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Those with chronic ankle instability (CAI) demonstrate deleterious changes in talar cartilage composition, resulting in alterations of talar cartilage loading behavior. Common impairments associated with CAI may play a role in cartilage behavior in response to mechanical loading. To identify mechanical and sensorimotor outcomes that are linked with the magnitude of talar cartilage deformation after a static loading protocol in patients with and those without CAI. Cross-sectional study. Laboratory setting. Thirty individuals with CAI and 30 healthy individuals. After a 60-minute off-loading period, ultrasonographic images of the talar cartilage were acquired immediately before and after a 2-minute static loading protocol (single-legged stance). Talar cartilage images were obtained and manually segmented to enable calculation of medial, lateral, and overall average talar thickness. The percentage change, relative to the average baseline thickness, was used for further analysis. Mechanical (ankle joint laxity) and sensorimotor (static balance and Star Excursion Balance Test) outcomes were captured. Partial correlations were computed to determine associations between cartilage deformation magnitude and the mechanical and sensorimotor outcomes after accounting for body weight. In the CAI group, greater inversion laxity was associated with greater overall (r = −0.42, P =.03) and medial (r = −0.48, P =.01) talar cartilage deformation after a 2-minute static loading protocol. Similarly, poorer medial-lateral static balance was linked with greater overall (r = 0.47, P =.01) and lateral (r = 0.50, P =.01) talar cartilage deformation. In the control group, shorter posterolateral Star Excursion Balance Test reach distance was associated with greater lateral cartilage deformation (r = 0.42, P =.03). No other significant associations were observed. In those with CAI, inversion laxity and poor static postural control were moderately associated with greater talar cartilage deformation after a 2-minute static loading protocol. These results suggest that targeting mechanical instability and poor balance in those with CAI via intervention strategies may improve how the talar cartilage responds to static loading conditions. [ABSTRACT FROM AUTHOR]

Hip pain is associated with impairments in postural control and balance. The Star Excursion Balance Test (SEBT) is a reliable and valid method for measuring dynamic postural control. To examine changes in dynamic postural control after hip arthroscopy and subsequent rehabilitation from baseline to 3 and 6 months postsurgery. Case series. Physiotherapy department. Sixty-seven individuals (47 men, 20 women; age = 31 ± 8 years, height = 1.78 ± 0.09 m, mass = 83 ± 15 kg) scheduled for hip arthroscopy to address chondrolabral conditions were matched with 67 healthy individuals serving as controls (47 men, 20 women; age = 31 ± 8 years, height = 1.77 ± 0.09 m, mass = 80 ± 16 kg). The hip arthroscopy group underwent postoperative rehabilitation including SEBT training. The SEBT reach normalized to limb length was collected before surgery (baseline) and at 3 and 6 months after arthroscopy and compared with that of the healthy matched control group. Repeated-measures analysis of variance was used to evaluate whether SEBT reach differed among the 3 time points, and t tests were used to evaluate between-limbs and between-groups differences. The SEBT reach in the hip arthroscopy group at baseline was less than that of the control group in all directions (P values <.001). At 3 months after arthroscopy, SEBT reach increased in the posteromedial (PM; P =.007), posterolateral (PL; P <.001), and anterolateral (AL; P <.001) directions from baseline. At 6 months after arthroscopy, all directions of reach had increased (P values <.001) from baseline. The anteromedial (mean difference [MD] = −2.9%, P =.02), PM (MD = −5.2%, P =.002), and AL (MD = −2.5%, P =.04) reach distances remained shorter at 6 months after surgery in the hip arthroscopy group than in the control group. No difference existed between the control and hip arthroscopy groups for reach in the PL direction (MD = −3.6%; P =.06). Dynamic balance control in the hip arthroscopy group at baseline was poorer than in a matched control group as measured using the SEBT. At 3 months after hip arthroscopy, we observed improvements in dynamic balance in the PM, PL, and AL SEBT directions. By 6 months after arthroscopy, all directions of SEBT reach had improved, but only the PL reach improved to the level of healthy control individuals. [ABSTRACT FROM AUTHOR]

