ankle sprains

[Guest guest]

Speaking of ankles...and exercises...

When I was in grade school, I remember my parents taking us to a

colleague at the rehab center where he worked (Dad was a PT, too).

All 4 of of us kids were evaluated and fitted for corrective

shoes...except the eldest, I think. She ended up with a corset

because of scoliosis. I'm #2, born 14 months after #1.

So I wore corrective shoes all my life. And as far back as I can

remember, I was told that I would not be allowed to go ice skating

because of my " weak ankles " .

Well, in my late 20s I had the opportunity to go ice skating for the

first time. I was amazed when, after 10 minutes on the ice, my left

ankle began to shake uncontrollably. But my right ankle was rock-

solid.

There's no visible difference between my ankles, but I wondered if

the right ankle might have developed more strength because I used my

right foot a LOT for the sustain pedal on the piano, and also for the

pedals in my car.

Can consistent, mild exercise make such a difference?

[Guest guest]

Can consistent, mild exercise make such a difference?

Yes, the skies the limit. Tai Chi, balance boards, Yoga, freeweight

squats, kettlebells, therabands and more can all greatly improve ankle

strength and function. Sit on the edge of bed and sketch the letters

of the alphabet in the air with your toes using your ankle rather than

hip or knee movements. This will tune up your ankles. From there you

want to get into the above exercises which are known technically as

'closed chain', which is a fancy way of saying exercises performed with

your body weight on your feet. Ice skating should be a cinch. You can

get to that level of strength in no time.

jo

[Guest guest]

>>>Can consistent, mild exercise make such a difference?<<<

It sure can. I remember a few years ago, after my second child I think, I was

joining a gym and had to have a fitness assessment before I started. Considering

I am right-handed, the instructor was very surprised at how strong my left arm

was. It was because I would hold a child on my left hip while I was doing things

with the right hand :-)

Cheers,

Tas'.

[Guest guest]

It could also be the direction that you were skating. I haven't done it in

many years but I remember that one leg would get more of a workout than the

other. The " inside " leg I think. So it would be the right leg if you were

skating clockwise.

Irene

At 09:24 AM 8/6/04, you wrote:

>Speaking of ankles...and exercises...

>

>When I was in grade school, I remember my parents taking us to a

>colleague at the rehab center where he worked (Dad was a PT, too).

>All 4 of of us kids were evaluated and fitted for corrective

>shoes...except the eldest, I think. She ended up with a corset

>because of scoliosis. I'm #2, born 14 months after #1.

>

>So I wore corrective shoes all my life. And as far back as I can

>remember, I was told that I would not be allowed to go ice skating

>because of my " weak ankles " .

>

>Well, in my late 20s I had the opportunity to go ice skating for the

>first time. I was amazed when, after 10 minutes on the ice, my left

>ankle began to shake uncontrollably. But my right ankle was rock-

>solid.

>

>There's no visible difference between my ankles, but I wondered if

>the right ankle might have developed more strength because I used my

>right foot a LOT for the sustain pedal on the piano, and also for the

>pedals in my car.

>

>Can consistent, mild exercise make such a difference?

>

>

>

>

>

>

>

>

[Guest guest]

(Note: while this is primarily about ankle sprains in atheletes, it may

be interesting to read if you are subject to ankle spraings. ~ Gretchen)

http://biomech.com/showArticle.jhtml;jsessionid=CJO5S2PQS5Y0CQSNDBCSKH0CJUMEKJVN\

?articleID=52601761

From Biomechanics November 2004

Evasive Maneuvers

By: C. Olmsted-Kramer, PhD, ATC, and Jay Hertel, PhD, ATC

Lateral ankle, or inversion, sprains are among the most common injuries

suffered by athletes.1 In the U.S. alone, it has been estimated that

more than 23,000 such sprains occur each day.2 In addition to a high

injury incidence, residual symptoms such as pain, inflammation, and

instability have been reported in more than 50% of those suffering a

lateral ankle sprain, and these symptoms may last years after injury.3,4

It has also been estimated that 55% of those suffering ankle sprains do

not seek medical care, indicating that the incidence of ankle sprains

may be higher than reported.5,6

Due to the high incidence of ankle sprains, combined with the high cost

of treatment and rehabilitation, prevention strategies have been

developed. Ankle taping and bracing, as well as ankle rehabilitation

programs, have been used to prevent the recurrence of lateral ankle

sprains. However, the clinical efficacy of these treatment and

rehabilitation strategies is not clearly understood.

