564

A
Prospective Study
of Ankle
Injury
Risk Factors
Judith F.
Baumhauer,* MD,
Denise M.
Alosa,† MS, ATC,
Per A. F. H.
Renström,* MD, PhD,
Saul
Trevino,‡ MD,
and Bruce
Beynnon,*§
PhD
From the
*Department
of
Orthopaedics
and
Rehabilitation,
McClure Musculoskeletal
Research
Center, University
of
Vermont,
Burlington,
and the
†Sports
and
Orthopaedic
Rehabilitation
Center, Colchester, Vermont,
and the
‡Department
of
Orthopedics, Baylor
College of Medicine, Houston,
Texas
ABSTRACT
Many
factors are
thought
to cause ankle
ligament
in-
juries.
The
purpose
of this
study
was to examine
injury
risk factors
prospectively
and determine if an abnor-
mality
in
any one
or a combination of factors identifies
an
individual,
or an
ankle,
at risk for
subsequent
inver-
sion ankle
injury.
We examined 145
college-aged
ath-
letes before the athletic season and measured
gener-
alized
joint laxity,
anatomic foot and ankle
alignment,
ankle
ligament stability,
and isokinetic
strength.
These
athletes were monitored
throughout
the season. Fifteen
athletes incurred inversion ankle
injuries.
Statistical
analyses
were
performed using
both
within-group (un-
injured
versus
injured groups)
data and
within-subject
(injured
versus
uninjured ankles)
data. No
significant
differences were found between the
injured (N
=
15)
and
uninjured (N
=
130) groups
in
any
of the
param-
eters measured.
However,
the eversion-to-inversion
strength
ratio was
significantly greater
for the
injured
group compared
with the
uninjured group. Analysis
of
the
within-subject
data demonstrated that
plantar
flex-
ion
strength
and the ratio of dorsiflexion to
plantar
flex-
ion
strength
was
significantly
different for the
injured
ankle
compared
with the contralateral
uninjured
ankle.
Individuals with a muscle
strength
imbalance as meas-
ured
by
an elevated eversion-to-inversion ratio exhib-
ited a
higher
incidence of inversion ankle
sprains.
Ankles with
greater plantar
flexion
strength
and a
smaller
dorsiflexion-to-plantar
flexion ratio also had a
higher
incidence of inversion ankle
sprains.
Ankle
ligament injuries
are the most common
injuries
in
sports
and recreational activities.19
Approximately
one
sprain
occurs
per 10,000 persons
each
day,
which means
27,000
ankle
ligament injuries
occur
every day
in the
United States. Ankle
ligament injuries
constitute about
25% of the
injuries
that occur in
running
and
jumping
sports49;
75% of all ankle
injuries
are ankle
sprains,29,30
and
85% of these
sprains
are caused
by
an inversion trauma.57
Many
studies have been done on the
diagnosis
and treat-
ment of acute ankle
sprains 1,8,19,27,28,31 ; however,
few stud-
ies have examined the causes of ankle
injury.24
With the
current
emphasis
on
injury prevention,
a
study designed
to
examine
potential
ankle
injury
risk factors is needed.
Risk factors can be classified as either extrinsic or in-
trinsic.48 Extrinsic factors include
training error, type
of
sport, playing time,
level of
competition, equipment,
and
environmental conditions.
Milgrom
et al. 53
prospectively
examined the incidence of inversion ankle
sprains
in mili-
tary
recruits.
They
found that extrinsic
factors,
such as
boot or shoe
type,
did not affect the incidence of
injury.
Intrinsic factors can be
physical
characteristics such as mal-
alignment, strength deficit,
limited
range
of
motion, joint
instability, generalized joint laxity, age,
and sex. Intrinsic
factors,
such as
previous history
of inversion ankle
sprains,
were found to be risk factors in this
military population.
