ANKLE INJURY TREATMENT AND PREVENTION:

A LITERATURE REVIEW

By: Bryan Walters

Faculty Advisor: Rodger Tepe, PhD

A senior research project submitted in partial requirement

for the degree Doctor of Chiropractic

11/15/2012

Walters: Ankle injury treatment and prevention Page 1

ABSTRACT

Objective

To overview and evaluate the recent literature concerning the efficacy of the most common ankle
injury prevention techniques. Emphasis was given to articles that focused specifically on the
prevention of sport related ankle injuries, although studies focusing on the general population
were also included. Attention was given to comparing the conservative care options, as well as a
comparison between conservative care and ankle injury prevention techniques.

Data Collection

Key word searches using GoogleScholar, PubMed, Index to Chiropractic Literature and
MANTIS/ChiroAccess from 1999-2013.

Conclusions

A consensus of systematic reviews and controlled studies support the conclusion that prevention
techniques are effective in reducing the incidence of recurrent ankle sprains among athletes.
Emerging evidence shows that neuromuscular training, balance training, and strengthening
exercises all play an effective role in the prevention of ankle injuries. Current evidence does not
clearly demonstrate the superiority of any single method of ankle injury prevention, however
combinations of education/counseling, exercise/stretches, balance training, and neuromuscular
training produce better outcome than any single intervention used alone. Further research is
needed to determine the most effective combination of interventions.

Key Words: Ankle injury, prevention, ankle sprain, ankle instability, athletes, protocol,
alternative treatment, training program, conservative treatment, exercise, wobble board
training, whole body vibration, bracing and taping.

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INTRODUCTION

Ankle injuries are frequently occurring among athletes of all types and all ages. There is a

substantial body of literature regarding ankle injury and ankle injury prevention among high

school and college athletes. The purposes of this literature review are: to review and critique the

existing literature; and consider the relative effectiveness of single vs. combinations of balance

training and strengthening exercises. Ankle injuries are among the most commonly occurring

sports injuries. 1 Approximately 4,000,000 athletic ankle injuries occur in the United States every

year, one-half involve severe sprains. 1 The incidence of ankle sprains has been estimated at 1

per 10,000 persons per day. 2 Many ankle injuries occur during sporting activities, and they are

one of the most common athletic injuries in amateur and professional athletes alike. 3, 4

Particularly, severe injuries such as ankle sprains are often associated with long-term time off,

increased and long-term disability. 2 Athletes who suffer from ankle sprains are more likely to

reinjure the same ankle, which can result in disability and can lead to chronic pain or instability

in 20% to 50% of these cases. 5, 6 Recent research has shown that the mean total costs (direct and

indirect costs) of one ankle sprain are approximately $360. 7 This indicates that the rough annual

estimate of the cost of ankle sprains is $43,200,000. Absence from paid or unpaid work was

responsible for up to 80% of these costs. 8 In addition, there is strong evidence that athletes have

a two-fold risk for re-injury after a previous ankle sprain, especially during the first year post-

injury. 9 A 20% reduction in numbers would equal 800,000 fewer ankle injuries per year.

Improving the joint position sense could also result in a reduction of the number of injuries.2

Professionals working in hospital emergency departments and emergency care settings treat

ankle sprains frequently. In fact, 10% of emergency department visits are due to ankle injuries

and 75% of these injuries are sprains. 10, 11 As a result, the enormous amount of resources

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devoted to treating ankle sprains is indicative that these injuries are a major health concern for all

medical professionals, including chiropractors .12 Any advances made in the area of sports-

related injuries could also prove to be a good resource for non-sports-related ankle injuries. The

relatively high rate of ankle injuries across all sports, as well as the severity and subsequent

negative consequences of ankle sprains on future sports participation motivates attention for

preventive measures against this type of injury.

DISCUSSION

Anatomy:

The ankle joint is a hinged synovial joint with primarily plantar flexion and dorsiflexion,

however, when the ranges of motion of the ankle and subtalar joints are taken together, they

make up complex movement functions which move as a universal joint. Athletes that are

commonly running and jumping often injure this delicate joint complex. 13 These specific

movements often result in ankle inversion during plantar flexion, which is the most common

type of ankle sprain. 14 Therefore, it has been suggested that strengthening the evertor muscles,

which provide support to the lateral ligaments of the ankle joint, will help to prevent recurrent

ankle inversions during sports. 15 Injuries can also occur to the medial ligaments of the ankle

joint. The medial ligaments of the ankle are known as the Deltoid ligament. Deltoid ligament

injuries can occur up to 18% of the time with ankle sprains. 16 This sprain occurs with over

pronation (eversion) trauma leading to forced external rotation and abduction of ankle. Many

athletes also experience high ankle sprains, which is a sprain of the syndesmotic ligaments that

connect the tibia and fibula on the lower leg. Syndesmotic ankle sprains are known as high

because their location on the lower leg is above the ankle. Although somewhat rare, high-ankle

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syndesmotic ankle sprains occur in up to 15% of ankle trauma injuries. 17 In view of appropriate

intervention strategies, the prevention of injuries must be considered a primary goal.

