Occurrence of Syndesmosis Ankle Sprains in Collegiate Athletes

OCCURRENCE OF SYNDESMOSIS ANKLE SPRAINS IN COLLEGIATE ATHLETES

WHEN UTILIZING PROPHYLACTIC LOWER BODY BRACES

A Thesis

Presented to the faculty of the Department of Kinesiology

California State University, Sacramento

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SCIENCE

Kinesiology

(Movement Studies)

Erin Nicole Snyder

SUMMER 2015

Erin Nicole Snyder

OCCURRENCE OF SYNDESMOSIS ANKLE SPRAINS IN COLLIGATE ATHLETES

WHEN UTILIZING PROPHYLACTIC LOWER BODY BRACES

A Thesis

Erin Nicole Snyder

Approved by:

______, Committee Chair Michael Wright, Ph.D.

______, Second Reader Heather Swanson, M.S.

______Date

iii

Student: Erin Nicole Snyder

I certify that this student has met the requirements for format contained in the University format manual, and that this thesis is suitable for shelving in the Library and credit is to be awarded for the thesis.

______, Department Chair ______Steven Gray, Ph.D Date

Department of Kinesiology

Abstract

OCCURENCE OF SYNDESMOSIS ANKLE SPRAINS IN COLLEGIATE ATHLETES

WHEN UTILIZING PROPHYLACTIC LOWER BODY BRACES

Erin Nicole Snyder

Introduction

Statement of Problem

The purpose of this project is to evaluate the occurrence of Syndesmosis Ankle Sprains in collegiate athletes when utilizing prophylactic ankle and/or knee support.

Sources of Data

Data was collected from a non-validated survey, which was created by the researcher for the purposes of this study. The participants were selected randomly from the National

Athletic Training Associations online member database of Certified Athletic Trainers employed at the collegiate setting. Once selected, the National Athletic Training

Research Survey Service emailed the participants with a link to the Survey. The survey was made available through Survey Monkey, an online survey service.

Conclusions Reached

The data collected revealed that out of the 161 total reported Syndesmosis Ankle Sprains,

47.2% of the injuries occurred while ankle support was being utilized. Where as, only

14.9% of the athletes were wearing a form of knee support at the time of injury, and

12.4% of injuries occurred with both ankle and knee support being utilized. Additionally, there was also an increased number of Syndesmosis Ankle Sprains reported in football when compared to other sports.

______, Committee Chair Michael Wright, Ph.D.

______Date

ACKNOWLEDGEMENTS

I would like to thank my committee, Michael Wright and Heather Swanson for their continued support and assistance with this project. I cannot thank them enough for their guidance throughout the Master’s program, especially during the thesis process.

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TABLE OF CONTENTS

Page

Acknowledgements ...... vii

List of Tables ...... xi

List of Figures ...... xii

Chapter

1. INTRODUCTION ...... 1

Statement of Purpose ...... 2

Statement of Problem ...... 3

Limitations ...... 3

Delimitations ...... 4

Assumptions ...... 4

Definitions of Terms ...... 4

Hypotheses ...... 6

2. REVIEW OF LITERATURE ...... 7

Introduction ...... 7

Anatomy of the Ankle ...... 8

Anatomy of the Knee ...... 10

Kinetic Chain of the Lower Body ...... 12

Injuries to the Ankle...... 12

Inversion/Eversion Ankle Sprains ...... 12

viii

Fractures to the Tibia and Fibula ...... 13

Syndesmosis Ankle Sprains ...... 13

Syndesmosis Ankle Sprain Grading Scale ...... 15

Causes ...... 15

Return to Participation ...... 16

Rehabilitation ...... 17

Surgical Intervention ...... 17

Ankle Support ...... 18

Usage/Indications of Ankle Support ...... 19

Types of Ankle Support ...... 19

Effects on other Joints ...... 20

Knee Support ...... 21

Usage/Indications of Knee Support ...... 21

Types of Knee Support ...... 22

Effects on other Joints ...... 22

Summary ...... 23

3. METHODOLOGY ...... 24

Participants ...... 24

Measures (Variables) ...... 25

Equipment/Instruments ...... 26

Procedures ...... 26

Design ...... 28 ix

Data Analysis…………………………...... 28

Summary……………………………………… ...... 28

4. RESULTS ...... 29

Overall Findings ...... 29

Occurrence of Syndesmosis Ankle Sprains ...... 30

Occurrence of Syndesmosis Ankle Sprains with Ankle Support ...... 30

Occurrence of Syndesmosis Ankle Sprains with Knee Support ...... 31

Occurrence of Syndesmosis Ankle Sprains with both Knee and Ankle Support .31

Injuries Requiring Surgical Interventions ...... 32

Breakdown of Syndesmosis Ankle Sprains by Collegiate Sport ...... 32

Average Return to Play after Syndesmosis Ankle Sprain ...... 36

Analyzing the Hypotheses ...... 37

5. DISCUSSION ...... 40

Survey Results ...... 40

Complications ...... 42

Future Directions ...... 43

Conclusions ...... 44

Appendix A. Informed Consent Form ...... 45

Appendix B. Survey Questions ...... 46

References ...... 50

LIST OF TABLES

Tables Page

1. Breakdown of Syndesmosis Ankle Sprains by Collegiate Sport ...... 33

2. Breakdown of Survey Responses by Sport ...... 35

LIST OF FIGURES

Figures Page

1. Bony Anatomy of the Ankle ...... 8

2. Ligamentous Anatomy of the Ankle ...... 9

3. Ligamentous Anatomy of the Syndesmosis ...... 10

4. Bony Anatomy of the Knee ...... 11

5. Ligamentous Anatomy of the Knee ...... 11

6. Average Return to Play Data for Non-Surgical Injuries ...... 36

7. Average Return to Play Data for Surgical Injuries ...... 37

xii 1

Chapter 1

INTRODUCTION

Injuries are a major component of athletics; the NCAA states, “While injuries are an inherent risk in any sport, understanding the cause of the injuries can help minimize those risks (“Sports Injuries”, 2014). In order to understand the cause of injuries much research is needed and continues to be done. This research includes tracking trends within sports as well as biomechanical studies analyzing the forces acting on a body part. Once the cause of injury is understood, methods for preventing such injuries can be developed and implemented into the athletic setting.

Although injury prevention is of utmost importance within athletics there has to be consideration as to whether preventing one injury leads to causing another. For example, in football, helmets were originally made out of leather straps, which simply covered the head. Throughout the years helmets have undergone many changes, eventually evolving into a hard plastic helmet in 1940. Better helmets lead to fewer cervical spine injuries, however the incidence of concussions increased. There is also question as to whether utilizing ankle braces in sports participation for injury prevention is negated due to the potential for knee injury to occur (Simpson et al., 2013). This theory pertains to the kinetic chain of the lower body in which joints of the body are connected to each other and movement at one joint causes movement at another joint (Starkey et al.

2010). Or in the case of bracing the ankle, the motion at the ankle would be limited and therefore could negatively affect the movement at the knee.

For the purposes of this study Syndesmosis Ankle Sprains were analyzed as

they relate to lower body prophylactic support. Syndesmosis Ankle Sprains are an injury

to the Syndesmosis of the lower leg (the area between the knee and ankle joint), which

typically occurs, from a forced external rotation and dorsiflexion of the foot. In particular

an occurrence was calculated for Syndesmosis Ankle Sprains occurring while

prophylactic lower body support was utilized and then compared to the occurrence of

Syndesmosis Ankle Sprains occurring without any prophylactic support. With the

assumption being if the joint above and below a specified area of the body are locked in

place and unable to accommodate for forces being placed on it from the outside, those

forces have to be absorbed which could potentially cause injury.

Statement of Purpose

The purpose of this study is to identify if collegiate athletes are at a higher

risk of sustaining a Syndesmotic Ankle Sprain when they are utilizing prophylactic lower

body support(s). Within this study there will be an in depth look at Syndesmosis Ankle

Sprains which occurred in the last calendar year (January 1, 2014 – December 31, 2014) throughout collegiate athletic programs and the types of prophylactic lower body support that was being used at the time of injury. A generalization will also be formed from the survey for which sports are more at risk.

