Foot & Ankle International

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Bilateral Deficits in Postural Control following Lateral Ankle Sprain

Todd Evans, Jay Hertel and Wayne Sebastianelli
Foot Ankle Int 2004 25: 833
DOI: 10.1177/107110070402501114
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FOOT & ANKLE INTERNATIONAL

Copyright 2004 by the American Orthopaedic Foot & Ankle Society, Inc.

Bilateral Deficits in Postural Control Following Lateral Ankle Sprain

Todd Evans, Ph.D., A.T.C.1 ; Jay Hertel, Ph.D., A.T.C.2 ; Wayne Sebastianelli, M.D.3
Cedar Falls, Iowa; University Park, Pennsylvania

ABSTRACT

INTRODUCTION

Background: Although postural control deficits have

been identified after lateral ankle sprains, objective and
subjective comparisons of data before and after injury are
limited. The purpose of this project was to prospectively
assess and compare the changes in postural control
and self-reported functional status in athletes who suffer
acute lateral ankle sprains. We evaluated postural control
and self-reported functional status before injury and
at 1, 7, 14, 21, and 28 days after acute lateral ankle
sprain. Methods: Postural control in single-limb stance
and self-reported functional status were evaluated in
460 collegiate athletes during preseason examinations.
Twenty-eight athletes suffered a lateral ankle sprain
during the competitive season and participated in testing
at 1, 7, 14, 21, and 28 days after injury. Results: Significant
deficits in postural control were noted in both the
injured and the uninjured ankles at 1 day after injury
compared to the baseline measurements taken during the
preseason examinations. Significant differences (p < .05)
also were noted between the uninjured and injured ankles
at 1, 7, and 21 days after injury. Conclusions: After
lateral ankle sprain, postural control deficits occur in
the injured and uninjured ankles, suggesting a central
impairment in neuromuscular control. Changes in selfreported functional status followed a trend of deficit
and improvement that was similar to that shown by
the postural control data taken after injury, but the two
measures did not strongly correlate.

As a marker of functional ankle instability, deficits in

postural control, which is the regulation of balance in an
upright stance, have been consistently identified in the
injured limb after lateral ankle sprains.5,6,9 11,12,20,28,30
These side-to-side deficits, however, have been based
almost exclusively on comparisons of injured to uninjured limbs.29 Postural control deficits after injury
support the notion of a neuromuscular component of
functional ankle instability, but they do not provide
insight into the magnitude of impairments seen after
ankle sprains. Although Leanderson et al.15 reported
a prospective study of 53 dancers of whom six had
suffered lateral ankle sprains, testing was not done at
consistent intervals after injury, and inferential statistics were not used for comparisons of data before and
after injury.
Further compounding the interpretation of comparisons made after injury is the potential for bilateral
neuromuscular deficits after unilateral lower extremity
injury. Several reports have suggested that after lower
extremity joint injury, neuromuscular deficits exist in
both the injured and the uninjured limbs.2,6,12,14,31
Altered thigh and hip muscle activation patterns have
been reported after severe lateral ankle sprains in
the ipsilateral and contralateral limbs.2 Friden et al.6
reported bilateral postural control deficits after acute
ankle sprains; however, these values were compared
to a group of healthy subjects and not to the
baseline values of injured subjects before the ankle
sprains occurred. Hertel et al.12 reported bilateral
improvements in postural control over the course of
1 month after acute ankle sprains; however, no baseline values were available for comparison. Because
of the limited comparisons of data before and after
injury, bilateral neuromuscular deficits associated with
acute ankle sprains have yet to be conclusively
established.

Key Words: Ankle Sprain; Postural Control; Athlete

1
2

University of Northern Iowa, Cedar Falls, Iowa

Penn State University, University Park, Pennsylvania

Corresponding Author:
Todd Evans, Ph.D., A.T.C.
University of Northern Iowa HPELS 203 WRC
Cedar Falls, Iowa 50614-0241
E-mail: todd.evans@uni.edu
For information on prices and availability of reprints, call 410-494-4994 X226.

