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Functional rehabilitation may improve the deficits associated with chronic ankle instability (CAI).   To determine if balance- and strength-training protocols improve the balance, strength, and functional performance deficits associated with CAI.   Randomized controlled clinical trial.   Athletic training research laboratory.   Participants were 39 volunteers with CAI, which was determined using the Identification of Functional Ankle Instability Questionnaire. They were randomly assigned to 1 of 3 groups: balance-training protocol (7 males, 6 females; age = 23.5 ± 6.5 years, height = 175.0 ± 8.5 cm, mass = 72.8 ± 10.9 kg), strength-training protocol (8 males, 5 females; age = 24.6 ± 7.7 years, height = 173.2 ± 9.0 cm, mass = 76.0 ± 16.2 kg), or control (6 males, 7 females; age = 24.8 ± 9.0 years, height = 175.5 ± 8.4 cm, mass = 79.1 ± 16.8 kg).   Each group participated in a 20-minute session, 3 times per week, for 6 weeks. The control group completed a mild to moderately strenuous bicycle workout.   Participants completed baseline testing of eccentric and concentric isokinetic strength in each ankle direction (inversion, eversion, plantar flexion, and dorsiflexion) and the Balance Error Scoring System (BESS), Star Excursion Balance Test (SEBT), and side-hop functional performance test. The same variables were tested again at 6 weeks after the intervention. Two multivariate repeated-measures analyses of variance with follow-up univariate analyses were conducted. The α level was set a priori at .05.   We observed time-by-group interactions in concentric ( P = .02) and eccentric ( P = .01) inversion, eccentric eversion ( P = .01), concentric ( P = .001) and eccentric ( P = .03) plantar flexion, BESS ( P = .01), SEBT ( P = .02), and side hop ( P = .004). With pairwise comparisons, we found improvements in the balance- and strength-training protocol groups in concentric and eccentric inversion and concentric and eccentric plantar flexion and the BESS, SEBT, and side hop (all P values = .001). Only the strength-training protocol group improved in eccentric eversion. The control group did not improve in any dependent variable.   Both training protocols improved strength, balance, and functional performance. More clinicians should incorporate hop-to-stabilization exercises into their rehabilitation protocols to improve the deficits associated with CAI.

Background Previous studies have confirmed that patients with functional ankle instability (FAI) have inadequate hip abductor muscle strength. Muscle strength training is a commonly used intervention in people with FAI. The effects investigated by previous studies have shown conflicting results. However, whether hip adduction and abduction isokinetic muscle strength training can improve muscle strength, balance, and gait in patients with FAI remains unclear. Objective The aim of this study was to observe whether muscle strength, balance, Cumberland Ankle Instability Tool (CAIT) score, plantar pressure, and gait can be improved in patients with FAI via isokinetic muscle strength training of the peri-ankle muscle groups combined with hip abduction and adductor muscle groups. Participants FAI ( n =70). Interventions The 70 FAI patients were randomly divided into an ankle isokinetic strength training (AIT) group and a hip isokinetic strength training (HIT) group. The AIT group underwent inversion/eversion and dorsiflexion/plantar flexion isokinetic concentric strength training; the HIT group underwent hip abduction and abduction isokinetic strength training based on ankle isokinetic strength training for six weeks. Main outcome measures Before and after training, isokinetic concentric force tests around the ankle and hip adduction and abduction, the Star Excursion Balance Test (SEBT), and plantar pressure and gait assessments were performed. Results After 6 weeks of training, significant changes in muscle strength were observed in ankle inversion, eversion, dorsiflexion, plantarflexion, and abduction for both the AIT and HIT groups (Group*Time, P  < 0.05). Furthermore, the HIT group exhibited greater increases in muscle strength compared to the AIT group (Group, P  < 0.05). Additionally, both groups showed varying degrees of improvement in dynamic balance, CAIT scores, and gait patterns (Time, P  < 0.05), with the HIT group demonstrating superior improvement compared to the AIT group (Group, P  < 0.05). Conclusions Isokinetic strength training through the peri-ankle muscles combined with the hip adductor and abductor muscles was more effective than peri-ankle strength training alone in improving muscle strength, balance, plantar pressure, gait, and self-reported scores in FAI patients. Trial registration This study is a randomized controlled clinical trial and has been registered in the China Clinical Trial Registry on 07/04/2022 with registration number ChiCTR2200058341.

