“Role of Timely Physical

Rehabilitation of ankle Sprain in

Sports injuries”

submitted by
abc
Student number: 110
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INSTITUTE OF HEALTH SCIENCES

FACULTY OF FOOD HEALTHSCIENCES &
TECHNOLOGY

2023
 TABLE OF CONTENTS

LIST OF TABLES......................................................................................v

LIST OF FIGURES....................................................................................v

1INTRODUCTION.....................................................................................1

1.1...................................................................................Purpose of the study

..................................................................................................................

1.2....................................................................................Context of the study

..................................................................................................................

1.3.......................................................................................Problemstatement
..............................................................................................................22

1.3.2........................................................................................Sub-problems
.

1.4............................................................................Significance of the study

..............................................................................................................23

1.5...........................................................................Delimitations of the study

..................................................................................................................

1.6.......................................................................................Definition of terms
..............................................................................................................23

1.7.................................................................................................Assumptions
..............................................................................................................25

2............................................................................................Literature review26

2.1...................................................................................................Introduction
..................................................................................................................

i
 2.2.........................................Definition of topic or background discussion.
...............................................................Error! Bookmark not defined.

2.3.....................................................First sub-problem discussion heading

...............................................................Error! Bookmark not defined.

2.3.1.......................................................................................Sub-heading 1
Error! Bookmark not defined.

2.3.2.......................................................................................Sub-heading 2
Error! Bookmark not defined.

2.3.3............Hypothesis 1 OR Proposition 1 OR Research Question 1

Error! Bookmark not defined.

2.4...............................................Second sub-problem discussion heading

...............................................................Error! Bookmark not defined.

2.4.1.......................................................................................Sub-heading 1
Error! Bookmark not defined.

2.4.2.......................................................................................Sub-heading 2
Error! Bookmark not defined.

2.4.3............Hypothesis 2 OR Proposition 2 OR Research Question 2

Error! Bookmark not defined.

2.5...............................................................Conclusion of Literature Review

...............................................................Error! Bookmark not defined.

2.5.1............................Hypothesis / Proposition / Research Question 1:

42

2.5.2............................Hypothesis / Proposition / Research Question 2:

42

3.....................................................................................Research methodology
.................................................................................................................43

ii
3.1..........................................................Research methodology / paradigm
..............................................................................................................43

3.2.........................................................................................Research Design
..............................................................................................................45

3.3...............................................................................Population and sample

..............................................................................................................46

3.3.1..............................................................................................Population
46

3.3.2............................................................Sample and sampling method

46

3.4............................................................................The research instrument

..............................................................................................................46

3.5....................................................................Procedure for data collection

..............................................................................................................47

3.6...............................................................Data analysis and interpretation

..............................................................................................................47

3.7...............................................................................Limitations of the study

..............................................................................................................47

3.8..................................................................................Validity and reliability

..............................................................................................................48

3.8.1.....................................................................................External validity
48

3.8.2......................................................................................Internal validity
48

3.8.3................................................................................................Reliability
49

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4.............................................................................................Research planning
.................................................................................................................50

4.1.....................................................................................................Time-table
..............................................................................................................50

4.2......................................................................................Consistency matrix
..............................................................................................................50

References..............................................................................................54

APPENDIX A...........................................................................................58

Actual Research Instrument.................................................................58

iv
 1 LIST OF TABLES

Table 1: List of respondents (if appropriate)..........Error! Bookmark not defined.

Table 2: Time-plan for completion of research report by xxxx.......................50

Table 3: Consistency matrix...............................................................................52

LIST OF FIGURES

Figure 1: Title of the Figure (reference)...............Error! Bookmark not defined.

v
1 CHAPTER

1.1 INTRODUCTION

The sprained ankle is the most common injury that causes pain. The statement of Watson-
Jones that, “it is worse to sprain an ankle pain than to break it” has foundation if every
sprain receives the same diagnosis and treatment.

Foot, composed of many bones, articulation and lot of muscles and ligaments, and is
mainly designed to provide stability and mobility. It is a key structure meant for walking,
jogging and jumping etc. the properties of foot to absorb undue shocks and to adopt
uneven surfaces make it a unique and vital organ of human body.

Ankle is an important joint of foot which plays a vital role in propelling the body forward.
A rather complicated anatomy and difficult understanding of its mechanics make it a
boring subject to study. Ankle and foot is continuously subjected to stress, shocks and
uneven surfaces, it is more prone to get injured. Ill fitting shoes over use and faulty sports
techniques make it more likely to become painful. A complete knowledge of its anatomy
and kinesiology is mandatory for the researcher to be able to assess, evaluate and diagnose
the problem properly.

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Ailing foot leaves not only functional impairments in an individual’s life especially in a
professional sportsman but also affects the economy of the country. Painful foot is greatly
detrimental to the quality and quantity of outcome of the sportsmen, therefore foot and
ankle should be given its due protocol and general public should be educated about foot
wears and its normal and abnormal mechanics which leads towards injuries. Sports
organizations should also be stressed to arrange physical rehabilitation therapist during the
sports sessions so that immediate consultation can reach the victims of injuries as it may
lead to longstanding functional impairment or disability.

Cathy Duddy, PT, DPT, MS, CSCS explains that an estimated one million patients per
year will sustain an acute ankle sprain. Eighty to ninety percent of ankle sprains are
inversion sprains, with damage involving the anterior Talo fibular ligament. Patients with
this type of lateral ankle sprain complain of pain, swelling and bruising of the lateral
malleolus and have difficulty with ambulation. Physical therapy intervention speeds the
recovery process and prevents reoccurring injuries. Ankle injuries are the most frequent
cause of physical rehabilitation therapist/physician evaluation in a sports-oriented
environment. The lateral ligaments are most commonly injured. With a detailed history,
physical and radiographic examination to avoid missing underlying pathology, the primary
care physician can diagnose and treat the majority of ankle injuries. Occasionally, stress

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radiographs, arthrograms, or magnetic resonance imaging (MRI) is needed. The vast
majority of ankle sprains can be treated with adhesive tape strapping or semi rigid
orthotics and non steroidal anti-inflammatory medication followed by rehabilitation. Key
points of rehabilitation are control of pain and swelling acutely with no steroidal anti-
inflammatory and RICE (rest, ice, compression, and elevation), then restoring normal
range of motion, strengthening muscle groups, and retraining proprioception of
the ankle joint.

1.2 Internal Structure of Ankle Joint

1.2.1 Ankle (Talocrural) joint

The joint is approximately uni axial. The lower end of the tibia and its medial malleolus,
with the lateral malleolus of the fibula and inferior transverse tibiofibular ligament, from a
deep recess for the body of the talus. Its line is judged by the anterior margin of the tibia's
end, which is palpable when the overlaying tendons are relaxed. Although it appears a
simple hinge, usually styled 'uni axial'. Its axis of rotation is dynamic, shifting during
dorsi- and plantar flexion.

Articular surfaces are covered by hyaline cartilage. The talar trochlear surface, convex
parasagitally, transversely gently concave, is wider in front; the distal tibial articular
surface is reciprocally curved. The talar articular surface for the medial malleolus is a
proximal area on the medical talar surface, being fairly flat, comma shaped and anteriorly
deeper. The larger lateral talar articular surface is triangular and vertically concave, that on
the lateral malleolus is reciprocally curved. Posteriorly the edge between the trochlear and
fibular articular surfaces of the talus is beveled to a narrow, flat triangular area articulating
with the inferior transverse tibiofibular ligament all surfaces are continuous. The bones are
connected by a fibrous capsule, medial (deltoid), anterior and posterior talofibular and
calcaneofibular ligaments.

1.2.2 Fibrous Capsule

Around the joint this is thin in front and behind, attached proximally to the borders of the
tibial and malleolar articular surfaces and distally to the talus near the margins of its
trochlear surface, except in front where it reaches the dorsum of the talar neck. It is

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strengthened by the strong collateral ligaments. Its posterior part is mainly of transverse
fibers. It blends with the inferior transverse ligament and is thickened laterally where it
reaches the fibular malleolar fossa. Synovial membrane Lining the capsule, it ascends as a
short vertical recess between the tibia and fibula.

1.2.3 Medial ligament (deltoid collateral)

This is a strong, triangular band, attached to the apex and the anterior and posterior
borders of the medial malleolus. Of its superficial fibers the anterior (tibio navicular) pass
forwards to the navicular tuberosity and behind this blend with the medial margin of the
plantar calcaneo navicular ligament; intermediate (tibio calcaneal) fibers descend almost
vertically to the whole length of the sustentaculum tali; posterior fibers (posterior
tibiotalar) pass postero laterally to the medial side of the talus and its medial tubercle. The
deep fibres (anterior tibio talar) pass from the tip of the medial malleolus to the non-
articular part of the medial talar surface. The ligament is crossed by the tendons of tibialis
posterior and flexor digitorum longus.

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1.2.4 Lateral Ligament

This comprises discrete parts. The interior talofibular ligament extends anteromedially
from the anterior margin of the fibular malleolus to the talus, attached in front of its lateral
articular facet and to the lateral aspects of its neck. The posterior talofibular ligament runs
almost horizontally from the distal part of the lateral malleolar fossa to the lateral tubercle
of the posterior talar process. A 'tibial slip' of fibres connects it to the medial mallcolus.
The calcaneofibular ligament, a long cord, runs from a depression anterior to the apex of
the fibular malleolus to a tubercle on the lateral calcaneal surface and is crossed by the
tendons of peroneous longus and brevis.

1.2.5 Relations

Anteriorly, from the medial side, are tibialis anterior, extensor hallucis longus, the anterior
tibial vessels, deep peroneal nerve, extensor digitorum longus and peroneus tertius;
posteriorly from the medial side, are tibialis posterior, flexor digitorum longus, the
posterior tibial vessels, tibial nerve, flexor hallucis longus; in the groove behind the lateral
malleolus are the tendons of peroneus longus and brevis.

