Chronic Complaints After Ankle Sprains

NewsBot · Oct 14, 2014

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Chronic Complaints After Ankle Sprains: A Systematic Review on Effectiveness of Treatments
John M. van Ochten, MD, Marienke van Middelkoop, PhD, Duncan Meuffels, PhD, Sita M.A. Bierma-Zeinstra, PhD
Journal of Orthopaedic & Sports Physical Therapy, Ahead of Print Pages: 1-52

Study Design
Systematic review.

Objective
To determine the effectiveness of treatments for patients with chronic complaints after an ankle sprain.

Background
Though most people recover completely after a lateral inversion ankle injury, a considerable percentage have persistent complaints. Currently, it is still unclear which treatment options are best for these patients.

Methods
A search was made in major databases as Pubmed, Embase, Cinahl and PEDro selecting RCTs and CCTs covering the period 1966 to October 2012. Because of clinical heterogeneity, data were analysed using a best-evidence synthesis.

Results
In total, 20 randomized controlled trials and 1 controlled clinical trial were included. These compared different treatments (training programs, physiotherapy, chiropractic/manual therapy, surgery, postoperative training and functional treatment). Limited to moderate evidence was found for effectiveness of a training program compared to conservative treatment, with respect to pain and function. Two studies found a decrease of recurrences after a proprioceptive training program. In four studies different surgical methods showed good results, but without comparing to a non-surgical control group. Limited evidence was found for the effectiveness of an early mobilizing program after surgery.

Conclusions
In chronic ankle complaints after an ankle sprain, a training program gives better results for pain and function, and a decrease of recurrent ankle sprains, than a ‘wait and see’ policy. There is insufficient evidence to determine the most effective surgical treatment, but limited evidence suggests that postoperative, early mobilization is more effective than plaster cast
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Admin2 · Oct 14, 2014

Related Threads:
Other threads tagged with ankle injury
Functional ankle instability
Treatment of ankle sprains
Immediate manipulation for ankle sprain
Prevention & Treatment of Ankle Sprains
Risk factors for ankle sprains
Return to play after ankle injury
Evidence for ICE after an ankle sprain
Ankle sprains increase risk for DVT

mike weber · Oct 14, 2014

Isn't it important to differentiate between high and low ankle sprains?

low get the mobilisation/training approach

high rest approach

while a high ankle sprain maybe rarer, it would be important to differentiate in a journal systematic review I would have thought?

NewsBot · Apr 29, 2016

Center Of Pressure during stance and gait in subjects with or without persistent complaints after a lateral ankle sprain
Wouter Kros, Noel L.W. Keijsers, John. M. van Ochten, Sita. M.A. Bierma-Zeinstra, Marienke van Middelkoop
Gait and Posture; Article in Press

Highlights
•We compare patients with and without persistent complaints after an ankle sprain.
•Patients with persistent complaints have a more lateral located loading response.
•Postural sway while standing with eyes open did not differ between groups.
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Study Aim
To investigate differences in the Center Of Pressure (COP) during gait and single leg stance between subjects with persistent complaints (PC) and without persistent complaints (NPC) after a lateral ankle sprain.

Methods
44 patients who consulted the general practitioner, 6 to 12 months prior to inclusion, with a lateral ankle sprain were included for the current study purpose. Using a 7-point Likert scale patients were divided into the PC or NPC group. All subjects filled out an online questionnaire, walked along a walkway and performed a single leg stance, both on the RSscan. Primary outcomes included the COP displacement, range and percentage used in mediolateral and anterioposterior direction.

Results
There was a trend (p < 0.05) towards a more medially COP trajectory during walking at 34-46% and 83-96% and more anteriorly at 21%-31% and 91%-100% of the stance phase in the PC group compared to NPC group. Additionally, the COP was more laterally located in the sprained leg compared to the non-sprained leg in the PC group in the loading response phase (p < 0.05). An interaction was found for the percentage of anterior-posterior range used in single leg stance without vision.

