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PubMed2002

Different functional treatment strategies for acute lateral ankle ligament injuries in adults.

BACKGROUND: Acute lateral ankle ligament ruptures are common problems in present health care. Early mobilisation and functional treatment are advocated as a preferable treatment strategy. However, functional treatment comprises a broad spectrum of treatment strategies and as of yet no optimal strategy has been identified. OBJECTIVES: The objective of this review is to assess different functional treatment strategies for acute lateral ankle ligament ruptures in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field. SELECTION CRITERIA: Randomised clinical trials describing skeletally mature individuals with an acute lateral ankle ligament rupture and comparing different functional treatment strategies were evaluated for inclusion. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of included trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences (WMD) for continuous outcome measures with 95 per cent confidence intervals (95%CI). Heterogeneity between trials was tested using a standard chi-squared test. MAIN RESULTS: Nine trials involving 892 participants were included. Lace-up ankle support had significantly better results for persistent swelling at short-term follow up when compared with semi-rigid ankle support (RR 4.19, 95% CI 1.26 to 13.98); elastic bandage (RR 5.48; 95% CI 1.69 to 17.76); and to tape (RR 4.07, 95% CI 1.21 to 13.68). Use of a semi-rigid ankle support resulted in a significantly shorter time to return to work when compared with an elastic bandage (WMD (days) 4.24; 95% CI 2.42 to 6.06); one trial found the use of a semi-rigid ankle support saw a significantly quicker return to sport compared with elastic bandage (RR 9.60; 95% CI 6.34 to 12.86) and another trial found fewer patients reported instability at short-term follow-up when treated with a semi-rigid support than with an elastic bandage (RR 8.00; 95% CI 1.03 to 62.07). Tape treatment resulted in significantly more complications, the majority being skin irritations, when compared with treatment with an elastic bandage (RR 0.11; 95% CI 0.01 to 0.86). No other results showed statistically significant differences. REVIEWER'S CONCLUSIONS: The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

Adult↗
PubMed2006

Effect of isokinetic training on strength, functionality and proprioception in athletes with functional ankle instability.

The purpose of this study was to investigate the effects of isokinetic exercise on strength, joint position sense and functionality in recreational athletes with functional ankle instability (FAI). Strength, proprioception and balance of 24 recreational athletes with unilateral FAI were evaluated by using isokinetic muscle strength measurement, ankle joint position sense and one leg standing test. The functional ability was evaluated using five different tests. These were; single limb hopping course (SLHC), one legged and triple legged hop for distance (OLHD-TLHD), and six and cross six meter hop for time (SMHT-CSMHT). Isokinetic peak torque of the ankle invertor and evertor muscles were assessed eccentrically and concentrically at test speeds of 120 degrees /s. Isokinetic exercise protocol was carried out at an angular velocity of 120 degrees /s. The exercise session was repeated three times a week and lasted after 6 weeks. At baseline, concentric invertor strength was found to be significantly lower in the functionally unstable ankles compared to the opposite healthy ankles (p < 0.001). This difference was not present after executing the 6 weeks exercise sessions (p > 0.05). Ankle joint position sense in the injured ankles declined significantly from 2.35 +/- 1.16 to 1.33 +/- 0.62 degrees for 10 degrees of inversion angle (p < 0.001) and from 3.10 +/- 2.16 to 2.19 +/- 0.98 degrees for 20 degrees of inversion angle (p < 0.05) following the isokinetic exercise. One leg standing test score decreased significantly from 15.17 +/- 8.50 to 11.79 +/- 7.81 in the injured ankles (p < 0.001). Following the isokinetic exercise protocol, all of the worsened functional test scores in the injured ankles as compared to the opposite healthy ankles displayed a significant improvement (p < 0.01 for OLHD and CSMHT, p < 0.001 for SLHC, TLHD, and SMHT). These results substantiate the deficits of strength, proprioception, balance and functionality in recreational athletes with FAI. The isokinetic exercise program used in this study had a positive effect on these parameters.

Adult↗
PubMed2001

The sprained ankle.

