Systematic Review of Postural Control and Lateral Ankle Inestability Part 1

8/11/2019 Systematic Review of Postural Control and Lateral Ankle Inestability Part 1

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Systematic Review of Postural Control and LateralAnkle Instability, Part I: Can Deficits Be DetectedWith Instrumented Testing?Patrick O. McKeon, PhD, ATC, CSCS*; Jay Hertel, PhD, ATC, FACSM*University of Kentucky, Lexington, KY; 3University of Virginia, Charlottesville, VA

Objective: To answer the following clinical questions: (1) Ispoor postural control associated with increased risk of a lateralankle sprain? (2) Is postural control adversely affected afteracute lateral ankle sprain? (3) Is postural control adverselyaffected in those with chronic ankle instability?

Data Sources: PubMed and CINAHL entries from 1966through October 2006 were searched using the terms ankle sprain, ankle instability, balance, chronic ankle instability,functional ankle instability, postural control, and postural sway .

Study Selection: Only studies assessing postural controlmeasures in participants on a stable force plate performing themodified Romberg test were included. To be included, a studyhad to address at least 1 of the 3 clinical questions stated aboveand provide adequate results for calculation of effect sizes orodds ratios where applicable.

Data Extraction: We calculated odds ratios with 95 %confidence intervals for studies assessing postural control asa risk factor for lateral ankle sprains. Effect sizes were estimated

with the Cohen d and associated 95 % confidence intervals forcomparisons of postural control performance between healthyand injured groups, or healthy and injured limbs, respectively.

Data Synthesis: Poor postural control is most likely associ-ated with an increased risk of sustaining an acute ankle sprain.Postural control is impaired after acute lateral ankle sprain, withdeficits identified in both the injured and uninjured sidescompared with controls. Although chronic ankle instability hasbeen purported to be associated with altered postural control,these impairments have not been detected consistently with theuse of traditional instrumented measures.

Conclusions: Instrumented postural control testing on sta-ble force plates is better at identifying deficits that areassociated with an increased risk of ankle sprain and that occurafter acute ankle sprains than at detecting deficits related tochronic ankle instability.

Key Words: ankle sprains, balance, chronic ankle instability,stabilometry

Lateral ankle sprains are extremely common amongphysically active individuals. Sprains to the lateralankle ligaments frequently result in pathologic laxity

and sensorimotor deficits about the ankle. Poor posturalcontrol performance, one facet of sensorimotor function,has been associated with lateral ankle instability sinceFreemans landmark works in the mid-1960s. 1,2 It has beensuggested that lateral ankle instability is often associatedwith poor postural control, which can be defined as theinability to maintain stability above a narrow base of support in single-limb stance 24 ; however, no uniformconsensus exists in the published literature. Numerousnoninstrumented and instrumented measures of posturalcontrol in single-limb stance have been reported in theankle instability literature over the past 4 decades, with

instrumented force plate measures becoming the goldstandard of assessment.Instrumented measures of postural control have been

used in an attempt to predict ankle sprain risk and to assesssensorimotor deficits after acute ankle sprains and in thosewith chronic ankle instability (CAI). Yet the disparatemethods and measures reported in the literature can makethe interpretation of this body of literature difficult. 5Inconsistent findings in the ankle instability and posturalcontrol literature make it difficult for health care providersto render informed clinical decisions when evaluating andtreating patients with ankle instability. To date, nosystematic reviews have thoroughly summarized the

research literature as it relates to instrumented posturalcontrol testing, lateral ankle sprains, and CAI. Acomprehensive summary of research findings in this areawill allow health care providers to make clinical decisionsrelating to ankle instability and postural control that areinformed by the best available evidence. Therefore, thepurposes of this systematic review are to answer thefollowing clinical questions: (1) Is poor postural controlassociated with increased risk of a lateral ankle sprain? (2)Is postural control adversely affected after acute lateralankle sprain? (3) Is postural control adversely affected inthose with CAI?

METHODS

Search StrategyWe searched PubMed and CINAHL entries from 1966

through October 2006 using the terms ankle sprain , ankleinstability , balance, chronic ankle instability , functional ankle instability , postural control , and postural sway .Relevant articles were also identified by cross-referencingthe citation lists of articles identified in the electronicsearch. A total of 144 articles were identified (Figure 1).

Criteria for Selecting Studies

Only studies assessing postural control measures inparticipants on a stable force plate performing the

Journal of Athletic Training 2008;43(3):293304g by the National Athletic Trainers Association, Incwww.nata.org/jat systematic review

Journal of Athletic Training 293


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modified Romberg test were included. We chose to onlyinvestigate studies that used the Romberg test on a stablesurface because we were most interested in assessing therelationships between ankle instability and static pos-tural control; studies assessing static postural control aremost commonly reported in the ankle instability literature.To be included, a study had to address at least 1 of the 3clinical questions stated above and provide adequateresults for calculation of effect size or odds ratio whereapplicable.

Assessment of Methodologic Quality

Included studies were evaluated using the PEDro scale. 6Consensus regarding the PEDro score for each article wasagreed upon by both authors.

Data Extraction and Statistical Analysis

For the assessment of predictive ability of posturalcontrol scores, 2 types of effect measures were calculatedbased on the data reported in the original articles. Wherepossible, we calculated odds ratios for sustaining an anklesprain between those in different categories based on theirpostural control measures (ie, group with lowest third of

performance scores versus highest third of performancescores 7). In addition, we calculated effect sizes (Cohen d)for postural control measures between those who went onto sustain acute ankle sprains and those who did not. Thestrength of effect sizes was interpreted using the guidelinesdescribed by Cohen, 8 with values less than 0.4 interpretedas weak, from 0.41 to 0.7 as moderate, and more than 0.7as strong. For both odds ratio and effect size estimates,95% confidence intervals (CIs) were calculated around thepoint estimates.

