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1.  Lateral and syndesmotic ankle sprain injuries: a narrative literature review 
Journal of Chiropractic Medicine  2011;10(3):204-219.
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.
PMCID: PMC3259913  PMID: 22014912
Ankle joint; Ankle injuries; Chiropractic; Physical therapy
2.  Ankle Injuries Among United States High School Sports Athletes, 2005–2006 
Journal of Athletic Training  2007;42(3):381-387.
Context: Ankle injuries are the most common sport-related injuries. To date, no studies have been published that use national data to present a cross-sport, cross-sex analysis of ankle injuries among US high school athletes.
Objective: To investigate the incidence rates of ankle injuries by sex, type of exposure, and sport.
Design: Descriptive epidemiologic study.
Setting: One hundred US high schools.
Patients or Other Participants: United States high school athletes.
Main Outcome Measure(s): We reviewed ankle injury data collected over the 2005–2006 school year from a nationally representative sample obtained by High School RIO, an injury surveillance system. Specific sports studied were boys' football, boys' and girls' soccer, girls' volleyball, boys' and girls' basketball, boys' wrestling, boys' baseball, and girls' softball.
Results: An estimated 326 396 ankle injuries occurred nationally in 2005–2006, yielding an injury rate of 5.23 ankle injuries per 10 000 athlete-exposures. Ankle injuries occurred at a significantly higher rate during competition (9.35 per 10 000 athlete-exposures) than during practice (3.63) (risk ratio = 2.58; 95% confidence interval = 2.26, 2.94; P < .001). Boys' basketball had the highest rate of ankle injury (7.74 per 10 000 athlete-exposures), followed by girls' basketball (6.93) and boys' football (6.52). In all sports except girls' volleyball, rates of ankle injury were higher in competition than in practice. Overall, most ankle injuries were diagnosed as ligament sprains with incomplete tears (83.4%). Ankle injuries most commonly caused athletes to miss less than 7 days of activity (51.7%), followed by 7 to 21 days of activity loss (33.9%) and more than 22 days of activity loss (10.5%).
Conclusions: Sports that combine jumping in close proximity to other players and swift changes of direction while running are most often associated with ankle injuries. Future research on ankle injuries is needed to drive the development and implementation of more effective preventive interventions.
PMCID: PMC1978459  PMID: 18059994
injury surveillance; injury epidemiology; lower extremity injuries
3.  Injury in the National Basketball Association 
Sports Health  2010;2(4):284-290.
Injury patterns in elite athletes over long periods continue to evolve. The goal of this study was to review of the injuries and medical conditions afflicting athletes competing in the National Basketball Association (NBA) over a 17-year period.
Descriptive epidemiological study.
Injuries and player demographic information were reported by each team’s athletic trainer. Criteria for reportable injuries were those that resulted in (1) physician referral, (2) a practice or game being missed, or (3) emergency care. The demographics, frequency of injury, time lost, and game exposures were tabulated, and game-related injury rates and 95% confidence intervals were calculated.
A total of 1094 players appeared in the database 3843 times (3.3 ± 2.6 seasons). Lateral ankle sprains were the most frequent orthopaedic injury (n, 1658; 13.2%), followed by patellofemoral inflammation (n, 1493; 11.9%), lumbar strains (n, 999; 7.9%), and hamstring strains (n, 413; 3.3%). The most games missed were related to patellofemoral inflammation (n, 10 370; 17.5%), lateral ankle sprains (n, 5223; 8.8%), knee sprains (n, 4369; 7.4%), and lumbar strains (n, 3933; 6.6%). No correlations were found between injury rate and player demographics, including age, height, weight, and NBA experience.
Professional athletes in the NBA experience a high rate of game-related injuries. Patellofemoral inflammation is the most significant problem in terms of days lost in competition, whereas ankle sprains are the most common injury. True ligamentous injuries of the knee were surprisingly rare. Importantly, player demographics were not correlated with injury rates. Further investigation is necessary regarding the consequences and sport-specific treatment of various injuries in NBA players.
Clinical Relevance:
Knowledge of these injury patterns can help to guide treatments and provide more accurate guidelines for an athlete to return to play.
PMCID: PMC3445097  PMID: 23015949
National Basketball Association; basketball injuries; injury epidemiology
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.
