Tare de Tot

1
Chronic Ankle Instability

HISTORICAL PERSPECTIVE HISTORICAL PERSPECTIVE
CLINICAL EVALUATION CLINICAL EVALUATION
TREATMENT GUIDELINES TREATMENT GUIDELINES
When Can I Return to Sport When Can I Return to Sport
E-MAIL: [email protected]
Fellow, AmericanAcademy of Podiatric Sports Medicine
Associate Clinical Professor, Dept. Of Applied Biomechanics,
California School of Podiatric Medicine
Douglas H. Richie Jr. D.P.M.
ANKLE SPRAINS ANKLE SPRAINS
Most common injury in Sports (40%)
Colville Colville
23,000 sprains / day in U.S.
Makhani, McCullock Makhani, McCullock
Account for 10% of all ER visits in U.S.
Holmer Holmer
Long term sequelae occur in up to 50% of patients
Anderson, Brostrom, Freeman, Smith Anderson, Brostrom, Freeman, Smith
Long Term Sequelae Long Term Sequelae
The development of residual
instability with pain and swelling
will occur in 20% to 40% of
people after a Grade II lateral
ankle sprain.
Bosien, 1955 Yeung, 1994
Brand, 1977 Dettori, 1994
Itay, 1982 Verhagen, 1995
Gerber, 1998
Bosien, 1955 Yeung, 1994
Brand, 1977 Dettori, 1994
Itay, 1982 Verhagen, 1995
Gerber, 1998
Biology of Ankle Sprain Tx Biology of Ankle Sprain Tx
1. Immediately after injury: RICE
~minimizes hemorrhage, swelling,
inflammation, cellular metabolism, pain.
2. Protection of ligaments: week 1-3
~proliferation phase: collagen
production
~ligament stress Type III (weaker)
collagen
3. Controlled mobilization: week 4-8
~maturation phase: final scar
formation
~controlled exercise increased
mech strength of ligament collagen
fiber orientation.
4. Final Maturation and Remodeling: 6-12 mos
~ Full return to activity
~ Full neuromuscular control
Biology of Ankle Sprain Tx Biology of Ankle Sprain Tx
RETURN TO PRE INJURY ACTIVITY RETURN TO PRE INJURY ACTIVITY
With Functional Treatment Protocol: With Functional Treatment Protocol:
GRADE III
6 weeks
GRADE III
6 weeks
GRADE II
12 days
GRADE II
12 days
Ardevol, 2002 Ardevol, 2002
Wilson, 2002 Wilson, 2002
2
J Athl Train. 2008 Sep-Oct;43(5):523-9. Ankle ligament healing after an
acute ankle sprain: evidence-based approach. Hubbard TJ, Hicks-Little CA.
Department of Kinesiology, The University of North Carolina at Charlotte, Charlotte, NC 28223, USA.
[email protected]
OBJECTIVE: To perform a systematic review to determine the healing time of the lateral ankle
ligaments after an acute ankle sprain.
DATA SOURCES: We identified English-language research studies from 1964 to 2007 by searching
MEDLINE, Physiotherapy Evidence Database (PEDro), SportDiscus, and CINAHL using the terms
ankle sprain, ankle rehabilitation, ankle injury, ligament healing, and immobilization.
STUDY SELECTION: We selected studies that described randomized, controlled clinical trials
measuring ligament laxity either objectively or subjectively immediately after injury and at least 1
more time after injury.
CONCLUSIONS/RECOMMENDATIONS: In the studies that we
examined, it took at least 6 weeks to 3 months before ligament healing
occurred. However, at 6 weeks to 1 year after injury, a large percentage of
participants still had objective mechanical laxity and subjective ankle
instability. Direct comparison among articles is difficult because of
differences in methods. More research focusing on more reliable methods of
measuring ankle laxity is needed so that clinicians can know how long
ligament healing takes after injury. This knowledge will help clinicians to
make better decisions during rehabilitation and for return to play.
Mechanical
ANKLE INSTABILITY ANKLE INSTABILITY
Functional
MECHANICAL INSTABILITY MECHANICAL INSTABILITY
Objective Measures: Objective Measures:
Anterior drawer
Talar tilt
Ligamentous laxity
FF & RF deformities
Tibial varum
Ankle axis deviation
Karlsson J, Bergsten T, Lasinger O, et al: Surgical
treatment of chronic lateral instability of the ankle
joint. Am J Sports Med 17:208-274,1989
Stress Radiographs Stress Radiographs
Anterior drawer Absolute Displacement: 10mm
Side to side: >3mm
Talar Tilt Side to side: >10
STRESS RADIOGRAPHY
Stress radiography has long been utilized to diagnose mechanical instability of the
lateral ligaments of the ankle. However, the reliability of these measures has been
questioned. Radiographic measure of anterior drawer and talar tilt show a low
sensitivity (50 and 36%) but a high specificity (100%). A critical review of seven
studies of stress radiography to diagnose ligament rupture after acute ankle sprain
concluded that talar tilt and anterior drawer stress x-rays are not reliable enough to
make the diagnosis of ligament rupture regardless of whether mechanical devices or
local anesthesia are used. Presently, the only possible valid use of stress radiography is
in the evaluation of patients with chronic mechanical instability of the ankle.
Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Daider, A, Baldt M et al. MRI versus lateral stress
radiography in acute lateral ankle ligament injuries. Journal of Computer Assisted Tomography 1997
March/April; 21(2): 280-285.
Ray, RG; Christensen, JC; Gusman, DN: Critical evaluation of anterior drawer measurement methods
in the ankle. Clin Orthop Relat Res, 215 224, 1997.
Harper, MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot
Ankle, 13:435 438, 1992.
Lohrer, H; Nauck, T; Arentz, S; Scholl, J: Observer reliability in ankle and calcaneocuboid stress
radiography. Am J Sports Med
3
SENSITIVITY VS SPECIFICITY
High sensitivity indicates that a test can be used for excluding,
or ruling out, a condition when it is negative, but does not
address the value of a positive test.
Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA.
1992;267:26382644.
Schulzer M. Diagnostic tests: a statistical review. Muscle Nerve.
1994;17:815 819
Specificity indicates the ability to use a test to recognize
when the condition is absent. A highly specific test has
relatively few false positive results, and therefore speaks to
the value of a positive test.
IMAGING THE ACUTE ANKLE SPRAIN
Imaging Osseous Injuries
Radiographs are ordered for 80 to 95% of patients who present to the hospital
emergency room after foot and ankle trauma, yet studies reveal that only 15% of these
patients actually have a bone fracture. (1-3) The Ottawa Ankle Rules were developed to
reduce unnecessary radiography of ankle sprain patient.. These rules are a clinical decision
guideline which state that radiographs of the ankle are necessary only when there is pain in
the malleolar zone and the patient exhibits any of the following findings: (1) bone
tenderness along the distal 6 cm of posterior edge of the of the medial or lateral malleolus, or
(2) bone tenderness directly on the tip of the medial or lateral malleolus, or (3) inability to
bear weight and walk 4 steps immediately after the injury or at the emergency department.
Radiographs of the feet are indicated when there is pain in the midfoot zone and any of the
following findings: (1) bone tenderness of the navicular or base of the 5
th
metatarsal, or (2)
inability to bear weight and walk 4 steps immediately after the injury or at the emergency
room.
Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to
develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med.
1992;21:384-399.
OTTAWA ANKLE
RULES
The Ottawa Ankle Rules have been extensively studied for accuracy in predicting
the presence of a fracture in the ankle and mid-foot of patients suffering an ankle
sprain. Bachman conducted a systematic review of 27 studies of 15,581 patients who
had suffered an ankle sprain. The Ottawa Ankle Rules demonstrated nearly 100%
sensitivity in detecting a fracture of the ankle or midfoot while specificity was quite
variable, ranging from 10% to 79%. The missed fracture rate was 1.4% which
indicates that less than 2% of patients who were negative for fracture according to the
Ottawa Ankle Rules, actually had a fracture.
Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa Ankle Rules to
exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003 Feb
22;326(7386):417
For example, using the Ottawa Ankle Rules, palpable bone tenderness at the fibular
malleolus may suggest a fracture and would mandate an x-ray.
When there is no palpable bone tenderness, it is highly likely that there is not a
fracture present- i.e. high value of sensitivity.
However, since many of these patients with palpable bone tenderness do not, in fact
show a fracture on subsequent x-ray, this test has low value of specificity. This test has
a high number of false positive results for bone tenderness, thus low value of
specificity.
When a test has few false positives, the value of a positive test is significant. For
example, a positive anterior drawer on manual stress exam of the ankle is correlated
with mechanical instability of the ankle. Thus, the anterior drawer has few false
positive results and has high value of specificity.
Sensitivity and specificity values provide useful information for interpreting the
results of diagnostic tests.
Sensitivity represents the ability of the test to recognize the condition when present.
A highly sensitive test has relatively few false negative results. High test sensitivity,
therefore, attests to the value of a negative test result.
High specificity attests to the value of a positive test result: there are relatively few
false positives.
Thus, palpable bone tenderness is highly
correlated with fracture, and absence of bone
tenderness is almost never seen when a fracture is
present. Therefore, a negative test result (i.e. no
bone tenderness) is almost never seen when there
is a fracture present (i.e. high sensitivity).
4
EVALUATING
LIGAMENTOUS
INJURY
The purpose of advanced imaging is to determine the exact
location of ligament injury and to grade severity of injury.
However, imaging studies which evaluate ligament integrity
have questionable value in the assessment of the acute ankle
injury since treatment decisions and outcomes are not
usually influenced by these studies.
Frost CL, Amendola A. Is stress radiography necessary in the diagnosis of acute or
chronic ankle instability? Clin J Sport Med 1999;9:40-45.
Griffith JF, Brockwell J. Diagnosis and imaging of ankle instability. Foot Ankle
Clin Am 2006;11: 475-496.
MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI) has replaced arthrography as
the preferred imaging technique to detect ligament rupture after
an ankle sprain. However, the accuracy, sensitivity and specificity
of this imaging technique to diagnose ligament injury in acute
ankle injuries is inconsistent, particularly when comparing studies
of acute injury vs chronic ankle instability. Breitenseher et al
found that MRI could detect lateral collateral ligament disruption
after acute ankle injury.
