Kyle B. Kosik

Prediction of Lateral Ankle Sprains in Football Players Based on Clinical Tests and Body Mass Index

Background: The lateral ankle sprain (LAS) is the most common injury suffered in sports, especially in football. While suggested in some studies, a predictive role of clinical tests for LAS has not been established. Purpose: To determine which clinical tests, focused on potentially modifiable factors of movement patterns and body mass index (BMI), could best demonstrate risk of LAS among high school and collegiate football players. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 539 high school and collegiate football players were evaluated during the preseason with the Star Excursion Balance Test (SEBT) and Functional Movement Screen as well as BMI. Results were compared between players who did and did not suffer an LAS during the season. Logistic regression analyses and calculated odds ratios were used to determine which measures predicted risk of LAS. Results: The LAS group performed worse on the SEBT–anterior reaching direction (SEBT-ANT) and had higher BMI as compared with the noninjured group (P < .001). The strongest prediction models corresponded with the SEBT-ANT. Conclusion: Low performance on the SEBT-ANT predicted a risk of LAS in football players. BMI was also significantly higher in football players who sustained an LAS. Identifying clinical tools for successful LAS injury risk prediction will be a critical step toward the creation of effective prevention programs to reduce risk of sustaining an LAS during participation in football.

Therapeutic interventions for improving self-reported function in patients with chronic ankle instability: a systematic review

Objective To identify which therapeutic intervention may be most effective for improving self-reported function in patients with chronic ankle instability (CAI). Design Systematic literature review. Articles were appraised using the Downs and Black Checklist by 3 reviewers. Data sources PubMed along with CINAHL, MEDLINE and SPORTDiscus within EBSCOhost for pertinent articles from their inception through August 2016. Eligibility criteria for selected studies Articles included were required to (1) be written in English, (2) report adequate data to calculate effect sizes, (3) identify patients with CAI, (4) use some form of therapeutic intervention and (5) use a self-reported questionnaire as a main outcome measurement. Results A broad spectrum of therapeutic interventions were identified related to balance training, multimodal rehabilitation, joint mobilisation, resistive training, soft-tissue mobilisation, passive calf stretching and orthotics. All of the articles included in the balance training category had moderate-to-strong Hedges g with none of the 95% CIs crossing 0. Hedges g effect sizes ranged from −0.67 to −2.31 and −0.51 to −1.43 for activities of daily living and physical activity, respectively. The multimodal rehabilitation category also produced moderate-to-strong Hedges g effect sizes but with large CIs crossing 0. Hedges g effect sizes ranged from −0.47 to −9.29 and −0.62 to −24.29 for activities of daily living and physical activity, respectively. Conclusions The main findings from this systematic review were balance training provided the most consistent improvements in self-reported function for patients with CAI.

Potential Corticomotor Plasticity in Those with and without Chronic Ankle Instability

Introduction Quantifying corticomotor alterations is important to understand the neurophysiological mechanisms that likely contribute to the neuromuscular control deficits observed in patients with chronic ankle instability (CAI). Corticomotor output mapping provides further insight into the changes within the motor cortex and identifies potential changes in the area of the motor cortex associated with selected muscles. Therefore, this investigation compared the corticomotor map output for the fibularis longus (FL) muscle in patients with and without CAI. Methods Eighteen CAI patients and 16 healthy controls (HC) volunteered. Transcranial magnetic stimulation was used to map the motor cortex’s representation of the FL. The normalized average of three motor evoked potentials at 100% of active motor threshold intensity was recorded for each scalp site on a 6 × 6 cm grid. Corticomotor output map was compared between groups through 1) the size of the corticomotor map area, 2) the volume of the corticomotor map, and 3) the location of cortical representation. Independent t-tests were used to assess group differences in each mapping outcome variable. Cohen’s d effect sizes along with 95% confidence intervals were calculated using the pooled SD values. Results CAI patients exhibited less map volume (P = 0.018, CAI = 8.2 ± 3.2 cm2 mV vs HC = 11.3 ± 3.9 cm2 mV) and map area (P = 0.046, CAI = 12.8 ± 6.0 cm2 vs HC: 17.4 ± 6.9 cm2) compared with HC. Conclusions The smaller map area and volume suggest a more concentrated area of neurons communicating with the FL muscle in patients with CAI. Consequently, motor cortical cells on the border of the FL excitation area are less committed to the proper function of the FL muscle and may be recruited by other surrounding areas. This may explain altered movement strategies that lead to ankle reinjury.

