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Athletic preinjury function is typically determined via subjective recall; however, obtaining preinjury function before injury occurs should be attempted in order to establish an individual baseline for postinjury comparison. The purpose of this study was to obtain preinjury baseline values for the Foot and Ankle Disability Index (FADI) and Foot and Ankle Disability Index sport version (FADISP), single-leg hop for distance, and Star Excursion Balance Test anterior reach and determine if athletes returned to those values following ankle injury. Out of 41 qualifying injuries, FADI/FADISP scores were significantly reduced at initial injury compared with baseline and all other time points (p p ≥ .98). Subjective and objective preinjury function can be reestablished by discharge from supervised treatment following low-grade ankle injury and maintained for at least 6 months following the cessation of treatment. However, testing metrics should be reviewed on an individual athlete basis, because group data may mask individual patient needs.

Athletic preinjury function is typically determined via patient recall, however obtaining preinjury function before injury occurs should be attempted. The purpose of this study was to obtain preinjury physical function baseline values using the Knee Injury and Osteoarthritis Outcome Score (KOOS), single-leg hop for distance (SLH), and Star Excursion Balance Test (SEBT) anterior reach to determine if athletes return to those baseline values following knee injury. Out of 27 qualifying injuries, KOOS scores were significantly reduced at initial injury compared to baseline and all follow-up points (p ≤ .02). In most instances, baseline KOOS scores were not met at the discharge time point. SLH and SEBT recovered to baseline values by discharge. Injury severity and previous injury created variations in KOOS scores across multiple time points. Subjective and objective preinjury function can be re-established following knee injury but recovery may not occur at discharge from rehabilitation.

Focused Clinical Question: In patients who have sustained a concussion, does vestibular rehabilitation therapy improve clinical symptoms of dizziness and self-reported balance deficits and/or influ...

Balance training typically features as a central component of exercise-based rehabilitation programs for patients with lateral ankle sprain and chronic ankle instability (CAI). The purpose of this study was to conduct a responder/non-responder analysis using existing data to identify factors associated with improvements in dynamic balance performance in CAI patients.Secondary data analysis.Data was used from 73 CAI patients who participated in 6 previous investigations that used the same balance training program. We defined treatment success as a patient exceeding the minimal detectable change score (8.15%) for the posteriomedial direction of the Star Excursion Balance Test (SEBT-PM). Baseline measures of participant and injury demographics, patient-reported function, and dynamic balance were entered into a step-wise logistic regression model to determine the best set of predictors of treatment success.Only 28 out of 73 patients (38.4%) demonstrated a successful improvement in SEBT-PM reach after balance training. Of the variables assessed, SEBT-PM reach distance ≤85.18% and self-reported function activities of daily living score ≤92.55% were significant predictors of treatment success (p0.001). If a patient met both these criteria there was a 70% probability of a successful treatment, indicating a 31.6% increase in the probability of a meaningful balance improvement after completing balance training.Without screening, less than 40% of CAI patients experience a meaningful improvement in SEBT-PM following balance training. Completing a brief pre-treatment assessment of a patient- and clinician-oriented outcome can significantly improve the probability of determining patients with CAI who may improve dynamic balance after balance training.

Lateral ankle sprain injury is the most common musculoskeletal injury incurred by individuals who participate in sports and recreational physical activities. Following initial injury, a high proportion of individuals develop long-term injury-associated symptoms and chronic ankle instability. The development of chronic ankle instability is consequent on the interaction of mechanical and sensorimotor insufficiencies/impairments that manifest following acute lateral ankle sprain injury. To reduce the propensity for developing chronic ankle instability, clinical assessments should evaluate whether patients in the acute phase following lateral ankle sprain injury exhibit any mechanical and/or sensorimotor impairments. This modified Delphi study was undertaken under the auspices of the executive committee of the International Ankle Consortium. The primary aim was to develop recommendations, based on expert (n=14) consensus, for structured clinical assessment of acute lateral ankle sprain injuries. After two modified Delphi rounds, consensus was achieved on the clinical assessment of acute lateral ankle sprain injuries. Consensus was reached on a minimum standard clinical diagnostic assessment. Key components of this clinical diagnostic assessment include: establishing the mechanism of injury, as well as the assessment of ankle joint bones and ligaments. Through consensus, the expert panel also developed the International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST). The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability. This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

Multiple treatment options have been shown to improve dorsiflexion range of motion (DFROM) group means in patients with chronic ankle instability (CAI). However, not all patients with CAI respond equally to these treatments. The aim of this study was to identify predictors of successfully improving dorsiflexion range of motion (DFROM) in patients with CAI. Patients with 92% posttest probabilities. Simple pretreatment assessments can dramatically improve treatment success probability following STARS in patients with CAI.

PURPOSE Current theoretical models suggest the importance of a bidirectional relationship between sensation and production in the vocal tract to maintain lifelong speech skills. The purpose of this study was to assess age-related changes in orofacial skilled force production and to begin defining the orofacial perception-action relationship in healthy adults. METHOD Low-level orofacial force control measures (reaction time, rise time, peak force, mean hold force (N) and force hold SD) were collected from 60 adults (19-84 years). Non-parametric Kruskal Wallis tests were performed to identify statistical differences between force and group demographics. Non-parametric Spearman's rank correlations were completed to compare force measures against previously published sensory data from the same cohort of participants. RESULT Significant group differences in force control were found for age, sex, speech usage and smoking status. Significant correlational relationships were identified between labial vibrotactile thresholds and several low-level force control measures collected during step and ramp-and-hold conditions. CONCLUSION These findings demonstrate age-related alterations in orofacial force production. Furthermore, correlational analysis suggests as vibrotactile detection thresholds increase, the ability to maintain low-level force control accuracy decreases. Possible clinical applications and treatment consequences of these findings for speech disorders in the ageing population are provided.

