How robust are clinical trials in primary and secondary ankle sprain prevention?

OBJECTIVES: Determine the statistical stability of RCTs examining primary and secondary prevention of ankle sprains. METHODS: Databases were searched to August 2023. We included parallel design RCTs, using conservative interventions for preventing ankle sprain, reporting dichotomous injury event outcomes. Statistical stability was quantified using Fragility Index (FI) and Fragility Quotient (FQ). Subgroup analyses were undertaken to test if FI varied based on by study objective, original approach to analysis (frequency vs time to event), follow-up duration, and pre-registration. RESULTS: 3559 studies were screened with 45 RCTs included. The median number of events required to change the statistical significance (FI) was 4 (IQR 1-6). FI was similar regardless of study objective, original analysis, follow-up duration, and pre-registration status. Median (IQR) FQ was 0.015 (0.005-0.046), therefore reversing events <2 patients/100 would alter significance. In 80% of studies the number of patients lost to follow-up was greater than the FI. CONCLUSION: RCTs informing primary and secondary prevention of ankle sprain are fragile. Only a small percentage of outcome event reversals would reverse study significance, and this is often exceeded by the number of drop outs. Robust reporting of dichotomous outcomes requires the use P values and key metrics such as FI or FQ.

Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis.

OBJECTIVE: To summarise and evaluate research on the diagnostic accuracy of clinical tests for ligamentous injury of the ankle syndesmosis. METHODS: CINAHL, Embase, and MEDLINE were searched from inception to February 12, 2021. Studies comparing clinical examination to arthroscopy, magnetic resonance imaging, or ultrasound were considered eligible. Meta-analysis was based on random effect modelling and limited to studies fulfilling all QUADAS-2 criteria. Sensitivity (SN), specificity (SP) and likelihood ratios determined diagnostic accuracy, all with 95% confidence intervals (CI). RESULTS: Six studies were included (512 participants; 13 clinical tests; 29% median prevalence). No individual test was associated with both high sensitivity and high specificity. Tests with the highest sensitivity were: palpation [SN 92% (95%CI 79-98)] and dorsiflexion lunge [SN 75% (95% CI 64-84%); n = 2 studies]. Tests with the highest specificity were: squeeze test [SP 85% (95% CI 81-89%); n = 4 studies] and external rotation [SP 78% (95% CI 73-82%); n = 4 studies]. CONCLUSIONS: Clinical examination should involve initial clustering of tests with high sensitivity (palpation; dorsiflexion lunge), followed by a test with high specificity (squeeze). However, as these tests cannot definitively stratify syndesmotic injuries into stable vs unstable, decisions on optimal management (conservative vs surgery) require additional imaging or arthroscopy.

Impact of 3D echocardiography on grading of mitral stenosis and prediction of clinical events

Background: The mitral valve orifice area (MVOA) is difficult to assess accurately by 2D echocardiography because of geometric assumptions; therefore, 3D planimetry may offer advantages. We studied the differences in MVOA measurements between the most frequently used methods, to determine if 3D planimetry would result in the re-grading of severity in any cases, and whether it was a more accurate predictor of clinical outcomes. Methods: This was a head-to-head comparison of the three most commonly used techniques to grade mitral stenosis (MS) by orifice area and to assess their impact on clinical outcomes. 2D measurements (pressure half-time (PHT), planimetry) and 3D planimetry were performed retrospectively on patients with at least mild MS. The clinical primary endpoint was defined as a composite of MV balloon valvotomy, mitral valve repair or replacement (MVR) and/or acute heart failure (HF) admissions. Results: Forty-one consecutive patients were included; the majority were female (35; 85.4%), average age 55 (17) years. Mean and peak MV gradients were 9.4 (4) mmHg and 19 (6) mmHg, respectively. 2D and 3D measures of MVOA differed significantly; mean 2D planimetry MVOA was 1.28 (0.40) cm2, mean 3D planimetry MVOA 1.15 (0.29) cm2 (P = 0.003). Mean PHT MVOA was 1.43 (0.44) cm2 (P = 0.046 and P < 0.001 in comparison to 2D and 3D planimetry methods, respectively). 3D planimetry reclassified 7 (17%) patients from mild-to-moderate MS, and 1 (2.4%) from moderate to severe. Overall, differences between the two methods were significant (X2, P < 0.001). Only cases graded as severe by 3D predicted the primary outcome measure compared with mild or moderate cases (odds ratio 5.7). Conclusion: 3D planimetry in MS returns significantly smaller measurements, which in some cases results in the reclassification of severity. Routine use of 3D may significantly influence the management of MS, with a degree of prediction of clinical outcomes.

