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Chronic Ankle Instability
HISTORICAL PERSPECTIVEHISTORICAL PERSPECTIVE
CLINICAL EVALUATIONCLINICAL EVALUATION
TREATMENT GUIDELINESTREATMENT GUIDELINES
“When Can I Return to Sport”“When Can I Return to Sport”
E-MAIL: [email protected]
Fellow, American Academy of Podiatric Sports Medicine
Associate Clinical Professor, Dept. Of Applied Biomechanics,
California School of Podiatric Medicine
Douglas H. Richie Jr. D.P.M.
Associate Professor of Podiatric Medicine, Western University of Health Sciences
Adjunct Associate Professor of Clinical Biomechanics, California School of Podiatric Medicine, Oakland CA
Douglas H. Richie, Jr. D.P.M.Seal Beach, [email protected]
Chronic Ankle Instability: Solving a Complicated Puzzle
ANKLE SPRAINSANKLE SPRAINSMost common injury in Sports (40%)
ColvilleColville
23,000 sprains / day in U.S.
Makhani, McCullockMakhani, McCullock
Account for 10% of all ER visits in U.S.
HolmerHolmer
Long term sequelae occur in up to 50% of patients
Anderson, Brostrom, Freeman, SmithAnderson, Brostrom, Freeman, Smith
Long Term SequelaeLong Term SequelaeThe development of residual instability with pain and swelling
will occur in 20% to 40% of
people after a Grade II lateral ankle sprain.
Bosien, 1955 Yeung, 1994
Brand, 1977 Dettori, 1994
Itay, 1982 Verhagen, 1995
Gerber, 1998
Bosien, 1955 Yeung, 1994
Brand, 1977 Dettori, 1994
Itay, 1982 Verhagen, 1995
Gerber, 1998
Chronic Ankle Instability: Solving a Complicated Puzzle
The Problem
Biology of Ankle Sprain TxBiology of Ankle Sprain Tx
1. Immediately after injury: RICE~minimizes hemorrhage, swelling,
inflammation, cellular metabolism, pain.
2. Protection of ligaments: week 1-3
~proliferation phase: collagen
production
~ligament stress Type III (weaker) collagen
3. Controlled mobilization: week 4-8~maturation phase: final scar
formation
~controlled exercise increased
mech strength of ligament collagen
fiber orientation.
4. Final Maturation and Remodeling: 6-12 mos~ Full return to activity
~ Full neuromuscular control
Biology of Ankle Sprain TxBiology of Ankle Sprain Tx RETURN TO PRE INJURY ACTIVITYRETURN TO PRE INJURY ACTIVITYWith Functional Treatment Protocol:With Functional Treatment Protocol:
GRADE III6 weeks
GRADE III6 weeks
GRADE II12 days
GRADE II12 days
Ardevol, 2002Ardevol, 2002
Wilson, 2002Wilson, 2002
J Athl Train. 2008 Sep-Oct;43(5):523-9. Ankle ligament healing after an acute ankle sprain: evidence-based approach. Hubbard TJ, Hicks-Little CA.
Department of Kinesiology, The University of North Carolina at Charlotte, Charlotte, NC 28223, USA.
OBJECTIVE: To perform a systematic review to determine the healing time of the lateral ankle
ligaments after an acute ankle sprain.
DATA SOURCES: We identified English-language research studies from 1964 to 2007 by searching
MEDLINE, Physiotherapy Evidence Database (PEDro), SportDiscus, and CINAHL using the terms
ankle sprain, ankle rehabilitation, ankle injury, ligament healing, and immobilization. STUDY SELECTION: We selected studies that described randomized, controlled clinical trials
measuring ligament laxity either objectively or subjectively immediately after injury and at least 1
more time after injury.
CONCLUSIONS/RECOMMENDATIONS: In the studies that we
examined, it took at least 6 weeks to 3 months before ligament healing
occurred. However, at 6 weeks to 1 year after injury, a large percentage of participants still had objective mechanical laxity and subjective ankle instability. Direct comparison among articles is difficult because of differences in methods. More research focusing on more reliable methods of measuring ankle laxity is needed so that clinicians can know how long ligament healing takes after injury. This knowledge will help clinicians to
make better decisions during rehabilitation and for return to play.
Chronic Ankle Instability: Solving a Complicated Puzzle
Definitions• Mechanical
ANKLE INSTABILITYANKLE INSTABILITY
• Functional
MECHANICAL INSTABILITYMECHANICAL INSTABILITYObjective Measures:Objective Measures:
• Anterior drawer
• Talar tilt
• Ligamentous laxity
• FF & RF deformities
• Tibial varum
• Ankle axis deviation
Karlsson J, Bergsten T, Lasinger O, et al: Surgical
treatment of chronic lateral instability of the ankle
joint. Am J Sports Med 17:208-274,1989
Stress RadiographsStress Radiographs
Anterior drawer – Absolute Displacement: 10mm
Side to side: >3mm
Talar Tilt – Side to side: >10º
SENSITIVITY VS SPECIFICITY
High sensitivity indicates that a test can be used for excluding,
or ruling out, a condition when it is negative, but does not
address the value of a positive test.
Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA .
1992;267:2638–2644.
Schulzer M. Diagnostic tests: a statistical review. Muscle Nerve.
1994;17:815– 819
Specificity indicates the ability to use a test to recognize
when the condition is absent. A highly specific test has
relatively few false positive results, and therefore speaks to
the value of a positive test.
STRESS RADIOGRAPHYStress radiography has long been utilized to diagnose mechanical instability of the
lateral ligaments of the ankle. However, the reliability of these measures has been
questioned. Radiographic measure of anterior drawer and talar tilt show a low
sensitivity (50 and 36%) but a high specificity (100%). A critical review of seven
studies of stress radiography to diagnose ligament rupture after acute ankle sprain
concluded that talar tilt and anterior drawer stress x-rays are not reliable enough to
make the diagnosis of ligament rupture regardless of whether mechanical devices or
local anesthesia are used. Presently, the only possible valid use of stress radiography is
in the evaluation of patients with chronic mechanical instability of the ankle.
Breitenseher MJ, Trattnig S, Kukla C, Gaebler C, Daider, A, Baldt M et al. MRI versus lateral stress
radiography in acute lateral ankle ligament injuries. Journal of Computer Assisted Tomography 1997
March/April; 21(2): 280-285.
Ray, RG; Christensen, JC; Gusman, DN: Critical evaluation of anterior drawer measurement methods
in the ankle. Clin Orthop Relat Res, 215 – 224, 1997.
Harper, MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot
Ankle, 13:435 – 438, 1992.
