Sports Med (2014) 44:1545–1556

DOI 10.1007/s40279-014-0218-2

SYSTEMATIC REVIEW

Chronic Ankle Instability in Sporting Populations

Alison Suzanne Attenborough • Claire E. Hiller •

Richard M. Smith • Max Stuelcken •

Andrew Greene • Peter J. Sinclair

Published online: 1 July 2014

Ó Springer International Publishing Switzerland 2014

Abstract Methods A systematic search of the MEDLINE, Web of

Background Chronic ankle instability (CAI) is a term Science, CINAHL, SPORTDiscus and AMED databases up
used to identify certain insufficiencies of the ankle joint until 1 October, 2013 produced 88 studies appropriate for
complex following an acute ankle injury. Acute ankle review. A calculated weighted percentage of the outcome data
injuries are often associated with sporting mishaps; how- allowed the comparison of figures across a range of sports.
ever, this review was the first to identify the aspects of CAI Results Soccer, basketball and volleyball were the most
(perceived instability, mechanical instability and recurrent represented sports and recurrent ankle injury/sprain was the
sprain), and persisting symptoms following an ankle sprain, most reported aspect of CAI. Soccer had the highest per-
that have been reported within sporting cohorts. centage of participants with recurrent sprain (61 %) and
Objective To determine the presence of common aspects mechanical instability (38 %), whilst track and field had the
of CAI within individual sports. highest percentage of participants with perceived instability
(41 %). Gymnasts had the highest percentage of ankles with
persisting symptoms following an initial ankle sprain.
Electronic supplementary material The online version of this Conclusion This review was the first to assess aspects of
article (doi:10.1007/s40279-014-0218-2) contains supplementary CAI within sporting cohorts and has identified limitations to
material, which is available to authorized users. the research reporting these data. The problem of CAI across
a range of sports remains unclear and thus advocates the need
A. S. Attenborough (&)
Discipline of Exercise and Sport Science, Faculty of Health for further controlled research in the area to ascertain the true
Sciences, University of Sydney, PO Box 170, Lidcombe, extent of CAI within sporting populations.
NSW 1825, Australia
e-mail: aatt4376@uni.sydney.edu.au

C. E. Hiller Key Points

Arthritis and Musculoskeletal Research Group, Faculty of Health
Sciences, The University of Sydney, Sydney, Australia
The prevalence of chronic ankle instability amongst
R. M. Smith  P. J. Sinclair sporting populations has not been broadly
Discipline of Exercise and Sport Science, Faculty of Health represented in previous literature
Sciences, The University of Sydney, Sydney, NSW, Australia
The three sports with the most chronic ankle
M. Stuelcken instability information were soccer, volleyball and
School of Health and Sport Sciences, Faculty of Science, Health,
Education and Engineering, University of the Sunshine Coast, basketball
Sunshine Coast, QLD, Australia
The majority of included studies examined the
A. Greene recurrent sprain aspect of chronic ankle instability
Postgraduate Medical Institute, Faculty of Health, Social Care with the percentage of participants sustaining two or
and Education, Anglia Ruskin University, Chelmsford, England, more sprains being 27 % (dance) to 61 % (soccer)
UK

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1546 A. S. Attenborough et al.

1 Introduction joint complex during anterior and inversion movements

[14]. Persisting physical laxity of the ankle ligaments is
The ankle accounts for a substantial percentage of acute often detectable following an acute ankle sprain, with an
sporting injuries [1, 2] with sprains, in particular lateral early study by Bosien et al. [19] finding that 60 % of ankles
ligament sprains, being the most common [3]. High-risk exhibit mechanical instability 2 years after an initial injury.
activities for ankle injury include team and court sports [4] Clinically, the anterior drawer and talar tilt tests are used to
as well as games involving contact, jumping manoeuvres, detect ligament laxity by determining the magnitude of
and/or indoor play [5]. Sports that fall into these categories movement of the talus in reference to the tibia [17].
are reported to have high instances of acute ankle sprains, A comprehensive overview of CAI within organised
with the literature classifying approximately 54 % of all sport and physical activities has not been reported. For this
injuries in volleyball [6, 7], 25 % of all injuries in bas- review, CAI will be defined as a condition that encom-
ketball [8, 9] and 17 % of all injuries in soccer [10–12] as passes one or more of three individual contributors that
acute ankle sprains. A review of ankle injuries across a persist following an acute ankle sprain; perceived ankle
range of 70 sports established that the ankle was the most instability, mechanical ankle instability and/or recurrent
commonly injured body region in a third of the sports and, ankle sprain [13]. The purpose of this review is to describe
when divided into injury type, 77 % of ankle injuries were CAI within samples of sporting cohorts to determine
found to be ankle sprains [4]. Although the burden of acute whether certain populations are more susceptible to
ankle injuries resulting from sporting participation is well developing the common characteristics of CAI and/or
known, the chronic nature of persisting conditions, such as persistent ankle sprain symptoms. Identifying the extent to
chronic ankle instability (CAI), needs clarification. which CAI is a problem within sporting populations will
CAI, covers a vast array of synonyms [13], but is steer further research into this area and ultimately lead to
essentially a term used to identify certain insufficiencies of better injury management and/or prevention strategies.
the ankle joint complex following an acute ankle injury. In
the past, it was thought that perceived and mechanical
instability described a complex continuum of pathological 2 Methods
factors related to CAI that, when presented together, lead to
recurrent sprain [14]. This was modelled on the basis that if 2.1 Search Strategy
an ankle had mechanical and/or perceived instability, then
it was susceptible to sprain [14]. While this remains true, Five online databases [MEDLINE (from 1950); Web of
research suggests that an individual can repeatedly sprain Science (from 1900), CINAHL (from 1982), SPORTDiscus
an ankle in the absence of any long-term perceptions of (from 1975), and AMED (from 1985)] were searched up to
instability [15]. More recently, an alternative model of CAI 1st October 2013. The MEDLINE search strategy
has been proposed that views recurrent sprains as a sub- (Table 1) was modified for the requirements of the
group of CAI that can present independently of perceived remaining databases. The online database ProQuest Dis-
or mechanical instability [13]. sertation & Theses (1997–June 2013) was then searched
Perceived instability is characterised by a feeling of using keywords ‘ankle instability’ or ‘unstable ankle’ to
‘giving way’ experienced at the ankle joint complex. First uncover theses that may contain content appropriate for
termed functional instability by Freeman in 1965 [16], it this review.
evolved into many different terms until Hiller et al. in 2011
[13] proposed that ‘perceived instability’ should be the 2.2 Inclusion and Exclusion Criteria
cohesive term used to describe this subjective measure-
ment. Despite a large proportion of ankles regaining a For inclusion in this review, articles had to satisfy all of
functional level of stability as a result of conservative three criteria set a priori; (1) be original peer-reviewed
rehabilitation, up to 20 % of people develop some degree research, (2) have reported the specific sport/physical
of long-term perceived instability following an initial ankle activity and (3) report a measure of CAI (perceived insta-
sprain [17]. It has been found that athletes report a greater bility, mechanical instability and/or two or more ankle
number of residual complaints compared with individuals injury/sprains) or persisting symptoms of an acute ankle
who participate in less demanding activities [18], which injury/sprain lasting C6 months. Articles were excluded if
increases the risk of athletes sustaining similar injuries in the full text was not available in English, participants were
the future [14]. a military-based cohort, they were review articles or case
Mechanical instability is a physiological laxity of the studies, CAI was the result of a fracture, data were the
lateral ankle ligaments responsible for supporting the ankle outcome of surgical procedures, duplicate data sets were