Recurrent injury patterns in adolescent rugby.

OBJECTIVES: To establish patterns of subsequent injury in U18 rugby, to quantify the burden of within season injury recurrence. DESIGN: Secondary analysis of prospective data. SETTING: 28 Schools in Ireland. PARTICIPANTS: 825 male rugby players (aged 15-18 years). MAIN OUTCOME MEASURES: Subsequent injuries were classified as: new, local or recurrent (same site and type as index injury). All recurrent injuries were sub-grouped by body part and diagnosis. Burden was based on frequency, days lost and injury proportion ratios. RESULTS: A total of 426 injuries were eligible for analysis, of which, 121 were subsequent injuries. The majority of subsequent injuries involved a different body part than their index injury. There were n = 23 cases of within season recurrence. 78% of recurrences occurred within 2 months of return to play. Recurrent injuries comprised 5% of all injuries and their cumulative time loss was 1073 days. Recurrent injury to the ankle ligaments, lumbar muscles and concussions carried the greatest burden. CONCLUSION: The burden of recurrent injury in U18 rugby is lower than in the professional game. However, this population could benefit from targeted secondary prevention efforts including reconsideration of return-to-play protocols for ankle sprain, lumbar muscles and potentially concussion.

Biotensegrity and myofascial chains: A global approach to an integrated kinetic chain.

Human movement is a complex orchestration of events involving many different body systems. Understanding how these systems interact during musculoskeletal movements can directly inform a variety of research fields including: injury etiology, injury prevention and therapeutic exercise prescription. Traditionally scientists have examined human movement through a reductionist lens whereby movements are broken down and observed in isolation. The process of reductionism fails to capture the interconnected complexities and the dynamic interactions found within complex systems such as human movement. An emerging idea is that human movement may be better understood using a holistic philosophy. In this regard, the properties of a given system cannot be determined or explained by its components alone, rather, it is the complexity of the system as a whole, that determines how the individual component parts behave. This paper hypothesizes that human movement can be better understood through holism; and provides available observational evidence in musculoskeletal science, which help to frame human movement as a globally interconnected complex system. Central to this, is biotensegrity, a concept where the bones of the skeletal system are postulated to be held together by the resting muscle tone of numerous viscoelastic muscular chains in a tension dependent manner. The design of a biotensegrity system suggests that when human movement occurs, the entire musculoskeletal system constantly adjusts during this movement causing global patterns to occur. This idea further supported by recent anatomical evidence suggesting that the muscles of the human body can no longer by viewed as independent anatomical structures that simply connect one bone to another bone. Rather, the body consists of numerous muscles connected in series, and end to end, which span the entire musculoskeletal system, creating long polyarticular viscoelastic myofascial muscle chains. Although theoretical, the concept of the human body being connected by these muscular chains, within a biotensegrity design, could be a potential underpinning theory for analyzing human movement in a more holistic manner. Indeed, preliminary research has now used the concept of myofascial pathways to enhance musculoskeletal examination, and provides a vivid example of how range of motion at a peripheral joint, is dependent upon the positioning of the entire body, offering supportive evidence that the body's kinetic chain is globally interconnected. Theoretical models that introduce a complex systems approach should be welcomed by the movement science field in an attempt to help explain clinical questions that have been resistant to a linear model.

RISUS study: Rugby Injury Surveillance in Ulster Schools.