The sprained ankle is the most common musculoskeletal injury seen by physicians caring for active youngsters and adults. It accounts for approximately one fourth of all sports-related injuries and is commonly seen in athletes participating in basketball, soccer, or football. It has been shown that one third of West Point cadets suffer an ankle sprain during their 4 years at the military academy. While diagnosis and management of the sprained ankle is usually straightforward, several serious injuries can masquerade as an ankle sprain, and it is important for the clinician to recognize these to prevent long-term morbidity. In this article the basic anatomy of the ankle, mechanisms by which the ankle is injured, and the differential diagnosis of the acutely injured ankle are reviewed. Appropriate evaluation of the injured ankle and the criteria that should be utilized for determining the necessity of radiographs are discussed as well as management of the acutely sprained ankle and the role of prevention in reducing the risk of ankle injury.

Ankle Injuries↗
PubMedDate not supplied

Arthroscopic findings in patients with chronic ankle instability.

BACKGROUND: There are little objective data on structural changes of the chronically unstable ankle. Such knowledge could help with preoperative planning. HYPOTHESIS: Preoperative ankle arthroscopy provides important insights into the causes and mechanisms of ankle instability and the resulting disability. STUDY DESIGN: Case series. METHODS: From 1993 to 1999, arthroscopic examination was performed in the ankles of 148 patients with symptomatic chronic ankle instability that had lasted 6 months or more. All structural changes were recorded and compared with the clinical diagnosis. RESULTS: A rupture or elongation of the anterior talofibular ligament was noted in 86% of ankles, of the calcaneofibular ligament in 64%, and of the deltoid ligament in 40%. Cartilage damage was noted in 66% of ankles with lateral ligament injuries, whereas 98% of the ankles with deltoid ligament injuries had cartilage damage. Although lateral instability could be verified arthroscopically in 127 patients, medial instability was presumed clinically in 38 patients but was actually detected in 54 patients arthroscopically. CONCLUSION: Preoperative ankle arthroscopy revealed an essential amount of information that would otherwise have been undetected. For instance, the ligaments showed typical abnormalities corresponding to different entities of ankle instability and different intraarticular pathologic conditions.

Adolescent↗
PubMedDate not supplied

Comparison of lateral ankle ligamentous reconstruction procedures.

The static restraints of various surgical procedures for chronic lateral ankle instability were compared. Forty cadaveric ankles were divided equally into the following five groups: 1) ankles with intact anterior talofibular and calcaneofibular ligaments, 2) ankles with incised anterior talofibular and calcaneofibular ligaments, 3) ankles with Chrisman-Snook procedure, 4) ankles with Watson-Jones procedure, or 5) ankles with modified Broström procedure. All ankles were placed in a mechanical apparatus for anterior drawer stress and inversion stress tests. After each application of force, a radiograph of the ankle joint was taken, and the anterior talar displacement and the talar tilt angle were measured. All procedures reduced anterior drawer and talar tilt when compared with the ankles with incised anterior talofibular and calcaneofibular ligaments. Significant differences were found among the groups for both inversion and anterior drawer stress at all forces, except for the third and fourth groups. The modified Broström group had the least amount of anterior talar displacement and talar tilt angle at all forces. There were no significant differences between the Watson-Jones and the Chrisman-Snook procedures in anterior talar displacement and talar tilt. The modified Broström procedure produced a greater mechanical restraint than either of the other procedures.

Ankle Joint↗
PubMed2004

Corrective-elongation osteotomy without bone graft for old ankle fracture with residual diastasis.

The main principle for treatment of ankle fractures is anatomic reduction until bony union is achieved. Old fractures of the ankle with residual diastasis, however, may cause persistent pain, joint effusion, and range-of-motion limitation, and make eventual ankle arthrodesis inevitable. Restoration of the integrity of the ankle mortise is the determining factor for successful repair of this type of ankle fracture. Old ankle fracture, where malunion has already occurred, is a great challenge for the orthopedic surgeon. Twelve such patients were treated by means of reconstructive corrective-elongation osteotomy without bone graft at the authors' institution from 1997 to 1999. These patients had persistent symptoms and radiographic evidence of a fibula that had healed in a shortened, rotated position, resulting in widening of the ankle mortise. The average time interval between injury and reconstructive operation was 18 months. At follow-up, which averaged 34 months, greatly improved ambulation and level of joint function was noted for all patients, and follow-up x-ray confirmed good ankle mortise geometry. The short-term results for these patients were good, with further follow-up planned to determine efficacy long term. In conclusion, reconstructive corrective-elongation osteotomy is a worthwhile procedure for old ankle fracture with malunion, and it can also postpone degenerative change in the ankle joint.

