Balance Control Deficits are Associated With Diminished Ankle Force Sense, Not Position Sense, in Athletes with Chronic Ankle Instability.

OBJECTIVES: To compare balance control and ankle proprioception between athletes with and without chronic ankle instability (CAI). A further objective was to explore the relationship between balance control performance and ankle proprioception in athletes with CAI. DESIGN: Cross-sectional study. SETTINGS: Sports Rehabilitation Laboratory. PARTICIPANTS: Eighty-eight recreational athletes (47 CAI and 41 healthy control) were recruited. INTERVENTIONS: No applicable. MAIN OUTCOME MEASURES: Balance control performance was assessed using the sway velocity of the center of the pressure during the one-leg standing tasks. Ankle proprioception, including joint position sense and force sense, were tested using absolute error (AE) associated with joint position reproduction and force reproduction tasks in 4 directions, that is, plantarflexion, dorsiflexion, inversion, and eversion. RESULTS: Athletes with CAI performed significantly worse than those without CAI in balance control tasks. In addition, CAI athletes showed significantly worse joint position sense and force sense in all 3 movement directions tested (plantarflexion, inversion, and eversion). Correlation analysis showed that the AE of the plantarflexion force sense was significantly moderately correlated with medial-lateral sway velocity in the one-leg standing with eyes open and closed conditions (r=.372-.403, P=.006-.012), and the AE of inversion force sense was significantly moderately correlated with medial-lateral sway velocity in the one-leg standing with eyes open (r=.345, P=.018) in athletes with CAI, but the joint position sense measures were not (all P>0.05). CONCLUSIONS: Athletes with CAI showed significantly impaired balance control performance and diminished ankle proprioception. Deficit in force sense was deemed as a moderate predictor of one-leg standing balance control deficits in athletes with dominant-side injury CAI, whereas ankle position sense may be a small predictor.

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.

Effects of Kinesio taping on lower limb biomechanical characteristics during unexpected jumping in patients with chronic ankle instability.

PURPOSE: The current biomechanical research on the application of Kinesio taping (KT) to patients with chronic ankle instability (CAI) has focused on testing the expected movements. However, unexpected movements are more common in actual sports. Therefore, the present study aimed to investigate the effects of KT on the biomechanical characteristics of the knee and ankle joints during unexpected jumping movements. METHODS: Twenty-one patients with unilateral CAI were recruited to capture the biomechanical parameters during unexpected jumping movements under different interventions: no taping (NT), placebo taping (PT), and KT. A one-way repeated measures analysis of variance was used to compare the differences in knee and ankle biomechanical characteristics among patients with CAI between the three intervention conditions. RESULTS: At initial contact, the KT group demonstrated a significant decrease in ankle plantarflexion and knee flexion angles compared to the NT group (p < 0.05). At the early landing phase, the KT group had a significant increase in peak ankle dorsiflexion angle, peak ankle eversion angle, peak ankle dorsiflexion moment, and peak ankle eversion moment compared to the NT and PT groups (p < 0.05). Furthermore, the KT group had a significantly reduced peak knee flexion angle, peak knee eversion angle, and peak vertical ground reaction force (p < 0.05) compared to the NT and PT groups. CONCLUSION: KT significantly improves the sprain-prone touchdown posture of patients with CAI. And reducing the risk of ankle sprains during the early landing phase by promoting ankle dorsiflexion and eversion angles and moments.

Individuals with chronic ankle instability show altered regional activation of the peroneus longus muscle during ankle eversion.

Individuals with chronic ankle instability (CAI) present muscular weakness and potential changes in the activation of the peroneus longus muscle, which likely explains the high recurrence of ankle sprains in this population. However, there is conflicting evidence regarding the role of the peroneus longus activity in CAI, possibly due to the limited spatial resolution of the surface electromyography (sEMG) methods (i.e., bipolar sEMG). Recent studies employing high-density sEMG (HD-sEMG) have shown that the peroneus longus presents differences in regional activation, however, it is unknown whether this regional activation is maintained under pathological conditions such as CAI. This study aimed to compare the myoelectric activity, using HD-sEMG, of each peroneus longus compartment (anterior and posterior) between individuals with and without CAI. Eighteen healthy individuals (No-CAI group) and 18 individuals with CAI were recruited. In both groups, the center of mass (COM) and the sEMG amplitude at each compartment were recorded during ankle eversion at different force levels. For the posterior compartment, the sEMG amplitude of CAI group was significantly lower than the No-CAI group (mean difference = 5.6% RMS; 95% CI = 3.4-7.6; p = 0.0001). In addition, it was observed a significant main effect for group (F1,32 = 9.608; p = 0.0040) with an anterior displacement of COM for the CAI group. These findings suggest that CAI alters the regional distribution of muscle activity of the peroneus longus during ankle eversion. In practice, altered regional activation may impact strengthening programs, prevention, and rehabilitation of CAI.

