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The purpose was to compare vertical ground reaction forces and sagittal-plane energy dissipation patterns of the lower extremity during a single-limb jump-stabilization task between individuals with chronic ankle instability who did or did not attend rehabilitation after their initial ankle sprain.Cross-sectional.Research laboratory.Eight participants with chronic ankle instability who did and 12 participants who did not attend rehabilitation were enrolled.Normalized vertical ground reaction force data were used to calculate the average loading rate, time to peak force, and the peak force. Sagittal plane kinematics and joint moments at the ankle, knee, and hip, were used to calculate each joint's relative energy dissipation at 50, 100, 150, and 200 ms post-landing.Participants who attended rehabilitation had a slower average loading rate (P = 0.025) and smaller peak vertical ground reaction force (P = 0.025). The average relative energy dissipation at the knee was higher in those who attended rehabilitation at the 100 ms (P = 0.041), 150 ms (P = 0.046), and 200 ms (P = 0.042) time intervals.Attending rehabilitation after an ankle sprain may have a beneficial effect on jump-stabilization outcomes among individuals with chronic ankle instability.

Athletic trainers’ reasons for selecting or avoiding certain evaluation techniques for patients with an ankle sprain are not fully understood. Such information is important to facilitating evidence-based practice and eliminating barriers. The purpose of this qualitative study was to determine what factors influence athletic trainers’ selection or avoidance of specific outcomes used to determine patients’ return to activity readiness following an ankle sprain. Participants cited many factors that facilitate and inhibit their use of best-practice recommendations and alternative methods for evaluating patients with ankle sprains. Athletic trainers’ should continue to promote facilitators and eliminate barriers to the use of best practices.

Athletic trainers are commonly responsible for clearing patients with ankle sprains for return to activity. What criteria athletic trainers typically use to determine return to activity readiness in this population remains unclear. The purpose of this qualitative study was to examine criteria athletic trainers use to determine patients’ return to activity readiness following an ankle sprain. Participants varied in selected clinician-, patient-rated, and functional assessments for patients with ankle sprains. As many selected methods did not agree with expert consensus recommendations, more work is likely needed to instill best practices for evaluation of patients with ankle sprains.

More than half of individuals with chronic ankle instability (CAI) experience lingering pain from a previous injury. However, there is little empirical evidence investigating the role pain has on health-related quality of life (HRQL). The purpose of this cross-sectional study was to compare physical and psychological HRQL between CAI individuals with and without pain. Group comparisons demonstrated that CAI individuals with pain displayed a lower physical and mental HRQL than those without pain. In addition, CAI individuals with pain reported greater injury-related fear. These findings suggest that persistent pain compounds the negative effect that ankle joint instability has on physical and mental HRQL outcomes. Therefore, conservative therapies should consider multimodal approaches rather than focusing on joint stability alone.

Purpose The aim of the study was to determine if corticospinal excitability and inhibition of the tibialis anterior during single-leg standing differs between individuals with chronic ankle instability (CAI), lateral ankle sprain coper, and healthy controls. Methods Twenty-three participants with CAI, 23 with lateral ankle sprain copers, and 24 healthy control participants volunteered. Active motor threshold (AMT), normalized motor-evoked potential (MEP), and cortical silent period (CSP) were evaluated with transcranial magnetic stimulation while participants performed a single-leg standing task. Results Participants with CAI had significantly longer CSP at 100% of AMT and lower normalized MEP at 120% of AMT compared to lateral ankle sprain copers (CSP100%: p = 0.003, MEP120%: p = 0.044) and controls (CSP 100%: p = 0.041, MEP120%: p = 0.006). Conclusion This investigation demonstrated altered corticospinal excitability and inhibition of the tibialis anterior during a single-leg standing in participants with CAI. Further research is needed to examine effects of corticospinal maladaptations to motor control of the tibial anterior on postural control performance in those with CAI.

Context: Quantifying early posttraumatic ankle osteoarthritis pathogenesis using compositional magnetic resonance (MR) imaging sequences is becoming more common. These MR sequences are often manually segmented to isolate the cartilage of interest before cartilage compositional values (eg, T1ρ or T2) are quantified. However, limited information is available regarding the reliability and reproducibility of manual segmentation for the entire talar dome. Objective: The purpose of this study was to determine the intraobserver and interobserver reliability of manually segmenting T1ρ MR sequences of the entire talar dome and 4 subregions of interest. Design: Descriptive observational study. Setting: Laboratory. Patients or Other Participants: Ten uninjured healthy individuals (4M and 6F: 21.40 [3.03] y, 170.00 [7.93] cm, 71.03 [14.97] kg) participated. Intervention: None. Main Outcome Measures: Two investigators manually segmented 10 T1ρ ankle MR sequences using ITK-SNAP software to calculate T1ρ mean relaxation times and cartilage volumes. Each observer repeated the segmentation twice, with segmentations separated by 1 month. Intraobserver and interobserver reliability was determined using intraclass correlation coefficients (ICCs) with 95% confidence intervals and root mean square coefficient of variations (RMSCVs). Results: For T1ρ relaxation time, intraobserver (ICC = .994–.997, RMSCV = 1.31%–1.51%) and interobserver reliability (ICC = .990, RMSCV = 2.36%) was excellent for the overall talar dome. Excellent intraobserver (ICC = .975–.980, RMSCV = 3.88%–4.59%) and excellent interobserver reliability (ICC = .970, RMSCV = 5.13%) was noted for overall talar cartilage volume. Conclusions: The results demonstrate that manual segmentation of the entire talar dome from a T1ρ MR is reliable and repeatable.

