6.1Need for the study
The ankle stability depends on static stability conferred by the bony architecture of ankle joint , it is more mobile mortise joint also known as a tongue and groove joint. Common cause of ankle instability is ankle sprains and ankle instability results from inadequate and inappropriate healing after ligamentous injury.1
The ankle is the most commonly injured joint in court games and team sports, such as rugby, soccer, volleyball, handball, and basketball. In a large-scale indoor volleyball, American football, martial arts, basketball, aero ball, ultimate Frisbee, flag football, cheerleading, indoor soccer, ice hockey, lacrosse, badminton and netball more than 80% of ankle injuries were ankle sprains.2Ankle sprains are the most common musculoskeletal injury found among all athletes regardless of age or level of participation. The ankle sprain injuries are most commonly seen in athletes 80% make recovery from conservative treatment but 20% develop mechanical or functional instability resulting in chronic ankle instability. It is usually occurring in jumping, landing, being stepped on and rotation around planted foot. The patient often complains of difficulty in apprehension on uneven surfaces and proprioception is often abnormal it affects the functional performance in athletes3.
Functional ankle instability (FAI) has been defined as recurrent instability or a sense of giving way.The majority of ankle sprains occur in individuals under 35 years of age, most commonly in thoseaged 15–19 years . They account for up to 40 % of all athletic injuries and are most commonly seen in athletes participating in basketball, soccer, running and ballet or dancing . Up to 53 % of basketball injuries and29 % of soccer injuries can be attributed to ankle injuries, and 12 % of time lost in football is due to ankle injury. The injury rate in volleyball players was 0.9 per 1,000 player hours with 0.7 % during practice and 2.6 % during games .4
Eighty percent of acute ankle sprains make a full recovery with conservative management, while 20% of acute ankle sprains develop mechanical or functional instability resulting in chronic ankle instability The patient often complains of difficulty and apprehension on uneven surfaces. Even a mild exacerbation can lead to short-term dysfunction.5
Grade I: Sprain of ATFL = mild swelling and tenderness, no instability. Grade II: ATFL tear, CFL strain = moderate swelling and tenderness, moderate laxity with anterior drawer, normal talar tilt. Grade III: ATFL and CFL complete rupture = severe swelling and tenderness, instability with anterior drawer and talar tilt.6
Mechanical insufficiencies proposed to be associated with the development of CAI include pathologic laxity, articular synovial changes, degenerative changes, and arthrokinematic restrictions.2 Functional insufficiencies proposed to contribute to the development of CAI include impaired proprioception, impaired neuromuscular control, impaired postural control, and deficits in strength.7CAI is dependent on the interaction of various mechanicaland functional insufficiencies, which give rise to the 2 frequentlyencountered clinical phenomena of subjective reportingof “giving way” of the ankle joint and subjective reportingof “feelings” of ankle joint instability.8
Oral medications also effectively reduce pain. A short course of nonsteroidal, anti-inflammatory medication and perhaps repeated applications of cold may also reduce free-radical-induced secondary tissue injury.56 Yet, early relief of the signs and symptoms of acute inflammation does not indicate advanced tissue repair.9
Rehabilitation must take into consideration normal tissue size, flexibility, muscular strength, power, and endurance. Control of swelling and effusion must be accomplished with frequent application of external pressure, modalities such as cryotherapy, and active range of motion (ROM).Ankle ligament laxity is associated with persisting deficits in explosive power, agility and proprioception10.
Ankle injuries are the most common injury in sport and recreational activity accounting for up to 45% of all sporting injuries11. More specifically, eighty-five percent of ankle injuries are sprains making the acute ankle sprain the most common musculoskeletal injury among athletes regardless of age or level of competition12. While the ankle has been reported as the body region most commonly involved in severe sporting injuries , it is the frequency and risk of re-injury, rather than the severity that makes ankle sprains problematic.13
Ankle injuries are the most common injury in sport, accounting for up to 45% of all injuries . It is the risk of re-injury that makes ankle injuries problematic, with recurrence in up to 73% of athletes. Ankle taping is commonly used to prevent ankle injury, and while taping does reduce the risk
of injury the mechanism underlying its effectiveness is not clear14.