Meta-analysis of the dosage of balance training on ankle function and dynamic balance ability in patients with chronic ankle instability.

OBJECTIVE: To explore and compare the dosage of balance training on ankle function and dynamic balance ability in patients with chronic ankle instability (CAI). METHODS: The PubMed, Embase, Web of Science, Medline, and Cochrane databases were searched up to December 2023. Quality assessment was carried out using the risk-of-bias guidelines of the Cochrane Collaboration, and the standardized mean differences (SMD) or mean differences (MD) for each outcome were compute. RESULTS: Among 20 eligible studies, including 682 participants were analyzed in this meta-analysis. The results of the meta-analysis demonstrated that balance training was effective in enhancing ankle function with self-functional scores (SMD = 1.02; 95% CI, 0.61 to 1.43; p < 0.00001; I2 = 72%) and variables associated with the ability of dynamic balance such as SEBT-A (MD = 5.88; 95% CI, 3.37 to 8.40; p < 0.00001; I2 = 84%), SEBT-PM (MD = 5.47; 95% CI, 3.40 to 7.54; p < 0.00001; I2 = 61%), and SEBT-PL (MD = 6.04; 95% CI, 3.30 to 8.79; p < 0.0001; I2 = 79%) of CAI patients. Meta-regression indicated that the intervention time might be the principal cause of heterogeneity (p = 0.046) in self-functional scores. In subgroup analyses of self-functional score across intervention types, among the intervention time, more than 20 min and less than 30 min had the most favorable effect (MD = 1.21, 95% CI: 0.96 to 1.46, p < 0.00001, I2 = 55%); among the intervention period, 4 weeks (MD = 0.84, 95% CI: 0.50 to 1.19, p < 0.00001, I2 = 78%) and 6 weeks (MD = 1.21, 95% CI: 0.91 to 1.51, p < 0.00001, I2 = 71%) had significant effects; among the intervention frequency, 3 times (MD = 1.14, 95% CI: 0.89 to 1.38), p < 0.00001, I2 = 57%) had significant effects. Secondly, in subgroup analyses of SEBT across intervention types, a 4-week and 6-week intervention with balance training 3 times a week for 20-30 min is the optimal combination of interventions to improve SEBT (dynamic balance) in patients with chronic ankle instability. CONCLUSION: Balance training proves beneficial for ankle function in patients with CAI. Intervention time constitutes a major factor influencing self-function in patients with CAI. It is recommended that the optimal dosage of balance training for CAI involves intervention three times a week, lasting for 20 to 30 min over a period of 4 to 6 weeks for superior rehabilitation.

Clinical outcomes of arthroscopic all-inside anterior talofibular ligament suture augmentation repair versus modified suture augmentation repair for chronic ankle instability patients.

BACKGROUND: To compare the clinical efficacies of arthroscopic anterior talofibular ligament suture augmentation repair and modified suture augmentation repair in patients with chronic ankle instability (CAI). METHODS: From October 2019 to August 2020, 100 patients with CAI were enrolled after propensity score matching analysis and observed for two years. Among them, 50 underwent modified suture augmentation repair and the other 50 underwent suture augmentation repair. The clinical efficacies of CAI treatments were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) clinical rating scale, visual analog scale (VAS), and anterior drawer test scores. RESULTS: The postoperative AOFAS score of the modified suture augmentation repair group (83.8 ± 11.3) was significantly higher than that of the suture augmentation repair group (76.3 ± 11.3; P = 0.001). The VAS (P = 0.863) and anterior drawer test (P = 0.617) scores were not significantly different between the two treatment groups. CONCLUSION: Both the modified suture augmentation repair and suture augmentation repair demonstrated good clinical efficacies. The AOFAS score of the modified suture augmentation repair group was superior to that of the conventional suture augmentation repair group. Thus, modified suture augmentation repair is a feasible and practical surgical technique for CAI treatment.

