Chronic Ankle Instability: Therapeutic Exercise and Data Analysis

Background and Objectives: Ankle injuries are the most common type of injury in healthy active individuals. If not treated properly, recurrent sprains can lead to a condition of chronic ankle instability (CAI). The present paper examines some subjects with a previous history of acute inversion ankle sprain who have developed a subsequent condition of instability, grouping them according to inclusion criteria and analyzing them through four field tests considered objective by the scientific literature: SEBT test, BEES test, TIBT test, SHT test. The data obtained were stored in order to compare them following a re-education protocol aimed at improving proprioception, balance, walking and strengthening the extrinsic and intrinsic muscles of the foot. per year. The subjects were then divided into two categories: subjects with CAI > 1 year and subjects with CAI ≤ 1 year. A protocol lasting 6 weeks was administered to both groups, trying to work on improving balance in single stance, improving static and dynamic stability, strengthening the gluteus medius and maximus (pelvis stabilizers) and strengthening of the intrinsic muscles of the foot. At the end of the protocol the subjects were all re-evaluated with the same field tests used previously and the data obtained were compared both with the pre-protocol data and with the data measured by the control subjects.

Risk factors for chronic ankle instability after first episode of lateral ankle sprain:A retrospective analysis of 362 cases

Background:Chronic ankle instability(CAI) is a common sequela following an acute lateral ankle sprain(LAS).To treat an acture LAS more effectively and efficiently,it is important to identify patients at substantial risk for developing CAI.This study identifies magnetic resonance imaging(MRI) manifestations for predicting CAI development after a first episode of LAS and explores appropriate clinical indications for ordering MRI scans for these patients.Methods:All patients with a first-episode LAS who received plain radiograph and MRI scanning within the first 2 weeks after LAS from December 1,2017 to December 1,2019 were identified.Data were collected using the Cumberland Ankle Instability Tool at final follow-up.Demographic and other related clinical variables,including age,sex,body mass index,and treatment were also recorded.Univariable and multivariable analyses were performed successively to identify risk factors for CAI after first-episode LAS.Results:A total 131 out of 362 patients with a mean follow-up of 3.0± 0.6 years(mean ± SD;2.0—4.1 years) developed CAI after first-episode LAS.According to multivariable regression,development of CAI after first-episode LAS was associated with 5 prognostic factors:age(odds ratio(OR)=0.96,95% confidence interval(95%CI):0.93-1.00,p=0.032);body mass index(OR=1.09,95%CI:1.02-1.17,p=0.009);posterior talofibular ligament injury(OR=2.17,95%CI:1.05-4.48,p=0.035);large bone marrow lesion of the talus(OR=2.69,95%CI:1.30-5.58,p=0.008),and Grade 2 effusion of the tibiotalar joint(OR=2.61,95%CI:1.39-4.89,p=0.003).When patients had at least 1 positive clinical finding in the 10-m walk test,anterior drawer test,or inversion tilt test,they had a 90.2% sensitivity and 77.4% specificity in terms of detecting at least 1 prognostic factor by MRI.Conclusion:MRI scanning is valuable in predicting CAI after first-episode LAS for those patients with at least 1 positive clinical finding in the10-m walk test,anterior drawer test,and inversion tilt test.Further prospective and large-scale studies are necessary for validation.

Chronic ankle instability is associated with proprioception deficits:A systematic review and meta-analysis

