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Ankle sprains: a balanced approach to treatment?

Balance and propioception training is commonly prescribed for the rehab and prevention of lateral ankle sprain injuries. But how effective is this approach? Andrew Hamilton looks at recent evidence…

Ankle sprains are one of the most common musculoskeletal injuries among sportsmen and women, and studies suggest that a significant proportion sports related injuries may be related to ankle instability1.

The most common single precipitating factor in lateral ankle sprain is a single-limb landing on an uneven surface2. In these circumstances, a rapid and combined motion of ankle plantar flexion and inversion can lead to excessive lateral motion, resulting in ankle sprain. Another possible factor in determining the likelihood of lateral ankle sprain is proprioception, which is an important element of the neuromuscular control. With sufficient proprioception, an athlete may be able to detect the speed and magnitude of perturbation in a timely fashion, and react with proper muscle activation and joint motion. However, the very nature of uneven terrain means that this is not always possible, even in athletes with excellent propioceptive skills. Moreover, the evidence for the role of propioceptive factors in precipitating ankle sprain is far from clear (as we will see later). Other factors relating to the risk of ankle sprain in athletes are shown in table 1 below.

Table 1: Risk factors for ankle sprain among athletic populations
Non-modifiable risk factorsModifiable risk factors
-Sex
-Age
-Height
-Race
-Foot/ankle anatomy
-Extremity alignment
-Previous ankle sprain
-Generalized Joint Laxity
-Weight
-Body mass index
-Bracing/taping
-Footwear
-Neuromuscular control
-Postural stability
-Muscle strength
-Exposure to sport
-Player position
-Playing surface
-Skill level

The nature of lateral ankle sprain means that once an injury has occurred, re-injury is very likely. This is because injury/ damage to the lateral ligaments and joint capsule very often impairs the ability of these structures to provide optimum mechanical restraint following injury3 4 5 6 7 8 9 10. Combined with any deficits in propioception, this results in a high re-injury rate. Indeed, studies have shown that 73% of individuals who sprain their ankles are likely to experience recurrent ankle injuries11.

Figure 1: Locations of stabilising ligaments in the lateral ankle

Figure 1: Locations of stabilising ligaments in the lateral ankle

Balance and propioception in lateral ankle sprain and reinjury

As mentioned above, a number of researchers have proposed that compromised neuromuscular control and proprioception of the ankle joint is a significant factor in the aetiology of both initial and recurrent ankle sprains. However, despite decades of research on ankle sprain, the evidence that this is the case remains inconclusive. In particular, studies have failed to find concrete evidence that subjects with ankle instability experience proprioception deficits compared to those without a history of ankle instability12. This issue is further complicated by the fact that there is no standard testing and training protocol for ankle proprioception.

For many clinicians, the working assumption is that impaired proprioception and/or balance play a significant role in the vulnerability to lateral ankle sprain. This is implicit in the balance and coordination training elements, which are common components of many intervention programs for the prevention and treatment of acute lateral ankle sprains and chronic ankle instability13 14. Furthermore, plenty of contemporary theory on this topic suggests that balance and coordination training may have both local and central effects on the sensorimotor system15 16 17 18 19.

Returning to play after high ankle sprain

Of great concern to athletes such as runners or footballers who suffer ankle sprain is how long it is likely to be before they can return to unrestricted sports activity. Because of the large number of variables affecting injury and rehab, it’s not possible to give firm prediction to clients. However, a study on collegiate footballers provides a useful insight, and suggests that findings from a physical examination may be more useful than scans such as MRI(38).

Twenty consecutive Division I collegiate football players from two teams with a diagnosis of a grade I high ankle sprain (syndesmosis sprain without diastasis) were studied. In particular, the researchers sought to establish whether clinical findings or MRI scans (or both) were useful indicators of the likely return-to-play time. Two clinical measurements of injury severity were determined:

  • The first was the height of the zone of injury upon a physical examination. Specifically, this was defined as the distance in centimetres from the distal tip of the fibula to the highest point of tenderness along the interosseous membrane and anteromedial aspect of the fibula (a method documented as a measure of injury severity in high ankle sprains(39)). This distance was measured by a single investigator for each of the two football teams under study, to minimize variability, and was recorded for subsequent analysis;
  • The second predictor of clinical severity was the height of the zone of injury, as defined by diagnostic musculoskeletal MRI scans. Ultrasound images were acquired using highfrequency linear transducers by experienced musculoskeletal ultrasound technologists and supervised by a musculoskeletal radiologist with 18 years of experience. The distance in centimetres from the tibiotalar joint line to the highest point of injury, as visualized on ultrasound, was measured and recorded for subsequent analysis. The anterior tibiofibular ligament was also evaluated and assessed for complete tear. If the anterior tibiofibular ligament and interosseous membrane were not torn on ultrasound, then 0 cm was recorded. If the anterior tibiofibular ligament was completely torn and the interosseous membrane was normal at ultrasound, then 1 cm was recorded as the proximal extent of the injury.