1.2.6 Vessels and nerve supply to the joint

Arteries are from malleolar rami of the anterior tibial and peroneal arteries. Nerves are
from the deep peroneal and tibial nerves.

1.2.7 Movements

When the movement is upright and the foot at the right angles to the leg active movements
of the joint is dorsiflexion and plantar flexion, the former moving the dorsum of the foot
towards the anterior calf thereby decreasing the angle between the leg and foot, the latter
moving the dorsum away from the anterior calf. Dorsiflexion is the 'close-packed' position,
with maximal congruence and ligamentous tension; from this position all major thrusting
movements are exerted, in walking, running and jumping. The malleoli embrace the talus;
even in relaxation no appreciable lateral movement can occur without stretch of the
inferior tibiofibular syndesmosis and slight bending of the fibula. The superior talar
surface is broader in front, and in dorsiflexion the malleolar gap is increased by slide

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lateral rotation of the fibula by "give" at the inferior tibiofibular syndesmosis and gliding
at the superior tibiofibular joint. The medial (deltoid) ligament is very strong and is even
able to resist forces which tear the bone to which it is attached. Its middle part, with the
calcaneo fibular ligament, binds the leg firmly to the foot; resisting displacements in all
directions the posterior Talo fibular ligament assists the calcaneo fibular in resisting
posterior displacement, deepening the joint for the talus. The anterior talo fibular ligament
limits anterior displacement. Planter flexion is limited by the opposing muscles, the
interior fibers of the medial (deltoid) and the anterior talo fibular ligaments. Dorsiflexion
is limited by the tendo calcaneous and contraction of triceps surae, the posterior fibres of
the medial (deltoid) and the calcaneo fibular ligaments. Dorsi- and plantar flexion are
increased by inter tarsal movements, adding about ten degree to the former, 20 degree to
the latter.

1.2.8 Accessory Movements

Slight amount of side-to-side gliding, rotation, abduction and adduction are permitted,
when the foot is plantar flexed.

1.2.9 Muscles producing movements

Dorsiflexion

Tibialis anterior assisted by extensors diditorum longus and hallucis longus, and
peroneus tertius.

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 Plantarflexion

Gastrocnemius and soleus, assisted by plantaris, tibialis posterior, flexors hallucis

longus and digitorum longus.

In symmetrical standing the line of the body weight in anterior to the ankle joints, which
are not even near their closed- packed position. Stability requires continuous action by
soleus, increasing (often involving gastrocnemius) with learning forward and vice versa. If
backward sway takes the projection of the center gravity ('weight line') posterior to the
transverse axes of the ankle joints, the plantar flexors relax and dorsi flexors contract.

1.2.10 Neurology of Ankle

Common Peroneal nerve.

After it bifurcates from the sciatic nerve, it passes between the biceps femoris
tendon and lateral head of the gastrocnemius muscle and then comes laterally
around the fibular neck and passes through an opening in the peroneus longus
muscle. Pressure or force against the force in this region can cause a neuropathy
Sensory changes occur in the distal lateral surface of the leg and dorsum of the foot
(except the little toe); muscles affected may include the dorsiflexors of the ankle
and evertors of the foot (peroneus longus and brevis, tibialis anterior, extensor
digitorum longus and brevis, extensor hallucis longus, and peroneus tertius).

Posterior tibial nerve

This nerve occupies a groove behind the medial malleolus along with the tendons
of the tibialis posterior, flexor hallucis longus, and flexor digitorum longus
muscles; the groove is covered by a ligament, forming a tunnel. Entrapment
usually from a space occupying lesions is known as a tarsal tunnel syndrome.
Sensory innervation includes the plantar surface of the foot and toes and the
dorsum of the distal phalanges. Muscle affected include intrinsic muscles of the
foot (abductor hallucis, flexor hallucis brevis, lumbricals, interossei, and quadratus
plantae); weakness and postural changes in the foot (pes cavus and clawing of the
toes) may occur.

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1.2.11 Plantar and calcaneal nerves

These branches of the posterior tibial nerve may become entrapped as they turn under the
medical aspects of the foot and pass through openings in the abductor hallucis muscle.
Over pronation presses the nerves against these openings. Irritation of the nerves may
elicit symptoms similar to acute foot strain (tenderness at the postero medial plantar aspect
of the foot), painful heel (inflamed calcaneal nerve), and pain in a Pes cavus foot. The
degree of muscle weakness will depend on which of the branches is involved.

1.2.12 Myology of Ankle

Plantar flexion is primarily caused by the two-joint gastrocnemius muscle and the one-
joint soleus muscle; they attach to the calcaneus via the Achilles tendon. Other muscles
passing posteriorly to the axis of motion for plantar flexion contribute little to that motion,
but they do have other functions. Tibialis posterior is a strong supinator and invertor that
help to control reverse pronation during gait. Flexor halucis longus and flexor digitorum
longus flex the toes and help in support the medical longitudinal arch. To prevent clawing
of the toes (MTP exclusion with IP flexion), intrinsic muscles must also function at the
MTP joints. Peroneus longus and brevis primarily evert the foot, and the longus gives
support to the transverse and lateral longitudinal arches. Side flexion of the ankle is caused

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by the tibialis anterior muscle (which also averts the ankle), the extensor hallucis longus
and extensor digitorum longus muscles (which also extend the toes), and the peroneus
tertius.

1.2.13 Muscle control of the ankle during gait

The ankle dorsi flexors function during the initial foot contact and load response (heel
strike to foot flat) to counter the plantar flexion torque to control the lowering of the
foot to the ground. They also function in supporting the swing phase to keep the foot
from plantar flexing and dragging the ground. With loss of the dorsi flexors, foot slap
occurs at initial contact, and the hip and knee flex excessively during swing (or else
toe drags on the ground).

The ankle plantar flexors begin functioning near the end of mid-stance and during
terminal stance and pressing (heel-off to toe-off) to control the rate of forward
movement of tibia and also to plantar flex the ankle for push-off.

1.3.1 Functional Anatomy

Normally, an external torsion exists in the tibia, so that the ankle mortise faces
approximately 15 degrees outward. With dorsiflexion, the foot moves up an slightly
laterally; with plantar flexion, the foot moves down and medially. Dorsiflexion is the
closed-packed, stable of the talocrural joint. Plantar flexion is the loose-packed

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position. This joint is more vulnerable to injury when walking in high heels because of
less stable plantar flexed position.

In a closed-chain, weight-bearing foot, supination of the subtalar and transverse tarsal

joints with a pronation twist of the forefoot increases the arch of the foot and is the
closed-packed or stable position of the joints of the foot. This is the position of the foot
assumes when a rigid lever is needed for propelling the body forward during the push-
off phase of ambulation.

During weight bearing, pronation of the subtalar and transverse tarsal joints causes the
arch of the foot to lower, and there is a relative supination of the forefoot with
dorsiflexion of the 1st and plantar flexion of the 5th metatarsals. This is the loose-
packed or mobile position of the foot and is assumed when the foot absorbs the impact
of weight bearing and rotational forces of the rest of the lower extremity and when the
foot conforms to the ground.

In the weight-bearing foot, subtalar motion and tibial rotation are interdependent.
Supination of the subtalar joint results in or is caused by lateral rotation of the tibia
and, conversely, pronation of the subtalar joint results in or is caused by medial
rotation of the tibia.

The arches of the foot are visualized as a twisted Osteo ligamentous plate, with the
metatarsals heads being the horizontally placed anterior edge of the plate, and the
calcaneus being the vertically placed posterior edge. The twist causes the longitudinal
and transverse arches. When bearing weight, the plate tends to untwist and flatten the
arches slightly.

Primary support of the arches comes from the spring ligament, with additional support
from the long plantar ligament, the plantar oponeurosis, and short plantar ligament.
During push-off in gait, as the foot plantar flexes and supinates and the metatarsal
phalangeal joints go into extension, increased tension is placed on the plantar
oponeurosis, which helps increase the arch (windlass effect).

In the normal static foot, muscles do little to support the arches. They contribute to
support during ambulation.

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 A person with a varus deformity of the calacaneus (Observed non-weight bearing) may
compensate by standing with a pronated (or everted) calcaneus posture. Pesplanus,
pronated foot, and flat foot are terms often inter changed to mean a pronated posture of
the hind foot and decreased medial longitudinal arch. Pescavus and supinated foot
describe a high-arched foot.

1.4.1 ANKLE INJURIES RELATED TO SPORTS

In a simple, anatomic, zone-specific approach, this chapter outlines a core spectrum of

sports pathology; including acute and chronic conditions. Evaluation and rehabilitation of
common ankle sprains and stressed, as these injuries make up the majority of all
musculoskeletal sprains. A brief discussion of sprains affecting the ankle is given.

1.4.2 Acute Ankle Injuries

Anterior pain

Tibiofibular Ligament and Syndesmosis Sprain

This "high ankle sprain” results from forceful external rotation of the foot, causing the
talus to "wedge" the distal tibia and fibula apart. This causes a sprain of the anterior
tibiofibular ligament and possibly a tear of the syndesmosis. Physical examination reveals

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pain and swelling over the anterior tibiofibular ligament and proximally over the
introsseous membrane. Pain is exacerbated by dorsiflexion of the foot ("wedging"the
tibiofibular ligament and syndesmosis) and by externally rotating the foot. Squeezing the
proximal tibia and fibula lessens the pain (positive squeeze test). X-ray films should be
taken to rule out associated fracture and for evidence of widening the mortise. If there are
no fractures and the mortise is not widened, this injury is treated as a sprain but take
significantly longer to heal. If widening of the mortise is evident, a syndesmotic screw
should be placed to stabilize the joint.