Context Athletic trainers (ATs) inconsistently apply Rehabilitation-Oriented Assessments (ROASTs) when deciding return-to-activity readiness for ankle sprain patients. Facilitators and barriers that are most influential to ATs' assessment selection remain unknown. Objective To examine facilitators of and barriers to ATs' selection of outcome assessments when determining return-to-activity readiness for patients with an ankle sprain. Design Cross-sectional study Setting Online survey Patients or Other Participants We sent an online survey to 10,000 clinically practicing ATs. The survey was accessed by 676 individuals, of which 574 submitted responses (85% completion rate) and 541 respondents met inclusion criteria. Main Outcome Measures The survey was designed to explore facilitators and barriers influencing ATs' selection of pain, swelling, range of motion, arthrokinematics, strength, balance, gait, functional capacity, physical activity level, and patient-reported outcomes assessments when making return-to-activity decisions for patients following an ankle sprain. The survey asked for reasons that participants choose to use, or not use, each measure (e.g., previous education, personal comfort, most appropriate, available/feasible, perceived value). The survey included 12 demographic items that characterized the sample of respondents and were examined as potential influences of the facilitators and barriers. Chi-square analyses identified relationships among participant demographics and facilitators or barriers to assessment selection. Results Selection of each ROAST and non-ROAST was most commonly facilitated by previous education, availability/feasibility, or perceived value. Avoidance of each ROAST was most commonly caused by lack of previous education, a lack of availability/feasibility, or a lack of perceived value. The presence of facilitators and barriers was affected by various demographic variables. Conclusions A variety of facilitators and barriers affect ATs' implementation of expert-recommended assessments when determining return-to-activity readiness in patients with an ankle sprain. Some subpopulations of ATs experience more favorable or prohibitive conditions for assessment use.

Clinical Scenario: Patients with chronic ankle instability (CAI) demonstrate deficits in both sensory and motor function, which can be objectively evaluated through static postural control testing. One intervention that has been suggested to improve somatosensation and, in turn, static postural control is plantar massage. Clinical Question: Does plantar massage improve static postural control during single-limb stance in patients with CAI relative to baseline? Summary of Key Findings: A search was performed for articles exploring the effect of plantar massage on static postural control in individuals with CAI. Three articles were included in this critically appraised topic including 1 randomized controlled trial and 2 crossover studies. All studies supported the use of plantar massage to improve static postural control in patients with CAI. Clinical Bottom Line: There is currently good-quality and consistent evidence that supports the use of plantar massage as an intervention that targets the somatosensory system to improve static postural control in patients with CAI. Future research should focus on incorporating plantar massage as a treatment intervention during long-term rehabilitation protocols for individuals with CAI. Strength of Recommendation: In agreement with the Center of Evidence-Based Medicine, the consistent results from 2 crossover studies and 1 randomized controlled trial designate that there is level B evidence due to consistent, moderate- to high-quality evidence.

The purpose of this study was to compare postural control and neurophysiologic components of balance after dry needling of the fibularis longus between individuals with chronic ankle instability (CAI) and a healthy control group.This quasi-experimental university-laboratory study included 50 adult volunteers-25 with CAI (16 female, 9 male; age: 26 ± 9.42 years; height: 173.12 ± 9.85 cm; weight: 79.27 ± 18 kg) and 25 healthy controls (15 female, 10 male; age: 25.8 ± 5.45 years; height: 169.47 ± 9.43 cm; weight: 68.47 ± 13 kg). Participants completed the Star Excursion Balance Test (SEBT), single-leg balance, and assessment of spinal reflex excitability before and after a single treatment of dry needling to the fibularis longus. The anterior, posterolateral, and posteromedial directions of the SEBT were randomized, and reach distances were normalized to a percentage of leg length. A composite SEBT score was calculated by averaging the normalized scores. Postural control was assessed in single-limb stance on a force plate through time-to-boundary measurements in eyes-open and eyes-closed conditions. Fibularis longus and soleus spinal reflexes were obtained by providing electrical stimulation to the common fibular and tibial nerves with participants lying prone. A Group × Time analysis examined changes in performance, and effect sizes were calculated to assess significance.Significant group × time interactions were identified for composite (P = .006) and posteromedial (P = .017) SEBT scores. Significant time effects for all directions of the SEBT, time to boundary with eyes open, and the mediolateral direction with eyes closed indicate improved postural control following treatment (P.008). Within-group effect sizes for significant time effects ranged from small to large, indicating potential clinical utility.Dry needling demonstrated immediate short-term improvement in measures of static and postural control in individuals with CAI as well as healthy controls.

While knee injury-related pain and functional limitations are common in the physically active, the impact on general health is not well documented. Further, it is not known how much these outcomes differ among individuals that did or did not have surgery following the knee injury, as well as compared to those without knee injury history. We examined differences in health-related quality of life (HRQoL) and general health among patients after knee surgery, knee injury that did not require surgery, and healthy controls. Knee surgery participants reported higher body mass index and lower SF-8 physical component scores than knee nonsurgery and control (p p = .01) than control participants. Patients after knee surgery report more adverse health effects than those with nonsurgically treated knee injuries.

Supervised physical therapy is the recommended care for an ankle sprain. Yet, recent evidence indicates some ankle sprain patients may not receive the recommended care, and instead, prescribed medication to alleviate symptoms. Therefore, the purpose of this study is to describe the percentage of patients reporting to an office-based physician in the U.S. that were or were not referred to physical therapy. Secondly, to describe the percentage of ankle sprain patients with or without medication administered, supplied or ordered.This was a secondary analysis of the cross-sectional National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016. The NAMCS is a multi-stage probability sample survey of visits to office-based physicians. The percentage and associated 95% confidence intervals (CI) were calculated for visits that had a physical therapy referral or a non-steroidal anti-inflammatory drug (NSAID), opioid and non-opioid analgesics administered, supplied or ordered. Sampled data were weighted to produce national-level estimates.A physical therapy referral was given for 16.8% (95% CI: 13.2, 21.2) of ankle sprain visits. Approximately 34.5% (95%CI: 30.5, 38.7) of all ankle sprain visits had a medication administered, supplied or ordered. NSAIDs (72.1%; 95% CI: 66.9,76.8) and opioids (21.0%; 95% CI: 16.3, 26.5) were the two most common types of medication.NSAIDs and opioid medication combined were administered, supplied or ordered more frequently than a referral to physical therapy. These findings provide evidence that suggests many ankle sprain patients reporting to an office-based physician are not receiving the recommended care; physical therapy. Rather, medication appears to be the primary type of care provided to patients. These data are important because it gives a focused area to improve the treatment of an ankle sprain by developing strategies that ensure all patients are provided the recommended care from the onset of entering the healthcare system.

