post
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.

Eric
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  #33  
Old 28th April 2012, 06:19 PM
drsha drsha is offline
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Default Re: Functional ankle instability

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.

Dennis
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  #34  
Old 23rd May 2012, 10:53 AM
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Default Re: Functional ankle instability

Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability.
Hoch MC, Andreatta RD, Mullineaux DR, English RA, Medina McKeon JM, Mattacola CG, McKeon PO.
J Orthop Res. 2012 May 18. doi: 10.1002/jor.22150.
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We examined the effect of a 2-week anterior-to-posterior ankle joint mobilization intervention on weight-bearing dorsiflexion range of motion (ROM), dynamic balance, and self-reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior-to-posterior joint mobilization treatments over 2 weeks. Weight-bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self-reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre-intervention), 24-48 h following the final treatment (post-intervention), and 1 week later (1-week follow-up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p < 0.05 for all) in all measures following the intervention compared to those prior to the intervention. No differences were observed in any assessments between the baseline and pre-intervention measures or between the post-intervention and 1-week follow-up measures (p > 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week
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  #35  
Old 1st October 2012, 05:50 PM
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Default Re: Functional ankle instability

Effects of Joint Mobilization on Ankle Dorsiflexion Range of Motion, Dynamic Postural Control and Self-Reported Patient Outcomes in Individuals with Chronic Ankle Instability
Master of Science in Exercise Science, University of Toledo, College of Health Science and Human Service, 2012.
Quote:
Objective: The purpose of this study was to evaluate the effects of joint mobilization on ankle dorsiflexion range of motion, dynamic postural control, and self-reported patient outcomes in individuals with chronic ankle instability (CAI). A secondary purpose was to determine which contributing factor or factors can improve a participant’s performance on the Star Excursion Balance Test.

Design: This research study was a single-blinded, randomized control trial with one between factor (2 levels: intervention and control) and one within factor (pre- and post-intervention). Participants: Seventeen participants with self-reported unilateral CAI, between 18 and 35 years of age, were recruited from the University of Toledo community and were randomly allocated to two groups, intervention and control.

Methods: Participants completed one testing session that included a non-weight bearing dorsiflexion measurement using a bubble inclinometer, a weight-bearing dorsiflexion measurement using the Weight Bearing Lunge Test and dynamic postural control measured by the Star Excursion Balance Test (SEBT) pre- and post-intervention. The intervention consisted of a Maitland Grade IV oscillatory anterior-to-posterior talar joint mobilization.

Main Outcome Measures: The main outcome measures were dorsiflexion range of motion, dynamic postural control and self-reported patient outcomes. Factors contributing to the performance of the SEBT in individuals with CAI were also determined. Statistical Analysis: The means and standard deviations of the absolute change scores were used for statistical analysis. The independent sample t-test was used to compare each dependent variable between the intervention and control groups. A Cohen’s d effect size along with 95% confidence intervals (CI) was calculated for each comparison between groups and between pre-and post-intervention measurements to determine the magnitude of the joint mobilization effect. A multiple linear backward regression model analysis was also performed to determine which dependent variables influence the improvement of the SEBT performance.

Results: There were no statistically significant results for the main outcome measures. However, large effect sizes were identified for the anterior reach of the SEBT, non-weight bearing dorsiflexion and a reduction in pain when comparing the two groups. A large effect size was also determined for non-weight bearing dorsiflexion, pain, and stability when comparing pre- and post-intervention scores for the joint mobilization group and for weight-bearing dorsiflexion for the control group.

Conclusion: A single dose of a Maitland Grade IV anterior-posterior talar glide joint mobilization did not result in statistically significant improvements in DF range of motion, dynamic postural control, and self-reported patient outcomes, but some of the outcome measures resulted in large effect sizes. This indicates that joint mobilizations may provide potential clinical benefits for the improvement in DF range of motion, dynamic postural control, and pain in patients with CAI
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  #36  
Old 27th February 2013, 12:02 PM
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Default Re: Functional ankle instability

In Vivo Kinematics of the Talocrural and Subtalar Joints With Functional Ankle Instability During Weight-Bearing Ankle Internal Rotation: A Pilot Study.
Kobayashi T, No Y, Yoneta K, Sadakiyo M, Gamada K.
Foot Ankle Spec. 2013 Feb 25.
Quote:
Functional ankle instability (FAI) may involve abnormal kinematics. However, reliable quantitative data for kinematics of FAI have not been reported. The objective of this study was to determine if the abnormal kinematics exist in the talocrural and subtalar joints in patients with FAI. Five male subjects with unilateral FAI (a mean age of 33.4 ± 13.2 years) were enrolled. All subjects were examined with stress radiography and found to have no mechanical ankle instability (MAI). Lateral radiography at weight-bearing ankle internal rotation of 0° and 20° was taken with the ankle at 30° dorsiflexion and 30° plantar flexion. Patients underwent computed tomography scan at 1.0 mm slice pitch spanning distal one third of the lower leg and the distal end of the calcaneus. Three-dimensional (3D) kinematics of the talocrural and subtalar joints as well as the ankle joint complex (AJC) were determined using a 3D-to-2D registration technique using a 3D-to-2D registration technique with 3D bone models and plain radiography. FAI joints in ankle dorsiflexion demonstrated significantly greater subtalar internal rotation from 0° to 20° internal rotation. No statistical differences in plantar flexion were detected in talocrural, subtalar or ankle joint complex kinematics between the FAI and contralateral healthy joints. During ankle internal rotation in dorsiflexion, FAI joints demonstrated greater subtalar internal rotation. The FAI joints without mechanical instability presented abnormal kinematics. This suggests that abnormal kinematics of the FAI joints may contribute to chronic instability. FAI joints may involve unrecognized abnormal subtalar kinematics during internal rotation in ankle dorsiflexion which may contribute to chronic instability and frequent feelings of instability.
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  #37  
Old 9th May 2013, 03:29 PM
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Default Re: Functional ankle instability

Effects of Chronic Ankle Instability on Energy Dissipation in the Lower Extremity
Terada, Masafumi; Pfile, Kate R.; Pietrosimone, Brian G.; Gribble, Phillip A.
Medicine & Science in Sports & Exercise: 8 May 2013
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Purpose: To investigate the influence of chronic ankle instability (CAI) on lower extremity joint energy dissipation patterns during a stop-jump task.