Purpose To compare the outcomes of anterior cruciate ligament (ACL) reconstruction with those of combined ACL and anterolateral ligament (ALL) reconstruction in ACL-deficient knees. The objective of this study was to improve knowledge regarding the treatment of ACL-deficient knees with combined ACL and ALL reconstruction. Combined ACL and ALL reconstruction has been hypothesized to result in better clinical and functional outcomes than isolated ACL reconstruction (ACLR). Methods One-hundred and seven adult male athletes with ACL tears and high-grade pivot shifts were randomized into two groups. Those in group A ( n  = 54) underwent ACLR, while those in group B ( n  = 53) underwent combined ACL and ALL reconstruction. The median age was 26 (18–40) and 24 (18–33) years in groups A and B, respectively, and the median follow-up was 60 (55–65) months. Physical examination findings, instrumented knee laxity tested using a KT-1000 arthrometer, and International Knee Documentation Committee Scale (IKDC) scores were used to evaluate the outcomes. Results One-hundred and two patients were available for follow-up: 52 in group A and 50 in group B. Postoperatively, the pivot shift was normal in 43 (82.7%) and 48 (96%) patients in groups A and B, respectively ( p  < 0.001). The median instrumented knee laxity was 2.5 ± 0.7 (1.2–6.1) mm in patients in group A and 1.2 ± 0.7 (1.2–3.2) mm in patients in group B ( p  < 0.001). Additionally, 44 (84.6%) patients in group A had normal IKDC scores and 3 (5.8%) had nearly normal scores, while 48 (96.0%) patients in group B had normal IKDC scores and 2 (4%) had nearly normal scores ( p  < 0.001). Conclusion Combined ACL and ALL reconstruction, compared with isolated ACLR resulted in favourable clinical and functional outcomes, as demonstrated by decreased rotational instability and instrumented knee laxity, a lower graft rupture rate and better postoperative IKDC scores. Level of evidence 1.

Individuals with chronic ankle instability (CAI) experience disease- and patient-oriented impairments that contribute to both immediate and long-term health detriments. Investigators have demonstrated the ability of targeted interventions to improve these impairments. However, the combined effects of a multimodal intervention on a multidimensional profile of health have not been evaluated. To examine the effects of a 4-week rehabilitation program on disease- and patient-oriented impairments associated with CAI. Controlled laboratory study. Laboratory. Twenty adults (5 males, 15 females; age = 24.35 ± 6.95 years, height = 169.29 ± 10.10 cm, mass = 70.58 ± 12.90 kg) with self-reported CAI participated. Inclusion criteria were at least 1 previous ankle sprain, at least 2 episodes of \"giving way\" in the 3 months before the study, and a Cumberland Ankle Instability Tool score ≤24. Individuals participated in 12 sessions over 4 weeks that consisted of ankle stretching and strengthening, balance training, and joint mobilizations. They also completed home ankle-strengthening and -stretching exercises daily. Dorsiflexion range of motion (weight-bearing-lunge test), isometric ankle strength (inversion, eversion, dorsiflexion, plantar flexion), isometric hip strength (abduction, adduction, flexion, extension), dynamic postural control (Y-Balance test), static postural control (eyes-open and -closed time to boundary in the anterior-posterior and medial-lateral directions), and patient-reported outcomes (Foot and Ankle Ability Measure-Activities of Daily Living and Foot and Ankle Ability Measure-Sport, modified Disablement in the Physically Active scale physical and mental summary components, and Fear-Avoidance Beliefs Questionnaire-Physical Activity and Fear-Avoidance Beliefs Questionnaire-Work) were assessed at 4 times (baseline, preintervention, postintervention, 2-week follow-up). Dorsiflexion range of motion, each direction of the Y-Balance test, 4-way ankle strength, hip-adduction and -extension strength, the Foot and Ankle Ability Measure-Activities of Daily Living score, the modified Disablement in the Physically Active scale-physical summary component score, and the Fear-Avoidance Beliefs Questionnaire-Physical Activity score were improved at postintervention ( < .001; effect-size range = 0.72-1.73) and at the 2-week follow-up ( < .001; effect-size range = 0.73-1.72) compared with preintervention. Hip-flexion strength was improved at postintervention compared with preintervention ( = .03; effect size = 0.61). Hip-abduction strength was improved at the 2-week follow-up compared with preintervention ( = .001; effect size = 0.96). Time to boundary in the anterior-posterior direction was increased at the 2-week follow-up compared with preintervention ( < .04; effect-size range = 0.61-0.78) and postintervention ( < .04) during the eyes-open condition. A 4-week rehabilitation program improved a multidimensional profile of health in participants with CAI.

