The effect of preventive measures on the incidence of ankle sprains.

Verhagen EA, van Mechelen W, de Vente W. Clin J Sport Med 2000 Oct;10(4):291-6.

OBJECTIVE.
To critically review the current data concerning the efficacy of preventive measures described in the literature, on the incidence of lateral ankle ligament injuries.

DATA SOURCES.
MEDLINE, Sportdiscus, and EMBASE were searched for papers published between 1980 and December 1998. Keywords used in the search were “prevention” in combination with “ankle,” “ankle taping,” “ankle bracing,” “orthosis,” “shoes,” and “proprioception.” Additional references were reviewed from the bibliographies of the retrieved articles.

STUDY SELECTION.
A study was included if: 1) the study contained research questions regarding the prevention of lateral ankle ligament injuries; 2) the study was a randomized controlled trial, a controlled trail, or a time intervention; 3) the results of the study contained incidence rates of lateral ankle ligament injuries as study outcome; and 4) the study met the cut-off score set for quality.

DATA EXTRACTION AND SYNTHESIS.
Two reviewers reviewed relevant studies for strengths and weaknesses in design and methodology, according to a standardized set of predefined criteria. Eight relevant studies met the criteria for inclusion and were analyzed.

MAIN RESULTS.
Overall, all studies reported a significant decrease in incidence of ankle sprains using the studied preventive measure. There was a great variety in methodology and study design between the eight analyzed studies, and every study had one or more drawbacks. Therefore, between studies only general results could be compared.

CONCLUSIONS.
The use of either tape or braces reduces the incidence of ankle sprains. Next to this preventive effect, the use of tape or braces results in less severe ankle sprains. However, braces seem to be more effective in preventing ankle sprains than tape. It is not clear which athletes are to benefit more from the use of preventive measures: those with or those without previous ankle sprains. The efficacy of shoes in preventing ankle sprains is unclear. It is likely the newness of the footwear plays a more important role than shoe height in preventing ankle sprains. Proprioceptive training reduces the incidence of ankle sprains in athletes with recurrent ankle sprains to the same level as subjects without any history of ankle sprains.

Limited dorsiflexion predisposes to injuries of the ankle in children.

Tabrizi P, McIntyre WM, Quesnel MB, Howard AW. J Bone Joint Surg Br 2000 Nov;82(8):1103-6

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7 degrees with the knee extended and 11.2 degrees with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8 degrees with the knee extended and 21.5 degrees with the knee flexed (p < 0.001, Student’s t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility.

Chronic recurrent ligament instability on the lateral ankle.

Becker HP, Rosenbaum D. Orthopade 1999 Jun;28(6):483-92.

According to the literature, chronic ankle instability occurs after acute rupture of the lateral ankle ligaments in 10-20% of the cases. The etiology of the instability are ligamentous damage and functional neuromuscular disorder of the peroneal muscles. The standards of diagnostics are the history with the frequency of inversion trauma per period and the interval from the primary trauma, the clinical examination and radiological stress tests. Newer diagnostic methods, up to now not well established in clinical routine, include stabilometry, cybex-measurements of the pronator muscles, the evaluation of peroneal reaction time on a tilting platform and dynamic pedography. Conservative management of chronic ankle instability consists of wearing ankle braces and rehabilitation programs concerned with peroneal muscle strengthening and coordination training. The indication for surgical reconstruction of the ankle ligaments are a well-documented mechanical instability with the neuromuscular reflexes intact and a failed physiotherapeutic training program. The surgical procedure should be selected according to a priority list: 1. anatomical repair, eventually augmented with periosteum from the fibula, 2. Watson-Jones tenodesis, and 3. Chrisman-Snook tenodesis to treat a concomittant subtalar instability.

Interventions for preventing ankle ligament injuries.

Quinn K, Parker P, de Bie R, Rowe B, Handoll H. Cochrane Database Syst Rev 2000;(2):CD000018.

BACKGROUND.
Some sports, for example basketball and soccer, have a very high incidence of ankle injuries, mainly sprains. This contributes to ankle sprains being one of the most commonly treated injuries.

OBJECTIVES.
To assess the effects of interventions used for the prevention of ankle ligament injuries or sprains in physically active individuals from adolescence to middle age.

SEARCH STRATEGY.
We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE (1966 to July 1996), EMBASE (1980 to September 1996), CINAHL (1982 to June 1996), and bibliographies of study reports. We also contacted colleagues and some trialists. Date of the most recent search: March 1997. S

ELECTION CRITERIA.
Randomised or quasi-randomised trials of interventions for the prevention of ankle sprains in physically active individuals from adolescence to middle age were included provided ankle sprains were recorded. Interventions include use of modified footwear and associated supports, adapted training programmes and health education.

DATA COLLECTION AND ANALYSIS.
At least four reviewers independently assessed methodological quality and extracted data. Wherever possible, results of outcome measures were pooled and sub-grouped by history of previous sprain.

MAIN RESULTS.
Five randomised trials with data for 3954 participants were included. All trials involved young, active, mostly male adults participating in high-risk, usually sporting, activities. With the exception of ankle disc training, all prophylactic interventions entailed the application of an external ankle support in the form of a semi-rigid orthosis, air-cast brace or high top shoes. There was a significant reduction in the number of ankle sprains in people allocated external ankle support (Peto odds ratio 0.49; 95% confidence interval 0.37 to 0.66). This reduction was greater for those with a previous history of ankle sprain, but still possible for those without prior sprain. There was no apparent difference in the degree of severity of the ankle sprain prevented nor any change to the incidence of other leg injuries. The protective effect of ‘high-top’ shoes remains to be established. There was limited evidence for reduction in ankle sprain for those with previous ankle sprains who did ankle disc training exercises.

REVIEWER’S CONCLUSIONS.
This review provides good evidence for the beneficial effect of ankle supports in the form of semi-rigid orthoses or air-cast braces to prevent ankle sprain during high-risk sporting activities (e.g. soccer, basketball). Participants with a history of previous sprain can be advised that wearing such supports may reduce the risk of incurring a future sprain. However, any potential prophylactic effect should be balanced against the baseline risk of the activity, the supply and cost of the particular device, and for some, the possible or perceived loss of performance. Further research is indicated principally to investigate other prophylactic interventions and general applicability.

The prevention of ankle sprains in sports. A systematic review of the literature.

Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. Am J Sports Med 1999 Nov-Dec;27(6):753-60.

To assess the published evidence on the effectiveness of various approaches to the prevention of ankle sprains in athletes, we used textbooks, journals, and experts in the field of sports medicine to identify citations. We identified 113 studies reporting the risk of ankle sprains in sports, methods to provide support, the effect of these interventions on performance, and comparison of prevention efforts. The most common risk factor for ankle sprain in sports is history of a previous sprain. Ten citations of studies involving athletes in basketball, football, soccer, or volleyball compared alternative methods of prevention. Methods tested included wrapping the ankle with tape or cloth, orthoses, high-top shoes, or some combination of these methods. Most studies indicate that appropriately applied braces, tape, or orthoses do not adversely affect performance. Based on our review, we recommend that athletes with a sprained ankle complete supervised rehabilitation before returning to practice or competition, and those athletes suffering a moderate or severe sprain should wear an appropriate orthosis for at least 6 months. Both coaches and players must assume responsibility for prevention of injuries in sports. Methodologic limitations of published studies suggested several areas for future research.