International Journal of
Therapies and Rehabilitation Research [E-ISSN: 2278-0343]
http://www.scopemed.org/?jid=12
IJTRR 2015, 4: 1 I doi: 10.5455/ijtrr.00000044
Original Article
Open Access
Prevalence of Ankle Sprain and Service Utilization among
Players of Punjab
Japneet Kaur & A G K Sinha
Japneet Kaur is MPT (Sports), Department of Physiotherapy, Punjabi University, Patiala, Punjab,
India.
AGK Sinha, Professor, Department of Physiotherapy, Punjabi University, Patiala, Punjab, India.
Corresponding Author: Japneet Kaur, Ph no. : 91-94635-03993, E-mail : [email protected]
ABSTRACT
Background: Ankle sprain is one of the most common musculoskeletal injuries in athletes. There is
paucity of literature on studies that examine the prevalence and service utilization of ankle sprain in
players of Punjab.
Aim: To determine the prevalence of ankle sprain and service utilization pattern among players of state
Punjab.
Methods: A survey was conducted on a random sample of 205 players (136 male, 69 female) using
interview schedule and clinical examination as tools of data collection.
Results: The point, 12 month and life-time prevalence of ankle sprain was 8.29%, 42.93% and 71.70%
respectively. 82.35% players with current ankle sprain had sustained ankle sprain on previous occasions
also. 58.82% ankle injured players did not seek professional help. Previous ankle sprain, reduced ankle
range of motion, weak planter flexor and evertor muscles along with balance deficits were significantly
associated with the occurrence of ankle sprain. The treatment provided to the players was tilted
towards the use of medicines, ice application and taping/bandaging. The component of exercise
therapy was found lacking in the management programme.
Conclusion: Considering the high rate of recurrence it is imperative that the players and coaches are
educated about the importance of complete phase wise management of ankle sprain.
Key Words: Ankle sprain, Prevalence, Exercise therapy, Service utilization
INTRODUCTION
Injuries have detrimental effect on performance and training of sports persons. Ankle sprain
accounts for 19% of all sports injuries (Orchad et al, 2003; Price et al, 2004), and results in 16% of all
sports injury time loss (Liu et al, 1994). Hootman et al, 2007 reported that ankle ligament sprains were
most common injury observed in collegiate athletes from 15 different sports, accounting for 15% of all
the reported injuries. The incidence of residual symptoms following an acute ankle sprain ranges
between 40% to 50% (Smith et al, 1986; Verhagen et al, 1995; Gerber et al, 1998; Van et al, 2008).
Studies on the prevalence and service utilization pattern of ankle sprain in sports have mostly
emerged from developed countries (Yeung et al, 1994; McKay et al, 2001; Woods et al, 2003; Hootman
et al, 2007; Agel et al, 2007; Dick et al, 2007; Nelson et al, 2007; Barouni et al, 2008). However similar
studies are lacking in Indian context. Punjab is a state in India that is known for its sporting talent and
sports culture. Investigators could not locate any study on the prevalence of ankle sprain among
players of Punjab. Such studies are required to sensitize the community about the problem and to plan
intervention. Keeping this in mind the present study was undertaken with the aim to study the
prevalence of ankle sprain and service utilization among players of Punjab.
MATERIALS AND METHODS
Sample of this cross sectional survey consisted of 205 players (136 males, 69 females) drawn
randomly from 13 different sports (fig. 1). The average age of subjects was 20.13 ± 1.41 years. Subjects
with minimum 2 years of regular participation in sports were included. This criterion was imposed in
order to eliminate the recreational players. Five levels of players i.e. district, university, state, national
and international were included (Figure 2). Subjects were recruited from Punjabi University, Patiala;
National Institute of Sports, Patiala; Punjab Agricultural University, Ludhiana; Government College of
Physical Education, Patiala; Polo Ground, Patiala; Mata Gujri College, Fatehgarh Sahib and Mohindra
College, Patiala. All subjects signed an informed consent. The data was collected during October 2013
to March 2014. Schedule interview and clinical examination were the tools of data collection.
Schedule interview
An initial draft of questionnaire was developed after a thorough review of literature, and its
content validity was established by a jury of experts. The final questionnaire consisted of 4 sections
comprising of questions on demographic profile; training profile; prevalence; current and past ankle
sprain, their symptoms, clinical findings, treatment and rehabilitation. Changes in physical function
following ankle sprain was recorded using Foot and Ankle Ability Measure (FAAM) that consisted of
two subscales of self reported activities, one for Activities of Daily Living (ADL) and other for Sporting
activities. The ADL subscale had 21 items related to daily life activities like standing, walking, squatting,
personal care, home activities etc.; while the sports subscale had 8 items related to sporting activities.