Recurrence of ankle sprain occurs in up to 73% of athletes15. In a study of Chinese athletes it was found that those with a past history of ankle sprain were up to five times more likely to re-injure their ankle than athletes with no history of ankle injury. In addition to the high rates of recurrence, up to 73% of athletes experienced significant disability and residual symptoms following ankle sprain, and 59% complained of one or more residual symptoms of pain, crepitus, instability or weakness. Furthermore, there was a trend towards an increased number of residual symptoms with an increased number of sprains.16
Chronic ankle instability is defined by repetitive bouts of ankle instability resulting in numerous ankle sprains17. Chronic ankle instability following ankle sprain has been proposed to be closely associated with residual symptoms, including recurrent injury18. Mechanical instability and functional instability have been proposed as possible causes of chronic ankle instability.19
Mechanical instability results from structural damage to the ligaments following ankle injury and is defined as movement beyond the physiological limit of the ankle’s range of motion. This increase in joint range may diminish the ability of the joint to passively restrain excess movement, causing the ankle to give way under conditions of mild stress20 . Chronic ankle instability, however, cannot solely be attributed to the presence of mechanical instability. A large percentage of individuals with complaints of chronic ankle instability do not exhibit any gross laxity of the ankle on examination . Furthermore, a study of 200 asymptomatic ankles found 11% of the ankles to be mechanically unstable . Additional factors other than mechanical instability must therefore contribute to chronic ankle instability following ankle sprain.21
Functional instability has also been proposed to contribute to chronic ankle instability. Functional instability was first defined as the patient’s complaint of giving way at the ankle joint and/or recurrent sprains.22 The definition of functional instability has since been broadened to encompass the contribution of neuromuscular and proprioceptive deficits23. Mechanical instability, impaired proprioception and weak musculature surrounding the ankle joint have been proposed to contribute to the development of functional instability24.
The types of ankle stabilizers commonly used are ankle braces with the main goal of both being to support the unstable ankle from injury without having an effect on athletic performance.7IfMulliganankletapingtechniqueproveseffectiveforathletes,withCAI,thenitcouldpotentiallychangeinjurymanagement,protocolsinclinicalpractice.Itwouldimprovethecostbenefitascomparedtotraditionaltapingandbracing .The functional instability can be improve with taping.
SubjectswithCAIsustainedtheinjurybecauseofalackofproprioceptionduetocentralmechanisms.ThiswouldexplainourfindingsofnosignificantdifferencebetweentheanklesinsubjectswithunilateralCAI.FurtherstudiesshouldincludetheeffectofMulliganankle taping on subjects with greater functional limitation as well as including a healthy control group of using uninjured contralateral ankle for comparison. Fibula was positioned significantly more anterior in relation to tibia in subjects with unilateral chronic ankle instability .Forfuturestudies,itwouldbeworthwhiletoinvestigatewhetherMulligantapingiseffectiveforthesesubjectswithunilateralCAI.25Mulligan ankle tape are cheaper. It is important to determine the effectiveness of mulligan taping and proprioceptive exercises on functional performance among athletes with chronic ankle instability the depth of literature is inadequate.Therefore, the purpose of this study is effect of mulligan taping on functional performance among athletes with chronic ankle instability.
Hypothesis:Null Hypothesis:There will not be any significant difference in mulligan taping and proprioceptive exercises on functional performance among collegiateathletes with chronic ankle instability.
6.2Review of Literature :-
Review on chronic instability.