Method: Nineteen participants with self-reported CAI and 19 healthy control participants volunteered. Participants performed 5 double-leg vertical stop-jump tasks onto a force plate. Lower extremity kinetics and kinematics were examined with an electromagnetic tracking system interfaced with a non-conductive force plate. Lower extremity joint energy dissipations were calculated for the hip, knee, and ankle in the sagittal plane during 50ms, 100ms, 150ms, and 200ms after initial contact (IC) with the force plate. Energy dissipation values were normalized to the product of body mass and height (J/N?m). Individual joint contribution to total lower extremity energy dissipation by the ankle, knee, and hip was reported as the percentage of energy dissipation by each joint over the total energy dissipation of all three joints. Independent t-tests and standard mean differences were conducted to assess differences in each dependent variable between the CAI and control groups. Significance was set a priori at p < 0.05.

Results: The CAI group demonstrated significantly less percentage of knee energy dissipation (p = 0.04) and higher percentage of ankle energy dissipation (p = 0.035) of the total energy dissipation during the 100ms immediately following IC compared to the control group.

Conclusion: We found altered energy dissipation patterns at the knee and ankle during a stop-jump task in the CAI group. These findings may provide insight into kinetic alterations that may be associated with CAI. Future research should consider this information as it may be used to develop more effective interventions to target these potentially modifiable energy dissipation patterns in those with CAI.
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  #38  
Old 29th June 2013, 12:23 AM
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Default Re: Functional ankle instability

Aquatic Training for Ankle Instability
Gioftsidou Asimenia, et al
Foot Ankle Spec June 27, 2013 1938640013493461
Quote:
The aim of the present study was to evaluate balance deficits after an ankle sprain in collegiate students and to examine the effectiveness of 2 different balance rehabilitation programs on balance ability. Thirty collegiate students with functional ankle instability were randomly divided into 2 groups. Both groups followed an intervention balance program for 6 weeks, 3 times per week, 20 minutes per session, using balance boards. One of the 2 training groups performed the exercises on the ground—the “Land” group (n = 15), and the other in a swimming pool—the “Aquatic” group (n = 15). Balance ability was assessed before and after the 6-week intervention program. Balance assessments included static (stability indices: total, anterior–posterior, medial–lateral) and dynamic (dynamic moving the cursor) stability tests on the Biodex Stability System (Biodex, Inc, Shirley, NY). The results showed that in both training groups balance ability of the injured leg was significantly improved after the training period. In the final measurements, no statistically significant differences between the injured and healthy limb were found. The present study indicates that the performance of balance exercises in or out of water by collegiate students with functional ankle instability improves their balance ability.
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  #39  
Old 31st July 2013, 12:16 PM
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Default Re: Functional ankle instability

Selection Criteria for Patients With Chronic Ankle Instability in Controlled Research: A Position Statement of the International Ankle Consortium
Phillip A. Gribble, Eamonn Delahunt, Chris Bleakley, Brian Caulfield, Carrie L. Docherty, François Fourchet, Daniel Fong, Jay Hertel, Claire Hiller, Thomas W. Kaminski, Patrick O. McKeon, Kathryn M. Refshauge, Philip van der Wees, Bill Vicenzino, Erik A. Wikstrom
J Orthop Sports Phys Ther 2013;43(8):585-591. doi:10.2519/jospt.2013.0303
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The International Ankle Consortium is an international community of researchers and clinicians whose primary scholastic purpose is to promote scholarship and dissemination of research-informed knowledge related to pathologies of the ankle complex. The constituents of the International Ankle Consortium and other similar organizations have yet to properly define the clinical phenomenon known as chronic ankle instability (CAI) and its related characteristics for consistent patient recruitment and advancement of research in this area. Although research on CAI and awareness of its impact on society and healthcare systems have grown substantially in the last 2 decades, the inconsistency in participant/patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalize this evidence to the target patient population. Therefore, there is a need to provide standards for patient/participant selection criteria in research focused on CAI, with justifications using the best available evidence.
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  #40  
Old 12th August 2013, 05:37 PM
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Default Re: Functional ankle instability

The Effectiveness of Foot Orthotics on Improving Postural Control in Individuals With Chronic Ankle Instability: A Critically Appraised Topic
Michael L. Gabriner, Brittany A. Braun, Megan N. Houston, and Matthew C. Hoch
Journal of Sports Rehabilitation (in press)
Quote:
Clinical Scenario: Chronic ankle instability (CAI) is a condition commonly experienced by physically active individuals. It has been suggested that foot orthotics may increase a CAI patient’s postural control. Clinical Question: For patients with CAI, is there evidence to suggest that an orthotic intervention will help improve postural control?

Summary of Key Findings: The literature was searched for studies of level 2 evidence or higher that investigated the effects of foot orthotics on postural control in patients with CAI.The search of the literature produced 5 possible studies for inclusion; 2 studies met the inclusion criteria and were included.One randomized controlled trial and 1 outcomes study were included. Foot orthotics appear to be effective at improving postural control in patients with CAI.