A quantitative assessment of the anterior tibiofibular gap with and without weight-bearing in healthy adults: An ultrasound-based study.

BACKGROUND: Difficulties in the accurate evaluation of tibiofibular clear space in plain radiographs are diagnostic problems in the clinical setting of syndesmosis injury. This study aimed to quantify the anterior tibiofibular gap (ATFG) with weight-bearing using ultrasonography. METHODS: In total, 32 healthy adults (16 men and 16 women) with 64 feet participated in this cross-sectional study. The ATFG was measured along the anterior inferior tibiofibular ligament for a US assessment conducted in both sitting and standing postures. The ankle joint was set on the tilt table at four different angles as follows: plantar flexion, 20° (P20); neutral position (N); dorsiflexion, 20° (D20); and dorsiflexion, 20°+ external rotation, 30° (D20ER30). The ankle joint position, sex, and side-to-side values were compared with and without weight-bearing. RESULTS: Under all ankle angle conditions, the ATFG was wider in the standing posture than in the sitting posture (p < 0.001). In both sitting and standing postures, the ATFG widened with increasing dorsiflexion angle, eventually reaching a maximum at D20ER30. The widening ratio (D20ER30/N) in the standing posture was higher in women than in men (p < 0.05). No statistical differences were identified side-to-side differences in the ATFG. CONCLUSIONS: Ultrasound measurements for identifying unphysiological increases in ATFG with weight bearing, especially given the side-to-side differences, may provide a means for quantitatively assessing syndesmosis injury in a clinical setting. Further research is warranted to clarify direct attribution as a clinical diagnostic utility of the ATFG measurements for syndesmosis injuries.

Effects of Rehabilitative Exercise and Neuromuscular Electrical Stimulation on Muscle Morphology and Dynamic Balance in Individuals with Chronic Ankle Instability.

Background and Objectives: Muscle atrophy caused by chronic ankle instability (CAI) can incur muscle weakness, altered movement patterns, and increased risk of injury. Previous studies have investigated the effects of rehabilitative exercises and neuromuscular electrical stimulation (NMES) on characteristics in CAI individuals, but few studies have examined their effects on foot and ankle muscle morphology. This study aimed to determine the effects of rehabilitative exercises and NMES on muscle morphology and dynamic balance in individuals with CAI. Materials and Methods: Participants with CAI (n = 47) were randomly divided into control (CG), rehabilitative exercise (REG), NMES (NG), and rehabilitative exercise and NMES combined (RNG) groups. The six-week intervention program consisting of rehabilitative exercises and NMES was applied to groups excluding CG. Muscle morphology and dynamic balance were evaluated using a portable wireless diagnostic ultrasound device and dynamic balance tests. For statistical analysis, an effect size with 95% confidence interval was calculated to assess mean differences according to intervention. Results: After six weeks, significant increases in morphology and dynamic balance were observed for all muscles except flexor hallucis longus (p > 0.05) in the intervention groups except for CG. However, no significant changes were observed in the CG (p > 0.05). Conclusions: These findings suggest that intervention programs may help prevent muscle atrophy and improve balance in CAI individuals.

Enhancing Post-Surgical Rehabilitation Outcomes in Patients with Chronic Ankle Instability: Impact of Subtalar Joint Axis Balance Exercises Following Arthroscopic Modified Broström Operation.

Background and Objectives: This study aimed to evaluate the effects of subtalar joint axis-based balance exercises on the anterior talofibular ligament (ATFL) thickness, ankle strength, and ankle stability after an arthroscopic modified Broström operation (AMBO) for chronic ankle instability (CAI). Materials and Methods: The study included 47 patients diagnosed with CAI who underwent AMBO and were randomly divided into three groups: control (n = 11), general balance exercise (n = 17), and subtalar joint axis balance exercise (n = 19), regardless of the affected area. Participants in the exercise rehabilitation group performed exercises for 60 min twice a week for six weeks, starting six weeks after AMBO. ATFL thickness, ankle strength, and ankle dynamic stability were measured using musculoskeletal ultrasonography, Biodex, and Y-balance test, respectively, before and after treatment. Results: Compared with the remaining groups, the subtalar joint axis balance exercise group had reduced ATFL thickness (p = 0.000), improved ankle strength for eversion (p = 0.000) and inversion (p = 0.000), and enhanced ankle stability (p = 0.000). Conclusions: The study results suggest that subtalar joint axis-based balance exercises may contribute to the early recovery of the ankle joint after AMBO.

