ANKLE SPRAINS Long Term Sequelae - Richie Brace Inc › images › PDF › Chronic... · Biology of Ankle Sprain Tx 1. Immediately after injury: RICE ~minimizes hemorrhage, swelling,

Chronic Ankle Instability

HISTORICAL PERSPECTIVEHISTORICAL PERSPECTIVE

CLINICAL EVALUATIONCLINICAL EVALUATION

TREATMENT GUIDELINESTREATMENT GUIDELINES

“When Can I Return to Sport”“When Can I Return to Sport”

E-MAIL: [email protected]

Fellow, American Academy of Podiatric Sports Medicine

Associate Clinical Professor, Dept. Of Applied Biomechanics,

California School of Podiatric Medicine

Douglas H. Richie Jr. D.P.M.

Associate Professor of Podiatric Medicine, Western University of Health Sciences

Adjunct Associate Professor of Clinical Biomechanics, California School of Podiatric Medicine, Oakland CA

Douglas H. Richie, Jr. D.P.M.Seal Beach, [email protected]

Chronic Ankle Instability: Solving a Complicated Puzzle

ANKLE SPRAINSANKLE SPRAINSMost common injury in Sports (40%)

ColvilleColville

23,000 sprains / day in U.S.

Makhani, McCullockMakhani, McCullock

Account for 10% of all ER visits in U.S.

HolmerHolmer

Long term sequelae occur in up to 50% of patients

Anderson, Brostrom, Freeman, SmithAnderson, Brostrom, Freeman, Smith

Long Term SequelaeLong Term SequelaeThe development of residual instability with pain and swelling

will occur in 20% to 40% of

people after a Grade II lateral ankle sprain.

Bosien, 1955 Yeung, 1994

Brand, 1977 Dettori, 1994

Itay, 1982 Verhagen, 1995

Gerber, 1998

Bosien, 1955 Yeung, 1994

Brand, 1977 Dettori, 1994

Itay, 1982 Verhagen, 1995

Gerber, 1998


The Problem

Biology of Ankle Sprain TxBiology of Ankle Sprain Tx

1. Immediately after injury: RICE~minimizes hemorrhage, swelling,

inflammation, cellular metabolism, pain.

2. Protection of ligaments: week 1-3

~proliferation phase: collagen

production

~ligament stress Type III (weaker) collagen

3. Controlled mobilization: week 4-8~maturation phase: final scar

formation

~controlled exercise increased

mech strength of ligament collagen

fiber orientation.

4. Final Maturation and Remodeling: 6-12 mos~ Full return to activity

~ Full neuromuscular control

Biology of Ankle Sprain TxBiology of Ankle Sprain Tx RETURN TO PRE INJURY ACTIVITYRETURN TO PRE INJURY ACTIVITYWith Functional Treatment Protocol:With Functional Treatment Protocol:

GRADE III6 weeks

GRADE III6 weeks

GRADE II12 days

GRADE II12 days

Ardevol, 2002Ardevol, 2002

Wilson, 2002Wilson, 2002

J Athl Train. 2008 Sep-Oct;43(5):523-9. Ankle ligament healing after an acute ankle sprain: evidence-based approach. Hubbard TJ, Hicks-Little CA.

Department of Kinesiology, The University of North Carolina at Charlotte, Charlotte, NC 28223, USA.

[email protected]

OBJECTIVE: To perform a systematic review to determine the healing time of the lateral ankle

ligaments after an acute ankle sprain.

DATA SOURCES: We identified English-language research studies from 1964 to 2007 by searching

MEDLINE, Physiotherapy Evidence Database (PEDro), SportDiscus, and CINAHL using the terms

ankle sprain, ankle rehabilitation, ankle injury, ligament healing, and immobilization. STUDY SELECTION: We selected studies that described randomized, controlled clinical trials

measuring ligament laxity either objectively or subjectively immediately after injury and at least 1

more time after injury.

CONCLUSIONS/RECOMMENDATIONS: In the studies that we

examined, it took at least 6 weeks to 3 months before ligament healing

occurred. However, at 6 weeks to 1 year after injury, a large percentage of participants still had objective mechanical laxity and subjective ankle instability. Direct comparison among articles is difficult because of differences in methods. More research focusing on more reliable methods of measuring ankle laxity is needed so that clinicians can know how long ligament healing takes after injury. This knowledge will help clinicians to

make better decisions during rehabilitation and for return to play.


Definitions• Mechanical

ANKLE INSTABILITYANKLE INSTABILITY

• Functional

MECHANICAL INSTABILITYMECHANICAL INSTABILITYObjective Measures:Objective Measures:

• Anterior drawer

• Talar tilt

• Ligamentous laxity

• FF & RF deformities

• Tibial varum

• Ankle axis deviation

Karlsson J, Bergsten T, Lasinger O, et al: Surgical

treatment of chronic lateral instability of the ankle

joint. Am J Sports Med 17:208-274,1989

Stress RadiographsStress Radiographs

Anterior drawer – Absolute Displacement: 10mm

Side to side: >3mm

Talar Tilt – Side to side: >10º

SENSITIVITY VS SPECIFICITY

High sensitivity indicates that a test can be used for excluding,

or ruling out, a condition when it is negative, but does not

address the value of a positive test.

Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA .

1992;267:2638–2644.

Schulzer M. Diagnostic tests: a statistical review. Muscle Nerve.

1994;17:815– 819

Specificity indicates the ability to use a test to recognize

when the condition is absent. A highly specific test has

relatively few false positive results, and therefore speaks to

the value of a positive test.

STRESS RADIOGRAPHYStress radiography has long been utilized to diagnose mechanical instability of the

lateral ligaments of the ankle. However, the reliability of these measures has been

questioned. Radiographic measure of anterior drawer and talar tilt show a low

sensitivity (50 and 36%) but a high specificity (100%). A critical review of seven

studies of stress radiography to diagnose ligament rupture after acute ankle sprain

concluded that talar tilt and anterior drawer stress x-rays are not reliable enough to

make the diagnosis of ligament rupture regardless of whether mechanical devices or

local anesthesia are used. Presently, the only possible valid use of stress radiography is

in the evaluation of patients with chronic mechanical instability of the ankle.

Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Daider, A, Baldt M et al. MRI versus lateral stress

radiography in acute lateral ankle ligament injuries. Journal of Computer Assisted Tomography 1997

March/April; 21(2): 280-285.

Ray, RG; Christensen, JC; Gusman, DN: Critical evaluation of anterior drawer measurement methods

in the ankle. Clin Orthop Relat Res, 215 – 224, 1997.

