Restrictions in ankle dorsiflexion range of motion (ROM) have been associated with decreased posterior talar glide in individuals with an acute lateral ankle sprain. Talocrural joint mobilizations may be used to restore joint arthrokinematics. Our purpose was to examine the effects of a single bout of anterior to posterior (AP) talocrural joint mobilization on self-reported function, dorsiflexion ROM, and posterior talar translation in individuals with an acute lateral ankle sprain. This single-blinded, randomized controlled trial utilized 17 volunteers (nine treatment and eight control) with an acute lateral ankle sprain (grade I/II) who were immobilized for a period of 1–7 days. The treatment group received a single 30-second bout of grade III AP talocrural joint mobilization the day their immobilization device was removed, while the control group did not receive any intervention. Active dorsiflexion ROM and posterior talar translation were assessed before, immediately after, and 24 hours after receipt of the treatment or control interventions. Self-reported function and pain were assessed before and 24 hours after the receipt of the treatment or control interventions using the foot and ankle disability index. Collectively all groups demonstrated improved dorsiflexion ROM and self-reported function. There was a significant decrease in pain perception at 24-hour follow-up for the treatment group. A single bout of AP talocrural joint mobilizations may not have an immediate effect on ankle dorsiflexion ROM, posterior talar translation, or self-reported function; however, they may have an immediate effect on pain perception in individuals with an acute lateral ankle sprain.
Arthrokinematics; Ankle sprain; Talocrural joint mobilization; Dorsiflexion; Self-reported function
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.
Prevention of ankle sprain, the most common sporting injury, is only possible once risk factors have been identified. Voluntary strength, proprioception, postural sway, and range of motion are possible risk factors. A systematic review was carried out to investigate these possiblities. Eligible studies were those with longitudinal design investigating ankle sprain in subjects aged ⩾15 years. The studies had to have measured range of motion, voluntary strength, proprioception, or postural sway before monitoring incidence of lateral ankle sprain. Dorsiflexion range strongly predicted risk of ankle sprain. Postural sway and possibly proprioception were also predictors. Therefore the preliminary evidence suggests that people with reduced ankle dorsiflexion range may be at increased risk of ankle sprain.
lateral ankle sprain; prediction; dorsiflexion
Ankle sprains are common in sports and can sometimes result in a persistent pain condition.
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.
Over around 4 years we studied 61 consecutive athletes with symptomatic chondral lesions to the talocrural joint causing persistent exertion ankle pain.
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.
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.
Ankle sprains are common within the general population and can result in prolonged disablement. Limited talocrural dorsiflexion range of motion (DF ROM) is a common consequence of ankle sprain. Limited talocrural DF ROM may contribute to persistent symptoms, disability, and an elevated risk for re-injury. As a result, many health care practitioners use hands-on passive procedures with the intention of improving talocrural joint DF ROM in individuals following ankle sprains. Dosage of passive hands-on procedures involves a continuum of treatment speeds. Recent evidence suggests both slow- and fast-speed treatments may be effective to address disablement following ankle sprains. However, these interventions have yet to be longitudinally compared against a placebo study condition.
We developed a randomized, placebo-controlled clinical trial designed to test the hypotheses that hands-on treatment procedures administered to individuals following ankle sprains during the post-acute injury period can improve short-, intermediate-, and long-term disablement, as well as reduce the risk for re-injury.
This study is designed to measure the clinical effects of hands-on passive stretching treatment procedures directed to the talocrural joint that vary in treatment speed during the post-acute injury period, compared to hands-on placebo control intervention.
http://www.clinicaltrials.gov identifier NCT00888498.
Temporomandibular disorders are a group of disorders affecting the temporomandibular joint and/or masticatory muscles. One of the signs associated with temporomandibular disorders is a reduction in mouth opening. During normal mouth opening, extension occurs at the cervical-cranial junction. The purpose of this investigation was to determine if manual therapy applied to the cervical-cranial junction would significantly improve mouth-opening capacity.
One hundred one participants were randomly assigned to either an Active Release Technique (ART) group; high-velocity, low-amplitude manipulation (HVLA) group; or control group. A blinded investigator measured mouth opening using a TheraBite range of motion scale (TheraBite Corporation, West Chester, PA). Participants received ART to the suboccipitals or HVLA to the cervical spine at C1 or sat with an investigator for 3 minutes with no treatment. After the treatment session, mouth opening was remeasured. A repeated-measures analysis of variance was used to compare the group mean values. The a priori α level was .05.