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.
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
5.  Surgical Considerations in the Treatment of Ankle Instability 
Journal of Athletic Training  2002;37(4):458-462.
Objective: To review the surgical indications, techniques, biomechanical testing, and clinical results reported for the most common surgical techniques used to treat ankle instability.
Data Sources: We searched MEDLINE from 1960–2001 using the terms ankle instability, functional ankle instability, mechanical ankle instability, ankle ligament surgery, Broström, Chrisman-Snook, and Evans.
Data Synthesis: Although 80% to 85% of acute ankle sprains are successfully treated with a functional ankle-rehabilitation program, the remaining 15% to 20% have recurrent ankle instability and reinjury, necessitating surgical intervention. The fundamentals of the surgical approach to lateral ankle instability are based on the anatomy of the lateral ankle ligaments, the anterior talofibular ligament, and the calcaneofibular ligament. Ankle-instability surgery has been broadly divided into an anatomic repair consisting of an imbrication of the lateral ligamentous complex and an ankle-ligament reconstruction. An ankle-ligament reconstruction weaves a harvested tendon graft, most commonly the peroneus brevis, to augment the lateral ligaments of the ankle. Goals of surgery are to reestablish ankle stability and function without compromising motion and without complications. Anatomic repair and imbrication of the lateral ligament complex with the Gould modification has an 85% to 95% success rate, and the risk of associated nerve injuries is low. This approach provides increased stability by reinforcing local host tissue, preserving subtalar and talocrural motion, eliminating the comorbidity associated with tendon-graft harvest, and offering a quicker functional recovery. One concern in using the anatomic approach is the resultant strength of the repair, although the literature does not support this concern. Ankle-reconstruction procedures that sacrifice tendons are thought to provide a stronger construct, and hence, more stability. This increased stability results in loss of talocrural and subtalar range of motion, prolonging recovery and decreasing sport performance. Adjacent nerve injury is more common with ankle-ligament reconstruction.
Conclusions/Recommendations: Based on the literature, we believe that a modified Broström lateral-ligament repair should be considered the first choice for persistent ankle instability refractory to a functional ankle-rehabilitation protocol. Ankle reconstruction with tendon augmentation should be reserved for patients with generalized ligamentous laxity or long-standing ligamentous insufficiency or as a salvage procedure in a patient with a failed modified Broström lateral-ligament repair.
PMCID: PMC164377  PMID: 12937567
Broström procedure; Chrisman-Snook procedure; Evans procedure
6.  Can Chronic Ankle Instability Be Prevented? Rethinking Management of Lateral Ankle Sprains 
Journal of Athletic Training  2002;37(4):430-435.
Objective: To pose the question, “Can chronic ankle instability be prevented?” The evaluation and treatment of chronic ankle instability is a significant challenge in athletic health care. The condition affects large numbers of athletes and is associated with reinjury and impaired performance. The management of acute injuries varies widely but in athletic training has traditionally focused on initial symptom management and rapid return to activity. A review of practice strategies and philosophies suggests that a more detailed evaluation of all joints affected by the injury, correction of hypomobility, and protection of healing structures may lead to a more optimal long-term outcome.
Background: Sprains to the lateral ankle are common in athletes, and the reinjury rate is high. These injuries are often perceived as being isolated to the anterior talofibular and calcaneofibular ligaments. It is, however, becoming apparent that a lateral ankle sprain can injure other tissues and result in joint dysfunction throughout the ankle complex.
Description: We begin by addressing the relationship between mechanical and functional instability. We then discuss normal ankle mechanics, sequelae to lateral ankle sprains, and abnormal ankle mechanics. Finally, tissue healing, joint dysfunction, and the management of acute lateral ankle sprain are reviewed, with an emphasis on restoring normal mechanics of the ankle-joint complex. A treatment model based on assessment of joint function, treatment of hypomobile segments, and protection of healing tissues at hypermobile segments is described.
PMCID: PMC164374  PMID: 12937564
joint mobilization; injury prevention
7.  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.
PMCID: PMC2724472  PMID: 19640309
8.  Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability 
Journal of Athletic Training  2002;37(4):364-375.
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.