Harper, MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot

Ankle, 13:435 – 438, 1992.

Lohrer, H; Nauck, T; Arentz, S; Sch¨oll, J: Observer reliability in ankle and calcaneocuboid stress

radiography. Am J Sports Med

MRI: ACUTE

VS

CHRONIC INJURY

In a mixed population of chronic and acute ankle

instability patients, MRI showed a 97%

sensitivity, 100% specificity and 97% accuracy.

However, when evaluating acute patients only,

the results were 100% for all three categories.

Oae K, Takao M, Uchio Y. Evaluation of anterior talofibular ligament injury with

stress radiography, ultrasonography and MR imaging. Skeletal Radiol 2010; 39:41-47.

Functional InstabilityFunctional InstabilityPatient History:Patient History:

Recurrent sprains and/or

feeling of giving way of

the ankle

Recurrent sprains and/or

feeling of giving way of

the ankleFreeman, 1965Freeman, 1965


Mechanical vs Functional Ankle

Instability: Why is this important?

Mechanical vs. FunctionalMechanical vs. Functional

No consistent cause-effect relationship has been found between mechanical instability

and functional instability of the ankle.

Moppes, 1982 Staples, 1975

Staples, 1972 Tropp, 1988

Functional Instab

93

Mechanical Instab

11866

Fig. 1 The association between functional

and mechanical instability of the ankle

joints in 444 soccer players

Tropp, H. Odenrick, P. Gillquist, J. Stabilometry recordings in

functional and mechanical instability of the ankle joint. Int J Sports

Medicine 6:180, 1985 1985

FIGURE 1 Persistent Ligamentous LaxityPersistent Ligamentous Laxity

CHRONIC ANKLE INSTABILITYCHRONIC ANKLE INSTABILITY

Deficit in Neuromuscular controlDeficit in Neuromuscular control

Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability J Athl Train 37 (4): 364, 2002

Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability J Athl Train 37 (4): 364, 2002

Functional InstabilityFunctional InstabilityMuscle

WeaknessMechanical

(anatomic)

Neuromuscular ControlNeuromuscular Control

Balance - PostureBalance - Posture Muscle Reaction TimeMuscle Reaction Time

ProprioceptionProprioception

??

FIGURE 2

Richie DH: Functional Instability of the Ankle and the Role of Neuromuscular

Control; A Comprehensive Review, J Foot and Ankle Surgery, 40:240-251, 2001.

Richie DH: Functional Instability of the Ankle and the Role of Neuromuscular

Control; A Comprehensive Review, J Foot and Ankle Surgery, 40:240-251, 2001.

http://www.youtube.com/watch?v=zAwHVXLo_xA

Functional InstabilityFunctional Instability

MANIFESTS WITH DEFICIENT POSTURE CONTROL (single

leg stance).

Karlsson, 1989

Jerosch, 1995

Lentell, 1990

Konradsen, 1993

KarlssonKarlsson, 1989, 1989

JeroschJerosch, 1995, 1995

LentellLentell, 1990, 1990

KonradsenKonradsen, 1993, 1993

MEASURING CHRONIC ANKLE INSTABILITY

Eechaute et al. systematically reviewed

the clinimetric qualities of patient-

assessed instruments for patients with

chronic ankle instability. They

concluded that two instruments—the

Foot and Ankle Disability Index (FADI)

and the Functional Ankle Ability

Measure (FAAM)—were the most

appropriate tools to quantify functional

disability for chronic ankle instability.

Eechaute C, Vaes P, Van Aerschot L et al. The clinimetric qualities of patient-assessed instruments for

measuring chronic ankle instability: a systematic review. BMC Musculoskelet Disord 2007;8:6.

BALANCE = POSTURAL CONTROL? BALANCE = POSTURAL CONTROL?

BALANCE: Ability of a human to remain upright in stance BALANCE: Ability of a human to remain upright in stance

POSTURAL CONTROL: Ability to keep the body’s center of gravity (COG) within the bordersof the base of support (Nashner 1985)

BALANCE is an activity which occurs both during static stanceand dynamic gait

BALANCE is an activity which occurs both during static stanceand dynamic gait

POSTURAL CONTROL is measured during quiet static stance.It has been studied during both double-limb and single limb support.

POSTURAL CONTROL is measured during quiet static stance.It has been studied during both double-limb and single limb support.

Postural Control and CAIPostural Control and CAI

Deficits in postural control appear to be the most consistent finding in patients with chronic ankle instability.Deficits in postural control appear to be the most consistent finding in patients with chronic ankle instability.

Garn SN, Newton RA: Kinesthetic awareness in subjects with multiple ankle sprains Phys Ther 68: 1667, 1988.Garn SN, Newton RA: Kinesthetic awareness in subjects with multiple ankle sprains Phys Ther 68: 1667, 1988.

Tropp H, Odenrick P: Postural control in single-limb stance. Jour Orthop Res 6: 833, 1988.Tropp H, Odenrick P: Postural control in single-limb stance. Jour Orthop Res 6: 833, 1988.

Gauffin H, Tropp H, Odenrick P: Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 9:141, 1988.

Gauffin H, Tropp H, Odenrick P: Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 9:141, 1988.

Forkin DM, Koczur C, Battle R, Newton RA: Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains. J Orthop Sports Phys Ther 23: 245, 1996.

Forkin DM, Koczur C, Battle R, Newton RA: Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains. J Orthop Sports Phys Ther 23: 245, 1996.

Perrin PP, Bene MC, Perrin CA, Durupt D: Ankle trauma significantly impairs postural control-a study in basketball players and controls. Int J sports Med 18: 387, 1997.

Perrin PP, Bene MC, Perrin CA, Durupt D: Ankle trauma significantly impairs postural control-a study in basketball players and controls. Int J sports Med 18: 387, 1997.

Postural Control

After Ankle Sprain

Postural Control

After Ankle Sprain

Loss of postural control has also been demonstrated in patients after acute ankle sprain.(Cornwall, MW, Murrell P. Postural sway following inversion sprain of the ankle. J Am Podiatr Med Assoc. 81:243-247, 1991.

Loss of postural control has also been demonstrated in patients after acute ankle sprain.(Cornwall, MW, Murrell P. Postural sway following inversion sprain of the ankle. J Am Podiatr Med Assoc. 81:243-247, 1991.

