'




80%-

Inversion Sprain

Am J Sports Med. 2005 Mar;33(3):415-23.

Intrinsic risk factors for inversion ankle sprains in male
subjects: a prospective study.
Willems TM, Witvrouw E, Delbaere K, Mahieu N, De
Bourdeaudhuij I, De Clercq D.

BACKGROUND: Many variables have been retrospectively

associated with ankle sprains. However, very little is known
about factors predisposing people to these injuries.

METHODS: A total of 241 male physical education

students were evaluated for possible intrinsic risk factors
for inversion sprains at the beginning of their academic
study.
The evaluated intrinsic risk factors included
anthropometrical characteristics, functional motor
performances, ankle joint position sense, isokinetic ankle
muscle strength, lower leg alignment characteristics,
postural control, and muscle reaction time during a sudden
inversion perturbation.
Subjects were followed prospectively for 1 to 3 years.

RESULTS: A total of 44 (18%) of the 241 male subjects

sustained an inversion sprain; 4 sprained both ankles.
Cox regression analysis revealed that male subjects with:
slower running speed
less cardiorespiratory endurance
less balance
decreased dorsiflexion muscle strength
decreased dorsiflexion range of motion
less coordination
faster reaction of the tibialis anterior and gastrocnemius

are at greater risk of ankle sprains.

Instability is due to four factors:

1) Osteocartilaginous configuration.
The talus is smaller posteriorly than anteriorly,
and hence the bony stability of the ankle is
lessened in the plantar-flexed position.

Instability is due to four factors:

2) Ligamentous structures
(static stabilizers)

Instability is due to four factors:

3) Musculotendinous units
(dynamic stabilizers)

Plantar/ Dorsi Flexors

Gastrocnemius, Soleus/ Tibialis anterior, Extensor
digitorum longus, Peroneus tertius

Invertor/Evertors
Tibialis anterios & posterior/ Extensor digitorum longus,
Peroneus longus, brevis & tertius)

TESTING OF DORSI AND PLANTAR FLEXION

ROM
The ROM is measured relative to neutral position of the foot.
Dorsi Flex (DF) ROM : 10-30 deg
Plantar Flex (PF) ROM: 40-65 deg.
Inversion: 30-50 deg.
Eversion: 15-20 deg.

Recommended ROM for testing

Functionally the typical ankle ROM during walking 10deg DF. and 20 deg
PF. For running 20 deg DF and 25 deg PF.
THE TESTED ROM MAXIMAL ROM
MUST ENSURE MAXIMAL DF (why???)

POSITIONING

2 joint muscle.

Kinematic analysis in ambulation reveals that during the

propulsive phase the knee is in a near extended position. In
stair climbing and descending knee flexion can approach 60
deg.

Recommendation : slight/moderate knee flexion

Measuring isokinetic Eversion/Inversion Torque

Invertor vs. evertor peak torque and power deficiencies associated

with lateral ankle ligament injury.
Wilkerson GB, Pinerola JJ, Caturano RW
(J Orthop Sports Phys Ther 1997 Aug;26(2):78-86)

30 physically active adolescents,ages 14-19 years,

who had recently a lateral ankle sprain or
symptoms of chronic lateral ankle instability.

Eversion/inversion testing was performed on

a Biodex isokinetic dynamometer at speeds of
30 and 120 degrees/sec.

The findings of this study suggest that a

lateral ankle ligament injury may be
associated with an evertor muscle
performance deficiency. Restoration of
a normal evertor/invertor strength
relationship may be accomplished
through performance of an ankle
strengthening program.

Concentric Torque (Nm)

full knee extension
velocity gender
deg/sec
30
m
f
60
m
f
120
m
f

dorsi plantar plantar

flexion flexion s flexion t
33
126
183
26
84
140
26
96
145
20
64
113
18
60
95
12
27
52

Concentric Torque (Nm)

velocity gender Inversion Eversion
deg/sec
30
m
32
28
f
24
23
60
m
26
24
f
20
16
120
m
22
19
f
16
13

Coefficients for prediction formulae for plantar flexor performance

Gender coefficient Peak

Torque
X1 (M) X0 (F)
39.2

Work
23.4

40-44 yr

-24.4

-6.2

50-54 yr

-35.2

-17.9

60-64 yr

-45.4

-24.8

Crural
Circumference
R2

3.1

1.8

0.79

0.63

PF strenght: gender coe. + age group coe. + crural cir.X crural cir. coe

Prediction formulae for invertor and evertor strength at 60 deg/sec

Women
Inv: 14.312+ (0.057 X weight)- (0.371X % body fat) + (0.504 X shoe size)
Ev: -15.726+ (0.061 X age)- (0.977X leg dominance) + (0.504 X height)

Peak Moment: ft*lb

Weight: kg
Shoe size: american system
Age: years
Height : inches
Leg dominance: 2 -non dominant 1- dominant

Ankle Muscles Torque Ratios (%)

velocity gender eve/inv drs/plt s drs/plt t
deg/sec
30
m
87
26
19
f
81
30
19
60
m
90
27
19
f
80
32
19
120
m
86
29
21
f
82
38
20

Instability is due to four factors:

4) Proprioceptive and stretch receptors in
and around the joint.
When the speed of loading overcomes the
dynamic or proprioceptive stabilizing effect of
the muskulotendinous units, the ligamnetous
structure is challenged.

