Fifth International Ankle Symposium - Jospt

Fifth International Ankle Symposium: Introduction

PATRICK O. MCKEON, PhD, ATC, CSCS1 • CARL G. MATTACOLA, PhD, ATC1

Fifth International Ankle Symposium October 17-20, 2012, Lexington, Kentucky J Orthop Sports Phys Ther 2013;43(3):A1-A12. doi:10.2519/jospt.2013.0301

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he Fifth International Ankle Symposium (IAS5), a multidisciplinary conference focused predominantly on ankle injury evaluation, rehabilitation, and prevention, was held in Lexington, KY and sponsored by the University of Kentucky’s College of Health Sciences. The organizing and scientific committee included Patrick McKeon (University of Kentucky), Carl Mattacola (University of Kentucky), Thomas Kaminski (University of Delaware), Jay Hertel (University of Virginia), Phillip Gribble (University of Toledo), Eamonn Delahunt (University College Dublin), Claire Hiller (University of Sydney), Carrie Docherty (Indiana University), Brent Arnold (Virginia Commonwealth University), Matthew Hoch (Old Dominion University), Bill Vicenzino (University of Queensland), and Tricia Hubbard Turner (University of North Carolina at Charlotte). IAS5 brought together over 90 clinicians and scientists from disciplines such as athletic training, physical therapy, sports medicine, orthopaedics, and biomechanics. Participants represented many countries, including the United States, Great Britain, Ireland, Qatar, South Africa, Australia, and the Netherlands. A call for abstracts was initially distributed in the summer of 2011. Prospective attendees were invited to submit abstracts for work related to original research, case studies, or clinical commentaries. All submitted abstracts were reviewed for scientific merit by members of the scientific committee. Fifty abstracts were accepted at the symposium, including 22 podium presentations and 28 posters of original research and case studies. The scientific program consisted of 11 presentations from internationally recognized experts and was designed to appeal to clinicians and scientists alike. The topics of these presentations included the benefits of prophylactic ankle bracing, the science behind barefoot running, advanced

taping and orthotic strategies for foot and ankle conditions, functional screening tools for ankle injuries, prognostic indicators for ankle sprains, neural issues associated with ankle instability, and surgical considerations for ankle osteoarthritis. A highlight from the symposium was the reception in which the University of Kentucky Bluegrass Ensemble featured music from central Kentucky. The scholarly and social interactions between presenters and attendees throughout the symposium accentuated the collaborative and collegial spirit of the IAS mission. Plans have already commenced for the Sixth International Ankle Symposium, which will be held in Ireland in 2015. On the following pages, you will find a summary statement, keynote addresses from invited lectures and workshops, and a program schedule. Later, in electronic format, these pages will include the abstracts of the original research, both podium and poster presentations, from IAS5.

Division of Athletic Training, College of Health Sciences, University of Kentucky, Lexington, KY.

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Fifth International Ankle Symposium: Summary Statement

Summary Statement PATRICK O. MCKEON, PhD, ATC, CSCS1 • CARL G. MATTACOLA, PhD, ATC1

Ankle sprains are one of the most common injuries sustained during physical activity. While they are often considered to be relatively benign injuries, the high recurrence rates and associated healthcare costs tell a much different story. It is clear that ankle instability is a complex clinical phenomenon that is multifactorial in nature. Since IAS4, there has continued to be a substantial increase in the research associated with ankle instability. The keynote presentations during IAS5 were given by foot and ankle experts, including physical therapists, athletic trainers, and orthopaedic physicians, who came together to provide the audience with the state-of-the-art evidence associated with such topics as barefoot running, surgical considerations for ankle arthritis, neurogenic responses to ankle sprain, and prognostic indicators for ankle sprain management. These presentations fostered much discussion among participants and afforded the opportunity to develop research collaborations across the world to address gaps in the current understanding of foot and ankle injury management. The abstracts that follow from the podium and poster presentations of IAS5 represent current advances in foot and ankle research evidence, which include the following: • Patient-, clinician-, and laboratory-oriented assessments for ankle instability • The long-term functional consequences of ankle injury • Foot and ankle biomechanics • The development of an animal model for ankle instability and osteoarthritis • Neurogenic consequences of ankle sprains • Novel ankle instability intervention strategies • Factors associated with the implementation of ankle instability prevention programs It was impressive to see many of the developments from the previous IAS meetings come to fruition. Of important note is that a common language across multiple institutions

and countries appears to be taking hold. The presentations were marked by consistent use of inclusion and exclusion criteria for those with chronic/functional ankle instability, which allowed further discussion and planning for potentially global multicenter ankle instability trials. In addition, much time was spent on the manifestation of chronic ankle instability from the patient’s perspective. A major gap that remains in the literature is whether ankle instability research captures those with the actual clinical phenomenon. What remains elusive is a complete description of the phenomenon itself. Much discussion was centered on defining the characteristics of this pathological population. Based on the keynote and research presentations, as well as the discussions, it was apparent that some of the research priorities outlined from the previous IAS had begun to take greater shape. Across the 3 days of the symposium, there was considerable scholarly and social interaction among the attendees, which led to many fruitful ideas and plans for collaborative research projects. The meeting also provided an opportunity for furthering the work of the International Ankle Consortium, a multidisciplinary group formed in 2004 at IAS2. At IAS5, there was a change in leadership, as Dr Kaminski and Dr Hertel, the original chairs of the consortium, passed the torch to Dr Gribble and Dr Delahunt, charging them with continuing the Consortium’s outstanding work into the future. From the discussions of the Consortium at IAS5, we look forward to the excellent ideas and direction Drs Gribble and Delahunt will provide. In summary, IAS5 has advanced the mission of the previous IAS meetings to build and refine the body of knowledge associated with ankle instability. The research progress from IAS5 combined with the work of the International Ankle Consortium will ensure that IAS6, to be held in Dublin, Ireland in 2015, will be an outstanding success.

Division of Athletic Training, College of Health Sciences, University of Kentucky, Lexington, KY.

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Fifth International Ankle Symposium: Keynotes

Keynote Addresses PROPHYLACTIC BRACING FOR THE PREVENTION OF ANKLE INJURIES: EVIDENCE IN ADOLESCENT ATHLETE POPULATIONS TIMOTHY A. MCGUINE, PhD, ATC Department of Orthopedics, University of Wisconsin-Madison, Madison, WI.

INTRODUCTION Approximately 7 million adolescents participate in high school sports in the United States.6 According to the Centers for Disease Control and Prevention, injury associated with sport, exercise, and recreation is a leading reason that people stop participating in physical activity.5 Ankle sprain is the most common musculoskeletal injury that occurs in high school sports.7 A significant portion of athletes who sustain an initial lateral ankle sprain will develop chronic ankle instability,1 which can lead to ankle osteoarthritis8 and cause individuals to be less physically active over their lifespan. Lace-up ankle braces are utilized by many adolescent athletes to prevent ankle injuries, but their use remains controversial.2

METHODS We conducted 2 randomized control trials of 1460 male and female basketball players from 46 high schools3 and 2081 high school football subjects from 50 high schools.4 In both studies, schools were stratified into 3 groups based on enrollment and allocated to the intervention or the control group. Intervention subjects were provided with lace-up ankle braces to use throughout the entire season, while controls were not provided braces. Certified athletic trainers at each school recorded athlete exposures (type of support worn on each ankle for each subject at each practice and competition) and lower extremity injury incidence throughout the season.

RESULTS Lace-up ankle braces reduced the incidence of acute ankle injuries by a factor of 2 to 3, regardless of sex, age, competition level, or body mass index. Notably, the lower incidence was found in subjects with and without a previous ankle injury. Interestingly, there was no difference in the severity of the ankle injuries sustained by subjects in both groups; however, there was a trend for an increased incidence of other lower extremity injuries in basketball players, but not in football players.

IMPLICATIONS Sports medicine providers should be aware that lace-up braces are a cost-effective method to reduce the incidence of

acute ankle injuries in adolescent athletes. This is especially true in school and team settings that do not allow for easy access to ankle injury prevention exercise programs. Additionally, because lace-up braces are continually evolving and differ with regard to comfort, stiffness, and materials, clinicians need to realize that there is no single lace-up brace suitable for all sports or athletes.

FUTURE RESEARCH Ankle injury prevention research is needed in adolescent athletes. For example, these findings have not been duplicated in other high-risk sports such as soccer or volleyball. In addition, research has not been published comparing athletes who utilize lace-up braces in conjunction with an injury prevention exercise program to athletes taking part in an exercise program or using braces alone. Conducting effective research in this population is costly and time consuming, as it needs to be conducted outside of traditional laboratory settings. However, this research has the potential to dramatically limit the impact musculoskeletal injuries have on US healthcare spending and may dramatically improve the quality of life for active individuals as they transition to adulthood.

