THE ANKLE SPRAIN: What Is the Current Evidence?

THE ANKLE SPRAIN: What is the current evidence?

Douglas H. Richie Jr. D.P.M. FACFAS, FAAPSM Seal Beach Podiatry Group Inc. Associate Clinical Professor, Department of Applied Biomechanics California School of Podiatric Medicine at Samuel Merritt University [email protected]

ANKLE SPRAINS

Most common injury in Sports (40%) Colville

23,000 sprains / day in U.S. Makhani, McCullock

Account for 10% of all ER visits in U.S. Holmer Long term sequelae occur in up to 50% of patients Anderson, Brostrom, Freeman, Smith Long Term Sequelae The development of residual instability with pain and swelling will occur in 20% to 40% of people after a Grade II lateral ankle sprain.

Bosien, 1955 Yeung, 1994 Brand, 1977 Dettori, 1994 Itay, 1982 Verhagen, 1995 Gerber, 1998 Chronic Ankle Instability: Solving a Complicated Puzzle

The Problem If patients return to activity before the ligaments have fully healed, the ligament may heal in an elongated state. This elongated ligament state could result in increased joint movement (mechanical laxity), which may lead to the development of CAI.

Denegar CR, Miller SJ III. Can chronic ankle instability be prevented? Rethinking management of lateral ankle sprains. J Athl Train. 2002;37(4):430–435. J Athl Train. 2008 Sep-Oct;43(5):523-9. Ankle ligament healing after an acute ankle sprain: evidence-based approach. Hubbard TJ, Hicks-Little CA. Department of Kinesiology, The University of North Carolina at Charlotte, Charlotte, NC 28223, USA. [email protected]

OBJECTIVE: To perform a systematic review to determine the healing time of the lateral ankle ligaments after an acute ankle sprain. DATA SOURCES: We identified English-language research studies from 1964 to 2007 by searching MEDLINE, Physiotherapy Evidence Database (PEDro), SportDiscus, and CINAHL using the terms ankle sprain, ankle rehabilitation, ankle injury, ligament healing, and immobilization. STUDY SELECTION: We selected studies that described randomized, controlled clinical trials measuring ligament laxity either objectively or subjectively immediately after injury and at least 1 more time after injury. CONCLUSIONS/RECOMMENDATIONS: In the studies that we examined, it took at least 6 weeks to 3 months before ligament healing occurred. However, at 6 weeks to 1 year after injury, a large percentage of participants still had objective mechanical laxity and subjective ankle instability. Direct comparison among articles is difficult because of differences in methods. More research focusing on more reliable methods of measuring ankle laxity is needed so that clinicians can know how long ligament healing takes after injury. This knowledge will help clinicians to make better decisions during rehabilitation and for return to play. How long does it take for the ankle ligaments to heal? Biology of Ankle Sprain Tx

1. Immediately after injury: RICE ~minimizes hemorrhage, swelling, inflammation, cellular metabolism, pain. 2. Protection of ligaments: week 1-3 ~proliferation phase: collagen production ~ligament stress Type III (weaker) collagen Biology of Ankle Sprain Tx 3. Controlled mobilization: week 4-8 ~maturation phase: final scar formation ~controlled exercise increased mech strength of ligament collagen fiber orientation. 4. Final Maturation and Remodeling: 6-12 mos ~ Full return to activity ~ Full neuromuscular control Microsc Microanal. 2011 October ; 17(5): 779–787. Quantification of Collagen Organization and Extracellular Matrix Factors within the Healing Ligament Connie S. Chamberlain, Erin M. Crowley, Hirohito Kobayashi, Kevin W. Eliceiri, and Ray. Vanderby. Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI, USA Laboratory for Optical and Computational Instrumentation, University of Wisconsin, Madison WI, USA Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin 53705 USA Abstract Ligament healing of a grade III injury (i.e. a complete tear) involves a multifaceted chain of events that forms a neoligament, which is more scar-like in character than the native tissue. The remodeling process may last months or even years with the injured ligament never fully recovering pre-injury mechanical properties. With tissue engineering and regenerative medicine, understanding the normal healing process in ligament and quantifying it provide a basis to create and assess innovative treatments. Ligament fibroblasts produce a number of ECM components, including collagen types I and III, decorin and fibromodulin. In primate studies, investigators have reported that the tensile strength of ligament tissue is within 80% of normal pre-injury strength at 12 months after injury. Therefore, most patients with ankle sprains are not performing rehabilitation, and those who are may be returning to exercise or physical activity well before the ligaments have undergone appropriate tissue healing.

Martin RB, Burr DB, Sharkey NA. Skeletal Tissue Mechanics. New York, NY: Springer-Verlag; 1998. “The literature shows that transected or torn ligaments do not recover completely (compositionally and morphologically), and that healing tissue is mechanically inferior. This study shows a persistent creeping of the granulation tissue that contributes to these reported problems in ligament healing. Within this granulation tissue is a collagen matrix that is initially, very disorganized (not statistically different than a random organization) and then it remodels to a more axial microstructure. However, the organization process slows and does not replicate native tissue over the time course of this study (four weeks).”

Microsc Microanal. 2011 October ; 17(5): 779–787. Quantification of Collagen Organization and Extracellular Matrix Factors within the Healing Ligament.Connie S. Chamberlain, et al. Measuring Ankle Laxity after Ankle Sprain

Hubbard and Cordova assessed the natural recovery of ankle ligament laxity after an acute LAS with an instrumented ankle arthrometer. More specifically, the authors quantified the anterior-posterior load displacement and inversion-eversion rotational laxity characteristics of the ankle-subtalar joint complex within three days after injury and again eight weeks after injury

The results indicate that ankle laxity did not significantly decrease over eight weeks which suggests that the lateral ligaments of the ankle need to be protected for longer than eight weeks if mechanical stability is to be restored after an acute LAS.

Hubbard TJ, Cordova ML. Mechanical Instability after an Acute Lateral Ankle Sprain. Arch Phys Med Rehabil. 2009;90:1142–1146. How long should the Grade II and III ankle sprain be protected?

Answer: 6 Months RETURN TO PRE INJURY ACTIVITY With Functional Treatment Protocol:

GRADE III 6 weeks Ardevol, 2002

GRADE II 12 days Wilson, 2002

Lancet 2009; 373: 575–81 Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

“Our findings confirm that severe ankle sprains have a protracted recovery period, and effects on ankle function are, for a few people, long lasting, and possibly, permanent.” DEGENERATIVE ARTHRITIS AND LAI

. Shifting of talus 1mm: Decreases contact area by 42%, doubles contact stress (Ramsey, Hamilton, 1976) . DJD of ankle 5 to 10 times more frequent in patients with LAI (Reick, 1986)

. 36 patients with LAI and DJD: 21/36 had inverted heels in gait (Harrington, 1979) The Ankle Sprain CONTROVERSIES

Surgery vs. Non-Surgery Operation vs. Cast vs. Early Mobilization

• Review of 12 prospective, randomized studies • 10 of the studies included high performance athletes • Duration of follow up: 6 months to 3.8 years

Kannus P, Renstrom P: Treatment for acute tears of the lateral ligaments of the ankle. Operation, Cast or early controlled mobilization. JBJS 73-A: 305, 1991 Operation vs. Cast vs. Early Mobilization

CONCLUSION

“After a critical review of these twelve studies, it is not difficult to select functional treatment as the treatment of choice for acute complete tears of the lateral ligaments of the ankle.”

Kannus P, Renstrom P: Treatment for acute tears of the lateral ligaments of the ankle. Operation, Cast or early controlled mobilization. JBJS 73-A: 305, 1991 Return To Activity

Return to work Surgery group 3 to 4 weeks longer than functional group Return to fitness activities Surgery group 2-3 weeks longer than functional group

Kaikkonen A, Kannus P, Jarvinen M: Surgery vs Functional treatment in ankle ligament tears. Clin. Orthop. 326: 194, 1996 “Furthermore, secondary surgical repair of the ruptured ankle ligaments (delayed anatomic repair) could be performed even years after the injury, if necessary, with results that were comparable with those achieved with primary repair”

Per Renstrom M.D. PhD. Foot and Ankle Clinics 4: 697, 1999 Cochrane Database Syst Rev. 2007 Apr 18;(2):CD000380. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Kantonsspital St.Gallen, Department of Orthopaedic Surgery, Rorschacherstrasse 95, St.Gallen, Switzerland, 9007 CH. [email protected] Update of: Cochrane Database Syst Rev. 2002;(3):CD000380. BACKGROUND: Ankle sprains are one of the most commonly treated musculoskeletal injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilization with plaster cast or splint, 'functional treatment' comprising early mobilization and use of an external support (e.g. ankle brace), and surgical repair or reconstruction. OBJECTIVES: We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (January 2006), the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE, CINAHL and reference lists of articles, and contacted researchers in the field. This review is considered updated to January 2006. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials comparing surgical with conservative interventions for treating ankle sprains in adults. DATA COLLECTION AND ANALYSIS: At least two authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. We performed sensitivity analyses to explore the robustness of the findings. MAIN RESULTS: Twenty trials were included. These involved a total of 2562 mostly young active adult males. All trials had methodological weaknesses. Specifically, concealment of allocation was confirmed in only one trial. Data for pooling individual outcomes were only available for a maximum of 12 trials and under 60% of participants. The findings of statistically significant differences in favour of the surgical treatment group for the four primary outcomes (non-return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability) when using the fixed-effect model were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomized) trial that had more extreme results. A corresponding drop in the I(2) statistics showed the remaining trials to be more homogeneous. The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. AUTHORS' CONCLUSIONS: There is insufficient evidence available from randomized controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. High quality randomized controlled trials of primary surgical repair versus the best available conservative treatment for well- defined injuries are required. Continuum of Care Sales Strategy

Rebound™ Ankle Brace walking boot with Stability Strap Soft Ankle Brace cast (instead of stirrup, lace-up D ankle brace, and/or sleeve) Chronic Ankle Instability: Solving a Complicated Puzzle

Definitions ANKLE INSTABILITY

• Mechanical

• Functional MECHANICAL INSTABILITY Objective Measures:

• Anterior drawer • Talar tilt • Ligamentous laxity • FF & RF deformities • Tibial varum • Ankle axis deviation Stress Radiographs Karlsson J, Bergsten T, Lasinger O, et al: Surgical treatment of chronic lateral instability of the ankle joint. Am J Sports Med 17:208-274,1989

Anterior drawer – Absolute Displacement: 10mm Side to side: >3mm

Talar Tilt – Side to side: >10º

SENSITIVITY VS SPECIFICITY

High sensitivity indicates that a test can be used for excluding, or ruling out, a condition when it is negative, but does not address the value of a positive test. Specificity indicates the ability to use a test to recognize when the condition is absent. A highly specific test has relatively few false positive results, and therefore speaks to the value of a positive test.

Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA. 1992;267:2638–2644.

Schulzer M. Diagnostic tests: a statistical review. Muscle Nerve. 1994;17:815– 819 STRESS RADIOGRAPHY Stress radiography has long been utilized to diagnose mechanical instability of the lateral ligaments of the ankle. However, the reliability of these measures has been questioned. Radiographic measure of anterior drawer and talar tilt show a low sensitivity (50 and 36%) but a high specificity (100%). A critical review of seven studies of stress radiography to diagnose ligament rupture after acute ankle sprain concluded that talar tilt and anterior drawer stress x-rays are not reliable enough to make the diagnosis of ligament rupture regardless of whether mechanical devices or local anesthesia are used. Presently, the only possible valid use of stress radiography is in the evaluation of patients with chronic mechanical instability of the ankle. Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Daider, A, Baldt M et al. MRI versus lateral stress radiography in acute lateral ankle ligament injuries. Journal of Computer Assisted Tomography 1997 March/April; 21(2): 280-285.

Ray, RG; Christensen, JC; Gusman, DN: Critical evaluation of anterior drawer measurement methods in the ankle. Clin Orthop Relat Res, 215 – 224, 1997.

Harper, MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot Ankle, 13:435 – 438, 1992.

