Management of Chronic Ankle Instability: Difference between revisions

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* Home based rehabilitation with high patient-responsibility had better outcomes compared to frequent clinic based treatments (Basset)
* Home based rehabilitation with high patient-responsibility had better outcomes compared to frequent clinic based treatments (Basset)


=== Personal recommendations ===
== Example Treatment Protocol ==
The instructor provides an example of her treatment protocol for the management of the chronic ankle instability.<ref name=":1" />


* Goal setting is critical!
=== General Principles ===
** Team effort
# Goal setting is critical  
** Athlete takes on responsibility
#* Team effort
* Posture
#* Athlete takes on responsibility
* Proximal stability: Hip and Knee
# Address postural stability
* Local stabilisers of the ankle and foot
# Include proximal stability, especially  hip and knee joints
* Dorsi-flexion is priority
# Focus on local stabilisers of the ankle and foot
* Cardio-vascular fitness
# Regaining dorsiflexion range of motion is priority
* Integrating exercises into the gym improves compliance
# Include cardio-vascular fitness
* Footwear and sports specific technique
# Integrate exercises into the gym to improve compliance
# Assess footwear and sports specific technique


==== Phase 1 ====
=== Phase 1 ===
'''Cardio-vascular fitness''' to include:
 
* Cycling
* Hydrotherapy  or swimming
* Walk
** Forwards and backwards
** Ladder: stride length, “Pink Panther”, heel-toe, big toe, placing of foo
 
'''Postural Control/ Balance''' exercises including:
 
* Pilates
* Short foot exercises
* Tibialis posterior re-education
 
'''Strengthening''' exercises including:
* Leg press
* Calf raises, theraband exercises
* Hamstring curls
* Bridging (glutes)
* Abdominal


* Cardio-vascular:
** Cycling
** Hydrotherapy  or Swimming ?
** Walk
*** Forwards and backwards;
*** Ladder: Stride length, “Pink Panther”, Heel-toe, Big toe, Placing of foot…….
* Postural Control/ Balance
** Pilates?
** Short foot exercises
** Tibialis posterior re-education
* Strengthening:
** Leg press
** Calf raises, theraband exercises
** Hamstring curls
** Bridging (glutes)
** Abdominal
* Neurodynamics and Flexibility
* Neurodynamics and Flexibility


==== Phase 2 ====
=== Phase 2 ===
'''Cardio-vascular fitness'''


* Cardio-vascular fitness:
* Running
** Running
* Elliptical
** Elliptical
* Stepper
** Stepper
* Rowing machine
** Rowing machine
* Functional strength:
** Modified lunges
** Squats: bilateral, single leg
** Single leg activity
* Balance training
** Aeroplane, SEBT (Star)
** Bosu ball, Balance pad, Wobble board
* Shoe assessment


==== Phase 3 ====
'''Functional strength'''
* Modified lunges
* Squats: bilateral, single leg
* Single leg activity
'''Balance training'''
* Aeroplane, SEBT (Star)
* Bosu ball, Balance pad, Wobble board
'''Shoe assessment'''


* Cardio-vascular:
=== Phase 3 ===
** Sport specific drills and skills
'''Cardio-vascular'''
** Endurance
* Sport specific drills and skills
** Terrain
* Endurance
* Balance/ function/ agility
* Terrain
** Jumping, skipping, landing
'''Balance/ function/ agility'''
** Multiple hops
* Jumping, skipping, landing
** Vertical jumps
* Multiple hops
* Integrate all aspects: sport specific but without compromising quality of movement.
* Vertical jumps
* Monitor pain!
'''Integration of sport specific activities''', but without compromising quality of movement.


'''Pain monitoring'''
*  
*  


== Resources <br>  ==
== Resources ==  
 
add appropriate resources here


== References  ==
== References  ==

Revision as of 17:41, 13 July 2022

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (10.07.2022)
Original Editor - Ewa Jaraczewska based on the course by Helene Simpson
Top Contributors - Ewa Jaraczewska, Jess Bell, Kim Jackson and Matt Huey

Definition of Chronic Ankle Instability (CAI)[edit | edit source]

Chronic ankle instability (CAI) has been defined as “repetitive bouts of lateral ankle instability resulting in numerous ankle sprains.”[1] Chronic instability refers to feeling of apprehension in the ankle, “giving way” and recurrent ankle sprains, persisting for a minimum of 6 months after the initial sprain.[2]Symptoms include:[2]

