Br J Sports Med 2003 Zöch 291 5

8/11/2019 Br J Sports Med 2003 Zch 291 5

1/6

REVIEW

Rehabilitation of ligamentous ankle injuries: a review ofrecent studiesC Zch, V Fialka-Moser, M Quittan. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .

Br J Sports Med2003;37:291295

There are many treatment modalities for anklerehabilitation. These are reviewed, and the mosteffective training programme for rapid restoration ofankle movement, strength, endurance, andproprioception is selected.. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . .

Ligamentous ankle injuries are the most com-mon sports trauma, accounting for 1030% ofall sports injuries.1 As most ankle sprains

occur during plantar flexion, supination, andinversion,2 3 they are most common in soccerplayers, but they can also occur in basketball, vol-leyball and all sports that involve jumping andsidestepping.4

Most (85%) ankle injuries are sprains,5 andonly a small percentage are caused by ankle liga-ment rupture. These injuries originate from the

weaker lateral ligaments in up to 85%, and only35% are isolated deltoid ligament sprains.5 6

The high incidence of ligamentous ankle

injuries requires clearly defined acute care and a

broad knowledge of new methods in rehabilita-tion. In addition to rapid pain relief, the main

objective of treatment is to quickly restore the

range of motion of the ankle without any major

loss of proprioception,7

thereby restoring fullactivity as soon as possible.

. . .early rehabilitation is regarded as themain aim

Before outlining recent studies in this field, we

would like to describe the standard treatmentprocedures for ligamentous ankle injuries. Gener-

ally, and most importantly, early rehabilitation is

regarded as the main aim.8 9 Immobilisation inplaster should be reserved for the worst cases as it

can result in local irritation,joint stiffness, muscle

atrophy, and extensive loss of proprioception.10 Nobenefit of surgical repair has been shown over

functional treatment with respect to repeat injuryor return to function.11

Rehabilitation is commonly divided into four

phases: the initial phase, early rehabilitation, laterehabilitation, and the functional phase.1 The

duration of each phase depends on the individual

healing process.The initial phase includes analgesic and anti-

phlogistic effects and the reduction of swelling.This is achieved by rest, elevation, ice in combina-

tion with compression, ultrasound and

electrotherapy,8 as well as oral treatment withnon-steroidal anti-inflammatory drugs and en-

zymes. To preserve neuromuscular coordination,

it is necessary to start gait trainingwithoutweight bearingas soon as possible.

The early rehabilitation phase aims to restorenormal range of motion of the ankle joints usingmanual treatment and kinetotherapy. Gentle pas-sive movement of the talocrural joint increasesrange of motion in the sagittal plane; self stretch-ing of theankle ligamentous system with a towel isuseful to increase dorsiflexion. The single planartilt board or a biomechanical ankle platformsystem can be used in the sitting position or stand-ing on two legs, and finally on one leg. In addition,cryotherapy and electrotherapy need to be contin-ued to reduce pain and swelling.

When the patient is able to tolerate full weightbearing, the phase of late rehabilitation isreached. The focus of this phase is training ofmuscle strength and endurance and neuromusc-ular performance. Isokinetic training is excellentfor initial strength training. Based on this,kinetotherapy eliminates proprioception deficits7

and improves strength and endurance usingfunctional exercises.

The functional phase prepares for a return tofull activity and includes jumping and running as

well as isokinetic exercises.

LITERATURE SEARCH

Our literature research included electronic data-bases (MedLine,Embase) from 1966 to April 2002using the following subject terms: ankle sprain,

ankle injuries,sports injuries. We then limited the

search using such terms as rehabilitation andproprioception. We also searched the bibliogra-

phies of the identified articles. The literatureresearch was carried out in English and German.

Following established criteria, levels of evidence

are graded as follows: level A, randomisedcontrolled trial/meta-analysis; level B, other evi-

dence; level C, consensus/expert opinion.12

Figure 1 Selection of studies. The six that met theinclusion criteria are discussed with an overview intable 1. An overview of the 18 excluded studies isgiven in table 2.

