Clinical Scenario: Approximately 30% of all first-time patients with LAS develop chronic ankle instability (CAI). CAI-associated impairments are thought to contribute to aberrant gait biomechanics, which increase the risk of subsequent ankle sprains and the development of posttraumatic osteoarthritis. Alternative modalities should be considered to improve gait biomechanics as impairment-based rehabilitation does not impact gait. Taping and bracing have been shown to reduce the risk of recurrent ankle sprains; however, their effects on CAI-associated gait biomechanics remain unknown. Clinical Question: Do ankle taping and bracing modify gait biomechanics in those with CAI? Summary of Key Findings: Three case-control studies assessed taping and bracing applications including kinesiotape, athletic tape, a flexible brace, and a semirigid brace. Kinesiotape decreased excessive inversion in early stance, whereas athletic taping decreased excessive inversion and plantar flexion in the swing phase and limited tibial external rotation in terminal stance. The flexible and semirigid brace increased dorsiflexion range of motion, and the semirigid brace limited plantar flexion range of motion at toe-off. Clinical Bottom Line: Taping and bracing acutely alter gait biomechanics in those with CAI. Strength of Recommendation: There is limited quality evidence (grade B) that taping and bracing can immediately alter gait biomechanics in patients with CAI.
Kimmery Migel and Erik Wikstrom
Erik A. Wikstrom and Patrick O. McKeon
Multiple treatment options have been shown to improve dorsiflexion range of motion (DFROM) group means in patients with chronic ankle instability (CAI). However, not all patients with CAI respond equally to these treatments. The aim of this study was to identify predictors of successfully improving dorsiflexion range of motion (DFROM) in patients with CAI. Patients with <11.41 cm of DFROM had a 98% probability of a meaningful DFROM improvement following ankle joint mobilizations. Individual predictors of success for plantar massage and calf stretching were also identified and resulted in >92% posttest probabilities. Simple pretreatment assessments can dramatically improve treatment success probability following STARS in patients with CAI.
Erik A. Wikstrom and Robert B. Anderson
The purpose of this investigation was to determine if stereotypical patterns of gait initiation are altered in those with posttraumatic ankle osteoarthritis. Ten subjects, five with unilateral ankle osteoarthritis and five uninjured controls, participated. Subjects completed the SF-36 and Ankle Osteoarthritis Scale to quantify self-reported disability as well as 10 dual-limb static stance trials and 10 gait initiation trials with each leg. Center of pressure outcomes were calculated for static balance trials while the peak center of pressure excursions were calculated for each phase of gait initiation. The results indicate greater self-reported disability (P < .05) and worse static postural control (P < .05) in the ankle osteoarthritis group. Nonstereotypical patterns were also observed during the first and third phases of gait initiation in those with ankle osteoarthritis. The results of this pilot study suggest that supraspinal motor control mechanisms may have changed in those with posttraumatic ankle osteoarthritis.
Erik A. Wikstrom, Cole Mueller and Mary Spencer Cain
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.
Erik A. Wikstrom, Sajad Bagherian, Nicole B. Cordero and Kyeongtak Song
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.
Susan Miniello, Geoffrey Dover, Michael Powers, Mark Tillman and Erik Wikstrom
Previous studies have suggested that cryotherapy affects neuromuscu-lar function and therefore might impair dynamic stability. If cryotherapy affects dynamic stability, clinicians might alter their decisions regarding returning athletes to play immediately after treatment.
To assess the effects of lower leg cold immersion on muscle activity and dynamic stability of the lower extremity.
Within-subject time-series design with 1 pretest and 2 posttests.
A climate-controlled biomechanics laboratory.
17 healthy women.
20-minute cold-water immersion.
Main Outcome Measures:
Preparatory and reactive electromyographic activity of the tibialis anterior and peroneus longus and time to stabilization after a jump landing.
Preparatory activity of the tibialis anterior increased after treatment, whereas preparatory and reactive peroneus longus activity decreased. Both returned to baseline after a 5-minute recovery. Time to stabilization did not change.
Lower leg cold-immersion therapy does not impair dynamic stability in healthy women during a jump-landing task. Return to participation after a cryotherapy treatment is not contraindicated for healthy athletes.
Sajad Bagherian, Khodayar Ghasempoor, Nader Rahnama and Erik A. Wikstrom
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.
Mutlu Cug, Erik A. Wikstrom, Bahman Golshaei and Sadettin Kirazci
Both female athletes’ participation in soccer and associated injuries have greatly increased in recent years. One issue is the 2–9 times greater incidence of noncontact anterior cruciate ligament (ACL) injuries in female athletes relative to male athletes in comparable sports. Several factors such as limb dominance and sporting history have been proposed to play a role in ACL incidence rates between male and female athletes. However, evidence about the effects of these factors and how they interact with sex is mixed, and thus no consensus exists.
To quantify the effects of sports participation, limb dominance, and sex on dynamic postural control and knee-joint proprioception.
University research laboratory.
19 male soccer players, 17 female soccer players, 19 sedentary men, and 18 sedentary women.
Joint-position sense was tested using reproduction of passive positioning on a Biodex isokinetic dynamometer (30°, 45°, and 60° from 90° of knee flexion). Three Star Excursion Balance Test directions were used to assess dynamic postural control.
Main Outcome Measure:
Normalized reach distance (% of leg length) in the anterior, posteromedial, and posterolateral directions on each leg quantified dynamic postural control. Average absolute error and constant error for both limbs quantified joint-position sense.
Posteromedial reach distance was significantly better in soccer players than sedentary individuals (P = .006). Anterior reach distance was significantly better (P = .04) in sedentary individuals than soccer players. No limb-dominance or sex differences were identified for dynamic postural control, and no differences in absolute- or constant-error scores were identified.
Sporting history has a direction-specific impact on dynamic postural control. Sporting history, sex, and limb dominance do not influence knee-joint proprioception when tested in an open kinetic chain using passive repositioning.
Christopher J. Burcal, Alejandra Y. Trier and Erik A. Wikstrom
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.
To determine if augmenting a balance-training protocol with STARS (BTS) results in greater improvements than balance training (BT) alone in those with CAI.
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.
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.
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.
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.
Erik A. Wikstrom, Sajad Bagherian, Gary Allen and Kyeongtak Song
Clinical Scenario: Balance impairment is common in patients with chronic ankle instability (CAI), especially during dynamic tasks. Manual therapies, such as ankle joint mobilizations are known to improve clinician-oriented outcomes such as dorsiflexion range of motion, but their impact on sensorimotor outcomes such as dynamic postural control and the retention of benefits remains less clear. Focused Clinical Question: Do anterior-to-posterior ankle joint mobilizations improve dynamic postural control in patients with CAI relative to a control condition and are those benefits retained after termination of the treatment? Summary of Key Findings: Three studies quantified the immediate effect and two studies quantified the retained benefit of anterior-to-posterior ankle joint mobilizations on improving Star Excursion Balance Test (SEBT) reach distances. Two studies demonstrated large immediate improvements in SEBT reach distances and those same investigations found that those large improvements were retained. Clinical Bottom Line: Ankle joint mobilization appears to improve SEBT reach distances and those improvements are retained. Strength of Recommendation: Strength of recommendation is a B due to inconsistent moderate-quality patient-oriented evidence.