Treatment:

In the acute injury situation, recommended care of an ankle sprain consists of rest, ice,

compression, and elevation. An ankle sprain is graded on a scale of 1-3, depending on severity,

with grade 3 being the most severe. While the injury requires certain amounts of rest based on

the grade of sprain, an athlete can begin rehab once they are medically cleared to do so. There

are a variety of interventions before and after a sprain that have been shown to be effective in

reducing the re-occurrence of sprains. Strategies to reduce ankle injuries generally have focused

on increasing strength, taping, use of braces, and /or improving balance/proprioception.

Strength and conditioning that focuses on prevention of ankle injuries uses resistance bands, and

isometric exercises training. These strength training exercises are commonly used to prevent

recurrent ankle sprains. The exercises aim to increase the strength of the ankle joint muscles and

prevent excessive inversion or eversion. Current research does not support a long-term reduction

in incidence, but rather a short-term effectiveness in preventation. 18 Strength training is most

beneficial with the help of a qualified professional.

The use of tape is also a common technique to use both pre- and post-ankle injury. Ankle taping,

most commonly used after an ankle injury, can be effective when applied properly. A 2010

review of seven studies found that taping was as effective as ankle braces, with a 71 percent

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reduction in sprains with taping versus a 69 percent reduction with braces. 19 However, it is

important to note that taping has more variables that can influence and even reduce its

effectiveness, including the skill of the trainer, the sport participated in, and the amount of

playing time.

Applying braces is another commonly used method for dealing with ankle injuries. Present

studies show that the commercially available semi-rigid braces can reduce the magnitude of

ankle angular displacement, as well as angular velocity during sudden supination motion. 20

Braces have been shown on average to reduce the inversion angular displacement by 35% when

compared with a control condition during sudden supination. Braces are widely available and

are easy to apply correctly without professional supervision.

Previous research has also shown that balance training with a Wobble Board can reduce ankle

injuries. 20, 21 In this context, recent studies have shown positive effects of different balance

exercise programs targeting the enhancement of proprioceptive, neuromuscular, and sensor

motor abilities 20, 21 through one leg standing 22 and wobble board exercise. 20 These techniques

have been shown to significantly reduce the number of ankle injuries amongst athletes, and have

the most promising preventative ability.

Taping

A study titled, “Effects of previous lateral ankle sprain and taping on the latency of the peroneus

longus,” 20 looked at how taping could improve the peroneus longus reaction to inversion. This

study goes on to say that, “The latency of the peroneus longus may be a key factor in the

prevention of lateral ankle sprain (LAS)”. The study had twenty-six participants, including

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thirteen participants with no previous history of LAS and thirteen participants with a history of

single LAS completed the testing. Ankle taping was applied in a closed basket weave technique

on one of the two testing days. The latency of the peroneus longus was determined by the onset

of muscle activity exceeding 10 SD from baseline activity, after initiation of the 25 degrees

inversion perturbation. A significant main effect (p < 0.05) was present for the ankle support

condition, with ankle taping causing a significant reduction in latency of the peroneus longus

(65.04 +/- 10.81 to 57.70 +/- 9.39 ms). There was no difference (p > 0.05) in latency between the

injury groups. This study concluded that ankle taping, immediately after application, reduces the

latency of the peroneus longus among participants with and without a history of LAS.

Bracing

A study titled, “A study of semi-rigid support on ankle supination sprain kinematics,” 19 looked

at how ankle braces could decrease the amount of supination/inversion during a sudden

supination motion. The study took eleven subjects ranging in age from 22 to 36 years and

subjected them into experimental procedures. The bracing condition of semi-rigid ankle braces

was investigated. The angular displacement and angular velocity of the ankle were compared.