Lohrer, H; Nauck, T; Arentz, S; Sch¨oll, J: Observer reliability in ankle and calcaneocuboid stress
radiography. Am J Sports Med
MRI: ACUTE
VS
CHRONIC INJURY
In a mixed population of chronic and acute ankle
instability patients, MRI showed a 97%
sensitivity, 100% specificity and 97% accuracy.
However, when evaluating acute patients only,
the results were 100% for all three categories.
Oae K, Takao M, Uchio Y. Evaluation of anterior talofibular ligament injury with
stress radiography, ultrasonography and MR imaging. Skeletal Radiol 2010; 39:41-47.
Functional InstabilityFunctional InstabilityPatient History:Patient History:
Recurrent sprains and/or
feeling of giving way of
the ankle
Recurrent sprains and/or
feeling of giving way of
the ankleFreeman, 1965Freeman, 1965
Chronic Ankle Instability: Solving a Complicated Puzzle
Mechanical vs Functional Ankle
Instability: Why is this important?
Mechanical vs. FunctionalMechanical vs. Functional
No consistent cause-effect relationship has been found between mechanical instability
and functional instability of the ankle.
Moppes, 1982 Staples, 1975
Staples, 1972 Tropp, 1988
Functional Instab
93
Mechanical Instab
11866
Fig. 1 The association between functional
and mechanical instability of the ankle
joints in 444 soccer players
Tropp, H. Odenrick, P. Gillquist, J. Stabilometry recordings in
functional and mechanical instability of the ankle joint. Int J Sports
Medicine 6:180, 1985 1985
FIGURE 1 Persistent Ligamentous LaxityPersistent Ligamentous Laxity
CHRONIC ANKLE INSTABILITYCHRONIC ANKLE INSTABILITY
Deficit in Neuromuscular controlDeficit in Neuromuscular control
Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability J Athl Train 37 (4): 364, 2002
Hertel, J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability J Athl Train 37 (4): 364, 2002
Functional InstabilityFunctional InstabilityMuscle
WeaknessMechanical
(anatomic)
Neuromuscular ControlNeuromuscular Control
Balance - PostureBalance - Posture Muscle Reaction TimeMuscle Reaction Time
ProprioceptionProprioception
??
FIGURE 2
Richie DH: Functional Instability of the Ankle and the Role of Neuromuscular
Control; A Comprehensive Review, J Foot and Ankle Surgery, 40:240-251, 2001.
Richie DH: Functional Instability of the Ankle and the Role of Neuromuscular
Control; A Comprehensive Review, J Foot and Ankle Surgery, 40:240-251, 2001.
http://www.youtube.com/watch?v=zAwHVXLo_xA
Functional InstabilityFunctional Instability
MANIFESTS WITH DEFICIENT POSTURE CONTROL (single
leg stance).
Karlsson, 1989
Jerosch, 1995
Lentell, 1990
Konradsen, 1993
KarlssonKarlsson, 1989, 1989
JeroschJerosch, 1995, 1995
LentellLentell, 1990, 1990
KonradsenKonradsen, 1993, 1993
MEASURING CHRONIC ANKLE INSTABILITY
Eechaute et al. systematically reviewed
the clinimetric qualities of patient-
assessed instruments for patients with
chronic ankle instability. They
concluded that two instruments—the
Foot and Ankle Disability Index (FADI)
and the Functional Ankle Ability
Measure (FAAM)—were the most
appropriate tools to quantify functional
disability for chronic ankle instability.
Eechaute C, Vaes P, Van Aerschot L et al. The clinimetric qualities of patient-assessed instruments for
measuring chronic ankle instability: a systematic review. BMC Musculoskelet Disord 2007;8:6.
BALANCE = POSTURAL CONTROL? BALANCE = POSTURAL CONTROL?
BALANCE: Ability of a human to remain upright in stance BALANCE: Ability of a human to remain upright in stance
POSTURAL CONTROL: Ability to keep the body’s center of gravity (COG) within the bordersof the base of support (Nashner 1985)
BALANCE is an activity which occurs both during static stanceand dynamic gait
BALANCE is an activity which occurs both during static stanceand dynamic gait
POSTURAL CONTROL is measured during quiet static stance.It has been studied during both double-limb and single limb support.
POSTURAL CONTROL is measured during quiet static stance.It has been studied during both double-limb and single limb support.
Postural Control and CAIPostural Control and CAI
Deficits in postural control appear to be the most consistent finding in patients with chronic ankle instability.Deficits in postural control appear to be the most consistent finding in patients with chronic ankle instability.
Garn SN, Newton RA: Kinesthetic awareness in subjects with multiple ankle sprains Phys Ther 68: 1667, 1988.Garn SN, Newton RA: Kinesthetic awareness in subjects with multiple ankle sprains Phys Ther 68: 1667, 1988.
Tropp H, Odenrick P: Postural control in single-limb stance. Jour Orthop Res 6: 833, 1988.Tropp H, Odenrick P: Postural control in single-limb stance. Jour Orthop Res 6: 833, 1988.
Gauffin H, Tropp H, Odenrick P: Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 9:141, 1988.
Gauffin H, Tropp H, Odenrick P: Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 9:141, 1988.
Forkin DM, Koczur C, Battle R, Newton RA: Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains. J Orthop Sports Phys Ther 23: 245, 1996.
Forkin DM, Koczur C, Battle R, Newton RA: Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains. J Orthop Sports Phys Ther 23: 245, 1996.
Perrin PP, Bene MC, Perrin CA, Durupt D: Ankle trauma significantly impairs postural control-a study in basketball players and controls. Int J sports Med 18: 387, 1997.
Perrin PP, Bene MC, Perrin CA, Durupt D: Ankle trauma significantly impairs postural control-a study in basketball players and controls. Int J sports Med 18: 387, 1997.
Postural Control
After Ankle Sprain
Postural Control
After Ankle Sprain
Loss of postural control has also been demonstrated in patients after acute ankle sprain.(Cornwall, MW, Murrell P. Postural sway following inversion sprain of the ankle. J Am Podiatr Med Assoc. 81:243-247, 1991.
Loss of postural control has also been demonstrated in patients after acute ankle sprain.(Cornwall, MW, Murrell P. Postural sway following inversion sprain of the ankle. J Am Podiatr Med Assoc. 81:243-247, 1991.
Friden T, Zatterstrom R, Lindstrand A, Moritz U: A stabilometric technique for evaluation of lower limb instabilities. Am J Sports Med 17: 118, 1989.Friden T, Zatterstrom R, Lindstrand A, Moritz U: A stabilometric technique for evaluation of lower limb instabilities. Am J Sports Med 17: 118, 1989.
Hertel J, Buckley WE, Denegar CR: Serial testing of postural control after acute lateral ankle sprain. J Athl Train 35: 363, 2001.Hertel J, Buckley WE, Denegar CR: Serial testing of postural control after acute lateral ankle sprain. J Athl Train 35: 363, 2001.