See end of article forauthors affiliations. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Dr Zch, Whringer Grtel18-20, 1090 Vienna,Austria;[email protected]

Accepted 26 March 2003. . . . . . . . . . . . . . . . . . . . . . .

291

www.bjsportmed.com

group.bmj.comon August 29, 2014 - Published bybjsm.bmj.comDownloaded from
http://group.bmj.com/http://bjsm.bmj.com/http://bjsm.bmj.com/http://group.bmj.com/http://bjsm.bmj.com/


2/6

A total of 24 articles were identified. Six met the following

inclusion criteria: high quality paper (randomised versus non-

randomised clinical trial, level A or B) providing primaryresearch data on treatment and rehabilitation. They present

specific up to date information on ankle rehabilitation focus-ing on proprioception and strength training.

We excluded 18 articles: two reviews on ankle rehabilitation

and ankle surgery; three articles providing basic knowledge ofproprioception and neuromuscular function; one article on

biomechanics; one article dealing with clinical examination;

11 articles emphasising orthoses from different producers andtherefore dealing with prevention. Figure 1 shows the path of

selection.

STUDY OF ASHTON-MILLER ET AL3

The best support for a near maximally inverted ankleat foot strike was found to be fully activated and strongevertor muscles

The protection of the inverted weight bearing ankle was

investigated by comparing the effect of strong evertor muscles,shoe height, athletic tape, and three different orthoses

(evidence level B, non-randomised clinical trial; table 1).

Maximal isometric eversion moment developed under fullweight bearing with the ankles in 15 of inversion was

measured in 20 healthy men, mean age 24 years. Tests wererepeated in 0 and 32 of ankle plantar flexion in low top and

three quarter top shoes with and without adhesive tape or one

of three ankle orthoses. With inactive evertor muscles, a three

quarter top shoe increased the baseline resistance to inversionby a factor of 1.42; if the same shoe was worn with a tape or

one of the orthoses, the baseline ankle resistance was

increased by a factor of 1.77. No significant differences werefound in the total eversion moments at 15 of inversion using

a tape or a brace with either shoe height. The best support

fora near maximallyinverted ankle at foot strikewas found tobe fully activated and strong evertor muscles, providing three

times greater protection than a tape or orthoses worn inside athree quarter top shoe.

STUDY OF UH ET AL10

Uh et al

10

studied the benefit of a single-leg strength trainingprogramme for the muscles around the untrained ankle (evi-dence level A, randomised controlled trial; table 1). They ran-

domised 10 men and 10 women aged 1840 years, with no

history of ankle injury, to a control and a training group. Iso-kinetic testing of the ankle muscles was performed on both

groups at the beginning and end of an eight week study

period. Measurements were performed in four directions(dorsiflexion, plantar flexion, inversion, and eversion) and in

two modes (concentric and eccentric) at two different speeds(30 and 120/s). Half of the training group trained the

dominant leg only, and the other half trained the non-

dominant leg only, three times a week for the eight weekperiod. The control group continued daily activities of living.

Table 1 Included studies

Study Methods Participants Interventions Measurements Outcomes Quality

Ashton-Milleret al3

Non-randomisedclinical trial,1 group

20 men, mean age 24,4 yearsInclusion criteria:No history of ankle injury in the6 months before testing, shoe size 10

Testing low- andthree-quarter-top shoeswith and without adhesivetape or one of threeorthoses in every subject

Isometric testing:maximal eversionmoment

Best protection fora near maximallyinverted ankle arestrong evertormuscles

B

Uhet al10 Prospective,randomised,controlled study,

3 groups

10 men, 10 women, 1840 yearsInclusion criteria:no history of ankle injury

Exclusion criteria:regular medication, regular strengthtraining

2 dynamic groups:strength training varyingin dominant/

non-dominant leg;1 control group: normalactivitiesDuration: 8 weeks

Isokinetic testing: peaktorque, power,endurance

Improvement inpeak torque in thetrained and

untrained ankle(via crossovereffect)

