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Lateral Ankle Sprain and Chronic Ankle Instability: A Critical Review Takumi Kobayashi and Kazuyoshi Gamada Foot Ankle Spec 2014 7: 298 originally published online 24 June 2014 DOI: 10.1177/1938640014539813 The online version of this article can be found at: http://fas.sagepub.com/content/7/4/298

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research-article2014

FASXXX10.1177/1938640014539813Foot & Ankle SpecialistFoot & Ankle Specialist

298

August 2014

Foot & Ankle Specialist

〈 Review 〉 Lateral Ankle Sprain and Chronic Ankle Instability

Takumi Kobayashi, PhD, PT, and Kazuyoshi Gamada, PhD, PT

A Critical Review

Abstract: Many studies investigated the contributing factors of chronic ankle instability, but a consensus has not yet been obtained. The objective of this critical review is to provide recent scientific evidence on chronic ankle instability, including the epidemiology and pathology of lateral ankle sprain as well as the causative factors of chronic ankle instability. We searched MEDLINE from 1964 to December 2013 using the terms ankle, sprain, ligament, injury, chronic, functional, mechanical, and instability. Lateral ankle sprain shows a very high recurrence rate and causes considerable economic loss due to medical care, prevention, and secondary disability. During the acute phase, patients with ankle sprain demonstrate symptoms such as pain, range of motion deficit, postural control deficit, and muscle weakness, and these symptoms may persist, leading to chronic ankle instability. Although some agreement regarding the effects of chronic ankle instability with deficits in postural control and/ or concentric eversion strength exists, the cause of chronic ankle instability remains controversial.

Levels of Evidence: Therapeutic Level IV: Review of Level IV studies Keywords: lateral ankle sprain; chronic ankle instability; functional ankle instability; mechanical ankle instability

Epidemiology

the incidence of LAS between males and females.4-9 A previous report summarizing 16 years of National Collegiate Athletic Association injury surveillance data for 15 sports indicated that basketball, soccer, volleyball, and gymnastics had high injury rates (1.01-1.30/1000 athlete-exposure), whereas baseball, softball, and ice hockey had low injury rates (0.230.32/1000 athlete-exposure).10 Many LAS

Lateral ankle sprain (LAS) is one of the most common injuries in competitive sports and recreational activities. LAS often occurs in persons less than Ankle injuries account for 10% to 30% of all 50 years old because it is frequently athletic injuries and 40% sustained during sports activity, but to 56% of injuries in certain sports.1 Ankle quite a few LAS are reported in the sprains comprise 70% or more of ankle injuries in elderly as well.” many sports,1 and LAS accounts for about 80% of ankle sprains.2,3 One ankle sprain occur on landing or turning during occurs per 10 000 person-days, and an sports activity with or without contact.3 estimated 2 million acute ankle sprains LAS often occurs in persons less than 50 occur each year in the United States (an years old because it is frequently incidence of 2.15 per 1000 person-years).4 sustained during sports activity, but quite The peak incidence of ankle sprain a few LAS are reported in the elderly as occurs between 15 and 19 years of age,4 well.11 LAS is often caused by relatively but there is no significant difference in minor events such as “falls,” “slipping,”

“

DOI: 10.1177/1938640014539813. From the Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Hokkaido, Japan (TK); Department of Rehabilitation, Hiroshima International University, Hiroshima, Japan (KG). Address correspondence to: Kazuyoshi Gamada, PhD, PT, Hiroshima International University, 555-36 Kurose Gakuendai, Bldg 1, Rm 705, Higashi Hiroshima, Hiroshima 739-2695, Japan; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)


vol. 7 / no. 4

“tripping,”11 and there are many hidden risks of LAS in the routine activities of daily life. The economic cost of treating and preventing LAS is large because the incidence of LAS is quite high.12-14 The indirect annual medical cost of treating LAS was $1.1 billion in United States high school soccer and basketball players.13 Furthermore, the annual cost in the Netherlands was estimated as €84 240 000,12 and Verhagen et al14 calculated that the cost of preventing one ankle sprain was approximately €444.03. Because the LAS recurrence rate is very high, symptoms often persist. After 6.5 years of follow-up among athletes with ankle sprain, 5% had to change and 4% had to stop their sport activities due to residual symptoms.15 Similarly, among nonathletes with ankle sprain, 6% were not able to continue their previous occupation and 15% required external support to continue their original occupation.15

Injury Mechanism LAS commonly occurs during plantar flexion and inversion with excessive ankle supination because the ankle joint is more unstable in plantar flexion when ankle inversion and internal rotation are thought to occur.16-18 Wright et al19 indicated that increased ankle inversion during foot contact might promote LAS based on a mathematical model. Konradsen and Voigt20 also showed that ankle inversion before foot contact in unstable ankles. However, recent case reports using a 3-dimensional motion analysis technique suggested that LAS occurs even during excessive ankle internal rotation with slight dorsiflexion.21-24 Fong et al21 indicated that LAS occurred during large ankle internal rotation with slight inversion on analysis of foot position at injury in tennis players. They considered that ankle internal rotation rather than ankle plantar flexion could also be one of the factors promoting LAS, especially when the foot is planted on the sports ground, preventing further plantar flexion into the ground during horizontal sideward movement as


in tennis. A similar finding was obtained from 3-dimensional motion analysis during the sidestep cutting.22,23 Based on these studies, excessive ankle inversion or internal rotation occurs in the noncontact LAS development, whereas the role of excessive plantar flexion remains uncertain.

Pathology and Prognosis Various tissues are damaged by LAS.25 The anterior talofibular ligament (ATFL) sustains the most damage, and to merge the calcaneofibular ligament (CFL) damage.26,27 In patients with LAS, the ATFL and CFL were injured in 73% to 96% and 80%, respectively.3,28,29 The diagnosis of LAS is primarily based on physical findings such as tenderness, hematoma, and anterior drawer test (ADT), but ATFL damage was confirmed by arthrogram in 52% of patients demonstrating tenderness of the ATFL, and CFL damage was confirmed in 72% of patients demonstrating tenderness in CFL.28,30 Although tenderness may have low specificity, van Dijk et al31 showed that a combination of tenderness, hematoma discoloration, and ADT in the subacute phase (5 days after injury) demonstrated a sensitivity of 96% and a specificity of 84% in 160 LAS patients. Although high intertester reliability was shown on stress X-rays,32 this examination often exacerbates pain in the acute phase. In addition, none of the reports indicated a high sensitivity or specificity of this examination. On magnetic resonance imaging after LAS, a high percentage of patients demonstrated injury to the posterior tibialis tendon, peroneus brevis, or peroneus longus in addition to ATFL and CFL damage.28 Thus, various combinations of these injuries may be the cause of symptoms, but identifying the damaged tissue in individual patients is difficult. On in vitro studies, the maximal load on ATFL and CFL was considered to be 231 to 297 N and 307 to 598 N, respectively.33,34 Using a simulation model, Leardini et al35 assumed that the ATFL extended in plantar flexion, whereas the CFL length showed little change during


dorsiflexion-plantar flexion. However, it is impossible to speculate on the load and direction of damage to each ligament, because varying degrees of excessive 3-dimensional load are added to each ligament during LAS occurrence. ATFL excision increased talar anterior translation during ankle plantar flexion and increased talar inversion/internal rotation during ankle rotation; these movements were further increased by resecting the CFL.36-41 Various symptoms such as swelling, pain, and range of motion (ROM) deficit occur in the acute or subacute phase of LAS. Ten days after LAS injury, swelling significantly decreases compared to that after 3 days, but there is no significant improvement in ROM deficit.42 Ankle dorsiflexion ROM deficit is associated with abnormal gait pattern due to decreases in step and single leg support time.43 In addition, proprioceptive function might be deficient because mechanoreceptors are damaged by LAS. Konradsen et al44 indicated that position sense in the ankle inversion direction was decreased compared to that on the uninjured side 12 weeks after LAS, whereas neuromuscular reaction time and ankle evertor strength were not significantly different between the injured and uninjured sides 3 to 12 weeks after LAS.44 However, many researchers have suggested that neuromuscular deficit and evertor strength weakness occur in chronic ankle instability (CAI) patients, and these functions might show progressive deficits over time. Postural control deficit after LAS was also suggested.45-51 Although these studies used different measurement methods, significant postural control deficits were noted on both the injured and uninjured sides 1 day after LAS.46 However, the center of gravity displacement was larger than that on the uninjured side 6 weeks after LAS.51 A recent meta-analysis52 has suggested that there is a significant decrease in static postural control in injured and uninjured sides at acute phase but failed to find significance in the uninjured side for CAI patients. Symptoms of LAS often persist, which may be because athletes with LAS often

299

300

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return to sports without consulting a medical care provider. Hubbard et al53 suggested that mechanical instability resulting from LAS persisted 8 weeks after injury. In a study reporting 6.5 years of follow-up data after LAS, 17% to 22% of patients complained of pain, 35% to 48% of patients reported an unstable feeling, and 26% to 33% of patients demonstrated persistent swelling.15 In addition, among patients with tenderness in the ATFL during the acute phase, 32% showed tenderness at the same point 7 years after injury.54 A high recurrence rate is considered one of the causes of persistent symptoms. The recurrence rate of LAS is reportedly as high as 56% to 74%.55-58 Predominant symptoms are pain and crepitus in the ankle with 1 to 3 reinjuries, and an unstable feeling in the ankle with 4 or more reinjuries.55 Thus, repetition of LAS leads to CAI.16

Chronic Ankle Instability A diagnosis of CAI is based on a history of multiple sprains and repeated episodes of an unstable feeling or givingway. Freeman et al59,60 first described functional instability in 1965 when they attributed CAI to proprioceptive deficits after LAS. Several decades later, Hertel et al16 defined the cause of CAI is either mechanical ankle instability (MAI) or functional ankle instability (FAI). MAI is, by definition, caused by ligament laxity, whereas FAI is caused by other factors, including proprioceptive deficits, neuromuscular deficits, postural control deficits, and muscle weakness. Recently, Hiller et al61 updated of Hertel’s CAI model16 that suggests there may be as many as 7 different subsets, which are dependent on the complex interaction of mechanical instability, perceived instability, and frequency of recurrent sprain. Furthermore, selection criteria for CAI were unified by the International Ankle Consortium in 2013.62

Mechanical Instability Structural instability after LAS is caused by “looseness” resulting from ligamentous collagen sequence changes

that occur during the healing process,63 and it might be further induced by physical limitations due to joint degeneration and synovial changes.16 There are few studies describing the association between MAI and CAI. In CAI patients, mechanical instability of the talocrural and subtalar joints was found in 24% to 68%64-67 and 58%,68 respectively. In MAI patients, talocrural anterior translation and internal rotation on the injured side were increased compared to those in the healthy ankle.36,37,39,41,69 Therefore, MAI might be the greatest contributor to CAI, making it important to distinguish subjects with MAI when conducting a study of CAI.70 Although such distinction would be difficult because most of the current MAI evaluation techniques are 1-dimensional methods such as manual testing or stress X-rays, Kobayashi et al71,72 demonstrated increased talocrural anterior translation and subtalar internal rotation during weightbearing ankle internal rotation in CAI subjects using 3-dimensional evaluations. Several reports have investigated the relationship of fibular malposition to CAI.73-77 Some studies suggested that CAI ankles showed a more posterior fibula position than the healthy side,73,74,78 but other studies suggested that CAI ankles showed a more anterior fibula position75 or no significant difference.76,77 Although these findings were not consistent, it was suggested that some kind of fibular malposition occurs in CAI. The inconsistent fibular position findings are due to the landmark that the position is compared to. Some studies compared fibula position to the tibia,9,43,168 and some studies compared the fibula position to the talus.76,77 Dikos et al79 indicated the presence of individual specificity in anteroposterior or mediolateral translation and rotation of the fibula. In future studies, it will be necessary to perform 3-dimensional evaluation, because these previous studies evaluated the fibula position using only 2-dimensional techniques (eg, lateral X-ray or computed tomography [CT]).