Predicting Ankle Injuries Predicting Ankle Injuries Prospective study of 119 male and 91 female high school basketball players
Prospective study of 119 male and 91 female high school basketball players
Subjects had no previous hx of injurySubjects had no previous hx of injury
Balance assessment with NeuroCom New Balance Master during pre-season
Balance assessment with NeuroCom New Balance Master during pre-season
Higher postural sway scores corresponded to increased ankle sprain injury rates (p=0.001)
Higher postural sway scores corresponded to increased ankle sprain injury rates (p=0.001)
Subjects with high sway scores had 7 times as many ankle sprains as subjects with low sway scores
Subjects with high sway scores had 7 times as many ankle sprains as subjects with low sway scores
McGuine TA, Greene JJ, Best T, Leverson G: Balance as a predictor of ankle injuries in high school basketball players. Clin Jour Sport Med 10: 239-244, 2000.
McGuine TA, Greene JJ, Best T, Leverson G: Balance as a predictor of ankle injuries in high school basketball players. Clin Jour Sport Med 10: 239-244, 2000.
Loss of Postural ControlLoss of Postural ControlRisk of future ankle injury:Risk of future ankle injury:
127 soccer players, mean age 24.6 years127 soccer players, mean age 24.6 years
postural sway measured in pre-season postural sway measured in pre-season
23 new ankle sprains in subsequent season:12 had pathologic sway
23 new ankle sprains in subsequent season:12 had pathologic sway
risk of sprain was 42% in those with abnormalpre-season sway
risk of sprain was 42% in those with abnormalpre-season sway
risk of sprain was 11% in those with normal pre-season sway
risk of sprain was 11% in those with normal pre-season sway
Tropp H, Edstrand J, Gillquist J: Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc 16: 64-66, 1984.Tropp H, Edstrand J, Gillquist J: Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exerc 16: 64-66, 1984.
POSTURAL CONTROLPOSTURAL CONTROLSensory Input:Sensory Input:
• Vision
• Vestibular • Somatosensory System
� Muscle Proprioception
� Joint Mechanoreceptors
� Cutaneous Afferents (sole of foot)
Postural ControlPostural ControlSensory Input: Joint MechanoreceptorsSensory Input: Joint Mechanoreceptors
ANKLE JOINT MECHANORECEPTORSANKLE JOINT MECHANORECEPTORS
• Type I: slow adapting, low threshold
Convey postural sense
• Type I: slow adapting, low threshold
Convey postural sense
• Type II: rapid adapting, low threshold
Convey sense at beginning of joint
movement
• Type II: rapid adapting, low threshold
Convey sense at beginning of joint
movement
• Type III: slow adapting, high threshold
Convey sense at extreme end ROM
• Type III: slow adapting, high threshold
Convey sense at extreme end ROM
Michelson JD, Hutchins C: Mechanoreceptors in human ankle
ligaments. J Bone Joint Surg (Br) 1995: 77-B : 210-24.
Michelson JD, Hutchins C: Mechanoreceptors in human ankle
ligaments. J Bone Joint Surg (Br) 1995: 77-B : 210-24.
Type II and III are most abundant in ankle ligamentsType II and III are most abundant in ankle ligaments
JOINT MECHANORECEPTORSJOINT MECHANORECEPTORS
• proprioception• proprioception
• control muscle stiffness and joint stability• control muscle stiffness and joint stability
• influence gamma motor neuron output:
determine length of muscle spindle fibers
• influence gamma motor neuron output:
determine length of muscle spindle fibers
Michelson JD, Hutchins C: Mechanoreceptors in human ankle
ligaments. J Bone Joint Surg (Br) 1995: 77-B : 210-24.
Michelson JD, Hutchins C: Mechanoreceptors in human ankle
ligaments. J Bone Joint Surg (Br) 1995: 77-B : 210-24.
• Influence discharge of 1A spindle afferents and
input on alpha motor neurons
• Influence discharge of 1A spindle afferents and
input on alpha motor neurons
• adjust muscle length or tension to protect joint
from injury
• adjust muscle length or tension to protect joint
from injury
Evidence of sensory nerve fibers and corpuscles, i.e. mechanoreceptors, within the ankle retinacula. The ankle retinacula
underwent MRI changes of thickening and altered signal intensity-similar to what is seen in plantar fasciitis. The ankle
retinacula are important sensors for proprioception of the ankle joint which respond to tension of the muscles and tendons to which they are attached, as
well as direct stretching when the ankle is moved in various directions.
Stecco C, Macchi V, Porzionato A et al. The ankle retinacula: Morphological evidence of the proprioceptive role of the fascial system. Cells Tissues Organs
Accessible online at www.karger.com/ctoDOI: 10.1159/000290225
Ankle Retinacula: Role in ProprioceptionAnkle Retinacula: Role in Proprioception
Postural ControlPostural Control
Sensory Input: Muscle spindle afferentsSensory Input: Muscle spindle afferents
MUSCLE SPINDLE
AFFERENTS
MUSCLE SPINDLE
AFFERENTS
SPINAL CORD
SPINDLE
GMSGMSGamma motor neurons (spinal)
Contraction of muscle spindles
Excitation of stretch receptors
Improved stretch reflex
Gamma motor neurons (spinal)
Contraction of muscle spindles
Excitation of stretch receptors
Improved stretch reflex
Gamma-muscle-spindle system
How does pain affect
postural control?
How does pain affect
postural control?
Pain and Loss of ProprioceptionPain and Loss of Proprioception
Afferent articular nerves found in joints of the LE:Afferent articular nerves found in joints of the LE:
Type I receptors: slow adapting mechanical anddynamic receptors
Type I receptors: slow adapting mechanical anddynamic receptors
Type II: rapidly adapting, mechanical anddynamic receptors
Type II: rapidly adapting, mechanical anddynamic receptors
Type III: high threshold, slow adapting, mechanical and dynamic
Type III: high threshold, slow adapting, mechanical and dynamic
Type IV: high threshold pain receptorsType IV: high threshold pain receptors
Wyke B: The neurology of joints. Ann R Coll Surg Engl 41: 24-50, 1967.Wyke B: The neurology of joints. Ann R Coll Surg Engl 41: 24-50, 1967.
Painful Subtalar Joint
and Chronic Ankle Instability
Painful Subtalar Joint
and Chronic Ankle Instability
EMG activity of the Peroneus Brevis andLongus is diminished in sinus tarsi syndrome.
EMG activity of the Peroneus Brevis andLongus is diminished in sinus tarsi syndrome.
Injection of local anesthetic into the sinustarsi restores normal EMG function.
Injection of local anesthetic into the sinustarsi restores normal EMG function.