Objective: To conduct a systematic review with metaanalysis assessing the effectiveness of joint mobilizations for improving dorsiflexion range of motion (DFROM) and dynamic postural control in individuals with chronic ankle instability. Data Sources: Electronic databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus) were searched from inception to January 2017. Study Selection: Included studies examined the isolated effects of joint mobilizations to enhance DFROM and dynamic postural control in individuals with chronic ankle instability and provided adequate data to calculate effect sizes (ESs) and 95% confidence intervals (CIs). Data Extraction: Two investigators independently assessed the methodologic quality, level of evidence, and strength of recommendation using the Physiotherapy Evidence Database scale and the Strength of Recommendation Taxonomy. We extracted the sample sizes, means, and standard deviations for DFROM and dynamic postural control and filtered the data based on control-to-intervention and preintervention-to-postintervention (pre-post) comparisons. Data Synthesis: We included 7 level 1 and 3 level 2 studies that had a median Physiotherapy Evidence Database score of 60% (range = 40%-80%). The magnitudes of control-tointervention and pre-post differences were examined using bias-corrected Hedges g ESs. Random-effects meta-analyses were conducted for each outcome measure and comparison. Positive ESs indicated better outcome scores in the intervention group than in the control group and at postintervention than at preintervention. The a level was set at .05. Meta-analysis revealed weak and moderate ESs for overall control-tointervention (ES = 0.41; 95% CI = 0.14, 0.68; P = .003) and pre-post (ES = 0.34; 95% CI = 0.20, 0.48; P < .001) DFROM analyses. Overall, dynamic postural control meta-analysis revealed moderate control-to-intervention (ES = 0.42; 95% CI =-0.14, 0.98; P=.14) and weak and moderate ESs for pre-post (ES = 0.37; 95% CI =-0.12, 0.87; P = .14) analyses. Conclusions: We observed grade A evidence that joint mobilizations can mildly improve DFROM among individuals with chronic ankle instability compared with controls and preintervention. We observed grade B evidence that indicated conflicting effects of joint mobilizations on dynamic postural control compared with controls and preintervention. [ABSTRACT FROM AUTHOR]

Context: Functional rehabilitation may improve the deficits associated with chronic ankle instability (CAI). Objective: To determine if balance- and strength-training protocols improve the balance, strength, and functional performance deficits associated with CAI. Design: Randomized controlled clinical trial. Setting: Athletic training research laboratory. Patients or Other Participants: Participants were 39 volunteers with CAI, which was determined using the Identifica- tion of Functional Ankle Instability Questionnaire. They were randomly assigned to 1 of 3 groups: balance-training protocol (7 males, 6 females; age = 23.5 ± 6.5 years, height = 175.0 ± 8.5 cm, mass = 72.8 ± 10.9 kg), strength-training protocol (8 males, 5 females; age = 24.6 ± 7.7 years, height = 173.2 ± 9.0 cm, mass = 76.0 ± 16.2 kg), or control (6 males, 7 females; age = 24.8 ± 9.0 years, height = 175.5 ± 8.4 cm, mass = 79.1 ± 16.8 kg). Intervention(s): Each group participated in a 20-minute session, 3 times per week, for 6 weeks. The control group completed a mild to moderately strenuous bicycle workout. Main Outcome Measure(s): Participants completed baseline testing of eccentric and concentric isokinetic strength in each ankle direction (inversion, eversion, plantar flexion, and dorsiflexion) and the Balance Error Scoring System (BESS), Star Excursion Balance Test (SEBT), and side-hop functional performance test. The same variables were tested again at 6 weeks after the intervention. Two multivariate repeated-measures analyses of variance with follow-up univariate analyses were conducted. The a level was set a priori at .05. Results: We observed time-by-group interactions in concentric (P = .02) and eccentric (P = .01) inversion, eccentric eversion (P = .01), concentric (P = .001) and eccentric (P = .03) plantar flexion, BESS (P = .01), SEBT (P = .02), and side hop (P = .004). With pairwise comparisons, we found improvements in the balance- and strength-training protocol groups in concentric and eccentric inversion and concentric and eccentric plantar flexion and the BESS, SEBT, and side hop (all P values = .001). Only the strength-training protocol group improved in eccentric eversion. The control group did not improve in any dependent variable. Conclusions: Both training protocols improved strength, balance, and functional performance. More clinicians should incorporate hop-to-stabilization exercises into their rehabilitation protocols to improve the deficits associated with CAI. [ABSTRACT FROM AUTHOR]