PMCID: PMC164367  PMID: 12937557
ankle sprain; talocrural joint; subtalar joint; mechanical instability; functional instability
9.  Treatment of acute ankle ligament injuries: a systematic review 
Lateral ankle sprains are common musculoskeletal injuries.
The objective of this study was to perform a systematic literature review of the last 10 years regarding evidence for the treatment and prevention of lateral ankle sprains.
Data source
Pubmed central, Google scholar.
Study eligibility criteria
Meta-analysis, prospective randomized trials, English language articles.
Surgical and non-surgical treatment, immobilization versus functional treatment, different external supports, balance training for rehabilitation, balance training for prevention, braces for prevention.
A systematic search for articles about the treatment of lateral ankle sprains that were published between January 2002 and December 2012.
Three meta-analysis and 19 articles reporting 16 prospective randomized trials could be identified. The main advantage of surgical ankle ligament repair is that objective instability and recurrence rate is less common when compared with non-operative treatment. Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. For non-surgical treatment, long-term immobilization should be avoided. For grade III injuries, however, a short period of immobilization (max. 10 days) in a below knee cast was shown to be advantageous. After this phase, the ankle is most effectively protected against inversion by a semi-rigid ankle brace. Even grades I and II injuries are most effectively treated with a semi-rigid ankle brace. There is evidence that treatment of acute ankle sprains should be supported by a neuromuscular training. Balance training is also effective for the prevention of ankle sprains in athletes with the previous sprains. There is good evidence from high level randomized trials in the literature that the use of a brace is effective for the prevention of ankle sprains.
Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. This systematic review supports a phase adapted non-surgical treatment of acute ankle sprains with a short-term immobilization for grade III injuries followed by a semi-rigid brace. More prospective randomized studies with a longer follow-up are needed to find out what type of non-surgical treatment has the lowest re-sprain rate.
PMCID: PMC3718986  PMID: 23712708
Chronic ankle instability; Ankle brace; External support; Surgical treatment; Balance training
10.  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.
PMCID: PMC1725120  PMID: 15665204
11.  The implementation effectiveness of the ‘Strengthen your ankle’ smartphone application for the prevention of ankle sprains: design of a randomized controlled trial 
Ankle sprains continue to pose a significant burden to the individual athlete, as well as to society as a whole. However, despite ankle sprains being the single most common sports injury and despite an active approach by various Dutch organisations in implementing preventive measures, large-scale community uptake of these preventive measures, and thus actual prevention of ankle sprains, is lagging well behind. In an attempt to bridge this implementation gap, the Dutch Consumer Safety Institute VeiligheidNL developed a freely available interactive App (‘Strenghten your ankle’ translated in Dutch as: ‘Versterk je enkel; available for iOS and Android) that contains - next to general advice on bracing and taping - a proven cost-effective neuromuscular program. The ‘Strengthen your ankle’ App has not been evaluated against the ‘regular’ prevention approach in which the neuromuscular program is advocated through written material. The aim of the current project is to evaluate the implementation value of the ‘Strengthen your ankle’ App as compared to the usual practice of providing injured athletes with written materials. In addition, as a secondary outcome measure, the cost-effectiveness will be assessed against usual practice.
The proposed study will be a randomised controlled trial. After stratification for medical caregiver, athletes will be randomised to two study groups. One group will receive a standardized eight-week proprioceptive training program that has proven to be cost-effective to prevent recurrent ankle injuries, consisting of a balance board (machU/ MSG Europe BVBA), and a traditional instructional booklet. The other group will receive the same exercise program and balance board. However, for this group the instructional booklet is exchanged by the interactive ‘Strengthen your ankle’ App.
This trial is the first randomized controlled trial to study the implementation effectiveness of an App for proprioceptive balance board training program in comparison to a traditional printed instruction booklet, with the recurrence of ankle sprains among athletes as study outcome. Results of this study could possibly lead to changes in practical guidelines on the treatment of ankle sprains and in the use of mobile applications for injury prevention. Results will become available in 2014.
Trial registration
The Netherlands National Trial Register NTR4027. The NTR is part of the WHO Primary Registries.
PMCID: PMC3923004  PMID: 24393146
Mobile health; Ankle sprains; Ankle injury; Prevention; Neuromuscular training
Describe ankle injury epidemiology among US high school athletes in 20 sports.
