Sensorimotor Deficits with Ankle Sprains and Chronic Ankle Instability

doi:10.1016/j.csm.2008.03.006

Clinics in Sports Medicine

Volume 27, Issue 3, July 2008, Pages 353-370

https://doi.org/10.1016/j.csm.2008.03.006 Get rights and content

The presence of sensorimotor deficits in patients who have suffered ankle sprains or who have chronic ankle instability has been recognized for several decades; however, a body of research literature has developed that elucidates potential physiologic explanations for these deficits. Alterations in a spectrum of sensorimotor measures make it apparent that conscious perception of afferent somatosensory information, reflex responses, and efferent motor control deficits are present with ankle instability. The specific origin of these deficits local to the ankle ligaments or at the spinal or supraspinal levels of motor control have yet to be fully elucidated. It is clear, however, that both feedback and feedforward mechanisms of motor control are altered with ankle instability.

Section snippets

Traditional Theory of Ankle Instability and Sensorimotor Deficits

Through a series of animal [17] and human [18], [19], [20], [21] studies in the 1960s Freeman and colleagues proposed a theory that “functional” (ie, sensorimotor) deficits after joint injuries were attributable to damage to the afferent receptors within the injured ligaments and joint capsule. They specifically referred to this concept as “articular deafferentation” and proposed that when the ankle ligaments were sprained there was disruption not only of the collagenous connective tissue but

Proprioception

Proprioception allows for the sensation of body movement and position. Although this term is often used (erroneously) in the orthopedic literature to convey the integration of afferent and efferent processes to allow for the dynamic stabilization of joints, proprioception is a purely afferent phenomenon on par with other sensory modalities. Proprioception is most often measured by assessing joint position sense, kinesthesia (sensation of movement), and force sense.

Motoneuron Pool Excitability

Arthrogenic muscle inhibition has been defined as a continuing reflex reaction of the musculature surrounding a joint after distension or damage to the structures of that joint [45]. Arthrogenic muscle inhibition is measured by assessing motoneuron pool excitability of a specific muscle group. This assessment is not a direct measure of muscle contraction output, but rather an estimation of how much of the alpha motoneuron pool for a specific muscle group is available and, in some measures,

Reflex Reactions to Inversion Perturbation

Several researchers have assessed muscular response to unexpected ankle inversion perturbations in an attempt to assess sensorimotor deficits associated with ankle instability. Considerable methodological differences exist across these studies, but in general a research subject stands on a trapdoor platform that is triggered to unexpectedly drop one of the subject's ankles into inversion (and sometimes plantar flexion or internal rotation too). Surface electromyography is used to assess the

Muscle Strength

It is often assumed that lateral ankle instability is associated with peroneal muscle weakness; however, there is not overwhelming experimental evidence to support this notion [59]. In addition to the peroneals, studies have also investigated the strength of the other prime movers about the ankle. If muscle strength deficits do exist after ankle sprain, the physiologic mechanism of such deficits is not readily apparent. Although mechanical damage to the peroneal tendons does occasionally occur

Postural Control

Measures of balance, or postural control, during single limb stance have frequently been used to estimate sensorimotor function in individuals who have lateral ankle instability. Postural control requires the integration of somatosensory, visual, and vestibular afferent information and appropriate efferent responses to control muscles in the trunk and extremities in an effort to maintain balance. Researchers have used noninstrumented and instrumented assessments of postural control in relation

Gait

There have been relatively few studies published that have examined gait deficits associated with acute ankle sprain or CAI.

Jump Landings

High-level sensorimotor function in individuals who have CAI has been assessed with various kinesiologic measures during jump landings. Assessment during such activities is advocated by researchers because landing from a jump is a frequent mechanism of lateral ankle sprain.

Contemporary Theory: Ankle Instability and Sensorimotor Deficits

Building from Freeman's original theory of joint deafferentation after ankle ligament injury that is based on a feedback-only model of proprioceptive and efferent motor control deficits, we are able to contextualize the current body of literature to form a more comprehensive theoretic model that encompasses both feedback and feedforward mechanisms of motor control deficits related to ankle instability (Fig. 4). Direct evidence to show mechanoreceptor deficits after ankle ligament injury remains

Summary

Alterations in a spectrum of sensorimotor deficits have been identified in individuals after acute ankle sprain and with chronic ankle instability. It is apparent that conscious perception of afferent somatosensory information, reflex responses, and efferent motor control deficits are present with ankle instability. The specific origin of these deficits local to the ankle ligaments or at the spinal or supraspinal levels of motor control have yet to be fully elucidated; however, it is clear that