Objectives Sensory Targeted Ankle Rehabilitation Strategies that stimulate sensory receptors improve postural control in chronic ankle instability participants. However, not all participants have equal responses. Therefore, identifying predictors of treatment success is needed to improve clinician efficiency when treating chronic ankle instability. Therefore, the purpose was to identify predictors of successfully improving postural control in chronic ankle instability participants. Design Secondary data analysis. Methods Fifty-nine participants with self-reported chronic ankle instability participated. The condition was defined as a history of at least two episodes of “giving way” within the past 6 months; and limitations in self-reported function as measured by the Foot and Ankle Ability Measure. Participants were randomized into three treatment groups (plantar massage, ankle joint mobilization, calf stretching) that received 6, 5-min treatment sessions over a 2-week period. The main outcome measure was treatment success, defined as a participant exceeding the minimal detectable change score for a clinician-oriented single limb balance test. Results Participants with ≥3 balance test errors had a 73% probability of treatment success following ankle joint mobilizations. Participants with a self-reported function between limb difference 2.5 errors had a 99% probability of treatment success following plantar massage. Those who sustained ≥11 ankle sprains had a 94% treatment success probability following calf stretching. Conclusions Self-reported functional deficits, worse single limb balance, and number of previous ankle sprains are important characteristics when determining if chronic ankle instability participants will have an increased probability of treatment success.

Background People with diabetes mellitus and peripheral neuropathy (DMPN) often have balance and mobility deficits. Time-to-boundary (TTB) is a parameter of postural control that combines position and velocity center of pressure data. While not previously investigated, assessment of TTB may provide new insight regarding postural control in people with DMPN. Research question Is TTB reduced and related to a measure of mobility in people with DMPN? Methods Thirteen people with DMPN without fall history and 13 healthy matched controls participated in this case-control study. Participants stood in double-limb stance on a force plate. The anterior-posterior and medial-lateral center of pressure position and velocity relative to the boundaries of the base of support were used to calculate TTB (s). Lower values indicate less postural control. Time-to-failure during single-limb stance was a secondary measure of postural control. Time to complete the Timed Up and Go (TUG) was our measure of mobility. Longer TUG times correspond to decreased mobility, strength, and balance. Independent t-tests or Mann-Whitney U tests were conducted to assess group differences. Bivariate correlations between task outcomes were conducted. Results Anterior-posterior TTB and single-limb stance times were shorter in people with DMPN (p ≤ 0.04). TUG times were longer in the DMPN group (p = 0.04). In the DMPN group, inverse relationships were observed between TTB and TUG (anterior-posterior R2 = .34; medial-lateral R2 = .49; both p = 0.01), but not between single-limb stance times and TTB or TUG. Significance TTB was a sensitive measure of postural control in people with DMPN. The detected relationship between TTB and TUG newly establishes TTB as a clinically meaningful indicator of balance and function. Study findings may serve to further guide balance screening and rehabilitation efforts in people with DMPN.

Lateral ankle sprains are the most common injuries sustained during physical activity. The epidemiologic trends associated with chronic ankle instability (CAI) suggest that current rehabilitation approaches may be inadequate. We sought to synthesize best-practices evidence for the rehabilitation of patients with acute ankle sprains and CAI through the integration of emerging paradigms in perception, the dynamics of skill acquisition, and the biopsychosocial model of function, disability, and health. From the best available evidence, 4 key factors emerged for effective treatment and rehabilitation strategies: pain reduction, external ankle support for up to 1 year, progressive return to motion, and coordination training. We combined these factors into a meta-theoretical framework that centers on the perceptual interdependence of the cellular, local, and global functioning levels by linking insights from the body-self neuromatrix, the dynamics of skill acquisition, and the biopsychosocial model. Based on the best-practice recommendations from systematic reviews, ankle-sprain rehabilitation represents a multidimensional phenomenon governed by perception. The impairments, activity limitations, and participation restrictions associated with CAI may be linked to perceptual-interdependence alterations. Pain and edema reduction, the use of external ankle support for up to 1 year, progressive return to motion, and coordination training foster enhanced perceptual interdependence from cells to society. Using the perceptual-interdependence framework for ankle-sprain rehabilitation, we offer new insights for charting the course of effective strategies for enhancing function, reducing disability, and preventing the long-term sequelae associated with CAI.

Single joint kinematic alterations have been identified during gait in those with chronic ankle instability (CAI). The purpose of this study was to compare sagittal plane hip, knee, and ankle kinematics during walking in participants with and without CAI. Twelve individuals with CAI and 12 healthy individuals walked on a treadmill at 1.5 m/s. Three-dimensional kinematics were analyzed using mean ensemble curves and independent t tests. Participants with CAI demonstrated less lower extremity flexion during the absorption phase of stance and the limb placement phase of swing, which may have implications for limb placement at initial contact.

Individuals with chronic ankle instability (CAI) have demonstrated deviations in gait initiation (GI) compared to healthy individuals. However, the intersession reliability of GI measures remains unknown in this population. The objective of this study was to determine the reliability and responsiveness of GI measures between two testing days in those with CAI. Twelve individuals with CAI volunteered. Participants performed barefoot GI on a force plate which captured center of pressure (COP). Data was collected on two separate occasions separated by one week. The GI profile was separated into three phases (S1, S2, and S3). S1 began from the deviation of normal balanced standing to the most posterolateral displacement under the stepping limb. S2 began from the end of S1 to the maximum medial position under the stance foot. S3 began at the end of S2 and continued until the vertical ground reaction force dropped below 100N. COP displacement (cm) was calculated as the sum of resultant vectors of the medial-lateral and anterior-posterior excursions for adjacent COP data points within each phase. The averages of 5 trials were used for analyses. Intraclass correlation coefficients (ICC(2,5)), standard error of measurement, and minimum detectable change (MDC) were calculated to determine reliability and responsiveness. S1, S2, and S3 displacement values were highly reliable between days (ICC(2,5) ≥0.76) with the exception of anterior-posterior S1 and medial-lateral S3. MDC values were relatively small (0.6-2.2cm). GI can be reliably assessed in those with CAI which is important for identifying interventions to alter GI profiles in these individuals.