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Chronic Ankle Instability in Sporting Populations 1547

Table 1 MEDLINE search strategy

(talocrural.mp. OR talo crural.mp. OR talocalcaneal.mp. OR talo calcaneal.mp. OR tibiotalar.mp. OR tibio talar.mp. OR talofibular.mp. OR
talo fibular.mp. OR ankle*.mp. OR ankle joint*.mp.)
AND
(sport*.mp. OR activit*.mp. OR play*.mp. OR athlet*.mp. OR exercis*.mp. OR physical*.mp.)
AND
(incidenc*.mp. OR prevalenc*.mp. OR epidemiolog*.mp. OR survey*.mp. OR statistic*.mp. OR pattern*.mp. OR frequenc*.mp. OR
distribution*.mp. OR risk.mp. OR rate.mp.)
AND
(ankle instabilit*.mp. OR chronic instabilit*.mp. OR instabilit*.mp. OR chronic.mp. OR joint instabilit*.mp. OR mechanical instabilit*.mp.
OR functional instabilit*.mp. OR perceived instabilit*.mp. OR subjective instabilit*.mp. OR unstab*.mp. OR lax*.mp. OR overus*.mp. OR
sprain*.mp. OR strain*.mp. OR inversion sprain*.mp. OR inversion injur*.mp. OR repeated sprain*.mp. OR repeated injur*.mp. OR
wound*.mp. OR injur*.mp. OR syndesmosis.mp. OR lateral ligament*.mp. OR collateral ligament*.mp. OR talofibular ligament*.mp. OR
talo fibular ligament*.mp. OR calcaneofibular ligament*.mp. OR calcaneo fibular ligament*.mp. OR recurrent.mp. OR pain*.mp. OR
swell*.mp. OR weak*.mp. OR giv* way.mp.)
limit to (english language and humans)

reported or the data reported could not be separated into probability of a participant with a prior sprain experiencing
specific sports. Age, sex, geographical location, ethnicity a recurrent sprain, compared with an individual incurring
and the level of athletic involvement of the participants his/her first sprain, was extracted if the p-value or 95 %
were not reasons for exclusion. confidence intervals were reported.
For perceived ankle instability, the number of partici-
2.3 Study Selection Process pants with a prior ankle sprain was extracted followed by
the number of these participants with perceived instability.
Two independent authors screened the title and abstract of Extracted data for mechanical ankle instability included the
the online database search results using the predetermined test used to define the laxity, the number of participants
inclusion and exclusion criteria. Full texts of the remaining with a previous ankle sprain, as well as the number of these
articles were retrieved and further screened by two inde- participants with mechanical instability.
pendent authors. Where consensus could not be reached, a For persisting symptoms, the number of participants
third author adjudicated the decision. with a prior ankle sprain was extracted as well as the
number of these participants with persisting symptoms
2.4 Data Extraction C6 months. The mean length of the follow-up period was
recorded as were the symptom/s reported.
Data were extracted by two of the review authors for all To allow for between-sport comparisons in the case that
included studies. The demographic and outcome data for more than one article reported a particular outcome, data
perceived ankle instability, mechanical ankle instability, were compared across papers by converting the figures to a
recurrent ankle injuries/sprains and persisting symptoms weighted percentage [4]:
were extracted by sport. For all included studies, partici- Pn
i¼1 ða  bÞ
pant number, age, sex and athletic status were extracted. Pn
i¼1 a
For recurrent data, the prospective or retrospective nature
of the study was determined. Where possible, ankle sprains where n is the number of articles being collated, i is an
have been reported separately to ankle injuries as the latter integer, a is the number of participants/ankles used for
may also have included tendonitis, bruising and impinge- analysis and b is the percentage of a displaying the aspect
ments. Where reported, the number of participants affected of CAI being calculated. For example, the weighted per-
by the injuries/sprains was recorded. The statistical centage for articles reporting perceived instability data:

Pn
i¼1 ðparticipants with a previous sprain  percentage of participants with perceived ankle instabilityÞ
Pn
i¼1 participants with a previous sprain

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1548 A. S. Attenborough et al.

If a sport was represented by more than one study, then S1. The weighted percentage data identifies that soccer
an a value was necessary for its inclusion in this equation. (61 %) and basketball (60 %) are the sports with the
Studies included for recurrent injury that recruited only highest number of participants with recurrent sprains.
individuals with a previous sprain history were excluded In comparison to the number of articles that describe
from the calculation of weighted percentages as any ankle recurrent ankle injury data, relatively few sports studies
injury within that study would show 100 % recurrence. have investigated perceived instability, mechanical insta-
bility or symptoms that persist following an ankle sprain.
The demographic and outcome data from studies reporting
3 Results perceived instability are presented in Table 4 with four
sports being represented; basketball, dance, netball and
Eighty-eight studies met the inclusion criteria for the track and field. Dance and soccer were the only two sports
review with the search process described in Fig. 1. Data in which articles reported mechanical instability data for
from the 88 included studies have been grouped together their participants (Table 5), with the anterior drawer test
by sport (Table 2) with soccer, volleyball and basketball being the most common tool for assessing mechanical
being the most represented sports. The decade in which all instability. Persisting symptoms following an ankle injury/
included articles were published is presented in Fig. 2. sprain were reported in American Football, badminton,
The weighted percentage data for recurrent information basketball, gymnastics, handball and soccer (Table 6).
is separated by sport in Table 3. Full demographic and Soccer, volleyball and basketball were the three sports
outcome data extraction of these recurrent injury studies that contributed the majority of CAI data for this review.
can be found in Electronic Supplementary Material Table As a result of studies reporting data for multiple sports, of

Fig. 1 Study selection flow

Identification

chart
Records identified through Additional records identified through
database searching other sources
(n = 10,459) (n = 6)

Records after duplicates removed

(n = 6,583)
Screening

Records screened Records excluded

(n = 6,583) (n = 5,807)

