Prediction of Recurrent Lateral Ankle Sprain and Ankle Pain Using Applied Care Strategies and Patient-Reported Outcomes.

CONTEXT: Lateral ankle sprain (LAS) patients often have deficient patient-reported outcomes (PROs) at return-to-activity (RTA), potentially increasing risk for recurrent LAS and ankle pain. Additionally, applied care strategies are known to correct impairments, but their ability to mitigate risk for long-term consequences remains unknown. OBJECTIVE: To determine if applied care strategies and PRO scores at RTA and 6-months post-RTA predict recurrent LAS and ankle pain 12 months after an acute LAS. DESIGN: Prospective cohort study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: We enrolled 63 individuals within one week of sustaining an acute LAS. MAIN OUTCOME MEASURES: Participants completed online surveys about their health history and recent LAS. At RTA and 6 months post-RTA, participants completed online surveys regarding demographics, applied care strategies, and patient reported outcomes (PROs): Foot and Ankle Disability Index, Identification of Functional Ankle Instability, Godin Leisure-Time Exercise Questionnaire, Short Form-8. At 12 months post-RTA, we asked participants if they sustained recurrent LAS. Chi-squares determined if recurrent LAS and ankle pain at 12-months were related to applied care strategies or ankle pain at RTA. Independent t-tests compared demographics and PROs at RTA and 6-months between participants with and without a recurrent LAS or ankle pain at 12-months. Logistic regression and area under the receiver operating characteristic (AUROC) analyses determined if demographics, applied care strategies, ankle pain at RTA, and PRO scores at RTA and 6-months predicted recurrent LAS and ankle pain at 12-months. RESULTS: Participants with a recurrent LAS had a lower walking boot use (P=0.05) and were taller than those without (P=0.03). Increased height and lack of walking boot use were predictive of recurrent LAS (P<0.01, R2=0.33, AUROC=0.81[0.68, 0.95]). CONCLUSIONS: LAS patients who are taller and do not use a walking boot might have greater risk for a recurrent LAS withing 12 months of RTA.

Influences of Athletic Trainers' Return-to-Activity Assessments for Patients With an Ankle Sprain.

CONTEXT: Athletic trainers (ATs) inconsistently apply rehabilitation-oriented assessments (ROASTs) when deciding return-to-activity readiness for patients with an ankle sprain. Facilitators and barriers that are most influential to ATs' assessment selection remain unknown. OBJECTIVE: To examine facilitators of and barriers to ATs' selection of outcome assessments when determining return-to-activity readiness for patients with an ankle sprain. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: We sent an online survey to 10 000 clinically practicing ATs. The survey was accessed by 676 individuals, of whom 574 submitted responses (85% completion rate), and 541 respondents met the inclusion criteria. MAIN OUTCOME MEASURE(S): The survey was designed to explore facilitators and barriers influencing ATs' selection of pain; ankle-joint swelling, range of motion, arthrokinematics, and strength; balance; gait; functional capacity; physical activity level; and patient-reported outcome assessments when making return-to-activity decisions for patients after an ankle sprain. The survey asked for reasons that participants chose to use or not use each measure (eg, previous education, personal comfort, most appropriate, available or feasible, perceived value, and other). The survey contained 12 demographic items that characterized the sample of respondents and were examined as potential influences on the facilitators and barriers. Chi-square analysis was used to identify relationships among participant demographics and facilitators of or barriers to assessment selection. RESULTS: Selection of each ROAST and non-ROAST was most commonly facilitated by previous education, availability or feasibility, or perceived value. Avoidance of each ROAST was most often caused by the lack of previous education, availability or feasibility, or perceived value. The presence of facilitators and barriers was affected by various demographic variables. CONCLUSIONS: A variety of facilitators and barriers affected ATs' implementation of expert-recommended assessments when determining return-to-activity readiness in patients with an ankle sprain. Some subpopulations of ATs experienced more favorable or prohibitive conditions for assessment use.

Effects of A Single Balance Training Session on Neural Excitability in Individuals With Chronic Ankle Instability.

