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The Effect of Joint Mobilization on Dynamic Postural Control in Patients With Chronic Ankle Instability: A Critically Appraised Topic

Kyle B. Kosik and Phillip A. Gribble

Clinical Scenario: Dorsiflexion range of motion is an important factor in the performance of the Star Excursion Balance Test (SEBT). While patients with chronic ankle instability (CAI) commonly experience decreased reach distances on the SEBT, ankle joint mobilization has been suggested to be an effective therapeutic intervention for targeting dorsiflexion range of motion. Clinical Question: What is the evidence to support ankle joint mobilization for improving performance on the SEBT in patients with CAI? Summary of Key Findings: The literature was searched for articles examining the effects of ankle joint mobilization on scores of the SEBT. A total of 3 peer-reviewed articles were retrieved, 2 prospective individual cohort studies and 1 randomized controlled trial. Only 2 articles demonstrated favorable results following 6 sessions of ankle joint mobilization. Clinical Bottom Line: Despite the mixed results, the majority of the available evidence suggests that ankle joint mobilization improves dynamic postural control. Strength of Recommendation: In accordance with the Centre of Evidence Based Medicine, the inconsistent results and the limited high-quality studies indicate that there is level C evidence to support the use of ankle joint mobilization to improve performance on the SEBT in patients with CAI.

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Diminished Plantar Cutaneous Sensation in Patients With Chronic Ankle Instability: A Critically Appraised Topic

Christina Jones, Kyle B. Kosik, Phillip Gribble, and Matthew C. Hoch

Clinical Question: Do individuals with chronic ankle instability have diminished plantar cutaneous sensation compared to ankle sprain copers or individuals with no history of ankle sprain? Clinical Bottom Line: Patients with chronic ankle instability have diminished plantar cutaneous sensation compared to healthy controls with no history of ankle sprain and ankle sprain copers.

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Knee Flexion Angle at Initial Contact During Jump Landing in Individuals With and Without Chronic Ankle Instability: A Critically-Appraised Topic

Jacob T. Hartzell, Kyle B. Kosik, Matthew C. Hoch, and Phillip A. Gribble

Clinical Scenario : Chronic ankle instability (CAI) is characterized by the residual symptoms and feelings of instability that persist after an acute ankle sprain. Current literature has identified several neuromuscular impairments associated with CAI that may negatively impact sagittal plane knee kinematics during dynamic activities. This has led researchers to begin examining sagittal plane knee kinematics during jump landing tasks. Understanding changes in movement patterns at the knee may assist clinicians in designing rehabilitation plans that target both the ankle and more proximal joints, such as the knee. Clinical Question : What is the evidence to support the notion that patients with CAI have decreased sagittal plane knee flexion angle at initial contact during a jump-landing task compared to healthy individuals? Summary of Key Findings : The literature was systematically searched for level 4 evidence or higher. The search yielded two case-control studies which met the inclusion criteria. Based on limited evidence, there are mixed results for whether sagittal plane knee kinematic at initial contact differ between those with and without CAI. Clinical Bottom Line : There is weak evidence to support changes in sagittal plane knee kinematics at initial contact during a jump landing in individuals with CAI compared to healthy controls. Strength of Recommendation : In accordance with the Centre for Evidence-Based Medicine, a grade of C for level 4 evidence is recommended due to variable findings.

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

Kyeongtak Song, Kyle B. Kosik, Phillip A. Gribble, and Erik A. Wikstrom

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.

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Joint Stabilization Surgery for Chronic Ankle Instability and Medial Ankle Osteoarthritis: A Critically Appraised Topic

Kyle B. Kosik, Kyeongtak Song, Phillip A. Gribble, Matthew C. Hoch, and Arjun Srinath