  • Lateral ankle pain
  • Chronic swelling
  • Difficulty walking on uneven terrain

Based on the International Classification of Function, Health and Disability (ICF) model, the effects of CAI on function and health include:

  • In terms of impairments:[3]
    • increased ligamentous laxity
    • proprioceptive deficits
  • In terms of activity limitations:[3]
    • inability to walk
    • inability to jump
  • In terms of participation:[3]
    • cessation of sport
    • withdrawing from or decreasing occupational involvement
    • decreasing the level of exercise
    • change in type of sport

Long Term Outcomes[edit | edit source]

Patients with CAI have a loss of physical quality of life. Treatments may improve stability but are taking a long time and may require specialised equipment. [2]Seven years post-ankle inversion trauma study by Konradsen et al[4] revealed the following:

  • 32% of patients reported chronic complaints of pain, swelling or recurrent sprains
  • 72% of the subjects with residual disability reported that they were functionally impaired by their ankle
  • 4% of patients experienced pain at rest and were severely disabled
  • 19% were bothered by repeated inversion injuries
  • 43% of these subjects felt that they could compensate by using an external ankle support
  • 85% of people who develop CAI after unilateral sprain reported problems in the contralateral ankle.

According to Hertel [5]one sprain guarantees another. [5][2]Struijs and Kerkhoffs[6]indicated that 30% recurrence of sprain happened within the first year after the injury.[2]

Additional reported long-term outcomes include:

  • Articular cartilage defects on the medial side of the joint due to:[2]
    • Tearing of ATFL and CFL
    • Altering and increasing peak cartilage strain
    • Leading to  tibiotalar cartilage degeneration (OA)
  • Anterior talar positional fault [7]
  • Altered movement patterns in unstable ankles:[2]
    • Landing in more dorsiflexion in an attempt to minimise reliance on lateral ligaments and increase bony stability
    • In drop jump: greater maximum calcaneal eversion and frontal displacement of the body
    • Faster time to peak ground reaction force in drop landing
    • Greater medial ground reaction force.
    • Metatarsal height is lowered during a terminal swing of gait

Mechanical and Functional Instability[edit | edit source]

There are two commonly accepted subgroups of CAI: mechanical instability and functional instability. [2][3]In Hertel's model [8] of ankle stability, mechanical and functional instability are part of a continuum. Recurrent sprain occurs when both conditions are present. [8]

Mechanical Instability[edit | edit source]

Mechanical instability is referred to as pathological ligamentous laxity about the ankle-joint complex[9]Mechanical instability may result from various anatomic changes that are present in isolation or in combination. They can lead to pathologies that are responsible for ankle instability. [3]

Functional Instability[edit | edit source]

There is no universally approved definition of functional ankle instability.[10] Based on definition established by Evans et al.,[11] functional instability is a subjective complaint of weakness.[11] Lentell and his colleagues [12] describes functional instability as ankle pain and the perception that the ankle is less functional than the other side or the situation prior to the injury. [12] Tropp et al. [13] concluded, that a joint motion that did not exceed normal physiologic limits, but was no longer controlled voluntarily, defines functional instability. [13]

Impaired proprioceptive and neuromuscular control can be responsible for functional instability.[8]

Table 1 summerises the causes and the results of mechanical and functional ankle instability:[2]

Diagnostic Procedures[edit | edit source]

Diagnostic procedures may help clinicians to confirm the presence of various ankle deficiencies, including range of motion limitation and perceived disability that leads to define a condition. The choice of the diagnostic tool should be based on the scientific evidence suggesting its consistent positive utility:[14]

  • Anterior drawer test is performed in slight knee flexion to relax the gastrocnemius, but Kovaleski et al[15]  suggested a testing position with the knee flexed to 90° and the ankle in 10° of plantar flexion to isolate the anterior talofibular ligament. [15] A bilateral comparison is recommended. [14] Excessive anterior translation and the lack of a solid end feel indicate positive test results.
  • Stress radiography is used to quantify the extent of ankle-joint laxity. It shows the separation of the bony joint structures while a force is applied. Clinically it helps to identify excessive strain within the ligamentous structures. A total anterior translation greater than 9 mm or translation greater than 5 mm (or both) when compared with the contralateral side indicates significant laxity of the anterior talofibular ligament. Pathologic laxity of the CF ligament is demonstrated by a talar tilt angle greater than 10° in total or more than 5° greater than the contralateral limb. [14]
  • MRI is not conclusive. Negative MRI results must be viewed with caution in a symptomatic patient and arthroscopy should be considered.[16]
  • Diagnostic ultrasound offers moderate to strong confirmation of lateral ligamentous injury, evidence suggests.[17]It shows an increased lateral ligament lengths during the anterior drawer and talar tilt tests among individuals with a history of CAI.[18]
  • Stable force plates are suggested for gait and hop stability assessment:[19]