Descriptive prospective epidemiology study.
Sports injury data for the 2005/06–2010/11 academic years were collected using an internet-based injury surveillance system, Reporting Information Online (RIO).
A nationwide convenience sample of US high schools.
Assessment of Risk Factors
Injuries sustained as a function of sport and gender.
Main Outcome Measures
Ankle sprain rates and patterns, outcomes, and mechanisms.
From 2005/06–2010/11, certified athletic trainers reported 5,373 ankle sprains in 17,172,376 athlete exposures [AEs], for a rate of 3.13 ankle sprains per 10,000 AEs. Rates were higher for girls than boys (RR 1.25, 95% CI 1.17–1.34) in gender-comparable sports and higher in competition than practice for boys (RR 3.42, 95% CI 3.20–3.66) and girls (RR 2.71, 95% CI 2.48–2.95). The anterior talofibular ligament was most commonly injured (involved in 85.3% of sprains). Overall, 49.7% of sprains resulted in loss of participation from 1–6 days. While 0.5% of all ankle sprains required surgery, 6.6% of those involving the deltoid ligament required surgery. Athletes were wearing ankle braces in 10.6% of all sprains. The most common injury mechanism was contact with another person (42.4% of all ankle sprains).
Ankle sprains are a serious problem in high school sports, with high rates of recurrent injury and loss of participation from sport.
PMCID: PMC3640618  PMID: 23328403
epidemiology; ankle; sprain; high school; sports
13.  Prophylactic Ankle Taping and Bracing: A Numbers-Needed-to-Treat and Cost-Benefit Analysis 
Journal of Athletic Training  2004;39(1):95-100.
Taping and bracing are thought to decrease the incidence of ankle sprains; however, few investigators have addressed the effect of preventive measures on the rate of ankle sprains. Our purpose was to examine the effectiveness of ankle taping and bracing in reducing ankle sprains by applying a numbers-needed-to-treat (NNT) analysis to previously published studies.
Data Sources:
We searched PubMed, CINAHL, SPORT Discus, and PEDro for original research from 1966 to 2002 with key words ankle taping, ankle sprains, injury incidence, prevention, ankle bracing, ankle prophylaxis, andnumbers needed to treat. We eliminated articles that did not address the effects of ankle taping or bracing on ankle injury rates using an experimental design.
Data Synthesis:
The search produced 8 articles, of which 3 permitted calculation of NNT, which addresses the clinical usefulness of an intervention by providing estimates of the number of treatments needed to prevent 1 injury occurrence. In a study of collegiate intramural basketball players, the prevention of 1 ankle sprain required the taping of 26 athletes with a history of ankle sprain and 143 without a prior history. In a military academy intramural basketball program, prevention of 1 sprain required bracing of 18 athletes with a history of ankle sprain and 39 athletes with no history. A study of ankle bracing in competitive soccer players produced an NNT of 5 athletes with a history of previous sprain and 57 without a prior injury. A cost- benefit analysis of ankle taping versus bracing revealed taping to be approximately 3 times more expensive than bracing.
Greater benefit is achieved in applying prophylactic ankle taping or bracing to athletes with a history of ankle sprain, compared with those without previous sprains. The generalizability of these results to other physically active populations is unknown.
PMCID: PMC385268  PMID: 15085217
ankle sprain; ankle prophylaxis; orthoses; injury incidence; injury prevention
14.  Predictive Factors for Lateral Ankle Sprains: A Literature Review 
Journal of Athletic Training  2002;37(4):376-380.
Objective: To review the prospective studies of ankle-ligament-injury risk factors.
Data Sources: We searched MEDLINE from 1978 to 2001 using the terms ankle, ligament, injury, risk factor, and epidemiology.
Data Synthesis: The results included many studies on the treatment and prevention of ankle injuries. There were, however, very few prospective studies focusing on identifying the risk factors that predispose an athlete to ankle-ligament trauma.
