Janet E. Simon

Critical review of self-reported functional ankle instability measures.

Background: Since functional ankle instability (FAI) lacks a “gold standard” measure, a variety of self-reported ankle instability measures have been created. The purpose of this study was to determine which ankle instability measure identifies individuals who meet a minimum acceptable criterion for FAI. Methods: Participants volunteered from a large university population which included 242 participants (104 males, 138 females; 21.4 ± 1.4 years). The predictor variables were seven ankle instability questionnaires: Ankle Instability Instrument (AII), Ankle Joint Functional Assessment Tool (AJFAT), Chronic Ankle Instability Scale (CAIS), Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM), Foot and Ankle Instability Questionnaire (FAIQ), and Foot and Ankle Outcome Score (FAOS). The outcome variable (MC_FAI) was created based on the minimum acceptable criteria for FAI. This was established as at least one ankle sprain and an episode of giving way. Data were modeled using chi-square and multinomial logistic regression. Results: The regression model revealed all of the questionnaires were more useful at identifying participants who did not meet the minimum criteria for FAI (No MC_FAI = 95.7%, MC_FAI = 55.6%, overall = 84.6%). Based on the Wald criterion, the full model was reduced to the CAIT, AII, and FAAM. The reduced model revealed the CAIT (X 2 = 8.756, p = 0.003) and AII (X 2 = 31.992, p = 0.001) as the only variables that had a significant relationship with the outcome variable. Conclusion: The model illustrates no single measure was able to predict if individuals met the minimally accepted criteria for FAI. However, a significantly accurate prediction of ankle stability status was produced by combining the CAIT and AII. Clinical Relevance: Based on the results we recommend that researchers and clinicians use both the CAIT and AII to determine ankle stability status.

Ankle strength and force sense after a progressive, 6-week strength-training program in people with functional ankle instability.

CONTEXT Although strength training is commonly used to rehabilitate ankle injuries, studies investigating the effects of strength training on proprioception have shown conflicting results. OBJECTIVE To determine the effects of a 6-week strength-training protocol on force sense and strength development in participants with functional ankle instability. DESIGN Randomized controlled clinical trial. SETTING University athletic training research laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 40 participants with functional ankle instability were recruited. They were randomly placed into a training group (10 men, 10 women: age = 20.9 ± 2.2 years, height = 76.4 ± 16.1 cm, mass = 173.0 ± 7.9 kg) or control group (10 men, 10 women: age = 20.2 ± 2.1 years, height = 78.8 ± 24.5 cm, mass = 173.7 ± 8.2 kg). INTERVENTION(S) Participants in the training group performed strength exercises with the injured ankle 3 times per week for 6 weeks. The protocol consisted of a combination of rubber exercise bands and the Multiaxial Ankle Exerciser, both clinically accepted strengthening methods for ankle rehabilitation. The progression of this protocol provided increasingly resistive exercise as participants changed either the number of sets or resistance of the Thera-Band or Multiaxial Ankle Exerciser. Main Outcome Measure(s): A load cell was used to measure strength and force sense. Inversion and eversion strength was recorded to the nearest 0.01 N. Force-sense reproduction was measured at 2 loads: 20% and 30% of maximal voluntary isometric contraction. RESULTS Increases in inversion (F(1,38) = 11.59, P < 0.01, η(p)(2) = 0.23, power = 0.91) and eversion (F(1,38) = 57.68, P < .01, η(p)(2) = 0.60, power = 0.99) strength were found in the training group at the posttest when compared with the control group. No significant improvements were noted in force-sense reproduction for either group. CONCLUSIONS Strength training at the ankle increased strength but did not improve force sense.

The Effect of Kinesio Tape on Force Sense in People With Functional Ankle Instability

Objective:To evaluate the effect of kinesio tape (KT) on proprioception of the ankle. Design:Case-control study. Setting:Controlled laboratory. Participants:Twenty-eight subjects participated in this study: 14 subjects were in the control group (no history of ankle injuries) and 14 subjects were in the functional ankle instability (FAI) group (history of ankle injuries and a recent history of giving way). Interventions:Subjects in the FAI group received lateral ankle sprain KT application, whereas those in the control group received no tape application. Main Outcome Measures:Proprioception was measured using eversion force sense. This task was performed at 30% of the eversion maximum voluntary isometric contraction. Force sense was tested at baseline, immediately after KT application, and 72 hours after KT application. Results:Results revealed a significant time by group interaction (P = 0.03). At baseline and immediately after KT, subjects in the FAI group had significantly more force sense errors than those in the control group. However, after wearing the tape for 72 hours, no significant differences were identified between the groups. Conclusions:We found that after wearing KT for an extended amount of time, proprioceptive deficits were improved. After the tape application, the improvements resulted in similar conscious proprioceptive awareness in both the subjects with and without ankle instability.

