Spiritual Fitness, Spiritual Readiness, and Depressive Symptoms in Reserve Officers' Training Corps Cadets.

CONTEXT: Over the past decade, the United States military has taken an interest in addressing soldiers' spiritual fitness and readiness to help improve their mental health and resiliency. Similar efforts have not been applied within the Reserve Officers' Training Corps (ROTC) population despite the mental health challenges these college students experience. OBJECTIVE: To examine spiritual readiness, spiritual fitness, and depressive symptoms in ROTC cadets. DESIGN: Cross-sectional study. SETTING: Web-based survey. PATIENTS OR OTHER PARTICIPANTS: We recruited ROTC cadets from 1 large southeastern university (n = 91 of 315, 28.9% response rate). The ROTC cadets (age = 21 ± 3 years; men = 68, 74.7%; women = 22, 24.2%; missing = 1, 1.1%) were mainly classified as juniors (n = 30, 33.0%) and in Army ROTC (ROTC branch: Army = 69, Air Force = 20, Navy = 2). MAIN OUTCOME MEASURE(S): The survey contained 3 validated instruments used to assess spiritual fitness (the Spiritual Fitness Inventory [SFI]), spiritual readiness (Spiritual Wellbeing Scale [SWBS]), and mental health via depressive symptoms (Patient Health Questionnaire [PHQ-9]). Results were analyzed using descriptive statistics and nonparametric Mann-Whitney U tests to compare belief in God or gods with the dependent measures. A Pearson correlation was calculated to assess the relationship between the SWBS score and PHQ-9 data. RESULTS: In total, 85.7% (n = 78/91) of ROTC cadets stated that they believed in God or gods. Overall, the cadets were considered to have average spiritual fitness (mean = 75.04 ± 14.89) and moderate spiritual well-being (mean = 90.46 ± 18.09). The average PHQ-9 score was 4.22 ± 5.25. Individuals who believed in God or gods had higher spiritual readiness (believer = 94.44 ± 16.10, nonbeliever = 67.00 ± 9.35; P ≤ .01). No statistically significant differences were noted for symptoms of depression (believer = 3.38 ± 4.90, nonbeliever = 6.60 ± 6.90; P = .143) or spiritual fitness (believer = 76.12 ± 14.78, nonbeliever = 64.40 ± 12.68; P = .054) in ROTC cadets based on belief status. CONCLUSIONS: Overall, the ROTC cadets had moderate to average spiritual fitness and readiness, with typical depressive symptoms scores. Spiritual readiness was different for those who believed in God or gods, and existential well-being was significantly correlated with depressive symptoms.

Are Prospective Criteria or Objective Clinical Measures Utilized in Return to Play (RTP) Decision Making After Ankle Surgery? A Scoping Review.

Background: Manuscripts discussing return to play (RTP) following ankle surgery are common. However, the definition for RTP and the method by which it is determined remains unclear. The purpose of this scoping review was to clarify how RTP is defined following ankle surgery in physically active patients, to identify key factors informing RTP decision making (such as objective clinical measures), and make recommendations for future research. Methods: A scoping literature review was performed in April 2021 using PubMed, EMBASE, and Nursing and Allied Health databases. Thirty studies met inclusion criteria: original research following ankle surgery reporting at least 1 objective clinical test and documentation of RTP. Data were extracted for study methods and outcomes (RTP definition, RTP outcomes, and objective clinical tests). Results: The scoping review found studies on 5 ankle pathologies: Achilles tendon rupture, chronic lateral ankle instability, anterior ankle impingement, peroneal tendon dislocation, and ankle fracture. RTP criteria were not provided in the majority of studies (18/30 studies). In the studies that provided them, the RTP criteria were primarily based on time postsurgery (8/12) rather than validated criteria. Objective clinical outcome measures and patient-reported outcome measures (PROMs) were documented for each surgery when available. Both clinical outcomes and PROMs were typically measured >1 year postsurgery. Conclusion: In physically active patients who have had ankle surgery, RTP remains largely undefined and is not consistently based on prospective objective criteria nor PROMS. We recommend standardization of RTP terminology, adoption of prospective criteria for both clinical measures and PROMs to guide RTP decision making, and enhanced reporting of patient data at the time of RTP to develop normative values and determine when the decision to RTP is not safe. Level of Evidence: Level IV, scoping review.