Background:Acute ankle injury causes damage to joint mechanoreceptors and deafferentation and contributes to proprioception deficits in patients with chronic ankle instability(CAI).We aimed to explore whether deficits of proprioception,including kinesthesia and joint position sense(JPS),exist in patients with CAI when compared with the uninjured contralateral side and healthy people.We hypothesized that proprioception deficits did exist in patients with CAI and that the deficits varied by test methodologies.Methods:The study was a systematic review and meta-analysis.We identified studies that compared kinesthesia or JPS in patients with CAI with the uninjured contralateral side or with healthy controls.Meta-analyses were conducted for the studies with similar test procedures,and narrative syntheses were undertaken for the rest.Results:A total of 7731 studies were identified,of which 30 were included for review.A total of 21 studies were eligible for meta-analysis.Compared with the contralateral side,patients with CAI had ankle kinesthesia deficits in inversion and plantarflexion,with a standardized mean difference(SMD)of 0.41 and 0.92,respectively,and active and passive JPS deficits in inversion(SMD=0.92 and 0.72,respectively).Compared with healthy people,patients with CAI had ankle kinesthesia deficits in inversion and eversion(SMD=0.64 and 0.76,respectively),and active JPS deficits in inversion and eversion(SMD=1.00 and 4.82,respectively).Proprioception deficits in the knee and shoulder of patients with CAI were not statistically significant.Conclusion:Proprioception,including both kinesthesia and JPS,of the injured ankle of patients with CAI was impaired,compared with the uninjured contralateral limbs and healthy people.Proprioception varied depending on different movement directions and test methodologies.The use of more detailed measurements of proprioception and interventions for restoring the deficits are recommended in the clinical management of CAI.

The relationship between pain and associated characteristics of chronic ankle instability:A retrospective study

Background'. Up to 74% of people with a history of ankle sprain develop chronic ankle instability (CAI). One commonly reported residualimpairment is ankle pain;however, it has not been included in models or inclusion criteria for CAL We investigated the prevalence of pain inpeople with CAI and the association between presence of pain and other CAI characteristics.Methods'. Retrospective data from 1147 participants with CAI (age 26.6 ± 10.7 years, 59% female) were collated from previous studies that usedthe Cumberland Ankle Instability Tool as an assessment tool. Pain was assessed from Item 1 of the Cumberland Ankle Instability Tool, whichasks participants about ankle pain. Responses were divided into 3 categories: pain during daily activities, pain during moderate/vigorous physicalactivities, and no pain. The presence of pain was analyzed with descriptive statistics, the correlation between pain category and CAI characteris・tics was analyzed by /2 tests and factors associated with each pain category were analyzed by logistic regression.Results'. Among the participants, 60.1% (n = 689) reported ankle pain. Of all participants, 12.4% (n = 142) reported pain during daily activities,47.7% (n = 547) reported pain during moderate/vigorous physical activities, and 39.9% (n = 458) reported no pain. There was a strong associationbetween ankle instability and ankle pain (/2 = 122.2, p < 0.001, OR = 53& 95% confidence interval (CI): 3.84—7.53). Perceived ankle instability,age and unilateral ankle sprains were independently associated with pain (ankle instability: /2 = 43.29, p < 0.001;age: /2 = 30.37,p < 0.001;unilateral ankle sprains: /2 = 6.25, p < 0.05). There was no significant difference in the presence of pain between genders.Conclusion-. The prevalence of pain in people with CAI was high and was related to perceived ankle instability. Number of sprains, age, genderand unilateral or bilateral sprain did not modify this result except for the first pain category (pain during daily activities). There is large gap incurrent knowledge about the impact of pain in people with CAI, and this topic needs further investigation.

Arthroscopic anatomical reconstruction of lateral collateral ligaments with ligament advanced reinforcement system artificial ligament for chronic ankle instability

BACKGROUND Recently,the use of ligament advanced reinforcement system(LARS)artificial ligament,a new graft which has several unique advantages such as no donor-site morbidity,early recovery and no risk of disease transmission which has been a significant breakthrough for anatomical ligament reconstruction.Growing studies suggested that the special design of the LARS ligament with open fibers in its intra-articular part was believed to be more resistant to torsional fatigue and wearing.However,the safety and efficacy of LARS artificial ligament for ankle joint lateral collateral ankle ligament reconstruction has not been defined to date.AIM To evaluate the clinical results of all-arthroscopic anatomical reconstruction of ankle joint lateral collateral ligaments with the LARS artificial ligament for chronic ankle instability.METHODS Twenty-two patients with chronic lateral instability underwent anatomical reconstruction of the lateral collateral ligaments of ankle with LARS artificial ligament.The visual analogue score(VAS),American Orthopaedic Foot and Ankle Society score(AOFAS score)and Karlsson score were used to evaluate the clinical results before and after surgery.RESULTS A total of 22 patients(22 ankles)were followed up for a mean of 12 mo.All patients reported significant improvement compared to their preoperative status.The mean AOFAS score improved from 42.3±4.9 preoperatively to 90.4±6.7 postoperatively.The mean Karlsson score improved from 38.5±3.2 preoperatively to 90.1±7.8 postoperatively.The mean VAS score improved from 1.9±2.5 preoperatively to 0.8±1.7 postoperatively.CONCLUSION All-arthroscopic anatomical reconstruction of the lateral collateral ligaments with LARS artificial ligament achieved a satisfactory surgical outcome for chronic ankle instability.

