The Effect of an Ankle Orthosis on Ankle Range of ...

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The Effect of an Ankle Orthosis on Ankle Range of Motion and Performance ). Preston Wiley, MPE, MD'

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on September 15, 2017. For personal use only. No other uses without permission. Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

B.M. Nigg, DrScNat2

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he general increase of physical activity for fitness and health reasons is associated with an increase of sports injuries in the industrialized countries. Sports injuries seem to occur frequently at two sites, the ankle and the knee joint complexes. It has been suggested that "the ankle sprain is p r o b ably the single most common injury in sports" (8).The implied costs for diagnosis, treatment, and rehabilitation of such injuries are substantial and present a major problem for the health care system. Additionally, such injuries present a loss of sports participation time and may have negative side effects for general health. Movement components in the ankle joint complex which are functionally of interest are inversion/eversion, dorsiflexion/plantar flexion, abduction/adduction, and anterior/ posterior translation of the foot with respect to the leg. The most common ankle ligament injuries involve the anterior talofibular and the calcaneofibular ligaments during forced plantar flexion and foot inversion. Consequently, ankle joint orthoses typically attempt to reduce foot inversion. Due to performance considerations, such orthoses typically attempt not to affect dorsiflexion/plantar flexion. Treatment of ankle joint sprains is performed in various ways (32). Typically, treatment of ankle joint sprains is nonsurgical and consists of modified activity, conservative treatment and rehabilitation, and/or the use of an ankle joint orthosis or a

Ankle joint orthoses are used for rehabilitation and/or prevention of ankle sprains. The purpose of this study was to determine the effect of the Malleolo@ ankle joint orthosis on active and passive range of motion reduction and on a jumping and a figureeight running test. Twelve subjects with a history of inversion ankle sprain and documented increased anterior translation in a drawer test participated in the study. Active and passive range of motion for inversion was determined with and without the orthosis and pre- and postexercise. Additionally, performance tests for figureeight running and jumping were administered. The results showed that the tested orthosis 1) restricted the active range of motion and passive inversion substantially, 2) reduced the other movement degrees of freedom only minimally, 3) provided the same movement restriction before and after exercise, and 4) did not affect performance. The Malleoloc ankle joint orthoses can, therefore, restrict ankle joint motion without affecting performance negatively.

Key Words: ankle, sprain, orthotics, function

' Associate Professor, Sport Medicine Centre, Faculty of Kinesiology, The University of Calgary, 2500 University Drive NW, Calgary, Alberta, Canada T2N IN4 Professor, Human Performance laboratory, Faculty of Kinesiology, The University of Calgary, Calgary, Alberta, Canada This project was supported by a grant from Bauerfeind GmbH, Germany.

taping system for return to activity. The prevention of ankle joint injuries is not well documented in the literature, although reviews on the subject support conservative action, such as ankle joint braces or ankle joint tap ing for preventative purposes (20). Results of a retrospective study (26) suggested that the use of an ankle joint orthosis may be more beneficial than the use of taping in the prevention of ankle joint injuries. Surve et al (31) showed that a semi-rigid ankle orthosis reduced the incidence of recurrent ankle sprains five-fold in a study with soccer players. However, the semi-rigid ankle orthosis did not reduce the occurrence of new ankle sprains. Sitler et al (30) showed that the use of an ankle orthosis produced a reduction in the frequency of ankle injuries in basketball players. Both studies (30.31) used large Sam-

ples and were prospective and randomized, providing good evidence for the possible beneficial preventive effects of ankle joint arthroses during selected sports activities. Tropp et al (33) found similar results in male soccer players, but the study design was less rigorous. The discussed evidence has given strong support to the application of ankle joint taping or orthoses for rehabilitation and/or prevention of ankle joint injuries. As a result, many taping methods have been developed and several types of ankle joint orthoses are produced commercially. Testing of orthoses and taping techniques for the ankle joint complex typically examine active range of m e tion and passive range of motion. Often, testing of active range of motion and passive range of motion before and after exercise has been a p Volume 23 Number 6 June 1996 JOSPT