Strength-Training Protocols to Improve Deficits in Participants With Chronic Ankle Instability: A Randomized Controlled Trial

CONTEXT Although lateral ankle sprains are common in athletes and can lead to chronic ankle instability (CAI), strength-training rehabilitation protocols may improve the deficits often associated with CAI. OBJECTIVE To determine whether strength-training protocols affect strength, dynamic balance, functional performance, and perceived instability in individuals with CAI. DESIGN Randomized controlled trial. SETTING Athletic training research laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 39 individuals with CAI (17 men [44%], 22 women [56%]) participated in this study. Chronic ankle instability was determined by the Identification of Functional Ankle Instability Questionnaire, and participants were randomly assigned to a resistance-band-protocol group (n = 13 [33%] age = 19.7 ± 2.2 years, height = 172.9 ± 12.8 cm, weight = 69.1 ± 13.5 kg), a proprioceptive neuromuscular facilitation strength-protocol group (n = 13 [33%], age = 18.9 ± 1.3 years, height = 172.5 ± 5.9 cm, weight = 72.7 ± 14.6 kg), or a control group (n = 13 [33%], age = 20.5 ± 2.1 years, height = 175.2 ± 8.1 cm, weight = 70.2 ± 11.1 kg). INTERVENTION(S) Both rehabilitation groups completed their protocols 3 times/wk for 6 weeks. The control group did not attend rehabilitation sessions. MAIN OUTCOME MEASURE(S) Before the interventions, participants were pretested by completing the figure-8 hop test for time, the triple-crossover hop test for distance, isometric strength tests (dorsiflexion, plantar flexion, inversion, and eversion), the Y-Balance test, and the visual analog scale for perceived ankle instability. Participants were again tested 6 weeks later. We conducted 2 separate, multivariate, repeated-measures analyses of variance, followed by univariate analyses on any significant findings. RESULTS The resistance-band protocol group improved in strength (dorsiflexion, inversion, and eversion) and on the visual analog scale (P < .05); the proprioceptive neuromuscular facilitation group improved in strength (inversion and eversion) and on the visual analog scale (P < .05) as well. No improvements were seen in the triple-crossover hop or the Y-Balance tests for either intervention group or in the control group for any dependent variable (P > .05). CONCLUSIONS Although the resistance-band protocol is common in rehabilitation, the proprioceptive neuromuscular facilitation strength protocol is also an effective treatment to improve strength in individuals with CAI. Both protocols showed clinical benefits in strength and perceived instability. To improve functional outcomes, clinicians should consider using additional multiplanar and multijoint exercises.

Reliability and Validity of a New Questionnaire Created to Establish the Presence of Functional Ankle Instability: The IdFAI

The purpose of this investigation was to examine the consistency (reliability) and accuracy (validity) of a new ankle instability questionnaire—the Identifi cation of Functional Ankle Instability (IdFAI). One hundred ten participants were asked to complete the IdFAI on 2 occasions and the Lower Extremity Functional Screen (LEFS) on 1 occasion. Test–retest reliability was evaluated by intraclass correlation coeffi cient (ICC 2,1). Convergent validity was evaluated by comparing the IdFAI with the LEFS using Spearman’s rho (� ). The dependent variables were the scores on the IdFAI and the LEFS. Test–retest reliability ranged from 0.81 to 0.94 for the questionnaire factors and was 0.92 for the overall questionnaire. Results of validity testing identifi ed a statistically signifi cant correlation between the IdFAI and LEFS (� = � 0.38, P � .01). The IdFAI is a simple, valid, reliable questionnaire that can be used to categorize an individual’s FAI status.