For the comparisons of postural control performancedeficits related to acute ankle sprains and CAI, estimates of effect size (Cohen d) and 95 % CIs were made (1) within

involved and uninvolved limbs in those with unilateralankle injuries, and (2) between the pathologic group andthe healthy control group. It was not possible to compareboth factors from all included studies.

Lastly, the quality of evidence used to answer each of the 3 questions was assessed with the Strength of Recommendation Taxonomy (SORT). 9 The SORT levelof recommendations range from 1 to 3, with 1 indicatinggood-quality, patient-oriented evidence; 2 indicatinglimited-quality, patient-oriented evidence; and 3 indicatingnonpatient-oriented evidence. The SORT strength of recommendations range from A through C, with Aindicating that the recommendation was based on consis-tent and good-quality, patient-oriented evidence; B that itwas based on inconsistent or limited-quality, patient-oriented evidence; and C that it was based on evidenceother than patient-oriented evidence. 9

RESULTS

Was Poor Postural Control Associated WithIncreased Risk of Lateral Ankle Sprain?

Six articles 3,7,1013 met the inclusion criteria to answer this

question (Table 1). The mean PEDro score for these articleswas 5.6. Three articles 3,7,11 provided sufficient data to allowcalculation of odds ratios (Figure 2), and 5 articles 7,1013allowed calculation of effect sizes (Figure 3). The pointmeasures of the odds ratios ranged from 1.22 to 6.70,indicating that athletes with poorer postural controlmeasures were at increased risk of ankle sprain. Only 1 of the 6 comparisons had a 95 % CI that crossed 1.0 for theodds ratio, and this comparison was between groupsrepresenting the best and middle tertiles of postural controlperformance in the study by McGuine et al. 7 Thus, the riskof ankle sprain did not increase for the group with poorerpostural control. In contrast, when the lower boundary of

Figure 1. Flow chart for selecting articles to be included in the systematic review to answer our 3 questions. Article reference numbersare superscripted.

294 Volume 43 N Number 3 N June 2008


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T a b l e 1 . A r t i c l e s I n c l u d e d t o A n s w e r t h e

Q u e s t i o n ,

W a s P o o r e r P o s t u r a l

C o n t r o l A s s o c i a t e d W i t h I n c r e a s e d R i s k o f A n k l e

S p r a i n ?

A u t h o r s

P E D r o

S c o r e

S t u d y

D e s i g n

I n c l u s i o n C r i t e r i a

A n k l e S p r a i n

D i a g n o s i s

L e n g t h o f

F o l l o w - U p

I n v o l v e d

S u b j e c t s

U n i n v o l v e d

S u b j e c t s

P o s t u r a l

C o n t r o l

I n s t r u m e n t

S a m p l i n g

R a t e

T r i a l

L e n g t h

N u m b e r o f

T r i a l s

D e p e n d e n t V a r i a b l e s

T r o p p e t

a l 3

4

P r o s p e c t i v e

c o h o r t

S o c c e r p l a y e r s p a r t i c i p a t i n g

i n a t l e a s t 5 0 % o f a l l

p r a c t i c e s e s s i o n s

O r t h o p a e d i c

s u r g e o n : e x a c t

i n j u r y d e f i n i t i o n

n o t p r o v i d e d

9 t o 1 0 m o n t h s

2 3

1 0 4

F o r c e p l a t e

3 1 H z

6 0 s

3 t r i a l s p e r

s i d e ( e y e s

o p e n )

C e n t e r o f p r e s s u r e

a r e a ( 6 1 %

c o n f i d e n c e e l l i p s e )

N o r e c e n t s e v e r e i n j u r y

N o h i s t o r y o f r e c e n t l o w e r

e x t r e m i t y i n j u r y o r

i n s u f f i c i e n t p r a c t i c e t i m e

d u r i n g p r e s e a s o n

B e y n n o n

e t a l

1 0

6


c o h o r t

C o l l e g i a t e s o c c e r ,

l a c r o s s e ,

o r f i e l d h o c k e y a t h l e t e

O r t h o p a e d i c

s u r g e o n : 3 - t i e r

g r a d i n g

s y s t e m

2 c o l l e g i a t e

s e a s o n s

2 0

9 8

N e u r o - t e s t

S y s t e m

( N e u r o C o m

I n t ,

C l a c k a m a s ,

O R )

N o n e s p

e c i f i e d

2 0 s

3 p e r s i d e

( e y e s o p e n )

A n t e r o p o s t e r i o r

c e n t e r o f g r a v i t y

s w a y

N o p r e v i o u s a n k l e l i g a m e n t

s p r a i n

, s u r g e r y o f t h e f o o t

o r a n k l e , t r a u m a t o t h e

l o w e r e x t r e m i t y

, o r u s e o f

a n k l e s u p p o r t

M c G u i n e

e t a l

7

6


c o h o r t

H i g h s c h o o l b a s k e t b a l l

p l a y e r s

A t h l e t i c t r a i n e r :

i n a b i l i t y t o

p r a c t i c e o r

c o m p e t e

b e c a u s e o f

i n j u r y

1 h i g h s c h o o l

s e a s o n

2 3

8 7

F o r c e p l a t e

1 0 0 H z

1 0 s

3 t r i a l s p e r

s i d e ( e y e s

o p e n , e y e s

c l o s e d )

C e n t e r o f g r a v i t y ( 6 / s )

N o p r e v i o u s a n k l e i n j u r y

w i t h i n t h e p a s t 1 2 m o n t h s

N o t u n d e r t r e a t m e n t f o r a n

i n n e r e a r o r s i n u s i n f e c t i o n

W a n g

e t a l

1 1

5


c o h o r t :

m a l e s

H i g h s c h o o l b a s k e t b a l l

p l a y e r s

P h y s i c a l

t h e r a p i s t :

i n a b i l i t y t o

p r a c t i c e o r

c o m p e t e o r

n e e d t o h a v e

t r e a t m e n t t o

p a r t i c i p a t e

1 h i g h s c h o o l

s e a s o n

1 8 a n k l e s 6 6 a n k l e s F o r c e p l a t e

6 0 0 H z

1 0 s

1 p e r s i d e

( e y e s o p e n )