Full-text articles assessed Full-text articles excluded

Eligibility

for eligibility (n = 688)

(n = 776)
No chronic ankle
instability data n=481
Sport not defined n=90
Not original research n=67
Full text not found n=16
Abstract only n=14
No English full text n=7
Cannot extract data n=5
Duplicate data n=5
Included

Studies included in
qualitative synthesis
(n = 88)

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Chronic Ankle Instability in Sporting Populations 1549

Table 2 Studies eligible for review separated by sport 3.1 Soccer

Sport Number of included References
articlesa Thirty-five articles have addressed aspects of CAI or per-
sisting symptoms within a soccer cohort (Table 2). Thirty-
Soccer 35 [10, 11, 20–52] one of these articles reported on recurrent ankle injury/
Basketball 19 [8, 9, 41, 49, 50, 53– sprain data. In soccer, 19 % of ankle sprains were recurrent
66]
and, of the participants sustaining ankle sprains, 61 % of
Volleyball 13 [6, 7, 41, 50, 67–75]
them had sprained ankles on more than one occasion
American 5 [41, 50, 76–78]
football
(Table 3). No articles investigated perceived instability
Cheerleading 3 [49, 79, 80]
within a soccer cohort. Three articles reported mechanical
ankle instability for soccer [22, 27, 44] with a weighted
Dance 3 [81–83]
percentage calculation indicating that 38 % of soccer
Gymnastics 3 [49, 84, 85]
players with a previous ankle injury/sprain sustained pro-
Handball 2 [86, 87]
longed ligament laxity as a result (Table 5). Three articles
Netball 2 [88, 89]
reported persisting symptoms following an ankle injury
Track and field 2 [90, 91]
sustained during soccer [22, 27, 42]. The symptoms
Aerobics 1 [92]
addressed were combinations of stiffness, pain, swelling,
Badminton 1 [93]
‘giving way’ and ‘instability’ which, when combined
Baseball 1 [50]
through a weighted percentage, indicated that 45 % of
Fencing 1 [94]
soccer players reported persisting symptoms following an
Floorball 1 [95]
ankle injury (Table 6).
Futsal 1 [96]
Ice hockey 1 [97]
3.2 Basketball
Rugby union 1 [98]
Softball 1 [50]
Nineteen of the included articles in this review addressed
Tennis 1 [99]
aspects of CAI in basketball with all 19 of these studies
Ultimate frisbee 1 [100]
reporting recurrent ankle injury/sprain data (Table 2).
Windsurfing 1 [101]
Twenty-eight percent of ankle sprains sustained during
Wrestling 1 [50]
basketball were recurrent and of participants reporting an
a
The total exceeds the number of studies included for review as ankle sprain, 60 % had sprained ankles on more than one
some reported chronic ankle instability data for a number of different occasion (Table 3). In basketball, the weighted percentage
sports
for perceived instability in individuals with previous ankle
sprains was 28 % [54, 60] (Table 4). No studies reported
45 mechanical instability data and only one study reported
Number of included articles

40 persisting symptoms following an ankle injury in basket-

35 ball, finding that 30 % of participants had ongoing symp-
30 toms (Table 6).
25
20
15
3.3 Volleyball
10
5
Thirteen articles have reported CAI data for volleyball, all
0 of which report recurrent injury information (Table 2). A
1970-1979 1980-1989 1990-1999 2000-2009 2010-present weighted percentage indicates that 46 % of ankle sprains
Decade of publication were recurrent and 50 % of participants with ankle sprains
Fig. 2 The decade of publication of articles included for review sprained on more than one occasion (Table 3). Perceived
and mechanical ankle instability have not been investigated
the 88 articles included for review, 62 reported CAI data in in a volleyball cohort and no data on persisting symptoms
soccer, volleyball and/or basketball (Table 2). These three following an ankle injury/sprain during volleyball have
individual sports have been described in more detail below. been reported.

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1550 A. S. Attenborough et al.

Table 3 Weighted percentage data for recurrent ankle injury information separated by sport
Recurrent ankle Participants with Recurrent ankle sprains Participants with
injuriesa recurrent ankle recurrent ankle
injuriesa,b,c sprainsb,c

Aerobics – 7 [92] – –
American football 22 [41, 77] – 43 [77, 78] 52 [76, 78]
Baseball 14 [50] – – –
Basketball 23 [41, 63, 64, 66] 73 [61] 28 [8, 9, 53–55, 58, 59] 60 [55, 56, 59, 60, 65]
Cheerleading 17 [79, 80] – 21 [49] –
Dance 5 [83] – – 27 [81]
Fencing – – 75 [94] –
Floorball – – 50 [95] 50 [95]
Futsal 57 [96] – – –
Gymnastics – – 25 [84] –
Handball 50 [87] 50 [87] – –
Netball 49 [89] – – –
Rugby union 27 [98] – 25 [98] –
Soccer 10 [23, 25, 30, 33, 39, 27 [23, 30] 19 [10, 11, 20, 21, 24, 28, 31, 61 [21, 36, 43]
41, 42, 52] 33–36, 38, 46, 47, 51, 52]
Softball 24 [50] – – –
Tennis – – 56 [99] –
Ultimate frisbee – 18 [100] – –
Volleyball 32 [41, 68] – 46 [6, 7, 67, 69, 72, 75] 50 [70, 73–75]
Windsurfing 73 [101] – 18 [101] –
Wrestling 5 [50] – – –
– indicates no information was available
a
Ankle injuries that have not been separated into specific injury types could include sprains, but also tendonitis, bruising and impingements
b
Prospective studies included in the weighted percentage reflect participants who injured/sprained an ankle during the study and the recurrent
nature of that particular injury, not the percentage of recurrence of the total study cohort as would be reported in retrospective study designs
c
Study must have reported on the number of individuals sustaining the injuries/sprains

Table 4 Summary of included studies reporting perceived ankle instability data separated by sport
Sport References n Age (years), Sex Athletic status Participants Participants with
Mean ± SD of participants with previously
previous ankle sprained ankles with
sprains, n perceived instability,
n (%)

Basketball Barrett et al. [54] 569 20.6 M 523 F 46 Collegiate 127 15 (12)
Leanderson et al. 96 25.5 M 96 Second division 88 46 (52)
[60]
Dance Rein et al. [82] 60 30.5 M 20 F 40 Professional and 23 0
amateur
Netball Hopper et al. [88] 228 19.2 F 228 National 265a 104 (39)a
Track and Edouard et al. [90] 25 22 ± 5 M 20 F 5 Regional/international 17 7 (41)
Field
M male, F female, SD standard deviation
a
Ankles not participants

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Chronic Ankle Instability in Sporting Populations 1551