Following both types of clinical assessment, all athletes followed a standardised treatment program and return-to-play criteria. Statistical modelling was used to determine time to return to unrestricted play as a function of injury severity and player position. The researchers found that the results determined from physical examination were significantly correlated with time to return to play (see figure 2). By contrast the results from the ultrasound scans had no significant bearing on the return to play time. The researchers concluded that injury severity on physical examination but not MRI scans were associated with the time to return to unrestricted athletic activity after injury.

Figure 2: The relationship between height of tenderness from fibula tip and return-to-play time

Figure 2: The relationship between height of tenderness from fibula tip and return-to-play time(38)

The higher the zone of injury from the distal fibula tip, the greater on average the number of days required to resume full sporting activity

In an attempt to provide more clarity regarding proprioception, balance and ankle sprain, a 2008 review study tried to answer the following three questions20:

1. Can prophylactic balance and coordination training reduce the risk of sustaining a lateral ankle sprain?

2. Can balance and coordination training improve treatment outcomes associated with acute ankle sprains?

3. Can balance and coordination training improve treatment outcomes in patients with chronic ankle instability?

In total, the results of eleven studies were combined; three of which were used to answer Q1, three to answer Q2 and five to answer Q3. The researchers concluded that prophylactic balance and coordination training substantially reduced the risk of ankle sprain in athletes, with the greatest effect observed in those with a history of sprain. There was also evidence that completing at least 6 weeks of balance and coordination training during recovery from an acute ankle sprain could substantially reduce the risk of recurrent ankle sprain for up to 1 year.

However, the researchers also drew attention to the fact that the improvements in instrumented measures of postural control associated with this training were not consistently measured from study to study, reducing the quality of the evidence. They also cautioned that the evidence was insufficient to assess the reduction in the risk of recurrent sprains, inconclusive to demonstrate improved instrumented postural control measures, and limited with respect to improvements in selfreported function in athletes with chronic ankle instability who complete balance and coordination training.

The findings from the above study fit with a very recent review study into ankle sprains in the athletic population21. This study acknowledges that altered neuromuscular control due to peripheral proprioception changes of the ankle joint may contribute to the high recurrence rate of lateral ankle sprain, and that after the initial injury, overstretched/loosened ligaments and joint capsule may hamper the function of those mechanoreceptors in those structures. It also reports that some researchers have reported prolonged peroneal muscle reflex latency in injured ankles22 23, and ankle position sense deficits in various testing protocols24 25 26.

However, the researchers go on to point out that despite this evidence, there are also many studies that contradict these findings. For example, in studies comparing healthy and unstable ankles, no peroneal reflex latency differences27 28 29, no position sense differences30 31 32, and no movement sense differences33 were found between healthy and unstable ankles. In addition, some studies indicate that the ability to sense ankle position is not a good predictor for future ankle sprains34.

Returning to play after high ankle sprain
Of great concern to athletes such as runners or footballers who suffer ankle sprain is how long it is likely to be before they can return to unrestricted sports activity. Because of the large number of variables affecting injury and rehab, it’s not possible to give firm prediction to clients. However, a study on collegiate footballers provides a useful insight, and suggests that findings from a physical examination may be more useful than scans such as MRI(38).