The repeated-measures analysis of variance showed no significant difference between the ART, HVLA, and control groups' pretreatment and posttreatment measurements (F = 0.41, P > .05).
Manual therapy to the cervical spine did not significantly improve mouth opening in this asymptomatic population. Future trials using participants with restricted mouth-opening measures are warranted.
Musculoskeletal manipulations; Temporomandibular joint; Range of motion; Articular; Chiropractic
High velocity low amplitude spinal manipulation (HVLA-SM) is used frequently to treat musculoskeletal complaints. Little is known about the intervention's biomechanical characteristics that determine its clinical benefit. Using an animal preparation, we determined how neural activity from lumbar muscle spindles during a lumbar HVLA-SM is affected by the type of thrust control and by the thrust's amplitude, duration, and rate. A mechanical device was used to apply a linear increase in thrust displacement or force and to control thrust duration. Under displacement control, neural responses during the HVLA-SM increased in a fashion graded with thrust amplitude. Under force control neural responses were similar regardless of the thrust amplitude. Decreasing thrust durations at all thrust amplitudes except the smallest thrust displacement had an overall significant effect on increasing muscle spindle activity during the HVLA-SMs. Under force control, spindle responses specifically and significantly increased between thrust durations of 75 and 150 ms suggesting the presence of a threshold value. Thrust velocities greater than 20–30 mm/s and thrust rates greater than 300 N/s tended to maximize the spindle responses. This study provides a basis for considering biomechanical characteristics of an HVLA-SM that should be measured and reported in clinical efficacy studies to help define effective clinical dosages.
The popping produced during high-velocity, low-amplitude (HVLA) thrust manipulation is a common sound; however to our knowledge, no study has previously investigated the location of cavitation sounds during manipulation of the upper cervical spine. The primary purpose was to determine which side of the spine cavitates during C1-2 rotatory HVLA thrust manipulation. Secondary aims were to calculate the average number of pops, the duration of upper cervical thrust manipulation, and the duration of a single cavitation.
Nineteen asymptomatic participants received two upper cervical thrust manipulations targeting the right and left C1-2 articulation, respectively. Skin mounted microphones were secured bilaterally over the transverse process of C1, and sound wave signals were recorded. Identification of the side, duration, and number of popping sounds were determined by simultaneous analysis of spectrograms with audio feedback using custom software developed in Matlab.
Bilateral popping sounds were detected in 34 (91.9%) of 37 manipulations while unilateral popping sounds were detected in just 3 (8.1%) manipulations; that is, cavitation was significantly (P < 0.001) more likely to occur bilaterally than unilaterally. Of the 132 total cavitations, 72 occurred ipsilateral and 60 occurred contralateral to the targeted C1-2 articulation. In other words, cavitation was no more likely to occur on the ipsilateral than the contralateral side (P = 0.294). The mean number of pops per C1-2 rotatory HVLA thrust manipulation was 3.57 (95% CI: 3.19, 3.94) and the mean number of pops per subject following both right and left C1-2 thrust manipulations was 6.95 (95% CI: 6.11, 7.79). The mean duration of a single audible pop was 5.66 ms (95% CI: 5.36, 5.96) and the mean duration of a single manipulation was 96.95 ms (95% CI: 57.20, 136.71).
Cavitation was significantly more likely to occur bilaterally than unilaterally during upper cervical HVLA thrust manipulation. Most subjects produced 3–4 pops during a single rotatory HVLA thrust manipulation targeting the right or left C1-2 articulation; therefore, practitioners of spinal manipulative therapy should expect multiple popping sounds when performing upper cervical thrust manipulation to the atlanto-axial joint. Furthermore, the traditional manual therapy approach of targeting a single ipsilateral or contralateral facet joint in the upper cervical spine may not be realistic.
