Proprioceptive Training & Its Implications on Ankle ... · 8/25/2011 · Results: Evidence surrounding ankle rehabilitation, proprioceptive training, balance training, fatigue, mobilization,

Jude A. Miller - 1 -

Proprioceptive Training & Its Implications on Ankle Rehabilitation:

A Literature Review

Jude A. Miller, DC Candidate

Advisor: Dennis Enix, DC, MBA

To satisfy the requirement for the completion of the Doctor of

Chiropractic degree, Logan College of Chiropractic


Abstract

Objective: The purpose of this study was to conduct a systematic review on ankle

instability and rehabilitative treatments for ankle instability and injury. An emphasis was

placed on the role of proprioception in the prevention and treatment of ankle injury.

Methods: A database search of PubMed, Science Direct, and Logan College of

Chiropractic’s electronic journal holdings, as well as paper journal holdings was

conducted to gather relevant articles concerning ankle instability and rehabilitative.

Discussion: A review of anatomy and neuroanatomy of the foot and ankle was conducted

with emphasis on structures relevant to ankle stability and proprioception.

Pathophysiology and pathomechanics of overuse injuries and ankle injuries specifically

sprains, is discussed.

Results: Evidence surrounding ankle rehabilitation, proprioceptive training, balance

training, fatigue, mobilization, and manipulation and their effects on ankle instability is

reviewed.

Conclusions: There are a large number of articles concerning ankle instability and

preventative and treatment options utilized for ankle injury and instability. Future

directions of research are discussed.

Key Indexing Terms: Ankle, foot, lower extremity, ankle instability, proprioception,

manipulation/mobilization, overuse injury, rehabilitation, fatigue, balance and a

combination of terms


Objective

The objective of this literature review is to analyze the current evidence

surrounding proprioceptive training and its role in ankle stability. Methodological and

theoretical contributions of the current literature will be discussed. A brief synopsis of

current terminology will be provided directly after the introduction. The synopsis’s

purpose is to clarify any possible confusion on the terms used within this paper.

Included in the body of this work is a brief review of the anatomy of the foot and

ankle region. A fundamental working knowledge of this anatomy is essential in the

understanding of the training methods discussed in this paper. A review of the

neuroanatomy and physiology involved in proprioception including the mechanisms of

mechanoreception and nociception and their effect on the brain’s interpretation of

proprioception. An understanding of the neurological influences surrounding

proprioception is vital to truly appreciate the mechanisms involved in proprioceptive

training and rehabilitation. Discussed in detail are the multiple modes of proprioceptive

training and their respective effects on ankle stability in the general population. Modes of

training that are discussed include ankle rehabilitation, proprioceptive training, balance

training, fatigue, mobilization, and manipulation.

The conclusion of the paper discusses the author’s opinion of the direction of

future studies and the implications of the current literature on the clinic applications in

the chiropractic profession.


Terminology

Sensorimotor System:

“Describes the sensory, motor, and central integration and processing components

involved in maintaining joint homeostasis during bodily movements.” 1

Proprioception:

Afferent information from interoceptive structures that contribute to joint

stability, postural control and a number of conscious sensations.1

Comprised of two subcomponents: sense of position (joint position sense) and

sense of limb movement (kinesthesia).2

Kinesthesia:

The ability to sense active or passive movement of the limbs and body.3

Joint Position Sense

The sense of position of a specific segment.2, 4

Often determined though measuring the accuracy of a patient to replicate a joint

angle either actively or passively in open or closed kinetic chains.5

Neuromuscular Control

“The unconscious activation of dynamic restraints occurring in preparation for

and in response to joint motion and loading for the purpose of maintaining and

restoring functional joint stability.” 1

Somatosensation:

o A global term for all sensation that arises from the periphery. Theses sensations

include: mechanoreception, themoreception, nociception, tactile sensations, and

proprioception.1


Methods

A database search of PubMed, Science Direct, and Logan College of Chiropractic’s

electronic journal holdings as well as paper journal holdings was conducted to gather

relevant articles concerning ankle instability and rehabilitative practices specific to ankle

rehabilitation. Numerous articles were found and data selection was based on relevancy,

date ranging from 1980 to present, English as language, study power, human

subjects/participants, and size. Search terms included ankle, foot, lower extremity, ankle

instability, proprioception, manipulation, mobilization, overuse injury, rehabilitation,

fatigue, balance and a combination of these terms. Of the 140 publications found to fit

the criteria a total of 61 articles were chosen for inclusion.