Taillard W, Meyer JM, Garcia J, Blanc Y: The sinus tarsi syndrome. Int Orthop5: 117-130, 1981.
Taillard W, Meyer JM, Garcia J, Blanc Y: The sinus tarsi syndrome. Int Orthop5: 117-130, 1981.
Sinus Tarsi Pain and Prolonged Peroneal Reaction TimeSinus Tarsi Pain and Prolonged Peroneal Reaction Time
18 pts with functional ankle instability 18 pts with functional ankle instability
8 healthy controls 8 healthy controls
measurement of peroneal reaction times with trapdoor mechanism and EMG readings of p. brevis and p. longus
measurement of peroneal reaction times with trapdoor mechanism and EMG readings of p. brevis and p. longus
recordings before and after injection of 2 mLof 1% Lidocaine into sinus tarsi
recordings before and after injection of 2 mLof 1% Lidocaine into sinus tarsi
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
Before Injection:Before Injection:
Subjects with Functional Instability of Ankle 82.0 ms Subjects with Functional Instability of Ankle 82.0 ms
Controls 72.0 ms Controls 72.0 ms
After Injection:After Injection:
Subjects with Functional Instability of Ankle 69.3 ms Subjects with Functional Instability of Ankle 69.3 ms
Controls 70.5 ms Controls 70.5 ms
P < 0.0001 P < 0.0001
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
Sinus Tarsi Pain and Prolonged Peroneal Reaction TimeSinus Tarsi Pain and Prolonged Peroneal Reaction Time
Peroneal Reaction: Stretch Reflex Peroneal Reaction: Stretch Reflex Receptors: Muscle SpindleReceptors: Muscle Spindle
Reflex: Afferent neurons connect to alphamotor neurons in spinal cord
Reflex: Afferent neurons connect to alphamotor neurons in spinal cord
Efferent: motor neurons stimulateperoneal muscle contraction
Efferent: motor neurons stimulateperoneal muscle contraction
Sensitivity: Gamma motor neurons(GMN’s) contract muscle spindles: lowers threshold of response
Sensitivity: Gamma motor neurons(GMN’s) contract muscle spindles: lowers threshold of response
inflammation from sprain causes irritability ofmechanoreceptors and nociceptors in the affectedankle and subtalar joints
inflammation from sprain causes irritability ofmechanoreceptors and nociceptors in the affectedankle and subtalar joints
excitation of leg flexors and inhibition of legextensors (shown in previous animal studieswith joint inflammation)
excitation of leg flexors and inhibition of legextensors (shown in previous animal studieswith joint inflammation)
inhibitory stimulation affects GMN’s of both extensors and peroneal muscles
inhibitory stimulation affects GMN’s of both extensors and peroneal muscles
local anesthetic reverses inhibitory stimulus of gamma motor neurons
local anesthetic reverses inhibitory stimulus of gamma motor neurons
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
Khin-Myo-Hla, Ishii T, Sakane M, Hayashi K: Effect of anesthesia of the sinus tarsi on peroneal reaction time in patients with functional instability of the ankle. Foot and Ankle Int 20,9: 554-558, 1999.
Theory of Prolonged Peroneal Reaction TimeTheory of Prolonged Peroneal Reaction Time
Postural ControlPostural Control
Sensory Input: Plantar cutaneous afferents
Sensory Input: Plantar cutaneous afferents
The Foot:A Major Proprioceptive Organ
The Foot:A Major Proprioceptive Organ
� Merkel Cell Complexes Pressured Deformation
� Merkel Cell Complexes Pressured Deformation
� Meissner CorpusclesVibration 5-40 Hz
� Meissner CorpusclesVibration 5-40 Hz
� Pacinian CorpusclesVibration 60-300 Hz
� Pacinian CorpusclesVibration 60-300 Hz
ISOLATING THE INPUT FROM
THE SOMATOSENSORY SYSTEM:
ISOLATING THE INPUT FROM
THE SOMATOSENSORY SYSTEM:
Muscle spindle afferents: Muscle spindle afferents: • short latency response, monosegmental reflex
Cutaneous receptors: Cutaneous receptors: • medium latency, polysynaptic spinal pathway
Ankle joint receptors: Ankle joint receptors:
• medium and long latency, polysynaptic pathway
Wu G, Chiang JH: The significance of somatosensory stimulations to the human
foot in the control of postural reflexes. Exp Brain Res 114: 163-169, 1997
Wu G, Chiang JH: The significance of somatosensory stimulations to the human
foot in the control of postural reflexes. Exp Brain Res 114: 163-169, 1997
Lower limb muscle activation during balance recovery is more adversely
affected by loss of muscle proprioceptive afferents than by
loss of plantar cutaneous afferents.
Lower limb muscle activation during balance recovery is more adversely
affected by loss of muscle proprioceptive afferents than by
loss of plantar cutaneous afferents.
Thoumie P, Do MC: Changes in motor activity and biomechanics during balance recovery following cutaneous and muscular deafferentation. Exp Brain Res 110: 289-297, 1996
Thoumie P, Do MC: Changes in motor activity and biomechanics during balance recovery following cutaneous and muscular deafferentation. Exp Brain Res 110: 289-297, 1996
Diener HC, Dichgans J, Guschlbauer B, Mau H: The significance of proprioception on postural stabilization as assessed by ischemia. Brain Res 296: 103-109, 1984
Diener HC, Dichgans J, Guschlbauer B, Mau H: The significance of proprioception on postural stabilization as assessed by ischemia. Brain Res 296: 103-109, 1984
- Diminish joint mechanoreceptors
with fixed ankle AFO braces
Wu G, Chiang JH. The significance of somatosensory stimulations to the human
foot in the control of postural reflexes. Exp Bran Res (1977) 114: 163-169.
Isolating the components of the somatosensory system
- 15 healthy subjects
- Sudden perturbation on a toes-up platform
- Diminish plantar mechanoreceptors with soft foam
“This suggests that the plantar cutaneous mechanoreceptors in the sole
of the foot and the joint receptors in the ankle joint play a minimal
role, if any, in the generation of short latency leg muscle responses
during sudden perturbation.”
“It seems that the only possibility for the mediation of the short latency
reflexes is by the muscle spindles in the stretched muscle.”
Hierarchy of importance of the components of the somatosensory system:
Wu G, Chiang JH. The significance of somatosensory stimulations to the human
foot in the control of postural reflexes. Exp Bran Res (1977) 114: 163-169.
Chronic Ankle Instability: Solving a Complicated Puzzle
The Neuromuscular Disconnect:
Evidence for a Central Mediated
Mechanism
Chronic Ankle Instability: Loss of Postural Control
Is this due to peripheral (feed-back) impairment or..
Is this due to central (feed-forward) alterations in motor control?