Keith W. Chan, Bryan C. Ding, and Kenneth J. Mroczek (2011) they concluded thatankle sprains are the most common injury that occur during athletic events, with the lateral ligamentous complex most frequently injured. Approximately 20% of acute ankle sprains develop functional or mechanical instability resulting in chronic ankle instability. Over the years, an improved understanding of the biomechanics and pathoanatomy has expanded our treatment options for lateral ankle instability. However, the optimal means of prevention and treatment is still not fully ascertained. Functional rehabilitation remains the mainstay of treatment for acute ankle sprains. In chronic instability, the Brostrom-Gould anatomic repair provides the best functional results for correctly indicated patients. Anatomic tenodesis or reconstruction via autograft or allograft is an excellent option to primarily reconstruct or augment an anatomic repair, although long-term follow-up is lacking. The Chrisman-Snook procedure has the best results amongst the nonanatomictenodesis reconstructions, which should be used primarily as salvage procedures given the high incidence of abnormal ankle kinematics and impaired subtalar motion with residual instability.5
Craig R. Denegar; Sayers J. Miller(2002) they conducted the study to begin by addressing the relationship between mechanical and functional instability. Then they discuss normal ankle mechanics, sequel to lateral ankle sprains, and abnormal ankle mechanics. Finally, tissue healing, joint dysfunction, and the management of acute lateral ankle sprain are reviewed, with an emphasis on restoring normal mechanics of the ankle-joint complex. A treatment model based on assessment of joint function, treatment of hypomobile segments, and protection of healing tissues at hypermobile segments is described. They believe that effective management of the acutely injured ankle requires greater protection from stress to healing tissues than is allowed with rapid return to weight bearing, walking, and functional exercises. The greatest challenge presented by CAI may not be in treatment but in prevention. Athletes suffering from CAI miss practices and competitions, require ongoing care to remain active, and often suffer from suboptimal performance.7
Review on taping
Sedabicici ,NihanKartas , GulBaltaci (2012)they tested the reliability of standing heel test with kinesiotapinghas been shown excellent in healthy population ( ICCs range = 0.78-0.96) and suggested that performance in kinesiotex tape showed higher numbers of heel rises. The purpose was this study to investigate effects of different types of taping on functional performance in athletes with chronic ankle sprain . They also concluded standing heel rise test while kinesiotaping did not limit the functional performance . And further research may help to reduce uncertainty of the effects of various types of ankle taping on functional performance.2
Akramamro , Ina Diener , Wafa Omar Bdair , Isra , Hameda ,Arwa I. Shalabi, Dua’ I. Ilyyan(2010 )demonstrated the 97% improve ment in vas when compared with the US and control group.the purpose of this study was to investigate mulligan technique used with combination of traditional physiotherapy. The use of MWM taping for LE corrects the positional fault of elbow joint and is effective in relieving pain. They also found that MWM led to statistically significant improve ment in functional performance. They also suggested that further study with larger sample size is require to examine effects of experimental treatment on MGS27.
Eamonn Delahunt, Angela McGrath, Naoise Doran, Garrett F. Coughlan(2010)they suggested fibular repositioning tape works after an acute ankle sprain , there is an anterior positional fault at inferior tibiofibular joint. And have shown. That fibular repositioning tape significantly reduced incidence of ankle joint in group of basket ball players. They concluded that ankle joint taping positively influence in subjects with CAI.7
KarinSamsson,TobiasHulenik,CherylNg,TobyHall,KimRobinson(2009).did a study on mulligan taping of anklethe purpose of this study to determine the influence of mulligan taping on unilateral chronic ankle instability. Their result showed that mulligan ankle taping under resting and fatigued conditions did not impact on static or dynamic balance in subjects with unstable ankle. They reported that fibula was positioned significantly more anterior in relation to tibia in subjects with unilateral CAI and also concluded that further studies would be worthwhile to investigate effectiveness of mulligan taping in subjects with unilateral CAI.25
Gary B. Wilkerson(2002)suggested a taping procedure for stabilization of subtalar joint referred to as subtalar sling of tape application resulted in resistance to inversion. They also concluded that further research is to be needed to assess displacement of foot and leg within transverse plane and effectiveness ofvarious taping methods to assess it.8
Mark D. Ricard, Stephen M. Sherwood, Shane S. Schulthies, Kenneth L. Knight (2000)the purpose pf this study was to compare the effects of tape, with and withoutprewrap, on dynamic ankle inversion before and after exercise. They showed that The dependent variableswere average inversion velocity, total inversion, maximum inversionvelocity, and time to maximum inversion. They collected data using electronic goniometerswhile subjects balanced on the right leg on an inversion
platform tilted about the medial-lateral axis to produce 15° ofplantar flexion.They found no significant differences between tapingto the skin and taping over prewrap for any of the variables
measured. They concluded that There was no difference in the amount ofinversion restriction when taping with prewrap was comparedwith taping to the skin. Tape and tape with prewrap significantly
reduced the average inversion velocity, maximum inversion,maximum inversion velocity, and the time to maximum inversion.Both taping conditions offered residual restriction afterexercise27.