The impact that visual perturbation has on upright postural stability in an athlete with a concussion has not been established. The present study aimed to characterize the influence that visual perturbation stimuli have on upright balance among athletes with acute concussions.A 2X2X2 repeated measure designed was used.The present study examined the influence visual perturbation has on individuals suffering from an acute concussion. Fourteen participants (7 with a concussion and 7 matched controls) underwent various balance assessments with and without visual perturbation.Overall, athletes with acute concussions demonstrated impairments in balance 24-48 hours following a concussion. However, when assessed using a visual perturbation task, athletes with acute concussions demonstrated improved balance, while control subjects did not show any significant changes during the same visual perturbation task.An athlete's ability to disregard visual perturbation stimuli is imperative for successful participation in sports. Due to the observed alterations in balance when given a visual perturbation task, it is suggested that athletes with acute concussions place more attention on the balance task and may disregard other less meaningful tasks.

The intrinsic muscles of the foot play a critical role in the regulation of absorption and propulsion during dynamic activities. Dysfunction of these may lead to an increased demand on the remaining components within the foot core system to maintain dynamic foot control, leading to a more rapid breakdown of these contributors and those proximal to the foot. Training the intrinsic foot muscles through a systematic progression of isolation via the short foot exercise offers the opportunity to reincorporate their contribution into the foot core system. This article discusses the function of the intrinsic foot muscles, their contributions to dynamic foot control, and a progressive training paradigm.

The Executive Committee of the International Ankle Consortium presents this 2016 position paper with recommendations for information implementation and continued research based on the paradigm that lateral ankle sprain (LAS), and the development of chronic ankle instability (CAI), serve as a conduit to a significant global healthcare burden. We intend our recommendations to serve as a mechanism to promote efforts to improve prevention and early management of LAS. We believe this will reduce the prevalence of CAI and associated sequelae that have led to the broader public health burdens of decreased physical activity and early onset ankle joint post-traumatic osteoarthritis. Ultimately, this can contribute to healthier lifestyles and promotion of physical activity.

Objectives To determine the effects of sensory-targeted ankle rehabilitation strategies on laboratory-oriented measures of single-leg balance in those with chronic ankle instability. Design Non-inferiority randomized controlled trial. Methods Seventy-seven participants with self-reported chronic ankle instability were randomized into 4 treatment groups: Ankle joint mobilization, plantar massage, triceps surae stretching, and a control group. All participants performed 3 trials of single-leg balance on a force plate with eyes open and closed at 3 time points (baseline, immediately after the first treatment, and following 6 treatments over 2 weeks). The spatial (standard deviation), temporal (velocity), and spatiotemporal (time-to-boundary) elements of center of pressure excursions in single-leg balance were evaluated with eyes open and eyes closed at each time point. Immediate and final change scores were calculated for each group from the baseline values on these variables. Results Joint mobilization produced immediate improvements in the temporal elements with eyes open and closed that exceeded the minimum detectable changes for these measures. Plantar massage and triceps surae stretching also enhanced the temporal element after a single treatment, but only with eyes closed. No substantial benefit of any of the interventions were found after 2-weeks of treatment, regardless of treatment group. Conclusions Sensory-targeted ankle rehabilitation strategies substantially improve single-leg postural control after one treatment, but these changes are short-lived. Future research is needed to determine whether combinations of sensory-targeted ankle rehabilitation strategies with other therapeutic interventions potentially improve single-leg balance stability in those with CAI compared to use in isolation. Clinical trial registration number NCT01541657.

Context: Anterior knee pain also known as patellofemoral pain syndrome is a frequently encountered musculoskeletal disorder that worsens with activity. The multifactorial etiology of patellofemoral pain syndrome alters lower-extremity mechanics, increasing patellofemoral joint stresses during weight-bearing tasks. Kinesio and McConnell tapings are often incorporated into the treatment, but their efficacy is still unclear. Objective: To test the efficacy of Kinesio taping, McConnell taping, and sham taping in improving knee mechanics and reducing pain during activity. Design: Cross-sectional design. Setting: Clinical biomechanics laboratory. Participants: Ten participants (age: 20.3 [1.5] y, height: 169.9 [10.4] cm, and mass: 70.17 [13.1] kg) with anterior knee pain and no history of trauma. Intervention: Three trials each of squat, drop jump, and step-down tasks with 3 taping conditions in a counterbalanced order. Main Outcome Measures: Two-dimensional motion capture data of lower-extremities in frontal and sagittal planes were recorded and analyzed using 3 iPads and Spark Motion® application. Pooled effect sizes (Hedges’ g), 95% confidence intervals, and repeated-measures analysis of variance (P Results: Significant reductions in Visual Analog Scale were recorded during squats between tapes (F2.505,12.867 = 3.407, P = .04, Hedges’ g = −0.70). Pairwise comparison showed a decrease in Visual Analog Scale for sham taping (mean difference = 1.14 cm, P = .01) and Kinesio taping (mean difference = 1.54 cm, P = .02) compared with baseline during squats. Conclusions: A variety of taping methods can potentially reduce perceived pain in individuals with patellofemoral pain syndrome, allowing clinicians to perform rehabilitation exercises. Sensory effects associated with short-term taping may be sufficient enough to modify knee pain acutely by afferent input blocking nocioceptive pain before the participants could adapt. Most interestingly, the sham taping technique demonstrated promise for enhancing functional outcomes, depending on the length of the tape and area covered.