Lohrer, H; Nauck, T; Arentz, S; Sch¨oll, J: Observer reliability in ankle and calcaneocuboid stress radiography. Am J Sports Med MRI: ACUTE VS CHRONIC INJURY In a mixed population of chronic and acute ankle instability patients, MRI showed a 97% sensitivity, 100% specificity and 97% accuracy. However, when evaluating acute patients only, the results were 100% for all three categories.

Oae K, Takao M, Uchio Y. Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging. Skeletal Radiol 2010; 39:41-47. Lateral Ankle Instability ASSOCIATED INJURIES:

Peroneal Tenosynovitis 47/61 77% Anterolateral impingement 41/61 67% Atten. Peroneal retin. 33/61 54% Ankle synovitis 30/61 49% Loose body 16/61 26% P. brevis tear 15/61 25% Talar lesion 14/61 23% Med. Tend. Tenosyn. 3/61 5%

DiGiovanni BF, Fraja CJ, Cohen, BE, Shereff MJ: Associated injuries found in chronic lateral ankle instability. Foot & Ankle 21: 805-815 Ankle Sprain Grade I. Ligament Stretch – No tear Minimal swelling tenderness No funct. Loss, No mechanical instability Grade II. Torn ATFL, Intact CFL Moderate pain, swelling Mild joint instability

Grade III. Torn ATFL, CFL (PTFL) Significant pain, swelling, lost ROM Functional and mechanical instability Articular vs. Ligament Restraint • 21 Cadaver specimens - neutral ankle • Axial load of 150 lbs. • Single plane force application • 100% inversion stability due to articular surface

Stormont et al: Stability of the Loaded Ankle. Am Jour Sports Med 13:295, 1985 Rupture of the ATFL occurs as an isolated injury in 66% of all ruptures of the ankle ligaments and occurs in combination with a rupture of the CFL in another 20%.

Brostro¨m L. Sprained ankles, I: anatomic lesions in recent sprains. Acta Chir Scand. 1964;128:483–495 Articular vs. Ligament Restraint • 19 cadaver specimens • 50 kg axial load, neutral ankle • Triplane subtalar force applied • No talar tilting with single ligament cut • 20° TT with double ligament cut

Cass Jr. Settles H: Ankle Instability Foot and Ankle 15: 134, 1994 Bahr et al reported small but observable laxity changes with sectioning of the ATFL alone, but they observed changes in laxity with sectioning of the ATFL and CFL. In similar studies, investigators also have reported increased laxity after sectioning of the ATFL alone and of the ATFL combined with the CFL. These studies demonstrated that damage to the ATFL and CFL results in increased mechanical laxity. If left untreated, this increased mechanical laxity may lead to the development of CAI.

Bahr R, Pena F, Shine J, et al. Mechanics of the anterior drawer and talar tilt tests: a cadaveric study of lateral ligament injuries of the ankle. Acta Orthop Scand. 1997;68(5):435–441.

Tohyama H, Beynnon BD, Renstro¨m PA, Theis MJ, Fleming BC, Pope MH. Biomechanical analysis of the ankle anterior drawer test for anterior talofibular ligament injuries. J Orthop Res. 1995;13(4): 609–614.

Hollis JM, Blasier RD, Flahiff CM. Simulated lateral ankle ligamentous injury: changes in ankle stability. Am J Sports Med. 1995;23(6):672–677. Hollis JM, Blasier RD, Flahiff CM, Hofmann OE. Biomechanical comparison of reconstruction techniques in simulated lateral ankle ligament injury. Am J Sports Med. 1995;23(6):678–682.

Functional Instability Patient History:

Recurrent sprains and/or feeling of giving way of the ankle Freeman, 1965 Chronic Ankle Instability: Solving a Complicated Puzzle

Mechanical vs Functional Ankle Instability: Why is this important? Mechanical vs. Functional No consistent cause-effect relationship has been found between mechanical instability and functional instability of the ankle.

Moppes, 1982 Staples, 1975 Staples, 1972 Tropp, 1988 With the large percentage of patients developing CAI, researchers during the past 40 years have tried to determine why an ankle sprain often continues to affect the patient. When examining the potential causes of CAI, Hubbard et al reported that mechanical laxity was the largest predictor of the development of CAI, explaining 31.3% of the variance with CAI group membership in their study.

Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int. 2007;28(3): 343–354. FIGURE 1

Functional Instab Mechanical Instab 93 66 118

Fig. 1 The association between functional and mechanical instability of the ankle joints in 444 soccer players

Tropp, H. Odenrick, P. Gillquist, J. Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Medicine 6:180, 1985 1985 Persistent Ligamentous Laxity

CHRONIC ANKLE INSTABILITY

Deficit in Neuromuscular control

Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability J Athl Train 37 (4): 364, 2002 FIGURE 2

Muscle Functional Instability Mechanical Weakness (anatomic)

Neuromuscular Control

Balance - Posture Muscle Reaction Time ? Proprioception

Richie DH: Functional Instability of the Ankle and the Role of Neuromuscular Control; A Comprehensive Review, J Foot and Ankle Surgery, 40:240-251, 2001. http://www.youtube.com/watch?v=zAwHVXLo_xA MEASURING CHRONIC ANKLE INSTABILITY

Eechaute et al. systematically reviewed the clinimetric qualities of patient- assessed instruments for patients with chronic ankle instability. They concluded that two instruments—the Foot and Ankle Disability Index (FADI) and the Functional Ankle Ability Measure (FAAM)—were the most appropriate tools to quantify functional disability for chronic ankle instability.

Eechaute C, Vaes P, Van Aerschot L et al. The clinimetric qualities of patient-assessed instruments for measuring chronic ankle instability: a systematic review. BMC Musculoskelet Disord 2007;8:6. Functional Instability MANIFESTS WITH DEFICIENT POSTURE CONTROL (single leg stance).

Karlsson, 1989 Jerosch, 1995 Lentell, 1990 Konradsen, 1993 FIGURE 3 Stabilometry Measurement

1. Sternum position 2. Hip position 3. Ankle position p. Hip angle Y. Ankle angle a. Force angle CP. Centre of pressure F. Total force Fz. Vertical force Fy.. Horizontal force

Tropp, Odenrick, Gillquist, 1985 Postural Sway

Defined: Measurement of the time and distance a subject spends away from the ideal center of balance. Dependent upon afferent input from joint, muscle, visual and vestibular receptors Center of Pressure = Center of Balance Center of Pressure accurately reflects the Center of Gravity (via mean projection of vertical projection).

Goldie PA, Bach TM, Evans OM: Force platform measures for evaluating postural control: Reliability and validity. Arch Phys Med Rehabil 70: 510- 517, 1989

BALANCE = POSTURAL CONTROL?

BALANCE: Ability of a human to remain upright in stance

POSTURAL CONTROL: Ability to keep the body’s center of gravity (COG) within the borders of the base of support (Nashner 1985) BALANCE is an activity which occurs both during static stance and dynamic gait

POSTURAL CONTROL is measured during quiet static stance. It has been studied during both double- limb and single limb support. Postural Control and CAI Deficits in postural control appear to be the most consistent finding in patients with chronic ankle instability.

Garn SN, Newton RA: Kinesthetic awareness in subjects with multiple ankle sprains Phys Ther 68: 1667, 1988.

Tropp H, Odenrick P: Postural control in single-limb stance. Jour Orthop Res 6: 833, 1988.

Gauffin H, Tropp H, Odenrick P: Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 9:141, 1988.

Forkin DM, Koczur C, Battle R, Newton RA: Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains. J Orthop Sports Phys Ther 23: 245, 1996.

Perrin PP, Bene MC, Perrin CA, Durupt D: Ankle trauma significantly impairs postural control-a study in basketball players and controls. Int J sports Med 18: 387, 1997. Postural Control After Ankle Sprain

Loss of postural control has also been demonstrated in patients after acute ankle sprain.(Cornwall, MW, Murrell P. Postural sway following inversion sprain of the ankle. J Am Podiatr Med Assoc. 81:243-247, 1991.

Friden T, Zatterstrom R, Lindstrand A, Moritz U: A stabilometric technique for evaluation of lower limb instabilities. Am J Sports Med 17: 118, 1989.

Hertel J, Buckley WE, Denegar CR: Serial testing of postural control after acute lateral ankle sprain. J Athl Train 35: 363, 2001. Predicting Ankle Injuries Prospective study of 119 male and 91 female high school basketball players Subjects had no previous hx of injury Balance assessment with NeuroCom New Balance Master during pre-season Higher postural sway scores corresponded to increased ankle sprain injury rates (p=0.001) Subjects with high sway scores had 7 times as many ankle sprains as subjects with low sway scores

McGuine TA, Greene JJ, Best T, Leverson G: Balance as a predictor of ankle injuries in high school basketball players. Clin Jour Sport Med 10: 239-244, 2000. Loss of Postural Control Risk of future ankle injury:

127 soccer players, mean age 24.6 years postural sway measured in pre-season 23 new ankle sprains in subsequent season: 12 had pathologic sway risk of sprain was 42% in those with abnormal pre-season sway risk of sprain was 11% in those with normal pre-season sway

Tropp H, Edstrand J, Gillquist J: Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc 16: 64-66, 1984. POSTURAL CONTROL Sensory Input:

• Vision • Vestibular • Somatosensory System  Muscle Proprioception  Joint Mechanoreceptors  Cutaneous Afferents (sole of foot) Postural Control Sensory Input: Joint Mechanoreceptors ANKLE JOINT MECHANORECEPTORS

• Type I: slow adapting, low threshold Convey postural sense • Type II: rapid adapting, low threshold Convey sense at beginning of joint movement • Type III: slow adapting, high threshold Convey sense at extreme end ROM

Type II and III are most abundant in ankle ligaments

Michelson JD, Hutchins C: Mechanoreceptors in human ankle ligaments. J Bone Joint Surg (Br) 1995: 77-B : 210-24. JOINT MECHANORECEPTORS • proprioception • control muscle stiffness and joint stability • influence gamma motor neuron output: determine length of muscle spindle fibers • Influence discharge of 1A spindle afferents and input on alpha motor neurons • adjust muscle length or tension to protect joint from injury

Michelson JD, Hutchins C: Mechanoreceptors in human ankle ligaments. J Bone Joint Surg (Br) 1995: 77-B : 210-24. Proprioception Joint Proprioceptors? • 12 non-injured subjects • Nine ankle joint position tasks • Braced vs. non-brace • Anesthetic to ATF & CF ligament Results: • No differences with & without anesthetic • Improvement with brace

Fuerbach, 1994 Proprioception “It appears that ligament mechanoreceptors contributed little to ankle joint proprioception and that afferent feedback from skin, muscle and other joint receptors was adequate for the positioning task of the present study.”

Fuerbach J.W., Grabiner M.D., Koh, T.J. et al. Effect of ankle orthosis and ankle joint ligament anesthetic on ankle joint proprioception. American Journal of Sports Medicine 22:223, 1994. Ankle Retinacula: Role in Proprioception

Evidence of sensory nerve fibers and corpuscles, i.e. mechanoreceptors, within the ankle retinacula. The ankle retinacula underwent MRI changes of thickening and altered signal intensity-similar to what is seen in plantar fasciitis. The ankle retinacula are important sensors for proprioception of the ankle joint which respond to tension of the muscles and tendons to which they are attached, as well as direct stretching when the ankle is moved in various directions.

Stecco C, Macchi V, Porzionato A et al. The ankle retinacula: Morphological evidence of the proprioceptive role of the fascial system. Cells Tissues Organs Accessible online at www.karger.com/cto DOI: 10.1159/000290225 Postural Control

Sensory Input: Muscle spindle afferents

MUSCLE SPINDLE SPINAL CORD AFFERENTS

SPINDLE MUSCLE SPINDLE AFFERENTS Effect of Muscular Fatigue on Postural Control

1. Muscle receptors are a primary source of joint position sense (Skinner, 1986)

2. Fatigue causes muscle spindle and Golgi tendon de- sensitization (Johnston et al., 1998) 3. Central and peripheral fatigue results in decreased efficiency of firing of contractile units of muscle (Linnamo, 1998) 4. Application of a FO may increase activation of the receptive field of afferent fibers for muscle activation (Rowinski et al, 1997 and Ochsendorf et al, 2000)

Subjects with functional instability of the ankle have been shown to have prolonged peroneal reaction time.