OBJECTIVE: To examine injury patterns in adolescent rugby players and determine factors associated with injury risk. DESIGN: Prospective injury surveillance study. SETTING: N=28 Grammar Schools in Ulster, Ireland (2014-2015 playing season). PARTICIPANTS: 825 adolescent rugby players, across in 28 school first XV rugby squads; mean age 16.9 years. MAIN OUTCOME MEASURES: Injuries were classified by body part and diagnosis, and injury incidence using injuries per 1000 match hours of exposure. HRs for injury were calculated through Cox proportional hazard regression after correction for influential covariates. RESULTS: A total of n=426 injuries were reported across the playing season. Over 50% of injuries occurred in the tackle situation or during collisions (270/426), with few reported during set plays. The 3 most common injury sites were head/face (n=102, 23.9%), clavicle/shoulder (n=65, 15.3%) and the knee (n=56, 13.1%). Sprain (n=133, 31.2%), concussion (n=81, 19%) and muscle injury (n=65, 15.3%) were the most common diagnoses. Injury incidence is calculated at 29.06 injuries per 1000 match hours. There were no catastrophic injuries. A large percentage of injuries (208/424) resulted in absence from play for more than 28 days. Concussion carried the most significant time out from play (n=33; 15.9%), followed by dislocations of the shoulder (n=22; 10.6%), knee sprains (n=19, 9.1%), ankle sprains (n=14, 6.7%), hand/finger/thumb (n=11; 5.3%). 36.8% of participants in the study (304/825) suffered at least one injury during the playing season. Multivariate models found higher risk of injury (adjusted HR (AHR); 95% CI) with: higher age (AHR 1.45; 1.14 to 1.83), heavier weight (AHR 1.32; 1.04 to 1.69), playing representative rugby (AHR 1.42; 1.06 to 1.90) and undertaking regular strength training (AHR 1.65; 1.11 to 2.46). Playing for a lower ranked team (AHR 0.67; 0.49 to 0.90) and wearing a mouthguard (AHR 0.70; 0.54 to 0.92) were associated with lower risk of injury. CONCLUSIONS: There was a high incidence of severe injuries, with concussion, ankle and knee ligament injuries and upper limb fractures/dislocations causing greatest time loss. Players were compliant with current graduated return-to-play regulations following concussion. Physical stature and levels of competition were important risk factors and there was limited evidence for protective equipment.

Gait Biomechanics in Participants, Six Months after First-time Lateral Ankle Sprain.

No research currently exists predicating a link between the injury-affiliated sensorimotor deficits of acute ankle sprain and those of chronic ankle instability during gait. This analysis evaluates participants with a 6-month history of ankle sprain injury to affirm this link. 69 participants with a 6-month history of acute first-time lateral ankle sprain were divided into subgroups ('chronic ankle instability' and 'coper') based on their self-reported disability and compared to 20 non-injured participants during a gait task. Lower extremity kinematic and kinetic data were collected from 200 ms pre- to 200 ms post-heel strike (period 1) and from 200 ms pre- to 200 ms post-toe off (period 2). The 'chronic ankle instability' subgroup (who reported greater disability) displayed increased knee flexion during period 1. During period 2, this subgroup exhibited greater total displacement at their ankle joint and greater extensor dominance at their knee. That many of these features are present, both in individuals with acute ankle sprain and those with chronic ankle instability may advocate a link between acute deficits and long-term outcome. Clinicians must be aware that the sensorimotor deficits of ankle sprain may persevere beyond the acute stage of injury and be cognizant of the capacity for impairments to pervade proximally.

Single-leg drop landing movement strategies 6 months following first-time acute lateral ankle sprain injury.

No research exists predicating a link between acute ankle sprain injury-affiliated movement patterns and those of chronic ankle instability (CAI) populations. The aim of the current study was to perform a biomechanical analysis of participants, 6 months after they sustained a first-time acute lateral ankle sprain (LAS) injury to establish this link. Fifty-seven participants with a 6-month history of first-time LAS and 20 noninjured participants completed a single-leg drop landing task on both limbs. Three-dimensional kinematic (angular displacement) and sagittal plane kinetic (moment of force) data were acquired for the joints of the lower extremity, from 200 ms pre-initial contact (IC) to 200 ms post-IC. Individual joint stiffnesses and the peak magnitude of the vertical component of the ground reaction force (GRF) were also computed. LAS participants displayed increases in hip flexion and ankle inversion on their injured limb (P < 0.05); this coincided with a reduction in the net flexion-extension moment at the hip joint, with an increase in its stiffness (P < 0.05). There was no difference in the magnitude of the peak vertical GRF for either limb compared with controls. These results demonstrate that altered movement strategies persist in participants, 6 months following acute LAS, which may precipitate the onset of CAI.

Single-leg drop landing motor control strategies following acute ankle sprain injury.