Clinical Scenario: Patients with chronic ankle instability (CAI) commonly display lower levels of self-reported function and health-related quality of life. Several rehabilitation interventions, including manual therapy, have been investigated to help CAI patients overcome these deficits. However, it is unclear if the addition of manual therapy to exercise-based rehabilitation is more effective than exercise-based rehabilitation alone. Clinical Question: Does incorporating manual therapy with exercise-based rehabilitation improve patient-reported outcomes when compared with exercise-based rehabilitation alone? Summary of Key Findings: The literature was searched for articles that examined the difference in outcomes for patients with CAI between manual therapy with exercise-based rehabilitation and exercise-based rehabilitation alone. A total of 3 peer-reviewed randomized controlled trials were identified. Two articles demonstrated improved patient-reported outcome scores following the incorporation of manual therapy with exercise-based rehabilitation, whereas one study found no statistically significant differences between interventions. Clinical Bottom Line: The current evidence suggests that incorporating manual therapy in addition to exercised-based rehabilitation may improve patient-reported outcome scores in patients with CAI. Strength of Recommendation: In accordance with the Strength of Recommendation Taxonomy, the grade of A is recommended due to consistent evidence from high-quality studies.

To examine the factor structure and validity of the Quick-FAAM in individuals with chronic ankle instability (CAI) and those classified as ankle sprain copers (ASC).Cross-sectional.Laboratory.Adult participants were included in both groups based on previously established criteria.The 12-item Quick-FAAM is scored on a 5-point Likert scale were scores are converted to a percentage (0-100%), and greater scores indicate greater function. The Cumberland Ankle Instability Tool (CAIT) is a 9-item scale used to assess impairments in individuals with a history of ankle sprain. Scores range from 0 to 30, and greater scores indicate greater impairment levels. Confirmatory factory analyses, internal consistency, and concurrent validity were determined. Known-groups validity and differences in scores between groups were examined. Alpha was set at p 0.05.The instruments were strongly correlated (r = 0.76, p 0.001), the Quick-FAAM internal consistency remained high (α = 0.94) and the single factor was confirmed. The cutoff score differentiating between the groups was 94.79%.The Quick-FAAM is a valid, shortened version of the FAAM. It also has the ability to discriminate between individuals with CAI and those classified as ASC. The Quick-FAAM should be considered for future use with individuals who have ankle sprain history.

Clinical Question: Do individuals with chronic ankle instability have diminished plantar cutaneous sensation compared to ankle sprain copers or individuals with no history of ankle sprain? Clinical Bottom Line: Patients with chronic ankle instability have diminished plantar cutaneous sensation compared to healthy controls with no history of ankle sprain and ankle sprain copers.

To compare ankle, knee and hip isometric peak torque between young and middle-aged adults with CAI, copers and un-injured controls.Cross-sectional.Research Laboratory.One hundred fifty-six young and middle-aged adults with or without CAI volunteered.A handheld dynamometer measured isometric dorsiflexion, plantarflexion, knee extension, hip extension and hip abduction peak force during a 5 s trial. Average peak torque was calculated and normalized to body mass.A significant Age by Injury interaction for dorsiflexion suggest middle-aged un-injured controls (p 0.001) and copers (p 0.001) had lower isometric peak torque compared to their young adult counterparts, but there were no differences between young and middle-aged adults with CAI (p 0.05). Significant Injury main effects suggest the CAI group had decreased plantarflexion (p = 0.004) and hip extension (p = 0.010) strength compared to un-injured controls, but not copers (p 0.05). Significant Age main effects for all primary outcome measures were observed, indicating peak torque decreased with age (p 0.05).Regardless of age, isometric ankle and hip peak torque was lower in participants with CAI compared to un-injured controls, but not copers. These findings provide further evidence towards the impact of CAI in both young and middle-aged adults.

Context: Patients with ankle sprains are often cared for by athletic trainers (ATs). Expert consensus was previously established for Rehabilitation-Oriented Assessments (ROASTs) that should be included in ankle sprain evaluations. However, it is unknown what methods ATs use to determine return-to-activity readiness following an ankle sprain. Objective: Our purpose was to identify ATs' methods for determining patients' return-to-activity readiness following an ankle sprain and demographic determinants of ATs' methods. Setting: Online survey Study Design: Cross-sectional study Level of Evidence: CEBM Level 1 Participants: We recruited 10,000 clinically practicing ATs. A total of 676 accessed the survey, 574 submitted responses (85% completion rate), and 541 respondents met inclusion criteria. Main Outcome Measures: We distributed an online survey to participants to ask them about their assessment of pain, swelling, range of motion, arthrokinematics, strength, balance, gait, functional capacity, physical activity level, and patient-reported outcomes in deciding return-to-activity. Descriptive statistics characterized participant demographics and frequencies of assessment measures used by ATs. Chi-square analyses identified relationships between demographics and assessment selection. Results: Pain, swelling, range of motion, strength, balance, gait, and functional capacity were assessed by 76–97% of ATs. Arthrokinematics, physical activity level, and patient-reported outcomes were assessed by 25–36% of participants. When selecting specific assessment methods, ATs often did not use recommended ROASTs. ATs with higher degrees, more advance educational programs, employment in non-traditional settings, more clinical experience, and familiarity with expert consensus recommendations were more likely to use ROASTs. Conclusions: Before approving return-to-activity for patients with ankle sprains, some recommended outcomes and assessment methods are not evaluated by ATs. Practice in non-traditional settings, more advanced degrees, more clinical experience, and familiarity with expert-consensus guidelines appear to facilitate use of ROASTs.

