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1.  Bone Microarchitecture of the Talus Changes With Aging 
Background
Fractures of the talus in the elderly are rare and usually result from high-impact injuries, suggesting only minor age-related bone structure changes. However, total ankle replacement failures with age often result from talar subsidence, suggesting age-related bone loss in the talus. Despite a number of histological analyses of talar microarchitecture, the effects of age and sex on talar microarchitecture changes remain poorly defined.
Questions/purposes
The aim of this study was to analyze changes or differences in the trabecular microarchitecture of the talus with regard to (1) age and (2) sex.
Methods
Sixty human tali were harvested from 30 patients at autopsy of three different age groups (20–40, 41–60, 61–80 years). The specimens were analyzed by radiography, micro-CT, and histological analysis. Given that there was no difference between the left and right talus, static histomorphometric parameters were assessed in three regions of interest of the right talus only (body, neck, head; n = 30).
Results
The talar body, neck, and head were affected differently by age-related changes. The greatest loss of bone volume with age was seen in the talar body (estimate: −0.239; 95% confidence interval [CI], −0.365 to −0.114; p < 0.001). In the talar neck (estimate: −0.165; 95% CI, −0.307 to −0.023; p = 0.025), bone loss was only moderate and primarily was the result of reduction in trabecular thickness (estimate: −1.288; 95% CI, −2.449 to −0.127; p = 0.031) instead of number (estimate: −0.001; 95% CI, −0.005 to −0.003; p = 0.593). Bone structure changes were independent of sex.
Conclusions
Age-related bone structure changes predominantly occur in the talar body, which poses a potential risk factor for total ankle replacement loosening. The moderate changes in the talar neck might explain the persistent low incidence of talar neck fractures with age.
Clinical Relevance
Our findings suggest that before total ankle replacement implantation, careful patient selection with dual-energy xray absorptiometry evaluation may be necessary to reduce the risk of talar implant subsidence.
doi:10.1007/s11999-013-3195-0
PMCID: PMC3792264  PMID: 23893363
2.  Arthroscopic Excision of Bone Fragments in a Neglected Fracture of the Lateral Process of the Talus in a Junior Soccer Player 
Arthroscopy Techniques  2014;3(3):e331-e334.
Fractures of the lateral process of the talus are uncommon and often overlooked. Typically, they are found in adult snowboarders. We report the case of an 11-year-old male soccer player who complained of lateral ankle pain after an inversion injury 6 months earlier. He did not respond to conservative treatment and thus underwent arthroscopic excision of fragments of the talar lateral process. The ankle was approached through standard medial and anterolateral portals. A 2.7-mm-diameter 30° arthroscope was used. Soft tissues around the talus were cleared with a motorized shaver, and the lateral aspect of the talar process was then visualized. The lateral process presented as an osseous overgrowth, and a loose body was impinged between the talus and the calcaneus. The osseous overgrowth was resected piece by piece with a punch, and the loose body was removed en block. The patient returned to soccer 5 weeks after the operation. This case exemplifies 2 important points: (1) This type of fracture can develop even in children and not only in snowboarders. (2) Arthroscopic excision of talar lateral process fragments can be accomplished easily, and return to sports can be achieved in a relatively short time.
doi:10.1016/j.eats.2014.01.014
PMCID: PMC4129989  PMID: 25126497
3.  Analysis of injuries' prevalence in surfers from Paraná seacoast 
Acta Ortopedica Brasileira  2013;21(4):213-218.
OBJECTIVE:
to analyze the prevalence of musculoskeletal injuries of surfers from the Paraná's seacoast.
METHODS:
Sixty men (27 ± 6 years) completed a surf semi structured questionnaire (category, time of daily practice, frequency and exercises performed before and/or after surfing) and characteristics of injuries induced by this sport. A descriptive analysis of the data on distribution of the relative frequency was performed.
RESULTS:
It was found that 70% of the respondents practiced surfing as a relaxing activity, 28% were amateurs and 2% were professionals, who were surfing for 10 years or more. Most of them surfed between 2 to 4 times a week during 2 to 4 hours a day. The most common exercise performed before surfing was upper and lower limbs stretching and no exercises at all was done after practice. The most common injury was contusion (29%), lower limb was the most affected segment (46%) and the most common cause of injury was due to contact with the board (52%). The interruption period mostly reported was 1-3 months and the most frequent treatment was taking medicines.
CONCLUSIONS:
Recreational was the predominant category of surfers with lower limb's contusion as the most common musculoskeletal injury, resulting from contact with the board, being treated with medication and rest. Level of Evidence II, Retrospective Study.
doi:10.1590/S1413-78522013000400006
PMCID: PMC3862004  PMID: 24453671
Athletic injuries; Prevalence; Physical therapy specialty
4.  Snowboarder's fracture caused by a wakeboarding injury: a case report 
Journal of Chiropractic Medicine  2010;9(4):174-178.
