Treatment of Chronic Ankle Instability in the Military Population: A Systematic Review

Background The high incidence of ankle sprain within the military sets the stage for prevalent chronic ankle instability. The purpose of this review was to compare and evaluate chronic ankle instability treatment strategies in the military population. Methods Electronic databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews guidelines for English-language, human studies with a military patient population that had been diagnosed with and treated for chronic ankle instability. Exclusion criteria were animal, cadaver, and review studies and case reports. Results Eight studies met the inclusion criteria, representing 695 military service members—625 males (89.9%) and 70 females (10.1%)—and 4 treatment strategies: Broström-related procedures, modified Watson-Jones procedure, Colville’s technique, and anatomic lateral ligament reconstruction using semitendinosus tendon allograft. The percentage of satisfactory outcomes was 100% for Colville’s technique, and ranged from 73.2% to 94.7% for Broström-related procedures and 72% to 80% for the modified Watson-Jones procedure. Mean American Orthopaedic Foot and Ankle Society scores, anterior drawer displacement, talar tilt, and visual analogue scale scores were also reported. Conclusion This review demonstrates that the Bröstrom procedure has consistently satisfactory outcomes within the military population, and Colville’s technique is another promising option for this patient population but would require additional studies to support this claim. Levels of Evidence: Level IV

Anatomical study of the inferior extensor retinaculum and the oblique superolateral band: implications for the Brostrom-Gould procedure

Purpose The Brostrom-Gould procedure is currently the gold standard surgical choice for the treatment of chronic ankle instability; it can significantly improve ankle function and stability in patients. However, recent studies have reported doubts regarding the feasibility of the inferior extensor retinaculum (IER) after Brostrom-Gould and therapeutic effects compared with the Brostrom procedure. The purpose of the present study was to observe the anatomical characteristics of the lateral part of the IER using cadaveric bodies in order to guide the surgical operation of chronic ankle instability. Methods Twenty-three cadaveric ankles were dissected. The morphology of the IER and its internal structure was observed and recorded for each ankle. The shortest distance between the Stem ligament of the IER and the anterior fibular periosteum (AFP) was measured and recorded, then attempts were made to suture the Stem to the AFP. Results Twelve of the cadaveric ankles were observed as having an oblique superolateral band (OSLB) that had a tough texture upward of the lateral IER connecting with SL, as are the characteristics of the oblique superolateral band (OSLB) reported in previous studies. The inner and outer membrane of the OSLB were connected with inner and outer membrane of Stem. The average value of the distance between the Stem and AFP was 11.60 ± 2.71 mm, and the maximum and the minimum distance were 19.04 mm and 6.53 mm, respectively. The P -value (P = 0.2) resulting from a single sample K-S test confirmed that the distribution of distances conformed to normality. None of the SL in the study could be sutured to the AFP. Conclusion The OSLB of the IER has a tough texture and connects with the Stem, and has the potential be utilised in the Brostrom-Gould procedure. However, we do not recommend utilization of the Stem in this operation regardless of the distance between the AFP and the Stem. When the Stem cannot be used to enhance repair in this operation, other solutions can be used for strengthening and to protect the repaired ATFL.

The Effect of Cognitive Task on Postural Control Dynamic Regularity of Athletes With Chronic Ankle Instability When Standing on an Unstable Surface

Background and Objectives: Postural control disorder is a common complication in patients with Chronic Ankle Instability (CAI). The present study aimed to investigate the effect of dual cognitive task on postural control behavior with regard to the Center of Pressure (CoP) signal regularity while standing on an unstable surface in athletes with CAI. Methods: In the present study, 58 men participated in two groups of healthy and patients with CAI. The CoP signal was examined in 4 different unstable states on the wobble board located at the center of the force plate. The regularity of the signals recorded from the force plate was investigated using sample entropy in two directions: anterior-posterior and medial-lateral. Results: In both groups, there was a significant difference in CoP’s sample entropy signal when performing a cognitive task with a postural task (P<0.001). There was a significant difference between the two groups in the cognitive task and the single task in the anteroposterior direction while standing on two legs. Conclusion: During dual tasks, the patients with CAI have a more dynamic regularity in the CoP signal than their normal counterparts. In the dual-task condition, more irregularities are observed in the CoP signal of healthy individuals. In unstable conditions, patients with CAI decrease the adaptability of postural control behavior with increasing CoP signal regularity.