Statement of Problem

The problem being analyzed in this study is whether or not there is an increased occurrence of SAS in collegiate level athletes when they are utilizing prophylactic lower body support. This is a problem needing analysis within athletics as there are always injuries occurring in sport and therefore preventative measures are taken, however, some preventative measures may be unknowingly causing injury to a different joint of the body. This being said it is important to analyze those preventative measures in order to determine if the benefit outweighs the potential risk to another part of the body.

The information gained from this study will help to determine if there is an increased occurrence of SAS among athletes utilizing prophylactic lower body support and therefore, determine if further biomechanical studies need to be done.

Limitations

The limitations of this study were the survey being a non-standardized survey. As well as the number of responses received from the survey and the accuracy and truthfulness of the responses. An additional limitation to this survey is the population assessed. By only surveying collegiate Certified Athletic Trainers (AT’s) the information gained by this study will not be generalizable to all athletes, just those at the collegiate level. Additionally the only perspective will be that of the AT’s, no other health care professional.

Delimitations

This study was delimitated to Certified Athletic Trainers (AT’s) working in

the collegiate setting registered and in good standing with the National Athletic Trainers’

Association (NATA). In order to remove limits within this study, the survey was

distributed to Certified Athletic Trainers (AT’s) working at all levels of collegiate

athletics, this was to avoid limiting the results to only Division I athletic programs.

Additionally the survey was distributed to AT’s working all sports; therefore the

information received could be generalized to all sports not just one particular sport.

Assumptions

It was assumed that all participants had an understanding of the subject

matter and therefore were answering the survey questions to the best of their ability. It

was also assumed that the respondents were answering honestly. Additionally, it was

assumed that all participants were currently employed as an AT within a collegiate athletic program.

Definition of Terms

1. Certified Athletic Trainer: Athletic Trainers (AT’s): health care professionals who

collaborate with physicians. The services provided by AT’s comprise prevention,

emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of

injuries and medical conditions (“Athletic Training” n.d.).

2. Prophylactic: An object used to prevent injury or disease

3. Syndesmosis: The articulation between the Tibia and Fibula. This area can be

subdivided into three regions the proximal syndesmosis, distal syndesmosis and

the interroseous membrane (Norkus & Floyd, 2001).

4. Syndesmosis Ankle Sprain (SAS): injury to any of the following structures:

anterior Tibiofibular ligament, posterior Tibiofibular ligament, interosseus

membrane, and interosseus ligament (Norkus & Floyd, 2001).

5. Lower Leg: The lower leg is defined in this study as the area between the knee

joint and ankle joint, composed of the tibia, fibula, syndesmosis (interosseus

membrane), muscles, and ligaments.

6. Ankle Support: An object used to maintain stabilization of the ankle joint and

therefore prevent injury to the ligamentous structures. For this study ankle support

is defined as a tape job, lace-up ankle brace, or rigid ankle brace.

7. Knee Support: An object used to maintain stabilization of the knee joint and

therefore prevent injury to the ligamentous structures. For this study knee support

refers to both off-the-shelf knee braces and custom knee braces.

8. Talocrural joint: A joint of the lower leg located between the foot and the shin

comprised of the talus, medial malleolus and lateral malleolus.

9. Ligaments: tissue within the body, which connects bone to bone.

10. Ankle Mortise: the junction of the distal tibia, fibula and talus (Starkey, Brown &

Ryan, 2010).

11. Kinetic Chain: different joints are directly or indirectly linked to each other, this

means motion at one joint causes motion at an adjacent joint (Starkey et al.,

2010).

Hypotheses

1. There will be an increased occurrence of Syndesmosis Ankle Sprains (SAS)

among athletes utilizing ankle support.

2. There will be an increased occurrence of SAS among athletes utilizing knee

support.

3. There will be an increased occurrence of SAS among athletes utilizing both ankle

and knee support.

4. There will be an increased occurrence of SAS in football when compared to other

sports.

Chapter 2

REVIEW OF LITERATURE

Introduction

Syndesmosis ankle sprains (also known as high ankle sprains) are an injury to the lower leg that occurs less frequently than lateral ankle sprains (Teramoto, Kura,

Uchiyama, Suzuki, & Yamashita, 2008). Although it is less frequently it is still an injury occurring and causing athletes to miss time. This being said there is more research needed to better understand the SAS injury. Within this Literature Review, current literature regarding the causation of Syndesmosis Ankle Sprains will be discussed as they compare to other injuries of the ankle and lower leg. Also, ankle and knee support will be assessed as possible contributing factors to Syndesmosis Ankle Sprains. The assumption behind this is that when you lock a joint in place and then have an outside force acting upon it you are causing a weakened area somewhere else in the kinetic chain and therefore a place for injury to occur. In order to analyze this hypothesis many components of injuries and anatomy to the lower extremity must be reviewed.

Anatomy of the Ankle

The talocrural joint (sometimes referred to as the true ankle joint and/or the ankle mortise) is comprised of the talus, and the distal portion of the tibia and fibula (also referred to as the medial malleolus and lateral malleolus respectively). The talocrural joint operates in a uniaxial plane (Norkus & Floyd, 2001).

In addition to the talocrural joint, the Subtalar joint is located just distal to the talus and encompasses the talus and calcaneus. The Subtalar joint is where ankle inversion and eversion occur (Norkus & Floyd, 2001).

Figure 1. Bony Anatomy of the Ankle

(http://www.kidport.com/reflib/science/humanbody/skeletalsystem/Ankle.htm)

In addition to the bones creating the ankle joint; there is an articular capsule that surrounds the joint and three sets of ligaments. The three sets of ligaments are split up into the medial, lateral and syndesmosis components. The medial ligamentous structure is the deltoid ligament. On the lateral aspect of the ankle there are three ligaments, the

Anterior Talofibular Ligament (ATF), the Posterior Talofibular ligament (PTF), and the

Calcaneofibular Ligament (CF).

Figure 2. Ligamentous Anatomy of the Ankle

(http://blog.corewalking.com/sprained-ankle/)

The syndesmosis component of the ligamentous structure can be further split into

three regions; the distal Tibiofibular joint (located near the ankle joint), interosseus membrane and the superior Tibiofibular joint (located near the knee). Of the three regions of the syndesmosis this study was primarily concerned with the distal Tibiofibular portion. There are 3 ligaments that form the distal Tibiofibular joint; the anterior

Tibiofibular ligament, posterior Tibiofibular ligament, and the interosseous ligament

(Norkus & Floyd, 2001).

Figure 3. Ligamentous Anatomy of the Syndesmosis

(http://www.omnipt.net/Injuries-Conditions/Ankle/Ankle-Issues/Ankle-Syndesmosis-

Injuries/a~121/article.html)

Anatomy of the Knee

The knee joint is comprised of 4 bones: the femur, tibia, fibula and the patella.

Ligaments connect these bones. These ligaments include the Anterior Cruciate Ligament

(ACL), Posterior Cruciate Ligament (PCL), Medial Collateral Ligament (MCL), and the

Lateral Collateral Ligament (LCL) (Starkey et al., 2010). The knee is a uniaxial joint,

which allows flexion and extension, which is carried out by the local musculature. Other

movements that occur at the knee are valgus and varus stresses as well as rotational

stresses, all of these are not natural motions of the knee and therefore are prevented by

the ligaments of the knee (Starkey et al., 2010).

Figure 4. Bony Anatomy of the Knee

(http://homepages.cae.wisc.edu/~jjordan/experiments/knee_treatments.html)

Figure 5. Ligamentous Anatomy of the Knee

(http://www.yourjointdoc.com/sports-knee-anatomy.html)

Kinetic Chain of the Lower Body

The kinetic chain is a way of describing how the joints of the lower body function

in regards to each other. For example, each joint has its own role when a person is

landing from a jump, or making a cut, however the motion one joint makes affects the

joint above or below it. In a normal healthy individual the joints within the kinetic chain

work together to produce efficient movements, however when an injury occurs to one

joint changes occur throughout the kinetic chain to compensate for the injured tissue. The

same is true when a prophylactic support is being used, restricting motion at one joint can

change the kinematics at a related joint. For example, when the ankle is braced, it has

been found through research that there is more external rotation torque at the knee

(Venesky, Docherty, Dapena & Schrader, 2006).

