Clinical Prevention Methods
The risk of acute and chronic injury in sport has been documented. Musculoskeletal injuries of the upper extremity seem to plague overhead athletes, whereas lower extremity injuries are more common in sports that involve running, cutting, and jumping. The high incidence of ankle sprains in contact and noncontact sport and the negative consequence for future sport participation call for preventive measures. In an attempt to prevent ankle sprains, prophylactic taping, braces, specially designed shoes, and proprioceptive training have been implemented. Balance and coordination training are common components of intervention programs for the prevention and treatment of acute lateral ankle sprains and chronic ankle instability.44 Flexibility has been presented as one of the primary etiological factors associated with injury and, specifically, with musculotendinous strains, the most frequent athletic related injury.45,46 Anecdotally, stretching has been promoted before athletic activity as a method of improving joint range of motion (ROM), muscle flexibility, improving performance, and preventing injury.45,46 However, its effects on performance and injury prevention are not clear. The next section reviews the literature to determine the effectiveness of these measures.
Prophylactic Ankle Bracing and Taping
The ankle joint is one of the most frequently injured sites for individuals who participate in recreational or competitive athletics. Garrick and Requa47 reviewed injuries treated in a sports medicine clinic over a 6.5-year period and determined that 25% of 12,681 injuries were to the ankle and foot. Ankle sprains accounted for approximately 85% of the injuries to this region. Most ankle sprains result from a stress on an inverted and plantarflexed (supinated) foot that damages the lateral ligaments. Individuals who sustain ankle sprains demonstrate high recurrence rates and disability and may develop chronic pain or chronic ankle instability.48
In theory, prophylactic taping has an effect by reducing ROM of plantarflexion and inversion of the ankle. However, research has shown that this restricting effect is lost after periods of exercise.49 This loss of effect does not occur when using a brace. Taping can be applied individually similar to braces, but the use of braces is more cost effective.50 Recent research strengthens the idea that taping and bracing act more by improving neuromuscular feedback than by restricting the ROM. Most evidence supports the prophylactic effects of the use of external support or balance/ coordination training in the prevention of first-time and recurrent sprains.51
There is historical evidence for use of prophylactic taping and bracing. A 1973 study of intramural college basketball players found a higher rate of ankle injury in untaped than taped participants (injury rate [IR] = 14.7 vs 32.8/1000 games) over 2 years.52 Ankle taping was more effective in those with a history of ankle sprains than in those without a prior ankle injury. The IR for those previously injured with tape was 16.4/1000 games and 55.3/1000 games for previously injured, untaped participants.52 Surve et al53 determined that a semirigid stirrup orthosis significantly reduced the incidence of ankle sprains in soccer players with previous ankle sprains. The study reported an incidence of ankle sprains in male soccer players with a history of injury while wearing a semirigid stirrup orthosis as 0.46/1000 playing-hours. This was significantly lower than the previously injured control group without external support of 1.16/1000 playing-hours. The reported incidence of participants without history of injury while wearing a semirigid stirrup orthosis was 0.97/1000 playing-hours compared to a control group without external support of 0.92/1000 playing-hours.53 Sitler et al54 evaluated the effect of a semirigid ankle brace in a 2-year randomized, clinical trial of 1601 intramural basketball players at West Point. The injury rate was significantly lower in the braced group (1.6 sprains/1000 AEs), whereas the unbraced control group had 5.2 sprains/1000 AEs. The study concluded that the risk of sustaining an ankle injury was 3 times greater for the control subjects not wearing an ankle stabilizer.54
More recently, McGuine et al55 examined the effectiveness of lace-up ankle braces on firsttime and recurrent ankle injuries in a group of high school basketball players. A key objective of this study was to determine whether using lace-up ankle braces reduces the number and severity of acute first-time ankle injuries. The study recruited 1460 players (720 in the control group and 740 in the braced group). Seventy-eight ankle sprains and fractures were sustained by the control group, and 27 ankle injuries occurred in the braced group out of 112,439 total exposures. The overall incidence of acute ankle injury per 1000 exposures was lower in the braced group (IR = 0.47/1000 AEs; 95% CI, 0.30, 0.74) than in the control group (IR = 1.41; 95% CI, 1.05, 1.89). McGuine et al48 defined first event acute ankle sprain as the first acute ankle sprain that occurred after the study began. Results for this study used this term. There were 75 first-event acute ankle injuries in the control group compared with 26 in the braced group (hazard ratio [HR] = 0.32; 95% CI, 0.20, 0.52; P < . 001). First-time acute ankle injuries occurred 68% less often in braced athletes than in controls. For players who reported a previous ankle injury, the incidence of acute ankle injury was lower in the braced group (IR = 0.83/1000 AEs; 95% CI, 0.37, 1.84) than in the control group (IR = 1.79; 95% CI, 0.98, 3.27), and first-event acute ankle injuries occurred about 60% less often in braced athletes than in controls (HR = 0.39; 95% CI, 0.17, 0.90; P = .028). For players who did not report a previous ankle injury, the incidence of a first-event acute ankle injury was lower in the braced group (IR = 0.40; 95% CI, 0.23, 0.70) than in the control group (IR = 1.35; 95% CI, 1.00, 1.81), and first-event acute ankle injuries occurred 70% less often in braced athletes than in controls (HR = 0.30; 95% CI, 0.17, 0.52; P < .001). Therefore, McGuine et al55 concluded that lace-up ankle braces reduce the incidence of injury in basketball athletes with and without a history of ankle injury.