Proprioception Studies of proprioceptive deficits have examined 3 distinct components: joint position sense, kinesthesia, and force sense (Tables 1 and 2). Glencross and Thornton80 first indicated the lack of joint position sense, and similar findings obtained with a goniometer or computer control systems were later published.81-83 In recent years, various joint angles were measured using an isokinetic dynamometer.84-92 Sekir et al91 compared the error of the joint position sense between CAI and the uninjured side in 24 subjects with unilateral CAI. In 10° and 20° of ankle inversion (1° per second angular speed), the error on the CAI side was significantly greater than that on the uninjured side in both positions. There are many studies suggesting that joint position sense in CAI ankles is significantly decreased based on similar measurements.85,87-89,92,93 However, some studies indicated contradictory findings,84,86,90 and a consensus has not yet been obtained (Table 1). The cause of this controversy is considered to involve differences in the inclusion criteria for CAI and the lack of standardized measurement systems.94 A recent meta-analysis95 has suggested that CAI subjects display consistent deficits in joint position sense when compared with people without CAI. Garn and Newton96 compared the error frequency during passive plantar flexion between CAI and the uninjured side in 30 unilateral CAI subjects, and they showed that kinesthesia was significantly decreased on the CAI side. Although similar findings have been reported,64,97,98 recent studies using motor control equipment suggested that there was no significant difference between CAI and the uninjured side regardless of movement direction (Table 2).99-101 However, definitive conclusions cannot be drawn because the number of reports is still limited. Force sense deficit was also investigated102-104 by measuring the degree of error when subjects reproduced a predetermined evertor torque (eg, 10% maximum voluntary isometric contraction [MVIC]). Based on

43 (22.4 ± 4.9 years)

19 males (19-26 years)

13 males, 11 females (18-25 years)


16 (20-31 years)

Fu and Hui-Chan (2005)85

Glencross and Thornton (1981)80

Gross (1987)86

Jerosch and Bischof (1996)87

10


Number of Subjects

Docherty (2006)103

Brown (2004)84

Boyle and Negus (1998)81

Author


Ankle instability

CAI

Multiple ankle sprains


FAI

Ankle instability

Indicate CAI, FAI, or Other

Studies Investigating Joint Position Sensea.

Table 1.

Presence of MAI

≥2 sprains

Group A: severe; group B: moderate; group C: mild

≥2 sprains/2 years

+

4 months to 13 years

≥8 months

≥3 months

Unilateral

Unilateral

Bilateral

Unilateral

Healthy ankles

Healthy ankles and normal subjects (N = 7)

Healthy ankles

Normal subjects (N = 20)



≥3 months

+

≥2 sprains/year (the past less than 1 year)

Control Group Normal subjects (N = 67)

Side of Instability (Unilateral/ Bilateral)

≥3 months

Time Since Last Sprain

≥2 sprains

History of Sprain

History of GivingWay

Isokinetic dynamometer (passive, 5°/15°/20° inversion, 5°/s)

Isokinetic dynamometer (active and passive, 10° eversion,10°/20° inversion, 5°/s)

Goniometer (15°/30°/40°/50° plantar flexion)

Isokinetic dynamometer (active and passive, 5° plantar flexion, 1° and 5°/s)

Electric goniometer (active, 10° inversion/20° eversion)

Isokinetic dynamometer (passive, dorsiflexion/ plantar flexion, inversion/ eversion, 2-20°/s)

Pedal goniometer (active and passive, 30%/60%/90% per maximum inversion, 5°/s)

Outcome Measurement

Significantly decreased

(continued)

Not significant

Significantly decreased (vs healthy); Not significant (among group)


No correlation error and FAI

Not significant

Significantly decreased in normal subjects (active, 30%; passive, all)

Results

vol. 7 / no. 4 Foot & Ankle Specialist 301


6 males, 15 females (30 ± 11 years)

24 (21 ± 2 years)

4 males, 6 females (18.3 ± 1.1 years)


Nakasa (2008)83

Santos and Liu (2008)90

Sekir (2007)91


Willems (2002)92

Witchalls (2012)93

Unstable ankle

CAI

FAI

FAI

Recurrent ankle sprain

FAI

FAI

FAI


− (manual test)

+/− (Stress X-ray)

− (manual test; ADT)


Presence of MAI

+

≥3 sprains

1.62 ± 1.61

+

≥2 sprains

≥3 months

45.9 ± 41.8 months

6 unilateral, 4 bilateral

Unilateral

Unilateral

+

≥2 sprains (less than 6 months)

Unilateral

Unilateral


Unilateral

+

+


≥4 sprains

≥1 sprain (the past less than 1 year)


≥7 sprains/year

History of Sprain


Stable ankles (N = 8)

Normal subjects (N = 53) and coper (N = 16)

Healthy ankles

Healthy ankle and normal subjects (N = 16)

Healthy ankles

Healthy ankles



Control Group

The Active Movement Extent Discrimination Apparatus footplate (inversion)

Isokinetic dynamometer (active and passive, 15°/ maximum minus 5° inversion, 5°/s)

Isokinetic dynamometer (passive, 10°/20° inversion, 1°/s)

Isokinetic dynamometer (passive, 30° inversion, 5°/s)

Foot plate (passive, inversion at 20° plantar flexion)

Isokinetic dynamometer (active and passive, 15° inversion/neutral/10° eversion, 2°/s)

Isokinetic dynamometer (active and passive, 15° inversion/neutral/10° eversion, 2°/s)

Computer control (passive, 10°/15°/20° inversion)

Outcome Measurement


Significantly decreased (only maximum minus 5° inversion)


Not significant

Significantly decreased (no correlation with MAI)


Significant decreased (only passive motion)

Significantly decreased (absolute error); Not significant (real error)

Results


Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test. a A blank cell indicates that data were not provided.


8 (19.21 ± 1.34 years)

Lee (2006)88

Lee and Lin (2008)89

23 (22-37 years)

Number of Subjects

Konradsen and Magnusson (2000)82

Author

Table 1. (continued)

302 August 2014






25 (18-41 years)

39 (21.3 ± 3.5 years)

Forkin (1996)97

Garn and Newton (1988)96

Hubbard and Kaminski (2002)100

Lentell (1995)65

Refshauge (2000)99

Refshauge (2003)98

Recurrent inversion sprain

Recurrent inversion sprain

CAI

FAI

CAI

Multiple ankle sprain

FAI

− (manual test; ADT/ talar tilt)

Presence of MAI

≥3 weeks

≥3 weeks

≥3 sprains (the past less than 2 years) ≥3 sprains/2 years

≥1 sprain (protected weightbearing and/or immobilization)

Both

Unilateral




Healthy ankles

Unilateral

1-60 months

≥2 sprains (2-20 times)

Healthy ankles

Healthy ankles


1-12 months

≥1 sprain

Healthy ankles (N = 13) and normal subjects (N = 20)

Control Group

Unilateral

Both



≥1 sprain (once within 1 year)

History of Sprain


Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; CAIT, Cumberland Ankle Instability Tool. a A blank cell indicates that data were not provided.


Number of Subjects

de Noronha (2007)101

Author


Studies Investigating Kinesthesiaa.

Table 2.

Motor control footplate (passive inversion and eversion, 0.1°/0.5°/2.5°/s)

Motor control footplate (passive dorsiflexion and plantar flexion, 0.1°/0.5°/2.5°/s)

Platform (passive inversion, 0.3°/s)

Threshold-to-detection of passive motion (passive inversion and eversion, 0.5°/s)



Motor control footplate (passive inversion/eversion, 0.1°/0.5°/2.5°/s)

Outcome Measurement

Significantly decreased (only eversion)

Not significant


Not significant



No correlation with CAIT score

Results


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August 2014


these studies, there was a correlation between the error in evertor torque (10, 30% MVIC) and CAI.102-104 It has also been reported that the peroneus longus resting motor threshold is higher in CAI.105 However, further examination of this issue is necessary to obtain more substantive evidence.

Neuromuscular The association between neuromuscular deficits and CAI has been considered based on neuromuscular reaction time, H:M ratio, and muscle activation (Tables 3-5). Most studies investigating neuromuscular reaction time used a trapdoor and measured the reaction time of the peroneus longus or tibialis anterior when the ankle was suddenly inverted.106-112 Some studies indicated that muscle reaction time was significantly delayed in CAI subjects,108-111,113 whereas other studies reported that there was no significant difference compared to that in healthy subjects.90,106,111,112 Furthermore, a recent meta-analysis has determined that there is a significant delayed in reaction time of the peroneus muscles in subjects with a previous ankle sprain.114 However, it is unknown in CAI subjects (Table 3). One of the causes of this controversy is that there was great variation in the CAI inclusion criteria among these studies. The unified CAI criteria were published by the International Ankle Consortium62; thus, future studies will be required to comply with these selection criteria. Furthermore, some studies have suggested that the H:M ratio of the peroneus longus or soleus is decreased in CAI subjects (Table 4).115-117 Muscle activities during various movements were also described.84,90,117-123 In CAI subjects, peroneus longus activity was decreased,122 whereas tibialis anterior activity was increased124 in the stance phase during gait. In jump landing, activities of the peroneus longus before initial contact and those of the soleus after landing were significantly decreased.84,118,119 Additionally, Lin et al125 indicated that tibialis anterior/peroneus co-contraction during prelanding and

peroneus longus activity during postlanding were decreased in CAI. In contrast, activity increased in the rectus femoris, tibialis anterior, and soleus on initial contact during side hop.120 It was suggested that abnormal muscle activity patterns in CAI subjects occur during various movements (Table 5).126