Injuries to the Ankle

Inversion/Eversion Ankle Sprains. Inversion Ankle Sprains (also referred to as

lateral ankle sprains) account for about 15% of all sports traumas (Tankevicius,

Launkaite, Krisciunas, & Skurvydas, 2013). This injury creates a burden to the person

suffering from the injury as they may miss work as well as time from activity. A forced

inversion motion of the foot while the foot is in a plantar flexed position causes inversion ankle sprains. This motion creates a great deal of stress on the Anterior Talofibular

Ligament (Kadakia & Haddad, 2003). Additional causes of inversion or eversion ankle

sprains can be from the weakness of musculature in the area as well as proprioception

deficits (Kadakia & Haddad, 2003). The inversion or eversion ankle sprain typically heals

without surgical intervention. The most common treatment options given to patients

suffering from an Inversion or Eversion Ankle Sprain is Rest, Ice, Compression, and

Elevation (RICE) as it is referred to by many health care professionals. After RICE there

are many other forms of treatment that can be prescribed for the patient such as electrical

stimulation, thermotherapy, Nonsteroidal Anti-inflammatories (NSAID’s) and

rehabilitation (Kaminski et al., 2013).

Fractures to the Tibia and Fibula. Fractures to the bony anatomy of the lower leg can occur in isolation or along with a Syndesmosis Ankle Sprain. When they happen in conjunction with a sprain the fracture is typically to the distal fibula; this is classified as a Weber B or C Fracture. Fractures can also occur to the proximal fibula due to the forceful external rotation, this fracture is called a Maisonneuve Fracture (Miller &

Skalak, 2014).

There are a number of fractures to the ankle and lower leg that can occur unrelated to a syndesmosis ankle sprain as well. These fractures range in location from the talus, malleoli, fibula, and tibia. Additionally there are several types of fractures whether they are comminuted, spiral, vertical, etc (Richards, Charran, Singhal, & McBride, 2013).

Syndesmosis Ankle Sprain. Recent research has identified that high ankle sprains occur more frequently in athletics when compared to that of the general public.

“Previously, distal Tibiofibular syndesmosis injuries were reported as accounting for 1% to 11% of all ankle injuries. Currently, however, from 17% to 74% of ankle injuries

14 among young athletes, especially football players, soccer players, skiers, and hockey players, are distal Tibiofibular syndesmosis injuries” (Teramoto et al., 2008). Hockey players encounter an unusual amount of syndesmosis ankle sprains; the theory behind this is the fixed nature of the foot and ankle when wearing a hockey boot (Wright, Barile,

Suprenant & Matava, 2004). With the knowledge of syndesmosis ankle sprains increasing in sport it is important to understand what is causing this increase in injuries.

Is it that prophylactic braces are being worn more frequently in all levels of competition and therefore the braces are stabilizing one joint and now injury is occurring at a different joint? The most common mechanism of injury for a high ankle sprain is forced dorsiflexion and external rotation of the foot. This combined motion forces the talus into the tibia and fibula, which widens the ankle mortise, however, syndesmosis ankle sprains have been known to occur under all other movements of the ankle joint (eversion, inversion, plantar flexion, pronation, and internal rotation). The opening of the ankle mortise causes stretching of the static stabilizers of the ankle; the Anterior and Posterior

Tibiofibular ligaments, interosseus membrane, and the interosseus ligament (Norkus &

Floyd, 2001). When the ankle is fixed and unable to compensate for rotation elsewhere in the kinetic chain, syndesmosis ankle sprains are likely to occur (Wright et al., 2004).

Although injury to the syndesmosis is thought to be specific to the distal component, the body is a unit and therefore injury can occur not only at the distal Tibiofibular joint but also at the proximal Tibiofibular joint. That being said it is not uncommon to see an athlete with a Syndesmosis Ankle Sprain also have pain at their lateral knee. This is due to a disruption to the proximal syndesmosis, which is caused by dorsiflexion and external

rotation of the talocrural joint with the knee in a flexed position (Solger, Schweim &

Tripp, 2013).

Syndesmosis Ankle Sprain Grading Scale. The severity of a Syndesmosis Ankle

Sprain is described on a grading scale with four levels (I, II, and III, IV). A Grade I sprain is an isolated injury to the Anterior Inferior Tibiofibular ligament (AITFL). A Grade II sprain encompasses not only the AITFL but also the interosseus ligament. A Grade III sprain refers to a complete tear of the Anterior Inferior Tibiofibular Ligament, Posterior

Inferior Tibiofibular Ligament and damage to the Interosseus ligament. A Grade IV and the most severe Syndesmosis Ankle Sprain involves damage to the deltoid ligament as well (Miller & Skalak, 2014).

Causes. Syndesmosis Ankle Sprains are more common in the athletic population than they are in the general public; however, when comparing intercollegiate athletes with intramural and other lower-level competitive sports, intercollegiate athletes have over a twofold increased rate of injury. This is believed to be due to the increased intensity at which these athletes are required to perform and therefore the added stresses imposed on the bodies (Waterman et al., 2011). Assessments of soccer athletes who suffer a syndesmosis ankle injury demonstrate a lateral force on the weight-bearing ankle being the cause of injury (Waterman, et. al. 2011). In sports such as hockey and skiing

Syndesmosis Ankle Sprains are common due to the fixed boot predisposing the athlete to a dorsiflexed position. In American football, Syndesmosis Ankle Sprains are seen when

an athlete is tackled and their foot is stuck in an externally rotated position when an

additional athlete comes in and tackles the athlete (Miller & Skalak 2014).

Return to Participation. Returning an athlete too soon to participation after suffering a Syndesmosis Ankle Sprain can prolong the already extensive recovery and

lead to chronic ankle instability. In order to prevent this from happening, a thorough

physical examination should be performed utilizing the external rotation test, squeeze

test, and cotton test (Teramoto et al., 2008). These tests can be used as a diagnostic tool

immediately after the injury occurs and also as a return to play guideline. There is a great

deal of ambiguity when it comes to the amount of time it takes a syndesmosis ankle

injury to heal. One method to estimate the amount of time lost for an athlete is to

measure the height of the point tenderness from the lateral malleolus; the higher the

tenderness, the longer the recovery time (Miller et al. 2012). This is a useful tool for

athletic trainers, physical therapists, and physicians to use as a guide for a return to play

timeline. Another method to estimate amount of time lost was thought to be magnetic

resonance imaging (MRI), however, it has been found that although MRI has a high rate

of intra observer reliability for diagnosis of a syndesmosis ankle sprain, there is little to

be said as far as determining a return to play timeline based on the MRI itself (Howard et

al., 2012). Further research needs to be done on this topic to determine a gold standard

for a return to play guidelines for athletes who suffer from syndesmosis ankle sprains.

Rehabilitation. Rehabilitation of any injury requires a progression through the three stages of a rehabilitation program, these stages are: acute inflammatory phase, fibroblastic repair phase, and the maturation-remodeling phase. With proper progression through these stages an athlete is able to allow the body to heal while building back up to pre-injury strength.

Rehabilitation for a syndesmosis ankle sprain is similar to the rehabilitation for a lateral ankle sprain; however, the time spent in each phase is extended to allow for the healing of the tissues. The process of rehabilitation is still pain management and inflammation control utilizing modalities such as ice and compression initially. The following stages include progressing from passive ankle exercises to resisted exercises, proprioception exercises, and eventually plyometrics and sport specific drills

(Pajaczkowski, 2007). It is vital for a practitioner to have a secure knowledge base on the stages of rehabilitation and when it is safe for an athlete to progress to a more advanced stage.

Surgical Intervention. Due to the possible severity of a syndesmosis ankle sprain, surgical intervention is becoming more popular as a treatment option (Teramoto et al., 2008). Other less severe high ankle sprains require a significant amount of time for healing and therefore an extended amount of time before returning to full participation can occur (Miller et al., 2012). Surgical interventions that are utilized to aid in the healing process of grade III or IV Syndesmosis Ankle Sprains include a screw fixation (Teramoto et al., 2008). Other forms of surgical intervention are screw fixation along with

18 anatomical ligament repairs using autograft tendons as well as debridement of the ankle joint itself. There is insufficient current research as to whether a screw fixation surgery is enough or if the debridement and graft reconstruction are necessary (Parlamas et al.,

2013). Overall, surgical intervention has been shown to prevent chronic syndesmosis injury and therefore ankle instability.