Clinical Scenario: Patients with chronic ankle instability (CAI) who require surgical intervention are often diagnosed with medial ankle osteoarthritis (OA). Lateral joint stabilization procedures are commonly performed among this patient population to restore bony alignment and improve cartilage loading patterns to increase patient-reported function and mitigate further degenerative changes. Focused Clinical Question: What is the available evidence to support joint stabilization procedures on patient-reported outcomes and progression of radiographic OA among patients with CAI who have medial ankle OA? Summary of Key Findings: An electronic search of relevant databases was performed to identify peer-reviewed articles examining preoperative and postoperative clinical outcomes and radiographic evidence of ankle OA. A total of 3 peer-reviewed articles were retrieved. All 3 articles employed a retrospective case series study design. All 3 articles demonstrated improved patient-reported outcomes at the final follow-up visit. Two articles demonstrated that between 11% and 27% of patients progressed in at least 1stage of radiographic ankle OA between the preoperative assessment and the final follow-up visit (40–56 mo). Clinical Bottom Line: Joint stabilization surgery for patients with CAI and medial ankle OA is associated with improved clinical outcomes and a low rate of worsening radiographic joint degeneration within the first 5 years. Strength of Recommendation: Consistent evidence exists across all 3 articles. However, this evidence is based on a low-quality study design. Therefore, there is a grade-C level of evidence to support joint stabilization for improving patient-reported and radiographic outcomes within the first 5 years after surgery for patients with CAI and medial ankle OA.

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Prediction of Recurrent Injury in the Same Competitive Sport Season Following Return-to-Play From an Ankle Sprain

Ryan S. McCann, Kyle B. Kosik, Masafumi Terada, and Phillip A. Gribble

Several investigators have aimed to predict recurrent injuries following acute ankle sprains, but none has done so in high school or collegiate athletes. The purpose of this study was to determine the ability of demographic, anthropometric, and disease- and patient-oriented outcomes to predict recurrent ankle sprains in athletes during the same competitive season following return to play from an ankle sprain. Only increased patient height and mass were associated with increased odds of sustaining a recurrent ankle sprain. Thus, taller and heavier patients might have the greatest risk of sustaining a recurrent ankle sprain in the same season as a previous ankle sprain.

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Health-Related Quality of Life Among Patients With Painful Chronic Ankle Instability

Kyle B. Kosik, Matthew C. Hoch, Stacey Slone, Katherine A. Bain, and Phillip A. Gribble

More than half of individuals with chronic ankle instability (CAI) experience lingering pain from a previous injury. However, there is little empirical evidence investigating the role pain has on health-related quality of life (HRQL). The purpose of this cross-sectional study was to compare physical and psychological HRQL between CAI individuals with and without pain. Group comparisons demonstrated that CAI individuals with pain displayed a lower physical and mental HRQL than those without pain. In addition, CAI individuals with pain reported greater injury-related fear. These findings suggest that persistent pain compounds the negative effect that ankle joint instability has on physical and mental HRQL outcomes. Therefore, conservative therapies should consider multimodal approaches rather than focusing on joint stability alone.

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Isometric Hip Strength and Patient-Reported Outcomes of Individuals With and Without Chronic Ankle Instability

Katherine A. Bain, Paige A. Clawson, Stacey A. Slone, Phillip A. Gribble, Johanna M. Hoch, Matthew C. Hoch, and Kyle B. Kosik

Context: Strength deficits and decreased scores on generic, dimension-specific, and region-specific health-related quality of life (HRQL) PRO measures are commonly documented among individuals with chronic ankle instability (CAI). However, it is unknown if there is a relationship between hip strength and self-reported patient-reported outcome (PRO) scores. Objective: To compare isometric peak torque for hip-extension (H-EXT) and hip-abduction (H-ABD), as well as PRO scores between CAI, lateral ankle sprain copers (LAS copers), and uninjured controls (UC). The secondary purpose was to examine the relationship between isometric hip peak torque and PROs in participants with CAI. Design: Cross-sectional. Setting: Laboratory. Participants: Sixty-three individuals, 45 women (23.02 [3.83] y, 165.91 [7.55] cm, 67.28 [11.95] kg) and 18 men (26.28 [5.43] y, 179.28 [9.01] cm, 83.87 [13.26] kg), grouped as uninjured control (n = 26), LAS coper (n = 15), or CAI (n = 22). Main Outcome Measures: The Foot and Ankle Ability Measure was used to assess region-specific HRQL. The Fear Avoidance Beliefs Questionnaire was used to assess injury-related fear. The Disablement in Physically Active was used to assess global HRQL. Isometric peak torque was measured with a handheld dynamometer for H-EXT and H-ABD. Results: No group differences were observed for H-ABD (P = .34) or H-EXT (P = .35). The CAI group had significantly worse scores on all PROs compared with LAS coper (P < .001) and HC (P < .001). Moderate–weak correlations were found between H-ABD and Foot and Ankle Ability Measure—activities of daily living (P = .047; ρ = .392) and Foot and Ankle Ability Measure-Sport (P = .013; ρ = .482) and H- EXT and Fear Avoidance Beliefs Questionnaire-Work (P = .007; ρ = −.517). Conclusions: Individuals with CAI displayed lower HRQL based on worse scores on generic, dimension-specific, and region-specific PROs compared with LAS copers and uninjured controls. There were no significant between-group differences for H-EXT and H-ABD isometric peak torque production, but there was a moderate positive relationship between isometric H-ABD and self-reported ankle disability in individuals with CAI.