Practice Patterns of Athletic Trainers Regarding the On-Site Management of Patients With Joint Dislocations.

CONTEXT: As part of clinical practice, athletic trainers (ATs) provide immediate management of patients with acute joint dislocations. Management techniques may include on-site closed joint reduction of the dislocated joint. Although joint reduction is part of the 2020 educational standards, currently practicing ATs may have various levels of exposure, knowledge, and skills. OBJECTIVE: To capture AT self-reported knowledge and practice patterns concerning closed joint reductions. DESIGN: Cohort study. SETTING: Online survey (Qualtrics). PATIENTS OR OTHER PARTICIPANTS: The survey link was emailed to 5000 certified ATs. A total of 772 responses were completed by certified ATs with clinical practice experience (15.4% response rate). MAIN OUTCOME MEASURE(S): Participants were asked to complete a survey about their practice patterns concerning patients with closed joint reductions, which included questions about the types of closed reductions ATs performed most commonly, the frequency of on-site reduction by ATs, and participants' demographic information. Additionally, the survey addressed the ATs' training and comfort level in performing closed reductions and knowledge of standing orders and the state practice act. RESULTS: Ninety percent (n = 694) of ATs reported ever performing a closed reduction (either with or without a physician present), with 10% (n = 78) stating they had never performed a joint reduction. The interphalangeal joint of the finger (73.2% of ATs), shoulder (63.3%), and patella (48.2%) were cited as the 3 most common reductions performed without a physician present. Only 46.5% (n = 359) of ATs indicated receiving training in joint-reduction techniques as part of their precertification athletic training curriculum or program; a greater percentage (64%) said they learned directly from a physician. Fewer than 60% of ATs reported having standing orders related to joint reductions. CONCLUSIONS: Considering the high percentage of ATs who reported performing closed joint reductions and the low percentage with formal training, further development of joint-reduction training and standing orders is warranted.

Comprehensive Arthroscopic Management for Severe Glenohumeral Arthritis in an Ultimate Fighting Championship Fighter: A Case Report.

CASE: A 41-year-old, former world-champion, mixed martial arts fighter presented with debilitating pain and loss of motion because of severe glenohumeral osteoarthritis (GHOA) in the setting of a previous shoulder instability stabilization procedure. Multiple conservative treatments failed to provide permanent relief, and he elected to undergo a comprehensive arthroscopic management (CAM) procedure for his GHOA. CONCLUSION: At 2-year follow-up, the CAM procedure was effective in returning them to fighting at a professional level. The CAM procedure can be considered in young and highly active patients to restore function, preserve anatomy, and delay progression to prosthetic arthroplasty.

Closed-Reduction Techniques for Glenohumeral-, Patellofemoral-, and Interphalangeal-Joint Dislocations.

Joint dislocations account for a small but important portion of all athletic injuries, with most occurring at the glenohumeral, patellofemoral, and interphalangeal joints. Athletic trainers are responsible for managing acute joint-dislocation injuries, which may include performing closed-reduction techniques when appropriate. To achieve optimal patient outcomes, the clinician should be formally trained and skilled in performing various techniques and familiar with the evidence supporting the selection of each technique. In this clinical review, we outline general reduction procedures and then summarize and synthesize the existing literature on common closed-reduction techniques for glenohumeral-, patellofemoral-, and interphalangeal-joint dislocations. When appropriate, the content has been adapted to be specific to the athletic trainer's scope of practice.

Wobble-Board Balance Intervention to Decrease Symptoms and Prevent Reinjury in Athletes With Chronic Ankle Instability: An Exploration Case Series.

Controlled research has shown that a single-exercise wobble-board intervention is effective at reducing symptoms and increasing function in patients with chronic ankle instability. However, the effectiveness of this protocol has not been documented in a realistic intercollegiate athletics environment. Eight intercollegiate athletes with chronic ankle instability participated in an 8-week (3 sessions/wk) wobble-board intervention. In a realistic environment, this simple intervention was feasible to implement and resulted in meaningful improvements in patient-reported stability for more than half of the patients (5 of 8) but only improved the global rating of function and pain for a minority of the patients (2 of 8 and 3 of 8, respectively). Not all patients experienced equal symptom reduction; however, no new ankle sprains occurred during the intervention.

Cardiovascular disease risk profile of NCAA Division III intercollegiate football athletes: a pilot study.