Postural Control Postural control deficit in CAI subjects has been extensively investigated. In recent years, not only static stability but also dynamic stability has been evaluated (Tables 6 and 7). Postural control deficit was first reported by Freeman et al,60 who found that of 33 unilateral CAI patients examined by Romberg test, 25% showed significant postural control deficits on the injured side compared to that on the uninjured side. Thereafter, many studies examining static stability in CAI subjects using techniques such as stabilometry or force plate were published.66,67,76,85,87-91,96,97,127-153 In these studies as well, the inclusion criteria of CAI showed great variability, and the results were not conclusive. However, recent studies described the inclusion criteria of CAI in greater detail (eg, histories of multiple sprains and givingway, disappearance of acute symptoms), and these studies have suggested decreased static stability in CAI (Table 6).90,91,129,144,146,148,149,154,155 Recent metaanalyses52,156,157 have suggested that there is a significant decrease in static postural control in CAI subjects. To examine dynamic stability, the Star Excursion Balance Test (SEBT) as a test of dynamic postural control suggested decreased dynamic stability in CAI subjects.76,135,158-162 Other studies using other evaluation techniques (eg, the quantity of center of gravity displacement and time to regain stability after jump landing,77,148,149,163-166 unplanned gait termination,167 or multiple hop test168) reported similar results. Therefore, it was suggested that dynamic postural control in CAI subjects is significantly decreased based on a recent meta-analysis.156


Muscle Strength It has long been reported that there is an association between muscle weakness and CAI (Table 8).169 Many studies measured ankle inversion/eversion and plantar flexion/dorsiflexion peak torque using an isokinetic dynamometer, but these studies demonstrated great variation in joint angle and angular velocity. Regarding eversion strength, some studies demonstrated a significant decrease in CAI subjects,90,92,170,171 whereas other studies did not detect significant differences between CAI and healthy subjects.64,76,91,128,143,172-178 Although a recent meta-analysis suggested that concentric eversion strength is decreased in CAI subjects regardless of angular velocity,179 there is not yet a consensus regarding the results of inversion and plantar flexion strength. Significant decreases in hip joint adduction, abduction, and extension strength in CAI subject were also described in some studies (Table 9).76,180,181 Among these, 2 studies obtained measurements using a handheld dynamometer (HHD),76,181 and 1 study used an isokinetic dynamometer.180 Although decreased hip abduction strength was shown in all studies, findings regarding extension strength were not consistent. Further examination of this issue is required due to the limited amount of research conducted to date.

Kinematics of Chronic Ankle Instability Talocrural and subtalar joint kinematics combine to form ankle joint kinematics. Most of the ankle joint plantar flexion/ dorsiflexion occurs in the talocrural joint, whereas similar amounts of ankle joint inversion/eversion and internal rotation/ external rotation occur in the talocrural and subtalar joints similarly.182-186 Maximal dorsiflexion of the ankle is considered stable due to the bony conformity known as the close-packed position.187,188 Therefore, the subtalar joint shows relatively greater mobility in dorsiflexion. On the contrary, the ankle is considered more unstable in plantar


30 (21-32 years)

4 males, 9 females (2449 years)

19 males (25.1 ± 1.9 years)




Konradsen and Ravn (1990)108

Lofvenberg (1995)109

Mitchell (2008)110


Vaes (2001)112

Vaes (2002)111

Unstable ankle

FAI

FAI

FAI

Chronic lateral instability

FI

CAI

FAI

FI

+/− (talar tilt)

+ (stress X-ray)

Presence of MAI

+

+

≥2 sprain (the past less than 6 months)

≥2 sprains

+

+

≥2 sprains (the past less than 2 years)

Multiple sprains

≥1 sprain (the past less than 2 years)

1-6 sprains

History of Sprain


≥3 months

≥6 months

≥2 months



Unilateral

Unilateral


Unilateral

Unilateral

Unilateral







Healthy ankles

Normal subjects

Healthy ankles

Control Group

Trap door (40° plantar flexion and 15° inversion; PL)

Trap door (40° plantar flexion and 15° inversion; PL)

Isokinetic dynamometer (reaction time to 120°/s inversion)

Not significant

Not significant

Not significant

Significantly delayed (PL, PB, and TA) (vs healthy/normal)

Significantly delayed (vs healthy ankles); not significant (vs normal subjects)

Trap door (PL/TA)

Tilt platform (20° plantar flexion and 3° inversion; PL/PB/ TA/EDL)

Significantly delayed

Significantly delayed (only eversion)

Significantly delayed

Not significant

Results

Trap door (30° inversion; PL/PB)

Active eversion and dorsiflexion (eversion; PL, dorsiflexion; TA)

Trap door (30° inversion; PL/PB)

Trap door (plantar flexion and inversion; PL/TA)

Outcome Measurement

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; PL, peroneus longus; PB, peroneus brevis; TA, tibialis anterior; EDL, extensor digitorum longus. a A blank cell indicates that data were not provided.


Kavanagh (2012)113



106

Number of Subjects

Karlsson and Andreasson (1992)107

Ebig (1997)

Author


Studies Investigating Muscle Reaction Timea.

Table 3.





Mcvey (2005)116

PalmieriSmith (2009)117

FAI

FAI

CAI

−

Presence of MAI ≥1 sprain (the past less than 1 year)

History of Sprain +

History of GivingWay ≥6 weeks


Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; PL, peroneus longus; TA, tibialis anterior; SOL, soleus. a A blank cell indicates that data were not provided.

10 males, 6 females

Number of Subjects

Kim (2012)115

Author


Studies Investigating Muscle H:M Ratioa.

Table 4.

Unilateral





Control Group

Significant decreased

Significant decreased (only SOL/ PL, vs healthy ankles)

Stimulator module (SOL/PL/TA)

Stimulator module (PL)

Significant decreased (only SOL)

Results Stimulator module (SOL/PL)

Outcome Measurement

306 Foot & Ankle Specialist August 2014

CAI

FAI

FAI




Lin (2011)125

Santilli (2005)122



−

+/− (manual test; ADT/ PDT/talar tilt)

Chronically unstable ankle

17 males, 16 females (17-52years)

Larsen and Lund (1991)121 +

+

+

≥2 sprains

≥2 sprains ≥2 sprains (the past less than 6 months)

+

+ (in sports)

≥2 sprains

FI


Delahunt (2007)120 + (manual test/ stress X-ray)

+ (in sports)

+ (in sports)

≥2 sprains

≥2 sprains

+

History of Giving-Way

FI

FI


Caulfield (2004)118


History of Sprain

15 males, 9 females (25 ± 1.3 years)

FAI

10

Brown (2004)84

Presence of MAI

Delahunt (2006)119


Number of Subjects

Author

Studies Investigating Muscle Activitya.

Table 5.

17-44 days

≤6 months

≥5 months

≥3 months


Unilateral

Unilateral

Unilateral

Unilateral



Healthy ankles


Post-surgery





Control Group

Force platform (30° plantar flexion and 15° inversion, reaction to 20% per pain threshold; TA/SOL/VM/BF/PL)

Gait (PL)

Running and stop-jump landing (TA/PL, TA/GL)

Foot plate (dorsiflexion/ plantar flexion/inversion/ eversion; PB/GM)

Lateral hop (PL/RF/TA/ SOL)

Single leg landing (drop jump) (PL/RF/TA/SOL)

Single leg landing (drop jump) and forward hop (SOL/PL/TA)

Landing (SOL/PL/TA/GL)

Outcome Measurement

(continued)

Significantly decreased SOL activity

Significantly decreased (stance phase)

Significantly decreased TA/PL cocontraction during pre-landing (stop-jump landing); significantly decreased PL during postlanding (stop-jump landing)

Significantly increased postsurgery (only plantar flexion)

Significantly increased RF, TA, and SOL (during 200 ms pre- and post-initial contact)

Significantly decreased PL activity (pre initial contact)

Significantly decreased PL activity (pre landing; both attempts)

Significantly decreased SOL activity (post landing)

Results



FI

FAI

CAI



20 (20.5 ± 1.0 years)

Ty Hopkins (2012)124

PalmieriSmith (2009)117

Wikstrom (2010)126

−

− (manual test; ADT/ talar tilt)

Presence of MAI

≥1 sprain (required immobilization for at least 3 days)

≥2 sprains

History of Sprain

+


2.9 ± 1.8 months


Unilateral

Unilateral



Planned and unplanned gait termination (SOL/ TA/Gmed)

Trap door during gait (30° inversion; PL)

Gait (PL/TA)



Platform (PL/TA/GM/GL)

Outcome Measurement


Control Group

Significantly different in SOL and TA during unplanned and planned gait termination (vs healthy ankles and normal subjects)

Significantly decreased PL activity

Significantly increased TA in 15% to 30% and 45% to 70% of stance; significantly increased PL in heel contact and toe off

Not significant

Results

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; PDT, posterior drawer test; PL, peroneus longus; PB, peroneus brevis; TA, tibialis anterior; EDL, extensor digitorum longus; SOL, soleus; GM, gastrocnemius medialis; GL, gastrocnemius lateralis; RF, rectus femoris; VM, vastus medialis; BF, biceps femoris; Gmed, gluteus medius. a A blank cell indicates that data were not provided.

Chronic ankle sprain


10 males, 4 females

Number of Subjects

Soderberg (1991)123

Author








Chrintz (1991)130

Cornwall and Murrell (1991)131

Docherty (2006)132

Forkin (1996)97

9 (22.89 ± 3.18 years)

Bernier (1997)128

Brown and Mynark (2007)129


Number of Subjects

Baier and Hopf (1998)127

Author



FAI

Chronic functional instability

CAI

FI

FAI


Studies Investigating Static Postural Controla.

Table 6.

+ (manual test)

+/− (stress X-ray)

− (manual test; ADT/talar tilt)

Presence of MAI

+

≥3 sprains


Healthy ankles

1-12 months


Healthy ankles (N = 28) and normal subjects (N = 41)

Healthy ankles



≥1 sprain

Unilateral


Unilateral

Unilateral


Control Group


12.35 months (average)

1.5-7 years

≥6 months

≥4 months


≥1 sprain

≥1 sprain (the past less than 2 years)

+

+

≥2 sprains


+


≥5 sprains/year

History of Sprain


Single leg standing with open and closed eyes (number of times lost balance)

Double, single, and tandem leg standing on firm and foam surfaces (Balance Error Scoring System; number of times lost balance)

Single leg standing with open and closed eyes (force plate; postural sway)

Single leg standing with open and closed eyes (balance retention time)

Standing retention for standardized tibial nerve stimulation (force plate; postural sway/TTS)

Double and single leg standing with open and closed eyes (balance system)


Outcome Measurement

(continued)

Significantly decreased (only 4 subjects)

Significantly decrease (single leg standing on firm and foam surfaces, in tandem leg standing on foam surfaces)

No significant sway amplitude; significant increase sway frequency


Significantly longer anterior-posterior TTS

Not significant

Not significant

Results





29 (21.4 ± 3.5 years)

15 females (19.7 ± 1.3 years)

Gauffin (1988)133

Goldie (1994)134

Hale (2007)135

Hertel and OlmstedKramer (2007)136


Fu and Hui-Chan (2005)85

Garn and Newton (1988)96

33

Number of Subjects

Freeman (1965)60

Author



CAI

CAI

FI

CAI


FI


+ (4 subjects) (manual test; ADT)

Presence of MAI

≥1 sprain (1-5 times)

≥1 sprain

≥1 sprain (42% more than 2)

>2 sprains

≥2 sprains (2-20 times)