Discussion

Anatomical Considerations

Foot & Ankle

The human foot and ankle are complex. They are comprised of multiple bones

that are affixed by a network of ligaments and muscles to allow for motion of the foot

and ankle as well as neuromuscular control of the joints. The ankle is a hinged joint that

is capable of one degree of freedom in the sagittal plane. This motion is dorsiflexion and

plantarflexion.

The foot is comprised of multifaceted joints allowing for motion in multiple

planes. This arrangement allows for a diverse set of motions including: inversion,

eversion, pronation, supination, flexion, extension, gliding, pivoting, and shearing. 6 The


feet are the main weight-bearing structures of the body. Through bipedal motion they are

loaded and unloaded repetitively. For bipedal motion the peripheral and central nervous

systems must work together through feed-forward and feed-back mechanisms to maintain

proprioceptive control of the body. The maintenance of proprioceptive control is a

primary mechanism for numerous activities of daily living.

Bony Structures

The human foot is comprised of 26 bones and 34 joints. The foot is divided into

three anatomical divisions: hindfoot, midfoot, and forefoot. The ankle is where the bones

of the leg, the tibia and fibula, articulate with the hindfoot. The joints that compose the

ankle are the distal tibiofibular and the talocrural or mortise joint.

The hindfoot is composed of two bones, the calcaneus and the talus, which serves

to connect the midfoot to the ankle. The articulations of the hindfoot include the subtalar

or talocalcaneal and the transverse tarsal, which is comprised of the talocalcaneonavicular

and the calcaneocuboid joints.

The midfoot consists of the cuboid, navicular, medial cuneiform, intermediate

cuneiform, and lateral cuneiform. The articulations of the midfoot include the distal

intertarsal joints: the two cuneonavicular joints, the cuboideonavicular joint, and the two

intercuneiform joints.

The forefoot consists of 19 bones not including the sesamoid bones. The bones

include five metatarsal bones, five proximal phalanxes, four middle phalanxes, and five

distal phalanxes. The articulations of the forefoot include: the five tarsometatarsal joints


or the joints of Lisfranc, the four intermetatarsal joints, five metatarsophalangeal joints,

four proximal interphalangeal joints, and five distal interphalangeal joints.7

Ligamentous & Muscular Structures

There are many musculoligamentous structures in the ankle and foot. Only those

structures most relevant to ankle stability are discussed. The first structures to be

discussed are the ligaments of the foot and ankle. The ankle has two primary bundles of

ligaments the lateral (collateral) ligaments of the ankle and the medial (deltoid) ligament

of the ankle.

Ligamentous structures of the foot that are essential for maintenance of proper

mechanics include: talocalcaneal interosseous ligament, bifurcate calcaneonavicular

ligament, interosseous cuneiform-metatarsal ligament, transverse metatarsal ligaments,

long plantar ligament, plantar aponeursis.8

The talus is the only bone in the human body to not have any direct muscular

attachments. The stability of the talus is maintained by the musculotendinous structures

that pass around it.6 Muscular control of the ankle and foot in dorsiflexion and

plantarflexion are influenced by the triceps surae and the long flexors and extensors.

Supination is controlled by flexor digitiorum longus, tibialis posterior, and tibialis

anterior. Pronation is controlled by peroneous longus, brevis and tertius, as well as

extensor digitiorum longus and brevis. Adduction and abduction are accomplished

through tibialis posterior and peroneous brevis, respectively.8


Proprioception

Proprioception is considered a deep sensation that is perceived though specialized

receptors called proprioceptors. Impulses are primarily perceived through Pacinian

corpuscles, joint receptors, muscle spindles, and Golgi tendon organs.9 Proprioception

effects can be conscious, unconscious, or through Ia afferent fibers.