OBJECTIVES: Concerns about the long-term cardiovascular health implications of American football participation have been investigated at the professional and Division I levels, but limited research is available at the less resourced Division III level. Therefore, the objective was to assess the cardiovascular disease risk profile of NCAA Division III intercollegiate football athletes. METHODS: Eighty-nine varsity football athletes (age = 19.6 ± 1.7 years, height = 1.81 ± 0.07m, weight = 92.7 ± 16.2kg; n = 21 linemen, n = 68 non-linemen) at a private Division III university volunteered to participate. During a preseason pre-participation physical examination, all participants completed a health history screening form (to assess personal and family history of cardiac related pathologies), and were assessed for height, weight, body mass index (BMI), and blood pressure (BP). Linemen only additionally gave a blood sample for fasting blood glucose and cholesterol analysis, and were assessed for waist and hip circumference, metabolic syndrome, and percent body fat (%BF). These measures were reported as averages and frequencies of elevated cardiovascular. Independent t-tests compared linemen to non-linemen, all other data was presented descriptively. RESULTS: On average, linemen were significantly taller, heavier, had a higher BMI and higher systolic BP than non-linemen (all P < 0.05); there was no difference in diastolic BP between the groups (P = 0.331). The average anthropometric and cardiac risk characteristics for linemen were largely within normal ranges, however analyzed individually, a substantial number of participants were at elevated risk (BMI ≥30 = 85.7%, %BF ≥25 = 71.4%, waist circumference ≥1 = 42.9%, hypertension = 9.5%, high density lipoproteins <40mg/dL = 42.9%, and triglycerides ≥150mg/dL = 6.7%; metabolic syndrome prevalence = 19%). CONCLUSIONS: Similar to research in elite athletics, linemen at a single Division III university have elevated cardiovascular disease risk. Physicians and other healthcare providers should consider this elevated risk during pre-participation physical examinations and in planning educational or dietary programming targeted to promoting cardiovascular health.

Establishing the Minimal Clinical Important Difference and Minimal Detectable Change for the Cumberland Ankle Instability Tool.

OBJECTIVE: To establish the minimal detectable change (MDC) and minimal clinically important difference (MCID) for the Cumberland Ankle Instability Tool (CAIT) in a population with chronic ankle instability (CAI). DESIGN: Experimental cohort. SETTING: Laboratory. PARTICIPANTS: A convenience sample of individuals with CAI (N=50; 12 men; 38 women; episodes of giving way, 5.84±12.54mo). CAI inclusion criteria included a history of an ankle sprain, recurrent episodes of giving way, and a CAIT score ≤25. INTERVENTIONS: Participants completed demographic information, an injury history questionnaire, and the CAIT. Participants then either participated in 4 weeks of wobble board balance training, resistance tubing strength training, or no intervention. After 4 weeks, participants recompleted the CAIT and recorded their global rating of change (GRC). MAIN OUTCOME MEASURES: Dependent variables were pre- and postintervention scores on the CAIT and postintervention GRC. The MDC with 95% confidence interval was calculated. A receiver operating characteristic (ROC) curve identified the optimal CAIT cut point (MCID) between improved and unimproved individuals on the basis of their GRC. The area under the curve was used to identify a significant ROC curve (α=.05). RESULTS: The average CAIT score preintervention was 16.8±5.6, and postintervention, it was 20.0±5.2. Thirty-one participants (62%) rated themselves as improved on the GRC scale, whereas 19 (38%) were not improved. The ROC curve was significant (area under the curve, .797; P=.001), indicating that the CAIT change score significantly predicted clinical status. The MDC was 3.08, and the MCID was ≥3 points. CONCLUSIONS: The CAIT has an MDC and MCID of ≥3 points. When CAIT scores are used to assess patient change over time, these scores should be used as a minimum threshold to indicate detectable and clinically meaningful improvement.

A Randomized Controlled Trial Comparing Rehabilitation Efficacy in Chronic Ankle Instability.