Friden T, Zatterstrom R, Lindstrand A, Moritz U: A stabilometric technique for evaluation of lower limb instabilities. Am J Sports Med 17: 118, 1989.Friden T, Zatterstrom R, Lindstrand A, Moritz U: A stabilometric technique for evaluation of lower limb instabilities. Am J Sports Med 17: 118, 1989.

Hertel J, Buckley WE, Denegar CR: Serial testing of postural control after acute lateral ankle sprain. J Athl Train 35: 363, 2001.Hertel J, Buckley WE, Denegar CR: Serial testing of postural control after acute lateral ankle sprain. J Athl Train 35: 363, 2001.

Predicting Ankle Injuries Predicting Ankle Injuries Prospective study of 119 male and 91 female high school basketball players

Prospective study of 119 male and 91 female high school basketball players

Subjects had no previous hx of injurySubjects had no previous hx of injury

Balance assessment with NeuroCom New Balance Master during pre-season

Balance assessment with NeuroCom New Balance Master during pre-season

Higher postural sway scores corresponded to increased ankle sprain injury rates (p=0.001)

Higher postural sway scores corresponded to increased ankle sprain injury rates (p=0.001)

Subjects with high sway scores had 7 times as many ankle sprains as subjects with low sway scores

Subjects with high sway scores had 7 times as many ankle sprains as subjects with low sway scores

McGuine TA, Greene JJ, Best T, Leverson G: Balance as a predictor of ankle injuries in high school basketball players. Clin Jour Sport Med 10: 239-244, 2000.

McGuine TA, Greene JJ, Best T, Leverson G: Balance as a predictor of ankle injuries in high school basketball players. Clin Jour Sport Med 10: 239-244, 2000.

Loss of Postural ControlLoss of Postural ControlRisk of future ankle injury:Risk of future ankle injury:

127 soccer players, mean age 24.6 years127 soccer players, mean age 24.6 years

postural sway measured in pre-season postural sway measured in pre-season

23 new ankle sprains in subsequent season:12 had pathologic sway

23 new ankle sprains in subsequent season:12 had pathologic sway

risk of sprain was 42% in those with abnormalpre-season sway

risk of sprain was 42% in those with abnormalpre-season sway

risk of sprain was 11% in those with normal pre-season sway

risk of sprain was 11% in those with normal pre-season sway

Tropp H, Edstrand J, Gillquist J: Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc 16: 64-66, 1984.Tropp H, Edstrand J, Gillquist J: Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc 16: 64-66, 1984.

POSTURAL CONTROLPOSTURAL CONTROLSensory Input:Sensory Input:

• Vision

• Vestibular • Somatosensory System

� Muscle Proprioception

� Joint Mechanoreceptors

� Cutaneous Afferents (sole of foot)

Postural ControlPostural ControlSensory Input: Joint MechanoreceptorsSensory Input: Joint Mechanoreceptors

ANKLE JOINT MECHANORECEPTORSANKLE JOINT MECHANORECEPTORS

• Type I: slow adapting, low threshold

Convey postural sense

• Type I: slow adapting, low threshold

Convey postural sense

• Type II: rapid adapting, low threshold

Convey sense at beginning of joint

movement

• Type II: rapid adapting, low threshold

Convey sense at beginning of joint

movement

• Type III: slow adapting, high threshold

Convey sense at extreme end ROM

• Type III: slow adapting, high threshold

Convey sense at extreme end ROM

Michelson JD, Hutchins C: Mechanoreceptors in human ankle

ligaments. J Bone Joint Surg (Br) 1995: 77-B : 210-24.



Type II and III are most abundant in ankle ligamentsType II and III are most abundant in ankle ligaments

JOINT MECHANORECEPTORSJOINT MECHANORECEPTORS

• proprioception• proprioception

• control muscle stiffness and joint stability• control muscle stiffness and joint stability

• influence gamma motor neuron output:

determine length of muscle spindle fibers

• influence gamma motor neuron output:

determine length of muscle spindle fibers





• Influence discharge of 1A spindle afferents and

input on alpha motor neurons

• Influence discharge of 1A spindle afferents and

input on alpha motor neurons

• adjust muscle length or tension to protect joint

from injury

• adjust muscle length or tension to protect joint

from injury

Evidence of sensory nerve fibers and corpuscles, i.e. mechanoreceptors, within the ankle retinacula. The ankle retinacula

underwent MRI changes of thickening and altered signal intensity-similar to what is seen in plantar fasciitis. The ankle

retinacula are important sensors for proprioception of the ankle joint which respond to tension of the muscles and tendons to which they are attached, as

well as direct stretching when the ankle is moved in various directions.

Stecco C, Macchi V, Porzionato A et al. The ankle retinacula: Morphological evidence of the proprioceptive role of the fascial system. Cells Tissues Organs

Accessible online at www.karger.com/ctoDOI: 10.1159/000290225

Ankle Retinacula: Role in ProprioceptionAnkle Retinacula: Role in Proprioception

Postural ControlPostural Control

Sensory Input: Muscle spindle afferentsSensory Input: Muscle spindle afferents

MUSCLE SPINDLE

AFFERENTS

MUSCLE SPINDLE

AFFERENTS

SPINAL CORD

SPINDLE

GMSGMSGamma motor neurons (spinal)

Contraction of muscle spindles

Excitation of stretch receptors

Improved stretch reflex

Gamma motor neurons (spinal)

Contraction of muscle spindles

Excitation of stretch receptors

Improved stretch reflex

Gamma-muscle-spindle system

How does pain affect

postural control?

How does pain affect

postural control?

Pain and Loss of ProprioceptionPain and Loss of Proprioception

Afferent articular nerves found in joints of the LE:Afferent articular nerves found in joints of the LE:

Type I receptors: slow adapting mechanical anddynamic receptors

Type I receptors: slow adapting mechanical anddynamic receptors

Type II: rapidly adapting, mechanical anddynamic receptors

Type II: rapidly adapting, mechanical anddynamic receptors

Type III: high threshold, slow adapting, mechanical and dynamic

Type III: high threshold, slow adapting, mechanical and dynamic

Type IV: high threshold pain receptorsType IV: high threshold pain receptors

Wyke B: The neurology of joints. Ann R Coll Surg Engl 41: 24-50, 1967.Wyke B: The neurology of joints. Ann R Coll Surg Engl 41: 24-50, 1967.

Painful Subtalar Joint

and Chronic Ankle Instability

Painful Subtalar Joint

and Chronic Ankle Instability

EMG activity of the Peroneus Brevis andLongus is diminished in sinus tarsi syndrome.

EMG activity of the Peroneus Brevis andLongus is diminished in sinus tarsi syndrome.