Karlsson J, Gunnar O. Andreasson G: The effect of external ankle support in chronic lateral ankle joint instability: an electromyographic study. Am J Sports Med 20: 257- 261, 1992.

Konradsen L and ravn Jb: Ankle instability caused by prolonged peroneal reaction time. Acta Orthop Scand 61: 388-390, 1990.

Konradsen L and Ravn JB: Prolonged peroneal reaction time in ankle instability. Int J Sports Med 12: 290-292, 1991.

Lofvenberg R, Karrholm J, Sundelin G, Ahlegren O: Porolonged reaction time in patients with chronic lateral instability of the ankle. Am J Sports Med 23: 414-417, 1995. Peroneal Reaction: Stretch Reflex Receptors: Muscle Spindle

Reflex: Afferent neurons connect to alpha motor neurons in spinal cord Efferent: motor neurons stimulate peroneal muscle contraction

Sensitivity: Gamma motor neurons (GMN’s) contract muscle spindles: lowers threshold of response How does pain affect postural control? Pain and Loss of Proprioception Afferent articular nerves found in joints of the LE:

Type I receptors: slow adapting mechanical and dynamic receptors Type II: rapidly adapting, mechanical and dynamic receptors Type III: high threshold, slow adapting, mechanical and dynamic Type IV: high threshold pain receptors

Wyke B: The neurology of joints. Ann R Coll Surg Engl 41: 24-50, 1967.

Painful Subtalar Joint and Chronic Ankle Instability EMG activity of the Peroneus Brevis and Longus is diminished in sinus tarsi syndrome.

Injection of local anesthetic into the sinus tarsi restores normal EMG function.

Taillard W, Meyer JM, Garcia J, Blanc Y: The sinus tarsi syndrome. Int Orthop 5: 117-130, 1981. Sinus Tarsi Pain and Prolonged Peroneal Reaction Time

18 pts with functional ankle instability 8 healthy controls measurement of peroneal reaction times with trapdoor mechanism and EMG readings of p. brevis and p. longus recordings before and after injection of 2 mL of 1% Lidocaine into sinus tarsi

Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999. Sinus Tarsi Pain and Prolonged Peroneal Reaction Time

Before Injection: Subjects with Functional Instability of Ankle 82.0 ms Controls 82.0 ms After Injection: Subjects with Functional Instability of Ankle 69.3 ms Controls 70.5 ms

P < 0.0001

inflammation from sprain causes irritability of mechanoreceptors and nociceptors in the affected ankle and subtalar joints excitation of leg flexors and inhibition of leg extensors (shown in previous animal studies with joint inflammation) inhibitory stimulation affects GMN’s of both extensors and peroneal muscles local anesthetic reverses inhibitory stimulus of gamma motor neurons

“We suggest that irritability of mechanoreceptors or nociceptors or both, induced by inflammation at the sinus tarsi, may suppress the activities of gamma motor neurons of peroneal muscles, which in turn might cause the symptoms of functional instability and prolonged PRT.”

Sensory Input: Muscle spindle afferents SPINAL CORD MUSCLE SPINDLE AFFERENTS

SPINDLE GMS Gamma-muscle-spindle system

Gamma motor neurons (spinal)

Contraction of muscle spindles

Excitation of stretch receptors

Improved stretch reflex

Postural Control

Sensory Input: Plantar cutaneous afferents The Foot: A Major Proprioceptive Organ

 Merkel Cell Complexes Pressured Deformation  Meissner Corpuscles Vibration 5-40 Hz  Pacinian Corpuscles Vibration 60-300 Hz

How long should the Grade II and III ankle sprain be protected?

Answer: 6 Months Persistent Ligamentous Laxity

CHRONIC ANKLE INSTABILITY

Deficit in Neuromuscular control

Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability J Athl Train 37 (4): 364, 2002

FIGURE 2

Muscle Functional Instability Mechanical Weakness (anatomic)

Neuromuscular Control

Balance - Posture Muscle Reaction Time ? Proprioception

• Vision • Vestibular • Somatosensory System  Muscle Proprioception  Joint Mechanoreceptors  Cutaneous Afferents (sole of foot) Chronic Ankle Instability: Loss of Postural Control

Is this due to peripheral (feed-back) impairment or..

Is this due to central (feed-forward) alterations in motor control?

THE BRAIN AND CHRONIC ANKLE INSTABILITY

Motor Cortex Changes can be can be measured using transcranial magnetic stimulation (TMS).

Cortical excitability measure the strength of connections between the primary motor cortex and the lower extremity muscles.

A relationship has been found between cortical excitablility and laxity of the ankle joint in CAI

Pietrosimone BG, McLeod MM, Ko JP, et al. Chronic ankle instability and corticomotor excitability of the fibularis longus muscle. J Athl Train 2012;47(6):621-626.

Needle AR, Palmer JA, Kesar TM, et al. Brain regulation of muscle tone in healthy and functionally unstable ankles. J Sport Rehabil 2013;22(3):202-211.

Needle AR, Baumeister J, Kaminski TW, et al. Neuromechanical coupling in the regulation of muscle tone and joint stiffness. Scand J Med Sci Sport In press.

Needle AR, Swanik CB, Farquhar WB, et al. Muscle spindle traffic in functionally unstable ankles during ligamentous stress. J Athl Train 2013;48(2):192-202.

McVey ED, Palmieri RM, Docherty CL, et al. Arthrogenic muscle inhibition in the leg muscles of subjects exhibiting functional ankle instability. Foot Ankle Int 2005;26(12):1055-1061.

Wikstrom EA, Brown CN. Minimum reporting standards for copers in chronic ankle instability research. Sports Med 2013 Oct 12. [Epub ahead of print.] Alterations in feed-forward motor control in CAI A. Altered hip biomechanics during dynamic balance tests: Gribble PA, Hertel J, Denegar CR. Chronic ankle instability and fatigue create proximal joint alterations during performance of the star excursion balance test. Int J Sports Med 2007;28:236–42. B. Altered ankle biomechanics during gait : Delahunt EMK, Caulfield B. Altered neuromuscular control and ankle joint kinematics during walking in subjects with functional instability of the ankle joint. Am J Sports Med 2006;34:1970–6.

Monaghan K, Delahunt E, Caulfield B. Ankle function during gait in patients with chronic ankle instability compared to controls. Clin Biomech 2006;21:168–74.

C. Different landing patterns : Caulfield B, Crammond T, O’Sullivan A, Reynolds S, Ward T. Altered ankle muscle activation during jump landing in participants with functional instability of the ankle joint. J Sport Rehabil 2004;13:189–200.

Caulfield B, Garrett M. Functional instability of the ankle: differences in patterns of ankle and knee movement prior to and post landing in a single leg jump. Int J Sports Med 2002;23:64–8.

Delahunt E, Monaghan K, Caulfield B. Changes in lower limb kinematics, kinetics, and muscle activity in subjects with functional instability of the ankle joint during a single leg drop jump. J Orthop Res 2002;24:1991–2000. CENTRAL NERVOUS SYSTEM ROLE IN CHRONIC ANKLE INSTABILITY The fact that bilateral neuromuscular control deficits are found at both the ankle and proximal joints strongly suggests that global coordination or training programs should be used for both the involved and uninvolved limbs of all patients with a history of lateral ankle trauma for the same reasons.

Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther 2007; 37:303–11. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for person with functionally unstable ankles. J Orthop Sports Phys Ther 1999;29:478–86.

Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study. Scand J Med Sci Sports 1997;7:172–7.

McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E, Bennett BC, Hertel J. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc 2008;40:1810–9. CHRONIC ANKLE INSTABILITY:

Evidence for the Role of the Central Nervous System With unilateral chronic ankle instability:

- bilateral hamstring inhibition with unilateral CAI - alterations in shank-rearfoot coupling during gait with CAI - delayed hip and thigh muscle activation patterns - Bilateral balance deficits are found which can improve with unilateral exercise BALANCE TRAINING The underlying neural adaptations of balance training occur at multiple sites within the central nervous system

Beck S, Taube W, Gruber M, Amtage F, Gollhofer A, Schubert M. Task-specific changes in motor evoked potentials of lower limb muscles after different training interventions. Brain Res 2007;1179:51–60.

Gruber M, Taube W, Gollhofer A, Beck S, Amtage F, Schubert M. Training specific adaptations of h- and stretch reflexes in human soleus muscle. J Mot Behav 2007;39.

Taube W, Gruber M, Beck S, Faist M, Gollhofer A, Schubert M. Cortical and spinal adaptations induced by balance training: correlation between stance stability and corticospinal activation. Acta Physiol (Oxford) 2007;189.

Taube W, Kullmann N, Leukel C, Kurz O, Amtage F, Gollhofer A. Differential reflex adaptations following sensorimotor and strength training in young elite athletes. Int J Sports Med 2007;28:999–1005. Postural Control • Improves after balance and coordination training exercises

Leanderson 1996, Goldie 1994, Pintsaar 1996, Tropp 1984 Balance exercises cause Bilateral Improvements

Gauffin, 1988 Hertel, 2001 McKeon PO, Hertel J. Systematic Reviw of postural control and lateral ankle instability, Part II: Is balance training clinically effective? Journal of Athletic Training 2008;43(3):305–315

“Prophylactic balance training substantially reduced the risk of sustaining ankle sprains, with a greater effect seen in those with a history of a previous sprain. Completing at least 6 weeks of balance training after an acute ankle sprain substantially reduced the risk of recurrent ankle sprains; however, consistent improvements in instrumented measures of postural control were not associated with training. Evidence is lacking to assess the reduction in the risk of recurrent sprains and inconclusive to demonstrate improved instrumented postural control measures in those with chronic ankle instability who complete balance training.” Gender Issues: Injury Patterns

250 2X

200

150 2X

Males Cases 100 Females 3X

50 9X

0 PFPS ITBFS Glut Med Sacroiliac Injury

Taunton et al., 2002 Hip Adduction

Hip Internal Rotation

Knee Abduction

Ferber et al., 2005 Ferber, 2008 ACUTE ANKLE SPRAIN: TREATMENT PROTOCOL Initial Evaluation

History- Mechanism, Wt. Bearing Status, Immediate Tx Presentation-Wt Bearing? Self-assessment of severity Radiographs-Almost every time! Exam-Edema, ecchymosis, erythema Palpation-Ligaments, osseous structures

Stress Exam- Anterior Drawer, Inversion-Eversion, Medial Calcaneal Glide DETERMINING SEVERITY OF INJURY • Prognosis • Timeline for return to sport • Timeline for complete recovery

CLINICAL TESTS FOR SEVERITY OF SPRAIN Ankle ROM Ankle Strength: DF/PF/Inv/Ev Swelling Wt. Bearing ability None have been validated as accurate prognostic indicators of recovery

Alonso et al, de Bie et al, Wilson and Gansneder “Among the clinical variables implemented in this study, the self reported functional variables (global function question, SF-36 PF) and the subjects ambulation status appear to be the best potential prognostic factors in predicting the number of days to return to sports in Division II athletes with acute lateral ankle sprains.”

