Ankle Sprain and Chronic Lateral Ankle Instability: Optimizing Conservative Treatment.

The management protocol for each case of ankle sprain should be individualized and optimized in order to reduce the likelihood of development of chronic instability. Initial treatment aims to address pain, swelling, and inflammation and facilitates regaining pain-free joint motion. Short-term joint immobilization is indicated in severe cases. Subsequently, muscle strengthening, balance training, and targeted activities to develop proprioception are added. Gradually, sports-related activities are added with the ultimate goal of bringing the individual back to preinjury level of activity. This protocol of conservative treatment should always be offered before considering any surgical intervention.

Chronic Lateral Ankle Instability: Can We Get Even Better with Surgical Treatment?

Lateral ligament attenuation may occur after repetitive ankle sprains, creating instability. Management of chronic ankle instability requires a comprehensive approach to mechanical and functional instability. Surgical treatment, however, is indicated when conservative treatment is not effective. Ankle ligament reconstruction is the most common surgical procedure to resolve mechanical instability. Anatomic open Broström-Gould reconstruction is the gold standard for repairing affected lateral ligaments and returning athletes to sports. Arthroscopy may also be beneficial for identifying associated injuries. In severe and long-standing instability, reconstruction with tendon augmentation could be necessary.

Multidirectional Chronic Ankle Instability: What Is It?

Not all ankle sprains are the same and not all ankles behave the same way after an injury. Although we do not know the mechanisms behind an injury producing an unstable joint, we do know ankle sprains are highly underestimated. While some of the presumed lateral ligament lesions might eventually heal and produce minor symptoms, a substantial number of patients will not have the same outcome. The presence of associated injuries, such as additional medial chronic ankle instability, chronic syndesmotic instability, has been long discussed as a possible reason behind this. To explain multidirectional chronic ankle instability, this article aims to present the literature surrounding the condition and its importance nowadays.

Sprain of the Medial Ankle Ligament Complex.

Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.

Can Weight-Bearing Computed Tomography Be a Game-Changer in the Assessment of Ankle Sprain and Ankle Instability?

Ankle sprain and chronic lateral ankle instability are complex conditions and challenging to treat. Cone beam weight-bearing computed tomography is an innovative imaging modality that has gained popularity, with a body of literature reporting reduced radiation exposure and operating time, and shortened examination time and a decreased time interval between injury and diagnosis. In this article, we make clearer the advantages of this technology and encourage researchers to investigate the area, and clinicians to use it as a primary mode of investigation. We also present clinical cases provided by the authors to illustrate those possibilities using advanced imaging tools.

Association between brachial-ankle pulse wave velocity and microvascular complications in type 2 diabetes mellitus.

PURPOSE/AIM: To investigate the relationship between brachial-ankle pulse wave velocity (baPWV) and microvascular complications in type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS: From 2019 to 2021, our hospital enrolled 322 patients with T2DM. Clinical information and biochemical indicators of patients were collected from the inpatient electronic medical record system and analyzed retrospectively. Fundus photography, nerve conduction testing, and sensory threshold measurement were all conducted on the subjects. We measured the pulse wave velocity on both sides of the arm and ankle, then averaged the results. The enrolled cases were divided into two groups based on the baPWV: Group 1 (

