Rebuilding Stability: Exploring the Best Rehabilitation Methods for Chronic Ankle Instability.

Background: Chronic Ankle Instability (CAI) is a common condition characterized by repeated episodes of ankle "giving way" and impaired balance, leading to functional limitations. Various rehabilitation techniques, including balance training, proprioceptive exercises, whole-body vibration (WBV), and novel approaches like stroboscopic vision, are used to address these deficits. This review evaluates the effectiveness of different rehabilitation interventions for CAI management. Methods: A review was conducted by analyzing 11 randomized controlled trials that investigated the impact of balance and proprioceptive training programs on CAI. The primary outcomes assessed were the Star Excursion Balance Test (SEBT), Cumberland Ankle Instability Tool (CAIT), and Foot and Ankle Ability Measure (FAAM). Methodological quality was assessed using the PEDro scale, and the risk of bias was evaluated with the ROB 2 tool. Results: All rehabilitation interventions demonstrated significant improvements in SEBT, CAIT, and FAAM scores. However, no single intervention was found to be consistently superior. Traditional balance training, strength exercises, BAPS, and WBV all provided meaningful functional gains. Stroboscopic vision training showed similar effectiveness compared to conventional approaches. The evidence supports a combination of balance and strength training for optimal recovery. Conclusions: Balance and proprioceptive exercises are effective in managing CAI, with improvements in both dynamic stability and subjective outcomes. No intervention stands out as the best, but personalized programs incorporating various methods are recommended. Future research should explore the long-term effects and potential synergies of combined interventions.

Impact of chronic ankle instability on gait loading strategy in individuals with chronic ankle instability: a comparative study.

BACKGROUND: Lateral ankle sprains rank among the most prevalent musculoskeletal injuries, while chronic ankle instability (CAI) is its most common cascade. In addition to the conflicting results of the previous studies and their methodological flaws, the specific gait loading strategy is still not well studied. PURPOSE: The study aimed to investigate the fluctuations in gait loading strategy in people with chronic ankle instability compared to health control. METHODS: A total of 56 male subjects participated in this study and were allocated into two groups: (A) CAI group: 28 subjects with unilateral CAI (age 24.79 ± 2.64 and BMI 26.25 ± 3.50); and (B) control group: 28 subjects without a history of ankle sprains (age 24.57 ± 1.17 and BMI 26.46 ± 2.597). Stance time, weight acceptance time, and load distribution were measured to investigate gait loading strategy. RESULTS: The study findings revealed that the CAI group had a significant higher load over the lateral rearfoot. However, MANOVA indicates that there was no overall significant difference in gait loading strategy between the CAI and control groups. Furthermore, in terms of stance time, time of weight acceptance phase, load over medial foot, and load over lateral foot, CAI and healthy controls seemed to walk similarly. CONCLUSIONS: The findings revealed that individuals with CAI had the significant alteration in the lateral rearfoot loading, suggesting a potential compensatory mechanism to address instability during the weight acceptance phase. This could manifest a laterally deviated center of pressure and increased frontal plane inversion during the early stance phase. However, it is acknowledged that these alterations could be both the result and the origin of CAI. The study highlights the vulnerability of CAI during the early stance phase, emphasizing the need for gait reeducation as individuals return to walking as healthcare clinicians should focus on treatment modalities aimed at reducing rearfoot inversion in individuals with CAI.

The impact of fatigue on dynamic balance in coopers athletes with chronic ankle instability.

Athletes who have successfully regained high sports performance despite prior inversion injuries, and who do not have persistent symptoms, are referred to as "copers" in the literature. The aim of the study was to assess dynamic stability under fatigue in patients with chronic ankle instability in comparison to healthy controls. We conducted a case - controlled study on a group of 60 young, physically active individuals aged 29.8 ± 4.6. They were divided into 3 groups: I - unilateral ankle instability n = 14, II - bilateral ankle instability n = 15, III - no ankle instability, n = 31. All participants filled out questionnaires on the health, the FADI and FADI-S. The study protocol consisted of a dynamic stability measurements by Biodex Balance System, followed by a fatigue test, followed by the series of the same measurements. General stability index value before and value after fatigue test did not differ significantly. The differences between groups in measurements taken before fatigue test (F (2.49) = 1.59; p = 0.214; ηp2 = 0.06) and after fatigue test also proved insignificant (F (2.49) = 1.28; p = 0.286; ηp2 = 0.05). The incidence of structural ankle instability did not affect functional stability. "Copers" had efficient neural-muscular control in dynamic stabilography tests.

Chronic ankle instability: a cadaveric anatomical and 3D high-resolution MRI study for surgical reconstruction procedures.