Background: Altered reorganization of the sensorimotor system after an initial lateral ankle sprain may lead to a chronic neuromuscular maladaptation in multiple body locations. Specifically, decreased diaphragm contractility has been observed in patients with chronic ankle instability (CAI). The diaphragm has an essential role in postural control. Decreased diaphragm contractility could associate with diminished postural control commonly observed in patients with CAI. However, no study has determined if diaphragm contractility contributes to postural control in a CAI population. Hypothesis: Decreased diaphragm contractility would be negatively associated with static postural control in patients with CAI. Study Design: Cross-sectional study design. Level of Evidence: Level 4. Methods: A total of 15 participants with CAI participated voluntarily. An ultrasonography assessment was performed to quantify the right and left hemidiaphragm thickness at the end of resting inspiration and expiration in supine while breathing quietly. The degree of diaphragm contractility was calculated from the diaphragm thickness. Participants performed 3 eyes-open trials of a 20-second single-leg balance task on the involved limb. Static postural control measures included the center of pressure velocity (COPV) and mean of time-to-boundary (TTB) minima in the anteroposterior (AP) and mediolateral directions. Results: Moderate correlations of the right hemidiaphragm contractility were observed with COPV (ρ = -0.54) and TTB mean minima (ρ = 0.56) ( P < 0.05) in the AP direction. The left hemidiaphragm contractility was moderately correlated with COPV (ρ = −0.56) and TTB mean minima (ρ = 0.60) ( P < 0.05) in the AP direction. Conclusion: Lower diaphragm contractility may be associated with diminished static postural control in the AP direction in patients with CAI. Clinical Relevance: This study highlights diaphragm contractility could be a potential connection with diminished static postural control in patients with CAI. Our data raise new avenues for future exploration including potential beneficial effects of implementation of diaphragm breathing exercises and techniques for restoring static postural control in patients with CAI.

Decreased hip strength is often present in patients with chronic overuse lower extremity injuries. The hand-held dynamometer (HHD) can be used in a clinical setting to quantify hip strength; however, reliability of the device remains unclear. The purpose of this study was to determine the interexaminer and intersession reliability of a HHD when measuring isometric hip abduction (HABD) and external rotation (HER) strength, both with and without a fixed strap. The HHD had good to high reliability regardless of examiner, session, or stabilization when measuring HABD (ICC = 0.885–0.977) and HER (ICC = 0.879–0.958) isometric strength. HHD is an appropriate instrument for measuring isometric hip strength.

Context: High vertical ground reaction force (vGRF) when initiating ground contact during jump landing is one biomechanical factor that may increase risk of anterior cruciate ligament injury. Intervention programs have been developed to decrease vGRF to reduce injury risk, yet generating high forces is still critical for performing dynamic activities such as a vertical jump task. Objective: To evaluate if a jump-landing feedback intervention, cueing a decrease in vGRF, would impair vertical jump performance in a separate task (Vertmax). Design: Randomized controlled trial. Patients (or Other Participants): Forty-eight recreationally active females (feedback: n = 31; 19.63 [1.54] y, 1.6 [0.08] cm, 58.13 [7.84] kg and control: n = 15; 19.6 [1.68] y, 1.64 [0.05] cm, 60.11 [8.36] kg) participated in this study. Intervention: Peak vGRF during a jump landing and Vertmax were recorded at baseline and 4 weeks post. The feedback group participated in 12 sessions over the 4-week period consisting of feedback provided for 6 sets of 6 jumps off a 30-cm box. The control group was instructed to return to the lab 28 days following the baseline measurements. Main Outcome Measures: Change scores (postbaseline) were calculated for peak vGRF and Vertmax. Group differences were evaluated for peak vGRF and Vertmax using a Mann–Whitney U test (P Results: There were no significant differences between groups at baseline (P > .05). The feedback group (−0.5 [0.3] N/kg) demonstrated a greater decrease in vGRF compared with the control group (0.01 [0.3] N/kg) (t(46) = −5.52, P max between groups (feedback = 0.9 [2.2] cm, control = 0.06 [2.1] cm; t(46) = 0.46, P = .64). Conclusions: While the feedback intervention was effective in decreasing vGRF when landing from a jump, these participants did not demonstrate changes in vertical jump performance when assessed during a different task. Practitioners should consider implementing feedback intervention programs to reduce peak vGRF, without worry of diminished vertical jump performance.

Background An ankle sprain is a common musculoskeletal injury treated in the emergency department. Rest, ice, compression, and elevation is the preferred method for managing the symptoms after an ankle sprain. However, many patients receive a medication, such as a nonsteroidal anti-inflammatory drug (NSAID) or an opioid. Objectives We sought to quantify the type of medication(s) used for an ankle sprain and to examine those across age and sex. Methods This was a retrospective review of the publicly available data collected through the National Hospital Ambulatory Medical Care Survey from 2006–2015. All cases with an isolated diagnosis of an ankle sprain were identified. Medication listed for each case was classified based on its detailed category and further explored across all 10 years, age, and sex. Results An estimated 9,052,678 ankle sprain visits occurred in emergency departments from 2006–2015. NSAIDs (56.1%) and opioid analgesic combination (28.4%) were the 2 most common medications. Regardless of the type, most medications were prescribed at discharge. The use of NSAIDs appears to have increased while opioid analgesic combinations decreased in 2010. NSAIDs were the most common medication identified with each age cohort; however, there was no apparent trend in medication for sex. Conclusions NSAIDs are the most common medication used for ankle sprain visits to the ED. Nevertheless, an opioid is also used at a relatively high rate for this injury. These findings provide awareness and opportunity to focus on strategies for reduction of opioid use.