Cavitation; Popping sound; High velocity thrust manipulation; Upper cervical
Ankle dorsiflexion range of motion (ROM) typically decreases after prolonged immobilization. Anterior-to-posterior talocrural joint mobilizations are purported to increase dorsiflexion ROM and decrease joint stiffness after immobilization. The purpose of this study was to determine if a single bout of Grade III anterior-to-posterior talocrural joint mobilizations immediately affected measures of dorsiflexion ROM, posterior ankle joint stiffness, and posterior talar translation in ankles of patients who had been immobilized at least 14 days. Ten physically active patients (5 males, 5 females; age=21.4±3.3 years) participated. Each had the ankle immobilized following a lower extremity injury for at least 14 days and presented with at least a 5° dorsiflexion ROM deficit compared to the contralateral ankle. A crossover design was employed so that half of the subjects received joint mobilizations first and half of the subjects received the control intervention (no treatment) first. All subjects ultimately received both treatments. Active dorsiflexion ROM was assessed with a bubble inclinometer, and posterior ankle stiffness and talar translation were assessed with an instrumented ankle arthrometer. After a single application of grade III anterior-to-posterior talocrural joint mobilization, dorsiflexion ROM and posterior ankle joint stiffness were significantly increased. There was also a trend toward less posterior talar translation immediately after mobilization. The trend toward decreased posterior talar translation and increased posterior ankle joint stiffness supports the positional fault theory. Correction of an anterior talar positional fault offers a possible explanation for these results.
Dorsiflexion; Grade III Mobilization; Positional Fault; Tibiotalar Joint
To examine the effects of stochastic resonance (SR) stimulation on the postural stability of subjects with functional ankle instability (FAI).
Experimental research design.
Sports medicine research laboratory.
12 subjects with FAI who reported a history of recurrent ankle sprains and “giving way” sensations at the ankle.
Subjects performed 20 s single‐leg balance tests under SR stimulation at 0.05 mA and 0.01 mA and under control conditions. Testing order was randomised. Stimulators that delivered subsensory stimulation to ankle muscles and ligaments were worn. Subjects were blinded to the test conditions, as SR stimulation was subsensory and stimulators were turned off during the control condition.
Main outcome measures
Anterior/posterior and medial/lateral centre‐of‐pressure velocities (COPVs) were combined to form a resultant vector (COPV‐R). The COPV‐R differences between the optimal SR stimulation and control conditions were analysed. Optimal SR stimulation was defined as the SR stimulation input intensity level (0.05 mA or 0.01 mA) that produced the greatest percentage improvement in postural stability compared with the control condition. Slower velocities indicated enhanced postural stability.
The optimal input intensity was 0.05 mA for nine subjects and 0.01 mA for the other three. The optimal SR stimulation significantly (p<0.05) improved COPV‐R compared with the control condition (6.60 (1.06) vs 7.20 (1.03) cm/s; mean (SD)).
SR stimulation may enhance signal detection of sensorimotor signals associated with postural stability. This result has clinical relevance as improvements in postural instability associated with FAI may decrease ankle sprain injury.
ankle; balance; postural stability; sprain; stochastic resonance
High velocity, low amplitude (HVLA) manipulation is an effective treatment for low back pain (LBP); however, the corresponding mechanisms are undetermined. Hypoalgesia is associated with HVLA manipulation and suggests specific mechanisms of action. An audible pop (AP) is also associated with HVLA manipulation; however, the influence of the AP on the hypoalgesia associated with HVLA manipulation is not established. The purpose of the current study was to observe the influence of the AP on hypoalgesia associated with HVLA manipulation.
The current study represents a secondary analysis of 40 participants. All participants underwent thermal pain sensitivity testing to their leg and low back using protocols specific to Aδ fiber mediated pain and temporal summation. Next, participants received HVLA manipulation to their low back and the examiner recorded whether or not an AP was perceived. Finally, participants underwent immediate follow up thermal pain sensitivity testing using the same protocols. Separate repeated measure ANOVAs were used to observe changes in pain sensitivity prior to and immediately following HVLA manipulation.
Hypoalgesia of Aδ fiber mediated pain was observed in the low back following HVLA (p< 0.05) and this was independent of whether an AP was perceived (p> 0.05). Hypoalgesia of temporal summation was observed in the lower extremity following HVLA (p< 0.05) and this was independent of whether an AP was perceived (p= 0.08). However, a moderate effect size for temporal summation was observed favoring participants in whom an AP was perceived.
The current study suggests hypoalgesia is associated with HVLA manipulation and occurs independently of a perceived AP. Inhibition of lower extremity temporal summation may be larger in individuals in whom an AP is perceived, but further study is necessary to confirm this finding.