Cross KM, Worrell TW, Leslie JE, Khalid RV: The relationship between self reported and clinical measures and the number of days of return to sport following acute lateral ankle sprains. J Ortho Sports Phys Ther 32: 16-23, 2002. PREDICTING DISABILITY 72 Hours post Grade II LAS:

• Swelling & ROM: poor predictor • Functional limitation: good predictor

40 m walk/run, Figure 8 Single hop, Stair hop, Cross-over hop

Wilson RW, Gansneder BM: Measures of functional limitation as predictors of disablement in athletes with acute ankle sprains. JOSPT 30(9) : 528, 2000 IMAGING THE ACUTE ANKLE SPRAIN Imaging Osseous Injuries

Radiographs are ordered for 80 to 95% of patients who present to the hospital emergency room after foot and ankle trauma, yet studies reveal that only 15% of these patients actually have a bone fracture. (1-3) The Ottawa Ankle Rules were developed to reduce unnecessary radiography of ankle sprain patient.. These rules are a clinical decision guideline which state that radiographs of the ankle are necessary only when there is pain in the malleolar zone and the patient exhibits any of the following findings: (1) bone tenderness along the distal 6 cm of posterior edge of the of the medial or lateral malleolus, or (2) bone tenderness directly on the tip of the medial or lateral malleolus, or (3) inability to bear weight and walk 4 steps immediately after the injury or at the emergency department. Radiographs of the feet are indicated when there is pain in the midfoot zone and any of the following findings: (1) bone tenderness of the navicular or base of the 5th metatarsal, or (2) inability to bear weight and walk 4 steps immediately after the injury or at the emergency room.

Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21:384-399. OTTAWA ANKLE RULES

The Ottawa Ankle Rules have been extensively studied for accuracy in predicting the presence of a fracture in the ankle and mid-foot of patients suffering an ankle sprain. Bachman conducted a systematic review of 27 studies of 15,581 patients who had suffered an ankle sprain. The Ottawa Ankle Rules demonstrated nearly 100% sensitivity in detecting a fracture of the ankle or midfoot while specificity was quite variable, ranging from 10% to 79%. The missed fracture rate was 1.4% which indicates that less than 2% of patients who were negative for fracture according to the Ottawa Ankle Rules, actually had a fracture.

Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003 Feb 22;326(7386):417

SENSITIVITY VS SPECIFICITY

Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA. 1992;267:2638–2644.

Schulzer M. Diagnostic tests: a statistical review. Muscle Nerve. 1994;17:815– 819 For example, using the Ottawa Ankle Rules, palpable bone tenderness at the fibular malleolus may suggest a fracture and would mandate an x-ray.

When there is no palpable bone tenderness, it is highly likely that there is not a fracture present- i.e. high value of sensitivity. However, since many of these patients with palpable bone tenderness do not, in fact show a fracture on subsequent x-ray, this test has low value of specificity. This test has a high number of false positive results for bone tenderness, thus low value of specificity.

When a test has few false positives, the value of a positive test is significant. For example, a positive anterior drawer on manual stress exam of the ankle is correlated with mechanical instability of the ankle. Thus, the anterior drawer has few false positive results and has high value of specificity. STRESS RADIOGRAPHY Stress radiography has long been utilized to diagnose mechanical instability of the lateral ligaments of the ankle. However, the reliability of these measures has been questioned. Radiographic measure of anterior drawer and talar tilt show a low sensitivity (50 and 36%) but a high specificity (100%). A critical review of seven studies of stress radiography to diagnose ligament rupture after acute ankle sprain concluded that talar tilt and anterior drawer stress x-rays are not reliable enough to make the diagnosis of ligament rupture regardless of whether mechanical devices or local anesthesia are used. Presently, the only possible valid use of stress radiography is in the evaluation of patients with chronic mechanical instability of the ankle. Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Daider, A, Baldt M et al. MRI versus lateral stress radiography in acute lateral ankle ligament injuries. Journal of Computer Assisted Tomography 1997 March/April; 21(2): 280-285.

Ray, RG; Christensen, JC; Gusman, DN: Critical evaluation of anterior drawer measurement methods in the ankle. Clin Orthop Relat Res, 215 – 224, 1997.

Harper, MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot Ankle, 13:435 – 438, 1992.

Lohrer, H; Nauck, T; Arentz, S; Sch¨oll, J: Observer reliability in ankle and calcaneocuboid stress radiography. Am J Sports Med MAGNETIC RESONANCE IMAGING

Magnetic resonance imaging (MRI) has replaced arthrography as the preferred imaging technique to detect ligament rupture after an ankle sprain. However, the accuracy, sensitivity and specificity of this imaging technique to diagnose ligament injury in acute ankle injuries is inconsistent, particularly when comparing studies of acute injury vs chronic ankle instability. Breitenseher et al found that MRI could detect lateral collateral ligament disruption after acute ankle injury.

TEAR OFLATERAL COLLATERAL 74% Sensitivity 100% Specificity

Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Daider, A, Baldt M et al. MRI versus lateral stress radiography in acute lateral ankle ligament injuries. Journal of Computer Assisted Tomography 1997 March/April; 21(2): 280-285.

MAGNETIC RESONANCE IMAGING: ACUTE SPRAIN Conversely, Verhaven et al showed:

TEAR OF ATFL 100% Sensitive 50% Specificity TEAR OF CFL 92% 100%

Verhaven EF, Shahabpour M, Handelberg FW, Vaes PH, Opdecam PJ. The accuracy of three- dimensional magnetic resonance imaging in the diagnosis of ruptures of the lateral ligaments of the ankle. Am J Sports Med 1991;19:583-587. Lateral Ankle Instability ASSOCIATED INJURIES:

DiGiovanni BF, Fraja CJ, Cohen, BE, Shereff MJ: Associated injuries found in chronic lateral ankle instability. Foot & Ankle 21: 805-815 OSTEOCHONDRAL LESIONS OF THE TALUS (OLT LESIONS) Plain radiographs will not often reveal the presence or extent of OLT lesions, particularly in cases of acute ankle trauma. There are benefits to using both CT and MR imaging when there is suspicion of an OLT lesion. A comparison study showed: MR Imaging 96% Sensitivity 96% Specificity CT Imaging 81% 99% Arthroscopy 100% 97%

While CT may show the extent of bone injury better, MR imaging is preferred as the initial tool to evaluate for OLT lesions since wider range of other pathologies can also be detected.

Verhagen, RA; Maas, M; Dijkgraaf, MG; et al.: Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT? J Bone Joint Surg Br. 87(1):41 – 6, 2005.

DeSmet, AA; et al.: Chronic ankle pain. American College of Radiology. ACR Appropriateness Criteria. Radiology, 215 Suppl:321 – 32, 2000.

ANKLE SPRAIN Initial Treatment: P ROTECTION R EST I CE C OMPRESSION E LEVATION

ANKLE SPRAIN

Immediate treatment:

Immobilization vs. “Protected Mobilization” Recommended: Dettori, 1994 Recommended: Eiff, 1994 Klein, 1993

Rehabilitation Immobilization decreases ligament repair via rate and strength of collagen synthesis.

Andriacchi, 1988 Buckwalter, 1995 Vialas, 1981 Rehabilitation Excessive motion, post injury, can lead to joint instability.

Burroughs, 1990 Buckwalter, 1996 Cawley, 1991

ANKLE SPRAIN: IMMOBILIZATION VS FUNCTIONAL TREATMENT A systematic review by Kerkhoffs et al. assessed the effectiveness of methods of immobilization for acute lateral ankle ligament injuries and compared immobilization with functional treatment methods. Functional interventions (which included elastic banding, soft cast, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures.

Kerkhoffs GM, Rowe BH, Assendelft WJ et al. Immobilization and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev 2002;3:CD003762. A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains Bruce D. Beynnon,*† PhD, Per A. Renström,‡ MD, PhD, Larry Haugh,† PhD, Benjamin S. Uh,† MD, and Howard Barker,† MD From the †Department of Orthopaedics & Rehabilitation, McClure Musculoskeletal Research Center, University of Vermont, Burlington, Vermont, and the ‡Department of Orthopaedics, Sports Medicine & Arthroscopy, Karolinska Institute, Stockholm, Sweden

Background: Acute ankle ligament sprains are treated with the use of controlled mobilization with protection provided by external support (eg, functional treatment); however, there is little information regarding the best type of external support to use. Hypothesis: There is no difference between elastic wrapping, bracing, bracing combined with elastic wrapping, and casting for treatment of acute, first-time ankle ligament sprains in terms of the time a patient requires to return to normal function. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: Patients suffering their first ligament injury were stratified by the severity of the sprain (grades I, II, or III) and then randomized to undergo functional treatment with different types of external supports. The patients completed daily logs until they returned to normal function and were followed up at 6 months. Results: Treatment of grade I sprains with the Air-Stirrup brace combined with an elastic wrap returned subjects to normal walking and stair climbing in half the time required for those treated with the Air-Stirrup brace alone and in half the time required for those treated with an elastic wrap alone. Treatment of grade II sprains with the Air-Stirrup brace combined with the elastic wrap allowed patients to return to normal walking and stair climbing in the shortest time interval. Treatment of grade III sprains with the Air-Stirrup brace or a walking cast for 10 days followed by bracing returned subjects to normal walking and stair climbing in the same time intervals. The 6-month follow-up of each sprain severity group revealed no difference between the treatments for frequency of reinjury, ankle motion, and function. Conclusion: Treatment of first-time grade I and II ankle ligament sprains with the Air-Stirrup brace combined with an elastic wrap provides earlier return to preinjury function compared to use of the Air-Stirrup brace alone, an elastic wrap alone, or a walking cast for 10 days. Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomized controlled trial. S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

Summary Background Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot, or 10-day below-knee cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle sprains. Lancet 2009; 373: 575–81 Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

Methods: We did a pragmatic, multicentre randomized trial with blinded assessment of outcome. 584 participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomized Controlled Trial, number ISRCTN37807450. Lancet 2009; 373: 575–81 Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

Results: Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI 2·4–15·0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was 8%; 95% CI 1·8–14·2, but there were little differences for pain, symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two cases), and deep-vein thrombosis (three cases). Lancet 2009; 373: 575–81 Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

Discussion Contrary to popular clinical opinion, a period of immobilization was the most effective strategy for promoting rapid recovery. This was achieved best by the application of a below-knee cast. The Aircast brace was a suitable alternative to below-knee casts. Results for the Bledsoe boot were disappointing, especially in view of the substantial additional cost of this device. Tubular compression bandage, which is currently the most commonly used of all the supports investigated, 6 was, consistently, the worst treatment. Lancet 2009; 373: 575–81 Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

“The below-knee cast had a wide-ranging effect—it reduced symptoms and pain in the early stage, and promoted faster recovery of function at 3 months.” Lancet 2009; 373: 575–81 Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

Interpretation: A short period of immobilization in a below-knee cast or Aircast results in faster recovery than if the patient is only given tubular compression bandage. We recommend below-knee casts because they show the widest range of benefit. Conclusion:

A short period of strict immobilization (7-10 days) followed by an intermediate period of controlled immobilization (4-6 weeks) is the optimal treatment of the Grade II and Grade III ankle sprain. Thereafter, the patient should be protected during sport with a mild degree of ankle support for at least 6 months. Types of Immobilization

Strict: Below knee cast Pneumatic walking boot with anterior shell

Moderate/Controlled: Walking boot (note: Pneumatic boot with shell is acceptable) Articulated footplate low profile ankle-foot orthosis

Mild: Lace-up ankle brace Taping ? : NO !!! ACUTE ANKLE SPRAIN: TREATMENT PROTOCOL

Initial Treatment Walking Boot (in 90% of cases) Weight Bearing to tolerance, except in High Ankle Sprain Sleep with Boot for 3-5 days Ankle Plantarflexion-Dorsiflexion T.I.D. Ice 20 min T.I.D. Immobilize vs. Mobilize

After acute sprain:

• Immobilize to allow pain free weight bearing • Must allow Active Range of Motion Functional Rehabilitation Program

Four Stages:

Range of Motion Strengthening

Proprioception

Activity-specific training

Rehabilitation Exercise and joint motion stimulate healing and influence the strength of ligaments after injury.

Buckwalter, 1995 Gomez, 1991 Iarvinen, 1993

Rehabilitation It can be concluded that for functional rehabilitation, loading of the ankle joint is desirable in order to increase joint stability.