TEAR OFLATERAL COLLATERAL 74% Sensitivity 100% Specificity
Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Daider, A, Baldt M et al. MRI versus lateral stress
radiography in acute lateral ankle ligament injuries. Journal of Computer Assisted Tomography 1997
March/April; 21(2): 280-285.
MAGNETIC RESONANCE IMAGING: ACUTE SPRAIN
Conversely, Verhaven et al showed:
TEAR OF ATFL 100% Sensitive 50% Specificity
TEAR OF CFL 92% 100%
Verhaven EF, Shahabpour M, Handelberg FW,
Vaes PH, Opdecam PJ. The accuracy of three-
dimensional magnetic resonance imaging in the
diagnosis of ruptures of the lateral ligaments of the
ankle. Am J Sports Med 1991;19:583-587.
MRI: CHRONIC ANKLE INSTABILITY
In patients with chronic ankle instability, MRI showed
100% specificity for the diagnosis of ATFL and CFL
tears and accuracy of 91.7% in ATFL and 87.5% in
CFL tears.
Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hariharan K. Accuracy
of MRI scan in the diagnosis of ligamentous and chondral pathology in the
ankle. Foot Ankle Surg 2010; 16(2): 78-80.
MRI: ACUTE
VS
CHRONIC INJURY
In a mixed population of chronic and acute ankle
instability patients, MRI showed a 97%
sensitivity, 100% specificity and 97% accuracy.
However, when evaluating acute patients only, the
results were 100% for all three categories.
Oae K, Takao M, Uchio Y. Evaluation of anterior talofibular ligament injury with stress
radiography, ultrasonography and MR imaging. Skeletal Radiol 2010; 39:41-47.
Functional Instability Functional Instability
Patient History: Patient History:
Recurrent sprains and/or
feeling of giving way of
the ankle
Recurrent sprains and/or
feeling of giving way of
the ankle
Freeman, 1965 Freeman, 1965
5
Mechanical vs. Functional Mechanical vs. Functional
No consistent cause-effect
relationship has been found
between mechanical instability
and functional instability of the
ankle.
Moppes, 1982 Staples, 1975
Staples, 1972 Tropp, 1988
Functional Instab
93
Mechanical Instab
118
66
Fig. 1 The association between functional
and mechanical instability of the ankle
joints in 444 soccer players
Tropp, H. Odenrick, P. Gillquist, J. Stabilometry recordings in
functional and mechanical instability of the ankle joint. Int J Sports
Medicine 6:180, 1985 1985
FIGURE 1
Muscle
Weakness
Mechanical
(anatomic)
Neuromuscular Control Neuromuscular Control
Balance - Posture Balance - Posture
Muscle Reaction Time Muscle Reaction Time
Proprioception Proprioception
? ?
FIGURE 2
Richie DH: Functional Instability of the Ankle and the Role of Neuromuscular
Control; A Comprehensive Review, J Foot and Ankle Surgery, 40:240-251, 2001.
Richie DH: Functional Instability of the Ankle and the Role of Neuromuscular
Control; A Comprehensive Review, J Foot and Ankle Surgery, 40:240-251, 2001.
Persistent Ligamentous Laxity Persistent Ligamentous Laxity
CHRONIC ANKLE INSTABILITY CHRONIC ANKLE INSTABILITY
Deficit in Neuromuscular control Deficit in Neuromuscular control
Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle
instability J Athl Train 37 (4): 364, 2002
Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle
instability J Athl Train 37 (4): 364, 2002
http://www.youtube.com/watch?v=im9voO0-HNI
http://www.youtube.com/watch?v=zAwHVXLo_xA
MANIFESTS WITH DEFICIENT
POSTURE CONTROL (single
leg stance).
Karlsson, 1989 Karlsson, 1989
Jerosch, 1995 Jerosch, 1995
Lentell, 1990 Lentell, 1990
Konradsen, 1993 Konradsen, 1993
Karlsson, 1989 Karlsson, 1989
Jerosch, 1995 Jerosch, 1995
Lentell, 1990 Lentell, 1990
Konradsen, 1993 Konradsen, 1993
6
MEASURING CHRONIC ANKLE INSTABILITY
Eechaute et al. systematically reviewed
the clinimetric qualities of patient-
assessed instruments for patients with
chronic ankle instability. They
concluded that two instrumentsthe
Foot and Ankle Disability Index (FADI)
and the Functional Ankle Ability
Measure (FAAM)were the most
appropriate tools to quantify functional
disability for chronic ankle instability.
Eechaute C, Vaes P, Van Aerschot L et al. The clinimetric qualities of patient-assessed instruments for
measuring chronic ankle instability: a systematic review. BMC Musculoskelet Disord 2007;8:6.
BALANCE = POSTURAL CONTROL? BALANCE = POSTURAL CONTROL?
BALANCE: Ability of a human to remain upright in stance BALANCE: Ability of a human to remain upright in stance
POSTURAL CONTROL: Ability to keep the bodys center
of gravity (COG) within the borders
of the base of support (Nashner 1985)
BALANCE is an activity which occurs both during static stance
and dynamic gait
BALANCE is an activity which occurs both during static stance
and dynamic gait
POSTURAL CONTROL is measured during quiet static stance.
It has been studied during both double-
limb and single limb support.
POSTURAL CONTROL is measured during quiet static stance.
It has been studied during both double-
limb and single limb support.
POSTURAL CONTROL POSTURAL CONTROL
Sensory Input: Sensory Input:
Vision
Vestibular
Somatosensory System
Muscle Proprioception
Joint Mechanoreceptors
Cutaneous Afferents (sole of foot)
Postural Control and CAI Postural Control and CAI
Deficits in postural control appear to be the most consistent
finding in patients with chronic ankle instability.
Deficits in postural control appear to be the most consistent
finding in patients with chronic ankle instability.
Garn SN, Newton RA: Kinesthetic awareness in subjects with multiple ankle
sprains Phys Ther 68: 1667, 1988.
Garn SN, Newton RA: Kinesthetic awareness in subjects with multiple ankle
sprains Phys Ther 68: 1667, 1988.
Tropp H, Odenrick P: Postural control in single-limb stance. Jour Orthop Res
6: 833, 1988.
Tropp H, Odenrick P: Postural control in single-limb stance. Jour Orthop Res
6: 833, 1988.
Gauffin H, Tropp H, Odenrick P: Effect of ankle disk training on postural
control in patients with functional instability of the ankle joint. Int J Sports
Med 9:141, 1988.
Gauffin H, Tropp H, Odenrick P: Effect of ankle disk training on postural
control in patients with functional instability of the ankle joint. Int J Sports
Med 9:141, 1988.
Forkin DM, Koczur C, Battle R, Newton RA: Evaluation of kinesthetic deficits
indicative of balance control in gymnasts with unilateral chronic ankle sprains.
J Orthop Sports Phys Ther 23: 245, 1996.
Forkin DM, Koczur C, Battle R, Newton RA: Evaluation of kinesthetic deficits
indicative of balance control in gymnasts with unilateral chronic ankle sprains.
J Orthop Sports Phys Ther 23: 245, 1996.
Perrin PP, Bene MC, Perrin CA, Durupt D: Ankle trauma significantly impairs
postural control-a study in basketball players and controls. Int J sports Med
18: 387, 1997.
Perrin PP, Bene MC, Perrin CA, Durupt D: Ankle trauma significantly impairs
postural control-a study in basketball players and controls. Int J sports Med
18: 387, 1997.
Postural Control
After Ankle Sprain
Postural Control
After Ankle Sprain
Loss of postural control has also been demonstrated in patients after acute
ankle sprain.(Cornwall, MW, Murrell P. Postural sway following inversion
sprain of the ankle. J Am Podiatr Med Assoc. 81:243-247, 1991.
Loss of postural control has also been demonstrated in patients after acute
ankle sprain.(Cornwall, MW, Murrell P. Postural sway following inversion
sprain of the ankle. J Am Podiatr Med Assoc. 81:243-247, 1991.
Friden T, Zatterstrom R, Lindstrand A, Moritz U: A stabilometric technique for
evaluation of lower limb instabilities. Am J Sports Med 17: 118, 1989.
Friden T, Zatterstrom R, Lindstrand A, Moritz U: A stabilometric technique for
evaluation of lower limb instabilities. Am J Sports Med 17: 118, 1989.
Hertel J, Buckley WE, Denegar CR: Serial testing of postural control after
acute lateral ankle sprain. J Athl Train 35: 363, 2001.
Hertel J, Buckley WE, Denegar CR: Serial testing of postural control after
acute lateral ankle sprain. J Athl Train 35: 363, 2001.
Predicting Ankle Injuries Predicting Ankle Injuries
Prospective study of 119 male and 91 female high
school basketball players
Prospective study of 119 male and 91 female high
school basketball players
Subjects had no previous hx of injury Subjects had no previous hx of injury
Balance assessment with NeuroCom New
Balance Master during pre-season
Balance assessment with NeuroCom New
Balance Master during pre-season
Higher postural sway scores corresponded to
increased ankle sprain injury rates (p=0.001)
Higher postural sway scores corresponded to
increased ankle sprain injury rates (p=0.001)
Subjects with high sway scores had 7 times as many
ankle sprains as subjects with low sway scores
Subjects with high sway scores had 7 times as many
ankle sprains as subjects with low sway scores
McGuine TA, Greene JJ, Best T, Leverson G: Balance as a predictor of ankle injuries in
high school basketball players. Clin Jour Sport Med 10: 239-244, 2000.
McGuine TA, Greene JJ, Best T, Leverson G: Balance as a predictor of ankle injuries in
high school basketball players. Clin Jour Sport Med 10: 239-244, 2000.
7
Loss of Postural Control Loss of Postural Control
Risk of future ankle injury: Risk of future ankle injury:
127 soccer players, mean age 24.6 years 127 soccer players, mean age 24.6 years
postural sway measured in pre-season postural sway measured in pre-season
23 new ankle sprains in subsequent season:
12 had pathologic sway
23 new ankle sprains in subsequent season:
12 had pathologic sway
risk of sprain was 42% in those with abnormal
pre-season sway
risk of sprain was 42% in those with abnormal
pre-season sway
risk of sprain was 11% in those with normal
pre-season sway
risk of sprain was 11% in those with normal
pre-season sway
Tropp H, Edstrand J, Gillquist J: Stabilometry in functional instability of the
ankle and its value in predicting injury. Med Sci Sports Exerc 16: 64-66, 1984.
