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Free papers #2

Screening and testing

Chair: Daniel Fong

#8 - The Foot Lift Test: A Validity Study

Presenting Author: Zoe Duong

Authors & Affiliations: Zoe Duong(1), Claire Hiller(1), Alycia Fong Yan(1), Patrick McKeon(2), Fereshteh Pourkazemi(1)
(1)   The University of Sydney, Sydney, Australia
(2)   Ithaca College, Ithaca, USA

Background: Ankle sprains are a common injury in the community and contribute to persistent postural control impairments. Accessible impairment-specific assessment tools may encourage clinicians to implement impairment-based rehabilitation to prevent onset of the chronic-sequelae associated with chronic ankle instability (CAI). CAI has been defined as having had at least one ankle sprain with repeated episodes of giving way and a loss of perceived function, commonly measured using the Cumberland Ankle Instability Tool (CAIT). Although endorsed by the International Ankle Consortium as a clinical measure of static postural control, the Foot Lift Test (FLT) has yet to be validated.

Objective(s): To explore the concurrent validity of the FLT against instrumented postural control measures that have detected single-limb postural control deficits in those with CAI compared to healthy participants. The specific instrumented postural control measures included centre of pressure (COP) velocity, area of excursions, and time-to-boundary (TTB).

Design & Methods: This cross-sectional study included 19 CAI and 17 control participants (21 women, 15 men; age=24.5±6.1 years). CAI participants scored ≤25 on the CAIT; controls had no ankle sprain history and scored ≥28 on the CAIT. Participants performed three trials of the FLT on a force plate with eyes open and eyes closed. COP velocity, area, and TTB were calculated for each trial and the average calculated for each visual condition. To determine concurrent validity between FLT and COP variables, the bivariate correlations among all variables were calculated using Pearson’s r or Spearman’s p correlation coefficients.

Results: Correlation between the FLT with eyes closed, and seven of nine force-plate variables was moderate to strong (p=0.41–r=0.67); COP standard deviation (SD) mediolateral (ML) (p=0.41), anteroposterior (AP) (p=0.57), COP velocity ML (r=0.53), AP (r=0.67), TTB minima AP (r=-0.59), TTB minima SD AP (r=-0.49), resultant velocity (r=0.64). Correlation between the FLT with eyes open, and three of nine force-plate variables was moderate (p=0.43–-0.46); COP velocity (p=0.43), TTB minima ML (p=-0.46), resultant velocity (p=0.44).

Conclusions: The FLT has a moderate to strong concurrent validity with force-plate variables that assess postural control. Our findings offer clinicians a valid, easy-to-use clinical tool to quantify postural control without equipment, uniquely assessing an outcome that has not been managed by existing clinical tests.


#9 - Relationship of dorsiflexion lunge test to common functional screening tasks in healthy adolescent athletes

Presenting Author: Kathryn Webster

Authors & Affiliations:Kathryn Webster(1), Alexander Geronimo(1), Daniel Chan(1), Kaveh Torabian(1), Deepak Kumar(1)
(1)   Boston University, Boston, MA USA

Background: As athletic participation continues to grow in adolescent populations, it is important to identify simple screening tools that may predict injury during sport performance. The dorsiflexion lunge test (DFLT) is a commonly used, simple, and reliable clinical measure of ankle dorsiflexion. This simple test may predict performance on other functional and clinical tests used in injury screening such as jump distance, single leg balance, jump landing positions, and squatting position.

Objective(s): The purpose of this study was to investigate the relationship between DFLT and performance during common injury screening tasks among healthy adolescent athletes.

Design & Methods: Nineteen healthy adolescents (13.7+/-1.9 years, 15M, 4F) who regularly participated in soccer, ice hockey, or swimming volunteered for this cross-sectional study. DFLT, normalized Y-balance, and single leg hop for distance (SLH) were collected bilaterally. Peak ankle, knee, and hip flexion angle during double-leg squat (DLS), single leg squat (SLS), and drop jump (DJ) were assessed bilaterally using a 12-camera motion capture system and averaged over 4 trials. Multiple linear regression was used to assess the relationship of DFLT with Y-balance, SLH, DLS, SLS, and DJ while controlling for age, sex, height, and BMI.