Objective
The purpose of this case report is to describe the clinical presentation of a patient who had a lateral talar process fracture due to a wakeboarding injury.
Clinical Features
A 29-year-old male patient sustained a left ankle injury when the front edge of his wakeboard became immersed in the water. As he fell forward, his foot remained attached to the board, leading to inversion and dorsiflexion stress of the ankle. He presented to a chiropractic clinic with diffuse ankle swelling, tenderness, and pain at the distal aspect of the lateral malleolus. Mild ligamentous laxity of the lateral supporting structures was observed during the physical examination.
Intervention and Outcome
Static and stress radiographs of the left ankle demonstrated a small (McCrory-Bladin type 1) lateral talar process fracture without evidence of gross instability. The patient was referred to a local orthopedic medical specialist for immobilization of the ankle. The patient was treated conservatively with an air cast walking boot for 2 weeks (non–weight-bearing) followed by a 2-week period of partial weight-bearing. At 6 weeks following the injury, a repeated radiographic examination demonstrated complete healing of the fracture. The patient reported minimal tenderness and normal ankle function.
Conclusion
Because of the similar mechanism of injury to those sustained in snowboarding, this case demonstrates the need for increased awareness of lateral process fractures in wakeboarders.
doi:10.1016/j.jcm.2010.08.001
PMCID: PMC3206565  PMID: 22027109
Chiropractic; Athletic injuries; Diagnostic imaging; Radiology; Talus; Snowboarding
5.  The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review 
Impingement syndromes of the ankle involve either osseous or soft tissue impingement and can be anterior, anterolateral, or posterior. Ankle impingement syndromes are painful conditions caused by the friction of joint tissues, which are both the cause and the effect of altered joint biomechanics. The distal fascicle of the anterior inferior tibiofibular ligament (AITFL) is possible cause of anterior impingement. The objective of this article was to review the literature concerning the anatomy, pathogenesis, symptoms and treatment of the AITFL impingement and finally to formulate treatment recommendations. The AITFL starts from the distal tibia, 5 mm in average above the articular surface, and descends obliquely between the adjacent margins of the tibia and fibula, anterior to the syndesmosis to the anterior aspect of the lateral malleolus. The incidence of the accessory fascicle differs very widely in the several studies. The presence of the distal fascicle of the AITFL and also the contact with the anterolateral talus is probably a normal finding. It may become pathological, due to anatomical variations and/or anterolateral instability of the ankle resulting from an anterior talofibular ligament injury. When observed during an ankle arthroscopy, the surgeon should look for the criteria described to decide whether it is pathological and considering resection of the distal fascicle. The presence of the AITFL and the contact with the talus is a normal finding. An impingement of the AITFL can result from an anatomical variant or anteroposterior instability of the ankle. The diagnosis of ligamentous impingement in the anterior aspect of the ankle should be considered in patients who have chronic ankle pain in the anterolateral aspect of the ankle after an inversion injury and have a stable ankle, normal plain radiographs, and isolated point tenderness on the anterolateral aspect of the talar dome and in the anteroinferior tibiofibular ligament. The impingement syndrome can be treated arthroscopically.
doi:10.1007/s00167-006-0275-7
PMCID: PMC1915597  PMID: 17237964
Ankle; Impingement syndrome; Anterior inferior tibiofibular ligament; Accessory fascicle
6.  Bone stress injury of the ankle in professional ballet dancers seen on MRI 
Background
Ballet Dancers have been shown to have a relatively high incidence of stress fractures of the foot and ankle. It was our objective to examine MR imaging patterns of bone marrow edema (BME) in the ankles of high performance professional ballet dancers, to evaluate clinical relevance.
Methods
MR Imaging was performed on 12 ankles of 11 active professional ballet dancers (6 female, 5 male; mean age 24 years, range 19 to 32). Individuals were imaged on a 0.2 T or 1.5 T MRI units. Images were evaluated by two musculoskeletal radiologists and one orthopaedic surgeon in consensus for location and pattern of bone marrow edema. In order to control for recognized sources of bone marrow edema, images were also reviewed for presence of osseous, ligamentous, tendinous and cartilage injuries. Statistical analysis was performed to assess the strength of the correlation between bone marrow edema and ankle pain.
Results
Bone marrow edema was seen only in the talus, and was a common finding, observed in nine of the twelve ankles imaged (75%) and was associated with pain in all cases. On fluid-sensitive sequences, bone marrow edema was ill-defined and centered in the talar neck or body, although in three cases it extended to the talar dome. No apparent gender predilection was noted. No occult stress fracture could be diagnosed. A moderately strong correlation (phi = 0.77, p= 0.0054) was found between edema and pain in the study population.
Conclusion
Bone marrow edema seems to be a specific MRI finding in the talus of professional ballet dancers, likely related to biomechanical stress reactions, due to their frequently performed unique maneuvers. Clinically, this condition may indicate a sign of a bone stress injury of the ankle.
doi:10.1186/1471-2474-9-39
PMCID: PMC2329634  PMID: 18371230
7.  The importance of early arthroscopy in athletes with painful cartilage lesions of the ankle: a prospective study of 61 consecutive cases 
Background
Ankle sprains are common in sports and can sometimes result in a persistent pain condition.