Conscious proprioception travels directly from the first order neuron to the

posterior white columns, which are composed of fasciculus gracilis and the cuneatus.

From there, the impulse ascends the spinal cord to the medullary nuclei. The second order

neuron crosses ventromedially as the internal arcuate fibers. It then turns upward to the

medial lemniscus and terminates in the ventroposterolateral nucleus of the thalamus. The

third order neuron then ascends from the thalamus to the posterior limb of the internal

capsule and terminates in the postcentral gyrus of the parietal lobe.

The first order neurons of unconscious proprioception terminate in laminae VI.

The second order neuron then goes to the dorsal spinocerebellar tract, which ascends to

the cerebellum. Proprioception carried via Ia afferent fibers functions as a spinal reflex.

The afferent fiber stimulates a lower motor neuron that goes directly back to skeletal

muscle.10

Pathophysiology & Pathomechanics

Overuse Injury

Overuse injuries are caused by cumulative micro-traumas or a combination of

macro and micro-traumatic events, and can be described as tissue damage that results at a

greater rate then the body can repair.11

Factors influencing overuse injuries can be


attributed to intrinsic and extrinsic factors. Renström states that “Extrinsic factors include

training errors, poor performance, poor techniques and inappropriate surfaces; intrinsic

factors including malalignment and muscle imbalance”. Overuse injuries can involve

bone, joints, ligaments, and soft tissue.12, 13

Foot structures and range of motion can be causative agents in overuse injuries.

Kaufman established overuse injury risk factors including: dynamic pes planus, pes

cavus, restricted ankle dorsiflexion, and increased hindfoot inversion. These maladies are

predisposing factors for overuse injuries and can all be addressed by non-invasive

interventions.11

Bone

Bones are the weight bearing structures of the body. Wolff’s Law states that

bones are dynamic in nature as their internal structures adapt to stresses placed upon

them. Stresses are influenced by body mass; increased mass increases overall bone

density and decreases bone loss. Overuse injuries sustained by bone commonly include

stress fractures, apophysitis, and periostitis.12

These stress-induced conditions are due to

the bones inability to adapt to the micro-traumas sustained during repetitive loading and

unloading.

Joint

Joints are subject to compressive, torsional, and shearing forces. Overuse injuries

of joints include: bursitis, osteochondritis, degenerative processes, and inflammatory

processes. These overuse injuries are often connected to malalignment of osseous


structures of the lower extremity causing pathomechanical stresses.14, 15

Alterations in Q-

angle, excessive acetabular retro or anteversion, tibial torsion, varousity, valgosity, or

over-pronation influence biomechanical stress patterns.14, 16

Soft Tissue

Soft tissues are generally non-weight bearing structures but are responsible for

motion of the skeletal system. Mechanical fatigue within tendons, ligaments, muscles,

and other soft tissues result in changes within their basic characteristics. Common

overuse injuries sustained by soft tissues include tendinopathies, compartment

syndromes, tears, ruptures, and other inflammatory processes.11, 12, 14, 17

Ankle Sprain

Ankle injuries rank as one of the most prevalent sports related injuries

reported.18, 19

Ankle sprains are common injuries in both athletic and non-athletic

populations. Yeung et al. reported that as much as 73% of athletes have recurrent ankle

injuries and 59% have residual symptoms.20

Residual effects of ankle sprains lead to

chronic ankle instability. Chronic ankle instability can be defined as repeated episodes of

ankle instability, with numerous ankle sprains or residual symptoms of giving way and

feelings of ankle joint instability. The residual symptoms can include mechanical

instability such as ligamentous laxity or functional instability, decreased proprioceptive

input without ligamentous laxity, or a combination of the two. These symptoms can lead

to loss of function, limitation of motion, and ankle pain.21, 22, 23


Ankle sprains are often thought of as an injury involving only the lateral ankle

ligaments, but often involves multiple structures. Ankle sprains are caused by sudden

inversion or eversion of the ankle, causing the ligamentous structures to be stretched

beyond their normal physiological and functional lengths. Ankle sprains have three

grades of severity.