Conclusion
The COP trajectory discriminates between patients with PC and NPC. This indicates that roll off during gait might play an important role in the recovery of patients after a lateral ankle sprain and could be used to monitor treatment.
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NewsBot · May 3, 2016

Gait Biomechanics in Participants, Six Months after First-time Lateral Ankle Sprain
C. Doherty et al
Int J Sports Med DOI: 10.1055/s-0035-1564172

No research currently exists predicating a link between the injury-affiliated sensorimotor deficits of acute ankle sprain and those of chronic ankle instability during gait. This analysis evaluates participants with a 6-month history of ankle sprain injury to affirm this link. 69 participants with a 6-month history of acute first-time lateral ankle sprain were divided into subgroups (?chronic ankle instability? and ?coper?) based on their self-reported disability and compared to 20 non-injured participants during a gait task. Lower extremity kinematic and kinetic data were collected from 200 ms pre- to 200 ms post-heel strike (period 1) and from 200 ms pre- to 200 ms post-toe off (period 2). The ?chronic ankle instability? subgroup (who reported greater disability) displayed increased knee flexion during period 1. During period 2, this subgroup exhibited greater total displacement at their ankle joint and greater extensor dominance at their knee. That many of these features are present, both in individuals with acute ankle sprain and those with chronic ankle instability may advocate a link between acute deficits and long-term outcome. Clinicians must be aware that the sensorimotor deficits of ankle sprain may persevere beyond the acute stage of injury and be cognizant of the capacity for impairments to pervade proximally.
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NewsBot · Dec 27, 2016

Impact of a Lateral Ankle
Sprain in General Practice:
Comparison between Patients
With and Without Persistent
Complaints after 6-12 Months
John M. van Ochten, Sita MA Bierma-Zeinstra, Patrick JE
Bindels, and Marienke van Middelkoop
JSM Foot Ankle 1(3): 1013.

Background: Although ankle sprains are common and often lead to persistent complaints, their impact on functioning and related costs remains unclear.
Objective: To investigate the impact of a lateral ankle sprain on functioning and heath care utilization at 6-12 months follow-up.
Design: Cross-sectional study.
Setting: General practice.
Patients: 204 subjects were included from general practice after a lateral ankle sprain 6-12 months previously; 96 reported persistent complaints and
108 reported no persistent complaints, measured on a 7”point” Likert scale (with a respectively 3-7score in the persistent complaints group and with a 1-2
points score in the group without complaints).
Assessment of Risk factors: A standardized questionnaire included the 7”point” Likert scale to measure recovery.
Main outcome measures: A standardized questionnaire assessing history, pain and function.
Results: A significantly higher BMI (26.9 and 24.9 kg/m2), higher pain scores at rest (1.87 vs. 0.44) and during exercise (3.62 vs. 1.25) and a lower Ankle
Function Score (72.47 vs. 82.90) were reported in the group with persistent complaints, while a higher percentage of patients without persistent complaints
participated in sports (77.8% vs. 36.4%).
Limitations in functioning due to ankle sprain and a high medical consumption (76.5% visiting the GP, 20.1% a specialist and 45.6% a physiotherapist) and
radiographic imaging (35.3%) were reported in both study groups.
Conclusions: A lateral ankle sprain has a high impact on functioning and physical health, especially in those with persistent complaints. In subjects with and
without persistent complaints, considerable use of health care resources was found 6-12 months after the initial visit to the general practitioner.
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Dr Toe · Jan 3, 2017

...and they all end in later life arthritis... yipee

NewsBot · Jul 24, 2017

Clinical and radiological predictors for persistent complaints five years after a lateral ankle sprain: a long-term follow-up study in primary care
Adinda K.E. Mailuhu et al
Journal of Science and Medicine in Sport ; Article in Press

Objectives
To examine the five-year prognosis and potential prognostic factors of patients with an acute lateral ankle sprain in primary care setting.