Injection of local anesthetic into the sinustarsi restores normal EMG function.

Injection of local anesthetic into the sinustarsi restores normal EMG function.

Taillard W, Meyer JM, Garcia J, Blanc Y: The sinus tarsi syndrome. Int Orthop5: 117-130, 1981.

Taillard W, Meyer JM, Garcia J, Blanc Y: The sinus tarsi syndrome. Int Orthop5: 117-130, 1981.

Sinus Tarsi Pain and Prolonged Peroneal Reaction TimeSinus Tarsi Pain and Prolonged Peroneal Reaction Time

18 pts with functional ankle instability 18 pts with functional ankle instability

8 healthy controls 8 healthy controls

measurement of peroneal reaction times with trapdoor mechanism and EMG readings of p. brevis and p. longus

measurement of peroneal reaction times with trapdoor mechanism and EMG readings of p. brevis and p. longus

recordings before and after injection of 2 mLof 1% Lidocaine into sinus tarsi

recordings before and after injection of 2 mLof 1% Lidocaine into sinus tarsi

Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.


Before Injection:Before Injection:

Subjects with Functional Instability of Ankle 82.0 ms Subjects with Functional Instability of Ankle 82.0 ms

Controls 72.0 ms Controls 72.0 ms

After Injection:After Injection:

Subjects with Functional Instability of Ankle 69.3 ms Subjects with Functional Instability of Ankle 69.3 ms

Controls 70.5 ms Controls 70.5 ms

P < 0.0001 P < 0.0001



Sinus Tarsi Pain and Prolonged Peroneal Reaction TimeSinus Tarsi Pain and Prolonged Peroneal Reaction Time

Peroneal Reaction: Stretch Reflex Peroneal Reaction: Stretch Reflex Receptors: Muscle SpindleReceptors: Muscle Spindle

Reflex: Afferent neurons connect to alphamotor neurons in spinal cord

Reflex: Afferent neurons connect to alphamotor neurons in spinal cord

Efferent: motor neurons stimulateperoneal muscle contraction

Efferent: motor neurons stimulateperoneal muscle contraction

Sensitivity: Gamma motor neurons(GMN’s) contract muscle spindles: lowers threshold of response

Sensitivity: Gamma motor neurons(GMN’s) contract muscle spindles: lowers threshold of response

inflammation from sprain causes irritability ofmechanoreceptors and nociceptors in the affectedankle and subtalar joints

inflammation from sprain causes irritability ofmechanoreceptors and nociceptors in the affectedankle and subtalar joints

excitation of leg flexors and inhibition of legextensors (shown in previous animal studieswith joint inflammation)

excitation of leg flexors and inhibition of legextensors (shown in previous animal studieswith joint inflammation)

inhibitory stimulation affects GMN’s of both extensors and peroneal muscles

inhibitory stimulation affects GMN’s of both extensors and peroneal muscles

local anesthetic reverses inhibitory stimulus of gamma motor neurons

local anesthetic reverses inhibitory stimulus of gamma motor neurons



Theory of Prolonged Peroneal Reaction TimeTheory of Prolonged Peroneal Reaction Time

Postural ControlPostural Control

Sensory Input: Plantar cutaneous afferents

Sensory Input: Plantar cutaneous afferents

The Foot:A Major Proprioceptive Organ

The Foot:A Major Proprioceptive Organ

� Merkel Cell Complexes Pressured Deformation

� Merkel Cell Complexes Pressured Deformation

� Meissner CorpusclesVibration 5-40 Hz

� Meissner CorpusclesVibration 5-40 Hz

� Pacinian CorpusclesVibration 60-300 Hz

� Pacinian CorpusclesVibration 60-300 Hz

ISOLATING THE INPUT FROM

THE SOMATOSENSORY SYSTEM:

ISOLATING THE INPUT FROM

THE SOMATOSENSORY SYSTEM:

Muscle spindle afferents: Muscle spindle afferents: • short latency response, monosegmental reflex

Cutaneous receptors: Cutaneous receptors: • medium latency, polysynaptic spinal pathway

Ankle joint receptors: Ankle joint receptors:

• medium and long latency, polysynaptic pathway

Wu G, Chiang JH: The significance of somatosensory stimulations to the human

foot in the control of postural reflexes. Exp Brain Res 114: 163-169, 1997

Wu G, Chiang JH: The significance of somatosensory stimulations to the human

foot in the control of postural reflexes. Exp Brain Res 114: 163-169, 1997

Lower limb muscle activation during balance recovery is more adversely

affected by loss of muscle proprioceptive afferents than by

loss of plantar cutaneous afferents.

Lower limb muscle activation during balance recovery is more adversely

affected by loss of muscle proprioceptive afferents than by

loss of plantar cutaneous afferents.

Thoumie P, Do MC: Changes in motor activity and biomechanics during balance recovery following cutaneous and muscular deafferentation. Exp Brain Res 110: 289-297, 1996

Thoumie P, Do MC: Changes in motor activity and biomechanics during balance recovery following cutaneous and muscular deafferentation. Exp Brain Res 110: 289-297, 1996

Diener HC, Dichgans J, Guschlbauer B, Mau H: The significance of proprioception on postural stabilization as assessed by ischemia. Brain Res 296: 103-109, 1984

Diener HC, Dichgans J, Guschlbauer B, Mau H: The significance of proprioception on postural stabilization as assessed by ischemia. Brain Res 296: 103-109, 1984

- Diminish joint mechanoreceptors

with fixed ankle AFO braces

Wu G, Chiang JH. The significance of somatosensory stimulations to the human

foot in the control of postural reflexes. Exp Bran Res (1977) 114: 163-169.

Isolating the components of the somatosensory system

- 15 healthy subjects

- Sudden perturbation on a toes-up platform

- Diminish plantar mechanoreceptors with soft foam

“This suggests that the plantar cutaneous mechanoreceptors in the sole

of the foot and the joint receptors in the ankle joint play a minimal

role, if any, in the generation of short latency leg muscle responses

during sudden perturbation.”

“It seems that the only possibility for the mediation of the short latency

reflexes is by the muscle spindles in the stretched muscle.”

Hierarchy of importance of the components of the somatosensory system:

Wu G, Chiang JH. The significance of somatosensory stimulations to the human

foot in the control of postural reflexes. Exp Bran Res (1977) 114: 163-169.


The Neuromuscular Disconnect:

Evidence for a Central Mediated

Mechanism

Chronic Ankle Instability: Loss of Postural Control

Is this due to peripheral (feed-back) impairment or..