o Grade 1 is a mild sprain with slight stretching and some damage to the fibrils of

the ligament, there is little to no instability, minimal swelling, and ability to bear

weight is intact.

o Grade 2 is a moderate sprain with partial tearing of the involved ligaments, some

instability, moderate pain, swelling, minimal bruising, and difficulty weight-

bearing.

o Grade 3 is a severe ankle sprain with ligament rupture, gross instability, severe

pain, swelling, extensive bruising, and inability to bear weight. 24

Biomechanically the subtalar joint is critical in the stability of the ankle.

The subtalar joint functions as a mitered hinge joint allowing for internal tibial rotation

while the hindfoot and forefoot are weight bearing. Throughout the gait cycle the center

of gravity shifts. During heel strike the center of gravity is posterior to the subtalar joint,

as the midfoot unlocks and the foot pronates the center of gravity is centered over the

subtalar joint. At this point, the ground reactive forces are in direct apposition to the

center of gravity. As the foot transfers into toe-off phase the center of gravity shifts

anterior to the subtalar joint. During motion the ground reactive force in relation to the


center of gravity creates a center of pressure on the subtalar joint. According to Tropp,

“Ankle synergy is defined as postural corrections taking place at the ankle; these

primarily occur through corrective motions of inversion and eversion in an effort to keep

the foot stable underneath the center of gravity. If pure ankle synergy takes place, no

shear forces are produced.” 25, 26

The musculotendinous and ligamentous structures surrounding the subtalar joint

are critical in offsetting the torsional and shearing forces produced when the ankle is not

in pure ankle synergy. If the foot begins to invert there is a lateral shift in the forces

acting on the ankle, and the opposite is true if the foot is everted. If the change in force is

uncompensated by the surrounding musculature in a prompt enough time the forces will

act through the leverage created and cause the surrounding ligamentous structures to be

stressed. The total force generated by the inversion or eversion event will dictate the

severity of the sprain.27

Results

Ankle Rehabilitation

The arthokinematics of the ankle and foot are complex, and the rehabilitation of

injuries to the ankle must be multifaceted to address the pathomechanics and

pathophysiology that attribute to ankle injuries. Functional rehabilitation of the ankle

often focuses on managing acute inflammatory processes, range of motion,

proprioception, balance, and strength training both as a preventative and post-injury

measures. The selection of treatment depends on the severity of the sprain. Grades I and


II generally respond to conservative treatment, while grade III may be non-responsive to

conservative can and may demand operative interventions.28

Rehabilitation should progress through a program starting with basic

interventions, progressing to more advanced interventions, and ending with sports

specific dynamic polymeric interventions.29

There is evidence to support functional ankle

rehabilitation that shows positive outcomes for reduction in reoccurrence, dynamic

postural control, and improved self-reported outcomes.30

Multiple interventions used

during functional rehabilitation has been shown to decrease overall lower extremity

injuries. Proprioceptive training is considered to be one of the key elements that should

be included in all functional ankle rehabilitation programs.31, 32

It has been shown to

reduce the incidence of ankle sprains in a population with a history of recurrent ankle

sprains to that of a population without a history of ankle sprains. Other interventions,

ankle taping and bracing, have also been linked to the reduction of ankle sprains and the

reduction of sprain severity.30

Balance training has been shown to have significant

reduction in ankle injuries, and exercises have been shown effective as rehabilitation for

ankle injuries.32

Proprioceptive Training & Ankle Stability

Proprioceptive afferentation through mechanoreception within Sherrington’s

definition of a proprioceptive field predominantly comes from density of in

mechanoreceptors in tissues such as facet capsules, ligaments, tendons, and muscles.34

Proprioceptive afferentation allows for neuromuscular control of dynamic actions

contributing to overall joint stability. Maintenance and improvements in neuromuscular


control through proprioceptive training could contribute greatly to increasing ankle

stability both prophylacticly and retrospectively.

