A Systematic Review on Ankle Injury.pdf

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Sports Med 2007; 37 (1): 73-94

0112-1642/07/0001-0073/$44.95/0

A Systematic Review on Ankle Injury

and Ankle Sprain in Sports

Daniel Tik-Pui Fong , 1 Youlian Hong , 2 Lap-Ki Chan , 1 Patrick Shu-Hang Yung 1 and

Kai-Ming Chan 1

1 Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Faculty of

Medicine, The Chinese University of Hong Kong, Hong Kong, China

2 Department of Sports Science and Physical Education, Faculty of Education, The Chinese

University of Hong Kong, Hong Kong, China

Contents

Abstract .....................................................................................73

1. Methods .................................................................................74

2. Results ...................................................................................76

2.1 Demographic Data ...................................................................76

2.2 Prevalence of Ankle Injuries in Different Sports ...........................................77

2.3 Prevalence of Ankle Sprains in Different Sports ...........................................77

2.4 Prevalence of Ankle Injury and Ankle Sprains in Different Countries ........................77

2.5 Incidence of Ankle Injuries .............................................................77

2.6 Incidence of Ankle Sprains .............................................................82

3. Discussion ................................................................................82

4. Conclusion ...............................................................................89

Abstract

This article systematically reviews epidemiological studies on sports injury

from 1977 to 2005 in which ankle injury was included. A total of 227 studies

reporting injury pattern in 70 sports from 38 countries were included. A total of

201 600 patients were included, with 32 509 ankle injuries. Ankle injury informa-

tion was available from 14 098 patients, with 11 847 ankle sprains. Results show

that the ankle was the most common injured body site in 24 of 70 included sports,

especially in aeroball, wall climbing, indoor volleyball, mountaineering, netball

and field events in track and field. Ankle sprain was the major ankle injury in 33 of

43 sports, especially in Australian football, field hockey, handball, orienteering,

scooter and squash. In sports injuries throughout the countries studied, the ankle

was the second most common injured body site after the knee, and ankle sprain

was the most common type of ankle injury. The incidence of ankle injury and

ankle sprain was high in court games and team sports, such as rugby, soccer,

volleyball, handball and basketball. This systematic review provides a summary

of the epidemiology of ankle injury in sports.

All around the world, people are participating in home and leisure accidents, occupational injuries

sports for personal interest, relaxation, health and and violence. [1-4] Sports injuries result in pain, loss

fitness training. However, sports is one of the major of playing or working time, as well as medical

causes of injuries, comparable to traffic accidents, expenditure. Severe injuries may result in bone frac-

Fong et al.

tures, functional instability, limited mobility, disa- to the anterior talofibular ligament. [41] In a survey

conducted in 1994 on 380 athletes with 563 sprained

chological problems and even death. For

ankles, Yeung et al. [21] reported that the majority of

world-class and commercial sports teams, absence

these injured athletes were pursuing running and

of key players due to unexpected injuries may result

jogging activities (25%), racquet sports (20%), ball

in defeats in major games and huge economic losses.

games (19%), soccer (14%) and fencing (6%). The

As a result of these undesired adverse effects, scien-

residual problem included pain (30.2%), instability

tists and medical specialists are actively working on

(20.4%), crepitus (18.3%), weakness (16.5%), stiff-

sports injury prevention. [5-7]

ness (14.6%) and swelling (13.9%). For ankles

sprained 1–4 times, the major residual problem is

Firstly, the problem had to be identified. In 1970,

pain (24–28%). For ankles sprained

≥

5 times, insta-

Roser and Clawson [8] conducted an epidemiological

bility problems arise, which becomes the major se-

study on football injuries in young athletes. In 1971,

quale (38%).

MacIntosh et al. [9] conducted a similar study on

In 1987, van Mechelen et al. [42] proposed a “se-

athletic injuries at the University of Toronto, Cana-

quence of injury prevention,” which described how

da. In 1972, Garrick [5] conducted a related study on

sports injury-related studies come together to form

the prevention of sports injuries, and in 1973, Gar-

the research framework. The first step is to identify

rick and Requa [10] studied the prevention of ankle

the extent of the sports injury problem by epidemiol-

sprains. To be more specific in identifying the prob-

ogy studies. The second step establishes the aetiolo-

lem, Garrick pioneered a series of ankle-sprain epi-

gy and mechanism of injuries and the third step

demiology studies from 1977. [11] Subsequent re-

designs and introduces preventive measures. Final-

search investigated ankle injuries in different sports

ly, the effectiveness of the preventive measures is

events including aerobic dance, [12] children and ado-

assessed by repeating the original epidemiology

lescent skiing, [13] women’s gymnastics, [14] ballet [15]