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

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.

Associations between Functional and Isolated Performance Measures in Collegiate Women’s Soccer Players

CONTEXT The Star Excursion Balance Test (SEBT) and Functional Movement Screen (FMS) are functional performance measures capable of predicting lower-extremity injury risk. While suboptimal SEBT and FMS performances are influenced by multiple factors, the contribution of hip strength and flexibility to these tests is mostly unknown. Examination of hip strength and flexibility influences on the SEBT and FMS may direct clinicians to better methods of correcting functional deficits. OBJECTIVE Determine the relationships of isometric hip strength and hip passive range of motion (PROM) with functional performance measures. DESIGN Cross-sectional. SETTING Athletic training facility. PARTICIPANTS 43 NCAA Division I womens soccer players (19.65 ± 1.12 y; 166.93 ± 3.84 cm; 60.99 ± 4.31 kg) volunteered. DATA COLLECTION AND ANALYSIS All participants were tested bilaterally in the SEBT; the deep squat, in-line lunge, hurdle step, and straight leg raise, comprising a lower-extremity FMS (FMS-LE); hip internal and external rotation PROM; and isometric hip extension strength (HEXT). The mean of the 3 averaged, normalized SEBT scores was used as a composite score. Pearson product moment correlations assessed relationships of SEBT and FMS-LE scores with PROM and HEXT. Significance was set a priori at P < .05. RESULTS Pearson correlations revealed anterior (ANT) SEBT scores had a low negative association with HEXT (r = -0.33,P = .004) and a low positive association with hip internal rotation PROM (PROM-IR) (r = .43,P = .003). All other correlations were negligible. CONCLUSIONS Flexibility training aimed at PROM-IR may contribute to improved ANT scores. Targeting HEXT and hip external rotation PROM are likely not preferred means of correcting deficits in SEBT and FMS-LE performance.

Variations in Star Excursion Balance Test Performance Between High School and Collegiate Football Players.

Abstract McCann, RS, Kosik, KB, Beard, MQ, Terada, M, Pietrosimone, BG, and Gribble, PA. Variations in Star Excursion Balance Test performance between high school and collegiate football players. J Strength Cond Res 29(10): 2765–2770, 2015—The Star Excursion Balance Test (SEBT) is a reliable inexpensive tool used to assess dynamic postural control deficits and efficacy in the prediction of musculoskeletal injuries, but with little previous consideration for performance differences across age and skill levels. The purpose of this study was to examine differences in SEBT scores between high school and collegiate football players. Three-hundred eighteen high school football players and 180 National Collegiate Athletic Association Division I collegiate football players volunteered to participate. Star Excursion Balance Test scores were obtained bilaterally for anterior (ANT), posterolateral (PL), and posteromedial (PM) directions, and for an overall composite (COMP) score. The mean of 3 trials from each leg was normalized to stance leg length and presented as a percentage score. Bilaterally averaged scores were compared between high school and collegiate football players using separate independent t-tests. A multiple linear backward regression determined the amount of variance in SEBT scores explained by age, mass, and height. Compared with collegiate athletes, high school athletes had lower PL (72.8 ± 11.4% vs. 77.1 ± 10.2%; p < 0.001), PM (83.5 ± 10.2% vs. 86.7 ± 10.7%; p = 0.001), and COMP (75.4 ± 8.5% vs. 78.0 ± 7.4%; p = 0.001) scores. Anterior scores did not differ between high school (69.9 ± 7.9%) and collegiate (70.3 ± 7.1%) athletes (p = 0.545). Age, mass, and height were not meaningful contributors to ANT (R 2 = 0.089; p < 0.001), PL (R 2 = 0.032; p < 0.001), PM (R 2 = 0.030; p = 0.002), and COMP (R 2 = 0.048; p < 0.001) variances. Disparity between high school and collegiate athletes should be considered when using the SEBT to identify risk of or deficits related to lower extremity injury in football players.