Anterior Tibial Tendon Rupture

This unusual injury is caused by force plantar flexion of the foot and ankle, causing
overstretching or rupture of the anterior tibial tendon. The subsequent loss of power of this
tendon results in an unsteady gait (the most common complaint) with weakness of ankle
dorsiflexion ("drop foot"). Physical examination reveals swelling or a mass (pseudo
tumor) and a palpable defect of the normal anterior prominence of the tendon with resisted
ankle dorsiflexion. Loss of active dorsiflexion of the ankle occurs in complete injuries. X-
ray films of the foot may reveal a dorsal exostosis of the first metatarsal-medial cuneiform
joint (this spur or the edge of inferior retinaculum may contribute to the rupture). In the
active patient, the loss of function of this tendon is significant and needs appropriate
referral for surgical repair as soon as possible. Generally, the primary repair ("end-to-end"
repair) is possible if done within several weeks after injury. After this time, more
complicated surgical repair techniques may be necessary to restore function.

Capsular Avulsion

This injury is caused by a plantar flexion force. This force is generally associated with
other injury to the ankle, including lateral sprain or malleolar fracture. Physical
examination reveals tenderness and a fullness of the anterior aspect of the ankle. The
instability caused by anterior capsule avulsion may be seen on plantar flexion lateral x-ray
films showing anterior talar subluxation on the tibia. Arthrographic confirmation of the
acute injury is possible but unnecessary, since it is treated as an ankle sprain.

Lateral Pain

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Grade I Sprain

This injury is a partial tear of the anterior talofibular ligament or the calcaneofibular
ligament. It is caused by an inversion force with the foot in plantarflexion (anterior
telofibular ligament) or dorsiflexion (calcaneofibular ligament). The injury has a 0 to 1
+anterior drawer test on physical examination (or x-ray). There is minimal swelling and
localized tenderness over the anterior talofibular ligament or calcaneofibular ligament, or
both. On x-ray examination there is no fracture, and the talar tilt test, if performed, is
negative.

Grade II Sprain

This injury involves a partial or complete tear of the anterior Talo fibular ligament. It is
caused by marked inversion and plantar flexion stress to the ankle. This calcaneo fibular
ligament remains intact, unless a dorsiflexion inversion force was primarily involved. The
athlete may report the history of a "pop" and an inability to bear weight on the affected
ankle. Physical examination reveals marked swelling and diffuse tenderness over the
general area of these ligaments. There is a 2+ anterior drawer test. X-ray examination
reveals a negative talar tilt but positive anterior instability.

Grade III Sprain

This injury is caused by severe inversion forces usually causing the anterior Talo fibular
and then the calcaneo fibular ligaments to rupture completely (with increasing degrees of
injury, the posterior Talo fibular ligament, than the tibiofibular and finally the deltoid

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ligament, may rupture). There is a history of severe pain and inability to bear weight.
Physical examination reveals marked swelling and diffuse tenderness (careful
neurovascular assessment is important, as compartment syndrome can occur).There is a 3+
anterior drawer sign. On stress x-ray examination, there is a positive anterior drawer test
and a positive talar tilt test. Although a few authors advocate surgical repair in the
competitive athlete, most agree to initial management, with surgical reconstruction
reserved for those with persistent, symptomatic instability. Casting has not been shown to
prevent future instability. If the ligaments fail to heal with standard ankle rehabilitation, a
later reconstruction can be performed to improve functional stability.

Peroneus tendon Injury

This injury is caused by plantar flexion inversion and may not occur in association with a
ligament injury. Extreme plantar flexion of the foot on the ankle, coupled with inversion
against sudden contraction of the peroneal muscles, may cause the superior peroneal
retinaculum to tear or strip its perosteal attachment off the fibula the tendons may sustain a
partial or complete tear. Physical examination reveals swelling and tenderness over this
area, and the tendons may subluxate upon inversion. If inversion is not possible, xylocaine
injection can allow pain relief for a more complete examination. X-ray films may show a
shallow peroneal groove, a flake of bone along the lateral ride of the fibula, or a superior
position of peroneus (with a peroneus longus tear). Treatment of the acute subluxation is
controversial. A trial of conservative care is reasonable, including padded reduction of the
tendons and casting with the foot ten degrees plantar flexed and slightly inverted for 4 to 6
weeks, followed by ankle rehabilitation. Complete tears of the tendons require surgical
treatment, and the more competitive athlete probably needs referral for possible surgical
intervention for acute subluxation.

Subtalar Sprain

Subtalar sprain is caused by a mechanism similar to that causing inversion ankle sprain.
The calcaneo fibular ligament, then the cervical ligament, and then portions of the
interosseous talocalcaneal ligament may tear. Physical examination reveals lateral
swelling and the sensation of an increased rotary sliding of the talus on the calcaneous
with both anterior drawer and inversion stress testing (motion in this joint is complex and

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three-planar). Swelling may be slightly distal to the usual site in ankle sprains, although
the injury often occurs in conjunction with the ankle injury. Anterior drawer stress x-ray
examination reveals an increase of more than 5 mm in the distance of the anterior aspects
of the talus on the calcaneus. On Boroden's view with inversion stress, lack of parallelism
of the posterior talocacaneal joint surfaces may be seen. Initial treatment is similar to that
for the ankle sprain. Chronic instability may require surgical reconstruction.

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Other Causes

Actual lateral pain can also be caused by fractures of the fibula, lateral talar facet, and
Osteo chondral dome.

Posterior Pain

Posterior Talofibular Ligament Sprain

The posterior talo fibular ligament tears as a result of dorsiflexion and external rotation of
the foot on the ankle. This ligament rarely tears as an isolated entity but may tear as a last
of the three lateral ligaments in a severe sprain. It may accompany a high ankle sprain, as
it has the same failure mechanism as the anterior tibiofibular ligament. Other than the local
area of tenderness, few other distinguishing findings are clinically useful. Magnetic
Resonance Imaging (MRI) can confirm the injury but is rarely necessary. Treatment is
directed towards the accompanying injury.

Fracture of the Trigonal Process of the Talus

This fracture occurs secondary to forced planar flexion. A fracture line can sometimes
show a distinct sharp border versus a non fused ostrigonuim. Initially, treatment is
conservative, as some cases resolves spontaneously. Initial immobilization for several
weeks is helpful for either condition followed by tapping to prevent plantar flexion or the
use of a "cam walker" with a hinge that restricts plantar flexion. Surgical excision should
be considered for persistent symptoms.

Other causes

The acute onset of posterior swelling at the ankle can be caused by Achilles tendon injury,
flexor hallucis longus tear, or fracture of the posterior process of the talus. Achilles tendon
injury is caused by an overload on the tendon as it forcefully plantar flexes the foot. A
history of an audible "pop" can sometimes be obtained. There is local tenderness over the
tendon, swelling and a palpable defect. In complete ruptures the foot does not plantar flex
as the examiner squeezes the calf musculature by the patient is prone with the knee flex 90
degrees (Thompson's Squeeze Test). Acute tears of the achilles can be treated

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conservatively in a plantarflexion caused for 23 months if the ends can be shown to
approximate each other. Ultra sonography or limited MRI can confirm end to end
positioning of the tendon if non surgical treatment is chosen. Surgical treatment for this
tendon has the advantages of perhaps a lower late re rupture rate and improved function,
although it is associated with the usual risk of surgery. Treatment by closed or surgical
means is controversial and is probably best determined in consult with an orthopedic
surgeon. Early consultation is advised.

In flexor hallucis longus tears, the repititive stress are from a forceful toe-off on the great
toe (such as occurs in ballet) may lead to injury. For high demand athletes (for example,
dancers) a tear of the flexor hallucis longus require surgical repair to achieve maximum
function.

Medial Pain

Deltoid Pain

The deltoid ligament can be torn with an aversion injury at the ankle or external rotation of
the foot. Isolated injury (complete rupture) of the deltoid ligament is rare, so care must be
taken to look for an accompanying injury (i.e.; Talardome, Medial or lateral malleolar
fracture). Physical findings include local swelling and tenderness over the ligament. There
may be ecchymosis (even of the close by posterior tibial tendon sheath). The aversion
stress x-ray examination confirms a deltoid ligament tear, revealing widening of the
medial malleolus-talus borders by more than three mm. Sprains with the negative talar tilt
test can be treated as a lateral ankle sprain. Treatment for a tear is directed at opposing the
ruptured ligament ends and keeping them securely positioned during healing. To secure
end apposition of the deltoid ligament, the other ankle structures (the syndesmosis, tibial
plafond, and fibula) must be stable anatomically aligned. The very nature of the deltoid
ligament tear implies a combined injury to the ankle with potential to highly unstable;
therefore prompt orthopedic referral of these injuries is usually necessary.

1.5.1 Chronic Ankle Pain

Anterior Pain

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Bony Impingement Lesions

Lesions include anterior talar or anterior tibial spurs. These spurs are often associated with
difficulty in obtaining full dorsiflexion of the ankle (such as deep sweating or a three point
stance in football, the pile in ballet, or shortening the stride length in running). On
examination, these spurs have local prominence and deep tenderness, and they cause pain
on forced dorsiflexion of the foot. X-ray findings, on oblique and lateral views reflect a
loss of the normal anterior bevel (angle) of the tibia and the talas (60 degrees) and
demonstrate the spurs. If these lesions are symptomatic a half inch heel lift can be used
initially, but surgical treatments may be necessary for resistant cases.

Soft Tissue Impingement

This type of impingement has a vague interior pain and stiffness similar to impingements
caused by spurs. The discomfort is anterior and is increased with dorsiflexion of the foot
on the ankle. Some impingements are caused by an accessory fibrous thickening of the
inferior fascicle of the anterior tibiofibular ligaments, which abuts on the talus causing
local tenderness. Suspension of the interolateral impingement can be somewhat clinically
confirmed by pain relief following xylocaine injection this area. MRI scan may define the
lesions. Another type of impingement involves intra articular fibrous scar thickening
following ankle trauma, which extends over the antero lateral corner of the talus. Clinical
findings are similar to those for the types already described, with some complaints of
catching and stiffness. MRI may confirm the diagnosis. If physical therapy measures fail
to relieve symptoms, arthroscopic excisions may be indicated.