study (step one). The epidemiology studies conduct-

and in all sports. [16] From 1980 onwards, numerous

ed by Garrick et al. [11-16] play an important role in

epidemiology studies were conducted on different

locating the problem of ankle sprains in sports,

sports, populations, genders, playing levels and in

within the model of “sequence of injury preven-

different countries. [3,16-21] In general, these studies

tion.” With this information, subsequent studies

reported that the ankle is one of the most traumatised

were performed to identify risk factors to injury [43]

body sites in sports injuries and accounts for

and injury mechanism, [44] to design prevention

10–30% of all sports injuries. In some sports, the

equipment [45,46] and to finally evaluate the effective-

percentage of ankle injuries is even higher (e.g. 40%

ness of these preventive measures. [47,48] The purpose

in mountaineering [22] and handball, [23] 41% in vol-

of the present study is to systematically review

leyball [24] and youth soccer, [25] 45% in female cheer-

epidemiology studies from 1977 to 2005 on sports

leading, [26] 46% in artistic gymnastics, [27] 53% [28]

injury, in order to identify the distribution of report-

and 54% [29] in softball and 56% in women’s floor-

ed injuries among ankle and other body sites and

ball [30] ). From epidemiological data collected from

summarise the type of ankle injury. The time span

1979 to 1987, Garrick and Requa [16] reported that

starts from the first epidemiology study on ankle

the percentage of ankle injuries could be as high as

sprains published by Garrick [11] in 1977. The find-

74% in softball, 76% in racquet sports and football,

ings will help sports medicine specialists to identify

77% in weight lifting and dancing, 79% in basket-

the patterns of ankle injury in sports and to direct

ball and 82% in volleyball. Ankle sprain is the most

future research.

common type of ankle injury and may account for

>80% and even as much as 100% of ankle injury

1. Methods

sustained in some sports (e.g. squash, [31] orienteer-

ing, [32] scooter, [33] soccer, [34] figure skating, [35] Aus- A systematic literature search of MEDLINE

tralian football, [36] rugby, [37] field hockey, [38] hand- (from 1966), ISI Web of Knowledge (Science Cita-

ball [39] and volleyball [24] ). In these sprains,

77% are tion Index Expanded, from 1985; Social Sciences

lateral sprains [40] and 73% involved rupture or tear Citation Index, from 1956; Arts and Humanities

≈

Sports Med 2007; 37 (1)

bility, permanent cease of sports participation, psy-

Ankle Injury and Ankle Sprain in Sports

Citation Index, from 1975), PubMed (from 1950); vals. In such cases, the studies were counted in each

and Sport Discuss (from 1975) was conducted dur- of the relevant time intervals; therefore, the total

ing the last week of January in 2006. The search number of counts exceeds the total number of stud-

keyword string was ‘ankle AND (injury OR injuries ies. The populations investigated were split into the

OR sprain) AND (sport OR sports) AND (epidemi- following five groups: (i) teams, where the subjects

ology OR epidemiologic OR epidemiological OR were from sports teams or clubs; (ii) public, where

survey OR statistics OR patterns OR pattern)’, the subjects were from the public population attend-

which appeared in the title, abstract or keyword ing accident and emergency departments in hospi-

fields. The initial total number of identified articles tals or sports medicine clinics; (iii) events, where the

from these databases was 744. After removing subjects were from competition events and games;

duplicates, the count was reduced to 676 articles. (iv) schools, where the subjects were from schools

The title and abstract of each entry was read to and universities; and (v) military, where the subjects

identify and exclude non-epidemiology and non- were military recruits. The number of patients were

related studies. Articles not written in English were categorised as 1–100, 101–500, 501–1000,

also excluded. After this trimming, the count was 1001–2000, 2001–5000, 5001–10 000 and >10 000.

reduced to 419 articles. Online and library searches The 227 included studies reported a total of 255

for the full text of these 419 articles was conducted. epidemiology reports, as some studies reported epi-

Articles not available in the library of The Chinese demiology in more than one sport. All epidemiology

University of Hong Kong were requested from other reports were categorised into the type of sport. Epi-

libraries in local universities. The total number of demiology studies reporting general sport injury

the articles for which the full text was retrieved was patterns in a country, but not on specific sport, were

331. categorised in to countries.

