Clinical evaluation of manual stress testing, stress ultrasound and 3D stress MRI in chronic mechanical ankle instability

Abstract Background Chronic ankle instability (CAI) arises from the two etiological factors of functional (FAI) and mechanical ankle instability (MAI). To distinguish the contributions of the two etiologies, it is necessary to quantitively assess functional and mechanical deficits. Validated and reproducible assessment of mechanical instability remains a challenge in current research and practice. Physical examination, stress sonography and a novel 3D stress MRI have been used, while stress radiography has been called into question and arthrometry is limited to research purposes. The interaction of these primarily mechanical measurements with the functional and subjective components of CAI are subject to debate. The aim of this study was the evaluation of the clinical and biomechanical preferences of the three different methods in the diagnosis of MAI. Methods In this cross-sectional diagnostic study, we compared three different diagnostic approaches to mechanical ankle instability: (1) manual stress testing (anterior drawer test [ADT] and talar tilt test [TTT]), (2) stress sonography and (3) 3D stress MRI (3SAM) The latter includes quantification of 3D cartilage contact area (CCA) in plantarflexion-supination compared to neutral-null position. We applied these measurements to a cohort of patients suffering from chronic mechanical ankle instability (n = 25) to a matched cohort of healthy controls (n = 25). Perceived instability was assessed using the Cumberland Ankle Instability Tool (CAIT) and Forgotten Joint Score (FJS). Functional deficits were measured using postural sway and the y-Balance test. Results Significant differences between the two groups (single-factor “group” ANOVA, p < 0.05) were found in all of the mechanical assessments with strong effect sizes. Spearman’s correlations were strong for CAIT and manual stress testing (TTT rho = − 0.83, ADT rho = − 0.81), 3D stress MRI (rho = − 0.53) and stress sonography (TTT rho = − 0.48, ADT rho = − 0.44). Furthermore, the correlation between manual stress testing and CCA in the fibulotalar articulation (CCAFT) was strong (rho = 0.54) and the correlations to stress sonography were moderate (ADT rho = 0.47 and TTT rho = 0.43). The calculation of cutoff values revealed a distance of > 5.4 mm increase in ligament length during stress sonography (sensitivity 0.92, specificity 0.6) and > 43% loss of articulating surface in the fibulotalar joint (CCAFT in supination-plantarflexion using 3SAM, sensitivity 0.71, specificity 0.8) as potential cutoff values for diagnosing MAI. Conclusions Manual stress testing showed to be a valuable method of identifying mechanical ankle instability. However, due to is subjective character it may overvalue patient-reported instability as a factor which explains the high correlation to the CAIT-score, but this may also reduce its value in diagnosing the isolated mechanical quality of the joint. Thus, there is a persisting need for objective and reproducible alternatives focusing on MAI. According to our results, 3D stress MRI and stress sonography represent valuable alternatives and may be used to quantitively assess mechanical ankle instability in research and practice. Trial registration German Registry of Clinical Trials # DRKS00016356, registered on 05/11/2019.

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Using Dynamic Portable Ultrasonography for the Diagnosis of Lateral Ankle Instability

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00079 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0007

Author(s):

Jirawat Saengsin ◽

Rohan Bhimani ◽

Go Sato ◽

Noortje Hagemeijer ◽

Bart Lubberts ◽

...

Keyword(s):