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Cited by (331)

Effect of sensor location for modifying center of pressure during gait using haptic feedback in people with chronic ankle instability
2024, Gait and Posture
Gait retraining using haptic biofeedback medially shifts the center of pressure (COP) while walking in orthopedic populations. However, the ideal sensor location needed to effectively shift COP medially has not been identified in people with chronic ankle instability (CAI).
Can a heel sensor location feasibly be employed in people with CAI without negatively altering kinematics? Does a heel sensor placement relative to the 5th metatarsal head (5MH) impact COP location while walking in people with CAI?
In this exploratory crossover study, 10 participants with CAI walked on a treadmill with vibration feedback for 10 minutes with a plantar pressure sensor under the heel and 5MH. Separate 2×2 repeated measures analyses of covariances (rmANCOVAs) were used to compare the averaged COP location and 3-D lower extremity kinematics from the first 10% of stance before and after training and between sensor locations. Baseline measures served as covariates to adjust for baseline differences.
Feedback triggered by a heel sensor resulted in 40% of participants avoiding a heel strike. There were no significant main effects or interactions between time and sensor location on COP location when controlling for baseline COP (p>0.05). However, with the 5MH placement, participants displayed less ankle internal rotation(IR) (5MH/Heel: −4.12±0.00º/ −6.43±0.62º), less forefoot abduction (-4.29±0.00º/ −5.14±1.01º), more knee flexion (3.40±0.32º/ 0.14±0.57º), less knee external rotation (-10.95±0.00º/-11.24±1.48º), less hip extension (-0.20±0.00º/-1.42±1.05º), and less hip external rotation (3.12±0.00º/3.75±1.98º).
A 5MH location may be more feasible based on difficulties maintaining heel strike when the sensor was under the heel. While no sensor location was statistically better at changing the COP, the 5MH location decreased proximal transverse plane motions making participants’ gait more like controls. Individual response variations support comprehensive lower extremity assessments and the need to identify responder profiles using sensory feedback in people with CAI.
The impact of whole-body vibration training and proprioceptive neuromuscular facilitation on biomechanical characteristics of lower extremity during cutting movement in individuals with functional ankle instability: A parallel-group study
2024, Clinical Biomechanics
We compared the effects of whole-body vibration training and proprioceptive neuromuscular facilitation on the biomechanical characteristics of the lower limbs in functional ankle instability patients during cutting movement to ascertain the superior rehabilitation method.
Twenty-two male College students with unilateral functional ankle instability volunteered for this study and were randomly divided into whole-body vibration training group and proprioceptive neuromuscular facilitation group. Kinematics data and ground reaction forces were collected using infrared motion capture system and 3-D force plates synchronously during cutting. Repeated measures two-way ANOVA was performed to analyze the data.
Both training methods reduced the maximum hip abduction angle (p = 0.010, effect size: proprioceptive neuromuscular facilitation = 0.69; whole-body vibration training = 0.20), maximum knee flexion angle (p = 0.008, effect size: proprioceptive neuromuscular facilitation = 0.39, whole-body vibration training = 1.26) and angular velocity (p = 0.014, effect size: proprioceptive neuromuscular facilitation = 0.62, whole-body vibration training = 0.55), maximum ankle inversion angular velocity (p = 0.020, effect size: proprioceptive neuromuscular facilitation = 0.52, whole-body vibration training = 0.81), and knee flexion angle at the time of maximum vertical ground reaction forces (p = 0.018, effect size: proprioceptive neuromuscular facilitation = 0.27, whole-body vibration training = 0.76), and increased the maximum ankle dorsiflexion moment (p = 0.049, effect size: proprioceptive neuromuscular facilitation = −0.52, whole-body vibration training = −0.22). Whole-body vibration training reduced the maximum ground reaction forces value in the mediolateral directions (p = 0.010, effect size = 0.82) during cutting movement.
These findings suggested that the two types of training might increase neuromuscular conduction function around the ankle. After these two types of training, functional ankle instability patients showed a similar risk of injury to the lateral ankle ligaments during cutting.
Understanding the effects of a sudden directional shift in somatosensory feedback and increasing task complexity on postural adaptation in individuals with and without chronic ankle instability
2024, Gait and Posture
Individuals with chronic ankle instability (CAI) present somatosensory dysfunction following an initial ankle sprain. However, little is known about how individuals with CAI adapt to a sudden sensory perturbation of instability with increasing task and environmental constraints to maintain postural stability.
Forty-four individuals with and without unilateral CAI performed the Adaptation Test to a sudden somatosensory inversion and plantarflexion perturbations (environment) in double-, injured-, and uninjured- limbs. Mean sway energy scores were analyzed using 2 (group) $\times$ 2 (somatosensory perturbations) $\times$ 3 (task) repeated measures analysis of variance.
