Ankle ligament injury is the most common injury in athletic activities. This study examined balance problems in athletes with acute lateral ankle sprains. Thirty male athletes aged 20 to 35 years with right dominant side and traumatic ankle sprain were recruited through simple nonprobability sampling. We measured the sway index and limits of stability with the Biodex Balance System under different conditions. Functional balance was evaluated with two clinical tests: the Functional Reach Test and the Star-Excursion Balance Test. The results showed that balance ability in patients with acute lateral ankle sprain was significantly weaker under closed- versus open-eye conditions. Symmetry of weight-bearing on involved and sound limb in bilateral standing was not significantly different, but weight-bearing on the nondominant limb was significantly higher than on the dominant limb. We can conclude that balance problems occur after acute ankle sprains because of proprioception deficits and that the unconscious (reflexive) aspect of proprioception is more severely affected than the conscious (voluntary) aspect

Akbari, M.

Faghihzadeh, S.

Farahini, H.

Karimi, H.

English

eprints Iran University of Medical Sciences

JRRD Volume 43, Number 7, Pages 819–824November/December 2006Journal of Rehabil itation Research & DevelopmentBalance problems after unilateral lateral ankle sprainsMohammad Akbari, PhD;1* Hossein Karimi, PhD;1 Hossein Farahini, PhD;2 Soghrat Faghihzadeh, PhD3Departments of 1Physical Therapy and 2Orthopedic Surgery, Iran University of Medical Sciences, Tehran, Iran; 3Department of Biostatistics, Tarbiat Modares University, Tehran, IranAbstract—Ankle ligament injury is the most common injury inathletic activities. This study examined balance problems in ath-letes with acute lateral ankle sprains. Thirty male athletes aged20 to 35 years with right dominant side and traumatic anklesprain were recruited through simple nonprobability sampling.We measured the sway index and limits of stability with the Bio-dex Balance System under different conditions. Functional bal-ance was evaluated with two clinical tests: the Functional ReachTest and the Star-Excursion Balance Test. The results showedthat balance ability in patients with acute lateral ankle sprain wassignificantly weaker under closed- versus open-eye conditions.Symmetry of weight-bearing on involved and sound limb inbilateral standing was not significantly different, but weight-bearing on the nondominant limb was significantly higher thanon the dominant limb. We can conclude that balance problemsoccur after acute ankle sprains because of proprioception deficitsand that the unconscious (reflexive) aspect of proprioception ismore severely affected than the conscious (voluntary) aspect.Key words: ankle, balance, consciousness, ligament, limits ofstability, proprioception, rehabilitation, sprain, stability, sway.INTRODUCTIONLateral ankle sprains are the most common acutepathology seen in athletic activities [1]. Up to one-sixth ofall time lost from sports is because of this type of injury[2]. Sixteen percent of all sports injuries are ankle ligamentsprains [3]. The cost for treatment and rehabilitation ofthese injuries is $2 billion a year [4]. Reducing the inci-dence of ankle ligament injuries depends on identifying theconditions under which such injuries occur (e.g., extrinsicvariables, such as height and ankle-specific measures, thatmight predispose athletes to such injuries) [4].Many researchers have reported that individuals witha history of ankle sprains are more susceptible to subse-quent ankle sprains or chronic ankle instability [5–7].Otter found that 73 percent of ankle sprains occur inankles that had previously been sprained [8]. Therefore,previously sprained ankles must have some risk factorsthat cause them to be recurrently sprained [5]. Numerousfactors and mechanisms are thought to contribute to thisincreased ankle sprain occurrence [9]. Some of these fac-tors are instability, muscle weakness, limited mobility ofthe ankle joint, problems related to footwear, and damageto the proprioceptors in the ligaments of the ankle [6,9].According to Michelson and Hutchins, two levels of pro-prioception exist: conscious (voluntary) and unconscious(reflexive). While the conscious aspect is involved inoverall control during sports and activities of daily living,the unconscious aspect is involved in joint stabilizationduring unexpected perturbations [10]. Nashner showedthat one of the main factors in reducing body sway in astanding position is proprioception [11].Abbreviations: FRT = Functional Reach Test, LOS = limits ofstability, ROM = range of motion, SEBT = Star-Excursion Bal-ance Test.