Effect of Proprioceptive Training on Fear of Re-Injury and Functional Performance in Athletes with Lateral Ankle Sprain (LAS)

Introduction

The LAS is the frequently accounted musculoskeletal injuries among sports-related and recreational athletes.¹ It has been found that in United Kingdom (UK) 85% of ankle sprains are LAS during sporting activities where patients less than 25 years of age sustained more injuries on fields with the incidence rate of 7 LAS per 1000.² Lateral ligament complex consists of fan like system of 3 structures which are anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL) that functions to resist the ankle inversion and also providing the controlled talus movement with ATFL checking the anterior subluxation, CFL to varus tilting and PTFL limiting excessive posterior displacement.^1,3 When an ankle undergoes excessive inversion at a high velocity it can lead to tear or stretching to lateral ligaments also called sprain or LAS.^4,5 Anatomically, medial malleolus are shorter than the lateral malleolus that allows the talus to go towards inversion than eversion¹ .

Ankle rehabilitation is structured and individualized. Cryotherapy, external pressures, active range of motion (ROM) exercises done initially are followed by pain-free ROM, weight bearing and balance exercises to normalize neuromuscular control, muscle strength, power and endurance to reach pre injury levels. Treatment eyes on re-gaining the normal joint functioning and specific exercises are focused which will be performed during the particular sport.⁶ LAS is significantly associated with distal fibular anterior positional fault which determined in relation with distal tibia. Thus, it is suggested to assess the mobility and position of distal fibula after acute ankle sprain and managed by methods like fibular mobilizations to enhance ROM.⁷

Proprioception is the sense of joint position and movements that arises through sensory neurons which are located in skin, muscles, joints, tendons and ligaments⁸ that includes both afferent and efferent signals to maintain stability, orientation and prevent injuries during activities. Proprioceptive training challenges the joints ability to detect and react the afferent input about joint position. Mechanoreceptors around ligaments, joint capsules activates more during end range movements and gets disrupted during injury. Ligament heals with collagen tissue post injury becomes stable mechanically but the healing of nervous tissue that is disrupted generally takes more time as nervous tissue healing is slow which finally results in decrease joint position sense leading to functional instability. Growing evidence supports reoccurrence of injury is due to impaired joint proprioception^9,10 and proprioceptive exercises are capable of reducing instability and improving the functional outcomes.¹¹

Injured athlete undergoes with various physical impairments like decrease strength and ROM, pain and psychological impacts like anxiety, depression, frustration, tension, decrease self- esteem and fear of re-injury which alters the return to sports time frame. Fear of re-injury is a fear of being susceptible to painful re-occurrence of injury though physical recovery is achieved. It has physiological effect on muscle guarding and psychological changes like distractions and lack of confidence towards injured site. Studies support that fear of re-injury also affects muscle recruitment and muscle activation patterns which influences neuromuscular functioning and affects the rehabilitation outcomes. Consequently, return to sports is delayed.^12,13. Tampa scale of kinesiophobia-11 (TSK-11) is a 11-statement 4-point likert scale questionnaire designed for chronic pain populations to assess fear of re-injury. Total scores ranges from 11 to 44 where higher scores signifies greater fear of re-injury.¹⁴

Functional performance deficits can decrease physical activities and results in other injuries. Studies has shown that functional performance deficits exists in individuals with feeling of giving away and functional performance tests (FPTs) are equitable means for testing functional ability, functional loss, tenderness and significant ligament instability.^1,15

Studies shows that negative emotion requires better cognitive neural processing in several regions of brain that are also essential for maintaining dynamic joint stability. Thus, increased neural demands due to high fear of re-injury can disrupt neuromuscular control.¹⁶ Though proprioceptive training acts on neuromuscular complex and joint movement sense there is lack of literature towards effect of proprioceptive training on fear of re-injury in LAS athletes which has chances of high reoccurrences and has been a hindrance for many athletes for returning to sports with same level of fitness as before.

Methods

Study design and procedure:

Pre-post experimental study design was used with athlete completing the self-reported TSK-11 scale to evaluate fear of re-injury in heterogeneous chronic pain population¹⁴ and functional performance tests (4-single limb hop test) with visual analog scale (VAS) was taken prior and after intervention. Instructions were given to athletes to perform quickly and best of 3 trials was taken in cases like any contralateral foot falls then athletes were asked to do retrials ^17,18. Also, athletes received a standard history, physical examination and special tests by physiotherapist.

Study participants and sampling:

Simple random sampling was used for selecting the samples in 2 different groups. Male athletes with history of lateral ankle injury more than once on same limb underage group 18-35 years showing positive anterior drawer and talar tilt tests were eligible under study. Subjects with visual difficulties, medial ankle sprain, lower limb fracture, concomitant injuries or pathology¹⁹ and neurological conditions were excluded.