Table 5 Summary of included studies reporting mechanical ankle instability data separated by sport
Sport References n Age (years), Sex Athletic status Test used to define Participants with Participants with
Mean ± SD of participants mechanical ankle previous ankle mechanical instability,
instability sprains, n n (%)

Dance Rein et al. 60 30.5 M 20 Professional Anterior drawer and 23 0

[82] F and amateur talar tilt
40
Soccer Rein et al. 60 26 M 60 Professional Anterior drawer and 32 0
[44] and amateur talar tilt
Brynhildsen 150 20 ± 3 F Third division Anterior drawer 73 20 (27)
et al. [22] 150
Ekstrand 180 24.6 ± 4.6 M Fifth division – 82 52 (63)
et al. [27] 180
M male, F female, SD standard deviation
– indicates no information was available

Table 6 Summary of included studies reporting persisting symptom data separated by sport
Sport References n Age (years), Sex Athletic Follow-up Persisting Participants Participants with
Mean ± SD status of period symptom with previous previously sprained/
participants (mean) ankle sprains/ injured ankles with
injuries, n persisting symptoms,
n (%)

American Taylor et al. 39 – – Collegiate 47 months Stiffness 44a 16 (36)a

[77]
Football Taylor et al. 39 – – Collegiate 47 months Pain 44a 10 (23)a
[77]
Taylor et al. 39 – – Collegiate 47 months Swelling 44a 8 (18)a
[77]
Badminton Fahlström 78 31.9 M 67 Competitive 35 months – 23 13 (57)
et al. [93] F 11 to beginner
Basketball Smith et al. 84 – M 84 High school – – 59 30 (51)
[65] athletes
Gymnastics Wadley 22 – F 22 Former 3 years – 14a 9 (64)a
et al. [85] collegiate
Handball Nielsen 221 C7 M Youth to C6 months Pain and 35 14 (40)
et al. [86] 109 adult instability
F
112
Soccer Brynhildsen 150 20 ± 3 F 150 Third – Pain, 73 35 (48)
et al. [22] division swelling,
‘giving
way’
Nielsen 123 C16 M Youth to 1 year Pain and 39 5 (13)
et al. [42] 123 adult instability
Ekstrand 180 24.6 ± 4.6 M Fifth – – 82 47 (57)
et al. [27] 180 division
M male, F female, SD standard deviation
– indicates no information was available
a
Ankles not participants

4 Discussion data for every aspect of CAI. Dance was the only sport that
had data reported for each aspect of CAI; perceived
Twenty-three sports are included in this review for data instability [82], mechanical instability [82] and recurrent
related to aspects of CAI and/or persisting symptoms fol- sprain [81, 83]. Within their respective cohorts, it is
lowing an ankle injury/sprain. No individual study reported reported that no dancers had perceived or mechanical

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1552 A. S. Attenborough et al.

instability, 27 % of dancers had sprained ankles on more talar tilt tests only provide a subjective interpretation of
than one occasion and 5 % of ankle injuries sustained ligamentous integrity. Furthermore, mechanical laxity
during dance were recurrent. might not be the lone source of mechanical instability [14].
Fifty-eight papers reported recurrent ankle injuries/ It has been suggested that arthrokinematic restrictions and
sprains, whilst only 27 papers reported recurrence in terms hypomobility of the ankle could similarly contribute to the
of the number of participants sustaining those injuries development and progression of CAI. Stress radiography
(Electronic Supplementary Material Table S1). Compared and instrumented arthrometry [14, 102] are more objective
with the injuries themselves, the number of individuals measures that evaluate mechanical stability at the ankle.
sustaining re-injuries is of more importance to sporting Normative values for arthrometry measures have been
populations and so future studies should consider reporting disseminated through the literature [103, 104] and future
the number of individuals who have recurrently sprained studies investigating mechanical ankle instability within
rather than the total number of recurrent sprains. This sporting populations should consider using these objective
would more accurately describe the degree to which CAI is measures as a means of comparison.
a problem within specific sporting cohorts and allow for Mechanical instability of the ankle is often assessed for
appropriate prevention strategies to be developed. signs of structural impairment within the acute phase of
The highest percentage of recurrent ankle injuries and injury. Whilst this provides an assessment of injury
sprains were recorded in windsurfing [101] (73 %) and severity, solely testing the mechanical laxity at this time
fencing [94] (75 %), respectively. Data from these sports, point does not give an indication of how the damage will
and others only represented by one publication, must be affect the individual long term. Long-term measures of
viewed with caution, as data combined from several studies mechanical instability are central to determining whether a
provide a more accurate reflection of a total population. persisting laxity predisposes the ankle to recurring sprains
Soccer (61 %) was the sport with the highest percentage of [14] or further pathologies [105]. Irrespective of the time
participants with recurrent ankle sprains. This percentage point at which the measure is taken, a pre-season/baseline
was the weighted data of three studies that reported indi- measure of mechanical stability should be considered in
vidual values of 55 % [43], 60 % [36] and 79 % [21]. future ankle injury research to account for inter-individual
Basketball had the second highest weighted percentage variability in ligament laxity. A pre-season, or pre-injury,
with 60 % of participants reporting recurrent sprains. Both measure of mechanical stability would act to ensure that
basketball and soccer are multidirectional sports involving any measure taken post-injury, whether in the acute or
repetitive running, cutting and jumping manoeuvres, whilst chronic phase, differs from an individual’s initial
trying to avoid contact with surrounding players. The assessment.
movement patterns of these two sports make it unsurprising Similar to mechanical instability, few studies have
that there are a high percentage of athletes sustaining investigated perceived ankle instability within sporting
recurrent ankle sprains during participation. Presumably, populations. Two studies have reported the measure in
sports similar to basketball and soccer, such as netball and basketball; one reported that 12 % of previous sprainers
futsal respectively, would report similar figures; however, had perceived instability [54], while the other reported a
previous investigations into netball [88, 89] and futsal [96] value of 52 % [60]. After converting these figures to a
have not addressed the recurrent nature of sprains sustained weighted percentage, 28 % of basketball players had per-
by individual participants. ceived instability. The highest percentage of athletes
Chronic measures of mechanical instability following an reporting perceived instability was 41 % in a cohort of
ankle sprain have not been frequently reported in the track and field athletes [90], with individuals involved in a
sporting literature, with dance and soccer being the only range of events; long-distance running, sprints, jumping
sports reporting this measure. Two of the studies (dance and throwing activities. Netball was the sport with the
[82]; soccer [44]) reported that none of their cohort had second highest figure of perceived instability, with 39 %
mechanical instability which, considering the involvement [88] of ankles being described as having perceived insta-
of the lower limb in these sports, necessitates the need for bility. None of the studies included in this review for
further research to validate these figures. Interestingly, the perceived instability used a valid or reliable tool to assess
study with the highest percentage of participants with this measure of CAI. Instead, the studies relied on partic-
mechanical instability failed to define the methodology ipant-answered questions regarding ankles that ‘give way’
used for its determination [27]. Three of the four studies in or are ‘unstable’. Three questionnaires that assess per-
this review for mechanical instability used the anterior ceived instability have recently been recommended for the
drawer test and/or talar tilt test to define mechanical identification of CAI in controlled research [102]; the
instability. Whilst both of these tests are widely used in Cumberland Ankle Instability Tool [106], Identification of
clinical assessment of the ankle, the anterior drawer and Functional Ankle Instability [107] and the Ankle Instability