833

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834

EVANS ET AL.

Foot & Ankle International/Vol. 25, No. 11/November 2004

In addition to limited comparisons of objective data,

there is limited research regarding changes in selfreported functional status after lateral ankle sprains.26
Although self-reported functional status commonly
is incorporated into the evaluation of outcomes in
general orthopaedics, it has yet to be adopted in
the daily practice of sports medicine. Furthermore, the
relationship between self-reported functional status and
specific components of functional instability, such as
postural control, has not been established.
The purpose of this project was to prospectively
assess and compare the changes in postural control
and self-reported functional status in athletes after acute
lateral ankle sprains. We compared the baseline healthy
measures to those recorded after lateral ankle sprain,
assessing postural control and self-reported functional
status before injury and at 1, 7, 14, 21, and 28 days
after an acute ankle sprain.
MATERIALS AND METHODS
Subjects

Before the start of their competitive season, we

assessed the postural control and the self-reported
functional status of 460 NCAA Division I collegiate
athletes (234 men and 226 women) from 23 sports.
Each subject was free of existing ankle sprains, as
well as acute or persistent orthopaedic pathology.
Throughout one academic year, 28 of the 460
athletes (11 males, 17 females; age = 19.7 1.4 years;
body mass index = 73.5 19.0 kg; height = 175.0
12.5 cm) suffered acute mild to moderate lateral ankle
sprain and participated in testing after injury. All injured
subjects were initially assessed by either a certified
athletic trainer or a team physician. In addition, only
those ankle sprains that resulted in limited participation
status for at least two consecutive days were included.
Twelve of the sprains were considered mild and 16
were moderate. Seventeen sprains occurred in the right
ankle and 11 occurred in the left ankle. Mild sprains
were classified as ligamentous pain and laxity at either
the anterior talofibular ligament or the calcaneofibular
ligament. Moderate sprains were classified as pain and
laxity of both ligaments. For the anterior talofibular ligament, laxity was assessed with the anterior drawer test,
while the talar tilt test was used to assess calcaneofibular ligament laxity. All injured subjects were free
of concomitant fractures and syndesmosis injuries. In
accordance with the Office of Regulatory Compliance,
all subjects provided informed consent.
Protocol

Postural control was measured as the center of

pressure (COP) excursion velocity (VEL) while each
athlete maintained a unilateral stance for 15 seconds,

for both the left leg and right leg, for three trials with
the eyes open. Subjects were asked to maintain a
single-leg, barefoot stance on a force plate (Advanced
Medical Technology Incorporated, [AMTI] Watertown,
MA). They were instructed to stand as motionless as
possible with their arms folded across the chest. The
nonstance leg was held in approximately 30 degrees
of hip flexion and 45 degrees of knee flexion and was
not allowed to touch the stance leg during testing. If
a touchdown (the nonstance leg touching the ground
during data acquisition) occurred or the subject touched
the nonstance leg to the stance leg, the trial was
terminated and repeated. Previous research conducted
in our laboratory (unpublished data) indicated that there
are no trends in terms of additional repeated trials
being necessary with the injured limb stance versus the
uninjured limb stance.
Each trial was 15 seconds long and was modeled
after Goldies previously reported methods which have
been shown to be reliable and valid.7 9 A rest period
of 30 seconds was given between trials. The subjects
completed three trials on each leg with the eyes open
to allow visual feedback during the maintenance of
balance. Subjects, therefore, performed a total of six
trials. The order of leg testing was counter-balanced
among all subjects during the baseline testing. Pilot
data from our lab revealed that individuals were typically
unable to complete 15 seconds of eyes closed balance
trials on the first day after an ankle sprain; therefore,
we did not incorporate eyes closed trials in our
current study.
The Athletic Training Outcomes Assessment (ATOA)
self-report survey1 and the SF-12 Health Survey32
were completed before the postural control testing.
Athletes were instructed to complete the health surveys
based upon their health status at the time. A detailed
health interview also was conducted. The preseason
assessments were done either during the usual physical
examinations or during a scheduled session before the
beginning of the competitive season.
In cooperation with the team physicians and certified athletic trainers, athletes who suffered a mild or
moderate lateral ankle sprain and missed at least 2
consecutive days of athletic participation without limits
were tested within 1 day of return to full weightbearing
ambulation. Although specific lateral ankle sprain rehabilitation protocols may have varied among athletic
trainers and physicians at our institution, they all
followed a functional rehabilitation program that emphasized control of pain and swelling, range of motion,
strengthening, and balance exercises, as well as gradual
return to functional activities, including weightbearing
as tolerated 24 hours after injury, with an emphasis
on functional weightbearing exercises. We did not

