Ankle strength is not strongly associated with postural stability in patients awaiting surgery for chronic lateral ankle instability

Abstract

Purpose

(1) To describe ankle strength and postural stability in patients with chronic lateral ankle instability and (2) to analyse the correlation between deficits in ankle strength and postural stability.

Methods

Results of preoperative isokinetic and balance tests in 203 patients whose contralateral ankle was normal were retrospectively reviewed. Isokinetic peak torque values of eversion and inversion at 2 angular velocities (30°/s and 120°/s) were measured in the injured and normal ankles. In the balance test, the percent differences of 3 actual scores (overall, anterior–posterior, and medial–lateral) between the injured and normal ankles were calculated. Additional statistical analyses were performed to evaluate weakness of ankle strength, postural stability deficits, and their correlation.

Results

Significant differences in 4 peak torque values and 4 relative peak torque values (peak torque/body weight) were found between the injured and normal ankles. All 8 values were significantly lower in the injured ankles. Weakness was severe during inversion and at 30°/s. In the balance test, 49 subjects (24.1%) had significant deficits in postural stability and 109 (53.7%) had favourable results. No strong association was found between weakness of ankle strength and deficits in postural stability.

Conclusions

Strength measurement alone is insufficient to evaluate preoperative functional deficits, and other functional tests are required to measure postural stability. The results of this study provide further evidence for a rehabilitation programme consisting of proprioceptive training as well as strengthening. The proprioceptive training must be an integral part of the rehabilitation programme in addition to strengthening exercise.

Level of evidence

Case series, Level IV.

This is a preview of subscription content, log in to check access.

References

  1. 1.

    Akhbari B, Salavati M, Mohammadi F, Safavi-Farokhi Z (2015) Intra- and inter-session reliability of static and dynamic postural control in participants with and without Patellofemoral pain syndrome. Physiother Can 67:248–253

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Almeida GPL, Monteiro IO, Marizeiro DF, Maia LB, de Paula Lima PO (2017) Y balance test has no correlation with the stability index of the Biodex Balance System. Musculoskelet Sci Pract 27:1–6

    PubMed  Google Scholar 

  3. 3.

    Amaral De Noronha M, Borges NG Jr (2004) Lateral ankle sprain: isokinetic test reliability and comparison between invertors and evertors. Clin Biomech (Bristol Avon) 19:868–871

    Google Scholar 

  4. 4.

    Arifin N, Abu Osman NA, Wan Abas WA (2014) Intrarater test-retest reliability of static and dynamic stability indexes measurement using the Biodex Stability System during unilateral stance. J Appl Biomech 30:300–304

    PubMed  Google Scholar 

  5. 5.

    Attenborough AS, Sinclair PJ, Sharp T, Greene A, Stuelcken M, Smith RM, Hiller CE (2017) The identification of risk factors for ankle sprains sustained during netball participation. Phys Ther Sport 23:31–36

    PubMed  Google Scholar 

  6. 6.

    Aydin T, Yildiz Y, Yildiz C, Atesalp S, Kalyon TA (2002) Proprioception of the ankle: a comparison between female teenaged gymnasts and controls. Foot Ankle Int 23:123–129

    PubMed  Google Scholar 

  7. 7.

    Aydog E, Aydog ST, Cakci A, Doral MN (2004) Reliability of isokinetic ankle inversion- and eversion-strength measurement in neutral foot position, using the Biodex dynamometer. Knee Surg Sports Traumatol Arthrosc 12:478–481

    PubMed  Google Scholar 

  8. 8.

    Bernier JN, Perrin DH (1998) Effect of coordination training on proprioception of the functionally unstable ankle. J Orthop Sports Phys Ther 27:264–275

    CAS  PubMed  Google Scholar 

  9. 9.

    Cho BK, Park JK, Choi SM, Kang SW, SooHoo NF (2017) The peroneal strength deficits in patients with chronic ankle instability compared to ankle sprain copers and normal individuals. Foot Ankle Surg. https://doi.org/10.1016/j.fas.2017.10.017

    Article  PubMed  Google Scholar 

  10. 10.

    Cho BK, Park JK, Choi SM, SooHoo NF (2018) The effect of peroneal muscle strength on functional outcomes after the modified brostrom procedure for chronic ankle instability. Foot Ankle Int 39:105–112

    PubMed  Google Scholar 

  11. 11.

    Chuter VH, Janse de Jonge XA (2012) Proximal and distal contributions to lower extremity injury: a review of the literature. Gait Posture 36:7–15

    PubMed  Google Scholar 

  12. 12.

    de Noronha M, Franca LC, Haupenthal A, Nunes GS (2013) Intrinsic predictive factors for ankle sprain in active university students: a prospective study. Scand J Med Sci Sports 23:541–547

    PubMed  Google Scholar 

  13. 13.

