ANKLE LIGAMENT STRAIN DURING SUPINATION SPRAIN INJURY – a Alt, W., Lohrer, H., & Gollhofer, A

Home , Strain (injury)

Vilas-Boas, Machado, Kim, Veloso (eds.) Portuguese Journal of Sport Sciences Biomechanics in Sports 29 11 (Suppl. 2), 2011

REFERENCES: ANKLE LIGAMENT STRAIN DURING SUPINATION SPRAIN INJURY – A Alt, W., Lohrer, H., & Gollhofer, A. (1999). FunctionalProperties of Adhesive Ankle Taping: COMPUTATIONAL BIOMECHANICS STUDY Neuromuscular and Mechanical Effects Before and After Exercise. Foot & Ankle International , 20(4), 238-45. Daniel Tik-Pui Fong1,2, Feng Wei3, Youlian Hong4,5, Tron Krosshaug6, Benesch, S., Putz, W., Rosenbaum, D., & Becker, H.-P. (2000). Reliability of Peroneal Reaction Time Roger C. Haut3 and Kai-Ming Chan1,2 Measurements. Clin Biomech , 15.

Cordova, M. L., Bernard, L. W., Au, K. K., Demchak, T. J., Stone, M. B., & Sefton, J. M. (2010). Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Cryotherapy and ankle bracing effects on peroneus longus response during sudden inversion. J 1 Electromyogr Kinesiol , 20, 248-53. Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China The Hong Kong Jockey Club Sports Medicine and Health Sciences Centre, Delahunt, E. (2007). Peroneal reflex contribution to the development of functional instability of the 2 ankle joint. Phys Ther Sport , 8, 98-104. Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China 3 Docherty, C. L., & Arnold, B. L. (2008). Force sence deficits in functionally unstable ankles. J Orthop Orthopaedic Biomechanics Laboratories, Michigan State University, USA Res , 26(11), 1489-93. Department of Sports Science and Physical Education, Faculty of Education, 4 Eechaute, C., Vaes, P., Duquet, W., & Gheluwe, B. v. (2009). Reliability ans discriminative validity of The Chinese University of Hong Kong, Hong Kong, China sudden ankle inversion measurements in patients with chronic ankle instability. Gait & Posture , 42(1), Department of Sports Medicine, Chengdu Sports University, Chengdu, China5 82-6. Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Frier, P. (1990). Effectiveness of taping for the prevention of ankle ligament sprains. Br J Sp Med , Ullevall Stadion, Oslo, Norway6 24(1), 47-50. Gribble, P. A., & Hertel, J. (2003). Considerations for normalizing measures of the star excursion This study presents ankle ligament strain data during a grade I mild anterior talofibular alance test. MPEES , 7(2), 89-100. ligamentous sprain. Kinematics data obtained during the injury and a 3BW were imported Hertel, J., & Olmsted-Kramer, L. C. (2007). Deficits in time-to-boundary measures of postural control to a validated dynamic foot model. Four simulations were done: (1) inversion, (2) with chronic ankle instability. Gait & Posture , 25, 247-51. inversion plus plantarflexion, (3) inversion plus internal rotation, and (4) inversion, plantarflexion and internal rotation. Results showed that in situation (1), the Hopkins, J. T., Brown, T. N., Christensen, L., & Palmieri-Smith, R. M. (2009). Deficits in Peronial calcaneofibular ligament was strained the most (12%), followed by the anterior talofibular Latency and Electromecanical Delay in Patients with Functionl Ankle Instability. J Orthop Res , 27(12), ligament (10%). In situations (2) and (3), both ligaments were strained to about 14-16%. 