Scheufflen, 1993 Sammarco, 1977 McCullough, 1980 Dorsiflexed Ankle Position • Talar position: close packed • Achilles tendon tension: joint compression • Lateral ligaments: minimal distraction torn ends re-opposed

Smith, Rico, Reischl, S. The influence of dorsiflexion in the treatment of severe ankle sprains: An anatomic study. Foot and Ankle 9:28, 1988

Acute Inversion Sprain

Position of ankle during sleep: • Foot plantarflexed • Unloaded ankle • Foot inverted • Prolonged abnormal positioning Solution: Dorsiflexion – night splinting Non-Pneumatic Walking Splint, With or Without Joints. Prefabricated, includes fitting and adjustment.

CODE: L4386

REIMBURSEMENT: $114 to $152 Rehabilitation • Dorsiflexed position of ankle most stable Smith 1988, Stormont 1985

• Early weight bearing increases stability of the ankle joint after injury McCullough 1980, Scheuffelen 1993 EQUALIZER AIR WALKER WALKING BOOTS Definitions: L 4360 (defined by HCPS): “Walking boot, pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment.”

L 4386: “Walking boot non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment.”

Myths of efficacy of walking boots

“boots are as effective as casts” Limiting Ankle Motion: A Comparison of Fiberglass Cast vs Walking Boots

Kadakia AR, Espinosa N, Smerek J et al. Radiographic comparison of sagittal plane stability between cast and boots. Foot Ankle Int. 29: 421- 426, 2008.

Raikin SM, Parks BG, Noll KH, Schon LC. Biomechanical evaluation of the ability of casts and braces to immobilize the ankle and hindfoot. Foot Ankle Int. 22: 214-219, 2001. Types of immobilizing devices tested:

Fiberglass Cast- short leg cast, below knee

Aircast® FP Foam Walker

Aircast® XP Pneumatic Walker

Aircast® SP Walker

Donjoy® MaxTrax Walker RESULTS Total Range of Motion

Fiberglass Cast 8.4 degrees* FP Foam Walker 16 degrees XP Pneumatic Walker 15.4 degrees Donjoy MaxTrax Walker 19.1 degrees SP Walker 39 degrees* No immobilization 70 degrees *P < 0.05 Kadakia AR, Espinosa N, Smerek J et al. Radiographic comparison of sagittal plane stability between cast and boots. Foot Ankle Int. 29: 421-426, 2008 SYNDESMOSIS INJURIES Incidence:

 15/1344 ankle sprains West Point, 1990  10% incidence – Cedell, 1975 Brostrom, 1965  5% incidence – Fallat, 1998

 18% incidence – Minnesota Viking Boytim et al 1991

DIASTASIS Radiographic Criteria: 1. Medial clear space - widened 2. Tibiofibular overlap - reduced 3. Tibiofibular clear space - increased

SYNDESMOTIC INJURIES

Overall, while radiographs can reveal frank diastasis of the ankle, they should not be relied upon to detect lesser degrees of syndesmotic injury. For evaluation of the ankle syndesmotic ligaments after acute injury, MRI has shown to have high sensitivity, specificity and accuracy, with reported sensitivity ranging from 93% to 100% and specificity ranging from 96% to 100% .

Vogl, TJ; Hochmuth, K; Diebold, T; et al.: Magnetic resonance imaging in the diagnosis of acute injured distal tibiofibular syndesmosis. Invest. Radiol. 32:401 – 409, 1997.

Muhle, C; Frank, LR; Rand, T; et al.: Tibiofibular syndesmosis: highresolution MRI using a local gradient coil. J. Comput. Assist. Tomogr. 22:938 – 944, 1998.

HIGH ANKLE SPRAIN: Initial Treatment Short leg cast, ankle plantarflexed 10 degrees and Int. Rotated Non-weight bearing with crutches or scooter ACUTE ANKLE SPRAIN: TREATMENT PROTOCOL

Strict: Below knee cast Pneumatic walking boot with anterior shell

Moderate/Controlled: Walking boot (note: Pneumatic boot with shell is acceptable) Articulated footplate low profile ankle-foot orthosis

Mild: Lace-up ankle brace Taping ? : NO !!! Functional Rehabilitation Program

Four Stages:

Range of Motion Strengthening

Proprioception

Activity-specific training

Postural Control

• Improves after balance and coordination training exercises

Leanderson 1996, Goldie 1994, Pintsaar 1996, Tropp 1984 Benefits of Balance Training after Lateral Ankle Sprain: Balance training is hypothesized to correct feed-forward and feedback neuromuscular control deficits

Beck S, Taube W, Gruber M, Amtage F, Gollhofer A, Schubert M. Task- specific changes in motor evoked potentials of lower limb muscles after different training interventions. Brain Res. 2007;1179: 51–60.

Gruber M, Taube W, Gollhofer A, Beck S, Amtage F, Schubert M. Training- specific adaptations of H- and stretch reflexes in human soleus muscle. J Mot Behav. 2007;39:68–78.

Horak FB, Henry SM, Shumway-Cook A. Postural perturbations: new insights for treatment of balance disorders. Phys Ther. 1997;77(5): 517–533. Benefits of Balance Training after Lateral Ankle Sprain:

Balance training improves postural control, a measure associated with an increased risk of sustaining LAS

Wang HK, Chen CH, Shiang TY, Jan MH, Lin KH. Risk-factor analysis of high school basketball-player ankle injuries: a prospective controlled cohort study evaluating postural sway, ankle strength, and flexibility. Arch Phys Med Rehabil. 2006;87(6):821–825.

McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006;34(7):1103–1111.

Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther. 1994;74(1): 17–28. Benefits of Balance Training after Lateral Ankle Sprain: Balance training reduces the recurrence of LAS

Emery C, Rose M, McAllister J, Meeuwisse W. A prevention strategy to reduce the incidence of injury in high school basketball: a cluster randomized controlled trial. Clin J Sport Med. 2007;17(1):17–24.

Holme E, Magnusson SP, Becher K, Bieler T, Aargaar P, Kjar M. The effect of supervised rehabilitation on strength, postural sway, position sense and reinjury risk after acute ankle ligament sprain. Scand J Med Sci Sports. 1999;9(2):104–109.

McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006;34(7):1103–1111.

McHugh M, Tyler T, Mirabella M, Mullany M, Nicholas S. The effectiveness of a balance training intervention in reducing the incidence of noncontact ankle sprains in high school football players. Am J Sports Med. 2007;35(8):1289–1294. Balance Training after LAS

• 4 fold reduction of recurrent sprain Holme, 1999

• 2 fold reduction Wester, 1996

Ankle Sprain Manipulative Therapy-Anecdotal Reports

Manipulative therapy techniques are theorized to reduce pain, improve function and increase ROM via the restoration of arthrokinematic motions (ie, roll, glide, spin)

Maitland GD. Peripheral manipulation. 2nd ed. Sydney, AUS: Butterworths; 1984. Maitland GD. Passive movement techniques of intra-articular and peri- articular disorders. Aust J Physiother. 1985;31(1):3–8.

Mulligan BR. Extremity joint mobilization combined with movements. N Z J Physiother. 1992;20:28–29.

Mulligan BR. Mobilization with movement (MWM’s). J Man Manip Ther. 1993;1:154–156.

Bleakley CM, McDonough M, MacAuley DC. Some conservative strategies are effective when added to controlled mobilization with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54:7–20.

Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Manipulative therapy for lower extremity conditions: expansion of literature review. J Manipulative Physiol Ther. 2009;32:53–71.

Van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilization in acute ankle sprain and function instability: a systematic review. Aust J Physiother. 2006;52:27–37.

Vicenzino B, Paungmali A, Teys P. Mulligan’s mobilization with- movement, positional faults and pain relief: current concepts from a critical review of literature. Man Ther. 2007;12:98–108.

Maitland GD. Peripheral Manipulation. 2nd ed. Sydney, AUS: Butterworths; 1984.

Whitman JM, Childs JD, Walker V. The use of manipulation in a patient with an ankle sprain injury not responding to conventional management: a case report. Man Ther. 2005;10:224–231.

O’Brien T, Vicenzino B. A study of the effects of Mulligan’s mobilization with movement treatment of lateral ankle pain using a case study design. Man Ther. 1998;3:78–84.

Dananberg HJ. Manipulation of the ankle as a method of treatment for ankle and foot pain. J Am Podiatr Med Assoc. 2004;94(4): 395–399. Ankle Sprain Manipulative Therapy-Clinical Trials

Wikstrom EA, McKeon PO. Manipulative therapy effectiveness Following acute lateral ankle sprains: a systematic review. Athletic Training and Sports Health Care. 2010.

Pellow JE, Brantingham JW. The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. J Manipulative Physiol Ther. 2001;24(1):17–24.

Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103(9):417–421. Conclusion

Short and long term disability after an acute LAS remains a public health concern. Research reports instability and joint laxity to still be present over six months after injury.

Acutely, evidence suggests rigid immobilization as an effective means to help restore joint stability. In addition to the need for proper acute care, two adjunctive therapies should be a part of the rehabilitation process: joint mobilizations and balance training.

The literature has reported the benefit of using both to help improve function and balance training has been shown to decrease reinjury rates. Further research is needed to examine dosage of treatments and rehabilitation modalities to best maximize function and prevent chronic joint dysfunction.

Hubbard TJ. Wikstrom EA. Ankle sprain: pathophysiology, predisposing factors, and management strategies Open Access Journal of Sports Medicine 2010:1 115–122 ACUTE ANKLE SPRAIN: Treatment Protocol Phase 2: Day 7 thru 21 Evaluate in clinic at Day 7: Ability to walk w/o boot, Rhomberg, Drawer , Pt self-assessment Walk w/o limp: Dispense articulated footplate ankle brace Walk with limp: Continue walking boot for 14 more days For All: Begin Functional Rehabilitation Protocol for 8-12 weeks Continuum of Care Sales Strategy

Rebound™ Ankle Brace walking boot with Stability Strap Soft Ankle Brace cast (instead of stirrup, lace-up D ankle brace, and/or sleeve) Velocity Ankle Brace by Donjoy

VELOCITY MS

VELOCITY LS (light support)

$96.95 ES Version Available in Black or White Color VELOCITY ES $86.95 MS Version Available in Black Color Only L1971 $76.95 LS Version Available in Black Color Only Product Diagram

Thermoformed Liner Width Adjustment Dual Closure Straps Slip-Resistant Texture Inversion/Eversion Resistance

Stability Strap Ventilation

Bilateral Hinge

Heel Cup Anatomical Footplate Alligator Strap-End L1906 Soft Ankle Braces

5/10/2014 METHOD OF IMMOBILIZATION In a separate article, Kerkhoffs et al. systematically assessed the effectiveness of various treatments of acute ruptures of the lateral ankle ligaments in adults. They found that lace-up supports were a more effective functional treatment than elastic bandaging. Lace-up supports resulted in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Tape resulted in more dermatological complications than elastic bandage. Struijs and Kerkhoffs could not be certain whether homeopathic ointment or physiotherapy significantly improved function due to a paucity of studies after an extensive review of the evidence.

Kerkhoffs GM, Struijs PA, Marti RK et al. Functional treatments for acute ruptures of the lateral ankle ligament: a systematic review. Acta Orthop Scand 2003;74:69–77. Exoform Ankle Brace Product Type: Figure 8 Lace Up

Performance Features

• Exoform's advanced design with Figure-8 heel lock strapping provides the compression and comfort of a soft ankle with 35% more protection then traditional stirrups • Figure-8 heel lock strapping performs consistently unlike taping that stretches over time • Without Figure-8 heel lock strapping, the Exoform offers the compression and comfort of a soft ankle with 20% more protection than a stirrup • The lowest profile and lightest ankle brace of Ossur’s entire family • Allows for normal plantar and dorsi flexion • Constructed of highly breathable, quick drying fabric

Sizing

• X Small – X Large

Options

• Exoform Ankle Brace • Exoform Ankle Brace with Figure-8 Straps

5/10/2014 Swedo Ankle Loc Product Type: Figure 8 Lace Up Performance Features

• Exclusive ANKLE LOK® offset panel traps the laces between the inner and outer flap to hold the laces tighter longer than any other brace. • Exclusive close spaced eyelets concentrate the holding power where it's needed most creating the most effective heel lock. • Full elastic back ensures complete unrestricted blood flow to the Achilles' tendon and virtually eliminates the chance for blistering • Internal U-shaped spiral stays provide extra support and further minimize the chance for ankle injury. • Arch fits the contour of the foot and is seamless so it virtually eliminates irritation to the bottom of the foot. • Triple layer vinyl laminate provides durability and comfort. • Optional side stabilizer inserts provide additional medial and lateral support for injured ankles. • Available in either black and white.