Lohrer H, Alt W, Gollhofer A (1999) they used electromyographic and goniometric methods to test 40 subjects to describe neuromuscular and biomechanical adaptation of the ankle with respect to application of different tapes and to exercise. The proprioceptive amplification ratio was calculated on the basis of the integrated reflex electromyographic results and on maximum inversion amplitude. Relevant stability gains were achieved immediately after applying tape. There was reduced tape stability after athletic exercise for one of two tape material tested .no further loosening was detected even after prolonged wearing of tape and they concluded that compared with unprotected ankle , taped ankle has significant increase in the proprioceptive amplification ratio28.
Michael J Callaghan(1997)theyinvestigated zinc oxide taping techniques on ankle and resulted in Hinton-Boswell method provided greatest resistance to inversion. They concluded that ankle taping did improve foot position awareness and so may have role in prevention of ankle sprain in athletes.10
S Robbins, E Waked and R Rappel (1995) they described that this randomized crossover comparison experiment which tests the hypothesis that ankle taping improves foot position awareness before and after exercise. 12 taped and 12 untaped healthy volunteers judged before and after exercise which consisted of playing basket ball and running for 30 minutes. Ankle taping was performed by certified athletic therapist. The taping procedure was gibeny basket wave with double heel-lock taping. They concluded that this study supports the hypothesis is tested that the taping improves foot position awareness .this experiment provides the strongest physiological evidence yet presented of potential use fullness of ankle taping in sports29.
Review on proprioception.
Eric Eils, Ralf Schroter, Marc Schroder, Joachim Gerss, Dieter Rosenbaum (2010) the purpose of this study was to investigate the effectiveness of multistation proprioceptive exercise program for the prevention of ankle injuries in basket ball players. Total 232 players participated in the study were randomly assigned to control and training group performed a multistation proprioceptive exercise program and control group continued with their normal work out routines. The result revealed significant improvement in joint position sense and single limb stance in training group. They concluded that multistation proprioceptive exercise program effectively prevented ankle injuries in basket ball players30.
Evert Verhagen, Allard van der Beek, Jos Twisk, LexBouter, Roald Bahr, Willem Mechelen (2004) they mentioned that ankle sprains are the most common injuries in a variety of sports. The purpose of this study was to determine the effectiveness of proprioceptive balance board program for ankle sprains in volley ball players. There were 116 male and female volley ball teams followed by prospectively during 2001-2002 season. Intervention teams followed by prescribed balance board training and control teams followed their normal training. The result of the study is a significant reduction in ankle sprain risk was found only for players with history of ankle sprains and they concluded that use of proprioceptive balance board training is effective for prevention of ankle sprain recurrences31.
Tine Willems, Erik Witvrouw, Jan Verstuyft, Peter Vaes, Dirk De Clercq (2002)the purpose of this study was to determine the patients with chronic ankle instability or without chronic ankle instability have worse proprioception or less invertor or evertor muscle strength . they assessed proprioception and muscle strength on Bisdex isokinetic dynamometer. Active and passive joint position sense was assessed at the ankle and they concluded that the possible cause of chronic ankle instability is a combination of diminished proprioception and evertor muscle weakness32.
J. Jerosch, I. Hoffstetter, H. Bork, M. Bischof (1995) in this study the ankle joints of 14 healthy volunteers and 16 patients with unstable joints were tested regarding their proprioceptive and functional capabilities. All of them were active athletes. Three tests were used of the study single leg stance test single leg jumping course test and angle reproduction test. The influence of three stabilization devices were lace on brace, Mikros stirrup brace and aircast taping on the proprioceptivity of stable and unstable ankle joints was evaluated. The difference in all measurements between standard vsMikros and standard vsaircast were significant. The result of three tests showed a highly significant difference between injured and not injured ankle joints33.
Review about foot and ankle disability index
Christophe Eechaute, Peter Vaes , Lieve Van Aerschot, Sara Asman and William Duquet (2007)