1541-6. In situation (4), the anterior talofibular ligament was strained to 20%. This study Hubbard, T., Kramer, L. C., Denegar, C. R., & Hertel, J. (2007). Correlations Among Multiple suggested that plantarflexion and internal rotation, together with inversion, may have Measures of Functional and Mechanical Instability in Subjects with Chronic Ankle Instability. J Athl greatly strained and torn the anterior talofibular ligament during the reported injury event. Train , 42(3), 361-6. Hume, P., & Gerrard, D. F. (2007). Effectiveness of external ankle support bracing and taping in rugby KEY WORDS: injury mechanism, injury aetiology, ankle inversion sprain. union. J Athle Train , 42(3), 361-6. Karlsson, J., & Andreasson, G. O. (1992). The effect of external ankle support in chronic lateral joint INTRODUCTION: Ankle sprain is a common sports trauma (Fong et al, 2007). A suggested instability: an electromyographic study. Am J Sports Med , 20(3), 257-61. mechanism is excessive ankle joint supination, which accounts for over 80% of all ankle Konradsen, L., & Ravs, J. B. (1990). Ankle instability caused by prolonged peroneal reaction time. sprain injuries. This mechanism has been widely presented in the literature clinically and Acta Orthop Scand , 61(5), 388-90. qualitatively as a combination of inversion and plantarflexion. A recent first ever Maroco, J. (2007). Análise estatística comutilização do SPSS. Lisboa: Edições Sílabo. biomechanics quantitative investigation on a real accidental supination ankle sprain injury Pijnappel, H. (2009). Medical Taping Concept Handbook. Aneid Press. event revealed that internal rotation also occurred in such an injury (Fong et al, 2009b). The injury was diagnosed as a grade I mild anterior talofibular ligamentous sprain immediately, Refshauge, K. M., Raymond, J., Kilbreath, S. L., Pengel, L., & Heijnen, I. (2009). The effect of ankle taping on detection of inversion-eversion movements in participants with recurrent ankle sprain. AmJ and was presented with the kinematics as captured by three video cameras, plus the plantar Sports Med , 37(2), 371-5. pressure data as captured by a pair of pressure insoles. In normal landing, the ground reaction force vector is close to the ankle joint centre, so the Rosenbaum, D., Becker, H. P., Gerngro, H., & Claes, L. (2000). Peroneal reacton times for diagnosis of functional ankle instability. Foot Ankle Surg , 6, 31-8. short moment arm results in a small ankle twisting torque which could be accommodated by the muscles and ligaments. An ankle sprain is probably caused by the deviation of such Sijmonsma, J. (2007). Taping Neuromuscular Manual. Espanola. ground reaction force vector from the ankle joint centre, usually at the lateral plantar edge Vaes, P., Duquet, W., & Gheluwe, B. v. (2002). Peroneal reaction times ans eversion motor response acting to the medial aspect during a sideway cutting movement, resulting in a large moment in healthy andunstable ankles. J Athl Train , 37(4), 475-480. arm and thus an explosive ankle supination torque (Fong et al, 2009a). Such torque would Vries, J. S., Kingma, I., Blankevoort, L., & Dijk, C. v. (2010). Difference in balance measures between trigger very fast joint twisting motion and stretch the lateral ligaments in a vigorous way. patients with chronic ankleinstability and patents after an acute ankle inversion trauma. Knee Surg Information on the ankle ligament strain during the injury may help a better understanding of Sports Traumatol Artgrosc , 18(5), 601-6 the injury aetiology and mechanism. This computational biomechanics study presents the ankle ligament strains during this real accidental injury event. Four simulations were conducted to show the effect of different combinations of joint orientation on the strain in

various ligaments. Since the injury was diagnosed as a grade I mild anterior talofibular ligamentous sprain, a high strain in this lateral ligament was expected.

METHODS: A three-dimensional multi-body dynamic foot model was used in this study (Wei et al, 2011). The model has been validated for studying ankle injury by a human cadaveric