The current literature is laden with studies of ankle stability through

proprioceptive training, although the concept of proprioception is often improperly

interchanged synonymously for balance, kinesthesia, joint position sense,

somatosensation, and reflexive joint stability.1 Ankle instability is intimately linked to a

history of ankle sprains. Ankle injuries have been shown to cause deficits in

proprioception, kinesthetic, and joint position sense.3, 35, 36, 37

Studies have established the

significance of maintaining and promoting proprioceptive input in order to properly

rehabilitate ankle instability.

Proprioceptive rehabilitative programs vary in methodology including: duration,

intensity and protocols, but report similar outcomes of decreased reoccurrence of ankle

sprains, decreased muscular response time, and increased proprioception.38-42

Balance

Balance training is becoming more commonplace in the preventive strategies of

numerous athletic programs and has been shown to decrease rates of ankle sprain

occurrence and reoccurrence.43, 44, 45

Recent studies have shown that the implementation

of a balance training regiment can decrease the incident of injuries to the ankles, knees,

hips, and lumbar spine. It has also been shown to be effective both as a preventative

measure and as a treatment for lateral ankle sprains and chronic ankle instability.35, 46

The

balance exercises that are often utilized comprise of variations of single leg stands,


unstable surfaces, wobble boards, etc. Each program can consist of sports specific

activities. These programs have been proven to be cost effective and efficient.

Balance measured through postural sway is a predictor for ankle injury. The

higher the postural sway, the more like the athlete is to sustain an ankle injury. McGuine

et al. stated that athletes with poor balance have nearly seven times the likelihood to

sustain an ankle injury as compared to athletes with good balance.43

Implementation of

balance programs have been shown effective for general performance enhancement

including optimizing sprint, jumping, and strength.47

Balance training results in

improvements of dynamic and static postural control, 48

and the implementation of

dynamic balance programs are more effective than static.49

Fatigue

Fatigue is a common component of any endurance or repetitive sport. Fatigue has

a deleterious effect on the body’s ability to maintain neuromuscular control, joint position

sense, kinesthesia, and proprioception. A number of studies have demonstrated fatigue’s

effect on spinal,50

upper,51

and lower extremities52, 53, 54

by worsening proprioception and

increasing the risk of joint injury or re-injury, thus leading to somatosensory defects,

increasing chronic instability.55

Mobilization and Manipulation

Mobilization is a manual therapy that consists of the passive movement of a joint

in order to achieve a therapeutic effect. There are five grades of mobilization, each

varying in velocity and amplitude. Grade V mobilization is also considered the


manipulation of a joint. The chiropractic management of ankle sprains varies and is

typically multimodal. The multimodality of treatments has been reflected in the current

literature and has resulted in a lack of a high level of evidence.56, 57

Joint mobilization and

manipulation for grade I and II ankle sprains has been shown to have significant effects

on the redistribution of load throughout the foot, 58, 59

increase dorsiflexion, reduction in

pain, and increased ankle function.57, 59, 60, 61

Conclusion

The ankle and foot are complex structures and the arthokinematics allow for

versatile function. The stability of the ankle is critical for bipedal motion. An intricate

part of the functionality of the ankle is due to somatosensation, primarily proprioception.

Ankle injury is the most common musculoskeletal injury and athletic performance places

the ankle at high risk for injury. There is substantial literature supporting proprioceptive

training as a preventative measure for ankle injury, but a large amount of the literature is

of low grade; few studies were of a high grade of evidence. Programs including

proprioception, balance, and endurance have been shown to decrease the incidence of

ankle injuries, specifically traumatic ankle inversion. The use of manipulation has been

shown to have significant advantages to treating grades I and II ankle sprains when

compared to control groups. Rehabilitation programs utilizing one or a combination of

the following components: proprioception, balance, fatigue avoidance, mobilization, and

manipulation, have been shown to be effective clinically in the treatment of both acute

and chronic ankle instability. These components are not only effective treatments, but

they decrease the likelihood of injury and reoccurrence of injury.