Methods: Eleven men with recurrent ankle lateral sprain in one limb were tested
using an isokinetic dynamometer. The tests consisted of 5 cycles of maximal
contraction in 30/s and 120/s. Both injured and non-injured ankles were tested.
Peak torque was recorded for analysis.

Results
The tests are reliable and intraclass coefficient
correlation varied from 0.71 to 0.95. Invertors
generated higher peak torques than evertors (P
0:03) when injured ankles were tested at 120 deg/s.
Conclusions
Isokinetic inversion/eversion tests showed to be
reliable. A decrease in peak torques can be seen
during higher velocity tests. The only difference
between invertors and evertors was seen when
injured ankles were tested at 120 deg/s. In this case
invertors showed higher peak torques.

Methods
Twenty-eight male handball players participated in the tests using an
ankle isokinetic inversioneversion movement investigation dynamometer
system. Thirty-three ankle joints were uninjured, but 23 underwent
recurrent lateral ligament sprains.
The ankle muscles were tested at four angular velocity values: 30deg/s,
60deg/s, 90deg/s and 120deg/s. The foot range of movements (RoM) was
from 20 deg of eversion to 70 deg of inversion position.
The values of peak torque (in Nm), its angle and torque at different angles
of the ankle invertor and evertor movements were obtained from the best
repetition at each angular velocity.

Significant decrease of the evertor muscles peak torque values after recurrent
ankle lateral ligament sprain, while these values for the invertor muscles did
not differ significantly, except for the slowest movements.
The ratio of the ankles evertor/invertor muscle mean torque value after the
recurrent lateral ligament sprain is significantly lower than for the uninjured
joints in the inversion positions of the RoM at 50 and 60 deg, when the
evertor muscles are extended. The weakness of the extended evertors in the
inversion positions of the range of movements (supination) of the foot could
lead to the repeated injury of the ankle lateral ligaments.

Selected papers reporting studies that were prospective in design

Balance and Posture

Muscle strength is a potentially important factor
contributing to postural control. Most of the studies that
included strength testing, muscle weakness was a
consistent risk factor for falls in the elderly.
Studies that evaluated the values of muscle strength
training often showed a reduction in fall rates although it
was unclear whether strength training alone led to a fall
reduction.
Muscle weakness is an important risk factor for falls that is
potentially responsive to therapeutic intervention.

What is Balance?
The ability to maintain the center-of-gravity
of an object within its base-of-support.
When?

Standing (static)
Walking - running (dynamic)
Sitting
Lying
Lifting

What is Posture?
The stereotypical alignment of body/limb
segments
Types

Standing (static)
Walking - running (dynamic)
Sitting
Lying
Lifting

Base of Support
Static

Dynamic

x
TM-L

TM-R

H-H
x - Vertical projection of COG

Walking

Stability & Balance

Result of interaction of many variables
(see model)
Limits of Stability - distance in any
direction a subject can lean away from
mid-line without altering the BOS
Determinants:
Firmness of BOS
Strength and speed of muscular responses
Range: 80 anteriorly; 40 posteriorly

Limits of Stability

Model Components
Musculoskeletal System
ROM of joints
Strength/power
Sensation
Pain
Reflexive inhibition

Abnormal muscle
tone
Hypertonia
(spasticity)
Hypotonia

Strategies to Maintain/Restore
Balance

Ankle
Hip
Stepping
Suspensory

Strategies are automatic and occur 85 to

90 msec after the perception of instability
is realized

Ankle Strategy
Used when
perturbation is
Slow
Low amplitude

Contact surface
firm, wide and
longer than foot
Muscles recruited
distal-to-proximal
Head movements
in-phase with hips

Ankle Strategy

Hip Strategy
Used when
perturbation is fast
or large amplitude
Surface is unstable
or shorter than feet
Muscles recruited
proximal-to-distal
Head movement
out-of-phase with
hips

Hip Strategy

Association between ankle muscle strength and limit of stability in older adults
Age and Ageing 2009 38(1):119-123
Itshak Melzer1, Nissim Benjuya2, Jacob Kaplanski3 and Neil Alexander4
1 Physical Therapy Department, Faculty of Health Sciences Ben-Gurion University of the Negev, Beer-Sheva, Israel
2 Kaye College of Education, Department of Physical Education Beer-Sheva, Israel
3 Department of Clinical Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
4 Institute of Gerontology, University of Michigan, MI, USA

Loss of balance and falls in the elderly constitute a major

problem associated with human suffering as well as high costs
for society.
Falls might occur during various daily activities. Many of these
activities are constrained by limits of stability (LOS).
LOS can be described as the maximum distance a person can
intentionally displace his/her centre of gravity, and lean his/her
body in a given direction without losing balance, stepping or
grasping.