CONTEXT: There is minimal patient-oriented evidence regarding the effectiveness of interventions targeted to reduce symptoms associated with chronic ankle instability (CAI). In addition, clinicians aiming to prioritize care by implementing only the most effective components of a rehabilitative program have very little evidence on comparative efficacy. OBJECTIVE: To assess the comparative efficacy of 2 common ankle rehabilitation techniques (wobble-board [WB] balance training and ankle strengthening using resistance tubing [RT]) using patient-oriented outcomes. DESIGN: Randomized controlled trial. SETTING: Laboratory. PATIENTS: 40 patients with CAI randomized into 2 treatment groups: RT and WB. CAI inclusion criteria included a history of an ankle sprain, recurrent "giving way," and a Cumberland Ankle Instability Tool (CAIT) score ≤25. INTERVENTIONS: Participants completed 5 clinician-oriented tests (foot-lift test, time-in-balance, Star Excursion Balance Test, figure-of-8 hop, and side-hop) and 5 patient-oriented questionnaires (CAIT, Foot and Ankle Ability Measure [FAAM], Activities of Daily Living [ADL] and FAAM Sport scale, Short-Form 36 [SF-36], and Global Rating of Function [GRF]). After baseline testing, participants completed 12 sessions over 4 wk of graduated WB or RT exercise, then repeated baseline tests. MAIN OUTCOME MEASURES: For each patient- and clinician-oriented test, separate 2 × 2 RMANOVAs analyzed differences between groups over time (alpha set at P = .05). RESULTS: There was a significant interaction between group and time for the FAAM-ADL (P = .04). Specifically, the WB group improved postintervention (P < .001) whereas the RT group remained the same (P = .29). There were no other significant interactions or significant differences between groups (all P > .05). There were significant improvements postintervention for the CAIT, FAAM-Sport, GRF, SF-36, and all 5 clinician-oriented tests (all P < .001). CONCLUSIONS: A single-exercise 4-wk intervention can improve patient- and clinician-oriented outcomes in individuals with CAI. Limited evidence indicates that WB training was more effective than RT. LEVEL OF EVIDENCE: Therapy, level 1b.

Patient-Reported Efficacy 6 Months After a 4-Week Rehabilitation Intervention in Individuals With Chronic Ankle Instability.

OBJECTIVE: To track the patient-reported efficacy of a 4-wk intervention (wobble board [WB] or resistance tubing [RT]) in decreasing symptoms of chronic ankle instability (CAI) at 6 mo postintervention (6PI) as compared with immediately postintervention (IPI). DESIGN: Randomized controlled trial. PARTICIPANTS: Fourteen of 21 participants (66.7%) responded to an electronic 6-m follow-up questionnaire (age 19.6 ± 0.9 y, height 1.63 ± 0.18 m, weight 70.5 ± 16.3 kg; 2 male, 12 female; 5 WB, 9 RT). All participants met CAI criteria at enrollment, including a history of ankle sprain and recurrent episodes of giving way. INTERVENTIONS: Participants completed either RT or WB protocols, both 12 sessions over 4 wk of progressive exercise. WB sessions consisted of five 40-s sets of clockwise and counterclockwise rotations. RT sessions consisted of 30 contractions against resistance tubing in each of 4 ankle directions. MAIN OUTCOME MEASUREMENTS: Patient-reported symptoms of "giving way" preintervention and at 6PI, global rating of change (GRC) frequencies at IPI and 6PI, and resprains at 6PI were reported descriptively. Changes in global rating of function (GRF) and giving way were compared using Wilcoxon tests, while GRC was compared with Fisher exact test. RESULTS: All participants reported giving way preintervention, only 57.1% reported giving way at 6PI. Resprains occurred in 21.4% of participants. Giving-way frequency (P = .017), but not GRF or GRC (P > .05), was significantly different at IPI vs 6PI. CONCLUSIONS: Simple 4-wk interventions maintained some but not all improvements at 6PI. At least 42.9% of participants would no longer meet the current study's CAI inclusion criteria due to a reduction in giving way.

Altered Kinematics and Time to Stabilization During Drop-Jump Landings in Individuals With or Without Functional Ankle Instability.