It is the opinion of the author that further studies should be conducted utilizing

single interventions to better classify the effectiveness of each individual treatment. More

studies should use objective stratifications to identify ankle instability such as

sonography or force plates. Future studies focusing on the cortical changes of the brain in

populations with documented chronic ankle instability should be performed to study the

changes that take place from proprioceptive training. Other areas of future study should

address: what role does the central nervous system play in the regulation of ankle

stability, the influence of athletic ability on ankle stability, and the effects of age on

proprioceptive training.

Chiropractic is known for treating neuromusculoskeletal injuries, primarily those

of the spine. Chiropractic can also treat problems of the upper and lower extremities.

Utilization of the rehabilitation processes discussed in this paper provides chiropractors

with effective non-invasive treatments for ankle instability.


References

1) Riemann, B. L. (2002). The Sensorimotor System, Part I & 2: The Physiologic Basis of Functional Joint Stablity. Journal of Athletic Training , 37 (1), 71-84.

2) Gilman, S. (2002). Joint Position Sense and Vibration Sense: Anatomical Orginization and Assesment. Journal of Neurology, Neurosurgery & Psychiatry , 73, 473-477.

3) Garn, S. N. (1988). Kinesthetic Awarness in Subjects with Multiple Ankle Sprains. Research , 68 (11).

4) Lonn, J. C. (2000). Position Sense Testing: Infulence of Starting Position and Type of Displacement. Archives of Physical Medicine and Rehabilitation , 81, 592-597.

5) Dover Geoffrey, P. M. (2003). Reliability of joint Position Sense and Force-Reproduction Measures During Internal and External Rotation of the Shoulder. Journal of Athletic Training , 38 (4), 304-310.

6) Kapandji, I. A. (1987). The Physiology of the Joints (5th Edition ed., Vol. 2). Loundon, New York, Oxford, Philadelphia, St. Louis, Toronto: Churchill Livingstone.

7) Netter, F. H. (2006). Atlas of Human Anatomy (4th Edition ed.). Philadelphia, PA: Saunders Elsevier.

8) Regnauld, B. (1986). The Foot. Berlin, Heidelberg, New York, Tokyo: Springer-Verlag.

9) Waxman, S. G. (1996). Correlative Neuroanatomy (24th edition ed.). St. Louis: :ange Medical Books/ McGraw-Hill.

10) Rubin, M. S. (2007). Netter's Concise Neuroanatomy. Philadelphia: Saunders Elsevier.

11) Kaufman, K. e. (1999). The Effect of Foot Structure and Range of Motion on Musculoskeletal Overuse Injuries. The American Journal of Sports Medicine , 27 (5), 585-593.

12) Renström P, J. R. (1985). Overuse injuries in sports. A review. Sports Medicine , 2 (5), 316-33.

13) O'Toole ML, H. W. (1989). Overuse injuries in ultraendurance triathletes. American Journal of Sports Medicine , 17 (4), 514-18.

14) Krivickas, L. (1997). Anatomical factors associated with overuse sports injuries. Sports Medicine , 24 (2), 132-46.


15) Khan K, B. J. (1995). Overuse injuries in classical ballet. Sports Medicine , 19 (5), 341-57.

16) Negus V, H. D. (2005). Associations between turnout and lower extremity injuries in classical ballet dancers. The Journal of Orthopedic & Sports Physical Therapy , 35 (5), 307-18.

17) Yeung EW, Y. S. (2001). A systematic review of interventions to prevent lower limb soft tissue running injuries. British Journal of Sports Medicine , 35, 383-89.

18) Garrick, J. (1977). The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. American journal of Sports Medicine , 241-242.

19) Watson, A. (1984). Sports injuries during one academic year in 6,799 Irish school children. American journal of Sports Medicine , 65-71.

20) Yeung M, C. K. (1994). An epidemiological survey on ankle sprain. British journal of Sports Medicine , 28 (2), 112-6.

21) Brown, C. (2011). Foot Clearance in Walking and Running in Individuals With Ankle Instability. American Journal of Sports Medicine , Preview.