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Chronic Ankle Instability in Sporting Populations 1553

Instrument [108]. These validated questionnaires should be studies, have made critically evaluating the quality of the
used in the future assessment of perceived instability included studies problematic. Prospective methodologies
within sporting cohorts. generally only report the recurrent nature of injuries sus-
For the most homogeneous account of CAI within tained during the study period and do not reflect the overall
sporting populations, the identification of perceived insta- recurrence of ankle injuries within the entire cohort being
bility within this review was based on an individual’s investigated. Comparison between individual prospective
perception of his/her ankle stability. Restricted sensory- studies is also made difficult by the varying length of the
motor control of the ankle joint complex has been sug- follow-up period. The probability of sustaining an injury
gested as a factor for functional limitations including over the course of a season is increased when compared
impaired proprioception and impaired neuromuscular and with a 1-day tournament, as the exposure rates will
postural control [14]. As well as using the validated per- cumulatively increase over a longer period of time. This
ceived instability questionnaires in future research, atten- being said, in the same way that injuries are more likely to
tion should be paid to sensory-motor measures such as occur during a match versus a training session [26, 36, 53,
balance assessment, joint position recognition and central 75], it could also be argued that in a tournament environ-
processing networks. ment, an individual might be more susceptible to injury
Despite persisting symptoms not being a part of the CAI based on competitive attitudes and performance outputs.
model proposed by Hiller et al. [13], it is important to Prospective study designs are seen as the preferred
recognise that chronic symptoms could be argued to be the methodology for injury studies because retrospective
biggest limiting factor affecting the continued participation questionnaires tend to underestimate the occurrence of
of individuals in their sporting pursuits. Within a sample of injury through recall bias [110]. This leads to a reduced
the general Australian community, 29 % of individuals confidence in reported data based on an individual’s like-
reported a previous ankle sprain [109]. Individuals that lihood of overlooking minor/moderate injuries if they are
were chronically affected by their previous sprain reported rehabilitated quickly; especially given that the majority of
weakness, pain, swelling and ‘giving way’ as the symptoms acute ankle sprains are classed as minor [55, 66]. Numer-
that signified their incomplete recovery. Of these individ- ous studies included in this review have employed retro-
uals, 55 % were forced to limit, or modify, activities of spective study designs for the recall of past ankle injuries,
daily living or sporting interests because of chronic and as a result, the frequency of recurrence in these studies
symptoms of the previous ankle sprain. Persisting symp- should be seen as a conservative estimate.
toms investigated in the reviewed studies included com- Differing injury definitions make comparisons between
binations of stiffness, pain, swelling, ‘giving way’ and studies difficult and potentially inappropriate. Personal
instability. Gymnastics [85] and badminton [93] had the interpretation of an injury definition could lead to misre-
highest percentage of persisting symptoms following an ported recurrence data, especially in self-reported retro-
ankle sprain, with 64 and 57 % respectively. spective studies. There were 79 studies included in this
The number of publications on the topic of this review review for having reported recurrent ankle injury data.
has been increasing over the decades, suggesting that the Fifty-two (66 %) of these investigations employed purely
importance of CAI in sporting populations is becoming time loss definitions for a reportable injury. An additional
well established in the literature. However, the aims of seven studies [29, 51, 54, 61, 67, 68, 92] incorporated a
the included studies show that the majority of the CAI time loss definition as one option to define a reportable
data are only being reported incidentally. Ten studies [7, injury, with other options including tissue damage, player
32, 38, 40, 45, 50, 62, 78, 91, 101] set out to specifically handicap, trivial complaints or functional limitations. Five
investigate a variable of CAI within their sporting cohort; studies [45, 73, 89, 94, 97] adopted medical attention as
however, these studies were only interested in the recur- their only definition of injury whilst 12 articles did not
rent nature of ankle injuries and no links between injury provide any definition of injury [23, 25, 55, 58, 65, 72, 74,
recurrence and CAI were made. It is understood that a 77, 83, 91, 100, 101]. The remaining three studies defined
history of a previous ankle sprain is a risk factor for a injury as pain or discomfort [63], an inversion injury
similar injury occurring in the future [6, 21, 29, 36, 61]; occurring during a match/training [40] or an event leading
however, linking this current knowledge in the athletic to swelling, bruising and limping [81]. It is difficult to
community with the idea of CAI needs to be addressed suggest one ankle injury definition across a range of sports
with more consideration. as each has its own special athletic requirements and
There are many limitations to a review of this nature in considerations. In saying that, it should be an aim of
terms of the methodology of the included studies. The research investigating sports with similar movement
numerous study designs within this systematic review, requirements to come to a consensus regarding what con-
along with the lack of quality assessment tools for cohort stitutes an ankle injury in their chosen field.

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1554 A. S. Attenborough et al.