P o s t u r a l s w a y

v a r i a b i l i t y i n

a n t e r o p o s t e r i o r

a n d m e d i o l a t e r a l

d i r e c t i o n s

N o p r e v i o u s l o w e r e x t r e m i t y

s u r g e r i e s

N o h i s t o r y o f i n j u r y w i t h

r e s i d u a l s y m p t o m s

N o l o w e r e x t r e m i t y

b i o m e c h a n i c a l

a b n o r m a l i t i e s

W i l l e m s

e t a l

1 2

6


c o h o r t :

m a l e s

P h y s i c a l e d u c a t i o n s t u d e n t s P h y s i c i a n :

r e d u c t i o n i n

p a r t i c i p a t i o n ,

n e e d f o r

m e d i c a l c a r e ,

a d v e r s e s o c i a l

o r e c o n o m i c

e f f e c t s

1 t o 3 a c a d e m i c

y e a r s

4 4

1 9 7

N e u r o C o m

B a l a n c e

M a s t e r

( N e u r o C o m

I n t )

N o n e s p

e c i f i e d

1 0 s

3 p e r s i d e

( e y e s o p e n ,

e y e s c l o s e d ) S

w a y v e l o c i t y ( 6 / s )

N o h i s t o r y o f g r a d e I I o r I I I

a n k l e s p r a i n

N o h i s t o r y o f l o w e r l e g , f o o t ,

o r a n k l e i n j u r y w i t h i n t h e

p a s t 6 m o n t h s

W i l l e m s

e t a l

1 3

6


c o h o r t :

f e m a l e s

P h y s i c a l e d u c a t i o n s t u d e n t s P h y s i c i a n :

r e d u c t i o n i n

s p o r t

p a r t i c i p a t i o n ,

n e e d f o r

m e d i c a l c a r e ,

a d v e r s e s o c i a l

o r e c o n o m i c

e f f e c t s

1 t o 3 a c a d e m i c

y e a r s

3 2

1 3 7

N e u r o C o m

B a l a n c e

M a s t e r

N o n e s p

e c i f i e d

1 0 s

3 p e r s i d e

( e y e s o p e n ,

e y e s c l o s e d ) S

w a y v e l o c i t y ( 6 / s )

N o h i s t o r y o f g r a d e I I o r I I I

a n k l e s p r a i n

N o h i s t o r y o f l o w e r l e g , f o o t ,

o r a n k l e i n j u r y w i t h i n t h e

p a s t 6 m o n t h s



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the odds ratio CI was greater than 1.0, the risk of anklesprain increased for the group with poorest postural control.

The results of the effect size analyses are less consistent,with point estimates ranging from 2 0.09 to 2.21 andpositive effect sizes indicating worse postural control inathletes who went on to sprain their ankles. In this subsetof studies, 3 of the 6 comparisons had CIs that crossedzero. When the lower boundary of the effect size CI crossedzero, whether or not those who went on to sprain theirankles had worse instrumented postural control perfor-mance scores than those who did not suffer sprains wasunclear. Based on this evidence, it appears that a consensus(albeit not unanimous) of evidence indicates that poorpostural control was associated with increased risk of ankle

sprain. The SORT level of evidence was 2 because themethodologic quality of included articles was not consis-tently high, with a grade of recommendation of B becauseof some inconsistent findings.

Was Postural Control Adversely Affected After AcuteLateral Ankle Sprain?

Seven articles 1420 met the inclusion criteria to answerthis question (Table 2). The mean PEDro score for thesearticles was 4.7. Authors of 3 articles 15,16,19 examinedgroup differences between an acute lateral ankle spraingroup and a healthy control group (Figure 4). The pointmeasures of effect size for group comparisons on the

Figure 2. Was poor postural control associated with increased risk of ankle sprain? Odds ratios and 95 % confidence intervals are shownfor postural control as a risk factor for lateral ankle sprains. Individuals who sustained a first-time ankle sprain had worse posturalcontrol measures than those who did not go on to sustain sprains. ML indicates mediolateral; AP, anteroposterior. Article referencenumbers are superscripted.

Figure 3. Was poor postural control associated with increased risk of ankle sprain? Effect sizes and 95 % confidence intervals comparethose who went on to sprain their ankles and those who did not. Findings are inconsistent as to whether those who sustained an anklesprain had poorer postural control than those who did not. EO indicates eyes open; EC, eyes closed. Article reference numbersare superscripted.



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T a b l e 2 . A r t i c l e s I n c l u d e d t o A n s w

e r t h e

Q u e s t i o n ,

I s P o s t u r a l C o n t r o l A d v e r s e l y A f f e c t e d b y A c u t e L a t e r a l A n k l e S p r a i n ?

A u t h o r s

P e d r o

S c o r e

S t u d y

D e s i g n


I n v o l v e d

G r o u p

C o m p a r i s o n

S u b j e c t s

P o s t u r a l C o n t r o l

I n s t r u m e n t

S a m p l i n g

R a t e

L e n g t h

o f T r i a l s

N u m b e r

o f T r i a l s


E v a n s e t

a l 1 4

4


c o h o r t

M a l e s a n d f e m a l e s f r e e f r o m

a n k l e i n j u r y a t b a s e l i n e

t e s t i n g ; m i l d ( i n j u r y t o 1

l a t e r a l l i g a m e n t ) t o m o d e r a t e

( 2

l a t e r a l l i g a m e n t s ) a n k l e

s p r a i n

1 1 m a l e s

1 7 f e m a l e s

0

F o r c e p l a t e

5 0 H z

1 5 s

3 t r i a l s p e r s i d e

( e y e s o p e n )

