Category: Article Summary

Proprioception and Postural Control: Clinical Insights from Recent Research

Leave a comment

Blog Post Author Biography: Dr. Brice Picot currently works at the Sciences et Technologies des Activités Physique et Sportives (STAPS), Université Savoie Mont Blanc and in the French association of Sports Physical Therapy. Brice does research in Traumatology, Rehabilitation Medicine and Physiotherapy. His current projects are focused on injury rehabilitation and prevention of Chronic Ankle Instability and ACL among athletes.

Citation: Sagnard T, Picot B, Forestier N. Proprioceptive acuity, proprioceptive weighting and balance in individuals with chronic ankle instability. Gait Posture. Published online March 15, 2025. doi:10.1016/j.gaitpost.2025.03.006

Take-to-the-Clinic Message:

  • Not all patients suffering from CAI exhibits postural impairments or proprioceptive acuity and reweighting deficits.
  • Poorer proprioceptive acuity is associated with increases postural sway, only in CAI patients.
  • Higher proprioceptive reweighting is observed when proprioception is disrupted in healthy individuals only.

Background: Chronic ankle instability (CAI) is a common consequence of repeated ankle sprains, often leading to impaired postural control and proprioception. Understanding the impact of these deficits is crucial for improving rehabilitation strategies.

Purpose: The purposes of this study were to evaluate proprioceptive and postural control deficits among CAI and healthy control individuals, and to assess whether these parameters were correlated among those two groups.

Methods: The study assessed 13 participants with chronic ankle instability (CAI) and 15 healthy controls to examine proprioception and balance deficits. Joint position sense (JPS) was evaluated in dorsiflexion and plantarflexion by calculating absolute and constant repositioning errors. Unipedal balance was measured using center of pressure (CoP) ellipse area and velocity to assess postural stability. Relative proprioceptive weighting (RPW) was determined by analyzing postural responses to triceps surae and lumbar multifidus tendinous vibrations.

Results: This study found nodifferences in proprioception or balance between CAI patients and healthy controls. However, within the CAI group, poorer accuracy in proprioceptive acuity was linked to greater difficulty maintaining balance, as shown by increased body sway. In contrast, for the control group, a different relationship emerged—those with greater proprioceptive errors tended to rely more on other sensory inputs for balance.

Rolling the field forward: Contrary to previous belief, not all CAI patients exhibited poor postural control or impaired proprioception. However, results from the present study suggests that contrary to healthy individuals, people with CAI still maintain an ankle steered strategy when proprioceptive signals are inaccurate. This could explain why CAI patients with unreliable acuity (i.e. high errors in JPS) exhibit poorer postural control while healthy control individuals do not. These findings highlight the importance of assessing both proprioception and balance in CAI patients to better address potential deficits in rehabilitation programs.

Question for the researchers:

  • How can we easily evaluate postural control deficits in CAI patients?
  • What are the normative values in errors of repositioning among healthy individuals?

External Ankle Support and Ankle Biomechanics in Chronic Ankle Instability

Leave a comment

Blog Post Author Biography: Patrick Rowe is a Physiotherapist, Lecturer & PhD Candidate in the College of Sport, Health & Engineering at Victoria University and the Centre of Health, Exercise & Sports Medicine at the University of Melbourne. Patrick has research expertise in the biomechanics of lateral ankle sprains and chronic ankle instability by using musculoskeletal modeling to explore how footwear and external ankle supports influence the lateral ankle ligament complex.

Citation: Rowe, P. L., Bryant, A. L., Egerton, T. & Paterson, K. L. External ankle support effects on ankle biomechanics in chronic ankle instability: systematic review and meta-analysis. Journal of Athletic Training (2022) doi:10.4085/1062-6050-0208.22.

Take-to-the-clinic message: This review found that ankle supports (taping and bracing) reduce inward motion but not inward position at ground contact in people with unstable ankles during landing. This may help prevent ankle sprains or lessen injury severity by limiting excessive inward movement. However, while ankle supports also reduce forward ankle motion, this could shift forces to the knee and hip, potentially increasing injury risk at these joints.

Background: Lateral ankle sprains are common among youth and adolescent athletes in high-demand, multidirectional sports, with up to 70–80% experiencing repeated sprains and chronic ankle instability (CAI). Biomechanical alterations in CAI, such as reduced plantarflexion and higher ground reaction forces during landing, contribute to instability. Athletes often use ankle supports (taping and bracing) to reduce sprain risk, but research is limited to non-randomized studies and lower-demand tasks. Therefore, we must explore whether external ankle supports influence ankle biomechanics during higher demand tasks (running, landing, and cutting), particularly in athletes at higher risk of sustaining a lateral ankle sprain and CAI.

Purpose: This systematic review aimed to compare the effects of external ankle supports compared to no support on ankle biomechanics in individuals with CAI during sports-related tasks.