OBJECTIVES: To quantitatively investigate the anatomy of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) for surgical reconstruction procedures in chronic ankle instability (CAI). METHODS: 3D MRI was performed on five fresh-frozen cadaveric ankles using six different spatial resolutions (0.3 × 0.3 × 0.3 mm3, 0.45 × 0.45 × 0.45 mm3, 0.6 × 0.6 × 0.6 mm3, 0.75 × 0.75 × 0.75 mm3, 0.9 × 0.9 × 0.9 mm3, 1.05 × 1.05 × 1.05 mm3). After comparing the MRI results with cadaver dissection, a resolution of 0.45 × 0.45 × 0.45 mm³ was selected for bilateral ankles MRI on 24 volunteers. Classification of the ATFL and four distances of surgically relevant bony landmarkers were analyzed (distance 1 and 3, the fibular origin of the ATFL and CFL to the tip of fibula, respectively; distance 2, the talar insertion of the ATFL to the bare zone of talus; distance 4, the calcaneal insertion of the CFL to the peroneal tubercle). RESULTS: In subjective evaluation, the interobserver ICC was 0.95 (95% confidence interval (CI): 0.94-0.97) between two readers. The spatial resolution of 0.3 × 0.3 × 0.3 mm3 and 0.45 × 0.45 × 0.45 mm3 received highest subjective score on average and demonstrated highest consistency with autopsy measurements in objective evaluation. Measurements on the 48 volunteer ankles, distance 1 in type I and II were 12.65 ± 2.08 mm, 13.43 ± 2.06 mm (superior-banded in Type II) and 7.69 ± 2.56 mm (inferior-banded in Type II) (means ± SD), respectively. Distance 2 in type I and II were 10.90 ± 2.24 mm, 11.07 ± 2.66 mm (superior-banded in Type II), and 18.44 ± 3.28 mm (inferior-banded in Type II), respectively. Distance 3 and 4 were 4.71 ± 1.04 mm and 14.35 ± 2.22 mm, respectively. CONCLUSION: We demonstrated the feasibility of quantifying the distances between bony landmarkers for surgical reconstruction surgery in CAI using high-resolution 3D MRI. CRITICAL RELEVANCE STATEMENT: High-resolution 3D MRI examination may have a guiding effect on the preoperative evaluation of chronic ankle instability patients. KEY POINTS: Spatial resolutions of 0.3 × 0.3 × 0.3 mm3 and 0.45 × 0.45 × 0.45 mm3 demonstrated highest consistency with autopsy measurements. The spatial resolution of 0.45 × 0.45 × 0.45 mm3 was conformed more to clinical needs. 3D MRI can assist surgeons in developing preoperative plans for chronic ankle instability.

Impact of subtalar joint mobilization on walking ability in patients with intra-articular varus of the hindfoot joint with chronic ankle instability.

BACKGROUND: Patients with chronic ankle instability (CAI) often experience recurrent swelling and pain, which hinder their ability to walk long distances. Emerging evidence suggests that joint mobilization can enhance ankle function in patients with CAI. OBJECTIVE: The aim of this study is to investigate the effects of subtalar joint mobilization on enhancing ankle stability, alleviating ankle pain, and improving the walking ability of patients diagnosed with CAI. METHODS: A retrospective analysis was conducted on 46 patients who were treated between April 2022 and October 2023. They were randomly divided into two groups: a treatment group with 23 cases receiving conventional treatment along with subtalar joint mobilization treatment, and a control group with 23 cases receiving only conventional treatment. The treatment duration was eight weeks. Pain levels and walking ability were assessed before and after the treatment period. RESULTS: After eight weeks of treatment, the treatment group showed significant increases in the number of heel raises on the affected leg (NLHSL), improvements in the star excursion balance test (SEBT), and higher American Orthopedic Foot and Ankle Society (AOFAS) scores compared to the control group. Additionally, resting pain (RVAS) and walking pain (WVAS) scores were significantly lower in the treatment group. However, there was no statistically significant difference in single-leg standing time (SLT) between the two groups. Within the control group, post-treatment assessments indicated significant improvements in dynamic balance and control measures (SLT, NLHSL, SEBT), but no significant changes were observed in pain levels (RVAS, WVAS) or rear foot function (AOFAS). In contrast, the treatment group showed significant improvements across all measured parameters (RVAS, WVAS, SLT, NLHSL, SEBT, and AOFAS) following treatment. CONCLUSION: Subtalar joint mobilization effectively reduces ankle pain and enhances walking ability among patients with CAI by improving ankle stability. The observed improvements in walking ability may stem from mitigating compensatory mechanisms associated with varus of the calcaneus and ankle instability.

Epidemiology of ankle sprain and chronic ankle instability in elite adolescent dancesport athletes.

