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Patients with lateral ankle sprains (LASs) often have deficient patient-reported outcomes (PROs) at return to activity (RTA), potentially increasing risk for recurrent LAS and ankle pain. Additionally, applied care strategies are known to correct impairments, but their ability to mitigate risk for long-term consequences remains unknown. To determine if applied care strategies and PRO scores at RTA and 6 months after RTA predict recurrent LAS and ankle pain 12 months after an acute LAS. Prospective cohort study. Online survey. We enrolled 63 individuals within 1 week of sustaining an acute LAS. Participants completed online surveys about their health history and recent LAS. At RTA and 6 months after RTA, participants completed online surveys regarding demographics, applied care strategies, and PROs, including the Foot and Ankle Disability Index (FADI), Identification of Functional Ankle Instability, Godin Leisure-Time Exercise Questionnaire, and Short Form-8 (SF8). At 12 months post-RTA, we asked participants if they sustained recurrent LASs. Chi-square analyses determined if recurrent LAS and ankle pain at 12 months were related to applied care strategies or ankle pain at RTA. Independent t tests compared demographics and PROs at RTA and 6 months between participants with and without a recurrent LAS or ankle pain at 12 months. Logistic regression and area under the receiver operating characteristic analyses determined if demographics, applied care strategies, ankle pain at RTA, and PRO scores at RTA and 6 months predicted recurrent LAS and ankle pain at 12 months. Participants with a recurrent LAS had a lower walking boot use (P =.05) and were taller than those without (P =.03). Increased height and lack of walking boot use were predictive of recurrent LAS (P <.01, R2 = 0.33, area under the receiver operating characteristic = 0.81 [0.68, 0.95]). Individuals with LAS who are taller and do not use a walking boot might have greater risk for a recurrent LAS withing 12 months of RTA. [ABSTRACT FROM AUTHOR]

Context: Many individuals who sustain a lateral ankle sprain (LAS) fail to return to prior activity due to residual symptoms; and report elevated levels of injury-related fear, decreased function, and decreased health-related quality of life (HRQOL). Additionally, individuals with history of LAS exhibit deficits in neurocognitive functional measures like visuomotor reaction time (VMRT), which contributes to worse patient-reported outcome scores. The aim of this study was to examine the relationship between HRQOL and lower-extremity (LE) VMRT in individuals with LAS history. Design: Cross-sectional. Methods: Young adult female volunteers with history of LAS (n = 22; age = 24 [3.5] y; height = 163.1 [9.8] cm; mass = 65.1 [11.5] kg; and time since last LAS = 67.8 [50.5] mo) completed HRQOL outcomes including the following: (1) Tampa Scale of Kinesiophobia-11, (2) Fear-Avoidance Beliefs Questionnaire, (3) Penn State Worry Questionnaire, (4) modified Disablement in the Physically Active Scale, and (5) Foot and Ankle Disability Index (FADI). Additionally, participants completed a LE-VMRT task by responding to a visual stimulus using their foot to deactivate light sensors. Participants completed trials bilaterally. Separate Spearman rho correlations were performed to assess the relationship between patient-reported outcomes assessing constructs of HRQOL and LE-VRMT bilaterally. Significance was set at P < .05. Results: There was a strong, significant negative correlation between FADI-Activities of Daily Living (ρ = -.68; P = .002) and FADI-Sport (ρ = -.76; P = .001) scores and injured limb LE-VMRT; moderate, significant negative correlations between the uninjured limb LE-VMRT and FADI-Activities of Daily Living (ρ = -.60; P = .01) and FADI-Sport (ρ = -.60; P = .01) scores; and moderate, significant positive correlations between the injured limb LE-VMRT and modified Disablement in the Physically Active Scale-Physical Summary Component (ρ = .52; P = .01) and modified Disablement in the Physically Active Scale-Total (ρ = .54; P = .02) scores. All other correlations were not statistically significant. Conclusions: Young adult women with history of LAS demonstrated an association between self-reported constructs of HRQOL and LE-VMRT. As LE-VMRT is a modifiable injury risk factor, future studies should examine the effectiveness of interventions designed to improve LE-VMRT and the impact on self-reported HRQOL. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Pain is a common symptom experienced by individuals who sustain an acute lateral ankle sprain and can continue to persist among those who develop chronic ankle instability. Most rehabilitation protocols for individuals with acute ankle sprains or chronic ankle instability focus on restoring physical impairments and have largely omitted any pain-relieving therapies. This impairment-based focus has led pain to be an understudied symptom among individuals with an ankle sprain history. Overlooking the role of pain has also left clinicians with little insight into whether pain experienced after an ankle sprain is local (i.e., peripheral sensitization) or widespread (i.e., central sensitization). Understanding the pain profiles for those with an ankle sprain history may represent an unexploited area for clinicians and future research to improve health outcomes for this patient population. Clinical Question: Is there evidence to suggest that pain mechanosensitivity levels are different between those with and without a history of lateral ankle sprain? Summary of Key Findings: The literature was systematically searched for Level 4 evidence or higher. The search yielded two cross-sectional case-control studies and one cross-sectional study that met the inclusion and exclusion criteria. Based on the available evidence, pain mechanosensitivity levels are lower across ligamentous stabilizers immediately after an acute ankle sprain and over lower extremity neuromuscular structures among individuals with chronic ankle instability. ClinicalBottom Line: There is weak evidence to support an ankle sprain history can affect local pain mechanosensitivity levels of structures surrounding the ankle but not at distant locations. Strength of Recommendation: Level 4 evidence is available according to the Center for Evidence-Based Medicine. [ABSTRACT FROM AUTHOR]

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 1 stage 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Altered reorganization of the sensorimotor system after an initial lateral ankle sprain may lead to a chronic neuromuscular maladaptation in multiple body locations. Specifically, decreased diaphragm contractility has been observed in patients with chronic ankle instability (CAI). The diaphragm has an essential role in postural control. Decreased diaphragm contractility could associate with diminished postural control commonly observed in patients with CAI. However, no study has determined if diaphragm contractility contributes to postural control in a CAI population. Hypothesis: Decreased diaphragm contractility would be negatively associated with static postural control in patients with CAI. Study Design: Cross-sectional study design. Level of Evidence: Level 4. Methods: A total of 15 participants with CAI participated voluntarily. An ultrasonography assessment was performed to quantify the right and left hemidiaphragm thickness at the end of resting inspiration and expiration in supine while breathing quietly. The degree of diaphragm contractility was calculated from the diaphragm thickness. Participants performed 3 eyes-open trials of a 20-second single-leg balance task on the involved limb. Static postural control measures included the center of pressure velocity (COPV) and mean of time-to-boundary (TTB) minima in the anteroposterior (AP) and mediolateral directions. Results: Moderate correlations of the right hemidiaphragm contractility were observed with COPV (ρ = -0.54) and TTB mean minima (ρ = 0.56) (P < 0.05) in the AP direction. The left hemidiaphragm contractility was moderately correlated with COPV (ρ = −0.56) and TTB mean minima (ρ = 0.60) (P < 0.05) in the AP direction. Conclusion: Lower diaphragm contractility may be associated with diminished static postural control in the AP direction in patients with CAI. Clinical Relevance: This study highlights diaphragm contractility could be a potential connection with diminished static postural control in patients with CAI. Our data raise new avenues for future exploration including potential beneficial effects of implementation of diaphragm breathing exercises and techniques for restoring static postural control in patients with CAI. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Patient-reported outcomes (PROs) can be used to assess and monitor psychological health following musculoskeletal injury. Studies have reported decreased psychological health after lateral ankle sprain (LAS) using numerous PROs. The purpose of this systematic review was to critically evaluate individual studies, summarize PROs utilized to quantify psychological health, and examine the effect of ankle injury on psychological health between groups (1 LAS, >1 LAS, and healthy controls). Databases searched included: CINAHL, MEDLINE, SPORTDiscus, APA, Psychinfo and PubMed Central. All case-control studies were critically appraised using the modified Downs and Black. Effect sizes (ES) were calculated between the groups (1 LAS, >1 LAS, healthy control) for each of the identified studies, for each included PRO used to quantify psychological impairments. Nine high-quality manuscripts were included. Overall, individuals with history of > 1 LAS self-reported greater psychological impairments compared to healthy controls (ES range = −0.37–12.16), while those with 1 LAS had similar psychological health to healthy control groups (ES rang e = −0.65–0.65). Conclusion: The main findings from this systematic review were individuals with > 1 LAS have increased levels of injury-related fear and decreased psychological health compared to healthy controls. PROs can aid clinicians in identifying psychological health concerns during rehabilitation. [ABSTRACT FROM AUTHOR]

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 women's 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. [ABSTRACT FROM AUTHOR]

Individuals with chronic ankle instability (CAI) present with alterations in the compositional structure of their talar articular cartilage. These alterations likely influence how the talar cartilage responds to the loading associated with activities of daily living, such as walking. Ultrasonography has emerged as an alternative imaging modality for assessing the amount of cartilage deformation in response to loading because it is clinically accessible and cost effective for routine measurements. To (1) compare talar-cartilage deformation in response to a standardized exercise protocol between those with and those without CAI and (2) examine the association between spatiotemporal walking gait parameters and cartilage deformation. Case-control study. Research laboratory. A volunteer sample of 24 participants with self-reported CAI (age = 23.2 ± 3.9 years, body mass index [BMI] = 25.1 ± 3.7 kg/m2) and 24 uninjured controls (age = 24.3 ± 2.9 years, BMI = 22.9 ± 2.8 kg/m2). Spatiotemporal walking gait was first assessed from 5 self-selected trials using an electronic walkway with data sampled at 120 Hz. An 8- to 13-MHz linear-array ultrasound transducer placed transversely in line with the medial and lateral malleoli captured 3 images before and after a standardized loading protocol consisting of 30 single- and double-limb squats, 2-minute single-limb balance, and 10 single-legged drops from a 40-cm-height box. After controlling for BMI, we found that the participants with CAI had greater deformation than the uninjured control participants (P =.034). No other between-groups differences were observed (P values >.05). No significant partial correlations were noted between talar-cartilage deformation and spatiotemporal gait parameters when controlling for BMI (P >.05). Individuals with CAI had greater talar-cartilage deformation in response to a standardized exercise protocol than control individuals. The amount of talar-cartilage deformation was not associated with the spatiotemporal walking gait. [ABSTRACT FROM AUTHOR]

Lateral ankle sprains are a commonly incurred injury in sports. They have a high recurrence rate and can lead to the development of persistent injury associated symptoms. We performed a quantitative synthesis of published case reports documenting the kinematics of acute lateral ankle sprains and episodes of 'giving-way' of the ankle joint to provide a comprehensive description of the mechanisms. A systematic literature search was conducted to screen records within MEDLINE® and EMBASE®. Additional strategies included manual search of specific journals, as well as contacting researchers in relevant communities to retrieve unpublished data. Twenty-four cases were included in the quantitative synthesis, 11 from individual case reports and 13 from four separate case series. Two authors independently reviewed all the articles and extracted ankle joint kinematic data. Excessive ankle inversion was the most pronounced kinematic pattern observed across all included cases, with a mean peak inversion angle of 67.5° (range 2.0 to 142) and a mean peak inversion velocity of 974°/s (range 468 to 1752). This was followed by internal rotation and plantar flexion, respectively. A homogeneous linear function revealed a mean inversion velocity across all cases of 337°/s (range 117 to 1400; R2 = 0.78; p < 0.0001). [ABSTRACT FROM AUTHOR]