Platelet-rich plasma injection for the treatment of ankle osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: Platelet-rich plasma (PRP) injection for ankle osteoarthritis (OA) treatment showed contradictory results. This review was aimed to pool individual studies which assessed the efficacy of PRP for ankle OA treatment. METHODS: This study was conducted following the preferred report items of systematic review and meta-analysis guideline. PubMed and Scopus were searched up to January 2023. Meta-analysis, or individual randomised controlled trial (RCT), or observational studies were included if they involved ankle OA with aged ≥ 18 years, compared before-after receiving PRP, or PRP with other treatments, and reported visual analog scale (VAS) or functional outcomes. Selection of eligible studies and data extraction were independently performed by two authors. Heterogeneity test using Cochrane Q test and the I2-statistic were assessed. Standardised (SMD) or unstandardised mean difference (USMD) and 95% confidence interval (CI) were estimated and pooled across studies. RESULTS: Three studies from meta-analysis and two individual studies were included, which consisted of one RCT and four before-after studies with 184 ankle OAs and 132 PRP. The average age was 50.8-59.3 years, and 25-60% of PRP injected cases were male. The number of primary ankle OA was accounted to 0-100%. When compared to before treatment, PRP significantly reduced VAS and functional score at 12 weeks with pooled USMD of - 2.80, 95% CI - 3.91, - 2.68; p < 0.001 (Q = 82.91, p < 0.001; I2 96.38%), and pooled SMD of 1.73, 95% CI 1.37, 2.09; p < 0.001 (Q = 4.87, p = 0.18; I2 38.44%), respectively. CONCLUSION: PRP may beneficially improve pain and functional scores for ankle OA in a short-term period. Its magnitude of improvement seems to be similar to placebo effects from the previous RCT. A large-scale RCT with proper whole blood and PRP preparation processes is required to prove treatment effects. Trial registration PROSPERO number CRD42022297503.

[A papula on the ankle after traveling the tropics: a case report of furuncular myiasis]. / Een papel op de enkel na een bezoek aan de tropen.

This case report concerns a 29-year-old patient presenting with an erythematous papula on his ankle after recent travels to Colombia. After applying fucidin ointment, prescribed by his general practitioner, a larva wound its way to the surface. We morphologically identified the parasite as the larva of Dermatobia hominis (human botfly).

Effects of Ankle-Foot Orthosis on Balance of Foot Drop Patients.

Ankle-Foot Orthoses (AFOs) are common non-surgical treatments used to support foot and ankle joint when their normal functioning is compromised. AFOs have relevant impact on gait biomechanics, while scientific literature about effects on static balance is less strong and confusing. This study aims to assess the effectiveness of a plastic semi-rigid AFO in improving static balance on foot drop patients. Results underline that no significant effects on static balance is obtained on the study population when the AFO is used on the impaired foot.

Determining key clinical predictors for chronic ankle instability and return to sports with cost of illness analysis: protocol of a prospective cohort study.

INTRODUCTION: Ankle sprains are common in sports and the general population. Although considered innocuous, a large proportion has residual complaints such as recurrent ankle sprains and develop chronic ankle instability. Although some predicting factors are identified, there is no unequivocality regarding the development of chronic ankle instability, nor about the optimal rehabilitation for an acute ankle sprain. Alongside the biomechanical impairments, ankle sprains are a burden on society due to substantial economic costs. Therefore, we aim to identify key clinical predictors of chronic ankle instability or recovery after acute lateral ankle sprain. Additionally, we aim to determine cost-of-illness of patients who developed chronic ankle instability. METHODS AND ANALYSIS: This prospective cohort study (Clinicaltrials.gov: NCT05637008 - pre-results) aims to recruit adult (18-55 years) patients with an acute lateral ankle sprain who are active in sports. Clinical assessments and patient-reported outcome measures will be used to collect data at 7-14 days, 6 weeks, 12 weeks and 12 months after enrolment in the study. The primary outcome will be chronic ankle instability at 12-month follow-up. Salient outcomes will be analysed by logistic regression to determine association with the development of chronic ankle instability. Participants will fill in a cost diary containing direct and indirect costs related to their injury. ETHICS AND DISSEMINATIONS: The ethical committee of the Antwerp University Hospital (B3002022000138) has given approval of the protocol and consent forms on 10 October 2022. We perform this study according to the Helsinki Declaration. We will present results at conferences or webinars and publish in peer-reviewed articles.NCT05637008.

Development and validation of a questionnaire to measure the severity of pain, functional limitations, and reduction of sports ability for german-speaking patients with osteochondral lesions of the ankle (OCLA-G).