Tropp H, Edstrand J, Gillquist J: Stabilometry in functional instability of the
ankle and its value in predicting injury. Med Sci Sports Exerc 16: 64-66, 1984.
Chronic Ankle Instability: Centrally
Mediated Mechanisms
Sedory et al revealed bilateral
hamstring inhibition in CAI patients
Sedory EJ, McVey ED, Cross KM,
Ingersoll CD, Hertel J. Arthrogenic
muscle response of the quadriceps and
hamstrings with chronic ankle
instability. J Athl Train 2007;42:35560.
Chronic Ankle Instability: Centrally
Mediated Mechanisms
Sedory et al revealed bilateral
hamstring inhibition in CAI patients
Sedory EJ, McVey ED, Cross KM,
Ingersoll CD, Hertel J. Arthrogenic
muscle response of the quadriceps and
hamstrings with chronic ankle
instability. J Athl Train 2007;42:35560.
J Sports Rehabil 2009 Aug;18(3):375-88.
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. Dept of Human Services,
University of Virginia, Charlottesville, VA,
USA.
Abstract
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 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
Postural Control Postural Control
Improves after balance and coordination
training exercises
training exercises
Leanderson 1996, Goldie 1994,
Pintsaar 1996, Tropp 1984
Leanderson 1996, Goldie 1994,
Pintsaar 1996, Tropp 1984
Balance exercises cause
Bilateral Improvements
Balance exercises cause
Bilateral Improvements
Gauffin, 1988
Hertel, 2001
Gauffin, 1988
Hertel, 2001
0
50
100
150
200
250
C
a
s
e
s
PFPS ITBFS Glut Med Sacroiliac
Injury
Gender Issues: Injury Patterns
Males
Females
Taunton et al., 2002
2X
2X
3X
9X
8
Ferber et al., 2005
Hip Adduction
Hip Internal Rotation
Knee Abduction
Of 165 patients who visited Ferbers clinic complaining of overuse running injuries
(33% PFPS; 25% ITBFS), 92 per cent had weak hip muscles.
As part of each patient's consultation, he gave them a program to improve hip
strength, along with other recommendations to speed their recovery.
89 per cent of the patients reported a significant improvement in pain within four
to six weeks.
Interventions: Exercise
Ferber, 2008
Ferber, 2008
POSTURAL CONTROL POSTURAL CONTROL
Sensory Input: Sensory Input:
Vision
Vestibular
Somatosensory System
Muscle Proprioception
Joint Mechanoreceptors
Cutaneous Afferents (sole of foot)
Peroneal Reaction: Stretch Reflex Peroneal Reaction: Stretch Reflex
Receptors: Muscle Spindle Receptors: Muscle Spindle
Reflex: Afferent neurons connect to alpha
motor neurons in spinal cord
Reflex: Afferent neurons connect to alpha
motor neurons in spinal cord
Efferent: motor neurons stimulate
peroneal muscle contraction
Efferent: motor neurons stimulate
peroneal muscle contraction
Sensitivity: Gamma motor neurons
(GMNs) contract muscle spindles:
lowers threshold of response
Sensitivity: Gamma motor neurons
(GMNs) contract muscle spindles:
lowers threshold of response
How does pain affect
postural control?
How does pain affect
postural control?
9
Pain and Loss of Proprioception Pain and Loss of Proprioception
Afferent articular nerves found in joints of the LE: Afferent articular nerves found in joints of the LE:
Type I receptors: slow adapting mechanical and
dynamic receptors
Type I receptors: slow adapting mechanical and
dynamic receptors
Type II: rapidly adapting, mechanical and
dynamic receptors
Type II: rapidly adapting, mechanical and
dynamic receptors
Type III: high threshold, slow adapting,
mechanical and dynamic
Type III: high threshold, slow adapting,
mechanical and dynamic
Type IV: high threshold pain receptors Type IV: high threshold pain receptors
Wyke B: The neurology of joints. Ann R Coll Surg Engl 41:
24-50, 1967.
Wyke B: The neurology of joints. Ann R Coll Surg Engl 41:
24-50, 1967.
Painful Subtalar Joint
and Chronic Ankle Instability
Painful Subtalar Joint
and Chronic Ankle Instability
EMG activity of the Peroneus Brevis and
Longus is diminished in sinus tarsi syndrome.
EMG activity of the Peroneus Brevis and
Longus is diminished in sinus tarsi syndrome.
Injection of local anesthetic into the sinus
tarsi restores normal EMG function.
Injection of local anesthetic into the sinus
tarsi restores normal EMG function.
Taillard W, Meyer JM,
Garcia J, Blanc Y: The sinus
tarsi syndrome. Int Orthop
5: 117-130, 1981.
Taillard W, Meyer JM,
Garcia J, Blanc Y: The sinus
tarsi syndrome. Int Orthop
5: 117-130, 1981.
Sinus Tarsi Pain and Prolonged Peroneal Reaction Time Sinus Tarsi Pain and Prolonged Peroneal Reaction Time
18 pts with functional ankle instability 18 pts with functional ankle instability
8 healthy controls 8 healthy controls
measurement of peroneal reaction times
with trapdoor mechanism and EMG readings
of p. brevis and p. longus
measurement of peroneal reaction times
with trapdoor mechanism and EMG readings
of p. brevis and p. longus
recordings before and after injection of 2 mL
of 1% Lidocaine into sinus tarsi
recordings before and after injection of 2 mL
of 1% Lidocaine into sinus tarsi
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the
sinus tarsi on peroneal reaction time in patients with functional instability
of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
Before Injection: Before Injection:
Subjects with Functional Instability of Ankle 82.0 ms Subjects with Functional Instability of Ankle 82.0 ms
Controls 82.0 ms Controls 82.0 ms
After Injection: After Injection:
Subjects with Functional Instability of Ankle 69.3 ms Subjects with Functional Instability of Ankle 69.3 ms
Controls 70.5 ms Controls 70.5 ms
P < 0.0001 P < 0.0001
Sinus Tarsi Pain and Prolonged Peroneal Reaction Time Sinus Tarsi Pain and Prolonged Peroneal Reaction Time
inflammation from sprain causes irritability of
mechanoreceptors and nociceptors in the affected
ankle and subtalar joints
inflammation from sprain causes irritability of
mechanoreceptors and nociceptors in the affected
ankle and subtalar joints
excitation of leg flexors and inhibition of leg
extensors (shown in previous animal studies
with joint inflammation)
excitation of leg flexors and inhibition of leg
extensors (shown in previous animal studies
with joint inflammation)
inhibitory stimulation affects GMNs of both extensors
and peroneal muscles
inhibitory stimulation affects GMNs of both extensors
and peroneal muscles
local anesthetic reverses inhibitory stimulus of gamma
motor neurons
local anesthetic reverses inhibitory stimulus of gamma
motor neurons
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus
tarsi on peroneal reaction time in patients with functional instability of the ankle.
Foot and Ankle Int 20,9: 554-558, 1999.
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus
tarsi on peroneal reaction time in patients with functional instability of the ankle.
Foot and Ankle Int 20,9: 554-558, 1999.
Theory of Prolonged Peroneal Reaction Time Theory of Prolonged Peroneal Reaction Time
Prolonged Peroneal Reaction Time (PRT) Prolonged Peroneal Reaction Time (PRT)
We suggest that irritability of mechanoreceptors
or nociceptors or both, induced by inflammation at
the sinus tarsi, may suppress the activities of
gamma motor neurons of peroneal muscles, which
in turn might cause the symptoms of functional
instability and prolonged PRT.
We suggest that irritability of mechanoreceptors
or nociceptors or both, induced by inflammation at
the sinus tarsi, may suppress the activities of
gamma motor neurons of peroneal muscles, which
in turn might cause the symptoms of functional
instability and prolonged PRT.
sinus tarsi on peroneal reaction time in patients with functional
instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
sinus tarsi on peroneal reaction time in patients with functional
instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
10
Sensory Input:
Plantar cutaneous afferents
Sensory Input:
Plantar cutaneous afferents
The Foot:
A Major Proprioceptive Organ
The Foot:
A Major Proprioceptive Organ
Merkel Cell Complexes
Pressured Deformation
Merkel Cell Complexes
Pressured Deformation
Meissner Corpuscles
Vibration 5-40 Hz
Meissner Corpuscles
Vibration 5-40 Hz
Pacinian Corpuscles
Vibration 60-300 Hz
Pacinian Corpuscles
Vibration 60-300 Hz
STUDIES OF FOS
AND POSTURAL CONTROL
STUDIES OF FOS
Lundin TM, Feurbach JW, Grabiner MD: Effect of plantar
flexor and dorsiflexor fatigue on unilateral postural control.
J Appl Biomech. 9:191, 1993.
Lundin TM, Feurbach JW, Grabiner MD: Effect of plantar
flexor and dorsiflexor fatigue on unilateral postural control.
J Appl Biomech. 9:191, 1993.
Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL:
Effect of rearfoot orthotics on postural sway after lateral
ankle sprain. Arch Phys Med Rehabil 82: 1000, 2001.
Effect of rearfoot orthotics on postural sway after lateral
ankle sprain. Arch Phys Med Rehabil 82: 1000, 2001.
Effect of rear-foot orthotics on postural control in healthy
subjects. J Sport Rehabil 10: 36, 2001.
Effect of rear-foot orthotics on postural control in healthy
subjects. J Sport Rehabil 10: 36, 2001.
STUDIES OF FOS
STUDIES OF FOS
Percy ML, Menz HB: Effects of prefabricated foot orthotics
and soft insoles on postural stability in professional soccer
players. J Am Podiatr Med Assoc 91:194, 2001.
Percy ML, Menz HB: Effects of prefabricated foot orthotics
and soft insoles on postural stability in professional soccer
players. J Am Podiatr Med Assoc 91:194, 2001.