C e n t e r o f p r e s s u r e v e l o c i t y

F r i d e n e t

a l 1 5

5

C a s e c o

n t r o l

M a l e s a n d f e m a l e s w i t h a c u t e

l a t e r a l a n k l e s p r a i n a n d n o

h i s t o r y o f p r e v i o u s i n j u r y ;

p o s i t i v e a n t e r i o r d r a w e r s i g n ;

n o r m a l r a d i o g r a p h s

1 0 m a l e s

4 f e m a l e s

2 2 m a l e s

3 3 f e m a l e s

F o r c e p l a t e

2 0 H z

2 5 . 6

s

3 p e r s i d e

( e y e s o p e n )

M e a n d i s t a n c e b e t w e e n m e d i o l a t e r a l

c e n t e r o f p r e s s u r e a n d r e f e r e n c e l i n e

o f f o o t

S D o f m e d i o l a t e r a l c e n t e r o f p r e s s u r e

d i s t a n c e f r o m r e f e r e n c e l i n e o f f o o t

M e a n m e d i o l a t e r a l s w a y v e l o c i t y

M e a n m e d i o l a t e r a l s w a y a m p l i t u d e

N u m b e r o f m e d i o l a t e r a l m o v e m e n t s

e x c e e d i n g 5 m m

N u m b e r o f m e d i o l a t e r a l m o v e m e n t s

e x c e e d i n g 1 0 m m

G u s k i e w i c z

a n d

P e r r i n

1 6

5


c o h o r t

H i s t o r y o f a c u t e a n k l e s p r a i n

t h a t o c c u r r e d w i t h i n 2 1 d a y s

o f t e s t i n g ; p a i n - f r e e r a n g e o f

m o t i o n a n d f u l l y a b l e t o b e a r

w e i g h t a t t i m e o f t e s t i n g

7 m a l e s

6 f e m a l e s

6 m a l e s

6 f e m a l e s

C h a t t e c x B a l a n c e

S y s t e m

( C h a t t e c x C o r p ,

C h a t t a n o o g a ,

T N )

1 0 0 H z

a n d

a n a l y z e d

a t 1 5 H z

1 0 s

1 p e r s i d e

( e y e s o p e n )

S w a y i n d e x

H e r t e l e t

a l 1 7

4

E x p o s t

f a c t o

A c u t e u n i l a t e r a l l a t e r a l a n k l e

s p r a i n t h a t w a s c o n s i d e r e d

m i l d ( i n j u r y t o 1 l a t e r a l

l i g a m e n t ) o r m o d e r a t e ( 2

l a t e r a l l i g a m e n t s )

9 m a l e s

8 f e m a l e s

0

F o r c e p l a t e

5 0 H z

5 s

3 t r i a l s p e r s i d e

( e y e s o p e n )

A n t e r o p o s t e r i o r , m e d i o l a t e r a l c e n t e r o f

p r e s s u r e l e n g t h

A n t e r o p o s t e r i o r , m e d i o l a t e r a l c e n t e r o f

p r e s s u r e v e l o c i t y

A n t e r o p o s t e r i o r , m e d i o l a t e r a l r a n g e o f

c e n t e r o f p r e s s u r e

L e a n d e r s o n

e t a l

1 8

7


c o h o r t

A g e 5

1 5 5

5 y ; t i m e b e t w e e n

i n j u r y a n d t r e a t m e n t 5

2 4 h ;

g r a d e 2 o r 3 i n v e r s i o n a n k l e

s p r a i n ; n o f r a c t u r e

4 8 m a l e s

2 5 f e m a l e s

0

P o r t a b l e

s t a b i l o m e t e r

1 0 H z

3 0 s

2 t r i a l s

( e y e s o p e n )

M e a n s w a y a m p l i t u d e i n

a n t e r o p o s t e r i o r , m e d i o l a t e r a l

d i r e c t i o n s

R o s e e t a l

1 9

4


c o h o r t

H i s t o r y o f g r a d e 1 o r 2

n o n c o n t a c t a n k l e s p r a i n

,

e i t h e r n e w o r r e c u r r e n t o n

t h e s a m e s i d e ; a g e b e t w e e n

1 8

a n d 2 5 y

1 8 m a l e s

1 f e m a l e

8 m a l e s

1 0 f e m a l e s

C h a t t a n o o g a

B a l a n c e

M a c h i n e

( C h a t t a n o o g a

G r o u p ,

H i x s o n ,

T N )

1 0 0 H z

1 0 s

1 p e r s i d e

( e y e s o p e n ,

e y e s c l o s e d )

S w a y i n d e x

T r o p p e t

a l 2 0

4

E x p o s t

f a c t o

M a l e s o c c e r p l a y e r s w i t h h i s t o r y

o f l a t e r a l a n k l e s p r a i n a n d

f u n c t i o n a l i n s t a b i l i t y o f 1 o r

b o t h a n k l e s

2 5 m a l e s

0

F o r c e p l a t e

N o n e s p

e c i f i e d

6 0 s

2 p e r s i d e

( e y e s o p e n )

A r e a ( 6 1 % c o n f i d e n c e e l l i p s e )



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injured side ranged from 2 0.25 to 2.66, with a positivevalue indicating poorer postural control in the injuredgroup than the uninjured group. Most of the effect sizevalues were moderate to strong, with CIs that did not crosszero. Comparisons between the uninjured limbs of theinjured group and the matched limbs in the control grouprevealed effect size point estimates ranging from 0.28 to1.21, with the majority having CIs that did not cross zero.Thus, deficits in postural control were seen in both theinjured and uninjured limbs of participants sustainingunilateral ankle sprains compared with the control group.

Authors of 6 articles 14,15,1720 examined side differencesbetween the acutely injured limb and the contralateralhealthy limb in participants with unilateral ankle sprains(Figure 5). The effect size point measures for sidecomparisons ranged from 2 0.41 to 2.13, with a positivevalue indicating poorer postural control in the injuredlimb. Most effect sizes were moderately to stronglypositive, but several had CIs that crossed zero. Based onthis evidence, it appears that postural control was adverselyaffected in both the injured and uninjured sides inindividuals with unilateral acute ankle sprains. The SORTlevel of evidence was 1, with a grade of recommendation of A. However, there is inconclusive evidence as to whetherside-to-side differences in postural control exist betweenthe injured and uninjured limbs after acute ankle sprains.For the intralimb comparison of patients with unilateralankle sprains, the SORT level of evidence was 2, with agrade of recommendation of B.