History of Sprain

+ (the past 3 months more than 2)

+

+


≥3 months

≥3 months

36.6 ± 30.3 months (average)

1-60 months

≥3 months


Unilateral

Unilateral

Both

Unilateral

Bilateral

Unilateral




Healthy ankles

Normal subjects (N = 15) and post training

Healthy ankles


Healthy ankles

Control Group

Double leg standing (open and closed eye) (force plate; postural sway and TTB)



Single leg standing (force plate and LED [sternum/ hip/ankle]; postural sway)


Double leg standing with open and closed eyes (Sensory Organization Test)

Romberg test with open and closed eyes

Outcome Measurement


(continued)

Significantly lower score for TTB


Significantly decreased (lateral direction)

Significantly increased COP and LED (sternum) displacement (vs normal subjects); significantly increased COP and LED (sternum and ankle) displacement (vs post training)



Significantly decreased (only 25% subjects)

Results

310 August 2014

11 females (1635 years)

41 (24 ± 7.9 years)


8 females (14-18 years)

16 (20-31 years)


15 (21-32 years)

Hiller (2007)138

Hubbard (2007)76

Isakov and Mizrahi (1997)139

Jerosch and Bischof (1996)87

Knapp (2011)140

Konradsen and Ravn (1991)141

Number of Subjects

Hiller (2004)137

Author



FI

CAI

Ankle instability

Chronically sprained ankles

CAI

FAI

FAI


+/− (manual test; ADT/ talar tilt)

+ (manual test; ADT)

+ (arthrometer)

+/−

Presence of MAI


≥3 sprains

5.8 ± 2.7 times

≥1 sprain (protected weightbearing and/ or immobilization)

History of Sprain

+


4 months to 13 years


Both

Unilateral

Unilateral

Unilateral

≥6 weeks

≥4 months


≥1 month





Healthy ankles

Healthy ankles




Control Group

Single leg standing (force plate; postural sway)

Barefoot, quiet, and singlelimb stance with open and closed eyes (force plate; postural sway)




Single leg standing and trap door (foot flat and demipoint) (3Space FASTRAK, 15° inversion; postural sway and perturbation time)

Single leg standing and trap door (foot flat and demi-point) (3Space FASTRAK, foot flat: 15° inversion/demi-point: 7.5° inversion; postural sway and perturbation time)

Outcome Measurement

(continued)

Significantly decreased (mediallateral direction)

Not significant


Not significant

Not significant

Significantly increased postural sway; significantly longer perturbation time

Significantly decreased postural sway (only demipoint); significantly longer perturbation time (foot flat and demi-point)

Results



8 (19.21 ± 1.34 years)



20 (20-24 years)

18 males, 14 females (males: 22.4 ± 5.8 years; females: 20.1 ± 1.9 years)


Lee (2006)88

Lee and Lin (2008)89

Lentell (1990)143

Levin (2012)154

McKeon and Hertel (2008)144

Michell (2006)145

Number of Subjects

Leanderson (1993)142

Author



+ (the past 1 year more than 2)

Single leg standing with open and closed eyes (force plate; postural sway) Healthy ankles and normal subjects (N = 16)

≥6 months


FAI


Normal subjects (N = 32) 10.3 ± 16.4 months (average)

7.8 ± 5.7 times

Romberg test with open and closed eyes


Single leg standing with open and closed eyes (force plate; postural sway and TTB)

Single leg standing (stabilometry; postural sway)

Outcome Measurement

Double to single leg stance with open and closed eyes (force plate; postural sway and TTS)

Healthy ankles

Healthy ankles


Normal subjects (N = 9) and control group (N = 11)

Control Group


CAI

+

Unilateral

CAI

≥6 months

Unilateral

Unilateral




CAI

+

+


Unilateral

≥1 sprain/year (the past less than 1 year)

≥1 sprain (protected weightbearing; the past less than 1 year)

≥2 sprains

History of Sprain

≥3 months


Presence of MAI


≥1 sprain (protected weightbearing and/ or immobilization)

FAI

FAI



(continued)

Not significant

Significantly decreased (only open eyes)

Significantly longer TTS




Significantly decreased (vs control group)

Results

312 August 2014

19 (26.5 ± 3.1 years)







Perrin (1997)147

Pope (2011)155

Ross and Guskiewicz (2004)148

Ross (2009)149

Rozzi (1999)150

Ryan (1994)66

Number of Subjects

Mitchell (2008)146

Author



Functionally unstable ankle


FAI

FAI

CAI

FAI


+/− (manual test; ADT)


Presence of MAI

+ (the past 1 year more than 6 times)

+

≥2 sprains

≥3 sprain (the past 18 months more than 2, and the past 6 months more than once)

+ (≥2 giving ways)

≥2 sprains

Less than 2 weeks (giving-way)

≥3 weeks

≥6 weeks

≥2 sprains

≥6 months


≤6 weeks

+

+/−


≥1 sprain (mean number; 6.0 ± 3.5)

10-15 times


History of Sprain

Unilateral

Unilateral

Unilateral

Unilateral


Healthy ankles

Normal subjects (N = 13) and post training






Control Group

Single leg standing (UniAxial Balance Evaluator; balance retention time)

Single leg standing (Biodex Stability System; Stability Index)

Single leg standing with open eyes (force plate; postural sway and TTS)

Single leg standing with open eyes (force plate; postural sway)

Single leg standing with open and closed eyes (force plate; postural sway and TTB)



Outcome Measurement

(continued)

Significantly decreased in healthy ankle


Significantly decreased postural sway; significantly longer TTS

Significantly decrease

Significantly greater anterior displacement of COP and TTB minima


Significantly decreased (open: anterior-posterior direction; close: medial-lateral direction)

Results



128 males


16 (22.1 ± 3.3 years)


Tropp (1985)67

Tropp and Odenrick (1988)152

Wikstrom (2010)77

You (2004)153

CAI

CAI

FI

FI

FAI

FAI



+ (44%)

− (manual test)

Presence of MAI

≥1 sprain/year (the past less than 1 year)

+

Unilateral

Both

Unilateral

Unilateral

≥1 sprain (required immobilization and/or nonweightbearing for at least 3 days) 3-6 months


Unilateral

+ (5.8 ± 5.2)

+

+


≥2 sprains

≥1 sprain (take a rest more than 1 week)

≥2 sprains

≥2 sprains (the past less than 6 months)

History of Sprain



Normal (N = 16) and coper (N = 16) subjects


Healthy ankles


Healthy ankles


Control Group


Single leg standing with open eyes (force plate; postural sway and TTB)

Single leg standing (force plate and LED [sternum/ hip/foot]; postural sway)

Single leg standing (Stabilometry; postural sway)

Single leg standing (Stabilometry; postural sway)

Single leg standing with closed eyes (number of times lost balance)


Outcome Measurement

Not significant

Significantly greater mediolateral and anteroposterior COP velocity (vs normal and coper subjects); significantly increased COP-COM moment arm (vs coper subjects)


Not significant

Not significant



Results

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; TTS, time to stabilization; TTB, time to boundary; COP, center of pressure; COP-COM, center of pressure–center of mass; LED, light emitting diodes. a A blank cell indicates that data were not provided.

56 males

24 (21 ± 2 years)

Sekir (2007)91

Tropp (1984)151


Number of Subjects


Author



10

24 females (20.0 ± 1.3 years)



29 (21.4 ± 3.5 years)





Brown (2010)163

Eechaute (2009)168

Gribble (2004)158

Hale (2007)136

Hertel (2006)159

Hoch (2012)160

Hubbard (2007)76

Olmsted (2002)161

Number of Subjects

Brown (2004)84

Author


+ (the past 1 year more than 3 times)


≥1 sprain

≥1 sprain

CAI

CAI

CAI

CAI

1 sprain


+

+

≥1 sprain

CAI

5.8 ± 2.7 times


≥1 sprain

CAI

+ (arthrometer)

+


CAI

CAI

FAI + (the past 1 year more than 2)


≥1 moderate to severe sprain (the past less than 1 year)

History of Sprain +

Presence of MAI ≥2 sprains/year (the past less than 1 year)


Studies Investigating Dynamic Postural Controla.

Table 7.

Healthy ankles normal subjects (N = 30)

Unilateral

Unilateral

≥6 weeks

≥6 weeks



≤6 weeks






Control Group


Unilateral

Unilateral

Both


≥6 weeks

≥3 months

≥3 months

≥3 months


SEBT

SEBT

SEBT

SEBT

SEBT

SEBT

Multiple hop test (number of times lost balance)

50% maximum height vertical jump in anterior, lateral, and medial directions (ground reaction force)

Landing (force plate; TTS)

Outcome Measurement

(continued)

Significantly decreased in all directions

Significantly decreased in posteromedial and anterior

Significantly decreased in anterior

Significantly decreased in anteromedial, posteromedial, medial (vs healthy ankles and normal subjects)

Significantly decreased in medial, posterolateral, and lateral

Significantly decreased in all directions (vs healthy ankles)

Significantly increased

Significantly decreased in anterior and lateral jumps

Significantly longer

Results





29 (21.8 ± 2.3 years)

28 males, 26 females (21.4 ± 1.7 yr)


20 (20.5 ± 1.0 years)

Ross and Guskiewicz (2004)148

Ross (2005)164

Ross (2009)149

Wikstrom (2005)165

Wikstrom 2007166

Wikstrom (2010)77


Wikstrom (2012)167

CAI

CAI

FAI

FAI

− (LigMaster)

+ (5.1 ± 4.6)

+ (5.1 ± 4.6)

≥1 sprain (required immobilization and/or non-weightbearing for at least 3 days)

≥1 sprain (required immobilization and/or non-weightbearing for at least 3 days)

+

+

+ (more than 2)


≥2 sprains

FAI


≥3 sprains (the past year more than 2)

+

+ (the past 1 year at least once)


FAI

4.6 ± 2.9 times

History of Sprain

≥2 sprains

+ (6 subjects) (manual test; ADT)

Presence of MAI

FAI

CAI


3-6 months

Unilateral




≥3 months 3-6 months


≥3 months




Control Group


Unilateral

Unilateral


≥3 weeks

≥6 weeks

3-6 months


Planned and unplanned gait termination (force plate; postural stability index)

Single leg hop stabilization (force plate; postural stability index)

Single leg landing (force plate; postural stability index)

Step down and single leg landing (force plate; TTS)

Single leg landing (force plate; postural sway and TTS)

Single leg landing (force plate; TTS)

Single leg landing (force plate; postural sway)

SEBT

Outcome Measurement

Significantly increased in anteroposterior direction (vs normal and coper subjects)

Significantly decreased in mediolateral direction (vs coper subjects); significantly increased in anteroposterior direction (vs normal subjects)

Significantly decreased in anteroposterior and vertical direction

Significantly longer anterior-posterior direction (both attempts)

Significantly decreased postural sway; significantly longer TTS

Significantly longer

Not significant

Significantly decreased in posteromedial

Results


Abbreviations: FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; TTS, time to stabilization; SEBT, star excursion balance test. a A blank cell indicates that data were not provided.