CONTEXT: It has been proposed that altered dynamic-control strategies during functional activity such as jump landings may partially explain recurrent instability in individuals with functional ankle instability (FAI). OBJECTIVE: To capture jump-landing time to stabilization (TTS) and ankle motion using a multisegment foot model among FAI, coper, and healthy control individuals. DESIGN: Cross-sectional study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Participants were 23 individuals with a history of at least 1 ankle sprain and at least 2 episodes of giving way in the past year (FAI), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers), and 23 individuals with no history of ankle sprain or instability in their lifetime (controls). Participants were matched for age, height, and weight (age = 23.3 ± 3.8 years, height = 1.71 ± 0.09 m, weight = 69.0 ± 13.7 kg). INTERVENTION(S): Ten single-legged drop jumps were recorded using a 12-camera Vicon MX motion-capture system and a strain-gauge force plate. MAIN OUTCOME MEASURES: Mediolateral (ML) and anteroposterior (AP) TTS in seconds, as well as forefoot and hindfoot sagittal- and frontal-plane angles at jump-landing initial contact and at the point of maximum vertical ground reaction force were calculated. RESULTS: For the forefoot and hindfoot in the sagittal plane, group differences were present at initial contact (forefoot: P = .043, hindfoot: P = .004). At the hindfoot, individuals with FAI displayed more dorsiflexion than the control and coper groups. Time to stabilization differed among groups (AP TTS: P < .001; ML TTS: P = .040). Anteroposterior TTS was longer in the coper group than in the FAI or control groups, and ML TTS was longer in the FAI group than in the control group. CONCLUSIONS: During jump landings, copers showed differences in sagittal-plane control, including less plantar flexion at initial contact and increased AP sway during stabilization, which may contribute to increased dynamic stability.

Noise-Enhanced Eversion Force Sense in Ankles With or Without Functional Instability.

CONTEXT: Force sense impairments are associated with functional ankle instability. Stochastic resonance stimulation (SRS) may have implications for correcting these force sense deficits. OBJECTIVE: To determine if SRS improved force sense. DESIGN: Case-control study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Twelve people with functional ankle instability (age = 23 ± 3 years, height = 174 ± 8 cm, mass = 69 ± 10 kg) and 12 people with stable ankles (age = 22 ± 2 years, height = 170 ± 7 cm, mass = 64 ± 10 kg). INTERVENTION(S): The eversion force sense protocol required participants to reproduce a targeted muscle tension (10% of maximum voluntary isometric contraction). This protocol was assessed under SRSon and SRSoff (control) conditions. During SRSon, random subsensory mechanical noise was applied to the lower leg at a customized optimal intensity for each participant. MAIN OUTCOME MEASURE(S): Constant error, absolute error, and variable error measures quantified accuracy, overall performance, and consistency of force reproduction, respectively. RESULTS: With SRS, we observed main effects for force sense absolute error (SRSoff = 1.01 ± 0.67 N, SRSon = 0.69 ± 0.42 N) and variable error (SRSoff = 1.11 ± 0.64 N, SRSon = 0.78 ± 0.56 N) (P < .05). No other main effects or treatment-by-group interactions were found (P > .05). CONCLUSIONS: Although SRS reduced the overall magnitude (absolute error) and variability (variable error) of force sense errors, it had no effect on the directionality (constant error). Clinically, SRS may enhance muscle tension ability, which could have treatment implications for ankle stability.

Recalibration and validation of the Cumberland Ankle Instability Tool cutoff score for individuals with chronic ankle instability.

OBJECTIVE: To independently recalibrate and revalidate the Cumberland Ankle Instability Tool (CAIT) cutoff score for discriminating individuals with and without chronic ankle instability (CAI). There are concerns the original cutoff score (≤27) may be suboptimal for use in the CAI population. DESIGN: Case control. SETTING: Research laboratory. PARTICIPANTS: Two independent datasets were used (total N=200). Dataset 1 included 61 individuals with a history of ≥1 ankle sprain and ≥2 episodes of giving way in the last year (CAI group) and 57 participants with no history of ankle sprain or instability in their lifetime (uninjured group). Dataset 2 included 27 uninjured participants, 29 participants with CAI, and 26 individuals with a history of a single ankle sprain and no subsequent instability (copers). INTERVENTIONS: All participants completed the CAIT during a single session. In dataset 1, a receiver operating characteristic (ROC) curve was calculated using the CAIT score and group membership as test variables. The ideal cutoff score was identified using the Youden index. The recalibrated cutoff score was validated in dataset 2 using the ROC analysis and clinimetric characteristics. MAIN OUTCOME MEASURES: CAIT cutoff score and clinimetrics. RESULTS: In dataset 1, the optimal cutoff score was ≤25, which is lower than previously reported. In dataset 2, the recalibrated cutoff score demonstrated a sensitivity of 96.6%, specificity of 86.8%, positive likelihood ratio of 7.318, and negative likelihood ratio of .039. There were 7 false positives and 1 false negative. CONCLUSIONS: The recalibrated CAIT score demonstrated very good clinimetric properties; all properties improved compared with the original cutoff score. Clinicians using the CAIT should use the recalibrated cutoff score to maximize test characteristics. Caution should be taken with copers, who had a high rate of false positives.