ISBS 2011 655 Porto, Portugal Vilas-Boas, Machado, Kim, Veloso (eds.) Portuguese Journal of Sport Sciences Biomechanics in Sports 29 11 (Suppl. 2), 2011 biomechanics study (Wei et al, 2010). Joint anatomical features were taken from computer tomography (CT) images. Detailed features of the foot/ankle complex were obtained by importing Digital Imaging and Communications in Medicine (DICOM) files from an individual CT scan into Materialise’s Interactive Medical Imaging Control System (MIMICS) (Materialise, Ann Arbor, MI). This yielded a three-dimensional surface model of the bones as Stereolithography (STL) files for export. To reduce the size of the surface files and subsequent model, the STL files were re-meshed in MIMICS to smooth the surface of each bone. Exported files were then imported into the three-dimensional solid modelling software SolidWorks (TriMech Solutions, LLC, Columbia, MD) as Mesh Files. SolidWorks along with the ScanTo3D package was used to further construct each bone and simplify the bone surfaces. SolidWorks Motion was then used to assemble bones, obtain proper positioning, add necessary components, and run simulations. The tibia was fixed in space, the fibula, Figure 2: Anterior views of the ankle model in (a) neutral position; (b) 48° inversion; (c) talus, and calcaneus were free to move, and the rest of the bones were fused together and inversion plus 20° plantarflexion; (d) inversion plus 30° internal rotation, and (e) combined moved as a rigid body. Twenty ligaments were included and represented as linear spring inversion, plantarflexion and internal rotation. elements (Figure 1), with stiffness values from the literature. A model sensitivity analysis was conducted to ensure that moderate ligament stiffness variations did not significantly alter Ligament strains were determined and were presented in percentage (%), which was the conclusions drawn from the model. relative elongation of the ligament. Only ligaments being strained 2% or more were presented in this report.

RESULTS: Figure 3 showed the strains of selected ligaments for the four motion scenarios. For scenario 1, the calcaneofibular ligament (CaFL) was strained the most at 12%, and the anterior talofibular ligament (ATaFL) and the lateral talocalcaneal ligament were strained to about 10%. In scenario 2 and 3 where 20° plantarflexion or 30° internal rotation was added, both CaFL and ATaFL were strained to 14-16%. In scenario 4 with a combined 48° inversion, 20° plantarflexion and 30° internal rotation, the ATaFL was strained the most at 20%, followed by CaFL which was strained to 16%.

Figure 1: The ankle model showing the locations of 20 modelled ligaments. (Full abbreviation details and stiffness of each ligament available from Wei et al, 2011).

To simulate the said injury event, approximately three times body load (1840 N) was applied to the proximal end of the model, proportionally distributing it between the tibia and the fibula with one-sixth of the loading in the fibula. The case report documented a maximum 48° ankle inversion, 20° plantarflexion and 30° internal rotation during the injury event. To systematically investigate the contribution of these planar motions to the injury, four scenarios were examined: (1) 48° inversion with an axis of rotation passing through the Figure 3: Strains in various selected ligaments for different ankle motions. (ATiFL: anterior calcaneus antero-posteriorly (Figure 2b); (2) 48° inversion plus 20° plantarflexion with an axis tibiofibular; PTiFL: posterior tibiofibular; CaFL: calcaneofibular; ATaFL: anterior talofibular; of rotation passing through the talus medial-laterally (Figure 2c); (3) 48° inversion plus 30° PTaFL: posterior talofibular; LTaCL: lateral talocalcaneal; ITaCL: interosseous talocalcaneal; internal rotation with an axis of rotation along the tibia and passing through the talus (Figure PTaCL: posterior talocalcaneal.) 2d); and (4) a combined 48° inversion, 20° plantarflexion and 30° internal rotation (Figure 2e).

ISBS 2011 656 Porto, Portugal Vilas-Boas, Machado, Kim, Veloso (eds.) Portuguese Journal of Sport Sciences Biomechanics in Sports 29 11 (Suppl. 2), 2011 biomechanics study (Wei et al, 2010). Joint anatomical features were taken from computer tomography (CT) images. Detailed features of the foot/ankle complex were obtained by importing Digital Imaging and Communications in Medicine (DICOM) files from an individual CT scan into Materialise’s Interactive Medical Imaging Control System (MIMICS) (Materialise, Ann Arbor, MI). This yielded a three-dimensional surface model of the bones as Stereolithography (STL) files for export. To reduce the size of the surface files and subsequent model, the STL files were re-meshed in MIMICS to smooth the surface of each bone. Exported files were then imported into the three-dimensional solid modelling software SolidWorks (TriMech Solutions, LLC, Columbia, MD) as Mesh Files. SolidWorks along with the ScanTo3D package was used to further construct each bone and simplify the bone surfaces. SolidWorks Motion was then used to assemble bones, obtain proper positioning, add necessary components, and run simulations. The tibia was fixed in space, the fibula, Figure 2: Anterior views of the ankle model in (a) neutral position; (b) 48° inversion; (c) talus, and calcaneus were free to move, and the rest of the bones were fused together and inversion plus 20° plantarflexion; (d) inversion plus 30° internal rotation, and (e) combined moved as a rigid body. Twenty ligaments were included and represented as linear spring inversion, plantarflexion and internal rotation. elements (Figure 1), with stiffness values from the literature. A model sensitivity analysis was conducted to ensure that moderate ligament stiffness variations did not significantly alter Ligament strains were determined and were presented in percentage (%), which was the conclusions drawn from the model. relative elongation of the ligament. Only ligaments being strained 2% or more were presented in this report.