Background The aim of the current study was to assess movement strategies during a single leg balance in chronic ankle instability individuals with unstable postural control strategy identified by Nyquist and Bode analyses in conjunction with sample entropy. Methods Thirty-three participants with self-reported chronic ankle instability and 22 healthy controls performed single-leg eyes closed static balance trials. The sagittal and frontal plane kinematics in the lower extremity and trunk as well as center of pressure trajectories were recorded during three, 20-second trials. The Nyquist and Bode stability analyses, which classify center of pressure waveforms as stable based on the resulting gain and phase margins, were performed to identify the presence of postural control deficits. Sample entropy was implemented to analyze movement strategies during the task. Findings Based on the Nyquist and Bode stability analyses, we included 19 out of 33 chronic ankle instability participants with unstable postural control strategy and 16 out of 22 controls with stable postural control strategy in the final analyses. Chronic ankle instability participants demonstrated a significantly lower sample entropy value in sagittal and frontal plane trunk kinematics and sagittal plane hip kinematics compared to the controls. No between-group differences existed in other kinematic measures. Interpretation The lower sample entropy values in participants with chronic ankle instability indicates that those with postural control deficits may increase reliance on the trunk and hip joint contributions to the maintenance of postural control, reflecting changes in the sensorimotor constraints on movement patterns during the task.

Clinical Scenario: Chronic ankle instability (CAI) is characterized by the residual symptoms and feelings of instability that persist after an acute ankle sprain. Current literature has identified several neuromuscular impairments associated with CAI that may negatively impact sagittal plane knee kinematics during dynamic activities. This has led researchers to begin examining sagittal plane knee kinematics during jump landing tasks. Understanding changes in movement patterns at the knee may assist clinicians in designing rehabilitation plans that target both the ankle and more proximal joints, such as the knee. Clinical Question: What is the evidence to support the notion that patients with CAI have decreased sagittal plane knee flexion angle at initial contact during a jump-landing task compared to healthy individuals? Summary of Key Findings: The literature was systematically searched for level 4 evidence or higher. The search yielded two case-control studies which met the inclusion criteria. Based on limited evidence, there are mixed results for whether sagittal plane knee kinematic at initial contact differ between those with and without CAI. Clinical Bottom Line: There is weak evidence to support changes in sagittal plane knee kinematics at initial contact during a jump landing in individuals with CAI compared to healthy controls. Strength of Recommendation: In accordance with the Centre for Evidence-Based Medicine, a grade of C for level 4 evidence is recommended due to variable findings.

An episode of ‘giving way’ at the ankle is described as excessive inversion of the rearfoot that does not result in an acute ankle sprain and is a unique feature associated with chronic ankle instability (CAI). Limited data currently exists describing the preparatory movement patterns and those that occur during an episode of ‘giving way. Therefore, this case report describes the movement patterns and the forces generated during an unintentional ‘giving way’ captured while an individual with unilateral CAI was performing a single-leg landing task in a research laboratory. The participant completed five single-leg landing trials for both limbs. 3D lower extremity kinematics and kinetics for the sagittal and frontal plane were extracted from 200 ms before and after initial contact (IC). Relative to the affected and un-affected single-leg landing trials, the ‘giving way’ episode was characterized by an increase in plantarflexion and hip extension moments before and after IC. The plantarflexion deviation dissipated (50 ms post-IC) and was followed by excessive ankle inversion. The ankle began to plantarflex again (150 ms post-IC) and the knee extended (50 ms post-IC) and adducted (100 ms post-IC). As a result, the ankle inversion angle plateaued at 150 ms post-IC. Furthermore, large sagittal plane internal joint moments were observed. In the frontal plane, the ‘giving way’ trial generated a large inversion joint moment which was counteracted by a large internal eversion joint moment. The observed plantarflexion and knee extension and adduction after initial contact likely contributed to preventing the ankle from continuing to invert and avoid an ankle sprain.

Chronic ankle instability (CAI) is associated with an increased risk of developing post-traumatic osteoarthritis (PTOA). Altered temporal gait parameters likely contribute to the early development and progression of PTOA in CAI. However, it is unknown if increased clinical symptoms of ankle PTOA influence temporal gait parameters among those with CAI.Compare temporal gait parameters and Ankle Osteoarthritis Scale (AOS) scores between individuals with and without CAI.Thirty CAI participants and 30 healthy-controls volunteered to participate in this retrospective case-control study. Participants completed the Pain and Disability subscales of the AOS. Temporal gait parameters were assessed using a GAITRite® electronic walkway. Participants performed 5 walking trials, which were subsequently combined into a single test. Temporal variables (swing, stance, single-limb support and double-limb support) were extracted for the involved limb and normalized to percent of gait cycle (%GC).Participants with CAI had higher scores on the Pain (P 0.001) and Disability (P = 0.001, d = 0.87[0.33,1.39]) subscales of the AOS. CAI individuals spent less time during swing (P = 0.022]) and single-limb support (P = 0.030) phases and more time during the double-limb support (P = 0.021) phase. Single-limb support time was moderately correlated with higher scores on the AOS pain (r=-0.416, P = 0.011) and disability (r=-0.473 P = 0.004) subscales.Individuals with CAI spend varying times in each phase of the gait cycle compared to uninjured controls. Individuals with CAI may adopt this abnormal gait strategy due to increased clinical symptoms of ankle PTOA. Rehabilitation programs should focus on minimizing the symptoms of ankle PTOA to restore normal temporal gait parameters.