Ankle Support

Ankle support plays a key role in athletics, whether prophylactically to prevent injury to the ankle joint or post injury to stabilize the joint and allow the athlete the chance to continue participating. Within this study the significance of ankle supports is to identify if they are a contributing factor to syndesmosis ankle sprains. There are many forms of ankle supports ranging from different types of athletic tape to different types of braces including, lace-up and hard support.

Previous research found ankle braces to be more cost effective, reusable and maintain support up to twice as long when compared to an open basket weave taping technique. Also, the integrity of an ankle brace holds up better to the elements of perspiration than does athletic tape. (Forbes, Thrussell, Haycock, Lohkamp, & White,

2013). When it comes to taping the ankle for support during athletic activity it is important to note there are different types of tape that can be utilized. Although both self- adherent tape and white cloth tape limits motion immediately after being applied, self- adherent tape is more effective at preventing motion in all directions throughout the duration of exercise (Purcell, Schuckman, Docert, Schrader & Poppy, 2009).

Usage/Indications of Ankle Support. The purpose of an ankle brace is to

support the ankle joint and limit motion (Venesky et al., 2006). Research has shown many braces to be effective at stabilizing the ankle joint. Ankle braces have many uses in the athletic population as well as the general public. Prophylactic ankle braces serve several purposes; post-injury as a support system for the damaged ligaments, added support for functioning ligaments to prevent an injury from occurring, and general support of the ankle joint for an individual who has weak ankle musculature (Distefano,

Padua, Brown, & Guskiewicz, 2008). Stabilization from an ankle brace can also be useful

as a preventative tool to avoid injury to the ankle from occurring (Distefano et al., 2008).

When an athlete is wearing an ankle brace there is limited movement allowed at the

Subtalar joint, which can effect the movement of the kinetic chain as a whole.

Types of Ankle Support. When an ankle is in need of support, there are three

general options the subject has: athletic tape, lace up ankle brace, or rigid ankle brace.

There are many different ankle tape techniques utilized by athletic trainers and

other medical professionals. All of these have the same goal in mind of preventing the

athlete’s ankle from inverting or everting and hyper plantar flexion. In order to prevent

such motions the athletic trainer places stirrups, which start on the medial lower leg and

wrap around to the lateral lower leg about half way up the lower leg. Additional

components of the ankle tape include heel locks and figure eights around the ankle to

lock the Subtalar joint in a neutral position.

A lace up ankle brace consists of cloth worn over the athletes sock, there are laces

in the front in which the athlete ties like a shoe to create tightness around the ankle joint,

in addition to the laces are two Velcro straps on either side of the ankle joint which wrap

around the heel of the foot creating a heel lock and a stirrup, these side straps prevent

inversion motion at the ankle

The rigid functional ankle brace utilizes plastic barriers on either side of the

malleoli to prevent inversion and eversion motion of the ankle. These braces are typically

used for athletes who are performing lateral and straightforward movements (McGinty,

2014).

Effects on Other Joints. Research has been done to analyze ankle support and the ensuing effects on the rest of the lower body. The research is somewhat inconclusive as some articles find there to be an effect on other joints of the body and others do not find an effect. One of the studies analyzed when an athlete lands on a slanted surface while wearing an ankle brace there is not an effect on knee torque; the observed effects of the ankle brace are stabilization and limited motion at the ankle joint solely, meaning that the knee is not limited in its motion when an athlete is wearing an ankle brace (Venesky et al. 2006). However, an additional study comparing females wearing lace up ankle braces to those not wearing ankle braces displayed a difference in the kinematics at the knee however these differences did not pose as a threat to increased knee injury when performing a drop landing test (Simpson, Yom, Fu, Arnett, O’Rourke, Brown, 2013).

Evaluating a persons gait mechanics with ankle tape versus without ankle tape displays a

21 more neutral position of the ankle at different phases of the walking cycle however, it did not show any kinematic changes at the knee (Chinn et al., 2014). One difference found was when an athlete is wearing a prophylactic ankle brace and quickly turns the trunk of their body; they are at a higher risk of knee injury because there is an increase in knee axial rotation (Santos, McIntire, Foecking, & Liu 2004). This supports the thought that the joint above and below an area can influence the chance of injury at that location.

Overall, the research is indecisive on whether wearing an ankle brace can negatively effect other joints of the body.

Knee Support

Although ankle injuries are the most common in athletics, knee injuries often result in more extensive time lost from participation. Many athletes who sustain a grade I or II inversion ankle sprain are able to continue participating in sport fairly quickly after injury. This is not commonly the case with knee injuries, which take an extensive recovery time (Baltaci et al., 2011). Movements of the lower body are all intertwined; moving the knee causes movement at the ankle and vice versa. Due to this, it is beneficial to have an understanding of the biomechanics involved when a knee brace is worn and there is limited motion at that joint.

Usage/Indications of Knee Support. Knee braces are used prophylactically as well as post injury to minimize injury and re-injury. Although there has been refuting research regarding whether knee braces are effective at minimizing injuries, they are still

being utilized. This could be due to the fact that there has been support for their use in

improving proprioception and coordination, which can help prevent injuries in the long

term. They are used to prevent injury to the ACL, PCL, MCL, and LCL (Baltaci et al.,

2011). Post injury, knee braces are utilized as the athlete is returning to participation in order to give more support to the damaged structures.

Types of Knee Support. There are a variety of knee braces serving different

purposes, it is important to know which type of brace is best suited for each individual

case. Such types include: neoprene sleeve, neoprene sleeve with medial and lateral

supports, and functional knee braces (custom and off the shelf). Neoprene sleeves with

medial and lateral support are utilized to prevent injury to the MCL and LCL or to

provide support to those structures post injury. Plain neoprene sleeves are used to aid in

the prevention of patellofemoral pathologies as well as to provide compression to the

knee. Functional knee braces are used both prophylactically as well as post rehabilitation,

these braces can be customized to fit the patient individually or purchased off-the-shelf in

prefabricated sizes, these braces serve to aid in support of the ligamentous structures during functional activities (Prentice, 2011).

Effects on Other Joints. Much research has been done to determine the effect ankle braces have on the knee; however, little has been done for the effect knee braces have on the ankle and lower leg. This especially is important for the purposes of this

study, is stabilizing the knee and limiting rotational forces causing increased stress to the

syndesmosis of the lower leg?

Summary

The purpose of this Literature Review was to compile and analyze the already existing research on syndesmosis ankle sprains; ankle, knee and lower leg injuries; as well as ankle and knee supports and their effects on the kinetic chain. There is a gap in

the current research as to the effect knee supports have on the ankle and lower leg. An

additional gap in the research is the effect an ankle support has on the Syndesmotic joint.

These are both focuses of this study. The purpose of this study is to evaluate if there is a correlation between the use of those lower body support devices and Syndesmosis Ankle

Sprains.

Chapter 3

METHODOLOGY

This study was designed to look at the occurrence of Syndesmosis Ankle Sprains among collegiate athletes while wearing ankle and/or knee support. The goal is to provide additional information on causes of SAS to better help Certified Athletic Trainers (AT’s),

Physical Therapists, Sports Medicine Physicians, and anyone else working with individuals who may suffer from a Syndesmosis Ankle Sprain.

Participants

The participants of this study are AT’s working in the collegiate setting who are registered and in good standing with the National Athletic Trainers’ Association

(NATA). The participants were chosen randomly by the NATA with the specified criteria provided by the researcher from the NATA database. The survey was disseminated to

1000 AT’s currently working in collegiate athletics. Once the participants were selected by the NATA, the survey was disseminated via email. This process was done by the

NATA solely; the researcher had no knowledge of whom the NATA chose to participate in the survey. Participants will be given an informed consent (See Appendix A) form to read and accept before participating in the survey. There was no risk associated with participation because the participants answered objective measures; there were no opinion questions on this survey. Participants were excluded from the study if they are not a practicing AT working at a collegiate setting. The goal was to receive 500 survey

25 responses back, knowing there will be participants who choose not to participate in the study. Additionally having 500 responses will ensure a well-diversified group of participants and provide enough data to have statistical significance.