There were significant interactions between the group, environment, and task (P $=$ .025). The CAI group adapted faster than healthy controls to a sudden somatosensory inversion perturbation in the uninjured- (P $=$ .002) and injured- (P $<$ .001) limbs, as well as a sudden somatosensory plantarflexion perturbation in the double- (P $=$ .033) and uninjured- (P $=$ .035) limbs. The CAI and healthy groups presented slower postural adaptation to a sudden inversion perturbation than a sudden somatosensory plantarflexion perturbation in double-limb (P $<$ .001). Whereas both groups demonstrated faster postural adaptation to a sudden somatosensory inversion perturbation compared to somatosensory plantarflexion perturbation while maintaining posture in the injured- (P $<$ .001) and uninjured- (P $<$ .001) limbs. The CAI and healthy groups adapted faster to a sudden somatosensory inversion perturbation in the injured- (P $<$ .001) and uninjured- (P $<$ .001) limbs than in double-limb, respectively.
Postural adaptation in individuals with and without CAI depended on environmental (somatosensory perturbations) and task constraints. The CAI group displayed comparable and faster postural adaptation to a sudden somatosensory inversion and plantarflexion in double-, injured-, and uninjured- limbs, which may reflect a centrally mediated alteration in neuromuscular control in CAI.
Using clinician-oriented and laboratory-oriented assessments to study dynamic stability of individuals with chronic ankle instability
2024, iScience
To compare the dynamic stability of lower extremities between Copers and individuals with chronic ankle instability (CAI) using clinician-oriented assessments (Y-balance test, YBT) and laboratory-oriented assessments (time to stabilization, TTS). 90 participants (Copers, 45; CAIs, 45) were recruited and measured by YBT and TTS to evaluate dynamic stability. The difference of dynamic stability between Copers and CAIs was examined using a two-factor MANOVA. Only for females in anterior direction, YBT scores for the AS side of Copers were significantly higher than that of CAIs. For males, the TTS of CAIs was significantly shorter than that of Copers in the anterior, lateral, and medial direction separately. For females, the TTS of CAIs is also significantly shorter than that of Copers in the anterior, lateral, and medial direction separately. There are opposite results when evaluating the dynamic stability difference between Copers and CAIs using YBT and TTS.
Exercise combined with electrical stimulation for the treatment of chronic ankle instability – A randomized controlled trial
2024, Journal of Electromyography and Kinesiology
To compare the short, medium, and long-term effects of balance exercises combined with either peroneal neuromuscular electrical stimulation (NMES) or peroneal transcutaneous electrical nerve stimulation (TENS) on dynamic postural control and patient reported outcome measures (PROMs) in patients with chronic ankle instability (CAI).
Thirty-four participants with CAI were randomly assigned to a 12-session home based exercise program combined with NMES (Ex-NMES) or TENS (Ex- TENS). Baseline postural control was tested with the modified Star Excursion Balance Test (mSEBT) and time to stabilization (TTS) after a single-leg drop-jump. The self-reported function was measured using the Cumberland Ankle Instability Tool (CAIT), the Identification of Functional Ankle Instability (IdFAI), and the Sports subscale of the Foot and Ankle Ability Measure (FAAM_Sport).
Both groups showed significant improvements in all self-reported outcome measures at the 12-month follow-up. Subjects in the Ex-NMES group had significantly better IdFAI (-4.2 [95% CI −8.1, −0.2]) and FAAM_Sport (13.7 [95% CI 2.2, 25.2]) scores at 6- and 12-month follow-up, respectively, compared to the Ex-TENS group. Medium to large between-group effect sizes were observed in self-reported functional outcomes and the mSEBT.
The consistent trend of improvement in self-reported functional outcomes when training is combined with NMES compared with training with TENS may indicate a potential benefit that should be further investigated as a treatment for patients with CAI.
Weighting of visual and auditory inputs in dancers with and without previous ankle injury
2023, Human Movement Science
Elite dance requires highly controlled balance performance in dynamic visual and auditory environments characterized by the use of stage lighting and music. Perturbing visual input is known to influence balance in dancers, but the effects of sounds have not been clearly established. Ankle inversion injuries are common in dancers and may also play a role in dancers' ability to respond to sensory perturbations. The aims of this study were to identify changes in static balance in response to visual or auditory perturbation in elite collegiate dancers with and without a history of ankle injury, and to describe coupling of measurements obtained from the waist and head during balance. Thirty-seven dancers: 22 controls and 15 with a history of ankle sprain, performed single-leg balance under static and dynamic visual and auditory conditions. Dancers demonstrated increased waist sway when viewing a dynamic visual scene and when presented with moving sounds and increased head sway with dynamic visuals. These results did not vary by history of ankle sprain. While dancers appear to dampen the impact of waist sway on head motion during single leg stance, even highly trained dancers may experience challenges controlling balance under perturbing visual and auditory conditions like those present during stage performance.