Clinical examination results in individuals with functional ankle instability and ankle-sprain copers.

CONTEXT: Why some individuals with ankle sprains develop functional ankle instability and others do not (ie, copers) is unknown. Current understanding of the clinical profile of copers is limited. OBJECTIVE: To contrast individuals with functional ankle instability (FAI), copers, and uninjured individuals on both self-reported variables and clinical examination findings. DESIGN: Cross-sectional study. SETTING: Sports medicine research laboratory. PATIENTS OR OTHER PARTICIPANTS: Participants consisted of 23 individuals with a history of 1 or more ankle sprains and at least 2 episodes of giving way in the past year (FAI: Cumberland Ankle Instability Tool [CAIT] score = 20.52 ± 2.94, episodes of giving way = 5.8 ± 8.4 per month), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers: CAIT score = 27.74 ± 1.69), and 23 individuals with no history of ankle sprain and no instability (uninjured: CAIT score = 28.78 ± 1.78). INTERVENTION(S): Self-reported disability was recorded using the CAIT and Foot and Ankle Ability Measure for Activities of Daily Living and for Sports. On clinical examination, ligamentous laxity and tenderness, range of motion (ROM), and pain at end ROM were recorded. MAIN OUTCOME MEASURE(S): Questionnaire scores for the CAIT, Foot and Ankle Ability Measure for Activities of Daily Living and for Sports, ankle inversion and anterior drawer laxity scores, pain with palpation of the lateral ligaments, ankle ROM, and pain at end ROM. RESULTS: Individuals with FAI had greater self-reported disability for all measures (P < .05). On clinical examination, individuals with FAI were more likely to have greater talar tilt laxity, pain with inversion, and limited sagittal-plane ROM than copers (P < .05). CONCLUSIONS: Differences in both self-reported disability and clinical examination variables distinguished individuals with FAI from copers at least 1 year after injury. Whether the deficits could be detected immediately postinjury to prospectively identify potential copers is unknown.

Customized noise-stimulation intensity for bipedal stability and unipedal balance deficits associated with functional ankle instability.

CONTEXT: Stochastic resonance stimulation (SRS) administered at an optimal intensity could maximize the effects of treatment on balance. OBJECTIVE: To determine if a customized optimal SRS intensity is better than a traditional SRS protocol (applying the same percentage sensory threshold intensity for all participants) for improving double- and single-legged balance in participants with or without functional ankle instability (FAI). DESIGN: Case-control study with an embedded crossover design. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Twelve healthy participants (6 men, 6 women; age = 22 ± 2 years, height = 170 ± 7 cm, mass = 64 ± 10 kg) and 12 participants (6 men, 6 women; age = 23 ± 3 years, height = 174 ± 8 cm, mass = 69 ± 10 kg) with FAI. INTERVENTION(S): The SRS optimal intensity level was determined by finding the intensity from 4 experimental intensities at the percentage sensory threshold (25% [SRS25], 50% [SRS50], 75% [SRS75], 90% [SRS90]) that produced the greatest improvement in resultant center-of-pressure velocity (R-COPV) over a control condition (SRS0) during double-legged balance. We examined double- and single-legged balance tests, comparing optimal SRS (SRS(opt1)) and SRS0 using a battery of center-of-pressure measures in the frontal and sagittal planes. MAIN OUTCOME MEASURE(S): Anterior-posterior (A-P) and medial-lateral (M-L) center-of-pressure velocity (COPV) and center-of-pressure excursion (COPE), R-COPV, and 95th percentile center-of-pressure area ellipse (COPA-95). RESULTS: Data were organized into bins that represented optimal (SRS(opt1)), second (SRS(opt2)), third (SRS(opt3)), and fourth (SRS(opt4)) improvement over SRS0. The SRS(opt1) enhanced R-COPV (P ≤ .05) over SRS0 and other SRS conditions (SRS0 = 0.94 ± 0.32 cm/s, SRS(opt1) = 0.80 ± 0.19 cm/s, SRS(opt2) = 0.88 ± 0.24 cm/s, SRS(opt3) = 0.94 ± 0.25 cm/s, SRS(opt4) = 1.00 ± 0.28 cm/s). However, SRS did not improve R-COPV over SRS0 when data were categorized by sensory threshold. Furthermore, SRS(opt1) improved double-legged balance over SRS0 from 11% to 25% in all participants for the center-of-pressure frontal- and sagittal-plane assessments (P ≤ .05). The SRS(opt1) also improved single-legged balance over SRS0 from 10% to 17% in participants with FAI for the center-of-pressure frontal- and sagittal-plane assessments (P ≤ .05). The SRS(opt1) did not improve single-legged balance in participants with stable ankles. CONCLUSIONS: The SRS(opt1) improved double-legged balance and transfers to enhancing single-legged balance deficits associated with FAI.