First-time injury

An important question that must be answered is whether a first time

lateral ankle sprain can be prevented. Although the answer to this

question remains unknown, it seems likely that it is possible to prevent

many first-time injuries. The mechanism for a lateral ankle sprain is

reported to be excessive supination of the rearfoot combined with

external rotation of the lower leg at initial contact of the foot with

the ground during walking, running, or landing from a jump.7,8

Fuller has suggested that an increased supination moment at the subtalar

joint is caused by an altered position and increased magnitude of the

vertical ground reaction force at initial foot contact.9 An increased

supination moment is also associated with the center of pressure (COP)

of the foot being medial to the subtalar joint axis. This increased

supination moment can cause excessive inversion and internal rotation of

the rearfoot in the closed chain and can lead to lateral ligament

injury.

The supination moment that occurs at the subtalar joint axis can be

countered by a pronation moment produced by the peroneal muscles.9

However, investigators have hypothesized that the peroneal muscles are

not fast enough to respond to the sudden inversion of the rearfoot that

occurs during a lateral ankle sprain.10,11 The peroneals do not have any

direct attachment to the talus, making them inefficient at slowing talar

inversion.

In certain situations, an athlete is put into a position where the

forces that act on the ankle are too great for the ligaments and muscles

surrounding the ankle to overcome. Under such circumstances, suffering a

lateral ankle sprain may be inevitable. A biomechanical " point of no

return " has been previously described in relation to anterior cruciate

ligament injuries in which the foot becomes planted on the ground and

the knee assumes an extreme valgus position with tibial external

rotation.12 At this point the ACL becomes maximally stressed and

complete rupture is likely. For lateral ankle sprains, a medially

deviated COP in relation to the subtalar joint axis, combined with

inefficient peroneal response, may put the ankle in a position of no

return. Thus, if the foot strikes the ground in an abnormal position

(i.e., the COP is medial to the subtalar joint axis) and the

compensatory pronation moment is less than the supination, injury to the

lateral ankle ligaments may be inevitable.

Lastly, it has been shown that an athlete with a higher than normal body

mass index is at an increased risk for lateral ankle sprain.13 Athletes

who are heavier are at an increased risk for suffering a lateral ankle

injury due to the increased mass that the joint must accommodate.14 The

ankle has a very small axis of rotation through which the entire body

weight must pass. An increased body mass will increase the forces

through the ankle joint and surrounding soft tissue structures, thus

increasing the risk for injury.

Taping and bracing

Preventive interventions such as taping and bracing are thought to

reduce ankle sprain incidence by providing mechanical support and

enhanced proprioception to the ankle.15,16 Although investigators have

assessed the effect of taping and bracing on factors such as range of

motion and functional performance,15,16 few authors have evaluated the

effect of taping and bracing on the incidence of ankle sprains.17-25

One way to analyze the effectiveness of an intervention is using a

statistic known as " number needed to treat. " 26,27 The NNT is the number

of interventions necessary to prevent one injury occurrence. A perfect

NNT would be one, meaning for every athlete taped or braced, the

intervention would prevent one ankle sprain. NNT is calculated by

subtracting the injury rate in the treatment group from the inverse of

the injury rate of the control group.

We applied the NNT statistic to three prospective studies that examined

the effectiveness of taping or bracing.28 We found that, regardless of

whether taping or bracing interventions were studied, the number needed

to treat was significantly lower for athletes with a history of sprain

than for those without such a history (Table 1).

Garrick18 examined the effectiveness of taping on collegiate intramural

basketball players. Results of the NNT analysis revealed that to prevent

one ankle sprain in intramural basketball players with a history of

sprain would require taping 26 ankles per game. To prevent an ankle

sprain in intramural basketball players without a history of sprain

would require taping 143 ankles per game. Knowing that, the sports

medicine team can save time and money by taping 26 rather than 143

ankles.

Sitler et al23 examined the effectiveness of bracing on the reduction of

ankle sprains using an Aircast Sports Stirrup in military academy

intramural basketball players. Results of the NNT analysis revealed that

to prevent an ankle sprain in an intramural basketball player with a

history of sprain would require bracing 18 ankles over the course of a

season. To prevent an ankle sprain in an intramural basketball player

without a history of sprain would require bracing 39 ankles over the

course of a season.

Surve et al21 examined the effectiveness of bracing on the reduction of

ankle sprains using an Aircast Sports Stirrup on competitive male soccer

players. Results of the NNT analysis revealed that to prevent an ankle

sprain in a soccer player with a history of sprain would require bracing

five ankles over the course of a season. To prevent an ankle sprain in a

soccer player without a history of sprain would require bracing 57

ankles over the course of a season.