BACKGROUND: Dancesport is performed in high-heeled shoes. Dancesport athletes may have a higher prevalence and incidence of ankle sprains, which can affect their performance. However, the occurrence of ankle sprains among dancesport athletes remains unclear. This study aimed to determine the prevalence and incidence of ankle sprains among elite dancesport athletes and to investigate the related information. METHOD: We conducted a mixed descriptive epidemiological study (cross-sectional and longitudinal) involving 198 elite adolescent dancesport athletes, using past medical records and questionnaires administered to the participants. Data on the occurrence of ankle sprains among all participants were compiled using medical records and information on injury mechanisms, missed days, severity types, and countermeasures for ankle sprains were collected. The prevalence of chronic ankle instability (CAI) among the participants was assessed using a questionnaire. Following the initial survey, we conducted a one-year follow-up study to investigate the incidence of ankle sprains, incidence rate per 1000 exposure hours, and recurrence of ankle sprains. RESULT: The cross-sectional study and longitudinal study included 198 participants and 92 elite dancesport athletes, respectively. The prevalence of ankle sprains and CAI was 49.5% and 45.1%, respectively. Of all ankle sprains, 88% were medial injuries. The most common injury mechanisms were turning (46.9%) and jumping (46.9%). The average number of missed days due to ankle sprains was 11.2 days. Most injuries were managed with rest, and only one male athlete underwent surgery due to an ankle sprain sustained during dancing. During the one-year follow-up, the incidence of ankle sprains, incidence rate per 1000 exposure hours, and recurrence rate of ankle sprains were 46.6% (male, 41.2%; female, 48.8%), 0.65 ankle sprains/1000 h, and 35.3%, respectively. No sex-related differences were observed. CONCLUSION: It is crucial to focus on the occurrence of ankle sprains and CAI in dancesport athletes with high heels. Future research should clarify the impact of ankle sprains on dancesport performance and develop preventive measures to reduce the incidence and recurrence of these associated injuries.

Utilising Xsens Gait Analysis to Improve Functional Outcomes in Chronic Ankle Instability: A Multifaceted Physiotherapy Approach.

Chronic ankle instability (CAI) is a common consequence of lateral ankle sprains, resulting in persistent pain, instability, and functional limitations. This case report investigates the effectiveness of a physiotherapy intervention for a 25-year-old female patient with CAI, marked by recurrent ankle sprains and persistent symptoms despite prior conservative treatments. The patient exhibited swelling, pain, and instability, with clinical assessment revealing significant ligament laxity and a high longitudinal arch in both feet. A comprehensive physiotherapy regimen focused on core, hip, and ankle muscle strength, dynamic balance, and proprioception was implemented, incorporating ankle stretches, joint mobilization, core strengthening, hip strengthening, and dynamic balance exercises on unstable surfaces. Pre-rehabilitation outcome measures included a numeric pain rating of 7/10, a Cumberland ankle instability tool (CAIT) score of 15/30, and a foot and ankle outcome score (FAOS) of 63%. Gait analysis revealed a speed of 0.79 m/s, a cadence of 99.24 steps/min, and a distance of 14.23 meters. Post-intervention, significant improvements were observed: pain reduced to 1/10, the CAIT score increased to 28/30, and the FAOS rose to 89%. Gait parameters also improved, with speed increasing to 0.90 m/s and distance to 15 meters. This case underscores the effectiveness of a targeted physiotherapy approach in managing CAI, highlighting the importance of a multi-dimensional rehabilitation strategy to enhance functional outcomes and reduce associated symptoms of CAI.

Effect of 6-week BFRT combined with IASTAM therapy on international standard dancers with chronic ankle instability.

Background: In sports dance events, athletes often face the risk of ankle injury and instability, which may have a negative impact on their training and athletic performance, and even hinder their rehabilitation process and increase the likelihood of re-injury. Objective: This study aims to observe the effects of exercise intervention (low-load ankle muscle strength training with blood flow restriction training (BFRT) equipment and balance training with blood flow restriction training equipment) combined with instrumentation therapy (Instrument-assisted soft tissue mobilization, IASTM) on ankle function, joint range of motion, and strength in sports dancers with chronic ankle instability (CAI). This study aims to provide an evidence-based approach to rehabilitation for athletes by comparing the effects of combination therapy approaches to traditional ankle strength and stability training. Methods: Forty-two subjects with ankle instability, restriction, or discomfort were selected as observation objects and randomly divided into three groups: the combined group (n = 14, blood flow restriction training combined with IASTM), the simple blood flow restriction training group (n = 15), and the conventional ankle strength and stability training group (n = 13). The intervention lasted for 6 weeks, once a week. The three groups were assessed with the Cumberland ankle instability assessment, Foot and Ankle Ability Measure (FAAM) ankle function assessment score, and ankle range of motion measurement before intervention, after the first intervention, and after 6 weeks of intervention. The ankle strength test was compared and analyzed only before and after intervention. Result: There was no significant difference in the participant characteristics of the three intervention groups. In terms of Cumberland Ankle Instability Tool (CAIT) scores, within-group comparisons showed that the scores after the first intervention and at the 6-week mark were significantly higher than before the intervention (P < 0.05). Between-group comparisons revealed that the combined intervention group had higher CAIT scores than the other two groups after the 6-week intervention. Regarding the FAAM functional scores, all three interventions significantly improved ankle joint function in patients with chronic ankle instability (P < 0.05), with the BFRT group showing significantly higher FAAM - Activities of Daily Living scale (FAAM-ADL) scores than the control group (P < 0.05). Both the combined and BFRT groups also had significantly higher FAAM-SPORT scores after the first intervention compared to the control (P < 0.05). In terms of ankle range of motion improvement, the combined intervention group showed a significant increase in ankle joint motion after the intervention (P < 0.05), particularly in the improvement of dorsiflexion ability (P < 0.05). As for ankle strength enhancement, all three intervention groups experienced an increase in ankle strength after the intervention (P < 0.05), with the combined intervention group showing a significant improvement in both dorsiflexion and inversion strength compared to the control group (P < 0.05). Conclusion: BFRT combined with IASTM, isolated BFRT, and conventional ankle strength and stability training significantly improve stability, functionality, and strength in CAI patients. The combined intervention demonstrates superior efficacy in improving ankle range of motion compared to isolated BFRT and conventional approaches.