Correlation of stress radiographs to injuries associated with lateral ankle instability

BACKGROUND Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability.AIM To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability.METHODS A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed.These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings.RESULTS A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology(P=0.008 for tendonitis and P=0.020 for peroneal tendon tears).A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability(P=0.043).CONCLUSION Although valuable in the clinical evaluation of ankle instability,stress radiographs are not an independent predictor of conditions associated with ankle in-stability.

The effect of baduanjin exercise in rehabilitation for functional ankle instability:A study protocol for a randomized controlled pilot trial

Introduction:Patients with functional ankle instability(FAI)have problems with joint control,balance,gait,and postural symmetry.Baduanjin is a type of traditional Chinese exercise that has been shown to be effective in treating many diseases and symptoms.However,to date,the effect of Baduanjin in patients with FAI has not been proved.This pilot trial is an assessor-blinded randomized controlled trial,and its objective is to study the efficacy and safety of Baduanjin on the rehabilitation of patients with FAI.Methods:Seventy-two participants,who are eligible according to specified inclusion and exclusion criteria,will be randomized(in a 1:1 ratio),using a random number table,into two groups:a Baduanjin group and a conventional treatment group.The Baduanjin group will be subjected to the Baduanjin exercise in addition to the conventional treatment therapy.Participants’exercise programs will be implemented for 4 weeks(5 days a week).All participants will be assessed at baseline,and after two and 4 weeks of treatment.The surface electromyography results of the bilateral erector spinae,tibialis anterior,and peroneus longus will be the primary outcomes,while the balance function under different conditions and the level of FAI in daily life measured using the Cumberland Ankle Instability Tool will be the secondary outcomes.Ethics and Dissemination:The trial has been approved by the Research Ethical Committee of Dongzhimen Hospital,the First Affiliated Hospital of Beijing University of Chinese Medicine(no.DZMEC-KY-2019-18),and it will follow the principles of the Consolidated Standards of Reporting Trials statements as well as the Declaration of Helsinki.The findings of this study will be submitted for publication in peer-reviewed journals.The results will also be disseminated to the participants via phone calls or e-mail.

Ankle Arthroscopy,Lateral Ligament Repair and Peroneal Tendon Reefing for Chronic Lateral Ankle Instability:The Triad vs Arthroscopy with Ligament Repair

Peroneal tendon and retinacular pathology contributes to chronic lateral ankle instability. The “gold standard” surgical treatment for chronic lateral ankle instability has been the Brostrom-Gould procedure with its modifications. An ankle arthroscopy is an adjuvant procedure to address any intra-articular pathology. We review our results of two study groups. The first group underwent an ankle arthroscopy and a Brostrom-Gould procedure. The second group (triad) underwent an ankle arthroscopy, the Brostrom-Gould procedure and excision of low lying peroneal muscle belly with tightening of the inferior peroneal retinaculum. The triad technique was performed on 97 patients and results compared to 71 ankle arthroscopies with the Brostrom-Gould procedure. The patients were contacted at a mean follow-up time of 30 months for postoperative ACFAS scores, VAS scores, and overall satisfaction. Patients were also asked to report incidence of ankle sprain recurrence. The average postoperative ACFAS hindfoot and ankle score was 92 for the triad group and 89 for the arthroscopic debridement and Brostrom-Gould group. The average overall satisfaction was 98% in the triad group and 91% in the scope and Brostrom group. There were 4 (4.3%) recurrences in the triad group and 12 (17.6%) in the Brostrom-Gould with scope group. Each group had a similar incidence of wound healing complications. Peroneal tendon and retinacular pathology contributes to continued ankle instability and pain. We believe that the triad procedure is superior to the Brostrom-Gould procedure.