REFERENCES 1. A nandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med. 2005;39:e14. http://dx.doi.org/10.1136/ bjsm.2004.011676 2. Dizon JM, Reyes JJ. A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport. 2010;13:309-317. http://dx.doi. org/10.1016/j.jsams.2009.05.002 3. McGuine TA, Brooks A, Hetzel S. The effect of lace-up ankle braces on injury rates in high school basketball players. Am J Sports Med. 2011;39:18401848. http://dx.doi.org/10.1177/0363546511406242 4. McGuine TA, Hetzel S, Wilson J, Brooks A. The effect of lace-up ankle braces on injury rates in high school football players. Am J Sports Med. 2012;40:49-57. http://dx.doi.org/10.1177/0363546511422332 5. National Center for Injury Prevention and Control. CDC Injury Research Agenda, 2009-2018. Atlanta, GA: Centers for Disease Control and Prevention; 2009. 6. National Federation of State High School Associations. 2011-12 High School Athletics Participation Survey Results. Available at: http://www.nfhs.org/ content.aspx?id=3282. Accessed September 19, 2012. 7. Nelson AJ, Collins CL, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train. 2007;42:381-387. 8. Valderrabano V, Hintermann B, Horisberger M, Fung TS. Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med. 2006;34:612-620. http:// dx.doi.org/10.1177/0363546505281813


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Fifth International Ankle Symposium: Keynotes NEUROGENIC RESPONSE TO ANKLE SPRAINS ARTHUR J. NITZ, PhD, PT Division of Physical Therapy, University of Kentucky, Lexington, KY.

Joint deafferentation is an often-observed and well-established complication following lateral ankle sprain and may be a major contributing factor to chronic ankle instability.2 Kennedy et al3 hypothesized that the failure of mechanoreceptors from knee joint injury leads to the loss of reflex muscular splinting/activation, rendering the joint vulnerable to additional repetitive trauma. Altered afferent neural signal from joint mechanoreceptors following ankle sprain is believed to lead to muscle weakness and atrophy and delayed or aborted rehabilitation to normalcy.10,11 However, careful analysis of ambulation impairment following severe ankle sprain reveals a gait pattern characteristic of neural injury: gastrocnemius gait. Furthermore, the rapidity of observed muscle wasting following grade 2 and grade 3 ankle sprains is often far in excess of that expected from disuse or reflex inhibition and may be better explained as the result of actual nerve injury.6 Electromyographic examination of patients with grade 2 and grade 3 ankle sprain confirms that motor denervation is present in a large percentage of these individuals. Review of the literature indicates that fibular nerve injury has been described as an observed complication following ankle sprain and fracture dating back to 1911. 9 A variety of clinicians have described, on a case-report basis, the presence of weakness and sensory impairment in the fibular nerve distribution following ankle joint injury that is consistent with neurapraxia or axonotmesis.1,5 The mechanism of injury has been attributed to a combination of neural stretch and compression of the fibular nerve as it wraps around the fibular head. Alternatively, Nobel7 observed an epineural hematoma at the popliteal space on rare occasions following ankle fractures, which he understood to be the result of a traction injury to the delicate vessels supplying the axons distally. Systematic electroneuromyographic analysis of grade 2 and grade 3 inversion ankle sprains has identified clear evidence of denervation in the fibular and the tibial nerve distribution.6 While a traction-compression mechanism is a reasonable explanation for the mechanism of injury to the fibular-innervated muscles in the leg,8 it is inadequate to explain similarly observed neural injury to the tibial-innervated muscles. A more reasonable explanation for tibialinnervated muscle denervation following inversion ankle sprain may be neurogenic inflammation. Animal models have demonstrated that soft tissue injury (inflammation) in the extremity leads to inflammatory responses in the neural system.4 Such neural inflammation may be mediated by biogenic amines such as histamine or neurotransmitters such as substance P or calcitonin gene-related peptide. It is entirely possible that early postinjury effects, such as profound muscle atrophy and impaired gait, are mediated through the neurogenic inflammatory cycle.

Clinical implications for this observed neural injury are significant. Neural injury following severe ankle sprain is far more common than generally conceded in the literature and should be considered as a likely complication with grade 2 and grade 3 sprains. Loss of normal motor innervation profoundly impacts the ability of the muscle’s typical dampening of joint reaction forces during functional activities. It is believed that diminished joint protection and overall loss of muscle function during the early weeks following severe ankle sprain account for much of the difficulty these patients experience in the rehabilitation process. Injury to the tibialand fibular-innervated muscles results in delay in the expected rehabilitation timeline following severe ankle sprain and should be factored into the development of tailored treatment programs for such patients.

REFERENCES 1. B rief JM, Brief R, Ergas E, Brief LP, Brief AA. Peroneal nerve injury with foot drop complicating ankle sprain: a series of four cases with review of the literature. Bull NYU Hosp Jt Dis. 2009;67:374-377. 2. Freeman MA, Dean MR, Hanham IW. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br. 1965;47:678-685. 3. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10:329-335. 4. Levine JD, Dardick SJ, Basbaum AI, Scipio E. Reflex neurogenic inflammation. I. Contribution of the peripheral nervous system to spatially remote inflammatory responses that follow injury. J Neurosci. 1985;5:1380-1386. 5. Meals RA. Peroneal-nerve palsy complicating ankle sprain. Report of two cases and review of the literature. J Bone Joint Surg Am. 1977;59:966-968. 6. Nitz AJ, Dobner JJ, Kersey D. Nerve injury and grades II and III ankle sprains. Am J Sports Med. 1985;13:177-182. 7. Nobel W. Peroneal palsy due to hematoma in the common peroneal nerve sheath after distal torsional fractures and inversion ankle sprains. J Bone Joint Surg Am. 1966;48:1484-1495. 8. O’Neill PJ, Parks BG, Walsh R, Simmons LM, Miller SD. Excursion and strain of the superficial peroneal nerve during inversion ankle sprain. J Bone Joint Surg Am. 2007;89:979-986. http://dx.doi.org/10.2106/JBJS.F.00440 9. Oppenheim H. Text-Book of Nervous Diseases. 5th ed. Edinburgh, UK: Otto Schulze & Company; 1911. 10. Palmieri RM, Ingersoll CD, Edwards JE, et al. Arthrogenic muscle inhibition is not present in the limb contralateral to a simulated knee joint effusion. Am J Phys Med Rehabil. 2003;82:910-916. http://dx.doi.org/10.1097/01. PHM.0000098045.04883.02 11. Stokes M, Young A. The contribution of reflex inhibition to arthrogenous muscle weakness. Clin Sci (Lond). 1984;67:7-14.

ALTERATIONS IN THE CENTRAL ORGANIZATION OF MOVEMENT: IMPLICATIONS FOR TREATING CHRONIC ANKLE INSTABILITY ERIK A. WIKSTROM Department of Kinesiology, University of North Carolina at Charlotte, Charlotte, NC.

Up to 74% of individuals who suffer an acute lateral ankle sprain develop residual symptoms.1 These residual symptoms include mechanical adaptations and both sensory and motor impairments.2 Further, evidence suggests that these impairments fall within a cascade of events that ultimately results



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Fifth International Ankle Symposium: Keynotes in both local adaptations about the ankle joint as well as alterations in the central organization of movement,2 creating a multifactorial mechanism of chronic ankle instability (CAI). Traditional rehabilitation strategies for acute ankle sprains and CAI focus on restoring motor impairments (eg, strength and coordination). Yet, the high recurrence rate of ankle sprains and high incidence of CAI development would suggest that focusing only on motor outputs while ignoring sensory dysfunction has been a mistake and may explain the lack of a truly effective therapeutic intervention for those with CAI. It is known that the sensorimotor system functions, in part, via a continuous processing of afferent information from a variety of sources.6 This afferent information is then used to fine tune motor output, creating a continuous feedback loop within the sensorimotor system. In those with CAI, it is hypothesized that the initial and subsequent sprains cause damage to the ligaments and surrounding tissue, which results in the loss of sensory information and subsequent impairments in motor function.6 Further, research has shown that the loss or disruption of normal sensory information via anesthesia or textured insoles results in motor function degradation in those with CAI.6,7 In other words, motor output in those with CAI can be manipulated by altering sensory inputs. Thus, it may be possible to use sensory-targeted interventions on those with CAI in an effort to improve the efficacy of sensory inputs and subsequently improve the efficacy of motor outputs. To date, a number of sensory interventions (eg, stochastic resonance, joint mobilizations, massage) have been investigated and demonstrated immediate effectiveness in those with CAI.3,4,5,8 More importantly, combining a sensorytargeted intervention (stochastic resonance) with a motortargeted strategy (balance training) has consistently resulted in better postural-control improvements than balance training alone.9,10 Thus, early evidence indicates that a variety of sensory-targeted techniques are effective at improving motor function in those with CAI. While the causal mechanism of sensory-targeted intervention effectiveness remains unknown, several theories have been proposed. For example, sensory-targeted interventions may heighten the sensitivity of the underlying receptors,8 restore or at least improve function of previously damaged receptors,4 or cause a reweighting of afferent information used by the central nervous system.6,7 While understanding the mechanism will allow a more effective intervention to be customized to the individual, further research is needed to determine the long-term benefits of sensory-targeted interventions in those with CAI.