A

Osborneet al13

Non-randomisedclinical trial,1 group

10 men and women, 1845 yearsInclusion criteria:non-rehabilitated, unilateral, inversionankle sprain 618 months before studyentryExclusion criteria:Contralateral ankle sprain, physicaltherapy, history of surgery in the lowerextremity, neurologic disorder

1 dynamic group: ankledisk training on theinjured ankleDuration: 8 weeks

EMG: muscle onsetlatency

Decrease ofmuscle onsetlatency in specificankle musclegroups, crossovereffect

B

Eils andRosenbaum14

Randomisedclinical trial,2 groups

12 male, 18 female, 1447 yearsInclusion criteria:repeated ankle inversion sprains,subjective feeling of giving wayExclusion criteria:pain

1 dynamic group:multistation proprioceptiveexercise,1 control group: normalactivitiesDuration: 6 weeks

Joint position sense,postural sway (forceplate), EMG: musclereaction times

Changes in jointposition sense,postural sway andmuscle reactiontime

A

Matsusakaet

al15

Randomised

clinical trial,2 groups

12 men, 10 women, 1825 years

Inclusion criteria:athletes with functional instability of oneankleExclusion criteria:fractures of the lower extremity, anyimpairments of the lower extremity,trunk or central nervous system

2 dynamic groups: ankle

disk training, one groupwith, one group withoutnon-elastic adhesive tapearound the lateralmalleolusDuration: 10 weeks

Stabilometry: postural

sway

Decrease in

postural sway

A

Nyanziet al5 Double-blindrandomisedcontrolled trial,2 groups

30 male and 21 female, 1465 yearsInclusion criteria:sustained injuries less than 100 hoursbefore study entryExclusion criteria:Previous similar injury within 1 year,sustained multiple injuries, diabetes,varicose veins, bone injuries

1 group: ultrasoundtherapy for 3 days,1 placebo groupDuration: 2 weeks

Pain (visual analoguescales), swelling (tapemeasure), range ofmovement (fluid filledgoniometer), weightbearing (two scalessimultaneously)

No better resultsthan placebo

A

EMG, Electromyography.

292 Zch, Fialka-Moser, Quittan

www.bjsportmed.com



3/6

The subjects who trained the dominant leg improved peak

torque values by 8.5% in the trained leg and 1.5% in the

untrained leg. The subjects who trained the non-dominant legimproved peak torque values by 9.3% in the trained leg and

3.5% in the untrained leg. The control group showed no

significant change in peak torque, power, or endurance.

STUDY OF OSBORNE ET AL13

Osborne et al13 investigated the effect of ankle disk training on

muscle reaction time in subjects with a history of ankle sprain

(evidence level B, non-randomised clinical trial; table 1). Eight

minimally symptomatic subjects with a history of non-

rehabilitated, unilateral, inversion ankle sprain performed 15minutes a day of ankle disk training for eight weeks on the

previously injured ankle. At study entry and after the training

period, both the injured and non-injured leg were tested forankle inversion perturbation monitored by fine wire electro-

myography. A significant decrease in the anterior tibialis onsetlatency was found in both ankles, indicating a proprioceptive

cross training effect.

Table 2 Excluded articles

Review Title

Safran et al8 Lateral ankle sprainsFink & Mizel21 Whats new in foot and ankle surgery?

