A Thesis
entitled
Ankle Function Alterations Following Acute Ankle Sprains Over a 14 Day Period
by
Michael S. P. Mayes, ATC
Submitted to the Graduate Faculty as partial fulfillment of the requirements for the
Master of Science Degree in Exercise Science
________________________________________
Phillip Gribble, PhD, Committee Chair
________________________________________
Brian Pietrosimone, PhD, Committee Member
________________________________________
Abbey Thomas, PhD, Committee Member
________________________________________
Patricia R. Komuniecki, PhD, Dean
College of Graduate Studies
The University of Toledo
August 2014
Copyright 2014, Michael Sean Patrick Mayes
This document is copyrighted material. Under copyright law, no parts of this document
may be reproduced without the expressed permission of the author.
An Abstract of
Ankle Function Alterations Following Acute Ankle Sprains Over a 14 Day Period
by
Michael S. P. Mayes
Submitted to the Graduate Faculty as partial fulfillment of the requirements for the
Master of Science Degree in Exercise Science
The University of Toledo
August 2014
Objective: The objective of this study was to determine the effects of an acute lateral
ankle sprain on self-reported function, self-reported pain, self-reported global function,
joint effusion, dorsiflexion range of motion, and dynamic stability over a 14 day period
following injury compared to healthy matched controls. Design and Setting: A casecontrol design was conducted in a laboratory setting. Subjects: Twenty-nine participants
with an acute lateral ankle sprain (LAS) were assigned to a LAS group (10 males, 19
females; 20.41 ± 2.18 years; 176.44 ± 11.00 cm; 74.22 ± 14.33 kg), and twenty-two
healthy participants were assigned to a control group (11 males, 11 females; 20.95 ± 2.97
years; 178.61 ± 10.96 cm; 76.39 ± 13.81 kg). Procedure: Experimental measures All
participants were asked to report for a total of five tests sessions done at 36 hours, 5, 7,
10, and 14 days following initial injury; or from the day of enrollment as a healthy
control. Each testing session lasted approximately 1 hour, with self-reported function and
self-reported pain was assessed using the FADI, FADI Sport and VAS. Dynamic balance
was assessed using the SEBT anterior, posteromedial, and posterolateral reach directions.
Ankle girth was measured using the figure-of-eight method. Dorsiflexion range of motion
was assessed using a goniometer. Frequency of rehabilitative exercises athletic, athletic
iii
participation and use of therapeutic modalities was collected using a treatment
questionnaire. Results: Significant differences were found fourteen days following injury
in all self-reported outcomes in the LAS group compared to Healthy controls (P≤0.05).
Significant decreases DF were found up to seven days post injury (P≤0.05). Significant
dynamic stability deficits were seen up to fourteen days following injury in the anterior
reach and posteromedial reach of the star excursion balance text (SEBT) (P≤0.05). No
significant findings were seen in the posterolateral reach direction of the SEBT (P≤0.05)
at any time point. No significant findings were seen in ankle girth (P≤0.05) at any time
point. Conclusion: Those who suffer from a LAS exhibit decreased self-reported
function, decreased dynamic postural control, decreased DF range of motion, increased
self-reported pain, and increased ankle girth. While studies investigating acute function
alterations in ankle sprains for 14 days following injury are limited, these results should
be taken into consideration when making rehabilitation and return-to-play decisions.
Clinicians may need to consider the possibility that a LAS return-to-play protocol time
frame should be increased further than two weeks post injury. Word Count: 396
iv
For mom, dad, and Jessica. You guys are my constant source of motivation and
happiness.
Table of Contents
Abstract
iii
Table of Contents
vi
List of Tables
ix
List of Abbreviations
x
I. Introduction
1
A. Problem Statement
3
B. Purpose Statement
4
C. Dependent Variables
4
D. Independent Variables
5
E. Hypotheses
5
II. Literature Review
III.
7
A. Lateral Ankle Sprain (LAS)
7
B. Chronic Ankle Instability
8
C. Dynamic Postural Control
10
D. Star Excursion Balance Test
12
E. Dorsiflexion Limitations
15
F. Foot and Ankle Disability Index (FADI)
15
Methods
18
A. Study Design
18
B. Participants
18
C. Procedures
19
D. Foot and Ankle Disability Index
19
vi
IV.
V.
E. Star Excursion Balance Test
20
F. Visual Analog Scale
21
G. Treatment Questionnaire
21
H. Dorsiflexion Range of Motion and Ankle Girth
21
I. Statistical Analysis
22
Results
23
A. Self-Reported Measures
23
B. Dorsiflexion and Ankle Girth Measures
24
C. Dynamic Postural Control Measures
24
Discussion
26
A. Self-Reported Measures
26
B. Dorsiflexion and Ankle Girth Measures
30
C. Dynamic Postural Control
31
D. Limitations
33
E. Future Research
33
F. Conclusion
34
References
35
Appendices
A. Tables
38
B. Consent Form
48
C. Foot and Ankle Disability Index
54
D. Star Excursion Balance Text Form
56
E. Treatment Questionnaire
57
vii
F. Ankle Range of Motion Form
59
viii
List of Tables
Table 1
Means and Standard Deviations for Participant Demographics ......................38
Table 2
Foot and Ankle Disability Index ......................................................................38
Table 3
Foot and Ankle Disability Index Sport ............................................................39
Table 4
Visual Analog Scale Pain.................................................................................39
Table 5
Visual Analog Scale Function .........................................................................40
Table 6
Global Function ...............................................................................................40
Table 7
Dorsiflexion Range of Motion .........................................................................41
Table 8
Ankle Girth ......................................................................................................41
Table 9
Star Excursion Balance Test Anterior..............................................................42
Table 10 Star Excursion Balance Test Posteromedial ....................................................42
Table 11 Star Excursion Balance Test Posterolateral .....................................................43
Table 12 FADI and FADI Sport Effect Sizes .................................................................44
Table 13 Dorsiflexion and Ankle Girth Effect Sizes ......................................................45
Table 14 VAS and Global Function Effect Sizes ...........................................................46
Table 15 Star Excursion Balance Test Effect Sizes ........................................................47
ix
List of Abbreviations
ADL............................Activities of Daily Living
CAI…………………..Chronic Ankle Instability
DF……………………Dorsiflexion
FAI…………………..Functional Ankle Instability
FADI…………………Foot and Ankle Disability Index
ICC…………………..Intraclass Correlation Coefficient
LAS…………………..Lateral Ankle Sprain
MAI………………….Mechanical Ankle Instability
ROM............................Range of Motion
SEBT…………………Star Excursion Balance Test
VAS…………………..Visual Analog Scale
WBLT………………..Weight Bearing Lunge Test
x
Chapter 1
Introduction
Lateral ankle sprains (LAS) are one of the most common athletic injuries in all
sporting arenas and are a frequently seen by Athletic Trainers.1 It is estimated that almost
23,000 ankle sprains occur daily in the United States,2 with about 85% of those sprains
affecting the lateral ligamentous structures.3 Depending on the severity of the sprain an
athlete may have symptoms for months or even years after initial injury.4, 5 With
conservative management and detailed, succinct rehabilitation, athletes theoretically
should be capable of returning to play with little to no residual side-effects. However,
residual symptoms may be present due to inadequate return-to-play protocols allowing
athletes to return to play with less than 100% of functional ability, decreased range of
motion (ROM), and increased pain, when compared to prior injury status. While most
ankle sprains are not seen as severe injuries, improper management can result in the
development of chronic ankle instability (CAI).6 CAI involves bouts of recurrent ankle
sprains brought about by chronic symptoms of persistent weakness, instability, and pain.
The incidence of residual symptoms and bouts of instability have been reported with
varying rates between 40 and 50%.3, 7, 8 Currently, the best predictor for CAI is previous
lateral ankle sprain,6, 9-11 indicating that clinicians may often underestimate the severity of
acquiring an ankle sprain. Current treatment strategies and rehabilitation protocols may
be ineffective in preventing residual, lasting symptoms that lead to the onset of CAI.6
Further understanding of the underlying symptom progression is needed to effectively
develop new rehabilitation strategies to alleviate the residual dysfunction associated with
CAI.
1
Current treatment strategies for an ankle sprain will undoubtedly address range of
motion, strength, and balance deficits in order to return a patient to his/her full health.
However, clinicians may overlook the self-reported outcomes of their own patients and
return them back to sport or work participation without fully alleviating the symptoms,
which may leave individuals susceptible for further injury. The ability to quantify selfreported function is an invaluable resource clinicians can use to track progress through a
rehabilitation program. Subjective reports of function completed by patients are
becoming an essential part of clinical practice for health care practitioners.12 Subjective
measures allow clinicians to assess changes in a patient’s functional limitations and
disabilities after designed clinical interventions.13 The Foot and Ankle Disability Index
(FADI) and Foot and Ankle Disability Sport (FADI Sport) assesses the level of perceived
disability in the ankle complex during activities of daily living and during sport activities,
respectively. To date, there has been no application of the FADI tools in assessing the
capability of a patient to return to his/her desired activity. Following a grade one LAS,
the current average return-to-play time for an athlete is between 3-7 days;14, 15 however,
self-reported symptoms of decreased function may be lasting for months following
injury.4, 5 Clinicians may be underestimating the length of time decreases in self-reported
functional ability are seen which may be causing them to advance patients through
rehabilitation protocols too quickly. Returning an athlete to activity prior to the return of
his/her full functional ability may be putting the individual at risk for further injury and
CAI.