Is this due to central (feed-forward) alterations in motor control?

Alterations in feed-forward motor control in CAI

A. Altered hip biomechanics during dynamic balance tests:Gribble PA, Hertel J, Denegar CR. Chronic ankle instability and fatigue create proximal jointalterations during performance of the star excursion balance test. Int J Sports Med 2007;28:236–42.

B. Altered ankle biomechanics during gait :Delahunt EMK, Caulfield B. Altered neuromuscular control and ankle joint kinematics during walking in subjects with functional instability of the ankle joint. Am J Sports Med 2006;34:1970–6.

Monaghan K, Delahunt E, Caulfield B. Ankle function during gait in patients with chronic ankle instability compared to controls. Clin Biomech 2006;21:168–74.

C. Different landing patterns :Caulfield B, Crammond T, O’Sullivan A, Reynolds S, Ward T. Altered ankle muscle activation during jump

landing in participants with functional instability of the ankle joint. J Sport Rehabil 2004;13:189–200.

Caulfield B, Garrett M. Functional instability of the ankle: differences in patterns of ankle and knee

movement prior to and post landing in a single leg jump. Int J Sports Med 2002;23:64–8.

Delahunt E, Monaghan K, Caulfield B. Changes in lower limb kinematics, kinetics, and muscle activity in

subjects with functional instability of the ankle joint during a single leg drop jump. J Orthop Res

2002;24:1991–2000.

CHRONIC ANKLE INSTABILITY:

Evidence for the Role of the Central Nervous System

With unilateral chronic ankle instability:

- bilateral hamstring inhibition with unilateral CAI

Chronic Ankle Instability: Centrally

Mediated Mechanisms

Sedory et al revealed bilateral

hamstring inhibition in CAI patients

Sedory EJ, McVey ED, Cross KM,

Ingersoll CD, Hertel J. Arthrogenic

muscle response of the quadriceps and

hamstrings with chronic ankle

instability. J Athl Train 2007;42:355–60.


Mediated Mechanisms

Sedory et al revealed bilateral

hamstring inhibition in CAI patients

Sedory EJ, McVey ED, Cross KM,

Ingersoll CD, Hertel J. Arthrogenic

muscle response of the quadriceps and

hamstrings with chronic ankle

instability. J Athl Train 2007;42:355–60.





- alterations in shank-rearfoot coupling during gait with CAI

J Sports Rehabil 2009 Aug;18(3):375-88.

Altered ankle kinematics and shank-rear-

foot coupling in those with chronic ankle

instability. Drewes LK, McKeon PO,

Paolini G, Riley P, Kerrigan DC, Ingersoll

CD, Hertel J. Dept of Human Services,

University of Virginia, Charlottesville, VA,

USA.

Abstract

CONTEXT: Kinematic patterns during gait have not been extensively studied in relation

to chronic ankle instability (CAI). OBJECTIVE: To determine whether individuals with

CAI demonstrate altered ankle kinematics and shank-rear-foot coupling compared with

controls during walking and jogging RESULTS: The CAI group demonstrated more

rear-foot inversion and shank external rotation during walking and jogging. There were

differences between groups in shank-rear-foot coupling during terminal swing at both

speeds. CONCLUSIONS: Altered ankle kinematics and joint coupling during the

terminal-swing phase of gait may predispose a population with CAI to ankle-inversion

injuries. Less coordinated movement during gait may be an indication of altered

neuromuscular recruitment of the musculature surrounding the ankle as the foot is

being positioned for initial contact






- delayed hip and thigh muscle activation patterns


Mediated Mechanisms

Bullock-Saxton et al and Bullock-

Saxon reported altered proximal

muscle activation patterns following

acute lateral ankle sprains. Bullock-

Saxon J. Sensory changes

associated with severe ankle sprain.

Scand J Rehabil Med 1995;27:161–7.Bullock-Saxton JE, janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip

extension. Int J Sports Med 1994;15:330–4

Scand J Rehabil Med 1995;27:161–7.Bullock-Saxton JE, janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip

extension. Int J Sports Med 1994;15:330–4






- delayed hip and thigh muscle activation patterns

- Bilateral balance deficits are found which

can improve with unilateral exercise

CENTRAL NERVOUS SYSTEM ROLE

IN CHRONIC ANKLE INSTABILITY

McKeon PO, Hertel J. Systematic review of postural control and lateral

ankle instability. Part 1: Can deficits be detected with instrumented

testing? J Athl Train 2008;43:293–304.

Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Balance capabilities after

lateral ankle trauma and intervention: a meta-analysis. Med Sci Sports

Exerc 2009.

Arnold BL, De La Motte S, Linens S, Ross SE. Ankle instability is

associated with balance impairments: a meta-analysis. Med Sci Sports

Exerc 2009;41:1048–

Unilateral Ankle Sprain = Bilateral Neuromuscular Deficits.

Three recent publications provided robust evidence that

postural control is compromised in the un-involved limb

after an acute ankle sprain:

CENTRAL NERVOUS SYSTEM ROLE

IN CHRONIC ANKLE INSTABILITY

Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther 2007;37:303–11. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for person with functionally unstable ankles. J Orthop Sports Phys Ther 1999;29:478–86.

Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study. Scand J Med Sci Sports 1997;7:172–7.

McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E, Bennett BC, Hertel J. Balance training improves function and postural control in those with chronic ankle instability. Med SciSports Exerc 2008;40:1810–9.

The fact that bilateral neuromuscular control deficits are found at

both the ankle and proximal joints strongly suggests that global

coordination or training programs should be used for both the

involved and uninvolved limbs of all patients with a history of lateral

ankle trauma for the same reasons.

Postural ControlPostural Control• Improves after balance and coordination

training exercises

• Improves after balance and coordination training exercises

Leanderson 1996, Goldie 1994, Pintsaar 1996, Tropp 1984

Leanderson 1996, Goldie 1994, Pintsaar 1996, Tropp 1984

Balance exercises cause Bilateral ImprovementsBalance exercises cause Bilateral Improvements

Gauffin, 1988Hertel, 2001Gauffin, 1988Hertel, 2001

BALANCE TRAINING

Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Balance

capabilities after lateral ankle trauma and intervention: a meta-

analysis. Med Sci Sports Exerc 2009.

Balance training improves postural

control scores of individuals with acute

ankle sprains and CAI

BALANCE TRAINING

Beck S, Taube W, Gruber M, Amtage F, Gollhofer A, Schubert M. Task-specific

changes in motor evoked potentials of lower limb muscles after different training interventions. Brain Res 2007;1179:51–60.

