Amy D Sman

Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review

Objectives To determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury. Design Systematic review. Data sources An electronic database search was conducted (to 6 August 2012) of databases such as: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information. Study selection Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies included participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard. Results The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies investigated diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR−1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83–100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was found for other tests. Conclusions This is the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. Few studies were identified and our findings show that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. Additional diagnostic tests, such as MRI, should be considered before making a final diagnosis of syndesmosis injury.

Systematic review of exercise for Charcot-Marie-Tooth disease

Charcot‐Marie‐Tooth disease (CMT) is a slowly progressive hereditary degenerative disease and one of the most common neuromuscular disorders. Exercise may be beneficial to maintain strength and function for people with CMT, however, no comprehensive evaluation of the benefits and risks of exercise have been conducted. A systematic review was completed searching numerous electronic databases from earliest records to February 2015. Studies of any design including participants of any age with confirmed diagnosis of CMT that investigated the effects of exercise were eligible for inclusion. Of 13,301 articles identified following removal of duplicates, 11 articles including 9 unique studies met the criteria. Methodological quality of studies was moderate, sample sizes were small, and interventions and outcome measures used varied widely. Although the majority of the studies identified changes in one or more outcome measurements across exercise modalities, the majority were non‐significant, possibly due to Type II errors. Significant effects described included improvements in strength, functional activities, and physiological adaptations following exercise. Despite many studies showing changes in strength and function following exercise, findings of this review should be met with caution due to the few studies available and moderate quality of evidence. Well‐powered studies, harmonisation of outcome measures, and clearly described interventions across studies would improve the quality and comparability of the evidence base. The optimal exercise modality and intensity for people with CMT as well as the long‐term safety of exercise remain unclear.

Prognosis of ankle syndesmosis injury.

PURPOSE Ankle syndesmosis injury has been associated with persistent pain and prolonged recovery; however, no predictors of prolonged recovery have been identified. The aims of this study were to establish prognosis for ankle syndesmosis injury compared with a lateral ankle sprain and to explore factors associated with prolonged recovery. METHODS Participants (n = 63) age 21 ± 3.2 yr, with acute ankle ligament injuries (diagnosed through magnetic resonance imaging), were recruited from 10 sport clubs and sports medicine and physiotherapy clinics in two Australian cities. Follow-up was until full recovery and with preinjury activity level. Time to return to play was compared between injury types using Kaplan-Meier survival curves. Secondary analysis investigated putative factors that increased risk of prolonged recovery. For this analysis, participants unrecovered at 2 wk completed the following: Fear Avoidance Beliefs Questionnaire (FABQ); Star Excursion Balance Test, weight-bearing lunge, and vertical jump (VJ). These variables were correlated with time to recovery using bivariate Pearsons r correlation coefficient. RESULTS The median recovery time for conservatively treated ankle syndesmosis injury was 62 and 15 d for lateral sprain. The sport-specific subscale scores of the FABQ were significantly higher (P = 0.017) for the ankle syndesmosis group, whereas vertical jump height was lower for this group, (P = 0.052). No baseline variables were strong predictors (r ≥ 0.6) of recovery. Moderate correlations were found for VJ (r = -0.471, P = 0.004) and the sport-specific subscale of the FABQ (r = 0.463, P = 0.004). CONCLUSIONS Conservatively treated ankle syndesmosis injuries took four times longer to recover than lateral ankle sprain. Tests such as VJ and FABQ may identify individuals at risk of prolonged recovery and allow health professionals to determine realistic and appropriate time to recovery.

Predictive factors for ankle syndesmosis injury in football players: A prospective study

OBJECTIVES Up to 25% of all ankle injuries involve the ankle syndesmosis and factors that increase risk have yet to be investigated prospectively. This study aimed to identify predictors of ankle syndesmosis injury in football players. DESIGN A prospective study. METHODS Rugby Union and Australian Football League players were recruited during 2010. Rugby League and different Rugby Union players were recruited during 2011. Baseline data collection included: age, body size, flexibility, strength and balance. Bivariate correlations were performed between all predictors. Variables with r ≥ 0.7 had only one variable entered in further analysis. Remaining predictor variables were analysed for association with the presence/absence of ankle syndesmosis injury. Variables with non-significant association with injury (p>0.2) were included in a backward step-wise Cox regression model. RESULTS 202 male participants aged 21 ± 3.3 years (mean ± SD) were recruited of whom 12 (5.9%) sustained an ankle syndesmosis injury. The overall incidence rate was 0.59/1000 h sport participation for Rugby Union and Rugby League. Australian Football League training data was not available. No significant predictors were identified; however, participants who sustained an injury during the season performed a higher vertical jump (63.6 ± 8.2 cm) and greater Star Excursion Balance Test reach (80.5 ± 5.3 cm), than participants who did not sustain an injury: 59.1 ± 7.8 cm for Vertical Jump and 77.9 ± 6.1 cm for Star Excursion Balance Test. This was normalised for height. CONCLUSIONS Variables such as age, body size, foot posture, flexibility and muscle strength did not increase risk of ankle syndesmosis injury. Jump height and balance performance may play a role in predicting ankle syndesmosis sprains.