Results: After controlling for age, sex, height, and BMI, DFLT was predictive of lower composite reach distances during y-balance (β=0.92, P=0.004, model R2=0.50) but its association with SLH was not significant. Lower DFLT was also predictive of lower peak ankle dorsiflexion during BLS, SLS, and DJ (P-value between <0.001 and 0.006, model R2 between 0.30 to 0.59), greater peak knee flexion during DJ (β=-1.28, P=0.026, Model R2=0.60), and greater peak hip flexion during SLS and BLS (P-value between 0.013 and 0.002, model R2 between 0.35 and 0.37).

Conclusions: Reduced DF was associated with lower Y-balance scores and greater hip or knee motion during DJ, BLS, and SLS, which could be a risk factor for lower extremity conditions such as chronic ankle instability or femoroacetabular impingement. Hence, DFLT might be a useful screening tool to identify at-risk adolescent athletes.


#10 - Identifying Deficits in Range-of-Motion, Joint Laxity, Ligament Thickness and Dynamic Balance 6-Months Following an Acute Lateral Ankle Sprain

Presenting Author: Bethany Wisthoff

Authors & Affiliations: Bethany Wisthoff(1), Carrie Docherty(2), Joseph Glutting(1), Geoffrey Gustavsen(1), Todd Royer(1), Charles Swanik(1), Thomas Kaminski(1)
(1)   University of Delaware, Newark, DE, USA
(2)    Indiana University, Bloomington, IN, USA

Background: Approximately 72% of patients following an ankle sprain have reported residual symptoms six to 18 months later. Of those, 40% reported at least one moderate to severe symptom, which included: perceived ankle weakness, perceived ankle instability, pain, and swelling. Previous research has shown that approximately 30% of patients suffering an initial ankle sprain will develop chronic ankle instability. Chronic ankle instability (CAI) is defined by those that have suffered recurrent ankle sprains, may have prolonged symptoms, and may exhibit mechanical and/or functional instability. Functional deficits have been seen in those with CAI, specifically to postural control or dynamic balance.

Objective(s): The objective was to determine if differences existed in dorsiflexion range-of-motion (DFROM), talocrural joint laxity, ligament thickness, and dynamic balance measures 6-months after an acute ankle sprain (AAS) in a college-aged population, compared to those with CAI, and to those without a history of ankle sprains (CON).

Design & Methods: One hundred and sixty-one subjects (96 females, 65 males) were recruited (55 AAS, 53 CON, 53 CAI). Musculoskeletal ultrasound was used to view the anterior talofibular ligament with stress using the LigMaster, including dynamic balance using the Y Balance Test and DFROM using a goniometer and the weight-bearing lunge test.

Results: Those who experienced an AAS had increased inversion (INV) stress, INV talofibular interval (TI), and anterior drawer (AD) stress compared to CON and CAI. Anterior talofibular ligament (ATFL) thickness was greater in AAS than CON, and greater in CAI than CON. In DFROM, CAI had less ROM than CON. In the Y Balance Test (YBT), CAI had less relative reach distance in anterior (ANT), posteromedial (PM), and composite (COMP) compared to CON. AAS also had less COMP percentage than CAI and CON.

Conclusions: Our results demonstrate that those that have sustained an AAS, regardless of whether or not they have sprained that ankle before, still show deficits in ankle laxity, ROM, and dynamic balance 6-months later.


#11 - Single-leg Hop Performance is a Predictor of Patient-Reported Outcomes Following a Lateral Ankle Sprain

Presenting Author: Janet Simon

Authors & Affiliations: Janet Simon(1), Jae Yom(1), Dustin Grooms(1)
(1)   Ohio University, Athens, OH, USA

Background: Lateral ankle sprains (LASs) are one of the most common injuries in sport and recent evidence as shown that individuals who have sustained a LAS have decreased subjective outcomes post-injury. The single-leg hop for distance (SLHOP) is a commonly used functional performance measure to determine return-to-play readiness. However, it is unknown if functional performance at return-to-play can predict future patient outcomes.

Objective(s): Determine if SLHOP performance and symmetry at return-to-play following a LAS would predict lower extremity patient-reported outcomes six months post-injury.