Ankle Instability ◽

Rank Correlation ◽

Tilt Test ◽

Lateral Ankle ◽

Anterior Translation ◽

Spearman’S Rank Correlation ◽

Cutoff Values ◽

Lateral Ankle Instability ◽

Talar Tilt ◽

Portable Ultrasonography

Category: Sports; Ankle Introduction/Purpose: Destabilizing injuries to the lateral ligament have relied on physical examination and radiographic stress test for diagnosis, with a focus on anterior translation and tilting of the talus relative to the tibial bone. Portable ultrasonography (PUS) has increasingly been used in the clinical setting, allowing dynamic and non-invasive evaluation. The primary aim of this study was to assess the anterior translation and tilting of the talus with PUS in various stages of lateral ankle ligamentous injury. Secondary, we compared the instability values measured with PUS with those measured on fluoroscopy. Third, we aimed to determine the optimal cutoff values of the PUS that distinguish stable from unstable state. Methods: 8 fresh-frozen cadaveric specimens underwent PUS and fluoroscopic evaluation for lateral ankle stability. The assessment was done with all ligaments intact and later with sequential transection of the anterior-talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior-talofibular ligament (PTFL). In all scenarios, 2 loading conditions were considered; 1) Performing the anterior drawer test under 50N and 80N of force, anterior translation was measured with PUS and fluoroscopy; 2) Performing the talar tilt test under 1.7Nm of torque, the lateral clear space (the distance between the fibular tip and lateral process of the talus) was measured with PUS, and the talar tilt angle was measured with fluoroscopy (Figure1). Pearson’s and Spearman’s rank correlation was used to determine the correlation. Youden’s J statistic was used to determine the optimal cutoff values for the PUS to distinguish intact or ATFL injury versus ATFL-CFL or ATFL-CFL-PTFL injuries under various loading conditions. Results: Strong positive correlations were found between PUS and fluoroscopic measurements (Pearson correlation:r=0.78- 0.85). PUS and fluoroscopic measurements during anterior translation and talar tilt test increased as additional ligaments were transected (Spearman’s rank correlation: anterior translation; r=0.74, p < 0.001: talar tilt; r=0.81, p<0.001). Inter-rater and intra- rater reliability for PUS and fluoroscopic measurements were all excellent (ICCs >=0.8). The optimal PUS cutoff values for distinguishing intact or ATFL injury from ATFL-CFL or ATFL-CFL-PTFL injuries were >=3.40mm (sensitivity 87.5%, specificity 81.25%) and >=4.78mm (sensitivity 87.5%, specificity 81.25%) of anterior talar translation under 50N and 80N of force respectively, as well as >=3.09mm (sensitivity 75%, specificity 93.75%) of the lateral clear space under 1.7Nm of torque. Conclusion: Portable ultrasonography for the diagnosis of lateral ankle instability was strongly correlated with fluoroscopic findings, and thus, can be a valuable diagnostic tool at the point of care. We recommend future in vivo research to investigate the accuracy of this new ultrasound application in a clinical setting.

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Effects of Hip Strengthening on Neuromuscular Control, Hip Strength, and Self-Reported Functional Deficits in Individuals With Chronic Ankle Instability

Journal of Sport Rehabilitation ◽

10.1123/jsr.2016-0143 ◽

2018 ◽

Vol 27 (4) ◽

pp. 364-370 ◽

Cited By ~ 4

Author(s):

Brent I. Smith ◽

Denice Curtis ◽

Carrie L. Docherty

Keyword(s):

Strength Training ◽

Ankle Instability ◽

External Rotation ◽

Neuromuscular Control ◽

Training Group ◽

Balance Test ◽

Patient Reported ◽

Hip Abduction ◽

Hip Strengthening ◽

Rotation Strength

Context: Deficits in ankle and hip strength and lower-extremity postural control are associated with chronic ankle instability (CAI). Following strength training, muscle groups demonstrate increased strength. This change is partially credited to improved neuromuscular control, and many studies have investigated ankle protocols for subjects with CAI. The effects of isolating hip musculature in strength training protocols in this population are not well understood. Objective: To examine the effects of hip strengthening on clinical and self-reported outcomes in patients with CAI. Design: Prospective randomized controlled clinical trial. Setting: Athletic training facility. Participants: Twenty-six participants with CAI (12 males and 14 females; age = 20.9 [1.5] y, height = 170.0 [12.7] cm, and mass = 77.5 [17.5] kg) were randomly assigned to training or control groups. Intervention: Participants completed either 4 weeks of supervised hip strengthening (resistance bands 3 times a week) or no intervention. Main Outcome Measures: Participants were assessed on 4 clinical measures (Star Excursion Balance Test in the anterior, posteromedial, and posterolateral directions; Balance Error Scoring System; hip external rotation strength; and hip abduction strength) and a patient-reported measure (the Foot and Ankle Ability Measure activities of daily living and sports subscales) before and after the 4-week training period. Results: The training group displayed significantly improved posttest measures compared with the control group for hip abduction strength (training: 446.3 [77.4] N, control: 314.7 [49.6] N, P < .01); hip external rotation strength (training: 222.1 [48.7] N, control: 169.4 [34.6] N, P < .01); Star Excursion Balance Test reach in the anterior (training: 93.1% [7.4%], control: 90.2% [7.9%], P < .01), posteromedial (training: 96.3% [8.9%], control: 88.0% [8.8%], P < .01), and posterolateral (training: 95.4% [11.1%], control: 86.6% [9.6%], P < .01) directions; Balance Error Scoring System total errors (training: 9.9 [6.3] errors, control: 21.2 [6.3] errors, P < .01); and the Foot and Ankle Ability Measure-sports score (training: 88.0 [12.6], control: 84.8 [10.9], P < .01). Conclusion: Improved clinical and patient-reported outcomes in the training group suggest hip strengthening is beneficial in the management and prevention of recurrent symptoms associated with CAI.