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Foot & Ankle International/Vol. 25, No. 11/November 2004

control the treatment intervention or the rehabilitation

protocol.
After the initial assessment following injury, postural
control and self-reported functional status were measured at 7, 14, 21, and 28 days after the injury. Testing
was done in one of five different athletic training rooms
or the athletic training research laboratory. The same
certified athletic trainer conducted all testing that was
done after injury.
Instruments

Postural control was measured with an AMTI

Accusway force plate (AMTI Inc., Watertown, MA) interfaced with a laptop computer using SWAYWIN95 software (AMTI Inc., Watertown, MA). Three-dimensional
ground reaction forces were collected at 50 Hz. The
AMTI force plate measures translational forces (Fx, Fy,
Fz) and moments of force (Mx, My, Mz), and the software program calculates COP trajectories. The origin of
the COP path was the initial point of COP during each
trial. The dependent measure was the COP excursion
velocity, defined as the distance or length of the path
created by the COP divided by the duration of the trial.
Self-reported health status was measured with a
modified version of the ATOA self-report survey1 and
the SF-12 Health Survey.32 The ATOA self-report survey
was developed to measure improvement in function in
injured physically active individuals.1 It consists of 12
items that can produce individual item scores as well as
three composite scores. The composite scores include
a functional outcomes subgroup (three items), a physical
outcomes subgroup (six items), and an overall score (all
12 items). The 12 items include activities of daily living,
work activities, sports-recreation-wellness (grouped as
functional outcome), movement, strength or power,
endurance, motor abilities, body structure, sensory
(grouped as physical outcomes), general health status,
specific medical condition, and psychosocial status.1
The survey was modified from its original version to
exclude the two items that measured satisfaction with
treatment and satisfaction with the certified athletic
trainer. In addition, the pretreatment and posttreatment
responses were not recorded on the same survey
page. Therefore, the subjects did not see their previous
responses. This version of the ATOA has been shown to
be reliable and sensitive to changes in the health status
of physically active individuals.4
The SF-12 Health Survey,32 adopted from the Medical
Outcomes Study Short Form Health Survey (SF-36), is
a 12-item health survey that is an accepted outcomes
questionnaire that can be used to evaluate a patients
vitality and general health-related functioning.32,33 It is
considered one of the best generic measures available
for use across diverse populations32 and has been
administered to measure the effects of chronic diseases,

POSTURAL CONTROL AFTER ANKLE SPRAIN

835

the effects on general health, and differences in

patient populations.32 It consists of 12 items separated
into eight dimensions that measure physical and
mental health. The eight dimensions include: 1) physical
functioning, 2) role limitations due to physical health
problems, 3) role disability due to emotional health
problems, 4) general mental health (1 to 4 estimated
with two items), 5) vitality, 6) social functioning, 7) bodily
pain, and 8) general health perception (estimated with
one item each). When totaled the SF-12 produces two
scores: the physical component summary scale (PCS)
and the mental component summary scale (MCS).
Statistical Analysis