BACKGROUND: There is no patient-reported functional scale specific for osteochondral lesion of the ankle (OCLA). Therefore, the objectives of this study were to develop a questionnaire that measures symptom severity, function, and sports capacity in patients with osteochondral lesions of the ankle and to determine the psychometric properties of the tool in German language (OCLA-G). METHODS: The OCLA-G questionnaire was developed according to the COSMIN guidelines. Scalable items were generated from a literature search, based on an evaluation of 71 own OCLA patients, and from expert opinions. Following a twofold item reduction the questionnaire underwent explorative data analysis and principal component analysis. Validity and reliability were analysed in four groups of participants (40 patients with OCLA, 40 patients with other foot and ankle injuries, 40 asymptomatic athletes serving as a population at risk, and 40 asymptomatic persons playing sports not at risk). The minimum age for participation in the study was set at 18 years. The mean age was 39.3 ± 15.1 years. RESULTS: The final OCLA-G questionnaire consists of eight and five questions to mirror activities of daily life (ADL) and sports, respectively. Excellent internal consistency (Cronbach's α = 0.950 for the ADL subscore and 0.965 for the sport subscale, respectively) was found. Spearman's rank correlation coefficients for test-retest reliability were 0.992 for the ADL subscore and 0.999 for the sport subscale (p < 0.001). The results of the exploratory and confirmatory factor analyses indicated that item difficulty was between 23.4 and 62.8. The Pearson correlation for the OCLA subscales ADL and sport was 0.853 (p < 0.001). Construct validity as tested against the SF-12 questionnaire subscales (Physical and Mental component scale) were r = -0.164 to -0.663 (p < 0.05). Statistically, there was no ADL and sport OCLA mean score difference between OCLA patients and patients with other foot and ankle injuries (p = 0.993 and 0.179, respectively), but both groups differed from the uninjured control groups (p < 0.001). There were no ceiling or floor effects. CONCLUSIONS: The OCLA-G was successfully developed as the first patient reported and injury specific outcome scale to measure the impact of OCLA induced symptoms on activities of daily living and sport. This study provides evidence for the reliability and validity of the OCLA-G assessing patients with OCLA. TRIAL REGISTRATION: The registration trial number is DRKS00009401 on DRKS. 'Retrospectively registered'. Date of registration: 10/12/2015.

Chronic Ankle Instability and Associated Self-Reported Function in South African Professional Ballet Dancers.

INTRODUCTION: Ankle sprains are the most common acute injury among dancers and may result in the development of chronic ankle instability (CAI). Chronic ankle instability is characterized by recurrent ankle sprains, incidents of the ankle "giving way," and sensations of instability and has been reported to negatively impact functioning and psychosocial status. The large number of ankle sprains in addition to contextual factors relating to professional dancing, suggests that CAI may be a significant problem in professional ballet dancers. This study aimed to determine the prevalence of CAI and describe the ankle injury history and level of self-reported function in South African ballet dancers. METHODS: This descriptive, cross-sectional study included all professional ballet dancers employed by three professional South African ballet companies (n = 65). The Identification of Functional Ankle Instability Questionnaire (IdFAI), Foot and Ankle Ability Measure (FAAM), Dance Functional Outcome Survey (DFOS), and a researcher-developed injury history questionnaire were completed by consenting participants. Descriptive statistics were calculated. RESULTS: A CAI prevalence of 73.3% CI [55.6%, 85.8%] was calculated among 30 participants. Twenty-five (83.3%) participants reported sustaining at least one significant ankle sprain with 88% (n = 22) indicating dance related activities as the cause. Dancers with CAI demonstrated a tendency to have less control over their ankles giving way and tended to take longer to recover from their ankles giving way than those dancers not affected. Eight participants (36.4%) with CAI were identified as having a significant level of disability on the FAAM activities of daily living (ADL) subscale and six participants (27.3%) on the sport subscale. Participants with CAI had a median total score of 83.5; IQR [80 - 90] on the DFOS. CONCLUSION: The self-reported function of South African professional ballet dancers is not severely affected, however, the high prevalence of CAI and reported symptoms is concerning. Education on CAI symptoms, prevention, and evidence-based management is recommended.