CONTEXT: Individuals with chronic ankle instability (CAI) demonstrate reduced spinal reflex modulation and corticospinal excitability of the soleus, which may contribute to decreased balance performance. OBJECTIVE: To determine the effects of a single session of balance training on Spinal-reflexive excitability modulation and corticospinal excitability in those with CAI. DESIGN: Randomized controlled trials. SETTING: Research laboratory. PARTICIPANTS: Thirty participants with CAI were randomly assigned to the balance training (BAL) or control (CON) group. MAIN OUTCOME MEASURES: Modulation of soleus spinal-reflexive excitability was measured by calculating relative change in normalized Hoffmann reflexes (ratio of the H-reflex to the M-wave) from prone to single-leg standing. Corticospinal excitability was assessed during single-leg stance using transcranial magnetic stimulation, outcomes of which included active motor threshold (AMT), motor evoked potential, and cortical silent period (CSP). Balance performance was measured with center of pressure velocity in anterior to posterior and medial to lateral directions. Separate 2 × 2 repeated-measures analyses of variance were employed to determine the effect of group (BAL and CON) and time (baseline and posttraining) on each dependent variable. RESULTS: There were significant group by time interactions in the modulation of soleus spinal-reflexive excitability (F1,27 = 4.763, P = .04); CSP at 100% AMT (F1,27 = 4.727, P = .04); and CSP at 120% AMT (F1,27 = 16.057, P < .01). A large effect size suggests increased modulation of spinal-reflexive excitability (d = 0.81 [0.03 to 1.54]) of the soleus in BAL compared with CON at posttest, while CSP at 100% (d = 0.95 [0.17 to 1.70]) and 120% AMT (d = 1.10 [0.29 to 1.84]) was reduced in BAL when compared with CON at posttest. CONCLUSION: After a single session of balance training, individuals with CAI initiated increases in spinal reflex modulation and corticospinal excitability of the soleus. Thus, individuals with CAI who undergo balance training exhibit positive neural adaptations that are linked to improvements in balance performance.

Cross-Education Balance Effects After Unilateral Rehabilitation in Individuals With Chronic Ankle Instability: A Systematic Review.

OBJECTIVE: To conduct a systematic review of existing literature on cross-education balance effects after unilateral training in the population with chronic ankle instability (CAI). DATA SOURCES: PubMed, SPORTDiscus, CINAHL Plus. STUDY SELECTION: To be included in the systematic review, studies were required to have been published in English, included participants with CAI, had participants undergo a unilateral therapeutic exercise for the lower extremity, and measured balance performance of the untrained lower extremity before and after the intervention. DATA EXTRACTION: The certainty of evidence in each included study was assessed via the Downs and Black checklist. A score of 24 to 28 indicated excellent or very low risk of bias; 19 to 23, good or low risk of bias; 14 to 18, fair or moderate risk of bias; and <14, poor or high risk of bias. We extracted information from each study regarding design, participant characteristics, inclusion criteria, independent and dependent variables, intervention, and results. Baseline and postintervention balance performance data for participants' untrained limbs were used to calculate the Hedges g effect sizes and 95% CIs. DATA SYNTHESIS: Our search returned 6 studies that met the inclusion criteria. The articles' risk of bias ranged from high to low (11-19). In 4 of 5 studies that examined unilateral balance training, the authors reported a cross-education effect. In the lone study that examined resistance training at the ankle joint, a cross-education effect was also present. Several cross-education effects were associated with large effect sizes. This systematic review was limited by a small number of studies that varied in methods and quality. CONCLUSIONS: Our results suggest that unilateral therapeutic exercise can improve balance performance of the untrained limb of individuals with CAI. More work is needed to determine which training protocols are most effective for generating a cross-education effect.

Assessments Used by Athletic Trainers to Decide Return-to-Activity Readiness in Patients.