Means for COP VEL were calculated for both limbs

by averaging the three trials for each testing session.
Separate 2 6 (side time) repeated measure analysis
of variances (ANOVA) were calculated for postural
control data. Separate repeated measures of ANOVA
also were calculated for ATOA and SF-12 data. To
determine the correlation of balance and self-reported
data, delta scores (change scores) were calculated for
each measure between each of the testing sessions.
Spearman rho coefficients between the postural control
delta scores of the injured ankle and the ATOA (total
composite score and individual items) and the SF-12
(total composite score only) delta scores were then
calculated for the following intervals: baseline day 1,
day 1 to day 7, day 1 to day 28.
RESULTS
Postural Control

There were significant main effects for both time

(F = 3.22, p < .01) and side (F = 8.90, p < .01) for
the postural control measure. Analysis revealed that
compared to the baseline data, significant deficits in
postural control existed for both the injured and the
uninjured ankles (p < .05) at day 1 (Figure 1). Significant
deficits also were found at day 7 in the injured
ankles (p < .05). Furthermore, there were significant
differences (p < 0.05) between the healthy and injured
ankles at 1, 7, and 21 days. Although the injured ankle
values were greater than the uninjured values at days
14 and 28, these differences were not statistically
significant. Whereas both the injured and uninjured
ankles improved 1 day after injury, the healthy ankle
approached baseline values sooner, with the injured
ankle showing significant deficits until 14 days after
injury. Means for the postural control and the selfreported data are reported in Table 1.
Self-reported Assessment

For both the ATOA (p = .001) and SF-12 data

(p = .001), significant time effects existed. Analysis

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EVANS ET AL.

Foot & Ankle International/Vol. 25, No. 11/November 2004

Center of Pressure Excursion Velocity (CM/second)

836

4.4

Healthy Ankles
Injured Ankles

4.2

*
*

4
3.8

3.6

3.4
3.2
3
Baseline

Day 1

Day 7

Day 14

Day 21

Day 28

Fig. 1: Eyes open postural control data for the injured and healthy ankles illustrates the postural control deficits that occurred immediately after
injury and the subsequent return towards baseline values. Indicates significant difference from baseline (p < .05); Indicates significant difference
between healthy and injured ankle (p < .05).

Table 1: Means of Postural Control and Self-reported Instruments (SD)

Measure
Ankle Uninjured
Ankle Injured
ATOA Composite
SF-12 Composite

Baseline

Day 1

Day 7

Day 14

Day 21

Day 28

10.69
(2.57)
11.08
(2.76)
45.36
(4.59)
51.68
(5.88)

11.72
(2.69)
12.75
(3.79)
28.31
(11.61)
42.6721 10.13494

10.67
(2.067)
12.37
(3.24)
38.91
(8.52)
45.19
(7.85)

10.63
(2.23)
11.48
(2.91)
39.50
(10.73)
46.73
(8.56)

10.96
(2.64)
11.72
(2.66)
43.32
(7.10)
48.43
(8.68)

10.80
(1.97)
11.34
(2.78)
44.05
(6.067)
48.39
(9.24)

revealed that for both surveys, scores were significantly

lower than baseline scores at 1, 7, and 14 days after
injury, with scores returning towards baseline beginning
at day 7 (Figure 2). Spearman rho coefficients produced
only low correlations (r < .49) between ATOA scores
and COP VEL, and the SF-12 and COP VEL (Table 2).
DISCUSSION

Our results indicate a significant deficit in COP VEL

in both the injured and uninjured limbs 1 day after
injury, as well as at seven days in the injured limbs
when compared to baseline measures. The COP VEL
is the distance or length of the path created by the
COP divided by the duration of the trial. Side-to-side
differences in COP VEL were present at 1, 7 and 21 days
as well. Significant changes in self-reported functional
status occurred after injury, and although these data
followed a similar trend, the objective and subjective
measures were not strongly correlated.