Context: Anterior cruciate ligament (ACL) reconstruction (ACLR) is the most commonly used method for helping athletes regain function and return to preinjury activity levels after ACL injury. Outcomes after ACLR have suggested that athletes return to a level of function that would support a return to sport participation; however, in a recent meta-analysis, pooled return rates were only 55%. It is unclear whether this discrepancy is a result of functional impairments. Objective: To compare patient-reported outcomes (PROs), dynamic balance, dynamic functional performance, strength, and muscular endurance in athletes who returned to sport (RTS) and athletes who did not return to sport (NRTS) after ACLR. Design: Case-control study. Setting: University research laboratory. Patients or Other Participants: Two groups of participants with primary unilateral ACLR: 18 RTS individuals (7 males, 11 females; age = 23 ± 11 years, height = 163.58 ± 40.41 cm, mass = 70.00 ± 21.75 kg, time since surgery = 4.02 ± 3.20 years) and 12 NRTS individuals (5 males, 7 females; age = 26 ± 13 years, height = 171.33 ± 48.24 cm, mass = 72.00 ± 21.81 kg, time since surgery = 3.68 ± 2.71 years). Intervention(s): The PROs consisted of the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, Tegner Activity Scale, and Marx Activity Scale. Functional performance outcome measures were the anterior and posteromedial reach on the Star Excursion Balance Test, a battery of single-legged- hop tests, isokinetic quadriceps and hamstrings strength at 608/s and 1808/s, and a novel step-down-to-fatigue test. All measures were taken during a single laboratory session. Main Outcome Measure(s): The Limb Symmetry Index was calculated for all functional performance measures. Mann- Whitney U tests were used to compare measures between groups (P, .10). Results: Compared with the RTS group, the NRTS group had lower scores on the International Knee Documentation Committee Subjective Knee Evaluation Form (RTS median = 92.52, range = 66.67-97.70; NRTS median = 82.76, range = 63.22-96.55; P = .03) and Knee Injury and Osteoarthritis Outcome Score Symptoms subscale (RTS median = 88, range = 54-100; NRTS median = 71, range = 54-100; P = .08). No differences were observed for any functional performance measures. Conclusions: The NRTS athletes displayed lower PROs despite demonstrating similar function on a variety of physical performance measures. These results further support existing evidence that physical performance alone may not be the ideal postoperative outcome measure. Measures of patients' symptoms and self-perceived physical function may also greatly influence postoperative activity choices. [ABSTRACT FROM AUTHOR]

Context: Despite the effectiveness of balance training, the exact parameters needed to maximize the benefits of such programs remain unknown. One such factor is how individuals should progress to higher levels of task difficulty within a balance-training program. Yet no investigators have directly compared different balance-training-progression styles. Objective: To compare an error-based progression (ie, advance when proficient at a task) with a repetition-based progression (ie, advance after a set amount of repetitions) style during a balance-training program in healthy individuals. Design: Randomized controlled trial. Setting: Research laboratory. Patients or Other Participants: A total of 28 (16 women, 12 men) physically healthy young adults (age = 21.57 ± 3.95 years, height =171.60 ± 11.03 cm, weight= 72.96 ± 16.18 kg, body mass index = 24.53 ± 3.7). Intervention(s): All participants completed 12 supervised balance-training sessions over 4 weeks. Each session consisted of a combination of dynamic unstable-surface tasks that incorporated a BOSU ball and lasted about 30 minutes. Main Outcome Measure(s): Static balance from an instrumented force plate, dynamic balance as measured via the Star Excursion Balance Test, and ankle force production in all 4 cardinal planes of motion as measured with a handheld dynamometer before and after the intervention. Results: Selected static postural-control outcomes, dynamic postural control, and ankle force production in all planes of motion improved (P < .05). However, no differences between the progression styles were observed (P > .05) for any of the outcome measures. Conclusions: A 4-week balance-training program consisting of dynamic unstable-surface exercises on a BOSU ball improved dynamic postural control and ankle force production in healthy young adults. These results suggest that an error-based balance-training program is comparable with but not superior to a repetition-based balance-training program in improving postural control and ankle force production in healthy young adults. [ABSTRACT FROM AUTHOR]