A study on atypical Kashin-Beck disease: an endemic ankle arthritis.

BACKGROUND: To study the epidemiological characteristics of atypical Kashin-Beck disease cases without characteristic hand lesions such as interphalangeal joint enlargement and brachydactyly and the characteristics of ankle joint lesions. METHODS: We investigated Kashin-Beck in the endemic villages in Heilongjiang Province. The patients were judged according to the "Diagnosis of Kashin-Beck Disease" (WS/T 207-2010). The severity of foot lesions was judged based on the changes of X-ray images. Residents of non-Kashin-Beck disease area were selected as normal controls in Jilin Province. RESULTS: A total of 119 residents over 40 years old were surveyed in a natural village in the non-endemic area. A total of 1190 residents over 40 years old were surveyed in 38 endemic areas of Kashin-Beck disease. A total of 710 patients with Kashin-Beck disease were detected, including 245 patients with grade I, 175 patients with grade II, 25 patients with grade III, and 265 atypical patients. Among all investigated patients, 92.0% (653/710) had ankle joint changes, and it was 80.0% (196/245) in grade I patients and 95.4% (167/175) in grade II. Varying degrees of ankle joint changes were found in both grade III and atypical patients. The grade of Kashin-Beck disease was correlated with the degree of ankle joint change (P < 0.001), and the correlation coefficient rs = 0.376. Atypical Kashin-Beck disease patients in mild and severe endemic area of Kashin-Beck disease were younger than those with typical Kashin-Beck disease. CONCLUSIONS: We found a correlation between the degree of ankle joint change and the grade of Kashin-Beck disease. The higher the grade of Kashin-Beck disease, the more serious the change of the ankle joint.

[Effect of moxibustion on the expressions of hypoxia inducible factor-1α and vascular endothelial growth factor in ankle synovial tissue of rats with adjuvant arthritis].

OBJECTIVE: To observe the effect of moxibustion on the expressions of hypoxia inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) in ankle synovial tissue of rats with adjuvant arthritis(AA), so as to explore the mechanism of moxibustion in inhibiting synovial angiogenesis and improving joint symptoms of rheumatoid arthritis. METHODS: Sixty healthy male SD rats were randomly divided into normal group, model group, moxibustion group and medication group, with 15 rats in each group. AA rat model was established by subcutaneous injection of Freund's complete adjuvant into the right hind paw. Rats in the moxibustion group were treated with "Zusanli" (ST36), "Guanyuan" (CV4) and "Ashi" point moxibustion, 20 min each time, once a day, for consecutive 3 weeks. Rats in the medication group were given methotrexate (0.35 mg/kg) intragastric administration, twice a week, for consecutive 3 weeks. Foot plantar volume of rats was measured by toe volume mea-suring instrument. HE staining was used to observe the histopathology of ankle synovium. The protein expressions of HIF-1α and VEGF in ankle synovial tissue were detected by immunohistochemistry and Western blot. RESULTS: Compared with the normal group, the foot plantar volume and the protein expressions of HIF-1α and VEGF in synovial tissue of ankle joint were significantly increased (P<0.01) in the model group, the synovial tissue showed obvious hyperplasia and a large number of neovasculogenesis. Following the interventions, the foot plantar volume and the protein expressions of HIF-1α and VEGF in synovial tissue of ankle joint were significantly decreased (P<0.05, P<0.01) in both moxibustion and medication groups in contrast to the model group, and there was no obvious proliferation of synovial tissue, and only a few neovascularization was observed. Compared with the medication group, the foot plantar volume was decreased (P<0.05) in the moxibustion group. CONCLUSION: Moxibustion can improve joint swelling and inhibit synovial angiogenesis in AA rats, and its mechanism may be related to down-regulating of HIF-1α and VEGF protein expressions.

