The Effects of Augmenting Balance Training with Stroboscopic Goggles on Postural Control in Chronic Ankle Instability Patients: A Critically Appraised Topic.

CLINICAL SCENARIO: Individuals with chronic ankle instability (CAI) typically complete balance training protocols to improve postural control and reduce recurrent injury risk. However, the presence of CAI persists after traditional balance training protocols suggesting that such programs may be missing elements that could be beneficial to patients. Visual occlusion modalities, such as stroboscopic goggles, may be able to augment balance training exercises to further enhance postural control gains in those with CAI. However, a cumulative review of the existing evidence has yet to be conducted. FOCUSED CLINICAL QUESTION: Does wearing stroboscopic goggles during balance training result in greater improvements to postural control than balance training alone in those with CAI? SUMMARY OF KEY FINDINGS: All 3 studies indicated that the stroboscopic goggles group had statistically significant improvements in either a measure of static or dynamic postural control relative to the standard balance training group. However, significant improvements were not consistent across all postural control outcomes assessed in the included studies. CLINICAL BOTTOM LINE: Postural control may improve more in those with CAI when stroboscopic goggles were worn while completing balance training exercises relative to completing balance training exercises alone. STRENGTH OF RECOMMENDATION: Overall, consistent moderate- to high-quality evidence was present in the 3 studies, suggesting grade C evidence for the use of stroboscopic goggles during balance training in those with CAI.

Patients Experience Significant and Meaningful Changes in Self-Report of Function During the First 2 Weeks After an Ankle Sprain Injury: A Report From the Athletic Training Practice-Based Research Network.

CONTEXT: Ankle sprains are common during sport participation and associated with long-term deficits in self-report of function. However, little is known of short-term changes in self-report of function following injury. The authors aimed to assess statistical and clinically meaningful changes in self-report of function, as measured by the Foot and Ankle Ability Measure (FAAM), during the first 2 weeks after an ankle sprain injury. DESIGN: A retrospective analysis of electronic medical records. METHODS: Eighty-eight patients, who were diagnosed with an ankle sprain injury by an athletic trainer, received usual care from an athletic trainer, and completed the FAAM during treatment at weeks 1 and 2 postinjury. The authors calculated the percentage of patients who reported clinically meaningful changes and used Wilcoxon signed-rank tests to compare differences in FAAM scores between time points. RESULTS: Between weeks 1 and 2, significant differences were noted for the FAAM Activities of Daily Living (FAAM-ADL) (P < .001) and FAAM Sport (FAAM-Sport) (P < .001). At the patient level, 86.5% (64/74) and 85.2% (69/81) of patients reported changes that exceeded the minimal clinically important difference value for the FAAM-ADL and FAAM-Sport, respectively, between weeks 1 and 2. At week 2, 31.8% (28/88) and 47.7% (42/88) of patients reported a score below 90% on the FAAM-ADL and below 80% on the FAAM-Sport subscale, respectively. Also, 36.4% (32/88) and 25.0% (22/88) of patients reported a score of 100% on the FAAM-ADL and FAAM-Sport subscales, respectively, at week 2. CONCLUSIONS: Patients report statistically significant and meaningful improvements in self-report of function during the first 2 weeks following ankle sprain injury. However, almost half of patients still report deficits in sport function at 2 weeks postinjury. Patient-reported outcome measures such as the FAAM, can help capture the patient's perception of function and inform patient care decisions. Research efforts should explore individual response patterns to treatment.

Reliability of Manually Segmenting T1ρ Magnetic Resonance Sequences of Talar Articular Cartilage.

