EFFECTIVENESS OF ULTRASONOGRAPHY IN DIAGNOSING CHRONIC LATERAL ANKLE INSTABILITY:A SYSTEMATIC REVIEW

Background

Chronic ankle instability (CAI) is a condition that often develops after repeated ankle sprains, increasing the suceptability of the ankle to move into excessive inversion when walking on unstable surfaces. Treatment for CAI costs approximately three billion health care dollars annually. Currently, common diagnostic tools used to identify ankle instability are arthroscopy, imaging, manual laxity testing, and self-reported questionnaires.

Purpose

The purpose of this systematic review was to investigate the effectiveness of ultrasonography in diagnosing CAI, in comparison with other diagnostic tools.

Methods

Search limits: articles published between the years 2000-2015, and articles that were peer reviewed and published in the English language. Databases searched: CINAHL, PubMed, Medline, Medline Plus, Science Direct, OVID, Cochrane, and EBSCO. Titles and abstracts of the 1,420 articles were screened for the inclusion criteria by two independent raters, with discrepancies solved by a third rater. The modified 14-point Quality Assessment of Diagnostic Accuracy Studies (QUADAS) scale was used to assess methodological quality of included articles.

Results

Six high quality articles were included in this systematic review, as indicated by high scores on the QUADAS scale, ranging from 10 to 13. Sensitivity of US ranged from: 84.6 % -100%, specificity of US ranged from: 90.9% − 100% and accuracy ranged from: 87% − 90.9%.

Discussion

The results of the included studies suggest that US is able to accurately differentiate between the grades of ankle sprains and between a lax ligament, torn ligament, thick ligament, absorbed ligament and a non-union avulsion fracture. These findings indicate that US is a reliable method for diagnosing CAI, and that US is able to classify the degree of instability.

Conclusion

Researchers found that US is effective, reliable, and accurate in the diagnosis of CAI.

Clinical Implications

US would allow for earlier diagnosis, which could increase the quality of care as well as decrease the number of outpatient visits. This could lead to improvement in treatment plans, goals and rehabilitation outcomes.

level of Evidence

1a     

NEUROMUSCULAR CONTROL DURING PERFORMANCE OF A DYNAMIC BALANCE TASK IN SUBJECTS WITH AND WITHOUT ANKLE INSTABILITY

Design

Cross‐sectional, controlled laboratory study

Background

Lateral ankle sprains are common injuries and often lead to chronic ankle instability (CAI). Individuals who previously sustained a lateral ankle sprain, but did not develop CAI, termed copers, may have altered postural control strategies compared to individuals who have developed CAI. These altered postural control strategies may allow for more appropriate dynamic stabilization of the ankle joint after injury compared to those seen in patients who have developed CAI.

Objective

To compare lower leg biomechanics, as well as electromyographic (EMG) activation of the tibilias anterior and peroneus longus muscles, during the posteromedial reach of the Star Excursion Balance Test (SEBT) in individuals with healthy ankles, copers, and those with CAI.

Participants and Methods

30 participants (12 control, 9 copers, 9 CAI) divided into three groups based on ankle sprain history and Cumberland Ankle Instability Tool score. Kinematic, kinetic, and EMG data were collected during three posteromedial reach trials on the SEBT.

Main Outcome Measures

Primary outcome measures include SEBT normalized reach distance in the posteromedial direction and average integrated EMG activation of the tibialis anterior and peroneus longus muscles during the reach. Secondary outcome measures included sagittal and frontal plane ankle complex angles and moments and sagittal plane knee angles and moments. Data were analyzed between groups using a one‐way ANOVA model.

Results

No significant differences in reach distance or kinematic and kinetic outcomes were found between groups. The activation of the tibialis anterior and peroneus longus muscles was significantly different between groups (p=0.033 and p=0.014, respectively). The post‐hoc analysis revealed that the coper group had significantly higher muscle activation compared to the control group, but not to the CAI group.