Sizing

• X Small – X Large

Options

• Black or White • Stabilizer strut

5/10/2014 Reimbursement

• L1906 – Most states have a reimbursement of around $90

5/10/2014 ACUTE ANKLE SPRAIN: Treatment Protocol Phase 3: Return to play Evaluation may occur between day 7 and day 21. Follow SARS Protocol Patient will move out of articulated footplate ankle brace to lace-up brace Evaluate for custom functional foot orthotic therapy Balance training to continue for 12 weeks total

STUDIES OF FO’S AND POSTURAL CONTROL

Lundin TM, Feurbach JW, Grabiner MD: Effect of plantar flexor and dorsiflexor fatigue on unilateral postural control. J Appl Biomech. 9:191, 1993.

Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 82: 1000, 2001.

Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rear-foot orthotics on postural control in healthy subjects. J Sport Rehabil 10: 36, 2001. STUDIES OF FO’S AND POSTURAL CONTROL

Percy ML, Menz HB: Effects of prefabricated foot orthotics and soft insoles on postural stability in professional soccer players. J Am Podiatr Med Assoc 91:194, 2001.

Rome K, Brown CL: Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Clinical Rehab18: 624, 2004. “Therefore, we recommend the use of orthotics during the acute and subacute phases for subjects after an ankle sprain. The use of orthotics provides somatosensory benefits because cutaneous afferents contribute to human balance control and may provide neutral alignment for proper muscle activation and reduce unnecessary strain on the already stressed soft tissue.”

Mattacola CG, Dwyer MK: Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train. Dec (4): 413-429, 2002.

RICHIE BRACE®

Grade II / III LAS “When can I return to sport?” TOOLS TO MONITOR RECOVERY Modification of outcome measurement techniques

• Clinical Assessment • Self Reported Assessment Performance Test Protocol 3 Subjective Questions: 1. Has the ankle recovered fully after the injury? Yes or No. If no, how does it compare to before the injury, better, same or worse. 2. Can you walk normally? 3. Can you run normally?

Kaikkonen A, Kannus P, Jarvinen M: A performance test protocol and scoring scale for the evaluation of ankle injuries. Am Journal Sports Medicine 22: 462, 1994. Performance Test Protocol 2 Clinical Measures: ROM – Ankle dorsiflexion, plantarflexion Anterior drawer sign 1 Functional Stability Test: Walking down staircase * 2 Muscle Strength Tests: Rising on heels Rising on toes 1 Balance Test: One legged stance on 10 cm square beam

Kaikkonen A, Kannus P, Jarvinen M: A performance test protocol and scoring scale for the evaluation of ankle injuries. Am Journal Sports Medicine 22: 462, 1994.

SPORTS ANKLE RATING SYSTEM

1. Quality of Life Measure 2. Clinical Rating Score 3. Single Assessment Numeric Evaluation (SANE)

Williams GN, Molloy JM, DeBernardino TM et al: Evaluation of the Sports Ankle Rating System in Young Athletic Individuals with Acute Lateral Ankle Sprains. Foot and Ankle Int 24:274, 2003 SPORTS ANKLE RATING SYSTEM 1. QOL Measure – patient based Evaluate Symptoms:

• Work/School Activities • Recreation • Sports • 5 questions per group • Grade 0 4 SPORTS ANKLE RATING SYSTEM – QUALITY OF LIFE MEASURE SCALE 1: SYMPTOMS Instructions: Please circle the answer that best describes your ankle symptoms during the last week

1. How often was your ankle painful? 2. How often did you experience ankle swelling? 3. How often did your ankle feel stiff? 4. How often did your ankle feel weak? 5. How often did your ankle give way?

Rate these 0 to 4 (4 being never or none)

0 1 2 3 4 SPORTS ANKLE RATING SYSTEM – QUALITY OF LIFE MEASURE SCALE 1: WORK / SCHOOL ACTIVITIES Instructions: Please circle the answer that best describes the impact that your ankle had on your work / school activities during the last week 1. How much difficulty did your ankle give you when you changed direction in your work / school activities 2. How much difficulty did your ankle give you in tasks that required squatting? 3. How painful was your ankle after performing your work / school activities for 30 minutes? 4. How often did your ankle feel weak? 5. How much did your ankle effect your performance at work / school?

Rate these 0 to 4 (4 being never or none) 0 1 2 3 4 SPORTS ANKLE RATING SYSTEM QUALITY OF LIFE MEASURE SCALE 1: RECREATION AND SPORTS Instructions: Please circle the answer that best describes the impact your ankle had on your sports and leisure activity during the last week 1. How much did your ankle effect your ability to perform your regular exercise program? 2. How much did your ankle effect your ability to change directions quickly? 3. How much did your ankle limit you when playing sports?

4. How much has your ankle caused you to adjust your competitive expectations/ aspirations? 5. How concerned were you about injuring your ankle when playing sports? Rate these 0 to 4 (4 being never or none) 0 1 2 3 4 SPORTS ANKLE RATING SYSTEM QUALITY OF LIFE MEASURE SCALE 1: ACTIVITIES OF DAILY LIVING Instructions: Please circle the answer that best describes describes the impact that your ankle had on your daily activities during the last week

1. How painful was your ankle during your daily activities? 2. How much difficulty did your ankle give you when you took care of yourself physically (for example, dressing or taking a shower? 3. How much difficulty did your ankle give you when you performed household chores? 4. How much did your ankle slow you down when you performed your daily activities? 5. How much did your ankle effect your ability to participate in your typical social activities? Rate these 0 to 4 (4 being never or none) 0 1 2 3 4 SPORTS ANKLE RATING SYSTEM QUALITY OF LIFE MEASURE SCALE 1: LIFESTYLE Instructions: Please circle the answer that best describes the impact that your ankle had on your lifestyle during the last week. 1. How much did your ankle effect your enjoyment of life? 2. How much confidence have you had in your ankle? 3. How often did your think about your ankle? (examples: my ankle hurts, my ankle won’t let me…) 4. How much did your injured ankle limit your ability to do the things you wanted to do? 5. How much did lifestyle changes caused by your ankle (for example, not being able to do something you wanted to) effect your ability to enjoy spending time with other people?

Rate these 0 to 4 (4 being never or none) 0 1 2 3 4 SPORTS ANKLE RATING SYSTEM

2. Clinical Rating Score Patient Based Section: • Pain, swelling, stiffness, giving-way, function • Visual Analog Scale 0 8 Process Based Section: • Gait, motion, strength, stability, postural stability, function • Grade 0 10 SPORTS ANKLE RATING SYSTEM 3. Single Assessment Numeric Evaluation “Rate your ankle’s function on a scale of 0 100” SPORTS ANKLE RATING SYSTEM – CLINICAL RATING SCORE Part I: SUBJECTIVE VISUAL ANALOG SCALES (Compiled by the Patient) Instructions: Each line below represents a range of function in the item listed to its left (Pain, Swelling, Stiffness, Giving Way, and Function). The left end of each line indicates severe difficulty in the listed item and the right end of each line indicates perfect function in that item. Please draw a vertical line across the point on each line that represents the level of difficulty you have experienced with your ankle in each item during the past week. You may mark anywhere along each line.

EXAMPLE constant symptoms no symptoms

PAIN severe pain no pain

SWELLING severe swelling no swelling

STIFFNESS very stiff no stiffness

GIVING WAY gives way often no giving way

FUNCTION walking on level totally normal surface is difficult ankle function

SPORTS ANKLE RATING SYSTEM

Postural Stability Assessment Single Leg Stance Test: Barefoot, stance on one leg Eyes closed Arms at sides Time compared to contralateral side

Star Excursion Balance Test (SEBT)

LAYOUT OF SEBT

LATERAL REACH ON SEBT

Photos From: Relationship between Ground Reaction Force and Stability Level of the Lower Extremity in Runners. Kimitake Sato, Monique Butcher-Mokha Barry University Miami Shores, FL

SPORTS ANKLE RATING SYSTEM

Ankle Function Assessment

• stand on one leg • hop laterally, as far as possible • three continuous hops • compare distance to un-involved leg

ANKLE PERFORMANCE MILESTONES

• Single leg stance (Romberg) • Lateral hop • Run down stairs • Toe/Heel Raise

CRITERIA FOR RETURN TO SPORT

In-Office Assessment On-Field Assessment

ON-FIELD ASSESSMENT • 40 METER RUN • FIGURE OF 8 RUN • CUTTING DRILLS • NON-CONTACT KICKING, RUNNING • SPORT SIMULATION • DEVELOP RESTRICTIONS AND LIMITATIONS BRACING THE ANKLE

• Enhance recovery ? • Protect from re-injury ? Prophylactic Ankle Bracing in Sport

Sitler, MR; Horodyski, M: Effectiveness of prophylactic ankle stabilizers of prevention of ankle injuries. Sports Med. 20:53 – 7, 1995.

Surve, I; Schwellnus, MP; Noakes, T; Lombard, C: A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the sport-stirrup orthosis. The American Journal of Sports Medicine. 22: 604-605, 1994

Thacker, SB; Stroup, DF; Branche, CM; et al.: The prevention of ankle sprains in sports. The American Journal of Sports Medicine. 27: 753 – 760, 1995.

Tropp, H; Askling, C; Gillquist, J: Prevention of ankle sprains. The American Journal of Sports Medicine. 13: 259 – 262, 1985.

Pedowitz, DI; Sudheer, R; Parekh, SG; Huffman, G; Sennett, BJ: Prophylactic bracing decreases ankle injuries in collegiate female volleyball players, American Journal of Sports Medicine. 36:324– 327,2008.

Frey, C, Feder KS, Sleight J: Prophylactic ankle brace use in high school volleyball players. Foot Ankle Int. 31: 296-300, 2010 Two recent prospective, randomized controlled studies of preventive ankle bracing:

McGuine TA, Brooks A, Hetzel S. The Effect of Lace-up Ankle Braces on Injury Rates in HighSchool Basketball Players. Am J Sports Med. 2011 September ; 39(9): 1840–1848.

McGuine TA, Hetzel S, Wilson J, Brooks A. The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. Am J Sports Med 2011 January; 40(1): 49-57. High School Basketball One Million Participants

National Federation of State High School Associations. [Accessed March 28, 2011] Athletics Participation Survey. 2007–08. Available at http://www.nfhs.org

16% of all Athletes get injured in a season of which ankle Injuries are most common (40% of all injuries)

Borowski LA, Yard EE, Fields SK, Comstock RD. The epidemiology of US high school basketball injuries, 2005–2007. Am J Sports Med. 2008; 36(12):2328–2335. Nelson AJ, Collins CC, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005–2006. J Athl Train. 2007; 42(3):381–387. High School Basketball Study

Purpose - This trial was undertaken to determine if lace-up ankle braces reduce the incidence and severity of acute first-time and recurrent ankle injuries sustained by high school basketball players.

Design - Randomized controlled trial; Level 1 evidence

Methods - A total of 1460 male and female basketball players from 46 high schools were randomly assigned to a braced or control group. The braced group players wore lace-up ankle braces during the 2009– 2010 basketball season.

McGuine TA, Brooks A, Hetzel S. The Effect of Lace-up Ankle Braces on Injury Rates in HighSchool Basketball Players. Am J Sports Med. 2011 September; 39(9): 1840–1848. High School Basketball

McGuine TA, Brooks A, Hetzel S. The Effect of Lace-up Ankle Braces on Injury Rates in HighSchool Basketball Players. Am J Sports Med. 2011 September ; 39(9): 1840–1848.