Fatigue's effect on eversion force sense in individuals with and without functional ankle instability.

CONTEXT: Force sense (FS), the proprioceptive ability to detect muscle-force generation, has been shown to be impaired in individuals with functional ankle instability (FAI). Fatigue can also impair FS in healthy individuals, but it is unknown how fatigue affects FS in individuals with FAI. OBJECTIVE: To assess the effect of fatigue on ankle-eversion force-sense error in individuals with and without FAI. DESIGN: Case control with repeated measures. SETTING: Sports medicine research laboratory. PARTICIPANTS: 32 individuals with FAI and 32 individuals with no ankle sprains or instability in their lifetime. FAI subjects had a history of ≥1 lateral ankle sprain and giving-way ≥1 episode per month. INTERVENTIONS: Three eversion FS trials were captured per load (10% and 30% of maximal voluntary isometric contraction) using a load cell before and after a concentric eversion fatigue protocol. MAIN OUTCOME MEASURES: Trial error was the difference between the target and reproduction forces. Constant error (CE), absolute error (AE), and variable error (VE) were calculated from 3 trial errors. A Group × Fatigue × Load repeated-measures ANOVA was performed for each error. RESULTS: There were no significant 3-way interactions or 2-way interactions involving group (all P > .05). CE and AE had a significant 2-way interaction between load and fatigue (CE: F1,62 = 8.704, P = .004; AE: F1,62 = 4.024, P = .049), and VE had a significant main effect for fatigue (F1,62 = 5.130, P = .027), all of which indicated increased FS error with fatigue at 10% load. However, at 30% load only VE increased with fatigue. The FAI group had greater error as measured by AE (F1,62 = 4.571, P = .036) but not CE or VE (P > .05). CONCLUSIONS: Greater AE indicates that FAI individuals are less accurate in their force production. Fatigue impaired force sense in all subjects equally. These deficits provide evidence of impaired proprioception with fatigue and in individuals with FAI.

Balance assessments for predicting functional ankle instability and stable ankles.

A number of instrumented and non-instrumented measures are used to detect balance deficits associated with functional ankle instability (FAI). Determining outcome measures that detect balance deficits associated with FAI might assist clinicians in identifying impairments that may otherwise go undetected with less responsive balance measures. Thus, our objective was to determine the balance measure that best predicted ankle group membership (FAI or stable ankle). Participants included 17 subjects without a history of ankle sprains (168±9 cm, 66±14 kg, 24±5 yr) and 17 subjects with FAI (172±9 cm, 71±11 kg, 22±3 yr). Balance trials were performed without vision and subjects stood on a single leg as motionless as possible for 20s. Balance was quantified with center-of-pressure measures (velocity, area) and error score. Measures were positively correlated with each other (r range: 0.60-0.76). The multifactorial model with all three measures best predicted group membership (F((3,30))=7.20, P=0.001; R(2)=0.42; percent classified correctly=77%), and was followed by the multifactorial model with resultant center-of-pressure velocity and error score (F((2,31))=8.73, P=0.001; R(2)=0.36; percent classified correctly=74%). The resultant center-of-pressure velocity (F((1,32))=13.46, P=0.001; R(2)=0.30; percent classified correctly=74%; unique variance=12.7%) and error score (F((1,32))=12.51, P=0.001; R(2)=0.28; percent classified correctly=71%; unique variance=12.0%) predicted group membership; however, 95th percentile center-of-pressure area ellipse did not (F((1,32))=4.16, P=0.05; R(2)=0.12; percent classified correctly=65%; unique variance=5.8%). A multifactorial single leg balance assessment is best for predicting group membership. COPV is the best single predictor of group membership, but clinicians may use error score to identify deficits associated with FAI if force plates are not available.