Figure 1: The ankle model showing the locations of 20 modelled ligaments. (Full abbreviation details and stiffness of each ligament available from Wei et al, 2011).

ISBS 2011 657 Porto, Portugal Vilas-Boas, Machado, Kim, Veloso (eds.) Portuguese Journal of Sport Sciences Biomechanics in Sports 29 11 (Suppl. 2), 2011

DISCUSSION: The injury event was a grade I mild anterior talofibular ligament sprain, which INFLUENCE OF ANKLE TAPING ON DYNAMIC BALANCE PERFORMANCE is characterized as minimum tearing of ligament fibers (Noyes et al, 1989). Previous studies reported that failure strain of ankle ligaments is in the range of 30-35% (Funk et al, 2000), Ian C. Kenny, Can Wu and Johnson McEvoy and ligament collagen fibers start to tear when half of the failure strain is reached (Yahia et al, 1990). The ATaFL ligament strain in this presented grade I sprain case reached 15-20% Biomechanics Research Unit, University of Limerick, Ireland strain, which is about half of the suggested failure strain. Therefore we believe that the reported ankle supination sprain case was caused by excessive strain in the anterior This research aimed to investigate the effect of ankle taping on dynamic balance talofibular ligament. performance. Eighteen recreational athletes without any previous ankle sprain history This study also showed that plantarflexion and internal rotation both play important roles in performed six star excursion balance tests on each leg; randomly three trials with taped an ankle supination injury. The highest strain seen in the anterior talofibular ligament with a ankles and three trials without. A three-layer modified closed-basket inelastic taping combined inversion, plantarflexion and internal rotation is in concert with the injury technique was used. Normalised (by leg length) reaching distance was measured. It was biomechanics documented in the accidental ankle injury incident (Fong et al, 2009b). While found 1. Movement direction significantly influenced normalised reaching distance clinically the ankle supination sprain injury mechanism has been typically presented as a (p<0.01); 2.No significant difference in performance between taped and un-taped combination of inversion and plantarflexion, this study revealed the importance of the internal conditions (p>0.05). Ankle taping did not affect dynamic balance performance therefore rotation component as it raised the strain to 20%, which is thought to induce collagen fiber taping could be used without risk of negative impact on balance, and protect from ankle tears in the anterior talofibular ligament. We wish that this study could raise a debate on sprain for sportspersons. ankle joint orientation during a supination sprain injury, and could inspire sports limb dominance, sprain, star excursion balance test. biomechanists to design proper intervention to prevent the injury. KEY WORDS:

INTRODUCTION: Ankle ligament sprain is among the highest rate of sports injuries (Dick et CONCLUSION: This study showed a high strain in the anterior talofibular ligament during an al., 2007) and is a major cause of athletes’ disability and time off sport. External support to accidental injury event in the laboratory which caused a grade I mild anterior talofibular the ankle joint by taping is considered to be at least a partial aid (Dick et al., 2007) and one ligamentous sprain. The results suggest that both plantarflexion and internal rotation, of the most widely used ankle sprain preventative methods. Although the mechanics of together with inversion, would greatly raise the strain and injure the anterior talofibular effectiveness of ankle taping is uncertain, sports people use taping not only to support an ligament. injured joint but also as a means to improve posture and balance (Ozer et al., 2009). Indeed,