[20]

  • Imaged guided injections of cortisone as clinical diagnostic tool: based on the review of the published literature for evidence, Delphi-based consensus of the experts from the European Society of Musculoskeletal Radiology indicated that intraarticular foot and ankle anaesthetic injections performed under imaging guidance offers precise information about pain source.[21]

Physiotherapy Management[edit | edit source]

While a surgical approach for treatment of acute lateral ankle ligament injuries is reserved for special cases, a conservative management is the treatment of choice. [22] Currently available modalities of choice include:[2]

  • Neuromuscular training
  • Balance training
  • Mobilisation
  • Neuromuscular control by peronei (theraband and isokinetic training have no effect on ankle evertor strength)[2]
  • Braces and taping
  • Flexibility and strength training

Neuromuscular Training[edit | edit source]

  • de Vries et al [23]concluded, that neuromuscular training alone demonstrates a positive short term outcome and patients had better function. [23]He stated that this type of training is a basis for the majority of conservative treatment regimes.[23][2]
  • Study by Kim et al[24]has found an altered gait pattern in athletes with unstable ankles. They showed a relatively inverted ankle position during the initial contact and midstance. Incorporating a six-week neuromuscular training immediately changed ankle orientation toward a relatively more inverted direction during jump landing, but showed no effect on walking and running.[24]
  • According to Guzmán-Muñoz and his colleagues[25]a four-week neuromuscular training improved postural control in college volleyball players with functional ankle instability (FAI) .[25]
Step 2
Step 1
Step 3

Guide to Neuromuscular Training[edit | edit source]

Neuromuscular training is an"unconscious activation of dynamic restraints in preparation and in response to joint motion and load to maintain and restore functional joint stability".[2]

Goals of neuromuscular training:

  1. To optimize lower limb postural control[2]
  2. To restore active stability by training [26]
Exercises[edit | edit source]

Exercises are performed in closed chain and functional positions:

  • single limb stance on wobble board or balance mat
  • single limb ball toss
  • single leg theraband kicks and step downs

Balance Training[edit | edit source]

  • Investigating functional ankle instability and Health-Related Quality of Life, Arnold et al[27]concluded that balance training can affect a multiple of joints and produce overall improvement.[2]
  • McKeon and his colleagues [19] showed that balance training significantly improves static postural control and dynamic postural control.[2]
  • A prospective cohort study by Sefton et al [28] found that rehabilitation affects sensorimotor system function.[2]
  • Based on the review of randomised controlled trials, Mollà Casanova et al [29] concluded, that balance training significantly improves functionality, instability, and dynamic balance outcomes in people with chronic ankle instability. [29]

Guide to Balance Training[edit | edit source]

Literature indicates, that the following balance measures should guide clinical practice. However de Vries et al[23]did not find their correlation with function:

  • Center-of pressure (COP) excursion. [30]
  • Time-to-boundary (TTB) after landing[31]
  • Peak plantar analysis[32]
  • SEBT
Proprioception[edit | edit source]

Kinesthesia and joint position sense (JPS) are usually impaired in patients with chronic ankle instability. [33]Testing methodology for proprioception include:

  • Kinesthesia : assessed using threshold-to-detection of passive motion[2]
  • Joint position sense : assessed using active and passive joint placing reproduction[2]
Therapeutic Interventions[edit | edit source]
  • Multi-station exercise regime once per week[2]
    • Ankle disc training, balance pad
  • Perturbation exercises with elastic tubing[34][2]
    • 4 exercises including front pull, back pull, crossover and reverse crossover, performed 3 times per week. Standard protocol includes 3 sets of 15 repetitions with resistance band while standing on affected leg.
    • Goal: to maintain alignment and stability.
    • Outcome: balace improved in 4 weeks

Mobilisation[edit | edit source]