22) Knapp D, L. S. (2011). Differential Ability of Selected Postural-Control Measures in the Prediction of Chronic Ankle Instability Status. Journal of Athletic Training , 46 (3), 257-62.

23) Hertel, J. (2002). Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. Journal of Athletic Training , 37 (4), 364-75.

24) Wolff MW, U. T. (2001). Management of Ankle Sprains. American Family Physician , 64 (3), 93-104.

25) Tropp, H. (2002). Commentary: Functional Ankle Instability Revisited. Journal of Athletic Training , 37 (4), 512-15.

26) Eslami M, B. M. (2007). Forefoot–rearfoot coupling patterns and tibial internal rotation during stance phase of barefoot versus shod running. Clinical Biomechanics , 22, 74-80.

27) Lin CF, C. C. (2011). Dynamic Ankle Control in Athletes With Ankle Instability During Sports Maneuvers. American Joirnal of Sports Medicine , Preview.

28) Lynch SA, R. (1999). Treatment of Acute Lateral Ankle Ligament Rupture in the Athlete Conservative Versus Surgical Treatment. Sports Medicine , 27 (1), 61-71.

29) Mattacola CG, D. M. (2002). Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. Journal of Athletic Training , 37 (4), 413-29.


30) Webster KA, G. P. (2010). Functional Rehabilitation Interventions for Chronic Ankle Instability: A Systematic Review. Journal of Sport Rehabilitation (19), 98-114.

31) Zöch C, F.-M. V. (2003). Rehabilitation of ligamentous ankle injuries: a review of recent studies. British Journal of Sports Medicine (37), 291-95.

32) , Z. A. (2010). Neuromuscular Training for Sports Injury Prevention: A Systematic Review. MEDICINE & SCIENCE IN SPORTS & EXERCISE , 42 (3), 413-21.

33) Verhagen EALM, M. W. (2000). The Effect of Preventive Measures on the Incidence of Ankle Sprains. Clinical Journal of Sport Medicine , 10, 291-96.

34) Burke, B. (2007). Sir Charles Sherrington’sThe integrative action of the nervous system: a centenary appreciation. Brain (130), 887-94.

35) Payne, K. A. (1997). Ankle Injuries and Ankle Strength, Flexibility, And Proprioceptiion in College Basketball Players. Journal of Athletic Training , 32 (3), 221-225.

36) Fu, A. S.-C. (2005). Ankle Joint Proprioception and Postural Control in Basketball Players With Bilateral Ankle Sprains. The American Journal of Sports Medicine , 33, 1174-1182.

37) Bressel, E. L. (2004). Ankle joint proprioception and passive mechanical properties of the calf muscles after an Achilles tendon rupture: a comparison with matched controls. Clinical Biomechanics , 19, 284-291.

38) EILS E, R. D. (2001). A multi-station proprioceptive exercise program in patients with ankle instability. MEDICINE & SCIENCE IN SPORTS & EXERCISE , 1991-8.

39) Verhagen E A L M, v. T. (2005). An economic evaluation of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball. British Journal of Sports Medicine (39), 111-15.

40) Kynsburg A, H. T. (2006). Changes in joint position sense after conservatively treated chronic lateral ankle instability. Knee Surg Sports Traumatol Arthrosc (14), 1299-1306.

41) Mohammadi F. (2007). Comparison of 3 Preventive Methods to Reduce the Recurrence of Ankle Inversion Sprains in Male Soccer Players. The American Journal of Sports Medicine , 35 (6).

42) Stasinopoulos D. (2004). Comparison of three preventive methods in order to reduce the incidence of ankle inversion sprains among female volleyball players. British Joirnal of Sports Medicine , 38, 182-85.


43) McGuine TA, G. J. (2000). Balance As a Predictor of Ankle Injuries in High School Basketball Players. Clinical Journal of Sport Medicine (10), 239-44.

44) McGuine TA, K. J. (2006). The Effect of a Balance Training Program on the Risk of Ankle Sprains in High School Athletes. The American Journal of Sports Medicine , 34 (7), 1103-12.