The revised CAI model [13] that incorporates recurrent 5. Backx FJ, Beijer HJ, Bol E, et al. Injuries in high-risk persons
sprain, perceived instability and mechanical instability as and high-risk sports: a longitudinal study of 1818 school chil-
dren. Am J Sports Med. 1991;19(2):124–30.
independent characteristics of CAI, combined with the 6. Bahr R, Bahr IA. Incidence of acute volleyball injuries: a pro-
International Ankle Consortium statement [102], recapitu- spective cohort study of injury mechanisms and risk factors.
lates the multifaceted nature of CAI and recognises the Scand J Med Sci Sports. 1997;7(3):166–71.
disablement that can arise from any number of its aspects. 7. Beneka A, Malliou P, Gioftsidou A, et al. Injury incidence rate,
severity and diagnosis in male volleyball players. Sport Sci
Most disabling to an athlete aiming for continued sporting Health. 2009;5(3):93–9.
participation are the persisting symptoms that can follow 8. Cumps E, Verhagen E, Meeusen R. Prospective epidemiological
an ankle sprain, the potential recurrent nature of the injury study of basketball injuries during one competitive season: ankle
possibly owing to mechanical laxity and the perceived loss sprains and overuse knee injuries. J Sports Sci Med.
2007;6(2):204–11.
of integrity of the ankle joint. 9. Dick R, Hertel J, Agel J, et al. Descriptive epidemiology of
collegiate mens basketball injuries: National Collegiate Athletic
Association Injury Surveillance System, 1988–1989, through
5 Conclusion 2003–2004. J Athl Train. 2007;42(2):194–201.
10. Agel J, Evans TA, Dick R, et al. Descriptive epidemiology of
collegiate men’s soccer injuries: National Collegiate Athletic
This review identifies studies that report aspects of CAI Association Injury Surveillance System, 1988–1989 through
and, although comparisons have been described within this 2002–2003. J Athl Train. 2007;42(2):270–7.
article, it is with caution that we draw these judgements 11. Aoki H, O’Hata N, Kohno T, et al. A 15-year prospective epi-
demiological account of acute traumatic injuries during official
because of the methodological differences between inves- professional soccer league matches in Japan. Am J Sports Med.
tigations. The most common aspect of CAI reported in the 2012;40(5):1006–14.
sporting literature was recurrent sprain. Soccer, basketball 12. Ekstrand J, Gillquist J. The avoidability of soccer injuries. Int J
and volleyball were the sports most represented in terms of Sports Med. 1983;4(2):124–8.
13. Hiller CE, Kilbreath SL, Refshauge KM. Chronic ankle insta-
the number of articles included for review. Dance was the bility: evolution of the model. J Athl Train. 2011;46(2):133–41.
only sport that provided data for each aspect of CAI, albeit 14. Hertel J. Functional anatomy, pathomechanics, and pathophys-
from different investigations. The percentage of partici- iology of lateral ankle instability. J Athl Train. 2002;37(4):
pants with recurrent sprain was highest in soccer with 364–75.
15. Tropp H, Ekstrand J, Gillquist J. Stabilometry in functional
61 %, followed by basketball with 60 %. Despite few instability of the ankle and its value in predicting injury. Med
articles reporting perceived instability and mechanical Sci Sports Exerc. 1984;16(1):64–6.
instability, track and field had the highest percentage of 16. Freeman MA. Instability of the foot after injuries to the lateral
individuals reporting perceived instability following an ligament of the ankle. J Bone Jt Surg Br. 1965;47(4):669–77.
17. Karlsson J, Lansinger O. Lateral instability of the ankle joint.
ankle sprain, whereas soccer had the highest percentage of Clin Orthop Relat Res. 1992;276:253–61.
individuals exhibiting mechanical instability. This review 18. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up
has identified limitations to current sporting research of inversion trauma of the ankle. Arch Orthop Trauma Surg.
reporting CAI data and concludes that the degree to which 1995;114(2):92–6.
19. Bosien WR, Staples OS, Russell SW. Residual disability fol-
CAI is a problem within specific sporting populations lowing acute ankle sprains. J Bone Jt Surg Am. 1955;37-
remains unclear. A(6):1237–43.
20. Árnason Á, Gudmundsson Á, Dahl HA, et al. Soccer injuries in
Acknowledgements No sources of funding were used to assist in Iceland. Scand J Med Sci Sports. 1996;6(1):40–5.
the preparation of this review. The authors have no potential conflicts 21. Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for
of interest that are directly relevant to the content of this review. injuries in football. Am J Sports Med. 2004;32(1 Suppl):5S–16S.
22. Brynhildsen J, Ekstrand J, Jeppsson A, et al. Previous injuries
and persisting symptoms in female soccer players. Int J Sports
Med. 1990;11(6):489–92.
23. Chomiak J, Junge A, Peterson L, et al. Severe injuries in football
References players influencing factors. Am J Sports Med. 2000;28(5):
S58–68.
1. Fong DT, Man CY, Yung PS, et al. Sport-related ankle injuries 24. Cloke DJ, Ansell P, Avery P, et al. Ankle injuries in football
attending an accident and emergency department. Injury. academies: a three-centre prospective study. Br J Sports Med.
2008;39(10):1222–7. 2011;45(9):702–8.
2. Garrick JG, Requa RK. The epidemiology of foot and ankle 25. Cloke DJ, Spencer S, Hodson A, et al. The epidemiology of
injuries in sports. Clin Sports Med. 1988;7(1):29–36. ankle injuries occurring in English football association acade-
3. Gerber JP, Williams GN, Scoville CR, et al. Persistent disability mies. Br J Sports Med. 2009;43(14):1119–25.
associated with ankle sprains: a prospective examination of an 26. Ekstrand J. Epidemiology of football injuries. Sci Sports.
athletic population. Foot Ankle Int. 1998;19(10):653–60. 2008;23(2):73–7.
4. Fong DT, Hong Y, Chan LK, et al. A systematic review on ankle 27. Ekstrand J, Gillquist J. The frequency of muscle tightness and
injury and ankle sprain in sports. Sports Med. 2007;37(1):73–94. injuries in soccer players. Am J Sports Med. 1982;10(2):75–8.