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plied to quantify possible loosening of the orthosis or the tape during the process of physical activity. Studies examining quasistatically the potential of ankle joint orthoses o r ankle joint taping to reduce active and/or passive range of motion have been published rather frequently (4,7,1012,14-16,18,19,24,27,29,34). Some studies analyzed kinematic and/or neuromuscular responses of the ankle joint complex with and without ankle joint orthoses or ankle joint taping (6,9,17,18,21,34). Only a few studies have examined the effects of selected semi-rigid ankle orthoses and/or taping on performance (1012,23). Studies where the actual effect of an ankle joint orthosis or of ankle joint taping has been analyzed during actual movements are not known to the author. Two studies are known to the authors where actual passive range of motion measurements were used to characterize a specific ankle joint orthosis and where results from a jumping performance test (10) or from a base running test (12) were simultaneously collected. Both studies, however, used subjects with no history of ankle pathology which limits their applicability. Ankle joint orthoses may be most beneficially used for prevention or rehabilitation by subjects with a history of ankle pathology. The purpose of this study was to test the effect of the Malleoloc@ankle joint orthosis (Bauerfeind GmbH, Germany) on active and passive range of motion reduction of the ankle joint complex and on a figureofeight running and jumping performance test. Ankle joint orthoses are developed currently to be used not only for rehabilitation but also for prevention of ankle joint injuries. The effect of such products on range of motion and performance are obviously important, since athletes d o not want performance negatively influenced by a preventive ankle joint orthosis.

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Hypothesis I ) The Malleoloc ankle joint orthosis will restrict active inversion/ eversion and anterior-posterior translation but not dorsiflexion/plantar flexion compared with the use of no orthosis. In addition, the Malleoloc ankle joint orthosis will restrict passive inversion in 20" dorsiflexion, neutral, and 15" and 30" plantar flexion compared with the use of no orthosis. 2) The use of the Malleoloc ankle joint orthosis will not significantly decrease the performance of a j u m p ing test or a figure-ofeight running test compared with the use of no orthosis.

METHODS

FIGURE 1. The Malleolo@ ankle joint orthosis.

Subjects Twelve subjects (>I8 years old) with a previous history of ankle sprain were recruited for this study. After obtaining informed consent, each subject's previously injured ankle was tested and documented clinically to show increased translation in an anterior drawer test compared with the other ankle before entry into the study. Four females and eight males were finally selected to participate in the study. Their average age was 24.2 years with a standard deviation of 3.8 years. Five left and seven right ankles were tested.

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Procedures Each subject was randomly assigned to one of two testing groups. Group 1 was tested using the Malleoloc (Figure 1) orthosis during the first testing session and no orthosis during the second testing session. Group 2 was tested with the inverse test sequence. During each test session, each subject was tested first for active range of motion, followed by the test for passive range of motion. At the beginning of each session,

each subject performed a standardized 5minute cycling warm-up. This was followed by the fitting of a standard low-cut laboratory shoe (make: Adidas, model: Detroit 33310), which was worn during both testing sessions. The subject was then placed in the range of motion fixture and tests were performed. This was followed by an exercise session consisting of running a figureeight course with cones 10 m apart for 5 minutes, cycling on a stationary bike for 10 minutes at a heart rate greater than 100 beats/ min, and, finally, jogging on a treadmill for 15 minutes at a heart rate greater than 150 beats/min. After this activity, range of motion measurements were repeated. Both active and passive range of motion were determined using an apparatus similar to that already described (2). This apparatus was allowed to quantify both active range of motion and passive range of motion for three rotational and three translational degrees of freedom of the ankle joint complex. Three rotational degrees of freedom were used for analysis in this study, dorsiflexion/plantar flexion, inversion/ever-