Basicinformation Title

Mascaro &Swanson1 Rehabilitation of the foot and ankle

Lephartet al7

The role of proprioception in the management and rehabilitation of athletic injuriesLynch &Renstrm2 Treatment of acute lateral ankle ligament rupture; conservative versus surgical treatment

Clinical trialsstudy Title Measurements Outcome Reason for exclusion

Karlsson &Andreasson 22

The effect of external ankle supportin chronic lateral ankle jointinstability

Stress radiographs in 20 patientswith chronic lateral ankle instabilitywith and without taping

Reduction of anterior talar translationand talar t il t with tape Focus on orthoses

Lfvenberg &Krrholm 6

The influence of an ankle orthosis onthe talar and calcaneal motions inchronic lateral instability of the ankle

Stereophotogrammetric analysis in14 ankles with chronic lateralinstability supported by a semirigidankle orthoses

Semirigid orthosis may provideenough external support to preventankle sprains and to protect ligamentreconstructions Focus on orthoses

Thonnardet al23 Stability of the braced ankle

Measurements of the bare ankle andthe braced angle torque relations in12 uninjured subjects under staticand dynamic conditions

Braces preload the ankle andmaintain a proper anatomic positionwith optimal contact between thearticular surfaces Focus on orthoses

De Simoniet al24

Clinical examination and magneticresonance imaging in the assessment

of ankle sprains treated with anorthosis

Clinical examination and MR of 30

patients before and after 12 weekstreatment with an ankle brace

MR findings correlate with clinical

tests in the acute phase but could notpredict clinical outcome Focus on orthoses

Frommeet al25Dependency of rearfoot pronationon physical strain during running

Examination of relation betweenrearfoot pronation and increasingphysical exertion during treadmillergometry in 20 subjects

The increase of the pronation angleis a function of the running speedwith an influence of fatigue Focus on biomechanics

Stacoffet al26Effects of foot orthoses on skeletalmotion during running

Kinematic effects of medial footorthoses on 5 healthy men usingskeletal markers at the calcaneusand tibia

Medially placed foot orthoses didnot change tibiocalcaneal movementpatterns Focus on orthoses

Vaeset al27

Static and dynamicroentgenographic analysis of anklestability in braced and non-bracedstable and functionally unstableankles

Digital roentgeno-cinemtaographicanalysis of a 50 ankle sprainsimulation in patients with functionalankle instability

Decrease in pathological supinetalar t il t in braced ankles Focus on orthoses

Simpsonet al4

A comparison of the Sport Stirrup,Malleoloc and Swede-O ankleorthoses for the foot-ankle kinematicsof a rapid lateral movement

Abilities of three different braces torestrict inversion without hinderingplantar/dorsiflexion in 19 subjectswith ankle sprain

Plantar flexion was inhibited for allbraces, less dorsiflexion wasexhibited for the Swede-O Focus on orthoses

Nesteret al28

Effect of foot orthoses on rearfootcomplex kinematics during walkinggait

Effect of anti-pronatory and

anti-supinatory foot orthoses on theangular displacement, velocity andaccelerations of the rearfoot complexduring gait in 12 subjects

Neither orthosis had a statisticallysignificant effect on rearfoot complexacceleration Focus on orthoses

Raikinet al29

Biomechanical evaluation of theability of casts and braces toimmobilise the ankle and hindfoot

Ability of 7 devices to immobilise aprosthetic ankle-foot complex againstplantar/dorsiflexion, inversion andeversion forces

Casts offered more resistance tomotion in all directions tested thanbraces Focus on orthoses

Kripset al11

Long term outcome of anatomicalreconstruction versus tenodesis forthe treatment of chronic anterolateralinstability of the ankle joint

Follow up after 12.3 years in 25patients with anatomicalreconstruction and in 29 patientswith tenodesis

Anatomical reconstruction deliverssignificantly more excellent results Focus on orthoses

Hertelet al30

Effect of rearfoot orthotics onpostural sway after lateral anklesprain

Analysis of variance on posturalsway length and velocity in 15athletes with acute lateral anklesprain and 5 different orthoses

Rearfoot orthotics were ineffective atimproving postural sway after lateralankle sprain Focus on orthoses

Kanbeet al31

The relation of the anterior drawersign to the shape of the tibialplatfond in chronic lateral instabilityof the ankle

Investigation of stress radiographs in71 patients with severe chroniclateral instability of the ankle