Design & Methods: Two-hundred thirty-six adolescent athletes (15.7±1.4years, 171.1±7.6cm, 70.3±15.3kg) were recruited. If an individual sustained a LAS during their sports season and missed sports participation, they were eligible for follow-up assessment. Twenty-two athletes were eligible and completed follow-up testing. Each participant performed three trials per leg of the SLHOP at return-to-play. The Pediatric Patient-Reported Outcomes Measurement Information System (PROMIS) Lower Extremity scale was completed at six months after return-to-play as the patient-reported outcome measure. A stepwise multiple linear regression was conducted to predict PROMIS Lower Extremity scale score from SLHOP distance on the injured and uninjured leg (cm), and limb symmetry (%).

Results: At step one of the analysis, injured limb SLHOP distance was entered into the regression equation and was significantly related to the PROMIS Lower Extremity scale F(1,21)=20.8, p<.001. The multiple correlation coefficient was 0.79, indicating approximately 62% of the variance of the PROMIS Lower Extremity scale scores could be accounted for by the injured limb SLHOP distance. Specifically, for every increase in one cm of SLHOP performance there would be an increase of 0.6 points on the PROMIS Lower Extremity scale. Uninjured limb SLHOP distance and limb symmetry did not enter into the equation at step two (p>.05).

Conclusions: The SLHOP conducted at time of return-to-play following a LAS can predict lower extremity patient-reported outcomes six months later. This indicates that clinicians may be able to use the SLHOP following a LAS to not only determine return-to-play readiness but a successful long-term outcome.


#12 - Prognostic models for identifying risk of poor outcome in people with acute ankle sprains: the SPRAINED development and external validation study

Presenting Author: David Keene

Authors & Affiliations: David Keene(1), Michael Schlüssel(1), Jacqueline Thompson(1), Daryl Hagan(1), Mark Williams(2), Christopher Byrne(3),Steve Goodacre(4), Matthew Cooke(5), Stephen Gwilym(1,6), Philip Hormbrey(6), Jennifer Bostock(7), Kirstie Haywood(5), David Wilson(6), Gary Collins(1), Sarah Lamb(1,5); on behalf of the SPRAINED study group.
(1)   Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
(2)    Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
(3)    Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
(4)    School of Health and Related Research, University of Sheffield, Sheffield, UK
(5)    Warwick Medical School, University of Warwick, Coventry, UK
(6)    Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
(7)    Patient and public involvement representative

Background: Ankle sprains are one of the most common musculoskeletal injuries. Although recovery can occur within weeks, many patients still have persistent problems with their ankle. In the acute phase there is no reliable way of establishing which patients are at risk of having a poor outcome. A prognostic model could help select patients for on-going monitoring or rehabilitation.

Objective(s): To develop and externally validate a prognostic model for identifying people at increased risk of poor outcome after an acute ankle sprain. Poor recovery was defined as presence of pain, functional difficulty or lack of confidence in the ankle at 9 months after injury.

Design & Methods: Twenty-three baseline candidate predictors were included together in a multivariable logistic regression model to identify the best predictors of poor recovery. Relationships between continuous variables and the outcome were modelled using fractional polynomials. Regression parameters were combined over 50 imputed data sets using Rubin's rule. To minimise overfitting, regression coefficients were multiplied by a heuristic shrinkage factor and the intercept re-estimated. Incremental value of candidate predictors assessed at 4 weeks after injury was explored using decision curve analysis and the baseline model updated. The final models included predictors selected based on the Akaike information criterion (p<0.157). Model performance was assessed by calibration and discrimination.

Results: Outcome rate was lower in the external validation (6.7%) than in the development data set (19.9%). Mean age (29.9 and 33.6 years), BMI (26.3 and 27.1 kg/m2), pain when resting (37.8 and 38.5 points) or weight bearing (75.4 and 71.3 points) were similar in both data sets. Age, BMI, pain when resting, pain bearing weight, ability to bear weight, days from injury until assessment and injury recurrence were the selected predictors. The baseline model had fair discriminatory ability (C-statistic 0.72; 95%CI: 0.66 to 0.79) but poor calibration. The updated model presented better discrimination (C-statistic 0.78; 95%CI: 0.72 to 0.84), but equivalent calibration.

Conclusions: Prognostic models performed reasonably well, and showed benefit compared with not using any model; therefore, the models may assist clinical decision-making when managing and advising ankle sprain patients in the ED setting. The models use predictors that are simple to obtain.