The motion-capture system was adopted to capture the three-dimensional coordinates of the

reflective markers used and detect the amount of supination. The coordinates of the reflective

markers were used to compute the ankle kinematics during simulated ankle supination. A

mechanical supination platform was used to simulate the sprain motions. The experimental

results showed that the semi-rigid brace tested significantly reduced the ankle angular

displacement and angular velocity compared with control conditions during sudden supination.

The study concluded that the semi-rigid-type brace can provide significant restriction to reduce

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the magnitudes of the angular displacement and angular velocity of the ankle during sudden

supination sprain.

While there are positives to taping and bracing, there are negative side effects, as well. If not

fitted properly, these methods can cause patient discomfort and skin irritation, and can have

relatively high costs. The negative side effects of bracing and taping justify the development of

an alternative method of prevention. 17, 18, 19

Prevention:

Exercise (strengthening)

A study titled, “Effects of strength training on strength development and joint position sense in

functionally unstable ankles,” looked at how resistance band training can increase joint position

sense. 23 This study’s objective was to examine the effects of ankle-strengthening exercises on

joint position sense and strength development in subjects with functionally unstable ankles. The

design used twenty health college students with a history of functional ankle instability. Subjects

were randomly assigned into a training or control group. The training group participated in a 6

week strength-training protocol using rubber tubing 3 times a week throughout the training

period. The control group did not participate in the strength training protocol. The study

indicated that ankle-strengthening exercises improved inversion joint position sense and plantar

flexion joint position sense in subjects with functionally unstable ankles. The study went on to

say that the improved joint position sense is most likely due to improvement in the muscle

spindle sensitivity, resulting in greater acuity in sensing joint position. This study concluded that

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the findings suggest that strength training can play the dual role of increasing both strength and

joint position sense.

A significant improvement in strength deficits following a strength training intervention was

shown a recent 2008 literature systemic review. This study is titled, “The effectiveness of active

exercise as an intervention for functional ankle instability”. 24 This review included sixteen

articles describing the active exercise treatment of functional ankle instability which met the

inclusion criteria. All subjects had a history of functional ankle instability either bilaterally or

unilaterally. One of the studies included in this review used a 6 week program with 12 exercises

and found that the exercise showed significant improvement in all ankle instability tests.25 The

review concluded that different interventions such as elastic band exercises, isokinetic exercises,

and bi-directional bicycle exercises translate to increased speed of muscle reaction to a

perturbation of the unstable ankle. Also, improving muscle reaction time for peroneus longus

and brevis through an intensive exercise program is an effective strategy for neuromuscular

adaptation to prevent recurrent sprains.

Balance and Proprioception

Proprioception is the body’s ability to transmit a sense of position, analyze that information and

react (consciously or unconsciously) to the stimulation with the proper movement. Simply put, it

is the body’s ability to know where all its parts are whether moving or still and what the body’s

relationship to gravity. Taken as a whole, proprioception includes all voluntary and involuntary

movement: balance, coordination and agility because the body’s proprioceptors control all these

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factors. Recent research points to the importance of restoring proprioception damaged muscles

and ligaments following an ankle sprain through specific exercises, wobble board training, and

whole body vibration. 9, 26, 27

McGuine, and Keene completed a randomized controlled clinical trial with seven hundred and

sixty five high school soccer and basketball players. This study titled, “The effect of a balance

training program on the risk of ankle sprains in high school athletes,”9 hypothesized that a

balance training program can reduce the risk of ankle sprains in high school athletes. The

study’s subjects were 523 girls and 242 boys from 12 different local area high schools Soccer

and Basketball programs that utilized certified athletic trainers. The subjects were divided into

control and intervention groups. The intervention group performed a 5-phase balance training

program during the season, Phase 1-4 were performed 5 days per week. Phase 5 was performed 3

days per week. Each phase consisted of a set of exercises which progressed in difficulty. Sixty-

two of the 765 subjects sustained an acute ankle sprain during their sports season. Overall, the

rate of ankle sprains was significantly lower for subjects in the intervention group with only a

6.1% ankle injury rate vs. the control group at 9.9%. The study went on to say that, Athletes in

the control group with a history of an ankle sprain had a 2-fold increased risk of sustaining a re-

injury, whereas athletes who performed the intervention program decreased their risk of a sprain

by one half. The ankle sprain rate for athletes without previous sprains was 4.3% in the

intervention group and 7.7% in the control group, but this difference was not considered

significant. The study concluded to say that “a balance training program will significantly reduce

the risk of ankle sprains in high school soccer and basketball players.”