No correlation between anteriordrawer and talar tilt

Focus on clinicalexamination

Rehabilitation of ankle injuries 293

www.bjsportmed.com



4/6

STUDY OF EILS AND ROSENBAUM14

Eils and Rosenbaum14 studied the effects of a six week multi-

station, low frequency exercise programme (evidence level A,

randomised controlled trial; table 1). They randomised 30subjects (18 male and 12 female) with chronic ankle instabil-

ity, repeated ankle inversion sprains, or a subjective feeling of

instability or giving way to an exercise group or a controlgroup. The control group were tested before and after the six

week period but did no exercise. The exercise group followed a

physiotherapy programme consisting of 12 different exercises

including both strength and proprioception training in theform of circuit training for 20 minutes once a week. Jointposition sense, postural sway, and muscle reaction times were

tested using a trap door and surface electromyography. After

the six week training period, improvements in the anklereproduction test were found in the exercise group for all the

test conditions. In the postural sway test, both groups

improved for all parameters. Muscle reaction times were pro-longed in both groups for all muscles. Integrated electromyog-

raphy showed only a slight decrease for the tibialis anterior

muscle in the experimental group. A questionnaire returnedone year after training showed a significantly (almost 60%)

reduced incidence of ankle inversions after the exercise

programme.

STUDY OF MATSUSAKAET AL15

Matsusakaet al15 tested the combination of ankle disk training

and tactile stimulation (evidence level A, randomised control-led trial; table 1). Twenty two students with unilateral

functional instability were randomised to two experimental

groups, both of which trained to stand on the affected limb onan ankle disk. Subjects in group 1 trained with two pieces of 1

cm wide non-elastic adhesive tape applied to the skin around

the lateral malleolus from the distal third of the lower leg tothe sole of the foot. The other group trained without the adhe-

sive tape. Before, during, and after the 10 week trainingprogramme (10 minutes a day, 5 times a week), postural sway

was tested in all subjects standing on the affected limb.

Postural sway values for group 1 had decreased significantlyafter four weeks. After six weeks of training they were within

the normal range. In contrast, the values in group 2 did not

significantly improve and they were not within the normalrange until after eight weeks of training.

STUDY OF NYANZI ET AL5

Nyanzi et al5 examined the use of ultrasound compared with

placebo (evidence level A, randomised controlled trial; table1). They included 51 patients with injuries sustained less than

100 hours before entry within the age range 1465 years and

randomised them to two groups. One group had ultrasoundtreatment at an intensity of 0.25 W/cm2 at a mark space ratio

of 1:4 at 3 MHZ for 10 minutes per session. The placebo groupwas not aware that the ultrasound machine was in its sham

phase. Treatment was given on three consecutive days. Both

groups wore Tubigrip (Seton, UK) after treatment. All patientswere measured on every day of the treatment period and for

14 days after the end of treatment, using a visual analoguescale to assess pain, tape measurement of the ankle to recordswelling, range of motion to determine mobility, and simulta-

neous weighing to assess ability to weight bear. No significant

differences in any outcome measure were found between thegroups.

DISCUSSIONAshton-Milleret al3 showed that no external support can pro-

vide the same degree of protection as strong evertor muscles.However, it may happen that the evertor muscles fail to

prevent an ankle inversion injury. The muscle onset latency istherefore responsible. A period of preactivation is needed to

develop sufficient force in the evertor muscles forlanding after

a jump. When recontact with the ground is earlier than

anticipatedfor example, when landing on an unseenobjectthere is inadequate time to prevent forced inversion.