Study Design Reliability/Responsiveness study. Objectives To determine the responsiveness of single-limb postural control variables in those with chronic ankle instability (CAI) over 2 weeks without intervention. The variables of interest included the spatial (area of a 95% confidence ellipse) and temporal (average velocity of COP excursions) elements of centre of pressure excursions (COP). Background Single limb balance assessment using an instrumented force plate is one of the most common assessments of sensorimotor dysfunction associated with CAI. These measures have been used in numerous investigations, but the responsiveness of these measures remains unclear. Methods and Measures Seventy-seven participants with self-reported CAI participated in this study. CAI was defined in accordance to the International Ankle Consortium guidelines. All participants performed three 10 s trials of single limb balance with eyes open and eyes closed. After a 2 week period, all participants were reassessed. To analyse the spatial and temporal elements of the COP excursions, the area of a 95% confidence ellipse (cm 2 ) and the average resultant velocity (cm/s) were calculated, respectively. The mean of 3 trials in each condition was used for analysis. To analyse the responsiveness, intraclass correlation coefficients (ICC (2,3) ), the standard error of measure (SEM), and the minimum detectable change (SEM*2 1/2 ) were calculated. Results The spatial element of COP excursions displayed strong responsiveness (eyes open ICC=0.78,SEM=1.7 cm 2 ,MDC=1.9 cm 2 ; eyes closed ICC=0.85,SEM=3.9 cm 2 ,MDC=5.6 cm 2 ). Similarly, the temporal element demonstrated excellent responsiveness (eyes open ICC=0.96,SEM=0.4 cm/s,MDC=0.55 cm/s; eyes closed ICC=0.91,SEM=0.8 cm/s,MDC=1.1 cm/s). Conclusion Based on the results of this study, both the spatial and temporal elements of COP excursions display excellent responsiveness over time in those with CAI. By understanding the normally occurring error associated with these single-limb balance measures, it is possible to determine the clinical meaningfulness of changes associated with injury and rehabilitation in the CAI population. Changes/differences beyond the MDCs associated with this study may be potentially meaningful.

Context: Therapeutic modalities that stimulate sensory receptors around the foot-ankle complex improve chronic ankle instability (CAI)–associated impairments. However, not all patients have equal responses to these modalities. Identifying predictors of treatment success could improve clinician efficiency when treating patients with CAI. Objective: To conduct a response analysis on existing data to identify predictors of improved self-reported function in patients with CAI. Design: Secondary analysis of a randomized controlled clinical trial. Setting: Sports medicine research laboratories. Patients or Other Participants: Fifty-nine patients with CAI, which was defined in accordance with the International Ankle Consortium recommendations. Intervention(s): Participants were randomized into 3 treatment groups (plantar massage [PM], ankle-joint mobilization [AJM], or calf stretching [CS]) that received six 5-minute treatments over 2 weeks. Main Outcome Measure(s): Treatment success, defined as a patient exceeding the minimally clinically important difference of the Foot and Ankle Ability Measure–Sport (FAAM–S). Results: Patients with ≤5 recurrent sprains and ≤82.73% on the Foot and Ankle Ability Measure had a 98% probability of having a meaningful FAAM–S improvement after AJM. As well, ≥5 balance errors demonstrated 98% probability of meaningful FAAM–S improvements from AJM. Patients Conclusions: Each sensory-targeted ankle-rehabilitation strategy resulted in a unique combination of predictors of success for patients with CAI. Specific indicators of success with AJM were deficits in self-reported function, single-limb balance, and

HOCH, M. C., and P. O. MCKEON. Peroneal Reaction Time after Ankle Sprain: A Systematic Review and Meta-analysis. Med. Sci. Sports Exerc., Vol. 46, No. 3, pp. 546–556, 2014. Background: Many studies have examined the temporal response of the peroneal muscles to sudden inversion perturbation in patients with a previous ankle sprain. The purpose of this systematic review with metaanalysis was to synthesize the evidence and determine whether peroneal reaction time (PRT) impairments are present after ankle sprain. Methods: An electronic search was conducted using PubMed Central and EBSCOhost (1965–January 2013). Articles were included if they 1) examined the PRT to sudden inversion perturbation in patients with a history of ankle sprain using a mechanical tilt platform, 2) made comparisons with a control group or contralateral limb with no history of ankle sprain, and 3) provided data for the calculation of effect sizes (ES). In addition to examining the overall effect of sustaining an ankle sprain on PRT, the effects of study design and subject characteristics on PRT were evaluated. Bias-corrected Hedges g ES and 95% confidence intervals (CI) were calculated to make comparisons across studies. Results: A total of 23 studies met the inclusion criteria. The overall ES was 0.67 (95% CI = 0.37–0.95, P G 0.001), indicating that a previous ankle sprain, regardless of study design or subject characteristics, resulted in moderate-to-strong PRT deficits. Further analyses determined studies with patients classified as having chronic ankle instability demonstrated large magnitude PRT deficits in between groups (ES = 0.72, 95% CI = 0.29–1.14, P = 0.001) and side-to-side (ES = 1.24, 95% CI = 0.70–1.79, P G 0.001) comparisons, whereas patients with all other ankle sprain histories demonstrated weak PRT alterations in between groups (ES = j0.21, 95% CI = j1.01 to 0.59, P = 0.61) and side-to-side (ES = 0.21, 95% CI = j0.19 to 0.60, P = 0.31) comparisons. Conclusions: Overall, this meta-analysis determined that individuals with a previous ankle sprain exhibit delayed PRT. Further analyses determined that these deficits are more evident in patients with chronic ankle instability when compared with the contralateral uninvolved limb or a healthy

Lateral ankle sprains are one of the most prevalent lower limb musculoskeletal injuries incurred by individuals who participate in recreational physical activities and sports.1 2 ### Propensity for the development of chronic ankle instability The misconception that acute lateral ankle sprains are innocuous injuries that require little treatment is common across patients and healthcare professionals; indeed, up to 50% of individuals who incur an acute lateral ankle sprain do not seek formal healthcare management for their injury.3 All too often colloquial terms such as a ‘rolled’ ankle or ‘twisted’ ankle are used to describe an acute lateral ankle sprain injury. In reality, acute lateral ankle sprains are rarely ever a ‘simple’ injury. …