Twenty consecutive Division I collegiate football players from two teams with a diagnosis of a grade I high ankle sprain (syndesmosis sprain without diastasis) were studied. In particular, the researchers sought to establish whether clinical findings or MRI scans (or both) were useful indicators of the likely return-to-play time. Two clinical measurements of injury severity were determined:

-The first was the height of the zone of injury upon a physical examination. Specifically, this was defined as the distance in centimetres from the distal tip of the fibula to the highest point of tenderness along the interosseous membrane and anteromedial aspect of the fibula (a method documented as a measure of injury severity in high ankle sprains(39)). This distance was measured by a single investigator for each of the two football teams under study, to minimize variability, and was recorded for subsequent analysis;

-The second predictor of clinical severity was the height of the zone of injury, as defined by diagnostic musculoskeletal MRI scans. Ultrasound images were acquired using high frequency linear transducers by experienced musculoskeletal ultrasound technologists and supervised by a musculoskeletal radiologist with 18 years of experience. The distance in centimetres from the tibiotalar joint line to the highest point of injury, as visualized on ultrasound, was measured and recorded for subsequent analysis. The anterior tibiofibular ligament was also evaluated and assessed for complete tear. If the anterior tibiofibular ligament and interosseous membrane were not torn on ultrasound, then 0 cm was recorded. If the anterior tibiofibular ligament was completely torn and the interosseous membrane was normal at ultrasound, then 1 cm was recorded as the proximal extent of the injury.

Following both types of clinical assessment, all athletes followed a standardised treatment program and return-to-play criteria. Statistical modelling was used to determine time to return to unrestricted play as a function of injury severity and player position. The researchers found that the results determined from physical examination were significantly correlated with time to return to play (see figure 2). By contrast the results from the ultrasound scans had no significant bearing on the return to play time. The researchers concluded that injury severity on physical examination but not MRI scans were associated with the time to return to unrestricted athletic activity after injury.

Balance and strength

One the face of it, it seems as though the evidence is contradictory – ie that balance training does appear to improve the prognosis for ankle sprain and reduce re-injury rates, but that there’s little evidence that improving propioception/ neuromuscular control produces positive results. Perhaps that because even with better/intact proprioception at the ankle joint, generating enough muscle strength that is fast enough to combat large and fast perturbations such as landing on an uneven surface is still a problem.

One possible explanation for the observations is the role of strength. A recent study has argued that improving muscle strength could actually play a more important role in ankle sprain prevention and rehab than improving proprioception35. Although the impact of muscle strength on ankle stability is unclear, muscle weakness has been reported in peroneal muscles, ankle dorsiflexors, and hip abductors in individuals with ankle instability36 37 38.

Although larger muscle activation can enhance the sensitivity of muscle spindles, strength training is not likely to reduce the incidents of initial and recurrent ankle sprains through enhancing neuromuscular control of the ankle joint. But what it may do is to help restore ankle muscle balance, position the ankle in more stable position (eg more dorsiflexion with a stronger tibialis anterior) and increase the strength of ligaments. In addition, a larger/ stronger muscle can also provide additional passive restraints to the ankle joint.

It follows from the above therefore that if balance training is beneficial in reducing the incidents of ankle sprains, it is most likely due to enhanced strength and stiffness in both muscles and ligaments at the ankle joint rather than enhanced neuromuscular control. In other words, while improving neuromuscular control and proprioception at the ankle joint may be ineffective at protecting the ankle from large and fast perturbations, balance training can increase the strength of muscles and ligaments around the ankle joint. Since ligaments are the primary stabiliser of the ankle joint, treatment protocols with a balance training component may benefit the subjects with unstable ankles.

Figure 3a – resisted dorsiflexion

Figure 3a – resisted dorsiflexion

Figure 3b – resisted plantarflexion

Figure 3b – resisted plantarflexion

Figure 3c – resisted eversion

Figure 3c – resisted eversion

Figure 3d – resisted inversion

Figure 3d – resisted inversion

Summary

Looking at the overall evidence, what can we conclude? Firstly it seems that ankle injury prevention and rehab programmes that focus purely on propioception improvement are likely to be of limited value – the evidence that propioceptive training confers benefits in terms of initial injury prevention or recurrence is quite weak. The evidence for balance training however is much stronger – although the benefits are most likely to occur as a result of improvements in muscular and ligament strength.

Although more research is needed in this area, the evidence to date suggests that improving ankle strength may be a valuable component of any prevention/rehab programme. Studies show that Thera-Band or multi-axial ankle exercises are effective in building ankle strength (for example, resisted dorsiflexion and platarflexion and resisted ankle eversion and inversion – see Figures 3a,b,c, and d). One study found gains of 20-50% over a 6-week intervention programme39. Balance protocols on wobble boards can also be adapted to help develop higher levels of ankle strength – for example by holding increasing amounts of weight at progressively more elevated positions during balance training.

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