Kenny & Jeyram (2009) reported modest but non-significant increases in jumping REFERENCES: performance with ankle taping applied. Taping is not only used for those with previous ankle Fong DTP, Chan YY, Mok KM, Yung PSH, Chan KM (2009a). Understanding acute ankle ligamentous sprain but also recommended to athletes by some trainers for athletes without previous ankle sprain injury in sports. Sports Medicine, Arthroscopy, Rehabilitation, Therapy and Technology, 1, 14. sprain as a way of preventing sports injury (Rarick et al., 1962). The information available Fong DTP, Hong Y, Chan LK, Yung PSH, Chan KM (2007). A systematic review on ankle injury and from current literature indicates that ankle taping restricts ankle range of motion (ROM) and ankle sprain in sports. Sports Medicine, 37(1), 73-94. controls postural sway related to ankle instability (Rose et al., 2002), which help to improve Fong DTP, Hong Y, Shima Y, Krosshaug T, Yung PSH, Chan KM (2009b). Biomechanics of balance ability. However, this does not necessarily imply that taping has a superior supination ankle sprain – a case report of an accidental injury event in laboratory. American Journal of preventive effect in real sports situations, because measurement of ankle ROM cannnot Sports Medicine, 37(4), 822-827. completely reflect ankle function in a weight-bearing situation (Arnold et al., 2009), and Funk JR, Hall GW, Crandall JR, Pilkey WD (2000). Linear and quasi-linear viscoelastic postural sway only represents static balance (Abian-Vicen et al., 2008) which fails to characterization of ankle ligaments. Journal of Biomechanical Engineering, 122(1), 9-14. estimate ankle function in a dynamic situation. The potential benefits of ankle taping for Noyes FR, Grood ES, Torzilli PA (1989). Current concepts review – the definitions of terms for motion prevention of ankle injury must be weighed against the possible detrimental effect on actual and position of the knee and injuries of the ligaments. Journal of Bone and Joint Surgery – American performance of the athlete. To replicate a competitive situation, jumping tests and static Volume, 71A(3), 465-472. balance tests are commonly employed to assess the effect of ankle taping on performance. Wei F, Hunley SC, Powell JW, Haut RC (2011). Development and validation of a computational model However, dynamic balance tasks, which cause the centre of gravity to move in response to to study the effect of foot constraint on ankle injury due to external rotation. Annals of Biomedical muscular activity (Kinzey & Armstrong, 1998), are seldom applied. The aim of the current Engineering. research was to ascertain whether ankle taping would influence dynamic balance control in Wei F, Villwock MR, Meyer EG, Powell JW, Haut RC (2010). A biomechanical investigation of ankle healthy individuals without previous ankle sprain. injury under excessive external foot rotation in the human cadaver. Journal of Biomechanical Engineering, 132(9), 091001. METHODS: Eighteen participants, ten male and eight female were recruited following Yahia L, Brunet J, Labelle S, Rivard CH (1990). A scanning electron microscopic study of rabbit institutional research board’s ethical consideration. Table 1 shows the subject characteristics. ligaments under strain. Matrix, 10(1), 58-64.

Table 1 Acknowledgement Subject characteristics This research project was made possible by resources donated by The Hong Kong Jockey Club Gender Number Age ± s.d. Height ± s.d. Body Mass ± s.d. BMI ± s.d. Charities Trust. It is a research project of The Hong Kong Research Institute of Textiles and Apparel (yrs) (m) (kg) (kg/m2) and is financially supported by the Innovation and Technology Fund from Innovation and Technology Female 8 24 ± 1.8 1.68 ± 0.06 60.25 ± 6.78 21.28 ± 1.50 Commission, Hong Kong Special Administrative Region Government, Project number: ITF/017/10TP. Male 10 22 ± 2.1 1.80 ± 0.07 76.64 ± 9.58 23.58 ± 3.02 Total 18 24.3 ± 1.8 1.75 ± 0.10 69.36 ± 11.74 22.56 ± 2.67

ISBS 2011 658 Porto, Portugal