Few studies have
attempted
to examine
many
of the in-
trinsic and extrinsic factors and their
relationship
to ankle
injury. 25,53,62,67
The
purpose
of this
study
was to examine
prospectively
the intrinsic risk factors for inversion ankle
sprains
in
college-aged
athletes. The factors examined include demo-
graphic information, ligamentous stability
of the
ankle,
muscle
strength
of the
ankle,
anatomic foot and ankle
alignment,
and
generalized joint laxity.
This
study
was de-
signed
to examine each of these risk factors before the ath-
letic season and to determine if a deficit in one or a com-
bination of these factors would
identify
an individual or a
specific
ankle at risk for an inversion ankle
injury.
Address correspondence
and
repnnt requests
to Bruce D
Beynnon, PhD,
Department
of
Orthopaedics
and
Rehabilitation, McClure Musculoskeletal Re-
search Center, University
of
Vermont, Stafford
Hall, Burlmgton,
VT 05405-
0084
No author or related institution has received
any
fmanaal benefit from re-
search in this
study
565
MATERIALS AND METHODS
Athletes who
played
in the
intercollegiate
outdoor
sports
of
lacrosse, soccer,
or field
hockey
were recruited for the
study.
One hundred
forty-five college-aged
athletes
(73
men,
72
women; age range,
18 to 23
years)
were tested
before the season (Table 1). Each athlete
completed
a
health
history survey
and an athletic
activity question-
naire before
being
tested. Individuals with
previous grade
II or III inversion ankle
sprain,
a
history
of a
surgical pro-
cedure
involving
the foot or
ankle,
or individuals who
regu-
larly
used an ankle brace or
tape
were excluded. After
pro-
viding
written
permission
for
testing,
each individual was
tested
by
the same observer
(JFB or DMA)
in each of the
following
four
parameters.
1. Generalized
joint laxity
was assessed
using
the modi-
fied
Beighton
method4
(Table 2).
2. Measurements of the foot and ankle anatomic
align-
ment were done
using
standardized
goniometric
tech-
niques, according
to the method of James et aI.4o (Table 3).
3. Provocative
testing
of ankle
ligament stability
was
performed using
the anterior drawer and talar tilt tests.
The anterior drawer test is a valid indicator of the
integrity
of the anterior talofibular
ligament.
39~42
The anterior
drawer test was
performed
with the
patient sitting,
the
knee flexed to
90,
and with the ankle in 10 of
plantar
flexion .6 The amount of anterior
displacement
of the talus
relative to the fibula was assessed. A
grading system
of 0
(mild
displacement),
1+
(moderate
displacement),
and 2 +
(severe
displacement)
was used. Anterior lateral
dimpling
of the skin in the area of the anterior talofibular
ligament
was
graded
as
grade
2 +. The talar tilt test was
performed
with the
subject sitting,
with the knee flexed to 90 and the
ankle in the neutral
position. Twenty degrees
or more of
calcaneal
inversion,
or a 10 difference between the
ankles,
was evaluated as a
positive
test. 17,20
Ligament sectioning
studies have correlated increased talar tilt with division of
the calcaneofibular
ligament. 41,50,60
4. Isokinetic ankle
strength
was assessed
using
the
Cybex
6000
dynamometer (Lumex Inc., Ronkonkoma,
New
York). Calibration of the
system
was
performed
at the start
TABLE 1
Subject Demographic
Data for
Uninjured
and
Injured Groups
a
Significant (P < 0.05).
of
testing
and at
monthly
intervals as recommended
by
the
system
manual.3 Ankle
plantar
flexion and dorsiflexion
and inversion and eversion
strength
were assessed for each
limb. Standardized
positioning
for this
testing
was done as
recommended
by
the
Cybex
Isolated Joint
Testing
& Ex-
ercise Handbook. Prior
investigations
have found this
method to be reliable.2,3,43 Five
practice repetitions
for each
ankle were
performed
before data collection to allow the
subject
to become familiar with the
equipment
and to war-
mup.
At a
speed setting
of 30
deg/sec,
five maximal
rep-
etitions were
performed throughout
the
subjects
full
range
of motion. The
subject
had a rest
period
of 3 to 5 minutes
between each test bout. Consistent verbal
encouragement
was
given.