123
Chronic Ankle Instability in Sporting Populations 1555

28. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a 50. Swenson DM, Yard EE, Fields SK, et al. Patterns of recurrent
prospective study. Med Sci Sports Exerc. 1983;15(3):267–70. injuries among US high school athletes, 2005–2008. Am J
29. Emery CA. The effectiveness of a neuromuscular prevention Sports Med. 2009;37(8):1586–93.
strategy to reduce injuries in youth soccer: a cluster-randomised 51. Waldén M, Hägglund M, Ekstrand J. Injuries in Swedish elite
controlled trial. Br J Sports Med. 2010;44(8):555–62. football: a prospective study on injury definitions, risk for injury
30. Engebretsen A, Myklebust G, Holme I, et al. Intrinsic risk fac- and injury pattern during 2001. Scand J Med Sci Sports.
tors for acute ankle injuries among male soccer players: a pro- 2005;15(2):118–25.
spective cohort study. Scand J Med Sci Sports. 2010;20(3): 52. Waldén M, Hägglund M, Ekstrand J. Time-trends and circum-
403–10. stances surrounding ankle injuries in men’s professional foot-
31. Faude O, Junge A, Kindermann W, et al. Risk factors for inju- ball: an 11-year follow-up of the UEFA Champions League
ries in elite female soccer players. Br J Sports Med. 2006;40(9): Injury Study. Br J Sports Med. 2013;47(12):748–53.
785–90. 53. Agel J, Olson D, Caq PCSM, et al. Descriptive epidemiology of
32. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk collegiate women’s basketball injuries: National Collegiate
factor for injury in elite football: a prospective study over two Athletic Association Injury Surveillance System, 1988–1989
consecutive seasons. Br J Sports Med. 2006;40(9):767–72. through 2003–2004. J Athl Train. 2007;42(2):202–10.
33. Hägglund M, Waldén M, Ekstrand J. Lower reinjury rate with a 54. Barrett JR, Tanji JL, Drake C, et al. High- versus low-top shoes
coach-controlled rehabilitation program in amateur male soccer: for the prevention of ankle sprains in basketball players: a
a randomized controlled trial. Am J Sports Med. 2007;35(9): prospective randomized study. Am J Sports Med. 1993;21(4):
1433–42. 582–5.
34. Hawkins RD, Fuller CW. A prospective epidemiological study 55. Colliander E, Eriksson E, Herkel M, et al. Injuries in Swedish
of injuries in four English professional football clubs. Br J elite basketball. Orthopedics. 1986;9(2):225–7.
Sports Med. 1999;33(3):196–203. 56. Cumps E, Verhagen E, Meeusen R. Efficacy of a sports specific
35. Hawkins RD, Hulse MA, Wilkinson C, et al. The association balance training programme on the incidence of ankle sprains in
football medical research programme: an audit of injuries in basketball. J Sports Sci Med. 2007;6(2):212–9.
professional football. Br J Sports Med. 2001;35(1):43–7. 57. Eils E, Schröter R, Schröder M, et al. Multistation propriocep-
36. Kofotolis ND, Kellis E, Vlachopoulos SP. Ankle sprain injuries tive exercise program prevents ankle injuries in basketball. Med
and risk factors in amateur soccer players during a 2-year period. Sci Sports Exerc. 2010;42(11):2098–105.
Am J Sports Med. 2007;35(3):458–66. 58. Garrick JG, Requa RK. Role of external support in the pre-
37. Kucera KL, Marshall SW, Kirkendall DT, et al. Injury history as vention of ankle sprains. Med Sci Sports. 1973;5(3):200–3.
a risk factor for incident injury in youth soccer. Br J Sports Med. 59. Kofotolis N, Kellis E. Ankle sprain injuries: a 2-year prospective
2005;39(7):462–6. cohort study in female Greek professional basketball players.
38. Le Gall F, CarIing C, ReiIiy T. Injuries in young elite female J Athl Train. 2007;42(3):388–94.
soccer players. Am J Sports Med. 2008;36(2):276–84. 60. Leanderson J, Nemeth G, Eriksson E. Ankle injuries in bas-
39. Lilley K, Gass E, Locke S. A retrospective injury analysis of ketball players. Knee Surg Sports Traumatol Arthrosc.
state representative female soccer players. Phys Ther Sport. 1993;1(3–4):200–2.
2002;3(1):2–9. 61. McKay GD, Goldie PA, Payne WR, et al. Ankle injuries in
40. Mohammadi F. Comparison of 3 preventive methods to reduce basketball: injury rate and risk factors. Br J Sports Med.
the recurrence of ankle inversion sprains in male soccer players. 2001;35(2):103–8.
Am J Sports Med. 2007;35(6):922–6. 62. Meeuwisse WH, Sellmer R, Hagel BE. Rates and risks of injury
41. Nelson A, Collins C, Yard E, et al. Ankle injuries among United during intercollegiate basketball. Am J Sports Med. 2003;31(3):
States high school sports athletes, 2005–2006. J Athl Train. 379–85.
2007;42(3):381–7. 63. Moiler K, Hall T, Robinson K. The role of fibular tape in the
42. Nielsen AB, Yde J. Epidemiology and traumatology of injuries prevention of ankle injury in basketball: a pilot study. J Orthop
in soccer. Am J Sports Med. 1989;17(6):803–7. Sports Phys Ther. 2006;36(9):661–8.
43. Putukian M, Knowles WK, Swere S, et al. Injuries in indoor 64. Orchard J, Hayes J. Using the world wide web to conduct epi-
soccer: the Lake Placid Dawn to Dark soccer tournament. Am J demiological research: an example using the National Basket-
Sports Med. 1996;24(3):317–22. ball Association. Int Sport Med J. 2001;2(2):1–15.
44. Rein S, Fabian T, Weindel S, et al. The influence of playing 65. Smith RW, Reischl SF. Treatment of ankle sprains in young
level on functional ankle stability in soccer players. Arch Orthop athletes. Am J Sports Med. 1986;14(6):465–71.
Trauma Surg. 2011;131(8):1043–52. 66. Zillmer DA, Powell JW, Albright JP. Gender-specific injury
45. Sharpe SR, Knapik J, Jones B. Ankle braces effectively reduce patterns in high school varsity basketball. J Womens Health.
recurrence of ankle sprains in female soccer players. J Athl 1992;1(1):69–76.
Train. 1997;32(1):21–4. 67. Aagaard H, Jørgensen U. Injuries in elite volleyball. Scand J
46. Söderman K, Adolphson J, Lorentzon R, et al. Injuries in ado- Med Sci Sports. 1996;6(4):228–32.
lescent female players in European football: a prospective study 68. Aagaard H, Scavenius M, Jorgensen U. An epidemiological
over one outdoor soccer season. Scand J Med Sci Sports. analysis of the injury pattern in indoor and in beach volleyball.
2001;11(5):299–304. Int J Sports Med. 1997;18(3):217–21.
47. Steffen K, Andersen TE, Bahr R. Risk of injury on artificial turf 69. Bahr R, Karlsen R, Lian Ø, et al. Incidence and mechanisms of
and natural grass in young female football players. Br J Sports acute ankle inversion injuries in volleyball: a retrospective
Med. 2007;41:i33–7. cohort study. Am J Sports Med. 1994;22(5):595–600.
48. Surve I, Schwellnus M, Noakes T, et al. A fivefold reduction in 70. Frey C, Feder K, Sleight J. Prophylactic ankle brace use in high
the incidence of recurrent ankle sprains in soccer players using school volleyball players: a prospective study. Foot Ankle Int.
the Sport-Stirrup orthosis. Am J Sports Med. 1994;22(5):601–5. 2010;31(4):296–300.
49. Swenson DM, Collins CL, Fields SK, et al. Epidemiology of US 71. Hadzic V, Sattler T, Topole E, et al. Risk factors for ankle sprain
high school sports-related ligamentous ankle injuries, in volleyball players: a preliminary analysis. Isokinet Exerc Sci.
2005/06–2010/11. Clin J Sport Med. 2013;23(3):190–6. 2009;17(3):155–60.

123
1556 A. S. Attenborough et al.