Study instruments and measures:

Towel, wobble board, elastic band, ball, marker, cones

Strengthening exercises: (Hold for 30 s, rest for 10 s, and repeat exercise 15 time 2 sets)

• Soleus and gastrocnemius stretch
• Calf stretch
• Tubing exercises and weight around ankle in sitting position (dorsiflexion, plantar flexion, inversion, eversion)
• Toe raises, stairs exercises²⁰

Outcome measure:

• Tampa scale of kinesiophobia to assess fear of reinjury.
• FPT to assess functional performance.

Data analysis:

Statistical analysis was performed by SPSS-17 for windows with alpha value was set as 0.05. Descriptive statistics was performed to find out mean, standard deviation for the demographic variable and outcome variables. Chi square test was performed to find out dominance among both groups. Unpaired t-test was used to find significant differences among demographic variable such as age and between group for FPT. MannWhitney U test was used for difference in scores between groups for TSK and VAS. Wilcoxon signed-rank sum test was used to find significant difference with in groups for TSK and VAS. Paired t-test was used to find significant differences within group for FPT. Microsoft excel, Msword was used to generate tables.

Results:

A total 30 athletes met the inclusion criteria, randomized into 2 different groups and undergone test process.

Discussion

The LAS has been known for its often reoccurrences and progressing to chronic ankle instability leading to off, from sporting and many functional activities. We attempted to verify by analyzing TSK-11, FPT and VAS scale prior to and after the intervention. Assessment was taken prior to and after the intervention. Anterior drawer and talar tilt test was performed to rule out the lateral ligament injury.

The result of current study showed significant differences post interventions as the level of confidence, self-esteem seemed high since athletes have performed the tasks that was far challenging to them post-injury. This intern can decrease negative emotions and could facilitate neuromuscular control since cognitive neural processing in brains several areas responsible for maintaining both. Also, increase impact on muscle recruitment and activation patterns, muscular endurance and influence on neuromuscular functioning and instability. Thus, improving balance and normalizing position sense.^11,12

Literature by Yong Woo An, where executive function training improved affective control and muscle coordination¹⁶ backing present study findings of proprioceptive training decreasing the psychological aspect of fear in athletes thus improving performance. Proprioceptive training protocol with graded forms of easy to high level training given provides more impact on neuromuscular control and on cognitive neural processing of brains region thus decreasing negative emotion or fear and FPTs again providing a feedback post intervention scale signifying a better quantitative results with positive effect.

Erik A. Wikstrom (2011)²¹ with contradictory findings, fear of re-injury does not differ those with and without CAI with TSK-17 scale also noted decrease in confidence in CAI, while present study focuses on TSK-11 which has same validity and reliability as pervious TSK scales but includes 6 less psychometrically poor items than TSK-^17.14

Control groups showed significant results with improved muscular firing and recruitment pattern with strength training that helped to regain strength, hence confidence to have a significant values.¹²Also, can be due to increase in evert or muscles concentric and eccentric strength to counteract the foot when goes towards inversion injury²².Similarly, relationship between muscle spindle sensitivity and ankle strengthening training on joint position sense²³ shows positive correlation decreasing TSK value. The LAS athletes were homogeneous in TSK, FPT and VAS in both the groups. While comparing the post test scores of TSK in between the groups, the mean and SD of post TSK in group-A was decreased to 18.87±2.39 and in group-B was reduced to 21.47±3.38. Similarly, the post test scores of FPT in between the groups, group-A declined to 80.07±4.28 and group-B was lessened to 84.20±3.82. Likewise, post test scores of VAS in between the groups, group-A dropped to 1.03±0.90 and in group-B decreased to 1.87±0.52. As proprioceptive training challenges joints ability to detect and react the afferent input about joint position and this challenges helps to reconnect the slow healing process of nervous tissue and enhance the neuromuscular functioning and thus decrease the subjective instability While strength training aids to counteract the stress on lateral ligament.^11,12

Hence, both the group has positive improvement on fear of re-injury and functional performance but experimental group can be effective strategy to cope with fear of reinjury and to perform better in functional abilities.

Study limitations were smaller sample size, timely follow up, postural alignments and faulty biomechanics was not focused, and reporting bias.

Recommendations: Objective scale to assess fear of re-injury, large population with both genders can be considered.

Conclusion

Both groups were found to be clinically significant. After statistical analysis, strengthening exercises with proprioceptive training was more effective than strengthening exercises only. Therefore, addressing proprioceptive training in rehabilitation of LAS is very effective to prevent reoccurrences and fear of movements.

Conflicts of interest

Declared.