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
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.
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
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.
ankle sprain; syndesmosis; deltoid ligament; subtalar joint
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.
Ankle injuries; Evidence-based practice; Rehabilitation; Systematic review; Therapy
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.
joint mobilization; injury prevention
OBJECTIVE: To investigate the relation between injury profiles - including assessment, treatment, severity, and the perceived reason for the injury - and participation in competitive netball. METHODS: Between 1985 and 1989, approximately 11,228 netball players participated in a 14 week netball competition held at the major competitive centre in Western Australia; 608 netball players presented to the first aid room with an injury and were assessed and treated by the same physiotherapist and St John First Aid officer. RESULTS: The overall incidence rate during competition was 5.4%, with more injuries occurring in the A grade level of play. Ankle injuries (84%) were most frequent, with 67% of these injuries diagnosed as lateral ligament sprains while a further 10% of players who suffered this classification of injury sustained a fracture to the ankle or foot. Few injuries occurred at the knee joint (8.3%) and only 1.8% of these injuries were diagnosed as an injury to the anterior cruciate ligament. The direct probability of a netball players' risk estimate was 0.054 per person per match which implied that netball was a relatively safe game. Injuries sustained during practice were not included in this study. CONCLUSIONS: Netball is a relatively safe game though the potential for injury increases with the level of competition.
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.
The incidence of ligamentous ankle injuries is known to be one of the most common athletic injuries that exists. Recently, there has been a great deal of interest regarding the increased risk of female ligamentous injury, such as the anterior cruciate ligament, lateral ankle sprains and others. The purpose of this study is to evaluate whether or not normal lateral ankle ligamentous laxity is similar in male and female athletes. This study selects 22 male and 27 female college athletes who have had no significant ligamentous ankle injuries requiring medical treatment. They were placed on a Telos ligamentous stress device and stressed to a level of 15 daN. Radiographs were then obtained to determine talar tilt at this level of ankle stress. Results were compared between men and women showing that there was a statistically significant difference. Women had a much greater ligamentous laxity of the lateral ankle than men.
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.
ligament; injury; risk factor
To obtain information regarding syndesmotic ankle sprains and to identify a specific treatment modality that reduces the recovery time for syndesmotic ankle sprains.
Design and Setting:
A mailed survey conducted from the Sports Medicine Department of Tufts University.
I sent a survey to the head athletic trainers of all 30 National Football League teams. Of the surveys mailed, 23 (77%) were returned.
The survey consisted of 8 questions pertaining to syndesmotic ankle sprains with respect to mechanism of injury, playing surface, diagnostic tests, immediate and follow-up treatment modalities, best treatment, recovery time, and taping procedure.
A variety of causes were noted as being responsible for syndesmotic ankle sprains; the most frequently described mechanism of injury involved a rotational component. Playing surface was not thought to be a factor in the incidence of syndesmotic ankle sprains. Most athletic trainers (96%) indicated that plain radiographs were part of the diagnostic process, while 52% noted that magnetic resonance imaging was also ordered for suspected syndesmotic ankle sprains. The most frequently used modalities during the acute stage were ice, electrical muscle stimulation, casting or bracing (or both), and nonsteroidal anti-inflammatory drugs. Proprioception training, ultrasound, and taping were the most commonly used modalities during follow-up treatment. Immobilization, cortico-steroid injection, and ice and exercise were reported to be the best treatments for reducing recovery time of syndesmotic ankle sprains.
To date, no treatment plan or modality for syndesmotic ankle sprains has been shown to effectively provide an early and safe return to football. Therefore, the need is clear for prospective studies comparing treatment protocols and severity of injury.
diastasis; distal tibiofibular syndesmosis
Ankle sprain is one of the most common injuries among athletes and instability and injury to this joint is responsible for long time loss of physical and recreational activity. Also, it can impose high costs to sport teams. Prevention of this injury is an important concern of practice and rehabilitation. One way of reducing the possibility of ankle joint injury is using an ankle orthosis. The present study aimed at inspecting the effects of two ankle orthoses on dynamic and semi-dynamic postural stability in athletes with chronic ankle instability (CAI).