Epidemiology of Football Injuries in the National Collegiate Athletic Association, 2004-2005 to 2008-2009

Background: Research has found that injury rates in football are higher in competition than during practice. However, there is little research on the association between injury rates and type of football practices and how these specific rates compare with those in competitions. Purpose: This study utilized data from the National Collegiate Athletic Association Injury Surveillance System (NCAA ISS) to describe men’s collegiate football practice injuries (academic years 2004-2005 to 2008-2009) in 4 event types: competitions, scrimmages, regular practices, and walkthroughs. Study Design: Descriptive epidemiological study. Methods: Football data during the 2004-2005 to 2008-2009 academic years were analyzed. Annually, an average of 60 men’s football programs provided data (9.7% of all universities sponsoring football). Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (RRs), 95% CIs, and injury proportions were reported. Results: The NCAA ISS captured 18,075 football injuries. Most injuries were reported in regular practices (55.9%), followed by competitions (38.8%), scrimmages (4.4%), and walkthroughs (0.8%). Most AEs were reported in regular practices (77.6%), followed by walkthroughs (11.5%), competitions (8.6%), and scrimmages (2.3%). The highest injury rate was found in competitions (36.94/1000 AEs), followed by scrimmages (15.7/1000 AEs), regular practices (5.9/1000 AEs), and walkthroughs (0.6/1000 AEs). These rates were all significantly different from one another. Distributions of injury location and diagnoses were similar across all 4 event types, with most injuries occurring at the lower extremity (56.0%) and consisting of sprains and strains (50.6%). However, injury mechanisms varied. The proportion of injuries due to player contact was greatest in scrimmages (66.8%), followed by regular practices (48.5%) and walkthroughs (34.9%); in contrast, the proportion of injuries due to noncontact/overuse was greatest in walkthroughs (41.7%), followed by regular practices (35.6%) and scrimmages (21.9%). Conclusion: Injury rates were the highest in competitions but then varied by the type of practice event, with higher practice injury rates reported in scrimmage. In addition, greater proportions of injuries were reported in regular practices, and greater proportions of exposures were reported in regular practices and walkthroughs. Efforts to minimize injury in all types of practice events are essential to mitigating injury incidence related to both contact and noncontact.

Current Health-Related Quality of Life in Former National Collegiate Athletic Association Division I Collision Athletes Compared With Contact and Limited-Contact Athletes.

CONTEXT Previous researchers have shown that current health-related quality of life (HRQoL) is lower in former National Collegiate Athletic Association Division I athletes than in nonathletes. However, evidence supports the idea that individuals in collision sports (football) may suffer more serious injuries that may affect them later in life. OBJECTIVE To measure HRQoL in former Division I collision, contact, and limited-contact athletes. DESIGN Cross-sectional study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 374 former Division I athletes between the ages of 40 and 65 years were separated into collision, contact, and limited-contact groups. INTERVENTION(S) All individuals completed the Short Form 36 version 2 via a computer. MAIN OUTCOME MEASURES(S) The dependent variables were the physical component and mental component summary scores and the physical functioning, physical role functioning, bodily pain, general health, vitality, social role functioning, emotional role functioning, and mental health scales. An initial multivariate analysis of covariance included data from the 2 domains: physical component and mental component summary scores. The second multivariate analysis of covariance included data from the 8 dimensions: physical function, role physical, bodily pain scale, general health, mental health, role emotional, social function, and vitality scales. The α level was set at P < .05 with a covariate of sex. RESULTS The responses were significantly lower (worse) for the former collision athletes compared with the contact and limited-contact athletes for the summary scores (F2,370 = 90.09, P < .01) and all 8 scales (F8,364 = 24.33, P < .01). The largest differences were between the collision and limited-contact athletes for the bodily pain and role physical scales, with mean differences of 12.91 and 11.80 points, respectively. CONCLUSIONS Competing at the Division I level can be strenuous on an athletes physical, mental, and social dimensions, which can affect the athlete later in life. Based on these data, collision athletes may sacrifice their future HRQoL compared with contact and limited-contact athletes.

Extended Use of Kinesiology Tape and Balance in Participants With Chronic Ankle Instability

CONTEXT Participants with chronic ankle instability (CAI) have been shown to have balance deficits related to decreased proprioception and neuromuscular control. Kinesiology tape (KT) has been proposed to have many benefits, including increased proprioception. OBJECTIVE To determine if KT can help with balance deficits associated with CAI. DESIGN Cohort study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS Thirty participants with CAI were recruited for this study. INTERVENTION(S) Balance was assessed using the Balance Error Scoring System (BESS). Participants were pretested and then randomly assigned to either the control or KT group. The participants in the KT group had 4 strips applied to the foot and lower leg and were instructed to leave the tape on until they returned for testing. All participants returned 48 hours later for another BESS assessment. The tape was then removed, and all participants returned 72 hours later to complete the final BESS assessment. MAIN OUTCOME MEASURE(S) Total BESS errors. RESULTS Differences between the groups occurred at 48 hours post-application of the tape (mean difference = 4.7 ± 1.4 errors, P < .01; 95% confidence interval = 2.0, 7.5) and at 72 hours post-removal of the tape (mean difference = 2.3 ± 1.1 errors, P = .04; 95% confidence interval = 0.1, 4.6). CONCLUSIONS The KT improved balance after it had been applied for 48 hours when compared with the pretest and with the control group. One of the most clinically important findings is that balance improvements were retained even after the tape had been removed for 72 hours.