Our primary finding was that bilateral impairments in

postural control during single-limb stance occurred after
unilateral ankle sprains. Injured subjects demonstrated
inferior postural control on both their injured and
their uninjured limb after acute ankle sprain compared
to baseline values. Our comparison of measures of
postural control after injury to baseline measures taken
before injury allowed us to definitively demonstrate
bilateral deficits after a unilateral acute ankle sprain
The existence of bilateral impairment after an ankle
sprain does not support the seminal hypothesis by
Freeman et al. of ligament mechanoreceptor damage
causing neuromuscular control deficits after injury.5
The existence of deficits in the uninjured contralateral
limb indicates that a centrally mediated mechanism is
contributing to the neuromuscular deficits associated
with acute joint injury.
Previous researchers have offered evidence of bilateral neuromuscular control deficits after unilateral ankle
sprain;2,6,12 however, the lack of preinjury data made

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Foot & Ankle International/Vol. 25, No. 11/November 2004

POSTURAL CONTROL AFTER ANKLE SPRAIN

837

ATOA Total
SF-12 PCS

55.0

Composite Score

50.0
45.0

40.0
35.0

Day 7

Day 14

30.0

25.0
20.0
Baseline

Day 1

Day 21

Day 28

Fig. 2: ATOA and SF-12 composite scores. Changes in self-reported assessment after injury and the subsequent return towards baseline values.
Indicate significant difference from baseline (p < .001).

Table 2: Spearman Coefficients Between Change Scores of ATOA, SF-12, and COP VEL
Subjective Measure
ATOA Composite Score
ATOA ITEMS
General Health
Specific medical condition
Daily living activities
Work activities
Sport/recreational activities
Movement
Strength
Endurance
Motor abilities
Body structure
Sensory
Psycho-social status
SF-12 Composite Score
Correlation

BaselineDay 1

Day 1Day 7

Day 1Day 14

Day 1Day 28

0.16

0.48

0.12

0.21

0.04
0.22
0.17
0.05
0.04
0.18
0.00
0.13
0.11
0.37
0.39
0.15
0.18

0.10
0.42
0.47
0.31
0.34
0.27
0.38
0.49
0.40
0.22
0.39
0.20
0.08

0.35
0.05
0.11
0.21
0.01
0.10
0.21
0.00
0.09
0.07
0.10
0.07
0.14

0.26
0.20
0.27
0.29
0.08
0.08
0.11
0.20
0.21
0.30
0.06
0.20
0.01

is significant at the .05 level (2-tailed).

definitive interpretation of these results impossible.

Friden et al.6 demonstrated impaired postural control
in both the involved and uninvolved limbs 3 and
8 days after an ankle sprain compared to healthy
subjects. Hertel et al.12 reported bilateral improvements
in postural control measures on injured and uninjured
limbs over the course of four weeks after an ankle
sprain. It must be noted that in these studies, as in our
current study, there were more pronounced postural
control impairments in the injured limbs than in the
uninjured limbs.
The clinical implications of our current postural control
findings must be considered. Acute inflammation associated with ankle sprains likely led to neuromuscular inhibition, and, thus, impaired postural control
in both the injured and uninjured limbs. As inflammation
subsided, the contralateral deficits were negated. This

is evidenced by the uninvolved limb only being significantly worse than baseline at 1 day after injury. The
ability of antiinflammatory modalities and medications to
lessen the neuromuscular effects associated with acute
joint injury is an area that warrants future research. The
consequences of impaired postural control bilaterally
also deserve consideration; poor postural control has
been shown to increase the risk of ankle sprains.16,28
However, this has not been studied in athletes with
impaired postural control after a recent ankle sprain.
Returning athletes to play too quickly after an ankle
sprain (i.e., before return of preinjury postural control)
may predispose them to further injuries.
As an adjunct to objective measurements, selfreported functional status has become a valuable tool
in orthopaedic rehabilitation.1,13 Whereas assessing
self-reported outcomes has been implemented to some

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EVANS ET AL.