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The Effect of Attending Physical Rehabilitation After the First Acute Lateral Ankle Sprain on Static Postural Control in Patients With Chronic Ankle Instability

Katherine L. Helly, Katherine A. Bain, Matthew C. Hoch, Nicholas R. Heebner, Phillip A. Gribble, Masafumi Terada, and Kyle B. Kosik

Context: Static postural control deficits are commonly documented among individuals with chronic ankle instability (CAI). Evidence suggests individuals with CAI who seek medical attention after an ankle sprain report fewer subjective symptoms. It is unknown if seeking medical attention and receiving supervised physical rehabilitation has a similar effect on objective outcomes, such as static postural control. Objective: To compare measures of single-limb postural control and center of pressure (COP) location between participants with CAI who did or did not self-report attending supervised rehabilitation at the time of their first lateral ankle sprain. Design: Retrospective cohort. Setting: Laboratory. Patients (or Other Participants): Twenty-nine participants with CAI who did (n = 14) or did not (n = 15) self-report attending supervised rehabilitation. Intervention(s): Self-reported attendance or not of supervised rehabilitation at the time of initial injury. Main Outcome Measures: Participants performed three 20-second trials of single-limb stance on a force plate with eyes open. Main outcome measures included the COP velocities, time-to-boundary (TTB) absolute minima, mean of TTB minima, and SD of TTB minima in the anteroposterior and mediolateral directions. The spatial distribution of the COP data points under the foot was quantified within 4 equally proportional sections labeled anteromedial, anterolateral, posteromedial, and posterolateral. Results: Participants who reported attending supervised rehabilitation after their initial ankle sprain had a lower COP velocity in the anterior–posterior direction (P = .030), and higher TTB anterior–posterior absolute minimum (P = .033) and mean minima (P = .050) compared with those who did not attend supervised rehabilitation. Conclusions: Among individuals with CAI, not attending supervised rehabilitation at the time of initial injury may lead to worse static postural control outcomes. Clinicians should continue advocating for patients recovering from an acute ankle sprain to seek medical attention and provide continued care in the form of physical rehabilitation.

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Acceleration and Jerk After a Jump Stabilization Task in Individuals With and Without Chronic Ankle Instability

Kyle B. Kosik, Kathryn Lucas, Matthew C. Hoch, Jacob T. Hartzell, Katherine A. Bain, and Phillip A. Gribble

Studies have demonstrated that individuals with chronic ankle instability (CAI) have diminished dynamic stability. Jerk-based measures have been utilized to examine dynamic balance because of their ability to quantify changes in acceleration and may provide an understanding of the postural corrections that occur during stabilizing following a jumping task. The purpose of this study was to compare acceleration and jerk following a jump stabilization task between individuals with CAI and the uninjured controls. Thirty-nine participants volunteered to participate in this case control study. Participants completed a jump stabilization task requiring them to jump off 2 feet, touch a marker set at 50% of their maximal vertical jump height, land on a single limb, and maintain balance for 3 seconds. Acceleration was calculated as the second derivative, and jerk was calculated as the third derivative of the displacement of the resultant vector position. Participants with CAI had greater acceleration (mean difference = 55.6 cm/s2; 95% confidence interval, 10.3 to 100.90; P = .017) and jerk compared with the uninjured controls (mean difference = 1804.5 cm/s3; 95% confidence interval, 98.7 to 3510.3; P = .039). These results suggest that individuals with CAI made faster and more frequent active postural control corrections to regain balance following a jump compared with the uninjured controls.