Peak
torque strength
values were obtained and
percent strength
deficits were calculated for each ankle
motion of each limb.
Eversion-to-inversion and
dorsiflexion-to-plantar
flex-
ion
strength
ratios were calculated
using
the raw
peak
torque strength
data for each individual.
Each athlete was monitored
during
his or her
sport
sea-
son.
Any
individual
sustaining
an ankle
injury
was evalu-
ated
initially by
a certified athletic trainer (DMA) and then
by
the
principal investigator
(JFB). Inversion ankle
sprains
were
graded I, II,
or III based on localized tender-
ness, swelling,
loss of
function,
and
ecchymosis.5
5
Univarient statistical
analyses (chi-square test, t-test,
and Pearson
product
moment correlation
coefficients) were
used to determine statistical
significance
for each of the
four
parameters
studied:
generalized joint laxity,
ankle
ligament stability,
anatomic foot and ankle
alignment,
and
isokinetic ankle
strength testing.
The data were
analyzed
for between
group
differences
(uninjured,
the control
group,
versus
injured groups)
and
within-subject
differ-
ences
(injured
versus
uninjured
ankles). The
demographic
data were examined
using
t-test
analysis
to determine
significant
differences between
injured
and
uninjured
(control)
groups.
Results are
given
as mean standard
deviation.
RESULTS
Demographic
data are
presented
in Table
1; significance
values
(P)
are included.
Of the 322 athletes (141 men,
181
women)
who
partici-
pated
in field
hockey, lacrosse,
or
soccer,
145 individuals
(45%)
were recruited to
participate
in this
prospective
ankle
sprain study.
Fifteen (10.3%)
of the
subjects
who
par-
ticipated
incurred an inversion ankle
sprain during
the
sports
season
(12
grade
I
sprains,
3
grade
II
sprains,
0
grade
III
sprains).
Of the 130 athletes in the
uninjured
group,
45 (35%) had a
prior history
of a
grade
I inversion
ankle
sprain.
Of the 15 athletes who sustained an inversion
ankle
injury,
4
(27%) had a
history
of a
grade
I inversion
ankle
sprain involving
the same ankle (P >
0.05).
Uninjured
Versus
Injured (Between-Group) Analysis
Using
t-test
analysis,
we found no
significant
differences
among
the
demographic
variables of
height, weight, sex,
or
566
TABLE 2
Modified
Beighton
Method to Assess Generalized Joint
Laxity

A score of 4 or more on a scale of 0 to 9 indicates
generalized joint laxity.
TABLE 3
Anatomic Measurements of the Foot and Ankle
Alignment
d James et a1.4
sport
(P
> 0.05).
Leg
dominance was
significantly different,
with left
leg-dominant subjects being
more
likely
to incur
an ankle
sprain
(P
=
0.041). No
significant
differences were
found between the
injured
(N
=
15)
and the
uninjured
(N
=
130) groups
for
generalized joint laxity
(P
=
0.739),
talar
tilt
(P
=
0.473),
or the anterior drawer test (P
=
0.078).
Means and standard deviations for the test
variables,
including peak torque strength,
measurements of the ana-
tomic
alignment
of the foot and
ankle,
and calculated
strength
and anatomic measurement ratios for the
ago-
nists and
antagonists
of the
ankle,
are
presented
in Table
4. When we examined ankle
strength,
no
statistically sig-
nificant differences were found (P > 0.05).
A
statistically
significant
difference was found between the
injured
and
uninjured (control)
values for subtalar eversion
range
of
motion
(P
=
0.04).
The
injured group
had a
higher
mean
eversion
range
of motion
(8.70

2.7)
than the
uninjured
(control) group (7.22

2.6).
The calculated eversion-to-
inversion
strength
ratio was also found to be
statistically
significant (P
< 0.04).
The
injured group
had an
average
eversion-to-inversion ratio of 1.0
compared
with 0.8 in the
uninjured
(control) group.
No other calculated ratio values
were found to be
significant.