Adult↗
PubMed2005

Results of an Internet survey determining the most frequently used ankle scores by AOFAS members.

BACKGROUND: With technological advances in ankle arthroplasty, there has been parallel development in the outcome instruments used to assess the results of surgery. The literature recommends the use of valid, reliable, and responsive ankle scores, but the ankle scores commonly used in clinical practice remain undefined. METHODS: An internet survey of members of the American Orthopaedic Foot and Ankle Society (AOFAS) was conducted to determine which three ankle scores they perceived as most commonly used in the literature, which ones they believe are validated, which ones they prefer, and which they use in practice. RESULTS: According to respondents, the three most commonly used scores were the AOFAS Ankle score, the Foot Function Index (FFI), and the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). The respondents believed that the AOFAS Ankle score, FFI, and MODEMS were validated. The FFI and MODEMS are validated, but the AOFAS ankle score is not validated. CONCLUSIONS: Most respondents preferred using the AOFAS Ankle score. The use of the empirical AOFAS Ankle score continues among AOFAS members.

Ankle↗
PubMed2005

Chronic pain after ankle fracture: an arthroscopic assessment case series.

BACKGROUND: The purpose of this study was to document findings of ankle arthroscopy in patients with residual complaints after an appropriately treated ankle fracture. METHODS: Patients who had ankle arthroscopy at the Alpine Orthosports Clinic between 1998 and 2000 were identified by a retrospective review of the ankle arthroscopy database. Fifty patients were identified who had arthroscopy for complaints after ankle fracture. The mean duration from injury to arthroscopy was 20.5 +/- 33.5 months, with a range of 2 to 184.6 months. RESULTS: There were 37 isolated fractures and 13 combination fractures. The Danis-Weber classification was used for lateral malleolar fractures. There were five type A, 14 type B, and 11 type C lateral malleolar fractures. RESULTS: Synovitis was present in 46 ankles and was located anterolaterally in 36. Synovitis was noted in 26 of the 30 ankles that had a lateral malleolar fracture. Arthrofibrosis was found in 20 ankles, with anterolateral joint involvement in 16. There was chondral damage noted in 45 ankles, 30 located on the talus and 15 on the tibia. Spurs were found in 15 ankles, and nine had loose bodies or debris. There were two postoperative complications: one patient had bleeding from a portal and the other had an area of paresthesia at the anterolateral portal site. CONCLUSION: Synovitis and chondral damage were more frequent than arthrofibrosis and spurs. Synovitis and arthrofibrosis were found most frequently in the anterolateral aspect of the joint. Also, the higher the lateral malleolar fracture was in relation to the syndesmosis, the higher was the occurrence of talar chondral damage.

Adult↗
PubMed1999

Instrumented measurement of anteroposterior and inversion-eversion laxity of the normal ankle joint complex.