Conclusion

CAI did not alter kinematic, kinetic, or reach performance during the SEBT. When compared to controls, copers appeared to have greater activation of the ankle musculature, which may increase stability of the ankle complex during a dynamic balance task.

Level of Evidence

Prospective Cohort level II     

COMPARISON OF ISOMETRIC ANKLE STRENGTH BETWEEN FEMALES WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME

Introduction:

Proximal and distal influences on the knee may be related as etiological factors of patellofemoral pain syndrome (PFPS). The distal factors include subtalar excessive pronation as well as medial tibia rotation, but no study has investigated whether ankle weakness could lead to alterations that influence the patellofemoral joint. Thus, the purpose of this study was to compare the ankle dorsiflexor and invertor muscles strength, as well as rearfoot eversion and the Navicular Drop Test (NDT) in females with PFPS to a control group of females of similar demographics without PFPS.

Methods:

Forty females, between 20 and 40 years of age (control group: n=20; PFPS group: n=20) participated. Rearfoot eversion range of motion and the NDT were assessed for both groups. The Numeric Pain Rating Scale and the Anterior Knee Pain Scale were used to evaluate the level of pain and the functional capacity of the knee during activities, respectively. Isometric ankle dorsiflexor and invertor strength was measured using a handheld dynamometer as the dependent variable.

Results:

The isometric strength of the dorsiflexor and invertor muscle groups in females with PFPS was not statistically different (P>0.05) than that of the control group. There was no statistically significant difference between groups for rearfoot eversion and NDT (p>0.05).

Discussion/Conclusion:

These results suggest that there is no difference between isometric ankle dorsiflexion and inversion strength, the NDT, and rearfoot eversion range of motion in females with and without PFPS.

Level of evidence:

3‐b     

RELIABILITY OF THREE MEASURES OF ANKLE DORSIFLEXION RANGE OF MOTION

Purpose/Background:

A variety of methods exist to measure ankle dorsiflexion range of motion (ROM). Few studies have examined the reliability of a novice rater. The purpose of this study was to determine the reliability of ankle ROM measurements using three different techniques in a novice rater.

Methods:

Twenty healthy subjects (mean±SD, age=24±3 years, height=173.2±8.1 cm, mass=72.6±15.2 kg) participated in this study. Ankle dorsiflexion ROM measures were obtained in a weight-bearing lunge position using a standard goniometer, digital inclinometer, and a tape measure using the distance-to-wall technique. All measures were obtained three times per side, with 10 minutes of rest between the first and second set of measures. Intrarater reliability was determined using an intraclass correlation coefficient (ICC_2,3) and associated 95% confidence intervals (CI). Standard error of measurement (SEM) and the minimal detectable change (MDC) for each measurement technique were also calculated.

Results:

The within-session intrarater reliability (ICC_2,3) estimates for each measure are as follows: tape measure (right 0.98, left 0.99), digital inclinometer (right 0.96; left 0.97), and goniometer (right 0.85; left 0.96). The SEM for the tape measure method ranged from 0.4–0.6 cm and the MDC was between 1.1–1.5 cm. The SEM for the inclinometer was between 1.3–1.4° and the MDC was 3.7–3.8°. The SEM for the goniometer ranged from 1.8–2.8° with an MDC of 5.0–7.7°.

Conclusions:

The results indicate that reliable measures of weight-bearing ankle dorsiflexion ROM can be obtained from a novice rater. All three techniques had good reliability and low measurement error, with the distance-to-wall technique using a tape measure and inclinometer methods resulting in higher reliability coefficients (ICC_2,3=0.96 to 0.99) and a lower SEM compared to the goniometer (ICC_2,3=0.85 to 0.96).

Level of Evidence:

2b     

Anatomic Relationship and Imaging Relevance of the Perforating Branches of the Peroneal Vessels to the Anterior Talofibular Ligament

Background

Patients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging.

Cold water immersion of the ankle decreases neuromuscular response of lower limb after inversion movement

Background

Cryotherapy has been associated with a significant decrease in nerve conduction velocity and muscle contraction with possible effects on exercise and physical training.