Alterations in feed-forward motor control in CAI
A. Altered hip biomechanics during dynamic balance tests:Gribble PA, Hertel J, Denegar CR. Chronic ankle instability and fatigue create proximal jointalterations during performance of the star excursion balance test. Int J Sports Med 2007;28:236–42.
B. Altered ankle biomechanics during gait :Delahunt EMK, Caulfield B. Altered neuromuscular control and ankle joint kinematics during walking in subjects with functional instability of the ankle joint. Am J Sports Med 2006;34:1970–6.
Monaghan K, Delahunt E, Caulfield B. Ankle function during gait in patients with chronic ankle instability compared to controls. Clin Biomech 2006;21:168–74.
C. Different landing patterns :Caulfield B, Crammond T, O’Sullivan A, Reynolds S, Ward T. Altered ankle muscle activation during jump
landing in participants with functional instability of the ankle joint. J Sport Rehabil 2004;13:189–200.
Caulfield B, Garrett M. Functional instability of the ankle: differences in patterns of ankle and knee
movement prior to and post landing in a single leg jump. Int J Sports Med 2002;23:64–8.
Delahunt E, Monaghan K, Caulfield B. Changes in lower limb kinematics, kinetics, and muscle activity in
subjects with functional instability of the ankle joint during a single leg drop jump. J Orthop Res
2002;24:1991–2000.
CHRONIC ANKLE INSTABILITY:
Evidence for the Role of the Central Nervous System
With unilateral chronic ankle instability:
- bilateral hamstring inhibition with unilateral CAI
Chronic Ankle Instability: Centrally
Mediated Mechanisms
Sedory et al revealed bilateral
hamstring inhibition in CAI patients
Sedory EJ, McVey ED, Cross KM,
Ingersoll CD, Hertel J. Arthrogenic
muscle response of the quadriceps and
hamstrings with chronic ankle
instability. J Athl Train 2007;42:355–60.
Chronic Ankle Instability: Centrally
Mediated Mechanisms
Sedory et al revealed bilateral
hamstring inhibition in CAI patients
Sedory EJ, McVey ED, Cross KM,
Ingersoll CD, Hertel J. Arthrogenic
muscle response of the quadriceps and
hamstrings with chronic ankle
instability. J Athl Train 2007;42:355–60.
CHRONIC ANKLE INSTABILITY:
Evidence for the Role of the Central Nervous System
With unilateral chronic ankle instability:
- bilateral hamstring inhibition with unilateral CAI
- alterations in shank-rearfoot coupling during gait with CAI
J Sports Rehabil 2009 Aug;18(3):375-88.
Altered ankle kinematics and shank-rear-
foot coupling in those with chronic ankle
instability. Drewes LK, McKeon PO,
Paolini G, Riley P, Kerrigan DC, Ingersoll
CD, Hertel J. Dept of Human Services,
University of Virginia, Charlottesville, VA,
USA.
Abstract
CONTEXT: Kinematic patterns during gait have not been extensively studied in relation
to chronic ankle instability (CAI). OBJECTIVE: To determine whether individuals with
CAI demonstrate altered ankle kinematics and shank-rear-foot coupling compared with
controls during walking and jogging RESULTS: The CAI group demonstrated more
rear-foot inversion and shank external rotation during walking and jogging. There were
differences between groups in shank-rear-foot coupling during terminal swing at both
speeds. CONCLUSIONS: Altered ankle kinematics and joint coupling during the
terminal-swing phase of gait may predispose a population with CAI to ankle-inversion
injuries. Less coordinated movement during gait may be an indication of altered
neuromuscular recruitment of the musculature surrounding the ankle as the foot is
being positioned for initial contact
CHRONIC ANKLE INSTABILITY:
Evidence for the Role of the Central Nervous System
With unilateral chronic ankle instability:
- bilateral hamstring inhibition with unilateral CAI
- alterations in shank-rearfoot coupling during gait with CAI
- delayed hip and thigh muscle activation patterns
Chronic Ankle Instability: Centrally
Mediated Mechanisms
Bullock-Saxton et al and Bullock-
Saxon reported altered proximal
muscle activation patterns following
acute lateral ankle sprains. Bullock-
Saxon J. Sensory changes
associated with severe ankle sprain.
Scand J Rehabil Med 1995;27:161–7.Bullock-Saxton JE, janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip
extension. Int J Sports Med 1994;15:330–4
Scand J Rehabil Med 1995;27:161–7.Bullock-Saxton JE, janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip
extension. Int J Sports Med 1994;15:330–4
CHRONIC ANKLE INSTABILITY:
Evidence for the Role of the Central Nervous System
With unilateral chronic ankle instability:
- bilateral hamstring inhibition with unilateral CAI
- alterations in shank-rearfoot coupling during gait with CAI
- delayed hip and thigh muscle activation patterns
- Bilateral balance deficits are found which
can improve with unilateral exercise
CENTRAL NERVOUS SYSTEM ROLE
IN CHRONIC ANKLE INSTABILITY
McKeon PO, Hertel J. Systematic review of postural control and lateral
ankle instability. Part 1: Can deficits be detected with instrumented
testing? J Athl Train 2008;43:293–304.
Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Balance capabilities after
lateral ankle trauma and intervention: a meta-analysis. Med Sci Sports
Exerc 2009.
Arnold BL, De La Motte S, Linens S, Ross SE. Ankle instability is
associated with balance impairments: a meta-analysis. Med Sci Sports
Exerc 2009;41:1048–
Unilateral Ankle Sprain = Bilateral Neuromuscular Deficits.
Three recent publications provided robust evidence that
postural control is compromised in the un-involved limb
after an acute ankle sprain:
CENTRAL NERVOUS SYSTEM ROLE
IN CHRONIC ANKLE INSTABILITY
Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther 2007;37:303–11. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for person with functionally unstable ankles. J Orthop Sports Phys Ther 1999;29:478–86.
Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study. Scand J Med Sci Sports 1997;7:172–7.
McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E, Bennett BC, Hertel J. Balance training improves function and postural control in those with chronic ankle instability. Med SciSports Exerc 2008;40:1810–9.
The fact that bilateral neuromuscular control deficits are found at
both the ankle and proximal joints strongly suggests that global
coordination or training programs should be used for both the
involved and uninvolved limbs of all patients with a history of lateral
ankle trauma for the same reasons.
Postural ControlPostural Control• Improves after balance and coordination
training exercises
• Improves after balance and coordination training exercises
Leanderson 1996, Goldie 1994, Pintsaar 1996, Tropp 1984
Leanderson 1996, Goldie 1994, Pintsaar 1996, Tropp 1984
Balance exercises cause Bilateral ImprovementsBalance exercises cause Bilateral Improvements
Gauffin, 1988Hertel, 2001Gauffin, 1988Hertel, 2001
BALANCE TRAINING
Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Balance
capabilities after lateral ankle trauma and intervention: a meta-
analysis. Med Sci Sports Exerc 2009.