Anterior Tibial Tendinitis

Anterior tibial tendonitis often occurs in a dancer after returning from a layoff. There is
local tenderness over the tendon at the level of the inferior retinaculum or at the level of
the naviculo cuneiform joint. The condition usually responds to a program of rest, ice
massage 10 minutes every 2 hours, gentle strengthening and stretching, and NSAIDs.
Ultrasound or phonophoresis may also be useful.

Extensor Digitorum Longus Tendinitis

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Extensor digitorum longus tendinitis is similar to anterior tibial tendinitis, except for its
location.

Peroneal Neuropathy

Entrapments of the deep peroneal nerve at the ankle can be caused by nerve lesions at the
level of the anterior tarsal tunnel, at the superior extensor retinaculum, or at the investing
fascia of the ankle. There may be wasting of the extensor digitorum brevis, a positive
Tinel's at the suspected site of entrapment, or a sensory disturbance in the dorsal web
space of the great and second toes. Symptoms may increase with plantar flexion, and some
of these lesions may be associated with impingement spurs. Electromyography (EMG) and
relief with xylocaine injection can support the diagnosis. Surgery may be indicated if
avoidance of aggravating positions and steroid injection at the site of neuropathy do not
help. Superficial peroneal neuropathy can be caused by compression at the level of the
compartmental fascial perforation in the distal third of the lower leg. It is manifested by
paresthesias over the dorsum of the foot.

Lateral pain

Impingements

Ankle instability of the lateral ligaments can cause the talus to slip too far forward on the
tibia, causing impact on the tibia and subsequent antero lateral ankle pain. Anterior drawer
and inversion stress testing should be done to document any underlying instability.

Posttraumatic ligament thickening calcifications and the ossubfibulare can also cause
impingements. Plain films may show the lesions, and CT will confirm them. Location of
tenderness and selective use of xylocaine injections compliment the workup of these
conditions.

A trial of non operative treatment can include ankle rehabilitation exercises, NSAIDs,
ankle bracing, and local steroids injections. With persistent symptoms and associated
instability, surgical treatment may be necessary.

Sinus tarsi Syndrome

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This syndrome can occur from injury to the subtalar joint, causing swelling and tenderness
in the sinus tarsi. Pes Planus and pronation increase stress in the subtalar area and may
aggravate the pain. Tenderness may be improved with xylocaine injection into the sinus
tarsi. X-ray findings of subtalar instability are described below under subtalar instability.
Initial treatment includes correction of pronation with orthosis, NSAIDs, and possibly a
local steroid injection. Varied results are obtained with surgical excision of the sinus tarsi.
Posttraumatic subtalar instability may require surgical reconstruction. Deep peroneal nerve
compression by the tendons of the extensor digitorum longus and the extensor digitorum
hallucis brevis under the fascia may also cause pain in this area, and neurolysis may be
corrective.

Subtalar Instability

Subtalar instability may present as lateral ankle pain with symptoms similar to those of
ankle sprains, such as pain and giving way. Instability may be congenital or may follow
trauma. In the unstable congenital variety, many "minor" sprains may occur. The area of
swelling and tenderness is distal to that seen with an ankle sprain, and there may be
associated pain in the sinus tarsi. With inversion stress testing there may be a sense of
subtle sliding and rotational instability, with the talus subluxating from the calcaneus. A
stress Broden's view radiographs may show the bottom of the talus going out of parallel
with the top of the calcaneus. An inversion stress view of the ankle may show a similar
lack of a parallel relationship. The anterior drawer stress x-ray film shows more than 5
mm of slippage of the talus on the calcaneus. Ankle bracing and rehabilitation may help,
but persistent symptoms may require surgical stabilization.

Paroneus Sublaxation

Sublaxations of the peroneal tendons may be due to (1) an incompetent sheath allowing
subluxation out of the peroneal groove at the distal fibula (if the groove is too shallow), (2)
an incompetent superior peroneal retinaculum, or (3) a bony avulsion of the retinaculum
from the fibula. The subluxation of the tendons over the anterior border of the fibula
against resisted eversion is diagnostic. Elimination of pain with xylocaine injection at the
site is helpful in demonstrating peroneal tendon pathology as the source of pain.
Conservative management includes ice, NSAIDs, taping the peroneal tendons in a reduced

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position for sport, orthotics (in a pronated foot to decrease lateral stresses), and ankle
bracing. Referral for surgical treatment is indicated if symptomatic subluxation persists.

Peroneus Tendinitis

Tendinitis of the peroneal tendons without subluxation over the fibula can be seen in the
following: between the peroneal tendons within their sheath; in partial tears; in accessory
slips of tendons in which friction develops; in association with avulsion fractures of the
calcaneo fibular ligament; or in posttraumatic conditions that narrow the fibula calcaneal
space. Initial treatment is ice, NSAIDs, lateral heel wedge for calcaneal varus,
phonophoresis, ankle rehabilitation, and ankle bracing. In resistant cases, CT or MRI may
be considered in order to identify the aforementioned pathology.

The most common cause for a persistently painful ankle is incomplete healing after an
ankle sprain. When ankle is sprained the connecting tissues, (ligament) between the bones
is stretched or torn. Without thorough and complete rehabilitation, the ligament or
surrounding muscles may remain weak, resulting in recurrent instability. As a result
additional ankle injuries are experienced. The most common sprain occurs from the
inversion stress when foot is slightly plantar flexed and results in stretch of the lateral
collateral ligaments. The frequent injury, forceful inversion, causes most ligamentous
injury and only rarely involves bone.

Other causes of chronic ankle pain include a torn or inflamed tendon, Arthritis of ankle
joint, a faulty gait and sports techniques, joint instability and dislocation Deformities (knee
and foot), altered biomechanics due to ill fitting shoes, an injury to the nerves that pass
through the ankle, a break (fracture) in one of the bones that make up the ankle joint. The
development of scar tissue in the ankle after sprain takes up space in the joint, thus putting
pressure on the ligament. Some more other causes are tendinitis, Gout, tarsal tunnel
syndrome, Reiter's syndrome, shin splints, Ankylosing spondylitis, Degenerative joint
disease (DJD) and joint trauma etc.

1.6.1 MANAGEMENT

Management will depend on the final diagnosis and should be personalized to the
individual's needs.

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Conservative treatments may include anti-inflammatory medications to reduce the
swelling and pain, an ankle brace or other supports, an injection of steroid medication, in
case of fracture immobilization to allow the bone to heel.

Physical Rehabilitation

Physical Rehabilitation is one of the growing fields and a physical and sports rehabilitation
therapist can perform significantly to re activate an injured patient. Physical Rehabilitation
is essentially one of the healing sciences, which pertains to the assessment and evaluation
of musculoskeletal and neurological disorders of function including pain and those of
psychosomatic origin.

It also deals with treatment by natural sources based on movement manual therapy and
other physical agents to relieve pain, promote healing, prevent or ameliorate deformity,
improve function, body health, stimulate or rehabilitate development in a child or
rehabilitate those impaired by disease or trauma. The main aim of physical Rehabilitation
is to relieve the pain, improve Circulation, strengthen Muscles, correct the deformities,
Promote the healing, return the disabled person to an active life. Electro and actinotherapy
is used to reach the above mentioned goal which includes heat and light, electrical
stimulation, electric nerve stimulation, short wave diathermy, microwave diathermy, infra
red rays hydrotherapy, interferential therapy, ultrasound therapy, hot and cold therapy,
tractions and manual therapy to improve ROM which includes mobilization, manipulation,
stretching and strengthening.

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1.7Problem statement

Previous studies reveal that most sportsmen have sprained their ankle at
some time and understand the pain and disability this can cause. Physical
Rehabilitation can help decrease the healing time and improve the tissue
function post injury through various techniques which include ultrasound,
soft tissue manipulation, exercise rehabilitation at the same time ensuring
that the tissue is not permanently weakened leading to possible re-injury.

Many people run off soft tissue injuries believing that they will heal
themselves or they don’t seek medical attention regularly and then only
look for treatment four or five months after injury when it becomes chronic
and is regularly limiting their performance in sports. Although physical
Rehabilitation can help at this time, recovery time is much quicker if the
injury is dealt with in the acute state resulting early return of the sports
person to sports.

1.8 Significance of the study

Ankle sprain is a common problem of a sportsman’s life. There are so many causes of it in
which physical rehabilitation is the best way of getting relief.

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This topic is related to my field of study. I will get proper information, guidance, and keep
in touch with my supervisor and colleagues.

Although it is very common problem but a few people seek proper medical attention
which can get them back to work in a shorter span.

The main purpose of the research is to find out the most frequently occurring grade of
ankle sprain in sportsmen and to determine the importance of timely commencement of
physical rehabilitation therapy with relation to speedy recovery.

Moreover, this study will provide guidance to create awareness in the community to seek
regular physical rehabilitation therapy for early cure and to know how many people are
satisfied with the current rehabilitation protocol practiced by sports rehabilitation
therapists.

1.1 Definition of terms

Age

Age is a very important factor which can play significant role in the incidence of a
disease. Most of the musculoskeletal diseases are age related and are common
in a specific age group.

Gender

There are many disorders of human body which are sex oriented in term of
activity and environmental factors. Most of the Injuries and diseases are common
in any particular sex which makes this variable an important one.

Grades of ankle sprain

Due to difference in the activity of sports played by a sportsman and of certain

environmental factors any one of three grades of ankle sprain can be frequently

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occurring in the sports person, as many outdoor sports are more demanding in
term of physical activity.

Timely Physical Rehabilitation

Physical rehabilitation aims to enhance and restore functional abilities and

qualities of life to those with physical impairments or disabilities and injuries by
using electro and actinotherapy equipment and manual therapy techniques if the
treatment is started earlier and regularly then fruitful results can be obtained

Sportsmen with ankle sprain

A sportsman can be anyone playing a game or involved in outdoor activity and

gets his ankle twisted by faulty position leading towards an injury to the ligaments
around ankle joint.

Speedy Recovery of Ankle Sprain

Speedy Recovery of ankle sprain can be defined as how early a sportsman with
ankle sprain gets back to his normal life after getting physical rehabilitation
therapy. However it depends on the grade of ankle sprain the sportsman is
suffering from.