CONTEXT: Quantifying early posttraumatic ankle osteoarthritis pathogenesis using compositional magnetic resonance (MR) imaging sequences is becoming more common. These MR sequences are often manually segmented to isolate the cartilage of interest before cartilage compositional values (eg, T1ρ or T2) are quantified. However, limited information is available regarding the reliability and reproducibility of manual segmentation for the entire talar dome. OBJECTIVE: The purpose of this study was to determine the intraobserver and interobserver reliability of manually segmenting T1ρ MR sequences of the entire talar dome and 4 subregions of interest. DESIGN: Descriptive observational study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Ten uninjured healthy individuals (4M and 6F: 21.40 [3.03] y, 170.00 [7.93] cm, 71.03 [14.97] kg) participated. INTERVENTION: None. MAIN OUTCOME MEASURES: Two investigators manually segmented 10 T1ρ ankle MR sequences using ITK-SNAP software to calculate T1ρ mean relaxation times and cartilage volumes. Each observer repeated the segmentation twice, with segmentations separated by 1 month. Intraobserver and interobserver reliability was determined using intraclass correlation coefficients (ICCs) with 95% confidence intervals and root mean square coefficient of variations (RMSCVs). RESULTS: For T1ρ relaxation time, intraobserver (ICC = .994-.997, RMSCV = 1.31%-1.51%) and interobserver reliability (ICC = .990, RMSCV = 2.36%) was excellent for the overall talar dome. Excellent intraobserver (ICC = .975-.980, RMSCV = 3.88%-4.59%) and excellent interobserver reliability (ICC = .970, RMSCV = 5.13%) was noted for overall talar cartilage volume. CONCLUSIONS: The results demonstrate that manual segmentation of the entire talar dome from a T1ρ MR is reliable and repeatable.

Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework-an international multidisciplinary consensus.

BACKGROUND: Despite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap. METHODS: We used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses. RESULTS: Sixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement-PAASS: Pain (during sport participation and over the last 24 hours), Ankle impairments (range of motion; muscle strength, endurance and power), Athlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), Sensorimotor control (proprioception; dynamic postural control/balance), Sport/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session). CONCLUSION: Expert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury. TRIAL REGISTRATION NUMBER: ACTRN12619000522112.

Progressive Visual Occlusion and Postural Control Responses in Individuals With and Without Chronic Ankle Instability.

CONTEXT: Prophylactic and rehabilitative balance training is needed to maximize postural control and develop appropriate sensory organization strategies. Partially occluding vision during functional exercise may promote appropriate sensory organization strategies, but little is known about the influence of partially occluded vision on postural control in those with and without a history of musculoskeletal injury. OBJECTIVE: To determine the effect of increasing levels of visual occlusion on postural control in a heterogeneous sample of those with and without chronic ankle instability (CAI). The secondary objective was to explore postural control responses to increasing levels of visual occlusion among those with unilateral and bilateral CAI relative to uninjured controls. DESIGN: Cross-sectional. SETTING: Sports medicine research laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-five participants with unilateral CAI, 10 with bilateral CAI, and 16 participants with no history of lower extremity injury. MAIN OUTCOME MEASURES: All participants completed four 3-minute postural control assessments in double-limb stance under the following 4 visual conditions: (1) eyes open, (2) low occlusion, (3) high occlusion, and (4) eyes closed. Low- and high-occlusion conditions were produced using stroboscopic eyewear. Postural control outcomes included time-to-boundary minima means in the anteroposterior (TTB-AP) and mediolateral directions (TTB-ML). Repeated-measures analysis of variances tested the effects of visual condition on TTB-AP and TTB-ML. RESULTS: Postural control under the eyes-open condition was significantly better (ie, higher) than the limited visual occlusion and eyes-closed conditions (P < .001) for TTB-AP and TTB-ML. For TTB-AP only, partially occluded vision resulted in better postural control than the eyes-closed condition (P ≤ .003). CONCLUSIONS: Partial and complete visual occlusion impaired postural control during dual-limb stance in a heterogeneous sample of those with and without CAI. Stroboscopic eyewear appears to induce postural control impairments to the same extent as complete visual occlusion in the mediolateral direction.

Assessing Step Count-Dependent Changes in Femoral Articular Cartilage Using Ultrasound.