Rome K, Brown CL: Randomized clinical trial into the
impact of rigid foot orthoses on balance parameters in
excessively pronated feet. Clinical Rehab18: 624, 2004.
Rome K, Brown CL: Randomized clinical trial into the
impact of rigid foot orthoses on balance parameters in
excessively pronated feet. Clinical Rehab18: 624, 2004.
Effect of foot orthotics on single- and double-limb dynamic
balance tasks in patients with chronic ankle instability.
Effect of foot orthotics on single- and double-limb dynamic
balance tasks in patients with chronic ankle instability.
Foot Ankle Spec. 2008 Dec;1(6):330-7. Sesma AR, Mattacola CG, Uhl TL, Nitz AJ, McKeon PO.
Division of Athletic Training, Departement of Rehabilitation Sciences, University of Kentucky,
Lexington, Kentucky 40536-0200, USA.
Foot Ankle Spec. 2008 Dec;1(6):330-7. Sesma AR, Mattacola CG, Uhl TL, Nitz AJ, McKeon PO.
Division of Athletic Training, Departement of Rehabilitation Sciences, University of Kentucky,
Lexington, Kentucky 40536-0200, USA.
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.
11
Effect of orthoses on postural stability in asymptomatic subjects
with rearfoot malalignment during a 6-week acclimation period.
Effect of orthoses on postural stability in asymptomatic subjects
with rearfoot malalignment during a 6-week acclimation period.
Arch Phys Med Rehabil. 2007 May;88(5):653-60. Mattacola CG, Dwyer MK, Miller
AK, Uhl TL, McCrory JL, Malone TR.Division of Athletic Training, College of Health
Sciences, University of Kentucky, Lexington, KY 40536-0200, USA.
[email protected]
Arch Phys Med Rehabil. 2007 May;88(5):653-60. Mattacola CG, Dwyer MK, Miller
AK, Uhl TL, McCrory JL, Malone TR.Division of Athletic Training, College of Health
Sciences, University of Kentucky, Lexington, KY 40536-0200, USA.
[email protected]
OBJECTIVE: To determine the effect of custom-fitted orthoses on postural sway over a 6-week acclimation period.
DESIGN: Repeated-measures analysis of variance on postural sway measures with factors being group (control,
malaligned), time (initial, 2 wk, 4 wk, 6 wk postintervention), and condition (with orthoses, without orthoses). For
single-limb stance, side (right, left) was analyzed to determine bilateral differences. SETTING: Biodynamics
laboratory. PARTICIPANTS: Twenty-one subjects, 11 asymptomatic with rearfoot malalignment and 10
asymptomatic with normal rearfoot alignment. INTERVENTIONS: Orthoses were prescribed and worn for 6 weeks.
Balance testing was performed on 4 different dates with each subject tested in both orthotic conditions. Postural
control was measured with three 10-second eyes-closed trials for single-limb stance, one 20-second eyes-closed
bilateral stance with the platform moving, and one 20-second eyes-open bilateral stance with the platform and
surroundings moving. MAIN OUTCOME MEASURES: Sway velocity (in deg/s) for single-limb stance and equilibrium
score for bilateral stance. RESULTS: Postural sway measures were significantly decreased during single-limb
testing with orthoses versus without orthoses, regardless of group. The orthotic intervention significantly improved
bilateral stance equilibrium score in the malaligned group at weeks 2, 4, and 6 when compared with measures at
the initial week. Equilibrium score of the malaligned group with orthoses at initial week was significantly lower
(worse) than the control group with orthoses at initial week; however, these results were not repeated during
measurements taken at weeks 2, 4, or 6. CONCLUSIONS: The application of orthoses decreased sway velocity for
single-limb stance, improving postural stability regardless of group when visual feedback was removed. During
bilateral stance, postural stability was initially worse for the malaligned group with and without orthoses when
compared with the control group; however, improvements were seen by week 2 and continued throughout the
remainder of testing. Clinically, the application of orthoses appears to improve postural control in people with
rearfoot malalignment, particularly when vision is removed.
The effect of 6 weeks of custom-molded foot orthosis intervention on
postural stability in participants with >or=7 degrees of forefoot varus.
The effect of 6 weeks of custom-molded foot orthosis intervention on
postural stability in participants with >or=7 degrees of forefoot varus.
Clin J Sport Med. 2006 Jul;16(4):316-22. Cobb SC, Tis LL, Johnson JT.
Center for Rehabilitation Research and Master of Athletic Training Program, Texas
Tech University Health Sciences Center, Lubbock, TX 79430-6226, USA.
[email protected]
Clin J Sport Med. 2006 Jul;16(4):316-22. Cobb SC, Tis LL, Johnson JT.
Center for Rehabilitation Research and Master of Athletic Training Program, Texas
Tech University Health Sciences Center, Lubbock, TX 79430-6226, USA.
[email protected]
OBJECTIVE: Postural stability (PS) was assessed in a group of participants with >or=7
degrees of forefoot varus (FV) after 6 weeks of custom-molded functional foot orthosis (FO)
intervention to investigate the effect of FO intervention in a population that may have
decreased PS due to their foot structure. DESIGN: A force platform was used to assess right
and left single-limb stance position and eyes open and eyes closed condition PS. SETTING: PS
was assessed in a biomechanics research laboratory. PARTICIPANTS: Twelve participants
with >or=7 degrees of FV (MFV) and 5 participants with <7 degrees of FV (LFV) participated
in the study. INTERVENTIONS: PS of the MFV group was assessed initially when FOs were
received and after 6 weeks of FO intervention. The LFV group PS was assessed during initial
and 6-week testing sessions. MAIN OUTCOME MEASURES: The root mean square of the
center of pressure velocity was used to quantify single-limb stance PS during no FO and FO
conditions. RESULTS: LFV group PS did not change significantly (P=0.829) over the 6-week
time period. Significant improvement was, however, reported in the MFV group
anteroposterior (P=0.003) and mediolateral (P=0.032) PS at the 6-week assessment versus
the initial assessment during both the noFO and FO conditions. CONCLUSIONS: Six weeks of
FO intervention may significantly improve PS in participants with >or=7 degrees of FV both
when wearing FOs and when not wearing FOs.
SUMMARY OF STUDIES OF
FOS AND POSTURAL SWAY
SUMMARY OF STUDIES OF
FOS AND POSTURAL SWAY
three studies utilized injured (ankle sprain) subjects : 2 studies used
custom FOs and showed improvements in the injured subjects only. One
study used pre-fabricated FOs and showed no improvements with or
without FOs.
three studies utilized injured (ankle sprain) subjects : 2 studies used
custom FOs and showed improvements in the injured subjects only. One
study used pre-fabricated FOs and showed no improvements with or
without FOs.
all studies, except two, showed improvements of postural control with
foot orthoses. The two studies (no improvement) both utilized pre-
fabricated foot orthoses
all studies, except two, showed improvements of postural control with
foot orthoses. The two studies (no improvement) both utilized pre-
fabricated foot orthoses
one study evaluated subjects with pronated feet and showed
improvement only after 4 wks.
one study evaluated subjects with pronated feet and showed
improvement only after 4 wks.
four studies utilized prefabricated orthoses four studies utilized prefabricated orthoses
two studies utilized custom orthoses fabricated from foam box impressions two studies utilized custom orthoses fabricated from foam box impressions
one study utilized direct mold custom orthoses one study utilized direct mold custom orthoses
no study used Root protocol of negative impression casting no study used Root protocol of negative impression casting
Therefore, we recommend the use of
orthotics during the acute and subacute
phases for subjects after an ankle sprain.
Therefore, we recommend the use of
orthotics during the acute and subacute
phases for subjects after an ankle sprain.
The use of orthotics provides somatosensory
benefits because cutaneous afferents
contribute to human balance control and
may provide neutral alignment for proper
muscle activation and reduce unnecessary
strain on the already stressed soft tissue.
The use of orthotics provides somatosensory
benefits because cutaneous afferents
contribute to human balance control and
may provide neutral alignment for proper
muscle activation and reduce unnecessary
strain on the already stressed soft tissue.
Mattacola CG, Dwyer MK: Rehabilitation of the ankle after acute
sprain or chronic instability. J Athl Train. Dec (4): 413-429, 2002.
Mattacola CG, Dwyer MK: Rehabilitation of the ankle after acute
sprain or chronic instability. J Athl Train. Dec (4): 413-429, 2002.
Correction of Lateral Body Sway=Concentric
Contraction of Medial Ankle Invertors
Correction of Lateral Body Sway=Concentric
Contraction of Medial Ankle Invertors
Reduce Pronation=
Reduce Supination Ankle Injuries???
Reduce Pronation=
Reduce Supination Ankle Injuries???
Patients with lateral
ankle instability have
weaker invertor ankle
strength
Patients with lateral
ankle instability have
weaker invertor ankle
strength
Munn J, Beard D, Refshauge K, Lee R: Eccentric muscle strength in
functional ankle instability. Med Sci Sport Exerc 35(2): 245, 2003.
Munn J, Beard D, Refshauge K, Lee R: Eccentric muscle strength in
functional ankle instability. Med Sci Sport Exerc 35(2): 245, 2003.
12
DETERMINING SEVERITY
OF INJURY
DETERMINING SEVERITY
OF INJURY
Prognosis Prognosis
Timeline for return to sport Timeline for return to sport
Timeline for complete recovery Timeline for complete recovery
CLINICAL TESTS FOR
SEVERITY OF SPRAIN
Ankle ROM Ankle ROM
Ankle Strength: DF/PF/Inv/Ev Ankle Strength: DF/PF/Inv/Ev
Swelling Swelling
Wt. Bearing ability Wt. Bearing ability
None have been validated as accurate
prognostic indicators of recovery
None have been validated as accurate
prognostic indicators of recovery
Alonso et al, de Bie et al, Wilson and Gansneder Alonso et al, de Bie et al, Wilson and Gansneder
Among the clinical variables implemented in this
study, the self reported functional variables (global
function question, SF-36 PF) and the subjects
ambulation status appear to be the best potential
prognostic factors in predicting the number of days
to return to sports in Division II athletes with acute
lateral ankle sprains.