REFERENCES 1. A nandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med. 2005;39:e14. http://dx.doi.org/10.1136/ bjsm.2004.011676 2. Hertel J. Sensorimotor deficits with ankle sprains and chronic ankle in-

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stability. Clin Sports Med. 2008;27:353-370. http://dx.doi.org/10.1016/j. csm.2008.03.006 Hoch MC, Andreatta RD, Mullineaux DR, et al. Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability. J Orthop Res. 2012;30:17981804. http://dx.doi.org/10.1002/jor.22150 Hoch MC, McKeon PO. Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability. J Orthop Res. 2011;29:326-332. http://dx.doi.org/10.1002/jor.21256 LeClaire JE, Wikstrom EA. Massage for postural control in individuals with chronic ankle instability. Athl Train Sports Health Care. 2012;4:213-219. http://dx.doi.org/10.3928/19425864-20120731-02 McKeon PO, Booi MJ, Branam B, Johnson DL, Mattacola CG. Lateral ankle ligament anesthesia significantly alters single limb postural control. Gait Posture. 2010;32:374-377. http://dx.doi.org/10.1016/j.gaitpost.2010.06.016 McKeon PO, Stein AJ, Ingersoll CD, Hertel J. Altered plantar-receptor stimulation impairs postural control in those with chronic ankle instability. J Sport Rehabil. 2012;21:1-6. Ross SE. Noise-enhanced postural stability in subjects with functional ankle instability. Br J Sports Med. 2007;41:656-659. http://dx.doi. org/10.1136/bjsm.2006.032912 Ross SE, Arnold BL, Blackburn JT, Brown CN, Guskiewicz KM. Enhanced balance associated with coordination training with stochastic resonance stimulation in subjects with functional ankle instability: an experimental trial. J Neuroeng Rehabil. 2007;4:47. http://dx.doi. org/10.1186/1743-0003-4-47 Ross SE, Guskiewicz KM. Effect of coordination training with and without stochastic resonance stimulation on dynamic postural stability of subjects with functional ankle instability and subjects with stable ankles. Clin J Sport Med. 2006;16:323-328.

BAREFOOT RUNNING: SHIFTING PARADIGMS REGARDING FOOTSTRIKES, FOOTWEAR, AND TREATMENT OF THE FOOT IRENE DAVIS, PhD, PT, FACSM, FAPTA, FASB Spaulding National Running Center, Harvard Medical School, Cambridge, MA.

INTRODUCTION The recent popularity of barefoot running has led to some very heated debates about its benefits and risks. Advocates argue that we have evolved to run barefoot and running in this way encourages a more natural footstrike pattern that may reduce the risk for injury. Opponents believe that the foot needs the additional support and cushioning that modern running shoes afford to reduce the risk for injury. These debates have been healthy and are leading to shifting paradigms in the way we think about footstrikes, footwear, and treatment of the foot.

FOOTSTRIKES Up to 88% of shod runners strike the ground with their heel first, otherwise known as a rearfoot strike (RFS) pattern.5 This strike pattern is associated with a very distinct impact transient in the vertical ground reaction force.2 However, the impact transient becomes significantly attenuated or eliminated when landing flat or on the ball of the foot with a forefoot strike (FFS) pattern.2,6 As the musculoskeletal system is viscoelastic in nature, our bones and muscles



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Fifth International Ankle Symposium: Keynotes are sensitive to impacts with high rates of loading. High rates of loading have been associated with common running injuries such as tibial stress fractures8 and plantar fasciitis.9 Two recent intervention studies3,4 have demonstrated reductions in load rates and improvement in pain and function after transitioning injured runners from an RFS to an FFS running pattern. Interestingly, Kenyans who have never worn shoes run with a mild FFS pattern, suggesting that this may be the way we were designed to run.6

FOOTWEAR Although running with an FFS pattern in shoes reduces load rates, only 1% to 2% of shod runners land in this way.5 It is difficult to make the transition in modern running shoes with elevated, cushioned heels. Additionally, these shoes filter out important sensory feedback from the plantar surface of the feet during landings.10 Therefore, running barefoot provides maximal sensory feedback. Another advantage is that removing the support (both arch support and stiff heel counter) of the modern running shoe results in strengthening of the foot musculature.1 A stronger foot is certainly a healthier foot. However, there are times when the sole of the foot needs protection. This has spawned a new line of minimal running footwear that is designed without any cushioning or support, attempting to mimic barefoot running. For this footwear to best facilitate an FFS pattern, it should be uncomfortable to land with an RFS pattern while running in them.

TREATMENT OF THE FOOT The standard of care for foot-related musculoskeletal problems, such as plantar fasciitis, often includes permanent foot orthotic devices.7 However, this is seldom the standard of care for any other part of the body, because it is understood that we would weaken those muscles with chronic brace use. The 20-plus muscles in the foot are designed to tolerate the repetitive loads of walking and running. In otherwise healthy individuals, these muscles have the same potential for strengthening as any other muscles. However, the foot is largely ignored in rehabilitation programs. More focus on foot mobility and strength is clearly needed. While barefoot/ minimal footwear running is essentially exercise for the foot, it needs to be transitioned slowly and preceded by a focused foot-strengthening program. For more information on transitioning, go to www.runsnrc.org.

SUMMARY As the modern shoe has become more cushioned and more controlling, our foot musculature has had significantly less demands placed upon it and our feet have become lazy. Returning to allowing our feet to move as they were designed to should help their overall long-term health.

REFERENCES 1. B rüggemann G-P, Potthast W, Braunstein B, Niehoff A. Effect of increased mechanical stimuli on foot muscles functional capacity. Proceedings of the International Society of Biomechanics. Cleveland, OH: 2005. 2. Cavanagh PR, Lafortune MA. Ground reaction forces in distance running. J Biomech. 1980;13:397-406. 3. Cheung RT, Davis IS. Landing pattern modification to improve patellofemoral pain in runners: a case series. J Orthop Sports Phys Ther. 2011;41:914919. http://dx.doi.org/10.2519/jospt.2011.3771 4. Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40:1060-1067. http://dx.doi. org/10.1177/0363546512439182 5. Larson P, Higgins E, Kaminski J, et al. Foot strike patterns of recreational and sub-elite runners in a long-distance road race. J Sports Sci. 2011;29:1665-1673. http://dx.doi.org/10.1080/02640414.2011.610347 6. Lieberman DE, Venkadesan M, Werbel WA, et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010;463:531-535. http://dx.doi.org/10.1038/nature08723 7. McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, Godges JJ. Heel pain—plantar fasciitis: clinical practice guidelines linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1-A18. http://dx.doi.org/10.2519/jospt.2008.0302 8. Milner CE, Ferber R, Pollard CD, Hamill J, Davis IS. Biomechanical factors associated with tibial stress fracture in female runners. Med Sci Sports Exerc. 2006;38:323-328. http://dx.doi.org/10.1249/01. mss.0000183477.75808.92 9. Pohl MB, Hamill J, Davis IS. Biomechanical and anatomic factors associated with a history of plantar fasciitis in female runners. Clin J Sport Med. 2009;19:372-376. http://dx.doi.org/10.1097/JSM.0b013e3181b8c270 10. Rose W, Bowser B, McGrath R, Salerno J, Wallace J, Davis I. Effect of footwear on balance. Proceedings of the American Society of Biomechanics. Long Beach, CA: 2011.

EVALUATION OF FOOT MOBILITY AND ORTHOTIC INTERVENTION MARK W. CORNWALL Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ.