Ultrasonography assessments of talar cartilage and ATFL after running in chronically unstable, coper, and healthy ankles: a case-control study.

BACKGROUND: Comparisons of talar cartilage and the anterior talofibular ligament (ATFL) profiles in individuals with different levels of chronic ankle instability (CAI) provide insight into early adaptation of tissue morphology. PURPOSE: This study compared morphologic response and recovery of the talar cartilage and ATFL before and after 30-min of self-paced treadmill running between individuals with CAI, coper (full recovery from a first-time ankle sprain), and healthy controls. METHODS: Sixty young males (24.8 years, 176.9 cm, 75.7 kg) were allocated into the CAI, coper, and healthy control group by their number of ankle sprains and scores on the self-reported ankle instability questionnaires (Cumberland Ankle Instability Tool, and Foot and Ankle Ability Measure-Activities of Daily Living). Ultrasonographic images in the cross-sectional area (CSA; overall, lateral, and medial) and ATFL length (unstressed and stressed and position) before and after treadmill running were recorded and analyzed. RESULTS: There were no group by time interactions in the talar cartilage CSA (F14,399 <1.09, p > .36 for all tests) and ATFL length (F14,399< .69, p > .79 for all tests). Regardless of time, CAIs had the largest overall (F2,399 = 42.68, p < .001), lateral (F2,399 = 37.16, p < .001), and medial (F2,399 = 36.57, p < .001) CSA of talar cartilage and the longest stressed-ATFL length (F2,399 = 54.42, p < .001), followed by copers and healthy controls. CONCLUSION: Morphologic features of the talar cartilage and ATFL appear to depend on the level of ankle instability (e.g. a history of recurrent ankle sprain).

Chronic Pain Influences Lower Extremity Energetics During Landing Cutting in Patients with Chronic Ankle Instability.

CONTEXT: Chronic ankle instability (CAI) patients exhibit altered movement patterns during jump landing/cutting movements. Persistent pain is one of the residual symptoms that may affect movements. Calculating joint energetics affected by chronic pain offers a novel method to understand how chronic pain influences energetics of lower extremity joints in CAI patients. OBJECTIVE: To identify the effects of chronic pain on lower extremity energy dissipation and generation during jump landing and cutting in CAI patients. DESIGN: Cross-sectional Study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Fifteen CAI patients with higher pain (6 males, 9 females; age=22.1±2.1year; height=1.74±0.09m; mass=71.3±10.6kg, pain=66.9±9.4), 15 CAI patients with lower pain (6 males, 9 females; age=22.3±2.1year; height=1.74±0.08m; mass=70.1±10.7kg, pain=89.3±2.6), and 15 healthy controls (6 males, 9 females; age=21.3±1.7year; height=1.73±0.08m; mass=70±10.3kg, pain=100±0). MAIN OUTCOME MEASURES: Ground reaction force data were collected during 5 trials of maximal jump landing/cutting tasks. Joint power was defined as the product of angular velocity and joint moment. Energy dissipation and generation by the ankle, knee, and hip joints were calculated by integrating regions of the joint power curve. RESULTS: CAI patients with higher pain displayed less ankle energy dissipation (p=.013 and p=.018) and generation in the ankle (p=.002 and p=.028) than CAI patients with lower pain and healthy controls during the jump landing/cutting phase. CAI patients with higher pain showed more hip energy generation than CAI patients with lower pain (P=.038) and healthy controls (P=.013) during the cutting phase. CONCLUSIONS: CAI patients with higher pain changed both energy dissipation and generation in the lower extremities, reducing the burden of the ankle joint during jump landing/cutting and having a hip dominant compensatory strategy during the cutting phase. Our results suggest that chronic pain could be one of the factors that affect motor strategies in the CAI population.