Among the clinical variables implemented in this
study, the self reported functional variables (global
function question, SF-36 PF) and the subjects
ambulation status appear to be the best potential
prognostic factors in predicting the number of days
to return to sports in Division II athletes with acute
lateral ankle sprains.
Cross KM, Worrell TW, Leslie JE, Khalid RV: The relationship between self
reported and clinical measures and the number of days of return to sport
following acute lateral ankle sprains. J Ortho Sports Phys Ther 32: 16-23,
2002.
Cross KM, Worrell TW, Leslie JE, Khalid RV: The relationship between self
reported and clinical measures and the number of days of return to sport
following acute lateral ankle sprains. J Ortho Sports Phys Ther 32: 16-23,
2002.
PREDICTING DISABILITY PREDICTING DISABILITY
72 Hours post Grade II LAS:
Swelling & ROM: poor predictor
Functional limitation: good predictor
40 m walk/run, Figure 8
Single hop, Stair hop, Cross-over hop
Wilson RW, Gansneder BM: Measures of functional limitation as predictors of
disablement in athletes with acute ankle sprains. JOSPT 30(9) : 528, 2000
TOOLS TO MONITOR
RECOVERY
TOOLS TO MONITOR
RECOVERY
Clinical Assessment Clinical Assessment
Self Reported Assessment Self Reported Assessment
Modification of outcome
measurement techniques
ANKLE SPRAIN ANKLE SPRAIN
Initial Treatment: Initial Treatment:
PP
R R
II
C C
EE
ROTECTION ROTECTION
EST EST
CE CE
OMPRESSION OMPRESSION
LEVATION LEVATION
13
A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle
Sprains
Bruce D. Beynnon,* PhD, Per A. Renstrm, MD, PhD, Larry Haugh, PhD,
Benjamin S. Uh, MD, and Howard Barker, MD From the Department of Orthopaedics & Rehabilitation,
McClure Musculoskeletal Research Center, University of Vermont, Burlington, Vermont, and the Department of
Orthopaedics, Sports Medicine & Arthroscopy, Karolinska Institute, Stockholm, Sweden
A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle
Sprains
Bruce D. Beynnon,* PhD, Per A. Renstrm, MD, PhD, Larry Haugh, PhD,
Benjamin S. Uh, MD, and Howard Barker, MD From the Department of Orthopaedics & Rehabilitation,
McClure Musculoskeletal Research Center, University of Vermont, Burlington, Vermont, and the Department of
Orthopaedics, Sports Medicine & Arthroscopy, Karolinska Institute, Stockholm, Sweden
Background: Acute ankle ligament sprains are treated with the use of controlled mobilization with protection provided by
external support (eg, functional treatment); however, there is little information regarding the best type of external support
to use. Hypothesis: There is no difference between elastic wrapping, bracing, bracing combined with elastic wrapping,
and casting for treatment of acute, first-time ankle ligament sprains in terms of the time a patient requires to return to
normal function. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: Patients suffering
their first ligament injury were stratified by the severity of the sprain (grades I, II, or III) and then randomized to undergo
functional treatment with different types of external supports. The patients completed daily logs until they returned to
normal function and were followed up at 6 months. Results: Treatment of grade I sprains with the Air-Stirrup brace
combined with an elastic wrap returned subjects to normal walking and stair climbing in half the time required for those
treated with the Air-Stirrup brace alone and in half the time required for those treated with an elastic wrap alone.
Treatment of grade II sprains with the Air-Stirrup brace combined with the elastic wrap allowed patients to return to normal
walking and stair climbing in the shortest time interval. Treatment of grade III sprains with the Air-Stirrup brace or a
walking cast for 10 days followed by bracing returned subjects to normal walking and stair climbing in the same time
intervals. The 6-month follow-up of each sprain severity group revealed no difference between the treatments for
frequency of reinjury, ankle motion, and function.
Conclusion: Treatment of first-time grade I and II ankle ligament sprains
with the Air-Stirrup brace combined with an elastic wrap provides earlier return
to preinjury function compared to use of the Air-Stirrup brace alone, an elastic
wrap alone, or a walking cast for 10 days.
Immediate treatment: Immediate treatment:
Immobilization
Recommended: Dettori, 1994 Recommended: Dettori, 1994
Protected Mobilization
Recommended: Eiff, 1994
Klein, 1993
Recommended: Eiff, 1994
Klein, 1993
vs. vs.
ANKLE SPRAIN ANKLE SPRAIN
ANKLE SPRAIN:
IMMOBILIZATION VS FUNCTIONAL TREATMENT
A systematic review by Kerkhoffs et al. assessed
the effectiveness of methods of immobilization
for acute lateral ankle ligament injuries and
compared immobilization with functional
treatment methods. Functional interventions
(which included elastic banding, soft cast, taping
or orthoses with associated coordination
training) were found to be statistically better
than immobilization for multiple outcome
measures.
Kerkhoffs GM, Rowe BH, Assendelft WJ et al. Immobilization and functional treatment for acute lateral
ankle ligament injuries in adults. Cochrane Database Syst Rev 2002;3:CD003762.
Rehabilitation Rehabilitation
Immobilization decreases
ligament repair via rate and
strength of collagen synthesis.
Andriacchi, 1988
Buckwalter, 1995
Vialas, 1981
Andriacchi, 1988
Buckwalter, 1995
Vialas, 1981
Excessive motion, post injury,
can lead to joint instability.
Burroughs, 1990
Buckwalter, 1996
Cawley, 1991
Burroughs, 1990
Buckwalter, 1996
Cawley, 1991
Lancet. 2009 Feb 14;373(9663):575-81. Mechanical supports for acute, severe
ankle sprain: a pragmatic, multicentre, randomized controlled trial.
BACKGROUND: Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to
assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot, or 10-day below-knee
cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle
sprains. METHODS: We did a pragmatic, multicentre randomised trial with blinded assessment of outcome. 584
participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency
departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance
by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were
measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot
and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomised
Controlled Trial, number ISRCTN37807450. RESULTS: Patients who received the below-knee cast had a more rapid
recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in
quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI
2.4-15.0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast
brace and tubular compression bandage was 8%; 95% CI 1.8-14.2, but there were little differences for pain,
symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least
effective treatment throughout the recovery period. There were no significant differences between tubular
compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences
between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two
cases), and deep-vein thrombosis (three cases). INTERPRETATION: A short period of
immobilisation in a below-knee cast or Aircast results in faster recovery than if
the patient is only given tubular compression bandage. We recommend below-
knee casts because they show the widest range of benefit. FUNDING: National
Co-ordinating Centre for Health Technology Assessment.
14
Exercise and joint motion stimulate
healing and influence the strength of
ligaments after injury.
Buckwalter, 1995
Gomez, 1991
Iarvinen, 1993
Buckwalter, 1995
Gomez, 1991
Iarvinen, 1993
It can be concluded that for
functional rehabilitation, loading of
the ankle joint is desirable in order to
increase joint stability.
Scheufflen, 1993
Sammarco, 1977
McCullough, 1980
Scheufflen, 1993
Sammarco, 1977
McCullough, 1980
Dorsiflexed Ankle Position Dorsiflexed Ankle Position
Talar position: close packed
Achilles tendon tension: joint compression
Lateral ligaments: minimal distraction
torn ends re-opposed
Smith, Rico, Reischl, S. The influence of dorsiflexion in the treatment of
severe ankle sprains: An anatomic study. Foot and Ankle 9:28, 1988
Smith, Rico, Reischl, S. The influence of dorsiflexion in the treatment of
severe ankle sprains: An anatomic study. Foot and Ankle 9:28, 1988
Acute Inversion Sprain
Position of ankle during sleep:
Foot plantarflexed
Unloaded ankle
Foot inverted
Prolonged abnormal positioning
Solution: Dorsiflexion night splinting
Non-Pneumatic Walking Splint, With
or Without Joints. Prefabricated,
includes fitting and adjustment.
CODE:
L4386
REIMBURSEMENT:
$114 to $152
CODE:
L4386
REIMBURSEMENT:
$114 to $152
METHOD OF IMMOBILIZATION
Lamb et al. conducted a single-blinded randomized control trial, assessing the
effectiveness of three different mechanical supports (the Aircast brace, the Bledsoe
boot or 10-day below-knee cast) against that of a double-layered tubular compression
bandage in promoting recovery after severe ankle sprains. They found that a short
period of immobilization in a below-knee cast or Aircast brace resulted in faster
recovery than if the patient is only given tubular compression bandage. They noted
clinically important benefits in terms of ankle function, pain, symptoms and activity at
3 months.
Lamb SE, Marsh JL, Hutton JL et al. Collaborative Ankle Support Trial (CAST Group). Mechanical
supports for acute, severe ankle sprain: a pragmatic, multicentre, randomized controlled trial. Lancet
2009;373:57581.
15
SYNDESMOSIS INJURIES
Incidence: Incidence:
15/1344 ankle sprains
West Point, 1990
10% incidence Cedell, 1975
Brostrom, 1965
5% incidence Fallat, 1998
18% incidence Minnesota Viking
Boytim et al 1991
DIASTASIS DIASTASIS
Radiographic Criteria: Radiographic Criteria:
1. Medial clear space
- widened
1. Medial clear space
- widened
2. Tibiofibular overlap
- reduced
2. Tibiofibular overlap
- reduced
3. Tibiofibular clear space
- increased
3. Tibiofibular clear space
- increased
HIGH ANKLE SPRAIN: Initial Treatment
Short leg cast, ankle plantarflexed
10 degrees and Int. Rotated
Non-weight bearing with crutches or scooter
16
Rehabilitation
Dorsiflexed position of ankle most stable
Early weight bearing increases stability of
the ankle joint after injury
Smith 1988, Stormont 1985
McCullough 1980,
Scheuffelen 1993
Immobilize vs. Mobilize
After acute sprain: After acute sprain:
Immobilize to allow pain free weight bearing
Must allow Active Range of Motion
Functional Rehabilitation Program Functional Rehabilitation Program
Four Stages: Four Stages:
Range of Motion Range of Motion
Strengthening Strengthening
Proprioception Proprioception
Activity-specific training Activity-specific training
training exercises
Leanderson 1996, Goldie 1994, Pintsaar 1996, Tropp 1984
Balance Training after LAS Balance Training after LAS
Holme, 1999
4 fold reduction of recurrent sprain 4 fold reduction of recurrent sprain
2 fold reduction 2 fold reduction
Wester, 1996
McKeon PO, Hertel J. Systematic Reviw of postural control and lateral ankle
instability, Part II: Is balance training clinically effective? Journal of Athletic
Training 2008;43(3):305315
McKeon PO, Hertel J. Systematic Reviw of postural control and lateral ankle
instability, Part II: Is balance training clinically effective? Journal of Athletic
Training 2008;43(3):305315
Prophylactic balance training substantially reduced the risk
of sustaining ankle sprains, with a greater effect seen in
those with a history of a previous sprain. Completing at least
6 weeks of balance training after an acute ankle sprain
substantially reduced the risk of recurrent ankle sprains;
however, consistent improvements in instrumented
measures of postural control were not associated with
training. Evidence is lacking to assess the reduction in the
risk of recurrent sprains and inconclusive to demonstrate
improved instrumented postural control measures in those
with chronic ankle instability who complete balance
training.