Conclusions/Recommendations: There is some agreement among authors with regard to the risk factors for ankle-ligament injury; however, considerable controversy remains. Although female athletes are at significantly greater risk of suffering a serious knee sprain, such as disruption of the anterior cruciate ligament, this does not appear to be the case for ankle-ligament sprains. Therefore, sex does not appear to be a risk factor for suffering an ankle-ligament sprain. Athletes who have suffered a previous sprain have a decreased risk of reinjury if a brace is worn, and the consensus is that generalized joint laxity and anatomical foot type are not risk factors for ankle sprains. However, the literature is divided with regard to whether or not height, weight, limb dominance, ankle-joint laxity, anatomical alignment, muscle strength, muscle-reaction time, and postural sway are risk factors for ankle sprains. Future research is needed on this topic to develop a consensus on all ankle-injury risk factors. This will allow future intervention studies to be designed that will reduce the incidence and severity of this common injury.
PMCID: PMC164368  PMID: 12937558
ligament; injury; risk factor
15.  Evidence-based treatment for ankle injuries: a clinical perspective 
The most common ankle injuries are ankle sprain and ankle fracture. This review discusses treatments for ankle sprain (including the management of the acute sprain and chronic instability) and ankle fracture, using evidence from recent systematic reviews and randomized controlled trials. After ankle sprain, there is evidence for the use of functional support and non-steroidal anti-inflammatory drugs. There is weak evidence suggesting that the use of manual therapy may lead to positive short-term effects. Electro-physical agents do not appear to enhance outcomes and are not recommended. Exercise may reduce the occurrence of recurrent ankle sprains and may be effective in managing chronic ankle instability. After surgical fixation for ankle fracture, an early introduction of activity, administered via early weight-bearing or exercise during the immobilization period, may lead to better outcomes. However, the use of a brace or orthosis to enable exercise during the immobilization period may also lead to a higher rate of adverse events, suggesting that this treatment regimen needs to be applied judiciously. After the immobilization period, the focus of treatment for ankle fracture should be on a progressive exercise program.
PMCID: PMC3103112  PMID: 21655420
Ankle injuries; Evidence-based practice; Rehabilitation; Systematic review; Therapy
16.  What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? 
Journal of Athletic Training  2012;47(4):435-443.
Ankle sprains are common problems in acute medical care. The variation in treatment observed for the acutely injured lateral ankle ligament complex in the first week after the injury suggests a lack of evidence-based management strategies for this problem.
To analyze the effectiveness of applying rest, ice, compression, and elevation (RICE) therapy begun within 72 hours after trauma for patients in the initial period after ankle sprain.
Study Selection:
Eligible studies were published original randomized or quasi-randomized controlled trials concerning at least 1 of the 4 subtreatments of RICE therapy in the treatment of acute ankle sprains in adults.
Data Sources:
MEDLINE, Cochrane Clinical Trial Register, CINAHL, and EMBASE. The lists of references of retrieved publications also were checked manually.
Data Extraction:
We extracted relevant data on treatment outcome (pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction) and assessed the quality of included studies. If feasible, the results of comparable studies were pooled using fixed- or random-effects models.
Data Synthesis:
After deduction of the overlaps among the different databases, evaluation of the abstracts, and contact with some authors, 24 potentially eligible trials remained. The full texts of these articles were retrieved and thoroughly assessed as described. This resulted in the inclusion of 11 trials involving 868 patients. The main reason for exclusion was that the authors did not describe a well-defined control group without the intervention of interest.
Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.
PMCID: PMC3396304  PMID: 22889660
ankle ligament injury; cryotherapy; bandages
17.  The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains 
Aim: To conduct a detailed analysis of ankle sprains sustained in English professional football over two competitive seasons.
Methods: Club medical staff at 91 professional football clubs annotated player injuries. A specific injury audit questionnaire was used together with a weekly form that documented each club's current injury status.
Results: Completed injury records for the two competitive seasons were obtained from 87% and 76% of the participating clubs. Ankle ligament sprains accounted for 11% of the total injuries over the two seasons, with over three quarters (77%) of sprains involving the lateral ligament complex. A total of 12 138 days and 2033 matches were missed because of ankle sprains. More sprains were caused by contact mechanisms than non-contact mechanisms (59% v 39%) except in goalkeepers who sustained more non-contact sprains (21% v 79%, p<0.01). Ankle sprains were most often observed during tackles (54%). More ankle sprains were sustained in matches than in training (66% v 33%), with nearly half (48%) observed during the last third of each half of matches. A total of 44% of sprains occurred during the first three months of the season. A high number of players (32%) who sustained ankle sprains were wearing some form of external support. The recurrence rate for ankle sprains was 9% (see methodology for definition of reinjury).