In this case, passive devices may help to protect the ankle at

15 of inversion by almost doubling its baseline resistance. Theauthors attribute the protection afforded by taping only to the

stabilising effect; proprioception is not mentioned.Uh et al10 claim to be the first to investigate the effect of

muscle training around one ankle on the strength of the mus-

cles around the contralateral ankle. They tried to show acrossover training effect by referring to the evaluations ofKomu e t a l.16 There are several theories to explain thiseffectfor example, enhancement of neuromuscular facilita-tion, the reduction of central inhibitory impulses to theuntrained limb, and undetectable isometric contractions ofthe untrained limb during strength training.10 The origin ofthe crossover training effect could not be explained satis-factorily in this study either (as the authors indicatethemselves); moreover, the improvements in strength andpower were not as impressive as in studies on other joints.However, these results must be seen against thebackground ofthe small cohort. The authors plan to carry out furtherresearch with larger numbers of subjects. In addition, it wouldbe interesting to investigate patients with a history of ankleinjury.

Some kind of crossover effect was also identified in thestudy of Osborne et al.13 They succeeded in demonstrating theeffects of proprioceptive crossover training. A previous study17

dealt with muscle onset latency: patients with uninjuredankles showed an increase in onset latency of both theanterior tibialis and posterior tibialis muscle. These results arein contrast with those presented in the more recent study, in

which the anterior tibialis muscle showed a significantdecrease in onset latency. The reason for this difference intraining effects in patients with or without a history of ankleinjuries is unclear. Further research on this that alsoinvestigates other muscle function parameters and considerscomplex physiological adaptations is required.

The strength of the study of Eils and Rosenbaum14 lies in itsbroad methodological approach. The test design includedthree different testing procedures before and after the trainingperiod and, in addition, the results were re-evaluated one yearafter training. The three test procedures allowed an overviewof multiple factors influenced by ankle training in a singlestudy. The re-evaluation was of particular interest becauserecurrent instability has been estimated to occur in 1020% ofpatients irrespective of the type of initial treatment.11 Strengthtraining in combination with proprioception training is thegenerally accepted programme for complex rehabilitation.Furthermore, it appears to be the only study in recent years in

which patients performed circuit training in a large group.Besides the documented clinical benefits, this group trainingmay prove to be highly cost effective.

Matsusaka et al15 also investigated the efficacy of propriocep-tion training. The experimental conditions were based on thefinding that ankle taping has more than just a supportive

function; the adhesive tape, placed on the area where the suralnerve provides cutaneous branches to thelateral side of thelegand foot, stimulates by traction the skin receptors during pos-tural correction on the ankle disk. In this way, the disturbanceof the afferent input from mechanoreceptors in the injuredligaments and capsule of the functionally instable ankle18 iscompensated. The mechanism of this process is not elucidatedby this study, but the results show that a combination of ankledisk training and non-elastic adhesive tape have a better effecton postural sway than applying only one of the methods.

The study of Nyanzi et al5 shows no significant results.Despite this, we thought it worthy of mention because it hasbeen suggested that ultrasound treatment improves the rateand quality of healing19 and reduces pain.20 The diversity of

294 Zch, Fialka-Moser, Quittan

www.bjsportmed.com



5/6

measurements included major clinical features of ankle

sprains such as pain, swelling, and reduced mobility.

Nevertheless, as the authors indicate, treatment using thedose and duration specified did not lead to significant results.

ConclusionImprovement in proprioception is important in ankle rehabili-

tation and this should be taken into consideration whensetting up a rehabilitation programme. Furthermore, it has

been shown that a combination of different exercises leads to

better results and allows earlier return to the activities of dailylife. The most efficient method of restoring range of motion

and proprioception seems to be ankle disk training together

with taping. In addition, isokinetic training increases thestrength of the injured leg as well as that of the uninjured leg

by the crossover training effect.

. . . . . . . . . . . . . . . . . . . . .Authors affiliationsC Zch, V Fialka-Moser, M Quittan, Department of Physical Medicineand Rehabilitation, University Hospital of Vienna, Vienna, Austria

REFERENCES1 Mascaro TB, Swanson LE. Rehabilitation of the foot and ankle. Orthop

Clin North Am1994;25:14760.2 Lynch SA, Renstrm PAFH. Treatment of acute lateral ankle ligament

rupture in the athlete: conservative versus surgical treatment. Sports Med1999;27:6171.