Isometric Hip Strength and Dynamic Stability of Individuals With Chronic Ankle Instability

CONTEXT   Compared with individuals who have a history of lateral ankle sprain (LAS) without markers of chronic ankle instability (CAI; LAS copers) and healthy people, those with CAI often exhibit neuromuscular impairments and dynamic-stability deficits at the hip. However, the influence of hip-strength deficits on dynamic stability remains unknown. OBJECTIVE   To compare isometric hip strength and dynamic stability in individuals with or without CAI and examine the degree of dynamic-stability variance explained by isometric hip strength. DESIGN   Case-control study. SETTING   Research laboratory. PATIENTS OR OTHER PARTICIPANTS   Sixty individuals (47 women, 13 men; age = 23.7 ± 4.6 years, height = 166.6 ± 7.7 cm, mass = 70.8 ± 15.7 kg) separated into CAI, LAS coper, and control groups based on previously established criteria. MAIN OUTCOME MEASURE(S)   Group differences in resultant vector time to stabilization (RVTTS) and isometric hip-extension, -abduction, and external-rotation strength were determined using 1-way analyses of covariance that controlled for sex and limb (dominant or nondominant) tested and Cohen d effect sizes (95% confidence intervals). Backward linear regressions and Cohen f2 effect sizes (95% confidence intervals) determined the amount of RVTTS variance explained by isometric hip strength. Significance was set a priori at P < .05. RESULTS   The CAI group had less isometric hip-extension strength than LAS copers ( P = .02, d = 0.72 [0.06, 1.34]) and controls ( P = .01, d = 1.19 [0.50, 1.84]) and less external-rotation strength than LAS copers ( P = .03, d = 0.78 [0.13, 1.41]) and controls ( P = .01, d = 1.02 [0.34, 1.65]). No group differences existed for RVTTS ( F2,57 = 1.16, P = .32) or abduction strength ( F2,57 = 2.84, P = .07). Resultant vector time to stabilization was explained by isometric hip strength for LAS copers ( R2 = 0.21, f2 = 0.27 [0.22, 0.32], P = .04) but not for the CAI ( R2 = 0.12, f2 = 0.14 [0.06, 0.22], P = .22) or control ( R2 = 0.10, f2 = 0.11 [0.03, 0.19], P = .18) groups. CONCLUSIONS   Participants with CAI had decreased isometric hip strength, but that did not equate to dynamic-stability deficits. Clinicians should include hip-muscle strengthening in rehabilitation protocols for patients with CAI, yet these gains may not enhance dynamic stability when landing from a jump.

Altered postural control variability in older-aged individuals with a history of lateral ankle sprain

The current study aimed to examine postural control performance during a single-leg balance task in elderly individuals with and without a previous history of lateral ankle sprain (LAS). Eighteen adults with a previous history of LAS (mean age = 66 years old) and 12 healthy controls (mean age = 65 years old) were included in the study. Participants performed three trials of a single-leg balance task during an eyes-opened condition for 20-s. Center of pressure (COP) trajectories in the anteroposterior (AP) and mediolateral (ML) directions were collected with a force plate. The following postural control measures were calculated in the AP and ML directions: 1) Sample Entropy (SampEn); 2) Approximate Entropy (ApEn); 3) mean of Time-to-Boundary minima (mean TTB); and 4) COP velocity (COPV). Older-age participants with a history LAS exhibited lower ApEn-AP, SampEn-AP, and SampEn-ML values compared to healthy controls (p < 0.05). The information gained from this investigation indicates more rigid postural control patterns, less adaptability, and more difficulty maintaining COP during a single-leg balance task in adults with a previous history of LAS. Our data suggest that there is a need to consider history of musculoskeletal injury when evaluating factors for postural control and fall risk in the elderly. Future investigations are needed to assess the effect of LAS on age-related declines in postural control and discern associations between potential risk factors of fall-related injuries and LAS in an elderly population.