25 (23.7 ± 4.9 years)

Number of Subjects

Plante (2013)162

Author


316 August 2014




21 males (19.3 ± 1.1 years)


Hartsell and Spaulding (1999)171

Hubbard (2007)76

Kaminski (1999)174

Lentell (1990)143

113

Bosien (1955)169

Fox (2008)178

9 (22.89 ± 3.18 years)

Number of Subjects

Bernier (1997)128

Author


CAI

FAI

CAI

CAI

FAI

FI


Studies Investigating Ankle Muscle Strengtha.

Table 8.

− (manual test)

+ (arthrometer)

+/− (stress X-ray)

Presence of MAI

+

≥1 sprain


+

+

≥2 sprains

5.8 ± 2.7 times

+

+

≥1 sprain

42% more than 2

≥2 sprains

History of Sprain


≥3 months

Unilateral

Unilateral

Healthy ankles



≥6 weeks


Healthy ankles


Control Group


Unilateral

Both

Unilateral


≥6 months

2-49 months

≥4 months


Isokinetic dynamometer (eversion, isometric and 30°/s)

Isokinetic dynamometer (eversion [Con/Ecc], 30/60/90/120/150/180°/s)

Isokinetic dynamometer (inversion, eversion, plantar flexion, and dorsiflexion, 30°/s)

Isokinetic dynamometer (inversion and eversion [Con/ Ecc], 60/120/180/240°/s)

Isokinetic dynamometer (inversion, eversion, plantar flexion, and dorsiflexion [Ecc], 90°/s)

Manual test (inversion and eversion at 40° plantar flexion)

Isokinetic dynamometer (inversion and eversion, 90°/s)

Outcome Measurement

(continued)

Not significant

Not significant

Significantly decreased in plantar flexion


Significantly decreased in plantar flexion

Significantly decreased in eversion (only 29 subjects)

Not significant

Results



15 (19.60 ± 1.72 years)



15 (22.1 ± 3.7 years)



McKnight and Armstrong (1997)172

Munn (2003)176

Pontaga (2004)177

Porter (2002)175

Ryan (1994)66


Number of Subjects

Lentell (1995)64

Author



FAI



FAI

FAI

CAI


+/− (manual test; ADT)

− (manual test; ADT/talar tilt)

+ (manual test)

Presence of MAI

+ (the past 1 year more than 6 times) +



≥3 sprains(the past 18 months more than 2, and the past 6 months more than once)

≥2 sprains


≥2 sprains (the past less than 1 year)


History of Sprain


Less than 2 weeks (givingway)

≥4 weeks

9.55 ± 11.54 months


Unilateral

Unilateral

Unilateral


Unilateral

Unilateral



Healthy ankles


Healthy ankles (N = 33)

Healthy ankles

Normal subjects (N = 14) and rehabilitation group (N = 14)


Control Group

Isokinetic dynamometer (eversion, isometric)

Isokinetic dynamometer (inversion and eversion, 30°/s)

Isokinetic dynamometer (dorsiflexion and eversion, 120/240°/s)

Isokinetic dynamometer (inversion and eversion, 30/60/90/120°/s)

Isokinetic dynamometer (inversion and eversion [Con/ Ecc], 60/120°/s)

Isokinetic dynamometer (inversion, eversion, plantar flexion, and dorsiflexsion [Con], 30/240°/s)

Isokinetic dynamometer (eversion; 30/90/150/210°/s)

Outcome Measurement


(continued)


Significantly increased in inversion

Not significant

Significantly decrease inversion (only 60, 90, and 120°/s)

Significantly decreased in inversion (only Ecc 60/120°/s)

Not significant

Not significant

Results

318 August 2014



Willems (2002)92

CAI

Chronic group

FI

FAI

Indicate CAI, FAI, or Other − (manual test)

Presence of MAI

+

+

≥3 sprains

+

+

≥2 sprains

≥2 sprains

History of Sprain


≥3 months

≥6 months

≥1.5 years



Unilateral

Unilateral


Normal subjects (N = 53) and coper (N = 16)

Acute LAS patients (N = 15)

Healthy ankles

Healthy ankles

Control Group

Abbreviations: FI, functional instability; FAI, functional ankle instability; CAI, chronic ankle instability; ADT, anterior drawer test; Con, concentric; Ecc, eccentric. a A blank cell indicates that data were not provided.


Wilkerson (1997)173

24 (21 ± 2 years)


91

Number of Subjects

Tropp (1986)170

Sekir (2007)

Author


Isokinetic dynamometer (inversion and eversion, 30/120°/s)

Isokinetic dynamometer (inversion and eversion, 30/120°/s)

Isokinetic dynamometer (dorsiflexion and eversion, 30/120°/s)

Isokinetic dynamometer (inversion and eversion [Coc/ Ecc], 120°/s)

Outcome Measurement

Significantly decreased in eversion

Not significant

Significantly decreased in eversion

Significantly decreased in inversion

Results


181


11 (30 years)

Nicholas (1976)180


5.8 ± 2.7 times

CAI

History of Sprain ≥2 sprains

+ (arthrometer)

Presence of MAI



Abbreviations: CAI, chronic ankle instability; HHD, handheld dynamometer. a A blank cell indicates that data were not provided.


23 (18-52 years)

Number of Subjects

Hubbard (2007)76

Friel (2006)

Author

Studies Investigating Hip and Knee Muscle Strengtha.

Table 9.

+


Unilateral

≥6 weeks

Both

Unilateral

≥3 months



Healthy ankles


Healthy ankles

Control Group

Isokinetic dynamometer (knee flexion, knee extension, hip adduction, hip abduction, and hip flexion, 5/15/30 rpm)

HHD (hip abduction and hip extension)

HHD (hip abduction and hip extension)

Outcome Measurement

Significantly decrease in hip adduction and hip abduction


Significantly decreased in hip abduction

Results


vol. 7 / no. 4

flexion. Thus, if the talocrural joint is not able to fully dorsiflex, the joint will not reach the close-pack position and may more easily show inversion and internal rotation.16,189 On gait analysis, the talocrural joint shows internal rotation and the subtalar joint shows internal rotation plus eversion during movement from heel contact to mid-stance.182,190 Then, from mid-stance to toe-off, the talocrural joint shows external rotation and eversion, and the subtalar joint shows external rotation plus inversion.182,190 During running, the ankle joint shows smaller plantar flexion after heel contact than that during gait, whereas ankle joint dorsiflexion and eversion in mid-stance were larger than those during gait.191,192 Several studies indicated a deficit in ankle joint dorsiflexion ROM in CAI subjects,160,162,189,193,194 because CAI ankles demonstrated talus anterior displacement.69,72,195,196 CAI subjects showed more ankle inversion than normal subjects during walking,189,197,198 and the center of pressure during the stance phase was more lateral.124,199,200 A similar finding was suggested during running,189,201-203 and ankle dorsiflexion was significantly decreased.189 In addition, the CAI ankle was more inverted before initial contact during drop jump landing119,125 and side hop,120,197 and the center of pressure was located more laterally from the early to mid-stance phase during lateral shuffling.204 In contrast, knee flexion was decreased before initial contact in the landing phase during vertical jump.205 However, these studies did not assess whether subjects had MAI; therefore, it is unknown whether MAI or FAI contributes more to these abnormal kinematics. Among recent studies that distinguished subjects with MAI, one study suggested that there was no significant difference in ankle joint kinematics during running among subjects with MAI, FAI, and Coper,206 but another study detected significant differences among these 3 groups.207 Thus, consensus on this issue has not yet been obtained. In drop jump landing, the MAI group showed significantly more


dorsiflexion at the initial contact and maximal inversion phase compared to that in the FAI and Coper groups,208 while subjects with ankle instability demonstrated less variability at the hip and knee,209 suggesting that landing strategies may change in CAI patients. Therefore, it will be necessary to distinguish subjects with MAI in future studies, in order to clarify the contribution of MAI to abnormal kinematics in CAI subjects. Some researchers have also indicated that persons with histories of multiple sprains who did not complain of an unstable feeling would comprise a more suitable control group than healthy subjects without sprain history.196,210 Therefore, abnormal ankle kinematics is present in CAI joints, and joint laxity is suspected of affecting other degrees-offreedom. However, past in vivo kinematic studies using surface markers often contained soft tissue artifacts211 and could not evaluate the kinematics of the talocrural and subtalar joints separately. Since a potential combined instability of the talocrural and subtalar joints is suspected, it is necessary to obtain detailed measurements of abnormal kinematics in each of these joints.69,71,72

Conclusion LAS is one of the most commonly occurring injuries, and subsequent development of CAI is also common. In the past, many studies have attempted to identify factors that promote CAI, which has multiple contributing causes. However, it is difficult to compare the findings of these studies due to the lack of a standardized set of inclusion criteria as well as the lack of a definitive consensus on what constitutes ankle instability.212 In the future, all studies will be required to comply the position statement of the International Ankle Consortium.62 These selection criteria are based on history of initial injury, history of ongoing bouts of instability, and ratings of patient perceived function and disability gathered from validated survey instruments. Furthermore, fracture or surgery and other significant lower


extremity joint injury should be absent, and an appropriate amount of time should have passed since suffering acute, inflammatory symptoms.62 In addition, a prospective study is needed to determine whether repeated LAS and giving-way is the cause of these abnormalities or whether persistent abnormalities predispose the patient toward recurrent LAS and giving-way.

References 1. Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37:73-94. 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. Woods C, Hawkins R, Hulse M, Hodson A. The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains. Br J Sports Med. 2003;37:233-238. 4. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92:2279-2284. 5. Baumhauer JF, Alosa DM, Renstrom AF, Trevino S, Beynnon B. A prospective study of ankle injury risk factors. Am J Sports Med. 1995;23:564-570. 6. Beynnon BD, Murphy DF, Alosa DM. Predictive factors for lateral ankle sprains: a literature review. J Athl Train. 2002;37:376-380. 7. Beynnon BD, Vacek PM, Murphy D, Alosa D, Paller D. First-time inversion ankle ligament trauma: the effects of sex, level of competition, and sport on the incidence of injury. Am J Sports Med. 2005;33:1485-1491. 8. Hosea TM, Carey CC, Harrer MF. The gender issue: epidemiology of ankle injuries in athletes who participate in basketball. Clin Orthop Relat Res. 2000;(372):45-49. 9. Murphy DF, Connolly DA, Beynnon BD. Risk factors for lower extremity injury: a review of the literature. Br J Sports Med. 2003;37:13-29. 10. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42:311-319.