Clinical Bottom Line: There is moderate evidence to support the use of foot orthotics in the treatment of CAI to help improve postural control. Strength of Recommendation: There is grade B evidence that foot orthotics help improve postural control in people with CAI. The Centre of Evidence Based Medicine recommends a grade of B for level 2 evidence with consistent findings
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  #41  
Old 12th August 2013, 05:39 PM
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Default Re: Functional ankle instability

Effect of a 2-Week Joint Mobilization Intervention on Single-Limb Balance and Ankle Arthrokinematics in Those With Chronic Ankle Instability
Matthew C. Hoch, David R. Mullineaux, Richard D. Andreatta, Robert A. English, Jennifer M. Medina-McKeon, Carl G. Mattacola, and Patrick O. McKeon
Journal of Sports Rehabilitation (in press)
Quote:
Context: A single talocrural joint mobilization treatment has improved spatiotemporal measures of postural control but not ankle arthrokinematics in individuals with chronic ankle instability. However, the effects of multiple treatment sessions on these aspects of function have not been investigated.

Objective: To examine the effect of a 2-week anterior-to-posterior joint mobilization intervention on instrumented measures of single-limb stance static postural control and ankle arthrokinematics in adults with chronic ankle instability.

Design: Repeated-measures. Setting: Research laboratory.

Participants: Participants included 12 individuals with chronic ankle instability (6 males, 6 females; age = 27.4 ± 4.3 years; height = 175.4 ± 9.78 cm; mass = 78.4 ± 11.0 kg). Intervention: Subjects received six treatments sessions of talocrural Grade II joint traction and Grade III anterior-to-posterior joint mobilization over 2 weeks.

Main Outcome Measures: Instrumented measures of single-limb stance static postural control (eyes open and closed) and anterior and posterior talar displacement and stiffnesswere assessed one week before the intervention (baseline), prior to the first treatment (pre-intervention), 24 - 48 hours following the final treatment (post-intervention), and one week later (1-week follow-up). Postural control was analyzed as center of pressure velocity, center of pressure range, the mean of time-to-boundary minima, and standard deviation of time-to-boundary minima in the anteroposterior and mediolateral directions for each visual condition.

Results: No significant differences were identified in any measures of postural control (p > 0.08) or ankle arthrokinematics (p > 0.21).

Conclusions: The 2-week talocrural joint mobilization intervention did not alter instrumented measures of single-limb stance postural control or ankle arthrokinematics. Despite the absence of change in these measures, this study continues to clarify the role of talocrural joint mobilization as a rehabilitation strategy for patients with chronic ankle instability.
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  #42  
Old 11th September 2013, 01:40 PM
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Default Re: Functional ankle instability

Changes in balancing ability of athletes with chronic ankle instability after foot orthotics application and rehabilitation exercises.
Lee HJ, Lim KB, Jung TH, Kim DY, Park KR.
Ann Rehabil Med. 2013 Aug;37(4):523-33.
Quote:
OBJECTIVE:
To compare the effect of foot orthotics and rehabilitation exercises by assessing balancing ability and joint proprioception in athletes who have chronic ankle instability.
METHODS:
Forty-one athletes who visited hospitals due to chronic ankle instability were randomly assigned to two groups. One group had ankle rehabilitation exercises while the other group had the same rehabilitation exercises as well as foot orthotics. Joint position sense of the ankle joint was examined by using an isokinetic exercise machine. Balancing abilities categorized into static, dynamic and functional balance abilities were evaluated by using computerized posturography. We tested the subjects before and after the four-week rehabilitation program.
RESULTS:
After the four-week treatment, for joint reposition sense evaluation, external 75% angle evaluation was done, revealing that the group with the application of foot orthotics improved by -1.07±1.64 on average, showing no significant difference between the two groups (p>0.05). Static, dynamic and functional balancing abilities using balance masters were evaluated, revealing that the two groups improved in some items, but showing no significant difference between them (p>0.05).
CONCLUSION:
This study found that athletes with chronic ankle instability who had foot orthotics applied for four weeks improved their proprioceptive and balancing abilities, but did not show additional treatment effects compared with rehabilitation exercise treatment.
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Old 12th September 2013, 03:15 PM
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Default Re: Functional ankle instability

Effectiveness of Ankle Taping on Ankle Joint Kinematics During Walking on Level Ground
Mohamed-Amine Choukou, Samia Hijazi
Foot Ankle Spec October 2013 vol. 6 no. 5 352-355
Quote:
Prescriptions for functional ankle instability are generally oriented to taping, which need to be validated as an efficient treatment. Therefore, the aim of this study was to investigate the effectiveness of ankle taping on the subject’s foot pressure and gait pattern, including mediolateral analysis, according to tape application side. A sample of 20 right-handed healthy subjects volunteered to participate in this study, which was composed of 3 taping conditions: “with taping of the right ankle,” “with taping of both ankles,” and “with taping of the left ankle.” Participants were asked to perform a walk on the walkway to get 2 footprints repeated 6 times. The variables measured were step length, step duration, double stance, and swing. The results clearly showed significant change in step duration and double phase when tape was applied to the left ankle, F(2, 54) = 12.03; P < .05. Significant changes were also observed for step length and swing when tape was applied to the both ankles, F(2, 54) = 10.71; P < .05]. This study showed that double stance and swing phase duration increases, and that the pressure is equalized on both feet when taping the unstable ankle. Taping a functionally unstable ankle is more likely to improve its stability.
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  #44  
Old 27th September 2013, 02:59 AM
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Default Re: Functional ankle instability