  • Limited ankle dorsiflexion during jogging and gait is considered a risk factor for recurrent sprains due to the following:[2]
    • Inability to reach ankle joint closed packed position during stance
    • Tendency to lock midfoot in supination
    • Centre of gravity moved laterally thus ankle joint becomes vulnerable to supination and a sprain
  • According to Westad et al[35]mobilisation with movement (MWM) technique used to treat peripheral joints was superior to placebo, but not to other medical or physiotherapy interventions. [35]
  • The results of a systematic review and meta-analysis by Weerasekara et al[36]suggested that mobilisation with movement intervention immediately benefitted patients with chronic ankle instability by increasing dorsiflexion range of motion. [36]
Therapeutic Interventions[edit | edit source]

Mulligan’s mobilisation with movement (MWM) technique should include the following:

  • Fibular glide at distal and proximal tibiofibular joint
  • Talar glide

Instructor's additional MWM technique includes midfoot mobility at navicular.[2]

Braces and taping[edit | edit source]

Taping[edit | edit source]

  • Hubbard and Cordova [37]found that mechanical laxity decreased after application of tape.[2]
  • Delahunt et al [38] found no  change in “actual” stability, but patients perceptions of stability were significantly improved (56%).[2]
  • Hopper and his colleagues [39] found, that Mulligan taping had no impact on neuromuscular control during static and dynamic balance.[2]
Therapeutic Intervention[edit | edit source]

The following taping techniques were clinically assessed:[2]

  • Lateral subtalar sling (aimed at resisting subtalar inversion)

[40]

  • Fibular repositioning, [41] but the exact mechanism in reducing incidence of sprains is unknown

[42]

  • The application of Kinesio Taping Method in preventing ankle sprains had no effect on muscle activation of the fibularis longus.[43]

Braces[edit | edit source]

No significant effect was found on function and balance with application of braces.[2]

  • Barlow at al[44] found that braces affect neuromuscular activity during walking which can assist with decreasing sprains.
  • Feger at al[45]were investigating the effect of ankle braces on lower extremity muscle activities during functional exercises:
    • Forward lunge: reduction of muscle activity during pre‐initial contact in the lateral gastrocnemius and post‐initial contact in the peroneus longus.
    • Star excursion: less muscle activity of the peroneus longus, lateral gastrocnemius, rectus femoris, and gluteus medius during balance anterior reach.
    • Anterior reach: significant reduction of thigh and total muscle activity
    • Posterolateral reach: significant reduction of gluteus medius activity
    • Single limb eyes closed balance, star excursion balance posteromedial reach, or during lateral hop exercises: no differences between braced and unbraced conditions
  • Janssen et al[46]submitted a protocol to assess effect of braces vs. neuromuscular exercises.[2]
  • Fuerst and colleagues[47]argued that individuals with ankle instability may benefit from a semi-rigid ankle brace to keep ankle inversion angles " in a range that is comparable to values of healthy people".[47]
Therapeutic intervention[edit | edit source]
  • Measurements to assess the effectiveness of using braces in patients with chronic ankle instability are not sensitive enough to assess dynamic stability[2]
  • Decisions regarding continuity of using braces should be based on:[2]
    • Data from acute ankle sprains and prevention of recurrent sprains for one year post-injury
    • Cost effectiveness and time efficiency

Flexibility and Strength Training[edit | edit source]

Flexibility:

Traditional concepts of flexibility exercises in the chronic ankle instability include stretches of soleus and gastronemius, performed 3 times for 30 second. [2] New protocol includes plantar fascia stretches and walking backwards.[48] This course instructor recommends neural roll-down, toe extensions stretches (flexor hallucis longus and big toe extension).[2]

Strength:

  • Meta-analysis by Arnold in 2009 on concentric evertor strength deficits:
    • No cause and effect between deficits and loss of functional stability
    • Not easy to detect evertor weaknesses
    • Isokinetic testing at slow speeds might maximize differences
  • Weakness of invertors (Wilkerson and Ryan)
  • Muscles co-contraction is essential:
    • Suggests bilateral calf raises
  • Short foot exercises (Lee 2012)/ Intrinsic foot exercises
  • Strength is important and should be included in rehabilitation

Conclusion[edit | edit source]