Blood flow restriction training improves the efficacy of routine intervention in patients with chronic ankle instability

As a new means of rehabilitation,blood flow restriction training(BFRT)is widely used in the field of musculoskeletal rehabilitation.To observe whether BFRT can improve the efficacy of routine rehabilitation intervention in patients with chronic ankle instability(CAI).Twenty-three patients with CAI were randomly divided into a routine rehabilitation group(RR Group)and a routine rehabilitationþblood flow restriction training group(RRþBFRT Group)according to the Cumberland Ankle Instability Tool(CAIT)score.The RR Group was treated with routine rehabilitation means for intervention,and the RRþBFRT Group was treated with a tourniquet to restrict lower limb blood flow for rehabilitation training based on routine training.Before and after the intervention,the CAIT score on the affected side,standing time on one leg with eyes closed,comprehensive scores of the Y-balance test,and surface electromyography data of tibialis anterior(TA)and peroneus longus(PL)were collected to evaluate the recovery of the subjects.Patients were followed up 1 year after the intervention.After 4 weeks of intervention,the RRþBFRT Group CAIT score was significantly higher than the RR Group(19.33 VS 16.73,p<0.05),the time of standing on one leg with eyes closed and the comprehensive score of Y-balance were improved,but there was no statistical difference between groups(p>0.05).RRþBFRT Group increased the muscle activation of the TA with maximum exertion of the ankle dorsal extensor(p<0.05)and had no significant change in the muscle activation of the PL with maximum exertion of the ankle valgus(p>0.05).There was no significant difference in the incidence of resprains within 1 year between the groups(36.36%VS 16.67%,p>0.05).The incidence of ankle pain in the RRþBFRT Group was lower than that in the RR Group(63.64%VS 9.09%,p<0.01).Therefore,four-weeks BFRT improves the effect of the routine intervention,and BFRT-related interventions are recommended for CAI patients with severe ankle muscle mass impairment or severe pain.

Effect of biophysical interventions on balance and postural control in patients with ankle instability:A systematic review

Ankle sprains have been one of the most prevalent injuries in active populations.This study aims to summarize the evidence of the effect of the biophysical techniques on balance and postural control in patients with ankle instability,and provide an overview of the application of biophysical interventions in patients with chronic ankle instability(CAI).A systematic search was conducted to include ten articles from 1989 to 2022 in this study.These articles were classified into two categories of balance and postural control.The authors identified a total of 1267 papers and decided to include 10 of them in the systematic review.The Star Excursion Balance Test(SEBT)technique can help clinicians identify balance deficits and postural control,including a comprehensive evaluation of joint stability,strength,and sensorimotor function that would be undetected with single-leg stance static tests.These ten studies involved 481 participants with a mean age of 25.5±6.3 years.The mean duration time of the interventions was 5.4±2.4 weeks and the mean session training duration time was 36.7±17.0 min.The Kinesio taping(KT)and both the soft and semi-rigid orthosis brace may be productive in enhancing dynamic balance assessed by Star Excursion Balance Test.The use of SG may improve perceived ankle instability and dynamic postural control(i.e.,anterior reach during SEBT)of patients with CAI.Regarding the intervention group,no homogeneity results in uncertainties about which techniques of intervention affect balance and postural control.

Effects of electroacupuncture on the proprioception of athletes with functional ankle instability

Objective To observe the efficacy differences between electroacupuncture （EA） and physiotherapy （PT） on the proprioception of athletes with functional ankle instability （FAI）. Methods Fifty athletes with FAI were randomly divided into an EA group and a PT group. The EA group was treated with EA at Jiexi （解溪 ST 41）, Kunlun （昆仑 BL 60）, Qjuxu （丘墟 GB 40） and Ashi points, and the PT group was treated with low frequency electrical stimulation and infrared radiation at medial malleolus and lateral malleolus, thrice each week for consecutive 8 weeks. The joint position sense： active （JPSA）, joint position sense： passive （JPSP） and Kinaesthesia （KT） were assessed at the ankle by use of Biodex System isokinetic dynamometer to test the proprioception before and after the treatment. Results In the EA group, JPSA of 11.09°±3.1° and JPSP of 9.67°±2.8° before the treatment were reduced to 9.14°±4.0° and 6.89°±3.3° respectively after the treatment, and there were statistically significant differences in comparison between pre- and post-treatment （all P〈0.05）. Comparison between the EA group and the PT group, there were significant differences in JPSA and JPSP （all P〈0.05）, no significant difference in KT （P〉0.05）. There were no significant differences in the indices of JPSA, JPSP and KT in the PT group after the treatment than those before the treatment （all P〉0.05）. Conclusion EA can effectively improve the proprioception of athletes with FAI and achieve a better efficacy as compared with the conventional physiotherapy.