321

322

August 2014


11. Braun BL. Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation. Arch Fam Med. 1999;8:143-148. 12. Hupperets MD, Verhagen EA, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ. 2009;339:b2684. 13. McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006;34:1103-1111. 14. Verhagen EA, van Tulder M, van der Beek AJ, Bouter LM, van Mechelen W. An economic evaluation of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball. Br J Sports Med. 2005;39:111-115.

ligamentous sprain injuries in sports: 2 cases during the 2008 Beijing Olympics. Am J Sports Med. 2011;39:1548-1552. 25. DiGiovanni BF, Partal G, Baumhauer JF. Acute ankle injury and chronic lateral instability in the athlete. Clin Sports Med. 2004;23:1-19. 26. Brostrom L. Sprained ankles, I: anatomic lesions in recent sprains. Acta Chir Scand. 1964;128:483-495. 27. Hubbard TJ, Hicks-Little CA. Ankle ligament healing after an acute ankle sprain: an evidence-based approach. J Athl Train. 2008;43:523-529. 28. Frey C, Bell J, Teresi L, Kerr R, Feder K. A comparison of MRI and clinical examination of acute lateral ankle sprains. Foot Ankle Int. 1996;17:533-537.

15. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg. 1995;114:92-96.

29. Labovitz JM, Schweitzer ME, Larka UB, Solomon MG. Magnetic resonance imaging of ankle ligament injuries correlated with time. J Am Podiatr Med Assoc. 1998;88:387-393.

16. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37:364-375.

30. Funder V, Jorgensen JP, Andersen A, et al. Ruptures of the lateral ligaments of the ankle. Clinical diagnosis. Acta Orthop Scand. 1982;53:997-1000.

17. Vitale TD, Fallat LM. Lateral ankle sprains: evaluation and treatment. J Foot Surg. 1988;27:248-258.

31. van Dijk CN, Lim LS, Bossuyt PM, Marti RK. Physical examination is sufficient for the diagnosis of sprained ankles. J Bone Joint Surg Br. 1996;78:958-962.

18. Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam Physician. 2001;63: 93-104. 19. Wright IC, Neptune RR, van den Bogert AJ, Nigg BM. The effects of ankle compliance and flexibility on ankle sprains. Med Sci Sports Exerc. 2000;32:260-265. 20. Konradsen L, Voigt M. Inversion injury biomechanics in functional ankle instability: a cadaver study of simulated gait. Scand J Med Sci Sports. 2002;12: 329-336. 21. Fong DT, Ha SC, Mok KM, Chan CW, Chan KM. Kinematics analysis of ankle inversion ligamentous sprain injuries in sports: five cases from televised tennis competitions. Am J Sports Med. 2012;40:2627-2632. 22. Fong DT, Hong Y, Shima Y, Krosshaug T, Yung PS, Chan KM. Biomechanics of supination ankle sprain: a case report of an accidental injury event in the laboratory. Am J Sports Med. 2009;37: 822-827. 23. Kristianslund E, Bahr R, Krosshaug T. Kinematics and kinetics of an accidental lateral ankle sprain. J Biomech. 2011;44:2576-2578. 24. Mok KM, Fong DT, Krosshaug T, et al. Kinematics analysis of ankle inversion

32. Lohrer H, Nauck T, Arentz S, Scholl J. Observer reliability in ankle and calcaneocuboid stress radiography. Am J Sports Med. 2008;36:1143-1149. 33. Funk JR, Hall GW, Crandall JR, Pilkey WD. Linear and quasi-linear viscoelastic characterization of ankle ligaments. J Biomech Eng. 2000;122:15-22. 34. Siegler S, Chen J, Schneck CD. The threedimensional kinematics and flexibility characteristics of the human ankle and subtalar joints—part I: kinematics. J Biomech Eng. 1988;110:364-373.

39. Kjaersgaard-Andersen P, Frich LH, Madsen F, Helmig P, Søgård P, Søjbjerg JO. Instability of the hindfoot after lesion of the lateral ankle ligaments: investigations of the anterior drawer and adduction maneuvers in autopsy specimens. Clin Orthop Relat Res. 1991;(266):170-179. 40. Rasmussen O, Tovborg-Jensen I. Anterolateral rotational instability in the ankle joint. An experimental study of anterolateral rotational instability, talar tilt, and anterior drawer sign in relation to injuries to the lateral ligaments. Acta Orthop Scand. 1981;52:99-102. 41. Rosenbaum D, Becker HP, Wilke HJ, Claes LE. Tenodeses destroy the kinematic coupling of the ankle joint complex. A three-dimensional in vitro analysis of joint movement. J Bone Joint Surg Br. 1998;80:162-168. 42. Wilson RW, Gieck JH, Gansneder BM, Perrin DH, Saliba EN, McCue FC 3rd. Reliability and responsiveness of disablement measures following acute ankle sprains among athletes. J Orthop Sports Phys Ther. 1998;27:348-355. 43. Crosbie J, Green T, Refshauge K. Effects of reduced ankle dorsiflexion following lateral ligament sprain on temporal and spatial gait parameters. Gait Posture. 1999;9: 167-172. 44. Konradsen L, Olesen S, Hansen HM. Ankle sensorimotor control and eversion strength after acute ankle inversion injuries. Am J Sports Med. 1998;26:72-77. 45. Akbari M, Karimi H, Farahini H, Faghihzadeh S. Balance problems after unilateral lateral ankle sprains. J Rehabil Res Dev. 2006;43:819-824. 46. Evans T, Hertel J, Sebastianelli W. Bilateral deficits in postural control following lateral ankle sprain. Foot Ankle Int. 2004;25: 833-839.

35. Leardini A, O’Connor JJ, Catani F, Giannini S. A geometric model of the human ankle joint. J Biomech. 1999;32:585-591.

47. Friden T, Zatterstrom R, Lindstrand A, Moritz U. A stabilometric technique for evaluation of lower limb instabilities. Am J Sports Med. 1989;17:118-122.

36. Bahr R, Pena F, Shine J, et al. Mechanics of the anterior drawer and talar tilt tests. A cadaveric study of lateral ligament injuries of the ankle. Acta Orthop Scand. 1997;68:435-441.

48. Golomer E, Dupui P, Bessou P. Spectral frequency analysis of dynamic balance in healthy and injured athletes. Arch Int Physiol Biochim Biophys. 1994;102: 225-229.

37. Bulucu C, Thomas KA, Halvorson TL, Cook SD. Biomechanical evaluation of the anterior drawer test: the contribution of the lateral ankle ligaments. Foot Ankle. 1991;11:389-393.

49. Guskiewicz KM, Perrin DH. Effect of orthotics on postural sway following inversion ankle sprain. J Orthop Sports Phys Ther. 1996;23:326-331.

38. Grace DL. Lateral ankle ligament injuries. Inversion and anterior stress radiography. Clin Orthop Relat Res. 1984;(183):153-159.


50. Hertel J, Buckley WE, Denegar CR. Serial testing of postural control after acute lateral ankle sprain. J Athl Train. 2001;36:363-368.

vol. 7 / no. 4

51. Orteza LC, Vogelbach WD, Denegar CR. The effect of molded and unmolded orthotics on balance and pain while jogging following inversion ankle sprain. J Athl Train. 1992;27:80-84. 52. Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Bilateral balance impairments after lateral ankle trauma: a systematic review and meta-analysis. Gait Posture. 2010;31:407-414.


20-year follow-up study. Foot Ankle Int. 1994;15:165-169. 66. Ryan L. Mechanical stability, muscle strength, and prorioception in the functionally unstable ankle. Aust J Physiother. 1994;40:41-47. 67. Tropp H, Odenrick P, Gillquist J. Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Med. 1985;6:180-182.

53. Hubbard TJ, Cordova M. Mechanical instability after an acute lateral ankle sprain. Arch Phys Med Rehabil. 2009;90:1142-1146.

68. Hertel J, Denegar CR, Monroe MM, Stokes WL. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc. 1999;31:1501-1508.

54. Konradsen L, Bech L, Ehrenbjerg M, Nickelsen T. Seven years follow-up after ankle inversion trauma. Scand J Med Sci Sports. 2002;12:129-135.

69. Caputo AM, Lee JY, Spritzer CE, et al. In vivo kinematics of the tibiotalar joint after lateral ankle instability. Am J Sports Med. 2009;37:2241-2248.

55. Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med. 1994;28:112-116.

70. Hertel J. Functional instability following lateral ankle sprain. Sports Med. 2000;29:361-371.

56. Swenson DM, Yard EE, Fields SK, Comstock RD. Patterns of recurrent injuries among US high school athletes, 2005-2008. Am J Sports Med. 2009;37:15861593.

71. Kobayashi T, No Y, Yoneta K, Sadakiyo M, Gamada K. In vivo kinematics of the talocrural and subtalar joints with functional ankle instability during weightbearing ankle internal rotation: a pilot study. Foot Ankle Spec. 2013;6:178-184.

57. Nielsen AB, Yde J. Epidemiology and traumatology of injuries in soccer. Am J Sports Med. 1989;17:803-807. 58. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med. 2001;35:103-108. 59. Freeman MA. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br. 1965;47:669-677. 60. 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. 61. Hiller CE, Kilbreath SL, Refshauge KM. Chronic ankle instability: evolution of the model. J Athl Train. 2011;46:133-141. 62. Gribble PA, Delahunt E, Bleakley C, et al. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the international ankle consortium. J Orthop Sports Phys Ther. 2013;43:585-591. 63. Hubbard TJ, Hertel J. Mechanical contributions to chronic lateral ankle instability. Sports Med. 2006;36:263-277. 64. Lentell G, Baas B, Lopez D, McGuire L, Sarrels M, Snyder P. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther. 1995;21:206-215. 65. Lofvenberg R, Karrholm J, Lund B. The outcome of nonoperated patients with chronic lateral instability of the ankle: a

72. Kobayashi T, Saka M, Suzuki E, et al. In vivo kinematics of the talocrural and subtalar joints during weightbearing ankle rotation in chronic ankle instability. Foot Ankle Spec. 2014;7:13-19. 73. Berkowitz MJ, Kim DH. Fibular position in relation to lateral ankle instability. Foot Ankle Int. 2004;25:318-321. 74. Eren OT, Kucukkaya M, Kabukcuoglu Y, Kuzgun U. The role of a posteriorly positioned fibula in ankle sprain. Am J Sports Med. 2003;31:995-998. 75. Hubbard TJ, Hertel J, Sherbondy P. Fibular position in individuals with self-reported chronic ankle instability. J Orthop Sports Phys Ther. 2006;36:3-9. 76. Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int. 2007;28:343-354. 77. Wikstrom EA, Tillman MD, Chmielewski TL, Cauraugh JH, Naugle KE, Borsa PA. Dynamic postural control but not mechanical stability differs among those with and without chronic ankle instability. Scand J Med Sci Sports. 2010;20:e137-e144. 78. Scranton PE Jr, McDermott JE, Rogers JV. The relationship between chronic ankle instability and variations in mortise anatomy and impingement spurs. Foot Ankle Int. 2000;21:657-664. 79. Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the