Was Postural Control Adversely Affected in ThoseWith Chronic Ankle Instability?

Authors of 8 articles 2128 met the inclusion criteria toanswer this question (Table 3). The mean PEDro score forthese articles was 4.3. Investigators in 7 studies 2124,2628examined differences between a CAI group and a group of healthy controls (Figure 6). The point estimates of thegroup comparison effect sizes ranged from 2 0.29 to 1.31,

with a positive effect size indicating worse postural controlin the CAI group and a negative effect size indicatingpoorer postural control in the control group. Most of theeffect sizes for group comparisons were positive, rangingfrom weak to strong effects; however, several of the CIsaround these point measures crossed zero.

Authors of 5 articles 22,24,25,27,28 studied differencesbetween limbs of a group reporting unilateral CAI(Figure 7). The point measures of these effect sizes rangedfrom 2 0.47 to 0.57, with a positive effect size indicatingpoorer postural control in the involved limb than theuninvolved limb. Most of the CIs around these pointmeasures crossed zero. Therefore, postural control ap-peared to be adversely affected in the presence of CAIwhen compared with a healthy sample, but the extent of the effect was uncertain because of inconsistent results withsmall effect sizes and large CIs. In contrast to acute anklesprains, evidence was not conclusive that unilateral CAIaffected the postural control of the uninvolved limb. TheSORT level of evidence was a 2, with a grade of recommendation of B.

DISCUSSION

Was Poor Postural Control Associated WithIncreased Risk of Lateral Ankle Sprain?

Six groups 3,7,1013 who answered this question providedgood representation of a heterogeneous population of males and females of various ages in various sports. Animportant consideration in injury predictor studies iswhether participants were equal at baseline on the mostimportant measures of interest. Within the includedstudies, the participants were free from ankle injury forat least 12 months. No differences were noted in instru-mented postural control measures between athletes whohad never suffered an ankle sprain and athletes who hadsustained their most recent ankle sprain more than12 months ago. 29 Of the included studies, only Tropp

Figure 4. Was postural control adversely affected by acute lateral ankle sprain? Effect sizes and 95 % confidence intervals compare posturalcontrol measures for injured groups (acute lateral ankle sprain) with healthy groups. Postural control was adversely affected by acute lateralankle sprain comparedwithhealthy controls.ML indicatesmediolateral; COP,center of pressure. Article referencenumbersare superscripted.



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et al 3 found that players with a history of ankle sprains hadno difference in the incidence of ankle injuries in thefollowing season. This is important because severalinvestigators 2931 have reported that the primary riskfactor in suffering an ankle sprain is a previous history of sprain.

When postural control performance in single-limb stance

was used as the sole predictor of ankle sprain risk,consistent predictive results were found. 3,7 However, whenmultiple predictors of ankle sprain risk were used, this wasnot the case. 9,12,13 For example, in a study of numerousother potential predictors, including lower extremityalignment, muscle strength and reaction time, and anklelaxity, Beynnon et al 10 noted that postural controlperformance did not predict ankle sprain risk in maleand female collegiate athletes. In males, increased talar tiltpredicted ankle sprain risk, and in females, increased tibialvarum and calcaneal eversion range of motion werepredictors. Conversely, in a study examining the roles of postural control, ankle strength, and flexibility in predict-

ing risk of ankle sprain, Wang et al 11 found that poorpostural control performance was the best predictor of ankle sprain. Yet postural control performance onlyaccounted for approximately 20 % of the variance inincreased injury risk and, curiously, the authors did notrecommend it as an effective injury predictor. Theinteraction between single-limb postural control and otherpotential risk factors is not clearly understood, as indicatedby the conflicting results of these multifactorial studies.

Measures of postural control varied within these studies.Willems et al 12,13 and Beynnon et al 10 used center of gravity(COG) excursion measures in single-limb stance. Thesemeasures did not detect postural control differencesbetween participants who went on to sprain their anklesand those who did not. Tropp et al 3 and Wang et al 11 usedcenter of pressure (COP) excursion measures and dididentify an increased risk of ankle sprain in those withpoorer scores. The COG excursion measured the move-ment of the vertical ground reaction force in relation to theforce plate during single-limb stance. The COP excursionmeasured the 3-dimensional interaction between the footand the force plate as the body attempted to maintain itself over a fixed base of support. The COP measures appeared

to be more sensitive in detecting postural control impair-ments in those at increased risk of ankle sprain. It is alsoimportant to note that Willems et al 12,13 identified differentcomponents of postural control in double-limb stance thatwere more strongly related to increased risk of anklesprain. Males with decreased directional control andfemales with decreased endpoint excursion in double-limbstance, as measured by the NeuroCom Balance Master(NeuroCom Int, Clackamas, OR), were at greater risk of sprain. 12 These tests indicate diminished volitional posturalcontrol and represent more challenging tasks to thesensorimotor system in keeping the center of gravity withinthe base of support.