Foot & Ankle International/Vol. 25, No. 11/November 2004

degree in most health care settings, it has yet to become

standard in most sports medicine settings. Survey
instruments are used to assess general, conditionspecific, or patient-specific outcomes22,34 and typically
assess clinical indicators, such as activities of daily
living, general health, work activities, and psychosocial
status. The instruments used in this study, the ATOA and
SF-12, are considered generic instruments, although the
ATOA was designed for assessing the health status of
physically active patients.1
Our results suggest that changes in self-reported
functional status, as reported with generic instruments,
follow a trend similar to that of postural control
after lateral ankle sprain. Comparable to the injured
ankle COP VEL scores, self-reported functional status
scores were significantly worse immediately and 7 days
after injury. Unlike the self-reported functional status
scores, however, COP VEL scores were not significantly
worse 14 days after injury than baseline measures.
Thus, at 14 days after injury, subjects continued to
subjectively report deficits even though postural control
had returned to close to baseline values. Furthermore,
the COP VEL and self-reported functional status scores
were not highly correlated at any interval.
One explanation for the low correlations is that
although linked to such anomalies as pain, inflammation, and muscle weakness, self-reported function
instruments are not sensitive to improvements and
deficits in neuromuscular performance. Through a retrospective study, Rose et al.26 assessed both balance
and self-reported functional status using the Olerud
and Molander questionnaire after noncontact ankle
sprains at 3, 7, and 14 days after injury. Similar to
our findings, they reported significant improvements in
questionnaire scores. They did not, however, find significant differences in balance scores between the injured
subjects and the controls, although they reported that
the injured subjects appeared to be less stable than the
controls. As in our study, other authors have compared
subjective and objective measures after lower extremity
injury. Rozzi et al.27 compared the effects of balance
training on balance parameters and self-reported functional status in subjects with functional ankle instability. Although significant improvements were found
for balance and functional assessment, a relationship between functional and subjective assessment
status was not established.27 Munn et al.17 reported
that although self-reported functional status scores can
indicate impairment in subjects with ankle instability,
agility scores were not highly correlated. Comparable
studies by Wilson and Gansneder35 and Cross et al.3
seem to indicate that self-reported limitations alone
have limited value in predicting variance in disability
duration after acute ankle sprains. In a series of
studies on patients with anterior cruciate ligament

problems, Risbert et al.,23 25 reported that subjective scales can be sensitive to change over time;
however, they vary in their relationship to neuromuscular impairments and disability. Pfeifer and Banzer,21
Neeb et al.,19 and Wojtys and Hutson36 also suggested
that self-reported measures are not consistently related
to objective measures.
A second explanation for the lack of high correlation
values between COP VEL scores and self-reported
functional status scores is that the generic self-reporting
tools used in this study are not sensitive enough to
detect changes in neuromuscular control. No items
on either the ATOA or the SF-12 exclusively address
balance or other parameters of neuromuscular control.
To clinically interpret our subjective results, it appears
that changes in neuromuscular markers of functional
instability, in this case postural control, are not strongly
correlated with self-reported functional changes. This
notion supports the clinical practice of implementing
both subjective and objective assessment strategies
when evaluating status after lateral ankle sprains.
In conclusion, our results suggest that immediately
after a lateral ankle sprain, bilateral postural control
deficits exist. Although previous research has demonstrated deficits in postural control in the injured limb,
deficits in the uninjured limb have not been compared
to preinjury measures. These bilateral deficits suggest
alterations in centrally-mediated neuromuscular control
processes after acute joint injury. Furthermore, although
changes in self-reported health status follow a trend
similar to changes in postural control after lateral ankle
sprains, changes in these two measures were not
highly correlated. These findings support the use of
both subjective and objective measures, as they may
reflect distinctly different components of impairment
and recovery.
REFERENCES