The response to each item was scored from 4 to 0, with 4 being “no difficulty” and 0 being “unable to
do the task”. The ADL and Sports subscale were scored separately (Martin et al, 2005). FAAM offers the
possibility to evaluate the patient according to his or her own functional demand (Burn et al, 2013).
Clinical examination: The clinical examination consisted of inspection, palpation, assessment of range
of motion of ankle, strength testing of the muscles surrounding the ankle, special tests of ankle joint
and balance tests of the lower extremity. The clinical examination of all subjects was performed by the
principal investigator.
The following criteria was used for considering a subject as afflicted with ankle sprain: History of
twisting of the foot and presence of any three of the following- Signs of swelling, tenderness and
ecchymosis on the medial / lateral aspect of ankle; symptoms of pain, weakness, inability to bear
weight; feeling of giving away; positive inversion and eversion stress tests or squeeze tests and balance
Kaur J et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 16-24
deficits in the affected limb.
The investigator personally went to the training centers and met the respective coaches.
Coaches were taken into confidence by explaining them in detail about the purpose, aim, objective and
significance of the study. Each player was then interviewed and clinically evaluated.
STATISTICAL ANALYSIS
On the basis of presence of ankle sprain at the time of survey the subjects were grouped in two
categories: Symptomatic and Asymptomatic. Data was analyzed using SPSS version 16.0. Mean,
Standard deviation and Percentages were used to prepare the summary statistics. Independent sample
t-test and chi-square test were used to determine the association of different variables with ankle
sprain. Statistical significance was accepted at p<0.05 level.
RESULTS
Out of the 205 players, 17 players were found afflicted with ankle sprain at the time of survey
showing the point prevalence rate of ankle sprain as 8.29%. The 12 month prevalence of ankle sprain in
this study was 42.93% (88 out of 205) while the life-time prevalence was 71.70% (147 out of 205). A
highly significant association (p<0.001) was observed between the occurrence of ankle sprain in past 12
months and the presence of ankle sprain in life-time (Table 1).
21.46% players had sprained their ankle once, 41.95% had sprained their ankles more than once
while 9.76% players reported having suffered from ankle sprain more than 5 times in their life.
55(26.83%) players never experienced ankle sprain in their life-time. Figure 3 represents the
distribution of different levels of players according to the number of ankle sprains experienced.
Significant association was not observed between the level of play and recurrence of ankle sprain.
Table 2 summarizes the clinical findings of the Symptomatic (n=17) and Asymptomatic (n=188)
group. Tenderness was the most common (100%) observation followed by positive inversion stress test
(64.71%). Tables 3, 4 and 5 display the active range of motion, the muscle strength and balance scores
respectively of symptomatic and asymptomatic group. The symptomatic group scored significantly less
in subscales and total scores of FAAM (Table 6). The service utilization pattern of the symptomatic
group is presented in table 7. 41.18% players sought professional help, out of which 23.53% consulted
a General Physician, 11.77% consulted a Physiotherapist while 5.88% took treatment as advised by the
coach. 52.94% took self treatment for ankle sprain. Ice application was the most common treatment
(82%) followed by immobilization. Exercise therapy was advised to just 29.41% players.