CONTEXT: Patients with ankle sprains are often cared for by athletic trainers (ATs). Expert consensus was previously established for Rehabilitation-Oriented Assessments (ROASTs) that should be included in ankle sprain evaluations. However, it is unknown what methods ATs use to determine return-to-activity readiness following an ankle sprain. OBJECTIVE: Our purpose was to identify ATs' methods for determining patients' return-to-activity readiness following an ankle sprain and demographic determinants of ATs' methods. SETTING: Online survey Study Design: Cross-sectional study Level of Evidence: CEBM Level 1 Participants: We recruited 10,000 clinically practicing ATs. A total of 676 accessed the survey, 574 submitted responses (85% completion rate), and 541 respondents met inclusion criteria. MAIN OUTCOME MEASURES: We distributed an online survey to participants to ask them about their assessment of pain, swelling, range of motion, arthrokinematics, strength, balance, gait, functional capacity, physical activity level, and patient-reported outcomes in deciding return-to-activity. Descriptive statistics characterized participant demographics and frequencies of assessment measures used by ATs. Chi-square analyses identified relationships between demographics and assessment selection. RESULTS: Pain, swelling, range of motion, strength, balance, gait, and functional capacity were assessed by 76-97% of ATs. Arthrokinematics, physical activity level, and patient-reported outcomes were assessed by 25-36% of participants. When selecting specific assessment methods, ATs often did not use recommended ROASTs. ATs with higher degrees, more advance educational programs, employment in non-traditional settings, more clinical experience, and familiarity with expert consensus recommendations were more likely to use ROASTs. CONCLUSIONS: Before approving return-to-activity for patients with ankle sprains, some recommended outcomes and assessment methods are not evaluated by ATs. Practice in non-traditional settings, more advanced degrees, more clinical experience, and familiarity with expert-consensus guidelines appear to facilitate use of ROASTs.

Perceived Instability, Pain, and Psychological Factors for Prediction of Function and Disability in Individuals With Chronic Ankle Instability.

CONTEXT: Chronic ankle instability (CAI) is associated with residual instability, pain, decreased function, and increased disablement. Injury-related fear has been associated with CAI, although its relationship to other impairments is unclear. The fear-avoidance model is a theoretical framework hypothesizing a relationship among pain catastrophizing, injury-related fear, chronic pain, and disability. It has been useful in understanding fear's influence in other musculoskeletal conditions but has yet to be studied in those with CAI. OBJECTIVE: To explore relationships among instability, pain catastrophizing, injury-related fear, pain, ankle function, and global disability in individuals with CAI. DESIGN: Cross-sectional study. SETTING: Anonymous online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 259 people, recruited via email and social media, with a history of ankle sprain completed the survey; of those, 126 participants (age = 32.69 ± 4.38 years, females = 84.92%, highly active = 73.81%) were identified as having CAI and were included in the analysis. MAIN OUTCOME MEASURE(S): Demographics of gender identity, age, and physical activity level were recorded. Assessments used were the Identification of Functional Ankle Instability questionnaire (instability), the Pain Catastrophizing Scale (pain catastrophizing), the Tampa Scale of Kinesiophobia-11 (injury-related fear), a numeric pain rating scale and activity-based question (pain presence), the Quick Foot and Ankle Ability Measure (ankle function), and the modified Disablement in the Physically Active Scale (disability). Relationships among variables were explored through correlation and regression analyses. RESULTS: After we controlled for instability and pain, pain catastrophizing and injury-related fear were significantly related to function and disability ratings in individuals with CAI. Together, the variables predicted 48.7% (P < .001) of the variance in function and 44.2% (P < .001) of the variance in disability. CONCLUSIONS: Greater instability, pain catastrophizing, injury-related fear, and pain predicted decreased function and greater disability in those with CAI. These findings are consistent with the hypothesized relationships in the fear-avoidance model, although further investigation is needed to determine causality of these factors in the development of CAI.

Corticospinal activity during a single-leg stance in people with chronic ankle instability.

PURPOSE: The aim of the study was to determine whether corticospinal excitability and inhibition of the tibialis anterior during single-leg standing differs among individuals with chronic ankle instability (CAI), lateral ankle sprain copers, and healthy controls. METHODS: Twenty-three participants with CAI, 23 lateral ankle sprain copers, and 24 healthy control participants volunteered. Active motor threshold (AMT), normalized motor-evoked potential (MEP), and cortical silent period (CSP) were evaluated by transcranial magnetic stimulation while participants performed a single-leg standing task. RESULTS: Participants with CAI had significantly longer CSP at 100% of AMT and lower normalized MEP at 120% of AMT compared to lateral ankle sprain copers (CSP100%: p = 0.003; MEP120%: p = 0.044) and controls (CSP100%: p = 0.041; MEP120%: p = 0.006). CONCLUSION: This investigation demonstrate altered corticospinal excitability and inhibition of the tibialis anterior during single-leg standing in participants with CAI. Further research is needed to examine the effects of corticospinal maladaptations to motor control of the tibial anterior on postural control performance in those with CAI.

Injury-Related Fear in Individuals With and Without Chronic Ankle Instability: A Systematic Review.