*Address all correspondence to Dr. Mohammad Akbari,Department of Physical Therapy, School of RehabilitationSciences, Iran University of Medical Sciences, PO Box15875-4391, Tehran, Iran; +9821-22227124; fax: +9821-22220946. Email: akbarimo43@yahoo.comDOI: 10.1682/JRRD.2006.01.0001819820JRRD, Volume 43, Number 7, 2006Body sway will increase if proprioception is deficientbecause of ligamentous injury [12]. In other words, bal-ance will be disturbed in such cases. Balance problemscan be measured by two different procedures: (1) clinicaltests and (2) laboratory tests with new equipment [13].Two examples of clinical procedures are the FunctionalReach Test (FRT) and the Star-Excursion Balance Test(SEBT) [14–15]. One new piece of laboratory equipmentfor evaluating balance is the Biodex Balance System(Biodex Medical Systems; Shirley, New York), whichcan be used for measuring body sway (balance index)and determining limits of stability (LOS) [16–17]. Bodysway and LOS can be measured in either bi- or unilateralstanding positions. Because the ankle joint has an essen-tial role in balance control, the location of the center ofpressure depends on the ankle joint position and leg mus-cle (plantar flexor and dorsiflexor) activity. Balance con-trol in unilateral standing will be disturbed in patientswith functional ankle instability [16].This study examined balance problems in athleteswith Rouzier Grade I and II unilateral lateral anklesprains. We were interested in the following questions:(1) Do any balance problems exist after traumatic ankleligament sprain? (2) Which aspect of balance ability suf-fers most? (3) What are the effects of vision (open orclosed eyes) on balance ability in patients with anklesprain?METHODSSubjectsThis study was a clinical trial that was conducted inphysical therapy clinics of the Sports Medicine Federa-tion of Iran between April 2003 and March 2004. Theethics committee of the Iran University of Medical Sci-ences approved the study. All subjects were informedabout the procedures and signed a consent form prior toparticipation. The subjects were 30 male athletesinvolved in multidirectional sports (football, volleyball,and martial arts). These athletes with right-side domi-nance and Grade I and II traumatic ankle sprain (accord-ing to Rouzier grading) were aged 22.8 ± 4.8 years [18].All data are presented as mean ± standard deviationunless otherwise noted. Subjects were excluded fororthopedic and/or neurological conditions, uncorrectedproblems with vision, chronicity and recurrence of thesprain, and left-side dominance.Data CollectionData collection included subject interviews, appropri-ate musculoskeletal evaluations, and performance on dif-ferent balance tests. Individual characteristics (age,weight, and height), job, grade of sprain, number ofinvolved ligaments, involved side, kind of sport, date ofinjury, and grade of pain were recorded with a question-naire. Ankle range of motion (ROM) was measured bygoniometer. Before being tested, subjects with severe painor joint swelling were treated to a level at which theycould bear full weight, their ankle muscle strength was atleast 4 according to the manual muscle test [19], and theirankle ROM was 80 percent of the normal range. Eachsubject participated in a training session before testingthat included an explanation of the procedure and per-formance of different parts of the main tests. Sway indexwas measured with the Biodex Balance System 945-302(Biodex Medical Systems; Shirley, New York) for bi- andunilateral standing on the involved and sound limb witheyes in the open and closed positions. LOS were meas-ured with this system for bi- and unilateral standing on theinvolved and sound limb. In addition, static balance wasevaluated with the FRT; a mean of three repetitions wasconsidered. Dynamic balance was evaluated with theSEBT; a mean of five repetitions was considered.Statistical Package for the Social Sciences, Version 10(SPSS, Inc; Chicago, Illinois), was used for statisticalanalysis. We used paired t-tests for comparing data relatedto balance ability of