Clinical Scenario: Patients with chronic ankle instability (CAI) who require surgical intervention are often diagnosed with medial ankle osteoarthritis (OA). Lateral joint stabilization procedures are commonly performed among this patient population to restore bony alignment and improve cartilage loading patterns to increase patient-reported function and mitigate further degenerative changes. Focused Clinical Question: What is the available evidence to support joint stabilization procedures on patient-reported outcomes and progression of radiographic OA among patients with CAI who have medial ankle OA? Summary of Key Findings: An electronic search of relevant databases was performed to identify peer-reviewed articles examining preoperative and postoperative clinical outcomes and radiographic evidence of ankle OA. A total of 3 peer-reviewed articles were retrieved. All 3 articles employed a retrospective case series study design. All 3 articles demonstrated improved patient-reported outcomes at the final follow-up visit. Two articles demonstrated that between 11% and 27% of patients progressed in at least 1stage of radiographic ankle OA between the preoperative assessment and the final follow-up visit (40–56 mo). Clinical Bottom Line: Joint stabilization surgery for patients with CAI and medial ankle OA is associated with improved clinical outcomes and a low rate of worsening radiographic joint degeneration within the first 5 years. Strength of Recommendation: Consistent evidence exists across all 3 articles. However, this evidence is based on a low-quality study design. Therefore, there is a grade-C level of evidence to support joint stabilization for improving patient-reported and radiographic outcomes within the first 5 years after surgery for patients with CAI and medial ankle OA.

Context: The Sensorimotor Network (SMN) is often overlooked when determining relationships between postural control and sensorimotor function. SMN functional connectivity (FC) represents the temporal synchrony of functionally linked but spatially divergent brain regions. This study aimed to determine the relationship between SMN-FC and static postural control in older adults with a history of lateral ankle sprain (LAS). Methods Data were analyzed from twenty older adults (mean age = 67.0±4.3yrs; 13 females) with a history of LAS. The SMN was identified from resting-state MRI data. Bilateral thalamic and post-central gyri regions of interest were identified. Balance was assessed for the involved and non-involved limbs via center of pressure velocity (COPV) in the medial-lateral (ML) and anterior-posterior (AP) directions. Results Contralateral SMN-FC was significantly associated with COPV_ML (r = -0.468, P = .05) and COPV_AP (r = -0.530, P = .02) in the non-involved limb. No significant association was observed between involved limb balance and contralateral SMN-FC (COPV_ML: r= -0.081, P = .75; COPV_AP: r = 0.136, P = .60). Conclusion Findings suggest a dissociation between SMN-FC and balance in older adults with a history of LAS. The sensorimotor system’s ability to communicate with itself after injury may have an impact on functional performance, such as balance.

Context: Strength deficits and decreased scores on generic, dimension-specific, and region-specific health-related quality of life (HRQL) PRO measures are commonly documented among individuals with chronic ankle instability (CAI). However, it is unknown if there is a relationship between hip strength and self-reported patient-reported outcome (PRO) scores. Objective: To compare isometric peak torque for hip-extension (H-EXT) and hip-abduction (H-ABD), as well as PRO scores between CAI, lateral ankle sprain copers (LAS copers), and uninjured controls (UC). The secondary purpose was to examine the relationship between isometric hip peak torque and PROs in participants with CAI. Design: Cross-sectional. Setting: Laboratory. Participants: Sixty-three individuals, 45 women (23.02 [3.83] y, 165.91 [7.55] cm, 67.28 [11.95] kg) and 18 men (26.28 [5.43] y, 179.28 [9.01] cm, 83.87 [13.26] kg), grouped as uninjured control (n = 26), LAS coper (n = 15), or CAI (n = 22). Main Outcome Measures: The Foot and Ankle Ability Measure was used to assess region-specific HRQL. The Fear Avoidance Beliefs Questionnaire was used to assess injury-related fear. The Disablement in Physically Active was used to assess global HRQL. Isometric peak torque was measured with a handheld dynamometer for H-EXT and H-ABD. Results: No group differences were observed for H-ABD (P = .34) or H-EXT (P = .35). The CAI group had significantly worse scores on all PROs compared with LAS coper (P P P = .047; ρ = .392) and Foot and Ankle Ability Measure-Sport (P = .013; ρ = .482) and H- EXT and Fear Avoidance Beliefs Questionnaire-Work (P = .007; ρ = −.517). Conclusions: Individuals with CAI displayed lower HRQL based on worse scores on generic, dimension-specific, and region-specific PROs compared with LAS copers and uninjured controls. There were no significant between-group differences for H-EXT and H-ABD isometric peak torque production, but there was a moderate positive relationship between isometric H-ABD and self-reported ankle disability in individuals with CAI.

Objective The objective of this pilot study was to examine the preliminary feasibility and efficacy of in vivo exposure therapy (IVET) to decrease injury-related fear in females with history of ACLR. Design Pilot Study. Setting Sports Medicine Research Laboratory. Participants 12 female participants with history of ACLR ( ≥ 1 year post-operative) were randomized into a 5-week IVET group (n = 6) or 5-week sham physical activity (PA) monitoring group (n = 6). Main outcome measures The independent variables were Group and Time. The dependent variables were the Photographic Series of Sports Activities for ACLR (PHOSA-ACLR) and the Tampa Scale of Kinesiophobia-11 (TSK-11) scores. A Group x Time repeated measures two-way analysis of variance was completed for the PHOSA-ACLR and the TSK-11. Partial η2 effect sizes were used to examine clinically meaningful differences. Results High retention and adherence rates were observed in the intervention group. The PHOSA-ACLR exhibited a significant main effect for Time (F1,10 = 9.92, p = 0.01, partial η2 = 0.50), but not for Group. No statistically significant or clinically meaningful differences were observed for the TSK-11. Conclusion Both groups exhibited decreased injury-related fear for specific functional tasks. Future research should further examine the efficacy of IVET and PA monitoring to decrease injury-related fear in patients after ACLR.

BackgroundDespite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap.MethodsWe used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses.ResultsSixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement—PAASS: Pain (during sport participation and over the last 24 hours), Ankle impairments (range of motion; muscle strength, endurance and power), Athlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), Sensorimotor control (proprioception; dynamic postural control/balance), Sport/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session).ConclusionExpert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury.Trial registration numberACTRN12619000522112.