OBJECTIVES: To evaluate changes in the femoral cartilage cross-sectional area (CSA) measured with ultrasound (US) between baseline and 1000, 2000, 3000, 4000, and 5000 steps of walking on a treadmill. METHODS: Forty-one healthy individuals completed a single testing session. Participants rested with their knees extended on a plinth for 45 minutes to unload the femoral cartilage. Ultrasound was used to acquire images of the femoral cartilage before the treadmill-walking protocol. After the baseline US acquisition, participants walked on a treadmill at their preferred overground walking speed for 1000 steps, after which additional US images of the femoral cartilage were acquired. This process was repeated after 2000, 3000, 4000, and 5000 steps. A 1-way repeated-measures analysis of variance compared the CSA across the 6 step counts. An analysis of variance with repeated measures on time and Bonferroni corrected planned comparisons (.05/5) were used to evaluate differences in the femoral cartilage at each step count compared to baseline. RESULTS: The study included 20 male and 21 female participants (mean age ± SD, 21.5 ± 2.8 years; mean body mass index, 24.3 ± 3.4 kg/m 2 ). The CSAs were significantly greater at the 2000-step (1.27 ± 1.75 mm 2 ; P < .001), 4000-step (0.89 ± 1.17 mm2; P < .001), and 5000-step (2.10 ± 1.73 mm 2 ; P < .001) points compared to baseline. The CSA was significantly less at the 3000-step point (1.05 ± 1.29 mm 2 ; P < .001) compared to baseline. CONCLUSIONS: Changes in the CSA after walking may be dependent on the number of steps. The participants had a significant decrease in the CSA after 3000 steps of normal walking and a significant increase in the CSA after 2000, 4000, and 5000 steps of normal walking.

Lack of Consensus on Return-to-Sport Criteria Following Lateral Ankle Sprain: A Systematic Review of Expert Opinions.

CONTEXT: Lateral ankle sprains (LAS) have one of the highest recurrence rates of all musculoskeletal injuries. An emphasis on rapid return to sport (RTS) following LAS likely increases reinjury risk. Unfortunately, no set of objective RTS criteria exist for LAS, forcing practitioners to rely on their own opinion of when a patient is ready to RTS. PURPOSE: To determine if there was consensus among published expert opinions that could help inform an initial set of RTS criteria for LAS that could be investigated in future research. EVIDENCE ACQUISITION: PubMed, CINHL, and SPORTDiscus databases were searched from inception until October 2018 using a combination of keywords. Studies were included if they listed specific RTS criteria for LAS. No assessment of methodological quality was conducted because all included papers were expert opinion papers (level 5 evidence). Extracted data included the recommended domains (eg, range of motion, balance, sport-specific movement, etc) to be assessed, specific assessments for each listed domain, and thresholds (eg, 80% of the uninjured limb) to be used to determine RTS. Consensus and partial agreement were defined, a priori, as ≥75% and 50% to 75% agreement, respectively. EVIDENCE SYNTHESIS: Eight domains were identified within 11 included studies. Consensus was reached regarding the need to assess sport-specific movement (n = 9, 90.9%). Partial agreement was reached for the need to assess static balance (n = 7, 63.6%). The domains of pain and swelling, patient reported outcomes, range of motion, and strength were also partially agreed on (n = 6, 54.5%). No agreement was reached on specific assessments of cutoff thresholds. CONCLUSIONS: Given consensus and partial agreement results, RTS decisions following LAS should be based on sport-specific movement, static balance, patient reported outcomes, range of motion, and strength. Future research needs to determine assessments and cutoff thresholds within these domains to minimize recurrent LAS risk.

