Prevention of ankle

From the

sprains

HANS TROPP,* MD, CARL ASKLING, RPT, AND JAN GILLQUIST, MD, PhD

Departments of Orthopaedic Surgery and Clinical Neurophysiology, University Hospital, Linkoping, Sweden
risk of ankle joint injury.21 On the basis of the assumption of Freeman et al.3 that ankle injury leads to a proprioceptive defect, coordination training with an ankle disk has been suggested1.11.16 and found to relieve symptoms and improve stabilometric results.22 The aim of the present study was to investigate the efficiency of a semirigid ankle orthosis and ankle-disk training in reducing the incidence of ankle sprains in soccer players.

ABSTRACT
Two different methods for the prevention of ankle joint injuries in soccer were tested. Coordination training on an ankle disk improves functional stabilty and postural control, whereas an orthosis provides mechanical support. Both techniques reduce the frequency of ankle sprains in soccer players with previous ankle problems. The orthosis is an alternative to taping, and can be used during the rehabilitation period after injury or when playing on uneven ground. Coordination training on an ankle disk ought to be included in the rehabilitation of ankle injuries to prevent functional instability. It may also be done prophylactically by players with previous ankle problems in order to break the vicious circle of recurrent sprains and feeling of giving way.

MATERIALS AND METHODS

sprains are common in soccer. 7,11,14 In a recent prospective study, 17% of all soccer injuries were ankle sprains, mostly affecting joints with a history of previous sprain. ODonoghue13 proposed that 85% of ankle sprains are of the inversion type and are confined to ligamentous structures. Prophylactic taping has become one of the main methods
Ankle

prevent ankle sprains. 1,5 It is done because it is assumed that external support increases ankle stability by reinforcing the ligaments and restricting motions such as extreme inversion. 6.9,12,17 Since ankle taping is expensive and the technique is difficult to learn, an alternative to prophylactic ankle taping would be valuable. A functional semirigid support has been claimed to be valuable in lateral sprains&dquo;; and taping and a semirigid support have been said to be equally effective in restricting ankle inversion. Stabilometry,18 which is a modified Romberg test, is an objective and quantitative method for the study of postural control. High stabilometry values correlate to functional instability, i.e., recurrent lateral sprains or a feeling of giving way.23 Pathologic stabilometric values indicate an increased
to
Address correspondence and repnnt requests to Hans Tropp, MD, University Hospital, Department of Clinical Neurophysiol, S-581 85 Linkoping, Sweden
259
*

Twenty-five male senior soccer teams in the Swedish naleague division VI were studied. Eighteen players in each team (N 450) were selected. They were questioned for past injuries and functional complaints and examined for positive anterior drawer sign.4, 8,10 Previous problems were defined as a history of ankle sprain during the last two seasons, anterior instability, or a feeling of giving way. The disposition of the study is shown in Figure 1. The men were allotted at random to one of three groups. Group 1 comprised 10 teams, each with 18 players who served as controls. Group 2 comprised seven teams that were provided with a special orthosis (&dquo;Step 1&dquo;, Patrick Inc., Linkoping, Sweden; Fig. 2) as an alternative to ankle taping. The device was applied over a cotton sock and tightened above the
tional
=

Figure 1. The disposition of the study.

260

during the preseason training March) and during the spring soccer season (January (April to June), for a total period of 6 months. Attendance records for matches and practice sessions were kept by each coach, who also reported every ankle injury. An ankle sprain was defined as an injury to the lateral ligaments of the ankle occurring during a scheduled match or practice session and causing the player to miss the next match or practice session. 2 Commonly accepted statistical methods, including the X
were

All teams
to

followed

test,

were

used.2o

RESULTS
439 players had had previous problems both ankles (Table 1). In Group 1 (controls, N 171) 30 players (17%) sustained an ankle sprain during the study period (Table 2). Nineteen sprains occurred among 75 men with a history of previous problems (25%), and 11 among 96 (11%) with no such history. The difference is

Forty-eight of the
one or
=

with

Figure 2. Special orthosis.

statistically significant (P < 0.05). Of the 60 players in Group 2 using the ankle orthosis, there were two sprains (3%), which was significantly lower than among the controls (P < 0.05; Table 3). Corresponding figures for Group 3 (N 142, of whom 65 were training on
=

TABLE 1

Players with and without

history of ankle problems&dquo;

Eleven of the initial 450 players

were

excluded because of acute

injuries.

Figure 3.

Ankle disk with

spherical undersurface.