Do individuals with ankle instability show altered lower extremity kinematics and kinetics during walking? A systematic review and meta-analysis.

OBJECTIVE: To determine if individuals with chronic ankle instability (CAI) demonstrate altered lower extremity kinematics and kinetics during walking. DATA SOURCES: Relevant studies were sourced from PubMed, Embase, Cochrane Library, Web of Science, EBSCO and PEDro. STUDY SELECTION: Kinematic and kinetic studies involving joint angle and/or joint moment measured in individuals with CAI were included. STUDY APPRAISAL AND SYNTHESIS METHODS: The Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool was used to assess literature quality. Weighted mean differences (WMDs) in joint angles and moments between CAI and controls were analyzed as continuous variables. RESULTS: 1261 articles were screened, with a final selection of 13 studies involving 729 participants. Compared to non-CAI controls, CAI participants showed significantly greater ankle inversion angle (degree) (WMD: 3.71, 95% CI: 3.15 to 4.27, p < 0.001), hip adduction angle (degree) (WMD: 1.60, 95% CI: 0.09 to 3.11, p = 0.04), and knee valgus moment (N m/kg) (WMD: 0.07, 95% CI: 0.01 to 0.13, p = 0.02) during walking. Additionally, there were no consistent findings or specific altered patterns in other lower extremity joint angles, or moment changes, regardless of the motion plane (sagittal, coronal, horizontal), for CAI compared with controls. CONCLUSIONS: This review provides further evidence of altered lower limb kinematics and kinetics in the frontal plane in CAI participants during certain walking phases, which may partially explain the high level of recurrent ankle sprains observed in the CAI population, and support hip abduction and ankle eversion motor control exercises for CAI rehabilitation. SYSTEMATIC REVIEW REGISTRATION NUMBER: Systematic Review Registration Number PROSPERO CRD42023420418. CONTRIBUTION OF THE PAPER.

Exploring low- and high-order functional connectivity in chronic ankle instability through resting-state fMRI.

BACKGROUND: The functional connectivity (FC) has emerged as a valuable tool for comprehending the cerebral operational mechanism. Understanding the FC changes in patients with chronic ankle instability (CAI) helps reveal the underlying central nervous system mechanisms of the disease and provides clues for developing personalized treatment plans. OBJECTIVES: To explore differences between low- and high-order FC in patients with CAI and healthy controls, as well as the correlation among the feature connections and clinical data. METHODS: In our study, we recruited 40 patients with CAI and 42 healthy individuals who had not experienced ankle injuries. All participants underwent clinical assessments of ankle joints, collected the number of ankle sprains within the past 6 months, and performed resting-state functional magnetic resonance imaging (rs-fMRI) scans. Pearson correlation and matrix variate normal distribution (MVND) were used to construct low-order and high-order FC networks, respectively. Feature selections between groups were performed by two-sample t-tests, and a multi-kernel support vector machine (MK-SVM) was subsequently applied to combine the multiple connection patterns for the classification. Using leave-one-out cross-validation (LOOCV) to assess classification performance and identify the consensus connections contributing most to classification. RESULTS: FC was reduced in certain brain regions of CAI patients. More consensus connections were recognized in low-order FC network than in high-order FC network. The highest classification accuracy of 91.30% was achieved by combining three connection patterns. The most discriminating functional connections were primarily centered on the default mode network and spanned the visual network, sensorimotor network, ventral attention network, and central executive network. In addition, FC strength in the left cingulate and paracingulate gyrus (DCG.L) and right superior temporal gyrus (STG.R) was negatively correlated with the number of ankle sprains in the past 6 months in all FC networks (p < 0.05). CONCLUSIONS: Abnormalities in connectivity in patients with CAI were observed in both low- and high-order FC networks. The adaptive changes in the brain related to CAI may extend beyond the sensorimotor networks, primarily involving higher-level default mode networks associated with attention. Moreover, the FC strength between DCG.L and STG.R may predict the risk of ankle re-sprains and help clinicians develop personalized treatment plans.

Myotonometric assessment of peroneus longus muscle mechanical properties during contraction in athletes with and without chronic ankle instability.