Objectives Although ankle sprains have the highest recurrence rate of any musculoskeletal injury, objective estimates of when an athlete is likely to return-to-play (RTP) are unknown. The purpose was to compare time to return-to-play probability timelines for new and recurrent ankle sprains in interscholastic athletes. Design Observational. Methods Ankle sprain data were collected at seven high schools during the 2007–2008 and 2008–2009 academic years. Ankle sprains were categorized by time lost from participation (same day return, next-day return, 3-day return, 7-day return, 10-day return, >22-day return, no return [censored data]). Time-to-event analyses were used to determine the influence of ankle injury history on return-to-play after an ankle sprain. Results 204 ankle sprains occurred during 479,668 athlete-exposures, 163 were new (4 censored) and 35 recurrent (1 censored). There was no significant difference ( p =0.89) between the time-to-event curves for new and recurrent ankle sprains. The median (inter-quartile rage) time to return-to-play for new sprains (inter-quartile range)=3 days (same day to 7 day return); recurrent sprains=next day return (next day to 7 day return). Noteworthy probabilities [95% CIs] include: same day return (new=25.2[18.7, 31.9], recurrent=17.1[6.6, 30.3]); next-day return (new=43.6[35.3, 52.7], recurrent=51.4[32.5, 67.5]); and 7-day return (new=85.9[73.8, 94.4], recurrent=94.3[47.8, 99.5]). Conclusions Previous injury history did not affect time until return-to-play probabilities for ankle sprains. Time until return-to-play analyses that describe the likelihood of return-to-play are useful to clinicians by providing prognostic guidelines and can be used for educating athletes, coaches, and parents about the likely timeframe of being withheld from play.

While research on chronic ankle instability (CAI) and awareness of its impact on society and health care systems has grown substantially in the last 2 decades, the inconsistency in participant/patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalise this evidence to the target patient population. Therefore, there is a need to provide standards for patient/participant selection criteria in research focused on CAI with justifications using the best available evidence. The International Ankle Consortium provides this position paper to present and discuss an endorsed set of selection criteria for patients with CAI based on the best available evidence to be used in future research and study designs. These recommendations will enhance the validity of research conducted in this clinical population with the end goal of bringing the research evidence to the clinician and patient.

Footwear interventions, including shoe insoles and foot orthoses, have the capacity to enhance balance control and gait in older people. This review assessed the evidence for the effect of footwear interventions on static and dynamic balance performance and gait in older populations and explored proposed theories for underlying sensorimotor and mechanical mechanisms. We searched the Medline, EMBASE, CINAHL (the Cumulative Index to Nursing and Allied Health Literature), and AMED databases and conducted hand searches. Of 115 relevant articles screened, 14 met the predefined inclusion criteria. Articles were grouped into one of three categories based on balance task (static balance performance during quiet standing, dynamic balance performance during walking, and dynamic balance performance during perturbed standing or functional tasks) and were scored for methodological quality using the Downs and Black Quality Index tool. Footwear interventions seem to alter underlying strategies controlling static and dynamic movement patterns through a combination of sensorimotor and mechanical mechanisms in older people, including those with chronic sensory and musculoskeletal conditions. Evidence shows a consistent trend toward footwear interventions markedly improving lateral stability measures, which are predictors of falls in the elderly. In-depth investigation of neurophysiologic responses to footwear interventions is necessary to help confirm any sensorimotor adaptations. The long-term effects of footwear interventions on balance, gait, and the prevention of falls in older people require further investigation. (J Am Podiatr Med Assoc 103(6): 516–533, 2013)

Lateral ankle sprains are a common consequence of physical activity. If not managed appropriately, a cascade of negative alterations to both the joint structure and a person's movement patterns continue to stress the injured ligaments. These alterations result in an individual entering a continuum of disability as evidenced by the ~30 % of ankle sprains that develop into chronic ankle instability (CAI) and up to 78 % of CAI cases that develop into post-traumatic ankle osteoarthritis (OA). Despite this knowledge, no significant improvements in treatment efficacy have been made using traditional treatment paradigms. Therefore, the purpose of this review is to (1) provide an overview of the consequences associated with acute lateral ankle sprains, CAI and post-traumatic ankle OA; (2) introduce the patient-, clinician-, laboratory (PCL)-oriented) model that addresses the lateral ankle sprains and their consequences from a constraints perspective; and (3) introduce the dynamic systems theory as the framework to illustrate how multiple post-injury adaptations create a singular pathology that predisposes individuals with lateral ankle sprains to fall into a continuum of disability. The consequences associated with lateral ankle sprains, CAI and ankle OA are similar and encompass alterations to the structure of the ankle joint (e.g. ligament laxity, positional faults, etc.) and the sensorimotor function responsible for proper ankle joint function (e.g. postural control, gait, etc.). Further, the impairments have been quantified across a range of patient-oriented (e.g. self-report questionnaires), clinician-oriented (e.g. bedside measures of range of motion and postural control), and laboratory-oriented (e.g. arthrometry, gait analysis) outcome measures. The interaction of PCL-oriented outcomes is critically important for understanding the phenomenon of CAI across the continuum of disability. Through the integration of all three sources of evidence, we can clearly see that an ankle sprain is more than just a peripheral musculoskeletal pathology with only local consequences. The dynamic systems theory illustrates that the organization of human movement/function is shaped by the interaction of (1) organismic constraints (health of the person); (2) task constraints; and (3) environmental constraints. However, ankle sprains increase the organismic constraints (i.e. changes in joint structure and sensorimotor function) that significantly hinder an individual's function and may be the underlying cause for the continuum of disability associated with CAI. To treat and/or prevent an individual from entering the continuum of disability, greater protection of the ankle ligaments is needed immediately after injury. Subsequent rehabilitation should then focus on goal-oriented rehabilitation (i.e. quality of the movement pattern) rather that task-oriented rehabilitation (i.e. do these exercises). When evaluating patients with ankle inversion trauma and/or instability, it is imperative to remember that an ankle sprain is not simply a local joint injury; it can result in a constrained sensorimotor system that leads to a continuum of disability and life-long consequences such as high injury recurrence and decreased quality of life if not managed properly.

