disabilities of patients while kinesiophobia was the strongest contributor to disability.97 Therefore, although pain intensity is not a direct measurement of kinesiophobia, our finding that Pain SP had a significant correlation with the duration of disability in the current study deemed reasonable.
The finding that PROM loss was correlated with the number of days to RTP was in agreement with a study by Wilson and Gansneder178 although the PROM loss at the acute testing session in the current study was smaller than MDC. Several literatures have reported that restricted dorsiflexion ROM is associated with traumatic lateral ankle sprain and chronic ankle instability.18,32,40,60,72,131,167,185 Furthermore, restricted dorsiflexion ROM has been reported to be associated with gross motor control alterations in various tasks29,54,143 and dynamic balance capabilities.5,71 Altered joint kinematics of the talocrural joint has been considered as a plausible mechanism for limited dorsiflexion ROM.32,167,172 Consequently, restoration of arthrokinematic movement of the talocrural joint after traumatic lateral ankle sprain has been shown to result in increased dorsiflexion ROM and improved function.18,20,24,60,70,130 Furthermore, dorsiflexion ROM reflects
36,92,93
correlated with the number of days to RTP in the current study. Nonetheless, clinicians need to interpret the result of the current study with caution as responsiveness of ankle joint ROM was questioned in a literature review.107
reported that swelling does not correlate with self-reported functions.102,135 Although Figure-8 method may be a reliable and valid method to measure the extent of swelling and inflammation and the mean difference of swelling at the acute testing session matched the MDC of .7cm, it may not reflect the severity of perceived activity limitations and participation restrictions at the initial post-injury stage.135And hence, it may not be suitable to predict the improvements of those variables. In fact, subjects in the current study went through a large change in their activity limitation and participation restriction status, from unable to continue sports activities with the FAAM-J SP of 14.1 ±3.5 to full participation with the FAAM-J SP of 28.3 ±3.9, however, the effect size of swelling was small. (TABLE 4-3)
Our finding that DF and EV strength loss did not correlate with the number days to RTP, was in agreement with a previous investigation.23
knowledge, the study by Cross et al23 is the only study which examined the prognostic ability of ankle joint strength measures for RTP after traumatic lateral ankle sprain. Although strength deficits have been reported following traumatic lateral ankle sprains,1,73 previous reports from various populations and settings conflict over the effects of traumatic lateral ankle sprains and simulated swelling on muscular function, or arthrogenic muscle response.65,91,126 Contrary to the common belief that periarticular muscles are inhibited by acute joint injuries,75,150 previous studies reported no effect or even facilitation of certain muscles surrounding the ankle joint, attributing it to the protective mechanism.91
Furthermore, a previous investigation showed that VAS scores of current level of pain explained a large amount of variance in the motor-neuron pool
excitability of the tibialis anterior, however, the scores did not explain those of the soleus or peroneus longus muscles in the acutely sprained ankles.91 Although it is common to assume an adverse relationship between pain and muscle inhibition, a previous report showed muscle activation was not affected in the presence of pain after knee injury116 and little evidence is available for the acutely sprained ankle joint. Additionally, to the authors' knowledge, few researches are available to show improvement in the ankle strength result in improvements in activity limitations and participation restrictions. Thus, although the DF and EV strength deficits at the acute testing session were larger than the respective MDC, they were not necessarily proportional to the duration of disability and may have little prognostic value after traumatic lateral ankle sprain.
Further research is needed in this area
The FAAM-J ADL did not have a significant correlation with the number of days to RTP in this study although the mean differences at the acute testing session as well as the improvement from the acute testing to the RTP testing sessions were larger than the MDC of the FAAM-J ADL. (TABLE 4-1 & 4-3) Because the FAAM-J ADL is not specific to sports activity limitations and participation restrictions, it may not be effective in predicting the number of days to RTP.
Based upon the measurements from 19 subjects who completed the RTP testing session, the effect sizes ranged from .3 to 1.5. In fact, the effect size for every measure except for swelling exceeded .8, showing large improvement
while swelling showed the least improvement with the effect size of .3.
Clinicians need to interpret the results of the current study with cautions.
In the
patient-are respected, patient oriented outcome measures patient-are considered as the gold-standard in the assessment of musculoskeletal conditions.27,129 However, they should not be considered the sole outcome measures, nor the significance of clinician-rated measures should be underestimated as clinician-rated measures are valuable in many aspects. Therefore, the FAAM-J SP should be considered a necessary but not sufficient measure in the assessment of traumatic lateral ankle sprains.
There were a couple limitations to be noted in this study. First, the rehabilitation process and RTP decisions in this study were not strictly controlled.
Although the purpose of this study was not to evaluate the effectiveness of a specific rehabilitation protocol or RTP guidelines, this might have influenced the results of the current study.
Second, the subject pool consisted only of a small number of competitive collegiate basketball players although the number of subjects in the current study is comparable to those in previous studies, n= 21178and 20.23 This was necessitated because a relative large percentage of potential subjects (41.6%) were excluded from the study. we performed a post hoc power analysis with a statistical software.51,52The variance of the duration of disability explained by valid three measures was .545 with set at 0.05. The analysis produced a power of .958. Therefore, we believe the subject pool of the current study is sufficient although the results of the current study are only applicable to the
specific population of the current study.
Furthermore, an injury can have different effects on the HR-QOL of physically active individuals and athletes than on that of the general population.109,159,163Therefore, clinicians need to be cautious to apply the results of the current study to different populations such general and/or youth populations. Future research should address these limitations by including a larger number of subjects from various sports, ages and different competitive levels.
Third, based upon the number of days to RTP, 11.7 ±6.4 days, majority of the traumatic lateral ankle sprains in the study are considered relatively minor.
Therefore, clinicians need to be careful in applying the results of the current study to relatively severe traumatic lateral ankle sprains.