involved and sound limbs and chi-square analyses for comparing sensitivity of the differentbalance tests to balance problems. An α level of 0.05 wasset for the analyses.RESULTSSubjects were 22.8 ± 4.8 years old, 74.14 ± 8.26 kg inmass, and 179.96 ± 7.05 cm tall. Of the 30 subjects, 17 hada right-side sprain and 13 had a left-side sprain; 14 subjectshad a Grade I and 16 had a Grade II sprain. One ligamentwas injured in 17 subjects, two ligaments were injured in5 subjects, and three ligaments were injured in 8 subjects.The anterior talofibular ligament was sprained in 26 sub-jects, the calcaneofibular ligament in 12 subjects, and theposterior talofibular ligament in 10 subjects.On the FRT, mean distance displaced in bilateralstanding was significantly lower than unilateral standingon involved and sound limbs (p < 0.001) (Table 1). Onthe SEBT, mean distance displaced in unilateral standingon involved and sound limbs was significantly different821AKBARI et al. Balance problems after unilateral lateral ankle sprains(Table 1). Balance index was significantly lower forbilateral standing with eyes open compared with eyesclosed (p < 0.001). With eyes open, balance ability forunilateral standing on involved limb was significantlylower compared with sound limb (p < 0.001). Balanceability for unilateral standing on sound limb was 24 per-cent better than on involved limb. Values for LOS forunilateral standing on involved and sound limbs were notsignificantly different (Table 1).Chi-square tests showed a strong relationship betweenthe scores of all balance tests in the study for detecting bal-ance problems after traumatic ankle ligament sprain (p >0.90) (Table 2).DISCUSSIONIn this study, the anterior talofibular ligament wassprained in 26 subjects, the calcaneofibular ligament in12 subjects, and the posterior talofibular ligament in 10subjects. This result agrees with Otter’s results [8]. Hereported that the anterior talofibular ligament is the mostcommonly injured, followed by the calcaneofibular liga-ment. The posterior talofibular ligament is injured onlyin severe sprains. This pattern of ligament sprain couldbe attributed to such factors as ankle joint structure,mechanism of injury (inversion), and strength of ankleligaments. The anterior talofibular ligament is the weak-est of the lateral ankle ligaments, and it acts againstinversion forces.The results of the balance tests in this study indicatethat after traumatic lateral ankle sprains, balance problemsoccur because of proprioceptive deficiency. The FRT wasused for evaluating static balance. This test is a valid andreliable clinical tool for evaluation of balance. FRT in thepresent study for bilateral standing was 29.20 ± 5.96 cmfor 20- to 35-year-old males. Duncan et al. reported thenormal value of that test to be 41.74 ± 4.75 cm for 20- to40-year-old persons [20]. A significant difference wasnoted between the results of this study for individuals withlateral ankle sprain and subjects with no ankle injuries.Our results show that functional test values were greaterTable 1.Comparison of mean values for sound and involved limb on different balance tests.Balance Test Sound Limb(Mean ± SD)Involved Limb(Mean ± SD) 95% CI t-Test p-ValueFRT (cm) 34.79 ± 7.22 30.39 ± 3.93 –3.44 to –5.36 –9.38 0.001SEBT (cm) 86.80 ± 9.34 84.97 ± 10.26 –0.25 to –3.42 –2.36 0.025DBO 1.84 ± 0.46 2.42 ± 0.93 0.89 to 0.26 3.68 0.001DBC 6.63 ± 2.38 6.58 ± 2.29 0.69 to –0.80 –1.46 0.885LOS (%) 17.6 ± 7.6 16.4 ± 7.7 0.61 to –2.95 –1.34 0.192LOST (s) 111.03 ± 35.22 122.60 ± 41.95 20.87 to 2.27 2.54 0.017WBC (kg) 53.93 ± 21.16 46.03 ± 21.16 7.87 to –23.73 –1.03 0.313WBO (kg) 45.73 ± 29.82 55.27 ± 29.82 12.80 to –31.74 –0.87 0.392CI = confidence interval, DBC = dynamic balance bilateral standing eyes closed, DBO = dynamic balance bilateral standing eyes open, FRT = Functional ReachTest, LOS = limits of stability, LOST = limits of stability time, SD = standard deviation, SEBT = Star-Excursion Balance Test, WBC = weight-bearing eyes closed,WBO = weight-bearing eyes open.Table 2.Distribution of scores on balance tests for involved limb (N = 30). Scores on all balance tests were divided into four groups to create classes.Number of individuals in each class was determined, and chi-square test indicated a strong relationship (p > 0.90).GroupStar-Excursion Balance TestFunctionalReach Test Dynamic Balance* Limits of Stability Limits