Context: Choosing to pursue an advanced degree in athletic training appears to indicate professional commitment and passion for the profession. Currently, there is a paucity of information regarding why some athletic trainers pursue enrollment in a postprofessional athletic training program (PPATP), indicating commitment to the profession, but later depart for another primary role outside of athletic training. Objective: To understand why athletic trainers invested in advanced training via a PPATP but then decided to leave the profession. Design: Qualitative study. Setting: Online data collection. Patients or Other Participants: Twelve graduates (8 women [67%], 4 men [33%], age = 31.58 ± 3.06 years) from PPATPs who no longer had primary employment as an athletic trainer. Data Collection and Analysis: Recruits responded to an email invitation to participate by completing a confidential online questionnaire. We analyzed data using a general inductive approach and secured trustworthiness using multiple-analyst triangulation, peer review, and member checks. Results: Two higher-order themes emerged regarding the career commitment of former athletic trainers who were PPATP graduates: (1) departure from an athletic training career and (2) partial continuance in athletic training. Two second-order themes emerged from the reasons for departure: (1) decreased recognition of value and (2) work-life imbalance. Finally, we identified 2 third-order themes from the participants' reasons for departure because of a perceived lack of value: (1) low salary and (2) long, inconsistent hours worked. Conclusions: Most of our participants intended to stay in the profession when they chose to attend a PPATP. However, during role inductance in either the clinical experience of the PPATP they attended or early in their careers, they began to have thoughts of leaving mainly because of inadequate financial compensation, challenging work schedules, or both. [ABSTRACT FROM AUTHOR]

Context: Deficits in dynamic postural control predict lower limb injury. Differing fatiguing protocols negatively affect dynamic postural control. The effect of high-intensity, intermittent exercise on dynamic postural control has not been investigated. Objective: To investigate the effect of a high-intensity, intermittent exercise protocol (HIIP) on the dynamic postural control of men and women as measured by the Star Excursion Balance Test (SEBT). Design: Descriptive laboratory study. Setting: University gymnasium. Patients or Other Participants: Twenty male (age = 20.83 ± 1.50 years, height = 179.24 ± 7.94 cm, mass = 77.67 ± 10.82 kg) and 20 female (age = 20.45 ± 1.34 years, height = 166.08 ± 5.83 cm, mass = 63.02 ± 6.67 kg) athletes. Intervention(s): We recorded SEBT measurements at baseline, pre-HIIP, and post-HIIP. The HIIP consisted of 4 repetitions of 10-m forward sprinting with a 90° change of direction and then backward sprinting for 5 m, 2 repetitions of 2- legged jumping over 5 hurdles, 2 repetitions of high-knee side stepping over 5 hurdles, and 4 repetitions of lateral 5-m shuffles. Participants rested for 30 seconds before repeating the circuit until they reported a score of 18 on the Borg rating of perceived exertion scale. Main Outcome Measure(s): A mixed between- and withinsubjects analysis of variance was conducted to assess time (pre-HIIP, post-HIIP) x sex interaction effects. Subsequent investigations assessed the main effect of time and sex on normalized maximal SEBT scores. We used intraclass correlation coefficients to determine the test-retest reliability of the SEBT and paired-samples t tests to assess the HIIP effect on circuit times. Results: We found a time x sex effect (F8,69 = 3.5; P range, <.001-.04; η² range, 0.057-0.219), with women less negatively affected. We also noted a main effect for time, with worse normalized maximal SEBT scores postfatigue (F8,69 -- 22.39; P < .001; η² range, 0.324-0.695), and for sex, as women scored better in 7 SEBT directions (F8,69 -- 0.84; P range, <.001-008; η² range, 0.088-0.381). The intraclass correlation coefficients demonstrated high (0.77-0.99) test-retest repeatability. Pairedsamples t tests demonstrated increases in circuit time post-HIIP (P < .001). Conclusions: The HIIP-induced fatigue negatively affected normalized maximal SEBT scores. Women had better scores than men and were affected less negatively by HIIP-induced fatigue. [ABSTRACT FROM AUTHOR]

The article discusses a randomized control trial which aimed at analyzing effect of strength-training protocols on dynamic balance, strength and functional performance in patients with chronic ankle instability (CAI). Topics discussed includes grouping of participants into resistance-band protocol group (RBP) and Proprioceptive neuromuscular facilitation (PNF) group, strength test adopted including plantar flexion, eversion and inversion, follow up of participants and dynamic balancing testing.