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sion, and anterior-posterior translation of the foot with respect to the leg. In addition, anterior translation of the foot with respect to the leg was tested. The subject's left leg was secured to the apparatus using a VW clamp below the knee and two "V" clamps above the ankle joint. The subject was seated so that his/her lower leg was perpendicular to the thigh. The subject's upper body was maintained in an upright position. A "C" clamp rested on the subject's thigh proximal to the knee, with a constant compressive force of 100 N applied to the knee, to load the foot on the foot plate. The subjects were barefoot in a court shoe to minimize slipping of the foot inside the shoe. The shoe was secured to a movable foot plate

Subjects were barefoot in a court shoe to minimize slipping of the foot inside the shoe. by Velcro@straps around the heel, the dorsum of the foot, and the metatarsal heads. The foot was placed on the plate so that the inversion/eversion axis of the foot plate was in line with the line formed by the center of the calcaneus and the second metatarsal head. The inversion/eversion axis was positioned between the center of the two malleoli. The dorsiflexion/plantar flexion axis was perpendicular to the inversion/ eversion and the abduction/adduction axes in the neutral position. Active range of motion and passive range of motion measurements were quantified with the foot plate (and, consequently, the subject's foot) with respect to 0" plantar flexion/dorsiflexion, inversion/eversion, and abduction/adduction.

For the assessment of the active range of motion, the subject was asked to perform a maximal rotation of the foot in the direction of interest, to maintain this position for 3 seconds, and to return to the relaxed neutral position. For the assessment of the passive range of motion, the subject was asked to relax the foot while a defined moment of force was applied with respect to one axis of rotation. This was done by extending the axis, fixing a wheel to the axis with a radius of 0.1 m, and loading the wheel tangentially with a defined mass. The product of weight X radius provided the moment of rotation. This moment turned the relaxed foot into a new position, which was determined as the passive range of motion value for the defined degree of freedom. These moments of rotation could be applied in all axis directions. However, for this study, the inversion moment is the important one since the brace is constructed to restrict inversion movement. Active range of motion testing followed the order of dorsiflexion, plantar flexion, eversion, and inversion. Inversion passive range of motion was tested at 20" dorsiflexion, neutral, 20" plantar flexion, and 40" plantar flexion. A moment of 12 Nm (which was determined in pilot measurements to be well tolerated by the test subjects) was applied at each foot position to produce the foot rotation for the passive range of motion measurements. Anterior translation was tested at 20" dorsiflexion, neutral, 15" plantar flexion, and 30" plantar flexion. A translational force of 180 N (which was determined in pilot measurements to be well tolerated by the test subjects) was applied to the foot plate acting in anterior foot direction at each plantar flexion/dorsiflexion angle of the foot. To determine range of motion variables, the Expervision HiRes 3 D motion analysis system (Motion Analysis Corporation, Santa Rosa, CA) was used. Three markers were applied

securely to the foot plate of the range of motion apparatus, and three markers were attached to the leg at the tibia1 tubercle, the anterior border of the tibia at mid-leg, and the medial malleolus (2). The markers were used to determine the variables of interest using a joint coordinate system approach for foot and leg (5.13). Three trials of each motion were performed and the average of these trials was taken as the value used for each movement variable. The reliability of the used range of motion apparatus has been discussed earlier (2,3,22). The maximal active inversion repeatability between days, for instance, has been determined to be 0.85". In general, the range of motion tests showed differences between days which were typically less than 1" and none of these differences were significant (2,3,22). The ankle orthosis was fitted directly onto the skin by experienced personnel and worn in the standard laboratory shoe without any socks. There was no attempt made after the exercise session to tighten the straps. The jumping performance test consisted of a jump with several steps of approach. The subjects were free to select the number of steps for the run-up. Typically, they used about five steps for the run-up. During the jump, the subjects reached for a set of light blades which were mounted horizontally to a vertical pole with a vertical distance of 1.2 cm (1/2 inch) between neighboring blades. The blades, which were touched by the jumper, would move and the highest blade touched indicated the maximal jumping height. Each subject had sufficient time to adjust to the j u m p ing test. For the actual test, the s u b jects were allowed to jump as often as they wanted until they could not improve performance anymore. The result of the highest jump was then used for further analysis. The subjects performed the jumping performance test with and without the ankle joint orthosis before and after the previously described exercise program. Volume 23 Number 6 June 1996 JOSPT