Ankle Brace The lace-up ankle brace selected for the study was the McDavid Ultralight 195 (McDavid Inc, Woodridge, Illinois), which is used by many collegiate and high school players in the United States (Figure 2). The brace can fit the right or left foot and is constructed of synthetic fabric. It is worn over a single pair of socks while laced in the front like a shoe. Two straps wrap around the ankle and are secured with Velcro while another elastic band wraps around the top of the ankle.

High School Basketball RESULTS

Acute Ankle Injuries (lateral, medial, syndesmotic sprains)

Control (unbraced) 78 injuries Braced 27 injuries

Overall incidence of ankle injury Control (1.41; 95% CI: 1.05, 1.89) Braced (0.47; 95% CI: 0.30, 0.74)

*First-event acute ankle injuries occurred 68% less often in braced athletes compared with controls.

McGuine TA, Brooks A, Hetzel S. The Effect of Lace-up Ankle Braces on Injury Rates in HighSchool Basketball Players. Am J Sports Med. 2011 September ; 39(9): 1840–1848.

High School Basketball

“The primary finding is that using a lace-up ankle brace reduced the incidence of acute ankle injuries by over 3 times in high school basketball players, regardless of their sex, age, level of competition, or body mass index.”

“..our results reveal that the incidence and severity of knee injuries were not affected by the use of the lace-up braces.”

McGuine TA, Brooks A, Hetzel S. The Effect of Lace-up Ankle Braces on Injury Rates in HighSchool Basketball Players. Am J Sports Med. 2011 September ; 39(9): 1840–1848. Summary: High School Basketball Study

CONCLUSIONS The use of a lace-up ankle brace reduced the incidence but not the severity of acute ankle injuries in male and female high school basketball athletes.

This protective effect was observed in adolescent athletes both with and without a previous ankle injury.

Use of the brace did not significantly increase the incidence or severity of acute knee injuries.

McGuine TA, Brooks A, Hetzel S. The Effect of Lace-up Ankle Braces on Injury Rates in HighSchool Basketball Players. Am J Sports Med. 2011 September ; 39(9): 1840–1848. High School Football

1.1 million high school interscholastic participants.

National Federation of State High School Associations. 2009-2010 High School Athletics Participation Survey. http://www.nfhs.org/ content.aspx?id=3282. Accessed March 17, 2011.

Ankle injuries occur frequently in high school football. Nationally, it is estimated that 24% (n = 78 000) of all ankle injuries (n = 327 000) that occur in high school athletes are sustained by football players.

Nelson AJ, Collins CC, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005–2006. J Athl Train. 2007;42(3):381-387. High School Football

McGuine TA, Hetzel S, Wilson J, Brooks A. The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. Am J Sports Med 2011 January; 40(1): 49-57.

Randomized prospective controlled trial—Level 1 study

2102 football players initially enrolled in the study

Randomized into two groups: Braced and Non-braced during entire season Ankle Brace-Football Study

McGuine TA, Hetzel S, Wilson J, Brooks A. The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. Am J Sports Med 2011 January; 40(1): 49-57.

The lace-up ankle brace selected for the study was the Don-Joy Ankle Stabilizing Brace (DonJoy Inc, Vista, California)

The brace is designed to fit the right or left foot, is constructed of synthetic fabric, and laced in the front like a shoe. Two straps wrap around the ankle and are secured with Velcro while another elastic wrap wraps around the top of the ankle.

High School Football Study

McGuine TA, Hetzel S, Wilson J, Brooks A. The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. Am J Sports Med 2011 January; 40(1): 49-57. RESULTS: Five hundred sixty-six participants (27.2%) sustained a total of 686 injuries for an overall injury rate of 5.47 per 1000 exposures.

A total of 95 (injury rate = 0.77/1000 exposures) first-event acute ankle injuries (lateral, medial, syndesmotic sprains, and fractures) were recorded.

Ankle Injuries: 68 in Control Group 27 in Braced Group (P=.001)

High School Football Study

McGuine TA, Hetzel S, Wilson J, Brooks A. The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. Am J Sports Med 2011 January; 40(1): 49-57.

RESULTS: The incidence of acute ankle injury was 61% lower for acute ankle injuries in the braced group.

The reduced rate of acute ankle injuries in the braced group was found in players both with and without a history of an ankle injury within the previous 12 months

The incidence of an acute ankle injury was reduced in the braced group by 70% (P = .004) for players who reported a previous ankle injury, and 57% (P = .010) for players with no previous ankle injury. Comparison of injury rates at the ankle

Basketball Football

Braced 0.47 0.48 Non Braced 1.41 1.12 High School Football Study CONCLUSION

The use of a lace-up ankle brace reduced the incidence but not the severity of acute ankle injuries in high school football athletes.

This protective effect was observed in players both with and without a history of ankle injury.

The use of the brace did not increase the incidence or severity of acute knee injuries or other lower extremity injuries.

McGuine TA, Hetzel S, Wilson J, Brooks A. The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. Am J Sports Med 2011 January; 40(1): 49-57. Financial Impact of Ankle Injuries

Knowles SB, Marshall SW, Miller T, et al. Cost of injuries from a prospective cohort study of North Carolina high school athletes. Inj Prev. 2007; 13:416–421.

US Consumer Product Safety Commission, Directorate of Economic Analysis. Injury Costs for ankle sprains/strains sustained in basketball, football, soccer, and volleyball players. Obtained through a data request. February 12.2009 Cost Benefit of Ankle Bracing: High School Football

Cost of taping on athlete for entire season: $40-$60

Cost of single ankle brace: $20-$30

Bracing will reduce number of ankle sprains in entire country Football 39,000 sprains prevented

McGuine TA, Hetzel S, Wilson J, Brooks A. The Effect of Lace-up Ankle Braces on Injury Rates in High School Football Players. Am J Sports Med 2011 January; 40(1): 49-57. Cost Benefit of Ankle Bracing

Cost of providing Ankle Braces to 1.1 Million High School Athletes: $40 Million

Cost of Ankle Injury in High School Football $12,000 Overall $581 Million per year

Reduced number of ankle injuries with brace: 61% or savings of $340 Million

US Consumers Product Safety Commission, Directorate of Economic Analysis. Ankle Sprain, Strain and Fracture Injury Costs for Football. Obtained through a data request on April 22, 2011. Objections to preventive ankle bracing in the athlete: • Cost • Diminish natural muscular activation needed for ankle stability • Reduced proprioception and postural control • Inhibit athletic performance Objections to preventive ankle bracing in the athlete: • Cost Cost to prevent one sprain during a season

Hx No Hx TAPE BRACE TAPE BRACE Garrick, Requa 2,778 910 15,281 5,005 Sitler et al 1,923 630 4,168 1,305 Surve et al 4,534 175 6,091 1,195

Olmstead LC, Vela LI, Denegar CR, Hertel J: Prophylactic ankle taping and bracing: A numbness needed-to-treat and cost-benefit analysis. J Athl Train. 39(1): 95-100, 2004 “Our cost-benefit analysis determined that ankle taping would be 3.05 times as expensive as ankle bracing over the course of a competitive season.”

Olmstead LC, Vela LI, Denegar CR, Jertel J: Prophylactic ankle taping and bracing: A numbness needed-to-treat and cost benefit analysis. J Athl Train. 39(1): 95-100, 2004. Monitor Return to Sport After Ankle Sprain: Take Home Message

1. Listen to your patient: their own assessment of injury is most important 2. Anterior Drawer is just as valuable as stress radiographs 3. Best functional tests: i. Single Foot Balance (Romberg) ii. Lateral Hop Test iii. Forward Hop Test 4. You cannot over-brace the injured ankle!

Objections to preventive ankle bracing in the athlete: • Cost • Diminish natural muscular activation needed for ankle stability • Reduced proprioception and postural control • Inhibit athletic performance Am J Sports Med. 1999 Nov-Dec;27(6):753-60. The prevention of ankle sprains in sports. A systematic review of the literature. Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA.

We identified 113 studies reporting the risk of ankle sprains in sports, methods to provide support, the effect of these interventions on performance, and comparison of prevention efforts.

Based on our review, we recommend that athletes with a sprained ankle complete supervised rehabilitation before returning to practice or competition, and those athletes suffering a moderate or severe sprain should wear an appropriate orthosis for at least 6 months. Cochrane Database Syst Rev. 2001;(3):CD000018. Interventions for preventing ankle ligament injuries. Handoll HH, Rowe BH, Quinn KM, de Bie R. Overall, 14 randomised trials with data for 8279 participants were included.

The main finding was a significant reduction in the number of ankle sprains in people allocated external ankle support (RR 0.53, 95% CI 0.40 to 0.69).

This reduction was greater for those with a previous history of ankle sprain, but still possible for those without prior sprain.

There was no apparent difference in the severity of ankle sprains or any change to the incidence of other leg injuries. Lakartidningen. 2002 Sep 5;99(36):3486-9. [Ankle braces prevent ligament injuries]. Karlsson J.

Five randomized trials totaling 3,954 participants were included.

The studies showed a significant reduction in the number of ankle sprains in individuals allocated to external ankle support. This reduction was greater for those with a previous history of ankle sprains. J Orthop Sports Phys Ther. 2003 Oct;33(10):572-7. The role of ankle bracing for prevention of ankle sprain injuries. Gross MT, Liu HY.

“Semirigid and laced ankle braces have significantly reduced the incidence of initial and recurrent ankle sprain injuries in athletic and military samples. With few exceptions, these braces do not appear to affect functional performance adversely. The prophylactic use of semirigid ankle braces appears warranted to reduce the incidence of initial and, in particular, recurrent ankle sprain injuries for individuals who participate in activities that have the highest risk for these injuries.” PREVENTION OF SPRAIN Handoll et al. also carried out a systematic review to assess the effects of interventions used for the prevention of ankle ligament injuries in physically active individuals. They concluded there is good evidence for the beneficial effect of ankle support in the form of semi-rigid orthoses or Aircast braces to prevent subsequent ankle sprains during high-risk sporting activity. There was limited evidence for reducing ankle sprains in patients with previous ankle sprains who did ankle disk training exercises. There was no conclusive evidence on the protective effect of ‘high-top’ shoes. Hupperets et al. evaluated the effectiveness of an unsupervised proprioceptive training programme on ankle sprain recurrence in athletes by means of a randomized control trial. They found that the use of such a programme is effective for the prevention of self-reported recurrence. It was specifically beneficial in athletes whose original sprain had not been medically treated. Although studies considered were of higher levels of evidence, small finite numbers once again preclude us from making any meaningful conclusions as to the strength of evidence.

Handoll HH, Rowe BH, Quinn KM et al. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev 2001;3:CD000018. Hupperets MD, Verhagen EA, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ 2009;339:b2684 J Sci Med Sport. 2009 Jul 7. [Epub ahead of print] A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. Dizon JM, Reyes JJ.

Epidemiological studies have shown that 10-28% of all sports injuries are ankle sprains, leading to the longest absence from athletic activity compared to other types of injuries. This study was conducted to evaluate the effectiveness of external ankle supports in the prevention of inversion ankle sprains and identify which type of ankle support was superior to the other. A search strategy was developed, using the keywords, ankle supports, ankle brace, ankle tapes, ankle sprains and athletes, to identify available literature in the databases (MEDLINE, PubMed, CINAHL, EMBASE, etc.), libraries and unpublished papers. Trials which consider adolescents and adults, elite and recreational players as participants were the study of choice. External ankle supports comprise ankle tape, brace or orthosis applied to the ankle to prevent ankle sprains. The main outcome measures were frequency of ankle sprains. Two reviewers assessed the quality of the studies included using the Joanna Briggs Institute (JBI Appraisal tool). Whenever possible, results were statistically pooled and interpreted. A total of seven trials were finally included in this study. The studies included were of moderate quality, with blinding as the hardest criteria to fulfill. The main significant finding was the reduction of ankle sprain by 69% (OR 0.31, 95% CI 0.18-0.51) with the use of ankle brace and reduction of ankle sprain by 71% (OR 0.29, 95% CI 0.14-0.57) with the use of ankle tape among previously injured athletes. No type of ankle support was found to be superior than the other. Br J Sports Med. 2010 Dec;44(15):1082-8. Epub 2010 Nov 3. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Verhagen EA, Bay K.