Design
Observational study

Methods
206 patients who participated in a cross-sectional study and visited their general practitioner with an acute lateral ankle sprain 6 to 12 months prior to inclusion were approached for a 5-year follow-up measurement consisting of an online questionnaire. At baseline patients completed standardized questionnaires, underwent a standardized physical examination and radiological examination (radiography and Magnetic Resonance Imaging) and scored their perceived recovery. Logistic regression analysis was used to examine potential predictive factors at baseline for the presence of persistent complaints after 5 years.

Results
132 (64.1%) patients completed the 5-year follow-up. 18.2% reported persistent complaints and 30.3% had a re-sprain during follow-up. Baseline persistent complaints 6-12 months after an acute lateral ankle sprain (OR 6.38; CI 95% 1.54-26.44), dominant leg injury (OR 4.89; CI 95% 1.16-20.62) and a recurrent ankle sprain (OR 9.81; CI 95% 2.17-44.47) were significant predictors for persistent complaints 5 years after an acute ankle sprain. Physical examination and radiological findings did not add to the predictive value of the prognostic model.

Conclusions
Almost 20% of patients with an acute lateral ankle sprain experience persistent complaints after 5 years follow-up. Predictive factors for persistent complaints can be identified.
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Admin2 · Feb 28, 2018

Clinical and radiological predictors for persistent complaints five years after a lateral ankle sprain: A long-term follow-up study in primary care
Adinda K.E. Mailuhu' et al
Journal of Science and Medicine in Sport

Objectives
To examine the five-year prognosis and potential prognostic factors of patients with an acute lateral ankle sprain in primary care setting.

Design
Observational study.

Methods
206 patients who participated in a cross-sectional study and visited their general practitioner with an acute lateral ankle sprain 6–12 months prior to inclusion were approached for a 5-year follow-up measurement consisting of an online questionnaire. At baseline patients completed standardized questionnaires, underwent a standardized physical examination and radiological examination (radiography and Magnetic Resonance Imaging) and scored their perceived recovery. Logistic regression analysis was used to examine potential predictive factors at baseline for the presence of persistent complaints after 5 years.

Results
132 (64.1%) patients completed the 5-year follow-up. 18.2% reported persistent complaints and 30.3% had a re-sprain during follow-up. Baseline persistent complaints 6–12 months after an acute lateral ankle sprain (OR 6.38; CI 95% 1.54–26.44), dominant leg injury (OR 4.89; CI 95% 1.16–20.62) and a recurrent ankle sprain (OR 9.81; CI 95% 2.17–44.47) were significant predictors for persistent complaints 5 years after an acute ankle sprain. Physical examination and radiological findings did not add to the predictive value of the prognostic model.

Conclusions
Almost 20% of patients with an acute lateral ankle sprain experience persistent complaints after 5 years follow-up. Predictive factors for persistent complaints can be identified.
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NewsBot · Oct 3, 2018

The Role of the Calcaneofibular Ligament in Chronic Ankle Pain Following Severe Ankle Sprains
Richard Alvarez, MD, Randall Marx, MD, Mark Mizel, MD, Loren Latta, DPhil, Paul Clifford, MD
AOFAS Annual Meeting 2018 1

Introduction/Purpose: Lateral ankle pain persists in 10%-20% of patients following severe ankle sprains treated non-operatively.
The authors hypothesize that the peroneal tendons may become interposed between the ruptured ends of the calcaneofibular
ligament (CFL). Though previously visualized and noted in the literature, no studies have evaluated this lesion biomechanically and
anatomically. The purpose of this study is to demonstrate that following a severe lateral ankle sprain that the interposition of the
peroneal tendons between the ruptured ends of the CFL can occur.
Methods: Eight fresh-frozen cadaveric lower extremity specimens (defrosted) were secured by the foot to a wooden board in
the method of Lauge-Hansen. A manual inversion force was then applied to the ankle, both with the ankle in plantar flexion and
also in a neutral position to approximate a severe ankle sprain. Magnetic resonance imaging (MRI) was then performed on each
ankle. Each specimen was then dissected to observe the integrity and relationship of the lateral ankle structures.
Results: Four of the eight specimens sustained CFL tears as viewed by MRI and confirmed through anatomic dissection. One of
the four specimens with a CFL tear had a mid substance ligament rupture with the proximal half of the ligament positioned
superficial to the peroneal tendon complex. This relationship was observed using the MRI.
Conclusion: Creating severe lateral ankle sprain produced ruptures of the CFL with interposition of the peroneal tendon
complex between the torn ends of the ligament was seen and identified. This phenomenon may prevent primary ligament healing
of the CFL and may be a contributing factor in the chronic ankle pain of non-surgically treated lateral ankle sprains. Perhaps
surgical intervention should be considered if clinical suspicion exists, such as with a Stener lesion of the hand.
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NewsBot · May 21, 2019