Supervised physical therapy is the recommended care for an ankle sprain. Yet, recent evidence indicates some ankle sprain patients may not receive the recommended care, and instead, prescribed medication to alleviate symptoms. Therefore, the purpose of this study is to describe the percentage of patients reporting to an office-based physician in the U.S. that were or were not referred to physical therapy. Secondly, to describe the percentage of ankle sprain patients with or without medication administered, supplied or ordered. This was a secondary analysis of the cross-sectional National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016. The NAMCS is a multi-stage probability sample survey of visits to office-based physicians. The percentage and associated 95% confidence intervals (CI) were calculated for visits that had a physical therapy referral or a non-steroidal anti-inflammatory drug (NSAID), opioid and non-opioid analgesics administered, supplied or ordered. Sampled data were weighted to produce national-level estimates. A physical therapy referral was given for 16.8% (95% CI: 13.2, 21.2) of ankle sprain visits. Approximately 34.5% (95%CI: 30.5, 38.7) of all ankle sprain visits had a medication administered, supplied or ordered. NSAIDs (72.1%; 95% CI: 66.9,76.8) and opioids (21.0%; 95% CI: 16.3, 26.5) were the two most common types of medication. NSAIDs and opioid medication combined were administered, supplied or ordered more frequently than a referral to physical therapy. These findings provide evidence that suggests many ankle sprain patients reporting to an office-based physician are not receiving the recommended care; physical therapy. Rather, medication appears to be the primary type of care provided to patients. These data are important because it gives a focused area to improve the treatment of an ankle sprain by developing strategies that ensure all patients are provided the recommended care from the onset of entering the healthcare system. [ABSTRACT FROM AUTHOR]

Context: People with chronic ankle instability (CAI) display a lower regional and global health-related quality of life (HRQoL). Examinations of HRQoL outcomes associated with CAI have addressed younger adults, restricting our understanding of the long-term consequences of CAI. Objective: To compare ankle regional and global HRQoL in middle-aged participants with and those without CAI. Design: Cross-sectional study. Setting: Laboratory. Patients or other participants: A total of 59 middle-aged volunteers, consisting of 18 with CAI (age = 50.2 ± 9.3 years), 17 who were ankle-sprain copers (age = 54.5 ± 8.7 years), and 24 uninjured controls (age = 56.7 ± 10.0 years). Main outcome measure(s): Participants completed the Foot and Ankle Disability Index (FADI) and the Patient-Reported Outcomes Measurement Information System Adult Profile. Regional HRQoL was assessed using the FADI Activities of Daily Living and Sport subscales. Global HRQoL was measured using the 43-item Patient-Reported Outcomes Measurement Information System Adult Profile, which contains 7 short forms-Physical Function, Pain Interference, Fatigue, Depression, Sleep Disturbance, Anxiety, and Ability to Participate in Social Roles and Activities. Separate Kruskal-Wallis tests were used to determine between-groups differences. Results: Middle-aged participants with CAI had lower scores on both subscales of the FADI than the coper and control groups (all P values <.001). Participants with CAI scored lower on the Physical Function (U = 116.0, z = -2.78, P = .005) and Ability to Participate in Social Roles and Activities (U = 96.0, z = -3.09, P = .002) subscales but higher on the Pain Interference (U = 144.0, z = -2.36, P = .02), Fatigue (U = 110.0, z = -2.72, P = .006), and Depression (U = 110.5, z = -2.91, P = .004) subscales than the control group. Participants with CAI also scored lower on the Physical Function (U = 74.5, z = -2.79, P = .005) and Ability to Participate in Social Roles and Activities (U = 55.0, z = -3.29, P = .001) subscales but higher on the Fatigue (U = 90.0, z = -2.09, P = .04) and Depression (U = 96.5, z = -1.97, P = .048) subscales than the coper group. Conclusions: Middle-aged participants with CAI displayed worse ankle regional and global HRQoL than their age-matched healthy counterparts and copers. These results demonstrated that CAI can affect HRQoL outcomes in middle-aged adults. [ABSTRACT FROM AUTHOR]