The NNT statistic offers a unique approach to examining the

effectiveness of a treatment in sports medicine and the results reported

here are limited to the small number of prospective studies on taping

and bracing that allow calculation of an NNT.28 Although other

prospective studies have examined taping or bracing for the prevention

of ankle sprains, the calculation of NNT was not possible because a

control group was not used.

Also, it is interesting to note that a prospective study looking at the

effectiveness of ankle taping on the reduction of ankle sprains has not

been conducted in more than 30 years. Taping is probably the most common

treatment performed by sports medicine professionals; however, its

effectiveness is severely understudied.

Preventive interventions

Balance deficits have been reported after lateral ankle sprain,29 and

poor balance has been shown to be predictive of lateral ankle sprain

risk.30 Balance training on balance boards and a variety of other

surfaces, including foam, has been shown to reduce the incidence of

ankle sprains17,31,32 as well as other lower extremity injuries.33 Three

prospective studies in the literature have identified a lower incidence

of ankle sprain in athletes with a history of sprain who completed

balance training than in those who did not.17,31,32

Tropp et al17 examined the effects of two preventive measures designed

to reduce ankle injury incidence in 25 male soccer teams in Sweden.

Players were divided into three groups: a control group receiving no

intervention, an orthosis group, and an ankle disk training group.

Results showed that the incidence of ankle sprains in players both with

and without a history of ankle sprain was the same in the ankle disk

training group as in the group in which the orthosis was used.

Bahr et al31 examined the effects of an injury prevention program that

incorporated balance board training, technical training for jumping and

landing, and an injury awareness session in Norwegian volleyball

players. Results indicated that the number of ankle injuries decreased

significantly in each of the two seasons the players participated in

this program (Table 2).

Stasinopoulos32 evaluated three preventive measures to reduce the

incidence of ankle sprains in Greek volleyball players and found results

similar to those of Tropp and Bahr. Fifty-two players with a history of

lateral ankle sprain were divided into three groups: a technical

training group, a balance training group, and an ankle orthosis group.

All three preventive methods reduced the number of ankle injuries the

following season. Interestingly, the ankle orthoses were not effective

in reducing sprains in players with a history of more than three ankle

sprains while the other two methods were effective in reducing recurrent

sprains in this population.

The specific parameters of prophylactic balance training programs have

not been investigated to date. There are no specific guidelines in terms

of the length of training programs or the intensity, duration,

frequency, or specific exercise selection within training sessions that

will lower ankle injury risk. The programs in the studies previously

described ranged from four to six months in overall length, but the

specific session lengths and numbers of sessions per week was quite

variable.

Conclusions

Preventive taping and bracing as well as balance training have been

shown to reduce the incidence of ankle sprain in those with a history of

sprain. Although the populations studied have been limited, it appears

that we can prevent recurrent sprains in certain athletes with a history

of ankle sprain. There do not seem to be differences between taping and

bracing in reducing sprains; however, bracing would logically appear to

be the more cost-effective and less time-consuming.28 Further research

on preventive measures for reducing ankle sprains is needed to identify

whether initial ankle sprains can be prevented as well as recurrent

sprains, across all age groups and activities.

C. Olmsted-Kramer, PhD, ATC, is the director of the athletic

training education program at Pennsylvania State University in State

College. Jay Hertel, PhD, ATC, is an assistant professor in the graduate

athletic training/sports medicine program at the University of Virginia

in Charlottesville.

References

1. Garrick JG. The frequency of injury, mechanism of injury, and

epidemiology of ankle sprains. Am J Sports Med 1977;5(6):241-242.

2. Kannus P, Renstrom P. Treatment for acute tears of the lateral

ligaments of the ankle: operation, cast, or early controlled

mobilization. J Bone Joint Surg 1991;73-A(2):305-312.

3. Gerber JP, GN, Scoville CR, et al. Persistent disability

associated with ankle sprains: a prospective examination of an athletic

population. Foot Ankle Int 1998;19(10):653-660.

4. Braun BL. Effects of ankle sprain in a general clinical population 6

to 18 months after medical evaluation. Arch Fam Med 1999;8(2):143-148.

5. RW, Reischl SF. Treatment of ankle sprains in young athletes.

Am J Sports Med 1986;14(6):465-471.

6. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in

basketball: injury rate and risk factors. Br J Sports Med

2001;35(2):103-108.

7. Ekstrand J, Tropp H. The incidence of ankle sprains in soccer. Foot

Ankle 1990;11(1):41-44.