72. Neri M. An epidemiological study of ankle sprains in volleyball 91. Malliaropoulos N, Ntessalen M, Papacostas E, et al. Reinjury
players. J Sports Traumatol Relat Res. 1991;13(4):241–8. after acute lateral ankle sprains in elite track and field athletes.
73. Schafle MD, Requa RK, Patton WL, et al. Injuries in the 1987 Am J Sports Med. 2009;37(9):1755–61.
national amateur volleyball tournament. Am J Sports Med. 92. Garrick JG, Gillien DM, Whiteside P. The epidemiology of
1990;18(6):624–31. aerobic dance injuries. Am J Sports Med. 1986;14(1):67–72.
74. Vařeka I, Vařeková R, Lehnert M, et al. The effect of foot type 93. Fahlström M, Björnstig U, Lorentzon R. Acute badminton
and laterality on ankle sprain in elite female volleyball athletes. injuries. Scand J Med Sci Sports. 1998;8(3):145–8.
Kinesiology. 2009;41(2):164–71. 94. Roi GS, Fascı̀ A. Survey of requests for medical assistance
75. Verhagen E, Van der Beek AJ, Bouter LM, et al. A one season during fencing matches. Italian Journal of Sport Traumatology.
prospective cohort study of volleyball injuries. Br J Sports Med. 1988;10(1):55–62.
2004;38(4):477–81. 95. Wikström J, Andersson C. A prospective study of injuries in
76. McHugh MP, Tyler TF, Mirabella MR, et al. The effectiveness licensed floorball players. Scand J Med Sci Sports.
of a balance training intervention in reducing the incidence of 1997;7(1):38–42.
noncontact ankle sprains in high school football players. Am J 96. Gayardo A, Matana SB, da Silva MR. Prevalence of injuries in
Sports Med. 2007;35(8):1289–94. female athletes of Brazilian futsal: a retrospective study. Revista
77. Taylor DC, Englehardt DL, Bassett FH. Syndesmosis sprains of Brasileira De Medicina Do Esporte. 2012;18(3):186–9.
the ankle: the influence of heterotopic ossification. Am J Sports 97. Wright RW, Barile RJ, Surprenant DA, et al. Ankle syndesmosis
Med. 1992;20(2):146–50. sprains in National Hockey League players. Am J Sports Med.
78. Tyler TF, McHugh MP, Mirabella MR, et al. Risk factors for 2004;32(8):1941–5.
noncontact ankle sprains in high school football players: the role 98. Sankey RA, Brooks JHM, Kemp SPT, et al. The epidemiology
of previous ankle sprains and body mass index. Am J Sports of ankle injuries in professional rugby union players. Am J
Med. 2006;34(3):471–5. Sports Med. 2008;36(12):2415–24.
79. Shields BJ, Fernandez SA, Smith GA. Epidemiology of cheer- 99. Hjelm N, Werner S, Renstrom P. Injury profile in junior tennis
leading stunt-related injuries in the United States. J Athl Train. players: a prospective two year study. Knee Surg Sports Trau-
2009;44(6):586–94. matol Arthrosc. 2010;18(6):845–50.
80. Shields BJ, Smith GA. Epidemiology of strain/sprain injuries 100. Reynolds KH, Halsmer SE. Injuries from ultimate frisbee. WMJ.
among cheerleaders in the United States. Am J Emerg Med. 2006;105(6):46–9.
2011;29(9):1003–12. 101. Dyson R, Buchanan M, Hale I. Incidence of sports injuries in
81. Hiller CE, Refshauge KM, Herbert RD, et al. Intrinsic predictors elite competitive and recreational windsurfers. Br J Sports Med.
of lateral ankle sprain in adolescent dancers: a prospective 2006;40(4):346–50.
cohort study. Clin J Sport Med. 2008;18(1):44–8. 102. Gribble PA, Delahunt E, Bleakley C, et al. Selection criteria for
82. Rein S, Fabian T, Zwipp H, et al. Postural control and functional patients with chronic ankle instability in controlled research: a
ankle stability in professional and amateur dancers. Clin Neu- position statement of the international ankle consortium. J Ort-
rophysiol. 2011;122(8):1602–10. hop Sports Phys Ther. 2013;43(8):585–91.
83. Rovere GD, Webb LX, Gristina AG, et al. Musculoskeletal 103. Kovaleski JE, Gurchiek LR, Heitman RJ, et al. Instrumented
injuries in theatrical dance students. Am J Sports Med. measurement of anteroposterior and inversion-eversion laxity of
1983;11(4):195–8. the normal ankle joint complex. Foot Ankle Int. 1999;20(12):
84. Marshall S, Covassin T, Dick R, et al. Descriptive epidemiology 808–14.
of collegiate women’s gymnastics injuries: National Collegiate 104. Schwarz NA, Kovaleski JE, Heitman RJ, et al. Arthrometric
Athletic Association Injury Surveillance System, 1988–1989 measurement of ankle-complex motion: normative values.
through 2003–2004. J Athl Train. 2007;42(2):234–40. J Athl Train. 2011;46(2):126–32.
85. Wadley GH, Albright JP. Women’s intercollegiate gymnastics: 105. Hubbard TJ, Cordova M. Mechanical instability after an acute
injury patterns and ‘‘permanent’’ medical disability. Am J Sports lateral ankle sprain. Arch Phys Med Rehabil. 2009;90(7):1142–6.
Med. 1993;21(2):314–20. 106. Hiller CE, Refshauge KM, Bundy AC, et al. The Cumberland
86. Nielsen AB, Yde J. An epidemiologic and traumatologic study ankle instability tool: a report of validity and reliability testing.
of injuries in handball. Int J Sports Med. 1988;9(5):341–4. Arch Phys Med Rehabil. 2006;87(9):1235–41.
87. Seil R, Rupp S, Tempelhof S, et al. Sports injuries in team 107. Simon J, Donahue M, Docherty C. Development of the Identi-
handball: a one-year prospective study of sixteen men’s senior fication of Functional Ankle Instability (IdFAI). Foot Ankle Int.
teams of a superior nonprofessional level. Am J Sports Med. 2012;33(9):755–63.
1998;26(5):681–7. 108. Docherty CL, Gansneder BM, Arnold BL, et al. Development
88. Hopper D, Elliott B. Lower limb and back injury patterns of elite and reliability of the ankle instability instrument. J Athl Train.
netball players. Sports Med. 1993;16(2):148–62. 2006;41(2):154–8.
89. Langeveld E, Coetzee FF, Holtzhausen LJ. Epidemiology of 109. Hiller CE, Nightingale EJ, Raymond J, et al. Prevalence and
injuries in elite South African netball players. S Afr J Res Sport impact of chronic musculoskeletal ankle disorders in the com-
Phys Educ Recreat. 2012;34(2):83–93. munity. Arch Phys Med Rehabil. 2012;93(10):1801–7.
90. Edouard P, Chatard JC, Fourchet F, et al. Invertor and evertor 110. Junge A, Dvorak J. Influence of definition and data collection on
strength in track and field athletes with functional ankle insta- the incidence of injuries in football. Am J Sports Med.
bility. Isokinet Exerc Sci. 2011;19(2):91–6. 2000;28(5 Suppl):S40–6.

123