3 Ashton-Miller JA, Ottaviani RA, Hutchinson Ch,et al. What bestprotects the inverted weightbearing ankle against further inversion. Am JSports Med1996;24:8009.

4 Simpson KJ, Cravens S, Higbie E,et al. A comparison of the SportStirrup, Malleoloc, and Swede-O ankle orthoses for the foot-anklekinematics of a rapid lateral movement. Int J Sports Med1999;20:396402.

5 Nyanzi CS, Langridge J, Heyworth JRC,et al. Randomized controlled

study of ultrasound therapy in the management of acute lateral ligamentsprains of the ankle joint. Clin Rehabil1999;13:1622.6 Lfvenberg R, Krrholm J. The influence of an ankle orthosis on the talar

and calcaneal motions in chronic lateral instability of the ankle. Am JSports Med1993;2:22430.

7 Lephart SM, Pincivero DM, Giraldo JL, et al. The role of proprioceptionin the management and rehabilitation of athletic injuries. Am J SportsMed1997;25:1307.

8 Safran MR, Zachazewski JF, Benedetti RS, et al. Lateral ankle sprains: acomprehensive review.Med Sci Sports Exerc1999;43847.

9 Dijk van CN. Management of the sprained ankle.Br J Sports Med2002;36:834.

10 Uh BS, Beynnon BD, Helie BV, et al. The benefit of a single-leg strengthtraining program for the muscles around the untrained ankle.Am J SportsMed2000;28:68573.

11 Krips R, Dijk van N, Halasi T, et al. Long-term outcome of anatomicalreconstruction versus tenodesis for the treatment of chronic anterolateralinstability of the ankle joint: a multicenter study. Foot Ankle Int2001;22:41521.

12 Siwek J, Gourlay ML. How to write an evidence-based clinical reviewarticle. Am Fam Physician2002;15;65:2518.

13 Osborne MD, Chou LS, Laskowski ER, et al. The effect of ankle disktraining on muscle reaction time in subjects with a history of ankle sprain.Am J Sports Med2001;29:62731.

14 Eils E, Rosenbaum D. A multi-station proprioceptive exercise program inpatients with ankle instability. Med Sci Sports Exerc2001;33:19918.

15 Matsusaka N, Yokoyama S, Tsurusaki T, et al. Effect of ankle disktraining combined with tactile stimulation to the leg and foot on functionalinstability of the ankle. Am J Sports Med2001;29:2530.

16 Komu PV, Viitasalo JT, Rauramaa R,et al. Effect of isometric strengthtraining on mechanical, electrical and metabolic aspects of musclefunction.Eur J Appl Physiol1978;40:4555.

17 Sheth P, Yu B, Laskowski ER, et al. Ankle disk training influencesreaction time of selected muscles in a simulated ankle sprain. Am J SportsMed1997;25:53843.

18 Freeman MAR, Dean MRE, Hanham IWF. The etiology and preventionof functional instability of the foot. J Bone Joint Surg [Br]1965;47:67885.

19 Dyson M. Mechanisms involved in therapeutic ultrasound. Physiotherapy1987;73:11620.

20 Makuloluwe RTB, Mouzas GL. Ultrasound in the treatment of sprainedankles.The Practitioner1977;218:5868.

21 Fink B, Mizel MS. Whats new in foot and ankle surgery. J Bone JointSurg [Am]2001;83:7916.22 Karlsson J, Andreasson GO. The effect of external ankle support in

chronic lateral ankle joint instability.Am J Sports Med1992;20:25761.23 Thonnard JL, Bragard D, Willems PA,et al. Stability of the braced

ankle, a biomechanical investigation. Am J Sports Med1996;24:35661.

24 De Simoni C, Wetz HH, Zanetti M,et al. Clinical examination andmagnetic resonance imaging in the assessment of ankle sprains treatedwith an orthosis.Foot Ankle Int1996;17:17782.