Gruber M, Taube W, Gollhofer A, Beck S, Amtage F, Schubert M. Training specific adaptations of h- and stretch reflexes in human soleus muscle. J Mot Behav2007;39.

Taube W, Gruber M, Beck S, Faist M, Gollhofer A, Schubert M. Cortical and spinal adaptations induced by balance training: correlation between stance stability and corticospinal activation. Acta Physiol (Oxford) 2007;189.

Taube W, Kullmann N, Leukel C, Kurz O, Amtage F, Gollhofer A. Differential reflex adaptations following sensorimotor and strength training in young elite athletes. Int J Sports Med 2007;28:999–1005.

The underlying neural adaptations of balance training

occur at multiple sites within the central nervous system

BALANCE TRAINING

Emery C, Rose M, McAllister J, Meeuwisse W. A prevention strategy to reducethe

incidence of injury in high school basketball: a cluster randomized controlled trial. Clin J Sports Med 2007;17:17–24.

Holme E, Magnusson SP, Becher K, Bieler T, Aargaar P, Kjar M. The effect of supervised rehabilitation on strength, postural sway, position sense and reinjuryrisk after acute ankle ligament sprain. Scand J Med Sci Sports 1999;9:104–9.

McHugh M, Tyler T, Mirabella M, Mullany M, Nicholas S. The effectiveness of a balance training intervention in reducing the incidence of noncontact ankle sprains in high school football players. Am J Sports Med 2007;35: 1289–94.

Accumulating evidence implicates balance training

programs as effective in reducing the recurrence of

lateral ankle sprain

McKeon PO, Hertel J. Systematic Reviw of postural control and lateral ankle instability, Part II: Is balance training clinically effective? Journal of Athletic Training 2008;43(3):305–315

McKeon PO, Hertel J. Systematic Reviw of postural control and lateral ankle instability, Part II: Is balance training clinically effective? Journal of Athletic Training 2008;43(3):305–315

“Prophylactic balance training substantially reduced the risk of sustaining ankle sprains, with a greater effect seen in those with a history of a previous sprain. Completing at least 6 weeks of balance training after an acute ankle sprain substantially reduced the risk of recurrent ankle sprains;however, consistent improvements in instrumented measures of postural control were not associated with training. Evidence is lacking to assess the reduction in the risk of recurrent sprains and inconclusive to demonstrate improved instrumented postural control measures in those with chronic ankle instability who complete balance training.”

Star Excursion Balance TestStar Excursion Balance Test (SEBT)(SEBT)

LAYOUT OF SEBTLAYOUT OF SEBT

LATERAL REACH ON SEBTLATERAL REACH ON SEBT

Photos From: Relationship between Ground Reaction Force and Stability Level of the Lower

Extremity in Runners. Kimitake Sato, Monique Butcher-Mokha Barry University Miami Shores, FL

Photos From: Relationship between Ground Reaction Force and Stability Level of the Lower

Extremity in Runners. Kimitake Sato, Monique Butcher-Mokha Barry University Miami Shores, FL


The Myth of Peroneal Muscular Weakness

Lateral Body Sway=CKC Pronation of STJLateral Body Sway=CKC Pronation of STJCorrection of Lateral Body Sway=Concentric

Contraction of Medial Ankle Invertors

Correction of Lateral Body Sway=ConcentricContraction of Medial Ankle Invertors

Reduce Pronation=

Reduce Supination Ankle Injuries???

Reduce Pronation=

Reduce Supination Ankle Injuries???

Patients with lateral ankle instability have weaker invertor ankle strength

Patients with lateral ankle instability have weaker invertor ankle strength

Munn J, Beard D, Refshauge K, Lee R: Eccentric muscle strength in functional ankle instability. Med Sci Sport Exerc 35(2): 245, 2003.

Munn J, Beard D, Refshauge K, Lee R: Eccentric muscle strength in functional ankle instability. Med Sci Sport Exerc 35(2): 245, 2003.

Sports Med. 2009;39(3):207-24. doi: 10.2165/00007256-200939030-00003. Treatment of common deficits associated with chronic ankle instability. Holmes A,

Delahunt E.

Lateral ankle sprains are amongst the most common injuries incurred by athletes, with the high rate of reoccurrence after initial injury becoming of great concern. Chronic ankle instability (CAI) refers to the development of repetitive ankle sprains and persistent residual symptoms post-injury. Some of the initial symptoms that occur in acute sprainsmay persist for at least 6 months post-injury in the absence of recurrent sprains, despite the athlete having returned to full functional activity. CAI is generally thought to be caused by mechanical instability (MI) or functional instability (FI), or both. Although previously discussed as separate entities, recent research has demonstrated that deficits associated with both MI and FI may co-exist to result in CAI. For clinicians, the main deficits associated with CAI include deficits in proprioception, neuromuscular control, strength and postural control. Based on the literature reviewed, it does seem that subjects with CAI have a deficit in frontal plane ankle joint positional sense. Subjects with CAI do not appear to exhibit any increased latency in the peroneal muscles in response to an external perturbation. Preliminary data suggest that feed-forward neuromuscular control may be more important than feed-back neuromuscular control and interventions are now required to address deficits in feed-forward neuromuscular control.

Balance training protocols have consistently been shown to improve postural stability in subjects with CAI. Subjects with CAI do not experience decreased peroneus longus strength, but instead may experience strength deficits in the ankle joint invertor muscles. These findings are of great clinical significance in terms of understanding the mechanisms and deficits associated with CAI. An appreciation of these is vital to allow clinicians to develop effective prevention and treatment programmes in relation to CAI.

0

50

100

150

200

250

Cases

PFPS ITBFS Glut Med Sacroiliac

Injury

Gender Issues: Injury Patterns

Males

Females

Taunton et al., 2002

2X

2X

3X

9X

Ferber et al., 2005

Hip Adduction

Hip Internal Rotation

Knee Abduction

Of 165 patients who visited Ferber’s clinic complaining of overuse running injuries

(33% PFPS; 25% ITBFS), 92 per cent had weak hip muscles.

As part of each patient's consultation, he gave them a program to improve hip

strength, along with other recommendations to speed their recovery.

89 per cent of the patients reported a significant improvement in pain within

four to six weeks.

Interventions: Exercise

Ferber, 2008 Ferber, 2008

STUDIES OF FO’S

AND POSTURAL CONTROL

STUDIES OF FO’S


Lundin TM, Feurbach JW, Grabiner MD: Effect of plantar flexor and dorsiflexor fatigue on unilateral postural control. J Appl Biomech. 9:191, 1993.