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A 2011 study titled, “Is Proprioceptive Training Effective in Reducing the Recurrence of Ankle

Sprains among athletes?” 26 was a systematic review or the effects of proprioceptive training in

reducing the recurrence of ankle sprains among athletes. This study included three randomized

controlled trials in their data collection. All three random controlled studies found that the

athletes participating in proprioceptive training experienced a significantly lower incidence of

recurrent ankle sprains than the control group participating in strength and conditioning

exercises. These results lead the research to suggest that proprioceptive training can be ver

effective for recurrent ankle sprains, but does not suggest that proprioception will prevent

primary ankle injuries. It would be helpful to determine if proprioceptive training can be used to

prevent primary injuries.

A 2004 study from The American Journal of Sorts Medicine hypothesized that a proprioceptive

balance board program would be effective for prevention of ankle sprains in volleyball players.
27
The study took 116 male and female volley ball teams during the 2001-2002 season. The

teams were randomized to either an intervention group or a control group. The control teams

followed their normal training routine. The intervention teams followed a prescribed balance

board training program. The coaches recorded their exposure on a weekly basis for each player.

If a player was injured, the coach would note so. The study found that there were significantly

lower ankle sprains in the intervention group when compared to the control group. A significant

difference was found only seen in players with a previous history of ankle injury. The study

could not conclude the prescribed balance board training program could prevent primary ankle

injuries. The study concluded that, “ Use of proprioceptive balance board program is effective

for prevention of ankle sprain recurrences.”

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Whole body vibration:

Although not studied specifically in relationship to ankle injury prevention, whole body vibration

has been shown to improve proprioception/balance, thus it may have potential to be included in a

multi-intervention program for ankle injury perception along with balance board training and

strength training. A whole body vibration machine uses a vibrating plate to transfer vibrations

into the body. These vibrations are picked up by the body’s proprioceptive mechanoreceptors.

The body has to sift through the extra proprioceptive signals to find out where the body is in

space. Therefore, whole body vibration trains the body to be more sensitive, and have an

improved proprioceptive ability.

A study titled, “effects of whole-body vibration training on explosive strength and postural

control in young female athletes” 28 aimed to evaluate the effectiveness of a whole body

vibration training program to improve neuromuscular performance in young elite female athletes.

The study took twenty three women basketball players and randomly assigned them to a control

group or to an intervention group. The control group performed its normal training program but

the whole body vibration group was subjected to fifteen weeks of whole body vibration training

in conjunction with their normal training. The study analyzed single limb standing balance for

both legs and with eyes open and closed at 3 item points” before training, after 8 week training

period, and after a further 7 week training period. The study found that the lateral deviation of

the center of pressure in the closed eyes test decreased significantly with whole body vibration in

both the right and left leg. They concluded that “15 weeks of whole-body vibration training

program improves explosive strength and postural stability in adolescent female basketball

players.”

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CONCLUSION

A consensus of systematic reviews and controlled studies support the conclusion that prevention

techniques are effective in reducing the incidence of recurrent ankle sprains among athletes. The

strength of this body of evidence is strongly supportive, but not yet compelling. Emerging

evidence shows that neuromuscular training, balance training, and strengthening exercises all

play an effective role in the prevention on ankle injuries. Current evidence does not clearly

demonstrate the superiority of any single method of ankle injury prevention, however

combinations of education/counseling, exercise/stretches, balance training, and neuromuscular

training produce better outcome than any single intervention used alone. Further research is

needed to determine the most effective combination of interventions.

Walters: Ankle injury treatment and prevention Page 13

REFERENCES

1. Anadacoomarasamy, L Barnsley. "Long term outcomes of inversion ankle injuries." Br J

Sports Med (2005): 39:e14

2. Kathryn A. Webster, Phillip A. Gribble. "Functional Rehabilitation Interventionsfor Chronic

Ankle Instability:A Systematic Review." Journal of Sport Rehabilitation (2010): 19, 98-114.