Dorsiflexion (DF) range of motion has been shown to commonly be restricted
following LAS and may add to residual symptoms which contribute to CAI.6, 16, 17 These
2
restrictions, along with proprioceptive deficits may lead to increased susceptibility to
further injury and repetitive bouts of LAS.18 Proprioceptive deficits have been seen to be
a common impairment after LAS,16 which is why rehabilitative protocols rigorously
address static and dynamic balance. Dynamic postural control deficits, measured by the
Star Excursion Balance Test (SEBT), have been observed in patients with CAI.19
Identification of factors that restrict patient rehabilitation gains and contribute to residual
instability may help clinicians and researchers develop more effective interventions for
LAS injuries and prevent CAI development. Residual symptoms of recurrent LAS could
significantly impair individuals’ functional ability and movement patterns, decreasing
their physical activity level through their life spans.20 With evidence documenting the
progression or regression of symptoms related to self-reported function, self-reported
pain, global function of how each participant is feeling overall through all activities, DF
range of motion, joint effusion, and dynamic postural control, we may be able to better
equip clinicians to return athletes to full participation in a safer manner with less
recurrence of injury and residual symptoms past their athletic careers.
Problem Statement
Limited research has been conducted on the effects of an acute lateral ankle sprain
on self-reported function, self-reported pain, self-reported global function, DF range of
motion, ankle joint effusion, and dynamic balance and how these symptoms progress
over a 14-day period. It is likely that misunderstanding of the progress of patient
outcomes leads to accelerated return to play protocols for ankle sprains, which may be
contributing to the development of ankle sprain recurrence.
3
Purpose Statement
The primary purpose of this study was to determine the effects of an acute lateral
ankle sprain on self-reported function, disability, and pain, as well as joint effusion, DF
range of motion, and dynamic stability over a 14 day period following injury compared to
healthy controls.
Dependent Variables
1) Foot and Ankle Disability Index (FADI)

Participants were given a 26 item subjective questionnaire on their
reported disability within activities of daily living
2) Foot and Ankle Disability Index Sport (FADI Sport)

Participants were given an 8 item subjective questionnaire on their
reported disability within sport performance
3) Visual Analog Scale for self-reported ankle function

Participants were given a 10 cm subjective scale and asked to report their
functional ability
4) Visual Analog Scale for self-reported pain

Participants were given a 10cm subjective scale and asked to report their
pain
5) Global Function
4

Participants were asked to rate their own global functional ability on a 0100% scale
6) Dynamic Postural Control

Assessed using the Star Excursion Balance Test. Reach directions used
included anterior, posteromedial, and posterolateral
7) Ankle Girth

Assessed using the Figure-of-Eight Measurement method
8) Dorsiflexion Range of Motion

Actively assessed using a goniometer
9) Treatment Questionnaire

Participants were given a questionnaire and were asked to report all
treatment they had been receiving for their lateral ankle sprain
10) Return-To-Play Time

Intercollegiate Athlete: Determined by when the participant was cleared
for full participation by their ATC

Non-Athlete: Determined by when the participant felt they were fully
functional and could return their activities
Independent Variables

Group (LAS/control)
5

Limb (injured/non-injured)

Time (36 hours, 5days, 7 days, 10 days, and 14 days postinjury/enrollment in the study)
Hypotheses
1) The LAS group will exhibit decreases in self-reported disability, self-reported pain,
self-reported global function, dorsiflexion range of motion, and dynamic postural
control while displaying increases in ankle girth, and self-reported pain, when
compared to matched control participants.
2) The LAS group will exhibit a positive relationship between time lapsed within the 14
day testing and increases in dorsiflexion range of motion, dynamic postural control,
and self-reported function, and decreases in ankle girth and self-reported pain and
disability.
3) No change will be observed within the control group in self-reported function,
disability, pain, global function, or dorsiflexion range of motion, dynamic postural
control and ankle girth over the 14 day testing period.
6
Chapter 2
Literature Review
Lateral Ankle Sprains (LAS)
The LAS has one of the highest occurrence rates among athletes, consisting of 1030% of injuries.1, 21, 22 It is reported that over 23,000 ankle sprains occur in the United
States per day, which is estimated to one sprain per 10,000 people daily.2 A LAS occurs
with extreme inversion and plantar flexion of the ankle. Signs and symptoms associated
with this injury include swelling, redness, heat, pain, and loss of function: in short, all of
the signs inflammation, as well as ecchymosis. An athlete may hear a snap or pop during
the moment of injury which can signify a rupture of one or more ligaments within the
lateral ligament complex consisting of the anterior talofibular ligament (ATF), posterior
talofibular ligament (PTF), and calcaneonavicular ligament (CF). The anterior talofibular
ligament (ATF) and calcaneonavicular ligament (CF) are relatively weak and prone to
rupture following the injury mechanism.23
The ankle joint is formed by a complex array of bony articulations, static
ligamentous supports, and musculotendinous attachments, which allow for static and
dynamic stabilization. The bony articulations are comprised of three distinct joints: The
talocrural joint, the subtalar joint, and the distal tibiofibular joint. The talocrural joint
consists of the dome of the talus, and the mortise formed by the distal articulation of the
tibia and fibula.6 Thought of as a hinge joint, allowing for isolated planter flexion and DF
movements primarily within the sagittal plane, the axis of rotation of the talocrural joint
7
passes through the lateral and medial malleoli.6 When the ankle is fully dorsiflexed
ligamentous support is crucial to prevent excess articular translations.6 The talocrural
joint receives its lateral ligamentous support from. The medial support comes from the
deltoid ligament. The ATF and CF provide support against excessive inversion of the
ankle, and are injured following a LAS 85% of the time.3
Depending on the severity of the sprain, an athlete may have symptoms for
months or even years after initial injury.4, 5 With conservative management and detailed,
succinct rehabilitation, athletes theoretically should be capable of returning to play with
little to no residual side-effects. Residual dysfunction could present as deficiencies in
self-reported function, self-reported pain, dynamic stability6, dorsiflexion (DF) range of
motion16, and strength.6 As a result, recurrence rates of ankle sprains can be as high as
80%.8 Currently, the best predictor for multiple ankle sprains is the history of at least one
LAS,6, 9-11 which may indicate that the severity of an athlete acquiring an ankle sprain
may often be underestimated by clinicians.24-28
Chronic Ankle Instability
CAI involves bouts of recurrent ankle sprains brought about by chronic symptoms
of persistent weakness, instability, and pain, and is also accompanied by a subjective
feeling of the ankle “giving way”.6 CAI can be divided into mechanical ankle instability
(MAI) and functional ankle instability (FAI), which combine together to create the
residual symptoms following initial injury.