Corrective Exercises Improve Movement Efficiency and Sensorimotor Function but Not Fatigue Sensitivity in Chronic Ankle Instability Patients: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of corrective exercises on functional movement patterns, sensorimotor function, self-reported function, and fatigue sensitivity in collegiate athletes with chronic ankle instability (CAI). DESIGN: A randomized controlled trial. SETTING: Laboratory of sports sciences. PARTICIPANTS: Forty male volunteers were randomly assigned to the experimental group (age 21.2 ± 1.7 years, height 174.5 ± 6.1 cm, and weight 69.6 ± 6.9 kg) or the control group (age 20.9 ± 1.8 years, height 178.2 ± 6.6 cm, and weight 68.8 ± 8.1 kg). INTERVENTION: Participants in the experimental group performed supervised corrective exercises 3 times per week for 8 weeks. Fatigue was induced with a progressive treadmill protocol before and after the 8-week intervention. MAIN OUTCOME MEASURES: Outcomes included movement efficiency during 3 squat tasks, static and dynamic postural control, strength of the ankle musculature, joint position sense, and self-reported function with the Foot and Ankle Ability Measure subscales. These outcomes were assessed before and immediately after fatiguing treadmill running both before and after 8-weeks of corrective exercises. RESULTS: Significant improvements in movement efficiency, sensorimotor function, and self-reported function were noted in the experimental group relative to the control group (P < 0.001), in a nonfatigued state. However, in a fatigued stated, the experimental intervention only improved static postural control (P = 0.016) relative to the control group. CONCLUSIONS: These findings demonstrate that 8-weeks of corrective exercises were effective at enhancing movement efficiency, sensorimotor function, and self-reported function in collegiate athletes with CAI. However, this intervention program has limited abilities at reducing the effects of fatigue.

Time-dependent tuning of balance control and aftereffects following optical flow perturbation training in older adults.

BACKGROUND: Walking balance in older adults is disproportionately susceptible to lateral instability provoked by optical flow perturbations. The prolonged exposure to these perturbations could promote reactive balance control and increased balance confidence in older adults, but this scientific premise has yet to be investigated. This proof of concept study was designed to investigate the propensity for time-dependent tuning of walking balance control and the presence of aftereffects in older adults following a single session of optical flow perturbation training. METHODS: Thirteen older adults participated in a randomized, crossover design performed on different days that included 10 min of treadmill walking with (experimental session) and without (control session) optical flow perturbations. We used electromyographic recordings of leg muscle activity and 3D motion capture to quantify foot placement kinematics, lateral margin of stability, and antagonist coactivation during normal walking (baseline), early (min 1) and late (min 10) responses to perturbations, and aftereffects immediately following perturbation cessation (post). RESULTS: At their onset, perturbations elicited 17% wider and 7% shorter steps, higher step width and length variability (+171% and +132%, respectively), larger and more variable margins of stability (MoS), and roughly twice the antagonist leg muscle coactivation (p-values<0.05). Despite continued perturbations, most outcomes returned to values observed during normal, unperturbed walking by the end of prolonged exposure. After 10 min of perturbation training and their subsequent cessation, older adults walked with longer and more narrow steps, modest increases in foot placement variability, and roughly half the MoS variability and antagonist lower leg muscle coactivation as they did before training. CONCLUSIONS: Findings suggest that older adults: (i) respond to the onset of perturbations using generalized anticipatory balance control, (ii) deprioritize that strategy following prolonged exposure to perturbations, and (iii) upon removal of perturbations, exhibit short-term aftereffects that indicate a lessening of anticipatory control, an increase in reactive control, and/or increased balance confidence. We consider this an early, proof-of-concept study into the clinical utility of prolonged exposure to optical flow perturbations as a training tool for corrective motor adjustments relevant to walking balance integrity toward reinforcing task-specific, reactive control and/or improving balance confidence in older adults. TRIAL REGISTRATION: clinicaltrials.gov ( NCT03341728 ). Registered 14 November 2017.

Six Sessions of Anterior-to-Posterior Ankle Joint Mobilizations Improve Patient-Reported Outcomes in Patients With Chronic Ankle Instability: A Critically Appraised Topic.