3. JG, Garrick. "Te frequenc of injury, mechanism of injury, and epidemiology of ankle sprains."
Am J Sports Med (1977): 5:241-242

4. PJ, Meeuwisse P. Fowler. "Frequency and predictability of sports injuries in intercollegiate

athletics." Can j Sports Sci (1988): 13:35-42

5. Bahr R, Bahr IA. Incidence of acute volley ball injuries: a prospective cohort study of injury
mechanisms and risk factors. Scand J Med Sci Sports. 1997;7:166-171

6. Sander E. Ligamentous injuries to the ankle. Am Fam Physician. 1980;22:132-138.

7. Milgrom c, Shalamkovitch N, Finestone A, Eldad A, Laor A, Danon YL, Lavie O, Wosk J,

Simkin A: Risk factors for lateral ankle sprains: a prospective study among military recruits.
Foot ankle. (1991), 12:26-30

8. Bahr., Bahr L: a incidence of acute volleyball injuries: a prospective cohort study of injury
mechanisms and risk factors. Scand J Med Sci Sports 1997, 7:66-67

9. McGuine TA, Keene JS. The Effect of a Balance Training Program on the Risk of Ankle
Sprains in High School Athletes. Am J Sports MED. Jul 2006;34(7):1103

10. Packer GJ, Goring CC, Gayner AD, Craxford A. Audit of ankle injuries in an accident and
emergency department. BMJ 1991;302;885-887

11. Karen A. Berk PA-S. Is proprioceptive training effective in reducing the recurrence of ankle
sprains among athletes?. (2011). Physcician assistant studies student scholarship. Paper 47

12. Hale, SA, Hertel, J, and Olmsted-Kramer, LC. The effect of a 4-week comprehensive
rehabilitation program on postural contol and lower extremity function in individuals with
chronic ankile instability. J Orth Sports Phys Ther 37;303-311. 2007

13. Mohammadi F. comparison of 3 preventive methods to reduce the recurrence of ankle

inversion sprains in male soccer players. Am J Sports Med. 2007;35(6):922-926

14. Tropp H, Askling c., Gillquist J. Prevention of ankle sprains. American Journal of Sports
Medicine. 1985;259-262

Walters: Ankle injury treatment and prevention Page 14

15. Lin et al. J Orthop Sports P Phys. 372-hys Ther 2006; 36: 372 384

16. Childs SG. Syndesmotic ankle sprain. Orthop Nurs. 2012 May-Jun;31(3):177-84

17. Mohammadi F. Comparison of 3 preventitive methods to reduce the recurrence f ankle

inversion sprains in male soccer plaers. Am J Sports Med. 2007;35(6):922-926

18. Dizon JM, Reyes JJ. A systematic review on the effectiveness of external ankle supports in
the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport.
2010;13(3):309-317

19. Tang YM, Wu ZH, Liao WH, Chan KM. A study of semi-rigid support on ankle supination
sprain kinematics.Scand J Med Sci Sports. 2010 Dec;20(6):822-6

20. MARKUS HU¨ BSCHER, ASTRID ZECH, KLAUS PFEIFER. "Neuromuscular Training
for Sports InjuryPrevention: A Systematic Review." Department of Sports Medicine (2010): 42,
No. 3, pp. 413–421.

21. Trevino SG, Davis P, Hecht Pj. "Management of acute and chronic lateral ligament injuries
aof the ankle." Orthop Clin North Am (1994): 25:1-16

22. Sekir U, Yildiz Y, Hazneci B, Ors F, Aydin T. Effect of isokinetic training on strength,
functionality and proprioception in athletes with functional ankle instability.Knee Surg Sports
Traumatol Arthrosc. 2007 May;15(5):654-64

23. Carrie L Docherty, Josef H. Moore, Brent L. Arnold. “Effects of strength training on strength
development and joint position sense in functionally unstable ankles.” Journal of athletic training
1998 Dec; 33(4):310-314

24. Janice K. Loudon, Marcio J. Santos, Leah Franks, Wen Liu. “the effectiveness of active
exercise as an intervention for functional ankle instability.” Sports Med. 2008: 38 (7):553-563.

25. Elis E, rosenbaum D. “A multi-station proprioceptive exercise program in patients with ankle
instability. Med Sci Sports Exerc 2001;33: 1991-8

26. Berk, Karen A. PA-S, “is Proprioceptive Training Effective in Reducing the Recurrence of
Ankle Sprains among Athletes?” (2011). Physician assistant Studies Student Scholarship.
Paper 47

27. Evert Verhagen, Allard Van der Beek, “The effect of a Proprioceptive Balance Board
Training Program for the Prevention of Ankle Sprains.” (2004). The american journal of sports
medicine. 32:1385

Walters: Ankle injury treatment and prevention Page 15

28. Azahara Fort, Daniel Romero, “Effects of Whole-body vibration Training on Explosive
strength and Postural control in Young Female Athletes.” (2012). The journal of strength and
conditioning research. 26 (4) 926-936.

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