1.2 Assumptions

There can be an association between physical rehabilitation and sportsmen with ankle
sprain. Sportsmen managed by physical rehabilitation therapist may get back to their
sports earlier than those who were not managed by physical rehabilitation therapist. In
majority of the cases sportsmen only get little injury to their ankle which if treated on time
may leads early toward sports. Male athletes likely to be more affected with young age as
in old age we can only find few sportsmen who also involve in less active games like golf.
It can be useful in epidemiological perspective to make new policies at government level
to increase the number of physical rehabilitation therapists so that the stay of patients in
the hospital can be shortened and they can get back to work earlier which can give positive

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effects on country economy. Lastly to create awareness about physical rehabilitation
therapy this study can play a significant role.

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2 CHAPTER:

LITERATURE REVIEW

2.1.1Introduction

Garrick was one of the first to identify the lateral ligaments of the ankle as the most
commonly injured structures in athletes, and subsequent reports support this finding. As a
result, retrospective and prospective studies have been performed to focus on the risk
factors for lower extremity injuries and ankle-ligament sprains. In this review, we made an
important distinction between retrospective and prospective studies. Only prospective
studies can control the multiple variables that are difficult to reliably obtain and evaluate
in a population of athletes at risk for suffering an ankle injury. For example, exposure data
can only be documented through a prospective investigation, while variables such as
baseline ankle laxity cannot be measured after the injury has occurred. There were too few
well-designed studies available in the literature to perform a systematic review and,
therefore, the purpose of our paper was to review prospective investigations of ankle-
ligament-injury risk factors. We did not include studies of lower extremity injuries as a
group, nor did we include retrospective studies. Our study was organized according to
intrinsic (those from within the body) and extrinsic (those from outside the body) risk
factors based on the classification system introduced by Williams. This review is
important because the risk factors that predispose an athlete to ankle-ligament trauma
should be understood before an intervention study designed to reduce the incidence of
these debilitating injuries is implemented.

2.1.2 Intrinsic Factors

The intrinsic risk factors for sprains of the lateral ankle ligaments investigated through
prospective studies include the following: previous sprain; sex; height and weight; limb
dominance; anatomic foot type and foot size; generalized joint laxity; anatomic alignment,
ankle-joint laxity, and range of motion of the ankle-foot complex; muscle strength; muscle
reaction time; and postural sway.

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Perhaps the most frequently studied risk factor for lateral ankle-ligament sprains is a
previous sprain of this complex. This is based on the fact that disruption of a ligament
compromises an important biomechanical stabilizer and creates partial deafferentation of
the ankle. The literature is divided with regard to whether or not a previous sprain has an
influence on the risk for a future sprain. One of the original prospective risk-factor studies
is the work of Ekstrand and Gillquist, who enrolled 124 soccer athletes, examined each
player at the beginning of the year, and then followed them for 1 year while documenting
exposure to practices and games. They reported an increased risk for lateral ankle-
ligament injury in athletes who had suffered a prior ankle-ligament sprain. Subsequent
studies of soccer and basketball athletes and military recruits undergoing basic training
found that they were at increased risk for lateral ankle-ligament injury after suffering a
prior ankle injury. In contrast, studies of athletes participating in similar sports have
revealed no increased risk for lateral ankle-ligament injury after suffering a prior ankle
injury. One explanation for the divergent findings may be that the condition of the joint
after injury not only depends on the index injury and the associated damage to the
ligaments, muscles, and deafferentation of the joint but also on what type of rehabilitation
was administered, whether or not the subject complied with the rehabilitation program,
and the quality of recovery that was achieved.

The incidence of knee injuries, particularly disruption of the anterior cruciate ligament, is
considerably greater for female athletes in comparison with male athletes; in contrast, the
disparity of ankle-ligament sprains between the sexes appears to be much smaller. Hosea
et al performed a comprehensive, prospective study on high school and collegiate
basketball players. Female athletes were at 25% increased risk of suffering a grade I ankle
sprain compared with male athletes; however, the relative risk between the sexes for the
more serious grade II and III sprains, ankle fractures, and syndesmotic sprains was not
significantly different. In addition, for both male and female athletes, the relative risk of
suffering an ankle sprain doubled as the level of competition increased from high school to
the collegiate level. This interesting finding is in contrast to anterior cruciate ligament
tears, which increase substantially with increasing levels of competition for female
athletes but not for males. Our group has recently completed a prospective study of
Division I collegiate athletes who participated in soccer, lacrosse, or field hockey. Before
the athletic season started, subjects without a history of lower extremity trauma were

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identified and suspected ankle-injury risk factors were measured. During the season,
subjects were continuously monitored and all ankle-ligament injuries were evaluated and
graded by the same investigator. Men and women differed substantially in terms of many
of the preseason risk factors (eg, height, weight, isokinetic strength, muscle-reaction time,
and range of motion of the foot and ankle), and this led us to analyze the risk factor data
separately for each sex. The number of ankle injuries per 1000 person-days of exposure to
sport was 1.6 for men and 2.2 for women, rates that were not significantly different.

Height and weight have been implicated as risk factors: when an athlete is in an at-risk
position for inversion ankle trauma, an increase in either height or weight proportionally
increases the magnitude of inversion torque that must be resisted by the ligaments and
muscles that span the ankle complex. The investigation of collegiate athletes by our
group demonstrated that height and weight were not independent risk factors for ankle
sprains. Similar findings were reported by Sitler et al. In contrast, Watson found that male
soccer athletes who sustained ankle sprains had greater height than those who did not.
Milgrom et al reported that during basic training, male military recruits who were taller
and heavier were at increased risk of suffering an ankle injury.

Limb dominance has been implicated as a risk factor for lower extremity trauma because
most athletes place a greater demand on their dominant limb. Therefore, they produce
increased frequency and magnitude of moments about the knee and ankle, particularly
during high-demand activities that place the ankle and knee at risk. The literature is
divided with regard to limb dominance as a risk factor for suffering an ankle-ligament
sprain. In our investigation, limb dominance was unrelated to risk of ankle injury for male
and female athletes participating in soccer and lacrosse and female athletes participating in
field hockey. Similarly, Surve et al found that soccer athletes reported no difference in the
incidence of ankle injuries between dominant and non dominant ankles. In contrast,
Ekstrand and Gillquist noted that the dominant leg sustained significantly more ankle
injuries in male soccer players, with 92% of ankle injuries affecting the dominant leg.
These contrasting findings may have been the result of different study designs or the
methods used for data analysis.

Anatomic foot type (pronated, supinated, or neutral) does not appear to be a risk factor for
ankle sprains; however, the classification system that characterizes anatomic foot type as

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pronated, supinated, or neutral may be inadequate for identifying abnormalities in foot
biomechanics. This approach has not been related to musculoskeletal abnormalities, it
lacks the specificity and sensitivity to identify abnormalities in foot biomechanics, and it is
evaluated while a subject is standing barefoot and not during a situation when the lower
extremity is at risk for injury. Therefore, specific and sensitive measurements of foot-
contact mechanics that can be used during dynamic, at-risk activity need to be developed
and used to determine if they are capable of identifying an ankle at risk for an inversion
sprain. Kaufman et al were the first to use such an approach. Dynamic measurements of
arch contact in Navy Sea, Air, and Land trainees were collected while they walked
barefoot and in military footwear. Dynamic Pes Planus, Pes cavus, and increased hind foot
inversion were risk factors that predisposed trainees to lower extremity overuse injury.
Similar studies of ankle- and knee-ligament injuries are needed in athletes who take part in
high-risk sports.

Milgrom et al showed that increased foot width is associated with an increased risk of
suffering a sprain of the lateral ankle ligaments. This finding can be explained, at least in
part, by the fact that during an inversion injury, an increased foot width is associated with
an increased moment arm and corresponding inversion moment in comparison with a
narrow foot.

Generalized joint laxity has no predictive value for ankle sprains when considering all
athletes as a group and men and women as separate groups. To most professionals
involved with the diagnosis and treatment of ankle injuries, increased joint laxity is
considered a “sure bet” risk factor for an ankle injury because it indicates that a soft tissue
restraint and its contribution to stability and neural intervention of the ankle complex may
have been compromised. However, the literature presents conflicting findings. Barrett et
al demonstrated that ankle laxity, measured with the standard anterior drawer and talar tilt
clinical examinations, did not predict ankle sprains. In our initial work on this
subject, measurement of ankle laxity with the anterior drawer test showed a trend in which
increased laxity was associated with an increased risk of ankle injury, while the talar tilt
test was not associated with injury. In our most recent study of collegiate athletes, the
same trend was observed among women, and increased talar tilt was associated with
increased risk of injury among men. This finding is supported by the earlier work of Glick
et al, who reported a higher incidence of lateral ankle-ligament sprains in American

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football athletes with an excessive talar tilt (defined as greater than 5°) in comparison with
those whose talar tilt was less than 5°. Likewise, Chomiak et al reported a higher
incidence of noncontact ankle sprains among soccer players with an excessive anterior
drawer and talar tilt. The discrepancy among these previous studies may derive from the
use of the clinical examination and a grading system to evaluate joint laxity, which are not
sensitive means of evaluating joint laxity, or from an inadequate sample size, which may
not have included a sufficient number of subjects with increased ankle laxity.

Our recent study of collegiate soccer, lacrosse, and field hockey athletes revealed that
ankle injuries were more common among women with increased tibial varum and
calcaneal eversion range of motion, while no such relationship was found for men. Thus,
alignment of the hind foot in combination with the lower extremity is important when
evaluating risk factors for inversion injury of the ankle.