TABLE 2

Ankle sprains in the control group

on a plastic sole and with lateral and medial straps. The orthosis provides medial and lateral support while allowing the plantar flexion and dorsiflexion necessary for play. It is designed to hold the ankle in a neutral position avoiding inversion, and to provide external support for ligamentous structures. The orthosis was offered to all players in this group. Sixty of 124 elected to use it in training and matches. The remaining players used no mechanical ankle support during the study period. In Group 3 all men with previous ankle problems were given a coordination training program (N 65). The exercises were performed on an ankle disk (LIC, Solna, Sweden; Fig. 3), which is a section of a sphere, with one leg extended straight and the other raised and flexed at the knee. The arms were folded over the chest. For the first 10 weeks the training time was 10 minutes five times weekly with one or both legs, depending on the previous problems, and then 5 minutes three times weekly. None of the men in any group used ankle taping during the study. Eleven of the 450 men (nine controls, and two from Group 3) were excluded because of acute injury to the lower extremity.

malleoli, the foot resting

TABLE 3
Ankle

sprains in the different groups

Ankle sprains among

TABLE 4 players with

previous problems

261

ankle disk) were seven sprains (5%), which also was significantly lower than in the controls (P < 0.01). Among the controls (Group 1), 75 men with previous ankle problems (Table 4) sustained 19 sprains (25%) compared to 3 of 65 (5%; P < 0.01) in Group 3 and 1 of 45 (2%; P < 0.01) in Group 2. Of players without any history of ankle problems, there was no difference in frequency of ankle joint injuries between the different groups. In Group 3 the incidence of injury was 5% in both players with a history of problems (N 65, all training) and without
=

previous problems (N
DISCUSSION

77,

not

training).

Players with a history of previous ankle problems suffered ankle sprains than those without any history. This is in accordance with the findings of Ekstrand and Gillquist.2 Predisposing factors must exist. In a previous study we found that impaired postural control as demonstrated by pathologic stabilometric results predicted future ankle injuries. 21 We suggest that functional factors such as muscular atrophy and impaired postural control are important in the development of functional instability and a predisposition to recurrent sprains. Ankle disk training improves stabilometric results and reduces symptoms.22 In the present study we found that ankle disk training reduced the incidence of ankle sprains among players with a history of related problems to the same level as among men without any history and to the
more

Figure 4. Eccentric alignment of body-weight transmission to ankle joint and point of calcaneal floor contact. If the ankle is inverted at the moment it touches the ground an inversion lever will be produced.
ACKNOWLEDGMENTS
This study was supported by grants from the Research Council of the Swedish Sport Association and the Vivian L. Smith Foundation for Restorative Neurology, Houston, Texas.

level as when the orthosis was used. The ankle orthosis probably acts through a different mechanism than the ankle disk training. Normally, aversion is initiated when the body weight is placed on the foot at the onset of stance, creating a valgus thrust on the subtalar joint. 15 If the ankle is inverted at the moment the foot touches the ground, the result could be a varus thrust owing to an inversion lever through the subtalar axis (Fig. 4). If the everting muscles are not strong enough to counteract this motion, the tensile strength of the lateral ligaments may be exceeded, resulting in injury. 12 If there is secondary muscular atrophy and loss of coordination it may be suspected that the ability of the pronators to counteract inversion is impaired. The orthosis may act by holding the ankle in a neutral position preventing initiation of inversion, and may also externally support the ligamentous structures. In players with a history of ankle problems, ankle disk training seems to be the method of choice because it diminishes functional instability22,25 and will probably break the vicious circle of recurrent sprains and subsequent atrophy.&dquo; After an initial sprain, further ankle disk training is indicated even if the player is able to return to soccer play, owing to the increased risk of reinjury. This may prevent residual disability and injury predisposition. The ankle orthosis ought to be used during the rehabilitation period before coordination training has achieved its prophylactic effect. It will also prove valuable when playing on uneven ground and in special situations when the risk of injury is considered to be greater than usual.
same

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Orthop

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20 Swinscow TDW Statistics at square one Br Med J 1976 21 Tropp H, Ekstrand J, Gillquist J: Stabilometry in functional instability of the ankle and its value in predicting injury Med Sci Sports 16 64-66, 1984 22 Tropp H, Gillquist J Factors affecting stabilometry recordings of single limb stance Am J Sports Med 12 185-188, 1984 23 Tropp H, Gillquist J Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Med In press 1985 24 Tropp H Pronator muscle weakness in functional instability of the ankle joint Med Sci Sports Exerc in press, 1985 25 Tropp H, Askling C Effects of ankle disk training on muscular strength and postural control Submitted for publication Am J Sports Med 1984