No research currently exists investigating the effect of acute injury on single-limb landing strategies. The aim of the current study was to analyze the coordination strategies of participants in the acute phase of lateral ankle sprain (LAS) injury. Thirty-seven participants with acute, first-time LAS and 19 uninjured participants completed a single-leg drop landing task on both limbs. Three-dimensional kinematic (angular displacement) and sagittal plane kinetic (moment-of-force) data were acquired for the joints of the lower extremity from 200 ms pre-initial contact (IC) to 200 ms post-IC. The peak magnitude of the vertical component of the ground reaction force (GRF) was also computed. Injured participants displayed a bilateral increase in hip flexion, with altered transverse plane kinematic profiles at the knee and ankle for both limbs (P < 0.05). This coincided with a reduction in the net-supporting flexor moment of the lower extremity (P < 0.05) and magnitude of the peak vertical GRF for the injured limb (21.82 ± 2.44 N/kg vs 24.09 ± 2.77 N/kg; P = 0.013) in injured participants compared to control participants. These results demonstrate that compensatory movement strategies are utilized by participants with acute LAS to successfully reduce the impact forces of landing.

Lower body reaction testing using ultrasonic motion capture.

This paper presents a lower body reaction test that utilizes a new portable ultra-sound based motion capture system (MobiFit) combined with a synchronized visual stimulus. This novel system was tested first for criterion validity and agreement against a gold standard laboratory based optical motion capture system (CODA). It was subsequently tested in the field during Gaelic football (GAA) team gym sessions with 35 subjects to demonstrate its utility and versatility. The lower body reaction test itself is novel in that it can be applied to a gross motor task. During testing, participants had sensors attached to their lower limbs and trunk. The speed of movement for each sensor was monitored at 500Hz using the Mobifit motion capture system, and reaction time was measured as the elapsed time from the appearance of a green indicator on the screen to a sensor reaching a set threshold velocity as the participant raised the corresponding leg. Pearson's correlation coefficient tested criterion validity against the CODA system and Intra class correlation coefficients and Bland-Altman plots assessed agreement of velocity measures obtained from the MobiFit and CODA systems. Results indicate that the MobiFit system is an accurate device to assess lower body reaction time and has advantage over standard laboratory measures in terms of portability and ease of set-up.

Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting?

Ice is commonly used after acute muscle strains but there are no clinical studies of its effectiveness. By comparison, there are a number of basic scientific studies on animals which show that applying ice after muscle injury has a consistent effect on a number of important cellular and physiological events relating to recovery. Some of these effects may be temperature dependant; most animal studies induce significant reductions in muscle temperature at the injury site. The aim of this short report was to consider the cooling magnitudes likely in human models of muscle injury and to discuss its relevance to the clinical setting. Current best evidence shows that muscle temperature reductions in humans are moderate in comparison to most animal models, limiting direct translation to the clinical setting. Further important clinical questions arise when we consider the heterogenous nature of muscle injury in terms of injury type, depth and insulating adipose thickness. Contrary to current practice, it is unlikely that a 'panacea' cooling dose or duration exists in the clinical setting. Clinicians should consider that in extreme circumstances of muscle strain (eg, deep injury with high levels of adipose thickness around the injury site), the clinical effectiveness of cooling may be significantly reduced.

Flow-mediated dilatation of the brachial artery is a poorly reproducible indicator of microvascular function in Type I diabetes mellitus.

BACKGROUND: Flow-mediated dilatation (FMD) of the brachial artery is commonly measured as a surrogate marker of endothelial function. Its measurement is, however, technically demanding and reports regarding its reproducibility have not always been favourable. AIM: Two Type I diabetes and control group comparator studies were conducted to assess the reproducibility of FMD and to analyse blood flow data normally discarded during FMD measurement. DESIGN: The studies were sequential and differed only with regard to operator and ultrasound machine. Seventy-two subjects with diabetes and 71 controls were studied in total. METHODS: Subjects had FMD measured conventionally. Blood velocity waveforms were averaged over 10 pulses post forearm ischaemia and their component frequencies analysed using the wavelet transform, a mathematical tool for waveform analysis. The component frequencies were grouped into 11 bands to facilitate analysis. RESULTS: Subjects were well-matched between studies. In Study 1, FMD was significantly impaired in subjects with Type I diabetes vs. controls (median 4.35%, interquartile range 3.10-4.80 vs. 6.50, 4.79-9.42, P < 0.001). No differences were detected between groups in Study 2, however. However, analysis of blood velocity waveforms yielded significant differences between groups in two frequency bands in each study. CONCLUSION: This report highlights concerns over the reproducibility of FMD measures. Further work is required to fully elucidate the role of analysing velocity waveforms after forearm ischaemia.