Randomised controlled trial protocol of foot and ankle exercise for children with Charcot-Marie-Tooth disease

INTRODUCTION Charcot-Marie-Tooth disease (CMT) is one of the most commonly inherited neuromuscular diseases--there is no effective treatment. Foot and ankle weakness is a major problem for children with CMT, thus interventions that focus on maintaining and increasing strength may provide a solution. RESEARCH QUESTION Is progressive resistance strength training an effective and safe intervention to improve strength, disability, gait and quality of life of children with CMT? PARTICIPANTS AND SETTING Sixty children (6 to 17 years) with confirmed CMT who reside in Sydney, Australia will be recruited via referral from a paediatric neurologist, advertisements or the Australasian Paediatric CMT Registry. INTERVENTION Participants will be randomised to undergo a 24-week, thrice weekly, high-intensity progressive resistance foot and ankle exercise programme (HIGH) or low-intensity foot and ankle exercise control programme (LOW). MEASUREMENTS Out-come measures will be conducted at baseline, 6, 12 and 24 months.The primary outcome is isometric dorsiflexion strength measured by hand-held dynamometry. Secondary outcomes include disability, gait, quality of life, functional ankle instability and muscle volume and fatty infiltration of the anterior compartment of the lower leg (determined by MRI). PROCEDURE Randomisation and allocation will be by a computer-generated algorithm, maintained and assigned by an external phone-based system, concealed to the investigators. Participants, parents and the outcome assessors will be blinded to group assignment. ANALYSIS Treatment effect between groups is by intention-to-treat with a linear regression approach to analysis of covariance using 95% CI and p < 0.05. DISCUSSION This study is the first randomised controlled trial to evaluate the risks and benefits of strengthening the affected muscles in children with CMT. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry. REGISTRATION NUMBER ACTRN12613000552785.

Systematic review of chronic ankle instability in children.

BackgroundChronic ankle instability (CAI) is a disabling condition often encountered after ankle injury. Three main components of CAI exist; perceived instability; mechanical instability (increased ankle ligament laxity); and recurrent sprain. Literature evaluating CAI has been heavily focused on adults, with little attention to CAI in children. Hence, the objective of this study was to systematically review the prevalence of CAI in children.MethodsStudies were retrieved from major databases from earliest records to March 2013. References from identified articles were also examined. Studies involving participants with CAI, classified by authors as children, were considered for inclusion. Papers investigating traumatic instability or instability arising from fractures were excluded. Two independent examiners undertook all stages of screening, data extraction and methodological quality assessments. Screening discrepancies were resolved by reaching consensus.ResultsFollowing the removal of duplicates, 14,263 papers were screened for eligibility against inclusion and exclusion criteria. Nine full papers were included in the review. Symptoms of CAI evaluated included perceived and mechanical ankle instability along with recurrent ankle sprain. In children with a history of ankle sprain, perceived instability was reported in 23-71% whilst mechanical instability was found in 18-47% of children. A history of recurrent ankle sprain was found in 22% of children.ConclusionDue to the long-lasting impacts of CAI, future research into the measurement and incidence of ankle instability in children is recommended.

Design and Reliability of a Novel Heel Rise Test Measuring Device for Plantarflexion Endurance

Background. Plantarflexion results from the combined action of the soleus and gastrocnemius muscles in the calf. The heel rise test is commonly used to test calf muscle endurance, function, and performance by a wide variety of professionals; however, no uniform description of the test is available. This paper aims to document the construction and reliability of a novel heel rise test device and measurement protocol that is suitable for the needs of most individuals. Methods. This device was constructed from compact and lightweight materials and is fully adjustable, enabling the testing of a wide variety of individuals. It is easy to assemble and disassemble, ensuring that it is portable for use in different settings. Findings. We tested reliability on 40 participants, finding excellent interrater reliability (ICC2,1 0.97, 95% CI: 0.94 to 0.98). Limits of agreement were less than two repetitions in 90% of cases and the Bland-Altman plot showed no bias. Interpretation. We have designed a novel, standardized, simple, and reliable device and measurement protocol for the heel rise test which can be used by researchers and clinicians in a variety of settings.