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Four-Week Ankle-Rehabilitation Programs in Adolescent Athletes With Chronic Ankle Instability

Journal of Athletic Training ◽

10.4085/1062-6050-41-19 ◽

2020 ◽

Vol 55 (8) ◽

pp. 801-810

Author(s):

M. Spencer Cain ◽

Rebecca J. Ban ◽

Yu-Ping Chen ◽

Mark D. Geil ◽

Benjamin M. Goerger ◽

...

Keyword(s):

Ankle Instability ◽

Chronic Ankle Instability ◽

Control Group ◽

Balance Test ◽

Rehabilitation Programs ◽

Patient Reported ◽

Hop Test ◽

Star Excursion Balance Test ◽

Platform System ◽

Clinical Measures

Context Researchers have shown that rehabilitation programs incorporating resistance-band and balance-board exercises are effective for improving clinical measures of function and patient-reported outcomes in individuals with chronic ankle instability (CAI). However, whether combining the 2 exercises increases improvement is unknown. Objective To determine the effectiveness of 3 rehabilitation programs on clinical measures of balance and self-reported function in adolescent patients with CAI. Design Randomized controlled clinical trial (Trail Registration Number: ClinicalTrails.gov: NCT03447652). Setting High school athletic training facilities. Patients or Other Participants Forty-three patients with CAI (age = 16.37 ± 1.00 years, height = 171.75 ± 12.05 cm, mass = 69.38 ± 18.36 kg) were block randomized into 4 rehabilitation groups. Intervention(s) Protocols were completed 3 times per week for 4 weeks. The resistance-band group performed 3 sets of 10 repetitions of ankle plantar flexion, dorsiflexion, inversion, and eversion with a resistance band. The Biomechanical Ankle Platform System group performed 5 trials of clockwise and counterclockwise rotations, changing direction every 10 seconds during each 40-second trial. The combination group completed resistance-band and Biomechanical Ankle Platform System programs during each session. The control group did not perform any exercises. Main Outcome Measure(s) Variables were assessed before and after the intervention: time-in-balance test, foot-lift test, Star Excursion Balance Test, side-hop test, figure-8 hop test, Foot and Ankle Ability Measure, and Cumberland Ankle Instability Tool. We conducted 4 separate multivariate repeated-measures analyses of variance, followed by univariate analyses for any findings that were different. Results Using the time-in-balance test, foot-lift test, Star Excursion Balance Test (medial, posteromedial, and posterolateral directions), and figure-8 hop test, we detected improvement for each rehabilitation group compared with the control group (P < .05). However, no intervention group was superior. Conclusions All 3 rehabilitation groups demonstrated improvement compared with the control group, yet the evidence was too limited to support a superior intervention. Over a 4-week period, either of the single-task interventions or the combination intervention can be used to combat the residual deficits associated with CAI in an adolescent patient population.

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Short-Term Effects of Balance Training with Stroboscopic Vision for Patients with Chronic Ankle Instability: A Single-Blinded Randomized Controlled Trial

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18105364 ◽

2021 ◽

Vol 18 (10) ◽

pp. 5364

Author(s):

Kyung-Min Kim ◽

María D. Estudillo-Martínez ◽

Yolanda Castellote-Caballero ◽

Alejandro Estepa-Gallego ◽

David Cruz-Díaz

Keyword(s):

Randomized Controlled Trial ◽

Outcome Measures ◽

Ankle Instability ◽

Controlled Trial ◽

Balance Training ◽

Chronic Ankle Instability ◽

Balance Test ◽

Training Groups ◽

Randomized Controlled ◽

Star Excursion Balance Test

Chronic Ankle Instability (CAI) is one of the most common musculoskeletal dysfunctions. Stroboscopic vision (SV) training has been deemed to enhance somatosensorial pathways in this population group; nevertheless, until recently no studies have addressed the additional effects of this treatment option to the traditional therapeutic approach. Methods: To evaluate the effectiveness of a partial visual deprivation training protocol in patients with CAI, a randomized controlled trial was carried out. Patients with CAI (n = 73) were randomized into either a balance training, SV training, or a control (no training) group. For participants assigned into training groups, they received 18 training sessions over 6 weeks. The primary outcome was dynamic balance as measured by the Star Excursion Balance Test assessed at baseline and after 6 weeks of intervention. Secondary outcome measures included ankle dorsiflexion range of motion, self-reported instability feeling, and ankle functional status. Results: Better scores in stroboscopic training and balance training groups in all outcome measures were observed in comparison with the control group with moderate to large effect sizes. Stroboscopic training was more effective than neuromuscular training in self-reported instability feeling (cohen’s d = 0.71; p = 0.042) and anterior reach distance of the star excursion balance test (cohen’s d = 1.23; p = 0.001). Conclusions: Preliminary findings from the effects of SV Stroboscopic training in patients with CAI, suggest that SV may be beneficial in CAI rehabilitation.