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Statistics


The figureeight running test consisted of a set-up with two markers placed on a longitudinal axis 10 m apart (markers 1 and 4) with two X two markers placed at the end of cross elements 5 m apart, crossing the longitudinal axis at 2.5 m (markers 2 and 6) and 7.5 m (markers 3 and 5) as illustrated in Figure 2. The subjects ran around the markers in a figureeight manner following the numbers from 1 to 6. Each subject had three trials from which the best hand-stopped running time ( 2 0.2 sec) was used as the performance variable. The subjects performed the figureeight running test with and without the ankle joint orthosis before and after the intensive activity program.

Errors in Measurements The errors in the ankle measurements due to the accuracy of the de-

The analysis of the collected range of motion data and the performance tests was performed using a two-way (time and condition) repeated measures analysis of variance on 14 variables (BMDP Statistical Software, University of California, Berkeley, CA) . The significance level was set at p = 0.01. No interaction effects were found, so post hoc paired t tests were performed.

RESULTS The results for the active range of motion tests for inversion, eversion, dorsiflexion, and plantar flexion for the braced and unbraced and pre- and postexercise conditions are summarized in Table 1. There were no significant differences between groups for order of testing. Thus, this aspect will not be further discussed. Active inversion was reduced by 11" (44%) in the preexercise condition and by 9" (35%) in the postexercise condition using the orthosis. Active dorsiflexion was reduced by 3" (13%) in the preexercise condition but not in the postexercise condition using the orthosis. Active plantar flexion was reduced by 6" (16%) in the pre-

Jnbraced Pre ("1

Ankle 22.2

34.3 11.5 25.1

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Braced

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X Dorsiflexion Plantar flexion Eversion Inversion

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exercise condition and by 4" (11%) in the postexercise condition wearing the orthosis. Active eversion was reduced by 3" (24%) in the preexercise condition and by 2" (21%) in the postexercise condition by the orthosis. There was n o significant difference between pre- and postexercise for the unbraced or braced conditions for any of the active range of motion test results. The results for inversion as measured in the passive range of motion test are summarized in Table 2. The results for passive inversion at 20" of dorsiflexion include only six subjects because of restricted range of motion for the other subjects. Brace loosening was minimal and statistically insignificant. The ankle orthosis reduced inversion significantly under all dorsiflexion and plantar flexion angles tested. Reduction of the inversion passive range of motion preexercise for 20" dorsiflexion, neutral, and 20" and 40" plantar flexion was 45, 50, 50, and 46%. respectively. Reduction of inversion passive range of motion postexercise for 20" dorsiflexion, neutral, and 20" and 40" plantar flexion was 42, 45, 50, and 39%, respectively. The results for anterior translation as measured in the anterior translation test are summarized in Table 3. The ankle joint orthosis reduced the average translation across the dorsiflexed/plantar flexed foot positions in the braced and unbraced condition and/or in the pre- and postexercise condition only mini-

termination of the marker position depend on the marker size, the field of view, and the position of the markers. For the reported angles in this study, the errors due to the above mentioned factors were smaller than 1".The accuracy of the translational results was better than 2 mm.

FIGURE 2. Schematic illustration of the positioning of the markers around which the test subjects had to run following the sequence from I to 6. The distance between markers I and 4 was 10 m and the distance between markers 2 and 6 and markers 3 and 5 was 5 m.