Balance training improves postural
control scores of individuals with acute
ankle sprains and CAI
BALANCE TRAINING
Beck S, Taube W, Gruber M, Amtage F, Gollhofer A, Schubert M. Task-specific
changes in motor evoked potentials of lower limb muscles after different training interventions. Brain Res 2007;1179:51–60.
Gruber M, Taube W, Gollhofer A, Beck S, Amtage F, Schubert M. Training specific adaptations of h- and stretch reflexes in human soleus muscle. J Mot Behav2007;39.
Taube W, Gruber M, Beck S, Faist M, Gollhofer A, Schubert M. Cortical and spinal adaptations induced by balance training: correlation between stance stability and corticospinal activation. Acta Physiol (Oxford) 2007;189.
Taube W, Kullmann N, Leukel C, Kurz O, Amtage F, Gollhofer A. Differential reflex adaptations following sensorimotor and strength training in young elite athletes. Int J Sports Med 2007;28:999–1005.
The underlying neural adaptations of balance training
occur at multiple sites within the central nervous system
BALANCE TRAINING
Emery C, Rose M, McAllister J, Meeuwisse W. A prevention strategy to reducethe
incidence of injury in high school basketball: a cluster randomized controlled trial. Clin J Sports Med 2007;17:17–24.
Holme E, Magnusson SP, Becher K, Bieler T, Aargaar P, Kjar M. The effect of supervised rehabilitation on strength, postural sway, position sense and reinjuryrisk after acute ankle ligament sprain. Scand J Med Sci Sports 1999;9:104–9.
McHugh M, Tyler T, Mirabella M, Mullany M, Nicholas S. The effectiveness of a balance training intervention in reducing the incidence of noncontact ankle sprains in high school football players. Am J Sports Med 2007;35: 1289–94.
Accumulating evidence implicates balance training
programs as effective in reducing the recurrence of
lateral ankle sprain
McKeon PO, Hertel J. Systematic Reviw of postural control and lateral ankle instability, Part II: Is balance training clinically effective? Journal of Athletic Training 2008;43(3):305–315
McKeon PO, Hertel J. Systematic Reviw of postural control and lateral ankle instability, Part II: Is balance training clinically effective? Journal of Athletic Training 2008;43(3):305–315
“Prophylactic balance training substantially reduced the risk of sustaining ankle sprains, with a greater effect seen in those with a history of a previous sprain. Completing at least 6 weeks of balance training after an acute ankle sprain substantially reduced the risk of recurrent ankle sprains;however, consistent improvements in instrumented measures of postural control were not associated with training. Evidence is lacking to assess the reduction in the risk of recurrent sprains and inconclusive to demonstrate improved instrumented postural control measures in those with chronic ankle instability who complete balance training.”
Star Excursion Balance TestStar Excursion Balance Test (SEBT)(SEBT)
LAYOUT OF SEBTLAYOUT OF SEBT
LATERAL REACH ON SEBTLATERAL REACH ON SEBT
Photos From: Relationship between Ground Reaction Force and Stability Level of the Lower
Extremity in Runners. Kimitake Sato, Monique Butcher-Mokha Barry University Miami Shores, FL
Photos From: Relationship between Ground Reaction Force and Stability Level of the Lower
Extremity in Runners. Kimitake Sato, Monique Butcher-Mokha Barry University Miami Shores, FL
Chronic Ankle Instability: Solving a Complicated Puzzle
The Myth of Peroneal Muscular Weakness
Lateral Body Sway=CKC Pronation of STJLateral Body Sway=CKC Pronation of STJCorrection of Lateral Body Sway=Concentric
Contraction of Medial Ankle Invertors
Correction of Lateral Body Sway=ConcentricContraction of Medial Ankle Invertors
Reduce Pronation=
Reduce Supination Ankle Injuries???
Reduce Pronation=
Reduce Supination Ankle Injuries???
Patients with lateral ankle instability have weaker invertor ankle strength
Patients with lateral ankle instability have weaker invertor ankle strength
Munn J, Beard D, Refshauge K, Lee R: Eccentric muscle strength in functional ankle instability. Med Sci Sport Exerc 35(2): 245, 2003.
Munn J, Beard D, Refshauge K, Lee R: Eccentric muscle strength in functional ankle instability. Med Sci Sport Exerc 35(2): 245, 2003.
Sports Med. 2009;39(3):207-24. doi: 10.2165/00007256-200939030-00003. Treatment of common deficits associated with chronic ankle instability. Holmes A,
Delahunt E.
Lateral ankle sprains are amongst the most common injuries incurred by athletes, with the high rate of reoccurrence after initial injury becoming of great concern. Chronic ankle instability (CAI) refers to the development of repetitive ankle sprains and persistent residual symptoms post-injury. Some of the initial symptoms that occur in acute sprainsmay persist for at least 6 months post-injury in the absence of recurrent sprains, despite the athlete having returned to full functional activity. CAI is generally thought to be caused by mechanical instability (MI) or functional instability (FI), or both. Although previously discussed as separate entities, recent research has demonstrated that deficits associated with both MI and FI may co-exist to result in CAI. For clinicians, the main deficits associated with CAI include deficits in proprioception, neuromuscular control, strength and postural control. Based on the literature reviewed, it does seem that subjects with CAI have a deficit in frontal plane ankle joint positional sense. Subjects with CAI do not appear to exhibit any increased latency in the peroneal muscles in response to an external perturbation. Preliminary data suggest that feed-forward neuromuscular control may be more important than feed-back neuromuscular control and interventions are now required to address deficits in feed-forward neuromuscular control.
Balance training protocols have consistently been shown to improve postural stability in subjects with CAI. Subjects with CAI do not experience decreased peroneus longus strength, but instead may experience strength deficits in the ankle joint invertor muscles. These findings are of great clinical significance in terms of understanding the mechanisms and deficits associated with CAI. An appreciation of these is vital to allow clinicians to develop effective prevention and treatment programmes in relation to CAI.
0
50
100
150
200
250
Cases
PFPS ITBFS Glut Med Sacroiliac
Injury
Gender Issues: Injury Patterns
Males
Females
Taunton et al., 2002
2X
2X
3X
9X
Ferber et al., 2005
Hip Adduction
Hip Internal Rotation
Knee Abduction
Of 165 patients who visited Ferber’s clinic complaining of overuse running injuries
(33% PFPS; 25% ITBFS), 92 per cent had weak hip muscles.
As part of each patient's consultation, he gave them a program to improve hip
strength, along with other recommendations to speed their recovery.
89 per cent of the patients reported a significant improvement in pain within
four to six weeks.