New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound.
Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS.
Knee Surg Sports Traumatol Arthrosc. 2013 Sep 26.
Quote:
PURPOSE:
To diagnose chronic ankle instability, clinicians frequently use manual anterior drawer test and stress radiography. However, both exams can yield incorrect results and do not reveal the extent of ankle instability. The use of stress ultrasound during a manual anterior drawer stress procedure might enable the diagnosis of chronic ankle instability.
METHODS:
Seventy-three patients with chronic ankle pain or laxity after remote ankle sprain were included. The study population included 41 males and 32 females. The mean age of the patients at the time of the operation was 29 years. A standardized physical examination (manual anterior drawer test), stress radiography and stress ultrasonography were performed to assess the anterior talofibular ligament (ATFL). Ultrasound images were taken in the resting position and the maximal anterior drawer position. The statistical significance of stress ultrasound among the three groups according to manual anterior drawer test and a specific degree (5 mm) of anterior translation of stress radiography were analysed. Correlation coefficients between stress ultrasound, stress radiography and manual anterior drawer test were calculated.
RESULTS:
There was a significant difference for ATFL length (ATFL stress) and ATFL ratio (ATFL stress/ATFL resting) among the three groups (both p < 0.001). However, there was no significant difference for anterior translation of stress radiography among three groups according to manual anterior drawer test (p = 0.159). There was a significant difference for ATFL length (ATFL stress) and ATFL ratio between two groups with 5-mm anterior translation of stress radiography (p = 0.002 and p = 0.011, respectively). The mean value of grade of manual anterior drawer test between the two groups also differed (p = 0.021). There was a moderately positive linear relationship between stress ultrasound and manual anterior drawer test. Also, there was a positive linear relationship between stress ultrasound and stress radiography.
CONCLUSION:
The results suggest that the value of ATFL length (ATFL stress) and ATFL ratio of stress ultrasound could be used for diagnosis of chronic ankle instability in addition to manual anterior drawer test and stress radiography
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  #45  
Old 27th September 2013, 03:34 AM
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Default Re: Functional ankle instability

Someone might find this interesting. Then again....

http://www.mdpi.com/2077-0383/2/2/22
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Old 16th October 2013, 10:14 PM
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Default Re: Functional ankle instability

The Effectiveness of Foot Orthotics on Improving Postural Control in Individuals With Chronic Ankle Instability: A Critically Appraised Topic
Michael L. Gabriner, Brittany A. Braun, Megan N. Houston, and Matthew C. Hoch
Jnl Sports Rehab (in press)
Quote:
Clinical Scenario: Chronic ankle instability (CAI) is a condition commonly experienced by physically active individuals. It has been suggested that foot orthotics may increase a CAI patient’s postural control.

Clinical Question: For patients with CAI, is there evidence to suggest that an orthotic intervention will help improve postural control?

Summary of Key Findings: The literature was searched for studies of level 2 evidence or higher that investigated the effects of foot orthotics on postural control in patients with CAI.The search of the literature produced 5 possible studies for inclusion; 2 studies met the inclusion criteria and were included.One randomized controlled trial and 1 outcomes study were included. Foot orthotics appear to be effective at improving postural control in patients with CAI.

Clinical Bottom Line: There is moderate evidence to support the use of foot orthotics in the treatment of CAI to help improve postural control. Strength of Recommendation: There is grade B evidence that foot orthotics help improve postural control in people with CAI. The Centre of Evidence Based Medicine recommends a grade of B for level 2 evidence with consistent findings
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Old 29th November 2013, 04:37 AM
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Default Re: Functional ankle instability

Prevalence of Chronic Ankle Instability in High School and Division I Athletes
Leah Tanen et al
Foot Ankle Spec November 27, 2013
Quote:
Objective. The purpose of this study was to determine the prevalence of chronic ankle instability among high school and collegiate athletes. Design. Descriptive epidemiological survey.

Methods. Athletes from four high schools and a division I university were contacted to participate. For collegiate athletes, a questionnaire packet was distributed during preparticipation physicals. For high school athletes, parental consent was obtained and then questionnaires were distributed during preparticipation physicals, parent meetings, or individual team meetings. All athletes completed the Cumberland Ankle Instability Tool for both their left and right ankles. Subjects also provided general demographic data and completed the Ankle Instability Instrument regarding history of lateral ankle sprains and giving way. Athletes were identified as having chronic ankle instability if they scored less than 24 on the Cumberland Ankle Instability Tool.

Results. Of the 512 athletes who completed and returned surveys, 23.4% were identified as having chronic ankle instability. High school athletes were more likely to have chronic ankle instability than their collegiate counterparts (P < .001). Chronic ankle instability was more prevalent among women than among men in both high school (P = .01) and collegiate settings (P = .01).

Conclusions. Findings of this study revealed differences in the distribution of chronic ankle instability that warrant further study.
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Old 11th December 2013, 10:42 PM
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Default Re: Functional ankle instability

In Vivo Kinematics of the Talocrural and Subtalar Joints During Weightbearing Ankle Rotation in Chronic Ankle Instability
Takumi Kobayashi
Foot Ankle Spec December 10, 2013
Quote:
Background. Chronic ankle instability (CAI) results in abnormal ankle kinematics, but there exists limited quantitative data characterizing these alterations. This study was undertaken to investigate kinematic alterations of the talocrural and subtalar joints in CAI.