Purpose
Primarily to evaluate clinical symptoms, signs, diagnostics and outcomes of surgery for symptomatic chondral injuries of the talo crural joint in athletes. Secondly, in applicable cases, to evaluate the accuracy of MRI in detecting these injuries. Type of study: Prospective consecutive series.
Methods
Over around 4 years we studied 61 consecutive athletes with symptomatic chondral lesions to the talocrural joint causing persistent exertion ankle pain.
Results
43% were professional full time athletes and 67% were semi-professional, elite or amateur athletes, main sports being soccer (49%) and rugby (14%). The main subjective complaint was exertion ankle pain (93%). Effusion (75%) and joint line tenderness on palpation (92%) were the most common clinical findings. The duration from injury to arthroscopy for 58/61 cases was 7 months (5.7–7.9). 3/61 cases were referred within 3 weeks from injury. There were in total 75 cartilage lesions. Of these, 52 were located on the Talus dome, 17 on the medial malleolus and 6 on the Tibia plafond. Of the Talus dome injuries 18 were anteromedial, 14 anterolateral, 9 posteromedial, 3 posterolateral and 8 affecting mid talus. 50% were grade 4 lesions, 13.3% grade 3, 16.7% grade 2 and 20% grade 1. MRI had been performed pre operatively in 26/61 (39%) and 59% of these had been interpreted as normal. Detection rate of cartilage lesions was only 19%, but subchondral oedema was present in 55%. At clinical follow up average 24 months after surgery (10–48 months), 73% were playing at pre-injury level. The average return to that level of sports after surgery was 16 weeks (3–32 weeks). However 43% still suffered minor symptoms.
Conclusion
Arthroscopy should be considered early when an athlete presents with exertion ankle pain, effusion and joint line tenderness on palpation after a previous sprain. Conventional MRI is not reliable for detecting isolated cartilage lesions, but the presence of subchondral oedema should raise such suspicion.
doi:10.1186/1749-799X-1-4
PMCID: PMC1635006  PMID: 17150124
8.  CAM-Type Impingement in the Ankle 
Background
Anterior ankle impingement with and without ankle osteoarthritis (OA) is a common condition. Bony impingement between the distal tibia and talus aggravated by dorsiflexion has been well described. The etiology of these impingement lesions remains controversial. This study describes a cam-type impingement of the ankle, in which the sagittal contour of the talar dome is a non-circular arc, causing pathologic contact with the anterior aspect of the tibial plafond during dorsiflexion, leading to abnormal ankle joint mechanics by limiting dorsiflexion.
Methods
A group of 269 consecutive adult patients from the University of Iowa Hospitals and Clinics who were treated for anterior bony impingement syndrome were evaluated as the study population. As a control group, 41 patients without any evidence of impingement or arthrosis were evaluated. Standardized standing lateral ankle radiographs were evaluated to determine the contour of the head/neck relationship in the talus. Two investigators made all the radiographic measurements and intra- and inter-observer reliability were measured.
Results
34% of patients were found to have some anterior extension of the talar dome creating a loss of the normal concavity at the dorsal medial talar neck. A group of 36 patients (13%) were identified as having the most severe cam deformity in order to assess any correlation with coexisting radiographic abnormalities. In these patients, a cavo-varus foot type was more commonly observed. Comparison with a control group showed much lower rates of anterior-medial cam-type deformity of the talus.
Conclusions
Cam type impingement of the ankle is likely a distinct form of bony impingement of the ankle secondary to a morphological talar bony abnormality. Based on the findings of this study, this form of impingement may be related to a cavovarus foot type. In addition, there may be long term implications in the development of ankle OA.
Level of Evidence
Level III
PMCID: PMC3565388  PMID: 23576914
9.  Primary Osseous Tumors of the Hindfoot: Why the Delay in Diagnosis and Should We Be Concerned? 
Background
Bony tumors of the foot account for approximately 3% of all osseous tumors. Diagnosis is frequently delayed as a result of lack of clinician familiarity and as a result of their rarity. The reasons for the delays, however, are unclear.
Questions/purposes
We therefore determined (1) how hindfoot tumors present and the specific reasons for delay in diagnosis; (2) whether the spectrum of disease varies between the talus and calcaneus; and (3) how these patients were treated.
Methods
We retrospectively reviewed the medical notes and imaging for all patients with 34 calcaneal and 23 talar tumors recorded in the Scottish Bone Tumour Registry. Demographics, presentation, investigation, histology, management, recurrence, and mortality were recorded.
Results
Hindfoot tumors present with pain and often swelling around the heel (calcaneus) or ankle (talus), most often misdiagnosed as soft tissue injury. Calcaneal lesions were more likely to be malignant than talar lesions: 13 of 34 versus three of 23.