Purpose To compare the “all-inside technique” for anterior cruciate ligament (ACL) reconstruction using a short, quadrupled semitendinosus tendon (ST4) autograft and suspensory cortical fixation on both the femoral and tibial side vs the “conventional technique” using a semitendinosus/gracilis (ST/G) autograft fixed with a suspensory device on the femoral side and with an interference screw on the tibial side, in terms of clinical and functional outcomes. Methods A total of 90 patients were enrolled, randomised into two groups, and prospectively followed. Group A comprised 45 patients treated with the all-inside technique and Group B included 45 patients treated with the conventional ACL technique (55 males, 35 females; mean age 28.7 ± 11.3 years). Patients completed the Lysholm knee score, the International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Score (KOOS), and the Knee Society Score (KSS) preoperatively and at 2 years postoperatively. Anterior tibial translation measurement (KT-1000 arthrometer) and isokinetic testing of the operative vs non-operative limb were also conducted and the limb symmetry index (LSI) was determined. Results At 24 months, the Lysholm, IKDC, KOOS, and KSS scores between the two groups were similar (n.s.). Anterior tibial translation between the operative and non-operative knee was also similar among the two groups (n.s.). Patients of Group A had significantly higher mean LSIs in terms of flexor peak torque (1.0 ± 0.1 vs 0.9 ± 0.1; p  < 0.001), time-to-peak (0.9 ± 0.1 vs 0.8 ± 0.1; p  < 0.001) and total work (0.9 ± 0.1 vs 0.8 ± 0.1; p  < 0.001) at 180°/s, and significantly better mean LSI for isometric flexor/extensor ratio at 90° (1.1 ± 0.3 vs 0.8 ± 0.2; p  < 0.001). Conclusion The all-inside ACL reconstruction with an ST4 autograft and cortical button fixation on both ends is a viable alternative to the conventional technique. It affords preservation of knee flexor strength, which is of advantage, especially when treating athletes with ACL injury. Level of evidence I.

Assessing global, regional, and fear-of-reinjury outcomes in individuals with chronic ankle instability (CAI) is critical to understanding the effectiveness of clinical interventions.   To determine the improvement of patient-reported outcomes after balance- and strength-training and control protocols among participants with CAI.   Randomized controlled clinical trial.   Athletic training research laboratory.   Thirty-nine volunteers with CAI who scored 11 or greater on the Identification of Functional Ankle Instability questionnaire were randomly assigned to 1 of 3 groups: balance-training protocol (7 males, 6 females; age = 23.5 ± 6.5 years, height = 175.0 ± 8.5 cm, mass = 72.8 ± 10.9 kg), strength-training protocol (8 males, 5 females; age = 24.6 ± 7.7 years, height = 173.2 ± 9.0 cm, mass = 76.0 ± 16.2 kg), or control (6 males, 7 females; age = 24.8 ± 9.0 years, height = 175.5 ± 8.4 cm, mass = 79.1 ± 16.8 kg).   Each group met for 20 minutes, 3 times each week, for 6 weeks. The control group completed a mild to moderately strenuous bicycle workout.   Global patient-reported outcomes, regional ankle function, and perceived instability were measured using the Disablement in the Physically Active Scale, the Fear-Avoidance Beliefs Questionnaire, the Foot and Ankle Ability Measure, and a visual analog scale for perceived instability. Participants completed the questionnaires at pretest and 6 weeks posttest. A multivariate repeated-measures analysis of variance with follow-up univariate analysis was conducted. The α level was set a priori at .05.   No time-by-group interaction was found ( P = .78, η = 0.09). However, we observed a main effect for time ( P = .001, η = 0.49). Follow-up univariate analyses revealed differences between the pretest and posttest for the Disablement in the Physically Active Scale ( P = .02, η = 0.15), Fear-Avoidance Beliefs Questionnaire ( P = .001, η = 0.27), Foot and Ankle Ability Measure-Activities of Daily Living subscale ( P = .003, η = 0.22), Foot and Ankle Ability Measure-Sport subscale ( P = .001, η = 0.36), and visual analog scale ( P = .008, η = 0.18).   Statistically, after the 6-week intervention, all groups improved in global and regional health-related quality of life. Clinicians should compare patient-reported outcomes with clinical measures to have a better understanding of progression during rehabilitation.