METHODS: An electronic literature search was employed to look for published randomized controlled trials, a controlled trials or time interventions containing research questions regarding the prevention of lateral ankle ligament injuries. Two reviewers reviewed relevant studies for strengths and weaknesses in design and methodology, according to a standardized set of predefined criteria. A total of 24 relevant studies met the criteria for inclusion and were analyzed. RESULTS: Overall taping, bracing and neuromuscular training were all effective for the prevention of ankle-sprain recurrences. The RRs of these prophylactic measures are of similar magnitude, ranging from 0.2 to 0.5 when compared with control groups. Although preventive effects have been reported in a general athletic population, evidence suggests this overall effect is due to a strong preventive effect in previously injured athletes and that any effect on fresh ankle sprains is either non-existent or very low.

CONCLUSIONS: Based on these outcomes, a combination of an external prophylactic measure (tape or brace) with neuromuscular training will achieve the best preventive outcomes with minimal burden for the athlete. Br J Sports Med. 2011 Apr;45(4):314. The effect of a lace-up ankle brace on ankle injury rates in adolescent basketball players. McGuine T, Brooks A, Hetzel S.

Design Prospective randomized controlled study using stratified cluster (school) randomization. Participants 1460 adolescent male and female (age 13-18) basketball players from 46 USA high schools.

Results The acute ankle injury rate (per 1000 exposures) was 1.41 in the control group, compared to 0.47 in the braced group. 75 controls (10.4%) sustained an acute ankle injury, compared to 26 athletes (3.5%) in the braced group (Cox HR 0.31, 95% CI 0.20 to 0.49). Lace- up ankle braces reduced the number of injuries in athletes with (HR 0.35, 95% CI 0.17 to 0.71) and without (HR 0.30, 95% CI 0.17 to 0.53) history of previous ankle injury.

Conclusion Lace-up ankle braces reduced the incidence of acute ankle injuries in male and female adolescent basketball players, independent of previous injury status. Br J Sports Med. 2011 Apr;45(4):355. Prevention of ankle sprains in sport: a systematic literature review. Kaplan Y.

19 RCTs were reviewed consisting of a total of 12 233 participants. The studies showed a significant reduction in the number of ankle sprains in individuals allocated to an external ankle support group. This reduction was greater for those with a previous history of ankle sprains. Braces seemed to be more effective in preventing ankle sprains than tape. Br J Sports Med. 2011 Apr;45(4):355. Prevention of ankle sprains in sport: a systematic literature review. Kaplan Y.

Appropriately applied braces, tape or orthoses, do not adversely affect performance.

Proprioceptive training reduced the incidence of ankle sprains in athletes with recurrent ankle sprains to the same level as subjects without any history of ankle sprains.

Conclusion Semi-rigid orthoses or aircasts are more effective than taping to reduce the incidence of sprains. Objections to preventive ankle bracing in the athlete: • Cost • Diminish natural muscular activation needed for ankle stability • Reduced proprioception and postural control • Inhibit athletic performance Objections to preventive ankle bracing in the athlete: • Cost Cost to prevent one sprain during a season

Hx No Hx TAPE BRACE TAPE BRACE Garrick, Requa 2,778 910 15,281 5,005 Sitler et al 1,923 630 4,168 1,305 Surve et al 4,534 175 6,091 1,195

Olmstead LC, Vela LI, Denegar CR, Jertel J: Prophylactic ankle taping and bracing: A numbness needed-to-treat and cost benefit analysis. J Athl Train. 39(1): 95-100, 2004. Objections to preventive ankle bracing in the athlete: • Cost • Diminish natural muscular activation needed for ankle stability J Athl Train. 2000 Oct;35(4):407-11. Long-term ankle brace use does not affect peroneus longus muscle latency during sudden inversion in normal subjects. Cordova ML, Cardona CV, Ingersoll CD, Sandrey MA.

RESULTS: Application of a lace-up or semirigid brace did not affect peroneus longus latency. Additionally, 8 weeks of long term ankle appliance use had no effect on peroneus longus latency.

CONCLUSIONS: The duration of the peroneus longus stretch reflex (latency) is neither facilitated nor inhibited with extended use of an external ankle support. Proprioceptive input provided by the muscle spindles within the peroneus longus does not appear to be compromised with the long- term use of ankle braces. Br J Sports Med. 2003 Jun;37(3):258-62. Peroneus longus stretch reflex amplitude increases after ankle brace application. Cordova ML, Ingersoll CD.

RESULTS: A 3 x 3 x 2 repeated measures analysis of variance showed that peroneus longus stretch reflex amplitude increased immediately after application of a lace up brace (67.1 (4.4)) compared with the semi-rigid (57.9 (4.3)) and control (59.0 (5.2)) conditions (p<0.05). Peroneus longus stretch reflex also increased after eight weeks of use of the semi-rigid brace compared with the lace up and control conditions (p<0.05).

CONCLUSIONS: Initial application of a lace up style ankle brace and chronic use of a semi-rigid brace facilitates the amplitude of the peroneus longus stretch reflex. It appears that initial and long term ankle brace use does not diminish the magnitude of this stretch reflex in the healthy ankle. J Orthop Sports Phys Ther. 1999 Mar;29(3):168-73; discussion 174-6. Peroneal motoneuron excitability increases immediately following application of a semirigid ankle brace. Nishikawa T, Grabiner MD.

RESULTS: The normalized H-reflex amplitude increased by approximately 10% during the braced condition compared to the nonbraced condition. The peroneus longus H-reflex latency and M-wave amplitude were not affected by the bracing condition. CONCLUSIONS: Application of the ankle brace excited afferents possibly arising from a number of candidate mechanoreceptors, 1 of which is likely cutaneous. The findings raise questions as to whether the increased motorneuron excitability can be used for the purposes of rehabilitation from ankle injury. J Orthop Res. 2002 Nov;20(6):1323-6. Increased reflex activation of the peroneus longus following application of an ankle brace declines over time. Nishikawa T, Ozaki T, Mizuno K, Grabiner MD.

In Experiment 2 the amplitude of the stretch reflex increased about 18% immediately after application of the brace relative to the nonbraced condition (p = 0.037). After 3 h, the stretch reflex amplitude was not different from that of initial non-braced condition. Scand J Med Sci Sports. 2007 Oct;17(5):539-46. Effect of inversion and ankle bracing on peroneus longus Hoffmann reflex. Sefton JM, Hicks-Little CA, Koceja DM, Cordova ML.

The PL H/M(max) ratio significantly increased during sudden inversion-no ankle brace condition compared with the flat surface no-ankle brace condition (P=0.04). Application of an ankle brace had no effect on PL H/M(max) ratio during inversion (P=0.78). During this study PL H/M(max) ratios increased during an inversion perturbation in healthy ankles. This is believed to occur due to heightened sensorimotor demand placed on the nervous system during this motion. Moreover, application of an ankle brace during inversion does not appear to affect PL H/M(max) ratio. J Athl Train. 2009 Jul–Aug; 44(4): 363–369. Copyright the National Athletic Trainers' Association, Inc

Ankle Bracing and the Neuromuscular Factors Influencing Joint Stiffness Steven M Zinder, PhD ATC,1 Kevin P Granata, PhD,2,3 Sandra J Shultz, PhD ATC FNATA FACSM,4 and Bruce M Gansneder, PhD5 Objections to preventive ankle bracing in the athlete: • Cost • Diminish natural muscular activation needed for ankle stability • Reduced proprioception and postural control ANKLE BRACING: Proprioception and Postural Control Studies showing favorable improvements of proprioception and postural control with ankle braces:

1. Feuerbach MA, Brabiner MO, Koh TJ, Weiker GG: Effect of an ankle orthosis and ankle ligament anesthesia on ankle joint proprioception. Am J Sports Med 1994; 20:223. 2. Jerosch J, Hoffstetter I, Bork H, et al. The influence of orthoses on the proprioception of the ankle joint. Knee Surg Sports Traumatol Arthrosc. 1995; 3:39-46. 3. Heit E, Lephart S, Rozzi S. The effect of ankle bracing and taping on joint position sense in the stable ankle. J Sport Rehabil 1996; 5:206-213 4. Konradsen L, Voight M, Hojsgaard C: Ankle inversion injuries: The role of the dynamic defense mechanism. Am Jour Sports Med 1997; 25:54. 5. Lofvengerg R, Karrholm J, Sudelin G, Ahigren O. Prolonged reaction time in patients with chronic lateral instability of the ankle. Am J Sports Med. 1995; 23:414-417. ANKLE BRACING: Proprioception and Postural Control (continued) Studies showing favorable improvements of proprioception and postural control with ankle braces:

6. Karlsson J, Andreasson GO: The effect of external ankle support in chronic lateral ankle joint instability: An electromyographic study. Am J Sports Med 1992; 20:257. 7. Nishikawa T, Grabiner MD. Peroneal motoneuron excitability increases immediately following application of a semi-rigid ankle brace. J Orthop Sports Phys Ther 1999; 29:168-173. 8. Cordova ML, Ingersoll CD. Peroneus longus stretch reflex amplitude increases after ankle brace application. Br J Sports Med 2003; 37:258-262. 9. Shima N, Maeda A, Hirohashi K. Delayed latency of peroneal reflex to sudden inversion with ankle taping or bracing. Int J Sports Med 2005; 26:476-480. 10. Baier M, Hopf T. Ankle orthoses effect on single-limb standing balance in athletes with functional ankle instability. Arch Phys Med Rehabil 1998; 79:939-944. J Sci Med Sport. 2011 Jan 14. [Epub ahead of print] Effects of soft and semi-rigid ankle orthoses on postural sway in people with and without functional ankle instability. Hadadi M, Mazaheri M, Mousavi ME, Maroufi N, Bahramizadeh M, Fardipour S.

In the FAI group, there was a tendency to lower COP parameters while wearing either of the orthoses, with soft brace having a greater effect. For 2 dependent variables, significant effect of brace was found only for the injured limb. Arch Phys Med Rehabil. 1998 Aug;79(8):939-44. Ankle orthoses effect on single-limb standing balance in athletes with functional ankle instability. Baier M, Hopf T.

In athletes with functional ankle instability, both a rigid and a flexible ankle orthosis significantly reduced mediolateral sway velocity. A flexible ankle orthosis also changed sway pattern significantly, by reducing the percentage of linear movements of less than 5 degrees per .01 sec. Objections to preventive ankle bracing in the athlete: • Cost • Diminish natural muscular activation needed for ankle stability • Reduced proprioception and postural control • Inhibit athletic performance Ankle Bracing and Athletic Performance

Cordova et al performed a meta analysis of 17 randomized controlled trials which used a cross-over design to measure effects of bracing on performance measures. The studies included comparison of tape, semi rigid and lace-up braces. Of these studies, approximately 30% used injured subjects.

• In terms of sprint speed, the largest effect was found with a lace up brace, which yielded a 1% impairment. • For agility speed, the net effects of all three supports was negative, but only by 0.5%.

• For vertical jump, a 1% decrease in performance was found in all three conditions.

Cordova ML, Scott BD, Ingersoll CD, Leblanc MJ. Effects of ankle support on Lower- Extremity Functional Performance: A meta-analysis. Med Sci Sports Exerc 2005; 37:635- 641. Ankle Bracing and Athletic Performance CONCLUSION The authors concluded that these negative effects are trivial for most individuals, but may have greater significance for elite athletes. They also recommended that the benefit of external ankle support in preventing injury outweighs the small negative effects on sports performance.

Cordova ML, Scott BD, Ingersoll CD, Leblanc MJ. Effects of ankle support on Lower-Extremity Functional Performance: A meta-analysis. Med Sci Sports Exerc 2005; 37:635-641. Prophylactic Ankle Bracing in Sport

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