Conclusions
Clinicians should be aware that hindfoot tumors can be initially misdiagnosed as soft tissue injuries and suspicion of a tumor should be raised in the absence of trauma or persistent symptoms. Lesions affecting the calcaneus are more likely to be malignant. Early diagnosis and adjuvant therapy are important.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2570-6
PMCID: PMC3563817  PMID: 23008022
10.  Osteochondritis Dissecans of the Talar Dome in a Collegiate Swimmer: A Case Report 
Journal of Athletic Training  1998;33(4):365-371.
Objective:
To present the case of an intercollegiate swimmer with a stage IV lateral talar dome injury and associated bony fragments.
Background:
Lack of distinct diagnostic symptoms, low index of clinical suspicion, and the difficulty of visualizing the early stages of this injury on standard x-rays cause frequent misdiagnosis of talar dome lesions.
Differential Diagnosis:
Ganglion cyst, with inflammatory synovitis secondary to rupture of cyst; loose bodies from previous occult fracture; osteochondral fracture.
Treatment:
Initial treatment with nonsteroidal antiinflammatory drugs and a posterior splint for comfort, followed by arthroscopic excision of loose bodies with abrasion and drilling arthroplasty.
Uniqueness:
Patient presented to the team physician for care of acute left medial ankle pain after the athletic trainer had attempted to rupture a ganglion cyst on the anterolateral aspect of the patient's ankle.
Conclusions:
Increased clinical suspicion is necessary to correctly diagnose osteochondral lesions, particularly in the early stages. Aggressive treatment of talar dome lesions has a good success rate and may be an attractive option for competitive athletes.
Images
PMCID: PMC1320590  PMID: 16558537
ganglion cyst; inflammatory synovitis; osteochondral fracture
11.  Update on anterior ankle impingement 
Anterior ankle impingement results from an impingement of the ankle joint by a soft tissue or osteophyte formation at the anterior aspect of the distal tibia and talar neck. It often occurs secondary to direct trauma (impaction force) or repetitive ankle dorsiflexion (repetitive impaction and traction force). Chronic ankle pain, swelling, and limitation of ankle dorsiflexion are common complaints. Imaging is valuable for diagnosis of the bony impingement but not for the soft tissue impingement, which is based on clinical findings. MR imaging and MR arthrography are helpful in doubtful diagnoses and the identification of associated injuries. Recommended methods for initial management include rest, physical therapy, and shoe modification. If nonoperative treatment fails, arthroscopic bony or soft tissue debridement both offer significant symptomatic relief with long-term positive outcomes in cases that have no significant arthritic change, associated ligament laxity, and chondral lesion.
doi:10.1007/s12178-012-9117-z
PMCID: PMC3535150  PMID: 22403038
Ankle; Impingement; Bony; Soft Tissue; Anterior; Ankle Pain; Chronic; Sport; Arthroscopy; Foot and Ankle; Musculoskeletal
12.  Long term outcomes of inversion ankle injuries 
Background: Ankle sprains are common sporting injuries generally believed to be benign and self limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms for months or even years.
Aims: To determine the proportion of patients presenting to an Australian sports medicine clinic who had long term symptoms after a sports related inversion ankle sprain.
Methods: Consecutive patients referred to the NSW Institute of Sports Medicine from August 1999 to August 2002 with inversion ankle sprain were included. Exclusion criteria were fracture, ankle surgery, or concurrent lower limb problems. A control group, matched for age and sex, was recruited from patients attending the clinic for upper limb injuries in the same time period. Current ankle symptoms, ankle related disability, and current health status were ascertained through a structured telephone interview.
Results: Nineteen patients and matched controls were recruited and interviewed. The mean age in the ankle group was 20 (range 13–28). Twelve patients (63%) were male. Average follow up was 29 months. Only five (26%) ankle injured patients had recovered fully, with no pain, swelling, giving way, or weakness at follow up. None of the control group reported these symptoms (p<0.0001). Assessments of quality of life using short form-36 questionnaires (SF36) revealed a difference in the general health subscale between the two groups, favouring the control arm (p<0.05). There were no significant differences in the other SF36 subscales between the two groups.
Conclusion: Most patients who sustained an inversion ankle injury at sport and who were subsequently referred to a sports medicine clinic had persistent symptoms for at least two years after their injury. This reinforces the importance of prevention and early effective treatment.
doi:10.1136/bjsm.2004.011676
PMCID: PMC1725165  PMID: 15728682
13.  Understanding acute ankle ligamentous sprain injury in sports 
This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.
doi:10.1186/1758-2555-1-14
PMCID: PMC2724472  PMID: 19640309
14.  Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace 
Background: Lateral ligament ankle sprains are the single most common sports injury.
Design: Prospective, randomised controlled trial.
Setting: Two accident and emergency departments.