Context Fear has been cited as the primary barrier to return to sport (RTS) by athletes after anterior cruciate ligament reconstruction (ACLR). Understanding the neural factors that contribute to fear after ACLR may help us to identify interventions for this population. Objective To characterize the underlying neural substrate of injury-related fear in patients after ACLR versus healthy matched control individuals during a picture imagination task (PIT) consisting of sport-specific images and images of activities of daily living (ADL). Design Case-control study. Setting Research laboratory. Patients or Other Participants A total of 24 right-hand–dominant participants (12 with left-sided ACLR and 12 control individuals) were enrolled. Participants underwent full-brain functional magnetic resonance imaging. Main Outcome Measure(s) Functional data were acquired using blood oxygen level–dependent (BOLD) echoplanar imaging. Independent t tests were conducted to identify between-groups differences in BOLD signal changes during all images of the PIT. Paired t tests were computed to examine differences in BOLD signal change between sport-specific and ADL images in the ACLR group. Results Increased activation in the inferior parietal lobule and the mediodorsal thalamus was observed during PIT in the ACLR group. An inability to suppress the default mode network in the ACLR group was noted. The ACLR group exhibited increased activation in the cerebellum and inferior occipital regions during the sport-specific images versus the ADL images, but no other regions of interest demonstrated differences. Conclusion After ACLR, patients may be more predisposed to fear, anxiety, and pain during sport-specific activities and ADLs. Psychosocial interventions may be warranted after ACLR to reduce injury-related fear and mitigate potentially maladaptive neuroplasticity.

Introduction Recent data indicate that patients treated in the emergency department for an ankle sprain receive multiple medications. However, research has not been able to accurately identify all the medications because of study limitations. The primary purpose of this study was to document the type of medication, number of doses, and number of encounters given a prescription at discharge or instructions to take over-the-counter medication. The secondary purpose was to determine if the proportion of encounters given each type of medication varied on the basis of age, sex, race, and year. Methods A retrospective record-based cohort study design was used to review the electronic medical records (N = 1740) of encounters reporting to a southeast academic level 1 trauma center and diagnosed with an ankle sprain between 2013 and 2017. All relevant data were extracted for nonsteroidal anti-inflammatory drugs, muscle relaxants, opioids, and nonopioid analgesics. Results Fifty-eight percent of the encounters had at least 1 dose of medication administered in the emergency department. Twenty-eight percent received a prescription at discharge, and 54.5% were instructed to take over-the-counter medication. Cumulatively, opioids accounted for most of the medications, but the yearly rates declined from 2013 to 2017. A greater proportion of patients aged ≤15 years received nonsteroidal anti-inflammatory drugs or nonopioid analgesics. Most of the patients aged >15 years received opioid medication. Discussion Patients are primarily given an opioid or nonsteroidal anti-inflammatory drug in the emergency department. Fewer patients receive a prescription at discharge but are regularly instructed to take over-the-counter medication.

Context: Static postural control deficits are commonly documented among individuals with chronic ankle instability (CAI). Evidence suggests individuals with CAI who seek medical attention after an ankle sprain report fewer subjective symptoms. It is unknown if seeking medical attention and receiving supervised physical rehabilitation has a similar effect on objective outcomes, such as static postural control. Objective: To compare measures of single-limb postural control and center of pressure (COP) location between participants with CAI who did or did not self-report attending supervised rehabilitation at the time of their first lateral ankle sprain. Design: Retrospective cohort. Setting: Laboratory. Patients (or Other Participants): Twenty-nine participants with CAI who did (n = 14) or did not (n = 15) self-report attending supervised rehabilitation. Intervention(s): Self-reported attendance or not of supervised rehabilitation at the time of initial injury. Main Outcome Measures: Participants performed three 20-second trials of single-limb stance on a force plate with eyes open. Main outcome measures included the COP velocities, time-to-boundary (TTB) absolute minima, mean of TTB minima, and SD of TTB minima in the anteroposterior and mediolateral directions. The spatial distribution of the COP data points under the foot was quantified within 4 equally proportional sections labeled anteromedial, anterolateral, posteromedial, and posterolateral. Results: Participants who reported attending supervised rehabilitation after their initial ankle sprain had a lower COP velocity in the anterior–posterior direction (P = .030), and higher TTB anterior–posterior absolute minimum (P = .033) and mean minima (P = .050) compared with those who did not attend supervised rehabilitation. Conclusions: Among individuals with CAI, not attending supervised rehabilitation at the time of initial injury may lead to worse static postural control outcomes. Clinicians should continue advocating for patients recovering from an acute ankle sprain to seek medical attention and provide continued care in the form of physical rehabilitation.

Several investigators have aimed to predict recurrent injuries following acute ankle sprains, but none has done so in high school or collegiate athletes. The purpose of this study was to determine ...

Context People with chronic ankle instability (CAI) display a lower regional and global health-related quality of life (HRQoL). Examinations of HRQoL outcomes associated with CAI have addressed younger adults, restricting our understanding of the long-term consequences of CAI. Objective To compare ankle regional and global HRQoL in middle-aged participants with and those without CAI. Design Cross-sectional study. Setting Laboratory. Patients or Other Participants A total of 59 middle-aged volunteers, consisting of 18 with CAI (age = 50.2 ± 9.3 years), 17 who were ankle-sprain copers (age = 54.5 ± 8.7 years), and 24 uninjured controls (age = 56.7 ± 10.0 years). Main Outcome Measure(s) Participants completed the Foot and Ankle Disability Index (FADI) and the Patient-Reported Outcomes Measurement Information System Adult Profile. Regional HRQoL was assessed using the FADI Activities of Daily Living and Sport subscales. Global HRQoL was measured using the 43-item Patient-Reported Outcomes Measurement Information System Adult Profile, which contains 7 short forms—Physical Function, Pain Interference, Fatigue, Depression, Sleep Disturbance, Anxiety, and Ability to Participate in Social Roles and Activities. Separate Kruskal-Wallis tests were used to determine between-groups differences. Results Middle-aged participants with CAI had lower scores on both subscales of the FADI than the coper and control groups (all P values Conclusions Middle-aged participants with CAI displayed worse ankle regional and global HRQoL than their age-matched healthy counterparts and copers. These results demonstrated that CAI can affect HRQoL outcomes in middle-aged adults.