Manual examination is the most common method for the evaluation of ankle anteroposterior (AP) and inversion-eversion (I-E) laxity. Objective assessment data of normal ankle laxity must be provided before comparison with an injured ankle can be made. The purpose of this study was to compare AP translation and I-E rotation at three force loads between dominant and nondominant ankles and to assess the test-retest reliability of a portable arthrometer in obtaining these measurements. The arthrometer consists of a frame that is fixed to the foot, a pad that is attached to the tibia, and a load-measuring handle that is attached to the foot plate through which the load is applied. A six-degrees-of-freedom spatial kinematic linkage system is connected between the tibial pad and the foot frame to measure motion. Instrumented measurement testing of total AP displacement and I-E rotation of both ankles was performed in 41 subjects (21 men and 20 women; mean age, 23.8 +/- 4.4 years). Subjects had no history of ankle injury. Subjects were tested in the supine position while lying on a table with the knee secured in extension and the foot positioned at 0 degrees of flexion. Laxity was measured from total AP displacement (millimeters) during loading to 125 N of AP force and from total I-E rotation (degrees of range of motion) during loading to 4000 N-mm. Reliability was evaluated by calculating intraclass correlation coefficients (2,1) at 75 N, 100 N, and 125 N of AP force and at 2000, 3000, and 4000 N-mm torque loads. Mean differences for displacement and rotation between the dominant and nondominant ankles at each of the force and torque loads were analyzed by dependent t-tests. For both the dominant and nondominant ankles, respectively, the reliability coefficients at each of the force loads for AP displacement (range, 0.82-0.89) and I-E rotation (range, 0.86-0.97) were high. The t-test analyses showed no significant differences (P > or = 0.05) for total AP displacement or I-E rotation between the dominant and nondominant ankles at any of the force loads. The results are clinically useful in providing information about the reliability of measures at different AP and I-E force loads using a portable ankle ligament arthrometer.

Adult↗
PubMed2006

Comparison of modified Broström and Evans procedures in simulated lateral ankle injury.

PURPOSE: The purpose of this study was to compare the modified Broström and Evans procedures for simulated lateral ankle instability in cadaveric lower extremities. METHODS: Six normal cadaveric ankles were loaded with inversion and internal rotation stress through the range of ankle flexion, and three-dimensional motion of the calcaneus and talus relative to the tibia were measured. An ankle stability testing device and a magnetic tracking system were used. Testing was performed in the intact condition, unstable condition after sectioning both the anterior talofibular (ATFL) and calcaneofibular ligaments (CFL), after the Gould modification of the Broström procedure, and after the Evans procedure. RESULTS: With inversion loading, both operations resulted in a significantly more stable ankle-hindfoot complex (calcaneal-tibial) than the unstable condition, but there was restricted motion after the Evans operation from neutral to plantarflexion. Tibiotalar inversion motion approximated normal after both operations, but subtalar motion was markedly restricted in the Evans procedure throughout the range of ankle flexion. With internal rotation loading, the Broström operation stabilized the ankle-hindfoot joint complex in plantarflexion. The Evans operation improved internal rotation stability, but restricted motion in all positions. Both operations improved tibiotalar internal rotation stability, but not to normal. The subtalar internal rotation was the same as the intact condition after the Broström operation, but markedly restricted after the Evans operation through the range of ankle flexion. CONCLUSIONS: Both operations improved ankle-hindfoot stability, but neither was successful in restoring it to normal as determined with the ankle stability testing device. The Evans procedure improved stability at the expense of creating abnormal subtalar function. The Broström operation improved stability without excessively restricting subtalar movement, but was not effective in addressing the internal rotation laxity.

Aged↗
PubMed1996

Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains.

If ankle proprioception can be determined to be impaired, then treatment can be more specifically directed toward correcting the proprioceptive deficit, thereby improving functional ability. The purpose of this study was to determine if collegiate level gymnasts with unilateral, multiple ankle sprains (ie., chronic ankle sprains) had decreased ability to detect passive plantar flexion of the ankle (ie., decreased ankle proprioception) and to determine if balance deficits existed during one-legged stance. Eleven gymnasts participated in 30 passive movement trials (15 movement and 15 nonmovement) presented randomly on both the injured and noninjured sides. The nonmovement trials consisted of either no movement of the ankle or passive movement of the ankle into 5 degrees of plantar flexion. Luce's choice theory determined that subjects were not biased in responding to a "yes" in perceiving movement or no movement during the movement/nonmovement trials of passive plantar flexion. Subjects were better able to detect movement during movement trials with their uninjured ankles than their injured ankles. Subjects also performed single 30-second trials of one-legged standing on each leg, with eyes open and with eyes closed. Subjects reported better balance when standing on the uninjured ankle during the one-legged stance conditions. Although our results cannot be extrapolated to balance abilities during complex gymnastic routines, they do suggest that physical therapy assessment includes passive detection of joint position as well as single-legged stance tests, and that perhaps rehabilitation programs incorporate sports-specific balance activities for such injuries.