Treatment and prevention of chronic ankle instability: An umbrella review of meta-analyses.

BACKGROUND: Chronic ankle instability (CAI) is a common and highly disabling condition. Although several studies have evaluated and analyzed prevention and treatment strategies for CAI, an unbiased and systematic synthesis of evidence is required to provide the most powerful and comprehensive evidence-based measures for the its prevention and treatment of CAI. This study aimed to synthesize evidence from the existing literature addressing the treatment and prevention of CAI. METHODS: The PubMed, Embase, Cochrane, and Web of Science databases were systematically searched for relevant studies from inception to December 12, 2023. Data on effect sizes and corresponding 95 % confidence intervals for selected intervention measures were extracted. Systematic reviews were assessed for quality of included studies using a measurement tool (i.e., "AMSTAR 2"). RESULTS: In total, 37 studies were included, among which 21 (57 %) were of high or moderate quality. Strong evidence suggested that lower weight (P < 0.001), lower body mass index (P = 0.002), and non-stability defects (P = 0.04) significantly reduced the risk of developing CAI. Strong evidence supported exercise and moderate evidence supported manual therapy, acupuncture, and surgery for improving CAI. Additionally, external support plays an active role in the treatment process of CAI. CONCLUSION: This is the first study synthesizing evidence supporting interventions for the treatment and prevention of CAI. Low body weight and body mass index were effective preventive measures against CAI. Exercise, manual therapy, acupuncture, and surgery can improve ankle function in patients with CAI. Plantar sensory treatment and neuromuscular training may be good therapeutic options for patients with CAI. LEVEL OF EVIDENCE: Level I.

The morphology of osseous structure in subtalar joint with chronic ankle instability.

BACKGROUND: Osseous structures have been demonstrated as risk factors for chronic ankle instability (CAI). Previously, the researchers only focused on the osseous structures of ankle, but ignored the osseous structures of subtalar joint(STJ). Accordingly, the aim of our study was to investigate the morphological characteristics of STJ osseous structures in CAI. METHODS: 52 patients with CAI and 52 sex- and age- matched control subjects were enrolled from The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. The lateral radiographs of ankle in weight-bearing were used to compare the diversity of the two groups. Specifically, The Length of calcaneus, Calcaneal facet height and Absolute foot height, Böhler's angle, Gissane's angle, Calcaneal inclination angle, Talocalcaneal angle, Tibiotalar angle, Tibiocalcaneal angle, Talar-horizontal angle, talar declination angle, facet inclination angle were gauged in the two groups. RESULTS: The Böhler's angle, Calcaneal inclination, Talocalcaneal angle, Tibiotalar angle, Talar-horizontal angle, Talar declination angle, Facet inclination angle and Absolute foot height of CAI group were significantly higher than normal control group (P < 0.05). There were no significant differences in Gissane's angle, Tibiocalcaneal angle, Length of calcaneus and Calcaneal facet height between patients with CAI and normal controls (P > 0.05). CONCLUSIONS: The osseous structures of STJ in CAI patients are different from normal people in morphology. Therefore, we should pay more attention to the changes of STJ anatomical parameters in the diagnosis and prevention of CAI. LEVEL OF EVIDENCE: Ⅲ.

MRI evaluation of ATFL and CFL ligamentization after anatomical surgical reconstruction with a hamstring graft.

BACKGROUND: Chronic ankle instability is frequent complication following ankle sprains. Anatomical reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) with a gracilis autograft is a validated reconstruction technique. The signal-to-noise quotient ankle (SNQA) score evaluates graft maturation with MRI and has been shown to be reproducible and reliable. The goal of this study was to evaluate the process of ligamentization of the anatomical reconstruction of the ankle using the SNQA. The hypothesis was that the SNQA signal of the ATFL and the CFL would decrease over time. METHODS: A prospective cohort of patients who underwent arthroscopic anatomical ATFL-CFL reconstruction was included. All patients underwent a follow-up MRI examination 3, 6. and 12 months after surgery and the SNQA score was determined. RESULTS: Twenty consecutive patients were included. The SNQA score decreased significantly over time for the ATFL (p = 0.001), the CFL (p < 0.001) and for the fibular bone tunnel-graft interface (p = 0.02). The SNQA scores of the ATFL were significantly higher than those of the CFL at 3 months (p = 0.01), 6 months (p = 0.003) and 12 months (p < 0.001), and then those of the fibular tunnel-graft interface at 12 months (p = 0.003). There was no difference in the SNQA score between the CFL and in the fibular graft-bone tunnel interface at any of the follow up periods. CONCLUSION: There is a process of graft maturation following anatomical ATFL and CFL reconstruction over time, which is faster for the CFL than for the ATFL during the first year. LEVEL OF EVIDENCE: II.