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Post ("1

SD

X

Pre ("1

SD

X

Post ("1

SD

Pre

Post

P

P

2.5 5.2

4.3 8.1

'Significant diiierences at the 1 % level.

TABLE 1. Means and standard deviations for the acfive range of motion in the braced and unbraced condition for the tests pre- and post-exercise. Comparative analysis is between pre-exercise unbraced and braced and post-exerci~eunbraced and braced.

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Unbraced Exercise Unit

20" DorsiflexionS Neutral 20" Plantar flexion 40" Plantar flexiont

Pre (O)

X

26.7 36.3 41.6 36.9

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Braced Post ("1

SD

X

6.7 7.0 8.8 8.7

26.6 36.6 42.4 36.1

SD

X

6.3 6.6 7.6 9.4

14.7 18.1 20.6 19.8

Pre (7

Pre

Post

SD

X

SD

P

P

2.3 4.5 5.6 4.8

15.5 20.1 21 .O 21.9

2.6 4.3 4.4 5.6

0.003' O.OOO* 0.000' O.OOO*

0.001 * O.OOO* 0.000' O.OOO*

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Post

(O)

* Significant ditierences at the I n o level. t All subjects could perform the test at 40" plantar flexion. However, for some subjects, this was associated with moderate pain. The tests in 20" dorsiflexion could only be performed by six of the 10 subjects.

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TABLE 2. Means and standard deviations for foot inversion as measured in the passive range of motion test for the four plantar flexed/dorsiflexed foot positions in the braced and unbraced condition for the tests pre- and post-exercise at each angle tested.

built to restrict excessive foot inversion. Studies analyzing the efficacy of ankle orthoses, therefore, used measures quantifying the restriction of the inversion movement of the foot in general and specifically in plantar flexion. The most common tests used were the quasistatic assessment of the active and passive range of motion. Controversy exists over whether the assessment of active range of motion or passive range of motion are reliable predictors of the functionality of an ankle orthosis (8). Other researchers, however, suggested that devices which limit the range of motion of the ankle joint complex are beneficial as long as they do not compromise the integrity of the joint functions (l,l5,18,28).

mally (relative changes between 5 to 15%). The results for the two performance tests for the braced and unbraced and for the pre- and postexercise conditions are summarized in Table 4. The use of the ankle joint orthosis did not affect performance. The differences of the test results for the different conditions were very small and none of them were significant for both performance tests.

DISCUSSION The most common mechanism of injury to the ankle joint complex is that of excessive inversion in a plantar flexed foot position. Consequently, ankle joint orthoses are typically

Unbraced Exercise Unit

PIT (an) -

X

20" Dorsiflexion Neutral 15" Plantar flexion 30" Plantar flexion

1.I 1.2 1.4 1.3

SD

0.39 0.31 0.32 0.31

During the last few years, ankle joint orthoses were frequently used for prevention of ankle joint injuries. Orthoses which are used for injury prevention should, however, not affect performance. Consequently, one must show for a functional and efficient ankle orthosis that: I) it restricts ankle joint inversion without affecting the other movement components of the ankle joint substantially, and 2) it does not affect performance negatively.

Effects on Ankle Joint Range of Motion The results of this study document that the Malleoloc ankle o r t h e

Braced X

1.3 1.4 1.5 1.5

post

(an)

pre (an)

SD

X

SD

X

0.35 0.33 0.41 0.41

1.1 1.1 1.3 1.2

0.21 0.34 0.29 0.27

1.1 1.3 1.5 1.4

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post (an)

Pre -

Post -

SD

P

P

0.37 0.29 0.35 0.35

0.586 0.520 0.409 0.191

0.1 24 0.323 0.586 0.169

TABLE 3. Means and standard deviations for passive anterior translation in the braced and unbraced condition tor the tests pre- and post-exercise at each angle tested. Comparison analysis is between pre-exercise unbraced and braced and post-exercise unbraced and braced.