Interventions: Exercise
Ferber, 2008 Ferber, 2008
STUDIES OF FO’S
AND POSTURAL CONTROL
STUDIES OF FO’S
AND POSTURAL CONTROL
Lundin TM, Feurbach JW, Grabiner MD: Effect of plantar flexor and dorsiflexor fatigue on unilateral postural control. J Appl Biomech. 9:191, 1993.
Lundin TM, Feurbach JW, Grabiner MD: Effect of plantar flexor and dorsiflexor fatigue on unilateral postural control. J Appl Biomech. 9:191, 1993.
Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 82: 1000, 2001.
Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 82: 1000, 2001.
Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rear-foot orthotics on postural control in healthy subjects. J Sport Rehabil 10: 36, 2001.
Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rear-foot orthotics on postural control in healthy subjects. J Sport Rehabil 10: 36, 2001.
STUDIES OF FO’S
AND POSTURAL CONTROL
STUDIES OF FO’S
AND POSTURAL CONTROL
Percy ML, Menz HB: Effects of prefabricated foot orthotics and soft insoles on postural stability in professional soccer players. J Am Podiatr Med Assoc 91:194, 2001.
Percy ML, Menz HB: Effects of prefabricated foot orthotics and soft insoles on postural stability in professional soccer players. J Am Podiatr Med Assoc 91:194, 2001.
Rome K, Brown CL: Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Clinical Rehab18: 624, 2004.
Rome K, Brown CL: Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Clinical Rehab18: 624, 2004.
IMPROVED POSTURAL CONTROL WITH
FO’S: PROPOSED MECHANISMS
IMPROVED POSTURAL CONTROL WITH
FO’S: PROPOSED MECHANISMS
1. Reducing range of motion of the ankle joint
and/or subtalar joint.
1. Reducing range of motion of the ankle joint
and/or subtalar joint.
2. Maintaining a “neutral position” at the subtalar
joint and enhancing ligament mechanoreceptor
function.
2. Maintaining a “neutral position” at the subtalar
joint and enhancing ligament mechanoreceptor
function.
3. Improving tactile sensation on the plantar surface of the foot.
3. Improving tactile sensation on the plantar surface of the foot.
4. Reducing muscular strain about the ankle.4. Reducing muscular strain about the ankle.
“Therefore, we recommend the use of orthotics during the acute and subacutephases for subjects after an ankle sprain.
“Therefore, we recommend the use of orthotics during the acute and subacutephases for subjects after an ankle sprain.
The use of orthotics provides somatosensorybenefits because cutaneous afferents contribute to human balance control and may provide neutral alignment for proper muscle activation and reduce unnecessary strain on the already stressed soft tissue.”
The use of orthotics provides somatosensorybenefits because cutaneous afferents contribute to human balance control and may provide neutral alignment for proper muscle activation and reduce unnecessary strain on the already stressed soft tissue.”
Mattacola CG, Dwyer MK: Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train. Dec (4): 413-429, 2002.
Mattacola CG, Dwyer MK: Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train. Dec (4): 413-429, 2002.
Chronic Ankle Instability: Solving a Complicated Puzzle
Relevance to other medical conditions
Patients at risk for catastrophic falls
Adult Acquired Flatfoot
Bunions and Hammertoes
Degenerative Arthritis of the Ankle and Hindfoot
1 out of 3 people over age 65 fall each year,
and half of these falls result in injury
Larsen ER,Mosekilde L, Foldspang A. Correlates of falling during 24 h among
elderly Danish community residents. Prev Med 2004;39:389-98.
Falls are the leading cause of injury in older adults
Falls are the leading cause of injury in older adults
Falls are the leading cause of accidental death in people over age 85
Falls are the leading cause of accidental death in people over age 85
Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.
Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992; 82(7):1020-3.
Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992; 82(7):1020-3.
Klein K, and Ritzel DO. Falls Pose a Serious Threat to the Elderly. National SafetyCouncil - Falls in the Home. http://www.nsc.org/issues/ifalls/falthreat.htm.Klein K, and Ritzel DO. Falls Pose a Serious Threat to the Elderly. National SafetyCouncil - Falls in the Home. http://www.nsc.org/issues/ifalls/falthreat.htm.
Centers for Disease Control. Falls Among Older Adults. Injury Fact Book 2001-2002. www.cdc.gov/ncipc/fact_book/15_Falls_Among_Older_Adults.htmCenters for Disease Control. Falls Among Older Adults. Injury Fact Book 2001-2002. www.cdc.gov/ncipc/fact_book/15_Falls_Among_Older_Adults.htm
Falls cause approximately 350,000 hip fractures per year, at a treatment cost of $35,000 per patient
Falls cause approximately 350,000 hip fractures per year, at a treatment cost of $35,000 per patient
Most of the falls resulting in hip fracture are related to balance disorders
Most of the falls resulting in hip fracture are related to balance disorders
Braithwiate RS, et al. Estimating Hip Fracture Morbidity, Mortality and Costs. JAGS 51:364-370, 2003.
Braithwiate RS, et al. Estimating Hip Fracture Morbidity, Mortality and Costs. JAGS 51:364-370, 2003.
Centers for Disease Control. Falls Among Older Adults. Injury Fact Book 2001-2002. www.cdc.gov/ncipc/fact_book/15_Falls_Among_Older_Adults.htm
Bloem, et al. An Update on Falls: Curr Opin Neurol, 2003; Vol 16(1):15-26.Bloem, et al. An Update on Falls: Curr Opin Neurol, 2003; Vol 16(1):15-26.
Centers for Disease Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [database online]. National Center for Injury Prevention and
Control, Centers for Disease Control and Prevention (producer). www.cdc.gov/ncipc/wisqars (2001).
The medical cost for treatment of fall-related injuries in the United States exceeds $20 billion annually, and is expected to climb to $32 billion by 2020
The medical cost for treatment of fall-related injuries in the United States exceeds $20 billion annually, and is expected to climb to $32 billion by 2020
Patients at increased risk of falling have consistently shown deficits in balance control.
Patients at increased risk of falling have consistently shown deficits in balance control.
Pekka K., et al. Fall-induced injuries and deaths among older adults. 1999 JAMA, vol. 28, no. 20.
Nevitt, M.C. (1997). Falls in the elderly: Risk factors and prevention. In Masdeu, J.C., Sudarsky, L., & Wolfson, L. (Eds) Gait disorders in aging. Falls and therapeutic strategies. Philadelphia, PA: Lipincott-Raven, 13-36.
Clark, S., Rose, D.J., & Fujimoto, K. (1997). Generalizability of the limits of stability test in the evaluation of dynamic balance among older adults. Archives of Physical Medicine and Rehabilitation, 78, 1078-1084.