Tropp et al.29 first described MAI as a cause of CAI due to pathologic ligament
laxity subsequent an ankle ligament injury. MAI is thought to be a cause of CAI due to
8
anatomic changes after the initial ankle sprain, which eventually lead to insufficiencies
that predispose individuals to multiple ankle sprains.6 These anatomic changes are
thought to include pathologic ligament laxity, impaired arthrokinematics, synovial
inflammation and impingement, and degenerative joint disease.1, 6 It has also been
defined as motion beyond the normal physiologic range of motion.30 FAI is the subjective
sense of joint instability and impairment caused by inhibition of the proprioceptive and
neuromuscular control of the foot and ankle.6, 31 Postural control deficits seen in these
individuals affected by FAI are expected to be a result of a combination of impaired
proprioception and neuromuscular control.6 Changes such as these limit an individuals’
dynamic stability and hinder ones’ ability to minimize sway following external
perturbation, possibly leading to a predisposition for recurrent episodes of instability.6
MAI and FAI may occur independent of each other; however, they are usually
not mutually exclusive, because both can result in the chronic “giving way” of the ankle
associated with CAI. Currently, the exact reason an individual acquires CAI is unclear;
however, investigators are suggesting that neuromuscular factors contribute to ankle
instability by disrupting the normal function of the uninjured muscles surrounding the
injured joint.16, 32 Understanding these neuromuscular responses after an injury to the
ankle joint may provide clinicians and researchers with essential information that leads to
improved treatment protocols. Effective prevention of recurrent ankle sprains relies on
ascertaining the mechanisms responsible for these neuromuscular dysfunctions. It is
hypothesized that a LAS damages the lateral mechanoreceptors, which creates altered
neuromuscular feedback due to changes in afferent inputs to the spinal cord.28 This
alteration is thought to inhibit spinal reflex excitability by decreasing the motor neuron
9
pool excitability (MNPE) to the surrounding ankle musculature, thereby causing a deficit
in reflexive motor output.25 This phenomenon in which the body reflexively decreases the
excitability of an injured joint’s surrounded musculature is termed arthrogenic muscle
inhibition (AMI).24, 25 Deficits seen in dynamic postural control, strength, and range of
motion can lead to a high rate of recurrent ankle sprains and potentially MAI and/or
FAI.3, 6, 9, 10
Dynamic Postural Control
Injury to the lateral ligament complex of the ankle can result in debilitating effects
to the dynamic support of the ankle.6 Neuromuscular feedback and proprioception
provide essential information to the brain and spinal cord for maintaining dynamic
balance and stability, while also helping to prevent injury.33 An injury to the ankle joint
will result in proprioceptive deficits, which will then be followed by a decrease in
neuromuscular control.6 These decrements adversely affect an individual’s dynamic
postural control and predispose them to recurrent instances of instability.6 This
predisposition could explain the residual instability related to FAI. Hertel et al.6 describes
the deficits in dynamic stability following LAS to be a compounding effect stemming
from nerve –conduction velocity, neuromuscular response time, static postural control,
and strength. Impaired nerve-conduction velocity has been seen in the common fibular
nerve following acute LAS, which provides researchers with an objective measure of
functional instability.34, 35 Slowed neuromuscular response times have also been
demonstrated in individuals with a history of LAS.36 Konradsen et al.36 examined muscle
activity, joint motion, and alteration of body center of pressure during sudden inversion
through external perturbation in 15 participants with a history of ankle instability and 15
10
healthy controls. Researchers found a prolonged reaction time in the unstable ankles,
which examiners believe enforces the theory of proprioceptive deficits being linked to
ankle instability.36
Strength deficits have been reported in individuals with a history of ankle
sprains37 and may be linked to alterations seen in dynamic postural control.6 However,
the extent of relation between strength and dynamic postural control is not known, and
strength deficits do not necessarily mean that balance impairments will follow. Hertel et
al.6 explained that strength deficits can be due to impaired neuromuscular recruitment,
muscle damage, or muscle atrophy.
The individual symptoms of dynamic instability are not mutually exclusive, but
occur in tandem with each other. Joint injury causes proprioceptive and neuromuscular
control deficits, which negatively affect dynamic stability of the ankle and can lead to the
predisposition of further ankle injury.6
Dynamic postural control can be assessed when the patient attempts to maintain a
stable base of support while completing multiple functional and dynamic movement
patterns.19 This may involve hopping or jump landing and immediately upon ground
impact attempting to remain motionless in a stable base of support.19 Or this could
involve purposeful reaching with a selected body segment while attempting to maintain a
stable base of support.19 In doing so, we may also ascertain, to an extent, the individual’s
strength and range of motion. The Star Excursion Balance Test (SEBT) is such a test in
which it is possible to inquire these measurements.19, 38 Clinicians may use the SEBT as a
11
way to measure the dynamic postural control deficits following an ankle sprain and as a
tool to objectively measure improvements during a rehabilitation program.
Star Excursion Balance Test
The ability to maintain balance during a dynamic task is clinically relevant in
injury prevention, as balance deficits can result in recurrence of LAS.16 The ability of
clinicians to be able to objectively measure a patient’s balance and dynamic postural
control may play a paramount role in injury prevention. The SEBT gives the clinician a
low-cost, reliable testing system that can be utilized in a time efficient manner.19, 38, 39
Munro et al39 conducted a study to determine the reliability of using the SEBT in a
clinical setting by examining the learning effect, test-retest reliability, and measurement
error.39 Their results indicated that there is high test-retest reliability with intraclass
correlation coefficients (ICC) of 0.84-0.92 for all 8 reach directions.39 When
administering the SEBT researchers suggest that 4 practice trials be performed to account
for a learning effect.39, 40
Originally designed as a grid pattern on the ground resembling a star, with the
eight lines 45 degrees away from each other and extending out from one center point.19, 39
Each of these designated lines serves as reach guidance for the patient completing the
test. While maintaining a stable base of support on the stance leg, the patient reaches with
the contralateral limb and touches their toe against the line once maximal distance is
reached. When maximum reach distance is achieved the clinician records the distance,
and the patient returns to a tandem stance while maintaining dynamic stability. In order to
perform these reaching tasks and attain a desirable score the stance leg requires ankle
12
dorsiflexion, knee flexion, hip-flexion range of motion along with ample strength,
proprioception, and neuromuscular control to perform each dynamic reaching task.38 If
only a short distance is achieved by the patient there may be a mechanical issue,
sensorimotor system deficit,41 or a lack of dynamic postural control.19
Performance in the SEBT may be influenced by specific anthropometric and
physiologic measures and normalization of the reach distances are necessary for accuracy
purposes. Munro and Herrington39 believed that when comparing separate individuals it
is important to normalize the reach distances by leg length. The leg length is determined
by measuring from the anterior superior iliac spine to the medial malleolus of the
individual while lying supine.39 To normalize the reach distance each reach distance is
divided by the individual’s leg length and multiplied by 100.39 When Gribble and Hertel42
compared the raw scores of healthy men and women they found that men were able to
reach significantly farther, on average, than women in all eight directions of the SEBT.
The researchers considered this difference may be due to the men being taller and,
naturally, having longer legs than the women. They then normalized all of the reaching
scores to leg length and found that the differences between sexes no longer existed in the
data.
Evidence now exists supporting the use of only three of the eight reach directions:
the anterior, posteromedial, and posterolateral directions.40 With a decrease in subsequent
reach directions needed, researchers have substantially streamlined the administration of
the SEBT. Researchers40, 43 have shown a functional redundancy exists within
administration of all 8 directions, and that validity of the test is not compromised when
only performing the three reaching directions. Using the anterior, posteromedial, and
13
posterolateral reach directions gives us a sufficient measurement of an individuals’
dynamic postural control.40 Researchers suggest that once you have normalized all of an
individual’s scores on the three reach directions a composite score should be calculated.
A composite reach distance gives clinicians a comprehensive view of how each
individual performed on the SEBT, and is determined by the sum of all three reach
directions divided by three times the limb length, multiplied by 100.44
The SEBT is a useful tool for objectively measuring a patient’s dynamic balance
following LAS and track improvement through a rehabilitation protocol19, 38, however,
another important clinical application for the SEBT is using the measured amount of
dynamic stability as a predictor of risk for an injury to the lower extremity.19, 44 Limited
research has been conducted on the ability of the SEBT to be predictor of injury to lower
extremity joint, however, Plisky et al.44 yielded significant results linking reach distance
to lower extremity injury. Researchers tested high school basketball players from 7
different schools before the start of their competition season, while documenting any
lower extremity injuries throughout the season. They reported that players with a right-toleft difference, in the anterior direction, of greater than 4cm were 2.5 times more likely to
suffer a lower extremity injury. Also, specifically female basketball players with a
composite score of less than 94% of their limb length are 6.5 times more likely to suffer a
lower extremity injury.44
Hoch et al45 performed a study examining the relationship between DF range of
motion measured with the Weight Bearing Lunge Test (WBLT) and normalized reach
directions in the anterior, posteromedial, and posterolateral directions of the SEBT. Once
normalized, researchers found a significant correlation between the anterior reach
14
direction and DF range of motion (r = 0.53, r2 = 0.28) (p < 0.001).45 The statistical results
indicate that 28% of the variance in the anterior reach direction of the SEBT can be
accounted for by DF range of motion. The researchers suggested that the anterior reach
direction of the SEBT may be a good clinical test to assess the effects DF restrictions
have on dynamic postural control.45
Dorsiflexion Limitations
During non-weight bearing DF the talus rolls and glides posteriorly in relation to
the calcaneus,41 however, while in gait the tibia will translate anteriorly on the talus. DF
is decreased following a LAS and is thought to contribute to the functional instability
associated with multiple ankle sprains.16 DF limitations can be caused by an excessively
anterior positioned talus creating abnormal or restricted posterior,46 and potentially
creating an abnormal axis of rotation at the talocrural joint.6 If the talocrural joint is
unable to fully dorsiflex, it will not reach a complete closed-pack position during stance,
and therefore, will be vulnerable to an injurious mechanism.6 This deficit, along with
being linked to functional instability,16 may contribute to an impaired sensorimotor
system function.46 This is theorized to occur by disrupting the normal transmission of
afferent information related to alterations in ankle rotation and tracking of the articular
surfaces.46 Restoration of normal DF range of motion following an acute LAS may help
decrease an individual’s susceptibility to future ankle sprains.18
Foot and Ankle Disability Index (FADI)
Traditionally, clinically measured outcomes for joint ability after injury include
strength, range of motion, and subjective balance assessment. In conjunction with these
15
measures, goals are produced by clinicians and are completed by patients, throughout a
rehabilitation program. These goals help clinicians make objective and safe return-to-play
decisions. However, clinicians may overlook self-reported functional limitations and
disabilities experienced by patients. The ability to quantify self-reported function is an
invaluable resource clinicians can use to track progress through a rehabilitation program.