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.

Biomechanical Effects of Chronic Ankle Instability on the Talar Cartilage Matrix: The Value of T1ρ Relaxation Mapping Without and With Mechanical Loading.

BACKGROUND: T1ρ mapping has been proposed for the detection of early cartilage degeneration associated with chronic ankle instability (CAI). However, there are limited data surrounding the influence of ankle loading on T1ρ relaxation. PURPOSE: To evaluate T1ρ relaxation times of talar cartilage, as an indicator of early degenerative changes, associated with CAI and to investigate the influence of acute axial in situ loading on T1ρ values in CAI patients and healthy controls. STUDY TYPE: Prospective. SUBJECTS: A total of 9 patients (age = 21.8 ± 2.5 years, male/female = 2/7) with chronic ankle instability and 18 healthy control subjects (age = 22.8 ± 3.6 years, male/female = 5/13). FIELD STRENGTH: 3 T. SEQUENCE: 3D gradient echo fast low-angle shot (FLASH) sequence augmented with a variable spin-lock preparation period. ASSESSMENT: Ankle T1ρ mapping was performed without and with axial loading of 500 N. The talar cartilage was segmented in five coronal slices covering the central talocrural joint. Median talar T1ρ values were separately calculated for the medial and lateral facets. STATISTICAL TESTS: Mann-Whitney U and Wilcoxon signed-rank tests, significance level: P < 0.05. RESULTS: For the combined cohorts, the statistical analysis yielded significantly lower T1ρ values with loading compared to the no-load measurement for both the lateral (no load: [51.0 ± 4.0] msec, load: [49.5 ± 5.4] msec) as well as the medial compartment (no load: [50.0 ± 5.4] msec, load: [47.8 ± 6.8] msec). In the unloaded scans, the CAI patients showed significantly increased talar T1ρ values ([53.0 ± 7.4] mse ) compared to the healthy control subjects ([48.8 ± 4.1] msec) in the medial compartment. DATA CONCLUSION: Increased talar T1ρ relaxation times in CAI patients compared to healthy controls suggest that T1ρ relaxation is a sensitive biomarker for CAI-induced early-stage cartilage degeneration. However, the load-induced T1ρ change did not prove to be a viable marker for the altered biomechanical properties of the hyaline talar cartilage. LEVEL OF EVIDENCE: 2 LEVEL OF EFFICACY: Stage 2.

The role of sural nerve reflexes during drop-landing in subjects with and without chronic ankle instability.

The purpose of this study was to investigate the functional role of cutaneous reflexes during a single-leg drop-landing task among healthy, neurologically intact adults, and to identify whether individuals with chronic ankle instability (CAI) demonstrate altered reflexes and subsequent ankle kinematics. All subjects were physically active adults and were categorized as control (n = 10, Male = 6, Female = 4) or CAI (n = 9, Male = 4, Female = 5) depending on whether they scored a 0 or ≥ 11 on the Identification of Functional Ankle Instability questionnaire, respectively. Subjects performed 30-40 single-leg drop-landing trials from a platform set to the height of their tibial tuberosity. Muscle activity of four lower leg muscles was collected via surface electromyography, while ankle kinematics were recorded via an electrogoniometer. Non-noxious stimulations were elicited randomly to the ipsilateral sural nerve at two unique phases of the drop-landing task (takeoff and landing). Unstimulated and stimulated trials were used to calculate middle latency reflex amplitudes (80-120 ms) and net ankle kinematics (140-220 ms) post-stimulation. Mixed-factor ANOVAs were used to identify significant reflexes within groups and differences in reflex amplitudes between groups. Unlike the CAI group, the control group experienced significant facilitation of the Peroneus Longus (PL) and inhibition of the Lateral Gastrocnemius (LG) when stimulated at takeoff, resulting in eversion immediately prior to landing. When stimulated at landing, the control group experienced significantly more inhibition of the PL compared to the CAI group (p = 0.019). These results suggest lower neural excitability for individuals with CAI, which may predispose them to recurrent injury during similar functional tasks.