CONTEXT: Injury-related fear has recently been recognized to exist in ankle sprain populations. It is unclear, however, if injury-related fear levels differ between those who develop chronic ankle instability (CAI) and those who do not and the best tools for assessing these differences. OBJECTIVE: The purpose of this study was to conduct a comprehensive systematic review investigating differences in injury-related fear between individuals with and without CAI. EVIDENCE ACQUISITION: Relevant studies from CINAHL Plus with full text, PubMed, and SPORTDiscus through November 2020 were included. All studies used the Tampa Scale of Kinesiophobia, Fear-Avoidance Beliefs Questionnaire, or Athlete Fear Avoidance Questionnaire as either a descriptor or a main outcome and provided comparison data between a CAI group and ankle sprain copers (COP) or controls (CON). The authors independently assessed methodological quality using the modified Downs and Black Quality Index. Studies were then grouped by between-group comparisons including CAI and CON, CAI and COP, and COP and CON. The authors calculated Hedge g effect sizes and 95% confidence intervals to examine group differences. EVIDENCE SYNTHESIS: A total of 11 studies were included in this review. In total, 8 studies provided data for the CAI and CON comparison, 7 for CAI and COP comparisons, and 4 for COP and CON comparisons. Methodological quality scores ranged from 60.0% to 86.7%, with 2 high-, and 9 moderate-quality studies. Overall, the evidence suggests that physically active individuals with CAI report higher levels of injury-related fear when compared with both COP and CON. Although limited, ankle sprain COP do not seem to differ from CON. CONCLUSION: Available evidence emphasizes the importance of injury-related fear in individuals who develop chronicity after ankle sprain injury. The Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia are useful for the identification of injury-related fear in individuals after sustaining an ankle sprain and should be used to inform rehabilitation strategies and to monitor efficacy in fear reduction.

Lumbopelvic Stability and Trunk Muscle Contractility of Individuals with Chronic Ankle Instability.

BACKGROUND: Chronic ankle instability (CAI) results in hip neuromuscular impairments that can perpetuate dysfunction through reduced lumbopelvic stability and subsequent malpositioning of the lower body during functional movement. Lumbopelvic stability might be further impaired through changes in trunk muscular contractility. However, lumbopelvic stability and trunk muscle morphology have not been compared between individuals with and without CAI. PURPOSE: To compare lumbopelvic stability and trunk muscle contractility between individuals with and without chronic ankle instability (CAI) and determine if lumbopelvic stability and trunk muscle contractility are associated with self-reported function. STUDY DESIGN: Case-control study. METHODS: Ten individuals with CAI, 10 ankle sprain copers (COP), and 10 healthy controls (CON) participated. Diagnostic ultrasound imaging was used to assess transversus abdominis (TrA) and lumbar multifidus (LM) muscle contractility. A percent change in contraction thickness from rested to contracted conditions was calculated for each muscle. Lumbopelvic stability was assessed using unilateral hip bridge, trunk flexion endurance, Biering-Sorensen, and side plank tests. Self-reported function was measured with the Foot and Ankle Ability Measure Activity of Daily Living (FAAM-ADL) and Sport (FAAM-S) subscales. One-way ANOVAs and Cohen's d effect sizes compared scores on clinician and patient-reported outcomes between groups. Pearson product moment correlations analyzed associations between self-reported function and trunk muscle contractility and lumbopelvic stability. Significance was set a priori at P<0.05. RESULTS: COP had significantly greater TrA contractility than CAI (P<0.01, d=2.65[1.45,3.85]) and CON (P=0.03, d=1.05[0.08,1.94]). Although not statistically significant, a large effect size suggest that CAI had lower TrA contractility than CON (P=0.12, d=0.92[-0.03,1.80]). No differences existed for LM contractility or lumbopelvic stability tests. A moderate direct correlation (r=0.65, P=0.04) existed between CON's TrA contractility and FAAM-ADL scores. CONCLUSION: Deficits in TrA contractility are a novel finding among individuals with CAI. While LM contractility and lumbopelvic stability did not differ between groups, future research should continue to examine their relevance to CAI. LEVEL OF EVIDENCE: 3b.

MYCOTIC PNEUMONIA AND ENCEPHALITIS IN SOUTHERN PUDU (PUDU PUDA).