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Ankle Injury Outcomes and PreventionSensorimotor Deficits with Ankle Sprains and Chronic Ankle Instability

Section snippets

Traditional Theory of Ankle Instability and Sensorimotor Deficits

Proprioception

Motoneuron Pool Excitability

Reflex Reactions to Inversion Perturbation

Muscle Strength

Postural Control

Gait

Jump Landings

Contemporary Theory: Ankle Instability and Sensorimotor Deficits

Summary

J Foot Ankle Surg

Aust J Physiother

Aust J Physiother

Gait Posture

Gait Posture

Gait Posture

Epidemiology of lower extremity injuries among U.S. high school athletes

Acad Emerg Med

Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives

J Athl Train

Epidemiological patterns of musculoskeletal injuries and physical training

Med Sci Sports Exerc

Musculoskeletal conditions in the United States

Ankle injuries in basketball: injury rate and risk factors

Br J Sports Med

Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation

Arch Fam Med

Long term outcomes of inversion ankle injuries

Br J Sports Med

Long-term follow-up of inversion trauma of the ankle

Arch Orthop Trauma Surg

An epidemiological survey on ankle sprain

Br J Sports Med

Clinical and functional status following lateral ankle sprains

Orthop Rev

Risk of degenerative ankle joint disease in volleyball players: study of former elite athletes

Int J Sports Med

Ligamentous posttraumatic ankle osteoarthritis

Am J Sports Med

Functional instability following lateral ankle sprain

Sports Med

Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability

J Athl Train

Mechanical contributions to chronic lateral ankle instability

Sports Med

The innervation of the ankle joint. An anatomical and histological study in the cat

Acta Anat

Treatment of ruptures of the lateral ligament of the ankle

J Bone Joint Surg Br

Instability of the foot after injuries to the lateral ligament of the ankle

J Bone Joint Surg Br

The etiology and prevention of functional instability of the foot

J Bone Joint Surg Br

Articular reflexes at the ankle joint: an electromyographic study of normal and abnormal influences of ankle-joint mechanoreceptors upon reflex activity in the leg muscles

Br J Surg

Proprioception at the ankle: the effect of anaesthetic blockade of ligament receptors

J Bone Joint Surg Br

Effect of lateral ankle joint anesthesia on center of balance, postural sway, and joint position sense

J Sport Rehabil

Effect of an ankle orthosis and ankle ligament anesthesia on ankle joint proprioception

Am J Sports Med

Evaluation of ankle proprioception following injection of the anterior talofibular ligament

J Orthop Sports Phys Ther

Effect of lateral ankle ligament anesthesia on single-leg stance stability

Med Sci Sports Exerc

Effect of peripheral afferent alteration of the lateral ankle ligaments on dynamic stability

Am J Sports Med

Ankle inversion injuries. The role of the dynamic defense mechanism

Am J Sports Med

Arthrogenic muscle inhibition in the leg muscles of subjects exhibiting functional ankle instability

Foot Ankle Int

Ankle sensorimotor control and eversion strength after acute ankle inversion injuries

Am J Sports Med

Kinesthetic awareness in subjects with multiple ankle sprains

Phys Ther

Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains

J Orthop Sports Phys Ther

The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle

Ankle Injury Outcomes and Prevention
Sensorimotor Deficits with Ankle Sprains and Chronic Ankle Instability