Our recent findings in athletes with chronic ankle instability (CAI) revealed increased tone and stiffness alongside reduced elasticity in the peroneus longus (PL) during myotonometric (MYO) measurements at rest, suggesting diagnostic relevance. MYO recordings during muscle contraction in healthy subjects showed an active muscle stiffness influence on MYO parameters, suggesting its potential impact on CAI-related MYO findings. However, it remains unknown whether PL stiffening observed recently in CAI athletes at rest can also be detected while PL muscle contraction. This study, using myotonometry, examines the PL mechanical properties during a motor task mimicking PL's biomechanical function, i.e., simultaneous isometric foot pronation and plantar flexion (IFPPF) at 30 % and 100 % of maximal voluntary contraction (MVC) in athletes with CAI. Nineteen adult male athletes with CAI (per International Ankle Consortium criteria) and 19 control (CO) athletes without lateral ankle sprain incidents comprised the study groups. Both groups had similar anthropometric parameters and training volume. Simultaneous force and MYO measurements were performed at 30 % and 100 % of MVC-IFPPF, using a MyotonPRO® device. Five MYO parameters were recorded in the PL: frequency, stiffness, decrement, relaxation time, and creep. No significant inter-group differences were observed in MYO parameters and force values measured during the 30 % and 100 % of MVC-IFPPF. This study, employing myotonometry, is the first to demonstrate the lack of significant differences between CAI and CO athletes in the MYO parameters measured in the PL muscle at submaximal and maximal contraction during simultaneous IFPPF, contrasting with our previous MYO results in CAI at rest.

Gait Characteristics and Deviation Factors of Backward Walking in Patients With Chronic Ankle Instability.

BACKGROUND: Despite growing applications of backward walking (BW) in assessing and rehabilitating neuromuscular conditions, its effects on gait in chronic ankle instability (CAI) remain unclear. Moreover, linking patient-reported and clinically generated measures is imperative for understanding CAI. HYPOTHESES: Patients with CAI will exhibit worse and compensatory spatio-temporal and kinetic gait parameters during BW, and patient-reported outcomes (PROs) will be correlated significantly with gait parameters. STUDY DESIGN: Case-control study. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 46 volunteers participated (23 per group). Patients filled out scales for pain, functions, and fear-avoidance beliefs before testing. All participants walked 6 times each in both forward and backward conditions, and gait was recorded using the Win-Track system. A 2-way mixed analysis of variance was performed to compare gait parameters. The relationship between PRO and gait outcomes was assessed through the Pearson product correlation coefficient. RESULTS: The CAI group demonstrated prolonged support and swing phases, increased walk-off angle, and plantar pressure area, but decreased step length and plantar pressure versus controls (P < 0.05). The CAI group had a smaller right walk-off angle during BW than FW; the control group showed the opposite (P < 0.05). The left single stance duration was greater in the CAI group, while the right was not (P < 0.05). PRO correlated significantly with gait parameters, particularly spatial parameters (P < 0.05). CONCLUSION: The CAI group exhibited worse gait parameters during BW. The CAI group exhibited a characteristic compensatory gait pattern. Linking the self-reported scores provides a better representation of gait changes in CAI. CLINICAL RELEVANCE: These results suggest that BW may be an effective strategy for identifying and evaluating CAI. It may be feasible to apply BW to the rehabilitation of CAI.

The Effect of Strength and Balance Training on Kinesiophobia, Ankle Instability, Function, and Performance in Elite Adolescent Soccer Players with Functional Ankle Instability: A Prospective Cluster Randomized Controlled Trial.

We aimed to implement strength and balance training for elite adolescent male soccer players with functional ankle instability (FAI) to assess kinesiophobia, ankle instability, ankle function, and performance. This cluster randomized controlled trial comprised 51 elite adolescent male soccer players with FAI recruited from six different teams, divided into strength, balance, and control groups (SG, n = 17; BG, n = 17; and CG, n = 17, respectively). The SG and BG underwent strength and balance training sessions three times per week for 6 weeks. Primary outcomes were the Tampa scale for kinesiophobia-17 (TSK) and Cumberland ankle instability tool (CAIT) scores to assess kinesiophobia and FAI, respectively. Secondary outcomes were ankle strength (four directions), dynamic balance, static balance (ellipse, displacement, velocity), and performance (figure 8 and side-hop tests). A significant interaction effect was observed for both TSK and CAIT post-intervention (both, P < 0.01). In post hoc analyses, the BG had significantly better outcomes in reducing TSK. The SG and BG showed greater improvements in CAIT scores. Regression analysis indicated that CAIT severity correlated significantly with TSK (P = 0.039, R = 0.289). For secondary outcomes, the SG and BG were superior in terms of ankle dorsiflexion/inversion strength, static balance displacement, and figure-8 and side-hop tests (all, P < 0.05). The BG showed significantly better static balance ellipse results (P < 0.05). The 6-week intervention significantly enhanced kinesiophobia management, ankle stability, and performance. Balance training effectively mitigated kinesiophobia and improved balance, compared with strength training alone. Even small variations in CAIT severity can influence kinesiophobia, highlighting the potential benefits of balance training. Integrating balance training into training programs can address both physical and psychological aspects of ankle instability. Research is recommended to explore the longitudinal effects of these interventions and their potential to prevent injury recurrence.

Comparison of Subjective and Biomechanical Outcomes Between Proprioceptive Training and Modified Broström-Gould Surgery for Chronic Ankle Instability: A Randomized Controlled Trial.