Objectives

To quantify the electromyographic response of the lateral gastrocnemius, tibialis anterior, fibularis longus, rectus femoris and gluteus medius to ankle inversion following cold water immersion.

Method

The peak values of the root mean square (RMS) were obtained from 35 healthy and active university subjects after the use of a tilt platform to force the ankle into 30º of inversion before, immediately after, and 10, 20, and 30 minutes after water immersion at 4±2ºC, for 20 minutes. The Shapiro-Wilk test, repeated measures analysis, Bonferroni''s post-hoc, and linear regression analysis provided the results.

Results

Peak RMS was significantly lower at all times after cold water immersion, with residual effect of up to 30 minutes, when compared to pre-immersion for all muscles, except for immediate post-immersion for the gluteus medius.

Conclusions

After cold water immersion of the ankle, special care should be taken in activities that require greater neuromuscular control.     

COMPARATIVE IMMEDIATE FUNCTIONAL OUTCOMES AMONG CRYOTHERAPEUTIC INTERVENTIONS AT THE ANKLE

Purpose/Background:

There is a lack of evidence detailing the immediate effects of different cryotherapy interventions at the ankle on functional outcomes such as balance and jumping tasks in a physically active population; therefore, the purpose of the present study is to compare the immediate effects of varied modes of cryotherapy applications to the ankle joint on Star Excursion Balance Test and vertical jump height performance. The authors hypothesized that cryotherapy would acutely decrease performance when compared to a control, and that concomitant compression would further hinder outcomes.

Methods:

A crossover study was conducted in a controlled laboratory setting. Thirty (9 men, 21 women) participants (20.6 ± 1.0 years, 1.7 ± 0.1 m, 67.5 ± 11.7 kg) were enrolled. The independent variable was treatment mode; no ice, ice without compression and ice with compression. Dependent variables included center of pressure (COP) excursions, dynamic balance reach distances and vertical jump height for the dominant leg. Participants underwent three separate testing sessions separated by 72‐hour rest intervals. The order of treatment and performance measures was randomized to prevent order effects. Normalized dynamic balance reach distances were assessed using the reliable modified Star Excursion Balance Test (SEBT). Center of pressure path length was assessed via a force platform during a single‐legged static balance task under eyes‐open and eyes‐closed conditions. Relative vertical jump height was assessed using a single‐legged vertical hop test. Group means and standard deviations were calculated by treatment mode. One‐way analyses of variance with Tukey''s post hoc test were used to calculate differences among treatment modes. p < 0.05 denoted statistical significance.

Results:

No statistically significant differences existed for all the performance measures among treatment modes.

Conclusions:

These findings suggest no immediate differences in lower extremity performance outcome measures between the respective treatment modes applied to the ankle in a young, healthy and physically active population. Additional investigation is warranted to study the related delayed effects of these interventions.

Levels of Evidence:

III     

Medial Foot Loading on Ankle and Knee Biomechanics

Background

The incidence of anterior cruciate ligament (ACL) injuries among females continues at disproportionate rates compared to males, with research indicating inconclusive multifactorial causality. Data from previous retrospective studies suggest an effect of abnormal foot and ankle bio-mechanics on pathology at the knee, including the ACL.

Objective

To determine if a relationship exists between plantar foot loading patterns during normal gait and high risk biomechanics purported to increase risk of ACL injury.

Methods

Dynamic barefoot plantar pressure distribution was measured on 33 female collegiate soccer players. Groups were divided according to their predominant gait loading pattern (medial or lateral). Three dimensional (3-D) motion analysis was conducted during drop vertical jumps to assess vertical ground reaction force and discrete angle and joint moment variables of the lower extremities.

Results

No significant differences occured in sagittal or coronal plane knee joint kinematics and kinetics between the medial and lateral loading groups.

Discussion

Dynamic foot and ankle biomechanics during gait do not appear to be related to lower extremity kinematics or kinetics during landing in collegiate female soccer players.