Ankle dorsiflexion and plantar-flexion range of motion does not appear to be related to the
risk of suffering an ankle sprain among collegiate soccer, lacrosse, and field hockey
athletes. Ankle range of motion is also not associated with injury in ballet and modern
dancers. Although most would consider it intuitive that lower extremity strength is related
to the risk of suffering an ankle-ligament sprain, only our group has investigated this with
a prospective study design, and the findings from these studies differ. In our earlier study
of collegiate athletes participating in soccer, lacrosse, and field hockey, ankle sprains were
associated with higher ratios between ankle inversion and eversion peak torques, higher
peak torques produced by plantar flexion, and a lower ratio between dorsiflexion and
plantar-flexion peak torques. In contrast, our recent study of the same level of athletes
participating in the same sports did not reveal differences in peak-torque values between
injured and uninjured athletes for dorsiflexion, plantar-flexion, inversion, and eversion
motions. In addition, the ratios between ankle eversion and inversion peak torques and
between dorsiflexion and plantar-flexion peak-torque values were not related to the risk of
suffering an ankle sprain. The differences between these studies may be explained by the
differences in the methods that were used to analyze the data. In the initial study, women
and men were analyzed as a group, while in the most recent study; women and men were
considered separately. This is important because peak torque is sex dependent, as are other
risk factors, and the analysis used combined data from men and women. Even risk factors
having similar effects in men and women may not be detected in analysis of combined

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data if high values for women correspond with low values for men. Conversely, variables
whose values differ greatly between the sexes may falsely appear to have an effect on risk
if women are inherently at higher risk. In addition, in the initial study, we did not
document exposure data and used the Student t test to analyze the data without adjustment
for different sports, which may have been associated with different baseline risk values. In
the recent investigation, we evaluated exposure data and performed data analysis using the
Cox regression model to take into account both time at risk for injury and differences in
risk associated with different sports.

Although previous studies have measured the peak torque developed during isokinetic
dorsiflexion-plantar-flexion and inversion-eversion motions, it is unclear how to interpret
these outcomes because most ankle injuries occur within a time interval that is much faster
than that required to develop peak torque and at much higher velocities that those used to
measure peak torque. From this perspective, both the force and temporal response of the
muscles that span the ankle are important to consider. Therefore, in our most recent
study of ankle-ligament injury risk factors, muscle-reaction time, or the time lag between
joint perturbation and muscle activation (sometimes called the closed-loop efferent reflex
response), was measured for dorsiflexion and inversion motions of the foot. Muscle-
reaction times for both modes of perturbation were not predictive of injury in men;
however, an interesting trend occurred in women. Compared with uninjured female
athletes, the gastrocnemius muscle of female athletes with ankle sprains required less time
to react, while the anterior tibialis muscle required more time to react in response to
dorsiflexion perturbation. This combination introduces the hypothesis that the protective
effect of the leg muscles on maintaining joint stiffness and stability through co contraction
may be compromised and suggests that a neuromuscular deficit may exist in those athletes
who are injured.

Recognizing that an athlete's centre of gravity changes during upright posture and that this
is under control of both the central and peripheral nervous systems, Tropp et al used a
force plate to characterize the change in an athlete's centre of gravity (eg, postural sway)
and related it to the risk of suffering an ankle injury. Postural sway was measured during
the preseason in soccer players who were then followed for a complete season. An
elevated postural-sway value identified an athlete at increased risk of suffering an ankle
sprain. Watson characterized postural sway with a practical approach that involved

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measurement of the duration of time a subject could maintain a single-leg stance without
touching down to recover balance. Those who could maintain a single-leg stance for at
least 15 seconds were considered to have normal posture, while those who touched down
to regain balance within the 15-second test were considered to have abnormal posture.
Ankle sprains affected more subjects with abnormal posture than with normal posture.
Similarly, McGuine et al used the NeuroCom Balance Master (NeuroCom International
Inc, Clackamas, OR) to measure postural sway among a cohort of high school basketball
players and demonstrated that subjects with increased sway scores suffered a 7-fold
increase in ankle sprains compared with those with normal sway. We also used the
NeuroCom system to measure postural sway, but we studied collegiate soccer, lacrosse,
and field hockey players who had not suffered prior injury to their lower extremities. We
did not find a relationship between sway score and risk of ankle sprain.

2.1.3 Extrinsic Factors

Extrinsic risk factors that have been investigated through prospective studies include
bracing and taping, shoe type, and the duration and intensity of competition and player
position. Review of the prospective studies of the effect of bracing on reduction in ankle
sprains revealed a consistent finding: athletes with a history of ankle sprains who use a
brace or tape experienced a lower incidence of ankle sprains. Tropp et al were the first to
investigate the effect of a brace on soccer players. Three groups of athletes, each with a
history of ankle sprain, were studied. The first group received no intervention. The second
used a brace, and the third performed ankle-disk training throughout their season. Athletes
who wore a brace or underwent ankle-disk training experienced a significant decrease in
the incidence of ankle sprains in comparison with the control group. The protective
mechanisms of the 2 interventions were thought to be different: the brace was
hypothesized to provide mechanical support, while the protection imparted by disk
training was attributed to a decrease in the functional instability of the ankle. Using a
prospective study design, Surve et al also studied the effect of braces on the incidence of
ankle-ligament injury among soccer players. Athletes were divided into 2 groups: those
with no prior ankle sprain and those with a history of ankle sprain. Subjects in each group
were then randomly assigned to the semi rigid brace or unbraced group. Those with prior
ankle sprains who used the brace had a reduced incidence of ankle sprains, but there was
no difference in the severity of ankle sprains with or without the use of the brace. These

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observations led the investigators to suggest that the protection provided by a brace was
not accomplished through mechanical support of the joint but through an improvement in
proprioception. Using a similar study design, Sitler et al performed the most
comprehensive prospective study of the effect of bracing on reducing ankle sprains among
collegiate basketball athletes. Athletes were divided into groups according to the presence
or absence of previous ankle sprains and were then randomly assigned to a group that
wore a brace or a group that received no brace or tape. All athletes wore the same high-top
basketball shoes, which provided an important control of this ankle-support variable. The
incidence of ankle sprains was lower in athletes with a history of ankle sprains who wore a
brace, but there was no difference in the severity of ankle sprains between the groups.
McKay et al5 also studied basketball players and reported that using ankle tape for support
decreased the risk of reinjury in athletes with a history of ankle-ligament sprains.

Another extrinsic risk factor that has undergone investigation is shoe type. One of the first
studies revealed that the incidence and severity of knee and ankle injuries in high school
football players were reduced when the length of the shoe cleats was reduced. In contrast,
2 prospective studies have shown no correlation between shoe type and ankle sprains for
military trainees and basketball players. Milgrom et al performed a well-controlled study
that followed male military trainees during basic training. Half of the trainees used three-
quarter-height basketball shoes (approximately 11 cm high) to train, while the other half
used lightweight infantry boots (approximately 22 cm high). The incidence of ankle
sprains between the trainees using the basketball shoes and those using the infantry boots
was no different. Barrett et al also performed a well-controlled study of basketball players
who were randomly assigned to groups wearing low-top shoes, high-top shoes, or high-top
shoes with an inflatable air chamber. No difference in the incidence of ankle sprains
among the shoe types was noted. Although this study was well controlled, the authors
stated that the low number of ankle sprains limited their findings. This is a concern
because shoe type might have been shown to reduce the incidence of ankle injury if a
larger sample size had been used. In the McKay et al study of basketball players, athletes
who wore shoes with air cells in the heel-cup portion were at significantly greater risk of
injuring the ankle than those who wore shoes without air cells. Although most would agree
that current athletic shoes offer limited support to an ankle in response to inversion
trauma, it is important to recognize that specific characteristics of the shoe may either

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reduce the risk of injury (eg, certain design characteristics may provide increased
proprioceptive input) or increase the risk of injury (eg, restricted ankle range of motion,
abnormal foot-shoe and shoe-surface traction, or increased inversion moment arm about
the ankle complex). We did not find information about the effect of different
characteristics of athletic shoes on the risk of ankle injury. Although several prospective
studies have recorded exposure data, only Ekstrand et al and Arnason et al have separated
their data by practices and games. Ekstrand et al found that twice as many injuries
occurred in soccer games as in practice, and there was no difference in risk of ankle injury
among player positions. Arnason et al reported 4.4 ankle sprains per 1000 hours of
participation in soccer games and only 0.1 sprains per 1000 hours of practice. Similar to
Ekstrand et al, Sitler et al noted no difference in risk of ankle injury among basketball
player position. Most professionals involved in the care of athletes would agree that
prevention of injury is important. However, when one considers the most common injury
experienced in sport, ankle-ligament sprains, a dilemma arises because there is very little
consensus in the literature with regard to the risk factors for ankle injury derived from
well-controlled, prospective investigations. Our review of the available prospective studies
found some consensus: (1) sex does not appear to be a risk factor for suffering an ankle
sprain, (2) the use of a brace is effective for reducing the risk of reinjuring the ankle, and
(3) foot type (classified as supinated, neutral, or pronated) and generalized joint laxity are
not ankle-injury risk factors. At this point, there is little consensus in the literature with
regard to whether or not height, weight, limb dominance, ankle-joint laxity, anatomical
alignment, muscle strength, muscle-reaction time, and postural sway are risk factors for
ankle sprains.

Most proposed risk factors for lateral ankle sprains remain controversial and require
further investigation. For example, our prior work on this subject revealed differences in
many of the intrinsic factors between male and female athletes. This led us to perform
separate analyses for each sex; however, very few researchers have taken this approach,
and most studies have focused only on male athletes. Many epidemiological studies have
been performed in soccer but none of them investigated the incidence of injury in
association with the utilization of clinical and rehabilitation services of the medical team.
This study aims was to examine such correlation in a National football team during the
recent 2010 World Cup. All injuries occurred to the Algerian National Team players

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during the pre competition stage and the World Cup were recorded, together with the
exposure. Moreover, duration and frequency of each consultation performed by doctors,
physiotherapists, masseurs and pitch rehabilitator was recorded.