Context:Following joint mobilizations, individuals with chronic ankle instability (CAI) have reported increased self-reported function as measured by the Foot and Ankle Ability Measure (FAAM).Objective:To examine the effect of a 2-week talocrural joint mobilization intervention on individual items of the FAAM in physically active adults with CAI.Participants:Twelve adults with CAI.Intervention:Self-reported function was documented with the FAAM-ADL and FAAM-Sport at preintervention and at 1-week postintervention. The joint mobilization intervention consisted of six treatments over 2 weeks. During each treatment, subjects received 4 minutes of talocrural traction and 8 minutes of Maitland Grade-III anterior-to-posterior talocrural joint mobilization.Main Outcome Measures:Participants completed the 21-item FAAM-ADL and 8-item FAAM-Sport.Results:Signifcant changes were detected between preintervention and 1-week follow-up measures for “Walking on even ground” (p = 0.06), “Going down stairs” (p = 0.07), “Walking on uneven ground” (p = 0.03), “Light to moderate work” (p = 0.06), “Heavy work” (p = 0.03), “Recreational activity” (p = 0.07), “Landing” (p = 0.03), “Low impact activities” (p = 0.07), and “Cutting” (p = 0.02). No signifcant changes were identifed in the other 20 items (p > 0.10).Conclusion:The fndings suggest talocrural joint mobilization may address specifc mechanical and functional impairments associated with the aforementioned tasks during physical activity.

Context: The mechanisms that contribute to the development of chronic ankle instability are not understood. Investigators have developed a hypothetical model in which neuromuscular alterations that stem from damaged ankle ligaments are thought to affect periarticular and proximal muscle activity. However, the retrospective nature of these studies does not allow a causal link to be established. Objective: To assess temporal alterations in the activity of 2 periarticular muscles of the rat ankle and 2 proximal muscles of the rat hind limb after an ankle sprain. Design: Controlled laboratory study. Setting: Laboratory. Patients or Other Participants: Five healthy adult male Long Evans rats (age = 16 weeks, mass = 400.0 ± 13.5 g). Intervention(s): Indwelling fine-wire electromyography (EMG) electrodes were implanted surgically into the biceps femoris, medial gastrocnemius, vastus lateralis, and tibialis anterior muscles of the rats. We recorded baseline EMG measurements while the rats walked on a motor-driven treadmill and then induced a closed lateral ankle sprain by overextending the lateral ankle ligaments. After ankle sprain, the rats were placed on the treadmill every 24 hours for 7 days, and we recorded postsprain EMG data. Main Outcome Measure(s): Onset time of muscle activity, phase duration, sample entropy, and minimal detectable change (MDC) were assessed and compared with baseline using 2-tailed dependent t tests. Results: Compared with baseline, delayed onset time of muscle activity was exhibited in the biceps femoris (baseline = −16.7 ± 54.0 milliseconds [ms]) on day 0 (5.2 ± 64.1 ms; t4 = −4.655, P = .043) and tibialis anterior (baseline = 307.0 ± 64.2 ms) muscles on day 3 (362.5 ± 55.9 ms; t4 = −5.427, P = .03) and day 6 (357.3 ± 39.6 ms; t4 = −3.802, P = .02). Longer phase durations were observed for the vastus lateralis (baseline = 321.9 ± 92.6 ms) on day 3 (401.3 ± 101.2 ms; t3 = −4.001, P = .03), day 4 (404.1 ± 93.0 ms; t3 = −3.320, P = .048), and day 5 (364.6 ± 105.2 ms; t3 = −3.963, P = .03) and for the tibialis anterior (baseline = 103.9 ± 16.4 ms) on day 4 (154.9 ± 7.8 ms; t3 = −4.331, P = .050) and day 6 (141.9 ± 16.2 ms; t3 = −3.441, P = .03). After sprain, greater sample entropy was found for the vastus lateralis (baseline = 0.7 ± 0.3) on day 6 (0.9 ± 0.4; t4 = −3.481, P = .03) and day 7 (0.9 ± 0.3; t4 = −2.637, P = .050) and for the tibialis anterior (baseline = 0.6 ± 0.4) on day 4 (0.9 ± 0.5; t4 = −3.224, P = .03). The MDC analysis revealed increased sample entropy values for the vastus lateralis and tibialis anterior. Conclusions: Manually inducing an ankle sprain in a rat by overextending the lateral ankle ligaments altered the complexity of muscle-activation patterns, and the alterations exceeded the MDC of the baseline data.

Objectives To determine if differences in weight-bearing ankle dorsiflexion range of motion (DFROM) and Star Excursion Balance Test (SEBT) reach distances were present between participants with chronic ankle instability (CAI) and healthy individuals. A secondary objective was to re-examine the relationship between these measures in participants with and without CAI. Design Case–control. Methods Thirty participants with CAI were matched to 30 healthy participants. All participants performed maximum reach in the anterior, posteromedial and posterolateral directions of the SEBT; as well as, the Weight-Bearing Lunge Test (WBLT) to measure DFROM. Dependent variables included maximal DFROM (cm) and normalized SEBT reach distances (%). Independent t -tests were used for group comparisons (a priori p ≤ 0.05). Simple-linear regression examined the relationship between the WBLT and each SEBT direction. Results Significant differences were detected between groups for the WBLT (CAI: 10.73 ± 3.44 cm, healthy: 12.47 ± 2.51 cm; p = 0.03) and anterior reach distance (CAI: 76.05 ± 6.25%, healthy: 80.12 ± 5.88%; p = 0.01). No differences were identified in posteromedial or posterolateral ( p s > 0.70) reach. The WBLT had a significant moderate correlation to anterior reach in both groups ( p s p s > 0.70). Conclusions The results indicate that participants with CAI demonstrated less DFROM and anterior SEBT reach distance compared to health controls. Additionally, both groups demonstrated similar correlations between WBLT and SEBT performance. These findings suggest that participants with CAI have alterations in ankle motion which may negatively influence dynamic postural control; however, the relationship between WBLT and SEBT performance is consistent in those with and without CAI.