The assessment of foot mobility is frequently a component of a clinical examination. These assessment procedures may be qualitative or quantitative in nature. The qualitative methods for assessing foot mobility include subjectively observing the amount of passive range of motion available at the various segments of the foot or the observation of the magnitude of change in a person’s foot posture, particularly the arch, from non–weight bearing to weight bearing.1 While often useful, these subjective measures are limited in their ability to further discriminate variations within normal or typical amounts of mobility. In an attempt to overcome this limitation, more objective methods have been proposed. These include goniometric and linear measurements. Because of the relatively poor reliability of goniometric measurement of the foot, linear measures of the position of the navicular bone relative to some reference position, usually subtalar joint neutral, to the person’s resting standing position have been advocated. Such measure-



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Fifth International Ankle Symposium: Keynotes ments have included both vertical and horizontal changes in the bone’s position and have been commonly referred to as navicular drop and navicular drift, respectively.4 Recently, another method has been advocated, which measures the change in the height of the dorsum of the foot or the change in the width of the foot to assess foot mobility between non– weight bearing and weight bearing.2 This method results in excellent intrarater and interrater reliability because the navicular bone and subtalar joint neutral position do not have to be palpated. The above objective measurement techniques may also be used to determine the amount of posting that is required for a foot orthotic. For example, knowing the change in the height of the dorsum of the foot that is necessary to relieve a person’s symptoms as a result of an intervention such as foot strapping, an orthotic can be constructed to match this observed change.3 The amount of posting would therefore be in millimeters rather than in degrees, however. This workshop session reviews the subjective and objective measures frequently employed to assess foot mobility. In addition, the use of these measures to determine the amount of foot orthotic posting is illustrated and discussed.

REFERENCES 1. H oppenfeld S, Hutton R. Physical Examination of the Spine and Extremities. New York, NY: Appleton-Century-Crofts; 1976. 2. McPoil TG, Vicenzino B, Cornwall MW, Collins N, Warren M. Reliability and normative values for the foot mobility magnitude: a composite measure of vertical and medial-lateral mobility of the midfoot. J Foot Ankle Res. 2009;2:6. http://dx.doi.org/10.1186/1757-1146-2-6 3. Meier K, McPoil TG, Cornwall MW, Lyle T. Use of antipronation taping to determine foot orthoses prescription: a case series. Res Sports Med. 2008;16:257-271. http://dx.doi.org/10.1080/15438620802310842 4. Menz HB, Munteanu SE. Validity of 3 clinical techniques for the measurement of static foot posture in older people. J Orthop Sports Phys Ther. 2005;35:479-486. http://dx.doi.org/10.2519/jospt.2005.2048

SHORT-FOOT EXERCISES: TRAINING THE FOOT CORE PATRICK O. MCKEON, PhD, ATC, CSCS Division of Athletic Training, College of Health Sciences, University of Kentucky, Lexington, KY.

The foot is a dynamic structure that is designed to accommodate the functional demands of absorption and propulsion during repetitive activities such as running.1 The architecture of the foot provides the ability to transition from a supple to a rigid body and supports the transitions between absorption and propulsion.5 Lower extremity injuries have been linked to alterations in foot function, but much of the research has been focused on the role of proximal contributions and/or the extrinsic foot muscles, such as tibialis posterior, for controlling foot motion and stability.2 However, the intrinsic foot muscles play an important role in providing stability of the

foot arches during these transitions, as well as provide relevant sensory information about foot posture and positioning.3,4 Recently, more attention has been devoted to these muscles and their functional role as foot stabilizers during dynamic activities.6 Short-foot exercises, developed by Janda et al,4 have gained popularity as a means of activating and strengthening the intrinsic foot muscles. The systematic process of these exercises is geared toward teaching a patient how to find a neutral foot position and maintain it by activation of the intrinsic foot muscles.3,4 This is much akin to teaching a patient how to find pelvic neutral and activate the abdominal core muscles. Based on the anatomical and biomechanical orientation of the intrinsic foot muscles, a key factor in the short-foot exercises is the ability to produce metatarsophalangeal joint flexion without concomitant interphalangeal joint flexion. Isolated flexion of the metatarsophalangeal joints results in a rising of the longitudinal arch and a subsequent shortened foot posture, hence the name short-foot exercises. As a patient gains the ability to maintain the shortfoot position, a gradual and logical progression from seated activities to standing dynamic activities can be implemented. The purpose of this workshop is to provide the audience with an overview of the functional role of the intrinsic foot muscles and training strategies using short-foot exercises.

REFERENCES 1. B ramble DM, Lieberman DE. Endurance running and the evolution of Homo. Nature. 2004;432:345-352. http://dx.doi.org/10.1038/nature03052 2. Chuter VH, Janse de Jonge XA. Proximal and distal contributions to lower extremity injury: a review of the literature. Gait Posture. 2012;36:7-15. http://dx.doi.org/10.1016/j.gaitpost.2012.02.001 3. Jam B. Evaluation and retraining of the intrinsic foot muscles for pain syndromes related to abnormal control of pronation. Orthop Div Rev. 2006;19:24-30. 4. Janda V, Vávrová M, Herbenová A, Veverková M. Sensory motor stimulation. In: Liebenson C, ed. Rehabilitation of the Spine: A Practitioner’s Manual. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2007:513-530. 5. Perry J, Burnfield JM. Gait Analysis: Normal and Pathological Function. 2nd ed. Thorofare, NJ: SLACK Incorporated; 2010. 6. Soysa A, Hiller C, Refshauge K, Burns J. Importance and challenges of measuring intrinsic foot muscle strength. J Foot Ankle Res. 2012;5:29. http://dx.doi.org/10.1186/1757-1146-5-29

FUNCTIONAL EVALUATION STRATEGIES FOR ANKLE INJURIES PHILLIP GRIBBLE, PhD, ATC, FNATA Musculoskeletal Health and Movement Science Laboratory, Department of Kinesiology, University of Toledo, Toledo, OH.

In an effort to reduce the high rate of ankle injury and reinjury in the physically active, clinicians and researchers continue to pursue the most effective prevention and intervention strategies for acute and recurrent ankle injury. Optimizing functional performance is an important clinical



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Fifth International Ankle Symposium: Keynotes goal, yet too often clinicians may not properly and adequately evaluate the modifiable impairments that create functional disabilities that predispose patients to lingering ankle instability and reinjury. Therefore, an important step in restoring functional movement and returning patients to desired activities is to implement the most effective tools for detecting functional impairments in patients with ankle instability. A paradigm of rehabilitation that presents the categories of impairments following musculoskeletal injury has been suggested by Denegar.2 This workshop focuses on impairments within this paradigm that are modifiable, such as range of motion, strength, balance, and pattern-generated movements, for which valid and reliable clinical evaluation tools exist, as well as new approaches to comprehensive evaluation of the impairments. Addressing these impairments systematically through the rehabilitation process should help achieve the paradigm’s pinnacle of returning the patient to desired functional activities. This summary will provide some of the specific recommendations discussed in the workshop. For ankle range of motion, the weight-bearing lunge test is suggested for assessment of ankle dorsiflexion.1,10 If deficits are discovered, clinicians can determine if arthrokinematic or soft tissue restrictions need to be addressed. Ankle strength deficits may persist but are not consistently observed in patients with ankle instability. In addition to assessing strength at the ankle, clinicians should also address the potential deficits in knee6 and hip strength4 that could create a functional limitation. One way to estimate appropriate integration of sensory and motor information is through balance assessments. New approaches to assessing deficits in static balance (minimizing body segment movement while maintaining a stable base of support) among patients with ankle instability include the Balance Error Scoring System,3 the demi-pointe test,9 and the foot-lift test.8 Dynamic balance (making purposeful body segment movements while maintaining a base of support) can be assessed with the Star Excursion Balance Test, which is very reliable and differentiates patients with ankle instability.5 When these impairments and disabilities are detected and addressed appropriately, progression to pattern-generated and functional movements is warranted. There is an abundance of functional movement tests available for laboratory and clinical implementation, including agility, hopping, landing, and gait assessments, that can demonstrate deficits in patients with ankle instability. Finally, in addition to assessment of contributions to physical function, it is strongly recommended that outcomes of patientreported function be included, using validated instruments to produce a comprehensive evaluation of functional deficits and successful progression of rehabilitation.7 This workshop provides recommendations for functional evaluation of ankle instability. Ultimately, it is up to the clinician to determine the most applicable evaluation tools for the targeted goals of the patient based on the best evidence and the available resources.