Energy efficient on-sensor processing in Body Sensor Networks.

Body Sensor Networks (BSNs) have tremendous potential in facilitating the real-time monitoring of the health of an individual in their own environment. However to truly exploit this potential, the powerful signal processing and analysis techniques available in the hospital environment must also be deployed in BSNs. In this paper, techniques in algorithm development, communications, hardware architecture and circuit design are described that will achieve the necessary power savings to make intelligent BSNs a reality.

Self-poisoning with metaldehyde.

Metaldehyde poisoning is rare. This case report details the largest toxic dose of self-poisoning with metaldehyde ever recorded in the literature to the authors' knowledge, the aim being to emphasise the features of metaldehyde toxicity and the potential for good clinical outcome. The patient was admitted unconscious with features consistent with poisoning. Appropriate critical care was instituted early with correction of his acid-base disorder, ventilatory support, correction of haemodynamic instability, anticonvulsant therapy and early admission to the critical care unit. An almost complete recovery was seen over the following weeks, the only lasting deficit being to short-term memory, a finding common to other reported incidents of metaldehyde toxicity. This case is notable in that the patient took more than one and a half times what is considered to be a lethal dose of metaldehyde (the largest reported), but has had a remarkably good clinical outcome that is proposed to be due to methodical and timely interventions delivered according to basic principles irrespective of the absence of the early identification of the poison. The case demonstrates several of the key features of metaldehyde toxicity and the emergency management of such a situation. The published literature pertaining to metaldehyde overdose is reviewed.

Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols.

BACKGROUND: The use of cryotherapy in the management of acute soft tissue injury is largely based on anecdotal evidence. Preliminary evidence suggests that intermittent cryotherapy applications are most effective at reducing tissue temperature to optimal therapeutic levels. However, its efficacy in treating injured human subjects is not yet known. OBJECTIVE: To compare the efficacy of an intermittent cryotherapy treatment protocol with a standard cryotherapy treatment protocol in the management of acute ankle sprains. SUBJECTS: Sportsmen (n = 44) and members of the general public (n = 45) with mild/moderate acute ankle sprains. METHODS: Subjects were randomly allocated, under strictly controlled double blind conditions, to one of two treatment groups: standard ice application (n = 46) or intermittent ice application (n = 43). The mode of cryotherapy was standardised across groups and consisted of melting iced water (0 degrees C) in a standardised pack. Function, pain, and swelling were recorded at baseline and one, two, three, four, and six weeks after injury. RESULTS: Subjects treated with the intermittent protocol had significantly (p<0.05) less ankle pain on activity than those using a standard 20 minute protocol; however, one week after ankle injury, there were no significant differences between groups in terms of function, swelling, or pain at rest. CONCLUSION: Intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury.

Are sports medicine journals relevant and applicable to practitioners and athletes?

OBJECTIVE: To examine the evidence base of sports medicine research and assess how relevant and applicable it is to everyday practice. METHODS: Original research articles, short reports, and case reports published in four major sport and exercise medicine journals were studied and classified according to the main topic of study and type of subjects used. RESULTS: The most common topic was sports science, and very few studies related to the treatment of injuries and medical conditions. The majority of published articles used healthy subjects sampled from the sedentary population, and few studies have been carried out on injured participants. CONCLUSIONS: There is a dearth of studies addressing diagnostic and treatment interventions in the sports medicine literature. The evidence base for sports medicine must continue to increase in terms of volume and quality.

The quality of research in sports journals.

OBJECTIVE: To examine the evidence base of sports medicine research. METHODS: A sample of four major journals that present core research in sport and exercise medicine (British Journal of Sports Medicine, Medicine and Science in Sports and Exercise, Journal of Sports Medicine and Physical Fitness, and Physical Therapy) was examined using assessment criteria taken from the READER method. RESULTS: Randomised controlled trials comprised 10% or less of all original research articles. Observational/descriptive studies were the most commonly published study design. There was a highly significant difference (p<0.0001) in the contents of the four journals but when they were compared by categorising the better quality methods together (randomised control trial, case-control, and cohort studies), the difference was not significant (p = 0.09). CONCLUSIONS: The overall pattern of publication type seems remarkably stable over medical journals, indicating that the quality of sports medicine research is comparable to that in other specialities.