Table 1: Association between presence of ankle sprain in past 12 months and presence of ankle sprain
in life-time
Kaur J et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 16-24
Presence of Ankle
Sprain in past 12 Total
χ2
months
Value
Yes
No
Presence
Yes 88
59
147
65.05
of Ankle
(59.9%)
(40.1%)
(100%)
Sprain in No
0
58
58
life-time
(0%)
(100%)
(100%)
Total
88
117
205
(42.9%)
(57.1%)
(100%)
Pχ2(1,.05) ≤3.84* Pχ2(1,.01) ≤6.64** Pχ2(1,.001) ≤10.83***
Table 2: Clinical findings of the Symptomatic and Asymptomatic group
Clinical Finding
Symptomatic
Percentage
Asymptomatic
Percentage
(n=17)
(%)
(n=188)
(%)
Swelling
4
23.53%
-
-
Ecchymosis
0
0%
-
-
Tenderness
17
100%
2
1.06%
64.71%
2
1.06%
Grade 2 6
35.29%
-
-
Grade 3 0
0%
-
-
Grade 4 0
0%
-
-
Positive Inversion 11
Stress Test
64.71%
5
2.66%
Positive Eversion 2
Stress Test
11.77%
-
-
Positive Anterior 4
Drawer Test
23.53%
1
0.53%
Positive Posterior 0
Drawer Test
0%
-
-
Positive
Test
0%
-
-
Grading- Grade 1 11
Special Tests
Squeeze 0
Table 3: Ankle Range of motion (in degrees) of the Symptomatic and Asymptomatic group
Kaur J et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 16-24
Symptomatic
Asymptomatic
(n=17)
(n=188)
Mean ± SD
Mean ± SD
Dorsiflexion
15.41 ± 13.63
19.66 ± 2.28
4.73***
Plantarflexion
39.41 ± 15.38
44.11 ± 5.83
4.90***
Inversion
26.94 ± 57.80
33.36 ± 3.22
3.47***
Eversion
11.55 ± 7.13
13.73 ± 1.66
3.29***
Range of Motion
*t∞, 0.05=1.96
**t∞, 0.01=2.58
t
***t∞, 0.001=3.29
Table 4: Mean muscle strength (in kilograms) of the Symptomatic and Asymptomatic group
Symptomatic
Asymptomatic
(n=17)
(n=188)
Mean ± SD
Mean ± SD
Dorsiflexion
10.30 ± 5.63
11.02 ± 3.65
1.23
Plantarflexion
9.65 ± 4.71
12.77 ± 3.97
5.82***
Inversion
7.94 ± 7.49
9.03 ± 3.17
1.61
7.09 ± 2.79
**t∞, 0.01=2.58
8.30 ± 2.84
***t∞, 0.001=3.29
Muscle group
Eversion
*t∞, 0.05=1.96
t
2.92**
Table 5: Balance scores (in seconds) of the Symptomatic and Asymptomatic group
Symptomatic (n=17) Asymptomatic (n=188)
Mean
SD
Mean
SD
t
Single
Leg Eyes open
Balance Test
Eyes closed
121
40
123
33
3.8***
63
51
87
29
3.31***
Stork
Test
17
15
57
3
5.42***
3
7.47***
Stand Eyes open
*t∞, 0.05=1.96
Eyes closed
7
**t∞, 0.01=2.58
5
11
***t∞, 0.001=3.29
Table 6: FAAM scores of Symptomatic and Asymptomatic group
Symptomatic
Asymptomatic
Kaur J et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 16-24
FAAM
(Total score)
FAAM
(ADL score)
FAAM
(Sports score)
*t∞, 0.05=1.96
(n=17)
(n=188)
Mean ± SD
Mean ± SD
66.88±13.42
113.91±7.56
14.16***
65.58±12.0
83.26±4.1
6.02***
17.47±6.6
31.12±2.7
8.48***
**t∞, 0.01=2.58
t
***t∞, 0.001=3.29
Table 7: Service utilization pattern of the symptomatic group
Items
Symptomatic
Percentage
(n=17)
(%)
Yes
7
41.18%
No
10
58.82%
General physician
4
23.53%
Coach
1
5.88%
Physiotherapist
2
11.77%
Self treatment
9
52.94%
Imaging
5
29.41%
Medicine
5
29.41%
Immobilization
10
58.82%
Icing
14
82.35%
exercise therapy
5
29.41%
Consultation with
Service Provider
Medical
Consultation
(crepe bandage / taping)
Kaur J et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 16-24
5.37%
soccer
athletics
27.80%
cycling
30.73%
collision sports
ball games
27.32%
racquet
2.93%
5.85%
Figure 1: Distribution of players according to their game
2.93%
5.37%
District
15.60%
58.05%
University
State
18.05%
National
International
Figure 2: Distribution of players according to their level of participation
60
50
University
40
District
30
State
20
National
10
International
0
1
2 to 5
>5
Figure 3: Distribution of different levels of players according to the number of ankle sprains sustained
DISCUSSION
The point prevalence of ankle sprain in players of Punjab was 8.29% during the time of survey.