Methods: This systematic review followed the Cochrane Handbook, PICOT framework, and PRISMA 2020 guidelines and was registered with PROSPERO in August 2020. A comprehensive search of MEDLINE, SPORTDiscus, and CINAHL in November 2021 identified randomized controlled or crossover studies on ankle biomechanics in individuals with CAI using external supports during landing, running, and directional changes. Studies were independently assessed for eligibility, appraised using the Cochrane risk-of-bias tool, and analyzed using random-effects meta-analysis with 95% confidence intervals.

Results: The literature search identified 162 studies, with 13 meeting inclusion criteria, totaling 248 CAI participants. Most studies had low to moderate risk of bias and examined various ankle supports, including non-elastic taping, semi-rigid bracing, soft bracing, and elastic taping. Landing (7 studies) and running (5 studies) were most commonly investigated, while change of direction tasks lacked homogenous data for meta-analysis. External ankle supports did not reduce inversion angle at initial contact during landing or running but showed very low-grade evidence of reducing frontal-plane and sagittal-plane excursion. These findings suggest ankle supports may influence some biomechanical aspects but with limited evidence supporting their overall effectiveness.

Rolling the field forward: This novel review provides further insight into how external ankle supports influence ankle biomechanics during high demand tasks, and the current literature suggests that external ankle support do not influence ankle inversion position prior to ground contact during running and landing. This challenges the current perception of the mechanical function of external ankle supports which is traditionally thought to adjust ankle inversion position during the pre-landing phase. In contrast, frontal plane excursion was found to be significantly reduced, which may be an important consideration for a typical lateral ankle sprain mechanism by limiting excessive inversion kinematics. Another major finding was the significant reduction in sagittal plane kinematics during running and landing. This may be considered either beneficial or detrimental due changes in ankle position (close-packed) or proximal loading at the hip and knee joints. However, it is difficult to determine this effect based on the limited evidence currently available. Future research should consider validated musculoskeletal, multi-segmental foot and ankle models to accurate measures to quantify joint kinematics, kinetics, joint contact, muscle, and ligament forces during high-demand sporting tasks. Adopting more sophisticated laboratory-based biomechanical approaches for CAI research will provide better translation to clinical and sporting environments and assist in reducing the burden of lateral ankle sprains.

Question for researchers: Based on the kinematic alterations of external ankle supports, does this lead to changes in tissue-based strains and forces at the lateral ankle ligament complex? In turn, do ankle-spanning musculotendinous structures perform differently during higher demand tasks when frontal and sagittal plane kinematics are limited? As a consequence of sagittal plane restrictions, do external ankle supports have negative implications to proximal structures (ie. knee) such as joint contact (tibiofemoral) and ligament (ACL) forces?

Do ankle braces affect functional performance?

Leave a comment

Blog Post Author Biography: Dr. Tomas Megalaa is a researcher and clinician, with expertise in sports injury prevention and rehabilitation. He has recently completed his PhD degree at the University of Sydney. Tomas has published multiple peer-reviewed articles and has extensive clinical and academic experience in Allied Health in Australia.

Citation: Megalaa T, Le PL, Fong Yan A, Beckenkamp PR, Hiller CE. Do ankle braces affect functional performance? A randomised double-blinded cross-over trial. JSAMS Plus. 2024;4:100061. DOI: 10.1016/j.jsampl.2024.100061.

Take-to-the-clinic message: Clinicians and sports practitioners can confidently prescribe ankle braces without concern of having a negative impact on functional performance. This study demonstrated that neither the KISS® nor Aircast ankle brace negatively affected objective measures of functional performance or balance in individuals with and without chronic ankle instability (CAI). Further, participants perceived greater stability and reassurance when they were wearing the KISS® ankle brace compared to no brace during the functional tasks.

Background: Ankle braces are effective in managing and preventing lateral ankle sprains. A new ankle brace, the Kinetic Impulse Suppression System® (KISS®), was developed to allow unrestricted ankle and foot movement within normal ranges while preserving subtalar joint motion in the frontal plane (inversion/eversion) and restricting only end-range joint motion. Despite the known protective benefits of ankle braces, concerns persist regarding their potential impact on functional performance.

Purpose: We aimed to compare the effects of two different ankle braces (KISS® and Aircast) with a no-brace condition on functional performance and perceptions of stability, confidence, and reassurance in individuals with and without CAI. The primary hypothesis was that wearing the KISS® brace would not impair functional performance compared to the no brace condition and participants would present a superior performance compared to the Aircast brace.