syndesmosis on axial CT imaging. J Orthop Trauma. 2012;26:433-438. 80. Glencross D, Thornton E. Position sense following joint injury. J Sports Med Phys Fitness. 1981;21:23-27. 81. Boyle J, Negus V. Joint position sense in the recurrently sprained ankle. Aust J Physiother. 1998;44:159-163. 82. Konradsen L, Magnusson P. Increased inversion angle replication error in functional ankle instability. Knee Surg Sports Traumatol Arthrosc. 2000;8:246-251. 83. Nakasa T, Fukuhara K, Adachi N, Ochi M. The deficit of joint position sense in the chronic unstable ankle as measured by inversion angle replication error. Arch Orthop Trauma Surg. 2008;128: 445-449. 84. Brown C, Ross S, Mynark R. Assessing functional ankle instability with joint position sense, time to stabilization, and electromyography. J Sport Rehabil. 2004;13:122-134. 85. Fu AS, Hui-Chan CW. Ankle joint proprioception and postural control in basketball players with bilateral ankle sprains. Am J Sports Med. 2005;33: 1174-1182. 86. Gross MT. Effects of recurrent lateral ankle sprains on active and passive judgements of joint position. Phys Ther. 1987;67: 1505-1509. 87. Jerosch J, Bischof M. Proprioceptive capabilities of the ankle in stable and unstable joints. Sports Exerc Injury. 1996;2:167-171. 88. Lee A, Lin W, Huang CH. Impaired proprioception and poor static postural control in subjects with functional instability of the ankle. J Exerc Sci Fitness. 2006;4:117-125. 89. Lee AJ, Lin WH. Twelve-week biomechanical ankle platform system training on postural stability and ankle proprioception in subjects with unilateral functional ankle instability. Clin Biomech (Bristol, Avon). 2008;23:1065-1072. 90. Santos MJ, Liu W. Possible factors related to functional ankle instability. J Orthop Sports Phys Ther. 2008;38:150-157. 91. Sekir U, Yildiz Y, Hazneci B, Ors F, Aydin T. Effect of isokinetic training on strength, functionality and proprioception in athletes with functional ankle instability. Knee Surg Sports Traumatol Arthrosc. 2007;15:654-664. 92. Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. J Athl Train. 2002;37:487-493.

323

324

August 2014


93. Witchalls J, Waddington G, Blanch P, Adams R. Ankle instability effects on joint position sense when stepping across the active movement extent discrimination apparatus. J Athl Train. 2012;47:627-634.

107. Karlsson J, Andreasson GO. The effect of external ankle support in chronic lateral ankle joint instability. An electromyographic study. Am J Sports Med. 1992;20:257-261.

120. Delahunt E, Monaghan K, Caulfield B. Ankle function during hopping in subjects with functional instability of the ankle joint. Scand J Med Sci Sports. 2007;17: 641-648.

94. Konradsen L. Factors contributing to chronic ankle instability: kinesthesia and joint position sense. J Athl Train. 2002;37:381-385.

108. Konradsen L, Ravn JB. Ankle instability caused by prolonged peroneal reaction time. Acta Orthop Scand. 1990;61: 388-390.

95. McKeon JM, McKeon PO. Evaluation of joint position recognition measurement variables associated with chronic ankle instability: a meta-analysis. J Athl Train. 2012;47:444-456.

109. Lofvenberg R, Karrholm J, Sundelin G, Ahlgren O. Prolonged reaction time in patients with chronic lateral instability of the ankle. Am J Sports Med. 1995;23: 414-417.

121. Larsen E, Lund PM. Peroneal muscle function in chronically unstable ankles. A prospective preoperative and postoperative electromyographic study. Clin Orthop Relat Res. 1991;(272): 219-226.

96. Garn SN, Newton RA. Kinesthetic awareness in subjects with multiple ankle sprains. Phys Ther. 1988;68:1667-1671.

110. Mitchell A, Dyson R, Hale T, Abraham C. Biomechanics of ankle instability. Part 1: reaction time to simulated ankle sprain. Med Sci Sports Exerc. 2008;40:1515-1521.

97. Forkin DM, Koczur C, Battle R, Newton RA. Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains. J Orthop Sports Phys Ther. 1996;23:245-250.

111. Vaes P, Duquet W, Van Gheluwe B. Peroneal reaction times and eversion motor response in healthy and unstable ankles. J Athl Train. 2002;37:475-480.

98. Refshauge KM, Kilbreath SL, Raymond J. Deficits in detection of inversion and eversion movements among subjects with recurrent ankle sprains. J Orthop Sports Phys Ther. 2003;33:166-173.

112. Vaes P, Van Gheluwe B, Duquet W. Control of acceleration during sudden ankle supination in people with unstable ankles. J Orthop Sports Phys Ther. 2001;31:741-752.

99. Refshauge KM, Kilbreath SL, Raymond J. The effect of recurrent ankle inversion sprain and taping on proprioception at the ankle. Med Sci Sports Exerc. 2000;32:10-15.

113. Kavanagh JJ, Bisset LM, Tsao H. Deficits in reaction time due to increased motor time of peroneus longus in people with chronic ankle instability. J Biomech. 2012;45: 605-608.

100. Hubbard TJ, Kaminski TW. Kinesthesia is not affected by functional ankle instability status. J Athl Train. 2002;37:481-486. 101. de Noronha M, Refshauge KM, Kilbreath SL, Crosbie J. Loss of proprioception or motor control is not related to functional ankle instability: an observational study. Aust J Physiother. 2007;53:193-198. 102. Arnold BL, Docherty CL. Low-load eversion force sense, self-reported ankle instability, and frequency of giving way. J Athl Train. 2006;41:233-238. 103. Docherty CL, Arnold BL, Hurwitz S. Contralateral force sense deficits are related to the presence of functional ankle instability. J Orthop Res. 2006;24:1412-1419. 104. Wright CJ, Arnold BL. Fatigue’s effect on eversion force sense in individuals with and without functional ankle instability. J Sport Rehabil. 2012;21:127-136.

114. Hoch MC, McKeon PO. Peroneal reaction time following ankle sprain: a systematic review and meta-analysis. Med Sci Sports Exerc. 2014;46:546-556. 115. Kim KM, Ingersoll CD, Hertel J. Altered postural modulation of Hoffmann reflex in the soleus and fibularis longus associated with chronic ankle instability. J Electromyogr Kinesiol. 2012;22:997-1002. 116. McVey ED, Palmieri RM, Docherty CL, Zinder SM, Ingersoll CD. Arthrogenic muscle inhibition in the leg muscles of subjects exhibiting functional ankle instability. Foot Ankle Int. 2005;26: 1055-1061. 117. Palmieri-Smith RM, Hopkins JT, Brown TN. Peroneal activation deficits in persons with functional ankle instability. Am J Sports Med. 2009;37:982-988.

105. Pietrosimone BG, Gribble PA. Chronic ankle instability and corticomotor excitability of the fibularis longus muscle. J Athl Train. 2012;47:621-626.

118. Caulfield B, Crammond T, O’Sullivan A. Altered ankle-muscle activation during jump landings in participants with functional instability of the ankle joint. J Sport Rehabil. 2004;13:189-200.

106. Ebig M, Lephart SM, Burdett RG, Miller MC, Pincivero DM. The effect of sudden inversion stress on EMG activity of the peroneal and tibialis anterior muscles in the chronically unstable ankle. J Orthop Sports Phys Ther. 1997;26:73-77.

119. Delahunt E, Monaghan K, Caulfield B. Changes in lower limb kinematics, kinetics, and muscle activity in subjects with functional instability of the ankle joint during a single leg drop jump. J Orthop Res. 2006;24:1991-2000.


122. Santilli V, Frascarelli MA, Paoloni M, et al. Peroneus longus muscle activation pattern during gait cycle in athletes affected by functional ankle instability: a surface electromyographic study. Am J Sports Med. 2005;33:1183-1187. 123. Soderberg GL, Cook TM, Rider SC, Stephenitch BL. Electromyographic activity of selected leg musculature in subjects with normal and chronically sprained ankles performing on a BAPS board. Phys Ther. 1991;71:514-522. 124. Ty Hopkins J, Coglianese M, Glasgow P, Reese S, Seeley MK. Alterations in evertor/ invertor muscle activation and center of pressure trajectory in participants with functional ankle instability. J Electromyogr Kinesiol. 2012;22:280-285. 125. Lin CF, Chen CY, Lin CW. Dynamic ankle control in athletes with ankle instability during sports maneuvers. Am J Sports Med. 2011;39:2007-2015. 126. Wikstrom EA, Bishop MD, Inamdar AD, Hass CJ. Gait termination control strategies are altered in chronic ankle instability subjects. Med Sci Sports Exerc. 2010;42: 197-205. 127. Baier M, Hopf T. Ankle orthoses effect on single-limb standing balance in athletes with functional ankle instability. Arch Phys Med Rehabil. 1998;79:939-944. 128. Bernier JN, Perrin DH, Rijke A. Effect of unilateral functional instability of the ankle on postural sway and inversion and eversion strength. J Athl Train. 1997;32:226-232. 129. Brown CN, Mynark R. Balance deficits in recreational athletes with chronic ankle instability. J Athl Train. 2007;42:367-373. 130. Chrintz H, Falster O, Roed J. Single-leg postural equilibrium test. Scand J Med Sci Sports. 1991;1:244-246. 131. Cornwall MW, Murrell P. Postural sway following inversion sprain of the ankle. J Am Podiatr Med Assoc. 1991;81:243-247. 132. 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.

vol. 7 / no. 4

133. Gauffin H, Tropp H, Odenrick P. Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med. 1988;9: 141-144. 134. Goldie PA, Evans OM, Bach TM. Postural control following inversion injuries of the ankle. Arch Phys Med Rehabil. 1994;75:969-975. 135. Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2007;37: 303-311. 136. Hertel J, Olmsted-Kramer LC. Deficits in time-to-boundary measures of postural control with chronic ankle instability. Gait Posture. 2007;25:33-39. 137. Hiller CE, Refshauge KM, Beard DJ. Sensorimotor control is impaired in dancers with functional ankle instability. Am J Sports Med. 2004;32:216-223. 138. 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. 139. Isakov E, Mizrahi J. Is balance impaired by recurrent sprained ankle? Br J Sports Med. 1997;31:65-67. 140. Knapp D, Lee SY, Chinn L, Saliba SA, Hertel J. Differential ability of selected postural-control measures in the prediction of chronic ankle instability status. J Athl Train. 2011;46:257-262.


147. Perrin PP, Bene MC, Perrin CA, Durupt D. Ankle trauma significantly impairs posture control—a study in basketball players and controls. Int J Sports Med. 1997;18:387-392. 148. Ross SE, Guskiewicz KM. Examination of static and dynamic postural stability in individuals with functionally stable and unstable ankles. Clin J Sport Med. 2004;14:332-338.

161. Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the star excursion balance tests in detecting reach deficits in subjects with chronic ankle instability. J Athl Train. 2002;37:501-506.

149. Ross SE, Guskiewicz KM, Gross MT, Yu B. Balance measures for discriminating between functionally unstable and stable ankles. Med Sci Sports Exerc. 2009;41: 399-407.

162. Plante JE, Wikstrom EA. Differences in clinician-oriented outcomes among controls, copers, and chronic ankle instability groups. Phys Ther Sport. 2013;14:221-226.

150. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for persons with functionally unstable ankles. J Orthop Sports Phys Ther. 1999;29:478-486.