The comparative effects of adhesive tape and three semirigid ankle orthoses on ankle functional range of motion were studied on 11 college football athletes. Maximum plantar flexion and maximum dorsiflexion were measured under five conditions to determine functional range of motion. Testing conditions included: control (no supportive device), adhesive tape with moleskin, the Airstirrup “Training” orthosis, the Active Ankle “Trainer” orthosis, and the Ankle Ligament Protector. A 200-Hz video camera was used to record subjects' motions in the sagittal plane while they ran a series of 40-yd sprints. Videotape was analyzed with the Peak Performance Technology Motion Measurement System. Data were analyzed with a Repeated Measures MANOVA. Differences were found among treatments for maximum plantar flexion and functional range of motion. Follow-up analyses indicated that the Ankle Ligament Protector was the only supportive device that was significantly more restrictive than the control. The Airstirrup, Active Ankle, and adhesive tape with moleskin do not significantly affect functional range of motion during running.
Gastrocnemius stretching exercises often are prescribed as part of the treatment program for patients with overuse injuries associated with limited ankle dorsiflexion. However, little is known about how the position of the subtalar joint during gastrocnemius stretching affects ankle dorsiflexion range of motion (ROM).
To determine the effect of subtalar joint position during gastrocnemius stretching on ankle dorsiflexion ROM.
This study was a 3-way mixed-model design. The 3 factors were subtalar joint position (supinated, pronated), lower extremity (experimental, control), and time (pretest, posttest). Lower extremity and time were the repeated measures.
University research laboratory.
Patients or Other Participants:
Thirty-three healthy volunteers (29 women, 4 men).
Participants performed a gastrocnemius stretching exercise 2 times daily for 3 weeks with the subtalar joint of the randomly assigned experimental side (dominant or nondominant) in the randomly assigned position (supination or pronation). The contralateral lower extremity served as the control.
Main Outcome Measure(s):
Before and after the 3-week gastrocnemius stretching program, we used goniometers to measure ankle dorsiflexion ROM in weight-bearing and non–weight-bearing positions with the subtalar joint positioned in anatomic 0°.
Ankle dorsiflexion ROM measured in weight-bearing and non–weight-bearing positions increased after the gastrocnemius stretching program (P = .034 and .003, respectively), but the increase in ROM did not differ based on subtalar joint position (P = .775 and .831, respectively).
Subtalar joint position did not appear to influence gains in ankle dorsiflexion ROM after a gastrocnemius stretching program in healthy volunteers.
subtalar joint pronation; subtalar joint supination
Background and Purpose
Limited research suggests that an effect of whole body vibration (WBV) on the central nervous system (CNS) is suppression. An indirect measure used to assess CNS level of activation is the Soleus H-reflex. If true suppression does occur, other factors such as range of motion may be impacted. The purpose of this study was to examine the impact of WBV on H-reflex amplitude and passive ankle dorsiflexion.
Subjects and Methods
Twenty-seven healthy volunteers between the ages of 21-41 participated. Subjects were randomly assigned to a control group (n=13) or WBV group (n=14). H-reflex and ankle dorsiflexion measures were assessed before and after a three minute WBV perturbation (40 μHz, amplitude 2-4 mm). These measurements were repeated every five minutes up to twenty minutes following the intervention.
The H-reflex amplitude showed a significant decrease (p<.05) between pre-test and initial post-test for both groups. The H-reflex returned to baseline within five minutes following the intervention. The dorsiflexion range of motion showed significant interaction (p<.05). All changes were less than 5 degrees; therefore, no clear clinical impact was evident.
The observed decrease in H-reflex amplitude immediately following WBV agreed with previous research indicating a lower level of CNS activation. However, since the control group also showed this change, WBV does not appear to be a key cause of suppression. Range of motion was not clinically significant for either group.