Conclusion: Ankle ligament sprains are common in football usually involving the lateral ligament complex. The high rate of occurrence and recurrence indicates that prevention is of paramount importance.
PMCID: PMC1724634  PMID: 12782548
18.  Ankles back in randomized controlled trial (ABrCt): braces versus neuromuscular exercises for the secondary prevention of ankle sprains. Design of a randomised controlled trial 
Ankle sprains are the most common sports and physical activity related injury. There is extensive evidence that there is a twofold increased risk for injury recurrence for at least one year post injury. In up to 50% of all cases recurrences result in disability and lead to chronic pain or instability, requiring prolonged medical care. Therefore ankle sprain recurrence prevention in athletes is essential. This RCT evaluates the effect of the combined use of braces and neuromuscular training (e.g. proprioceptive training/sensorimotor training/balance training) against the individual use of either braces or neuromuscular training alone on ankle sprain recurrences, when applied to individual athletes after usual care.
This study was designed as three way randomized controlled trial with one year follow-up. Healthy individuals between 12 and 70 years of age, who were actively participating in sports and who had sustained a lateral ankle sprain in the two months prior to inclusion, were eligible for inclusion. After subjects had finished ankle sprain treatment by means of usual care, they were randomised to any of the three study groups. Subjects in group 1 received an eight week neuromuscular training program, subjects in group 2 received a sports brace to be worn during all sports activities for the duration of one year, and group 3 received a combination of the neuromuscular training program and a sports brace to be worn during all sports activities for the duration of eight weeks. Outcomes were assessed at baseline and every month for 12 months therafter. The primary outcome measure was incidence of ankle sprain recurrences. Secondary outcome measures included the direct and indirect costs of recurrent injury, the severity of recurrent injury, and the residual complaints during and after the intervention.
The ABrCt is the first randomized controlled trial to directly compare the secondary preventive effect of the combined use of braces and neuromuscular training, against the use of either braces or neuromuscular training as separate secondary preventive measures. This study expects to identify the most effective and cost-efficient secondary preventive measure for ankle sprains. The study results could lead to changes in the clinical guidelines on the prevention of ankle sprains, and they will become available in 2012.
Trial registration
Netherlands Trial Register (NTR): NTR2157
PMCID: PMC3195211  PMID: 21951559
19.  Ankle Sprain Injuries: A 2-Year Prospective Cohort Study in Female Greek Professional Basketball Players 
Journal of Athletic Training  2007;42(3):388-394.
Context: Ankle sprains are a common basketball injury. Therefore, examination of risk factors for injury in female professional basketball players is worthwhile.
Objective: To examine rates of ankle sprains, associated time missed from participation, and risk factors for injury during 2 consecutive seasons.
Design: Prospective cohort study.
Setting: Eighteen professional basketball facilities.
Patients or Other Participants: We observed 204 players from 18 female professional basketball teams for 2 consecutive seasons during a 2-year period.
Main Outcome Measure(s): Using questionnaires, we recorded the incidence of ankle sprains, participation time missed, and mechanisms of injury in games and practice sessions. Potential risk factors, such as age, body mass, height, training experience, and history of ankle sprain, were examined using multivariate logistic regression.
Results: Fifty of the 204 participants sustained ankle injuries; injuries included 32 ankle sprains, which translated to an ankle sprain rate of 1.12 per 1000 hours of exposure to injury. The 32 players missed 224.4 training and game sessions and an average of 7.01 sessions per injury. Most injuries occurred in the key area of the basketball court and were the result of contact. Injury rates during games were higher than injury rates during practice sessions. Centers, followed by guards and forwards, had the highest rate of injury. Players who did not wear an external ankle support had an odds ratio of 2.481 for sustaining an ankle sprain.
Conclusions: Female professional basketball athletes who did not wear an external ankle support, who played in the key area, or who functioned as centers had a higher risk for ankle sprain than did other players.
PMCID: PMC1978460  PMID: 18059995
risk factors; team sports; injury epidemiology; injury prevention
20.  Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomised controlled trial 
British Journal of Sports Medicine  2014;48(16):1235-1239.