Method: Fifty patients presenting consecutively were randomised into two equal groups: one group was treated with an elastic support bandage and the other with an Aircast ankle brace. All patients were given a standardised advice sheet referring to rest, ice, compression, and elevation. Patients were reviewed after 48–72 hours, 10 days, and one month.
Primary outcome measure: Ankle joint function assessed at 10 days and one month using the modified Karlsson scoring method (maximum score 90).
Secondary outcome measure: The difference in ankle girth (swelling) and pain score at 10 days.
Results: Seventeen patients in the elastic support bandage group (six defaulted, two excluded) and 18 patients in the Aircast ankle brace group (six defaulted, one excluded) completed the study. There were no significant differences between the two groups at presentation in terms of age (mean 35.3 and 32.6 years respectively), sex, dominant leg, left or right ankle injured, previous injury, time to presentation (median three and four hours respectively), difference in ankle girth (mean 14.5 and 14.3 mm respectively), and pain scores (mean 6.2 and 5.8 respectively). The Karlsson score was significantly higher in the Aircast ankle cast group than in the elastic bandage group at 10 days (mean 50 v 35, p = 0.028, 95% confidence interval (CI) 1.7 to 27.7) and one month (mean 68 v 55, p = 0.029, 95% CI 1.4 to 24.8) (Student's t test). There was no difference between the groups in the secondary outcome measures (swelling, p = 0.09; pain, p = 0.07). When hierarchical multiple regression analysis was used to correct for possible baseline confounding factors, the Aircast ankle brace group was significantly associated with higher Karlsson scores at 10 days (p = 0.009) and one month (p = 0.024).
Conclusion: The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with standard management with an elastic support bandage.
doi:10.1136/bjsm.2003.009233
PMCID: PMC1725120  PMID: 15665204
15.  The 2BFit study: is an unsupervised proprioceptive balance board training programme, given in addition to usual care, effective in preventing ankle sprain recurrences? Design of a Randomized Controlled Trial 
Background
There is strong evidence that athletes have a twofold risk for re-injury after a previous ankle sprain, especially during the first year post-injury. These ankle sprain recurrences could result in disability and lead to chronic pain or instability in 20 to 50% of these cases. When looking at the high rate of ankle sprain recurrences and the associated chronic results, ankle sprain recurrence prevention is important.
Objective
To evaluate the effect of a proprioceptive balance board training programme on ankle sprain recurrences, that was applied to individual athletes after rehabilitation and treatment by usual care.
Methods/Design
This study was designed as a randomized controlled trial with a follow-up of one year. Healthy individuals between 12 and 70 years of age, who were actively participating in sports and who had sustained a lateral ankle sprain up to two months prior to inclusion, were eligible for inclusion in the study. The intervention programme was compared to usual care. The intervention programme consisted of an eight-week proprioceptive training, which started after finishing usual care and from the moment that sports participation was again possible. Outcomes were assessed at baseline and every month for 12 months. The primary outcome of this study was the incidence of recurrent ankle injuries in both groups within one year after the initial sprain. Secondary outcomes were severity and etiology of re-injury and medical care. Cost-effectiveness was evaluated from a societal perspective. A process evaluation was conducted for the intervention programme.
Discussion
The 2BFit trial is the first randomized controlled trial to study the effect of a non-supervised home-based proprioceptive balance board training programme in addition to usual care, on the recurrence of ankle sprains in sports. Results of this study could possibly lead to changes in practical guidelines on the treatment of ankle sprains. Results will become available in 2009.
Trial registration
ISTRCN34177180.
doi:10.1186/1471-2474-9-71
PMCID: PMC2412867  PMID: 18492235
16.  Discriminating Between Copers and People With Chronic Ankle Instability 
Journal of Athletic Training  2012;47(2):136-142.
Context:
Differences in various outcome measures have been identified between people who have sprained their ankles but have no residual symptoms (copers) and people with chronic ankle instability (CAI). However, the diagnostic utility of the reported outcome measures has rarely been determined. Identifying outcome measures capable of predicting who is less likely to develop CAI could improve rehabilitation protocols and increase the efficiency of these measures.
Objective:
To determine the diagnostic utility and cutoff scores of perceptual, mechanical, and sensorimotor outcome measures between copers and people with CAI by using receiver operating characteristic curves.
Design:
Case-control study.
Setting:
Sports medicine research laboratory.
Patients or Other Participants:
Twenty-four copers (12 men, 12 women; age = 20.8 ± 1.5 years, height = 173 ± 11 cm, mass = 78 ± 27 kg) and 24 people with CAI (12 men, 12 women; age = 21.7 ± 2.8 years, height = 175 ± 13 cm, mass = 71 ± 13 kg) participated.
Intervention(s):
Self-reported disability questionnaires, radiographic images, and a single-legged hop stabilization test.
Main Outcome Measure(s):
Perceptual outcomes included scores on the Foot and Ankle Disability Index (FADI), FADI-Sport, and a self-report questionnaire of ankle function. Mechanically, talar position was quantified by measuring the distance from the anterior tibia to the anterior talus in the sagittal plane. Sensorimotor outcomes were the dynamic postural stability index and directional indices, which were calculated during a single-legged hop stabilization task.