Methods. A total of 14 male patients with unilateral CAI (mean age = 21.1 ± 2.5 years) were enrolled. Computed tomography and fluoroscopic imaging of both lower extremities during weightbearing passive ankle joint complex (AJC) rotation were obtained. Three-dimensional bone models created from the computed tomography images were matched with the fluoroscopic images to compute the 6 degrees-of-freedom talocrural, subtalar, and AJC kinematics. Results. In 20° plantarflexion, ankles with CAI demonstrated significantly increased anterior translation of the talocrural joint during AJC internal rotation from 5° to 7° and significantly decreased talocrural internal rotation within an AJC arc of motion from −1° to 5°. CAI joints demonstrated significantly increased internal rotation of the subtalar joint within an AJC arc of motion from −1° to 3°.

Discussion. In CAI, altered subtalar internal rotation occurs with increased talocrural anterior translation and reduced talocrural internal rotation during weightbearing ankle internal rotation in plantarflexion. These results suggest that altered subtalar mechanics may contribute to CAI symptoms
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Old 16th December 2013, 05:59 PM
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Default Re: Functional ankle instability

Effects of fatiguing treadmill running on sensorimotor control in athletes with and without functional ankle instability.
Steib S, Hentschke C, Welsch G, Pfeifer K, Zech A.
Clin Biomech (Bristol, Avon). 2013 Aug;28(7):790-5. doi: 10.1016/j.clinbiomech.2013.07.009.
Quote:
BACKGROUND:
Sensorimotor control is permanently impaired following functional ankle instability and temporarily decreased following fatigue. Little is known on potential interactions between both conditions. The purpose was to investigate the effect of fatiguing exercise on sensorimotor control in athletes with and without (coper, controls) functional ankle instability.
METHODS:
19 individuals with functional ankle instability, 19 ankle sprain copers, and 19 non-injured controls participated in this cohort study. Maximum reach distance in the star excursion balance test, unilateral jump landing stabilization time, center of pressure sway velocity in single-leg-stance, and passive ankle joint position sense were assessed before and immediately after fatiguing treadmill running. A three factorial linear mixed model was specified for each outcome to evaluate the effects of group, exhausting exercise (fatigue) and their interactions (group by fatigue). Effect sizes were calculated as Cohen's d.
FINDINGS:
Maximum reach distance in the star excursion balance test, jump stabilization time and sway velocity, but not joint position sense, were negatively affected by fatigue in all groups. Effect sizes were moderate, ranging from 0.27 to 0.68. No significant group by fatigue interactions were found except for one measure. Copers showed significantly larger prefatigue to postfatigue reductions in anterior reach direction (P≤0.001; d=-0.55) compared to the ankle instability (P=0.007) and control group (P=0.052).
INTERPRETATION:
Fatiguing exercise negatively affected postural control but not proprioception. Ankle status did not appear to have an effect on fatigue-induced sensorimotor control impairments.
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Old 18th December 2013, 12:26 PM
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Default Re: Functional ankle instability

In Vivo Kinematics of the Talocrural and Subtalar Joints During Weightbearing Ankle Rotation in Chronic Ankle Instability.
Kobayashi T, Saka M, Suzuki E, Yamazaki N, Suzukawa M, Akaike A, Shimizu K, Gamada K.
Foot Ankle Spec. 2013 Dec 10.
Quote:
Background. Chronic ankle instability (CAI) results in abnormal ankle kinematics, but there exists limited quantitative data characterizing these alterations. This study was undertaken to investigate kinematic alterations of the talocrural and subtalar joints in CAI.

Methods. A total of 14 male patients with unilateral CAI (mean age = 21.1 ± 2.5 years) were enrolled. Computed tomography and fluoroscopic imaging of both lower extremities during weightbearing passive ankle joint complex (AJC) rotation were obtained. Three-dimensional bone models created from the computed tomography images were matched with the fluoroscopic images to compute the 6 degrees-of-freedom talocrural, subtalar, and AJC kinematics.

Results. In 20° plantarflexion, ankles with CAI demonstrated significantly increased anterior translation of the talocrural joint during AJC internal rotation from 5° to 7° and significantly decreased talocrural internal rotation within an AJC arc of motion from -1° to 5°. CAI joints demonstrated significantly increased internal rotation of the subtalar joint within an AJC arc of motion from -1° to 3°.

Discussion. In CAI, altered subtalar internal rotation occurs with increased talocrural anterior translation and reduced talocrural internal rotation during weightbearing ankle internal rotation in plantarflexion. These results suggest that altered subtalar mechanics may contribute to CAI symptoms
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  #51  
Old 1st January 2014, 12:10 PM
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Default Re: Functional ankle instability

Postural-Stability Tests That Identify Individuals with Chronic Ankle Instability.
Linens SW, Ross SE, Arnold BL, Gayle R, Pidcoe P.
J Athl Train. 2013 Dec 30
Quote:
Context :  Chronic ankle instability (CAI) is characterized by repeated ankle sprains, which have been linked to postural instability. Therefore, it is important for clinicians to identify individuals with CAI who can benefit from rehabilitation. Objective :  To assess the likelihood that CAI participants will exhibit impaired postural stability and that healthy control participants will exhibit better test performance values.

Design :  Case-control study. Setting :  Laboratory. Patients or Other Participants :  People with CAI (n = 17, age = 23 ± 4 years, height = 168 ± 9 cm, weight = 68 ± 12 kg) who reported ankle "giving-way" sensations and healthy volunteers (n = 17, age = 23 ± 3 years, height = 168 ± 8 cm, weight = 66 ± 12 kg).

Intervention(s) :  Participants performed 7 balance tests: Balance Error Scoring System (BESS), time in balance, foot lift, single-legged stance on a force plate, Star Excursion Balance Test, side hop, and figure-of-8 hop.