Uninjured
Versus
Injured (Within-Subject) Analysis
Using chi-square analysis,
we found no
statistically sig-
nificant differences between the
injured
and
uninjured
ankles when we examined limb dominance or ankle
liga-
ment
stability
(P > 0.05). Two-tailed t-tests were used to
analyze
ankle
strength variables,
measurements of foot
and ankle anatomic
alignment,
and calculated
strength
and anatomic measurement ratios for the
agonists
and an-
tagonists
of the ankle (Table 4).
Statistically significant
variables included
plantar
flexion
strength (P
=
0.036);
the
injured
ankle had a
higher
mean
torque
value (72.20

23.33
foot-pounds)
than the
uninjured (control)
ankle
(68.33 19.26
foot-pounds).
Subtalar inversion
range
of
motion was found to be
statistically significant (P
=
0.034);
the
injured
ankle had a
higher
mean inversion
range
of
motion
(20.27

4.11)
than the
uninjured (control)
ankle
(19.0

3.4).
The calculated
strength
ratios of dorsiflexion
to
plantar
flexion were
statistically significant
(P
=
0.031),
with the
uninjured
(control)
mean
dorsiflexion-to-plantar
flexion ratio value
(0.373) higher
than the
injured
dorsiflexion-to-plantar
flexion ratio
(0.348).
The anatomic
eversion-to-inversion ratio was also
statistically signifi-
cant
(P
=
0.03);
the mean
uninjured (control)
eversion-to-
inversion anatomic ratio (0.479)
was
higher
than the mean
injured
eversion-to-inversion anatomic ratio
(0.424).
DISCUSSION
An estimated 2 million
patients
sustain ankle
sprains
each
year,
which results in
large
costs.&dquo; The rehabilitation and
recovery
time
may vary
from 1 week for a
grade
I
sprain
to
several months for a severe
grade
II or III
sprain.
Soboroff
et aI. 64
analyzed
the costs for the treatment of these
injuries
and found them to
range
in United States dollars from
$318
to
$914 per sprain.
Studies that examine the
potential
causes of athletic
injury
11-13,21,67
are limited in their
retrospective analyses
of
these factors 12 because
specific injuries
were not re-
ported 38,65
and because of their risk factor selection.32,63
The
reliability
of the
techniques
used in this
study
have
not been
presented previously.
In our
study,
test-retest
reliability
measures were obtained for each factor inves-
tigated
and were found to be
highly
reliable with few
exceptions.3
These reliable measures included
general-
ized
joint laxity,
ankle
ligament stability testing,
and
ankle
strength testing (r ranged
from 0.76 to 1.0). The
use of intrarater measurement
techniques
for anatomic
measurements of the foot and ankle were found to be
reliable in earlier studies.26,69
Despite using
these tech-
niques
in the
present study,
anatomic measurements of
subtalar inversion and eversion were
moderately
vari-
able and therefore unreliable (r <
0.75).
Studies
specifi-
cally addressing
the
reliability
of subtalar
range
of mo-
tion measurements are
sparse. Subsequent
studies
aimed at
improving
the
reliability
of subtalar
range
of
motion measurements
using
modified
techniques
are
needed. The
high
test-retest
reliability
of the
remaining
measurements
suggest
that the
significant
differences
567
TABLE 4
Analysis
Between
Injured
and
Uninjured Groups
a
Injured group
(N
=
15); uninjured group (N
=
130).
b
I, injured; U, uninjured.
c
DF:PF,
dorsiflexion to
plantar flexion; E:I,
eversion to inversion.
d
Significant (P < 0.05).
found in this
study
are not the result of measurement
error or
produced by conditioning
effects.
There is
conflicting
evidence to
support
the claim that
the
presence
of
generalized joint laxity may predispose
an
athlete to
joint ln~LlTy.15,16,34,44 Using
similar criteria to de-
fine
generalized joint laxity,
Nicholas54 found a
significant
correlation between this factor and
ruptured
knee
liga-
ments ;
Carter and Sweetnam
15
found a
positive
correlation
with
patella dislocations;
and Carter and Wilkinson 16
found an increased incidence of
congenital
dislocations of
the
hip. Klemp
and Learmonth44 examined ballet dancers
during
a
10-year period
and found no difference in
injury
rate between the dancers classified as
hypermobile
and
those classified as normal.