A Novel Technique for Lateral Ankle Ligament Reconstruction with Total Ankle Total Talus Replacement: A Case Report.

CASE: A 65-year-old man with severe left talar avascular necrosis, arthritis, and chronic lateral ankle instability underwent total ankle total talus replacement (TATTR) with lateral ligament reconstruction. Tibial component placement was performed using preoperative computed tomography navigation and patient-specific guides. A custom, total talus replacement to mate with the fixed-bearing tibial component was implanted. Last, a modified Brostrom procedure was performed to restore lateral ankle stability. The patient has performed well through 1 year with improved pain-free function. CONCLUSION: This case report details a novel technique for performing a modified Brostrom procedure in conjunction with TATTR to restore lateral ankle stability.

Comparison between a novel helical and a posterior ankle-foot orthosis on gait in people with unilateral foot drop: a randomised crossover trial.

BACKGROUND: Neuromuscular disease and peripheral neuropathy may cause drop foot with or without evertor weakness. We developed a helical-shaped, non-articulated ankle-foot orthosis (AFO) to provide medial-lateral stability while allowing mobility, to improve gait capacity. Our aim was to evaluate the effect of the helical AFO (hAFO) on functional gait capacity (6-min walk test) in people with peripheral neuropathy or neuromuscular disease (NMD) causing unilateral drop foot and compare with a posterior leaf spring AFO (plsAFO). Secondary aims were to compare functional mobility, 3D kinematic and kinetic gait variables and satisfaction between the AFOs. METHODS: Single centre, randomised crossover trial from January to July 2017 in 20 individuals (14 with peripheral neuropathy and 6 with NMD, 12 females, mean age 55.6 years, SD 15.3); 10 wore the hAFO for the first week and 10 wore the plsAFO before switching for the second week. The 6-min walk test (6MWT), Timed Up and Go (TUG) test and 3D gait analysis were evaluated with the hAFO, the plsAFO and shoes only (noAFO) at inclusion and 1 week after wearing each orthosis. Satisfaction was evaluated with the Quebec user evaluation of satisfaction with assistive technology (QUEST). RESULTS: Median [interquartile range] 6MWT distance was greater with the hAFO (444 m [79]) than the plsAFO (389 m [135], P < 0.001, Hedge's g = 0.6) and noAFO (337 m [91], P < 0.001, g = 0.88). TUG time was shorter with the hAFO (8.1 s [2.8]) than the plsAFO (9.5 s [2.6], P < 0.001, g = - 0.5) and noAFO (10.0 s [2.6]), P < 0.001, g = - 0.6). The plsAFO limited plantarflexion during the loading response (plsAFO - 7.5 deg [6.0] vs. noAFO -13.0 deg [10.0], P = 0.0007, g = - 1.0) but the hAFO did not (- 11.0 deg [5.1] vs. noAFO, P = 0.05, g = - 0.5). Quasi-stiffness was lower for the hAFO than plsAFO (P = 0.009, g = - 0.7). The dimensionless eversion moment was higher (though not significantly) with the hAFO than noAFO. Neither orthosis reduced ankle power (P = 0.34). Median total QUEST score was higher for the hAFO (4.7 [0.7]) than the plsAFO (3.6 [0.8]) (P < 0.001, g = 1.9). CONCLUSIONS: The helical orthosis significantly and considerably improved functional gait performance, did not limit ankle mobility, increased lateral stability, though not significantly, and was associated with greater patient satisfaction than the posterior leaf spring orthosis. Trial registration The trial began before registration was mandatory.

Development of convolutional neural network model for diagnosing osteochondral lesions of the talus using anteroposterior ankle radiographs.