Whole body vibration; H-reflex; Soleus muscle
The aim of this study was to examine the long-term effects of static stretching of the plantar-flexor muscles on eccentric and concentric torque and ankle dorsiflexion range of motion in healthy subjects. Seventy five healthy male volunteers, with no previous history of trauma to the calf that required surgery, absence of knee flexion contracture and no history of neurologic dysfunction or disease, systemic disease affecting the lower extremities were selected for this study. The participants were divided into three equal groups. The control group did not stretch the plantar-flexor muscles. Two Experimental groups (trained and untrained) were instructed to perform static stretching exercise of 30 second duration and 5 repetitions twice daily. The stretching sessions were carried out 5 days a week for 6 weeks. The dorsiflexion range of motion was measured in all subjects. Also measured was the eccentric and concentric torque of plantar-flexors at angular velocities of 30 and 120°/s pre and post stretching. Analysis of variance showed a significant increase in plantar-flexor eccentric and concentric torque (p < 0.05) of trained and untrained groups, and an increase in dorsiflexion range of motion (p < 0.05) at both angular velocities for the untrained group only. The static stretching program of plantar-flexors was effective in increasing the concentric and eccentric plantarflexion torque at angular velocities of 30 and 120°/s. Increases in plantar-flexors flexibility were observed in untrained subjects.
calf muscle; isokinetic torque; static stretching
To compare changes in jump height and running velocity with and without pre‐event high‐velocity, low‐amplitude manipulation (HVLA).
A crossover study design with elite healthy athletes was used. After a 15 min warm‐up, the subjects were tested for countermovement jump height (CMJ) and flying 40 m sprint time (SPRINT). A sport chiropractor then evaluated each subject. Subjects were randomised to either HVLA (applied to joints based on examination) or placebo (simulated performance‐enhancement stickers). They then rested for 60 min, performed another 15 min warm‐up, and were retested. The protocol was repeated 48 h later with the alternative intervention. The mean of two sprints and three jumps were analysed, as well as peak performances. The sample size was based on prior results from the effects of stretching.
19 subjects involved in sprint sports were enrolled; two were too sore to participate on day 2, and one could only participate in the jump (all had HVLA on day 1). Of the 17 participants analysed, seven were female, age range was 19–35, and 17 were national or world‐class athletes. The ranges for baseline measures were: SPRINT 4.1–5.5 s; CMJ 47.4–92.7 cm. Overall, the greater than expected variability in this pilot study led to the study being underpowered. Subjects tended to perform better after HVLA for both CMJ and SPRINT (both mean and peak results), but none of the results were statistically significant (p = 0.30–0.61).
Although the larger than expected variability in the pilot study means that the observed clinically relevant differences were not statistically significant, the direction and magnitude of the changes associated with HVLA suggest that it may be beneficial. That said, the increased soreness after HVLA suggests that it may be detrimental. HVLA warrants further study.
performance enhancement; elite athlete; crossover; manipulation
Objective: To compare the effectiveness and safety of the triple combination Phlogenzym (rutoside, bromelain, and trypsin) with double combinations, the single substances, and placebo.
Design: Multinational, multicentre, double blind, randomised, parallel group design with eight groups structured according to a factorial design.
Setting: Orthopaedic surgery and emergency departments in 27 European hospitals.
Participants: A total of 721 patients aged 16–53 years presenting with acute unilateral sprain of the lateral ankle joint.
Primary efficacy criteria: (a) Pain on walking one or two steps, as defined by the patient on a visual analogue scale. (b) The range of motion, as measured by the investigator and expressed as a sum of flexion and extension. (c) The volume of the injured ankle measured with a volometer.
Results: At the primary end point at seven days, the greatest reduction in pain was in the bromelain/trypsin group (73.7%). The Phlogenzym group showed a median reduction of 60.3%, and the placebo group showed a median reduction of 73.3%. The largest increase in range of motion (median) was in the placebo group (60% change from baseline). The Phlogenzym group showed a median increase of 42.9%. The biggest decrease in swelling was in the trypsin group (3.9% change from baseline). The Phlogenzym group showed a –2.30% change from baseline and the placebo group a –2.90% change. In the subgroup analysis of patients who did not use a Caligamed brace, Phlogenzym was superior to placebo for the summarising directional test of the primary efficacy criteria (MW = 0.621; LB-CI 0.496; p = 0.029; one sided Wei-Lachin procedure). The vast majority of doctors and patients rated the tolerability of all treatments tested as very good or at least good.
Conclusions: Phlogenzym was not found to be superior to the three two-drug combinations, the three single substances, or placebo for treatment of patients with acute unilateral sprain of the lateral ankle joint. The small subgroup of patients treated without the support of a Caligamed brace showed evidence of superiority of Phlogenzym over placebo. Further research is warranted to study this effect of Phlogenzym in patients treated without ankle support.