17
Star Excursion Balance Test Star Excursion Balance Test (SEBT) (SEBT)
LAYOUT OF SEBT LAYOUT OF SEBT
LATERAL REACH ON SEBT LATERAL REACH ON SEBT
Photos From: Relationship between Ground Reaction Force and Stability Level of the Lower
Extremity in Runners. Kimitake Sato, Monique Butcher-Mokha Barry University Miami Shores, FL
Photos From: Relationship between Ground Reaction Force and Stability Level of the Lower
Extremity in Runners. Kimitake Sato, Monique Butcher-Mokha Barry University Miami Shores, FL
ACUTE ANKLE SPRAIN:
TREATMENT PROTOCOL
Initial Evaluation
History- Mechanism, Wt. Bearing Status, Immediate Tx
Presentation-Wt Bearing? Self-assessment of severity
Radiographs-Almost every time!
Exam-Edema, ecchymosis, erythema
Palpation-Ligaments, osseous structures
Stress Exam- Anterior Drawer, Inversion-Eversion,
Medial Calcaneal Glide
ACUTE ANKLE SPRAIN:
TREATMENT PROTOCOL
Initial Treatment
Walking Boot (in 90% of cases)
Weight Bearing to tolerance, except in High Ankle Sprain
Sleep with Boot for 3-5 days
Ankle Plantarflexion-Dorsiflexion T.I.D.
Ice 20 min T.I.D.
ACUTE ANKLE SPRAIN: Treatment Protocol
Evaluate in clinic at Day 7: Ability to walk w/o boot,
Rhomberg, Drawer , Pt self-assessment
Walk w/o limp: Dispense articulated footplate ankle brace
Phase 2: Day 7 thru 21
Walk with limp: Continue walking boot for 14 more days
For All: Begin Functional Rehabilitation Protocol for 8-12
weeks
Continuum of Care Sales
Strategy
walking boot
cast
Rebound Ankle Brace
with Stability Strap
(instead of stirrup, lace-up
ankle brace, and/or sleeve)
Soft Ankle Brace
D
Velocity Ankle Brace by Donjoy
VELOCITY LS
(light support)
$96.95 ES Version Available in Black or White Color
$86.95 MS Version Available in Black Color Only
$76.95 LS Version Available in Black Color Only
VELOCITY ES
L1971
VELOCITY MS
18
Product Diagram
Al l i gator Strap-End
Stabi l i ty Strap
Thermoformed Li ner
Sl i p-Resi stant
Texture
Inversi on/Eversi on
Resi stance
Anatomi cal Footpl ate
Venti l ati on
Bi l ateral
Hi nge
Heel Cup
Wi dth Adjustment
Dual Cl osure
Straps
L1906 Soft Ankle Braces
3/26/2011
Exoform Ankle Brace
Product Type: Figure 8 Lace Up
3/26/2011
Exoform's advanced design with Figure-8 heel lock strapping
provides the compression and comfort of a soft ankle with 35%
more protection then traditional stirrups
Figure-8 heel lock strapping performs consistently unlike taping
that stretches over time
Without Figure-8 heel lock strapping, the Exoform offers the
compressionand comfort of a soft ankle with 20% more
protection than a stirrup
The lowest profile and lightest ankle brace of Ossurs entire
family
Allows for normal plantar and dorsi flexion
Constructed of highly breathable, quick drying fabric
Performance Features
X Small X Large
Sizing
ExoformAnkle Brace
ExoformAnkle Brace with Figure-8 Straps
Options
Swedo Ankle Loc
Product Type: Figure 8 Lace Up
3/26/2011
ExclusiveANKLE LOK offset panel traps the laces between the inner
and outer flap to hold the laces tighter longer than any other brace.
Exclusive close spaced eyelets concentrate the holding power where
it's needed most creating the most effective heel lock.
Full elastic back ensures complete unrestricted blood flow to the
Achilles' tendon and virtually eliminates the chance for blistering
Internal U-shaped spiral stays provide extra support and further
minimize the chance for ankle injury.
Arch fits the contour of the foot and is seamless so it virtually
eliminates irritation to the bottom of the foot.
Triple layer vinyl laminate provides durability and comfort.
Optional side stabilizer inserts provide additional medial and lateral
support for injured ankles.
Available in either black and white.
Performance Features
X Small X Large
Sizing
Black or White
Stabilizer strut
Options
Reimbursement
L1906 Most states have a reimbursement of
around $90
3/26/2011
ACUTE ANKLE SPRAIN: Treatment Protocol
Evaluation may occur between day 7 and day 21.
Follow SARS Protocol
Phase 3: Return to play
Patient will move out of articulated footplate ankle brace to
lace-up brace
Evaluate for custom functional foot orthotic therapy
Balance training to continue for 12 weeks total
19
Grade II / III LAS Grade II / III LAS
When can I return to sport? When can I return to sport?
TOOLS TO MONITOR RECOVERY TOOLS TO MONITOR RECOVERY
Clinical Assessment Clinical Assessment
Self Reported Assessment Self Reported Assessment
3 Subjective Questions:
1. Has the ankle recovered fully after
the injury?
Yes or No. If no, how does it compare to
before the injury, better, same or worse.
2. Can you walk normally?
3. Can you run normally?
Kaikkonen A, Kannus P, Jarvinen M: A performance test protocol and scoring
scale for the evaluation of ankle injuries. Am Journal Sports Medicine 22: 462,
1994.
1994.
Performance Test Protocol Performance Test Protocol
2 Clinical Measures:
ROM Ankle dorsiflexion, plantarflexion
Anterior drawer sign
Walking down staircase *
Rising on heels
Rising on toes
1994.
1994.
1 Functional Stability Test:
2 Muscle Strength Tests:
1 Balance Test:
One legged stance on 10 cm square beam
Performance Test Protocol Performance Test Protocol
SPORTS ANKLE RATING SYSTEM SPORTS ANKLE RATING SYSTEM
1. Quality of Life Measure
2. Clinical Rating Score
3. Single Assessment Numeric
Evaluation (SANE)
Williams GN, Molloy JM, DeBernardino TM et al: Evaluation of the Sports Ankle
Rating System in Young Athletic Individuals with Acute Lateral Ankle Sprains.
Foot and Ankle Int 24:274, 2003
Williams GN, Molloy JM, DeBernardino TM et al: Evaluation of the Sports Ankle
Rating System in Young Athletic Individuals with Acute Lateral Ankle Sprains.
Foot and Ankle Int 24:274, 2003
SPORTS ANKLE RATING SYSTEM CLINICAL RATING SCORE SPORTS ANKLE RATING SYSTEM CLINICAL RATING SCORE
Part I: SUBJECTIVE VISUAL ANALOG SCALES (Compiled by the Patient) Part I: SUBJECTIVE VISUAL ANALOG SCALES (Compiled by the Patient)
Instructions: Each line below represents a range of function in the item listed to its left
(Pain, Swelling, Stiffness, Giving Way, and Function). The left end of each line indicates
severe difficulty in the listed item and the right end of each line indicates perfect function
in that item. Please draw a vertical line across the point on each line that represents the
level of difficulty you have experienced with your ankle in each item during the past week.
You may mark anywhere along each line.
Instructions: Each line below represents a range of function in the item listed to its left
(Pain, Swelling, Stiffness, Giving Way, and Function). The left end of each line indicates
severe difficulty in the listed item and the right end of each line indicates perfect function
in that item. Please draw a vertical line across the point on each line that represents the
level of difficulty you have experienced with your ankle in each item during the past week.
You may mark anywhere along each line.
EXAMPLE constant symptoms no symptoms
PAIN
SWELLING
STIFFNESS
GIVING WAY
FUNCTION
PAIN
SWELLING
STIFFNESS
GIVING WAY
FUNCTION
severe pain no pain
severe swelling no swelling
very stiff no stiffness
gives way often no giving way
walking on level
surface is difficult
totally normal
ankle function
20
Evaluation
Evaluation
Rate your ankles function on a
scale of 0 100
ANKLE PERFORMANCE MILESTONES ANKLE PERFORMANCE MILESTONES
Single leg stance (Romberg) Single leg stance (Romberg)
Lateral hop Lateral hop
Run down stairs Run down stairs
Toe/Heel Raise Toe/Heel Raise
Postural Stability Assessment
Single Leg Stance Test:
Barefoot, stance on one leg
Eyes closed
Arms at sides
Time compared to contralateral side Time compared to contralateral side
Ankle Function Assessment
stand on one leg
hop laterally, as far as possible
three continuous hops
compare distance to un-involved leg
CRITERIA FOR RETURN TO SPORT CRITERIA FOR RETURN TO SPORT
In-Office Assessment In-Office Assessment
On-Field Assessment On-Field Assessment
ON-FIELD ASSESSMENT ON-FIELD ASSESSMENT
40 METER RUN 40 METER RUN
FIGURE OF 8 RUN FIGURE OF 8 RUN
CUTTING DRILLS CUTTING DRILLS
NON-CONTACT KICKING, RUNNING NON-CONTACT KICKING, RUNNING
SPORT SIMULATION SPORT SIMULATION
DEVELOP RESTRICTIONS AND
LIMITATIONS
DEVELOP RESTRICTIONS AND
LIMITATIONS
21
BRACING THE ANKLE BRACING THE ANKLE
Enhance recovery ? Enhance recovery ?