The role of the anterior talofibular ligament area as a morphological parameter of the chronic ankle sprain
Jong-UkMuna1Hyung RaeChob1Yoo JunSungbKeum NaeKangcJungminLeedYoungJoodYoung UkKimd
Journal of Orthopaedic Science; 16 May 2019

Background
Repetitive microtrauma can result in a hypertrophied ATFL. Previous studies have found that the anterior talofibular ligament thickness (ATFLT) is correlated with lateral ankle sprains, ligament injuries and chronic stroke in patients, and thickened anterior talofibular ligament (ATFL) has been considered to be a major morphologic parameter of hypertrophied ATFL. However, hypertrophy is different from thickness. Thus, we devised the anterior talofibular ligament area (ATFLA) as a new morphological parameter to evaluate the hypertrophy of the whole ATFL.

Methods
ATFL samples were collected from 53 patients with sprain group and from 50 control subjects who underwent magnetic resonance imaging (MRI) of the ankle and revealed no evidence of lateral ankle injury. Axial T1-weighted MRI images were collected at the ankle level from all subjects. We measured the ATFLA and ATFLT at the anterior margin of the fibular malleolus to the talus bone on the MRI using a picture archiving and communications system. The ATFLA was measured as the whole cross-sectional ligament area of the ATFL that was most hypertrophied in the axial MR images. The ATFLT was measured as the thickest point between the lateral malleolus and the talus of the ankle.

Results
The average ATFLA was 25.0 ± 6.0 mm2 in the control group and 47.1 ± 10.4 mm2 in the sprain group. The average ATFLT was 2.3 ± 0.6 mm in the control group and 3.8 ± 0.6 mm in the hypertrophied group. Patients in sprain group had significantly greater ATFLA (p < 0.001) and ATFLT (p < 0.001) than the control subjects. A Receiver Operator Characteristics curve analysis showed that the best cut-off point of the ATFLA was 34.8 mm2, with 94.3% sensitivity, 94.0% specificity, and an AUC of 0.97 (95% CI, 0.94–1.00). The optimal cut-off point of the ATFLT was 3.1 mm, with 86.8% sensitivity, 86.0% specificity, and AUC of 0.95 (95% CI, 0.92–0.99).

Conclusion
ATFLA is a new morphological parameter for evaluating chronic ankle sprain, and may even be more sensitive than ATFLT.
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NewsBot · Nov 18, 2020

Quality of life, function and disability in individuals with chronic ankle symptoms: a cross-sectional online survey
M M Al Mahrouqi et al
J Foot Ankle Res. 2020 Nov 16;13(1):67

Background: Chronic ankle conditions affect approximately 20% of Australian adults. Although there is a plethora of research on chronic hip and knee conditions, there is limited understanding of the impact of ankle problems. Thus, the significance of chronic ankle conditions is not clear. The aim of this study was to compare self-reported function, disability, instability, physical activity and quality of life (QoL) between adults with and without ankle symptoms. A secondary aim was to explore factors associated with QoL.

Method: Individuals with symptoms of ankle pain and stiffness (symptomatic individuals) and controls with no ankle pain or stiffness (asymptomatic individuals) completed a cross-sectional online survey. The survey included the Ankle Osteoarthritis Scale (AOS), Foot and Ankle Ability Measure (FAAM), Cumberland Ankle Instability Tool (CAIT), International Physical Activity Questionnaire (IPAQ), Assessment of QoL (AQoL-6D), and questions about ankle injury history.