Ankle sprain is the most common sports-related injury with a high rate of recurrence and associated costs. Recent studies have emphasised the effectiveness of both neuromuscular training and bracing for the secondary prevention of ankle sprains.
To evaluate the effectiveness of combined bracing and neuromuscular training, or bracing alone, against the use of neuromuscular training on recurrences of ankle sprain after usual care.
384 athletes, aged 18–70, who had sustained a lateral ankle sprain, were included (training group n=120; brace group n=126; combi group n=138). The training group received an 8-week home-based neuromuscular training programme, the brace group received a semirigid ankle brace to be worn during all sports activities for 12 months, and the combi group received both the training programme, as well as the ankle brace, to be worn during all sports activities for 8 weeks. The main outcome measure was self-reported recurrence of the ankle sprain.
During the 1-year follow-up, 69 participants (20%) reported a recurrent ankle sprain: 29 (27%) in the training group, 17 (15%) in the brace group and 23 (19%) in the combi group. The relative risk for a recurrent ankle sprain in the brace group versus the training group was 0.53 (95% CI 0.29 to 0.97). No significant differences were found for time losses or costs due to ankle sprains between the intervention groups.
Bracing was superior to neuromuscular training in reducing the incidence but not the severity of self-reported recurrent ankle sprains after usual care.
PMCID: PMC4145426  PMID: 24398222
Ankle injuries; Injury Prevention; Sports rehabilitation programs; Issues related to taping and bracing; Intervention effectiveness
21.  Ankle injuries in basketball: injury rate and risk factors 
Objectives—To determine the rate of ankle injury and examine risk factors of ankle injuries in mainly recreational basketball players.
Methods—Injury observers sat courtside to determine the occurrence of ankle injuries in basketball. Ankle injured players and a group of non-injured basketball players completed a questionnaire.
Results—A total of 10 393 basketball participations were observed and 40 ankle injuries documented. A group of non-injured players formed the control group (n = 360). The rate of ankle injury was 3.85 per 1000 participations, with almost half (45.9%) missing one week or more of competition and the most common mechanism being landing (45%). Over half (56.8%) of the ankle injured basketball players did not seek professional treatment. Three risk factors for ankle injury were identified: (1) players with a history of ankle injury were almost five times more likely to sustain an ankle injury (odds ratio (OR) 4.94, 95% confidence interval (CI) 1.95 to 12.48); (2) players wearing shoes with air cells in the heel were 4.3 times more likely to injure an ankle than those wearing shoes without air cells (OR 4.34, 95% CI 1.51 to 12.40); (3) players who did not stretch before the game were 2.6 times more likely to injure an ankle than players who did (OR 2.62, 95% CI 1.01 to 6.34). There was also a trend toward ankle tape decreasing the risk of ankle injury in players with a history of ankle injury (p = 0.06).
Conclusions—Ankle injuries occurred at a rate of 3.85 per 1000 participations. The three identified risk factors, and landing, should all be considered when preventive strategies for ankle injuries in basketball are being formulated.
Key Words: basketball; ankle; injury; risk; prevention
PMCID: PMC1724316  PMID: 11273971
Introduction and Background:
Lateral ankle sprains (LAS) are common in sports medicine and can result in a high rate of re‐injury and chronic ankle instability (CAI). Recent evidence supports the use on mobilizations directed at the ankle in patients who have suffered a LAS. The Mulligan Concept of Mobilization‐with‐Movement (MWM) provides an intervention strategy for LASs, but requires pain‐free mobilization application and little literature exists on modifications of these techniques.
To present the use of a modified MWM to treat LASs when the traditional MWM technique could not be performed due to patient reported pain and to assess outcomes of the treatment.
Case Description:
The subject of this case report is a 23 year‐old female collegiate basketball player who had failed to respond to initial conservative treatments after being diagnosed with a lateral ankle sprain. The initial management and subsequent interventions are presented. After re‐examination, the addition of a modification of a MWM technique produced immediate and clinically significant changes in patient symptoms. The use of the modified‐MWM resulted in full resolution of symptoms and a rapid return to full athletic participation.