Twenty basketball players with CAI and fifteen non-injured athletes volunteered to participate in this study. Biodex Balance System was used to assess the participants’ postural stability in bilateral position at level 8 and level 2. Repeated measures analysis of variance (ANOVA) was performed in order to examine the effects of ankle orthoses. Statistical significance level was determined at P< 0.05.
Statistical analyses revealed the significant effect of ankle supports on dynamic and semi-dynamic postural stability in the two groups and results indicated there wasn't significant difference between groups.
According to our results the orthoses improved both dynamic and semi-dynamic postural stability. Therefore, orthoses can prevent injury and its reoccurrence.
Postural Balance; Ankle; Joint Instability; Basketball; Orthoses
Objective: To review the literature that provides information to assist in analyzing the role of the foot in acute and chronic lateral ankle injury.
Data Sources: We searched MEDLINE, CINAHL, Institute for Scientific Information's Web of Science, and SPORT Discus from 1965–2005 using the terms lateral, ankle, ligament, injury, risk factors, foot, subtalar joint, talocrural joint, gait analysis, and foot biomechanics.
Data Synthesis: We found substantial information on the incidence and treatment of lateral ankle sprains in sport but very few articles that focused on risk factors associated with these injuries and even less information on the foot as it relates to this condition. Moreover, little information was available regarding the risk factors associated with the development of chronic instability after a lateral ankle sprain. We critically analyzed the foot articulations and the foot's role in the mechanism of injury to assist our clinical synopsis.
Conclusions/Recommendations: An in-depth review of the foot complex in relation to lateral ankle sprains strongly suggested its importance when treating and preventing inversion ankle trauma. Throughout the literature, the only static foot measurements that show a significant correlation to this condition are an identified cavovarus deformity, increased foot width, and increased calcaneal eversion range of motion. Authors also provided dynamic measurements of the foot, which produced several significant findings that we discuss. Although our findings offer some insight into the relationship between foot characteristics and lateral ankle injuries, future research is needed to confirm the results of this review and expand this area of investigation.
ankle instability; chronic ankle instability; ankle ligaments; ankle sprain; foot classification; risk factors
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.
Broström procedure; Chrisman-Snook procedure; Evans procedure
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
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
Objective: To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for men's basketball and identify potential areas for injury prevention initiatives.
Background: Collegiate men's basketball is a contact sport in which numerous anatomical structures are susceptible to both acute and overuse injuries. To date, no comprehensive reporting of injury patterns in NCAA men's basketball has been published.
Main Results: The overall rate of injury was 9.9 per 1000 athlete-exposures for games and 4.3 per 1000 athlete-exposures for practices. Approximately 60% of all injuries were to the lower extremity, with ankle ligament sprains being the most common injury overall and knee internal derangements being the most common injury causing athletes to miss more than 10 days of participation. A trend of increasing incidence of injuries to the head and face was noted over the 16-year span of the study, which may be related to an observed increase in physical contact in men's basketball over the past 2 decades.
Recommendations: These results provide the most comprehensive description of injury patterns in NCAA men's basketball to date. Many of the most common injuries seen in men's basketball, such as ankle ligament sprains and knee internal derangements, may be at least partially preventable with interventions such as taping and bracing and neuromuscular training. However, randomized controlled trials assessing the efficacy of such preventive measures among collegiate men's basketball players are clearly lacking. The increase in head and facial injuries may indicate that officials need to assess the increased tolerance for physical contact in men's basketball seen over the past 2 decades.