Conclusion

The exact cause of the abnormal differences in female landing biomechanics has not been irrefutably defined. This study suggests no effect of foot and ankle biomechanics exists on the landing mechanics of female soccer players.     

Determination of consistent patterns of range of motion in the ankle joint with a computed tomography stress-test

Background

Measuring the range of motion of the ankle joint can assist in accurate diagnosis of ankle laxity. A computed tomography-based stress-test (3D CT stress-test) was used that determines the three-dimensional position and orientation of tibial, calcaneal and talar bones. The goal was to establish a quantitative database of the normal ranges of motion of the talocrural and subtalar joints. A clinical case on suspected subtalar instability demonstrated the relevance the proposed method.

Methods

The range of motion was measured for the ankle joints in vivo for 20 subjects using the 3D CT stress-test. Motion of the tibia and calcaneus relative to the talus for eight extreme foot positions were described by helical parameters.

Findings

High consistency for finite helical axis orientation (n) and rotation (θ) was shown for: talocrural extreme dorsiflexion to extreme plantarflexion (root mean square direction deviation (η) 5.3° and θ: SD 11.0°), talorucral and subtalar extreme combined eversion–dorsiflexion to combined inversion–plantarflexion (η: 6.7°, θ: SD 9.0° and η:6.3°, θ: SD 5.1°), and subtalar extreme inversion to extreme eversion (η: 6.4°, θ: SD 5.9°). Nearly all dorsi – and plantarflexion occurs in the talocrural joint (θ: mean 63.3° (SD 11°)). The inversion and internal rotation components for extreme eversion to inversion were approximately three times larger for the subtalar joint (θ: mean 22.9° and 29.1°) than for the talocrural joint (θ: mean 8.8° and 10.7°). Comparison of the ranges of motion of the pathologic ankle joint with the healthy subjects showed an increased inversion and axial rotation in the talocrural joint instead of in the suspected subtalar joint.

Interpretation

The proposed diagnostic technique and the acquired database of helical parameters of ankle joint ranges of motion are suitable to apply in clinical cases.     

ROLLER MASSAGER IMPROVES RANGE OF MOTION OF PLANTAR FLEXOR MUSCLES WITHOUT SUBSEQUENT DECREASES IN FORCE PARAMETERS

Background:

Limited dorsiflexion range of motion (ROM) has been linked to lower limb injuries. Improving limited ankle ROM may decrease injury rates. Static stretching (SS) is ubiquitously used to improve ROM but can lead to decreases in force and power if performed prior to the activity. Thus, alternatives to improve ROM without performance decrements are needed.

Objectives/Purpose:

To compare the effects of SS and self massage (SM) with a roller massage of the calf muscles on ankle ROM, maximal voluntary contraction (MVC) force F100 (force produced in the first 100 ms of the MVC), electromyography (EMG of soleus and tibialis anterior) characteristics of the plantar flexors, and a single limb balance test.

Methods:

Fourteen recreationally trained subjects were tested on two separate occasions in a randomized cross‐over design. After a warm up, subjects were assessed for passive dorsiflexion ROM, MVC, and a single‐limb balance test with eyes closed. The same three measurements were repeated after 10 minutes (min) of rest and prior to the interventions. Following the pre‐test, participants randomly performed either SS or SM for 3 sets of 30 seconds (s) with 10s of rest between each set. At one and 10 min post‐interventions the participants repeated the three measurements, for a third and fourth cycle of testing.

Results:

Roller massage increased and SS decreased maximal force output during the post‐test measurements, with a significant difference occurring between the two interventions at 10 min post‐test (p < 0.05, ES = 1.23, 8.2% difference). Both roller massage (p < 0.05, ES = 0.26, ~4%) and SS (p < 0.05, ES = 0.27, ~5.2%) increased ROM immediately and 10 min after the interventions. No significant effects were found for balance or EMG measures.

Conclusions:

Both interventions improved ankle ROM, but only the self‐massage with a roller massager led to small improvements in MVC force relative to SS at 10 min post‐intervention. These results highlight the effectiveness of a roller massager relative to SS. These results could affect the type of warm‐up prior to activities that depend on high force and sufficient ankle ROM.