163. Brown CN, Bowser B, Orellana A. Dynamic postural stability in females with chronic ankle instability. Med Sci Sports Exerc. 2010;42:2258-2263.

151. Tropp H, Ekstrand J, Gillquist J. Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc. 1984;16:64-66.

164. Ross SE, Guskiewicz KM, Yu B. Single-leg jump-landing stabilization times in subjects with functionally unstable ankles. J Athl Train. 2005;40:298-304.

152. Tropp H, Odenrick P. Postural control in single-limb stance. J Orthop Res. 1988;6:833-839.

165. Wikstrom EA, Tillman MD, Borsa PA. Detection of dynamic stability deficits in subjects with functional ankle instability. Med Sci Sports Exerc. 2005;37:169-175.

153. You SH, Granata KP, Bunker LK. Effects of circumferential ankle pressure on ankle proprioception, stiffness, and postural stability: a preliminary investigation. J Orthop Sports Phys Ther. 2004;34:449-460. 154. Levin O, Van Nevel A, Malone C, Van Deun S, Duysens J, Staes F. Sway activity and muscle recruitment order during transition from double to single-leg stance in subjects with chronic ankle instability. Gait Posture. 2012;36:546-551.

141. Konradsen L, Ravn JB. Prolonged peroneal reaction time in ankle instability. Int J Sports Med. 1991;12:290-292.

155. Pope M, Chinn L, Mullineaux D, McKeon PO, Drewes L, Hertel J. Spatial postural control alterations with chronic ankle instability. Gait Posture. 2011;34:154-158.

142. Leanderson J, Wykman A, Eriksson E. Ankle sprain and postural sway in basketball players. Knee Surg Sports Traumatol Arthrosc. 1993;1:203-205.

156. Arnold BL, De La Motte S, Linens S, Ross SE. Ankle instability is associated with balance impairments: a meta-analysis. Med Sci Sports Exerc. 2009;41:1048-1062.

143. Lentell G, Katzman LL, Walters MR. The relationship between muscle function and ankle stability. J Orthop Sports Phys Ther. 1990;11:605-611.

157. 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.

144. McKeon PO, Hertel J. Spatiotemporal postural control deficits are present in those with chronic ankle instability. BMC Musculoskelet Disord. 2008;9:76. 145. Michell TB, Ross SE, Blackburn JT, Hirth CJ, Guskiewicz KM. Functional balance training, with or without exercise sandals, for subjects with stable or unstable ankles. J Athl Train. 2006;41:393-398. 146. Mitchell A, Dyson R, Hale T, Abraham C. Biomechanics of ankle instability. Part 2: postural sway-reaction time relationship. Med Sci Sports Exerc. 2008;40:1522-1528.

and dynamic postural control deficits are present in those with chronic ankle instability. J Sci Med Sport. 2012;15:574579.

158. Gribble PA, Hertel J, Denegar CR, Buckley WE. The effects of fatigue and chronic ankle instability on dynamic postural control. J Athl Train. 2004;39:321-329. 159. Hertel J, Braham RA, Hale SA, OlmstedKramer LC. Simplifying the star excursion balance test: analyses of subjects with and without chronic ankle instability. J Orthop Sports Phys Ther. 2006;36:131-137. 160. Hoch MC, Staton GS, Medina McKeon JM, Mattacola CG, McKeon PO. Dorsiflexion


166. Wikstrom EA, Tillman MD, Chmielewski TL, Cauraugh JH, Borsa PA. Dynamic postural stability deficits in subjects with self-reported ankle instability. Med Sci Sports Exerc. 2007;39:397-402. 167. Wikstrom EA, Hass CJ. Gait termination strategies differ between those with and without ankle instability. Clin Biomech (Bristol, Avon). 2012;27:619-624. 168. Eechaute C, Vaes P, Duquet W. The dynamic postural control is impaired in patients with chronic ankle instability: reliability and validity of the multiple hop test. Clin J Sport Med. 2009;19: 107-114. 169. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am. 1955;37:1237-1243. 170. Tropp H. Pronator muscle weakness in functional instability of the ankle joint. Int J Sports Med. 1986;7:291-294. 171. Hartsell HD, Spaulding SJ. Eccentric/ concentric ratios at selected velocities for the invertor and evertor muscles of the chronically unstable ankle. Br J Sports Med. 1999;33:255-258. 172. McKnight CM, Armstrong CW. The role of ankle strength in functional ankle instability. J Sport Rehabil. 1997;6:21-29. 173. Wilkerson GB, Pinerola JJ, Caturano RW. Invertor vs. evertor peak torque and power deficiencies associated with lateral ankle ligament injury. J Orthop Sports Phys Ther. 1997;26:78-86.

325

326

August 2014


174. Kaminski TW, Perrin DH, Gansneder BM. Eversion strength analysis of uninjured and functionally unstable ankles. J Athl Train. 1999;34:239-245. 175. Porter GK Jr, Kaminski TW, Hatzel B, Powers ME, Horodyski M. An examination of the stretch-shortening cycle of the dorsiflexors and evertors in uninjured and functionally unstable ankles. J Athl Train. 2002;37:494-500. 176. Munn J, Beard DJ, Refshauge KM, Lee RY. Eccentric muscle strength in functional ankle instability. Med Sci Sports Exerc. 2003;35:245-250. 177. Pontaga I. Ankle joint evertor-invertor muscle torque ratio decrease due to recurrent lateral ligament sprains. Clin Biomech (Bristol, Avon). 2004;19:760-762. 178. Fox J, Docherty CL, Schrader J, Applegate T. Eccentric plantar-flexor torque deficits in participants with functional ankle instability. J Athl Train. 2008;43:51-54. 179. Arnold BL, Linens SW, de la Motte SJ, Ross SE. Concentric evertor strength differences and functional ankle instability: a metaanalysis. J Athl Train. 2009;44:653-662. 180. Nicholas JA, Strizak AM, Veras G. A study of thigh muscle weakness in different pathological states of the lower extremity. Am J Sports Med. 1976;4:241-248. 181. Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train. 2006;41:74-78. 182. de Asla RJ, Wan L, Rubash HE, Li G. Six DOF in vivo kinematics of the ankle joint complex: application of a combined dualorthogonal fluoroscopic and magnetic resonance imaging technique. J Orthop Res. 2006;24:1019-1027.

188. Stormont DM, Morrey BF, An KN, Cass JR. Stability of the loaded ankle. Relation between articular restraint and primary and secondary static restraints. Am J Sports Med. 1985;13:295-300. 189. Drewes LK, McKeon PO, Kerrigan DC, Hertel J. Dorsiflexion deficit during jogging with chronic ankle instability. J Sci Med Sport. 2009;12:685-687. 190. Arndt A, Westblad P, Winson I, Hashimoto T, Lundberg A. Ankle and subtalar kinematics measured with intracortical pins during the stance phase of walking. Foot Ankle Int. 2004;25:357-364. 191. Reinschmidt C, van den Bogert AJ, Lundberg A, et al. Tibiofemoral and tibiocalcaneal motion during walking: external vs. skeletal markers. Gait Posture. 1997;6:98-109. 192. Reinschmidt C, van Den Bogert AJ, Murphy N, Lundberg A, Nigg BM. Tibiocalcaneal motion during running, measured with external and bone markers. Clin Biomech (Bristol, Avon). 1997;12:8-16. 193. 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;30:1798-1804. 194. 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. 195. Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Arch Phys Med Rehabil. 2010;91:1267-1271.

183. Leardini A, O’Connor JJ, Catani F, Giannini S. Kinematics of the human ankle complex in passive flexion; a single degree of freedom system. J Biomech. 1999;32:111-118.

196. Wikstrom EA, Tillman MD, Chmielewski TL, Cauraugh JH, Naugle KE, Borsa PA. Discriminating between copers and people with chronic ankle instability. J Athl Train. 2012;47:136-142.

184. Mattingly B, Talwalkar V, Tylkowski C, Stevens DB, Hardy PA, Pienkowski D. Three-dimensional in vivo motion of adult hind foot bones. J Biomech. 2006;39: 726-733.

197. Delahunt E, Monaghan K, Caulfield B. Altered neuromuscular control and ankle joint kinematics during walking in subjects with functional instability of the ankle joint. Am J Sports Med. 2006;34:1970-1976.

185. Schmidt R, Cordier E, Bertsch C, et al. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int. 2004;25:31-36.

198. Monaghan K, Delahunt E, Caulfield B. Ankle function during gait in patients with chronic ankle instability compared to controls. Clin Biomech (Bristol, Avon). 2006;21:168-174.

186. Wong Y, Kim W, Ying N. Passive motion characteristics of the talocrural and the subtalar joint by dual Euler angles. J Biomech. 2005;38:2480-2485.

199. Nawata K, Nishihara S, Hayashi I, Teshima R. Plantar pressure distribution during gait in athletes with functional instability of the ankle joint: preliminary report. J Orthop Sci. 2005;10:298-301.

187. Hayes A, Tochigi Y, Saltzman CL. Ankle morphometry on 3D-CT images. Iowa Orthop J. 2006;26:1-4.

200. Nyska M, Shabat S, Simkin A, Neeb M, Matan Y, Mann G. Dynamic force


distribution during level walking under the feet of patients with chronic ankle instability. Br J Sports Med. 2003;37:495-497. 201. Chinn L, Dicharry J, Hertel J. Ankle kinematics of individuals with chronic ankle instability while walking and jogging on a treadmill in shoes. Phys Ther Sport. 2013;14:232-239. 202. Morrison KE, Hudson DJ, Davis IS, et al. Plantar pressure during running in subjects with chronic ankle instability. Foot Ankle Int. 2010;31:994-1000. 203. Schmidt H, Sauer LD, Lee SY, Saliba S, Hertel J. Increased in-shoe lateral plantar pressures with chronic ankle instability. Foot Ankle Int. 2011;32:1075-1080. 204. Huang PY, Lin CF, Kuo LC, Liao JC. Foot pressure and center of pressure in athletes with ankle instability during lateral shuffling and running gait. Scand J Med Sci Sports. 2011;21:e461-e467. 205. Gribble P, Robinson R. Differences in spatiotemporal landing variables during a dynamic stability task in subjects with CAI. Scand J Med Sci Sports. 2010;20:e63-e71. 206. Brown C, Padua D, Marshall SW, Guskiewicz K. Individuals with mechanical ankle instability exhibit different motion patterns than those with functional ankle instability and ankle sprain copers. Clin Biomech (Bristol, Avon). 2008;23:822-831. 207. Brown C. Foot clearance in walking and running in individuals with ankle instability. Am J Sports Med. 2011;39:17691776. 208. 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. 209. 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. 210. Hertel J, Kaminski TW. Second international ankle symposium summary statement. J Orthop Sports Phys Ther. 2005;35:A2-A6. 211. Shultz R, Kedgley AE, Jenkyn TR. Quantifying skin motion artifact error of the hindfoot and forefoot marker clusters with the optical tracking of a multisegment foot model using single-plane fluoroscopy. Gait Posture. 2011;34:44-48. 212. 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.