Main Outcome Measure(s) :  Balance was quantified with errors (score) for the BESS, length of time balancing (seconds) for time-in-balance test, frequency of foot lifts (score) for foot-lift test, velocity (cm/s) for all center-of-pressure velocity measures, excursion (cm) for center-of-pressure excursion measures, area (cm2) for 95% confidence ellipse center-of-pressure area and center-of-pressure rectangular area, time (seconds) for anterior-posterior and medial-lateral time-to-boundary (TTB) measures, distance reached (cm) for Star Excursion Balance Test, and time (seconds) to complete side-hop and figure-of-8 hop tests. We calculated area under the curve values and cutoff scores and used the odds ratio to determine if those with and without CAI could be distinguished using cutoff scores.

Results :  We found significant area-under-the-curve values for 4 static noninstrumented measures, 3 force-plate measures, and 3 functional measures. Significant cutoff scores were noted for the time-in-balance test (≤25.89 seconds), foot-lift test (≥5), single-legged stance on the firm surface (≥3 errors) and total (≥14 errors) on the BESS, center-of-pressure resultant velocity (≥1.56 cm/s), standard deviations for medial-lateral (≤1.56 seconds) time-to-boundary and anterior-posterior (≤3.78 seconds) time-to-boundary test, posteromedial direction on the Star Excursion Balance Test (≤0.91), side-hop test (≥12.88 seconds), and figure-of-8 hop test (≥17.36 seconds).

Conclusions :  Clinicians can use any of the 10 significant measures with their associated cutoff scores to identify those who could benefit from rehabilitation that reestablishes postural stability.
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Old 30th January 2014, 07:13 PM
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Default Re: Functional ankle instability

Impact of Fibular Torsion and Rotation on Chronic Ankle Instability
Murat Bozkurt, Nihal Apaydin, Ergin Tonuk, Cetin Isik, Nurdan Cay, Gulbiz Kartal, Halil Ibrahim Acar, Shane R. Tubbs
Foot and Ankle Surgery; Available online 30 January 2014
Quote:
Background
The fibula is known not to involve in transmission of weight but known simply as an ankle stabilizer. However, its main function in stabilizing the ankle remains obscure. Since the fibula has an impact on torsion and rotation of the ankle, its effect on lateral ankle instability should be investigated.

Materials and Methods
Twenty patients with lateral ankle instability (Group 1) and 19 healthy volunteers (Group 2) were included in the study. The tibiofibular and talofibular relationships were evaluated using MRI images. Fibular torsion and rotation angles were calculated using a new method. Range of motion of the ankle joint was investigated while the knee was at flexion (900) and extension (00). The comparisons performed between the 2 groups and independent from the groups were statistically evaluated and, the p value of <0.05 was considered as statistically significant.

Results
A significant difference was found between the two groups for age (p < 0.05). There were no statistically significant differences between the right and left sides for all measurements in the group 1 and 2 (p > 0.05). There was a statistically significant difference between the two groups in dorsal flexion when the knee is at flexion (900) and extension (00) position. There was also a statistically significant difference between the two groups in plantar flexion which was measured while the knee was at extension (00) position. No statistically significant difference was found between both groups in terms of fibular torsion and rotation. However, independent from the groups when the patients were divided into 2 groups according to whether the fibula localized posteriorly or not, in patients with posteriorly localized fibula it was demonstrated that fibular torsion and rotation statistically significantly increased.

Conclusion
We did not detect any relationship between fibular torsion and rotation and ankle instability. However, independent from the groups when the patients were divided into 2 groups according to whether the fibula localized posteriorly or not, we realized that in patients with posteriorly localized fibula, fibular torsion and rotation significantly increased. This finding did not explain the cause of instability. However, it may gain significance with new further studies regarding ankle instability.
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Old 3rd March 2014, 08:31 PM
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Default Re: Functional ankle instability

The brain: A new frontier in ankle instability research
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Old 5th March 2014, 04:52 PM
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Default Re: Functional ankle instability

Predictors of chronic ankle instability after an index lateral ankle sprain: A systematic review.
Pourkazemi F, Hiller CE, Raymond J, Nightingale EJ, Refshauge KM.
J Sci Med Sport. 2014 Feb 6.
Quote:
OBJECTIVES:
To identify the predictors of chronic ankle instability after an index lateral ankle sprain.
DESIGN:
Systematic review.
METHODS:
The databases of MEDLINE, CINAHL, AMED, Scopus, SPORTDiscus, Embase, Web of Science, PubMed, PEDro, and Cochrane Register of Clinical Trials were searched from the earliest record until May 2013. Prospective studies investigating any potential intrinsic predictors of chronic ankle instability after an index ankle sprain were included. Eligible studies had a prospective design (follow-up of at least three months), participants of any age with an index ankle sprain, and had assessed ongoing impairments associated with chronic ankle instability. Eligible studies were screened and data extracted by two independent reviewers.
RESULTS:
Four studies were included. Three potential predictors of chronic ankle instability, i.e., postural control, perceived instability, and severity of the index sprain, were investigated. Decreased postural control measured by number of foot lifts during single-leg stance with eyes closed and perceived instability measured by Cumberland Ankle Instability Tool were not predictors of chronic ankle instability. While the results of one study showed that the severity of the initial sprain was a predictor of re-sprain, another study did not.
CONCLUSIONS:
Of the three investigated potential predictors of chronic ankle instability after an index ankle sprain, only severity of initial sprain (grade II) predicted re-sprain. However, concerns about validity of the grading system suggest that these findings should be interpreted with caution.
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Old 12th March 2014, 08:44 PM
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Default Re: Functional ankle instability

MULTI-SEGMENTED FOOT LANDING KINEMATICS IN SUBJECTS WITH CHRONIC ANKLE INSTABILITY
R De Ridder, T Willems, J Vanrenterghem, M Robinson, T Palmans, P Roosen
Br J Sports Med 2014;48:584 doi:10.1136/bjsports-2014-093494.66
Abstracts from the IOC World Conference on Prevention of Injury & Illness in Sport, Monaco 2014
Quote:
Background Chronic ankle instability (CAI) is associated with inadequate control during landing tasks. Joint kinematics have been shown influential in the capacity to accommodate for the incurred high loading.