Level of Evidence:

2c     

IMMEDIATE EFFECTS OF CRYOTHERAPY ON STATIC AND DYNAMIC BALANCE

Purpose/Background:

Cryotherapy is commonly used in physical therapy with many known benefits; however several investigations have reported decreased functional performance following therapeutic application thereof. The purpose of this study was to determine the effect of cryotherapy applied to the ankle on static and dynamic standing balance. It was hypothesized that balance would be decreased after cryotherapy application.

Methods:

Twenty individuals (aged 18 to 40 years) participated in this research project. Each participant was tested under two conditions: an experimental condition where subjects received ice water immersion of the foot and ankle for 15 minutes immediately before balance testing and a control condition completed at room temperature. A Biodex® Balance System was used to quantify balance using anterior/posterior (AP), medial/lateral (ML), and overall balance indices. Paired t‐tests were used to compare the balance indices for the two conditions with alpha set at 0.05 a priori. Effect size was also calculated to account for the multiple comparisons made.

Results:

The static balance indices did not display statistically significant differences between the post‐cryotherapy and the control conditions with low effect sizes. Dynamic ML indices significantly increased following the cryotherapy application compared to the control exhibiting a moderate effect size indicating decreased balance following cryotherapy application. No differences were noted between experimental and control conditions for the dynamic AP or overall balance indices while a small effect size was noted for both.

Conclusions:

The results suggest that cryotherapy to the ankle has a negative effect on the ML component of dynamic balance following ice water immersion.

Clinical Relevance:

Immediate return to play following cryotherapy application is cautioned given the decreased dynamic ML balance and potential for increased injury risk.

Level of Evidence:

3b Case‐control study     

THE RELATIONSHIP BETWEEN ISOTONIC PLANTAR FLEXOR ENDURANCE,NAVICULAR DROP,AND EXERCISE-RELATED LEG PAIN IN A COHORT OF COLLEGIATE CROSS-COUNTRY RUNNERS

Purpose:

The purpose of this study was to examine the relationships between isotonic ankle plantar flexor endurance (PFE), foot pronation as measured by navicular drop, and exercise-related leg pain (ERLP).

Background:

Exercise-related leg pain is a common occurrence in competitive and recreational runners. The identification of factors contributing to the development of ERLP may help guide methods for the prevention and management of overuse injuries.

Methods:

Seventy-seven (44 males, 33 females) competitive runners from five collegiate cross-country (XC) teams consented to participate in the study. Isotonic ankle PFE and foot pronation were measured using the standing heel-rise and navicular drop (ND) tests, respectively. Demographic information, anthropometric measurements, and ERLP history were also recorded. Subjects were then prospectively tracked for occurrence of ERLP during the 2009 intercollegiate cross-country season. Multivariate logistic regression analysis was used to examine the relationships between isotonic ankle joint PFE and ND and the occurrence of ERLP.

Results:

While no significant differences were identified for isotonic ankle PFE between groups of collegiate XC runners with and without ERLP, runners with a ND >10 mm were almost 7 times (OR=6.6, 95% CI=1.2–38.0) more likely to incur medial ERLP than runners with ND <10 mm. Runners with a history of ERLP in the month previous to the start of the XC season were 12 times (OR=12.3, 95% CI=3.1–48.9) more likely to develop an in-season occurrence of ERLP.

Conclusion:

While PFE did not appear to be a risk factor in the development of ERLP in this group of collegiate XC runners, those with a ND greater than 10 mm may be at greater odds of incurring medial ERLP.

Level of Evidence:

2b.     

CLINICAL APPLICATIONS OF CRYOTHERAPY AMONG SPORTS PHYSICAL THERAPISTS

Background

Therapeutic modalities (TM) are used by sports physical therapists (SPT) but how they are used is unknown.

Purpose

To identify the current clinical use patterns for cryotherapy among SPT.

