Sports Medicine Research: In the Lab & In the Field: Finding Who Will Develop Chronic Ankle Instability (Sports Med Res)
Wednesday, March 23, 2016

Finding Who Will Develop Chronic Ankle Instability

Recovery from a first-time lateral ankle sprain and the predictors of chronic ankle instability: A Prospective Cohort Analysis.

Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, and Delahunt E. Am J Sports Med. 2016; [Epub ahead of print].

Take Home Message: Following a first-time lateral ankle sprain, a patient who was unable to complete the single-leg drop landing and drop vertical jump at 2 weeks post injury was more likely to be classified as having chronic ankle instability. Patient-reported outcomes at 6 months was also associated with onset of chronic ankle instability.

Lateral ankle sprains are a common injury in sports and are the gateway to chronic ankle instability. No study has tracked people after their first lateral ankle sprain to identify early motor control impairments that may predict chronic ankle instability. By finding ways to identify patients who may be susceptible to chronic ankle instability, clinicians can begin to develop effective interventions that could halt the progression of chronic ankle instability. Therefore, Doherty and colleagues completed a cohort study of people with a first time lateral ankle sprain to identify motor control deficits that predict chronic ankle stability. Eighty-two (54 male) recreationally active patients who sustained a lateral ankle sprain in the past 2 weeks participated in the current study. The authors evaluated participants 3 times: 2 weeks, 6 month, and 12 months post injury. To assess chronic ankle instability, all patients completed the Cumberland Ankle Instability Tool and the activities of daily living and sport subscale of the Foot and Ankle Ability Measure. The authors classified participants with chronic ankle instability at the 12-month visit. Patients also completed 5 movement tasks: single-limb stance (eyes open and eyes closed), Star Excursion Balance Test (anterior, posterolateral, and posteromedial reach), single-leg drop landing, drop vertical jump and walking gait). The authors assessed range of motion and force plate data (for example, center of pressure or ground reaction force). Of the 70 patients who completed all follow-ups, 28 (40%) were categorized as having chronic ankle instability. At 2 weeks, a patient who was unable to complete the single-leg drop landing and drop vertical jump were more likely to develop chronic ankle instability. At 6 months, a participant who reported lower levels of activities of daily living on the Foot and Ankle Ability Measure and who had altered joint positions in the sagittal plane during the Star Excursion Balance Test were more likely to develop chronic ankle instability.

Overall, the data presented in this study suggests that there are early findings that may warn us about people at risk for chronic ankle instability following a patient’s initial lateral ankle sprain. If these findings are confirmed, clinicians could identify patients who may be susceptible to chronic ankle instability and begin to intervene as early as possible to mitigate motor control deficits. Specifically, the authors found that the inability to perform single-leg drop landing and drop vertical jump at 2 weeks was key as was patient-reported function during activities of daily living. This highlights the importance of using patient-reported outcomes in our assessments. Future research should focus on identifying the best possible rehabilitative methods of negating or reversing the onsets of chronic ankle instability. This can potentially lead to clinicians screening first time lateral ankle sprain patients within the first 2 weeks of injury and implementing a rehabilitation program, which would best suit the needs of that particular patient to avoid long-term deficits. Until this future research can be done, clinicians should consider using patient-reported outcomes and assess a patient’s ability to perform the two functional tasks to screen for potential risk of chronic ankle instability.

Questions for Discussion: Do you currently use any methods which you believe help identify patients who may be at risk for chronic ankle instability? Do you utilize any screening tools which were used in this study in your current practice?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

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Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, & Delahunt E (2016). Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability: A Prospective Cohort Analysis. The American Journal of Sports Medicine PMID: 26912285

3 comments:

Tyler Keith said...

The idea of recognizing potential patients who have increased risk of chronic ankle instability two weeks post injury is interesting. One aspect that I'm interested in is the level of rehabilitative exercises these participants completed prior to the two week post injury measurements. For example, a subject who was able to complete some strengthening, balance, and proprioceptive exercises may perform better on the single-leg landing and drop vertical jump than those who received no treatment. I would think that incorporating rehab exercises or any sort of therapeutic intervention will decrease the likelihood of not being able to complete the tasks measured in this study. Therefore, incorporating therapeutic interventions may be able to decrease the chance of chronic ankle instability. However, it is too difficult to conclude that from this study, and further research would need to be completed.

In my clinical experience, I have not been able to find a screening tool that is effective the majority of the time for being able identify individuals with higher risk of CAI. I believe balance tests may be a great clinical tool, but if there are no baseline measures of balance, than it is difficult to link poor balance post injury to increased risk of CAI, if they already had poor balance prior to the injury. Either way, I believe balance and postural control will eventually be measured in a way that will allow clinicians to identify individuals with greater risk of CAI.

Chris said...

Functional screening and patient reported outcome measures seems to be a novel idea in identifying possible predispositions to developing CAI. Lateral ankle sprains being as common in athletics as they are need to be addressed so that they do not develop into further chronic conditions such as CAI. I think it was wise that these clinicians looked at activity levels as a predisposition to developing CAI rather than other first-time sprainers who become Copers. This relates off of the Functional Screening tools that this article looked into. If a person is less physically active due to pain, instability, or other complicating factors of CAI, their functionality will be impaired similarly due to these same factors and the non-usage of the limb.

Building off of Tyler's ideas, an epidemiological investigation in to the treatment and rehabilitation of first-time sprainers would be beneficial in the development of CAI vs. Copers. Do CAI patients tend to receive similar care as Coper's or do CAI patients have any other tendencies, like we see in this article like functionality and PROs, that may be identifying factors in CAI patients. Moving these potential CAI patients to Coper's would be beneficial not only in further injury prevention but Activity Level impacting Quality of Life as we can see from this article.

Jeffrey Driban said...

Tyler and Chris thanks for the great comments and study ideas. I wonder if the STAR program we previously described would be one treatment strategy to prevent the risk of CAI - http://www.sportsmedres.org/2016/02/aiming-for-stars-for-chronic-ankle-instability.html. So far, it's mostly been tested on people with CAI.
Tyler's comment makes me wonder if we should be trying to collect baseline balance measures at the beginning of the season so we can detect deviations after an injury (like we do with neurocognitive testing for concussions).
Chris, I agree that the potential benefits for helping someone become a coper instead of developing CAI is huge; not just for the patient but from a public health point of view.

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