Bestwick-Stevenson, Thomas
(2024)
Risk factors of ankle sprains and ankle injuries using mixed methods.
PhD thesis, University of Nottingham.
Abstract
Background
Ankle sprains are a common injury, in both the general population and physically active population. Residual symptoms are also common months and years after the injury, and many never fully recover. However, limited is known about the risk factors for suffering and recovering from an ankle sprain.
Purpose
Examine potential risk factors, to see if they are associated with either suffering an ankle sprain or recovering poorly from the injury.
Chapter overviews
The setup and results of a longitudinal multicentre cohort study is described. The study involved 1356 patients with ankle sprains and 151 control subjects, who completed a questionnaire at time of recruitment, plus 3 and 12 months later. Patients with ankle sprains tended to be younger and had a higher proportion of female and alcohol drinkers, but there were no significant differences between the groups in terms of body mass, height, body mass index (BMI), ethnicity, or smoking status.
Among ankle sprain patients, 52% were physically active, and this group was significantly younger with a higher proportion of alcohol drinkers compared to the control group.
After three months, 47% of ankle sprain patients had a poor recovery, while 25% still experienced poor recovery 12 months following the injury. A higher BMI and the injury mechanism were associated with poor recovery at both 3- and 12-months post ankle sprain. Highest level of education, smoking (amount per day), and alcohol consumption were also significantly different between those who did and did not suffer poor recovery 3 months post ankle sprain, whereas no significant difference was found for age, body mass, height, sex, ethnicity, smoking status, weight-bearing status, plus previous injury to; either same, or opposite ankle. Poor recovery 12 months post ankle sprain was associated with higher body mass and decreased height, while there was no significant difference in age, smoking (status, amount per day, and number of years), alcohol consumption (status, and amount of unit per week), sex, ethnicity, and highest education.
A systematic review was conducted examining if the risk of suffering an ankle sprain differs between sports. 4 electronic databases were searched, plus recent/in-press editions of relevant journals. The criteria for study selection were specific, including case-control studies, cohort studies, nested case-control studies, and randomised trials, with adults and a control group examining the effect of exposure to any of the included sports (Olympic sports, American football, and cricket) on the occurrence of ankle sprains. The search returned 6414 studies after deduplication. 9 studies were included in the final review. Network meta-analysis showed that football, basketball, and handball had a significantly higher risk of ankle sprains, while athletics, baseball, American football, ice hockey, wrestling, field hockey, and tennis had a significantly lower risk. There was no significant difference for volleyball, rugby union, and gymnastics.
The incidence of ankle injuries in four professional American sport leagues was examined. Public injury data from National Football League (NFL), National Basketball Association (NBA), National Hockey League (NHL), and Major League Baseball (MLB) from 2007 to 2019 were extracted and analysed. The results show mean ankle injury incidence was highest in NBA followed by NFL, while the incidence was lower in NHL and MLB.
Two feasibility studies were also conducted to examine whether it would be feasible to conduct clinical trials to examine whether completing a warm-up with or without stretches prior to sport/exercise would reduce the incidence of ankle sprains, and whether there is an association with balance and/or strength between those who suffer an ankle sprain and if any differences in strength and balance is present before the injury or arises because of the injury was conducted.
The study examining warm-ups, with and without stretches recruited 28 individuals aged 18-44 who participated in sports at least twice a week. Participants were randomly assigned to one of two groups, either warm-up with stretches or warm-up without stretches. Both groups completed an identical aerobic warm-up, with the stretch group also completing static lower limb stretches. Participants conducted the warm-up protocol for 16 weeks prior to sporting participation and received a questionnaire every two weeks, inquiring about injuries, sports they had participated in, and if they had completed the warm-up protocol before each sporting participation or not. 14 participants were randomly assigned to both the stretch and non-stretch groups, and 2 ankle injuries occurred in both groups. The protocol was found to be feasible.
The study examining the association of balance and strength with suffering an ankle sprain recruited 22 active individuals aged 18-44 who had not previously suffered an ankle sprain. Participants completed two testing sessions, six months apart, consisting of the same balance and strength protocols. Balance was tested through a single leg balance test and strength through a calf raise test, with each test conducted three times on each limb non-consecutively. 2 participants suffered an ankle sprain. The study was found to be feasible, but more sophisticated measurement may ease comparisons.
Conclusion
The research in this thesis adds to the limited research regarding potential risk factors for suffering an ankle sprain, and factors which may influence either recovery from the injury or suffering a re-injury.
Ankle sprain patients were younger and more likely to consume alcohol, some factors were also found to be associated with poor recovery, with higher BMI associated with poor recovery at both 3- and 12-months post ankle sprain. Participating in football, basketball, and handball was found to produce an increased risk of suffering an ankle sprain, while participating in athletics, baseball, American football, ice hockey, wrestling, field hockey, and tennis produced a decreased risk of suffering an ankle sprain, and no significant difference for volleyball, rugby union, and gymnastics. Similar results were also found in professional American sports, with ankle injury incidence being highest in NBA followed by NFL while the incidence was lowest in NHL and MLB. A study examining the effects of warm-ups, with and without stretching, at reducing the incidence of ankle sprains, and another examining the association of balance and strength with ankle sprains were both found to be feasible.
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