We examined the effect of a 2-week anterior-to-posterior ankle joint mobilization intervention on weight-bearing dorsiflexion range of motion (ROM), dynamic balance, and self-reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior-to-posterior joint mobilization treatments over 2 weeks. Weight-bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self-reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre-intervention), 24-48 h following the final treatment (post-intervention), and 1 week later (1-week follow-up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week.

Purpose: The purpose of this study was to investigate the vibrotactile detection thresholds of the plantar cutaneous afferents in subjects with chronic ankle instability compared with healthy control subjects. Methods: Eight adults with chronic ankle instability and eight adults with no ankle sprain history participated. Vibrotactile detection thresholds were assessed using a mechanical stimulus generator system, mounted onto an articulated microscope arm, which delivered sinusoidal vibrotactile inputs to the foot sole at three different sites: head of the first metatarsal, base of the fifth metatarsal, and the heel. Vibrotactile stimulation was delivered at a range of test frequencies that corresponded to the known responsiveness of cutaneous mechanoreceptors in the glabrous skin of the foot sole (10, 25, and 50 Hz). Probe displacement measures (dB) from the last eight displacement trials that contained 50% positive detection responses were averaged to obtain a single threshold estimate for each test frequency and site combination. Results: The results of this study indicate that no significant group-by-site interactions were found for any test frequencies (P > 0.29). However, group main effects were present at the 10-Hz (P < 0.0001), 25-Hz (P = 0.03), and 50-Hz (P = 0.04) test frequencies, indicating that subjects with chronic ankle instability had significantly higher detection thresholds or less sensitivity when stimulation sites were pooled. Conclusions: The results of this study indicate that subjects with chronic ankle instability may demonstrate decreased sensitivity on the plantar surface of the foot. These alterations in plantar cutaneous somatosensation may help explain the underlying mechanisms associated with the prolonged sensorimotor system impairments in postural control and gait commonly exhibited by people with chronic ankle instability

Dosage for the galvanic stimulation for iontophoresis varies. Clinicians manipulate the duration or the amplitude of the current, but it is not known which is more effective. We compared the anesthetic effect of lidocaine HCL (2%) by manipulating the current parameters on 21 healthy volunteers (age: 21.2 ± 4.2, height 170.7 ± 10.2 cm, mass 82.1 ± 19.2 kg). Three conditions were administered in a random order using a Phoresor II® with 2 mL, 2% lidocaine HCL in an iontophoresis electrode. (1) HASD (40 mA*min): High amplitude (4 mA), short duration (10 min), (2) LALD (40 mA.min): Low amplitude (2 mA), long duration (20 min), (3) Sham condition (0 mA, 20 min). Semmes-Weinstein monofilament (SWM) scores were taken pre and post intervention to measure sensation changes. Two-way ANOVA with repeated measures was used to compare sensation. Both iontophoresis treatments: LALD (4.2 ± 0.32 mm) and HASD (4.2 ± 0.52 mm) significantly increased SWM scores, indicating an increase in anesthesia, compared to the sham condition (3.6 ± 0.06 mm) p < 0.05. Neither LALD nor HASD was more effective and there was no difference in anesthesia with the sham. Lidocaine delivered via iontophoresis reduces cutaneous sensation. However, there was no benefit in either a HASD or LALD treatment.

Reduced dorsiflexion is a clinical consideration during the management and rehabilitation of several lower extremity injuries (Landrum et al., 2008;Youdas et al., 2009). Decreases in dorsiflexion are often the result of triceps surae muscle tightness (You et al., 2009) or local arthrokinematic restrictions in posterior talar glide in reference to the ankle mortise (Denegar et al., 2002). Additionally, reduced dorsiflexion has been and identified as a risk factor for sustaining lower extremity injury in military recruits (Pope et al., 1998), male physical education students (Willems et al., 2005), and adult volleyball players (Hadzic et al., 2009). Reduced dorsiflexionmay bemodifiable risk factor for lower extremity injury that can be easily identified during clinical examination. The weight-bearing lunge test (WBLT) is a functional and reliable method to indirectly assess dorsiflexion by measuring the maximal advancement of the tibia over the rearfoot in a weightbearing position (Bennell et al., 1998). Previous investigators (Bennell et al., 1998;Jones et al., 2005;Vicenzino et al., 2006) have reported robust inter-tester and intersession reliability associated with the assessment of WBLT performance in healthy adults along with a robust correlation(r 1⁄4 0.95) between degrees of dorsiflexion range of motion and maximal lunge distance. Furthermore, there is a significant positive correlation between WBLT performance and peak ankle sagittal plane kinematics during walking and running (Barrett & Caulfield, 2009); as well as, reach distance on the Star Excursion Balance Test (Hoch et al., 2010b). Lunge distance asymmetries on the WBLT have been used to identifyweight-bearingdorsiflexion impairments in individualswith

Background: Muscle energy techniques (METs) have been used to treat cervical and thoracic range of motion (ROM) restrictions for over 40 years. Of the trials published on METs, most have examined the effectiveness of METs on ROM in the cervical and thoracic spine. Objectives: The aim of this systematic review was to investigate the sensitivity of cervical and thoracic rotation active range of motion, as an objective measure of function, for detecting changes associated with individuals receiving METs compared to (1) individuals receiving no treatment and (2) individuals receiving manipulation. Methods: Relevant databases were searched from January 1970 up to March 2010. Methodological quality of each included study was assessed using the PEDro scale. Effect sizes (Hedges' g) and their 95% confidence intervals were calculated for active rotation ROM scores between and within the MET and comparison groups. Results: Five randomized controlled trials were included in this review. Four studies address...

