Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System.

BACKGROUND: Whereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System. METHODS: This was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed. RESULTS: Of 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs. CONCLUSION: Fractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity. LEVEL OF EVIDENCE: 3b.

Foot impairments contribute to functional limitation in individuals with ankle sprain and chronic ankle instability.

PURPOSE: To investigate the clinical measures of foot posture and morphology, multisegmented joint motion and play, strength, and dynamic balance in recreationally active young adults with and without a history of a lateral ankle sprain (LAS), copers, and chronic ankle instability (CAI). METHODS: Eighty recreationally active individuals (healthy: n = 22, coper: n = 21, LAS: n = 17, CAI: n = 20) were included. Foot posture index (FPI), morphologic measures, joint motion (weight-bearing dorsiflexion (WBDF), rearfoot dorsiflexion, plantar flexion, inversion, eversion; forefoot inversion, eversion; hallux flexion, extension), joint play (proximal and distal tibiofibular; talocrural and subtalar, forefoot; 1st tarsometatarsal and metatarsophalangeal), strength (dorsiflexion, plantar flexion, inversion, eversion, hallux flexion, lesser toe flexion), and Star Excursion Balance Test (SEBT) (anterior, posteromedial, posterolateral) were assessed. RESULTS: There were no group differences in FPI or morphological measures. LAS and CAI groups had decreased ankle dorsiflexion (p = 0.001) and greater frontal plane motion (p < 0.001), first MT plantar flexion, and sagittal excursion (p < 0.001); increased talocrural glide (p = 0.02) and internal rotation (p < 0.001) and decreased forefoot inversion joint play (p < 0.001); and decreased strength in all measures (p < 0.001) except dorsiflexion compared to healthy controls. The LAS group also demonstrated decreased distal tibiofibular (p = 0.04) and forefoot general laxity (p = 0.05) and SEBT performance (anterior: p = 0.02; posteromedial: p < 0.001; posterolateral: p < 0.001). CONCLUSION: Individuals with LAS or CAI have increased pain, impaired physiologic and accessory joint motion, ligamentous tenderness, and strength in the foot and ankle. Clinicians should assess the multiple segments of the ankle-foot complex when caring for individuals with an LAS or CAI. LEVEL OF EVIDENCE: II.

Mortarmen's Knee: Adult-Onset Tibial Tubercle Exostoses in 2 Infantrymen.

Two 20-year-old male patients presented together to a multidisciplinary primary care sports medicine clinic with reports of focal swelling and pain at the left anterior knee just distal to the patella. Both patients enlisted together, chose the same occupational specialty, and trained together, resulting in similar exposure to training loads. Following examination, radiographic imaging was ordered for both patients. Radiographs of both patients revealed exostosis and fragmentation, with multiple ossicles of the tibial tubercle. J Orthop Sports Phys Ther 2018;48(6):510. doi:10.2519/jospt.2018.8005.

Surface electromyography and plantar pressure during walking in young adults with chronic ankle instability.

PURPOSE: Lateral ankle sprains are common and can manifest into chronic ankle instability (CAI) resulting in altered gait mechanics that may lead to subsequent ankle sprains. Our purpose was to simultaneously analyse muscle activation patterns and plantar pressure distribution during walking in young adults with and without CAI. METHODS: Seventeen CAI and 17 healthy subjects walked on a treadmill at 4.8 km/h. Plantar pressure measures (pressure-time integral, peak pressure, time to peak pressure, contact area, contact time) of the entire foot and nine specific foot regions and medial-lateral location of centre of pressure (COP) were measured. Surface electromyography (EMG) root mean square (RMS) amplitudes throughout the entire stride cycle and area under RMS curve for 100 ms pre-initial contact (IC) and 200 ms post-IC for anterior tibialis, peroneus longus, medial gastrocnemius, and gluteus medius were collected. RESULTS: The CAI group demonstrated a more lateral COP throughout the stance phase (P < 0.001 and Cohen's d > 0.9 for all 10 comparisons) and significantly increased peak pressure (P = 0.025) and pressure-time integral (P = 0.049) under the lateral forefoot. The CAI group had lower anterior tibialis RMS areas (P < 0.001) and significantly higher peroneus longus, medial gastrocnemius, and gluteus medius RMS areas during 100 ms pre-IC (P < 0.003). The CAI group had higher gluteus medius sEMG amplitudes during the final 50 % of stance and first 25% of swing (P < 0.05). CONCLUSIONS: The CAI group had large lateral deviations of their COP location throughout the entire stance phase and increased gluteus medius muscle activation amplitude during late stance through early swing phase. LEVEL OF EVIDENCE: III.

Gait disorder is the cardinal sign of normal pressure hydrocephalus: a case study.

Normal pressure hydrocephalus (NPH) is one of the few reversible causes of dementia in older adults and accounts for approximately 6% of all dementias. The cardinal sign of NPH is a hypokinetic gait disorder in which the older adult's feet look as though they are glued to the floor. The gait also has been described as magnetic. People with NPH also may have mild dementia and bladder and bowel incontinence. A 78-year-old man exhibited symptoms of NPH for at least 4 years before being diagnosed. A neurological assessment of the patient revealed gait, posture, and balance abnormalities; mild dementia; and urinary urgency, frequency, nocturia, and incontinence at least once a day. His risk factors for NPH included diabetes and hypertension. A computed tomography (CT) scan revealed dilated lateral ventricles in the brain. A lumbar puncture was used to remove 50 ml of cerebrospinal fluid, which resulted in a transient improvement in his gait for approximately 18 hours. A ventriculoperitoneal shunt was then inserted in the patient, and during a 1-year period his symptoms gradually improved. He recovered without any complications and was eventually able to resume his usual activities. When the gait associated with NPH is observed in an older adult, he or she should be referred to a neurologist or multidisciplinary team for a comprehensive evaluation. If an individual receives treatment for NPH, he or she may have an improved quality of life and the opportunity to reduce functional limitations and disability. Families may also experience positive outcomes, such as having a loved one who is cognitively improved and requires less care.