Prevalence of ankle sprain in past 12 months for this sample was 42.93% and life-time prevalence was
71.70%. History of ankle sprain in life-time was significantly associated (p<0.001) with occurrence of
ankle sprain in past 12 months. This suggests that history of ankle sprain is a strong predictor for the
occurrence of ankle sprain. This finding is in agreement with McKay et al (2001) and Barouni et al
(2008). McKay et al (2001) reported that players with a history of ankle injury were five times more
likely to sustain an ankle injury. Barouni et al (2008) observed that among the athletes with a history of
ankle sprain, 61.22% already had at least one recurrence.
In the present study all the players in the symptomatic group (100%, n=17) and 1.06% (n=2)
players from the asymptomatic group reported tenderness over the ankle. 64.71% (n=11) players from
the symptomatic group had Grade 1 tenderness while 35.29% (n=6) had Grade 2 tenderness. Swelling
was observed in 23.53% (n=4) players in the symptomatic group. 64.71% (n=11) players had positive
inversion stress test which suggests that in maximum players (64.71%) it was the lateral ligamentous
complex that was injured.
Apart from these signs of acute inflammation, symptomatic subjects also demonstrated limited
active range of motion, weak muscle strength and poor balance. A highly significant difference
(p<0.001) was observed between the active range of motion of the ankle for the symptomatic and the
asymptomatic group. The differences for the mean value of Single Leg Balance Test with eyes open and
eyes closed and the Stork Stand Test with eyes open and eyes closed were highly significant (p<0.001)
between the groups. Highly significant difference between the muscle strength of plantarflexors
(p<0.001) and evertors (p<0.01) of the symptomatic and asymptomatic group was observed. This
observation is in agreement with Konradsen et al, 1998; Willems et al, 2002 and Fox et al, 2008.
Konradsen et al reported changes in ankle eversion strength after acute inversion injury. Researcher
has used a simple strain gauge for measuring muscle strength in kilograms which is portable, easy to
administer and interpret, still the results were similar to those studies that have used sophisticated
equipments (Willems et al, 2002; Fox et al, 2008). This advocates that a simple instrument like strain
gauge can be used to measure muscle strength of the ankle muscles and its use in the clinical setting
for quantitative evaluation of muscle power should be promoted.
These observations highlight the need for inclusion of appropriate exercise therapy measures in
the management of ankle sprain to address the specific deficits in range, balance and strength.
Konradsen et al observed that it takes about six weeks for normalization of the eversion strength
following lateral ankle sprain. It is imperative that players are prescribed appropriate exercise
programme after the acute management of ankle sprain and encouraged to adhere to the exercise
programme.
The management of ankle sprain consists of 3 distinct phases of damage control, restoration of
musculoskeletal deficits and functional retraining (Mattacola et al, 2002). However this practice was
ignored in majority of players. The treatment provided to the players was tilted towards the use of
medicines, ice application and taping/bandaging. The component of exercise therapy was found lacking
in the management programme. Exercise therapy was advised to just 29.41% and only 11.7% (2 out of
17) had adhered to exercise therapy protocol. The players consider ankle sprain a trivial problem and
did not give much importance to exercise therapy. Lack of awareness about the long term
consequences of poorly rehabilitated ankle sprain and about the steps of management of ankle sprain
could be the plausible reasons for this behavior. Future studies are required to examine whether
players education about the cause of recurrence and management of ankle sprain result in compliance
Kaur J et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 16-24
of exercise therapy.
Limitations of the study include relatively small sample size, exclusion of psychological factors
and the recall bias associated with retrospective method of enquiry. There is a need for cross
validation of the findings yielded by this study. Similar works can be carried out on larger samples and
specific games. In conclusion, this study highlights three main points: occurrence and recurrence of
ankle sprain is common among sports persons of Punjab, previous history of ankle sprain and
inadequate management is significantly associated with occurrence of ankle sprain and the component
of exercise therapy to address the deficit of range, strength and proprioception are grossly lacking in
the management. Considering the high rate of recurrence it is of vital importance that the players and
coaches are educated about the importance of complete phase wise management of ankle sprain. The
availability of physiotherapist at training and competition venue may ensure better compliance to
complete rehabilitation protocol and prevent recurrence of ankle sprain.
ACKNOWLEDGEMENTS: Our sincere thanks to all the subjects who willing participated in the study and
helped us accomplish our aim. We would also thank the coaches and the administrations of the
institutes where the study was conducted for showing trust in the study and providing the necessary
help when required.
CONFLICTS OF INTEREST: There are no conflicts of interest.
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