Methods: A randomised double-blinded cross-over trial was conducted in people (18-65 years) with and without CAI (determined using the International Ankle Consortium criteria). Participants completed an array of functional performance tests under three conditions: wearing the KISS® ankle brace, the Aircast A60 ankle brace, and no brace (control). The order of condition was randomly allocated, a researcher not involved in data collection applied the braces and the ankle was covered with a black sleeve to keep the assessor blinded to condition. Tests included the side hop test, Star Excursion Balance Test (SEBT), triple hop test, modified T-agility test, and vertical jump test. Perceptions of stability, confidence, and reassurance were also recorded on a 10-point numerical rating scale. Statistical analyses included linear mixed models to assess performance and subjective measures across conditions.

Results: A total of 42 participants were included (21 with and 21 without CAI), 24 females and18 males, with mean (SD) age of 25.4 (7.8) years. No significant differences were found between the three conditions for any objective functional performance measure, including the side hop test (p=0.96), SEBT (p>0.92), triple hop test (p=0.97), agility test (p=0.21), or vertical jump tests (p>0.97). However, subjective measures showed that participants felt significantly more stable and reassured while wearing the KISS brace compared to no brace (p=0.03 and p=0.046, respectively) after performing the side hop test.

Rolling the field forward: This study provides strong evidence that ankle braces do not impair functional performance, addressing a common concern among clinicians, trainers, and athletes. Future research should explore the long-term effects on perception of brace use and evaluate whether different brace designs influence injury prevention strategies and athletic performance. Studies involving elite athletes may help determine if subtle biomechanical effects of bracing emerge in high-performance settings.

Question for the researchers: Given the subjective preference for the KISS brace over the no-brace condition, do you anticipate that different brace designs could have a greater perceived impact on confidence and injury prevention? Would further testing in high-performance athletes reveal different functional outcomes?

‌Low Ankle-GO Score While Returning to Sport After Lateral Ankle Sprain Leads to a 9-fold Increased Risk of Recurrence: A Two-year Prospective Cohort Study

Leave a comment

Blog Post Author Biography: Lauren Forsyth is a Research Associate in the department of Biomedical Engineering at the University of Strathclyde and a Strength and Conditioning Coach. Dr Forsyth’s research aims to develop objective functional assessment techniques and rehabilitation interventions for people with chronic ankle instability.

Citation: Picot B, François Fourchet, Lopes R, et al. Low Ankle-GO Score While Returning to Sport After Lateral Ankle Sprain Leads to a 9-fold Increased Risk of Recurrence: A Two-year Prospective Cohort Study. Sports Medicine – Open. 2024;10(1). doi: 10.1186/s40798-024-00693-w

Take-to-the-clinic message: The Ankle-GO score is an objective assessment of functional performance and self-reported function which can be used to guide return to sport (RTS) decisions after lateral ankle sprain (LAS) and inform clinical management. When patients scored low of the Ankle-GO their 2-year risk of ankle sprain recurrence was nine times higher. Women also tended to have a fourfold higher risk of reinjury within two years, despite an initial Ankle-GO score comparable to men. Clinicians should therefore be more cautious of lower scores for women.

Background: Lateral ankle sprain (LAS) reported as the most common sports-related injury, followed by high recurrence and development of CAI. Despite impairments and residual functional deficiencies, research shows that nearly 50% of patients return to sport (RTS) within three days after LAS, and 80% within a week. However, there is no published evidence-based criteria to guide a patient’s return to sport (RTS), which may explain the high recurrence. The Ankle-GO™ is a valid and reliable score which aims to score patients to facilitate a safe RTS, while minimising the risk of recurrent injuries.

Purpose: The aim of this study was to assess the efficacy of the Ankle-GO – a new functional score for LAS – to distinguish patients at risk of recurrent LAS within two years after the initial injury.

Methods: The study recruited 64 patients (36 Male/28 Female) from the same clinic from January-August 2021. All participants were recruited within one month of initial LAS, and, following consultation, each participant received personalised rehabilitation for 8 weeks.  Two months after LAS each participant completed the Ankle-GO score. The Ankle-GO score includes two self-reported questionnaires (The Foot and Ankle Ability Measure and the Ankle Ligament Reconstruction-Return to Sport after Injury) and four functional tests (single-leg stance test, modified star excursion balance test, side hop test, and figure-of-8 test). Each item is scored with a maximum total score of 25 points. A lower score indicates lower function. The rate of reinjury was recorded two years following the initial injury. Fifty-four participants (23 Male/31 Female) reported whether they had suffered a recurrent LAS (ie. a new LAS of the same location and type), and the mechanism of the reinjury (ie. contact or non-contact).

Results: Eighteen participants suffered a reinjury (33.3%) with non-contact mechanisms at the two-year follow up. The Ankle-GO score at two-months post-LAS was lower in patients with a recurrent LAS (by 3.7 points) and predicted the risk of reinjury. An Ankle-GO score of less than eight points indicated a 9-times higher risk of recurrent LAS. The same cut-off score (8 points) identified a return to preinjury level of sports four months after LAS. Women and men reported comparable Ankle-GO scores, however women tended to have a 4-times higher risk of recurrent LAS after two years.