Functional ankle instability and health-related quality of life.

CONTEXT: To our knowledge, no authors have assessed health-related quality of life (HR-QOL) in participants with functional ankle instability (FAI). Furthermore, the relationships between measures of ankle functional limitation and HR-QOL are unknown. OBJECTIVE: To use the Short Form-36v2 Health Survey (SF-36) to compare HR-QOL in participants with or without FAI and to determine whether HR-QOL was related to functional limitation. DESIGN: Cross-sectional study. SETTING: Sports medicine research laboratory. PATIENTS OR OTHER PARTICIPANTS: Sixty-eight participants with FAI (defined as at least 1 lateral ankle sprain and 1 episode of giveway per month) or without FAI were recruited (FAI group: n = 34, age = 25 ± 5 years, height = 1.71 ± 0.08 m, mass = 74.39 ± 12.78 kg, Cumberland Ankle Instability Tool score = 19.3 ± 4; uninjured [UI] group: n = 34, age = 23 ± 4 years, height = 1.69 ± 0.08 m, mass = 67.94 ± 11.27 kg, Cumberland Ankle Instability Tool score = 29.4 ± 1). MAIN OUTCOME MEASURE(S): All participants completed the SF-36 as a measure of HR-QOL and the Foot and Ankle Ability Measure (FAAM) and the FAAM Sport version (FAAMS) as assessments of functional limitation. To compare the FAI and UI groups, we calculated multiple analyses of variance followed by univariate tests. Additionally, we correlated the SF-36 summary component scale and domain scales with the FAAM and FAAMS scores. RESULTS: Participants with FAI had lower scores on the SF-36 physical component summary (FAI = 54.4 ± 5.1, UI = 57.8 ± 3.7, P = .005), physical function domain scale (FAI = 54.5 ± 3.8, UI = 56.6 ± 1.2, P = .004), and bodily pain domain scale (FAI = 52.0 ± 6.7, UI = 58.5 ± 5.3, P < .005). Similarly, participants with FAI had lower scores on the FAAM (FAI = 93.7 ± 8.4, UI = 99.5 ± 1.4, P < .005) and FAAMS (FAI = 84.5 ± 8.4, UI = 99.8 ± 0.72, P < .005) than did the UI group. The FAAM score was correlated with the physical component summary scale (r = 0.42, P = .001) and the physical function domain scale (r = 0.61, P < .005). The FAAMS score was correlated with the physical function domain scale (r = 0.47, P < .005) and the vitality domain scale (r = 0.36, P = .002). CONCLUSIONS: Compared with UI participants, those with FAI had less HR-QOL and more functional limitations. Furthermore, positive correlations were found between HR-QOL and functional limitation measures. This suggests that ankle impairment may reduce overall HR-QOL.

Repeatability of the modified Oxford foot model during gait in healthy adults.

BACKGROUND: The Oxford foot model (OFM) is a multi-segment model for calculating hindfoot and forefoot motion. Limited information is available regarding the repeatability and error of this model in adults. Therefore the purpose of this study was to assess the intra-tester reliability of OFM hindfoot and forefoot gait kinematics in adults at initial contact (IC) and toe-off (TO). METHODS: Seventeen healthy adults (age=25.1±4.8 years, height=1.75±0.10m, weight=74.0±12.4kg) were tested on a single visit, during which 1 examiner recorded 2 sessions. For each session, 10 walking trials were recorded using a 12-camera motion analysis system (Vicon, Oxford, UK). Markers were removed and re-applied between sessions. Dynamic hindfoot and forefoot angles were calculated both with and without referencing to neutral stance (assuming neutral stance angles are zero in all planes). Using the 10 trial average, intraclass correlation coefficients (ICC(2,k)) and standard errors of the measurement were calculated for each reference condition, anatomical plane, and joint (hindfoot, forefoot). RESULTS: Referencing to neutral stance resulted in good reliability (ICC≥0.83) and small error (≤2.45°) for hindfoot and forefoot angle in all planes. Without referencing to neutral stance, sagittal and transverse plane reliability were also good (ICC≥0.90) and error small (≤3.14°); however, frontal plane reliability was poor (ICC≤0.77), with large error (≥4.86°). DISCUSSION: Our results show that overall the OFM is reliable during adult gait. Reliability for adults is higher than previously reported in children. Referencing joint angles to neutral stance decreased error by up to 2° from previous reports.