The purpose of this article is to review the literature that discusses normal anatomy and biomechanics of the foot and ankle, mechanisms that may result in a lateral ankle sprain or syndesmotic sprain, and assessment and diagnostic procedures, and to present a treatment algorithm based on normal ligament healing principles.
Literature was searched for years 2000 to 2010 in PubMed and CINAHL. Key search terms were ankle sprain$, ankle injury and ankle injuries, inversion injury, proprioception, rehabilitation, physical therapy, anterior talofibular ligament, syndesmosis, syndesmotic injury, and ligament healing.
Most ankle sprains respond favorably to nonsurgical treatment, such as those offered by physical therapists, doctors of chiropractic, and rehabilitation specialists. A comprehensive history and examination aid in diagnosing the severity and type of ankle sprain. Based on the diagnosis and an understanding of ligament healing properties, a progressive treatment regimen can be developed. During the acute inflammatory phase, the goal of care is to reduce inflammation and pain and to protect the ligament from further injury. During the reparative and remodeling phase, the goal is to progress the rehabilitation appropriately to facilitate healing and restore the mechanical strength and proprioception. Radiographic imaging techniques may need to be used to rule out fractures, complete ligament tears, or instability of the ankle mortise. A period of immobilization and ambulating with crutches in a nonweightbearing gait may be necessary to allow for proper ligament healing before commencing a more active treatment approach. Surgery should be considered in the case of grade 3 syndesmotic sprain injuries or those ankle sprains that are recalcitrant to conservative care.
An accurate diagnosis and prompt treatment can minimize an athlete's time lost from sport and prevent future reinjury. Most ankle sprains can be successfully managed using a nonsurgical approach.
Ankle joint; Ankle injuries; Chiropractic; Physical therapy
Objective: To describe the functional anatomy of the ankle complex as it relates to lateral ankle instability and to describe the pathomechanics and pathophysiology of acute lateral ankle sprains and chronic ankle instability.
Data Sources: I searched MEDLINE (1985–2001) and CINAHL (1982–2001) using the key words ankle sprain and ankle instability.
Data Synthesis: Lateral ankle sprains are among the most common injuries incurred during sports participation. The ankle functions as a complex with contributions from the talocrural, subtalar, and inferior tibiofibular joints. Each of these joints must be considered in the pathomechanics and pathophysiology of lateral ankle sprains and chronic ankle instability. Lateral ankle sprains typically occur when the rearfoot undergoes excessive supination on an externally rotated lower leg. Recurrent ankle sprain is extremely common; in fact, the most common predisposition to suffering a sprain is the history of having suffered a previous ankle sprain. Chronic ankle instability may be due to mechanical instability, functional instability, or most likely, a combination of these 2 phenomena. Mechanical instability may be due to specific insufficiencies such as pathologic laxity, arthrokinematic changes, synovial irritation, or degenerative changes. Functional instability is caused by insufficiencies in proprioception and neuromuscular control.
Conclusions/Recommendations: Lateral ankle sprains are often inadequately treated, resulting in frequent recurrence of ankle sprains. Appreciation of the complex anatomy and mechanics of the ankle joint and the pathomechanics and pathophysiology related to acute and chronic ankle instability is integral to the process of effectively evaluating and treating ankle injuries.
ankle sprain; talocrural joint; subtalar joint; mechanical instability; functional instability
Spinal manipulation (SM) is a form of manual therapy used clinically to treat patients with low back and neck pain. The most common form of this maneuver is characterized as a high velocity (duration < 150ms), low amplitude (segmental translation < 2mm, rotation < 4°, and applied force 220-889N) impulse thrust (HVLA-SM). Clinical skill in applying an HVLA-SM lies in the practitioner's ability to control the duration and magnitude of the load (i.e., the rate of loading), the direction in which the load is applied, and the contact point at which the load is applied. Control over its mechanical delivery presumably related to its clinical effects. Biomechanical changes evoked by an HVLA-SM are thought to have physiological consequences caused, at least in part, by changes in sensory signaling from paraspinal tissues.