1. Albohm, MJ; Wilkerson, GB: An outcome assessment of care

provided by certified athletic trainers. J. Rehabil. Outcomes
Measures 3(3):51 56, 1999.
2. Bullock-Saxton, JE; Janda, V; Bullock, MI: The influence of
ankle sprain injury on muscle activation during hip extension. Int.
J. Sports Med. 15:330 334, 1994.
3. Cross KM; Worrell TW; Leslie JE; et al: The relationship between
self-reported and clinical measures and the number of days to
return to sport following acute lateral ankle sprains. J. Orthop.
Sports Phys. Ther. 32:16 23, 2002.
4. Evans, TA; Denegar CR; Hertel, J; et al: (Dissertation) The
Reliability, Validity, Sensitivity, And Standard Values Of The
Athletic Training Outcome Assessment Self-Report Instrument.
The Pennsylvania State University, State College, PA. 2002.
5. Freeman, MAR; Dean, MRE; Hanham, IWF: The etiology and
prevention of functional instability of the foot. J. Bone Joint Surg.
47B:676 685, 1965.

Downloaded from fai.sagepub.com at UNIVERSITY OF BRIGHTON on July 17, 2014

Foot & Ankle International/Vol. 25, No. 11/November 2004

6. Friden, T; Zatterstrom, R; Lindstrand, A; et al: A stabilometric
technique for evaluation of lower limb instabilities. Am. J. Sports
Med. 17:118 122, 1989.
7. Goldie, PA; Bach, TM; Evans, OM: Force platform measures
for evaluating postural control: reliability and validity. Arch. Phys.
Med. Rehabil. 70:510 517, 1989.
8. Goldie, PA; Evans, OM; Bach, TM: Steadiness in one-legged
stance: development of a reliable fore-platform testing procedure.
Arch. Phys. Med. Rehabil. 73:348 354, 1992.
9. Goldie, PA; Evans, OM; Bach, TM: Postural control following
inversion injuries of the ankle. Arch. Phys. Med. Rehab.
75:969 975, 1994.
10. Golomer, E; Dupui, P; Bessou, P: Spectral frequency analysis
of dynamic balance in healthy and injured athletes. Arch. Int.
Physiol. Biomech. Biophys. 102:225 229, 1994.
11. Guskiewicz, KM; Perrin, DH: Effect of orthotics on postural
sway following inversion ankle sprain. J. Orthop. Sports Phys.
Ther. 23:326 331, 1996.
12. Hertel, J; Buckley, WE; Denegar, CR: Serial testing of
postural control after acute lateral ankle sprain. J Athletic Train.
36:363 368, 2001.
13. Jette, AM: Outcomes research: Shifting the dominant research
paradigm in physical therapy. Phys. Ther. 75(11):965 970, 1995.
14. Konishi, Y; Konishi, H; Fukubayashi, T: Gamma loop
dysfunction in quadriceps on the contralateral side in patients
with ruptured ACL. Med. Sci. Sports Ex. 35:897 900, 2003.
15. Leanderson J, Eriksson E, Nilsson C: Proprioception in classical
ballet dancers: a prospective study of the influence of an ankle
sprain on proprioception in the ankle joint. Am. J. Sports Med.
24:370 374, 1996.
16. McGuine, TA, Greene, JJ; Best, T; Leverson, G: Balance as a
predictor of ankle injuries in high school basketball players. Clin.
J. Sports Med. 10:239 244, 2000.
17. Munn, J; Beard, DJ; Refshauge, KM; et al: DO functionalperformance tests detect impairment in subjects with ankle
instability? J. Sport Rehabil. 11:40 50, 2002.
18. Myers, JB; Riemann, BL; Hwang, JH; et al: Effect of peripheral
afferent alteration of the lateral ankle ligaments on dynamic
stability. Am. J. Sports Med. 31:498 506, 2003.
19. Neeb, TB; Aufdemkampe, G; Wagener, JHD; et al: Assessing
anterior cruciate ligament injuries: The association and differential
value of questionnaires, clinical tests, and functional tests. J.
Orthop. Sports Phys. Ther. 26(6):324 331, 1997.
20. Neugebauer, V; Schaible, HG: Evidence for a central component
in the sensitization of spinal neurons with joint input during
development of acute arthritis in cats knee. J. Neurophysiol.
64:299 311, 1990.
21. Pfeifer, K; Banzer, W: Motor performance in different dynamic
tests in knee rehabilitation. Scand. J. Med. Sci. Sport Ex.
9(1):19 27, 1999.