Systematic review of the methodological quality of patient-reported outcome measure for patients with chronic ankle instability.

OBJETIVE: Chronic ankle instability is generally associated with ankle sprain. Its consequences can be measured by means of patient-reported outcome measures (PROMs). The aim of this review is to identify the PROMs specifically available for chronic ankle instability and to evaluate their methodological quality and that of the cross-cultural adaptations made. DATA SOURCES: Papers were retrieved from PubMed, Embase, Scopus and Google Scholar databases, with no time limit applied, based on the following inclusion criteria: (1) type of participants: patients with chronic ankle instability, over 18 years of age; (2)type of study: those specifically focused on this pathology, using PROMs specific to chronic ankle instability and published in English; (3) type of outcome: measurement properties based on COSMIN criteria in patient-reported outcomes associated with chronic ankle instability. METHODS: This systematic review, following the COSMIN checklist, was conducted to determine the methodological quality of PROMs specific to foot and ankle pathologies, for patients presenting chronic ankle instability. RESULTS: Of the 576 studies identified in the initial search, 34 were included in the final analysis of measurement properties. Four - the Ankle Instability Instrument, the Chronic Ankle Instability Scale, the Cumberland Ankle Instability Tool and the Identification of Functional Ankle Instability - were original questionnaires, and the remaining 30 were cross-cultural adaptations. CONCLUSION: The Cumberland Ankle Instability Tool and the Identification of Functional Ankle Instability questionnaires can be useful instruments for evaluating chronic ankle instability, both in patients with this condition and also in non-pathological patients.

Effects of dual-task training on chronic ankle instability: a systematic review and meta-analysis.

BACKGROUND: Dual-task training has been a popular intervention for individuals with balance impairments. However, the effects of dual-task training on chronic ankle instability (CAI) have not been comprehensively analyzed and reliable clinical evidence is scarce. The purpose of this systematic review and meta-analysis is to evaluate the effectiveness of dual-task training on postural stability and functional ability in individuals with CAI. METHODS: PubMed, Web of Science, EBSCO, Cochrane Library, Physiotherapy Evidence Database (PEDro), and China National Knowledge Infrastructure (CNKI) were researched from inception to November 2022. This study was conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers assessed the studies for inclusion and extracted data. The Cochrane Risk of Bias list was used to assess the risk of bias in included studies. Mean differences (MD) with a 95% confidence interval (CI) were calculated with the RevMan 5.3 software. RESULTS: A total of 7 randomized controlled trials with 192 CAI met the inclusion criteria. The meta-analysis results showed that compared with the control group, dual-task training significantly improved the Y-balance test (MD = 1.60, 95% CI: -0.00 to 3.21, P = 0.050) and reduced COP-area (MD = - 0.94, 95% CI: -1.62 to - 0.26, P = 0.007) in individuals with CAI. However, there is no significant difference between dual-task training and the control group on COP-velocity (MD = - 0.26, 95% CI: -0.70 to 0.17, P = 0.240), hop test (MD = - 0.20, 95% CI: -0.66 to 0.26, P = 0.386) and BESS (MD = - 1.24, 95% CI: -2.95 to 0.48, P = 0.157) in individuals with CAI. CONCLUSION: This meta-analysis showed that dual-task training may be effective in improving static and dynamic postural stability. However, more high-quality randomized controlled trials are needed to verify the short and long-term effectiveness of dual-task training on CAI.

Balance training benefits chronic ankle instability with generalized joint hypermobility: a prospective cohort study.

BACKGROUND: Balance training is the first choice of treatment for chronic ankle instability (CAI). However, there is a lack of research on the effects of balance training in CAI with generalized joint hypermobility (GJH). This study is to compare the outcomes of balance training in CAI patients with and without GJH. METHODS: Forty CAI patients were assigned into the GJH group (Beighton ≥ 4, 20) and non-GJH group (Beighton < 4, 20) and they received same 3-month supervised balance training. Repeated measure ANOVA and independent t test were used to analyze self-reported questionnaires (Foot and ankle ability measure, FAAM), the number of patients experiencing ankle sprain, isokinetic muscle strength and postural control tests (Star excursion balance test, SEBT and Balance errors system, BES) before training, post-training immediately, and post-training 3 months, respectively. RESULTS: At baseline, no differences were found between groups with except for GJH group having poorer SEBT in the posteromedial direction (83.6 ± 10.1 vs 92.8 ± 12.3, %) and in the posterolateral direction (84.7 ± 11.7 vs 95.7 ± 8.7, %). Following the balance training, GJH group demonstrated lower re-sprain ratio (immediately after training, 11.1% vs 23.5%, 3 month after training, 16.7% vs 29.4%) than non-GJH group, as well as greater FAAM-S score, plantarflexion strength and dorsiflexion strength at post-training immediately and 3 months, and both groups improved similarly in the FAAM-A score, muscle strength and balance control (SEBT in the posterior-lateral and posterior-medial directions, and BES scores) compared with baseline. CONCLUSIONS: CAI patients with GJH gained equally even better postural stability and muscle strength after the balance training than the non-GJH patients. Balance training could still be an effective treatment for CAI patients with GJH before considering surgery. TRIAL REGISTRATION: ChiCTR1900023999, June 21st, 2019.