Sex Differences in the Relationship of Hip Strength and Functional Performance to Chronic Ankle Instability Scores

Background: Preliminary studies have reported differences in strength and functional performance between sexes for patients with anterior cruciate ligament injury or reconstruction. Similar sex differences may occur in chronic ankle instability (CAI) populations. Factors like hip abduction strength and functional performance may be contributors to sex differences in CAI populations, but their presence and magnitude is unclear. While decreased hip abductor strength, functional performance, and self-reported instability scores have all been shown in association with CAI, any sex difference in the relationship between these indicators is unclear. The study was to determine if sex differences are present in the relationship between these indicators in individuals with CAI.Methods：Thirty-two women and twenty-nine men with unilateral CAI took part. Hip abductor strength and functional performance were respectively assessed using a hand-held dynamometer and the figure-8-hop test. All 61 participants scored the Cumberland Ankle Instability Tool (CAIT) for self-reported ankle instability.Results: Normalized hip abductor strength and functional performance measures for females were lower than for males. The self-reported ankle instability CAIT score, where higher values represent less instability, was significantly and positively correlated with normalized hip abductor strength and functional performance on the affected side in females (all p < 0.01), but not in males (all p > 0.19).Conclusions: Sex differences were observed in the relationships of normalized hip abductor strength and functional performance to CAIT scores from the CAI, holding for females but not males, and suggesting that evaluation and rehabilitation strategies should be sex-specific.

Effect of Kinesiology Tape on Muscle Activation of Lower Extremity and Ankle Kinesthesia in Individuals With Unilateral Chronic Ankle Instability

Background: The purpose of the study was to determine the effect of kinesiology tape (KT) on lower limb muscle activation during computerized dynamic posturography (CDP) tasks and ankle kinesthesia in individuals with chronic ankle instability (CAI).Methods: Thirty-five men with CAI participated in this study. The experimental procedure followed a repeated measures design. Muscle activation of lower extremity and ankle kinesthesia of participants were measured using four taping treatments, namely, KT, athletic tape (AT), sham tape (ST), and no tape (NT) in a randomized order. Muscle activation was assessed using surface electromyography (sEMG) synchronized with CDP tests from seven lower extremity muscles of the unstable limb. Ankle kinesthesia was measured by using a threshold to detect the passive motion direction of the unstable ankle. Parameters were analyzed by using a one-way repeated measures ANOVA and followed by pairwise comparisons with a Bonferroni correction.Results: No significant difference was observed among different taping treatments for the majority of parameters during CDP. Except for condition 4 with open eyes, sway-referenced surface, and fixed surround in the sensory organization test (SOT), gastrocnemius medialis root mean square (RMS) was 28.19% lower in AT compared with NT (p = 0.021, 95% CI = 0.002–0.039), while gastrocnemius lateralis RMS was 20.25% lower in AT compared with KT (p = 0.038, 95% CI = 0.000–0.021). In forward-small sudden translation from motor control test (MCT), for peroneal longus (PL), RMS was 24.04% lower in KT compared with ST (p = 0.036, 95% CI = 0.000–0.018). In toes-down sudden rotation from adaption test (ADT), for PL, RMS was 23.41% lower in AT compared with ST (p = 0.015, 95% CI = 0.002–0.027). In addition, no significant difference was observed for a threshold to the detection of passive motion direction among different taping treatments.Conclusion: This study indicated that KT had minimal effect on the muscle activation of the unstable lower limb during static stance, self-initiated, and externally triggered perturbation tasks from CDP and ankle kinesthesia among individuals with CAI, suggesting that the benefit of KT was too small to be clinically worthwhile during application for CAI.

Effects of dry needling in gluteus medius muscle in individuals with chronic ankle instability: a randomized single-blinded controlled clinical trial

IntroductionBackground: Lateral ankle sprain (LAS) is the most common musculoskeletal injuries in sport and general population. The goal of the present study was to observe the effectiveness of dry needling (DN) in gluteus medius muscle in patients with chronic ankle instability (CAI).Material and methodsA two-arm (1:1), single-blinded (participants), randomized clinical trial was performed in 40 subjects with chronic ankle instability and were divided in two groups: intervention group who received one session of dry needling in the most hyperalgesic gluteus medius myofascial trigger point (MTrP), (n = 20) and control group (n = 20). Dynamic balance, pain intensity, pain pressure threshold (PPT) and ankle dorsiflexion range of motion (ROM) were assessed at baseline, post-intervention and a 1-week follow up.ResultsThe experimental group reported significant differences with respect to the control group for the anterior and medial dynamic balance (p = .001), PPT -ATL (p = .002) and ankle dorsiflexion ROM (p = .001).ConclusionsThe findings of the present study suggested that the DN in the most hyperalgesic MTrP of the Gmed muscle may increase the anterior and medial dynamic balance, ankle ROM and PPT-ATL at short-term in individuals with CAI. Pain intensity benefits were reported in both groups. Future studies should consider DN as a possible intervention in conjunction with a physical therapy program for individuals with CAI.

Talar Cartilage Deformation and Spatiotemporal Gait Patterns in Individuals with and without Chronic Ankle Instability.