This case series describes six confirmed cases of mycotic encephalitis and/or mycotic pneumonia in southern pudu (Pudu puda). One case involved a 10.5-yr-old intact female that presented with an inability to stand, eventually progressing to grand mal seizures. Magnetic resonance imaging showed a lesion within the cerebellar vermis with edema causing cerebellar herniation. The animal was euthanized based on a grave prognosis. Gross and histologic examination revealed primary central nervous system phaeohyphomycosis. Curvularia spicifera was sequenced from the cerebellar tissue. This is the first time this fungus has been reported as a primary central nervous system infection in an artiodactyl species. The remaining five cases occurred in neonates between 17 and 67 days old. Clinical signs varied widely, including facial swelling, weakness, posterior paresis, and sudden death. Antifungal therapy was initiated in three neonatal animals but was unsuccessful in each case. All neonates had active mycotic pneumonia caused by Aspergillus fumigatus or Mucor spp. at time of death; four of these animals also had disseminated disease that caused mycotic encephalitis. This case series indicates that fungal disease should be included in the differential diagnosis list of any pudu presenting for neurologic or respiratory clinical signs.

Neural excitability of lower extremity musculature in individuals with and without chronic ankle instability: A systematic review and meta-analysis.

This systematic review and meta-analysis examined differences in lower extremity neural excitability between ankles with and without chronic ankle instability (CAI). We searched the literature for studies that compared corticomotor or spinal reflexive excitability between a CAI group and controls or copers, or between limbs of a CAI group. Random effects meta-analyses calculated pooled effect sizes for each outcome. Nineteen studies were included. Meta-analyses of motor thresholds of the fibularis longus (Z = 1.17, P = 0.24) and soleus (Z = 0.47, P = 0.64) exhibited no differences between ankles with and without CAI. Pooled data indicate that ankles with CAI had reduced soleus spinal reflexive excitability (Z = 2.18, P = 0.03) and significantly less modulation of the soleus (Z = 6.96, P < 0.01) and fibularis longus (Z = 4.75, P < 0.01) spinal reflexive excitability when transitioning to more challenging stances. Pre-synaptic inhibition was facilitated in ankles with CAI (Z = 4.05, P < 0.01), but no difference in recurrent inhibition existed (Z = 1.50, P = 0.13). Soleus spinal reflexive activity is reduced in those with CAI. Reduced ability of ankles with CAI to modulate soleus and fibularis longus reflexive activity may contribute to impaired balance.

An intervention based on the health belief model led to improvements in self-efficacy towards ERIPP participation and functional performance in club sport athletes: a pilot study.

OBJECTIVES: To determine if an intervention based on the Health Belief Model (HBM) could improve attitudes towards exercise-related injury prevention program (ERIPP) participation and functional performance in club sport participants. DESIGN: Repeated measures METHODS: Participants completed the HBM Scale (HBMS) and Theory of Planned Behavior Scale (TPBS) to assess attitudes towards ERIPP participation at three time points (pre-measure, post-measure, follow-up measure). The HBM based intervention was delivered immediately following the pre-measure containing: 1) education on ERIPPs, benefits and barriers to participating, strategies to overcome barriers, risk factors and consequences for lower extremity injuries, and strategies to prevent lower extremity injuries 2) individualized feedback on functional performance 3) demonstration and participation in the 11+. Attitudes towards injury prevention were compared using the subscales of the HBMS and TPBS at all three time points. Functional performance was compared at the pre-measure and follow-up measure. RESULTS: Significant improvements with large effect sizes were detected in individual self-efficacy from pre-test (0.73±4.48) to post-test (2.93±4.30; P=0.05; ƞ2=0.18) and pre-test to follow-up (3.20±3.49; P=0.04; ƞ2=0.20) and community led self-efficacy from pre-test (4.40±2.75) to post-test (6.07±3.43; P=0.02; ƞ2=0.24) and pre-test to follow-up (7.07±2.05; P=0.001; ƞ2=0.44). Additionally, significant improvements were found in the LESS-RT following the intervention. CONCLUSIONS: The intervention based on the HBM led to improvements in individual and community led self-efficacy indicating an enhancement in the participants' confidence in their ability to participate in an ERIPP. Future research should investigate the effectiveness of individualized interventions to improve attitudes towards and adherence to ERIPPs.

Use of Social or Behavioral Theories in Exercise-Related Injury Prevention Program Research: A Systematic Review.