Rolling the field forward: The Ankle-GO score offers a new objective criterion for RTS after LAS. This can aid clinical decision making to address the high recurrence rates of LAS. These recurring injuries are often explained by a lack of informed guidance to RTS.

Recently the PAASS framework was published to inform the RTS decision (PAASS: Pain, Ankle impairments, Athlete perception, Sensorimotor control, Sport/functional performance). The Ankle-GO is a step to establishing a specific objective criterion. It should be noted that the Ankle-GO does not include all items related to the PAASS framework. Thus, to gain a broader perspective during clinical assessment the Ankle-GO score may need to be used in conjunction with other clinical assessments.

Question for the researchers: The ANKLE-GO was conducted on participants two months following initial injury, and after a personalized rehabilitation plan had been administered. Do the researchers know how the personalized programme affected the Ankle-GO scores, and do they have a recommended time point for clinicians of when the Ankle-GO could be used? As a result, how may this affect the reinjury risk for patients?

Use of Functional Tests to Predict Ankle Instability Development

Leave a comment

Blog Post Author Biography: Luke Donovan is an Associate Professor at the University of North Carolina at Charlotte in the Department of Applied Physiology, Health, and Clinical Sciences and a certified athletic trainer. Dr. Donovan’s research aims to develop clinical measurement techniques for assessing gait and rehabilitation strategies among patients with chronic ankle instability.

Citation: Shein Lumbroso D, Gottlieb U, Zimmerman DR, Springer S. Functional tests as predictors of ankle instability six months after an acute lateral ankle sprain. J Sports Med Phys Fitness. 2023 Apr;63(4):570-579. doi: 10.23736/S0022-4707.22.14395-1.

Take-to-the-clinic message: Following an acute lateral ankle sprain, balance performance on foam in tandem stance, willingness to perform a single-limb drop landing task, and limb-dominance of the injured ankle were associated with the development of ankle instability 6-months after the initial injury. Clinicians can use these functional tasks and descriptive information to identify patients that may be at a greater risk of experiencing residual symptoms following a lateral ankle sprain. 

Background: Lateral ankle sprains (LAS) are one of the most common musculoskeletal injuries among individuals who are physically activity. It has been estimated that as high as 2 out of 3 individuals who experience a LAS develop a long-term condition characterized by repetitive ankle sprains and/or feelings of instability known as chronic ankle instability (CAI). Identifying individuals at risk of developing CAI as close to the initial injury as possible may help clinicians implement rehabilitative strategies to mitigate the development of the chronic condition. Given the sensorimotor disruption affiliated with CAI, the authors hypothesized that functional tasks that require attention and cognitive demand would be capable of discriminating between individuals who recover from the LAS (copers) vs individuals who do not (ankle instability).

Purpose: The purpose of this study was to prospectively determine whether performance on various functional tasks within 3-weeks of an acute LAS, as well as other demographic information could predict ankle instability outcomes 6-months after the initial injury. Specifically, the authors evaluated performance on the balance error scoring system (BESS) with a dual-cognitive task (Modified-BESS), a single-limb drop landing (SLDL) task and drop-vertical jump (DVJ) task.

Methods: The authors completed a prospective study of individuals who experienced a LAS within 3-weeks of data collection. To be included in the study, participants were required to be between the ages of 18 and 35. In addition, the LAS must have been associated with inflammatory symptoms and caused at least 1-day of interruption in their physical activity. 

Participants who enrolled in the study completed a one-hour data collection session. During this session, participants provided demographic information (age, gender, weight, height, injured leg, dominant leg, and physical activity). Next, participants completed the Modified-BESS, the SLDL, and the DVJ tasks. The Modified-BESS task reflected the previously reported BESS procedures (eyes closed balancing on firm/foam surfaces during double-limb, single-limb and tandem stance), but also included a dual-task component (Backward Digits Span Task). A 40-cm box was used for both the SLDL and DVJ tasks. After completing the data collection sessions, participants were contacted every month to determine whether they re-injured the involved ankle. After 6-months, participants completed the Cumberland Ankle Instability Tool (CAIT) to determine their status as either potential ankle instability or potential copers. Since a patient is not considered to be diagnosed with CAI until 12-months post-injury, the authors found the term ‘potential’ to be most appropriate.  Individuals who scored lower than a 24 on the CAIT and/or experienced any re-sprain during the follow-up period were classified as ‘potential ankle instability’. Participants who scored 24 or greater on the CAIT and did not experience any re-sprains were classified as ‘potential copers’. 