The inconsistent findings of the included studies mayalso be due to different definitions of lateral ankle sprainand variations in the length of time participants werefollowed after baseline testing. The definition of anklesprain varied across studies, from not being fully described 3to using descriptions in previously published gradingsystems. 10,12,13 Some injury definitions required the ankleinjury to prevent a player from participating in a practiceor game, 7 whereas others allowed players to continue sportparticipation if they required treatment. 11 In all thesestudies, ankle sprains were diagnosed by an athletictrainer, 9 physiotherapist, 10 or physician. 3,7,8,11 The timeparticipants were followed for ankle sprain after baselinetesting varied from the length of a single high school sports

season9,10

to up to 3 academic years.7,11

Those studies withfollow-up times of less than 1 year 3,7,11 showed moreconsistent findings of poor postural control performance asan injury risk factor than those studies with longer follow-up periods. 7,8,11

Although agreement within the literature suggests thatpoor postural control was associated with an increased riskof ankle sprain, some findings were inconsistent with thetraditional measures of postural control in single-limbstance. The choice of measurement technique and predic-tive model may significantly confound the relationshipbetween postural control and ankle sprain risk. The task of static single-limb stance on a force plate may not be

Figure 5. Was postural control adversely affected by acute lateralankle sprain? Effect sizes and 95 % confidence limits comparepostural control performance between injured and uninjured limbsin those with acute lateral ankle sprains. Whether actual deficits inpostural control exist when comparing the injured with theuninjured side in those who suffered acute lateral ankle sprain isinconclusive. The results of Tropp et al 20 are not shown here due tothe large confidence intervals associated with the point measure ofeffect size (effect size forCOP area = 0.23, 95 % confidence interval =2 51.22, 51.48). ML indicates mediolateral; COP, center of pressure;AP, anteroposterior. Article reference numbers are superscripted.



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T a b l e 3 . I n c l u d e d A r t i c l e s t o A n s w

e r t h e

Q u e s t i o n : I s P o s t u r a l C o n t r o l A d v e r s e l y A f f e c t e d b y

C h r o n i c A n k l e I n s t a b i l i t y ?

A u t h o r s

P e d r o

S c o r e

S t u d y

D e s i g n


I n v o l v e d

S u b j e c t s

C o m p a r i s o n

S u b j e c t s

P o s t u r a l C o n t r o l

I n s t r u m e n t

S a m p l i n g

R a t e

T r i a l

L e n g t h

N o . o f T r i a l s


B a i e r a n d

H o p f 2 1

5

R a n d o m i z e d

c o n t r o l l e d

t r i a l

C

o m p e t i t i v e a t h l e t e s w i t h

r e c u r r e n t a n k l e s p r a i n s

a n d f e e l i n g o f g i v i n g w a y

1 0 m a l e s

1 2 f e m a l e s

1 8 m a l e s

4 f e m a l e s

F o r c e p l a t e

1 0 0 H

z

2 5 s

1 p e r s i d e

( e y e s o p e n )

M e a n m e d i o l a t e r a l s w a y v e l o c i t y

M e a n a n t e r o p o s t e r i o r s w a y v e l o c i t y

T o t a l s w a y v e l o c i t y

P e r c e n t a g e o f a n g u l a r d i f f e r e n c e s , 5 6

P e r c e n t a g e o f a n g u l a r d i f f e r e n c e s . 1 7 5 6

B e r n i e r

e t a l

2 2

5

C a s e c o n t r o l H

i s t o r y o f a n k l e s p r a i n

,

f o l l o w e d b y r e p e a t e d

e p i s o d e s o f g i v i n g w a y ;

n o o t h e r h i s t o r y

o f a n k l e , f o o t , k

n e e , o r

h i p i n j u r y

8 m a l e s

1 f e m a l e

6 f e m a l e s

3 m a l e s

C h a t t e c x B a l a n c e

S y s t e m

( C h a t t a n o o g a

G r o u p ,

H i x s o n ,

T N )

N o t s p e c i f i e d

1 0 s

1 p e r s i d e

( e y e s o p e n ,


S w a y i n d e x

C o r n w a l l a n d

M u r r e l l 2 3

4

C a s e c o n t r o l H

i s t o r y o f u n i l a t e r a l l a t e r a l

a n k l e s p r a i n w i t h i n p a s t

2 y e a r s

1 2 m a l e s

8 f e m a l e s

3 0

F o r c e p l a t e

1 0 H z

1 2 . 8

s 1 p e r s i d e

( e y e s o p e n ,


S w a y a m p l i t u d e

S w a y f r e q u e n c y

H e r t e l a n d

O l m s t e d -

K r a m e r

2 4

3

C a s e c o n t r o l F e m a l e s o c c e r p l a y e r s ; a t

l e a s t 1 a n k l e s p r a i n ;

r e c u r r e n t e p i s o d e s o f

g i v i n g w a y i n 3 m o n t h s

b e f o r e s t u d y

1 5 f e m a l e s

9 f e m a l e s

F o r c e p l a t e

5 0 H z

1 0 s

3 p e r s i d e

( e y e s o p e n )

M e d i o l a t e r a l c e n t e r o f p r e s s u r e v e l o c i t y

A n t e r o p o s t e r i o r c e n t e r o f p r e s s u r e

v e l o c i t y

M e d i o l a t e r a l c e n t e r o f p r e s s u r e r a n g e

A n t e r o p o s t e r i o r c e n t e r o f p r e s s u r e r a n g e

M e d i o l a t e r a l c e n t e r o f p r e s s u r e

% r a n g e

u s e d

A n t e r o p o s t e r i o r c e n t e r o f p r e s s u r e

%

r a n g e u s e d

M e d i o l a t e r a l c e n t e r o f p r e s s u r e S D

A n t e r o p o s t e r i o r c e n t e r o f p r e s s u r e S D

I s a k o v a n d

M i z r a h i 2 5

3

E x p o s t f a c t o C

o m p e t i t i v e f e m a l e

g y m n a s t s ; p a s t h i s t o r y

o f a t l e a s t 3 a n k l e s p r a i n s ;

a s y m p t o m a t i c 4 m o n t h s

8

0

F o r c e p l a t e

5 0 H z

3 5 s

3 p e r s i d e

( e y e s o p e n ,


M e d i o l a t e r a l f o r c e

A n t e r o p o s t e r i o r f o r c e

P e r r i n e t a l

2 6

4

C a s e c o n t r o l M

a l e p r o f e s s i o n a l

b a s k e t b a l l p l a y e r s w i t h

h i s t o r y o f r e p e a t e d a n k l e

s p r a i n s

1 5 m a l e s

5 0 m a l e s

a n d

f e m a l e s

F o r c e p l a t e


2 0 s

1 p e r s i d e

( e y e s o p e n ,


A r e a o f c e n t e r o f p r e s s u r e d i s p l a c e m e n t

N o . o f a n t e r o p o s t e r i o r a n d m e d i o l a t e r a l

d i s p l a c e m e n t s

R o z z i e t a l

2 7

5

C a s e c o n t r o l M

a l e s a n d f e m a l e s ; a t

l e a s t 2 a n k l e s p r a i n s ;

c u r r e n t l y h a v i n g

w e a k n e s s o r i n s t a b i l i t y

8 m a l e s

5 f e m a l e s

7 m a l e s

6 f e m a l e s

B i o d e x S t a b i l i t y

S y s t e m ( S h i r l e y ,

N Y )