Subjective reports of function completed by patients are becoming an essential part of
clinical practice for health care practitioners.12 Subjective measures allow clinicians to
assess changes in a patients functional limitations and disabilities after designed clinical
interventions.13
The Foot and Ankle Disability Index (FADI) was designed to give clinicians such
a tool to assess the amount of self-reported disability related to foot and ankle
pathologies. The Foot and Ankle Disability Index Sport (FADI Sport) allows the clinician
to break down sport specific tasks for greater sensitivity in functional limitations.13 The
FADI was developed to be region and task specific, covering aspects of activities of daily
living.13 The FADI Sport assesses more dynamic tasks which are more specific to athletic
participation in order to detect deficits in higher functioning participants.13 Each task is
given a score by the patient; 0 (unable to do) to 4 (no difficulty at all). There are also 4
pain items listed on the FADI, which are given scores ranging from 0 (no pain at all) to 4
(unbearable).
Hale and Hertel13 conducted a study examining the intersession reliability during
1 and 6 week intervals, the sensitivity to differences between healthy participants and
participants with CAI, and the sensitivity to changes in function in those with CAI after
rehabilitation, of the FADI and FADI Sport. Fifty recreationally active participants
16
completed the FADI and FADI Sport in three different testing sessions: week 1, week 2,
and week 7. Each participant completed a separate survey for their limb with CAI and
their uninvolved limb. During the study one group of participants was included into a 4week ankle rehabilitation program, to assess the changes in function after a rehabilitation
program. ICC was calculated comparing weeks 1 and 2, and weeks 1 and 7. The
researchers found ICC values at week 1 were 0.89 and 0.84 and over 6 weeks at 0.92 and
0.93 for the FADI and FADI Sport, for the involved limbs. Both survey’s scores were
significantly less for the involved limbs of participants with CAI when compared to their
uninvolved limbs.
Both the FADI and FADI Sport appear to be valuable tools in assessing subjective
deficits in ankle function. The use of self-reported function instruments such as these can
be an invaluable and reliable tool in a clinical setting.13 Both are cost-effective and allow
a clinician to make a more informed return-to-play decision regarding ankle injuries and
ankle instability.
17
Chapter 3
Methods
Study Design
This study used a case-control design.
Participants
Participants were primarily recruited from The University of Toledo
intercollegiate athletics. Prior to participation in the study all participants read and signed
an informed consent form approved by the University of Toledo Institutional Review
Board. Participants within the ankle sprain group were included if they were over 18
years of age, presented with an acute LAS that resulted in swelling, pain, and temporary
loss of function within 36 hours of the initial injury, and had no other lower extremity
injury in the prior six months. Participants were excluded from the study if they had a
vestibular disorder or previous history of fractures or surgery to their ankles. As this was
part of a larger study assessing aspects of central nervous system excitability, additional
exclusion criteria included a concussion or head injury in the past 6 months, history of a
stroke, cardiac condition, cancer in the thigh musculature, cardiac pacemaker, implanted
cardiac defibrillator or were currently pregnant/breast feeding.
Healthy controls had no previous injury to the ankle, knee, or hip and were
recruited following enrollment of an acute LAS participant. The limb of the control
participants was matched to the injured limb of the LAS participants. If the LAS
18
participant was afflicted on the right side, then the healthy control performed all
assessments on the right side. This was done to avoid any issues of unmatched
comparisons of limb dominance that could occur with the randomization of limb
assignment in the healthy control group.
Procedures
All participants were asked to report for a total of five tests sessions done at 36
hours, 5, 7, 10, and 14 days following initial injury or enrollment in the case of the
healthy control group. Each testing session lasted approximately 1 hour, with selfreported disability, function and pain assessed using the FADI, FADI Sport and VAS.
Dynamic balance was assessed using the SEBT. Ankle girth was measured using the
figure-of-eight method.25 Dorsiflexion range of motion was assessed using a goniometer.
Frequency of rehabilitative exercises, athletic participation and use of therapeutic
modalities was collected using a treatment questionnaire.
Foot and Ankle Disability Index
All participants completed the Foot and Ankle Disability Index (FADI) and the
FADI Sport at each session. These measurements provided us with knowledge of any
presence of subjective disability related to ankle instability. Of the 32 items on the
questionnaire, 26 of them are related to deficits in participants’ activities of daily living
and pain. The remaining eight items are related to participation in physical activity. The
FADI has a total point value system ranging from 0-104, while the FADI Sport is scored
from 0-32. Both the FADI and FADI Sport are converted separately to percentages of
disability, with 100% representing no dysfunction at all.
19
Star Excursion Balance Test
The directions utilized within this study were anterior, posteromedial, and
posterolateral. One and a half inch tape (Johnson & Johnson white porous Coach tape,
Skillman, NJ) was utilized to make a testing grid. The anterior reach direction required
the participants to place the great toe in the middle of the testing grid. The posteromedial
and posterolateral reach directions both required the participants to place their heels in
the center of the testing grid. While keeping their hands on their hips and stance heel in
contact with the floor, they reached as far as they could with their non-stance foot. When
maximal distance was achieved, each participant was instructed to lightly tap his/her foot
on the tape grid with the most distal part of his/her foot, and then return the reaching limb
back to the center of the testing grid without shifting weight or losing balance. When the
participant lightly tapped the tape grid the researcher made a mark on the tape to record
the distance achieved. If the participant is judged to have made a heavy contact with the
ground and tape grid, shift his/her weight on the stance leg, have his/her heel come off of
the ground, remove his/her hands from their waist, or touch the ground with his/her
reaching limb while returning back to the center of the grid, the trial was discarded and
then repeated. Verbal or visual encouragement was not given to any of the participants
during testing.
Prior to the measurements beginning, the primary investigator demonstrated each
reach direction. The participants were given four practice trials in each reach direction.40
The participants performed three test trials in each direction in order for an average
measurement to be taken. To compare performances between participants, reach
distances were normalized to each participants leg length.42 This is done by measuring
20
from the anterosuperior iliac spine to the medial malleolus, and correlating leg length to
reach performance.42 Researchers have concluded that because of limb length
discrepancies, performance differences between participants can be negated through this
normalization process. After normalizing the reach distances, performance is expressed
as a percentage of limb length.
Visual Analog Scale
Participants were given a paper with two, 10cm lines each titled differently for
pain or ankle function (Appendix E). The lines are meant to act as a scale to allow the
participant to subjectively grade his/her own pain level and self-reported ankle function.
With respect to the grading system, the far left being very low and the far right being very
high, the participants were asked to make a single vertical mark on each line, indicating
how they felt relative to each category, at that point in time. A millimeter tape measure
was used to measure where each participant marked on the scale. The measurement was
then converted to a score ranging from 0-100, according to where the participant marked
on the scale.
Treatment Questionnaire
Participants were given a questionnaire related to treatment strategies done for
their acute lateral ankle sprain. Treatment strategies included within the questions are
medication use, therapeutic modalities, frequency of therapeutic exercise, and frequency
of sport related participation including practice and games. Additionally, they were asked
to rate their own overall global function on a percentage scale of 0-100% functional as
limited by the injured ankle.
21
Ankle Girth and Dorsiflexion Range of Motion
Participants were asked to sit on a treatment table within the athletic training
room at the University of Toledo with their knees extended and feet and ankles hanging
off of the table. The examiner performed the figure-of-eight measurement method for
ankle girth with the ankle positioned in a neutral position.47 Three consecutive active
measurements were performed for an average to be attained for each ankle.
The goniometer was placed on the lateral aspect of the ankle joint, with the
fulcrum placed on the lateral malleolus to make a 90° angle between the stationary arm
and movement arm. The stationary arm was placed parallel along the longitudinal axis of
the fibula, while the movement arm was placed parallel along the fifth ray of the lateral
aspect of the foot. With the patient in a neutral, 90°, the examiner asked the patient to
actively dorsiflex to end range of motion. Then the examiner performed three consecutive
active dorsiflexion range of motion measurements and an average was calculated for each
ankle. Participants returned to a resting position in between each of the three trials.
Statistical Analysis
For each of the included outcome measures, a 2x5 repeated measures ANOVA
was used to determine if differences exist between groups over the selected time points.
Tukey’s post hoc testing was used in the event of significant interactions. Effect sizes
using Cohen’s d from the pooled standard deviations were employed to further explore
these parametric differences. Participants were excluded from analysis at time points they
did not report for testing. All statistical analyses were performed using SPSS 19.0 (SPSS
inc., Chicago, IL) statistical software package. Statistical significance was set a priori at
P<0.05.