athletic injuries; injury prevention; ankle injuries; knee injuries; head injuries; facial injuries
Ankle sprains are common injuries that often lead to functional ankle instability (FAI), which is a pathology defined by sensations of instability at the ankle and recurrent ankle sprain injury. Poor postural stability has been associated with FAI, and sports medicine clinicians rehabilitate balance deficits to prevent ankle sprains. Subsensory electrical noise known as stochastic resonance (SR) stimulation has been used in conjunction with coordination training to improve dynamic postural instabilities associated with FAI. However, unlike static postural deficits, dynamic impairments have not been indicative of ankle sprain injury. Therefore, the purpose of this study was to examine the effects of coordination training with or without SR stimulation on static postural stability. Improving postural instabilities associated with FAI has implications for increasing ankle joint stability and decreasing recurrent ankle sprains.
This study was conducted in a research laboratory. Thirty subjects with FAI were randomly assigned to either a: 1) conventional coordination training group (CCT); 2) SR stimulation coordination training group (SCT); or 3) control group. Training groups performed coordination exercises for six weeks. The SCT group received SR stimulation during training, while the CCT group only performed coordination training. Single leg postural stability was measured after the completion of balance training. Static postural stability was quantified on a force plate using anterior/posterior (A/P) and medial/lateral (M/L) center-of-pressure velocity (COPvel), M/L COP standard deviation (COPsd), M/L COP maximum excursion (COPmax), and COP area (COParea).
Treatment effects comparing posttest to pretest COP measures were highest for the SCT group. At posttest, the SCT group had reduced A/P COPvel (2.3 ± 0.4 cm/s vs. 2.7 ± 0.6 cm/s), M/L COPvel (2.6 ± 0.5 cm/s vs. 2.9 ± 0.5 cm/s), M/L COPsd (0.63 ± 0.12 cm vs. 0.73 ± 0.11 cm), M/L COPmax (1.76 ± 0.25 cm vs. 1.98 ± 0.25 cm), and COParea (0.13 ± 0.03 cm2 vs. 0.16 ± 0.04 cm2) than the pooled means of the CCT and control groups (P < 0.05).
Reduced values in COP measures indicated postural stability improvements. Thus, six weeks of coordination training with SR stimulation enhanced postural stability. Future research should examine the use of SR stimulation for decreasing recurrent ankle sprain injury in physically active individuals with FAI.
High ankle sprains are common in athletes who play contact sports. Most high ankle sprains are treated nonsurgically with a rehabilitation program.
All years of PUBMED, Cochrane Database of Systematic Reviews, CINAHL PLUS, SPORTDiscuss, Google Scholar, and Web of Science were searched to August 2010, cross-referencing existing publications. Keywords included syndesmosis ankle sprain or high ankle sprain and the following terms: rehabilitation, treatment, cryotherapy, braces, orthosis, therapeutic modalities, joint mobilization, massage, pain, pain medications, TENS (ie, transcutaneous electric nerve stimulation), acupuncture, aquatic therapy, strength, neuromuscular training, perturbation training, and outcomes.
Level of evidence, 5. A 3-phase rehabilitation program is described. The acute phase is directed at protecting the joint while minimizing pain, inflammation, muscle weakness, and loss of motion. Most patients are treated with some form of immobilization and have weightbearing restrictions. A range of therapeutic modalities are used to minimize pain and inflammation. Gentle mobilization and resistance exercises are used to gain mobility and maintain muscle size and strength. The subacute phase is directed at normalizing range of motion, strength, and function in activities of daily living. Progressive mobilization and strengthening are hallmarks of this phase. Neuromuscular training is begun and becomes the central component of rehabilitation. The advanced training phase focuses on preparing the patient for return to sports participation. Perturbation of support surfaces, agility drills, plyometrics, and sport-specific training are central components of this phase.