8. Bahr R, Bahr IA. Incidence of acute volleyball injuries: a

prospective cohort study of injury mechanisms and risk factors. Scan J

Med Sci Sports 1997;7(3):166-171.

9. Fuller EA. Center of pressure and its theoretical relationship to

foot pathology. J Am Podiatr Med Assoc 1999;89(6):278-291.

10. Isakov E, Mizrahi J, Solzi P, et al. Response of the peroneal

muscles to sudden inversion stress during standing. Int J Sports Biomech

1986;2:100-106.

11. Konradsen L, Voigt M, Hojsgaard C. Ankle inversion injuries. The

role of the dynamic defense mechanism. Am J Sports Med 1997;25(1):54-58.

12. Ireland ML. Anterior cruciate ligament injuries in the female

athlete: epidemiology. J Athl Train 1999;34:150-154.

13. Tyler TF, McHugh MP, Tetro DT, et al. Risk factors for ankle sprains

in high school athletes. J Athl Train 2004;39(Suppl):S-37.

14. Milgrom C, Shlamkovitch N, Finestone A. Risk factors for lateral

ankle sprain: a prospective study among military recruits. Foot Ankle

1991;12(1):26-30.

15. Wilkerson GB. Biomechanical and neuromuscular effects of ankle

taping and bracing. J Athl Train 2002;37(4):436-445.

16. Cordova ML, Ingersoll CD, Palmieri RM. Efficacy of prophylactic

ankle support: an experimental perspective. J Athl Train

2002;37(4):446-457.

17. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J

Sports Med 1985;13(4):259-262.

18. Garrick JG, Requa RK. Role of external support in the prevention of

ankle sprains. Med Sci Sports 1973;5(3):200-203.

19. Quigley TB, J, J. A protective wrapping for the ankle.

JAMA 1946;123:924.

20. Sharpe SR, Knapik J, B. Ankle braces effectively reduce the

recurrence of ankle sprains in female soccer players. J Athl Train

1997;32(1):21-24.

21. Surve I, Schwellnus MP, Noakes T, Lombard C. A fivefold reduction in

the incidence of recurrent ankle sprains in soccer players using the

Sport-Stirrup orthosis. Am J Sports Med 1994;22(5):601-606.

22. Rovere GD, e TJ, Yates CS, Burley K. Retrospective comparison

of taping and ankle stabilizers in preventing ankle injuries. Am J

Sports Med 1988;16(3):228-233.

23. Sitler M, J, Wheeler B, et al. The efficacy of a semi-rigid

ankle stabilizer to reduce ankle injuries in basketball. A randomized

clinical study at West Point. Am J Sports Med 1994; 22(4):454-461.

24. Simon JE. Study of comparative effectiveness of ankle taping and

wrapping on the prevention of ankle injuries. Athl Train J

1969;4(1):6-7.

25. Amoroso PJ, JB, Bickley B, et al. Braced for impact: reducing

military paratroopers ankle sprains using outside-the-boot braces. J

Trauma 1998;45(3):575-580.

26. Cook RJ, Sackett DL. The number needed to treat: a clinically useful

measure of treatment effect. BMJ 1995;310(6977): 452-454.

27. Chatellier G, Zapletal E, Lemaitre D, Menard J, Degoulet P. The

number needed to treat: a clinically useful nomogram in its proper

context. BJM 1996;312(7028):426-429.

28. Olmsted LC, Vela LI, Denegar CR, Hertel J. Prophylactic ankle taping

and bracing: a numbers needed to treat and cost-benefit analysis. J Athl

Train 2004;39(1):95-100.

29. Hertel J, Buckley WE, Denegar CR. Serial testing of postural control

after acute lateral ankle sprain. J Athl Train 2001;36(4):363-368.

30. McGuine TA, Greene JJ, Best T, Leverson G. Balance as a predictor of

ankle injuries in high school basketball players. Clin J Sport Med

2000;10(4):239-244.

31. Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of

acute ankle sprains in volleyball after the introduction of an injury

prevention program: a prospective cohort study. Scan J Med Sci Sports

1997;7(3):172-177.

32. Stasinopoulus D. Comparison of three preventive methods in order to

reduce the incidence of ankle inversion spans among female volleyball

players. Br J Sports Med 2004;38(2):182-185.

33. Wedderkopp N, Kaltoft M, Lundgaard B, et al. Prevention of injuries

in young female players in European team handball. A prospective

intervention study. Scan J Med Sci Sports 1999;9(1):41-47.