Effect of exercise interventions and prophylactic devices on reducing peroneal muscle reaction time by sudden ankle perturbation:A systematic review and meta-analysis

The purpose of this study was to determine whether interventions could improve peroneal reaction time in both healthy and those with injured ankle participants based on a systematic review and meta-analysis.An electronic search of the following database was carried out:MEDLINE,ScienceDirect and SPORTDiscus(1965–2020).Studies utilising sudden ankle inversion to measure peroneal reaction times were selected.28 studies were included for the systematic review,and 18 studies for the meta-analysis.The peroneal reaction time for pre-and post-intervention were compared into two groups,Group 1 was therapeutic exercise intervention,and Group 2 was prophylactic devices.The results showed a statistically significant difference in reduced peroneal reaction time in favour of participants in the exercise group(SMD=0.74,95%CI[1.09,0.39],p<0.001,I^(2)80%),while the prophylactic devices group showed no significant difference between control and intervention group.The effect size measured was 0.81 and 0.31 in Group 1 and Group 2,respectively.Faster peroneal muscle onset reaction time post-intervention,which was found following therapeutic exercise,should be considered for rehabilitation and preventing of ankle sprain injury.

A new method of anterior talofibular ligament reconstruction:Arthroscopically artificial ligament reconstruction with tensional remnant-repair

Purpose:To investigate the clinical effects of arthroscopically artificial ligament reconstruction with tensional remnant-repair in patients who are obese,and/or with demand for highly intensive sports,and/or with poor-quality ligament remnants.Methods:A retrospective case series study was performed on patients treated by arthroscopically anterior talofibular ligament(ATFL)reconstruction with tensional remnant repair technique from January 2019 to August 2021.General data,including demographics,surgical time,and postoperative adverse events,were recorded.The American Orthopaedic Foot and Ankle Society score(AOFAS),foot and ankle ability measure(FAAM),visual analog scale(VAS),and anterior talar translation were measured preoperatively and at 6 weeks,3 months,and 2 years postoperatively.Ultrasonography examination was performed preoperatively and 2 years postoperatively to evaluate the ATFL.Data were analyzed using SPSS 19.0.F test was used to analyze the pre-and postoperative VAS,FAAM,and AOFAS scores.The significance was set at p<0.05.Results:There were 20 males and 10 females among the patients with a mean age of(30.71±5.81)years.The average surgical time was(40.21±8.59)min.No adverse events were observed after surgery.At 2 years postoperatively,the anterior talar translation test showed grade 0 laxity in all patients.VAS score significantly decreased from preoperatively to 6 weeks,3 months,and 2 years postoperatively(p<0.001).Improvement of FAAM score and the AOFAS score from preoperatively to 6 weeks,3 months,and 2 years postoperatively was statistically significant(p<0.001).At 3 months postoperatively,most patients(23/30)could return to their pre-injured activities of daily living status.At 2 years postoperatively,all patients were able to return to their pre-injured activities of daily living status,and almost every patient(18/19)who expected highly intensive sports returned to sports with only 1 obese patient failing to achieve the goal.The ultrasonography examination at 2 years postoperatively showed that there was a linear band structure of soft tissue on the tension-rich fiber tape image from the fibular to the talar attachment sits of ATFL.Conclusion:The novel arthroscopically artificial ligament reconstruction with tensional remnant-repair technique for ATFL achieved satisfactory clinical outcomes in the short and medium term after operation,and allowed early return to pre-injured activities,which could be a reliable option for patients with chronic lateral ankle instability.