BACKGROUND: The use of social or behavioral theories within exercise-related injury prevention program (ERIPP) research may lead to a better understanding of why adherence to the programs is low and inform the development of interventions to improve program adherence. There is a need to determine which theories have been used within the literature and at what level theory was used to further the field. OBJECTIVE: To determine which social or behavioral science theories have been incorporated within ERIPP research and assess the level at which the theories were used. The key question guiding the search was "What social or behavioral theories have been used within ERIPP research?" METHODS: A systematic review of the literature was completed with an appraisal of bias risk using a custom critical appraisal tool. An electronic search of EBSCOhost (Academic Search Complete, CINAHL, Medline, Psychology and Behavioral Sciences Collection) and PubMed was completed from inception to October 2018. Studies investigating attitudes towards ERIPP participation with the use of a social or behavioral theoretical model or framework were eligible for inclusion. RESULTS: The electronic search returned 7482 results and two articles were identified though a hand search, which resulted in ten articles meeting inclusion criteria. Four different behavioral or social theoretical models or frameworks were identified including the health action process approach model, health belief model, self-determination theory, and theory of planned behavior. Six studies utilized the theory at a B level meaning a theoretical construct was measured while four utilized the theory at the C level meaning the theory was tested. The mean critical appraisal score was 78%, indicating a majority of the studies were higher quality. CONCLUSION: There has been an increase in the use of theory within literature that is specific to ERIPP participation. Additionally, the use of theory has shifted from guiding program design to the measurement of theoretical constructs and testing of the theoretical models.

Landing Kinematics and Isometric Hip Strength of Individuals With Chronic Ankle Instability.

BACKGROUND: Chronic ankle instability (CAI) is associated with hip strength deficits and altered movement in the lower extremity. However, it remains unclear how hip strength deficits contribute to lateral ankle sprain (LAS) mechanisms. We aimed to compare lower extremity landing kinematics and isometric hip strength between individuals with and without CAI and examine associations between hip kinematics and strength. METHODS: Seventy-six individuals completed 5 single-leg landings, during which we collected three-dimensional ankle, knee, and hip kinematics from 200 milliseconds pre-initial contact to 50 milliseconds post-initial contact. We calculated average peak torque (Nm/kg) from 3 trials of isometric hip extension, abduction, and external rotation strength testing. One-way analyses of variance assessed group differences (CAI, LAS coper, and control) in hip strength and kinematics. Pearson product moment correlations assessed associations between hip kinematics and strength. We adjusted the kinematic group comparisons and correlation analyses for multiple comparisons using the Benjamini-Hochberg method. RESULTS: The CAI group exhibited less hip abduction during landing than LAS copers and controls. The CAI group had lower hip external rotation strength than LAS copers (P = .04, d = 0.62 [0.05, 1.17]) and controls (P < .01, d = 0.87 [0.28, 1.43]). Effect sizes suggest that the CAI group had deficits in EXT compared with controls (d = 0.63 [0.06, 1.19]). Hip strength was not associated with hip landing kinematics for any group. CONCLUSION: Altered landing mechanics displayed by the CAI group may promote mechanisms of LAS, but they are not associated with isometric hip strength. However, hip strength deficits may negatively impact other functional tasks, and they should still be considered during rehabilitation. LEVEL OF EVIDENCE: Level III, case-control study.

Isometric Hip Strength and Dynamic Stability of Individuals With Chronic Ankle Instability.