22
Chapter 4
Results
Self-Reported Measures
For the FADI, a significant interaction for time and group was observed
(P<0.001, Table 2). Post-hoc testing revealed that the LAS group had significantly more
self-reported disability during ADL’s compared to the control group at 36 hours
(P<0.001), 5 days (P=0.001), 7 days (P=0.005), 10 days (P=0.001), and 14 days
(P=0.001). For the FADI Sport, a significant interaction effect (P<0.001, Table 3) was
also observed. Post-hoc testing revealed greater disability during sports and physical
activity in the LAS group compared to the control group at 36 hours (P<0.001), 5 days
(P<0.001), 7 days (P=0.002), 10 days (P<0.001), and 14 days (P=0.002). For the VAS
Pain scale, a significant interaction effect (P<0.001, Table 4) was observed. Post-hoc
testing revealed that LAS group had more pain compared to the control group at 36 hours
(P<0.001), 5 days (P<0.001), 7 days (P=0.001), 10 days (P=0.002), and 14 days
(P=0.003). For the VAS Function scale, a significant interaction effect (P<0.001, Table
5) was demonstrated. Post-hoc testing revealed decreased function in the LAS group
compared to the control group at 36 hours (P<0.001), 5 days (P<0.001), 7 days
(P=0.001), 10 days (P<0.001), and 14 days (P=0.026). Lastly, for Global Function a
significant interaction effect (P<0.001, Table 6) was also demonstrated. Post-hoc testing
revealed less Global Function in the LAS group compared to the Control group at 36
23
hours (P<0.001), 5 days (P<0.001) 7 days (P=0.002), 10 days (P<0.001), and 14 days
(P<0.001).
Dorsiflexion and Ankle Girth Measures
Musculoskeletal measures of DF and girth measurements of swelling are
presented in Table 7 and 8. For the DF measures a significant interaction effect (P<0.001)
was found. Post-hoc testing revealed less DF range of motion in the LAS group
compared to the control group at 36 hours (P<0.001) and 7 days (P=0.037). No
statistically significant differences were observed at 5 days (P=0.061), 10 days
(P=0.714), and 14 days (P=0.145). Although no significant differences were see at days
5, 10, and 14, moderate effect sizes indicated decreased DF range of motion at 36 hours
(d= -1.19, 95%CI: -1.90,-0.42), 5 days (d = -0.77, 95%CI: -1.46,-0.04), and 7 days (d= 0.51, 95%CI: -1.20,0.19). For the Figure 8 Girth Measurement no significant interaction
effect (P=0.132) was found. While no statistically significant differences were observed
in the ankle girth measurements, a moderate effect size indicated increased ankle
swelling in the LAS group at day 14 (d = -0.41, 95%CI: -1.10,0.31) (Table 13).
Dynamic Postural Control Measures
Average reach distances for the SEBT are reported in Tables 9-11. For the
anterior reach of the SEBT no significant interaction effect (P=0.125), main effect for
group (P=0.220), or main effect for time (P=0.092) was found. While no statistically
significant differences were observed in the anterior reach, moderate effect sizes
indicated reduced postural control at 36 hours (d = -0.59, 95%CI: -1.31,0.16), 5 days (d =
-0.45, 95%CI: -1.17,0.29), and 7 days (d = -0.64, 95%CI: -1.36,0.12) post injury (Table
24
15). In the posteromedial reach direction of the SEBT a significant main effect for time
(P=0.028) was found. No significant main effect for group (P=0.05) or interaction effect
(P=0.172) was found. Post hoc testing revealed, for the posteromedial reach of the SEBT,
significant differences in 36 hours-7 days (P=0.015), 36 hours-10 days (P=0.009) and 36
hours-14 days (P=0.011). While no statistically significant interaction effect was seen in
posteromedial reach distance, a strong-to-moderate effect size indicated reduced postural
control at 36 hours (d= -0.97, 95%CI: -1.70,-0.18), 5 days (d= -0.80, 95%CI: -1.53,0.03), 7 days (d= -0.43, 95%CI: -1.15,0.31), 10 days (d= -0.58, 95%CI: -1.30,0.17), and
14 days (d= -0.64, 95%CI: -1.36,0.12) (Table 15). In the posterolateral reach direction of
the SEBT a significant main effect for time (P<0.001). No main effect for group
(P=0.265) or interaction effect (P=0.464) was found. Significant main effects for time
were observed, indicating both groups improved when comparing 36 hours-5 days
(P=0.019), 36 hours-7 days (P=0.003), 36 hours-10 days (P=0.009) and 36 hours-14 days
(P=0.001). While no statistically significant differences were observed in the
posterolateral reach, moderate effect sizes indicated reduced postural control at 36 hours
(d = -0.51, 95%CI: -1.23,0.24), 5 days (d = -0.40, 95%CI: -1.11,0.34), and 7 days (d = 0.52, 95% CI: -1.24,0.23) compared to the control group (Table 15).
25
Chapter 5
Discussion
We conducted this study to determine the effects of an acute lateral ankle sprain
on self-reported function, disability and pain, as well as joint effusion, DF range of
motion, and dynamic stability over a 14 day period following injury compared to healthy
matched controls. In the ankle sprain group, all self-reported outcomes were negatively
affected throughout the 14 days post injury, indicating that perceived functional ability
may be significantly decreased longer than two weeks past the time of injury. Concurrent
results were observed in measures of dynamic stability, as significant deficiencies were
seen in the injured group 14 days post injury. Dorsiflexion range of motion measurements
were significantly decreased all the way to 7 days after the initial sprain. After one week,
range of motion deficits improved within the injured group. Swelling within the affected
ankle in the injured group lasted until 10 days after injury. Our results are unique because
self-reported function, self-reported pain, DF ROM, ankle girth, and dynamic stability
have not been tracked after acute ankle sprains over a 14 day period. If we know when
self-reported measures, ROM, girth, and dynamic stability return to a normal, healthy
state, we can clinically advance patients back to activity in a safer manner. Doing so may
help avoid further episodes of ankle instability.
Self-Reported Measures
There were significant differences in self-reported function and disability between
the LAS and control groups at each time point. Within our results, each self-reported
26
outcome gradually improved throughout a two week period post-injury. However, the
LAS group means did not return to a level of function equivalent to those of healthy
participants. Rehabilitation protocols being utilized with participants in our study may not
have been addressing self-reported outcomes to the extent needed. Following a LAS
many individuals return to full participation within a two week time frame, theoretically
with little to no residual side-effects. However, residual symptoms may be present due to
inadequate return-to-play protocols allowing athletes to return to play with less that 100%
of functional ability, when compared to prior injury status. Most ankle sprains are not
seen as severe injuries, which can cause improper management of them and result in the
development of chronic ankle instability (CAI).6 It has been reported that residual
symptoms are seen in 40-50% of individuals who suffer from at least one ankle sprain.3, 7
With our best predictor of CAI being a history of one lateral ankle sprain,6, 9-11 indicating
that clinicians may often underestimate the severity of an athlete acquiring an ankle
sprain. If clinicians are returning patients to sport or work participation while residual
symptoms are present they may be putting the patient at risk for CAI and further injury.
Current treatment strategies and rehabilitation protocols may be ineffective at preventing
residual, lasting symptoms that lead to the onset of CAI.6 Residual dysfunction could
present as deficiencies in dynamic stability6, dorsiflexion (DF) range of motion16, selfreported function, and strength.6 This may be a defining factor as to why recurrent ankle
sprains are so prevalent.
The ability to quantify self-reported function and disability is an invaluable
resource clinicians can use to track progress through a rehabilitation program. Subjective
reports of function completed by patients are becoming an essential part of clinical
27
practice for health care practitioners.12 Subjective measures allow clinicians to assess
changes in a patients’ functional limitations and disabilities after designed clinical
interventions.13 Scores for both the FADI and FADI Sport were consistently less in the
LAS group compared to healthy participants. We expected the decreased scores within
the LAS group after the initial injury. Presumably the participants should return to full
activity with no lingering disability, in order to avoid further bouts of instabiltiy, but this
was not demonstrated in this sample population. The majority of our participants were
involved with intercollegiate, varsity athletics, and when examining days 7-14 we see
surprisingly low FADI Sport reported measures. When tracking each participant’s
returned to activity we see that, on average, a RTP time frame was 5.97 days post injury.
Because our participants are returning to activity within 14 days they are returning to
sport while scoring below an 80% on the FADIS, and some as low as 62%.
Current recommendations regarding LAS rehabilitation focus on returning a
patient to full participation within one week14 and some report athletes returning as soon
as 3 days.15 McKeon et al.15 compared return-to-play probability timelines for initial and
recurrent ankle sprains in athletes to identify when an athlete is likely to RTP following
an ankle sprain. The primary return-to-activity timeline was 1-3 days,15 regardless of
injury history. While a quick return to activity may be desirable, our results demonstrated
athletes were scoring as low as 45% on the FADI Sport at 5 days following injury in
addition to reporting an overall Global Function below 80% and as low as 62%. By 3
days post-injury an athlete may be capable of performing many sport related activities;
however, our data demonstrate that athletes do not perceive themselves to be fully
functional by that time.