Objective The purpose of this study was to evaluate whether multi-segmented foot kinematics of the impact phase of landing tasks can reveal further control issues in subjects with CAI, copers, and controls.

Design Case-control design.

Setting All subjects were evaluated in a laboratory setting with a 3D kinematic setup.

Participants 96 recreationally active subjects (38 subjects with CAI, 28 copers and 30 controls) were included in the study.

Risk factor assessment All subjects performed a vertical drop and side jump landing task. Data were collected using a force plate and a 6-camera opto-electronic system.

Main outcome measurements Foot and ankle kinematics were registered using a rigid foot model and the six-segment Ghent Foot Model (GFM), along with vertical ground reaction forces. Group differences were evaluated using Statistical Parametric Mapping and ANOVA with post-hoc Bonferroni correction.

Results In general, similar sagittal plane differences were found for vertical drop and side jump. Subjects with CAI and copers exhibited less plantar flexion at touch down. In addition, unlike the coper group, the CAI group demonstrated a stiffer landing pattern (smaller ROM) compared to the control group, leading to higher loading rates. Furthermore, subjects with CAI had a more inverted midfoot position compared to controls during side jump and more midfoot in/eversion ROM than copers during vertical drop. Copers exhibited less plantarflexion/dorsiflexion ROM in the lateral and medial forefoot for both conditions.

Conclusions Subjects with CAI displayed an altered, stiffer kinematic landing strategy and related alterations in landing kinetics, which might predispose them for episodes of giving way and actual ankle sprain events.
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Old 18th March 2014, 11:52 PM
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Default Re: Functional ankle instability

Systematic review of chronic ankle instability in children
Melissa Mandarakas, Fereshteh Pourkazemi, Amy Sman, Joshua Burns and Claire E Hiller
Journal of Foot and Ankle Research 2014, 7:21 doi:10.1186/1757-1146-7-21
Quote:
Background
Chronic ankle instability (CAI) is a disabling condition often encountered after ankle injury. Three main components of CAI exist; perceived instability; mechanical instability (increased ankle ligament laxity); and recurrent sprain. Literature evaluating CAI has been heavily focused on adults, with little attention to CAI in children. Hence, the objective of this study was to systematically review the prevalence of CAI in children.

Methods
Studies were retrieved from major databases from earliest records to March 2013. References from identified articles were also examined. Studies involving participants with CAI, classified by authors as children, were considered for inclusion. Papers investigating traumatic instability or instability arising from fractures were excluded. Two independent examiners undertook all stages of screening, data extraction and methodological quality assessments. Screening discrepancies were resolved by reaching consensus.

Results
Following the removal of duplicates, 14,263 papers were screened for eligibility against inclusion and exclusion criteria. Nine full papers were included in the review. Symptoms of CAI evaluated included perceived and mechanical ankle instability along with recurrent ankle sprain. In children with a history of ankle sprain, perceived instability was reported in 23-71% whilst mechanical instability was found in 18-47% of children. A history of recurrent ankle sprain was found in 22% of children.

Conclusion
Due to the long-lasting impacts of CAI, future research into the measurement and incidence of ankle instability in children is recommended.
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Old 8th April 2014, 12:30 AM
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Default Re: Functional ankle instability

The Influence of Ankle Dorsiflexion and Self-Reported Patient Outcomes on Dynamic Postural Control in Participants with Chronic Ankle Instability
Masafumi Terada, Matthew S. Harkey, Ashley M. Wells, Brian G. Pietrosimone, Phillip A. Gribble
Gait & Posture; Available online 3 April 2014
Quote:
Highlights
•Decreased dorsiflexion was associated with diminished dynamic postural control.
•Increased ankle stiffness was associated with diminished dynamic postural control.
•Patient-and-clinician generated measures of function should be assessed separately.
Quote:
We investigated the influence of ankle dorsiflexion range of motion (DF-ROM) and self-reported patient outcomes on dynamic postural control assessed with the Star Excursion Balance Test (SEBT) in individuals with chronic ankle instability (CAI). Twenty-nine participants with self-reported CAI volunteered. The primary outcome measurements were categorized into clinician-and patient-generated. Clinician-generated outcome measurements included anterior (SEBT-A), posteriormedial (SEBT-PM) and posteriorlateral (SEBT-PL) reach distances (cm) normalized by leg length (cm) of the SEBT, maximum weight-bearing dorsiflexion (WB-DF) (cm), and open-chain DF-ROM (degrees). Self-reported patient-generated outcome measures included the Foot and Ankle Ability Measure and the level of perceived pain, stiffness, stability, and function of their involved ankle on a 10-cm visual analogue scale (VAS). Pearson product moment correlations were used to examine the relationship of the SEBT performances with DF-ROM and self-reported patient outcome measures. A multiple linear regression was performed to determine the influence of patient- and clinician-generated measures on the SEBT. SEBT-A performance was significantly and fairly correlated with WB-DF (r = 0.410, p = 0.014), perceived ankle stiffness(r = 0.477, p = 0.014), and open-chain DF-ROM (r = 0.404, p = 0.015). The strongest predictor of the variance in SEBT-A was the combination of the variance in WB-DF and VAS-stiffness (R2 = 0.348, p = 0.004). There were no significant correlations with the SEBT-PM and SEBT-PL. WB-DF and VAS-stiffness may represent targets for intervention that need to be addressed to produce the best outcome in participants with CAI when altered dynamic postural control is detected on the SEBT-A.
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Old 24th April 2014, 05:50 AM
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Default Re: Functional ankle instability