2 0 s

3 p e r s i d e

( e y e s o p e n )

S w a y i n d e x

T r o p p e t a l

2 8

4

E x p o s t f a c t o H

i s t o r y o f u n i l a t e r a l

f u n c t i o n a l a n k l e

i n s t a b i l i t y f o r m o r e

t h a n 1 . 5 y

1 2 m a l e s

3 f e m a l e s

0

F o r c e p l a t e


6 0 s

2 p e r s i d e

( e y e s o p e n )

A r e a o f 6 1

% c o n f i d e n c e e l l i p s e



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challenging enough to elucidate differences in posturalcontrol among individuals who are at greater risk of anklesprain. More large-scale, high-quality prospective studiesare needed to test this possibility. Clinically, posturalcontrol can be easily assessed in an effort to identify peoplewho may be at greater risk for sustaining an ankle sprain.A better understanding of these deficits may allow us tomore effectively target these people for a preventionprogram that lessens the ankle sprain risk.

Was Postural Control Adversely Affected After AcuteLateral Ankle Sprain?

The included studies provided a good representation of sex and severity of ankle sprain. 1420 Evidence is strongthat postural control deficits were present in individualsafter acute lateral ankle sprain. These deficits were detectedregardless of the differences in instrumented posturalcontrol measurement and were most apparent whenacutely injured subjects were compared with a healthycontrol group.

In a true prospective study, Evans et al 14 identifiedpostural control deficits present in both the injured and

uninjured limbs of individuals after unilateral anklesprains. Comparisons to baseline preinjury measuresrevealed that postural control deficits resolved at thesecond follow-up (7 days) for the uninjured limbs butremained for at least 4 weeks after injury in the injuredlimbs. The impairments seen in the injured limbs weregreater than those seen in the uninjured limbs. Friden etal15 found diminished postural control in the injured anduninjured limbs of athletes after acute ankle sprainscompared with a reference group. Diminished posturalcontrol in both limbs of individuals after acute ankle sprainhelps to explain the inconsistencies in side-to-side deficits.Tropp et al 20 first proposed a central change in postural

control due to unilateral ankle sprain. It is likely that side-to-side differences within acutely injured participants werenot consistently present in the studies we reviewed becausecentral impairments led to bilateral postural controldeficits after acute lateral ankle sprain.

Baseline preinjury measures of postural control areessential for confirming these deficits. Based on thesefindings, we recommend that the uninjured limb not beused as a control limb when making side-to-side compar-isons for impaired postural control after acute anklesprains. Instead, we recommend making comparisons withbaseline measures from the injured limb or comparisonswith a healthy reference group. Further research isnecessary to identify the potential mechanisms related tothe central changes associated with impaired posturalcontrol in single-limb stance bilaterally after acute anklesprain.

Freeman 1 and Freeman et al 2 initially proposed that thepostural control deficits after acute ankle sprains were dueto damaged ligamentous and articular mechanoreceptors inthe injured ligaments. However, the deficits may indicate alarger motor control deficit. 32 Postural control deficits

have been detected in both injured and uninjured limbsafter acute unilateral ankle sprain. 14 Alterations in musclesproximal to the ankle have also been identified in thosewith a history of ankle sprain. 3234 Bullock-Saxton et al 33and Bullock-Saxton 34 found alterations in hip extensoractivity in both injured and uninjured limbs after severeunilateral ankle sprains. These proximal alterations may berelated to kinetic and kinematic changes noted in single-limb drop landings 35 and the Star Excursion Balance Testperformance of those with repetitive ankle sprains. 36 If central and proximal deficits occur after ankle sprains,local rehabilitation strategies that focus only on restoringrange of motion and strength of the muscles surrounding

Figure 6. Was postural control adversely affected by chronic ankle instability? Effect sizes and 95 % confidence intervals compare healthyand chronic ankle instability groups. Whether postural control deficits existed in those with CAI compared with healthy controls is unclear.Effect sizes for Tropp 28 (COP area = 0.96, 95 % confidence interval [CI] = 2 24.91, 26.83) and Cornwall and Murrell 23 (anteroposterior COPlength = .29, 95 % CI = 2 17.60, 18.18; mediolateral COP length = .46, 95 % CI = 2 17.43, 18.35) are not shown due to wide CIs. AP indicatesanteroposterior; ML, mediolateral; EC, eyes closed; EO, eyes open; COP, center of pressure. Article reference numbers are superscripted.



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the injured ankle may not be adequate to reduce the risk of injury recurrence. Strategies that instead focus on restoringglobal coordination, such as dynamic balance training,may produce improvement in treatment outcomes relatedto lateral ankle sprain. 27,30 Several investigators have

found improvements in both trained and untrained limbsafter a unilateral balance training intervention. 27,37,38Based on this evidence, we recommend implementationof balance training for the uninjured limb and training theproximal musculature during the period of restrictedweight-bearing and function for the injured ankle, as wellas closed chain exercises to challenge the entire injured limbonce full weight-bearing is possible in an effort to preventrecurrent ankle sprains.