Study Design

Cross-sectional survey.

Methods

All members (7283) of the Sports Physical Therapy Section of the APTA were recruited. A scenario-based survey using pre-participation management of an acute or sub-acute ankle sprain was developed. A Select Survey link was distributed via email to participants. Respondents selected a treatment approach based upon options provided. Follow-up questions were asked. The survey was available for two weeks with a follow-up email sent after one week. Question answers were the main outcome measures.

Results

Reliability: Cronbach''s alpha=>0.9. The SPT response rate = 6.9% (503); responses came from 48 states. Survey results indicated great variability in respondents’ approaches to the treatment of an acute and sub-acute ankle sprain.

Conclusions and Clinical Relevance

SPT applied cryotherapy with great variability and not always in accordance to the limited research on the TM. Continuing education, application of current research, and additional outcomes based research needs to remain a focus for clinicians.

Level of Evidence

3     

Lower limb ice application alters ground reaction force during gait initiation

BACKGROUND:

Cryotherapy is a widely used technique in physical therapy clinics and sports. However, the effects of cryotherapy on dynamic neuromuscular control are incompletely explained.

OBJECTIVES:

To evaluate the effects of cryotherapy applied to the calf, ankle and sole of the foot in healthy young adults on ground reaction forces during gait initiation.

METHOD:

This study evaluated the gait initiation forces, maximum propulsion, braking forces and impulses of 21 women volunteers through a force platform, which provided maximum and minimum ground reaction force values. To assess the effects of cooling, the task - gait initiation - was performed before ice application, immediately after and 30 minutes after removal of the ice pack. Ice was randomly applied on separate days to the calf, ankle and sole of the foot of the participants.

RESULTS:

It was demonstrated that ice application for 30 minutes to the sole of the foot and calf resulted in significant changes in the vertical force variables, which returned to their pre-application values 30 minutes after the removal of the ice pack. Ice application to the ankle only reduced propulsion impulse.

CONCLUSIONS:

These results suggest that although caution is necessary when performing activities that require good gait control, the application of ice to the ankle, sole of the foot or calf in 30-minute intervals may be safe even preceding such activities.     

INJURY RISK IS ALTERED BY PREVIOUS INJURY: A SYSTEMATIC REVIEW OF THE LITERATURE AND PRESENTATION OF CAUSATIVE NEUROMUSCULAR FACTORS

Background:

Active adults commonly present with lower extremity (LE) injuries from a variety of professional and amateur sports activities. Decreased LE function significantly alters daily life and subsequent injuries increase this impact. The purpose of this systematic review was to examine the association between previous injury and the risk of re‐injury, and to describe the changes in kinematics and motor programming that may contribute to this relationship.

Methods:

A preliminary search was conducted to determine the four most common LE injuries on PubMed, CINAHL and Web of Science. These injuries, in a healthy active adult population, were hamstring strain (HS), anterior cruciate ligament injury (ACL), achilles tendon pathology, and ankle sprain. After these injuries were established, the search for this systematic review found evidence relating these injuries to re‐injury. Articles related to degenerative changes were excluded. Twenty‐six articles were included in the systematic review detailing the risk of re‐injury from a previous injury and were graded for quality.

Results:

ACL injury was linked to a successive injury of the same ACL, and other injuries in the LE. HS was associated with subsequent ipsilateral HS and knee injuries. Previous achilles tendon rupture increased the risk of an analogous injury on the contralateral side. An ankle sprain was associated with a re‐injury of either the ipsilateral or the contralateral ankle. Post‐injury changes were present in strength, proprioception, and kinematics, which may have led to overall changes in motor control and function.

Conclusion:

This review provides insight into the changes occurring following common LE injuries, how these changes potentially affect risk for future injury, and address the needs of the active adult population in rehabilitation.

Clinical Relevance:

Current research on previous injury and re‐injury is of high quality, but scarce quantity. Deficits following an injury are known, but how these deficits correlate or lead to re‐injury requires further exploration.

Level of Evidence:

1