Adolescent↗
PubMed1999

Balance training for persons with functionally unstable ankles.

STUDY DESIGN: A nonrandomized 2-group pretest-posttest design. OBJECTIVES: To determine the effects of a 4-week balance training program during stance on a single leg. BACKGROUND: Individuals who have experienced multiple episodes of inversion ankle sprains often participate in balance training programs. Balance training is performed to treat existing proprioceptive deficits and to restore ankle joint stability, presumably by retraining altered afferent neuromuscular pathways. The effectiveness of such programs on individuals with functionally unstable ankles has yet to be established. METHODS AND MEASURES: Prior to and following training, subjects with self-reported functionally unstable ankles (5 women and 8 men, mean age = 21.9 +/- 3.1 years) and nonimpaired subjects (6 women and 7 men, mean age = 21.2 +/- 2.5 years) completed a static balance assessment for both limbs as well as the ankle joint functional assessment tool questionnaire (AJFAT). The subjects from both groups participated in a unilateral, multilevel, static and dynamic balance training program 3 times a week for 4 weeks. Subjects from the experimental group trained only the involved limb, and the nonimpaired group trained a randomly selected limb. A stability index (SI) was calculated during the balance assessment to indicate the amount of platform motion. Compared to low stability indices, high stability indices indicate greater platform motion during stance and therefore less stability. RESULTS: Following training, subjects from both groups demonstrated significant improvements in balance ability. When balance was assessed at a low resistance to platform tilt (stability level 2), the posttraining scores of both the subjects with unstable ankles (mean SI = 2.63 +/- 1.92) and the nonimpaired subjects (mean SI = 2.69 +/- 2.32) were significantly better than their pretraining scores (mean SIs = 5.93 +/- 3.65 and 4.67 +/- 3.43, respectively). Assessed at a high resistance to platform tilt (stability level 6), the posttraining scores of both subjects with unstable ankles (mean SI = 1.27 +/- 0.66) and the nonimpaired subjects (mean SI = 1.37 +/- 0.66) were significantly better than their pretraining scores (mean SIs = 2.30 +/- 1.88 and 2.04 +/- 1.43, respectively). Additionally, the posttraining AJFAT scores of subjects with unstable ankles (25.78 +/- 3.80) and the nonimpaired subjects (29.15 +/- 5.27) were significantly greater than their pretraining scores (17.11 +/- 3.44 and 22.92 +/- 5.22, respectively), indicating an overall improvement in perceived ankle joint functional stability. CONCLUSIONS: This study suggests that balance training is an effective means of improving joint proprioception and single-leg standing ability in subjects with unstable and nonimpaired ankles.

Adolescent↗
PubMed1992

[Diagnostic arthroscopy and arthroscopic surgery of the upper ankle joint].

Arthroscopy of the ankle joint was limited to the anterior compartments for a long time. The key to the entire diagnostic and therapeutic arthroscopy procedure on the ankle joint was the distension of the joint space through modern distraction techniques. The distraction devices available make arthroscopic surgery of the ankle joint as effective as in other joints like the knee and shoulder. Distension of the joint space allows visualization of all compartments, including the posterior ankle. In the case of hidden cartilage pathology of the posterior talus, an osteotomy linked with hardware removal through a second operation can be avoided today. The indications for arthroscopy of the ankle are pain, swelling, instability, hemarthrosis and joint locking. Generally, arthroscopy of the ankle joint is performed utilizing three general portals: anterolateral, anteromedial and posterolateral. Arthroscopic standard equipment, including the small joint set, is sufficient to treat the major part of ankle pathology through the standard portals. Arthroscopic ankle joint debridement in degenerative arthritis, removal of osteophytes, elimination of loose bodies and the management of soft tissue and bony impingement are possible. A complete synovectomy can be performed, including the posterior compartments. The treatment of osteochondritis dissecans is facilitated through the transmalleolar approach in combination with the distraction device. Arthroscopic ankle arthrodesis is possible and induces less trauma because an arthrotomy can be avoided. In our opinion diagnostic arthroscopy and arthroscopic surgery of the ankle joint is a procedure of great benefit for the patients if the indications are strictly adherred to.