Deep learning is an advanced machine learning technique that is used in several medical fields to diagnose diseases and predict therapeutic outcomes. In this study, using anteroposterior ankle radiographs, we developed a convolutional neural network (CNN) model to diagnose osteochondral lesions of the talus (OLTs) using ankle radiographs as input data. We evaluated whether a CNN model trained on anteroposterior ankle radiographs could help diagnose the presence of OLT. We retrospectively collected 379 cases (OLT cases = 133, non-OLT cases = 246) of anteroposterior ankle radiographs taken at a university hospital between January 2010 and December 2020. The OLT was diagnosed using ankle magnetic resonance images of each patient. Among the 379 cases, 70% of the included data were randomly selected as the training set, 10% as the validation set, and the remaining 20% were assigned to the test set to evaluate the model performance. To accurately classify OLT and non-OLT, we cropped the area of the ankle on anteroposterior ankle radiographs, resized the image to 224 × 224, and used it as the input data. We then used the Visual Geometry Group Network model to determine whether the input image was OLT or non-OLT. The performance of the CNN model for the area under the curve, accuracy, positive predictive value, and negative predictive value on the test data were 0.774 (95% confidence interval [CI], 0.673-0.875), 81.58% (95% CI, 0.729-0.903), 80.95% (95% CI, 0.773-0.846), and 81.82% (95% CI, 0.804-0.832), respectively. A CNN model trained on anteroposterior ankle radiographs achieved meaningful accuracy in diagnosing OLT and demonstrated that it could help diagnose OLT.

Is the EQ-5D-5L a responsive test to evaluate results in elective foot and ankle surgery?

PURPOSE: To analyze the responsiveness and the minimally clinical important change (MCIC) of the EuroQol (EQ) 5D-5 L score in patients that had undergone foot/ankle surgery. METHODS: Patients that underwent elective foot/ankle surgery from January 2019 to December 2020 were included. They were assessed with the EQ-5D-5L, visual analogue pain scale and Manchester Oxford Foot Questionnaire (MOXFQ) preoperatively and 1 year postoperatively. The pre-post differences of all variables, Effect Size (ES) and MCIC were analyzed. RESULTS: 167 patients. All variables showed a significant pre-post improvement. The ES for EQ-index and EQ-VAS were 0.61 and 0.33 respectively. MCIC for EQ-index was 0.17 and EQ-VAS was 8.54. MOXFQ index ES was 1.46 and the MCIC was 23.8. VAS decreased from 59.4 to 26.62. CONCLUSION: The EQ-5D-5L is a sensitive test to detect changes after elective foot and ankle surgery with good responsiveness relative to the ES values in the EQ-index. LEVEL OF EVIDENCE: II.

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.

Bone Stress Injuries at the Ankle and Foot.

Bone stress injuries (BSIs) are a frequent finding in athletes, particularly of the foot and ankle. A BSI is caused by recurring microtrauma to the cortical or trabecular bone exceeding the repair capacity of normal bone. The most frequent fractures at the ankle are low risk, characterized by a low risk for nonunion. These include the posteromedial tibia, the calcaneus, and the metatarsal diaphysis. High-risk stress fractures have a higher risk for nonunion and need more aggressive treatment. Examples are the medial malleolus, navicular bone, and the base of the second and fifth metatarsal bone.Imaging features depend on the primary involvement of cortical versus trabecular bone. Conventional radiographs may remain normal up to 2 to 3 weeks. For cortical bone, early signs of BSIs are a periosteal reaction or the "gray cortex sign," followed by cortical thickening and fracture line depiction. In trabecular bone, a sclerotic dense line may be seen. Magnetic resonance imaging enables early detection of BSIs and can differentiate between a stress reaction and a fracture. We review typical anamnestic/clinical findings, epidemiology and risk factors, imaging characteristics, and findings at typical locations of BSIs at the foot and ankle that may help guide treatment strategy and patient recovery.