However,
the small number of
hypermobile
individuals in this dance
group (N
=
11)
made
statistical
analysis
difficult. The
present study
found no
correlation between
generalized joint laxity
and the inci-
dence of inversion ankle
sprains.
Anatomic variants of the
foot, including
cavovarus and
pes planus deformities,
have been
implicated
in foot and
ankle
injuries.23,36 59 Hughes35
found an increased inci-
dence of metatarsal stress fractures
among military per-
sonnel with forefoot varus deformities. Dahle et aI.21 cat-
egorized
foot
types
as
pronated, supinated,
or neutral and
found no
relationship
between foot
type
and ankle
sprain
incidence. The small number of ankle
sprains (N
=
5) may
have limited these results.
Donatelli,23
in an extensive ex-
amination of foot and ankle
biomechanics, suggested
that
individuals with
pes
cavus deformities
may
be
prone
to
ankle
sprains.
He found that
typically
these
subjects
are
unable to
pronate
their foot
adequately
and have decreased
subtalar eversion.
They
are unable to
adapt
to
changes
in
terrain
surfaces, leaving
the ankle more vulnerable to an
ankle
sprain.
The measurements of anatomic
alignment
obtained in
this
study
were not found to be
significantly
different be-
tween
groups
or within
subjects (P
>
0.05),
with the ex-
ception
of subtalar motion. Greater inversion and eversion
range
of motion in the
injured
ankle and
injured group,
respectively,
were found (P < 0.05).
Because of the low re-
liability
of the subtalar anatomic measurements (r <
0.75),
the
significance
of this
finding
needs verification.
Earlier studies have concentrated on
examining
the defi-
cits
resulting
from ankle
injury.
Ekstrand and
Tropp25
found that individuals with a
previous history
of an ankle
sprain
with
damage
to the lateral
ligament complex
are two
to three times more
likely
to sustain a
subsequent
ankle
injury.
Bosien et all stated that after an inversion ankle
sprain
the evertor musculature can remain weak for more
than 10
years.
These studies evaluated two individual sta-
bilizing components
of the ankle
joint,
static and
dynamic
stabilizers. The lateral
ligament complex
functions as a
568
static stabilizer of the ankle
joint preventing
excessive in-
version motion. In a
ligament sectioning study,60
the
anterior talofibular
ligament
limited inversion in ankle
plantar flexion,
and the calcaneofibular
ligament
func-
tioned to limit inversion in ankle dorsiflexion.
Investiga-
tions
reported by
Renstrom and Theis 61 and Colville et aI.18
further
support
these
findings.
The anterior talofibular
ligament
became strained when the ankle was stressed
with an inversion force while in
plantar
flexion. The cal-
caneofibular
ligament produced
a similar
pattern
in dor-
siflexion. Brostrom 8,9 and Brostrom et all found that ei-
ther the anterior talofibular
ligament
or a combination of
this
ligament
and the calcaneofibular
ligament
were
rup-
tured in 85% of the inversion ankle
sprains.
The clinical
provocative
tests of the anterior drawer and talar tilt have
been used
extensively
to evaluate the
integrity
of these
ligaments.38,39,45,62 Using
these
techniques
when examin-
ing
athletes before the
sports season,
we found no
signifi-
cant differences in the ankle
ligament stability
between
injured
and
uninjured
ankles or
groups
(P
>
0.05).
A number of studies have indicated that a
positive
his-
tory
of an inversion ankle
sprain may
be a
predictive
factor
for
subsequent
ankle
injury.8,24,25,53
This
finding suggests
that
prior injury
to the lateral
ligament complex may
result
in a
deficiency
in its role as a static stabilizer of the ankle.
Our
study
did not
support
this
finding.
The lack of
support
for this
finding may
be because of an inherent selection bias
of the
study
in
obtaining
athletes for
participation.