Incidence of injuries was 7.54 per 1000h exposure and six players were injured at the
beginning of the stage but all players were available for official matches. Difference in the
duration of rehabilitation sessions on the field was present among the players who joined
the camp already injured and the players who were not injured at the commencement of
the camp (8.83±10.63 vs. 2.00±4.46 hours, P<0.05) while there was no difference in
rehabilitation between players that occurred in an injury during after the beginning of the
camp and uninjured players. To examine the effect of six weeks of strength and
proprioception training on eversion to inversion isokinetic strength ratios in subject with
unilateral functional ankle instability study was done. 38 subjects were randomly assigned
to one of four treatment groups’ strength training proprioception training strength and
proprioception training control. There was found no significant difference in average
torque and peak torque E/I ratios of the functionally unstable ankle for any of the groups
after training compared with before which was concluded as six weeks of strength and
proprioception training alone or combined had no effect on isokinetic measures of strength
in subjects with self reported unilateral functional instability which created a room for
further studies to be carried out on this. The purpose of study was to examine a young
athletic population to update the data regarding epidemiology and disability associated
with ankle injuries. At the United States Military Academy, all cadets presenting with
ankle injuries during a 2-month period were included in this prospective observational
study. The initial evaluation included an extensive questionnaire, physical examination,
and radiographs. Ankle sprain treatment included a supervised rehabilitation program.
Subjects were re evaluated at 6 weeks and 6 months with subjective assessment, physical
examination, and functional testing. The mean age for all subjects was 20 years (range,
17–24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There
were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately
medial injuries, 76 were lateral, and 16 were Syndesmosis sprains. Ninety-five percent had
returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of
function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral
hop test when compared with the uninjured side. At 6 months, all subjects had returned to

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full activity; however, 40% reported residual symptoms and 2.5% had a decrement of
>20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of
chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the
grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a
Syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in
collision sports. This study demonstrates that even though our knowledge and
understanding of ankle sprains and rehabilitation of these injuries have progressed in the
last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early
return to sports occurs after almost every ankle sprain; however, dysfunction persists in
40% of patients for as long as 6 months after injury. Syndesmosis sprains are more
common than previously thought, and this confirms that Syndesmosis sprains are
associated with prolonged disability

This is a timely and interesting study by van Rijn and colleagues, in which they
investigated recovery from lateral ankle sprain. Re-injury is common after ankle sprain,
and recovery often is incomplete. But what exactly does recovery mean for individuals
who have sustained a lateral ankle sprain, and how can this recovery best be measured?
These are the fundamental questions addressed in this article. There are good reasons to
investigate these questions. One reason is that the recovery is fundamentally relevant to
both patients and clinicians alike. Understanding recovery from the patient's perspective
can assist clinicians in tailoring treatment appropriately to optimize recovery. Another
reason is that a measure of recovery that is meaningful to patients aligns with the current
paradigm of patient-centred health care. A third reason is that this knowledge will enable
development of a standardized measure of recovery for use in clinical trials.
Currently, there exists a great disparity in how recovery from ankle sprain is measured.
Approaches include using pain or function scores as a proxy for recovery, reports of
“giving way” of the ankle, or the patient's perception of overall recovery. One obvious
problem with the heterogeneity of these outcome measures is that the same construct
clearly is not being measured. The consequence of this problem is high variability in
reported outcomes, which confounds meaningful interpretation of the literature. A parallel
situation exists in the field of low back pain. In a systematic review of all clinical trials in
the past 10 years that measured recovery from back pain as an outcome, it was found that
66 different measures had been used by researchers. Given the relevance of recovery as an

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outcome, there is a need to develop a measure that is meaningful to patients and that can
be standardized for use in clinical trials so that the literature can be more readily
compared. In this study, van Rijn and colleague’s analyzed data attained from a
randomized controlled trial to investigate treatment efficacy for acute lateral ankle sprain.
The authors sought explanatory variables for self-reported recovery by analyzing the
extent to which different outcomes were associated with recovery and how baseline scores
of different variables influence this association in patients after acute lateral ankle sprain.
The variables investigated were outcomes assessed by questionnaires for the clinical trial.
These measures included self-reported pain intensity (at rest, while walking, and while
running) and giving way of the ankle (while walking), both measured on an 11-point
visual analogue scale, and an ankle function score consisting of 5 categories (pain,
instability, weight bearing, swelling, and gait pattern), scored from 0 to 100 points.

Significant associations were found between patients' self-reported recovery and pain
during activities requiring high loads to the ankle: running (at 4 weeks, 8 weeks, and 3
months) and giving way of the ankle while walking on a rough surface (at 8 weeks and 3
months). Intuitively, it makes sense that, of the variables analyzed, pain during tasks that
involve greater forces to the ankle would be more strongly associated with patients'
perceived recovery compared with low-load activities such as walking on a flat surface, as
found in this study. Baseline scores were found to contribute less to patient-reported
recovery.

These findings provide a useful advancement in the development of a measure of recovery

from ankle sprain by identifying some functional outcomes that correlate with patient-
perceived recovery. However, it is possible that there are dimensions of recovery relevant
to patients other than the functional variables explored in this study. For this reason,
further research will be useful before these outcome measures can be established as “best
practice” to evaluate recovery from acute lateral ankle sprain. As van Rijn and colleagues
acknowledge, further insight into the underlying meaning of recovery in this population is
particularly needed. One approach to investigate this question further would be to conduct
interviews with individuals who have sustained an acute ankle sprain in order to establish
the determinants of recovery from the patients' perspective. This information would enable
the development of a definition or concept of recovery that is truly patient-centred.

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Optimal measures of recovery from ankle sprain can subsequently be considered after this
step. Depending on the domains identified, candidate instruments include the self-reported
pain intensity scales during running, or giving way of the ankle while walking on a rough
surface, used in the study by van Rijn and colleagues. Another potential instrument is the
Cumberland Ankle Instability Tool, a 9-item scale that is a simple, valid, and reliable tool
to assess the severity of functional ankle instability.

It was interesting to see that that no associations between recovery and mean differences
in the outcomes were found at the 12-month follow-up in this study. There are a number of
possible explanations for this finding that the authors explore, including recall bias, the
impact of recurrent sprains, and adaptations or adjustments to manage living with the
condition over the long term. Recall bias may well affect retrospective evaluation over this
period of time. Recurrent episodes within the first 3 months of injury did not affect
perceived recovery at 12 months, but it is possible that re-sprains after that period would
affect this recovery.

Adaptations to living with other chronic musculoskeletal conditions have been described
for work-related upper-limb disorders and low back pain. For those with chronic low back
pain, the absence of symptoms is not always a clear indicator of recovery. For example,
some patients with zero pain (on 11-point numerical rating scales) consider themselves
unrecovered because they need to “manage the potential for pain” or “be careful” to avoid
recurrence of the condition. Patients achieve this aim by using adaptive strategies to
reduce the risk of recurrence or to adapt to living with back pain to achieve acceptable
levels of function and quality of life. Similar adaptive strategies and readjustments to
accommodate living with persistent symptoms have been described for people with upper-
limb pain where “being better” involved redefining the meaning of self and
accommodating pain as part of patients' lives.

Therefore, it might be reasoned that recovery from lateral ankle sprain may similarly be
indicated not only by changes in the state of the disorder but also by readjustments to
working around the disorder or adaptations to live with the disorder. Qualitative research
will be useful to explore this question and to identify a “pool” of relevant domains to
assess recovery in this population.

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This approach can be intrinsically valuable to better understand recovery from the patients'
perspective and to develop outcome measures to evaluate recovery that are relevant to this
patient group. However, the value of using a single-item instrument of global recovery
also should be considered, possibly as a supplemental measure. Such an instrument is
highly appealing as a patient-centred measure of recovery because it automatically
captures domains that are relevant to each individual. The low respondent burden,
versatility, and simplicity of a single-item instrument are additional positive attributes.
Single-item global assessment scales have high validity and responsiveness in
musculoskeletal clinical research and are considered the optimal reference standard
against which other instruments are evaluated. An obvious limitation is the lack of specific
detail about the factors contributing to the patients' recovery status, which can be captured
by more specific measures, as outlined above. In conclusion, this study initiates an
important new research direction in musculoskeletal ankle research. Development of a
standardized measure of recovery will enable recovery data from clinical trials to be
compared meaningfully and, therefore, attain more precise and valid estimates of
treatment efficacy and prognosis.
Physical therapists frequently make important point-of-care decisions for musculoskeletal
injuries and conditions. In the Military Health System (MHS), these decisions may occur
while therapists are deployed in support of combat troops, as well as in a more traditional
hospital setting. Proficiency with the musculoskeletal examination, including a
fundamental understanding of the diagnostic role of musculoskeletal imaging, is an
important competency for physical therapists. The purpose of this article is to present 3
cases managed by physical therapists in unique MHS settings, highlighting relevant
challenges and clinical decision making. Clinical pathways from point of care are
discussed, as well as the reasoning that led to decisions affecting definitive care for each
of these patients. In each case, emergent treatment and important combat evacuation
decisions were based on a combination of examination and management decisions
1 year outcome of standard medical care of acute ankle sprains in a general clinical based
population was assessed by a self administrated survey which was mailed to all adult
patients who presented to a health system provider for evaluation of ankle sprain. Most of
the patients sought medical evaluation shortly after injury and were immobilized or
braced; 32.7% reported formal or home based physical therapy. Six to eighteen months
after injury 72.6 percent reported residual symptoms. Which was concluded as residual

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lifestyle limiting symptoms are common 6 to eighteen months after injury. Ankle sprain
may be more problematic than generally thought, or standard medical treatment may be
inadequate. Which provides a room to identify effective methods to reduce the long term
functional limitations of ankle sprain in general clinic population

2.1.4 Conclusion

The recent literature has provided important advances with regard to identifying ankle-
injury risk through well-controlled, prospective studies, along with the importance of
physical rehabilitation therapy in ankle sprains. Yet much work is required to properly
identify the importance of physical rehabilitation therapy of ankle sprain in sports injuries
emphasizing the time factor as the delay in commencement of the treatment may leads
towards a prolonged recovery period. One cannot describe fast recovery without
understanding the grades of ankle sprain which are important to find out in sportsmen that
which grade of ankle sprain is commonly occurring and what is the impact of regular
physical rehabilitation therapy on speedy recovery. This creates a gap for the researcher to
do his studies to fill the gap as in his target population this study may be very first of its
kind.