The influence of ankle dorsiflexion and self-reported patient outcomes on dynamic postural control in participants with chronic ankle instability
Masafumi Teradaemail address, Matthew S. Harkey, Ashley M. Wells, Brian G. Pietrosimone, Phillip A. Gribble
Gait & Posture; Article in Press
Quote:
Highlights
•Decreased dorsiflexion was associated with diminished dynamic postural control.
•Increased ankle stiffness was associated with diminished dynamic postural control.
•Patient-and-clinician generated measures of function should be assessed separately.
Quote:
We investigated the influence of ankle dorsiflexion range of motion (DF-ROM) and self-reported patient outcomes on dynamic postural control assessed with the Star Excursion Balance Test (SEBT) in individuals with chronic ankle instability (CAI). Twenty-nine participants with self-reported CAI volunteered. The primary outcome measurements were categorized into clinician-and patient-generated. Clinician-generated outcome measurements included anterior (SEBT-A), posteriormedial (SEBT-PM) and posteriorlateral (SEBT-PL) reach distances (cm) normalized by leg length (cm) of the SEBT, maximum weight-bearing dorsiflexion (WB-DF) (cm), and open-chain DF-ROM (°). Self-reported patient-generated outcome measures included the foot and ankle ability measure and the level of perceived pain, stiffness, stability, and function of their involved ankle on a 10-cm visual analog scale (VAS). Pearson product moment correlations were used to examine the relationship of the SEBT performances with DF-ROM and self-reported patient outcome measures. A multiple linear regression was performed to determine the influence of patient- and clinician-generated measures on the SEBT. SEBT-A performance was significantly and fairly correlated with WB-DF (r=0.410, p=0.014), perceived ankle stiffness (r=0.477, p=0.014), and open-chain DF-ROM (r=0.404, p=0.015). The strongest predictor of the variance in SEBT-A was the combination of the variance in WB-DF and VAS-stiffness (R2=0.348, p=0.004). There were no significant correlations with the SEBT-PM and SEBT-PL. WB-DF and VAS-stiffness may represent targets for intervention that need to be addressed to produce the best outcome in participants with CAI when altered dynamic postural control is detected on the SEBT-A.
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Old 17th May 2014, 04:53 AM
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Default Re: Functional ankle instability

The effects of mobilization with movement on dorsiflexion range of motion, dynamic balance, and self-reported function in individuals with chronic ankle instability.
Gilbreath JP, Gaven SL, Van Lunen L, Hoch MC.
Man Ther. 2014 Apr;19(2):152-7.
Quote:
Previous studies have examined the effectiveness of a manual therapy intervention known as Mobilization with Movement (MWM) to increase dorsiflexion range of motion (ROM) in individuals with chronic ankle instability (CAI). While a single talocrural MWM treatment has increased dorsiflexion ROM in these individuals, examining the effects of multiple treatments on dorsiflexion ROM, dynamic balance, and self-reported function would enhance the clinical application of this intervention. This study sought to determine if three treatment sessions of talocrural MWM would improve dorsiflexion ROM, Star Excursion Balance Test (SEBT) reach distances, and self-reported function using the Foot and Ankle Ability Measure (FAAM) in individuals with CAI. Eleven participants with CAI (5 Males, 6 Females, age: 21.5 ± 2.2 years, weight: 83.9 ± 15.6 kg, height: 177.7 ± 10.9 cm, Cumberland Ankle Instability Tool: 17.5 ± 4.2) volunteered in this repeated-measures study. Subjects received three MWM treatments over one week. Weight-bearing dorsiflexion ROM (cm), normalized SEBT reach distances (%), and self-reported function (%) were assessed one week before the intervention (baseline), prior to the first MWM treatment (pre-intervention), and 24–48 h following the final treatment (post-intervention). No significant changes were identified in dorsiflexion ROM, SEBT reach distances, or the FAAM-Activities of Daily Living scale (p > 0.05). Significant changes were identified on the FAAM-Sport (p = 0.01). FAAM-Sport scores were significantly greater post-intervention (86.82 ± 9.18%) compared to baseline (77.27 ± 11.09%; p = 0.01) and pre-intervention (79.82 ± 13.45%; p = 0.04). These results indicate the MWM intervention did not improve dorsiflexion ROM, dynamic balance, or patient-centered measures of activities of daily living. However, MWM did improve patient-centered measures of sport-related activities in individuals with CAI.
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Old 20th May 2014, 08:35 PM
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Default Re: Functional ankle instability

Lateral ankle and hindfoot instability: A new clinical based classification
F.G. Usuelli et al
Foot and Ankle Surgery
Quote:
Ankle sprains are one of the most common soft tissue injuries accounting for nearly 40% of sports injuries.

There are large number of procedures for its treatment reported in the literature with largely good results.

The ankle forms a functional unit with the subtalar joint.

We present a new classification for peritalar lateral instability.

There are two intents of this classification. Firstly, the classification demonstrates an assessment and treatment guideline for the many causes of peritalar lateral instability. The second use of the classification is for research purposes so that cohorts of patients can be accurately described and the efficacy of different operations in different groups can be properly assessed.
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