Background: Recent research has demonstrated that patients with ankle sprain who are discharged from the emergency department (ED) are prescribed an opioid. Minimizing the exposure to opioids is important to help prevent future abuse and misuse of these medications.Objective: Identify ED visit characteristics for an ankle sprain that are associated with an opioid given in the ED, prescribed at discharge, or both.Design: Retrospective analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS).Setting: Hospital.Participants: Isolated ankle sprain visits to a United States ED.Main Outcome Measurements: The main outcome was an opioid given in the ED, prescribed at discharge, or both between 2010 and 2015. Explanatory variables included age, sex, race, attending physician or resident, and geographic location of the hospital. A multiple logistic regression was performed to assess the independent association between an opioid given in the ED, prescribed at discharge, or both, and all explanatory variables. The analysis accounted for the cluster, strata, and probability weights for each year of the NHAMCS.Results: Ankle sprain visits for patients ≤17 years of age had a lower odds of an opioid being given in the ED, prescribed at discharge, or both, compared to visits for patients 18 to 24 years of age (adjusted odds ratio [aOR] = 0.26 [95% confidence interval (CI) = 0.1, 0.5]; P < .001). Visits in the West (aOR = 2.5 [95% CI = 1.2, 5.4]) or South (aOR = 2.9 [95% CI = 1.6, 5.4]; P = .010) had higher odds of an opioid being given in the ED, prescribed at discharge, or both, compared to visits in the Northeast.Conclusions: Ankle sprain visits for patients ≤17 years of age had a lower odds of an opioid compared to visits for patients 18 to 24 years of age. Ankle sprain visits in the South or West had a higher odds of an opioid compared to visits in the Northeast. These findings provide a direction for future work aimed at minimizing exposure to opioids after an ankle sprain. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: An ankle sprain is a common musculoskeletal injury treated in the emergency department. Rest, ice, compression, and elevation is the preferred method for managing the symptoms after an ankle sprain. However, many patients receive a medication, such as a nonsteroidal anti-inflammatory drug (NSAID) or an opioid.Objectives: We sought to quantify the type of medication(s) used for an ankle sprain and to examine those across age and sex.Methods: This was a retrospective review of the publicly available data collected through the National Hospital Ambulatory Medical Care Survey from 2006-2015. All cases with an isolated diagnosis of an ankle sprain were identified. Medication listed for each case was classified based on its detailed category and further explored across all 10 years, age, and sex.Results: An estimated 9,052,678 ankle sprain visits occurred in emergency departments from 2006-2015. NSAIDs (56.1%) and opioid analgesic combination (28.4%) were the 2 most common medications. Regardless of the type, most medications were prescribed at discharge. The use of NSAIDs appears to have increased while opioid analgesic combinations decreased in 2010. NSAIDs were the most common medication identified with each age cohort; however, there was no apparent trend in medication for sex.Conclusions: NSAIDs are the most common medication used for ankle sprain visits to the ED. Nevertheless, an opioid is also used at a relatively high rate for this injury. These findings provide awareness and opportunity to focus on strategies for reduction of opioid use. [ABSTRACT FROM AUTHOR]

Background: Chronic ankle instability (CAI) is associated with hip strength deficits and altered movement in the lower extremity. However, it remains unclear how hip strength deficits contribute to lateral ankle sprain (LAS) mechanisms. We aimed to compare lower extremity landing kinematics and isometric hip strength between individuals with and without CAI and examine associations between hip kinematics and strength. Methods: Seventy-six individuals completed 5 single-leg landings, during which we collected three-dimensional ankle, knee, and hip kinematics from 200 milliseconds pre–initial contact to 50 milliseconds post–initial contact. We calculated average peak torque (Nm/kg) from 3 trials of isometric hip extension, abduction, and external rotation strength testing. One-way