CONTEXT: Compared with individuals who have a history of lateral ankle sprain (LAS) without markers of chronic ankle instability (CAI; LAS copers) and healthy people, those with CAI often exhibit neuromuscular impairments and dynamic-stability deficits at the hip. However, the influence of hip-strength deficits on dynamic stability remains unknown. OBJECTIVE: To compare isometric hip strength and dynamic stability in individuals with or without CAI and examine the degree of dynamic-stability variance explained by isometric hip strength. DESIGN: Case-control study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Sixty individuals (47 women, 13 men; age = 23.7 ± 4.6 years, height = 166.6 ± 7.7 cm, mass = 70.8 ± 15.7 kg) separated into CAI, LAS coper, and control groups based on previously established criteria. MAIN OUTCOME MEASURE(S): Group differences in resultant vector time to stabilization (RVTTS) and isometric hip-extension, -abduction, and external-rotation strength were determined using 1-way analyses of covariance that controlled for sex and limb (dominant or nondominant) tested and Cohen d effect sizes (95% confidence intervals). Backward linear regressions and Cohen f2 effect sizes (95% confidence intervals) determined the amount of RVTTS variance explained by isometric hip strength. Significance was set a priori at P < .05. RESULTS: The CAI group had less isometric hip-extension strength than LAS copers ( P = .02, d = 0.72 [0.06, 1.34]) and controls ( P = .01, d = 1.19 [0.50, 1.84]) and less external-rotation strength than LAS copers ( P = .03, d = 0.78 [0.13, 1.41]) and controls ( P = .01, d = 1.02 [0.34, 1.65]). No group differences existed for RVTTS ( F2,57 = 1.16, P = .32) or abduction strength ( F2,57 = 2.84, P = .07). Resultant vector time to stabilization was explained by isometric hip strength for LAS copers ( R2 = 0.21, f2 = 0.27 [0.22, 0.32], P = .04) but not for the CAI ( R2 = 0.12, f2 = 0.14 [0.06, 0.22], P = .22) or control ( R2 = 0.10, f2 = 0.11 [0.03, 0.19], P = .18) groups. CONCLUSIONS: Participants with CAI had decreased isometric hip strength, but that did not equate to dynamic-stability deficits. Clinicians should include hip-muscle strengthening in rehabilitation protocols for patients with CAI, yet these gains may not enhance dynamic stability when landing from a jump.

ACUTE LATERAL ANKLE SPRAIN PREDICTION IN COLLEGIATE WOMEN'S SOCCER PLAYERS.

BACKGROUND: Women's soccer has among the highest injury rates in collegiate sports, and lateral ankle sprains (LAS) are among the most commonly occurring injuries in that athletic population. However, no established LAS prediction model exists for collegiate women's soccer players.The purpose of this study was to develop a prediction model for acute LAS injuries in collegiate women's soccer players utilizing previous ankle sprain history, height, mass, and BMI as potential predictors.The authors' hypothesized that collegiate women's soccer players with greater height, mass, and body mass index (BMI), as well as a previous history of ankle sprain would have greater odds of sustaining a LAS. STUDY DESIGN: Prospective cohort study. METHODS: Forty-three NCAA Division I women's soccer players' (19.7 ± 1.1yrs, 166.8 ± 3.7cm, 60.8 ± 4.4kg) height, mass, and BMI were measured one week before beginning preseason practices. Additionally, participants reported whether or not they had sustained a previous ankle sprain. The team athletic trainer tracked LASs over the competitive season. Independent t-tests, binary logistic regression analyses, receiver operating characteristic (ROC) curves, and diagnostic statistics assessed the ability of the variables to differentiate between those that did and did not sustain a LAS. RESULTS: Participants that sustained a LAS (n = 8) were significantly taller than those that did not sustain a LAS (n = 35) (t41 = -2.87, p = 0.01, d = 0.83[0.03,1.60]). A logistic regression analysis (odds ratio=1.30[1.00,1.70]) and area under the ROC curve analysis (AUROC=0.73[0.58,0.89], p=0.04) further exhibited predictive value of height. A height cutoff score of 167.6cm demonstrated excellent sensitivity (0.88), moderate specificity (0.51), and a favorable diagnostic odds ratio (7.5). A logistic regression analysis (odds ratio=1.87[1.22,1.98]) exhibited predictive value of previous ankle sprain history. That variable was also associated with good sensitivity (0.75) and specificity (0.71) within the model, as well as a favorable DOR (7.37). Mass and BMI demonstrated no predictive value for LAS. CONCLUSION: Taller collegiate women's soccer players and those with previous ankle sprain history may have a greater predisposition to LAS. LEVEL OF EVIDENCE: 1b.

Hip strength and star excursion balance test deficits of patients with chronic ankle instability.