If activation of afferent pathways does contribute to the effects of an HVLA-SM, it seems reasonable to anticipate that neural discharge might increase or decrease in a non-linear fashion as the thrust duration thrust approaches a threshold value. We hypothesized that the relationship between the duration of an impulsive thrust to a vertebra and paraspinal muscle spindle discharge would be non-linear with an inflection near the duration of an HVLA-SM delivered clinically (<150ms). In addition, we anticipated that muscle spindle discharge would be more sensitive to larger amplitude thrusts.
A neurophysiological study of spinal manipulation using the lumbar spine of a feline model.
Impulse thrusts (duration: 12.5, 25, 50, 100, 200, and 400 ms; amplitude 1 or 2mm posterior to anterior) were applied to the spinous process of the L6 vertebra of deeply anesthetized cats while recording single unit activity from dorsal root filaments of muscle spindle afferents innervating the lumbar paraspinal muscles. A feedback motor was used in displacement control mode to deliver the impulse thrusts. The motor's drive arm was securely attached to the L6 spinous process via a forceps.
As thrust duration became shorter the discharge of the lumbar paraspinal muscle spindles increased in a curvilinear fashion. A concave up inflection occurred near the 100ms duration eliciting both a higher frequency discharge compared to the longer durations and a substantially faster rate of change as thrust duration was shortened. This pattern was evident in paraspinal afferents with receptive fields both close and far from the midline. Paradoxically, spindle afferents were almost twice as sensitive to the 1mm compared to the 2mm amplitude thrust (6.2 vs 3.3 spikes/s/mm/s). This latter finding may be related to the small vs large signal range properties of muscle spindles.
. The results indicate that the duration and amplitude of a spinal manipulation elicits a pattern of discharge from paraspinal muscle spindles different from slower mechanical inputs. Clinically, these parameters may be important determinants of an HVLA-SM's therapeutic benefit.
lumbar spine; spinal manipulation; chiropractic; osteopathy; paraspinal muscles; muscle spindle
[Purpose] This study investigated the effects of walking with talus taping on the ankle
dorsiflexion passive range of motion (DF PROM) in individuals with limited ankle DF PROM.
[Subjects] Fifteen ankles with limited DF PROM were examined. [Methods] After rigid
strapping tape was applied to the ankles from the talus to the calcaneus, progressing
posteriorly and inferiorly, the subjects walked on a walkway for 10 min. Using a
goniometer, the ankle DF PROM was measured with the knee extended before and after walking
with talus taping. The difference in ankle DF PROM between before and after walking with
talus taping was analyzed using the paired t-test. [Results] The ankle DF PROM was
significantly increased after walking with talus taping. [Conclusion] Our findings
indicate that walking with talus taping is effective for increasing the ankle DF PROM in
individuals with limited ankle DF PROM.
Ankle passive range of motion; Mobilization with movement; Talus taping
Altered joint arthrokinematics can affect structures distal and proximal to the site of dysfunction. Hypomobility of the proximal tibiofibular joint may limit ankle dorsiflexion and indirectly alter stresses about the knee.
To examine the effect of addressing hypomobility of the proximal tibiofibular joint in an individual with lateral knee pain.
A 24 year old female recreational runner presented with a three month history of right lateral knee pain. Limited right ankle dorsiflexion was noted and determined to be related to decreased mobility of the proximal tibiofibular joint, as well as, the talocrural and distal tibiofibular joints. Functional movement deficits were noted during the squat test and step down test. Treatment was performed three times over the course of two weeks which included proximal tibiofibular joint manipulation and an exercise program consisting of hip strengthening, balance, and gastrocnemius/soleus muscle complex stretching.
Immediately following intervention, improvements were noted for ankle dorsiflexion, squat test, and step down test. One week following the initial intervention the patient reported she was able to run pain free.
Addressing impairments distant to the site of dysfunction, such as the proximal tibiofibular joint, may be indicated in individuals with lateral knee pain.
ankle sprain; arthrokinematics; manipulation
To determine if ankle muscular strength, flexibility and proprioception can predict ankle injury in college basketball players and to compare ankle injury rates in female and male players.
Design and Setting:
In this prospective, correlational study, subjects were tested at the start of the competitive season for ankle joint muscle strength, flexibility, and proprioception. The first ankle injury for each subject was recorded on an injury report form, and the data were analyzed to determine if any of these preseason measurements predicted future injury. The setting was a competitive 9-week season for four women's and four men's college basketball teams.