analyses of variance assessed group differences (CAI, LAS coper, and control) in hip strength and kinematics. Pearson product moment correlations assessed associations between hip kinematics and strength. We adjusted the kinematic group comparisons and correlation analyses for multiple comparisons using the Benjamini-Hochberg method. Results: The CAI group exhibited less hip abduction during landing than LAS copers and controls. The CAI group had lower hip external rotation strength than LAS copers (P =.04, d = 0.62 [0.05, 1.17]) and controls (P <.01, d = 0.87 [0.28, 1.43]). Effect sizes suggest that the CAI group had deficits in EXT compared with controls (d = 0.63 [0.06, 1.19]). Hip strength was not associated with hip landing kinematics for any group. Conclusion: Altered landing mechanics displayed by the CAI group may promote mechanisms of LAS, but they are not associated with isometric hip strength. However, hip strength deficits may negatively impact other functional tasks, and they should still be considered during rehabilitation. Level of Evidence: Level III, case-control study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Women's soccer has among the highest injury rates in collegiate sports, and lateral ankle sprains (LAS) are among the most commonly occurring injuries in that athletic population. However, no established LAS prediction model exists for collegiate women's soccer players. The purpose of this study was to develop a prediction model for acute LAS injuries in collegiate women's soccer players utilizing previous ankle sprain history, height, mass, and BMI as potential predictors. The authors' hypothesized that collegiate women's soccer players with greater height, mass, and body mass index (BMI), as well as a previous history of ankle sprain would have greater odds of sustaining a LAS. Study Design: Prospective cohort study. Methods: Forty-three NCAA Division I women's soccer players' (19.7±1.1yrs, 166.8±3.7cm, 60.8±4.4kg) height, mass, and BMI were measured one week before beginning preseason practices. Additionally, participants reported whether or not they had sustained a previous ankle sprain. The team athletic trainer tracked LASs over the competitive season. Independent t-tests, binary logistic regression analyses, receiver operating characteristic (ROC) curves, and diagnostic statistics assessed the ability of the variables to differentiate between those that did and did not sustain a LAS. Results: Participants that sustained a LAS (n = 8) were significantly taller than those that did not sustain a LAS (n = 35) (t41 = - 2.87, p = 0.01, d = 0.83[0.03,1.60]). A logistic regression analysis (odds ratio = 1.30[1.00,1.70]) and area under the ROC curve analysis (AUROC = 0.73[0.58,0.89], p = 0.04) further exhibited predictive value of height. A height cutoff score of 167.6cm demonstrated excellent sensitivity (0.88), moderate specificity (0.51), and a favorable diagnostic odds ratio (7.5). A logistic regression analysis (odds ratio = 1.87[1.22,1.98]) exhibited predictive value of previous ankle sprain history. That variable was also associated with good sensitivity (0.75) and specificity (0.71) within the model, as well as a favorable DOR (7.37). Mass and BMI demonstrated no predictive value for LAS. Conclusion: Taller collegiate women's soccer players and those with previous ankle sprain history may have a greater predisposition to LAS. Level of evidence: 1b [ABSTRACT FROM AUTHOR]

Objectives: To examine isometric hip strength in those with and without CAI, and determine the degree of Star Excursion Balance Test (SEBT) variance explained by isometric hip strength.Design: Single-blinded, cross-sectional, case-control study.Methods: Thirty individuals with CAI, 29 lateral ankle sprain (LAS) copers, and 26 healthy controls participated. We assessed dynamic postural control with the SEBT anterior (SEBT-ANT), posteromedial (SEBT-PM), and posterolateral (SEBT-PL) reaches, and isometric hip extension (EXT), abduction (ABD) and external rotation (ER) strength with hand-held dynamometry. The CAI and LAS coper groups' involved limbs and randomly selected limbs in controls were tested. Separate Kruskal-Wallis tests compared SEBT scores and isometric hip strength between groups. Backwards linear regression models determined the degree of SEBT variance explained by isometric hip strength. Statistical significance was set a priori at P<0.05.Results: The CAI group had lower SEBT-ANT scores compared to LAS copers (P=0.03) and controls (P=0.03). The CAI group had lower ABD compared to LAS copers (P=0.03) and controls (P=0.02). The CAI group had lower ER compared to LAS copers (P=0.01) and controls (P=0.01). ER (R2=0.25, P=0.01) and ABD (R2=0.25, P=0.01) explained 25% of the CAI group's SEBT-PM and SEBT-PL variances, respectively.Conclusions: The CAI group had deficient dynamic postural control and isometric hip strength compared to LAS copers and controls. Additionally, the CAI group's isometric hip strength significantly influenced dynamic postural control performance. Future CAI rehabilitation strategies should consider hip muscular strengthening to facilitate improvements in dynamic postural control. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Previous investigations have identified impaired trunk and postural stability in individuals with chronic ankle instability (CAI). The diaphragm muscle contributes to trunk and postural stability by modulating the intra-abdominal pressure. A potential mechanism that could help to explain trunk and postural stability deficits may be related to altered diaphragm function due to supraspinal sensorimotor changes with CAI. The purpose of this study was to examine the diaphragm contractility in individuals with CAI and healthy controls. Methods: Twenty-seven participants with self-reported CAI and 28 healthy control participants volunteered. A portable ultrasound unit was used to visualize and measure the right and left hemidiaphragm thickness at the end of resting inspiration and expiration in supine while breathing quietly. The diaphragm movement was imaged and recorded on B-mode ultrasonography. The degree of diaphragm contractility was calculated from the mean of three images from the end of resting inspiration and expiration. Independent t-tests were used to compare the degree of diaphragm thickness of right and left sides between the CAI and the control groups. Results: The CAI group had a smaller degree of left hemidiaphragm contractility compared with the control group (P = 0.03). There was no between-group difference in other diaphragm variables. Conclusion: Individuals with CAI appear to have altered diaphragm contractility, which may be an illustration of diaphragm dysfunction and central nervous system changes in CAI population. The association between CAI and altered diaphragm contractility provides clinicians a more comprehensive awareness of proximal impairments associated with CAI. Future investigation is needed to determine whether altered contractility of the diaphragm contributes to functional impairments, activity limitations, and participant restrictions commonly observed in patients with CAI. [ABSTRACT FROM AUTHOR]

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 6 11.4% vs. 77.1 6 10.2%; p , 0.001), PM (83.5 6 10.2% vs. 86.7 6 10.7%; p = 0.001), and COMP (75.4 6 8.5% vs. 78.0 6 7.4%; p = 0.001) scores. Anterior scores did not differ between high school (69.9 6 7.9%) and collegiate (70.3 6 7.1%) athletes (p = 0.545). Age, mass, and height were not meaningful contributors to ANT (R2 = 0.089; p , 0.001), PL (R2 = 0.032; p , 0.001), PM (R2 = 0.030; p = 0.002), and COMP (R2 = 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. [ABSTRACT FROM AUTHOR]

• Two factors in the restricted principal component analysis were identified. • The internal consistency of both subscales were acceptable. • The ankle-specific FABQ should be used in patients with ankle sprain history. To perform an exploratory factor analysis of the Fear-Avoidance Beliefs Questionnaire in patients with chronic ankle instability. A cross-sectional survey study was utilized. The Fear-Avoidance Beliefs Questionnaire was administered to patients with chronic ankle instability who met the inclusion criteria. Both an unrestricted and restricted factor analysis with varimax rotation were utilized to explore the factor structure of the instrument. Kaiser-Meyer-Olkin values were used to determine sampling adequacy. Bartlett's test of sphericity was used to justify that the correlations were suitable for the principal component analysis. The restricted two-factor analysis resulted in two factors with acceptable internal consistency values. The Keiser-Meyer-Olkin value was acceptable (0.81), and Bartlett's test of sphericity was significant (χ2 (55) = 515.59, p < 0.001). The ankle-specific Fear-Avoidance Beliefs Questionnaire consists of two stable factors and should be used to further examine fear-avoidance beliefs in people with chronic ankle instability. [ABSTRACT FROM AUTHOR]