ofStability TimeClass n Class n Class n Class n Class n1 61–71 7 18–23 7 4.7–5.6 8 4–12 7 193–234 72 72–82 8 24–29 10 3.6–4.6 8 13–21 8 150–192 83 83–93 8 30–35 5 2.5–3.5 7 22–30 8 107–149 84 94–104 7 36–40 8 1.4–2.4 7 4–12 7 64–106 7*Test performed while subjects’ eyes were open.822JRRD, Volume 43, Number 7, 2006while subjects were standing on one limb compared withbilateral standing. This may be due to the fact that subjectsuse their free limb as a balancing lever during unilateralstanding. However, the results indicate that static balanceof athletes with ligament sprain becomes abnormalbecause of proprioceptive deficiency.In comparing the results of the FRT for unilateralstanding on the sound or involved limb, we noted asignificant difference. The static balance on the involvedlimb was 12.7 percent lower than on the sound limb. TheSEBT was used for dynamic balance evaluation. Meanvalues for the sound and involved limbs were signifi-cantly different [14].The balance index was significantly lower for bilat-eral standing with eyes open compared with eyes closed.The sensorimotor system normally uses inputs from threeafferent systems: vestibular, somatosensory, and visual.When one of those systems (somatosensory) is impaired,the two intact systems compensate for the impaired one tosome extent. But when the subject closes his or her eyes,only one intact afferent system remains for balance con-trol. Therefore, balance index in the eyes-closed situationbecomes higher compared with eyes open [13–14,21].With eyes open, unilateral standing balance on theinvolved limb was significantly lower compared with thesound limb. Balance control while subjects were standingon the sound limb was 24 percent better than on theinvolved limb. This result agrees with Freeman et al. [6],Nashner [11], Garn and Newton [12], Tropp and Oden-rick [16], Bullock-Saxton et al. [22], Lentell et al. [9],and Leanderson et al. [23], who all reported that impair-ment of proprioception has a major effect on balanceafter lateral ankle sprains.LOS in unilateral standing on the involved and soundlimbs were not significantly different, but test duration onthe sound limb was shorter than on the involved limb,which means that motor control of the involved limb wasdisturbed.The results reveal that after Grade I and II lateralankle sprains, balance problems occur and are a result ofproprioceptive deficits, especially the unconscious(reflexive) part of proprioception as opposed to the con-scious (voluntary) part [10]. This factor probably playsan important role in recurrence of ankle sprain. There-fore, an effective rehabilitation program for managingproprioceptive deficits should be followed.CONCLUSIONSFrom these results, we can conclude that after acuteankle sprains, the unconscious (reflexive) part of pro-prioception is more severely affected than the conscious(voluntary) part. In other words, improvement of the con-scious part of proprioception can occur during the firstmonth of treatment, but for improvement of the uncon-scious part, we have to wait about 3 to 6 months, depend-ing on the degree of injury.ACKNOWLEDGMENTSThis material was based on work supported by theTarbiat Modares University, Tehran, Iran. We would alsolike to thank the Department of Physical Therapy of theSports Medicine Federation of Iran, Tehran, Iran, for useof their equipment and facilities.The authors have declared that no competing interestsexist.REFERENCES  1. Brand RL, Black HM, Cox JS. The natural history of inad-equately treated ankle sprains. Am J Sports Med. 1977;5(6):248–49. [PMID: 931035]  2. Garrick JG. The frequency of injury, mechanism of injury,and the epidemiology of ankle sprains. Am J Sports Med.1977;5(6):241–42. [PMID: 563179]  3. Maehlum S, Daljord OA. Acute sports injuries in Oslo: Aone-year study. Br J Sports Med. 1984;18(3):181–85.[PMID: 6435714]  4. 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Proprio-ception in classical ballet dancers. A prospective study ofthe influence of an ankle sprain on proprioception in theankle joint. Am J Sports Med. 1996;24(3):370–74.[PMID: 8734890]Submitted for publication January 2, 2006. Accepted inrevised form April 4, 2006.

Balance problems after unilateral lateral ankle sprains

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Balance problems after unilateral lateral ankle sprains

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