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The fibula and talus position difference in functional and mechanical ankle instability: MRI findings

Journal of Orthopaedic Surgery ◽

10.1177/2309499020984575 ◽

2021 ◽

Vol 29 (1) ◽

pp. 230949902098457

Author(s):

Chengjie Yuan ◽

Genrui Zhu ◽

Zhifeng Wang ◽

Chen Wang ◽

Xu Wang ◽

...

Keyword(s):

Healthy Volunteers ◽

Ankle Instability ◽

Medial Malleolus ◽

Mechanical Instability ◽

Mri Findings ◽

Functional Instability ◽

Post Hoc Analysis ◽

Ankle Stability ◽

Post Hoc

Purpose: This study aimed to use MRI to evaluate the fibula and talus position difference in functional and mechanical ankle stability patients. Methods: 61 and 68 patients with functional and mechanical instability, and 60 healthy volunteers were involved. Based on the axial MRI images, the rotation of the talus was identified through the Malleolar Talus Index (MTI). The position relative to the talus (Axial Malleolar Index, AMI) and medial malleolus (Intermalleolar Index, IMI) were used to evaluated the displacement of the fibula. Results: Post hoc analysis showed that the values of malleolar talus index was significantly larger among mechanical instability (89.18° ± 2.31°) than that in functional instability patients (86.55° ±61.65°, P < 0.001) and healthy volunteers (85.59° ± 2.42°, P < 0.001). The axial malleolar index of the mechanical instability patients (11.39° ± 1.41°) were significantly larger than healthy volunteers (7.91° ± 0.83°) (P < 0.0001). There were no statistically significant differences in the above three indexes between the functional instability patients and healthy volunteers. Conclusion: The functional instability patients didn’t have a posteriorly positioned fibula and an internally rotated talus. The malleolar talus index was significantly larger among mechanical instability patients than that in functional instability patients. Increased malleolar talus index may become a new indirect MRI sign for identifying functional and mechanical instability patients.

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Comparison of Two Rehabilitation Protocols on Patient- and Disease-Oriented Outcomes in Individuals With Chronic Ankle Instability

International Journal of Athletic Therapy & Training ◽

10.1123/ijatt.2016-0054 ◽

2017 ◽

Vol 22 (3) ◽

pp. 57-65 ◽

Cited By ~ 3

Author(s):

Kyle Kosik ◽

Masafumi Treada ◽

Ryan McCann ◽

Samantha Boland ◽

Phillip A. Gribble

Keyword(s):

Ankle Instability ◽

Dynamic Balance ◽

Controlled Trial ◽

Intervention Programs ◽

Foot And Ankle ◽

Balance Test ◽

Randomized Controlled ◽

Rehabilitation Protocols ◽

Main Effect ◽

Ability Measure

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.

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Comparison of the effect of foot orthoses on Star Excursion Balance Test performance in patients with chronic ankle instability

Prosthetics and Orthotics International ◽

10.1177/0309364618792718 ◽

2018 ◽

Vol 43 (1) ◽

pp. 6-11 ◽

Cited By ~ 3

Author(s):

Faezeh Abbasi ◽

Mahmood bahramizadeh ◽

Mohammad Hadadi

Keyword(s):

Ankle Sprain ◽

Ankle Instability ◽

Dynamic Balance ◽

Chronic Ankle Instability ◽

Textured Surface ◽

Foot Orthoses ◽

Textured Surfaces ◽

Balance Test ◽

Star Excursion Balance Test ◽

Foot Orthosis

Background: Chronic ankle instability as a prevalent consequence of ankle sprain causes various impairments such as balance and postural control deficits. Foot orthoses are one of the common interventions for rehabilitation of patients with chronic ankle instability. Objectives: To investigate the effect of custom-molded foot orthoses with textured surfaces on dynamic balance of chronic ankle instability patients and to compare their effects with other types of foot orthoses. Study design: This is a repeated measure design. Methods: A total of 30 participants were recruited based on the guideline introduced by the International Ankle Consortium. The effect of prefabricated, custom-molded, and custom-molded with textured surface foot orthoses was evaluated on dynamic balance by the Star Excursion Balance Test. Normalized reach distances in anteromedial, medial, and posteromedial directions of the test were computed to be used for statistical analysis. Results: The foot orthoses increased reach distances compared to the no-orthosis conditions in all three directions. The custom-molded with textured surface foot orthosis has significant differences compared with prefabricated foot orthosis ( p = 0.001) in all measured directions and with custom-molded foot orthosis ( p < 0.01) in medial and posteromedial directions. Conclusion: Foot orthoses improve reach distances in patients with chronic ankle instability. Custom-molded with textured surface foot orthosis has a more pronounced effect compared with other foot orthoses. Clinical relevance The custom-molded foot orthosis with textured surface could be an effective device to improve dynamic balance in chronic ankle instability (CAI) patients. It may be considered as an efficient intervention to reduce ankle sprain recurrence in these individuals, although further research should be conducted.