Results: A total of 394 individuals (270 symptomatic and 124 asymptomatic) with mean age of 48.8 (standard deviation (SD): 12.1) years and body mass index of 28.7 (7.7) kgm- 2 completed the survey. Standardized mean differences (SMD) were large to very large (1.45 to 3.20) for greater disability (AOS) and instability (CAIT), and poorer function (FAAM) in symptomatic compared to asymptomatic individuals. Individuals with ankle symptoms had higher body mass index and lower QoL (medium effect: SMD > 1). There were no differences in self-report physical activity between groups. Lower activities of daily living (ADL) function (FAAM-ADL) best explained QoL in a multiple regression model (R2 = 0.66, p = 0.001).

Conclusion: Individuals with ankle symptoms reported ankle instability, greater disability, compromised function and worse QoL compared to asymptomatic individuals. There was a strong relationship between ankle function and QoL. Ankle-specific ability during ADL best explained the reduced QoL in individuals with ankle symptoms. Clinicians and researchers should consider ankle function as an antecedent to poorer QoL in patients who have ankle symptoms.
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NewsBot · Dec 23, 2021

The presence of persistent symptoms 12 months following a first lateral ankle sprain: A systematic review and meta-analysis
FrederickMichelsabc et al
Foot and Ankle Surgery; 15 December 2021

Highlights
•The occurrence of remaining symptoms at 12 months is much lower in the current analysis than in previous studies. This may be explained by focusing on study quality and exclusion of patients with previous injuries.
•This study demonstrates that symptoms continue to decrease between 6 and 12 months. This novel information is useful in treatment strategies. A higher threshold to consider a surgical treatment is recommended in the first 12 months after a first LAS.
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Background
A lateral ankle sprain (LAS) is the most common musculoskeletal injury in the physically active population. It is uncertain what percentage of these patients develop persisting symptoms including pain, recurrent sprains and subjective instability. This systematic review was conducted to assess the presence and duration of persistent symptoms after a first LAS.

Methods
A systematic review of the Medline, Web of Sciences, Embase, CINAHL and Pedro databases was performed to identify peer-reviewed articles concerning the occurrence and duration of remaining symptoms after a first LAS. Inclusion criteria focused on selection of patients without previous ankle injuries and study quality. One of the following outcomes had to be described: subjective instability, resprains, remaining symptoms.

Results
In total, 15 studies were included. The occurrence of patients with subjective instability decreased from 37.9% (95%CI [6.0-69.7]) at 3 months to 16.1% (95%CI [7.8-24.3]) at 6 months and 8.1% (95%CI [3.3-13.3]) at 12 months. The occurrence of patients with a recurrent LAS was 15.8% (95%CI [6.3-25.3]) at 12 months. The occurrence of patients with residual pain decreased from 48.6% (95%CI [23.6-73.5]) at 3 months, to 21.5% (95%CI [2.8-40.2]) at 6 months and 6.7% (95%CI [3.2-10.1]) at 12 months.

Conclusion
This study offers new insights in the presence of remaining symptoms after a first LAS and the development of chronic ankle instability. Twelve months following an initial LAS, a significant number of patients may still have symptoms. The incidence of subjective instability, and pain, continues to decrease until 12 months post-injury. This new information may suggest that a longer period of non-operative treatment may be warranted before recommending surgical intervention in patients with a first LAS.
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NewsBot · Dec 13, 2022

Chiropractic Management of Chronic Ankle Pain and Limited Mobility in a Pediatric Athlete: A Case Report
Randy L.HewittDCJennifer L.BrockerDC
Journal of Chiropractic Medicine; 13 December 2022

Objective
The purpose of this case study was to report the chiropractic management of a teenage athlete who had chronic pain after a lateral ankle sprain.