O12 Prediction of recurrent injury following return-to-play from an ankle sprain

Study Design Prospective cohort study. Objectives Determine the ability of clinical outcomes and anthropometrics to predict recurrent injuries in athletes during the same competitive season following return-to-play (RTP) from an ankle sprain. Background Prediction of recurrent injury may be a valuable step towards minimising long-term consequences of ankle sprains. Limited investigation has predicted single-season recurrent ankle sprains in competitive athletes. Methods and Measures We evaluated 60 high school and collegiate athletes at RTP following an ankle sprain (F:17, M:43; 17.9±3.3 years; 178.6±10.8 cm; 85.0±24.8 kg). Clinical outcomes included pain (100 mm visual analogue scale), swelling (figure-of-eight girth measurement), dorsiflexion ROM (weight-bearing lunge test), ligamentous laxity (anterior drawer and talar tilt tests), and the Foot and Ankle Ability Measure activity of daily living (FAAM-ADL) and sport (FAAM-S) subscales. Anthropometric outcomes included height, mass, and body mass index (BMI). After RTP, athletic trainers documented recurrent ankle sprains during the same competitive season. Results Patients with (n=8) and without (n=52) recurrent ankle sprains did not differ in involved-limb pain (12.8±16.1 vs 9.8±13.7, p=0.58), swelling (56.7±4.1 vs 54.4±5.1 cm, p=0.23), dorsiflexion ROM (7.6±4.1 vs 6.9±3.6 cm, p=0.58), FAAM-ADL (85.1±9.1 vs 86.4%±10.8%, p=0.73), and FAAM-S (70.3±10.0 vs 64.8%±19.8%, p=0.44) at RTP. Anterior drawer (p=0.64) and talar tilt (p=0.25) laxity (+/-) was not associated with recurrent injury status. Patients with recurrent ankle sprains had greater height (185.7±9.9 vs 177.5±10.6 cm, p=0.04), mass (104.7±29.7 vs 81.9±22.8 kg, p=0.01), and BMI (30.1±6.7 vs 25.7±5.5 kg/m2, p=0.05) than patients without recurrent ankle sprains. Area under receiver operating characteristic curves (AUROC) and diagnostic odds ratios (DOR) exhibited predictive value for height (AUROC=0.71, DOR=4.93), mass (AUROC=0.75, DOR=12.21) and BMI (AUROC=0.71, DOR=9.48). Conclusions Athletic patients with greater height, mass, and BMI demonstrated greater odds of recurrent ankle sprains in the same competitive season following RTP. Taller and heavier patients may benefit from weight-management education before RTP to prevent recurrent ankle sprains.

P19 Re-examining self-reported instability and injury history to differentiate chronic ankle instability and coper patients

Study Design Case-control study. Objectives To explore self-reported responses for differentiating CAI(chronic ankle instability) and lateral ankle sprain(LAS)-Coper status. Background Self-reported instability and disability in conjunction with patient history have been used to differentiate CAI and LAS-Copers, but certain self-reported evaluation tools, such as the Identification of Functional Ankle Instability (IdFAI), may contain some redundancy. It remains unknown if other potential patient history items in concert with selected items from the IdFAI could create more efficient identification of CAI and LAS-Copers. Methods and Measures Data were extracted from 241 participants enrolled in previous laboratory studies that compared CAI(n=128) and LAS-Coper(n=113) groups classified by the guidelines of the International Ankle Consortium. Responses on each item of the IdFAI were examined, and patients responded if they had received formalised rehabilitation for their previous LAS(Y/N). Chi-square analyses were used to explore response distributions. Results Many of the items on the IdFAI resulted in statistically significant response distributions. Of note, 84% of CAI patients responded their ankle gives way(item#6) at least monthly, while 98.8% of LAS-Copers answered yearly or never(p<0.001). Similarly, 85.8% of CAI patients felt their ankle was unstable at least monthly during sport activity(item#10), while 96.4% of LAS-Copers responded yearly or never(p<0.001). More CAI patients reported using crutches than LAS-Copers (item#4)(p=0.006), but distribution of performing rehabilitation was not significantly different between the cohorts(p=0.06). Conclusions The frequency of giving-way and feeling unstable seems to differentiate CAI versus LAS-Copers effectively, which could be used to focus the categorization of patients with a history of LAS with the deficits that need addressing, while utilisation of crutches and initial rehabilitation was less definitive. Additional exploration on the severity of the previous LAS, and the interactions with utilisation of crutches and participation in rehabilitation is needed to shape future interventions for those with LAS history.