Measures (Variables)

The variables in this study include:

1. Number of SAS reported by the AT’s surveyed

2. Number of SAS diagnosed by a physician

3. Number of athletes wearing ankle support when the injury occurred

4. Number of athletes wearing knee support when the injury occurred

5. Number of athletes wearing both ankle and knee support when the injury occurred

6. Number of SAS reported where no form of support was utilized

7. Number of lateral ankle sprains among the athletes within the same calendar year

8. Number of lower leg fractures within the same calendar year

9. Number of athletes requiring surgery for SAS

10. Most frequently answered amount of time for return to full game participation for

non-surgical cases

11. Most Frequently answered amount of time for return to full game participation for

surgical cases

Equipment/Instruments

The instrument utilized in this study is a non-validated Survey, which was created by

the researcher utilizing Survey Monkey. For the purposes of this study the survey does

not need to be validated, as the data being collected is only numerical and nominal data.

There will be no interpretation of the data required allowing for a survey without

reliability and validity to be acceptable. Survey Monkey is an online service that allows

for researchers to create a survey that can be distributed to participants and for data to be

collected. Another instrument will be the NATA membership database in which the

collegiate level AT’s will be randomly selected.

A link was emailed to the participants; if they chose to participate they answered the survey questions and then submit those answers to Survey Monkey. Once the survey was submitted to Survey Monkey the researcher had access to the anonymous responses. The data was then stored within Survey Monkey and a password protected excel spreadsheet within the researchers hard drive.

Procedures

A non-validated questionnaire designed by the researcher (See Appendix B) was used to gather data. The questionnaire in this study is considered non-validated as it is an independent survey created for the purposes of this study and it has not been previously utilized and therefore tested and the data being collected does not require a validated survey. The reliability and validity of this survey has not been established, as the questions being asked are specific to the purposes of this study, however this method of

surveying athletic trainers has previously been utilized effectively to obtain injury

information. The researcher submitted the survey to the NATA through the “Research

Survey Service” provided by the NATA. The NATA then randomly selected 1000

collegiate level AT’s from the NATA membership database. Once selected the survey

was emailed to the participants by the NATA research survey service with a link to the

Survey Monkey website where they were asked to give informed consent before

completing the survey. The participants gave their consent for participation by reading

the informed consent that has been reviewed and approved by the California State

University, Sacramento Internal Review Board (IRB) and choosing to partake in the

study.

The questionnaire included questions regarding the AT’s experiences with

Syndesmosis Ankle Sprains among their athletes using check box and drop down menu

questions.

Once the participant was done recording their responses they submit the survey

results back to Survey Monkey. The researcher then obtained the data from Survey

Monkey. This helps to maintain anonymity of the responses. Once data was collected

from Survey Monkey the researcher compiled all the results in an excel spreadsheet.

Once the data was compiled analysis began. The survey was dispersed on February 12th,

2015 with a reminder email sent on February 23rd, 2015. The survey remained open until

March 1st, 2015.

Design

This study was conducted using a survey distributed by the NATA research survey

service on behalf of the researcher to the randomly selected members who anonymously

filled out a survey using Survey Monkey. The Data was then received and reviewed by

the researcher and compiled into an excel spreadsheet. Once all Data was collected data analysis was performed through excel by the researcher and verified by committee members for fidelity of treatment. The data collected looked for correlations among the variables of the study.

Data Analysis

The results of this study were analyzed using descriptive statistics, such as: percentages, frequencies and averages. Trends within the variables were also found through the use of descriptive statistics. All data analysis was done using excel on the researchers computer.

Summary

The purpose of the methods within this study were to look for an increased occurrence of Syndesmosis Ankle Sprains when athletes are wearing ankle support and/or knee support. With the Assumption being if a joint is fixated and unable to adjust for forces placed upon it, the kinetic chain is going to breakdown somewhere, and this somewhere being the syndesmosis of the lower leg for the purposes of this study.

Chapter 4

RESULTS

Overall Findings

To begin discussing the results of this study, it is necessary to identify that only 166 responses were returned of the 1000 distributed. After analyzing the 166 responses, 26 of those were excluded due to the respondent not being able to agree to the terms of the survey and therefore not having any data to be analyzed. Multiple variables were measured throughout this survey. These variables include:

1. Number of SAS reported by the AT’s surveyed: 231 total

2. Number of SAS diagnosed by a physician: 161 total

3. Number of athletes wearing ankle support when the injury occurred: 76 total

4. Number of athletes wearing knee support when the injury occurred: 24 total

5. Number of athletes wearing both ankle and knee support when the injury

occurred: 20

6. Number of SAS reported where no form of support was utilized: 41 total

7. Number of lateral ankle sprains among the athletes within the same calendar year:

862

8. Number of lower leg fractures within the same calendar year: 65

9. Number of athletes requiring surgery for SAS: 9

10. Most frequently answered amount of time for return to full game participation for

non-surgical cases: 1-3 weeks

11. Most Frequently answered amount of time for return to full game participation for

surgical cases: 2-6 months

Occurrence of Syndesmosis Ankle Sprains

For this study, the occurrence of Syndesmosis Ankle Sprains (SAS) was determined through a non-validated questionnaire. The results of the questionnaire were compiled into excel for data analysis. Two categories of SAS were totaled through this survey. One, the total number of SAS reported by the AT’s in the last calendar year (January 1, 2014 – December 31, 2014). This number was 231. The other category, the total SAS diagnosed by a physician as well as by the AT. This number was 161. Therefore, a physician diagnosed 69.70% of the SAS reported in this survey. Of the 161 SAS reported, 120 of the injuries (74.53%) occurred while the athlete was utilizing some type of lower body support.

Occurrence of Syndesmosis Ankle Sprains with Ankle Support

For the analysis of the occurrence of SAS with ankle support, respondents were asked to respond only for the SAS, which had a confirmed diagnosis, by a physician.

Of those 161 confirmed by a physician, 48 of the athletes were wearing ankle tape at the time of injury, 25 of the athletes were utilizing a lace-up ankle brace, and 3 a rigid ankle brace. This being said, 76 of the 161 injuries occurred while an athlete was wearing some type of ankle support. This means, 47.2% of the SAS injuries occurred while ankle support was being utilized. From this data, the first hypothesis that states:

there will be an increased occurrence of SAS among athletes utilizing ankle support

was accepted.

Occurrence of Syndesmosis Ankle Sprains with Knee Support

For the analysis of the occurrence of SAS with knee support, respondents were

asked to respond only for the SAS, which had a confirmed diagnosis, by a physician.

Of the 161 SAS, 24 athletes were utilizing a type of knee support. 0 were reported

utilizing a neoprene sleeve at the time of injury, 6 were wearing an off the shelf knee

brace and 18 a custom knee brace. This being said 14.9% of the reported SAS injuries

occurred when an athlete was utilizing a knee support. From this data, the second

hypothesis that states: there will be an increased occurrence of SAS among athletes

utilizing knee support was rejected.

Occurrence of Syndesmosis Ankle Sprains with both Knee and Ankle Support

For the analysis of the occurrence of SAS with knee support, respondents were asked to respond only for the SAS, which had a confirmed diagnosis, by a physician.

Of the 161 SAS reported, 20 athletes were using a form of ankle and knee support simultaneously. Although the type of ankle and knee support was not specified, the

AT’s stated that these athletes were wearing both ankle and knee support at the time of injury. These 20 athletes equal 12.4% of the total SAS injuries in this study. From this data, the third hypothesis that states: there will be an increased occurrence of

SAS among athletes utilizing both ankle and knee support was rejected.

Injuries Requiring Surgical Intervention

Of the 161 SAS confirmed by a physician, 9 athletes required surgical

intervention for their injury. This equates to only 5.5% of the athletes with SAS in

this study requiring surgical intervention. Of the 9 requiring surgical intervention, 7

of the athletes were football, 1 women’s basketball and 1 volleyball. Additional

information about these surgical cases reveals that 2 of the athletes were not using

any lower body support at the time of injury, 3 were utilizing ankle tape, 1 athlete was

using a lace-up ankle brace, and 1 both ankle and knee support. The remaining 2

injuries could not be determined based on the answers to the questionnaire as to the

support being used at time of injury.

Breakdown of Syndesmosis Ankle Sprains by Collegiate Sport

For the Breakdown of SAS by collegiate sport, after the initial exclusion took place, there were 140 surveys to be analyzed, however, a secondary exclusion had to be done for the breakdown by sport specific results. This was due to some participants improperly answering the primary and/or secondary sport question. This caused an additional 34 surveys to be excluded from this data set analysis. Out of the

now 106 surveys being analyzed, there were a total of 131 SAS injuries, which

occurred and can be linked to a specific sport (See Table 1).

