Prevention of ankle sprains

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

From the Departments of Orthopaedic Surgery and Clinical Neurophysiology, University

Hospital, Linkoping, Sweden

ABSTRACT risk of ankle joint injury.21 On the basis of the assumption

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 sup-
port. 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.
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.
MATERIALS AND METHODS
Twenty-five male senior soccer teams in the Swedish na-
tional league 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.

Ankle sprains are common in soccer. 7,11,14 In a recent pro- The disposition of the study is shown in Figure 1. The
spective study,’ 17% of all soccer injuries were ankle sprains, men were allotted at random to one of three groups. Group
mostly affecting joints with a history of previous sprain. 1 comprised 10 teams, each with 18 players who served as
O’Donoghue13 proposed that 85% of ankle sprains are of the controls. Group 2 comprised seven teams that were provided
inversion type and are confined to ligamentous structures. with a special orthosis (&dquo;Step 1&dquo;, Patrick Inc., Linkoping,
Prophylactic taping has become one of the main methods Sweden; Fig. 2) as an alternative to ankle taping. The device
to prevent ankle sprains. 1,5 It is done because it is assumed was applied over a cotton sock and tightened above the
that external support increases ankle stability by reinforcing
the ligaments and restricting motions such as extreme in-
version. 6.9,12,17 Since ankle taping is expensive and the tech-
nique is difficult to learn, an alternative to prophylactic
ankle taping would be valuable. A functional semirigid sup-
port 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
*
Address correspondence and repnnt requests to Hans Tropp, MD, Uni-
versity Hospital, Department of Clinical Neurophysiol, S-581 85 Linkoping,
Sweden Figure 1. The disposition of the study.
259
260

All teams were followed

during the preseason training
(January March) and during the spring soccer season
to
(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.
Commonly accepted statistical methods, including the X2
test, were used.2o

RESULTS

Forty-eight of the 439 players had had previous problems

with both ankles (Table 1). In Group 1 (controls, N
one or
=
171) 30 players (17%) sustained an ankle sprain during
Figure 2. Special orthosis. 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
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
=

TABLE1
Players with and without a 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
malleoli, the foot resting 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 TABLE 3
to all players in this group. Sixty of 124 elected to use it in Ankle sprains in the different groups
training and matches. The remaining players used no me-
chanical ankle support during the study period.
In Group 3 all men with previous ankle problems were
given a coordination training program (N 65). The exer-
=

cises 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 TABLE 4
arms were folded over the chest. For the first 10 weeks the Ankle sprains among players with previous problems
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.
 261

ankle disk) were seven sprains (5%), which also was signifi-
cantly 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 =
77, not training).

DISCUSSION

Players with a history of previous ankle problems suffered

more 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 patho-
logic stabilometric results predicted future ankle injuries. 21
We suggest that functional factors such as muscular atrophy
and impaired postural control are important in the devel-
opment of functional instability and a predisposition to
recurrent sprains. Ankle disk training improves stabilome-
tric 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
same 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 sus-
pected that the ability of the pronators to counteract inver-
sion 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 dimin-
ishes 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 rehabili-
tation 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.
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.
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