POSTURAL CONTROL AFTER ANKLE SPRAIN

839

22. Riddle, DL; Stratford, PW: Use of generic versus regionspecific functional status measures on patients with cervical
spine disorders. Phys. Ther. 78(9):951 963, 1998.
23. Risberg, MA, Beynnon, BD; Peura, GD, UH, BS: Proprioception
after anterior cruciate ligament reconstruction with and without
bracing. Knee Surg. Sport Trauma Arthros. 7(5):303 309,
1999.
24. Risberg, MA, Holm, I; Tjomsland, O; Ljunggren, E, Ekeland,
A: Prospective study of changes in impairments and disabilities
after anterior cruciate ligament reconstruction. J. Orthop. Sports
Phys. Ther. 29(7):400 412, 1999.
25. Risberg, MA, Holm, I; Steen H; Beynnon, BD: Sensitivity
to changes over time for IKDC form, the Lysholm score,
and the Cincinnati knee score: Prospective study of 120 ACL
reconstructed patients with a 2-year follow-up. Knee Surg. Sport
Traum. Arthros. 7(3):152 159, 1999.
26. Rose, A; Lee, RJ; Williams, RM; et al: Functional instability
in non-contact ankle ligament injuries. Brit. J. Sports Med.
34:352 358, 2000.
27. Rozzi, SL, Lephart, SM; Sterner, R; Kuligowski, L: Balance
training for persons with functionally unstable ankles. J. Orthop.
Sports Phys. Ther. 29:478 486, 1999.
28. Tropp, H; Ekstrand, J; Gillquist, J: Stabilometry in functional
instability of the ankle and its value in predicting injury. Med. Sci.
Sport Ex. 16:64 66, 1984.
29. Tropp, H; Odenrick, P; Gillquist J: Stabilometry recordings in
functional and mechanical instability of the ankle joint. Int. J.
Sports Med. 6:180 182, 1985.
30. Tropp, H; Odenrick, P: Postural control in single-limb stance. J.
Orthop. Res. 6:833 839, 1988.
31. Urbach, D; Nebelung, W; Weiler, HT, et al.: Bilateral deficit of
voluntary quadriceps muscle activation after unilateral ACL tear.
Med. Sci. Sports Exerc. 31:1691 1696, 1999.
32. Ware, JE; Kosinski, M; Keller, SD: SF-12: How to score the SF12 physical and mental health summary scales (2nd Ed.). Boston,
The Health Institute, New England Medical Center, 1995.
33. Ware, JE; Kosinski, M; Keller, SD: A 12-item short form health
survey: Construction of scales and preliminary tests of reliability
and validity. Med Care. 34:220 233, 1996.
34. Westaway, MD; Stratford, PW; Binkley, JM: The patientspecific functional scale: validation of its use in persons with
neck dysfunction. J. Orthop. Sports Phys. Ther. 27:331 338,
1998.
35. Wilson, RW; Gansneder, BM: Measures of functional limitation
as predictors of disablement in athletes with acute ankle sprains.
J. Orthop. Sports Phys. Ther. 30:528 535, 2000.
36. Wojtys, EM; Huston, LJ: Longitudinal effects of anterior
cruciate ligament injury and patellar tendon autograft
reconstruction on neuromuscular performance. Am. J. Sports
Med. 28:336 344, 2000.

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