Results:
Perceptual outcomes demonstrated diagnostic accuracy (range, 0.79–0.91), with 95% confidence intervals ranging from 0.65 to 1.00. Sensorimotor outcomes also were able to discriminate between copers and people with CAI but with less accuracy (range, 0.69–0.70), with 95% confidence intervals ranging from 0.37 to 0.86. The mechanical outcome demonstrated poor diagnostic accuracy (0.52).
Conclusions:
The greatest diagnostic utility scores were achieved by the self-assessed disability questionnaires, which indicated that perceptual outcomes had the greatest ability to accurately predict people who became copers after their initial injuries. However, the diversity of outcome measures that discriminated between copers and people with CAI indicated that the causal mechanism of CAI is probably multifactorial.
PMCID: PMC3418124  PMID: 22488278
self-report disability; positional fault; dynamic postural control
17.  DIAGNOSIS OF AN ISOLATED POSTERIOR MALLEOLAR FRACTURE IN A YOUNG FEMALE MILITARY CADET: A RESIDENT CASE REPORT 
Background and Purpose:
The ankle is the most commonly injured joint during athletic activity. While ankle sprains are certainly the most common injury, ankle fractures can occur frequently. One type of ankle fracture with a reportedly low incidence is the isolated posterior malleolar fracture. Because of the low incidence, isolated posterior malleolar fractures can present a diagnostic challenge. The purpose of this case report is to describe the diagnostic process used for this rare injury that occurred in a physically active college-aged female who injured her ankle when landing from a fall during performance on a military obstacle course.
Case Description:
A 19 year old female United States Military Academy cadet presented to a direct access physical therapy clinic. She was limping, not using any assistive device, and was wearing an ace bandage around her right ankle/foot. Two days earlier she fell from a “10 foot high” structure while performing the military obstacle course. She did not recall details of impact, but she was told by several bystanders that it appeared that she landed on her right foot followed immediately by a transition to her buttocks and then to her back.
Outcomes:
Ottawa Ankle Rules and ligamentous testing were negative; however, she was tender to palpation just anterior to the achilles tendon and lateral to the posterior edge of the medial malleolus. Based on mechanism of injury and tenderness of the posterior ankle, a potential posterior ankle fracture was suspected and subsequently confirmed by radiographic studies of the ankle including standard radiographs and computerized tomography.
Discussion:
While the Ottawa Ankle Rules are generally effective in detecting many types of ankle fractures, clinicians should not rely solely on such prediction rules. This case highlights the importance of completing a thorough history and performing a thorough physical examination. This case report focuses on differential diagnosis. It is important to consider all aspects of the patient evaluation process collectively instead of examination pieces individually.
PMCID: PMC3325632  PMID: 22530191
Direct access; Ottawa Ankle Rules; posterior malleolus fracture
18.  Clinical Examination Results in Individuals With Functional Ankle Instability and Ankle-Sprain Copers 
Journal of Athletic Training  2013;48(5):581-589.
Context:
Why some individuals with ankle sprains develop functional ankle instability and others do not (ie, copers) is unknown. Current understanding of the clinical profile of copers is limited.
Objective:
To contrast individuals with functional ankle instability (FAI), copers, and uninjured individuals on both self-reported variables and clinical examination findings.
Design:
Cross-sectional study.
Setting:
Sports medicine research laboratory.
Patients or Other Participants:
Participants consisted of 23 individuals with a history of 1 or more ankle sprains and at least 2 episodes of giving way in the past year (FAI: Cumberland Ankle Instability Tool [CAIT] score = 20.52 ± 2.94, episodes of giving way = 5.8 ± 8.4 per month), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers: CAIT score = 27.74 ± 1.69), and 23 individuals with no history of ankle sprain and no instability (uninjured: CAIT score = 28.78 ± 1.78).
Intervention(s):
Self-reported disability was recorded using the CAIT and Foot and Ankle Ability Measure for Activities of Daily Living and for Sports. On clinical examination, ligamentous laxity and tenderness, range of motion (ROM), and pain at end ROM were recorded.
Main Outcome Measure(s):
Questionnaire scores for the CAIT, Foot and Ankle Ability Measure for Activities of Daily Living and for Sports, ankle inversion and anterior drawer laxity scores, pain with palpation of the lateral ligaments, ankle ROM, and pain at end ROM.
Results:
Individuals with FAI had greater self-reported disability for all measures (P < .05). On clinical examination, individuals with FAI were more likely to have greater talar tilt laxity, pain with inversion, and limited sagittal-plane ROM than copers (P < .05).