Safety and efficacy of progressive resistance exercise for Charcot-Marie-Tooth disease in children: a randomised, double-blind, sham-controlled trial

BACKGROUND Exercise is potentially therapeutic for neuromuscular disorders, but a risk of harm exists due to overwork weakness. We aimed to assess the safety and efficacy of progressive resistance exercise for foot dorsiflexion weakness in children with Charcot-Marie-Tooth disease. METHODS We did this randomised, double-blind, sham-controlled trial across the Sydney Childrens Hospitals Network (NSW, Australia). Children aged 6-17 years with Charcot-Marie-Tooth disease were eligible if they had foot dorsiflexion weakness (negative Z score based on age-matched and sex-matched normative reference values). We randomly allocated (1:1) children, with random block sizes of 4, 6, and 8 and stratification by age, to receive 6 months (three times per week on non-consecutive days; 72 sessions in total) of progressive resistance training (from 50% to 70% of the most recent one repetition maximum) or sham training (negligible non-progressed intensity), using an adjustable exercise cuff to exercise the dorsiflexors of each foot. The primary efficacy outcome was the between-group difference in dorsiflexion strength assessed by hand-held dynamometry (expressed as a Z score) from baseline to months 6, 12, and 24. The primary safety outcome was the between-group difference in muscle and intramuscular fat volume of the anterior compartment of the lower leg assessed by MRI (expressed as a scaled volume) from baseline to 6 months and 24 months. Participants, parents, outcome evaluators, and investigators other than the treatment team were masked to treatment assignment. Analysis was by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613000552785. FINDINGS From Sept 2, 2013, to Dec 11, 2014, we randomly assigned 60 children to receive progressive resistance exercise (n=30) or sham training (n=30), and 55 (92%) children completed the trial. ANCOVA-adjusted Z score differences in dorsiflexion strength between groups were 0 (95% CI -0·37 to 0·42; p=0·91) at 6 months, 0·3 (-0·23 to 0·81; p=0·27) at 12 months, and 0·6 (95% CI 0·03 to 1·12; p=0·041) at 24 months. Scaled muscle and fat volume was comparable between groups at 6 months (ANCOVA-adjusted muscle volume difference 0, 95% CI -0·03 to 0·10, p=0·24; and fat volume difference 0, 95% CI -0·01 to 0·05, p=0·25) and 24 months (0, -0·08 to 0·12, p=0·67; and 0, -0·05 to 0·03, p=0·58). No serious adverse events were reported. INTERPRETATION 6 months of targeted progressive resistance exercise attenuated long-term progression of dorsiflexion weakness without detrimental effect on muscle morphology or other signs of overwork weakness in paediatric patients with Charcot-Marie-Tooth disease. FUNDING Muscular Dystrophy Association and Australian National Health and Medical Research Council.

Effectiveness of a single platelet-rich plasma injection to promote recovery in rugby players with ankle syndesmosis injury

Aims To determine whether a single ultrasound-guided platelet-rich plasma (PRP) injection into the anterior inferior tibiofibular ligament (AITFL) reduces the time for rugby athletes to return to function and match play following MRI confirmed ankle syndesmosis injury. Methods Cohort controlled pilot study. 10 Rugby Union players were recruited during the 2014 season, and consented to receive a single autologous PRP injection into the AITFL within 14 days of MRI confirmed ankle syndesmosis injury. A historical control group included 11 comparable Rugby Union players between 2011 and 2013 who were treated conservatively with the same inclusion criteria and rehabilitation protocol as the intervention group. Participants followed a standardised rehabilitation protocol involving simple milestones for progression. Early functional tests were performed 2 weeks after the removal of the CAM (controlled ankle motion) boot. Time to return to play was recorded. Repeat functional testing occurred within 1 week of return to play. Results Groups were comparable in anthropometrics, playing position and MRI injury severity. Time to return to play was significantly less in the intervention group (p=0.048). Following return to play, athletes in the intervention group showed higher agility (p=0.002) and vertical jump (p=0.001). There was a lower level of fear avoidance associated with rugby in the intervention group (p=0.014). Conclusions This pilot study shows that, following ankle syndesmosis injury, a single autologous PRP injection may accelerate safe and successful return to Rugby Union, with improved functional capacity and reduced fear avoidance. It demonstrates the feasibility of a randomised controlled trial to further assess this therapy. Trial registration number ANZCTRN12614000055606.

Syndesmosis ankle injury in football players: a pilot study

Materials and methods We recruited football players from Sydney University Rugby Union and AFL clubs. The only exclusion criterion was symptoms at the time of screening that would affect baseline testing performance. Trained assessors conducted pre-season screening and participants were then followed for the season. The suite of baseline tests included vertical jump, star excursion balance test, single leg triple hop for balance and heel rise test. History of ankle injury and competition level was also recorded. Players who sustained an ankle injury during the season were retested within 2 weeks of injury or on removal of the boot, and when returned to play. Re-testing involved the weight bearing lunge, vertical jump, star excursion balance and a fear avoidance beliefs questionnaire.