A convenience sample of 31 female and 11 male college basketball players.
Subjects were tested for ankle dorsiflexion range of motion, various measures of ankle proprioception, and isokinetic peak torque of ankle dorsiflexion-plantar flexion and eversion-inversion at 30°/sec and 180°/sec before the start of the conference basketball seasons. Data were analyzed using a series of multiple regression equations to determine the variance in ankle injury attributed to each variable.
Various measures of proprioception predicted left ankle injury in all subjects (p < .05), while ankle strength and flexibility measures failed to account for additional variance. There was no statistically significant difference in ankle injury rate between women and men.
Ankle joint proprioceptive deficits can be used to predict ankle injury, but further research is needed to identify other sources of variance. In our study, ankle injury rate was similar in female and male college basketball players.
athletic injuries; college athletes; range of motion
Many lower limb disorders are related to calf muscle tightness and reduced dorsiflexion of the ankle. To treat such disorders, stretches of the calf muscles are commonly prescribed to increase available dorsiflexion of the ankle joint.
To determine the effect of static calf muscle stretching on ankle joint dorsiflexion range of motion.
A systematic review with meta‐analyses.
A systematic review of randomised trials examining static calf muscle stretches compared with no stretching. Trials were identified by searching Cinahl, Embase, Medline, SportDiscus, and Central and by recursive checking of bibliographies. Data were extracted from trial publications, and meta‐analyses performed that calculated a weighted mean difference (WMD) for the continuous outcome of ankle dorsiflexion. Sensitivity analyses excluded poorer quality trials. Statistical heterogeneity was assessed using the quantity I2.
Five trials met inclusion criteria and reported sufficient data on ankle dorsiflexion to be included in the meta‐analyses. The meta‐analyses showed that calf muscle stretching increases ankle dorsiflexion after stretching for ⩽15 minutes (WMD 2.07°; 95% confidence interval 0.86 to 3.27), >15–30 minutes (WMD 3.03°; 95% confidence interval 0.31 to 5.75), and >30 minutes (WMD 2.49°; 95% confidence interval 0.16 to 4.82). There was a very low to moderate statistical heterogeneity between trials. The meta‐analysis results for ⩽15 minutes and >15–30 minutes of stretching were considered robust when compared with sensitivity analyses that excluded lower quality trials.
Calf muscle stretching provides a small and statistically significant increase in ankle dorsiflexion. However, it is unclear whether the change is clinically important.
stretching; dorsiflexion; Achilles tendon; gastrocnemius; soleus
OBJECTIVE—To test the
hypothesis that the proprioceptive regulation of voluntary movement is
disturbed by Parkinson's disease, the effects of experimental
stimulation of proprioceptors, using muscle vibration, on the
trajectories of voluntary dorsiflexion movements of the ankle joint
were compared between parkinsonian and control subjects.
patients with Parkinson's disease, on routine medication (levodopa in
all but one), and an equal number of age matched, neurologically intact
controls, were trained initially to make reproducible ankle
dorsiflexion movements (20° amplitude with a velocity of 9.7°/s)
following a visual "go" cue while movement trajectories were
recorded goniometrically. During 50% of the experimental trials,
vibration (105 Hz; 0.7 mm peak to peak) was applied to the Achilles
tendon during the ankle movement to stimulate antagonist muscle
spindles; vibrated and non-vibrated trials were interspersed randomly.
Subjects' performance was assessed by measuring end point
position—that is, the ankle angle attained 2 seconds after the visual
"go" cue, from averaged (20 trials) trajectories.
analysis of the end point amplitudes of movement showed that, whereas
the amplitudes of non-vibrated movements did not differ significantly
between patients with Parkinson's disease and controls, antagonist
muscle vibration produced a highly significant reduction in the
amplitudes of ankle dorsiflexion movements in both the patient and
control groups. However, the extent of vibration induced undershooting
produced in the patients with Parkinson's disease was significantly
less than that in the controls; the mean vibrated/non-vibrated ratios
were 0.86 and 0.54 for, respectively, the patient and control groups.
present finding of a reduction of vibration induced ankle movement
errors in parkinsonian patients resembles qualitatively previous
observations of wrist movements, and suggests that Parkinson's disease
may produce a general impairment of proprioceptive guidance.