REFERENCES 1. B ennell KL, Talbot RC, Wajswelner H, Techovanich W, Kelly DH, Hall AJ. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiother. 1998;44:175-180. 2. Denegar CR. A rehabilitation paradigm for restoring neuromuscular control following athletic injury. Athl Ther Today. 1998;3:12-16. 3. Docherty CL, Valovich McLeod TC, Shultz SJ. Postural control deficits in participants with functional ankle instability as measured by the Balance Error Scoring System. Clin J Sport Med. 2006;16:203-208. 4. Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train. 2006;41:74-78. 5. Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012;47:339-357. http://dx.doi.org/10.4085/1062-6050-47.3.08 6. Gribble PA, Robinson RH. An examination of ankle, knee, and hip torque production in individuals with chronic ankle instability. J Strength Cond Res. 2009;23:395-400. http://dx.doi.org/10.1519/JSC.0b013e31818efbb2 7. Hiller CE, Kilbreath SL, Refshauge KM. Chronic ankle instability: evolution of the model. J Athl Train. 2011;46:133-141. http://dx.doi. org/10.4085/1062-6050-46.2.133 8. Hiller CE, Refshauge KM, Herbert RD, Kilbreath SL. Balance and recovery from a perturbation are impaired in people with functional ankle instability. Clin J Sport Med. 2007;17:269-275. http://dx.doi.org/10.1097/ JSM.0b013e3180f60b12 9. Hiller CE, Refshauge KM, Herbert RD, Kilbreath SL. Intrinsic predictors of lateral ankle sprain in adolescent dancers: a prospective cohort study. Clin J Sport Med. 2008;18:44-48. http://dx.doi.org/10.1097/ JSM.0b013e31815f2b35 10. Hoch MC, McKeon PO. Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability. J Orthop Res. 2011;29:326-332. http://dx.doi.org/10.1002/jor.21256

CLINICAL INDICATORS FOR ANKLE SPRAIN PROGNOSIS CHRIS M. BLEAKLEY, PhD, BSc, MCSP, SRP Ulster Sports Academy, Faculty of Life and Health Sciences, University of Ulster, Antrim, UK.

Ankle sprains can have a variable clinical outcome. Clinicians are encouraged to adopt an evidence-based approach to their assessment. Central to this is the selection of key clinical tests that inform diagnosis and provide accurate prognostication for recovery. Developing a more informed and streamlined approach to clinical assessment of ankle sprain is important, particularly for practitioners with limited direct access to diagnostic imaging or working under significant time constraints (eg, accident and emergency practitioners). The Ottawa ankle rules can be used to accurately rule out bony injury1; in some departments, concern over litigation means that these are often used in conjunction with radiographs. Early identification of syndesmotic involvement is essential. These injuries are typically underreported4 and significantly increase recovery time. Syndesmotic involvement also limits or contraindicates the potential for early functional treatment, particularly accelerated rehabilitation protocols. Differentiation between specific injuries to the lateral ligament complex can be difficult in the acute setting. Delaying physical examination for 4 to 5 days postinjury can



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Fifth International Ankle Symposium: Keynotes improve the sensitivity and specificity of clinical stress tests, particularly when used in combination with accurate history taking, palpation, and observation of bruising. 3 While there is no such thing as a simple ankle sprain, practitioners should be cognizant of key recovery milestones. Ideally, pain and self-reported function should improve significantly over the first 2 weeks after ankle sprain.7 Patients failing to track this course of recovery or who do not tolerate progressive rehabilitation should be investigated for concomitant or occult injuries. These may include (but are not limited to) osteochondral deficits, sinus tarsi syndrome, posterior or anterolateral impingement, neurogenic pain. Patients with a combination of altered joint mechanics and certain anatomical traits (eg, os trigonum, large or ragged synovial recess) may be most at risk of posttraumatic impingement.5 Where possible, prognostication models should be informed by empirical evidence. There have been few large prospective studies in this area. There are limited data2,6,8 to suggest that pain at rest, early reinjury, syndesmotic involvement, and low levels of subjective function are associated with poor long-term outcome. There is empirical evidence to suggest that key prognostic indicators for poor recovery after other types of musculoskeletal injuries may also inform clinical decisions after ankle sprain. These include psychosocial factors, distress, previous sick leave, high pain intensity, and low levels of education. Effective rehabilitation will be guided by skilled and evidence-based assessment of the injured ankle. Patients with a greater perceived risk of pain may be less compliant with rehabilitation. Intervention programs should be adapted based on patients’ prognostic profile and include consideration of key anatomical, clinical, physiological, and psychosocial factors.

REFERENCES 1. B achmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326:417. http://dx.doi.org/10.1136/bmj.326.7386.417 2. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19:653-660. 3. Kerkhoffs GM, van den Bekerom M, Elders LA, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012;46:854-860. http://dx.doi.org/10.1136/ bjsports-2011-090490 4. McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN. Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc. In press. http://dx.doi.org/10.1007/s00167-012-2205-1 5. O’Sullivan E, Bowyer G, Webb AL. The synovial fold of the distal tibiofibular joint: a morphometric study. Clin Anat. In press. http://dx.doi.org/10.1002/ ca.22140 6. van Middelkoop M, van Rijn RM, Verhaar JA, Koes BW, Bierma-Zeinstra SM. Re-sprains during the first 3 months after initial ankle sprain are related to incomplete recovery: an observational study. J Physiother. 2012;58:181188. http://dx.doi.org/10.1016/S1836-9553(12)70109-1 7. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, BiermaZeinstra SM. What is the clinical course of acute ankle sprains? A sys-

tematic literature review. Am J Med. 2008;121:324-331.e7. http://dx.doi. org/10.1016/j.amjmed.2007.11.018 8. Wilson RW, Gansneder BM. Measures of functional limitation as predictors of disablement in athletes with acute ankle sprains. J Orthop Sports Phys Ther. 2000;30:528-535.

SURGICAL CONSIDERATIONS FOR ANKLE ARTHRITIS STEVEN J. LAWRENCE, MD Department of Orthopedic Surgery, University of Kentucky, Lexington, KY.

The articular surfaces of the ankle are subject to high-level stresses with weight-bearing activities. The talus must absorb significant compressive, shear, and edge-loading forces on a daily basis. Supraphysiologic injury to the chondral surface of the talus or tibia and/or ligamentous instability may initiate a degenerative process, because chondrocytes have a limited healing response. Arthritis is subdivided into posttraumatic and primary osteoarthritis. Recent prospective studies have validated the severe functional and psychosocial limitations associated with end-stage arthritis.1,2 The degenerative process may be initiated by an isolated event such as an osteochondral defect. Furthermore, peripheral osteophyte formation may result in painful impingement in the end ranges of joint motion. Impingement may predate central chondral loss. Finally, joint instability may also generate excessive joint contact pressures. Surgical treatments continue to evolve to minimize pain and functional disability of ankle osteoarthritis. Fracture repair addresses the osseous component of the injury, but associated chondral/ligamentous injury is often underappreciated. Over 60% of unstable ankle fractures have concomitant chondral injuries. 3 Intraoperative fluoroscopic assessment of osteophytic impingement and joint stress testing provides objective means to assist in making an accurate diagnosis and selecting appropriate treatment. Small-joint arthroscopy and ankle joint replacement are evolving treatment modalities with obvious advantages over open surgical procedures and joint arthrodesis, respectively. Ligament repair/reconstruction is performed to restore joint congruity. Joint lavage with chondral debridement and microfracture is a popular means to treat select osteochondral lesions. Unfortunately, fibrocartilage fills the void rather than articular cartilage. Total ankle replacement and ankle arthrodesis are salvage treatments reserved for advanced arthritis.4 Recent prospective studies with intermediate follow-up did not report significant improvements in pain relief or function when total ankle replacement was compared to joint arthrodesis.

REFERENCES 1. Glazebrook M, Daniels T, Younger A, et al. Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis. J Bone Joint Surg Am. 2008;90:499-505. http://dx.doi.org/10.2106/



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Fifth International Ankle Symposium: Keynotes JBJS.F.01299 2. L oren GJ, Ferkel RD. Arthroscopic assessment of occult intra-articular injury in acute ankle fractures. Arthroscopy. 2002;18:412-421. 3. Saltzman CL, Kadoko RG, Suh JS. Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop Surg. 2010;2:1-7. http://dx.doi.org/10.4055/ cios.2010.2.1.1 4. Saltzman CL, Zimmerman MB, O’Rourke M, Brown TD, Buckwalter JA, Johnston R. Impact of comorbidities on the measurement of health in patients with ankle osteoarthritis. J Bone Joint Surg Am. 2006;88:2366-2372. http://dx.doi.org/10.2106/JBJS.F.00295

CHRONIC ANKLE INSTABILITY: AN EVOLUTION OF UNDERSTANDING CLAIRE HILLER, PhD Faculty of Health Sciences, University of Sydney, Sydney, Australia.