The purpose of this study was to examine the effects of a single joint mobilization treatment on dorsiflexion range of motion (DF ROM), posterior talar glide, and dynamic and static postural control in individuals with self-reported chronic ankle instability (CAI). In this randomized cross-over study, subjects received a Maitland Grade III anterior-to-posterior joint mobilization treatment and a control treatment of rest for 5 min. Weight-bearing DF ROM, instrumented posterior talar displacement and posterior stiffness, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and time-to-boundary (TTB) single-limb stance static postural control were assessed on both treatment days in 9 males and 11 females with CAI. The results indicated that the joint mobilization treatment was associated with significantly greater DF ROM (p = 0.01) and TTB in the anterior-posterior direction with eyes-open (p 0.05). This indicates that a single joint mobilization treatment has mechanical and functional benefits for addressing impairments in sensorimotor function and arthrokinematic restrictions commonly experienced by individuals with CAI.

Despite a history of a lateral ankle sprain, some individuals (copers) return to high-level activities (i.e. jumping, pivoting) without recurrent injury or loss of function while others develop chronic ankle instability (CAI). Understanding the differences between these groups may provide insight into the mechanisms of CAI. The objectives of this investigation were to: (1) compare traditional center of pressure [COP], time-to-boundary [TTB], and center of pressure–center of mass [COP–COM] moment arm measures of postural control among controls, established copers, and subjects with CAI and (2) determine the accuracy of these postural control measures at discriminating between established copers and subjects with CAI using receiving operating characteristic curves. 48 subjects (control = 16, coper = 16, CAI = 16) completed two, 30-s trials of single-leg stance on a force plate with their eyes open. Coper and CAI subjects stood on their involved limb while controls stood on a matched limb. The results indicated that mediolateral (p < 0.01) and anteroposterior (p < 0.01) COP velocity was greater in individuals with CAI relative to both copers and controls. Similarly, the peak COP–COM moment arm in the anteroposterior direction (p < 0.01) and the resultant mean COP–COM moment arm (p < 0.01) were increased in individuals with CAI relative to copers. These measures also reached asymptotic significance (p < 0.05) indicating that they successfully discriminated between established copers and individuals with CAI.

Ankle sprains are the most frequently occurring orthopedic injury among the physically active. The number 1 risk factor for suffering an ankle sprain is a history of a previous sprain. Those with a history of ankle sprain often report recurrent bouts of ankle instability and decreased functional capacity. Several mechanical and functional deficits have been identified that may contribute to residual symptoms, sequelae, and functional loss. One is decreased dorsiflexion range of motion. This deficit could predispose the patient to alterations in the ankle axis of rotation, changes in alignment and tracking of bony surfaces, and disrupted proprioceptive input to the sensorimotor system resulting in future ankle sprains or ankle osteoarthritis. Therefore, improving accessory and physiological motion at the talocrural joint is a clinical consideration. Joint mobilizations could be an effective intervention for addressing these alterations during rehabilitation. A joint-mobilization technique known as mobilization with movement (MWM) is of particular interest because this method is the concurrent application of an accessory mobilization with active or passive physiological movement.

Numerous structural and functional alterations have been identified as contributing factors associated with chronic ankle instability (CAI). However, little evidence has connected local instability with self-reported disability or functional loss. The dynamical-systems theory of motor control offers a constraints-led approach for interpreting movement dysfunction based on organismic, task-specific, and environmental factors. These factors interact to organize sensorimotor coordination, creating functional variability to complete movement goals. The International Classification of Functioning, Disability, and Health (ICF) is a model of health, examining function at the level of the body or body parts, the whole person, and the whole person in his or her environment. Combining the fundamental components of both theories offers a model that may recognize the link between instability and function. The purpose of this literature review is to discuss the dynamic systems theory, the ICF model, and how integrating both concepts can be used to address, track, and interpret deficits associated with CAI. Ankles sprains are the most frequently reported injury among physically active individuals.1 Approximately 1 of 3 people who sustain a single ankle sprain experience reoccurring sprains and residual bouts of joint instability known as chronic ankle instability (CAI).2 In addition, ankle sprains are one of the major contributing factors in the development of posttraumatic ankle osteoarthritis.3 High reoccurrence rates and the prevalence of long-term functional loss related to ankle sprains begs the question if current rehabilitation strategies are effective.4 Examining CAI through the integration of the most contemporary theory of motor control and the most contemporary model of health may provide a comprehensive assessment of a person’s overall functional ability and elucidate the link between disability and health in this population. Recent advancement in motor control theory may help interpret how sources of functional loss and disability are manifestations of impaired sensorimotor coordination.5,6 This theory, known as dynamic systems, views movement from a context-specific perspective. The dynamic systems theory aims to explain how we use the freedom of the sensorimotor system to develop strategies to cope with changes in health, task complexity, and the environment.5 Similarly, the International Classification of Functioning, Disability, and Health (ICF) examines the effects of injury and illness on the dynamic nature of function based on quality of life, overall health status, and impairment associated with societal and environmental factors.7 The authors are from the Division of Athletic Training, University of Kentucky, College of Health Sciences, Lexington, Ky. Originally submitted April 6, 2009. Accepted for publication June 4, 2009. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Matt Hoch, MS, ATC, Division of Athletic Training & Rehabilitation Sciences Doctoral Program, University of Kentucky, College of Health Sciences, Wethington Building, Room 206B, 900 South Limestone, Lexington, KY 40536-0200; e-mail: mcho222@uky.edu. doi:10.3928/19425864-2010xxxx-xx

The uses of external support and balance/coordination training have demonstrated to be effective interventions for the prevention of ankle sprains, especially in those who have a history of ankle sprain. The purpose of this article is to identify areas where evidence has been established to support the use of these interventions for the prevention and enhancement of outcomes of lateral ankle sprain. In addition, areas of deficiency in the evidence are discussed related to these interventions. Finally, future directions for clinicians and researchers as per the use of these interventions are discussed.