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2.2 Alternative Hypothesis

H1=There is impact of timely physical rehabilitation on speedy recovery of ankle sprain in

sports injuries

H2=There is impact of regular physical rehabilitation on speedy recovery of ankle sprain

in sports injuries.

2.3 Null Hypothesis

Ho=There is no impact of timely physical rehabilitation on speedy recovery of ankle

sprain in sports injuries

H0=There is no impact of regular physical rehabilitation on speedy recovery of ankle

sprain in sports injuries.

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3 CHAPTER

3.1 RESEARCH METHODOLOGY

3.1.1 Outlines of this Chapter

The purpose of this chapter is to describe the research design, population of interest and
procedures which are adopted to complete the study. This chapter includes research
design, population of interest and development of questionnaire, data collection technique,
instrumentation of the study and data collection. The study was organized to determine the
role of timely physical rehabilitation therapy of ankle sprain in sports injuries.

Research Frame Work

The conceptual framework contains the key factors, the variables and presumed
relationship amongst them. The main aim of this research is to understand the factors
influencing speedy recovery of ankle sprain in sports injuries demonstrating that this can
be achieved by timely commencement of physical rehabilitation therapy and attending
regular physical rehabilitation therapy session. To support this argument, an initial
framework based on the literature review and the underlying theory was drawn up. This
framework is used to interpret the research question that the study is embarking.

Timely commencement of

Physical Rehab.Therapy (IV-1)

Speedy Recovery of ankle

sprain in sports
injuries(DV)

Regular Physical Rehabilitation

therapy (IV 2)

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3.1.2 Why we use convenience sampling technique

This sampling technique is used because of shortage of time and less availability of sports
men of ankle sprain. The sportsmen who were available at the time of data collection are
included in the sample at various physical therapy and sports centres of Penang.

3.1.3 Development of Questionnaire

A questionnaire is simply a formalized set of questions for collection of information. It is

set of questions for the purpose of data collection.

Questionnaire is of two types

1. Open Ended

2. Close Ended

A questionnaire consisting of close ended was developed with the help of supervisor,
seniors, guides, books, internet, magazines etc. The validity of questionnaire is checked by
pilot study, supervisor, senior teachers and guide so to delete the unnecessary questions
according to requirement.

3.1.4 Pilot Study

Pilot study was conducted on first 10 patients.

1. To test the validity of questionnaire.

2. The time it takes to complete the questionnaire.

3. To delete the unnecessary questions in the questionnaire.

4. Whether the purpose of study is fulfilled with this questionnaire.

3.1.5 Data Collection Technique

Data can be collected by these methods.

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 1. Direct personal interview method.

2. Mailed questionnaire method

3. Telecommunication and electronic media.

Direct Personal Interview Method

In direct personal interview method the researcher approaches to the respondents directly
and interview them. The formation supplied by this informant is recorded by researcher.
The data collected by this method is considered accurate and complete.

Mailed Questionnaire Method

Questionnaire is the list of questions is related to the field of enquiry. This list is sent to
respondents by mail with a request that they please sent back to the researcher after filling
the enquiries. This method is cheap but in this method no response rate is very high.

Telecommunication and Electronic media

In this modern world, the most efficient way of data collection is the electronic media like
telephone, and internet.

The direct personal interview method is used to collect the data from the sportsmen. It is
more reliable and accurate than other techniques because the researcher directly collects
the data from its respondents.

Data was collected from all the sportsmen who were having ankle sprain at that time
without keeping gender differences by direct personal interview.

3.1.6 Research Design

A research design is the arrangement of conditions for collection and analysis of data in a
manner that aims to combine relevance to the research propose with economy in
procedure.

This is a descriptive (no experimental) case study and is going to be carried out on the
sportsmen of NEWYORK suffering from ankle sprain. This cross sectional descriptive

- 45 -
study is to find out the speedy recovery of ankle injuries by timely commencement of
physical rehabilitation. This is quick and relatively easy to perform and give a fair idea.
This cross sectional study will be used in this study because the data will be collected only
once to get the information from the selected patients.

3.1.7 Population and sample

Population

The target population is the patients of ankle sprain who are being treated in physiotherapy
and sports clinics of NEWYORK.

Sample and sampling method

Sample size is 100 sportsmen suffering from ankle sprain which will be collected from
Physiotherapy and sports clinics of NEWYORK.

Convenience sampling technique is used to collect the sample. Non probability sampling
technique is a method in which those respondents or subjects are selected for study that is
available easily. The advantage of this method is that we can conduct study easily but the
sample can be biased one. The reliability of the judgement sampling depends on the
experience and skills of the researchers which results in the selection of the sample.

3.1 The research instrument

Describe the actual instrument (eg open questionnaire, interview schedule, mathematical
model, conjoint questionnaire) that you will use for your own research, indicating how
each part addresses a specific issue in your research. Create and include your actual
instrument in an Appendix, with a covering letter to the potential respondent motivating
them to participate. If it is a standard instrument that has been previously published or has
been used before, discuss its advantages and shortcomings as they relate to your use of it.

- 46 -
3.2 Procedure for data collection

The following steps are adopted to collect the data:

1. A questionnaire was developed with the help of research supervisor and senior
teachers.

2. Pilot study was conducted.

3. Before visiting sports centres and physical therapy clinics, permission from
concerned authorities was taken.

4. The data was collected from MONTH 2023 to MONTH, 2023.

5. By applying appropriate statistical technique a sample of 100 respondents was

interviewed.

6. A post survey was conducted to test the reliability of the study.

3.3 Data analysis and interpretation

Describe how you will analyse the data. REFERENCE appropriate methodological
sources, and describe how these methods will be applied in your analysis process. Eg
regression analysis, descriptive statistics, content analysis.

3.4 Limitations of the study

This research aims to develop awareness in population about physical rehabilitation.

Author being a physiotherapist has most access to Rehabilitation clinics, therefore data
will be collected from Physio clinics and Sports rehabilitation centres in Penang as a result
the outcomes of this research may not be appropriate for other states

- 47 -
Data collection will be done from various physio and sports clinics of NEWYORK. So
results and conclusions can only be applicable on patients of Penang or those patients who
come for treatment in those Rehabilitation and sports centres from where data will be
collected. This research revolves around the physical causes of ankle sprain so results and
conditions will be only applicable for these causes. Due to shortage of time the researcher
has to complete research work within 2 to 3 months.

Limitations identify and anticipate potential weaknesses in your study relating to the
methodology, sampling, analysis methods, etc. Describe these potential weaknesses and
their implications, particularly with respect to the interpretation of your findings. Bullet
points are fine here.

3.5 Validity and reliability

Describe what each of these in the context of your own research. If you choose to use
other validation criteria (particularly in qualitative or interpretive research), then discuss
them here. For each criterion discuss how you will ensure it happens or at least make
every effort to ensure it in your research. Remember to REFERENCE your statements.
No “textbook summaries”.

3.5.1 External validity

Describe (REFERENCE your source) how your research meets or does not meet the
external validity criteria. If necessary, explain how YOU will try to maximise your
validity.

3.5.2 Internal validity

Describe (REFERENCE your source) how your research meets or does not meet the
internal validity criteria. If necessary, explain how YOU will try to maximise your
validity.

- 48 -
 3.5.3 Reliability

Describe (REFERENCE your source) how your research meets or does not meet the
reliability criteria. If necessary, explain how YOU will try to maximise your reliability.

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4 RESEARCH PLANNING

4.1 Time-table

Table 1: Time-plan for completion of research report by xxxx

date date date date date date date

Finalise proposal

Gain approval

Gather data

Do data analysis

Write report

Finalise report

4.2 Consistency matrix

A consistency matrix is a powerful tool in assisting you to align your sub-problems, the
references that you used to investigate each sub-problem in turn and the hypothesis or
proposition or research question that resulted from the literature that you reviewed. It also
lists the analysis method you will use to analyse the data.

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It is also a process model – you carry out each step of your research in the sequence shown
in the consistency matrix, which is shown on the next page.

- 51 -
Table 2: Consistency matrix

Research problem stated here

Sub-problem Literature Review Hypotheses or Propositions or Source of data Type of data Analysis
Research questions

sub- List the most important Actual Hypothesis 1 OR proposition 1 Actual interview / Note the type Describe the
Actual
problem 1 references that you OR research question 1 stated here in questionnaire questions of data, eg specific
stated fully as referred to when writing exactly the same words as in the text that will provide the nominal, analysis

the literature review for of the proposal, and based on the data, preferably in ordinal, etc method you
in the text
literature that you reviewed in the words will use
sub-problem 1.
previous step Or other specific
sources of data, eg
stock exchange

- 52 -
Research problem stated here

Sub-problem Literature Review Hypotheses or Propositions or Source of data Type of data Analysis
Research questions

sub- List the most important Actual Hypothesis 2 OR proposition 2 Actual interview / Note the type Describe the
Actual
problem 2 references that you OR research question 2 stated here in questionnaire questions of data, eg specific
stated fully as referred to when writing exactly the same words as in the text that will provide the nominal, analysis

the literature review for of the proposal and based on the data, preferably in ordinal, etc method you
in the text
literature that you reviewed in the words will use.
sub-problem 2.
previous step Or other specific
sources of data eg stock
exchange

So on if more
sub-problems

- 53 -
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Books/websites Consulted

Foot and ankle pain(by rene cailliet,M.D)

Hand book of sports medicine(by WADE A. Lillegard Karens.Rucker)

Ankle Injuries related to sports(by Jeffrey D. Patterson)

www.medicalmultimediagroup.com

www.scoi.com/anklanat.htm

www.orthopaedics.hss.edu/services/conditions

www.intlinesketing.about,com

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 www.apta.org

APPENDIX A

Actual Research Instrument – this is essential in your proposal to evaluate the effectiveness of
your instrument in gathering the required data, and or ethics approval

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