Lundin TM, Feurbach JW, Grabiner MD: Effect of plantar flexor and dorsiflexor fatigue on unilateral postural control. J Appl Biomech. 9:191, 1993.

Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 82: 1000, 2001.

Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 82: 1000, 2001.

Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rear-foot orthotics on postural control in healthy subjects. J Sport Rehabil 10: 36, 2001.

Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rear-foot orthotics on postural control in healthy subjects. J Sport Rehabil 10: 36, 2001.

STUDIES OF FO’S


STUDIES OF FO’S


Percy ML, Menz HB: Effects of prefabricated foot orthotics and soft insoles on postural stability in professional soccer players. J Am Podiatr Med Assoc 91:194, 2001.

Percy ML, Menz HB: Effects of prefabricated foot orthotics and soft insoles on postural stability in professional soccer players. J Am Podiatr Med Assoc 91:194, 2001.

Rome K, Brown CL: Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Clinical Rehab18: 624, 2004.

Rome K, Brown CL: Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Clinical Rehab18: 624, 2004.

IMPROVED POSTURAL CONTROL WITH

FO’S: PROPOSED MECHANISMS

IMPROVED POSTURAL CONTROL WITH

FO’S: PROPOSED MECHANISMS

1. Reducing range of motion of the ankle joint

and/or subtalar joint.

1. Reducing range of motion of the ankle joint

and/or subtalar joint.

2. Maintaining a “neutral position” at the subtalar

joint and enhancing ligament mechanoreceptor

function.

2. Maintaining a “neutral position” at the subtalar

joint and enhancing ligament mechanoreceptor

function.

3. Improving tactile sensation on the plantar surface of the foot.

3. Improving tactile sensation on the plantar surface of the foot.

4. Reducing muscular strain about the ankle.4. Reducing muscular strain about the ankle.

“Therefore, we recommend the use of orthotics during the acute and subacutephases for subjects after an ankle sprain.

“Therefore, we recommend the use of orthotics during the acute and subacutephases for subjects after an ankle sprain.

The use of orthotics provides somatosensorybenefits because cutaneous afferents contribute to human balance control and may provide neutral alignment for proper muscle activation and reduce unnecessary strain on the already stressed soft tissue.”

The use of orthotics provides somatosensorybenefits because cutaneous afferents contribute to human balance control and may provide neutral alignment for proper muscle activation and reduce unnecessary strain on the already stressed soft tissue.”

Mattacola CG, Dwyer MK: Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train. Dec (4): 413-429, 2002.

Mattacola CG, Dwyer MK: Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train. Dec (4): 413-429, 2002.


Relevance to other medical conditions

Patients at risk for catastrophic falls

Adult Acquired Flatfoot

Bunions and Hammertoes

Degenerative Arthritis of the Ankle and Hindfoot

1 out of 3 people over age 65 fall each year,

and half of these falls result in injury

Larsen ER,Mosekilde L, Foldspang A. Correlates of falling during 24 h among

elderly Danish community residents. Prev Med 2004;39:389-98.

Falls are the leading cause of injury in older adults

Falls are the leading cause of injury in older adults

Falls are the leading cause of accidental death in people over age 85

Falls are the leading cause of accidental death in people over age 85

Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.

Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992; 82(7):1020-3.

Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992; 82(7):1020-3.

Klein K, and Ritzel DO. Falls Pose a Serious Threat to the Elderly. National SafetyCouncil - Falls in the Home. http://www.nsc.org/issues/ifalls/falthreat.htm.Klein K, and Ritzel DO. Falls Pose a Serious Threat to the Elderly. National SafetyCouncil - Falls in the Home. http://www.nsc.org/issues/ifalls/falthreat.htm.

Centers for Disease Control. Falls Among Older Adults. Injury Fact Book 2001-2002. www.cdc.gov/ncipc/fact_book/15_Falls_Among_Older_Adults.htmCenters for Disease Control. Falls Among Older Adults. Injury Fact Book 2001-2002. www.cdc.gov/ncipc/fact_book/15_Falls_Among_Older_Adults.htm

Falls cause approximately 350,000 hip fractures per year, at a treatment cost of $35,000 per patient

Falls cause approximately 350,000 hip fractures per year, at a treatment cost of $35,000 per patient

Most of the falls resulting in hip fracture are related to balance disorders

Most of the falls resulting in hip fracture are related to balance disorders

Braithwiate RS, et al. Estimating Hip Fracture Morbidity, Mortality and Costs. JAGS 51:364-370, 2003.

Braithwiate RS, et al. Estimating Hip Fracture Morbidity, Mortality and Costs. JAGS 51:364-370, 2003.

Centers for Disease Control. Falls Among Older Adults. Injury Fact Book 2001-2002. www.cdc.gov/ncipc/fact_book/15_Falls_Among_Older_Adults.htm

Bloem, et al. An Update on Falls: Curr Opin Neurol, 2003; Vol 16(1):15-26.Bloem, et al. An Update on Falls: Curr Opin Neurol, 2003; Vol 16(1):15-26.

Centers for Disease Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [database online]. National Center for Injury Prevention and

Control, Centers for Disease Control and Prevention (producer). www.cdc.gov/ncipc/wisqars (2001).

The medical cost for treatment of fall-related injuries in the United States exceeds $20 billion annually, and is expected to climb to $32 billion by 2020

The medical cost for treatment of fall-related injuries in the United States exceeds $20 billion annually, and is expected to climb to $32 billion by 2020

Patients at increased risk of falling have consistently shown deficits in balance control.

Patients at increased risk of falling have consistently shown deficits in balance control.

Pekka K., et al. Fall-induced injuries and deaths among older adults. 1999 JAMA, vol. 28, no. 20.

Nevitt, M.C. (1997). Falls in the elderly: Risk factors and prevention. In Masdeu, J.C., Sudarsky, L., & Wolfson, L. (Eds) Gait disorders in aging. Falls and therapeutic strategies. Philadelphia, PA: Lipincott-Raven, 13-36.

Clark, S., Rose, D.J., & Fujimoto, K. (1997). Generalizability of the limits of stability test in the evaluation of dynamic balance among older adults. Archives of Physical Medicine and Rehabilitation, 78, 1078-1084.

Newton, R.A. (1997). Balance screening of an inner city older adult population. Archives of Physical Medicine and Rehabilitation, 78, 587-591.