OBJECTIVES: To examine isometric hip strength in those with and without CAI, and determine the degree of Star Excursion Balance Test (SEBT) variance explained by isometric hip strength. DESIGN: Single-blinded, cross-sectional, case-control study. METHODS: Thirty individuals with CAI, 29 lateral ankle sprain (LAS) copers, and 26 healthy controls participated. We assessed dynamic postural control with the SEBT anterior (SEBT-ANT), posteromedial (SEBT-PM), and posterolateral (SEBT-PL) reaches, and isometric hip extension (EXT), abduction (ABD) and external rotation (ER) strength with hand-held dynamometry. The CAI and LAS coper groups' involved limbs and randomly selected limbs in controls were tested. Separate Kruskal-Wallis tests compared SEBT scores and isometric hip strength between groups. Backwards linear regression models determined the degree of SEBT variance explained by isometric hip strength. Statistical significance was set a priori at P<0.05. RESULTS: The CAI group had lower SEBT-ANT scores compared to LAS copers (P=0.03) and controls (P=0.03). The CAI group had lower ABD compared to LAS copers (P=0.03) and controls (P=0.02). The CAI group had lower ER compared to LAS copers (P=0.01) and controls (P=0.01). ER (R2=0.25, P=0.01) and ABD (R2=0.25, P=0.01) explained 25% of the CAI group's SEBT-PM and SEBT-PL variances, respectively. CONCLUSIONS: The CAI group had deficient dynamic postural control and isometric hip strength compared to LAS copers and controls. Additionally, the CAI group's isometric hip strength significantly influenced dynamic postural control performance. Future CAI rehabilitation strategies should consider hip muscular strengthening to facilitate improvements in dynamic postural control.

Associations Between Functional and Isolated Performance Measures in College Women's Soccer Players.

CONTEXT: The Star Excursion Balance Test (SEBT) and Functional Movement Screen (FMS) are functional performance measures capable of predicting lower-extremity injury risk. While suboptimal SEBT and FMS performances are influenced by multiple factors, the contribution of hip strength and flexibility to these tests is mostly unknown. Examination of hip strength and flexibility influences on the SEBT and FMS may direct clinicians to better methods of correcting functional deficits. OBJECTIVE: Determine the relationships of isometric hip strength and hip passive range of motion (PROM) with functional performance measures. DESIGN: Cross-sectional. SETTING: Athletic training facility. PARTICIPANTS: 43 NCAA Division I women's soccer players (19.65 ± 1.12 y; 166.93 ± 3.84 cm; 60.99 ± 4.31 kg) volunteered. DATA COLLECTION AND ANALYSIS: All participants were tested bilaterally in the SEBT; the deep squat, in-line lunge, hurdle step, and straight leg raise, comprising a lower-extremity FMS (FMS-LE); hip internal and external rotation PROM; and isometric hip extension strength (HEXT). The mean of the 3 averaged, normalized SEBT scores was used as a composite score. Pearson product moment correlations assessed relationships of SEBT and FMS-LE scores with PROM and HEXT. Significance was set a priori at P < .05. RESULTS: Pearson correlations revealed anterior (ANT) SEBT scores had a low negative association with HEXT (r = -0.33,P = .004) and a low positive association with hip internal rotation PROM (PROM-IR) (r = .43,P = .003). All other correlations were negligible. CONCLUSIONS: Flexibility training aimed at PROM-IR may contribute to improved ANT scores. Targeting HEXT and hip external rotation PROM are likely not preferred means of correcting deficits in SEBT and FMS-LE performance.

Therapeutic interventions for improving self-reported function in patients with chronic ankle instability: a systematic review.

OBJECTIVE: To identify which therapeutic intervention may be most effective for improving self-reported function in patients with chronic ankle instability (CAI). DESIGN: Systematic literature review. Articles were appraised using the Downs and Black Checklist by 3 reviewers. DATA SOURCES: PubMed along with CINAHL, MEDLINE and SPORTDiscus within EBSCOhost for pertinent articles from their inception through August 2016. ELIGIBILITY CRITERIA FOR SELECTED STUDIES: Articles included were required to (1) be written in English, (2) report adequate data to calculate effect sizes, (3) identify patients with CAI, (4) use some form of therapeutic intervention and (5) use a self-reported questionnaire as a main outcome measurement. RESULTS: A broad spectrum of therapeutic interventions were identified related to balance training, multimodal rehabilitation, joint mobilisation, resistive training, soft-tissue mobilisation, passive calf stretching and orthotics. All of the articles included in the balance training category had moderate-to-strong Hedges g with none of the 95% CIs crossing 0. Hedges g effect sizes ranged from -0.67 to -2.31 and -0.51 to -1.43 for activities of daily living and physical activity, respectively. The multimodal rehabilitation category also produced moderate-to-strong Hedges g effect sizes but with large CIs crossing 0. Hedges g effect sizes ranged from -0.47 to -9.29 and -0.62 to -24.29 for activities of daily living and physical activity, respectively. CONCLUSIONS: The main findings from this systematic review were balance training provided the most consistent improvements in self-reported function for patients with CAI.