Indi-
viduals with a
prior history
of an ankle
sprain
of
grade
II
or III were excluded from the
present study
to eliminate
subjects
with chronic ankle
instability
from the acute in-
jury population.
The musculotendinous units
crossing
the ankle
joint,
such as the
peroneal muscles,
function as
dynamic
stabi-
lizers of the ankle and assume an
important
role when the
static stabilizers are
compromised.
Bosien et al. and
Staples 66
found
long-term
evertor muscle weakness after
inversion ankle
sprains. Tropp
et
aI.,68
in an isokinetic
evaluation of
peroneal
muscle
strength
in
functionally
un-
stable
ankles,
concluded
peroneal
muscle weakness is a
component
of functional
instability
of the ankle.
Through
the influence of
previous investigations
on rehabilita-
tion, 1,47,66,68
rehabilitative efforts to return athletes to
sport
have concentrated on
strength training
to
develop
the
dy-
namic stabilizers of the ankle. This limited
approach
to
ankle rehabilitation after
injury
has not been
proven
to
decrease the incidence of these
injuries.
In the
present paper,
two different
strategies
were used
to
investigate
ankle
strength:
1) mean
peak torque
for each
ankle motion and 2)
strength
ratios between
agonists
and
antagonists
of the ankle. No
significant
differences in the
mean
peak torque strength
measurements were found for
TABLE 5
Within
Subject Analysis
of
Injured
and
Uninjured GroupSa
a
Injured group (N
=
15); uninjured group (N
=
15).
b
I, injured; U, uninjured.
c
Significance
P < 0.05.
d
DF:PF,
dorsiflexion to
plantar flexion; E:I,
eversion to inversion.
569
any
of the ankle motions between the
injured
and unin-
jured groups
(Table 5).
A difference in
plantar
flexion
strength
was the
only statistically significant finding
(P <
0.05) revealed after we evaluated this
parameter
within
subjects
between
uninjured
and
injured
ankles (Table 4).
The
injured
ankle had a
higher
mean
plantar
flexion
peak
torque
when
compared
with the
uninjured
ankle. The
mechanism of a lateral ankle
sprain
involves subtalar
inversion and tibiotalar
plantar
flexion. The increased
plantar
flexion
strength
of the
injured
ankle
may apply
increased tension to the Achilles
tendon, shortening
the
musculotendinous unit.
Shortening
the musculotendinous
unit
may position
the foot in an attitude of
greater plantar
flexion and therefore a more unstable
position, possibly
in-
creasing
the risk of inversion
injury.
Some studies have shown a
positive
correlation between
muscle imbalance and
injury.ll,i4,51 Strength
imbalance re-
search has
primarily
involved the knee.11,33
Although
nor-
mative isokinetic data are available for the
ankle,22,55,58,70
no studies have measured ankle
strength
or calculated
strength
ratios before
injury
to evaluate if
strength
deficits
or imbalances contribute to
injury.
To address this
issue,
we calculated
strength
ratios from isokinetic
strength
data
for the
agonists
and
antagonists
of the ankle
(dorsiflexion
to
plantar flexion;
eversion to inversion). The calculated
strength
ratio for dorsiflexion to
plantar
flexion was
sig-
nificant for the
within-subject
data (P < 0.05) (Table 4). The
injured
ankle had a lower mean
dorsiflexion-to-plantar
flexion
strength
ratio than the
uninjured
ankle (0.34 and
0.37, respectively).
Normative mean data for dorsiflexion-
to-plantar
flexion
strength
ratios
range
between 0.34 and
0.36, correlating positively
with the values obtained in this
study. 22,58
Because of the absence of other
prospective
in-
jury
studies
examining
these
ratios,
no
comparisons
are
available.
The eversion-to-inversion
strength
ratio was the
only
ra-
tio found to be
significantly
different between the
injured
and
uninjured groups.