45) McLeod TCV. (2008). The Effectiveness of Balance Training Programs on Reducing the Incidence of Ankle Sprains in Adolescent Athletes. Journal of Sport Rehabilitation (17), 316-23.

46) McKeon PO, H. J. (2008). Systematic Review of Posturai Controi and Laterai Aniiie instabiiity, Part ii: is Baiance Training Ciinicaiiy Effective? Journal of Athletic Training , 43 (3), 305-15.

47) Zech, A. H. (2010). Balance Training for Neuromuscular Control and Performance Enhancement: A Systematic Review. Journal of Athletic Training , 45 (4), 392-403.

48) MCKEON, P. O. (2008). Balance Training Improves Function and Postural Control in Those with Chronic Ankle Instability. MEDICINE & SCIENCE IN SPORTS & EXERCISE , 1810-19.

49) Hoch M, S. C. (2010). Balance Training for Patients With Chronic Ankle Instability. ATHLETIC THERAPY TODAY , 9-11.

50) Pinsault, N. V. (2010). Degradation of Cervical Joint position Sense Following Muscular Fatigue in Humans. Spine , 35 (3), 294-297.

51) Tripp, B. L. (2004). Functional Fatigue Decreases 3-Dimensional Multijoint Position Reprodution Acuity in the Overhead-Throwing Athlete. Journal of Athletic Training , 39 (4), 316-320.

52) Huston JL, S. M. (2005). The effects of calf-muscle fatigue on sagittal- plane joint position sense in the ankle. Journal of Sports Rehabilitation , 14, 168-84.

53) Sandrey Michelle A., K. T. (2008). The Effects of Eversion Fatigue on Frontal Plane Joint Position Sense in the Ankle. Journal of Sport Rehabilitation , 17, 257-68.

54) Gribble Phillip A., H. J. (2004). The Effects of Fatigue and Chronic Ankle Instability on Dynamic Postural Control. Journal of Athletic Training , 39 (4), 321-29.

55) Lina YH, L. C. (2008). The effects of muscle fatigue and proprioceptive deficits on the passive joint senses of ankle inversion and eversion. Isokinetics and Exercise Science , 16, 101-5.


56) Hoskins W, M. A. (2006). CHIROPRACTIC TREATMENT OF LOWER EXTREMITY CONDITIONS: A LITERATURE REVIEW. Journal of Manipulative and Physiological Therapeutics , 29 (8), 658-71.

57) Brantingham JW, G. G. (2009). MANIPULATIVE THERAPY FOR LOWER EXTREMITY CONDITIONS: EXPANSION OF LITERATURE REVIEW. Journal of Manipulative and Physiological Therapeutics , 32, 53-71.

58) - - - -S.-B.-d.-C. (2006). IMMEDIATE EFFECTS OF MANIPULATION OF THE TALOCRURAL JOINT ON STABILOMETRY AND BAROPODOMETRY IN PATIENTS WITH ANKLE SPRAIN. Journal of Manipulative and Physiological Therapeutics , 30 (3), 186-92.

59) de Souza MvS, V. C. (2006). FORCE-DISPLACEMENT RELATIONSHIP DURING ANTEROPOSTERIOR MOBILIZATION OF THE ANKLE JOINT. Journal of Manipulative and Physiological Therapeutics , 31 (4), 285-92.

60) Pellow JE, B. J. (2001). The Efficacy of Adjusting the Ankle in the Treatment of Subacute and Chronic Grade I and Grade II Ankle Inversion Sprains. Journal of Manipulative and Physiological Therapeutics , 24 (1), 17-24.

61) Venturini C, P. M. (2007). STUDY OF THE FORCE APPLIED DURING ANTEROPOSTERIOR ARTICULAR MOBILIZATION OF THE TALUS AND ITS EFFECT ON THE DORSIFLEXION RANGE OF MOTION. Journal of Manipulative and Physiological Therapeutics , 30 (8), 593-97.

Documents

Proprioceptive Training & Its Implications on Ankle ... · 8/25/2011 · Results: Evidence surrounding ankle rehabilitation, proprioceptive training, balance training, fatigue, mobilization,