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Screening Using the SDQ Total Difficulties Scale: An Analog Test of Three Cutoff Values

10.31234/osf.io/wvzfm ◽

2019 ◽

Author(s):

Tyler L Renshaw

Keyword(s):

Well Being ◽

The Self ◽

Self Report ◽

Future Research ◽

Subjective Well Being ◽

Analog Test ◽

Research And Practice ◽

Cutoff Values ◽

Dependent Variables ◽

Strengths And Difficulties

This brief report presents an analog test of the relative classification validity of three cutoff values (CVs; 16, 18, and 20) derived from responses to the self-report version of the Strengths and Difficulties Questionnaire: Total Difficulties Scale. Results from Bayesian t-tests, using several school-specific subjective well-being indicators as dependent variables, yielded evidence suggesting all CV models effectively differentiated between students with lower and higher levels of risk. Evidence also indicated that the lowest CV (16) was more effective than the higher CVs (18, 20) at identifying students with greater levels of risk, and that the higher CVs functioned comparably well. Implications for future research and practice are noted.

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Exercise-Based Rehabilitation and Manual Therapy Compared With Exercise-Based Rehabilitation Alone in the Treatment of Chronic Ankle Instability: A Critically Appraised Topic

Journal of Sport Rehabilitation ◽

10.1123/jsr.2019-0337 ◽

2020 ◽

Vol 29 (5) ◽

pp. 684-688 ◽

Cited By ~ 1

Author(s):

Bridget M. Walsh ◽

Katherine A. Bain ◽

Phillip A. Gribble ◽

Matthew C. Hoch

Keyword(s):

Manual Therapy ◽

Ankle Instability ◽

Patient Reported Outcome ◽

Chronic Ankle Instability ◽

Current Evidence ◽

Bottom Line ◽

Patient Reported ◽

Outcome Scores ◽

The Difference ◽

Improve Patient

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.

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PROMIS and FAAM Minimal Clinically Important Differences in Foot and Ankle Orthopedics

Foot & Ankle International ◽

10.1177/1071100718800304 ◽

2018 ◽

Vol 40 (1) ◽

pp. 65-73 ◽

Cited By ~ 21

Author(s):

Man Hung ◽

Judith F. Baumhauer ◽

Frank W. Licari ◽

Maren W. Voss ◽

Jerry Bounsanga ◽

...

Keyword(s):

Patient Reported Outcomes ◽

Minimum Clinically Important Difference ◽

Measurement Information ◽

Diagnostic Study ◽

Foot And Ankle ◽

Meaningful Change ◽

Level Of Evidence ◽

Patient Reported ◽

Level I

Background: Establishing score points that reflect meaningful change from the patient perspective is important for interpreting patient-reported outcomes. This study estimated the minimum clinically important difference (MCID) values of 2 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Foot and Ankle Ability Measure (FAAM) Sports subscale within a foot and ankle orthopedic population. Methods: Patients seen for foot and ankle conditions at an orthopedic clinic were administered the PROMIS Physical Function (PF) v1.2, the PROMIS Pain Interference (PI) v1.1, and the FAAM Sports at baseline and all follow-up visits. MCID estimation was conducted using anchor-based and distribution-based methods. Results: A total of 3069 patients, mean age of 51 years (range = 18-94), were included. The MCIDs for the PROMIS PF ranged from approximately 3 to 30 points (median = 11.3) depending on the methods being used. The MCIDs ranged from 3 to 25 points (median = 8.9) for the PROMIS PI, and from 9 to 77 points (median = 32.5) for the FAAM Sports. Conclusions: This study established a range of MCIDs in the PROMIS PF, PROMIS PI, and FAAM Sports indicating meaningful change in patient condition. MCID values were consistent across follow-up periods, but were different across methods. Values below the 25th percentile of MCIDs may be useful for low-risk clinical decisions. Midrange values (eg, near the median) should be used for high stakes decisions in clinical practice (ie, surgery referrals). The MCID values within the interquartile range should be utilized for most decision making. Level of Evidence: Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

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