28
While VAS scales for both pain and function improved in the injured group
during the 14 days that were monitored, the LAS group did not return to a pain-free state
or felt that they were functioning without restrictions compared to their healthy
counterparts. Our data shows VAS function scores ranging as low as 78% and VAS pain
scores as high as 22 at day 7. Significant differences between groups lasted until day 14
as we see VAS function scores as low as 91%, and VAS pain scores as high as 14. As
stated early, participants included within this study averaged a RTP time of 5.97 days
following injury. This suggests clinicians are regularly returning intercollegiate, varsity
athletes back to activity while they are still experiencing significant levels of function
loss and pain. This may further support the theory that athletes are returning to sport
participation before they are asymptomatic and possibly increasing their susceptibility for
further injury.
Clinicians may need to consider the possibility that a LAS return-to-play protocol
time frame should be increased further than two weeks, or the possibility that increased
limitations within sport participation must be implemented. Clinicians should also
consider including assessments of patient reported outcomes, such as those within this
study, to ascertain self-reported limitations.
Dorsiflexion and Ankle Girth Measures
Diminished DF ROM following LAS is thought to contribute to functional
instability and lead to residual bouts of instability.16 Dorsiflexion measurements within
the LAS group were significantly decreased at 36hours, day 5, and day 7. Range of
motion within the LAS group did not begin to normalize to the level of the healthy group
29
until day 10, meaning that any athlete who returned to sport participation on or before
day 7 was suffering from significant decreases in dorsiflexion range of motion. . If
patients are unable to return to full DF ROM, it is a possibility that this places them at a
greater risk for re-injury, as the ankle is held in a more plantarflexed state thoughout the
gait cycle.16 The ankle is at its least stable position while plantar flexed. Currently the
exact degree of deficit in DF ROM to contribute to CAI and residual instability is not
known. However, individuals with CAI have been seen with decreases in DF between
4.28 and 5.38 degrees.48 Ankle DF restrictions have also been seen to affect landing
mechanics in individuals with CAI.49
This finding of decreased DF may also be linked to decreases seen in the anterior
reach of the SEBT, resulting in decreased dynamic postural control before day 10. Hoch
et al.45 found a significant correlation between the anterior reach direction of the SEBT
and DF ROM. Statistical results indicated that 28% of the variance in the anterior reach
direction of the SEBT can be accounted for by DF ROM. We can interpret this as if
clinicians increase DF ROM we may be able to increase dynamic postural control
following ankle injury. Even though researchers45 within this study utilized the WBLT to
measure ankle DF ROM, as opposed to using a goniometer, we can still interpret results
in the same manner; with decreases in DF ROM we may see decreased dynamic stability.
It will be important in the future to also assess open chain DF ROM as there may be
important differences between these two methods and how each form of this ROM is
utilized during functional tasks.
The lack of significant increases in ankle girth findings within the LAS group
may be due to the fact that the majority of sprains within this study were a grade one. If
30
more severe sprains were included within this study we may have seen magnified
differences between groups.
Dynamic Postural Control
When examining the anterior and posteromedial reaches of the SEBT our results
showed a significant difference between groups at each time point except at days 5 and 7
respectively. We can interpret these findings as an improvement in symptoms and a
subsequent decrease at days 10 and 14. This may be from early RTP decisions releasing
athletes to full participation while residual symptoms are still present. When participants
were returning between days 5-7 we see a decline in their dynamic stability. Also, similar
to the self-reported outcomes, we can interpret this as lingering deficits lasting up to 14
days post injury. After two weeks of recovery and rehabilitation, athletes did not return
back to normal dynamic postural control. Within the posteromedial and posterolateral
reach directions we can see that the participants did gradually improve at each time point,
except in the PM reach at day 5. Despite significant improvement being seen in these
directions, if participants never return back to a healthy level they will possibly be at
further risk of re-injury when in competition. Their dynamic postural control never fully
recovered within 14 days following LAS. If we continue to compare these results to the
FADI, FADI Sport, VAS Pain, VAS Function, Global Function, DF ROM, and ankle
girth we can see a tendency of decreased function. Participants report that they feel
decreased function, and increased disability and pain over 14 days post injury, and
simultaneously demonstrated decreased dynamic postural control, suggesting that LAS
significantly affects athletes and sport performance 14 days after initial injury. As
discussed above, DF limitations are related to performance in the anterior reach of the
31
SEBT.45 If athletes return to activity prior to DF ROM returning to normal, it is likely
that their dynamic stability also suffers. This may be linked to results seen in the FADI
Sport, VAS Function, and Global Function. While DF ROM is decreased and inhibiting
dynamic stability, patients may feel functional deficits. The individual symptoms of
dynamic instability and decreased self-reported outcomes are not mutually exclusive, but
rather may occur in tandem with each other. Joint injury causes proprioceptive and
neuromuscular control deficits, which negatively affect dynamic stability of the ankle and
can lead to the predisposition of further ankle injury.6 Additional work is needed to
understand how patient and clinician generated outcomes influence and interact with each
other in order to determine better return to play protocols for LAS.
Return-to-Play
Common RTP time frames range between 3-7 days following a lateral ankle
sprain. Our study shows similar results, with participants returning to activity in an
average of 5.97 days following injury. However, typical tissue healing timeframes for
ligaments range between 6-12 weeks while scar tissue matures to full tensile strength.50
Our results show that residual symptoms following an acute LAS are lasting up to 14
days. These time frames suggest that athletes are routinely returning to participation prior
to complete healing of the ankle sprain and prior to full tissue healing. Participants
included within this study returned to sport participation following a LAS while still
symptomatic. When considering the high recurrence rates of ankle sprains and
subsequent CAI, clinicians may be putting athletes at further risk for re-injury by
advancing them to RTP too quickly. When returning to participation prior to the ankle
being fully healed, athletes are still experiencing symptoms of decreased self-reported
32
function, increased pain, decreased dorsiflexion, and decreased dynamic stability. Doing
so may actually cause symptoms to worsen, as seen in our dynamic stability results.
These results are of clinical importance to athletic trainers for decreasing the risk of
further injury to athletes receiving treatment following a LAS.
Limitations
This study included a relatively small sample size. With more participants it is
possible that different results could be attained, such as magnified differences in our
outcomes because a broader range of severity of ankle sprain could be gathered. More
participants would mean more variability in the grade level of sprains we would gather,
being as most participants within this study suffered only grade one sprains. Also,
previous history of ankle sprains was not documented; therefore, it is possible that a
number of LAS participants may have already had CAI, FAI, or MAI, which may have
predisposed them to the most current injury being researched within this study. If that
were the case, our outcome measures could have been influenced by pre-existing deficits
in function, pain, ROM, girth, and dynamic stability. While the majority of injured
participants included with the study had only a grade 1 LAS as diagnosed by a certified
athletic trainer, we included other levels of severity of LAS, which may have introduced
variability in the severity of pain, loss of function, loss of ROM, increased girth, and
decreased dynamic stability. Additionally, the standard of care among participants was
not controlled, which may influence the self-reported outcomes and contribute to the
recovery time difference for each participant. It will be important in larger studies in the
future to consider controlling for these clinical factors.
33
Future Research
Future research should take into account the possibility that LAS patients may
have a history of previous ankle sprains and document, if possible, how many each
participant has sustained and when the last LAS occurred. Further investigation is needed
to see if the standard and extent of treatment and rehabilitation influences changes see in
self-reported function, self-reported pain, global function, dynamic postural control, and
motor neuron pool excitability. If more information is known on specific rehabilitation
and treatment protocols and how they affect function following an ankle sprain clinicians
may be able to provide better care for their athletes and limit repeated ankle sprains.
Also, future research should include more participants and be conducted for a longer
period of time in order to investigate when and if self-reported measures return to normal.
If clinicians know when an athlete feels fully functional with no self-reported pain then
they may be able to return the athletes back to activity at a safer time and decrease the
propensity of CAI. Future studies should also examine neuromuscular function of the
lower leg following an acute LAS to ascertain how AMI may affect or be affected by
other symptoms of a lateral ankle sprain and how AMI may change over time following a
LAS. If we know how neuromuscular function changes after an acute LAS we may be
able to provide better treatment protocols aimed at decreasing further injury once
returned to sport activity.
Conclusion
Those who experienced a LAS exhibited decreased self-reported function,
decreased dynamic postural control, decreased DF range of motion, increased self-
34
reported pain, and increased ankle girth compared to healthy participants. While studies
investigating acute alterations in the FADI, FADI Sport, VAS Pain, VAS Function,
Global Function, DF range of motion, ankle girth, and dynamic stability for 14 days
following a LAS are limited, these results should be taken into consideration when
making return-to-play decisions. Clinicians may need to consider the possibility that a
LAS return-to-play protocol time frame should be increased further than two weeks.