Protect from re-injury ? Protect from re-injury ?
METHOD OF IMMOBILIZATION
In a separate article, Kerkhoffs et al. systematically
assessed the effectiveness of various treatments of
acute ruptures of the lateral ankle ligaments in
adults. They found that lace-up supports were a more
effective functional treatment than elastic bandaging.
Lace-up supports resulted in less persistent swelling
in the short term when compared with semi-rigid
ankle supports, elastic bandaging and tape. Tape
resulted in more dermatological complications than
elastic bandage. Struijs and Kerkhoffs could not be
certain whether homeopathic ointment or
physiotherapy significantly improved function due to
a paucity of studies after an extensive review of the
evidence.
Kerkhoffs GM, Struijs PA, Marti RK et al. Functional treatments for acute ruptures of the lateral ankle
ligament: a systematic review. Acta Orthop Scand 2003;74:6977.
TAPING AND BRACING
IMPROVE PROPRIOCEPTION.
TAPING AND BRACING
IMPROVE PROPRIOCEPTION.
Garn, 1998 Friden, 1989 Garn, 1998 Friden, 1989
Guskiewicz, 1996 Heit, 1989 Guskiewicz, 1996 Heit, 1989
Jerosch, 1995 Tropp, 1985 Jerosch, 1995 Tropp, 1985
Feuerbach, 1994 Feuerbach, 1994
Garn, 1998 Friden, 1989 Garn, 1998 Friden, 1989
Guskiewicz, 1996 Heit, 1989 Guskiewicz, 1996 Heit, 1989
Jerosch, 1995 Tropp, 1985 Jerosch, 1995 Tropp, 1985
Feuerbach, 1994 Feuerbach, 1994
TAPING AND BRACING THE ANKLE
WILL LIMIT INVERSION / EVERSION.
TAPING AND BRACING THE ANKLE
WILL LIMIT INVERSION / EVERSION.
Hughes, 1983 Lofuenberg, 1993 Hughes, 1983 Lofuenberg, 1993
Myburgh, 1984 Shapiro, 1994 Myburgh, 1984 Shapiro, 1994
Gross, 1987 Thonnard, 1996 Gross, 1987 Thonnard, 1996
Greene, 1990 Vaes, 1998 Greene, 1990 Vaes, 1998
Hughes, 1983 Lofuenberg, 1993 Hughes, 1983 Lofuenberg, 1993
Myburgh, 1984 Shapiro, 1994 Myburgh, 1984 Shapiro, 1994
Gross, 1987 Thonnard, 1996 Gross, 1987 Thonnard, 1996
Greene, 1990 Vaes, 1998 Greene, 1990 Vaes, 1998
Loses up to 40% restrictive function
after 10 minutes of exercise.
Glick, 1976 Fumich, 1981 Greene, 1990 Glick, 1976 Fumich, 1981 Greene, 1990
ANKLE TAPING ANKLE TAPING
Brace vs Non-brace Brace vs Non-brace
SIGNIFICANT REDUCTION
OF INJURIES.
Rovere, 1988 Rovere, 1988
Sitler, 1994 Sitler, 1994
Surve, 1994 Surve, 1994
Rovere, 1988 Rovere, 1988
Sitler, 1994 Sitler, 1994
Surve, 1994 Surve, 1994
22
Prophylactic Ankle Bracing in Sport
Sitler, MR; Horodyski, M: Effectiveness of prophylactic ankle stabilizers of
prevention of ankle injuries. Sports Med. 20:53 7, 1995.
Surve, I; Schwellnus, MP; Noakes, T; Lombard, C: A fivefold reduction in the
incidence of recurrent ankle sprains in soccer players using the sport-stirrup
orthosis. The American Journal of Sports Medicine. 22: 604-605, 1994
Thacker, SB; Stroup, DF; Branche, CM; et al.: The prevention of ankle sprains in
sports. The American Journal of Sports Medicine. 27: 753 760, 1995.
Tropp, H; Askling, C; Gillquist, J: Prevention of ankle sprains. The American Journal
of Sports Medicine. 13: 259 262, 1985.
Pedowitz, DI; Sudheer, R; Parekh, SG; Huffman, G; Sennett, BJ: Prophylactic bracing
decreases ankle injuries in collegiate female volleyball players, American Journal of
Sports Medicine. 36:324 327,2008.
Frey, C, Feder KS, Sleight J: Prophylactic ankle brace use in high school volleyball
players. Foot Ankle Int. 31: 296-300, 2010
J Sci Med Sport. 2009 Jul 7. [Epub ahead of print] A systematic review on the
effectiveness of external ankle supports in the prevention of inversion ankle
sprains among elite and recreational players. Dizon JM, Reyes JJ.
J Sci Med Sport. 2009 Jul 7. [Epub ahead of print] A systematic review on the
effectiveness of external ankle supports in the prevention of inversion ankle
sprains among elite and recreational players. Dizon JM, Reyes JJ.
Epidemiological studies have shown that 10-28% of all sports injuries are ankle sprains, leading to the
longest absence from athletic activity compared to other types of injuries. This study was conducted to
evaluate the effectiveness of external ankle supports in the prevention of inversion ankle sprains and
identify which type of ankle support was superior to the other. A search strategy was developed, using
the keywords, ankle supports, ankle brace, ankle tapes, ankle sprains and athletes, to identify available
literature in the databases (MEDLINE, PubMed, CINAHL, EMBASE, etc.), libraries and unpublished papers.
Trials which consider adolescents and adults, elite and recreational players as participants were the study
of choice. External ankle supports comprise ankle tape, brace or orthosis applied to the ankle to prevent
ankle sprains. The main outcome measures were frequency of ankle sprains. Two reviewers assessed the
quality of the studies included using the Joanna Briggs Institute (JBI Appraisal tool). Whenever possible,
results were statistically pooled and interpreted. A total of seven trials were finally
included in this study. The studies included were of moderate quality, with
blinding as the hardest criteria to fulfill. The main significant finding was
the reduction of ankle sprain by 69% (OR 0.31, 95% CI 0.18-0.51) with
the use of ankle brace and reduction of ankle sprain by 71% (OR 0.29,
95% CI 0.14-0.57) with the use of ankle tape among previously injured
athletes. No type of ankle support was found to be superior than the
other.
PREVENTION OF SPRAIN
Handoll et al. also carried out a systematic review to assess the effects of
interventions used for the prevention of ankle ligament injuries in physically
active individuals. They concluded there is good evidence for the beneficial
effect of ankle support in the form of semi-rigid orthoses orAircast braces to
prevent subsequent ankle sprains during high-risk sporting activity. There was
limited evidence for reducing ankle sprains in patients with previous ankle
sprains who did ankle disk training exercises. There was no conclusive
evidence on the protective effect of high-top shoes. Hupperets et al. evaluated
the effectiveness of an unsupervised proprioceptive training programme on
ankle sprain recurrence in athletes by means of a randomized control trial.
They found that the use of such a programme is effective forthe prevention of
self-reported recurrence. It was specifically beneficial in athletes whose
original sprain had not been medically treated. Although studies considered
were of higher levels of evidence, small finite numbers once again preclude us
from making any meaningful conclusions as to the strength of evidence.
Handoll HH, Rowe BH, Quinn KM et al. Interventions for preventing ankle ligament injuries. Cochrane
Database Syst Rev 2001;3:CD000018. Hupperets MD, Verhagen EA, van Mechelen W. Effect of
unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled
trial. BMJ 2009;339:b2684
1601 U.S. Military cadets 1601 U.S. Military cadets
Randomized, prospective study Randomized, prospective study
No evidence of FI No evidence of FI
Intra-mural basketball Intra-mural basketball
1424 non-injured, 177 prev. injured 1424 non-injured, 177 prev. injured
13,430 athlete exposures 13,430 athlete exposures
Randomized brace assignment B/L
(Aircast Sport Stirrup)
Randomized brace assignment B/L
(Aircast Sport Stirrup)
All ankle injuries evaluated by 2 M.D.s All ankle injuries evaluated by 2 M.D.s
Sitler M, Ryan J, Wheeler B et al: The efficacy of a semi rigid ankle stabilizer to
reduce ankle injuries in basketball. Am Jour Sports Med 22: 454-461, 1994.
2.9% of subjects (46) had ankle sprain 2.9% of subjects (46) had ankle sprain
Injury rate was 1.4 x greater injured vs non Injury rate was 1.4 x greater injured vs non
Of the 46 injuries: Of the 46 injuries:
No difference in severity No difference in severity
No difference in non-contact sprains No difference in non-contact sprains
RESULTS RESULTS
11 in brace group
35 in control group
11 in brace group
35 in control group
Brace vs control Brace vs control
OF 46 INJURED SUBJECTS OF 46 INJURED SUBJECTS
RESULTS by POSITION RESULTS by POSITION
43% - Guard
39% - Forward
18% - Center
43% - Guard
39% - Forward
18% - Center
23
Ankle bracing was protective for both prev.
inj. And non inj. groups
Ankle bracing was protective for both prev.
inj. And non inj. groups
ATF ruptured in 66% of injuries ATF ruptured in 66% of injuries
CF ruptured in 17% of injuries CF ruptured in 17% of injuries
Greater reduction of CF injuries with brace Greater reduction of CF injuries with brace
No difference in knee injuries:
brace vs control
No difference in knee injuries:
brace vs control
RESULTS RESULTS
Randomized, prospective study Randomized, prospective study
Senior club soccer player S. Africa Senior club soccer player S. Africa
258 prev. injured 258 prev. injured
SOCCER SOCCER
246 no prev. history 246 no prev. history
Excluded gross pathologic ankles Excluded gross pathologic ankles
Random assignment of braces
(Aircast sport stirrup)
Random assignment of braces
(Aircast sport stirrup)
Unilateral use of brace dominant or
injured side
Unilateral use of brace dominant or
injured side
Surve I, Schwellnus MP, Nokes T, Lombard C: Ankle sprains in soccer players using the
Sport Support Orthosis. Am Jour Sports Med. 22: 601-606, 1994.