Clinical Scenario: Chronic ankle instability (CAI) is a complex musculoskeletal condition that results in sensorimotor and mechanical alterations. Manual therapies, such as ankle joint mobilizations, are known to improve clinician-oriented outcomes like dorsiflexion range of motion, but their impact on patient-reported outcomes remains less clear. Focused Clinical Question: Do anterior-to-posterior ankle joint mobilizations improve patient-reported outcomes in patients with chronic ankle instability? Summary of Key Findings: Three studies (2 randomized controlled trials and 1 prospective cohort) quantified the effect of at least 2 weeks of anterior-to-posterior ankle joint mobilizations on improving patient-reported outcomes immediately after the intervention and at a follow-up assessment. All 3 studies demonstrated significant improvements in at least 1 patient-reported outcome immediately after the intervention and at the follow-up assessment. Clinical Bottom Line: At least 2 weeks of ankle joint mobilization improves patient-reported outcomes in patients with chronic ankle instability, and these benefits are retained for at least a week following the termination of the intervention. Strength of Recommendation: Strength of recommendation is grade A due to consistent good-quality patient-oriented evidence.

The Effect of Core Stability Training on Functional Movement Patterns in College Athletes.

Context: Preparticipation examinations are the standard approach for assessing poor movement quality that would increase musculoskeletal injury risk. However, little is known about how core stability influences functional movement patterns. Objective: The primary purpose of this study was to determine the effect of an 8-week core stability program on functional movement patterns in college athletes. The secondary purpose was to determine if the core stability training program would be more effective in those with worse movement quality (ie, ≤14 baseline functional movement screen [FMS] score). Design: Quasi-experimental design. Setting: Athletic training facility. Participants: One-hundred college athletes. Main Outcome Measures: Functional movement patterns included the FMS, lateral step-down, and Y balance test and were assessed before and after the 8-week program. Intervention: Participants were placed into one of the 2 groups: intervention and control. The intervention group was required to complete a core stability training program that met 3 times per week for 8 weeks. Results: Significant group × time interactions demonstrated improvements in FMS, lateral step-down, and Y balance test scores in the experimental group relative to the control group (P < .001). Independent sample t tests demonstrate that change scores were larger (greater improvement) for the FMS total score and hurdle step (P < .001) in athletes with worse movement quality. Conclusions: An 8-week core stability training program enhances functional movement patterns and dynamic postural control in college athletes. The benefits are more pronounced in college athletes with poor movement quality.

Hop Stabilization Training Improves Neuromuscular Control in College Basketball Players With Chronic Ankle Instability: A Randomized Controlled Trial.

CONTEXT: Neuromuscular control deficit has been reported in people with chronic ankle instability (CAI) and hopping exercises have been recommended as a functional training tool to prevent lower limb injury, but its effects on lower-extremity neuromuscular control in those with CAI are unclear. OBJECTIVE: To investigate the effect of hop stabilization training on neuromuscular control and self-reported function in college basketball players with CAI. STUDY DESIGN: A randomized controlled trial. SETTING: Research Laboratory. Patients (or Other Participants): A total of 28 college basketball players with CAI were randomly assigned to the experimental hop stabilization group (age = 22.78 [3.09] y, weight = 82.59 [9.51] kg, and height = 187.96 [7.93] cm) or the control group (age = 22.57 [2.76] y, weight = 78.35 [7.02] kg, and height = 185.69 [7.28] cm). INTERVENTION: Participants in the experimental group performed supervised hop stabilization exercises 3 times per week for 6 weeks. The control group received no intervention. MAIN OUTCOME MEASURES: Preparatory and reactive muscle activation levels and muscle onset time were assessed from 8 lower-extremity muscles during a jump-landing task before and after the 6-week training program. RESULTS: Significant improvements in preparatory muscle activation, reactive muscle activation, and muscle onset time were noted across the lower-extremity in the experimental group relative to the control group (P < .05). Self-reported function also improved in the experimental group relative to the control group (P < .05). CONCLUSIONS: These findings demonstrate that 6 weeks of hop stabilization training is effective in improving neuromuscular control and self-reported function in college basketball players with CAI. Hop stabilization exercises can be incorporated into the rehabilitation program for CAI.

Motoneuron Function Does not Change Following Whole-Body Vibration in Individuals With Chronic Ankle Instability.