Background The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation. Questions/purposes We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients. Methods Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1–7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12–43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%). Results With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance. Conclusions Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device. Level of Evidence Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

This study assesses femoral neck shortening and its effect on gait pattern and muscle strength in patients with femoral neck fractures treated with internal fixation. Seventy-six patients from a multicenter randomized controlled trial participated. Patient characteristics and Short Form 12 and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were collected. Femoral neck shortening, gait parameters, and maximum isometric forces of the hip muscles were measured and differences between the fractured and contralateral leg were calculated. Variables of patients with little or no shortening, moderate shortening, and severe shortening were compared using univariate and multivariate analyses. Median femoral neck shortening was 1.1 cm. Subtle changes in gait pattern, reduced gait velocity, and reduced abductor muscle strength were observed. Age, weight, and Pauwels classification were risk factors for femoral neck shortening. Femoral neck shortening decreased gait velocity and seemed to impair gait symmetry and physical functioning. In conclusion, internal fixation of femoral neck fractures results in permanent physical limitations. The relatively young and healthy patients in our study seem capable of compensating. Attention should be paid to femoral neck shortening and proper correction with a heel lift, as inadequate correction may cause physical complaints and influence outcome.

Purpose Some researchers have suggested that bone bruises are evidence of rotational instability. The hypothesis was that the extent of lateral bone edema is correlated with the presence of an anterolateral ligament (ALL) injury. The main objective was to determine whether there was a correlation between the presence of an ALL injury the extent of bone bruises. Methods A prospective diagnostic study enrolled all the patients who suffered an acute anterior cruciate ligament (ACL) who were operated on within 8 weeks. The extent of bone bruising according to the ICRS classification was measured on preoperative MRIs by two independent blinded raters twice with an interval of 4 weeks. Dynamic ultrasonography (US) to look for ALL injury and the pivot shift test were performed before the ACL surgery. The correlation between ALL injury and bone bruises, and the correlation between an ALL injury and a high-grade pivot shift test were determined. Results Sixty-one patients were included; 52% of patients had an ALL injury on US. The extent of lateral bone bruise was not related to the presence of an ALL injury, nor related to the presence of a high-grade pivot shift. A grade 2 or 3 pivot shift was significantly correlated with an ALL injury ( p  < 0.0001). Inter- and intra-rater reliability for the bone bruise rating was excellent. Conclusion The extent of lateral bone bruise is not correlated with ALL injury or a high-grade pivot shift; thus, it is not correlated with rotational instability of the knee. Level of evidence II.

Background Lateral ankle sprain (LAS) is a common injury. Conservative care is not uniformly effective. Chronic ankle instability (CAI) results in up to 70% of patients with LAS in the physically active population. LAS, together with subsequent osteochondral lesions and pain in many patients, leads to the development of post-traumatic osteoarthritis, resulting in a substantial direct and indirect personal and societal health burden. Dextrose prolotherapy (DPT) is an injection-based therapy for many chronic musculoskeletal conditions but has not been tested for CAI. This protocol describes a randomized controlled trial to test the efficacy of DPT versus normal saline (NS) injections for chronic ankle instability (CAI). Methods and analysis A single-center, parallel-group, randomized controlled trial will be conducted at a university-based primary care clinic in Hong Kong. A total of 114 patients with CAI will be randomly allocated (1:1) to DPT and NS groups. The primary outcome will be the Cumberland Ankle Instability Tool scores at 1 year. The secondary outcomes will be the number of re-sprains in 1 year, the Star Excursion Balance Test, the 5-level of EuroQol 5-dimension questionnaire, and the Foot and Ankle Ability Measure. All outcomes will be evaluated at baseline and at 16, 26, and 52 weeks using a linear mixed model. Discussion We hypothesized the DPT is a safe, easily accessible, and effective treatment for patients with CAI. This RCT study will inform whether DPT could be a primary non-surgical treatment for CAI. Trial registration Chinese Clinical Trial Registry ChiCTR2000040213 . Registered on 25 November 2020.