  • Comprehensive rehabilitation approach
  • Functional balance training with global coordination training for both limbs
  • Proximal core
  • Supervision
  • Attention
  • Physiotherapeutic supervision ensures compliance (Kooijman, Leemrijse, Basset).
    • Supervised sessions: 2 - 3 sessions per week for 2 weeks and then once a week for 4 to 6 weeks
    • Duration of supervised sessions: 20 - 30 minutes
    • Correct alignment: shank rotation and rearfoot position (McKeon 2009)
    • Teach landing skills: pre and post landing
  • Physiotherapists are excellent role models for athletes (Chevan).
  • Attentional demands: Multi-task study:
    • simultaneous cognitive task diminish postural stability (Rahnama 2010)
  • Visual compensation
  • Home based rehabilitation with high patient-responsibility had better outcomes compared to frequent clinic based treatments (Basset)

Example Treatment Protocol[edit | edit source]

The instructor provides an example of her treatment protocol for the management of the chronic ankle instability.[2]

General Principles[edit | edit source]

  1. Goal setting is critical
    • Team effort
    • Athlete takes on responsibility
  2. Address postural stability
  3. Include proximal stability, especially hip and knee joints
  4. Focus on local stabilisers of the ankle and foot
  5. Regaining dorsiflexion range of motion is priority
  6. Include cardio-vascular fitness
  7. Integrate exercises into the gym to improve compliance
  8. Assess footwear and sports specific technique

Phase 1[edit | edit source]

Cardio-vascular fitness to include:

  • Cycling
  • Hydrotherapy  or swimming
  • Walk
    • Forwards and backwards
    • Ladder: stride length, “Pink Panther”, heel-toe, big toe, placing of foo

Postural Control/ Balance exercises including:

  • Pilates
  • Short foot exercises
  • Tibialis posterior re-education

Strengthening exercises including:

  • Leg press
  • Calf raises, theraband exercises
  • Hamstring curls
  • Bridging (glutes)
  • Abdominal
  • Neurodynamics and Flexibility

Phase 2[edit | edit source]

Cardio-vascular fitness

  • Running
  • Elliptical
  • Stepper
  • Rowing machine

Functional strength

  • Modified lunges
  • Squats: bilateral, single leg
  • Single leg activity

Balance training

  • Aeroplane, SEBT (Star)
  • Bosu ball, Balance pad, Wobble board

Shoe assessment

Phase 3[edit | edit source]

Cardio-vascular

  • Sport specific drills and skills
  • Endurance
  • Terrain

Balance/ function/ agility

  • Jumping, skipping, landing
  • Multiple hops
  • Vertical jumps

Integration of sport specific activities, but without compromising quality of movement.