Results: Thirty-three individuals completed the study where 21 of the individuals met the potential ankle instability criteria 6-months following their initial injury. Specific to the main outcome measures, the authors found that for every 1-point increase observed on the Foam-Tandem stance task (part of the Modified BESS) increased the odds of developing ankle instability by 1.5. In addition, participants who were unwilling to complete the SLDL increased their odds of developing ankle instability by 10. Finally, individuals who sustained a LAS to their non-dominant limb had a 6 times greater odds of developing ankle instability when compared to individuals who sprained the ankle on the dominant limb. 

Rolling the field forward: The authors report that various functional tests, as well as demographic information may help clinicians prospectively identify individuals at a heightened risk of developing ankle instability 6-months after the initial injury. Clinicians can incorporate functional tasks as an evaluation tool to help guide the return to activity process.

Question for the researchers: The criteria required participants to be within 3-weeks of the LAS at the time of data collection; however, the time since injury was not reported. Did the authors observe differences in time since ankle sprain among participants? Do the authors have a recommendation as to when clinicians should incorporate these functional tasks as part of their evaluation?

Dual-Task Postural Control Assessment in Individuals with Chronic Ankle Instability

Leave a comment

Blog Post Author Biography: Dr. Matthew Hoch is a Professor in the Department of Athletic Training and Clinical Nutrition and the Senior Associate Director for the Sports Medicine Research Institute at the University of Kentucky. Dr. Hoch’s interests include the investigation of rehabilitation interventions for patients with chronic ankle instability.

Citation: Choi JY, Yoo T, Burcal CJ, Rosen AB. Dual-task differences in individuals with chronic ankle instability: A systematic review with meta-analysis. Gait Posture. 2023; 106(28-33). DOI: 10.1016/j.gaitpost.2023.08.013

Take-to-the-clinic message: The clinical utility of dual-task assessments is continually evolving for an array of sports medicine applications. This meta-analysis sought to examine the ability of dual-task balance and gait assessments to identify performance deficits in people with chronic ankle instability. The literature to date is unable to consistently identify balance or gait deficits using dual-task testing paradigms. However, trends in the data suggest that further examining dual-task assessments utilizing more challenging tasks may yield different insights.

Background: Ligamentous injuries, such as lateral ankle sprains, create complex sensorimotor alterations which often manifest clinically as impairments in postural control and gait. Understanding the interaction of cognitive and sensorimotor function using dual-task assessments has emerged as a potential area to advance care for musculoskeletal conditions. Several studies have applied dual-task balance and gait assessments to assess performance in people with chronic ankle instability. However, the conclusiveness of these studies is difficult to determine without more advanced analysis.

Purpose: The purpose of this systematic review and meta-analysis was to determine differences in dual-tasking assessing gait and postural control in individuals with chronic ankle instability compared to healthy controls.

Methods: This systematic review and meta-analysis searched for articles using multiple relevant databases from inception through 2022. Peer-reviewed observational studies which incorporated single- and dual-task assessments to study motor performance related to gait, balance, or other functional performance outcomes in patients with a history of ankle sprain or chronic ankle instability along with either a healthy reference group or limb were included. Two reviewers applied the 22-item Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement to assess risk of bias and methodological quality of the included studies. Separate, random effect meta-analyses were used to evaluate mediolateral and anteroposterior directions of balance-related outcomes. Additional supporting analyses were applied to evaluate heterogeneity and potential bias from unpublished studies.

Results: A total of nine studies were included in the systematic review. Five studies met the requirements to be included in the meta-analysis. The average STROBE score was 13.3±3.8 indicating a moderate level of study quality. Six the included studies examined dual-task balance while three focused on dual-task gait. The results of the meta-analyses determined that dual-tasking affected postural control outcomes in the control group. However, no differences were identified in the chronic ankle instability group or when comparing healthy and chronic ankle instability groups.

Rolling the field forward: The primary finding of this study was that dual-tasking did not significantly impact postural control outcomes in individuals with chronic ankle instability. However, trends within the available data indicated that studies applying more challenging balance tasks demonstrated trends towards poorer postural control under the dual-task condition. This indicates that future studies and clinical investigations should explore coupling dual-task balance assessments or exercises with more challenging and potentially dynamic balance tasks. This systematic review was only able to identify three studies which examined dual-task gait in chronic ankle instability patients and identified mixed results. The application of dual-task gait requires additional study before strong recommendations can be made. Cumulatively, this study suggests that the field may need to explore different mechanisms to effectively integrate dual-task paradigms into the clinical management for patients with a history of ankle sprain.

Question for the researchers: Many of the included studies used an approach to dual-tasking by adding cognitive load through tasks such as serial subtraction. Do you think utilizing cognitive challenges associated with greater demand on sensory integration or decision making could produce different results in patients with a history of ankle sprain or instability?