Chronic ankle instability (CAI) is a common problem following ankle sprain. A recent survey in Australia found 61% of the 751 people surveyed had a history of an ankle sprain and 13.5% of these (8.3% of whole survey) had ongoing problems; of those with problems, many had problems lasting more than 10 years.8 These problems included pain, weakness, instability, swelling, and activity limitations.9 Historically, CAI has been considered to consist of 2 main subgroups, mechanical and functional instability. While mechanical instability is relatively well defined, functional instability has been shown to have a wide range of definitions. Hertel7 proposed a model where mechanical and functional insufficiencies exist separately, and where they occur together, recurrent sprain results. After observation in the clinic and a few studies, an evolution of the Hertel model has been proposed.10 The evolved model proposes that there are 3 main subcategories of CAI: mechanical instability, perceived instability, and recurrent sprain. These subgroups can overlap in various combinations, and 7 subgroups result. Data from previous studies were used to test the 2 models, and the evolved model provided the best fit for all the ankles. Each subgroup or combination of subgroups may exhibit different characteristics that would enable rehabilitation programs to be more clearly targeted. Exploration of this theory has been considered in 3 ways. First, specific tests across 2 studies were compared. Balance was worse than external controls for all subgroups involving perceived instability, but the severity of the imbalance was different between subgroups. Recovery from a perturbation was slower for all subgroups. Second, a systematic review of studies that include participants with recurrent sprain compared to external controls have demonstrated differences in a number of variables.6 Closer examination of 2 of these, inversion and eversion strength and peroneal reaction time, revealed differences between subgroups. Third, a group of studies by Brown1 and Brown et al,2-4 which separated CAI

into groups with and without mechanical instability, demonstrated different effects on kinetics and kinematics in stopjump and single-leg landings and in gait. The evolved model has a number of issues that need to be resolved. Hypomobility is sometimes present in CAI and should be represented and explored. Giving way where an actual “rolling-over” incident occurs is certainly a perception of instability, but should it be considered similar to a recurrent sprain? Other symptoms, such as pain and swelling, should also be considered. It may also be that the model is actually an extension of pathology, such as nerve injury or syndesmosis disruption. Syndesmosis injury, without diastasis or fracture, is increasingly being identified as occurring during all grades of lateral ankle sprain and may be the factor that leads to the development of CAI.5 Future research should more closely define the research participants in terms of the model to explore and refine the model and related insufficiencies. The ability to subcategorize and characterize CAI would enable more targeted rehabilitation programs and potentially assist in prevention of CAI.

REFERENCES 1. B rown C. Foot clearance in walking and running in individuals with ankle instability. Am J Sports Med. 2011;39:1769-1776. http://dx.doi. org/10.1177/0363546511408872 2. Brown C, Bowser B, Simpson KJ. Movement variability during single leg jump landings in individuals with and without chronic ankle instability. Clin Biomech (Bristol, Avon). 2012;27:52-63. http://dx.doi.org/10.1016/j. clinbiomech.2011.07.012 3. Brown CN, Padua DA, Marshall SW, Guskiewicz KM. Hip kinematics during a stop-jump task in patients with chronic ankle instability. J Athl Train. 2011;46:461-467. 4. Brown CN, Padua DA, Marshall SW, Guskiewicz KM. Variability of motion in individuals with mechanical or functional ankle instability during a stop jump maneuver. Clin Biomech (Bristol, Avon). 2009;24:762-768. http:// dx.doi.org/10.1016/j.clinbiomech.2009.07.001 5. de César PC, Avila EM, de Abreu MR. Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int. 2011;32:1110-1114. http://dx.doi.org/10.3113/ FAI.2011.1110 6. Delahunt E, Coughlan GF, Caulfield B, Nightingale EJ, Lin CW, Hiller CE. Inclusion criteria when investigating insufficiencies in chronic ankle instability. Med Sci Sports Exerc. 2010;42:2106-2121. http://dx.doi.org/10.1249/ MSS.0b013e3181de7a8a 7. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37:364-375. 8. Hiller CE, Kilbreath SL, Refshauge KM. Chronic ankle instability: evolution of the model. J Athl Train. 2011;46:133-141. http://dx.doi. org/10.4085/1062-6050-46.2.133 9. Hiller CE, Nightingale EJ, Lin CW, Coughlan GF, Caulfield B, Delahunt E. Characteristics of people with recurrent ankle sprains: a systematic review with meta-analysis. Br J Sports Med. 2011;45:660-672. http://dx.doi. org/10.1136/bjsm.2010.077404 10. Hiller CE, Nightingale EJ, Raymond J, et al. Prevalence and impact of chronic musculoskeletal ankle disorders in the community. Arch Phys Med Rehabil. 2012;93:1801-1807. http://dx.doi.org/10.1016/j.apmr.2012.04.023



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CFifth o m bInternational i n e d S eAnkle c t i Symposium: o n s M eSchedule eting

Schedule CMS Orthopaedic and Sports Physical Therapy Section Programming Schedule 2007

RESEARCH PRESENTATIONS

The following abstracts are available online only at www.jospt.org.

Th u r s d a y , O c t o b e r 1 8

Cortical Inhibition Is Related to Ankle Laxity Needle AR, Kesar TM, Palmer JA, Binder-MacLeod SA, Swanik CB

Star Excursion Balance Testing Predicts Ankle Injuries in American Football Players Gribble PA, Ericksen HM, Ford AS, Harkey MS, Luc BA, McLeod MM, Morrell MD, Nelson BD, Pfile KR, Pietrosimone BG, Quinlevan ME, Stout MW, Terada M

February tk-tk, 2007 t San California Correlated With 2 Balance Tests andDiego, Timed Functional Ankle Instability Is Weakly

Session 1, 9:00 AM-10:00 AM

Time-to-Return-to-Play Do tem zzrit do commod tis Probabilities adigna facil ulput Not Differ Between New and Recurrent nit, consent non eu feum quat vel dit, si Ankle Sprains tisim nisis essent alismol utpat, commodio Medina McKeon JM, Whittington AG, conulput aliquatumsan etuer irit aliscidui Uhl TL, Bush HM, McKeon PO

Tu e s d a y , Ja n u a r y 2 Force-Displacement Characteristics of the Ankle in Individuals With Without ex eugiam incinisit nim euiand etum eum dolor Chronic Ankle Instability sum accummo dolore dit wis alisit, susto Choisne J, Hoch MC, Ringleb SI, dolore conullam exeros atum in hendigna McKeon PO feu facipsu sciniat vel ut nonulput vulla acincilis nullam nibh eugait ad endiam Biomechanical of an nulla commolo Characteristics rerilit ut nis eugait nulput Accidental Ankle Sprain do odiam quisim zzrilla ad modio dolum Terada M, PA dolorperate conGribble ut la facillam dit il ut nis alis acillamcorem dolenisi. Wiscil utpat, velessi blaorem zzrit Session 2, 10:30 ad ming et inAM-12:00 ut ad temPM quis ad Impact of Dual-Tasking on Postural Control min esto cor ad dolobore diam zzrit in Those With Chronic Ankle Instability praessissent exercil iquate ea feuis Burcal CJ,doloreet, Drabik con EC, velit Wikstrom delismod vel ex EA et et, vent velisit adionse el el utpat. Duis Development of an Animal Model at acing euis eugait iure tetueof velis ad Chronic Ankle Instability dunt adio odolut doloreet non ut ut Delahunt d’Helft C, Brama endre PA autpatem E, dolore doloreetuero enibh er sectet accum do do eniam A Between-Group Analysis of consectem Inversion quis nos do conse magna anddolobor EversionsitStrength Does Not vero odolore dolenit esecte Distinguish Those and Without tem inibh ex eaWith adiamet, quipit aute Ankle Instability dit adignit adit amconse tat, sumsan Kaminski Liu K, Gustavsen utatummyTW, nonse coreriu scilit G volobore faccum ver adit nibh erostisi. Step-Training and Heel-Raise Exercises With Restriction Enhance Iduis Blood-Flow acilit augait, velessit lut prat. DuAnkle Muscle Strength in Volleyball Players isit num zzriliquisi enit lutate tat exercipLin W, Du J, Hertel J it praestrud tetuerit la feuis accumsan ero doluptat.