    De Ridder R, Witvrouw E, Dolphens M, Roosen P, Van Ginckel A (2017) Hip strength as an intrinsic risk factor for lateral ankle sprains in youth soccer players: a 3-season prospective study. Am J Sports Med 45:410–416

    PubMed  Google Scholar 

  14. 14.

    Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E (2016) Single-leg drop landing movement strategies in participants with chronic ankle instability compared with lateral ankle sprain ‘copers’. Knee Surg Sports Traumatol Arthrosc 24:1049–1059

    PubMed  Google Scholar 

  15. 15.

    Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C (2014) The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med 44:123–140

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Fong DT, Hong Y, Chan LK, Yung PS, Chan KM (2007) A systematic review on ankle injury and ankle sprain in sports. Sports Med 37:73–94

    PubMed  Google Scholar 

  17. 17.

    Friel K, McLean N, Myers C, Caceres M (2006) Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl Train 41:74–78

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Glave AP, Didier JJ, Weatherwax J, Browning SJ, Fiaud V (2016) Testing postural stability: are the star excursion balance test and biodex balance system limits of stability tests Consistent?. Gait Posture 43:225–227

    PubMed  Google Scholar 

  19. 19.

    Gribble PA, Hertel J, Plisky P (2012) Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train 47:339–357

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Gribble PA, Terada M, Beard MQ, Kosik KB, Lepley AS, McCann RS, Pietrosimone BG, Thomas AC (2016) Prediction of lateral ankle sprains in football players based on clinical tests and body mass index. Am J Sports Med 44:460–467

    PubMed  Google Scholar 

  21. 21.

    Hanci E, Sekir U, Gur H, Akova B (2016) Eccentric training improves ankle evertor and dorsiflexor strength and proprioception in functionally unstable ankles. Am J Phys Med Rehabil 95:448–458

    PubMed  Google Scholar 

  22. 22.

    Hrysomallis C, McLaughlin P, Goodman C (2007) Balance and injury in elite Australian footballers. Int J Sports Med 28:844–847

    CAS  PubMed  Google Scholar 

  23. 23.

    Kaminski TW, Dover GC (2001) Reliability of inversion and eversion peak-and average-torque measurements from the Biodex system 3 dynamometer. J Sport Rehabil 10:205–220

    Google Scholar 

  24. 24.

    Karnofel H, Wilkinson K, Lentell G (1989) Reliability of isokinetic muscle testing at the ankle. J Orthop Sports Phys Ther 11:150–154

    CAS  PubMed  Google Scholar 

  25. 25.

    McCann RS, Crossett ID, Terada M, Kosik KB, Bolding BA, Gribble PA (2017) Hip strength and star excursion balance test deficits of patients with chronic ankle instability. J Sci Med Sport 20:992–996

    PubMed  Google Scholar 

  26. 26.

    McKeon JM, McKeon PO (2012) Evaluation of joint position recognition measurement variables associated with chronic ankle instability: a meta-analysis. J Athl Train 47:444–456

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Michels F, Pereira H, Calder J, Matricali G, Glazebrook M, Guillo S, Karlsson J, Acevedo J, Batista J, Bauer T, Calder J, Carreira D, Choi W, Corte-Real N, Glazebrook M, Ghorbani A, Giza E, Guillo S, Hunt K, Karlsson J, Kong SW, Lee JW, Michels F, Molloy A, Mangone P, Matsui K, Nery C, Ozeki S, Pearce C, Pereira H, Perera A, Pijnenburg B, Raduan F, Stone J, Takao M, Tourne Y, Vega J (2017) Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-017-4556-0

    Article  PubMed  Google Scholar 

  28. 28.

    Mohammadirad S, Salavati M, Takamjani IE, Akhbari B, Sherafat S, Mazaheri M, Negahban H (2012) Intra and intersession reliability of a postural control protocol in athletes with and without anterior cruciate ligament reconstruction: a dual-task paradigm. Int J Sports Phys Ther 7:627–636

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    Munn J, Beard DJ, Refshauge KM, Lee RY (2003) Eccentric muscle strength in functional ankle instability. Med Sci Sports Exerc 35:245–250

    PubMed  Google Scholar 

  30. 30.

    Pearce CJ, Tourne Y, Zellers J, Terrier R, Toschi P, Silbernagel KG, Eskka-Afas Ankle Instability Group (2016) Rehabilitation after anatomical ankle ligament repair or reconstruction. Knee Surg Sports Traumatol Arthrosc 24:1130–1139

    PubMed  Google Scholar 

  31. 31.

    Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Bruggemann GP, Best R (2013) Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg 133:1129–1141

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Plisky PJ, Gorman PP, Butler RJ, Kiesel KB, Underwood FB, Elkins B (2009) The reliability of an instrumented device for measuring components of the star excursion balance test. N Am J Sports Phys Therapy: NAJSPT 4:92

    Google Scholar 

  33. 33.