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McGuine et al56 continued examining the effectiveness of lace-up ankle braces on first-time and recurrent ankle injuries in a group of high school football players. A total of 2081 athletes (control, n = 1088; braced, n = 993) had 125,419 football exposures, resulting in 95 first-event acute ankle injuries (control, 68; braced, 27). The incidence of ankle injury per 1000 exposures was significantly lower for the braced group (0.48) than for the control group (1.12). The RR of sustaining of an ankle injury in the braced group was 0.435 (95% CI, 0.281, 0.674). The incidence of an acute ankle injury was reduced in the braced group by 70% for players who reported a previous ankle injury and 57% for players with no previous ankle injury. Overall, using a lace-up ankle brace reduced the incidence of acute ankle injuries by 61% in high school football players.
Olmsted et al50 investigated the works of Garrick and Requa,47 Sitler at al,54 and Surve et al53 to determine numbers needed to treat (NNT). NNT can provide the clinical usefulness of an intervention by producing estimates of the number of treatments to prevent 1 injury occurrence. In collegiate intramural basketball players, the prevention of 1 ankle sprain required the taping of 26 athletes with a history of ankle sprain and 143 with no prior history. In a military academy intramural basketball program, prevention of 1 sprain required bracing of 18 athletes with a history of ankle sprain and 39 with no history. Ankle bracing in competitive soccer players produced an NNT of 5 athletes with a history of previous sprain and 57 with no prior injury.50 McGuine et al56 also produced the NNT for each of their studies (14.5 for the basketball athletes and 28.3 for the football athletes). It can be considered that a high school team of 60 football players that 1 to 3 ankle injuries can be avoided during the season depending on the athletes’ prior histories.
A final review by Parkkari et al7 summarized prevention programs and their effectiveness. The review identified 16 randomized controlled trials (RCTs) that have been published on prevention of sports injuries from 1970 to 2000. Four of these studies examined ankle stabilizers and provided high-quality evidence that use of semirigid ankle stabilizers reduces the risk of ankle sprains, especially among those with previous ankle instability problems. Recurrent ankle sprains can be prevented by ankle supports (ie, semirigid orthoses) in high-risk sporting activities, such as soccer and basketball.52-55,57
Prevention Methods 257 Figure 11-4. Proprioceptive training.
In the 2013 National Athletic Trainers’ Assocation position statement titled “Conservative Management and Prevention of Ankle Sprains in Athletes,”48 the use of prophylactic bracing and taping was supported for those with a history of ankle injury. Athletes with previous ankle sprains who braced or taped the ankle had approximately 70% fewer ankle injuries than athletes without prophylactic support. Participants who had a previous history of ankle sprains had a reduction in the incidence of ankle sprains when wearing a semirigid brace. However, in athletes with no history of ankle injuries, there was no difference in the incidence of ankle sprains between the control and braced groups.
These results demonstrate a benefit in ankle taping52 and semirigid54,55 and lace-up55,56 ankle bracing as beneficial in reducing the incidence of acute ankle injuries. This protective effect was observed in players with and with no history of ankle injury. Wearing ankle braces may be a cost-effective injury prevention strategy compared to ankle taping. But, there are other intervention options available to reduce the incidence of ankle sprains.