Stair Test Te consequisit, commolo reetum zzrillan Pourkazemi F, Hiller C, Raymond J, vel eriurer sum quisl dolesed minibh eum Refshauge K acipis aut vel do dipsum augait, quatue digna aci tionullam dolor sendio odolor adiam iure nitbnim F r itat. d aUt y , accum Octo e r dion 19 ut nulputatie modo commodipis aliqui Session 9:00 te tie feu1,faci blaAM-10:00 faciduisit,AM vel etummy The Dynamics of in Minimalist nibh essequisi euisRunning ea ad eraessequam, vel and Lightweight Shoes Areiurer Not sit, the vullums Same ipsum del dolor susci exer as Barefoot vullutat. RunningIquisi. andiamcon Bonacci J, Saunders Hicks sandit A, Lor ing ercilit autemPU, quipsum Vicenzino B, Spratford W wisit, veraesequat. Obortio nsequi te te magnim incipsum volore tissim Shank-Rearfoot Joint During ipsusto er init nonCoupling henim nullam, Jogging in Young Adults With Chronic vel diam, venibh elesecte do commod Ankle A Cross-Correlation erosInstability: et lametum vero consed euisse Analysis facil iuscipit, sit vullaor senibh ero Herb Chinn blametue L, Dicharry J, Hertel doloreC,velisisi dolor alisci J ex exer se ero dolesto et accum iure Starconsenibh ExcursionelBalance Test asulputat a Predictor dolutatuerit for Ankle Injury in Rugby Players do commy nonsecte feugiamet Sman AD,feu Hiller CE, Nicholson at augue facilisci eu faccum LL, Rae KL, Refshauge KM volorer cipsuscipit am, commy nibh etum num ad et wisit dunt init wis Physiotherapeutic of Cuboid nonsequisi esedTreatment etum zzriure tatis Syndrome Secondary to Lateral Ankle num nit, vel ip euip et loboreet Sprain With Mulligan’s Mobilization-Withvelendre essit dolobore et prat vel Movement: A Case Study iriliscilit ver sum quam dolorerosto Simpson H sum zzrilit nullandip odio dolorer eugait il incip exeraestrud dolenim ing et nim eugait lummoluptat Session 2, 2:00 PM-3:00 PM at lum adigna facidunt eu facilla Gaitdolortis Kinematics Change With the quisi accum zzrit nis nullam Application of Ankle Tape in Subjects blan ut nonsequisl erit, commod With Chronic Ankleeril Instability dolorpero dolor in volore facil Chinn L, Hart J, Saliba S, Wilder R, iure eniamcor suscin elenim dolorer Hertel J sequam, consecte dip ex eliquiscilit dion vel utet, sit alismod do odolore

doluptat utatuero consequis dolorem Thequi Effect of Footwear on velendigniam Multisegment blandip etumsan Footnos Kinematics During Running in ad endipsustie dolent alit prat Individuals With Low and Typical Arch min vel iustrud tationsenit acipsusto Structure euguer si tion ulla feumsan dreros Joshi Bauer TR, ad temMN, do ea feumRL, velKlinkner duis accum Cobb SC quis adipsum iure moloreet alit ad doluptat. Ut iusto el ilit nit prat Quantification of Ankle Sprain Risk iniat. Among nonulput nibh erosto el ullutet College Football Players Rud modipit la acip et, vel ex eum Wilkerson Guadagno veliquissedGB, magna adiam Jnulput irit wis dolor aut alisl dolor ad te dolore tat S aam t uquat. r d aDuissequip y , O c t o benim e r quam 20 ing eumsandre eugait aute digna Session 1, 10:15 AM-11:30 AMzzrit, sim aliquis iscipit irilit lum Long-Term Impact of Ankle Injury ilit praesto doloreet landre do con Nightingale EJ, Hiller CE, A, utetue faccummy nullutemSman zzriustrud Burns J, Refshauge KR mincidunt at. Niscidunt verit, con volortie con vel ut dolorer iliquamet Stances of Balancewis Error Scoring lan vullandit adit loboreSystem tetummo That Identify Those With Chronic Ankle dipsum zzril erit, si. Instability Ross BLquatum ExerLinens at. NosSW, alisis nosSE, nonArnold henit am, iure faccum zzrit, vero eriureros nulla amet utem quisl ea feugiat. Nim ea accum inciliquat.

POSTER PRESENTATIONS

Elisl er iustie vel dipsum verosto delessed The followingvoluptat abstracts are doloreratum nis adavailable delestrudonline only at www.jospt.org. exer sum nim ent non ulputet at, quissim exer Th in erilit ndigna u r accumsa s d a y, O c t o aliquatem ber 18 voloborero et dolobore cortiscillum dolore 4:00 PMdo exero consectet veliqua dolut PM-6:00 ver sismod Footwear Affects Foot mconsectem quisMultisegment alit at. Kinematics During the Loading Response Summy nit lorpero commodiatio Subphase of Walking Gait odolut esequatet in volore facinit lum Cobb Joshi MN, Bauer RL, in euiSC, tatuer irit la commy nulla Klinkner TR facinibh esequis ciliquam quamet,


43-03 Ankle Symposium Schedule.indd 11

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Fifth International Ankle Symposium: Schedule Active Ankle Motion May Result in an Anterior Talar Position Fault in AnkleInjured Subjects: A Preliminary Study Croy T, Cosby N, Hertel J

Proprioception After Ankle Instability Surgery: A Pilot Study Gutierrez GM, Mroczek K, Chapman C, Sheskier S

Chronic Ankle Instability in Children: A Systematic Review Mandarakas M, Pourkazemi F, Sman A, Burns J, Hiller CE

Altered Lower Extremity Kinematics During a Forward-Side Jump for Ankle Instability Subjects Denning M, Seeley MK, Reese S, Francom D, Hopkins JT

Anterior Talocrural Joint Laxity: A Criterion-Related Study of the Anterior Drawer Test of the Ankle Hertel J, Croy T, Koppenhaver S, Saliba S

Basketball Coaches’ Attitudes and Behaviors Regarding the Use of Ankle Braces and Exercise Programs to Prevent Ankle Injuries McGuine TA, Brooks MA, Penuto A

Effect of Ankle Joint Mobilization on Initial Contact Plantar Flexion Angle in Participants With Chronic Ankle Instability Doherty C, Cusack K, Wilson L, Delahunt E

Peroneal Reaction Time in Individuals With a History of Ankle Sprain: A Systematic Review With Meta-analysis Hoch MC, McKeon PO

Decreased Dynamic Postural Control in Individuals With Chronic Ankle Instability With a Dorsiflexion Deficit: A Preliminary Study McKeon PO, Hoch MC

Effects of Talocrural Joint Mobilizations in Individuals With Diminished Dorsiflexion Range of Motion After Ankle Sprain Donovan L, Brandt J, Cosby N, Hertel J

Altered Lower Extremity Mechanics During a Forward-Side Jump in Ankle Instability Subjects Hopkins JT, Denning M, Reese S, Francom D, Seeley MK

Development of a Model of Ankle Health Evans TA, Snyder KR, Neibert PJ, Weiss WM, Haak TL

Analysis of Foot and Ankle Ability Measure-Sport Items Following Joint Mobilization in Individuals With Chronic Ankle Instability Houston MN, Hoch MC

Leg-Spring Behavior and Foot Mobility Changes During an Exhaustive, ConstantVelocity Treadmill Run in Adolescents Fourchet F, Girard O, Kelly L, Horobeanu C, Millet GP

Physical Activity Levels in Those With Chronic Ankle Instability Hubbard-Turner T, Turner MJ

Diagnostic Ultrasound of the Anterior Talofibular Ligament: A Technical Note Frederick ED, Mattacola CG, Moore R Kinematic Analysis of Selected Reach Directions of the Star Excursion Balance Test Compared to the Y-Balance Test Fullam K, Ditroilo M, Caulfiled B, Delahunt E Lower-Leg Kinesio Tape Application Reduces Rate of Loading in Subjects With Medial Tibial Stress Syndrome Griebert MC, Needle AR, Kaminski TW

Relationships Between Self-Reported Ankle Function and Postural Modulation of Hoffmann Reflex in Patients With Chronic Ankle Instability Kim KM, Hart JM, Saliba SA, Weltman AL, Hertel J Evidence for a Curvilinear Relationship Between Number of Lateral Ankle Sprains and Ankle Complex Laxity Kovaleski JE, Heitman RJ, Gurchiek LR, Hollis JM

Syndesmotic Sprains in Adolescents Nussbaum E, Gatt CJ Predictors of Ankle Instability in Children With Charcot-Marie-Tooth Disease Rose KJ, Hiller CE, Mandarakas M, Raymond J, Burns J Can Ankle Range-of-Motion and Ligament-Laxity Measures Predict Self-Reported Ankle Function? Rosen AB, Brown CN Changes in Gluteal Muscle Activity During Running With the Use of Foot Orthoses in Males With Achilles Tendinopathy Smith MM, Honeywill C, Creaby MW, Wyndow N, Crossley K Gait Initiation Is Altered in Those With Chronic Ankle Instability Wikstrom EA, McKeon PO, Hass CJ Peak Posterior Ground Reaction Forces Differ Between Individuals With Functional Ankle Instability and Copers Wright CJ, Arnold BL, Ross SE

Examining the Accuracy of Existing Methods to Calculate Dynamic Postural Stability in Healthy, Coper, and Unstable Ankles Liu K, Glutting J, Kaminski TW


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Fifth International Ankle Symposium: Abstracts

Fifth International Ankle Symposium: Abstracts

Abstracts The Journal of Orthopaedic & Sports Physical Therapy is pleased to publish abstracts of the Fifth International Ankle Symposium, which took place in Lexington, Kentucky, October 17 to October 20, 2012. This collection of abstracts provides a brief summary of the research presented at that meeting. These abstracts were selected by the meeting research committee but did not undergo peer review by the editorial board of the Journal. Each abstract represents a short summary of a project, often presenting only preliminary data. These summaries do not permit a full evaluation of the scientific rigor with which the work was conducted, but they provide an idea of the type of clinical questions being researched by individuals participating in that meeting.