Waiting to return an athlete to activity until all outcome measures have returned to 100%
functional ability may be clinically impractical in some instances. However, greater
attention to deficits should be made prior to making a return-to-play decision.
35
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39
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40
Appendix A
Tables
Table 1. Means and Standard Deviations for Participant Demographics
Age
Height
LAS
LAS
LAS
Group
(years)
(cm)
Mass (kg) Sex
Grade 1 Grade 2 Grade 3
20.41 ±
176.44 ±
74.22 ±
M=10,
LAS (n=29)
n=18
n=10
n=1
2.18
11.00
14.33
F=19
Healthy
(n=22)
20.95 ±
2.97
178.61 ±
10.96
76.39 ±
13.81
M=11,
F=11
Table 2. Food and Ankle Disability Index
Muscle
FADI 36
Hours
FADI 5
Days
FADI 7
Days
FADI 10
Days
FADI 14
Days
Group by Time (F =25.755 ;
P<0.001)
Healthy
LAS (n=10)
(n=12)
Post-hoc
p-value
71.60 ± 15.44
99.82 ± 0.84
<0.001
85.04 ± 13.95
99.86 ± 0.62
0.001
89.52 ± 11.06
99.82 ± 0.84
0.005
92.18 ± 10.99
99.82 ± 0.84
0.001
96.60 ± 4.56
99.82 ± 0.84
0.001
FADI=Foot and Ankle Disability Index
41
Cohen’s d
(95% CI)
-2.84
(-3.70,-1.86)
-1.65
(-2.38,-0.86)
-1.45
(-2.15,-0.67)
-1.08
(-1.76,-0.35)
-1.07
(-1.75,-0.34)
Group
Time
F=43.86
P=0.000
F =25.731 ;
p <0.001
36 hours-5 days:
<0.001
36 hours-7 days:
0.001
36 hours-10 days:
<0.001
36 hours-14 days:
<0.001
Table 3. Foot and Ankle Disability Index Sport
Group by Time (F=23.888 ;
p<0.001)
FADIS
LAS (n=11)
Healthy (n=21)
FADIS 36
Hours
56.79 ± 32.18 100.00 ± 0.00
FADIS 5
Days
70.30 ± 25.40 100.00 ± 0.00
FADIS 7
Days
80.10 ± 18.27 100.00 ± 0.00
FADIS 10
Days
84.03 ± 19.66 100.00 ± 0.00
FADIS 14
Days
92.63 ± 9.83
100.00 ± 0.00
FADIS=Foot and Ankle Disability Index Sport
Post-hoc
p-value
<0.001
<0.001
0.002
<0.001
0.002
Cohen’s d
(95% CI)
-2.33
(-3.18,-1.35)
-2.03
(-2.85,-1.10)
-1.89
(-2.70,-0.98)
-1.41
(-2.17,-0.57)
-1.30
(-2.06,-0.47)
Group
Time
F=32.253
P<0.001
F =23.888;
P<0.001
36 hours-5 days:
0.001
36 hours-7 days:
0.006
36 hours-10 days:
0.003
36 hours-14 days:
0.000
Group
Time
F=43.060
; P<0.001
F=30.241;
P<0.001
36 hours-5 days:
0.000
36 hours-7 days:
0.001
36 hours-10 days:
0.000
36 hours-14 days:
0.000
Table 4. Visual Analog Scale Pain
Group by Time(mm) (F=29.841
; P<0.001)
VAS Pain
VAS Pain
36 Hours
VAS Pain
5 Days
VAS Pain
7 Days
VAS Pain
10 Days
VAS Pain
14 Days
LAS (n=15)
Post-hoc
p-value
Cohen’s d
(95% CI)
Healthy (n=21)
33.27 ± 18.46
0.14 ± 0.65
<0.001
18.20 ± 17.87
0.05 ± 0.22
<0.001
11.00 ± 12.63
0.05 ± 0.22
0.002
5.93 ± 8.35
0.10 ± 0.44
0.003
2.73 ± 4.62
0.00 ± 0.00
0.003
VAS=Visual Analog Scale
42
2.79
(1.82,3.65)
1.58
(0.79,2.30)
1.35
(0.59,2.05)
1.09
(0.36,1.77)
0.92
(0.21,1.60)
Table 5. Visual Analog Scale Function
VAS
Function
VAS
Function
36 Hours
VAS
Function 5
Days
VAS
Function 7
Days
VAS
Function
10 Days
VAS
Function
14 Days
Group by Time(mm)
(F=34.474 ; P<0.001)
Healthy
LAS (n=15)
(n=21)
65.60 ± 18.68
Post-hoc
p-value
Cohen’s d
(95% CI)
<0.001
-2.87
(-3.73,1.88)
99.95 ± 0.22
79.23 ± 17.83
99.95 ± 0.22
<0.001
-1.81
(-2.55,0.99)
89.07 ± 10.59
99.95 ± 0.22
0.001
-1.60
(-2.32,0.81)
92.07 ± 9.17
99.95 ± 0.22
<0.001
-1.24
(-1.93,0.49)
96.10 ± 5.18
100.00 ± 0.00
0.026
-1.17
(-1.86,0.43)
Group
Time
F=47.8
P<0.001
F =34.602;
P<0.001
36 hours-5 days:
<0.001
36 hours-7 days:
0.003
36 hours-10 days:
<0.001
36 hours-14 days:
<0.001
VAS=Visual Analog Scale
Table 6. Global Function
Global Function
Global Function
36 Hours
Global Function
5 Days
Global Function
7 Days
Global Function
10 Days
Global Function
14 Days
Group by Time (F=52.414 ;
P<0.001)
Healthy
LAS (n=15)
(n=21)
Post-hoc
p-value
68.87 ± 16.47
100.00 ± 0.00
<0.001
83.47 ± 12.70
100.00 ± 0.00
<0.001
89.60 ± 10.93
100.00 ± 0.00
0.003
92.47 ± 10.34
100.00 ± 0.00
0.001
96.40 ± 4.98
100.00 ± 0.00
<0.001
43
d (95% CI)
Group
Time
-2.95
(-3.82,-1.94)
-2.03
(-2.79,-1.18)
-1.48
(-2.19,-0.71)
-1.14
(-1.82,-0.40)
-1.13
(-1.81,-0.39)
F=41.01
P<0.001
F =52.414
; P=0.001
Table 7. Dorsiflexion Range of Motion
DF
DF Ant 36
Hours
DF Ant 5
Days
DF Ant 7
Days
DF Ant 10
Days
DF Ant 14
Days
Group by Time(degrees)
(F=34.474 ; P<0.001)
Healthy
LAS (n=15)
(n=18)
Post-hoc
p-value
8.85 ± 2.45
11.83 ± 2.54
<0.001
9.60 ± 3.02
11.72 ± 2.54
0.061
10.84 ± 2.52
12.04 ± 2.14
0.037
11.33 ± 2.76
12.20 ± 1.94
0.714
11.39 ± 2.78
12.26 ± 1.78
0.16
Cohen’s d
(95% CI)
-1.19
(-1.90,-0.42)
-0.77
(-1.46,-0.04)
-0.51
(-1.20,0.19)
-0.37
(-1.05,0.33)
-0.38
(-1.06,0.32)
Group
Time
F=47.857
;P<0.001
F=34.602 ;
P<0.001
36 hours-5 days:
<0.001
36 hours-7 days:
0.003
36 hours-10 days:
<0.001
36 hours-14 days:
<0.001
DF=Dorsiflexion
Table 8. Ankle Girth
Group by Time(cm) (F=1.806 ;
P=0.132)
Girth
Girth 36
Hours
Girth 5
Days
Girth 7
Days
Girth 10
Days
Girth 14
Days
Post-hoc
p-value
LAS (n=14)
Healthy (n=18)
51.58 ± 4.11
52.70 ± 4.35
0.561
51.21 ± 4.13
52.80 ± 4.17
0.284
51.47 ± 4.04
52.79 ± 4.10
0.479
51.09 ± 4.43
52.51 ± 4.10
0.281
50.95 ± 4.11
52.67 ± 4.28
0.456
44
Cohen’s d
(95% CI)
0.26
(-.096,0.44)
-0.38
(-1.08,0.33)
-0.32
(-1.02,0.39)
-0.33
(-1.03,0.38)
-0.41
(-1.10,0.31)
Group
Time
F =.932;
P=0.342
F=3.546 ;
P=0.009
36 hours-5 days:
0.164
36 hours-7 days:
0.807
36 hours-10 days:
0.202
36 hours-14 days:
0.008
Table 9. Star Excursion Balance Test Anterior Reach
Group by Time (F=2.090 ;
P=0.125)
SEBT Ant LAS (n=13) Healthy (n=17)
SEBT Ant
36 Hours
0.62 ± 0.11
0.67 ± 0.08
SEBT Ant
5 Days
0.64 ± 0.09
0.68 ± 0.08
SEBT Ant
7 Days
0.64 ± 0.08
0.68 ± 0.07
SEBT Ant
10 Days
0.65 ± 0.07
0.67 ± 0.07
SEBT Ant
14 Days
0.67 ± 0.06
0.68 ± 0.08
SEBT Ant=Star Excursion Balance Test
Anterior
Post-hoc
p-value
0.007
0.077
0.029
0.037
0.04
Cohen’s d
(95% CI)
-0.59
(-1.31,0.16)
-0.45
(-1.17,0.29)
-0.64
(-1.36,0.12)
-0.27
(-0.99,0.46)