The
uninjured group
had a mean
eversion-to-inversion ratio of
0.8,
and the
injured group
value was 1.0. Reexamination of the data ratios of the in-
jured group
showed that 67% of these individuals had an
eversion-to-inversion ratio of 1.0 or more. It is
important
to
reiterate that the eversion and inversion mean
peak torque
values
analyzed
as
independent
variables were not found
to be
significant.
The interaction of eversion with inversion
as a
strength
ratio was
significant.
This
suggests
the im-
portance
of ratio
analysis
in
identifying
muscle imbalances
in individuals
susceptible
to an inversion ankle
injury.
The
development
of isokinetic
testing
devices has
enabled the clinician to
quantify strength
measurements
objectively. Early
work focused on normative
data;
sub-
sequently,
the natural
progression
has turned toward iden-
tifying pathologic
causes.
Strength
imbalance research has
been a useful tool in
working
toward this
goal. Many
in-
vestigators
would
agree
that
measuring
muscle
strength
is
a
complex
endeavor.33,46,56 Muscles
vary
in the force
they
are able to
generate depending
on the
speed
of the con-
traction,
the
type
of contraction
(eccentric
versus concen-
tric),
the
length
of the muscle
during contraction,
and the
muscle fiber
type.
The
technique
used in this
study
meas-
ured muscle
strength
at one
speed
of
contraction,
concen-
trically throughout
a full
range
of motion and in an
open
kinetic chain with a subtalar neutral
position.
Within the
limitations of this
testing method,
the eversion-to-
inversion
strength
ratio
appears
to
identify
an individual
at risk for ankle
injury.
The increased
peroneal
muscle
strength may represent
an
adaptive
mechanism to
protect
an ankle
susceptible
to
injury. However,
a
simple expla-
nation for this
finding
is not
apparent.
Lentell et aI. 46 stated that ankle
sprains
most often occur
in closed kinetic chain activities where the evertor muscles
contract
eccentrically
to resist excessive motion at
high
velocity. Tropp67
has done extensive research
examining
proprioceptive
factors in
response
to
injury using
stabil-
ometry.
He found athletes with
abnormally high
stabil-
ometry readings
to be at an increased risk for
injury.
This
would
suggest
that future muscle
strength
evaluation
should include
higher
test
speeds,
eccentric
contractions,
closed kinetic chain
dynamics,
and
proprioceptive testing.
With further definition of these
complex
interactions
involving
muscle
strength,
information
linking
muscle
imbalance to
injury may
be better understood.
SUMMARY
This
study
examined intrinsic risk factors and their rela-
tionship
to ankle
injury
in a
specified
athletic
population.
Generalized
joint laxity,
anatomic measurements of the
foot and ankle anatomic
alignment,
and ankle
ligament
stability
were not found to be
significant
risk factors lead-
ing
to ankle
injury.
A
history
of a
previous
mild ankle
sprain
was not found to increase the risk of
sustaining
a
subsequent
inversion ankle
injury.
Individuals with a
muscle
strength
imbalance as calculated
by
an elevated
eversion-to-inversion
strength
ratio
(>1.0)
had a
higher
in-
cidence of inversion ankle
injury.
Ankles with a
greater
plantar
flexion
strength
and an associated muscle
strength
imbalance,
as calculated
by
a smaller dorsiflexion-to-
plantar
flexion
ratio,
had a
higher
incidence of inversion
ankle
sprain.
Further
study
aimed at
altering strength
deficits and imbalances identified before the athletic sea-
son are
planned
to examine if these
changes
will decrease
the incidence of ankle
injury
and aid in
injury prevention.
ACKNOWLEDGMENTS
The authors thank the athletic
training departments
of the
University
of
Vermont,
Saint Michaels
College,
and the
University
of New
Hampshire.
Thanks also
go
to the
Sports
and
Orthopaedic
Rehabilitation Center for the use of their
facility
and
equipment
and to the thesis committee of Neil
Vroman, PhD,
Robert
Kertzer, PhD,
and Dan
Sedory, MS,
ATC,
of the
University
of New
Hampshire.
This
project
was
partial
fulfillment of a Masters
Degree
of Science at the
University
of New
Hampshire
for Denise
Alosa,
ATC.
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