RESEARCH PRESENTATION ABSTRACTS TIME-TO-RETURN-TO-PLAY PROBABILITIES DO NOT DIFFER BETWEEN NEW AND RECURRENT ANKLE SPRAINS Medina McKeon JM, Whittington AG, Uhl TL, Bush HM, McKeon PO Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY; Department of Biostatistics, University of Kentucky, Lexington, KY STUDY DESIGN: Observational. OBJECTIVES: To compare time-to-return-to-play probabilities for new versus recurrent ankle sprains in interscholastic athletes. BACKGROUND: While ankle sprains are fairly common, there are few prognostic indicators supporting an estimate of when an athlete will return to participation. Additionally, it is unknown how subsequent ankle sprains may influence return-to-play timelines. METHODS: New (no prior ankle sprain) versus recurrent (history of sprain to the same ankle) ankle sprains were compared for time-to-return-toplay timelines. The outcome associated with all ankle sprains was time lost from participation (time-loss intervals: same-day return, next-day return, 3-day return, 7-day return, 10-day return, 22-day return, no return [censored data]). Kaplan-Meier time-to-event probabilities estimators using censored data were calculated to determine the influence of ankle injury history on return to play and compared using a Mantel-Cox log rank test. The estimated time-to-event probability is the predictive probability of return at a given time point. RESULTS: Across 2 academic years, there were 201 ankle sprains (164 new [4 censored], 37 recurrent [1 censored]). For both new and recurrent ankle sprains, the median time-to-event probability (interquartile range) was 3 days (next day to 7 days). The Mantel-Cox log rank test revealed no significant difference (P = .93) between the time-to-event curves for new and recurrent ankle sprains. CONCLUSION: There was no difference in time-to-return-to-play timelines between new and recurrent ankle sprains. Possibly, there is an increased risk of reinjury based on inadequate restrictions from participation, and a more conservative return-to-play consideration for ankle sprains may be warranted. Furthermore, while epidemiological studies are imperative for describing clinical phenomena, they are typically not directly applicable to clinicians. The time-to-event analyses that describe the likelihood of return to play are immediately useful to clinicians by providing guidelines for describing return-to-play prognoses to athletes, coaches, and parents.

FORCE-DISPLACEMENT CHARACTERISTICS OF THE ANKLE IN INDIVIDUALS WITH AND WITHOUT CHRONIC ANKLE INSTABILITY Choisne J, Hoch MC, Ringleb SI, McKeon PO Department of Mechanical and Aerospace Engineering, Old Dominion

University, Norfolk, VA; Department of Human Movement Sciences, Old Dominion University, Norfolk, VA; Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY STUDY DESIGN: Case-control. OBJECTIVES: Compare the anterior and posterior force-displacement characteristics of the ankle between subjects with chronic ankle instability (CAI) and healthy control subjects. BACKGROUND: Individuals with CAI have demonstrated several mechanical impairments, including increased anterior laxity, restricted posterior talar glide, and anterior talar positional faults. However, it is unclear if deviations in anterior and posterior talar/subtalar displacement are present at varying levels of force application. METHODS: Twenty individuals with self-reported CAI (11 women, 9 men; mean  SD age, 23.4  5.4 years; height, 174.6  7.8 cm; mass, 76.9  17.8 kg) and 20 matched healthy individuals (11 women, 9 men; age, 23.9  3.8 years; height, 171.0  7.4 cm; mass, 74.8  14.7 kg) underwent 3 trials for anterior and posterior displacement using a Hollis ankle arthrometer. A maximum force of 125 N or 170 N was applied in the anterior or posterior direction, respectively. An average force-displacement curve was created for each subject after normalizing displacement data to 100% of maximum force. Mean ensemble curves with 95% confidence intervals (CIs) were created to represent the force-displacement relationship from 20% to 100% of maximum force for each group in each direction. Areas of nonoverlap between the 95% CI of each group were considered statistically different (P.05). RESULTS: Significant differences were detected between groups in the posterior force-displacement curve. The mean ensemble curves demonstrated that subjects with CAI had less posterior displacement from 20% (control, 1.36  0.61 mm; CAI, 0.65  0.36 mm) to 40% (control, 3.25  0.98 mm; CAI, 2.46  0.75 mm) of maximal force. No differences were identified in the anterior force-displacement mean ensemble curves between groups. CONCLUSION: Reduced posterior displacement was demonstrated in the lower force ranges (30-70 N) of the force-displacement curve of individuals with CAI. This deviation may be the result of mechanical alterations, such as an anterior talar positional fault in relation to the ankle mortise, which is supported by the lack of group differences in anterior displacement. The clinical manifestations and implications of these findings necessitate further exploration.

BIOMECHANICAL CHARACTERISTICS OF AN ACCIDENTAL ANKLE SPRAIN Terada M, Gribble PA Department of Kinesiology, University of Toledo, Toledo, OH STUDY DESIGN: Case report. OBJECTIVES: To present biomechanical characteristics of an accidental ankle sprain during a stop-jump task. BACKGROUND: A more definite description of lower extremity biomechanical characteristics at the time of injury would improve the understanding of injury mechanisms and may contribute to development of improved management of ankle injury. CASE DESCRIPTION: A recreationally active male (height, 180.3 cm; mass, 79.5 kg; 20 years old) with unilateral chronic ankle instability experienced an accidental ankle sprain during a bilateral stop-jump task in a motion analysis laboratory. Kinematics and kinetics were collected with a motion-capture system synchronized with 2 force plates. At 19 millisec-


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Fifth International Ankle Symposium: Abstracts onds after initial contact (IC), the noninjured ankle was unloaded, leaving the injured ankle with 100% of the loading, and this was designated as the injury period. Kinematics, energetics, joint coupling, and the location of the center of mass (COM) were calculated during the 19-millisecond period after IC. The injury trial was compared with the ensemble average of 5 noninjury trials. OUTCOMES: In the injury trial, ankle inversion and dorsiflexion rapidly increased and peaked during the 19-millisecond period after IC, with greater changes in the knee-ankle joint coupling patterns. The injury trial exhibited higher total absolute energy dissipation in the sagittal plane (–4.03 J/Nm) and corresponding increased ankle energy dissipation (absolute, –1.60 J/Nm; relative, 39.70%) compared to the noninjury trials (total, –3.19 J/Nm; ankle absolute, –0.66 J/Nm; ankle relative, 20.64%). In the noninjury trials, increased ankle energy generation in the frontal plane (0.14 J/Nm) was noted compared to the injury trial (0.05 J/Nm). The location of the COM was slightly higher in the injury trial (0.94 m) than in the noninjury trials (0.89 m). CONCLUSION: Higher sagittal plane and lower frontal plane energy dissipation, along with a higher location of the COM, were associated with a documented ankle sprain. Future research should consider this information to develop more effective intervention and prevention for recurrent ankle sprains.

IMPACT OF DUAL-TASKING ON POSTURAL CONTROL IN THOSE WITH CHRONIC ANKLE INSTABILITY Burcal CJ, Drabik EC, Wikstrom EA University of North Carolina at Charlotte, Charlotte, NC; San Jose State University, San Jose, CA STUDY DESIGN: Cross-sectional. OBJECTIVES: To quantify the effects of dual-tasking on postural control in those with chronic ankle instability (CAI) relative to uninjured controls. BACKGROUND: Those with CAI have postural control impairments possibly due to alterations in sensory, motor, and/or cognitive processes. Dualtasking, which is simultaneously performing postural control and cognitive tasks, is thought to tax an individual’s limited attentional resources. However, little is known about how dual-tasking affects the postural control of those with CAI. METHODS: Twenty individuals with CAI (mean  SD age, 21.9  5.5 years; height, 169.3  7.7 cm; mass, 72.6  16.9 kg) and 20 uninjured controls (age, 21.0  2.0 years; height, 175.0  11.2 cm; mass, 71.3  15.0 kg) participated. All participants completed three 30-second trials of a baseline cognitive condition while seated (backward counting by 3 from a 3-digit number). Next, three 30-second baseline postural control trials (single-leg stance with eyes open) were completed. Finally, three 30-second dual-task trials were completed. These trials required participants to count backward by 3 while simultaneously maintaining a single-leg stance. Cognitive outcomes included the total number of correct cognitive responses and the percentage of correct responses. Postural control outcomes included average sway in the anteroposterior (AP) and mediolateral (ML) directions. Change scores were calculated for each group and the 3 trial averages were submitted to independent-samples t tests. RESULTS: Significant group differences (P.05) the change scores for the total number of counting responses (CAI, 2.5  2.5; control, 2.7  3.2) or percentage of correct counting responses (