Conclusions:
Differences in both self-reported disability and clinical examination variables distinguished individuals with FAI from copers at least 1 year after injury. Whether the deficits could be detected immediately postinjury to prospectively identify potential copers is unknown.
doi:10.4085/1062-6050-48.3.15
PMCID: PMC3784359  PMID: 23914879
laxity; chronic ankle instability; giving way; range of motion
19.  Pseudo-aneurysm of the anterior tibial artery, a rare cause of ankle swelling following a sports injury 
Background
Ankle pain and swelling following sports injuries are common presenting complaints to the accident and emergency department. Frequently these are diagnosed as musculoskeletal injuries, even when no definitive cause is found. Vascular injuries following trauma are uncommon and are an extremely rare cause of ankle swelling and pain. These injuries may however be limb threatening and are important to diagnose early, in order that appropriate treatment can be delivered. We highlight the steps to diagnosis of these injuries, and methods of managing these injuries. It is important for clinicians to be aware of the potential for this injury in patients with seemingly innocuous trauma from sports injuries, who have significant ankle pain and swelling.
Case presentation
A young, professional sportsman presented with a swollen, painful ankle after an innocuous hyper-plantar flexion injury whilst playing football, which was initially diagnosed as a ligamentous injury after no bony injury was revealed on X-Ray. He returned 2 days later with a large ulcer at the lateral malleolus and further investigation by duplex ultrasound and transfemoral arteriogram revealed a Pseudo-Aneurysm of the Anterior Tibial Artery. This was initially managed with percutaneous injection of thrombin, and later open surgery to ligate the feeding vessel. The patient recovered fully and was able to return to recreational sport.
Conclusion
Vascular injuries remain a rare cause of ankle pain and swelling following sports injuries, however it is important to consider these injuries when no definite musculo-skeletal cause is found. Ultrasound duplex and Transfemoral arteriogram are appropriate, sensitive modalities for investigation, and may allow novel treatment to be directed percutaneously. Early diagnosis and intervention are essential for the successful outcome in these patients.
doi:10.1186/1471-227X-5-9
PMCID: PMC1266360  PMID: 16225679
20.  Qualitative Task Analysis to Enhance Sports Characterization: A Surfing Case Study 
Journal of Human Kinetics  2014;42:245-257.
The aim of this study was to develop a Matrix of Analysis for Sports Tasks (MAST), regardless of the sports activity, based on practice classification and task analysis. Being this a qualitative research our main question was: in assessing sports’ structure is it possible to make the characterization of any discipline through context and individuals’ behaviours? The sample was within a surf discipline in a competition flowing having 5 of the top 16 Portuguese surfers training together. Based on a qualitative method, studying the surf as the main activity was an interpretative study case. The MAST was applied in four phases: taxonomy; tasks and context description; task analysis; teaching and performance strategies. Its application allowed the activities’ characterization through the observation, surfer’s opinions and bibliographical support. The triangulation of the data was used as an information data treatment. The elements were classified by the challenges proposed to the practitioners and the taxonomy was constituted by the sport activities, group, modality and discipline. Surf is a discipline of surfing which is a sliding sport modality, therefore, a nature sport. In the context description, we had the wave’s components and constraints and the surfboards’ qualities. Through task analysis we obtained a taxonomy of surf manoeuvres. The structural and functional analysis allowed finding solutions for learning of surf techniques with trampoline and skateboards because these fit in sliding sports. MAST makes possible the development of strategies that benefit teaching and performance intervention.
doi:10.2478/hukin-2014-0078
PMCID: PMC4234763  PMID: 25414757
qualitative research; taxonomy; structural analysis; functional analysis; nature sports; sliding sports
21.  Arthroscopic excision of separated ossicles of the lateral malleolus 
Journal of Orthopaedic Science  2013;18(5):733-739.
Background
We have conducted a retrospective review of 19 patients for whom 20 separated ossicles of the lateral malleolus were excised arthroscopically. We examined the operating methods, findings, and overall results.
Methods
The patients’ indications for this procedure were as follows. The main complaints were pain alone; ossicle sizes were small and ankle instability was minimal. There were 12 ankles of 12 males and eight ankles of seven females. The patients’ average age was 17.6 years. A 2.7-mm, 30° arthroscope was inserted into the ankle joint through the anterolateral portal. Instruments were inserted through the accessory anterolateral portal, and ossicles were removed piece by piece. Talar tilt angles and anterior displacements were examined and compared before and after surgery by use of stress radiographs. Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scales were assessed pre and postoperatively.
Results
All patients recovered their original levels of activity. The mean talar tilt angle changed from 6.1° ± 2.4° preoperatively to 6.0° ± 1.8° postoperatively (p = 0.93), and the mean anterior displacement changed from 5.9 ± 1.7 mm preoperatively to 6.1 ± 2.0 mm postoperatively (p = 0.42). Average JSSF ankle/hindfoot scale improved from 77.6 ± 2.6 points preoperatively to 97.2 ± 5.2 points postoperatively (p < 0.01).