-0.08
(-0.80,0.64)
Group
Time
F =1.574;
P=0.220
F=2.385 ;
P=0.092
36 hours-5 days: 0.164
36 hours-7 days: 0.807
36 hours-10 days: 0.202
36 hours-14 days: 0.008
Table 10. Star Excursion Balance Test Posteromedial Reach
Group by Time (F=1.714 ;
P=0.172)
SEBT PM
LAS (n=13)
Healthy (n=17)
SEBT PM
36 Hours
0.78 ± 0.12
0.89 ± 0.11
SEBT PM
5 Days
0.82 ± 0.08
0.90 ± 0.11
SEBT PM
7 Days
0.84 ± 0.10
0.89 ± 0.11
SEBT PM
10 Days
0.84 ± 0.11
0.91 ± 0.11
SEBT PM
14 Days
0.84 ± 0.09
0.90 ± 0.10
SEBT PM=Star Excursion Balance Test
Posteromedial
Post-hoc
p-value
0.006
0.018
0.176
0.011
0.018
45
Cohen’s d (95%
CI)
-0.97
(-1.70, -0.18)
-0.80
(-1.53,-0.03)
-0.43
(-1.15,0.31)
-0.58
(-1.30,0.17)
-0.64
(-1.36,0.12)
Group
Time
F =4.198;
P=0.050
F =3.219; P=0.028
36 hours-5 days:
0.090
36 hours-7 days:
0.015
36 hours-10 days:
0.009
36 hours-14 days:
0.011
Table 11. Star Excursion Balance Test Posterolateral Reach
Group by Time (F=0.824 ;
P=0.464)
SEBT PL
LAS (n=13)
Healthy (n=17)
SEBT PL
36 Hours
0.73 ± 0.13
0.80 ± 0.12
SEBT PL
5 Days
0.77 ± 0.10
0.81 ± 0.13
SEBT PL
7 Days
0.79 ± 0.10
0.84 ± 0.12
SEBT PL
10 Days
0.80 ± 0.09
0.83 ± 0.13
SEBT PL
14 Days
0.81 ± 0.10
0.84 ± 0.12
SEBT PL=Star Excursion Balance Test
Posterolateral
Post-hoc
p-value
0.118
0.239
0.066
0.177
0.158
46
Cohen’s d (95%
CI)
-0.51
(-1.23,0.24)
-0.40
(-1.11,0.34)
-0.52
(-1.24,0.23)
-0.26
(-0.98,0.47)
-0.24
(-0.96,0.49)
Group
Time
F=1.293;
P=0.265
F =7.824 ; P<0.001
36-5 days: 0.019
36-7 days: 0.003
36-10 days: 0.009
36-14 days: 0.001
Table 12. FADI and FADI Sport Effect Sizes
d=-2.84 (0.86,0.99)
d=-1.65 (0.72,0.79)
d=-1.45 (0.71,0.77)
d=-1.08 (0.68, 0.73)
d=-1.07 (0.68, 0.73)
d=-2.33 (0.86, 0.98)
FADI 36
Hours
FADI 5 Days
d=-2.03 (0.82, 0.93)
FADI 7 Days
d=-1.89 (0.81, 0.90)
FADI 10
Days
FADI 14
Days
FADIS
36hours
FADIS 5
Days
-4
-3.5
d=-1.41 (0.77, 0.84)
d=-1.30 (0.76, 0.83)
-3
-2.5
-2
-1.5
95% Confidence Interval
47
-1
-0.5
0
Table 13. Dorsiflexion and Ankle Girth Effect Sizes
d=-1.19 (0.71,0.77)
d=-0.76(0.68, 0.72)
d=-0.51 (0.68,0.71)
d=-0.37 (0.68, 0.70)
d=-0.38 (0.68, 0.70)
d=-.26 (0.69, 0.71)
Dorsiflexion
36hours
Dorsiflexion 5
Days
Dorsiflexion 7
Days
Dorsiflexion 10
Days
Dorsiflexion 14
Days
Girth 36 Hours
d=-0.38 (0.69, 0.71)
d=-0.32 (0.69, 0.71)
d=-0.33 (0.69, 0.71)
d=-0.41 (0.69, 0.72)
Girth 5 Days
-2.5
-2
-1.5
-1
-0.5
95% Confidence Interval
48
0
0.5
1
Table 14. VAS and Global Function Effect Sizes
d=2.79 (0.98,0.85)
d=1.58 (0.79,0.72)
d=1.35 (0.76,0.70)
d=1.09 (0.73, 0.68)
d=0.92 (0.71, 0.67)
d=-2.87 (0.86, 0.99)
d=-1.81 (0.74, 0.82)
VAS Pain 36 Hours
d=-1.60 (0.72, 0.79)
VAS Pain 5 Days
-1.24 (0.69, 0.74)
VAS Pain 7 Days
d=-1.13 (0.68, 0.73)
VAS Pain 10 Days
d=-2.95 (0.87, 1.00)
VAS Pain 14 Days
VAS Function 36
Hours
VAS Function 5 Days
d=-2.03 (0.76, 0.85)
d=-1.48 (0.71,0.78)
VAS Function 7 Days
d=-1.13 (0.69, 0.74)
VAS Function 10 Days
d=-1.13 (0.68, 0.73)
VAS Function 14 Days
-5
-4
-3
-2
-1
0
1
95% Confidence Interval
49
2
3
4
5
Table 15. Star Excursion Balance Test Effect Sizes
d=-0.59 (0.72,0.75)
d=-0.45 (0.72,0.74)
d=-0.64 (0.72,0.76)
d=-0.27 (0.72, 0.73)
d=-0.08 (0.72, 0.72)
d=-0.97 (0.73, 0.79)
d=-0.8 (0.73, 0.77)
d=-0.43 (0.72, 0.74)
SEBT-A 36 Hours
SEBT-A 5 Days
SEBT-A 7 Day
SEBT-A 10 Days
SEBT-A 14 Days
SEBT-PM 36 Hours
SEBT-PM 5 Days
SEBT-PM 7 Days
SEBT-PM 10 Days
SEBT-PM 14 Days
SEBT-PL 36 Hours
SEBT-PL 5 Days
SEBT-PL 7 Days
SEBT-PL 10 Days
SEBT-PL 14 Days
d=-0.58 (0.72, 0.75)
d=-0.64 (0.72, 0.76)
d=-0.51 (0.72, 0.75)
d=-0.40 (0.72, 0.74)
d=-0.52 (0.72, 0.75)
d=-0.26 (0.72, 0.73)
d=-0.24 (0.72, 0.73)
-2
-1.5
-1
-0.5
0
95% Confidence Interval
50
0.5
1
Appendix B
Consent Form
51
m
52
53
54
55
Appendix C: Foot and Ankle Disability Index
56
Appendix C
Foot and Ankle Disability Index
57
58
Appendix D
Star Excursion Balance Test Form
59
Appendix E
Treatment Questionnaire
Treatment Questionnaire
Subject #_____
Session Date:_____
Leg: R
L
Are you currently taking any medications for pain? Explain:
How often are you using pain relieving modalities such as
Ice? __________________________________
Electrical Stimulation? ___________________
Other:_________________________________
Are you currently able to walk without assistance? If no, please explain (i.e. crutches,
boot, air cast) __________________________________________________________
Do you currently have any difficulty completing activities of daily living due to any
injury?
Explain._________________________________________________________________
How many times per week are you currently participating in rehabilitative exercises?
________________________________________________________________________
How often are you participating in practice activities?
________________________________________________________________________
60
How often are you participating in games?
________________________________________________________________________
Comments_______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Visual Analog Scale-Pain
Please rate the amount of pain that you are currently experiencing on the scale below.
|
|
No pain
Mild
|
Moderate
|
Severe
|
Worst pain possible
Visual Analog Scale-Function
Please rate the level of function that you are currently experiencing on the scale below.
|
|
|
|
No Pain/Limitation
|
Worst Pain/Limitation
Global Function Scale
Please rate on a scale of 0-100 (percent) your current level over overall function:
%
61
Appendix F
Ankle Range of Motion Form
Ankle Range of Motion
Subject #:________
Session Date: _______________
In Standing
Trial 1: _______________
Trial 2: _______________
Trial 3: _______________
Supine
Trial 1: _______________
Trial 2: _______________
Trial 3: _______________
62
Leg:
R
L