Newton, R.A. (1997). Balance screening of an inner city older adult population. Archives of Physical Medicine and Rehabilitation, 78, 587-591.
Whipple, R. (1997). Improving balance in older adults: identifying the significant training stimuli. In Masdeu, J.C., Sudarsky, L., & Wolfson, L. (eds.) Gait disorders in aging. Falls and therapeutic strategies. Philadelphia, PA: Lipincott-Raven, 355-79.
Shumway-Cook A., Gruber W., Baldwin M., Liao S. (1997). Effect of Multidimensional Exercises on Balance, Mobility, & Fall Risk in Community-Dwelling Older Adults. Physical Therapy, 77, 46-57.
Chronic Ankle Instability: Athlete Chronic Ankle Instability: Athlete
Repetitive Falls: ElderlyRepetitive Falls: Elderly What are the commoncausative factors?
What are the commoncausative factors?
Increased postural sway
Conflicting sensory inputs
Increased reflex latency
Delayed muscle reaction times
Strength deficit in LE musculature
Pain
Decreased joint range of motion
Compensated positioning of LE skeletal segments
Foot problems, which
affect 1 in 3older people have been
associated with falls
Menz HB, Tiedemann A, Kwan MM, Plumb K, Lord S. Foot pain in community-dwelling
older people: an evaluation of the Manchester Foot Pain and Disability Index. Rheumatology
2006;45:863-7.
Menz HB, Jordan KP, Roddy E, Croft PR. Characteristics of primary care consultations for
musculoskeletal foot and ankle problems in the UK. Rheumatology 2010;49:1391-8.
Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and
ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol
2004;159:491-8.
Hill C, Gill T, Menz H, Taylor A. Prevalence and correlates of foot pain in a population-based
study: the NorthWest Adelaide Health Study. J Foot Ankle Res 2008;1:2
Martin J. Spink, BPod, Mohammad R. Fotoohabadi, PhD, Elin Wee, BPhysio, Keith D.
Hill, PhD, Stephen R. Lord, PhD, Hylton B. Menz, PhD. Foot and Ankle Strength,
Range of Motion, Posture, and Deformity Are Associated With Balance and Functional
Ability in Older Adults. Arch Phys Med Rehabil 2011;92:68-75.
“Foot posture (measured using the FPI) was found to be an independent
predictor of postural sway on the foam, with a more pronated (flatter) foot
corresponding to a poorer performance. This is consistent with a previous
study of young adults that reported having a flatter foot resulted in
increased anteroposterior sway.”
Hylton B. Menz, B Pod (Hons), and Stephen R. Lord, PhD.The Contribution of Foot
Problems to Mobility Impairment and Falls in Community-Dwelling Older People J
Am Geriatr Soc 49:1651–1656, 2001.
“In conclusion, these findings
provide further evidence that
foot problems (foot pain,
hallux valgus, hammertoes)
are a risk factor for falls and
that this increased risk is
mediated, in part, via
impaired balance and
reduced ability to perform
functional tasks integral to
daily living.”
Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a
prospective study. J Gerontol A Biol Sci Med Sci 2006;61:866-70.
The aim of this study was to determine whether a series of tests of foot and
ankle characteristics are associated with falls in older people. Compared to
nonfallers, fallers exhibited reduced ankle flexibility, more severe hallux
valgus deformity, and reduced plantar tactile sensitivity.
Fallers were also more likely to have weak toe plantarflexor muscles, and had
a higher prevalence of disabling foot pain.
Independent risk factors for falling:
foot pain
reduced range of motion
toe weakness
toe deformity
Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a
prospective study. J Gerontol A Biol Sci Med Sci 2006;61:866-70.
Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. ISB Clinical Biomechanics Award
2009: toe weakness and deformity increase the risk of falls in older people. Clin Biomech
2009;24:787-91
Karen J. Mickle , Bridget J. Munro , Stephen R. Lord , Hylton B. Menz , Julie R. Steele. Toe
weakness and deformity increase the risk of falls in older people Clinical Biomechanics 24
(2009) 787–791
Clinical relevance
“The hallux and lesser toes are vital structures that assist with stability
during gait and balance tasks. This study has shown that the presence of
hallux valgus, lesser toe deformity and reduced plantar flexion strength
of the hallux and lesser toes increase the risk of falling in older people.
In particular, hallux strength and the presence of lesser toe deformities
were independent predictors of falls. Furthermore, individuals with
hallux valgus and lesser toe deformities had weaker flexor muscles of
the associated toes. Interventions designed to increase strength of the toe
flexor muscles combined with treatment of those older individuals with
toe deformities may be beneficial, and a clinical trial that determines
whether these interventions can reduce the risk of falling is
recommended.”
Participants in the intervention group (n=153) experienced 36% fewer falls than participants in the control group (incidence rate ratio 0.64,
95% confidence interval 0.45 to 0.91, P=0.01).
Spink et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in
community dwelling older people with disabling foot pain: randomized controlled
trial. BMJ 2011;342:d3411 doi:10.1136/bmj.d3411
Conclusions“The findings of this study show that a multifaceted podiatry
intervention is an effective falls prevention strategy in older people with
disabling foot pain and an increased risk of falls. The reduction in falls
is likely to be related to the significant improvements found in several
measures of foot and ankle strength and range of motion, balance, and
functional ability. The components of the intervention are inexpensive
and relatively simple to implement, suggesting that the programme
could be incorporated into routine podiatry practice or
multidisciplinary falls prevention clinics.”
“Among the clinical variables implemented in this study, the self reported functional variables (global function question, SF-36 PF) and the subjects ambulation status appear to be the best potential prognostic factors in predicting the number of days to return to sports in Division II athletes with acute lateral ankle sprains.”
“Among the clinical variables implemented in this study, the self reported functional variables (global function question, SF-36 PF) and the subjects ambulation status appear to be the best potential prognostic factors in predicting the number of days to return to sports in Division II athletes with acute lateral ankle sprains.”
Cross KM, Worrell TW, Leslie JE, Khalid RV: The relationship between self reported and clinical measures and the number of days of return to sport following acute lateral ankle sprains. J Ortho Sports Phys Ther 32: 16-23, 2002.
Cross KM, Worrell TW, Leslie JE, Khalid RV: The relationship between self reported and clinical measures and the number of days of return to sport following acute lateral ankle sprains. J Ortho Sports Phys Ther 32: 16-23, 2002.
PREDICTING DISABILITYPREDICTING DISABILITY72 Hours post Grade II LAS:
• Swelling & ROM: poor predictor
• Functional limitation: good predictor
40 m walk/run, Figure 8Single hop, Stair hop, Cross-over hop
Wilson RW, Gansneder BM: Measures of functional limitation as predictors of disablement in athletes with acute ankle sprains. JOSPT 30(9) : 528, 2000