Ageing is associated with decreased LOS , muscle

strength and foot sensation .

The relationships between lower-limb muscle strength and

falls are unclear. Several studies show minimal or no
differences in strength between fallers and non-fallers .

The aims of this study are to investigate how two specific

tests of postural control, LOS and postural stability, relate
to ankle muscle strength and foot sensation in older adults.

Subjects
Forty-three participants (77.8 6.2 years) were recruited from
two protected retirement homes .
Participants had to be at least 65 years of age and ambulate
independently.
Individuals with neurological disorders were excluded.
All participants provided informed consent, in accordance with
approved procedures by the Helsinki ethical committee.

Testing protocol
Limits of stability
Participants stood upright on a force plate with their unshod
feet as close together as possible and arms at their sides. The
instructions were to keep the body rigid and lean forward,
backward, left and right as far as possible, maintain the full
plantar surface of the feet in contact with the force plate and
hold in each extreme position for 2 s.
The dependent LOS variables included the maximum
anteroposterior displacement of centre of pressure (CoP)
(AP-LOS, defined as anterior minus posterior CoP
displacement). To control for foot length, the functional
stability limits (FSLs) were calculated and computed as the
peak AP-LOS as a per cent of foot length. The LOS test in
older adult fallers is consistent and reliable . The average of
five trials was used in the analysis.

Postural stability (PS)

Participants stood upright on a force plate for 30 s as still
as possible, with their unshod feet as close as possible.
Dependent variables were the maximum CoP sway
distance in the medio-lateral direction (ML sway) and in
the anteriorposterior direction (AP sway), the average
velocity of CoP sway and the CoP sway area.
Given that two trials of PS are thought to be a reliable
estimate of PS, the average of two trials was used for the
analysis.

Ankle plantar (PF) and dorsiflexor (DF) strength

Maximum isometric PF and DF strength were measured in
semi-sitting position on a dynamometer chair (Biodex
System 2, Shirley, NY, USA) with the ankle in a neutral
position.
Participants held the contraction up to 3 s. The absolute
values (in Nm) and the average of three trials were used in
the analysis.

AP-LOS was significantly correlated with both DF (r = 0.3, P <

0.05) and PF strength (r = 0.55, P < 0.001).
FSLs were significantly correlated with only PF strength (r =
0.4, P < 0.01).
The relationship between PF strength and the anterior CoP
displacement was also highly significant (r = 0.65, P < 0.001),
while the correlation between DF strength and peak posterior
CoP displacement was borderline significant (r = 0.38, P =
0.09).
In males, the correlations between PF strength and AP-LOS
and FSLs were even higher (r = 0.69, P = 0.003 and r = 0.63, P
< 0.01, respectively). Ankle muscle strength and postural sway
measures were not significantly correlated. Postural sway was
not correlated with LOS or FSLs (Table 2).

Discussion

The present analyses show that PF strength is more strongly

associated with AP-LOS than DF strength but neither are
associated with PS. Perhaps the contribution of plantarflexors
is larger simply because the anterior lean distance (controlled
by PF) is larger than the posterior lean distance (controlled by
DF) within the LOS test. However, the correlation between DF
strength and posterior CoP displacement did not reach
significance, suggesting that PF strength may be more critical
to preventing falls during reaching or bending activities.
Regarding ankle range of motion, it is unlikely that LOS in the
present study was limited due to decreased ankle dorsiflexion
range of motion. In a previous study the extent of dorsiflexion
range of motion used in older adults when leaning forward
during the AP-LOS was 3.8. Mean dorsiflexion values for older
adults is much higher, ranging from 13.5 to 10.1 .

Reduced muscle strength may lead to a fall during a more

dynamic task, including reaching or bending movements, and
is a relatively less important contributor to quiet stance. Thus,
we suggest that balance training should incorporate exercises
that closely mimic extreme reaching tasks, thereby providing
the muscle activation and functional challenge to maintain
balance when nearing the LOS.
In conclusion, plantarflexors muscle strength plays a more
significant role in decreased AP-LOS in older adults may thus
help us to explain fall that occur during reaching tasks.

Training to avoid falls should consider

functional ankle strength training, reaching
tasks such as reaching and bending.