Table 1

Breakdown of Syndesmosis Ankle Sprains by Collegiate Sport

Sport Diagnosed SAS by a physician % Of SAS by sport Men’s Basketball 9 6.87% Women’s Basketball 7 5.34% Men’s Soccer 3 2.29% Women’s Soccer 9 6.87% Football 83 63.36% Men’s Tennis 0 0.00% Women’s Tennis 0 0.00% Men’s Track & Field 0 0.00% Women’s Track & Field 2 1.53% Volleyball 2 1.53% Men’s Lacrosse 1 0.76% Women’s Lacrosse 0 0.00% Men’s Gymnastics 0 0.00% Women’s Gymnastics 1 0.76% Baseball 2 1.53% Softball 2 1.53% Men’s Hockey 5 3.82% Women’s Hockey 0 0.00% Wrestling 3 2.29% Women’s Field Hockey 1 0.76% Women’s rugby 1 0.76% Spirit squad 0 0.00% Swimming 0 0.00% Rodeo 0 0.00% Cheer 0 0.00%

Of the 131 SAS reported within a specific sport, 83 were reported injuries to

football athletes. This accounts for 63.36% of the total SAS. From this data, the

hypothesis stating that there will be an increased occurrence of SAS in football when

compared to other sports was accepted.

Further analyzing the sport specific answers, 106 surveys were included in the analysis of sport specific injuries. Therefore, there was an opportunity for 212 different teams to be included as there was a primary and secondary sport assignment portion of the survey for each survey answered. Out of the possible 212 teams, there were a total of 164 that met the inclusion criteria. 35 of the included surveys were answered by AT’s who work with a football team (either primary or secondary), this accounts for 21.34% of the surveys (See Table 2).

Table 2

Breakdown of Survey Responses by Sport

Number of teams Sport % Survey respondents by sport included Men’s Basketball 11.59% 19 Women’s Basketball 12.80% 21 Men’s Soccer 3.66% 6 Women’s Soccer 7.32% 12 Football 21.34% 35 Men’s Tennis 3.66% 6 Women’s Tennis 3.05% 5 Men’s Track & Field 2.44% 4 Women’s Track & Field 2.44% 4 Volleyball 7.32% 12 Men’s Lacrosse 3.66% 6 Women’s Lacrosse 0.61% 1 Men’s Gymnastics 0.00% 0 Women’s Gymnastics 0.61% 1 Baseball 5.49% 9 Softball 6.10% 10 Men’s Hockey 1.22% 2 Women’s Hockey 0.61% 1 Wrestling 1.22% 2 Women’s Field Hockey 1.22% 2 Women’s rugby 0.61% 1 Spirit squad 1.22% 2 Swimming 0.61% 1 Rodeo 0.61% 1 Cheer 0.61% 1

Average Return to Play after Syndesmosis Ankle Sprain

The return to play question asked for the respondent to choose the average

amount of time it took their SAS injuries to return to full game participation for non-

surgical as well as surgical injuries. The most common answer for the non-surgical injuries was 1-3 weeks, which accounted for 38.9% of the total responses for non- surgical injuries.

15 Number of responses 10

0 up to 1 1-3 wks 1 mo 1-2 mo 2-6 mo greater week than 6 mo Average RTP

Figure 6. Average Return to Play Data for Non-Surgical Injuries

The most common response for the surgical cases was 2-6 months, which accounted for 38.10% of the responses for the surgical injuries.

9 8 7 6

Number of 5 responses 4 3 2 1 0 up to 1 1-3 wks 1 mo 1-2 mo 2-6 mo greater week than 6 mo Average RTP

Figure 7. Average Return to Play Data for Surgical Injuries

Analyzing the Hypotheses

Four hypotheses related to the occurrence of a SAS occurring while an athlete utilized prophylactic lower body support were evaluated using descriptive data analysis.

These hypotheses were:

1. There will be an increased occurrence of Syndesmosis Ankle Sprains (SAS)

among athletes utilizing ankle support.

In order to evaluate this hypothesis, an assessment of the total SAS that occurred in this study was done and then compared to those in which the athlete was utilizing only an ankle support at the time of injury. Out of the 161 total SAS reported by the respondents in this study, 76 of the athletes (47.2%) were wearing an ankle support at the time of injury. Due to the high percentage of athletes who were utilizing a form of ankle support at the time of injury this hypothesis has been accepted. It is evident from this study that the athletes who sustained an SAS injury commonly were wearing ankle support at the time of injury.

2. There will be an increased occurrence of SAS among athletes utilizing knee

support.

In order to evaluate this hypothesis, an assessment of the total SAS that occurred in this study was done and then compared to those in which the athlete was utilizing only knee support at the time of injury. Out of the 161 total SAS reported in this study, 24 (14.9%) of the injuries occurred while an athlete was wearing a knee support only. Due to the low percentage of SAS injuries with knee support being utilized, this hypothesis has been rejected. There was not a high enough prevalence of SAS injuries occurring while knee support was being worn.

3. There will be an increased occurrence of SAS among athletes utilizing both ankle

and knee support.

In order to evaluate this hypothesis, an assessment of the total SAS that occurred in this study was done and then compared to those in which the athlete was utilizing both ankle and knee support at the time of injury. The results for this hypothesis were very limited, out of the 161 total SAS; only 20 (12.4%) athletes were utilizing both types of support at the time of injury. This limited amount of injury occurring with both forms of support being worn does not give reason enough to accept this hypothesis and so it has been rejected. Therefore, there is not significant data to support the theory that an athlete utilizing both ankle and knee support is at a higher risk of suffering a SAS injury.

4. There will be an increased occurrence of SAS in football when compared to other

sports.

For the sport specific SAS, the total number of SAS decreased to 131 due to several respondents not appropriately selecting the team they cover. However, after analysis there was an overwhelming amount of SAS occurring in football when compared to the other sports. There was a total of 83 football related SAS that occurred, this accounts for 63.36% of the total SAS in this study. It is important to note however, that

21.34% of answers came from an AT who works with football. Therefore there was potential for more football injuries to be reported. Overall however, the high occurrence of SAS in football as reported by the survey results allows the researcher to accept this hypothesis. There was an increased incidence of SAS in football when compared to the other sports.

Chapter 5

DISCUSSION

The purpose of this study was to analyze Syndesmosis Ankle Sprains (SAS), which

occurred in the last calendar year at the collegiate level. In order to do this, 1000

Collegiate level Certified Athletic Trainers (ATs) were surveyed asking retrospective questions about Syndesmosis Ankle Sprains which occurred to the athletes they care for.

The focus was if the athletes were utilizing prophylactic ankle and/or knee support at the time of injury.

Survey Results

The results found in this study suggest that there was a higher incidence of SAS occurring amongst athletes who were utilizing ankle support at the time of injury. This coincides with the first hypothesis, which stated that there would be a higher occurrence amongst athletes utilizing ankle support. The information found in this study supports research in which the primary mechanisms of a SAS are defined as external rotation and hyper dorsiflexion (Norkus & Floyd, 2001), although ankle support is utilized to prevent these motions at the ankle the supports can only withstand so much force before they too fail and allow the ankle to move in such positions. Additional research supports that the foot being in a fixed position such as in a hockey skate or ski boot predispose an athlete to a SAS (Norkus & Floyd 2001), this fixed position is in theory what ankle tape and brace are trying to mimic which agrees with the fact that there was an increased

41 occurrence of SAS amongst athletes utilizing ankle support when compared to those without support.

As discussed previously there is limited research indicating the effects on the ankle and lower leg when a knee support is being utilized, the results of this study agree with this notion that there may not be as pertinent a reason to analyze these effects as the occurrence of SAS with knee support was only 14.9%, much lower than the occurrence of SAS without any support being utilized, which was 25.5%.

Analysis of the occurrence of SAS while an athlete was utilizing both ankle and knee support again was low in number at only 12.4% of the total SAS reported in this study therefore there was not a high enough occurrence from this study alone to warrant a much needed analysis of the effects on the Syndesmosis of the lower leg when both ankle and knee support are being utilized.