Pain monitoring

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Hertel J. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train. 2002 Dec;37(4):364-375.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 Simpson H. Chronic Ankle Instability Course. Physiopedia 2022
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Hiller CE, Kilbreath SL, Refshauge KM. Chronic ankle instability: evolution of the model. Journal of athletic training. 2011 Mar;46(2):133-41.
  4. ↑ Konradsen L, Bech L, Ehrenbjerg M, Nickelsen T. Seven years follow-up after ankle inversion trauma. Scand J Med Sci Sports. 2002 Jun;12(3):129-35.
  5. ↑ 5.0 5.1 Hertel J. Immobilisation for acute severe ankle sprain. Lancet. 2009 Feb 14;373(9663):524-6.
  6. ↑ Struijs PA, Kerkhoffs GM. Ankle sprain. BMJ Clin Evid. 2010 May 13;2010:1115.
  7. ↑ Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Arch Phys Med Rehabil. 2010 Aug;91(8):1267-71.
  8. ↑ 8.0 8.1 8.2 Hertel J. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train. 2002 Dec;37(4):364-375
  9. ↑ Tropp H. Commentary: Functional Ankle Instability Revisited. J Athl Train. 2002 Dec;37(4):512-515.
  10. ↑ Konradsen L. Factors Contributing to Chronic Ankle Instability: Kinesthesia and Joint Position Sense. J Athl Train. 2002 Dec;37(4):381-385.
  11. ↑ 11.0 11.1 Evans GA, Hardcastle P, Frenyo AD. Acute rupture of the lateral ligament of the ankle. To suture or not to suture? J Bone Joint Surg Br. 1984 Mar;66(2):209-12
  12. ↑ 12.0 12.1 Lentell G, Katzman LL, Walters MR. The Relationship between Muscle Function and Ankle Stability. J Orthop Sports Phys Ther. 1990;11(12):605-11.
  13. ↑ 13.0 13.1 Tropp H, Odenrick P, Gillquist J. Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Med. 1985 Jun;6(3):180-2.
  14. ↑ 14.0 14.1 14.2 Gribble PA. Evaluating and differentiating ankle instability. Journal of athletic training. 2019 Jun;54(6):617-27.
  15. ↑ 15.0 15.1 Kovaleski JE, Norrell PM, Heitman RJ, Hollis JM, Pearsall AW. Knee and ankle position, anterior drawer laxity, and stiffness of the ankle complex. J Athl Train. 2008 May-Jun;43(3):242-8.
  16. ↑ Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hariharan K. Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle. Foot Ankle Surg. 2010 Jun;16(2):78-80.
  17. ↑ Oae K, Takao M, Uchio Y, Ochi M. Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging. Skeletal Radiol. 2010 Jan;39(1):41-7.
  18. ↑ Croy T, Saliba SA, Saliba E, Anderson MW, Hertel J. Differences in lateral ankle laxity measured via stress ultrasonography in individuals with chronic ankle instability, ankle sprain copers, and healthy individuals. J Orthop Sports Phys Ther. 2012 Jul;42(7):593-600.
  19. ↑ 19.0 19.1 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 Sci Sports Exerc. 2008 Oct;40(10):1810-9.
  20. ↑ Vicon. Vicon Gait and Posture Biomechanics. 2018. Available from: https://www.youtube.com/watch?v=D6JMr-ZPbjQ [last accessed 9/07/2022]
  21. ↑ Sconfienza LM, Adriaensen M, Albano D, Alcala-Galiano A, Allen G, Aparisi Gómez MP, Aringhieri G, Bazzocchi A, Beggs I, Chianca V, Corazza A, Dalili D, De Dea M, Del Cura JL, Di Pietto F, Drakonaki E, Facal de Castro F, Filippiadis D, Gitto S, Grainger AJ, Greenwood S, Gupta H, Isaac A, Ivanoski S, Khanna M, Klauser A, Mansour R, Martin S, Mascarenhas V, Mauri G, McCarthy C, McKean D, McNally E, Melaki K, Messina C, Mirón Mombiela R, Moutinho R, Olchowy C, Orlandi D, Prada González R, Prakash M, Posadzy M, Rutkauskas S, Snoj Ž, Tagliafico AS, Talaska A, Tomas X, Vasilevska Nikodinovska V, Vucetic J, Wilson D, Zaottini F, Zappia M, Obradov M. Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle. Eur Radiol. 2022 Feb;32(2):1384-1394
  22. ↑ Aicale R, Maffulli N. Chronic lateral ankle instability: topical review. Foot & Ankle International. 2020 Dec;41(12):1571-81.
  23. ↑ 23.0 23.1 23.2 23.3 de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD004124.
  24. ↑ 24.0 24.1 Kim E, Choi H, Cha JH, Park JC, Kim T. Effects of Neuromuscular Training on the Rear-foot Angle Kinematics in Elite Women Field Hockey Players with Chronic Ankle Instability. J Sports Sci Med. 2017 Mar 1;16(1):137-146.
  25. ↑ 25.0 25.1 Guzmán-Muñoz E, Daigre-Prieto M, Soto-Santander K, Concha-Cisternas Y, Méndez-Rebolledo G, Sazo-Rodríguez S, Valdés-Badilla P. The effects of neuromuscular training on the postural control of university volleyball players with functional ankle instability: A pilot study. Archivos de medicina del deporte. 2019;35(5):283-7