    Postle K, Pak D, Smith TO (2012) Effectiveness of proprioceptive exercises for ankle ligament injury in adults: a systematic literature and meta-analysis. Man Ther 17:285–291

    CAS  PubMed  Google Scholar 

  34. 34.

    Salavati M, Moghadam M, Ebrahimi I, Arab AM (2007) Changes in postural stability with fatigue of lower extremity frontal and sagittal plane movers. Gait Posture 26:214–218

    PubMed  Google Scholar 

  35. 35.

    Sekir U, Yildiz Y, Hazneci B, Ors F, Aydin T (2007) Effect of isokinetic training on strength, functionality and proprioception in athletes with functional ankle instability. Knee Surg Sports Traumatol Arthrosc 15:654–664

    PubMed  Google Scholar 

  36. 36.

    Sherafat S, Salavati M, Ebrahimi Takamjani I, Akhbari B, Mohammadirad S, Mazaheri M, Negahban H (2013) Intrasession and intersession reliability of postural control in participants with and without nonspecific low back pain using the Biodex Balance System. J Manipulative Physiol Ther 36:111–118

    PubMed  Google Scholar 

  37. 37.

    Sierra-Guzman R, Jimenez F, Abian-Vicen J (2018) Predictors of chronic ankle instability: analysis of peroneal reaction time, dynamic balance and isokinetic strength. Clin Biomech (Bristol Avon) 54:28–33

    Google Scholar 

  38. 38.

    Terrier R, Degache F, Fourchet F, Gojanovic B, Forestier N (2017) Assessment of evertor weakness in patients with chronic ankle instability: functional versus isokinetic testing. Clin Biomech (Bristol Avon) 41:54–59

    Google Scholar 

  39. 39.

    Thompson C, Schabrun S, Romero R, Bialocerkowski A, van Dieen J, Marshall P (2018) Factors contributing to chronic ankle instability: a systematic review and meta-analysis of systematic reviews. Sports Med 48:189–205

    PubMed  Google Scholar 

  40. 40.

    Van Deun S, Staes FF, Stappaerts KH, Janssens L, Levin O, Peers KK (2007) Relationship of chronic ankle instability to muscle activation patterns during the transition from double-leg to single-leg stance. Am J Sports Med 35:274–281

    PubMed  Google Scholar 

  41. 41.

    Vuurberg G, Pereira H, Blankevoort L, van Dijk CN (2017) Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-017-4730-4

    Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Webster KA, Gribble PA (2013) A comparison of electromyography of gluteus medius and maximus in subjects with and without chronic ankle instability during two functional exercises. Phys Ther Sport 14:17–22

    PubMed  Google Scholar 

  43. 43.

    Wilkerson GB, Giles JL, Seibel DK (2012) Prediction of core and lower extremity strains and sprains in collegiate football players: a preliminary study. J Athl Train 47:264–272

    PubMed  PubMed Central  Google Scholar 

  44. 44.

    Wilkerson GB, Pinerola JJ, Caturano RW (1997) Invertor vs. evertor peak torque and power deficiencies associated with lateral ankle ligament injury. J Orthop Sports Phys Ther 26:78–86

    CAS  PubMed  Google Scholar 

  45. 45.

    Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D (2002) Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. J Athl Train 37:487–493

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Wong DL, Glasheen-Way M, Andrews LF (1984) lsokinetic evaluation of the ankle lnvertors and evertors. J Orthop Sports Phys Ther 5:246–252

    CAS  PubMed  Google Scholar 

  47. 47.

    Yildiz Y, Aydin T, Sekir U, Hazneci B, Komurcu M, Kalyon TA (2003) Peak and end range eccentric evertor/concentric invertor muscle strength ratios in chronically unstable ankles: comparison with healthy individuals. J Sports Sci Med 2:70–76

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Zech A, Hubscher M, Vogt L, Banzer W, Hansel F, Pfeifer K (2009) Neuromuscular training for rehabilitation of sports injuries: a systematic review. Med Sci Sports Exerc 41:1831–1841

    PubMed  Google Scholar 

Download references

Funding

No funding.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Ki-Sun Sung.

Ethics declarations

Conflict of interest

All authors declare that we have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study, informed consent form is not required.

Appendix

Appendix

See Tables 7 and 8.

Table 7 Reported intraclass correlation coefficient of the stability index of the Biodex Stability System
Table 8 Test–retest reliability of the measurement systems in the pilot study

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ko, K.R., Lee, H., Lee, W. et al. Ankle strength is not strongly associated with postural stability in patients awaiting surgery for chronic lateral ankle instability. Knee Surg Sports Traumatol Arthrosc 28, 326–333 (2020). https://doi.org/10.1007/s00167-018-4960-0

Download citation

Keywords

  • Chronic ankle instability
  • Ankle strength
  • Postural stability
  • Rehabilitation