Whipple, R. (1997). Improving balance in older adults: identifying the significant training stimuli. In Masdeu, J.C., Sudarsky, L., & Wolfson, L. (eds.) Gait disorders in aging. Falls and therapeutic strategies. Philadelphia, PA: Lipincott-Raven, 355-79.

Shumway-Cook A., Gruber W., Baldwin M., Liao S. (1997). Effect of Multidimensional Exercises on Balance, Mobility, & Fall Risk in Community-Dwelling Older Adults. Physical Therapy, 77, 46-57.

Chronic Ankle Instability: Athlete Chronic Ankle Instability: Athlete

Repetitive Falls: ElderlyRepetitive Falls: Elderly What are the commoncausative factors?

What are the commoncausative factors?

Increased postural sway

Conflicting sensory inputs

Increased reflex latency

Delayed muscle reaction times

Strength deficit in LE musculature

Pain

Decreased joint range of motion

Compensated positioning of LE skeletal segments

Foot problems, which

affect 1 in 3older people have been

associated with falls

Menz HB, Tiedemann A, Kwan MM, Plumb K, Lord S. Foot pain in community-dwelling

older people: an evaluation of the Manchester Foot Pain and Disability Index. Rheumatology

2006;45:863-7.

Menz HB, Jordan KP, Roddy E, Croft PR. Characteristics of primary care consultations for

musculoskeletal foot and ankle problems in the UK. Rheumatology 2010;49:1391-8.

Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and

ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol

2004;159:491-8.

Hill C, Gill T, Menz H, Taylor A. Prevalence and correlates of foot pain in a population-based

study: the NorthWest Adelaide Health Study. J Foot Ankle Res 2008;1:2

Martin J. Spink, BPod, Mohammad R. Fotoohabadi, PhD, Elin Wee, BPhysio, Keith D.

Hill, PhD, Stephen R. Lord, PhD, Hylton B. Menz, PhD. Foot and Ankle Strength,

Range of Motion, Posture, and Deformity Are Associated With Balance and Functional

Ability in Older Adults. Arch Phys Med Rehabil 2011;92:68-75.

“Foot posture (measured using the FPI) was found to be an independent

predictor of postural sway on the foam, with a more pronated (flatter) foot

corresponding to a poorer performance. This is consistent with a previous

study of young adults that reported having a flatter foot resulted in

increased anteroposterior sway.”

Hylton B. Menz, B Pod (Hons), and Stephen R. Lord, PhD.The Contribution of Foot

Problems to Mobility Impairment and Falls in Community-Dwelling Older People J

Am Geriatr Soc 49:1651–1656, 2001.

“In conclusion, these findings

provide further evidence that

foot problems (foot pain,

hallux valgus, hammertoes)

are a risk factor for falls and

that this increased risk is

mediated, in part, via

impaired balance and

reduced ability to perform

functional tasks integral to

daily living.”

Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a

prospective study. J Gerontol A Biol Sci Med Sci 2006;61:866-70.

The aim of this study was to determine whether a series of tests of foot and

ankle characteristics are associated with falls in older people. Compared to

nonfallers, fallers exhibited reduced ankle flexibility, more severe hallux

valgus deformity, and reduced plantar tactile sensitivity.

Fallers were also more likely to have weak toe plantarflexor muscles, and had

a higher prevalence of disabling foot pain.

Independent risk factors for falling:

foot pain

reduced range of motion

toe weakness

toe deformity

Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a

prospective study. J Gerontol A Biol Sci Med Sci 2006;61:866-70.

Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. ISB Clinical Biomechanics Award

2009: toe weakness and deformity increase the risk of falls in older people. Clin Biomech

2009;24:787-91

Karen J. Mickle , Bridget J. Munro , Stephen R. Lord , Hylton B. Menz , Julie R. Steele. Toe

weakness and deformity increase the risk of falls in older people Clinical Biomechanics 24

(2009) 787–791

Clinical relevance

“The hallux and lesser toes are vital structures that assist with stability

during gait and balance tasks. This study has shown that the presence of

hallux valgus, lesser toe deformity and reduced plantar flexion strength

of the hallux and lesser toes increase the risk of falling in older people.

In particular, hallux strength and the presence of lesser toe deformities

were independent predictors of falls. Furthermore, individuals with

hallux valgus and lesser toe deformities had weaker flexor muscles of

the associated toes. Interventions designed to increase strength of the toe

flexor muscles combined with treatment of those older individuals with

toe deformities may be beneficial, and a clinical trial that determines

whether these interventions can reduce the risk of falling is

recommended.”

Participants in the intervention group (n=153) experienced 36% fewer falls than participants in the control group (incidence rate ratio 0.64,

95% confidence interval 0.45 to 0.91, P=0.01).

Spink et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in

community dwelling older people with disabling foot pain: randomized controlled

trial. BMJ 2011;342:d3411 doi:10.1136/bmj.d3411

Conclusions“The findings of this study show that a multifaceted podiatry

intervention is an effective falls prevention strategy in older people with

disabling foot pain and an increased risk of falls. The reduction in falls

is likely to be related to the significant improvements found in several

measures of foot and ankle strength and range of motion, balance, and

functional ability. The components of the intervention are inexpensive

and relatively simple to implement, suggesting that the programme

could be incorporated into routine podiatry practice or

multidisciplinary falls prevention clinics.”

“Among the clinical variables implemented in this study, the self reported functional variables (global function question, SF-36 PF) and the subjects ambulation status appear to be the best potential prognostic factors in predicting the number of days to return to sports in Division II athletes with acute lateral ankle sprains.”

“Among the clinical variables implemented in this study, the self reported functional variables (global function question, SF-36 PF) and the subjects ambulation status appear to be the best potential prognostic factors in predicting the number of days to return to sports in Division II athletes with acute lateral ankle sprains.”

Cross KM, Worrell TW, Leslie JE, Khalid RV: The relationship between self reported and clinical measures and the number of days of return to sport following acute lateral ankle sprains. J Ortho Sports Phys Ther 32: 16-23, 2002.

Cross KM, Worrell TW, Leslie JE, Khalid RV: The relationship between self reported and clinical measures and the number of days of return to sport following acute lateral ankle sprains. J Ortho Sports Phys Ther 32: 16-23, 2002.

PREDICTING DISABILITYPREDICTING DISABILITY72 Hours post Grade II LAS:

• Swelling & ROM: poor predictor

• Functional limitation: good predictor

40 m walk/run, Figure 8Single hop, Stair hop, Cross-over hop

Wilson RW, Gansneder BM: Measures of functional limitation as predictors of disablement in athletes with acute ankle sprains. JOSPT 30(9) : 528, 2000

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