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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.

•Associations were found between chronic ankle instability and altered corticospinal excitability and inhibition of the tibialis anterior during single-leg standing.•Individuals with chronic ankle instability may have an increase in sensitivity of inhibitory intermediate neurons and a decrease in sensitivity of excitatory neurons in the corticospinal pathway.•Individuals with chronic ankle instability may encounter more difficulty controlling the tibialis anterior muscle during a single-leg stance.

ABSTRACTObjectivesSupervised 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.MethodsThis 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.ResultsA 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.ConclusionsNSAIDs 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.

Pain during a neurocognitive hop-to-stabilization (HTS) task may contribute to poor performance and slower reaction times, which are two factors that can increase the risk for injury among individuals with chronic ankle instability (CAI). The purpose of this preliminary analysis was to explore the relationship between movement-evoked pain (MEP), reaction time, and stability during a neurocognitive HTS task among those with CAI. Twelve young-adults with self-reported CAI (66% female, ages 18-35 year) volunteered to participate. The International Ankle Consortium guidelines for including individuals with CAI into research studies were followed. The HTS task required participants to start at a distance equal to 40% of their height away from a landing area. Participants were instructed to react as quickly as possible to a visual cue by jumping forward from both feet over a 30cm hurdle, land within the target area on the correct leg (red light, right leg) and stabilize for five seconds. A FitLight sensor placed on top of the hurdle calculated reaction time and a Vicon Blue Trident inertial measurement unit secured over L4/L5 calculated the dynamic postural stability index (DPSI) for each trial. The average across five trials were used for statistical analysis. MEP was assessed using a 10cm Visual Analog Scale. Pearson correlation coefficients demonstrated greater MEP was associated with slower reaction time, but not the DPSI. These findings suggest that greater MEP may interfere with a person’s ability to rapidly respond to visual stimuli during dynamic activities, which may further increase the risk for joint injury.

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.

ObjectiveTo identify which therapeutic intervention may be most effective for improving self-reported function in patients with chronic ankle instability (CAI).DesignSystematic literature review. Articles were appraised using the Downs and Black Checklist by 3 reviewers.Data sourcesPubMed along with CINAHL, MEDLINE and SPORTDiscus within EBSCOhost for pertinent articles from their inception through August 2016.Eligibility criteria for selected studiesArticles 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.ResultsA 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.ConclusionsThe main findings from this systematic review were balance training provided the most consistent improvements in self-reported function for patients with CAI.