Evaluation of chronic ankle instability and subtalar instability using the angle between the anterior talofibular ligament and calcaneofibular ligament.

PURPOSE: A series of studies have reported a change in the length or thickness of the anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments in patients with chronic ankle instability. However, no study has examined the changes in the angle between the ATFL and CFL in patients diagnosed with chronic ankle instability. Therefore, this study analyzed the change in the angle between the ATFL and CFL in patients diagnosed with chronic ankle instability to confirm its relevance. METHODS: This retrospective study included 60 patients who had undergone surgery for chronic ankle instability. Stress radiographs comprising the anterior drawer test, varus stress test, Broden's view stress test, and magnetic resonance imaging (MRI) were performed in all patients. The angle between the ATFL and CFL was measured by indicating the vector at the attachment site, as seen on the sagittal plane. Three groups were classified according to the angle between the two ligaments measured by MRI: group I when the angle was > 90°, Group II when the angle was 71-90°, and Group III when the angle was ≤ 70°. The accompanying injuries to the subtalar joint ligament were analyzed via MRI. RESULTS: A comparison of the angles between the ATFL and CFL measured on MRI in Group I, Group II, and Group III with the angles measured in the operating room revealed a significant correlation. Broden's view stress test revealed a statistically significant difference among the three groups (p < 0.05). The accompanying subtalar joint ligament injuries differed significantly among the three groups (p < 0.05). CONCLUSION: The ATFL-CFL angle in patients with ankle instability is smaller than the average angle in ordinary people. Therefore, the ATFL-CFL angle might be a reliable and representative measurement tool to assess chronic ankle instability, and subtalar joint instability should be considered if the ATFL-CFL angle is 70° or less. LEVEL OF EVIDENCE: Level III.

Arthroscopic Broström-Gould repair has comparable radiological and clinical outcomes compared to traditional open Broström-Gould repair in high-demand patients.

PURPOSE: This study sought to confirm whether traditional open Broström-Gould repair and arthroscopic Broström-Gould repair for chronic ankle instability (CAI) would produce comparable radiological and clinical outcomes in high-demand patients. METHODS: This retrospective case-cohort study included high-demand patients, as determined by a pre-injury Tegner Activity Level ≥ 6, who underwent Broström-Gould repair and were followed up for ≥ 2 years. Patients were divided into the arthroscopic Broström-Gould repair group (AS Group) and the open Broström-Gould repair group (Open Group). Perioperative radiological assessments were performed. The Tegner Activity Levels, Foot and Ankle Outcome Scores (FAOSs), Karlsson and Peterson (K-P) scores, and American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores were evaluated clinically. RESULTS: A total of 65 patients (31 from the AS Group and 34 from the Open Group) were included in the study. There were no differences in age, sex, body mass index, preoperative anterior talar translation, talar tilt, signal-to-noise ratio, FAOS, K-P score, or AOFAS score between the two groups (n.s.). The preinjury median Tegner Activity Level was 7 and unchanged at the final follow-up in both groups. Postoperative stress radiographs showed improvement; however, the groups did not differ significantly. The FAOS, K-P scores, and AOFAS scores improved in each group (P < 0.001). However, the clinical scores did not differ between the groups (all n.s.). CONCLUSIONS: Traditional open and arthroscopic Broström-Gould repair for CAI in high-demand patients had comparable radiological and clinical outcomes. Clinically, arthroscopic Broström-Gould repair may represent a viable surgical alternative to open Broström-Gould repair in high-demand patients. LEVEL OF EVIDENCE: Level III.