Conclusions
Arthroscopic excision of separated ossicles of the lateral malleolus achieved good results with minimum incisions, and relatively early resumption of daily and sports activity was possible. However, when the ossicles were embedded within the fibers of the anterior talofibular ligament, it was impossible to avoid cutting of ligament fibers. To reduce the possibility of ligament dysfunction, we believe postoperative treatment should conform to the accepted method for treatment of acute ankle sprains.
doi:10.1007/s00776-013-0412-3
PMCID: PMC3778221  PMID: 23728893
22.  Completely extruded talus without soft tissue attachments 
Clinics and Practice  2011;1(1):e12.
A completely extruded talus without any remaining soft tissue attachments is extremely rare. The present report describes treatment of a 45-year-old man who sustained a completely extruded talus injury following a rock-climbing fall. Upon admission, the extruded talus was deep-frozen in our bone bank. The open ankle joint underwent massive wound debridement and irrigation for 3 days. Four days later we performed a primary subtalar fusion between the extruded talus and the calcaneus, anticipating revascularization from the calcaneus. However, aseptic loosening and osteolysis developed around the screw and talus. At 12 months post-trauma we performed a tibiocalcaneal ankle fusion with a femoral head allograft to fill the talar defect. Follow-up at 24 months post-trauma showed the patient had midfoot motion, tibio-talar-calcaneal fusion, and was able partake in 4-hour physical activity twice per week.
doi:10.4081/cp.2011.e12
PMCID: PMC3981216  PMID: 24765266
completely extruded talus; primary subtalar fusion; osteolysis.
23.  Long-term follow-up after surgical treatment of talar fractures 
International Orthopaedics  2009;35(1):93-99.
Displaced talar neck and body fractures are rare and serious injuries with important outcomes. The aim of our study was to evaluate the long-term outcomes of these fractures after operative treatment in our centre between 1993 and 2005. Displaced talar fractures have a high rate of long-term complications. This was a retrospective study concerning 20 patients with an average follow-up of 7.5 years. The final follow-up examination included determination of the AHS score (ankle–hindfoot scale) from the American Orthopaedic Foot and Ankle Society (AOFAS), range of motion evaluation and radiological analysis. Mean age at the time of trauma was 38.8 years. This study comprised ten talar neck fractures and ten talar body fractures. We always used a single surgical approach and obtained anatomical reduction in 30% of the whole series of both groups. Four early complications were noted in four patients (20%). We noted no skin complications and the rate of consolidation was 100%. Four patients (20%) developed avascular necrosis of the talus, and at final follow-up seven patients (35%) had undergone secondary surgery. Radiographic analysis showed an osteoarthritis rate of 94% and a malunion rate of 59%. The mean AOFAS score was 66.9/100 and range of motion was systematically decreased. Contrary to undisplaced talar fractures, displaced talar fractures are a therapeutic challenge with many early or late complications. The outcome often revealed stiffness and osteoarthritis.
doi:10.1007/s00264-009-0930-y
PMCID: PMC3014484  PMID: 20033158
24.  Delayed presentation of a loose body in undisplaced paediatric talar neck fracture 
World Journal of Orthopedics  2014;5(3):398-401.
Fractures of the talus are rare in children. A high index of suspicion is needed to avoid missing such an injury, which is not an uncommon occurrence especially with undisplaced fractures. We present an unusual case of an undisplaced talar neck fracture in a five-year-old child leading to a delayed presentation of a symptomatic osteochondral loose body in the ankle joint. To our knowledge there are no reports in the literature of osteochondral loose bodies occurring in conjunction with an associated undisplaced talar neck fracture in either children or adults. The loose body was removed using anterior ankle arthroscopy. The child had an uneventful post operative recovery and regained full range of movement and function of his ankle joint and was discharged at one year follow-up. We aim to highlight the need to have a low threshold to further evaluate symptomatic children after fracture healing of an undisplaced talar neck fracture for a possible associated loose body in the ankle joint.
doi:10.5312/wjo.v5.i3.398
PMCID: PMC4095036  PMID: 25035846
Talus; Fracture; Loose body; Ankle arthroscopy; Children
25.  Delayed surgical treatment for neglected or mal-reduced talar fractures 
International Orthopaedics  2005;29(5):326-329.
From 1993 to 2002, we treated nine patients for neglected or mal-reduced talar fractures. Average patient age was 39 (20–64) years and average follow-up 53 months. The time interval between injury and index operation ranged from 4 weeks to 4 years. Surgical procedures included open reduction with or without bone grafting in six cases, open reduction combined with ankle fusion in one case, talar neck osteotomy in one case, and talar neck osteotomy combined with subtalar fusion in one case. All cases had solid bone union. One patient developed avascular necrosis of the talus needing subsequent ankle arthrodesis. In six patients, adjacent hindfoot arthrosis occurred. The overall AOFAS ankle–hindfoot score was in average 77.4. We conclude that in neglected and mal-reduced talar fractures, surgical treatment can lead to a favourable outcome if the hindfoot joints are not arthritic.
doi:10.1007/s00264-005-0675-1
PMCID: PMC3456640  PMID: 16094539

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