Was Postural Control Adversely Affected in ThoseWith Chronic Ankle Instability?

Based on our systematic review, it is unclear whether

postural control deficits were present in individuals withCAI when compared with a control group. Moderate tostrong effect sizes showed such differences, but the CIsaround these point measures were very wide and tended tocross zero. The relatively small sample sizes in the includedstudies and discrepancies in the definition of CAI acrossstudies may have been factors. It was also unclear whetherside-to-side deficits were present in individuals withunilateral CAI.

The contributing factors to CAI are not well under-stood. 39 Most commonly, CAI has been defined as ahistory of an ankle sprain followed by several episodes of recurrent sprains or the feeling of the ankle giving way. 39

However, inconsistencies in the reported inclusion andexclusion criteria for establishing CAI status across theincluded studies are troubling. Clearly, more uniforminclusion and exclusion criteria for CAI across studies areneeded. There were relatively small sample sizes (8 to 22participants) consisting of relatively young, healthy adultswho were physically active at the time of the study. 2128The subtle deficits in postural control that may contributeto CAI have not been consistently detected by instrument-ed measures of static postural control in single-limb stance.The lack of consistent criteria for CAI, along with thevarious sampling rates, trial time lengths, and dependentmeasures used for instrumented postural control testing,make comparisons across these studies difficult andcomprehensive conclusions hard to draw.

All the participants in these studies were able tosuccessfully complete the task of standing on one limbduring the trials that were analyzed. However, none of theauthors reported or compared the number of failed trials

between healthy and CAI groups. The subtle deficit inpostural control may not be detected in the successful trialsbut in the number of times an individual had to repeattrials after failed attempts. Freeman 1 and Freeman et al 2noted balance deficits based on the participant andexaminer reports of impaired postural control in single-limb stance in those with CAI. Objective reports of postural impairments associated with CAI through theBalance Error Scoring System have also shown promise indetecting differences between those with and withoutCAI. 40 The Balance Error Scoring System is used toevaluate how many postural errors a person commits inattempting to maintain postural control over a period of

Figure 7. Was postural control adversely affected by chronic ankle instability? Effect sizes and 95 % confidence intervals compare affectedand unaffected limbs in those with unilateral chronic ankle instability. Whether postural control deficits exist in the affected limb versus theunaffected limb in those with unilateral CAI is unclear. Results of Tropp 28 are not displayed due to wide confidence intervals around theeffect size (COP area = .26, 95 % confidence interval = 2 32.54, 33.06). EC indicates eyes closed; EO, eyes open; AP, anteroposterior; ML,mediolateral. Article reference numbers are superscripted.



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time on stable and unstable surfaces in single-leg andtandem-leg stance. Examining postural control that leadsto failure in CAI may be more beneficial than examiningwhen individuals succeed.

As stated above, the traditional measures and techniquesof instrumented postural control assessment may not besensitive enough to detect these deficits associated withCAI. A recent development in postural control assessmentin those with CAI is examining the spatiotemporal

characteristics of the COP during single-limb stance.24,41

Time to boundary (TTB), a novel instrumented force platemeasure derived from the dynamic systems theory of motorcontrol, examines the intrinsic components of COPassociated with changes in direction relative to theboundaries of the base of support. The TTB estimatesthe amount of time the sensorimotor system has to make apostural correction in order to maintain the body over itsbase of support. 24,4044 Less TTB indicates diminishedpostural control. This measurement technique detectsdifferent components of postural control than the tradi-tional measures such as COP velocity and range. 41 Herteland Olmsted-Kramer 24 established TTB deficits in individ-uals with unilateral CAI compared with healthy individu-als. Thus, those with CAI had less time to make posturalcorrections in single-limb stance. These TTB deficits werealso detected in the unaffected limbs of those withunilateral CAI when compared with healthy controls.These findings may point toward similar bilateral motorcontrol deficits previously identified in those with acuteankle sprains.

As discussed previously, after an acute sprain, cleardeficits in postural control in both the injured anduninjured limbs have been measured with traditionalmeasures of COP. However, these measures were notdifferent from baseline values by approximately 4 weeks. 14The deficits in postural control associated with CAI appear

to be more subtle than with acute sprains, and morecomplex functional tasks may allow for better identifica-tion of these deficits. Postural control deficits have beenreported with more challenging postural control tasks, suchas time to stabilization after a jump-landing task 45 and theStar Excursion Balance Test (a test of dynamic bal-ance). 36,46,47 In these techniques, participants were askedto perform more demanding tasks that emphasize main-taining postural control during dynamic activities. Thesemeasures have shown promise in detecting postural controlimpairments associated with CAI.

Postural control deficits in those with CAI have not beenconsistently detected with traditional measures of posturalcontrol in single-limb stance. Therefore, the clinicaldiagnosis of CAI should not be based solely on staticpostural control testing with traditional force platemeasures. More challenging tasks, such as the StarExcursion Balance Test, and functional tasks, such as jump landings, may demonstrate more clinically relevantdetection of postural control impairments related to CAI.

CONCLUSIONS

Poor postural control is most likely associated with anincreased risk of sustaining an acute ankle sprain. Posturalcontrol is clearly impaired after acute lateral ankle sprains,with deficits identified in both the injured and uninjured

limbs compared with controls. Although CAI has beenpurported to be associated with altered postural control,these impairments have not been detected consistently withthe use of traditional instrumented measures.

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Patrick O. McKeon, PhD, ATC, CSCS, and Jay Hertel, PhD, ATC, FACSM, contributed to conception and design; acquisition and analysis and interpretation of the data; and drafting, critical revision, and final approval of the article.Address correspondence to Patrick O. McKeon, PhD, ATC, CSCS, Division of Athletic Training, University of Kentucky, College of Health Sciences, Wethington Building, Room 206C, 900 South Limestone, Lexington, KY 40536-0200. Address e-mail to Patrick.McKeon @uky.edu.

Systematic Review of Postural Control and Lateral Ankle Inestability Part 1

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