CONTEXT: Following a lateral ankle sprain, ∼40% of individuals develop chronic ankle instability (CAI), characterized by recurrent injury and sensations of giving way. Deafferentation due to mechanoreceptor damage postinjury is suggested to contribute to arthrogenic muscle inhibition (AMI). Whole-body vibration (WBV) has the potential to address the neurophysiologic deficits accompanied by CAI and, therefore, possibly prevent reinjury. OBJECTIVE: To determine if an acute bout of WBV can improve AMI and proprioception in individuals with CAI. DESIGN AND PARTICIPANTS: The authors examined if an acute bout of WBV can improve AMI and proprioception in individuals with CAI with a repeated-measures design. A total of 10 young adults with CAI and 10 age-matched healthy controls underwent a control, sham, and WBV condition in randomized order. SETTING: Biomechanics laboratory. INTERVENTION: WBV. MAIN OUTCOME MEASURES: Motoneuron pool recruitment was assessed via Hoffmann reflex (H-reflex) in the soleus. Proprioception was evaluated using ankle joint position sense at 15° and 20° of inversion. Both were assessed prior to, immediately following, and 30 minutes after the intervention (pretest, posttest, and 30mPost, respectively). RESULTS: Soleus maximum H-reflex:M-response (H:M) ratios were 25% lower in the CAI group compared with the control group (P = .03). Joint position sense mean constant error did not differ between groups (P = .45). Error at 15° in the CAI (pretest 0.8 [1.6], posttest 2.0 [2.8], 30mPost 2.0 [1.9]) and control group (pretest 0.8 [2.0], posttest 0.6 [2.9], 30mPost 0.5 [2.1]) did not improve post-WBV. Error at 20° did not change post-WBV in the CAI (pretest 1.3 [1.7], posttest 1.0 [2.4], 30mPost 1.5 [2.2]) or control group (pretest -0.3 [3.0], posttest 0.8 [2.1], 30mPost 0.6 [1.8]). CONCLUSION: AMI is present in the involved limb of individuals with CAI. The acute response following a single bout of WBV did not ameliorate the presence of AMI nor improve proprioception in those with CAI.

Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium.

Lateral ankle sprain injury is the most common musculoskeletal injury incurred by individuals who participate in sports and recreational physical activities. Following initial injury, a high proportion of individuals develop long-term injury-associated symptoms and chronic ankle instability. The development of chronic ankle instability is consequent on the interaction of mechanical and sensorimotor insufficiencies/impairments that manifest following acute lateral ankle sprain injury. To reduce the propensity for developing chronic ankle instability, clinical assessments should evaluate whether patients in the acute phase following lateral ankle sprain injury exhibit any mechanical and/or sensorimotor impairments. This modified Delphi study was undertaken under the auspices of the executive committee of the International Ankle Consortium. The primary aim was to develop recommendations, based on expert (n=14) consensus, for structured clinical assessment of acute lateral ankle sprain injuries. After two modified Delphi rounds, consensus was achieved on the clinical assessment of acute lateral ankle sprain injuries. Consensus was reached on a minimum standard clinical diagnostic assessment. Key components of this clinical diagnostic assessment include: establishing the mechanism of injury, as well as the assessment of ankle joint bones and ligaments. Through consensus, the expert panel also developed the International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST). The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability. This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

Effects of a stocking on plantar sensation in individuals with and without ankle instability.