25 Fromme A, Winkelmann F, Thorwesten L, et al. Pronationswinkel desRckfues beim Laufen in Abhngigkeit von der Belastung.Sportverl.-Sportschad1997;11:527.

26 Stacoff A, Reinschmidt C, Nigg B M, et al. Effects of foot orthoses onskeletal motion during running. Clin Biomech 2000;15:5464.

27 Vaes PH, Duquet W, Casteleyn PP, et al. Static and dynamicroentgenographic analysis of ankle stability in braced and nonbracedstable and functionally unstable ankles.Am J Sports Med1998;26:692702.

28 Nester CJ, Hutchins S, Bowker P. Effect of foot orthoses on rearfoot

complex cinematics during walking gait. Foot Ankle Int2001;22:1339.29 Raikin SM, Parks BG, Noll KH,et al. Biomechanical evaluation of theability of casts and braces to immobilize the ankle and hindfoot. FootAnkle Int2001;22:21419.

30 Hertel J, Denegar CR, Buckley WE, et al. Effect of rearfoot orthotics onpostural sway after lateral ankle sprain.Arch Phys Med Rehabil2001;82:10003.

31 Kanbe K, Hasegawa A, Nakajima Y,et al. The relationship of theanterior drawer sign to shape of the tibial platfond in chronic lateralinstability of the ankle. Foot Ankle Int2002;23:11822.

Take home message

A combination of isokinetic strength training with proprio-ception training shortens rehabilitation and serves as sec-ondary prophylaxis.

Rehabilitation of ankle injuries 295

www.bjsportmed.com



6/6

doi: 10.1136/bjsm.37.4.291

2003 37: 291-295Br J Sports MedC Zch, V Fialka-Moser and M Quittanreview of recent studiesRehabilitation of ligamentous ankle injuries: a

http://bjsm.bmj.com/content/37/4/291.full.htmlUpdated information and services can be found at:

These include:

References

http://bjsm.bmj.com/content/37/4/291.full.html#related-urlsArticle cited in:

http://bjsm.bmj.com/content/37/4/291.full.html#ref-list-1

This article cites 27 articles, 11 of which can be accessed free at:

serviceEmail alerting

box at the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up in the

CollectionsTopic

(743 articles)Trauma(823 articles)Injury

Articles on similar topics can be found in the following collections

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:

http://bjsm.bmj.com/content/37/4/291.full.htmlhttp://bjsm.bmj.com/content/37/4/291.full.htmlhttp://bjsm.bmj.com/content/37/4/291.full.html#related-urlshttp://bjsm.bmj.com/content/37/4/291.full.html#related-urlshttp://bjsm.bmj.com/content/37/4/291.full.html#ref-list-1http://bjsm.bmj.com/cgi/collection/traumahttp://bjsm.bmj.com/cgi/collection/traumahttp://bjsm.bmj.com/cgi/collection/traumahttp://bjsm.bmj.com/cgi/collection/traumahttp://group.bmj.com/group/rights-licensing/permissionshttp://group.bmj.com/group/rights-licensing/permissionshttp://journals.bmj.com/cgi/reprintformhttp://journals.bmj.com/cgi/reprintformhttp://group.bmj.com/subscribe/http://group.bmj.com/http://bjsm.bmj.com/http://bjsm.bmj.com/http://group.bmj.com/http://bjsm.bmj.com/http://group.bmj.com/subscribe/http://journals.bmj.com/cgi/reprintformhttp://group.bmj.com/group/rights-licensing/permissionshttp://bjsm.bmj.com/cgi/collection/traumahttp://bjsm.bmj.com/cgi/collection/injuryhttp://bjsm.bmj.com/content/37/4/291.full.html#related-urlshttp://bjsm.bmj.com/content/37/4/291.full.html#ref-list-1http://bjsm.bmj.com/content/37/4/291.full.html

Br J Sports Med 2003 Zöch 291 5

Documents

Transcript of Br J Sports Med 2003 Zöch 291 5