Participant-Level Improvements in Health-Related Quality of Life in Those With Chronic Ankle Instability

Leave a comment

Blog Post Author Biography: Dr. Cameron Powden is an Associate Professor in the Department of Athletic Training at the University of Indianapolis. Dr. Powden’s interests include the investigation of clinically relevant interventions for ankle sprains and chronic ankle instability.

Citation: Powden CJ, Koldenhoven RM, Simon JE, et al. Participant-Level Analysis of the Effects of Interventions on Patient-Reported Outcomes in Patients With Chronic Ankle Instability. Journal of Sport Rehabilitation. 2023;32(2):124-132. DOI: 10.1123/jsr.2022-0053

Take-to-the-clinic message: This investigation matches previous literature indicating that the available chronic ankle instability (CAI) interventions are capable of improving self-reported ankle function, global well-being, and injury-related fear at the group level for patients with CAI. This study uniquely assessed individual level responses of patients with CAI to multimodal interventions. Between 13.8% and 53.3% of patients demonstrated improvements, for individual patient-reported outcomes (PROs), that exceeded the minimal detectable change (MDC) of the measure. These findings signify that individually, we may hope to only have about half of our patients have meaningful improvements following intervention.

Background: CAI intervention studies have often focused on improving physical impairments of the ankle complex. Recently, increased emphasis has been placed on the sensory-perceptual impairments associated with CAI. This has resulted in CAI investigations examining the health-related quality of life (HRQoL) through PROs of those with CAI, and the influence of intervention on such PROs. While most studies have assessed self-reported ankle function and through the lens of group level response, there is a need to investigate the impact of interventions on other aspects of HRQoL (such as global well-being and injury-related fears) and the individual level response to treatment within those with CAI.

Purpose: To evaluate improvements in multiple domains of HRQoL, self-reported ankle function, global well-being, and injury-related fear, following multimodal interventions in patients with CAI by using group- and participant-level responder analyses.

Methods: A secondary analysis was completed on a compiled data set of original, participant-level data from seven previously published investigations. Each of the investigations investigated self-reported function in patients with CAI. A total of 136 physically active individuals with self-reported CAI were included in the analysis. These individuals underwent a wide range of multimodal interventions that ranged from 1 to 6 weeks in length, 1 to 12 supervised sessions, and may have included a home intervention component. PROs included were the Foot and Ankle Ability Measure (FAAM) ADL and Sport, Tampa Scale of Kinesiophobia-11 (TSK-11), Fear Avoidance Belief Questionnaire (FABQ) and the Disablement in the modified Physically Active Scale (mDPA) physical summary component (PSC) and the mental summary component (MSC). The research team examined preintervention to postintervention changes in each PRO, as well as effect sizes (ES) and individual-level response rates through changes exceeding published MDCs.

Results: There was significant improvement in ankle-specific function following intervention that was associated with strong ESs and responder rates of 39.0% to 53.3%. There was a significant reduction in injury-related fear following intervention that was associated with moderate to strong effects and responder rates of 13.8% to 51.4%. Finally, there was a significant improvement in global well-being that was associated with strong effects and responder rates of 31.3%. 

Rolling the field forward: This investigation is part of the expanding evidence regarding interventions for those with CAI. It builds on previous multimodal intervention studies by combining various intervention protocols to allow for robust group and individual level analysis. The findings indicate that patients with CAI exhibit holistic HRQoL improvements following varied interventions. This investigation continues the exploration into individual-level responses within the CAI population. Further research is needed to better understand the clinical impact of this new form of analysis. Lastly, to enhance the ability to examine CAI interventions, at the group and individual level, there is a need to identify common clinician-, laboratory-, and patient-oriented outcome measures to allow for robust and comparative analysis.

Question for the researchers: What interventions would be beneficial for CAI patients to enhance aspects of HRQoL? How do researchers and clinicians work to develop common outcome measures to explore? Can the individual level responder analysis be used in clinical practice to examine patient progress?

Impact of Electrical Stimulation with Balance Training in those with CAI

Leave a comment

Blog Post Author Biography: Alan Needle is a Professor at Appalachian State University in the Department of Public Health and Exercise Science and the Department of Rehabilitation Sciences. He has been a certified and licensed athletic trainer since 2007, and conducts research related to assessing and treating neurological impairments in individuals with ankle sprains and chronic ankle instability.

Citation: Gottlieb U, Hayek R, Hoffman JR, Springer S. Exercise combined with electrical stimulation for the treatment of chronic ankle instability – A randomized controlled trial. J Electromyogr Kines. 2024; 74: 102856. https://doi.org/10.1016/j.jelekin.2023.102856.

Take-to-the-clinic message: Combining neuromuscular electrical stimulation with balance exercises improved long-term ankle function in individuals with chronic ankle instability better than therapeutic exercise combined with transcutaneous electrical nerve stimulation. These effects were observed with 12 total treatment sessions over 4-6 weeks, with improvements seen at 6 and 12 months following the intervention.