Context: Chronic ankle instability (CAI) is characterized by repeated ankle sprains, which have been linked to postural instability. Therefore, it is important for clinicians to identify individuals with CAI who can benefit from rehabilitation. Objective: To assess the likelihood that CAI participants will exhibit impaired postural stability and that healthy control participants will exhibit better test performance values. Design: Case-control study. Setting: Laboratory. Patients or Other Participants: People with CAI (n = 17, age = 23 ± 4 years, height = 168 ± 9 cm, weight = 68 ± 12 kg) who reported ankle "giving-way" sensations and healthy volunteers (n = 17, age = 23 ± 3 years, height = 168 ± 8 cm, weight = 66 ± 12 kg). Intervention(s): Participants performed 7 balance tests: Balance Error Scoring System (BESS), time in balance, foot lift, single-legged stance on a force plate, Star Excursion Balance Test, side hop, and figure-of-8 hop. Main Outcome Measure(s): Balance was quantified with errors (score) for the BESS, length of time balancing (seconds) for time-in-balance test, frequency of foot lifts (score) for foot-lift test, velocity (cm/s) for all center-of-pressure velocity measures, excursion (cm) for center-of-pressure excursion measures, area (cm²) for 95% confidence ellipse center-of-pressure area and center-of-pressure rectangular area, time (seconds) for anterior-posterior and medial-lateral time-to-boundary (TTB) measures, distance reached (cm) for Star Excursion Balance Test, and time (seconds) to complete side-hop and figure-of-8 hop tests. We calculated area-under-the-curve values and cutoff scores and used the odds ratio to determine if those with and without CAI could be distinguished using cutoff scores. Results: We found significant area-under-the-curve values for 4 static noninstrumented measures, 3 force-plate measures, and 3 functional measures. Significant cutoff scores were noted for the time-in-balance test (≤25.89 seconds), foot-lift test (≥5), single-legged stance on the firm surface (3 errors) and total (≥14 errors) on the BESS, center-of-pressure resultant velocity (≥1.56 cm/s), standard deviations for medial-lateral (≤1.56 seconds) time-to-boundary and anterior-posterior (≤3.78 seconds) time-to-boundary test, posteromedial direction on the Star Excursion Balance Test (≤0.91), side-hop test (≥12.88 seconds), and figure-of-8 hop test (≥17.36 seconds). Conclusions: Clinicians can use any of the 10 significant measures with their associated cutoff scores to identify those who could benefit from rehabilitation that reestablishes postural stability. [ABSTRACT FROM AUTHOR]

The article discusses a study conducted to investigate the effect of fatiguing exercise on static and dynamic balance abilities in athletes who successfully returned to preinjury levels of sport activity after an ankle sprain. The study concluded that in athletes who had an ankle sprain, tiring exercise significantly affected static and dynamic postural control, alterations of dynamic postural control were greater, and ongoing deficits in sensorimotor control may contribute to reinjury risk.