Instead of focusing research on the risk of injury to the Syndesmosis when knee support is being utilized as well as when both ankle and knee support are being utilized it would be more beneficial to focus on the inherent risks associated with SAS and football activity. In this study, 63.36% of the total reported SAS by sport identified their injuries with football athletes, therefore over half of the reported injuries occurred in football, with the next highest percentage being 6.87% for both Men’s Basketball and Women’s

Soccer. These results agree with the research, which states that an important risk factor to

SAS is the sport being played; football, basketball and soccer being primary culprits for

SAS injuries (Waterman et al. 2011).

Complications

Throughout the course of this study there were several complications that arose causing the results of this study to be insignificant. One of these complications was a lack of responses from the surveyed Athletic Trainers. The survey was emailed to 1000 AT’s with the hope of receiving at least 500 responses, unfortunately, the researcher only received 166 total responses back and 24 of those were excluded from the data set as the participants were not currently working in a clinical setting in which they work with athletes who have the potential for SAS’s. Due to the limited number of responses it is difficult to gain any significant data from the survey.

Although the hypotheses in this study were able to be accepted or rejected based on descriptive data, this does not give us a true idea of whether there is an increased incidence of SAS injury involved when an athlete is utilizing a form of lower body support. In order to do this a Pearson Product Correlation comparing a group of athletes who were participating without support vs. a group of athletes participating with support when an injury occurred would be needed. Where as, this project was a retrospective study where the injury already occurred and then data was collected based on the support they were utilizing. This study assumed that all participants already had an SAS injury.

Data was not collected for the number of athletes who competed with ankle and/or knee supports who did not suffer any SAS injuries.

Additionally, although the total lateral ankle sprains and lower leg fractures within the same calendar year were collected, there was no data collected as to whether those

43 athletes were utilizing any form of support at the time of injury. If this data had been collected a correlation could also have been performed.

Future Directions

In order to further expand on this study, collecting injury data from the NCAA Injury

Surveillance System (ISS) would be beneficial. As the survey technique used in this study did not prove to be effective. ISS collects voluntary injury data submitted at the end of the academic year by schools and universities through each schools internal injury data collection system. This would be an effective way to collect injury data and therefore find trends and patterns among teams across the country. Having access to this data could provide real number data for injuries that have occurred within the last calendar year rather than assuming the respondents answered truthfully and accurately to the survey. As the data is coming from the internal injury tracking system utilized by the individual schools, in which the AT’s input injury data, such as the type of support being utilized when the injury occurred, at the time of injury. This service would provide specific data as opposed to anecdotal data from the AT’s. Having access to the database values would not only give a larger data set as there would be no limit to the responses received but also give the most accurate numbers for the amount of SAS injuries in the previous calendar year.

An additional area of study that could be done to further expand on the topic of SAS would be a biomechanical study to analyze the actual forces being applied to the

Syndesmosis of the lower leg when lower body supports are being utilized. This

information would allow Athletic Trainers, Sports Medicine Physicians, Physical

Therapists, etc. to decide whether or not the benefit of the lower body support outweighs

the potential for injury at the Syndesmosis of the lower leg.

Conclusions

The analysis of the data in this study revealed that there was a high percentage of

SAS injuries among athlete who were wearing ankle support at the time of injury.

Additionally, there were increased SAS injuries reported amongst football AT’s.

Although insight was gained as to the occurrence of SAS injuries while lower body supports were being utilized by athletes, there was not enough information from this study to provide athletic trainers, physical therapists, sports medicine physicians, and any other medical professional working with athletes a definitive answer as to the risk of sustaining a SAS injury when utilizing a lower body support. Unfortunately to most accurately obtain such data, a biomechanical study would need to take place to determine the forces being placed on the syndesmosis of the lower leg when an athlete is wearing ankle and/or knee support. This data would give a better understanding to the kinetic chain and its interaction at the syndesmosis of the lower leg.

APPENDIX A

Informed Consent Form

Dear Certified Athletic Trainer: I am a Graduate Student in the Kinesiology department at California State University, Sacramento. I am conducting a survey in which I request your assistance in answering a few questions. The survey will take approximately 10-15 minutes for you to complete.

Certified Athletic Trainers who are working at the Collegiate level have been asked to participate in this survey. Your participation may benefit the Athletic Training profession by providing a better understanding of Syndesmosis ankle injuries. If any discomfort is felt during the process, you are free to withdraw. The California State University, Sacramento Institutional Review Board has approved this study for the Protection of Human Subjects.

This is a completely anonymous questionnaire. To ensure confidentiality participants will not be identified, no individual participant, clinical site or facts that might allude to the identity of any participant will be documented, discussed outside the confines of our research group, and will not be published at any time. All information obtained will be kept strictly confidential. All materials will be stored in a secure, password protected location and access will be restricted to researcher only.

As Certified Athletic Trainers working in the field your personal experiences with Syndesmosis ankle injuries make your input invaluable. Please take a few minutes to fill out the anonymous questionnaire. Please complete and submit the survey by 11:59 PM on March 1, 2015.

Thank you for your time and consideration. Sincerely, Erin Snyder, ATC California State University, Sacramento [email protected]

If you have any comments or questions, please contact myself or one of my committee members Dr. Michael Wright [email protected] or Heather Swanson [email protected]

By checking the boxes below you are giving your informed consent for participation in this study.

I agree to the terms and conditions above and hereby give my informed consent. I acknowledge that I am currently working as a Certified Athletic Trainer at the Collegiate level

APPENDIX B

Survey Questions

What level of collegiate athletics are you employed in?

 Division 1 Football Bowl  Division 2 Subdivision (FBS)  Division 3  Division 1 Football Championship  Junior College Subdivision (FCS)

What is your primary sport assignment?

MBB M T&F BSB WBB W T&F SB MSOC VB M Hockey WSOC MLAX W Hockey FB WLAX Wrestling MTEN MGYM WTEN WGYM Other (please specify) ______

How many Syndesmosis Ankle Sprains If there is a difference between the did your team experience this past numbers diagnosed by a physician calendar year (January 1, 2014 - versus total count, were there any December 31, 2014)? specific reasons for this? (Please explain) ______How many Syndesmosis Ankle Sprains ______diagnosed by a physician did your team ______experience this past calendar year ______(January 1, 2014 – December 31, 2014)? ______

**FOR THE REMAINDER OF THE SURVEY PLEASE ANSWER BASED ON THE SYNDESMOSIS ANKLE SPRAINS THAT WERE DIAGNOSED BY A PHYSICIAN.

**PLEASE READ ALL OF THE BELOW OPTIONS AND CHOOSE THE MOST APPROPRIATE CATEGORY FOR YOUR ATHLETES.

Of those Syndesmosis Ankle Sprains, Of those syndesmosis ankle sprains, how many were wearing ankle tape? how many were wearing a custom knee ____ brace? ___

Of those Syndesmosis Ankle Sprains, how many were wearing a lace up ankle Of those Syndesmosis Ankle Sprains, brace? how many required surgical ____ intervention? ____

Of those syndesmosis ankle sprains, What was the average RTP time frame how many were wearing a rigid type for the non-surgical injuries? ankle brace? Less than 1 week 2-3 weeks ____ 1 month 1-2 months 3-6 months > 6 months

Of those syndesmosis ankle sprains, What was the average RTP time frame how many were wearing both ankle and for the surgical injuries? knee support? ____ Less than 1 week 2-3 weeks 1 month 1-2 months 3-6 months > 6 months Of those syndesmosis ankle sprains, how many were wearing a neoprene sleeve with hinges? How many lateral ankle sprains did your ____ team experience this calendar year (January 1, 2014- December 31, 2014)? _____ Of those syndesmosis ankle sprains, how many were wearing a off the shelf How many lower leg (tibia, fibula) knee brace? fractures did your team experience this ____ calendar year (January 1, 2014- December 31, 2014)? ____

Are you responsible for another team?

Yes No

IF YES:

What is your primary sport assignment?

MBB M T&F BSB WBB W T&F SB MSOC VB M Hockey WSOC MLAX W Hockey FB WLAX Wrestling MTEN MGYM WTEN WGYM Other (please specify) ______

**FOR THE REMAINDER OF THE SURVEY PLEASE ANSWER BASED ON THE SYNDESMOSIS ANKLE SPRAINS THAT WERE DIAGNOSED BY A PHYSICIAN.