TABLE 4. Means and standard deviations of the results tor the jumping performance and the figure-eight running tests in the braced and unbraced condition tor the tests pre- and post-exercise.

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sis provided the functional results for which it was constructed. The maximal active range of motion reduction occurred for inversion (44% pre-exercise and 35% postexercise) and was present for all test subjects included in the study. In comparison, the DonJoy ALPdDbrace has been reported to provide, in a similar test, an active range of motion inversion reduction of 19% (11) in noninjured ankles. Additionally, the influence of the Malleoloc ankle joint orthosis on eversion, plantar flexion, and dorsiflexion was rather small. Although the reductions of active range of motion for dorsiflexion (preexercise) and plantar flexion (pre- and postexercise) were significant, changes of only 1-5" are not considered physiologically relevant. The passive range of motion for inversion in the four plantar flexed and dorsiflexed foot positions is a test which probably simulates actual movement situations better than the active range of motion measurements. The foot movement is produced with an external moment, a mechanism which shows some similarity (at least in force application) to a landing of the foot in walking or maybe running. Of course, this force application is smaller in magnitude and occurs in a much longer time frame compared with the force application during actual locomotion. From the tested foot position, only the inversion movement for the neutral and the 20" plantar flexed position could be collected without encumbrance. Only six of the 12 subjects could perform the test movement in the 20" dorsiflexed position without discomfort. The test in the 40" plantar flexed position was performed by all test subjects. However, some of them described the movement as slightly painful. For this reason, only the results for the neutral and the 20" plantar flexed position will be discussed further. The ankle joint orthosis used in this study reduced the passive range of motion for inversion in the neutral and the JOSFT Volume 23 Number 6 June 1996

20" plantar flexed foot position by 45 to 50%. This reduction is substantial and compares well with the other orthoses tested earlier. The restriction of ankle joint inversion in the 20" plantar flexed foot position of 50%. the position in which most lateral ankle sprains are believed to occur, was substantial and underlines that the Malleoloc ankle joint orthosis restricted the passive range of motion inversion as intended. An ankle joint orthosis or a tape application is only good if it provides its supporting function during the entire duration of an activity. To study the durability of the ankle s u p port, all measurements were performed before and after rigorous activity. The results addressing this aspect of the study did not show a significant change in restriction of inversion in the active range of motion and passive range of motion tests due to activity for the ankle joint orthosis used in this study. Average inversion values were, however, slightly but not significantly higher after exercise compared with before exercise (between 0.4 and 2.2"). Similar minimal differences before and after activity have been reported for ankle joint orthoses in other studies (4,10,12,14-16). In comparison with results from semi-rigid ankle joint orthoses, ankle taping strategies showed a decrease in effectiveness to restrict inversion after exercise (10, 15.35). In contrast, the ankle joint orthosis used in this study showed no loss of its ability to restrict active range of motion or passive range of motion after intensive exercise. Range of motion studies have been performed with many other ankle joint orthoses and/or taping of the ankle joint. A reduction of passive inversion due to ankle orthoses or selected taping techniques has been reported by several authors. Reductions of passive inversion using various ankle joint orthoses have been measured and reported. Passive range of motion reductions were reported for the following orthoses:

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40% for the AirStirrup@orthosis (15); 46% for the ALP orthosis (10); 46% before and 39% after exercise for the AirStirrup, 48% before and 44% after exercise for the ALP orthosis, and 30% before and 8% after exercise for the Swede-O-Universal@ orthosis (12) using an analog ankle stability test instrument; 25% before and 18% after exercise for taping, 12% before and 8% after exercise for the Swede-0 orthosis, and 20% before and 19% after exercise for the AirStirrup orthosis (16) using a Biodex dynamometer system. Reductions were determined for the total inversion/eversion range of motion as 29% before and 27% after exercise for the SportStirrup@orthosis; 27% before and 25% after exercise for the ALP orthosis; 21% before and 16% after exercise for the Swede-O orthosis; and 18% before and 13% after exercise for the Kallassy@orthosis (4) using a Cybex I1 isokinetic dynamometer; 15% before and 15% after exercise for the AircastdD orthosis and 21% before and 23% after exercise for the ALP orthosis using a Biodex dynamometer (14). The corresponding reductions of passive range of motion for inversion of the ankle joint orthosis used in this study were between 45 and 50% for neutral and 20" plantar flexion and compares well with the published data for other ankle stabilizing procedures. Such comparisons, however, should be considered with caution since various techniques for assessing passive range of motion have been applied and passive range of motion definitions were not always identical. In summary, the Malleoloc ankle joint orthosis used in this study restricted ankle joint inversion at least as well as the other orthoses which have been discussed in the literature and maintained the restrictive function after exercise and activity. Furthermore, it restricted the other movements of the foot, specifically plantar flexion/dorsiflexion only minimally.


Effeds on Performance The major purpose of this study was to quantify how an ankle joint orthosis, which restricts foot inversion substantially but does not affect the other foot functions substantially, influences performance. Sports in which an ankle joint orthosis may be used in a preventive function include activities with movements with high changes in speed and direction (as was tested in a figureeight running course) or movements with frequent jumping activities. The results of this study showed that the Malleoloc ankle joint orthosis did not affect the performance variables for the figure eight and the jumping tests.

The results of this study showed that the Malleoloc ankle joint orthosis did not affect the performance variables for the figure eight and the jumping tests.

for the Air-Stirrup orthosis. These results suggest that performance may be affected by the construction of a specific ankle joint orthosis, and further research may reveal the factors which are responsible for such an influence on performance. However, the current knowledge does not allow an answer to this question. The interpretation of results from tests which have been used in the literature, including the methodology applied in this study, for the assessment of the functionality and effectiveness of ankle joint orthoses, concentrating specifically on the assessment of the active and passive range of motion, is rather limited. To the knowledge of the authors, it has not been shown yet that these range of motion tests are a good indicator of functionality and effectiveness. Further development of tests assessing the functionality of ankle joint orthoses during actual movement, which are functionally loading the ankle joint and the orthoses, is needed. Such tests should, however, take into account that the movement of the shoe, the movement of the orthosis, and the movement of the foot are not necessarily identical (25) and should concentrate on the movement of the foot in the shoe.

CONCLUSION The effect of selected ankle joint orthoses on performance-related activities has been tested by other authors. The ALP orthosis was tested with respect to the ability to actively produce an inversion ankle joint moment, and it was shown that it did not affect this moment-producing ability if compared to the situation without any orthosis (11) and vertical jump (10). The ability to "run the bases" was assessed for three different ankle joint orthoses (12). They found no difference between the no orthosis situation for this test and for the ALP and the Swede-0 orthoses. However, they found a reduction of the "run the bases" performance of 7%

The results of this study allow the following conclusions: 1) the Malleoloc ankle joint orthosis which was used in this study substantially restricted the active range of motion and passive inversion. The restriction of inversion is, if compared with results for selected ankle joint orthoses in other studies, rather favorable for the tested ankle joint orthosis; 2) the tested ankle joint orthosis reduced the other movement degrees of freedom only minimally; 3) the restricting effect of the tested ankle joint orthosis was identical before and after exercise; 4) ankle joint orthoses can affect performance negatively. It is not known which construction pa-

rameters are responsible for such a reduction in performance. The Malleoloc ankle joint orthosis did not affect performance in this study; and 5) ankle joint orthoses, therefore, can be constructed to functionally restrict foot inversion without affecting perJOSPT formance negatively.

ACKNOWLEDGMENTS The authors express their sincere appreciation to P. Estabrooks, T.S. Fung, and V. Fisher for their help in data collection and analysis. This project was supported by a grant from Bauerfeind GmbH, Germany.

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