Context: Interactive gaming systems have the potential to help rehabilitate patients with musculoskeletal conditions. The Nintendo Wii Balance Board, which is part of the Wii Fit game, could be an effective tool to monitor progress during rehabilitation because the board and game can provide objective measures of balance. However, the validity and reliability of Wii Fit balance scores remain unknown. Objective: To determine the concurrent validity of balance scores produced by the Wii Fit game and the intrasession and intersession reliability of Wii Fit balance scores. Design: Descriptive laboratory study. Setting: Sports medicine research laboratory. Patients or Other Participants: Forty-five recreationally active participants (age = 27.0 ± 9.8 years, height = 170.9 ± 9.2 cm, mass = 72.4 ±11.8 kg) with a heterogeneous history of lower extremity injury. Intervention(s): Participants completed a single-limb-stance task on a force plate and the Star Excursion Balance Test (SEBT) during the first test session. Twelve Wii Fit balance activities were completed during 2 test sessions separated by 1 week. Main Outcome Measure(s): Postural sway in the antero- posterior (AP) and mediolateral (ML) directions and the AP, ML, and resultant center-of-pressure (COP) excursions were calculated from the single-limb stance. The normalized reach distance was recorded for the anterior, posteromedial, and posterolateral directions of the SEBT. Wii Fit balance scores that the game software generated also were recorded. Results: All 96 of the calculated correlation coefficients among Wii Fit activity outcomes and established balance outcomes were interpreted as poor (r < 0.50). Intrasession reliability for Wii Fit balance activity scores ranged from good (intraclass correlation coefficient [ICC] = 0.80) to poor (ICC = 0.39), with 8 activities having poor intrasession reliability. Similarly, 11 of the 12 Wii Fit balance activity scores demonstrated poor intersession reliability, with scores ranging from fair (ICC = 0.74) to poor (ICC = 0.29). Conclusions: Wii Fit balance activity scores had poor concurrent validity relative to COP outcomes and SEBT reach distances. In addition, the included Wii Fit balance activity scores generally had poor intrasession and intersession reliability. [ABSTRACT FROM AUTHOR]

Reference: Hegedus EJ, McDonough SM, Bleakley C, Baxter D, Cook CE. Clinician-friendly lower extremity physical performance tests in athletes: a systematic review of measurement properties and correlation with injury. Part 2: the tests for the hip, thigh, foot, and ankle including the Star Excursion Balance Test. Br J Sports Med. 2015;49(10):649-656. Clinical Question: Do individual physical performance tests (PPTs) for the lower extremity have any relation to injury in athletes 12 years of age and older? Data Sources: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to locate articles. Three databases were searched from inception to January 13, 2014: PubMed, CINAHL, and SPORTDiscus. Search phrases were sport, athletics, athletes, and injuries combined with strength, power, endurance, agility, and function. Reference lists of all remaining articles and personal collections of the authors were then reviewed for any missing articles. Study Selection: Studies were included according to the following criteria: (1) published in English, (2) presented as complete articles (ie, no abstracts or posters), and (3) involved human participants. Studies were excluded on the following criteria: (1) a combination of PPTs was examined, (2) the results were measured using equipment that was expensive or not readily available to the average clinician, (3) the PPTs examined impairment-level data, (4) the PPTs examined tasks not relevant to the lower extremity, or (5) the participants scored 4 or less on the Tegner Activity Scale. The final analysis involved 31 studies. Data Extraction: The name of the PPT and methods were extracted. Each PPT was then critiqued using the Consensus-Based Standards for the Selection of Health Measurement Instruments, a 4-point Likert scale. Data were also summarized using a score of unknown, strong, moderate, limited, or conflicting for the best evidence synthesis. Main Results: A total of 14 PPTs were examined; however, names and methods of the PPTs were inconsistent throughout the literature. In descending order, based on frequency of appearance in the literature, the PPTs were (1) 1-legged hop for distance, (2) vertical jump, (3) Star Excursion Balance Test, (4) shuttle run, (5) 6-m timed hop, (6) triple hop, (7) 40-yd sprint, (8) triple crossover hop for distance, (9) 6-m timed crossover hop, (10) T-agility, (11) hexagon hop, (12) medial hop, (13) lateral hop, and (14) multi-stage fitness (beep test). The Star Excursion Balance Test in the anterior, posteromedial, and posterolateral directions was the only test that could help identify injury risk. The 1-legged hop for distance and hexagon hop showed a moderate ability to differentiate between normal and unstable ankles. In dancers, the medial hop in dancers differentiated between painful and normal hips with moderate evidence. Conclusions: Very little evidence supports the use of PPTs for athletes with lower extremity injuries. A panel of experts needs to standardize the names and methods of widely accepted tests. [ABSTRACT FROM AUTHOR]