The influence of ankle dorsiflexion and self-reported patient outcomes on dynamic postural control in participants with chronic ankle instability
Introduction
Chronic ankle instability (CAI) is common following an acute ankle sprain in physically active populations. It has been reported that 32–74% of individuals sustaining an acute ankle sprain develop CAI [1], [2] that is characterized by self-reported disability, pain, repeated episodes of “giving-way,” and/or recurrent ankle sprains [3]. The presence of CAI leads to a decrease in activity level [2] and a lower quality of life [1], [4], and is a leading contributor to the development of posttraumatic osteoarthritis in the ankle [5].
The development of CAI following an initial ankle sprain is highly complex [6], resulting from multiple sensorimotor and mechanical insufficiencies. Impaired sensorimotor control has been demonstrated in individuals with CAI [6], [7], [8], [9], [10], [11], which may manifest as decreased functional performance and diminished postural control [12]. The Star Excursion Balance Test (SEBT) has been described as a reliable clinician-generated measure of dynamic postural control [13]. It has been used previously to show increased risk of acute lateral ankle sprain [14], [15]. Additionally, decreased reach distances of the SEBT and altered proximal joint neuromuscular control has been observed in individuals with CAI [12], [16], which suggests that CAI may constrain the sensorimotor control system. While the SEBT has been used to estimate sensorimotor function in individuals with CAI [13], mechanical insufficiencies, such as mechanical deficits in weight bearing dorsiflexion (WB-DF), are associated with CAI, negatively influencing dynamic control measured with the SEBT-A in CAI populations [17], [18]. Therefore, the SEBT may be a global measure that assesses the ability of individuals with ankle pathology to organize both sensorimotor and mechanical functions.
Assessing ankle dorsiflexion range of motion (DF-ROM) in the weight bearing position has been suggested as a viable alternative to open-chain goniometric measurements of ankle DF-ROM (open-chain DF) [19]. While a relationship between the WB-DF and the anterior reach of the SEBT (SEBT-A) has been shown to be present in individuals with CAI [17], [18], there is little evidence to substantiate any correlation between the SEBT-A, and other directions such as the posteriormedial (SEBT-PM) and posteriorlateral (SEBT-PL), and open-chain DF, as well as between WB-DF and open-chain DF assessments in the CAI population. Decreased ankle DF-ROM has been observed in both the weight bearing and open-chain positions during gait [20], [21]. The availability of DF-ROM in the weight-bearing and open-chain positions could influence ankle motions during functional tasks. Examining interactions among these three measures may provide additional insight into the influence of the availability of DF-ROM on dynamic postural control, and provide a foundation for continued work to identify the most effective interventions after SEBT performance deficiency is detected.
Patient-generated outcome measures have been emphasized in health care [22] and provide valuable information on how the patient experiences physical limitations and disability due to CAI. Various self-reported questionnaire have been developed in previous literature to quantify physical limitations and disability associated with CAI [4], [23]. Enchaute et al. [23] suggested that the foot and ankle ability measure (FAAM) is the most appropriate self-reported questionnaires to assess disability in individuals with CAI. A visual analog scale (VAS) is also commonly used to assess the levels of the typical symptoms (perceived pain, instability, and limited function) across the continuum of disability associated with ankle injuries [24]. The interaction of patient-generated and clinician-generated outcome measures is crucially important to assess how impairments measured with clinician-generated variables contribute to patient-reported functional disability and understanding of the phenomenon of CAI [25]. However, it is unknown how functional impairment measured with the SEBT is related to self-reported functional disability in CAI participants. Examining the correlation between the SEBT and self-reported outcomes may help to improve the identification of deficits related to CAI.
Therefore, the purposes of this study were to determine (1) if the SEBT-A, SEBT-PM, and SEBT-PL are correlated with WB-DF, open-chain DF, and patient-oriented outcomes (FAAM and VAS) in individuals with CAI; and (2) if WB-DF is correlated with open-chain DF in this population. Additionally, we examined which of these variables provided the greatest contribution to global dysfunction measured with the SEBT in participants with CAI.
Section snippets
Participants
Twenty-nine participants with self-reported CAI were recruited from the University community (Table 1). We included participants who had: (1) a previous history of at least one acute ankle sprain that caused swelling, pain, and temporary loss of function; (2) at least two episodes of “giving way” in the previous 6 months; (3) self-reported functional disability as a result of their ankle sprain history by scoring ≤90% on the foot and ankle ability measure (FAAM) activities of daily living
Results
Means and standard deviations for the SEBT-A, SEBT-PM, SEBT-PL, WB-DF, open-chain DF, and self-reported outcome measures can be found in Table 2. The normalized reach distance of the SEBT-A was correlated fairly with the WB-DF (r = 0.410, p = 0.014), open-chain DF (r = 0.404, p = 0.015), and VAS-stiffness (r = 0.477, p = 0.014). The WB-DF also had a fair correlation to open-chain DF (r = 0.448, p = 0.004). All correlations with the SEBT-PM and SEBT-PL were weak or fair and not statistically significant. The
Discussion
Maximum WB-DF and VAS-stiffness predicted over a third of the variance in SEBT-A in participants with CAI. Positive correlation coefficients indicate that smaller DF-ROM and increased self-reported ankle stiffness may be responsible for reduced dynamic postural control assessed with the anterior reach distance of the SEBT. Similarly, Hoch et al. [17] observed a positive and fair correlation (r = 0.47) between SEBT-A performance and the WBLT. Our current study identified a similar correlation
Limitations
Two examiners assessed the SEBT measures, WB-DF, and open-chain DF. This may influence measurement reliability and validly. However, previous investigations support that all measurement tools used in this study are reliable and valid [27], [28], [29], [31].
We assessed open-chain active DF-ROM with the knee straight. It may be that the active DF-ROM measurement does not provide information of how much total amount of ankle DF-ROM is available at the talocrual joint due to a potential effect of
Conclusion
Our current study found that the strongest predictors of the SEBT-A were the WB-DF and VAS-stiffness. These findings suggest that decreased WB-DF available and increased ankle joint stiffness may negatively influence SEBT-A performance, while these measures of ankle joint mechanical integrity did not seem to influence the performance of the SEBT-PM or SEBT-PL. Clinicians may target these factors for intervention that need to be addressed to produce the best outcome in individuals with CAI when
Acknowledgement
This study that was part of a randomized controlled trial investigating the effect of joint mobilization on neural excitability, DF-ROM, and dynamic postural control in participants with CAI was supported by the National Athletic Trainers’ Association Research and Education Foundation (Dallas, TX) through its Osternig Master's Grant Program.
Financial disclosure: We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit
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