INTRODUCTION: It is unknown whether footwear has a beneficial or deleterious effect on cutaneous sensitivity. We aimed to test a preliminary model of footwear and its effect on tactile perception among groups of controls, copers, and chronic ankle instability participants. METHODS: Light-touch thresholds were obtained for 45 participants (age: 20.2 ± 2.8 years; height: 167.6 ± 9.8 cm; mass: 66.3 ± 14.7 kg) using Semmes-Weinstein monofilaments at the head of the first metatarsal (1MT), base of the fifth metatarsal (5MT), and calcaneus (CAL). Baseline measurements were compared with those taken after wearing a nylon stocking for 5 min. RESULTS: Thresholds were increased at all 3 sites when the stocking was worn (P < 0.05). Controls had an increase at 1MT, copers had an increase at 5MT and CAL, and chronic ankle instability had an increase at CAL. CONCLUSIONS: Cutaneous thresholds increase when subjects wear a nylon stocking, a model for the sensory effects of footwear. A history of ankle injury appears to influence which sites have altered sensibility. Muscle Nerve, 2016. Muscle Nerve 55: 513-519, 2017.

Visual Utilization During Postural Control in Anterior Cruciate Ligament- Deficient and -Reconstructed Patients: Systematic Reviews and Meta-Analyses.

OBJECTIVE: To determine whether anterior cruciate ligament-deficient (ACL-D) individuals and individuals with a reconstructed anterior cruciate ligament (ACL-R) rely more heavily on visual information to maintain postural control. DATA SOURCES: PubMed, CINAHL, and SPORTDiscus databases were searched from their earliest available date to May 24, 2016, using a combination of keywords. STUDY SELECTION: Articles were included if they reported any instrumented static single-leg balance outcome in both a patient and control sample. The means and SDs of these outcomes must have been reported with both eyes open and eyes closed. DATA EXTRACTION: Sample sizes, means, and SDs of single-leg balance measures for each group's eyes open and eyes closed testing conditions were extracted. The methodological quality of included studies was independently evaluated by multiple authors using an adapted version of the Quality Index. DATA SYNTHESIS: Effect sizes were calculated by dividing the differences in change between eyes closed and eyes open in the ACL-D and control group and the ACL-R and control group by the pooled SD from the eyes closed trials for each analysis. Significant differences between the ACL-D and control group (effect size, -1.66; 95% confidence interval [CI], -2.90 to -.41) were noted. The ACL-R and control group were not different (effect size, -.61; 95% CI, -2.17 to .95). CONCLUSIONS: ACL-D individuals but not individuals with ACL-R demonstrate a greater reliance on visual information during single-leg stance compared with healthy individuals.

Balance Training Versus Balance Training With STARS in Patients With Chronic Ankle Instability: A Randomized Controlled Trial.

CONTEXT: Both balance training and selected interventions meant to target sensory structures (STARS) have been shown to be effective at restoring deficits associated with chronic ankle instability (CAI). Clinicians often use multiple treatment modalities in patients with CAI. However, evidence for combined intervention effectiveness in CAI patients remains limited. OBJECTIVE: To determine if augmenting a balance-training protocol with STARS (BTS) results in greater improvements than balance training (BT) alone in those with CAI. DESIGN: Randomized-controlled trial. SETTING: Research laboratory. PATIENTS: 24 CAI participants (age 21.3 ± 2.0 y; height 169.8 ± 12.9 cm; mass 72.5 ± 22.2 kg) were randomized into 2 groups: BT and BTS. INTERVENTIONS: Participants completed a 4-week progression-based balance-training protocol consisting of 3 20-min sessions per week. The experimental group also received a 5-min set of STARS treatments consisting of calf stretching, plantar massage, ankle joint mobilizations, and ankle joint traction before each balance-training session. MAIN OUTCOME MEASURES: Outcomes included self-assessed disability, Star Excursion Balance Test reach distance, and time-to-boundary calculated from static balance trials. All outcomes were assessed before, and 24-hours and 1-week after protocol completion. Self-assessed disability was also captured 1-month after the intervention. RESULTS: No significant group differences were identified (P > .10). Both groups demonstrated improvements in all outcome categories after the interventions (P < .10), many of which were retained at 1-week posttest (P < .10). Although 90% CIs include zero, effect sizes favor BTS. Similarly, only the BTS group exceeded the minimal detectable change for time-to-boundary outcomes. CONCLUSIONS: While statistically no more effective, exceeding minimal detectable change scores and favorable effect sizes suggest that a 4-week progressive BTS program may be more effective at improving self-assessed disability and postural control in CAI patients than balance training in isolation.