Background: While therapeutic exercises are a common method for treating individuals with chronic ankle instability (CAI), continued high rates of re-injury and many required treatment sessions creates a need for manners to augment CAI rehabilitation. In individuals with ACL injury, forms of electrical stimulation, including transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES) are often implemented to address neurological changes following injury. TENS and NMES have shown limited efficacy in individuals with CAI; however, it is unclear how they would affect function when combined with therapeutic exercise.

Purpose: This study aimed to assess the short, medium, and long-term effects of balance training in conjunction with NMES or TENS on dynamic postural control and patient-reported outcome measures.

Methods: This study implemented a double-blind randomized controlled trial design conducted in 34 young adults with CAI, following International Ankle Consortium guidelines. Participants were randomized into groups receiving NMES or TENS over the peroneal (fibularis) muscles, while all individuals conducted ankle rehabilitation exercises emphasizing static and dynamic balance. Outcome measures included dynamic balance conducted through a Y-balance test and time-to-stabilization from a single-leg drop jump. Patient function was quantified through the Foot and Ankle Ability Measure (FAAM) activities of daily living (FAAM-ADL) and sport subscales (FAAM-Sport), as well as the Cumberland Ankle Instability Tool (CAIT) and Identification of Functional Ankle Instability (IdFAI) instrument. Participants were instructed on performing the balance exercises and operation of a portable electrical stimulation device, with exercises being conducted during active stimulation. Participants performed 12 total treatment sessions over a period of 4 to 6 weeks, with follow-up immediately, 6-months, and 12-months following the intervention.

Results: Of the 34 individuals who enrolled in the study, 10 out of 14 participants in the NMES group completed the study, while 14 out of 15 participants in the TENS group completed the study. Patient-reported outcome measures improved across both groups at the 12-month follow-up. The NMES group showed improvements beyond the TENS group at 6 and 12 months for the IdFAI and FAAM-Sport measures. Large, but non-significant effects were observed in dynamic balance measures following the intervention.

Rolling the field forward: The researchers in this study explored how augmenting rehabilitation with treatments designed to be neuromodulatory (i.e. improve muscle reflexive actions) may improve clinician- and patient-oriented measures of function. The results showed improved long-term improvements in perceived disease-oriented function in individuals that received exercise and NMES, compared to those receiving exercise and TENS, with these improvements being in disease-oriented outcomes (IdFAI) and those reflecting more challenging function (FAAM-Sport). Importantly, these outcomes were achieved with a program carried out at home.

Question for the researchers: Do the authors feel that balance exercises were the ideal therapeutic exercise to pair with the NMES and TENS interventions? Given the programming needed on the stimulators, what steps would be needed to make this treatment more accessible to the average practicing clinician?

Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries

Leave a comment

Blog Post Author Biography:  Alexandra DeJong Lempke is an Assistant Professor in the Department of Physical Medicine & Rehabilitation at Virginia Commonwealth University, and has a clinical background as a certified athletic trainer. Dr. DeJong Lempke’s research focuses on biomechanical gait assessments of lower limb and ankle injuries through wearable technologies.

Citation: Kenneth C. Lam, Ashley N. Marshall, R. Curtis Bay, Erik A. Wikstrom; Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries: A Report From the Athletic Training Practice-Based Research Network. J Athl Train. 2023; 58 (7-8): 627–634. doi: https://doi.org/10.4085/1062-6050-0111.22

Take-to-the-clinic message: Athletes across the United States self-reported residual pain, dysfunction, and disability at the time of return to sport after a lateral ankle sprain. Clinicians should implement patient-reported outcomes to catch lingering deficits post-ankle sprain to help guide return to sport decision-making.

Background: Lateral ankle sprains (LAS) are extremely common in sport and are often viewed as insignificant injuries with quick recoveries. Most patients return to sport within 10 days of injury, yet it is not clear if athletes may have lingering symptoms that may affect their long-term health. Understanding how patients with ankle sprains feel at the time of return to sport is important to catch residual problems post-injury and help with clinical decision-making.

Purpose: The purpose of this study was to evaluate self-reports of improvement, pain, function, and disability at return to sport after an LAS injury using single-item patient-reported outcome measures.