Clinical Features
A 15-year-old male patient presented with persistent ankle pain due to an inversion sprain while playing soccer approximately 8.5 months prior. Emergency department records noted a left lateral ankle sprain, including the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The examination revealed ankle tenderness upon palpation, limited active and passive dorsiflexion range of motion, restricted talocrural joint posterior glide, and moderate lateral compartment muscular hypertonicity.

Intervention and Outcome
Chiropractic management included high-velocity, low-amplitude chiropractic ankle manipulation and education on home-based ankle dorsiflexion stretching. After 4 treatments, the athlete returned to unencumbered athletic participation. Follow-up evaluation at 5 months revealed no pain or functional complaints.

Conclusion
This teen athlete's chronic pain from a lateral ankle sprain resolved with a short course of chiropractic manipulation coupled with home-based stretching.
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NewsBot · Sep 5, 2023

Factors associated with persistent pain in college athletes with a history of lateral ankle sprain
Yuta Koshino et al
Phys Ther Sport. 2023 Aug 30

Objectives: To determine the factors associated with and prevalence of persistent pain in college athletes with chronic ankle instability (CAI) and with previous lateral ankle sprain (LAS) without CAI.

Design: Cross-Sectional Study.

Setting: Online survey at one university.

Participants: Of the 385 respondents surveyed online, 140 were identified as having experienced at least one LAS (CAI group: 69, coper group: 24, LAS group not classified as either: 47).

Main outcome measures: Factors associated with the presence of pain during activities of daily living (ADL) and sports were identified using multivariate logistic regression analyses. Independent variables were demographics, injury characteristics, the Identification of Functional Ankle Instability (IdFAI) score, the Foot and Ankle Ability Measure Sports (FAAM-Sports) and ADL subscales, and the Tampa Scale for Kinesiophobia-11 score.

Results: The prevalence of pain during ADL and sports in the three groups was 16.7%-42.0% and 33.3%-56.5%, respectively. FAAM-Sports and IdFAI score were significantly associated with pain during ADL and sports in the CAI group (odd ratio: 0.923 and 1.145), respectively. No significant pain-related factors were found in the coper and LAS groups.

Conclusions: Lower self-reported function and greater perceived ankle instability may be important factors in pain management in athletes with CAI.
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NewsBot · Sep 15, 2023

Falls and falls-related injuries in individuals with chronic ankle symptoms: a cross-sectional study
Munira M. Al Mahrouqi, Bill Vicenzino, David A. MacDonald & Michelle D. Smith
Journal of Foot and Ankle Research volume 16, Article number: 49 (2023)

Background
Falls are a major public health concern globally. While falls are associated with osteoarthritis and persistent pain at the hip and knee, falls have not been investigated in people with chronic ankle symptoms. This study aimed to compare self-reported history of falls between adults with and without chronic ankle symptoms. Secondary aims were to compare concern about falling and balance confidence between groups, and to identify factors associated with falling.

Methods
A total of 226 participants (134 with chronic ankle pain and/or stiffness and 92 controls) participated in this cross-sectional case–control study. Participants completed an online questionnaire about falls in the past 12 months, injuries associated with falling, concern about falling, balance confidence, function, pain and multimorbidity.

Results
Eighty-six (64%) participants with chronic ankle symptoms and 24 (26%) controls reported at least one fall in the last 12 months (p < 0.001). Participants with chronic ankle symptoms reported more falls, more injurious falls, and more hospitalisations because of a fall than controls (p > 0.002). There was a small effect for lower balance confidence and higher concern about falling in symptomatic participants (standardised mean difference: 0.39–0.49; p > 0.017). Logistic regression analysis identified that falling was associated with the presence of ankle symptoms (3.08 (1.20, 7.92); p = 0.02) and concern about falling (odds ratio (95% confidence intervals): 1.13 (1.05, 1.23); p = 0.002).

Conclusions
Falls and falls-related injuries are a problem in individuals with chronic ankle symptoms. The high falls occurrence and concern about falling in individuals with chronic ankle symptoms suggest the need for clinicians to assess these factors in this population.
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