Ankle Injuries↗
PubMedDate not supplied

Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation.

OBJECTIVE: To assess the 1-year outcome of standard medical care of acute ankle sprains in a general clinic-based population. DESIGN: A self-administered survey was mailed to all adult patients who presented to a health system provider for evaluation of ankle sprain. SETTING: A regional primary care health system. PARTICIPANTS: Four hundred sixty-seven (66.5%) of 702 patients with ankle sprains evaluated by a system physician from April 1, 1995, to March 31, 1996. MAIN OUTCOME MEASURES: Prevalence and severity of self-reported ankle pain, swelling, perceived instability, and perceived weakness 6 to 18 months after medical evaluation. RESULTS: Most patients sought medical evaluation shortly after injury and were immobilized or braced; 32.7% reported formal or home-based physical therapy. Six to 18 months after injury, 72.6% reported residual symptoms. Of these, 40.4% reported at least 1 moderate to severe symptom, most commonly perceived ankle weakness; 40.3% were unable to walk 1 mile; and 43.3% were unable to jump or pivot on the ankle without symptoms. Factors associated with moderate to severe residual symptoms were reinjury of the ankle (odds ratio [OR], 7.21; 95% confidence interval [CI], 4.14-12.68), activity restriction longer than 1 week (OR, 2.04; 95% CI, 1.25-3.32), and limited weight bearing longer than 28 days (OR, 2.16; 95% CI, 1.28-3.63). CONCLUSIONS: Residual lifestyle-limiting symptoms are common 6 to 18 months after an ankle sprain. Ankle sprains may be more problematic than generally thought, or standard medical treatment may be inadequate. Further studies evaluating treatment regimens are needed to identify effective methods to reduce the long-term functional limitations of ankle sprain in general clinic populations.

Acute Disease↗
PubMed2002

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

BACKGROUND: Inversion injuries, primarily sprains, of the ankle are one of the most commonly treated injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and the use of an external support (e.g. ankle brace or taping), and surgical repair or reconstruction. OBJECTIVES: We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute injuries to the lateral ligament complex of the ankle in adults. DATA COLLECTION AND ANALYSIS: At least two, usually three, reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled using fixed and random effects models and relative risks with 95% confidence intervals for dichotomous outcomes calculated. Heterogeneity between trials was tested using a standard chi-squared test. We undertook sensitivity analyses to explore the effects of inclusion of quasi-randomised trials and subgroup analyses by the two main methods of conservative treatment. MAIN RESULTS: Seventeen studies, involving a total of 1950 mostly young active adult males, were included. All trials had methodological flaws. In particular, allocation was rated as effectively concealed in only one trial and there was no report of masking outcome assessors to the interventions in any trial. Outcome measures were variously defined and data for pooling for individual outcomes were only available for a maximum of 11 studies. While there were statistically significant differences for three primary outcomes (non-return to pre-injury level of sports; undefined pain or pain on activity; and subjective or functional instability) in favour of the surgical treatment group using the fixed effects model, these findings failed to demonstrate robustness in sensitivity analyses. Exclusion of the data from explicitly quasi-randomised trials or, given the highly statistically significant heterogeneity, analyses using the random effects model modified these findings to non-statistically significant differences. There was no statistically significant difference in ankle sprain recurrence, the other primary outcome measure. Though there was a statistically significantly higher incidence of objective instability in conservatively treated patients, the functional implications of this are uncertain. There was some evidence for a lower incidence of long-term ankle swelling in surgically treated patients. However, as well as tending to take longer to resume normal activities, including work, there was some limited evidence from a few trials for a higher incidence of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. Subgroup analyses by type of conservative treatment (plaster cast or functional treatment) revealed no statistically significant differences in effect for any of the six outcomes examined. REVIEWER'S CONCLUSIONS: There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. Sufficiently powered, good quality and adequately reported randomised trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

Acute Disease↗
PubMed1995

Biomechanical analysis of the ankle anterior drawer test for anterior talofibular ligament injuries.