Using Ankle Bracing and Taping to Decrease Range of Motion and Velocity During Inversion Perturbation While Walking.

CONTEXT Prophylactic ankle supports are commonly used. However, the effectiveness of external supports in preventing an inversion stress has been debated. OBJECTIVE To evaluate how ankle bracing and taping affect inversion range of motion, time to maximum inversion, inversion velocity, and perceived ankle stability compared with a control condition during a dynamic inversion perturbation while walking. DESIGN Crossover study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 42 physically active participants (16 men, 26 women; age = 21.2 ± 3.3 years, height = 168.9 ± 8.9 cm, mass = 66.1 ± 11.4 kg) volunteered. INTERVENTION(S) Participants walked on a custom-built walkway that suddenly inverted their ankles to 30° in 3 conditions: brace, tape, and control (no external support). We used an ASO ankle brace for the brace condition and a closed basketweave technique for the tape condition. Three trials were completed for each condition. Main Outcome Measure(s) Maximum inversion (degrees), time to maximum inversion (milliseconds), and inversion velocity (degrees per second) were measured using an electrogoniometer, and perceived stability (centimeters) was measured using a visual analog scale. RESULTS Maximum inversion decreased more in the brace condition (20.1°) than in the control (25.3°) or tape (22.3°) conditions (both P values = .001), and the tape condition restricted inversion more than the control condition (P = .001). Time to maximum inversion was greater in the brace condition (143.5 milliseconds) than in the control (123.7 milliseconds; P = .001) or tape (130.7 milliseconds; P = .009) conditions and greater in the tape than in the control condition (P = .02). Inversion velocity was slower in the brace condition (142.6°/s) than in the control (209.1°/s) or tape (174.3°/s) conditions (both P values = .001) and slower in the tape than in the control condition (P = .001). Both the brace and tape conditions provided more perceived stability (0.98 cm and 0.94 cm, respectively) than the control condition (2.38 cm; both P values = .001). CONCLUSIONS Both prophylactic conditions affected inversion range of motion, time to maximum inversion, inversion velocity, and perceived ankle stability. However, bracing provided more restriction at a slower rate than taping.

Altered Vertical Ground Reaction Forces in Participants With Chronic Ankle Instability While Running

CONTEXT Altered gait kinetics may increase the risk of long-term injuries in participants with chronic ankle instability (CAI). Vertical ground reaction forces (vGRFs) can provide insight into how body loading is altered. OBJECTIVE To compare the components of vGRFs while running in participants with or without CAI. DESIGN Cohort study. SETTING University biomechanics laboratory. PATIENTS OR OTHER PARTICIPANTS Twenty-four experienced, college-aged runners. Groups were categorized by the presence (CAI group) or absence (control group) of CAI through self-reported questionnaires. INTERVENTION(S) After a warm-up period, all participants ran on an instrumented treadmill for 5 minutes at 3.3 m/s. Data were collected during the last 30 seconds. Five continuous trials of heel-to-toe running were identified per participant and averaged for statistical analysis. MAIN OUTCOME MEASURE(S) The dependent variables were impact peak force (N/body weight [BW]), active peak force (N/BW), time to impact peak force (milliseconds), time to active peak force (milliseconds), and average loading rate ([N/BW]/s). RESULTS A difference was found between groups (P = .002). The CAI group had higher impact peak forces (P = .001) and active peak forces (P = .002) compared with the control group. The CAI group also had an increased loading rate (P = .001) and a shorter time to reach the active peak force (P = .001) compared with the control group. No difference was seen between groups in the time to reach the impact peak force (P = .952). CONCLUSIONS Participants with CAI produced altered vGRFs and loading rates while running. Altered loading rates could predispose individuals with CAI to stress-related injuries and repetitive sprains.