The Effect of 2 Forms of Talocrural Joint Traction on Dorsiflexion Range of Motion and Postural Control in Those With Chronic Ankle Instability.

CONTEXT: Talocrural joint mobilizations are commonly used to address deficits associated with chronic ankle instability (CAI). OBJECTIVE: Examine the immediate effects of talocrural joint traction in those with CAI. DESIGN: Blinded, crossover. SETTING: Laboratory. PARTICIPANTS: Twenty adults (14 females; age = 23.80 ± 4.02 y; height = 169.55 ± 12.38 cm; weight = 78.34 ± 16.32 kg) with self-reported CAI participated. Inclusion criteria consisted of a history of ≥1 ankle sprain, ≥2 episodes of giving way in the previous 3 mo, answering "yes" to ≥4 questions on the Ankle Instability Instrument, and ≤24 on the Cumberland Ankle Instability Tool. INTERVENTION: Subjects participated in 3 sessions in which they received a single treatment session of sustained traction (ST), oscillatory traction (OT), or a sham condition in a randomized order. Interventions consisted of four 30-s sets of traction with 1 min of rest between sets. During ST and OT, the talus was distracted distally from the ankle mortise to the end-range of accessory motion. ST consisted of continuous distraction and OT involved 1-s oscillations between the mid and end-range of accessory motion. The sham condition consisted of physical contact without force application. Preintervention and postintervention measurements of weight-bearing dorsiflexion, dynamic balance, and static single-limb balance were collected. MAIN OUTCOME MEASURES: The independent variable was treatment (ST, OT, sham). The dependent variables included pre-to-posttreatment change scores for the WBLT (cm), normalized SEBTAR (%), and time-to-boundary (TTB) variables(s). Separate 1-way ANOVAs examined differences between treatments for each dependent variable. Alpha was set a priori at P < .05. RESULTS: No significant treatment effects were identified for any variables. CONCLUSION: A single intervention of ST or OT did not produce significant changes in weight-bearing dorsiflexion range of motion or postural control in individuals with CAI. Future research should investigate the effects of repeated talocrural traction treatments and the effects of this technique when combined with other manual therapies.

Reliability of two-point discrimination thresholds using a 4-2-1 stepping algorithm.

PURPOSE: A 4-2-1 stepping algorithm reliably captures light touch thresholds but has not been used to assess two-point discrimination (TPD) thresholds. Therefore, the purpose of this investigation was to determine the intra- and inter-rater reliability of a 4-2-1 stepping algorithm at determining TPD thresholds. MATERIALS AND METHODS: Fifteen healthy, physically active young adults were assessed twice over a 1-week period using digital calipers and a 4-2-1 stepping algorithm. TPD thresholds were assessed by an expert and a novice examiner at each time point. Reliability was assessed on the plantar surface of the foot at the head of the first and base of the fifth metatarsal. RESULTS: Three intra-rater intraclass correlation coefficient (ICC) values exceeded 0.75 and were interpreted as good. The inter-rater reliability was good with ICC values ranging from 0.76 to 0.93 at both sites during both test sessions. CONCLUSIONS: The 4-2-1 stepping algorithm demonstrates good intra- and inter-tester reliability at determining TPD thresholds on the plantar surface of the foot at the head of the first and base of the fifth metatarsal in young healthy adults.

2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains.

The Executive Committee of the International Ankle Consortium presents this 2016 position paper with recommendations for information implementation and continued research based on the paradigm that lateral ankle sprain (LAS), and the development of chronic ankle instability (CAI), serve as a conduit to a significant global healthcare burden. We intend our recommendations to serve as a mechanism to promote efforts to improve prevention and early management of LAS. We believe this will reduce the prevalence of CAI and associated sequelae that have led to the broader public health burdens of decreased physical activity and early onset ankle joint post-traumatic osteoarthritis. Ultimately, this can contribute to healthier lifestyles and promotion of physical activity.