**PLEASE READ ALL OF THE BELOW OPTIONS AND CHOOSE THE MOST APPROPRIATE CATEGORY FOR YOUR ATHLETES.

Of those Syndesmosis Ankle Sprains, Of those syndesmosis ankle sprains, how many were wearing ankle tape? how many were wearing a custom knee ____ brace? ____

Of those Syndesmosis Ankle Sprains, Of those Syndesmosis Ankle Sprains, how many were wearing a lace up ankle how many required surgical brace? intervention? ______

Of those syndesmosis ankle sprains, What was the average RTP time frame how many were wearing a rigid type for the non-surgical injuries? ankle brace? ____ Less than 1 week 2-3 weeks 1 month 1-2 months 3-6 months > 6 months Of those syndesmosis ankle sprains, how many were wearing both ankle and What was the average RTP time frame knee support? for the surgical injuries? ____ Less than 1 week 2-3 weeks 1 month 1-2 months Of those syndesmosis ankle sprains, 3-6 months > 6 months how many were wearing a neoprene sleeve with hinges? ____ How many lateral ankle sprains did your team experience this calendar year (January 1, 2014- December 31, 2014)? Of those syndesmosis ankle sprains, _____ how many were wearing a off the shelf knee brace? How many lower leg (tibia, fibula) ____ fractures did your team experience this calendar year (January 1, 2014- December 31, 2014)? ____

REFERENCES

Athletic Training. (n.d.) Retrieved from http://www.nata.org/athletic-training.

Baltaci, G., Aktas, G., Camci, E., Oksuz, S., Yildiz, S., Kalaycioglu, T. (2011). The effect

of prophylactic knee bracing on performance: balance, proprioception,

coordination, and muscular power. Knee Surg Sports Traumatol Arthrosc. 19,

1722-1728.

Chinn, L., Dicharry, J., Hart, J.M., Saliba, S., Wilder, R., Hertel, J. (2014). Gait

Kinematic After Taping in Participants with Chronic Ankle Instability. Journal of

Athletic Training. 49 (3), 322-330.

DiStefano, L.J., Padua, D.A., Brown, C.N., Guskiewicz, K.M. (2008). Lower Extremity

Kinematics and Ground Reaction Forces After Prophylactic Lace-up Ankle

Bracing. Journal of Athletic Training . 43 (3), 234-241.

Forbes, H., Thrussell, S., Haycock, N., Lohkamp, M., White, M. (2013). The Effect of

Prophylactic Ankle Support During Simulated Soccer Activity. Journal of Sport

Rehabilitation. 2013 (22), 170-176.

Howard, D.R., Rubin, D.A., Hillen, T.J., Nissman, D.B., Lomax, J., Williams, T., . . .

Matava, M.J. (2012). Magnetic Resonance Imaging as a Predictor of Return to

Play Following Syndesmosis (High) Ankle Sprains in Professional Football

Players. SportsHealth. 4 (6), 535-543.

Kadakia, A.R., Haddad, S.L. (2003). The role of ankle bracing and taping in the

secondary prevention of ankle sprains in athletes. International SportMed

Journal. 4 (5) 1-10.

Kaminski, T. W., Hertel, J., Amendola, N., Docherty, C.L., Dolan, M.G., Hopkins, J.T.,

… Richie, D. (2013). National Athletic Trainer’ Association Position Statement:

Conservative Management and Prevention of Ankle Sprains in Athletes. Journal

of Athletic Training. 48 (4) 528-545.

Lamb, S.E., Nakash, R.A., Withers, E.J., Clark, M., Marsh, J.L., Wilson, S., . . . Cooke,

M.W. (2005). Clinical and cost effectiveness of mechanical support for severe

ankle sprains: design of a randomised controlled trial in the emergency

department. BMC Musculoskeletal Disorders. 6 (1), 1471-2474.

McGinty, J. (2014). Ankle Bracing and the Athlete. Ankle-Foot Orthoses. 26-27.

Miller, B.S., Downie, B.K., Johnson, P.D., Schmidt, P.W., Nordwall, S.J., Kijek, T.G.,

. . . Carpenter, J.E. (2012). Time to Return to Play After High Ankle Sprains in

Collegiate Football Players: A Prediction Model. Sports Health. 4 (6), 504-509.

Miller, T.L. & Skalak T. (2014). Evaluation and Treatment Recommendations for Acute

Injuries to the Ankle Syndesmosis Without Associated Fracture. Sports Med. 44,

179-188.

Norkus, S.A., Floyd, R.T. (2001). The Anatomy and Mechanisms of Syndesmotic Ankle

Sprains. Journal of Athletic Training. 36 (1), 68-73.

Pajaczkowski, J.A. (2007). Rehabilitation of distal Tibiofibular syndesmosis sprains: A

case report. Journal of Canadian Chiropractic Association. 51 (1), 42-49.

Parlamas, G., Hannon, C.P., Murawski, C.D., Smyth, N.A., Ma, Y., . . . Kennedy, J.G.

(2013). Treatment of chronic Syndesmotic injury: a systematic review and meta-

analysis.Knee Surg Sports Traumatol Arthrosc. 21 (2013), 1931-1939.

Prentice, W.E. (2011). The Knee and Related Structures. In M. Ryan & W. Glass (Eds.),

Princliples of Athletic Training: A Competency-Based Approach (556-604).

McGraw Hill: New York.

Purcell, S.B., Schuckman, B.E., Docherty, C.L., Schrader, J. & Poppy, W. (2009).

Differences in Ankle Range of Motion Before and After Exercise in 2 Tape

Conditions. The American Journal of Sports Medicine. 37 (2). 383-389.

Richards, P.J., Charran, A.K., Singhal, R., & McBride, D.J. (2013). Ankle fractures and

dislocations: A pictorial review. Trauma. 15 (3), 196-221.

Santos, M.J., McIntire, K., Foecking, J., Lie, W. (2004). The effects of ankle bracing on

motion of the knee and the hip joint during trunk rotation tasks. Clinical

Biomechanics. 19 (2004), 964-971.

Solger, E.A., Schweim, J.J., Tripp, P.M. (2013). Proximal and Distal Tibiofibular

Syndesmosis Injury in a Collegiate Football Athlete. International Journal of

Athletic Therapy & Training. 18 (3), 24-27.

Simspon, K.J., Yom, J.P., Fu, Y., Arnett, S.W., O’Rourke, S., & Brown, C.N. (2013).

Does Wearing a Prophylactic Ankle Brace During Drop Landings Affect Lower

Extremity Kinematics and Ground Reaction Forces? Journal of Applied

Biomechanics. 2013 (29), 205-213.

Sports Injuries. (2014) Retrieved from http://www.ncaa.org/health-and-safety/medical-

conditions/sports-injuries

Starkey, C., Brown, S.D., & Ryan, J. (2010). Knee Pathologies. In Q. McDonald(Eds.),

Examination of Orthopedic and Athletic Injuries (289-369). F.A. Davis

Company: Philadelphia.

Tankevicius, G., Lankaite, D., Krisciunas, A., Skurvydas, A. (2013). Early Isometric

Eversion and Inversion Changes After Acute Ankle Sprains. Biomedicinos

Mokslai. 4 (91), 53-61.

Teramoto, A., Kura, H., Uchiyama, E., Suzuki, D., & Yamashita, T. (2008). Three-

Dimensional Analysis of Ankle Instability After Tibiofibular Syndesmosis

Injuries. A Biomechanical Experimental Study. The American Journal of Sports

Medicine. 36 (2), 348-352

Venesky, K., Docherty, C.L., Dapena, J., Schrader, J. (2006). Prophylactic Ankle Braces

and Knee Varus-Valgus and Internal-External Rotation Torque. Journal of

Athletic Training . 41 (3), 239-244.

Waterman, B.R., Belmont, P.J., Cameron, K.L., Svoboda, S.J., Alitz, C.J., Owens, B.D.

(2011). Risk Factors for Syndesmosis and Medial Ankle Sprain: Role of Sex,

Sport, and Level of Competition. American Journal of Sports Medicine. 39 (5),

992-998.

Wright, R.W., Barile, R.J., Suprenant, D.A., Matava, M.J. (2004). Ankle Syndesmosis

Sprains in National Hockey League Players. The American Journal of Sports

Medicine. 32 (8), 1941-1945.