Studies have demonstrated that individuals with chronic ankle instability (CAI) have diminished dynamic stability. Jerk-based measures have been utilized to examine dynamic balance because of their ability to quantify changes in acceleration and may provide an understanding of the postural corrections that occur during stabilizing following a jumping task. The purpose of this study was to compare acceleration and jerk following a jump stabilization task between individuals with CAI and the uninjured controls. Thirty-nine participants volunteered to participate in this case control study. Participants completed a jump stabilization task requiring them to jump off 2 feet, touch a marker set at 50% of their maximal vertical jump height, land on a single limb, and maintain balance for 3 seconds. Acceleration was calculated as the second derivative, and jerk was calculated as the third derivative of the displacement of the resultant vector position. Participants with CAI had greater acceleration (mean difference = 55.6 cm/s2; 95% confidence interval, 10.3 to 100.90; P = .017) and jerk compared with the uninjured controls (mean difference = 1804.5 cm/s3; 95% confidence interval, 98.7 to 3510.3; P = .039). These results suggest that individuals with CAI made faster and more frequent active postural control corrections to regain balance following a jump compared with the uninjured controls.

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.

Considering the high recurrent injury rates, athletes may receive clearance for return-to-play (RTP) from a lateral ankle sprain (LAS) before impairments and activity limitations are resolved. The purpose of this study was to examine residual structural and functional impairments and activity limitations at RTP in athletes with a LAS. We found that athletes demonstrated increased ankle ligamentous laxity and reduced self-reported function, dorsiflexion ROM, and dynamic postural control at RTP. Athletes with a LAS likely require more extensive care to resolve impairments and activity limitation before RTP.

The current study aimed to examine postural control performance during a single-leg balance task in elderly individuals with and without a previous history of lateral ankle sprain (LAS). Eighteen adults with a previous history of LAS (mean age = 66 years old) and 12 healthy controls (mean age = 65 years old) were included in the study. Participants performed three trials of a single-leg balance task during an eyes-opened condition for 20-s. Center of pressure (COP) trajectories in the anteroposterior (AP) and mediolateral (ML) directions were collected with a force plate. The following postural control measures were calculated in the AP and ML directions: 1) Sample Entropy (SampEn); 2) Approximate Entropy (ApEn); 3) mean of Time-to-Boundary minima (mean TTB); and 4) COP velocity (COPV). Older-age participants with a history LAS exhibited lower ApEn-AP, SampEn-AP, and SampEn-ML values compared to healthy controls (p 0.05). The information gained from this investigation indicates more rigid postural control patterns, less adaptability, and more difficulty maintaining COP during a single-leg balance task in adults with a previous history of LAS. Our data suggest that there is a need to consider history of musculoskeletal injury when evaluating factors for postural control and fall risk in the elderly. Future investigations are needed to assess the effect of LAS on age-related declines in postural control and discern associations between potential risk factors of fall-related injuries and LAS in an elderly population.

Clinical Scenario: Dorsiflexion range of motion is an important factor in the performance of the Star Excursion Balance Test (SEBT). While patients with chronic ankle instability (CAI) commonly experience decreased reach distances on the SEBT, ankle joint mobilization has been suggested to be an effective therapeutic intervention for targeting dorsiflexion range of motion. Clinical Question: What is the evidence to support ankle joint mobilization for improving performance on the SEBT in patients with CAI? Summary of Key Findings: The literature was searched for articles examining the effects of ankle joint mobilization on scores of the SEBT. A total of 3 peer-reviewed articles were retrieved, 2 prospective individual cohort studies and 1 randomized controlled trial. Only 2 articles demonstrated favorable results following 6 sessions of ankle joint mobilization. Clinical Bottom Line: Despite the mixed results, the majority of the available evidence suggests that ankle joint mobilization improves dynamic postural control. Strength of Recommendation: In accordance with the Centre of Evidence Based Medicine, the inconsistent results and the limited high-quality studies indicate that there is level C evidence to support the use of ankle joint mobilization to improve performance on the SEBT in patients with CAI.

Proximal neuromuscular alterations are hypothesized to contribute to the patient- and disease-oriented deficits observed in CAI individuals. The objective was to compare the efficacy of two 4-week intervention programs with or without proximal joint exercises. Twenty-three individuals with CAI completed this single-blinded randomized controlled trial. Outcome measures included the Star Excursion Balance Test (SEBT) and the Foot and Ankle Ability Measure (FAAM). A time main effect was observed for the FAAM-ADL (p = .013), FAAM-Sport (p = .012), and posteromedial (p = .04) and posterolateral (p = .003) SEBT reach directions. No group main effect or time by group interaction was found. Four weeks of supervised rehabilitation improved self-reported function and dynamic balance in people with CAI.

We draw the reader’s attention to the two-part editorial by Buttner and colleagues.1 2 The authors have made a compelling argument for the need to assess the risk of bias for individual articles included in the systematic reviews. We appreciate Buttner et al 1 2 for using our systematic review as an example of why assessing risk of bias is important and the impact it may have on the findings. Our systematic review summarised therapeutic interventions for improving region-specific patient-reported outcomes (PROs) for patients with chronic ankle instability (CAI).3 A comprehensive literature search was conducted to identify articles based on our inclusion criteria. We did not limit our systematic review to randomised controlled trials (RCTs) because we sought to compile a complete list of all possible treatment options available in the literature. We felt that coalescing all available literature would give clinicians and researchers a single reference source when considering the type of intervention to implement, as well …