Prev. Hist. - Braced 127 16 * Prev. Hist. - Braced 127 16 *
Prev. Hist. Control 131 42 Prev. Hist. Control 131 42
No Hist. - Braced 117 32 No Hist. - Braced 117 32
No Hist. - Control 129 33 No Hist. - Control 129 33
P < 0.001 P < 0.001
NN Sprains Sprains
RESULTS RESULTS
SEVERITY OF SPRAIN SEVERITY OF SPRAIN
Significant difference only with
previously injured
Significant difference only with
previously injured
Dominant vs Non Dominant Dominant vs Non Dominant
No difference in frequency of sprains No difference in frequency of sprains
No difference in injury rates No difference in injury rates
KNEE KNEE
Brace vs non brace
We postulate that the main
effect of the orthosis is to
improve proprioceptive
function of the previously
injured ankle rather than to
provide mechanical support
alone.
We postulate that the main
effect of the orthosis is to
improve proprioceptive
function of the previously
injured ankle rather than to
provide mechanical support
alone.
Surve I, Schwellnus MP, Nokes T, Lombard C: Ankle
sprains in soccer players using the Sport Support
Orthosis. Am Jour Sports Med. 22: 601-606, 1994.
Surve I, Schwellnus MP, Nokes T, Lombard C: Ankle
sprains in soccer players using the Sport Support
Orthosis. Am Jour Sports Med. 22: 601-606, 1994.
Ankle Braces Prevent Sprains
in Female Basketball Players
Ankle Braces Prevent Sprains
in Female Basketball Players
Prospective study of 204 professional basketball players during 2 seasons Prospective study of 204 professional basketball players during 2 seasons
32 ankle sprains; Rate of 1.12 per 1000 hours of exposure 32 ankle sprains; Rate of 1.12 per 1000 hours of exposure
Ankle sprain more frequent in Center position, then guard, then forward Ankle sprain more frequent in Center position, then guard, then forward
Players without an ankle brace were 2.4 times more likely to sprain Players without an ankle brace were 2.4 times more likely to sprain
Kofotolis N, Kellis E. Ankle sprain
injuries: a 2-year prospective cohort
study in female Greek professional
basketball players. J Athle Train.
2007 Jul-Sep; 42(3): 388-94.
Kofotolis N, Kellis E. Ankle sprain
injuries: a 2-year prospective cohort
study in female Greek professional
basketball players. J Athle Train.
2007 Jul-Sep; 42(3): 388-94.
24
Prophylactic Bracing in Female Volleyball Players Prophylactic Bracing in Female Volleyball Players
Significant reduction of injury rate with brace (P= .001) Significant reduction of injury rate with brace (P= .001)
Prospective study at U Penn from 1998-2005 Prospective study at U Penn from 1998-2005
All athletes required to wear ankle braces (Active Ankle) All athletes required to wear ankle braces (Active Ankle)
One injury in 13,500 exposures: 0.07 per 1000 exposures One injury in 13,500 exposures: 0.07 per 1000 exposures
Compared to NCAA female average: 0.98 per 1000 exposures Compared to NCAA female average: 0.98 per 1000 exposures
Pedowitz DI, Reddy S, Parekh SG, Huffman GR, Sennett BJ. Prophylactic bracing
decreases ankle injuries in collegiae female volleyball players. Am J Sports Med,
208 Feb; 36(2): 324-327.
Pedowitz DI, Reddy S, Parekh SG, Huffman GR, Sennett BJ. Prophylactic bracing
decreases ankle injuries in collegiae female volleyball players. Am J Sports Med,
208 Feb; 36(2): 324-327.
52 female volleyball players with ankle sprain the previous year 52 female volleyball players with ankle sprain the previous year
Comparison of three prevention programs during the subsequent season: Comparison of three prevention programs during the subsequent season:
Technical training Technical training
Proprioceptive training Proprioceptive training
Ankle brace Ankle brace
All three methods equally effective in preventing another sprain All three methods equally effective in preventing another sprain
Ankle braces not as effective in athletes with more than 3 prev. sprains Ankle braces not as effective in athletes with more than 3 prev. sprains
Stasinopoulos D. Comparison of three preventive methods in order to reduce the
incidence of ankle inversion sprains among female volleyball players. Br J Sports
Med, 2004 Apr: 38(2): 182-185.
Stasinopoulos D. Comparison of three preventive methods in order to reduce the
incidence of ankle inversion sprains among female volleyball players. Br J Sports
Med, 2004 Apr: 38(2): 182-185.
RESULTS
Regardless of gender there was no significant
difference in the ability of each brace to prevent
injury (p = 0.691). In addition, the braced group
did not have any significant advantage in
preventing injury when compared to the control
group (p = 0.824).
Frey, C, Feder KS, Sleight J: Prophylactic ankle brace use in
high school volleyball players. Foot Ankle Int. 31: 296-300,
2010
In the group that wore the non-rigid brace, there was
a statistically significant increase in female ankle
sprains as compared to male ankle sprains (p =
0.045). There was an even more significant increase in
ankle sprains seen in the group of women wearing a
non-rigid brace as compared to
the group of women wearing a semi-rigid or rigid
brace (p = 0.0032).
RESULTS
2010
DISCUSSION
The authors conclude that ankle braces
should be recommended for female players
with or without a history of ankle sprains.
When a brace is used, a rigid or semi-rigid
device should be used.
2010 TAPE TAPE
Karlsson, American Journal of Sports Medicine 20: 257 Karlsson, American Journal of Sports Medicine 20: 257--260, 1992 260, 1992 Karlsson, American Journal of Sports Medicine 20: 257 Karlsson, American Journal of Sports Medicine 20: 257--260, 1992 260, 1992
No reduction of talar tilt or
anterior talar translation
Unstable ankles = longer
peroneal reaction time
Tape = shorter reaction time;
unstable ankles only
25
Vaes P.H. et al: Static and Dynamic Roentgenographic Analysis of Ankle Vaes P.H. et al: Static and Dynamic Roentgenographic Analysis of Ankle
Stability in Braced and Non Stability in Braced and Non--braced Stable and Functionally Unstable Ankles. braced Stable and Functionally Unstable Ankles.
Am Journal Sports Medicine 26:692, 1998 Am Journal Sports Medicine 26:692, 1998
Vaes P.H. et al: Static and Dynamic Roentgenographic Analysis of Ankle Vaes P.H. et al: Static and Dynamic Roentgenographic Analysis of Ankle
Stability in Braced and Non Stability in Braced and Non--braced Stable and Functionally Unstable Ankles. braced Stable and Functionally Unstable Ankles.
Am Journal Sports Medicine 26:692, 1998 Am Journal Sports Medicine 26:692, 1998
TALAR TILT - UNSTABLE ANKLES
NON-BRACED BRACED
13.1
16.6
9.8
110.6pixels
4.8 *
12.0
6.4
92.4pixels
Supine
Standing
Dynamic
Speed
* p < 0.001
p < 0.01
(40-80 msec)
Hx No Hx
TAPE BRACE TAPE BRACE
Garrick, Requa 2,778 910 15,281 5,005
Sitler et al 1,923 630 4,168 1,305
Surve et al 4,534 175 6,091 1,195
Cost to prevent one sprain during a season Cost to prevent one sprain during a season
Olmstead LC, Vela LI, Denegar CR, Hertel J: Prophylactic ankle taping and bracing: A
numbness needed-to-treat and cost-benefit analysis. J Athl Train. 39(1): 95-100, 2004
Olmstead LC, Vela LI, Denegar CR, Hertel J: Prophylactic ankle taping and bracing: A
numbness needed-to-treat and cost-benefit analysis. J Athl Train. 39(1): 95-100, 2004
Our cost-benefit analysis
determined that ankle taping
would be 3.05 times as expensive
as ankle bracing over the course of
a competitive season.
Our cost-benefit analysis
determined that ankle taping
would be 3.05 times as expensive
as ankle bracing over the course of
a competitive season.
Olmstead LC, Vela LI, Denegar CR, Jertel J: Prophylactic ankle taping and
bracing: A numbness needed-to-treat and cost benefit analysis. J Athl Train.
39(1): 95-100, 2004.
Olmstead LC, Vela LI, Denegar CR, Jertel J: Prophylactic ankle taping and
bracing: A numbness needed-to-treat and cost benefit analysis. J Athl Train.
39(1): 95-100, 2004.
Monitor Return to Sport After Ankle Sprain: Monitor Return to Sport After Ankle Sprain:
Take Home Message Take Home Message
1. Listen to your patient: their own assessment of injury
is most important
1. Listen to your patient: their own assessment of injury
is most important
2. Anterior Drawer is just as valuable as stress radiographs 2. Anterior Drawer is just as valuable as stress radiographs
3. Best functional tests: 3. Best functional tests:
i. Single Foot Balance (Romberg) i. Single Foot Balance (Romberg)
ii. Lateral Hop Test ii. Lateral Hop Test
iii. Forward Hop Test iii. Forward Hop Test
4. You cannot over-brace the injured ankle! 4. You cannot over-brace the injured ankle!
Lateral Ankle Instability Lateral Ankle Instability
ASSOCIATED INJURIES: ASSOCIATED INJURIES:
Peroneal Tenosynovitis
Anterolateral impingement
Atten. Peroneal retin.
Ankle synovitis
Loose body
P. brevis tear
Talar lesion
Med. Tend. Tenosyn.
47/61
41/61
33/61
30/61
16/61
15/61
14/61
3/61
77%
67%
54%
49%
26%
25%
23%
5%
DiGiovanni BF, Fraja CJ, Cohen, BE, Shereff MJ: Associated injuries
found in chronic lateral ankle instability. Foot & Ankle 21: 805-815
DiGiovanni BF, Fraja CJ, Cohen, BE, Shereff MJ: Associated injuries
found in chronic lateral ankle instability. Foot & Ankle 21: 805-815

Tare de Tot

Uploaded by

Copyright:

Available Formats

Tare de Tot

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Tare de Tot

Uploaded by

Copyright:

Available Formats

1

Chronic Ankle Instability

You might also like