Methods: This was a retrospective study of 637 patients with LAS who returned to sport within 60 days of injury. The researchers identified LAS cases from electronic medical records within the 2010-2021 Athletic Training Practice-Based Research Network database (AT-PBRN; 69 clinical practice sites with athletic trainers). The research team assessed pertinent patient details, such as school level, gender, and sport. They also assessed patient-reported outcome measures relevant to LAS at initial injury evaluation and at the time of return to sport:

  • Improvement – Global Rating of Change
  • Pain – Numeric Pain Rating Scale
  • Function – Global Rating of Function
  • Disability – Global Rating of Disability

Results: The LAS patients assessed in this study were about equal genders (53.2% males), were primarily secondary school aged (79.1% of the sample) and participated in field or court sports (78% played in either basketball, football, soccer, or volleyball). Most patients returned to sport within 8 days after LAS. About 2 in every 3 patients reported a meaningful improvement at return to sport, or feeling at least “quite a bit better” on the Global Rating of Change scale. Most patients also still felt they had lingering deficits at return to sport, particularly for lingering pain (~65%), reduced function (~86%), and residual disability (~36%).

Rolling the field forward: This research shows that although LAS patients improve after their injury, many patients still feel like they have not fully recovered when they return to their sport. Clinicians should incorporate objective measures like patient-reported outcomes into return-to-sport decisions to best understand deficits related to LAS and advocate for athlete well-being.

Question for the researchers: Do you think that incorporating patient-reported outcome measures specific to the ankle would have uncovered more lingering deficits at return to sport? How do you think external pressures, such as competition timepoints, may have influenced the findings? Would it be possible to determine if repeat injuries occurred among those with lingering deficits, signaling Chronic Ankle Instability?

Association Between Ankle Osteoarthritis, Injury, Surgery, Health Related Quality of Life

Leave a comment

Blog Post Author Biography:  Erik Wikstrom is an Associate Professor and Athletic Trainer at the University of North Carolina at Chapel Hill.  Dr. Wikstrom has spent the last 20+ years studying the consequences of and optimizing interventions for ankle sprains and chronic ankle instability.

Citation:  Paget L, Aoki H, Kemp S, Lambert M, Readhead C, Stokes K, Viljoen W, Reurink G, Tol J, Kerkoffs G, Gouttebarge V.  Ankle osteoarthritis and its association with severe ankle injuries, ankle surgeries and health-related quality of life in recently retired professional male football and rugby players: a cross-sectional observational study.  BMJ Open. 2020;10:e036775.  Doi:10.1136/bmjopen-2020-036775.

Take-to-the-clinic message: A history of severe ankle injury and/or ankle surgery increases a professional footballer’s risk of ankle osteoarthritis (OA).  Educating professional footballers, and all athletes, about the long-term risks of ankle injuries and surgeries will be critical to engaging athletes in ankle injury prevention as well as proper treatment protocols post injury and post operatively.  While the presence of ankle OA did not reduce mental or physical quality of life at the time of assessment (~5 years post retirement, ~36 years of age) the impact of ankle OA later in life has been shown to be more severe in other investigations. 

Background: Ankle injuries are very common in football (soccer) and rugby.  Previous ankle injuries, including ankle sprains, are an important risk factor for ankle OA and the presence of OA, in any joint, has been associated with poor mental and physical health-related quality of life.  However, there is limited data on how ankle injuries and surgeries relate to ankle OA and quality of life in retired football and rugby players.

Purpose: The aims of the study were to determine: i) the prevalence of ankle OA in recently retired professional football and rugby players, ii) the association between ankle injury, ankle surgery, and ankle OA, and iii) differences in mental and physical quality of life between those with and without ankle OA.

Methods: A cross-sectional questionnaire based observational study of recently retired male professional football and rugby players was conducted.  A total of 401 foot and 152 rugby players volunteered and completed the survey (response rate of 56%).  The survey captured demographics, severe ankle injury and ankle surgery history, presence of an ankle OA diagnosis, and quality of life via the PROMIS General Health short form. A logistic regression determined the association between severe ankle injuries and surgeries with ankle OA after adjusting for age and BMI while Mann-Whitney U tests compared quality of life between those with and without ankle OA.

Results: Recently retired professional footballers and rugby players were more likely to have ankle OA than the general population.  Retired football, but not rugby, players with a history of severe ankle injuries and/or ankle surgeries had an increased risk of developing ankle OA compared to their counterparts who did not sustain such injuries or undergo ankle surgeries.  The presence of ankle OA did not reduce mental or physical quality of life of recently retired footballers who were about 5 years post retirement.

Rolling the field forward: This research is part of a growing body of evidence highlighting the long-term negative impact of ankle injuries and surgeries among both athletes and the physically active.  This knowledge helps to further emphasize the need to educate athletes and other stakeholders on the importance of primary and secondary preventive measures for ankle injuries in order to reduce the burden of such injuries after the athlete’s playing career and later in life.

Question for the researchers: Why did the authors choose a whole body questionnaire instead of a region-specific questionnaire such as the Foot and Ankle Ability Measure?  With hindsight, do the authors believe that a more region-specific questionnaire may have been more sensitive to potential quality of life declines in this relatively young sample?