ABSTRACT Context: Research has demonstrated individuals with chronic ankle instability (CAI) present with alterations in the compositional structure of the talar articular cartilage. These alterations likely influence how the talar cartilage responds to loading associated with activities of daily living, such as walking. Ultrasonography has emerged as an alternative imaging modality to assess the amount of cartilage deformation in response to loading because it can be clinically accessible and cost-effective for routine measurements. Objective: To compare talar cartilage deformation in response to a standardized exercise protocol between those with and without chronic ankle instability. Secondly, to examine the association between spatiotemporal walking gait parameters and cartilage deformation. Design: Case-control. Setting: Research Laboratory. Patients or Other Participants: A volunteer sample of 24 participants with self-reported CAI (age = 23.2 ± 3.9 years; BMI = 25.1 ± 3.7 kg/m2) and 24 un-injured controls (age = 24.3 ± 2.9 years; BMI = 22.9 ± 2.8 kg/m2). Main Outcome Measure(s): Spatiotemporal walking gait was first assessed from five self-selected trials using an electronic walkway with data sampled at 120Hz. An 8-to-13MHz linear-array ultrasound transducer placed transversely in line with the medial and lateral malleoli captured three images before and after a standardized loading protocol consisting of 30 single and double-limb squats, 2-minute single-limb balance and 10 single-leg drops from a 40cm height box. Results: After controlling for body mass index, participants with chronic ankle instability had greater deformation compared to the un-injured controls (p=0.034). No other significant between group differences were observed (p&gt;0.05). No significant partial correlations were observed between talar cartilage deformation and spatiotemporal gait parameters when controlling for body mass index (p&gt;0.05). Conclusions: Individuals with CAI had greater talar cartilage deformation in response to a standardized exercise protocol than controls. The amount of talar cartilage deformation was not associated with spatiotemporal walking gait.

Cross-cultural Adaptation, Reliability and Validity of the Cantonese-Chinese Cumberland Ankle Instability Tool (CAIT-HK)

Acute ankle sprains are common amongst athletes, and screening is essential in preventing these long-term sequelae. Self-reported questionnaires, such as the Cumberland Ankle Instability Tool (CAIT), may help identify individuals with chronic ankle instability. To date, a Cantonese-Chinese version of the CAIT does not exist. Although several studies have cross-culturally adapted the CAIT into Chinese and Taiwan-Chinese, there are cultural differences in language use. A cross-cultural adaptation and validation of the CAIT were carried out: 46 individuals who were native in Cantonese completed the Cantonese-Chinese version of the CAIT and Chinese Foot and Ankle Outcome Score. For the test-retest analysis, the intraclass correlation coefficient was 0.874. Internal consistency showed a Cronbach's ɑ value of 0.726. Construct validity against the FAOS was fair but significant with a Spearman's correlation coefficient of 0.353, 0.460, 0.303, 0.369 and 0.493 for the categories of symptoms, pain, daily function, sports function, and quality of life respectively. A cut-off score of 20.5 was determined to differentiate healthy individuals from those with chronic ankle instability for this study population. The original English CAIT was successfully translated, cross-culturally adapted and validated into Cantonese-Chinese.

Effects of midfoot joint mobilization on perceived ankle-foot function in chronic ankle instability. A crossover clinical trial

BackgroundChronic ankle instability (CAI) is a complex clinical entity that commonly includes ankle-foot impairment.ObjectiveTo investigate the effects of midfoot joint mobilizations and a one-week home exercise program (HEP) compared to a sham intervention and HEP on pain, patient-reported outcomes (PROs), ankle-foot joint mobility, and neuromotor function in young adults with CAI.MethodsTwenty participants with CAI were instructed in a stretching, strengthening, and balance HEP and were randomized a priori to receive midfoot joint mobilizations (forefoot supination, cuboid glide and plantar 1st tarsometatarsal) or a sham laying-of-hands. Changes in foot morphology, joint mobility, strength, dynamic balance, and PROs assessing pain, physical, and psychological function were assessed pre-to-post treatment and one-week following. Participants crossed-over to receive the alternate treatment and were assessed pre-to-post treatment and one-week following. Linear modelling was used to assess changes in outcomes.ResultsParticipants who received midfoot mobilization demonstrated significantly greater perceived improvement immediately posttreatment in the single assessment numeric evaluation (Sham: 5.0±10.2%; Mobilization: 43.9±26.2%; β: 6.8 p<0.001, Adj R2:0.17) and Global Rating of Change (Sham: −0.1±1.1; Mobilization: 1.1±3.0; β: 1.8 p=0.01, Adj R2:0.12). Following the mobilization intervention, participants demonstrated greater improved rearfoot inversion mobility (Sham: 4.4±8.4°; Mobilization: −1.6±6.1°; β: −6.37, p=0.01, Adj R2:0.19), plantarflexion mobility (Sham: 2.7°±6.4; Mobilization: −1.7°±4.3; β: −4.36, p=0.02, Adj R2:0.07), and posteromedial dynamic balance (Sham: 2.4±5.9%; Mobilization: 6.0±5.4%; β: 3.88, p=0.04, Adj R2:0.10) compared to controls at 1-week post-treatment.ConclusionParticipants with CAI who received midfoot joint mobilization had greater perceived improvement and physical signs that may benefit this clinical population.