After the initial application of the modified‐MWM, the patient reported immediate pain‐free ankle motion and ambulation. Following a total of 5 treatments, using only the modified MWM and taping technique, the patient was discharged with equal range of motion (ROM) bilaterally, a decreased Disablement in the Physically Active (DPA) Scale score, and an asymptomatic physical exam. Follow‐up exam 6 weeks later indicated a full maintenance of these results.
Recent evidence has been presented to support the use of mobilization techniques to treat patient limitations following ankle injury; however, the majority of evidence is associated with addressing the talar and dorsiflexion limitations. Currently, little evidence is available regarding the use of the MWM technique designed for LASs and the expected outcomes. This case adds to the emerging evidence supporting the use for MWMs to treat ankle pathology and introduces a modification that may be applied in cases where patient reported pain prevents traditional application.
Level of Evidence:
Level 5; Single case report.
PMCID: PMC4127516  PMID: 25133082
Lateral ankle sprain; mobilization with movement
23.  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 
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.
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.
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.
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
PMCID: PMC2412867  PMID: 18492235
24.  Descriptive Epidemiology of Collegiate Women's Basketball Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2003–2004 
Journal of Athletic Training  2007;42(2):202-210.
Objective: To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for women's basketball and to identify potential areas for injury prevention initiatives.
Background: The number of colleges participating in women's college basketball has grown over the past 25 years. The Injury Surveillance System (ISS) has enabled the NCAA to collect and report injury trends over an extended period of time. This has allowed certified athletic trainers and coaches to be more informed regarding injuries and to adjust training regimens to reduce the risk of injury. It also has encouraged administrators to make rule changes that attempt to reduce the risk of injury.
Main Results: From 1988–1989 through 2003–2004, 12.4% of schools across Divisions I, II, and III that sponsor varsity women's basketball programs participated in annual ISS data collection. Game and practice injury rates exhibited significant decreases over the study period. The rate of injury in a game situation was almost 2 times higher than in a practice (7.68 versus 3.99 injuries per 1000 athlete-exposures, rate ratio = 1.9, 95% confidence interval = 1.9, 2.0). Preseason-practice injury rates were more than twice as high as regular-season practice injury rates (6.75 versus 2.84 injuries per 1000 athlete-exposures, rate ratio = 2.4, 95% confidence interval = 2.2, 2.4). More than 60% of all game and practice injuries were to the lower extremity, with the most common game injuries being ankle ligament sprains, knee injuries (internal derangements and patellar conditions), and concussions. In practices, ankle ligament sprains, knee injuries (internal derangements and patellar conditions), upper leg muscle-tendon strains, and concussions were the most common injuries.
Recommendations: Appropriate preseason conditioning and an emphasis on proper training may reduce the risk of injury and can optimize performance. As both player size and the speed of the women's game continue to increase, basketball's evolution from a finesse sport to a high-risk contact sport also will continue. The rates of concussions and other high-energy trauma injuries likely will increase. The NCAA ISS is an excellent tool for identifying new risk factors that may affect injury rates and for developing consistent injury definitions in order to improve the research and provide a source of clinically relevant data.
PMCID: PMC1941290  PMID: 17710168
athletic injuries; injury prevention; ankle sprains; knee injuries; anterior cruciate ligament injuries; stress fractures; concussions
25.  Assessment of the Injured Ankle in the Athlete 
Journal of Athletic Training  2002;37(4):406-412.
Objective: To present appropriate tools to assist in the assessment and evaluation of ankle injuries in athletes.
Data Sources: A MEDLINE search was performed for the years 1980–2001 using the terms ankle injuries and ankle sprains.
Data Synthesis: Ankle sprains are the most common injuries sustained by athletes. In order to render appropriate treatment, a proper evaluation must be made. Assessment of ankle injuries includes obtaining a good history of the mechanism of injury, a thorough physical examination, and judicious use of radiographic evaluation and special tests. I will outline techniques for diagnosing the most common ankle injuries among athletes.
Conclusions/Recommendations: In order to provide appropriate treatment, the examiner must differentiate among injuries to the lateral ankle-ligament complex, subtalar joint, deltoid ligament, and syndesmosis. It is important to realize that injury can occur to any or all of these structures simultaneously.
PMCID: PMC164372  PMID: 12937562
ankle sprain; syndesmosis; deltoid ligament; subtalar joint

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