Background: Both proprioceptive training and modified Broström-Gould surgery can improve ankle stability in patients with chronic ankle instability (CAI), but further biomechanical evaluation is necessary to determine the optimal treatment. Purpose: To compare the clinical outcomes and biomechanical changes after proprioceptive training versus modified Broström-Gould surgery in patients with CAI. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 56 patients with CAI were assigned randomly to either a nonoperative group (n = 28) who underwent 3 months of proprioceptive training or an operative group (n = 28) who underwent modified Broström-Gould surgery. Foot and Ankle Ability Measure (FAAM) scores, foot pressure during walking, center of pressure (COP) velocity, and time for the COP to reach the balance boundary (time to boundary [TTB]) during single-leg standing were collected before the intervention (baseline) and at 3, 6, and 12 months after the intervention. Two-way repeated-measures analysis of variance was used to compare group differences and changes over time. Results: The nonoperative group had significant improvements from baseline in FAAM-Sports score and significantly decreased TTB in both the anterior-posterior and medial-lateral directions at all timepoints, while the operative group showed significant improvements only in FAAM-Sports scores and TTB and COP velocity in the anterior-posterior direction at 6 and 12 months postintervention. During walking, the nonoperative group had significantly increased peak force under the medial foot at 3 months, which dropped back to baseline levels at 12 months, while the operative group had significantly increased peak force under the medial midfoot and hindfoot that persisted until 12 months (P < .05). Conclusion: In this study, both proprioceptive training and modified Broström-Gould surgery led to improved subjective functional scores, foot pressure distribution during walking, and postural stability during standing for patients with CAI but with different biomechanical patterns. Proprioceptive training led to an earlier recovery of sports function and better medial-lateral stability recovery, while surgery provided more persistent results. Registration: ChiCTR1900023999 (Chinese Clinical Trial Registry).

Uphill Treadmill Running and Joint Mobilization Improve Dynamic Stability and Ankle Dorsiflexion Range of Motion in Young Adults With Chronic Ankle Instability: A Four-Arm Randomized Controlled Trial.

OBJECTIVE: To observe the effect of uphill running and the combined effect of uphill running plus joint mobilizations on dynamic stability and ankle dorsiflexion in young adults with chronic ankle instability (CAI). DESIGN: Four-arm randomized controlled trial. SETTING: A college rehabilitation center. PARTICIPANTS: Individuals with CAI (N=73). INTERVENTIONS: Participants were randomly assigned to 4 groups: combined uphill running and joint mobilization (URJM), uphill running alone (UR), joint mobilization alone (JM), and control group. The URJM and UR groups received 20-minute running sessions, and the URJM and JM groups received ankle joint mobilizations, all 3 times a week for 4 weeks. MAIN OUTCOME MEASURES: Cumberland Ankle Instability Tool (CAIT) and Y-balance test (YBT) in anterior, posteromedial (PM), and posterolateral (PL) directions for dynamic stability; weight-bearing lunge test and non-weight-bearing ankle dorsiflexion degree using a goniometer (NWBG) for dorsiflexion. RESULTS: The UR group showed significant improvements in CAIT, YBT-PL, YBT-PM, and NWBG compared to the control group. The URJM group demonstrated large treatment effects in NWBG compared to both UR and JM groups. Responder analysis indicated that the UR, JM, and URJM groups had a higher likelihood of achieving clinically significant changes (exceeding minimal detectable change or minimal clinically important difference) in CAIT, YBT-PM, YBT-PL, and NWBG compared with the control group. Additionally, the combination of UR and JM was superior to either intervention alone for NWBG, with success rates 1.55 times greater than UR alone and 2.08 times greater than JM alone. CONCLUSIONS: A 4-week UR program improves the subjective feeling of instability, dynamic postural control, and ankle dorsiflexion in young adults with CAI. Compared to UR or JM alone, their combined application can better improve the non-weight-bearing ankle dorsiflexion range of motion.

Lateral ligament reconstruction and additive medial ligament reconstruction in chronic ankle instability: a retrospective study.