  26. ↑ Loudon JK, Santos MJ, Franks L, Liu W. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review. Sports Med. 2008;38(7):553-63.
  27. ↑ Arnold BL, Wright CJ, Ross SE. Functional ankle instability and health-related quality of life. J Athl Train. 2011 Nov-Dec;46(6):634-41.
  28. ↑ Sefton JM, Yarar C, Hicks-Little CA, Berry JW, Cordova ML. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2011 Feb;41(2):81-9.
  29. ↑ 29.0 29.1 Mollà-Casanova S, Inglés M, Serra-Añó P. Effects of balance training on functionality, ankle instability, and dynamic balance outcomes in people with chronic ankle instability: systematic review and meta-analysis. Clinical Rehabilitation. 2021 Dec;35(12):1694-709.
  30. ↑ Yousefi M, Sadeghi H, Ilbiegi S, Ebrahimabadi Z, Kakavand M, Wikstrom EA. Center of pressure excursion and muscle activation during gait initiation in individuals with and without chronic ankle instability. Journal of Biomechanics,2020, 18.
  31. ↑ Hertel J, Olmsted-Kramer LC, Challis JH. Time-to-boundary measures of postural control during single leg quiet standing. J Appl Biomech. 2006 Feb;22(1):67-73.
  32. ↑ Orlin MN, McPoil TG. Plantar Pressure Assessment. Physical Therapy 2000; 80( 4): 399–409
  33. ↑ Ma T, Li Q, Song Y, Hua Y. Chronic ankle instability is associated with proprioception deficits: a systematic review and meta-analysis. Journal of sport and health science. 2021 Mar 1;10(2):182-91.
  34. ↑ Han K, Ricard MD, Fellingham GW. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. J Orthop Sports Phys Ther. 2009 Apr;39(4):246-55.
  35. ↑ 35.0 35.1 Westad K, Tjoestolvsen F, Hebron C. The effectiveness of Mulligan's mobilisation with movement (MWM) on peripheral joints in musculoskeletal (MSK) conditions: A systematic review. Musculoskeletal Science and Practice. 2019 Feb 1;39:157-63
  36. ↑ 36.0 36.1 Weerasekara I, Deam H, Bamborough N, Brown S, Donnelly J, Thorp N, Rivett DA. Effect of Mobilisation with Movement (MWM) on clinical outcomes in lateral ankle sprains: a systematic review and meta-analysis. The Foot. 2020 Jun 1;43:101657.
  37. ↑ Hubbard TJ, Cordova M. Effect of ankle taping on mechanical laxity in chronic ankle instability. Foot Ankle Int. 2010 Jun;31(6):499-504.
  38. ↑ Delahunt E, McGrath A, Doran N, Coughlan GF. Effect of taping on actual and perceived dynamic postural stability in persons with chronic ankle instability. Arch Phys Med Rehabil. 2010 Sep;91(9):1383-9.
  39. ↑ Hopper D, Samsson K, Hulenik T, Ng C, Hall T, Robinson K. The influence of Mulligan ankle taping during balance performance in subjects with unilateral chronic ankle instability. Phys Ther Sport. 2009 Nov;10(4):125-30.
  40. ↑ UCO GATP. Sunderland Special Strip 2 SubTalar Sling - Side View. 2017. Available from: https://www.youtube.com/watch?v=hTQjt7vGNCw [last accessed 13/7/2022]
  41. ↑ Moiler K, Hall T, Robinson K. The role of fibular tape in the prevention of ankle injury in basketball: A pilot study. J Orthop Sports Phys Ther. 2006 Sep;36(9):661-8.
  42. ↑ Brooke Larson. Fibular Repositioning Taping Technique. 2018. Available from: https://www.youtube.com/watch?v=CRuWvtMmPKw[last accessed 13/7/2022]
  43. ↑ Briem K, Eythörsdöttir H, Magnúsdóttir RG, Pálmarsson R, Rúnarsdöttir T, Sveinsson T. Effects of kinesio tape compared with nonelastic sports tape and the untaped ankle during a sudden inversion perturbation in male athletes. J Orthop Sports Phys Ther. 2011 May;41(5):328-35.
  44. ↑ Barlow G, Donovan L, Hart JM, Hertel J. Effect of lace-up ankle braces on electromyography measures during walking in adults with chronic ankle instability. Physical Therapy in Sport. 2015 Feb 1;16(1):16-21.
  45. ↑ Feger MA, Donovan L, Hart JM, Hertel J. Effect of ankle braces on lower extremity muscle activation during functional exercises in participants with chronic ankle instability. Int J Sports Phys Ther. 2014 Aug;9(4):476-87
  46. ↑ Janssen KW, van Mechelen W, Verhagen EA. Ankles back in randomized controlled trial (ABrCt): braces versus neuromuscular exercises for the secondary prevention of ankle sprains. Design of a randomised controlled trial. BMC Musculoskelet Disord. 2011 Sep 27;12:210.
  47. ↑ 47.0 47.1 Fuerst P, Gollhofer A, Wenning M, Gehring D. People with chronic ankle instability benefit from brace application in highly dynamic change of direction movements. Journal of Foot and Ankle Research. 2021 Dec;14(1):1-1.
  48. ↑ Lee KY, Lee HJ, Kim SE, Choi PB, Song SH, Jee YS. Short term rehabilitation and ankle instability. Int J Sports Med. 2012 Jun;33(6):485-96.
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