The rehabilitation guidelines discussed may assist clinicians in managing syndesmotic ankle sprains.
syndesmosis ankle sprain; distal tibiofibular sprain; syndesmosis instability; ankle rehabilitation
The ligament sprain of the lateral ankle is the most frequent injury that occurs when participating in sports. Whole body vibration (WBV) is a training method that has been recently introduced as a rehabilitative tool for treatment of athletes. It has been hypothesized that the transmission of mechanical oscillations from the vibrating platform may lead to physiological changes in muscle spindles, joint mechanoreceptors, as well as improve balance.
The aim of this study was to assess the effects of a 6‐week WBV training program on the reflex response mechanism of the peroneus longus (PL), peroneus brevis (PB) and anterior tibialis (AT) muscles in ankle inversion at 30º from horizontal, in a static position.
This study was a single‐blinded and randomized controlled trial. Forty‐four healthy, physically active participants were randomly split into two groups: the experimental group (n = 26) (the WBV training) and control group (n = 18). Reaction time (RT), maximum electromyographic (EMG) peak (peak EMG), time to the maximum peak EMG (peak EMG time) and reflex electrical activity of all the muscles were assessed before and after the WBV training through surface EMG.
After 6‐weeks WBV training, there were no significant changes in the variables analysed for all the muscles involved.
A 6‐week WBV training does not improve the reflex response mechanism of the lateral stabilizing muscles of the ankle.
Level of evidence:
Ankle sprain; reaction time; reflex electrical activation; surface electromyography; whole body vibration training
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.
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.
Direct access; Ottawa Ankle Rules; posterior malleolus fracture
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.
injury surveillance; injury epidemiology; lower extremity injuries
Ankle sprains are very common injuries seen in the athletic and young population. Majority of patients will improve with a course of rest and physical therapy. However, with conservative management about twenty percent of all patients will go on to develop chronic lateral ankle instability. This manuscript describes our detailed surgical technique of a modification to the original Broström procedure using three suture anchors to anatomically reconstruct the lateral ankle ligaments to treat high demand patients who have developed chronic lateral ankle instability. The rationale for this modification along with patient selection and workup are discussed. Both the functional outcomes at the two year follow up along with the complications and the detailed postoperative rehabilitation protocol for the high demand athletes are also presented. This modified Broström procedure is shown in both illustrative format and intra-operative photos.
Objective To evaluate the effectiveness of an unsupervised proprioceptive training programme on recurrences of ankle sprain after usual care in athletes who had sustained an acute sports related injury to the lateral ankle ligament.
Design Randomised controlled trial, with one year follow-up.
Setting Primary care.
Participants 522 athletes, aged 12-70, who had sustained a lateral ankle sprain up to two months before inclusion; 256 (120 female and 136 male) in the intervention group; 266 (128 female and 138 male) in the control group.
Intervention Both groups received treatment according to usual care. Athletes allocated to the intervention group additionally received an eight week home based proprioceptive training programme.
Main outcome measure Self reported recurrence of ankle sprain.
Results During the one year follow-up, 145 athletes reported a recurrent ankle sprain: 56 (22%) in the intervention group and 89 (33%) in the control group. Nine athletes needed to be treated to prevent one recurrence (number needed to treat). The intervention programme was associated with a 35% reduction in risk of recurrence. Cox regression analysis showed significantly fewer recurrent ankle sprains in the intervention than in the control group. This effect was found for self reported recurrent ankle sprains (relative risk 0.63, 95% confidence interval 0.45 to 0.88), recurrent ankle sprains leading to loss of sports time (0.53, 0.32 to 0.88), and recurrent ankle sprains resulting in healthcare costs or lost productivity costs (0.25, 0.12 to 0.50). No significant differences were found between medically treated athletes in the intervention group and medically treated controls. Athletes in the intervention group who were not medically treated had a significantly lower risk of recurrence than controls who were not medically treated.
Conclusions The use of a proprioceptive training programme after usual care of an ankle sprain is effective for the prevention of self reported recurrences. This proprioceptive training was specifically beneficial in athletes whose original sprain was not medically treated.
Trial registration ISTRCN34177180
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.