Background: Ligamentous lesions of the ankle joint are common. Isolated medial ligament injuries are rare but are often associated with lateral ligament injuries, isolated medial ligament lesions are often overlooked. The present study aimed to evaluate the clinical and functional differences in the outcomes of isolated lateral and combined medial and lateral ligament reconstruction. The study is based on patient-reported outcome measurements and motion sensor technology to assess these outcomes. Objective: The purpose of this study was to compare the clinical and functional outcomes of isolated lateral and combined lateral and medial ankle ligament reconstruction. Methods: From December 2014 to August 2018, 111 patients underwent either isolated lateral ligament (LG) or medial and lateral ligament (MLG) reconstruction. Of the 104 patients meeting the inclusion criteria, 49 had LG and 55 had MLG reconstruction. Outcome measures included the Short Form-36 Health Survey SF-36, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAMG), Tegner Activity Scale, the European Foot and Ankle Society (EFAS), American Orthopaedic Foot and Ancle Society (AOFAS) hindfoot score, and the Karlsson Peterson Score. Mobility and stability were assessed using the Ortheligent™ motion sensor for both healthy and treated ankles. Results: While there were no significant differences in outcome scores between the groups, overall scores improved after treatment (p >0.00). Notably LG showed improved movement, with better dorsal extension measured by the Sensor (p ÷ 0.02). The sensor's results correlated significantly with FAOS subscales for pain (p ÷0.05), stiffness (p ÷ 0.01), ADL (p ÷0.02), and sports (p >0.00). Conclusion: Postoperative results, regardless of LG or MLG, showed significant subjective well-being improvement. LG's advantages were highlighted by a significant improvement in dorsal extension, supported by correlated results from a portable motion sensor assessing ankle stability.

A new patient-reported outcome measure for the evaluation of ankle instability: description of the development process and validation protocol.

BACKGROUND: Acute ankle sprains represent one of the most common traumatic injuries to the musculoskeletal system. Many individuals with these injuries experience unresolved symptoms such as instability and recurrent sprains, leading to chronic ankle instability (CAI), which affects their ability to maintain an active lifestyle. While rehabilitation programs focusing on sensorimotor, neuromuscular, strength and balance training are primary treatments, some patients require surgery when rehabilitation fails. A critical analysis of the patient-reported outcome tools (PROs) used to assess CAI surgical outcomes raises some concerns about their measurement properties in CAI patients, which may ultimately affect the quality of evidence supporting current surgical practice. The aim of this research is to develop and validate a new PRO for the assessment of ankle instability and CAI treatment outcomes, following recent methodological guidelines, with the implicit aim of contributing to the generation of scientifically meaningful evidence for clinical practice in patients with ankle instability. METHODS: Following the COnsensus-based Standards for the selection of Health Measurement Instruments (COSMIN), an Ankle Instability Treatment Index (AITI) will be developed and validated. The process begins with qualitative research based on face‒to‒face interviews with CAI individuals to explore the subjective experience of living with ankle instability. The data from the interviews will be coded following an inductive approach and used to develop the AITI content. The preliminary version of the scale will be refined through an additional round of face‒to‒face interviews with a new set of CAI subjects to define the AITI content coverage, relevance and clarity. Once content validity has been examined, the AITI will be subjected to quantitative analysis of different measurement properties: construct validity, reliability and responsiveness. DISCUSSION: The development of AITI aims to address the limitations of existing instruments for evaluating surgical outcomes in patients with CAI. By incorporating patient input and adhering to contemporary standards for validity and reliability, this tool seeks to provide a reliable and meaningful assessment of treatment effects. TRIAL REGISTRATION: Not applicable.

Does chronic ankle instability patients lead to changes in biomechanical parameters associated with anterior cruciate ligament injury during landing? A systematic review and meta-analysis.

Objective: This study aimed to determine if patients with chronic ankle instability (CAI) exhibit biomechanical changes associated with the increased risk of anterior cruciate ligament (ACL) injury during landing tasks. Study Design: This study was conducted through systematic review and meta-analysis. Data Sources: Searches were conducted in May 2024 across five electronic databases, including Web of Science, Scopus, PubMed, SPORTDiscus, and Cochrane Library. Eligibility Criteria: Studies were included if they (1) involved subjects with CAI and healthy controls and (2) assessed biomechanical variables such as ground reaction forces, joint angles, and joint torques. Results: Of the 675 identified studies, 171 were included in the review, and 13 were eligible for meta-analysis. The reviewed studies clearly defined research objectives, study populations, consistent participant recruitment, and exposures, and they used valid and reliable measures for outcomes. However, areas such as sample size calculation, study sample justification, blinding in assessments, and addressing confounders were not robust. This meta-analysis involved 542 participants (healthy group: n = 251; CAI group: n = 291). Compared with healthy individuals, patients with CAI exhibited a greater peak vertical ground reaction force (peak VGRF; SMD = 0.30, 95% CI: 0.07-0.53, p = 0.009), reduced hip flexion angles (SMD = -0.30, 95% CI: -0.51 to -0.17, p < 0.0001), increased trunk lateral flexion (SMD = 0.47, 95% CI: 0.05 to 0.9, p = 0.03), greater hip extension moments (SMD = 0.47, 95% CI: 0.09-0.84, p = 0.02), and increased knee extension moments (SMD = 0.39, 95% CI: 0.02-0.77, p = 0.04). Conclusion: During landing tasks, patients with CAI demonstrate increased hip extension moments and knee extension moments, decreased hip flexion angles, increased peak VGRF, and increased trunk lateral flexion angles. These biomechanical variables are associated with an elevated risk of ACL injuries.Systematic Review Registration: Identifier CRD42024529349.