The effect of sectioning the anterior talofibular ligament on the load-displacement behavior of the ankle was evaluated in vitro during the anterior drawer test using the flexibility approach. Controlled forces were applied across the ankle joint in the anterior-posterior direction, and the resulting displacements were measured at four flexion angles (10 degrees of dorsiflexion, neutral, and 10 degrees and 20 degrees of plantar flexion). The anterior talofibular ligament then was sectioned, and the anterior-posterior loadings were repeated at the four flexion angles. Two parameters were developed to describe the nonlinear load-displacement response of the ankle joint: neutral zone laxity (joint displacement between +/- 2.5 N) and flexibility (a measure of the nonlinear load-displacement response of the ankle between 10 and 50 N of anterior drawer loading). After sectioning the anterior talofibular ligament, significant increases in neutral zone laxity were observed at all angles of ankle flexion. The largest increases in neutral zone laxity were found with the ankle in 10 degrees of plantar flexion (76.3% increase) and 20 degrees of plantar flexion (89.7% increase). After sectioning the ligament, a significant increase (19.3%) in flexibility of the ankle was observed at 10 degrees of dorsiflexion, but no change in flexibility was observed with the ankle in the neutral and plantar flexed positions. These findings indicate that anterior drawer testing of the anterior talofibular ligament-deficient ankle between 10 degrees and 20 degrees of plantar flexion results in the largest increase in neutral zone laxity compared with the normal ankle with intact ligaments.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2006

Contralateral force sense deficits are related to the presence of functional ankle instability.

Residual symptoms that often follow lateral ankle sprains can lead to functional ankle instability. Proprioceptive deficits have been identified as one factor that may contribute to the presence of functional ankle instability. Sixty participants were recruited to participate in the study. Seven questions were used to determine the presence of functional ankle instability in each participant. A point was added for each "yes" response to produce an index that represents an interval data scale of functional ankle instability. Contralateral force sense and active joint reposition sense were measured in all participants. Pearson product moment correlations were calculated to determine the relationship between functional ankle instability and force sense and active joint reposition sense. We found a significant relationship with force sense and functional ankle instability. Specifically, force sense variable error at both test forces (10 and 30% of maximal voluntary isometric contraction) were positively correlated to the presence of functional ankle instability, r=0.26; p<or=0.05 and r=0.25; p<or=0.05, respectively. All other force sense correlations were not statistically significant. No significant correlations were identified between active joint reposition sense and functional ankle instability. This study indicates that participants with functional ankle instability have deficits in low load force sense, but not active joint reposition sense.

Adolescent↗
PubMed1986

Position dependence of stretch reflex dynamics at the human ankle.

The purpose of this study was to examine the effect of ankle position on the human ankle stretch reflexes during tonically-maintained contractions over most of the range of motion. The ankle was placed at randomly selected mean positions. Target levels of triceps surae (TS) or tibialis anterior (TA) tonic contractions were generated while the ankle was displaced by small amplitude, stochastic perturbations. System identification techniques were used to identify the stretch reflex dynamics at each combination of tonic level and ankle angle. As shown previously, the TS stretch reflex was characterized by an unidirectional, velocity-sensitive impulse response function whereas the TA stretch reflex was characterized by a linear impulse response function between ankle velocity and TA EMG. TS stretch reflexes showed a strong dependence on ankle position while TA stretch reflexes did not. Thus the TS stretch reflex magnitude increased greatly as the ankle was progressively dorsiflexed. In contrast, ankle mean position had only a minor effect on the TA stretch reflex magnitude. Our results indicate that the position-dependent facilitation of the TS stretch reflex is not due to changes in the level of skeletal motoneuron excitability. Rather, this effect may be accounted for by mechanisms that modulate the efficacy of the stochastic ankle perturbation. Such mechanisms could include position-induced: modulation of monosynaptic and polysynaptic afferent inputs to skeletal motoneurons, alterations in the extent of fusimotor drive and changes in the transmission of the joint perturbation to spindle receptors. Such mechanisms are discussed in terms of the differences between TS and TA stretch reflexes. Finally, the functional significance of position-dependent reflex responses are considered.

Adult↗