The full text of each of the 331 retrieved articles In each sport and country, the most common

was read in order to determine inclusion or exclu- injured body sites and ankle injury types were

sion in the analysis. To be included in the analysis, ranked by weighted prevalence percentages. The

the study must report epidemiology findings of inju- following 11 body site groups were created: (i)

ries sustained in one or more sports activities, and ankle; (ii) foot; (iii) leg/shin/calf; (iv) knee; (v)

should fulfill either one of the two following crite- thigh/hamstring; (vi) hip; (vii) trunk/back/spine;

ria: (i) the study must report injury at ankle joint, (viii) shoulder; (ix) arm/elbow; (x) hand/fingers;

with either prevalence percentage compared with and (xi) head/neck/face. Some studies reported the

other body sites, or the incidence rate among the percentage of injury of several body sites, such as

surveyed sample; (ii) the study must report ankle foot and ankle, hip and thigh, or arm and shoulder.

sprain injury, with either prevalence percentage For these studies, the combined percentages were

among other ankle injury types, or the incidence rate divided evenly for each included body site. Some

among the surveyed sample. Review articles, case studies combined the whole upper or lower extremi-

reports and current concepts were excluded. After ty and made the distribution pattern among each

the screening process, the final number of articles body site too superficial. In these cases, the study

included in the analysis was 227. was excluded as it failed to comply with the inclu-

Demographic data of the studies were sum- sive criteria that the study must report injury pattern

marised, which included the geographical location, in different body sites, with ankle injury reported.

period of the study, population, prospective or retro- However, if an ankle and hand injury were separate-

spective nature of the study and patient number. The ly reported from lower and upper extremities, the

geographical location was summarised in to the study was included and the percentages of lower and

country and continent where the study was conduct- upper extremity were considered in the leg (leg/shin/

ed. The period of study was categorised in 5-year calf) and arm (arm/elbow) categories. Ankle injury

intervals as pre-1980, 1981–5, 1986–90, 1991–5, type was classified into the following 11 categories:

1996–2000 and 2001–5. Some investigations had a (i) sprain; (ii) fracture; (iii) strain; (iv) abrasion; (v)

study period overlapping two or more 5-year inter- contusion; (vi) tendinitis; (vii) blister; (viii) im-

Sports Med 2007; 37 (1)

Fong et al.

pingement; (ix) cramp; (x) bruise; and (xi) lacera-

tion.

Among injured body sites, prevalence was repre-

sented by weighted percentages. This is calculated

by the sum of the percentage of injury in a specific

body site, times the number of all injuries in each

included study, then divided by the sum of the total

number of all injuries. Among ankle injury types,

prevalence was represented by weighted percent-

ages, calculated by the sum of the percentage of

ankle injury type, times the number of all ankle

injuries in each included study, then divided by the

sum of the total number of all ankle injuries. The

calculations are shown in the following mathemati-

cal formulae:

Table I. Geographical distribution of the studies included in this

review

Continent Countries

Europe (116) UK (34), Sweden (18), Denmark (16),

Holland (9), Finland (7), Germany (7),

Norway (6), France (3), Greece (3), Iceland

(2), Croatia (2), Czechoslovakia (1), Turkey

(1), Switzerland (1), Austria (1), Belgium (1),

Ireland (1), Italy (1), Spain (1), Poland (1)

North America (77) US (62), Canada (11), Mexico (2),

Guatemala (1), Dominica (1)

Australasia (30) Australia (21), New Zealand (9)

Asia (11) Hong Kong (4), Japan (2), Korea (1), Saudi

Arabia (1), Singapore (1), Lebanon (1), Iran

(1)

South America (5) Argentina (2), Brazil (2), Trinidad and

Tobago (1)

Africa (1)

Nigeria (1)

weighted percentage (body site) =

N/A (15)

Total (255) a

a The total count exceeds the number of studies as some

studies reported epidemiology findings in more than one

country.

N/A = data not available.

∑

total

case

× n

percentage

(

body

site

)

∑

total

case

weighted

percentage

(

ankle

injury

type

)

tion of geographical location of the studies is shown

in table I. The results showed that most of the

studies were conducted in the US (24.3%), followed

by the UK (13.3%), Australia (8.2%), Sweden

(7.1%) and Denmark (6.3%).

The period of study, population investigated, na-

∑

total

ankle

injuries

percentage

(

ankle

injury

type

)

∑

total

ankle

injuries

ture of the study and the patient number are sum-

where n is number of epidemiology reports in one

marised in table II. The majority of the studies were

specific sport or country.

published between 1986 and 2000, with an even

In addition, the incidence rate of ankle injuries

distribution in this time span. However, 37 studies

and ankle sprains were reported in incidence per

1000 person-hour/person-year/person-season/per-

(12.9%) did not report the duration of study. The

son-exposure.

populations investigated were predominantly from

sports teams and clubs (40.5%), followed by the

2. Results

public (29.5%), competition events (15.4%),

schools (11.0%) and the military (0.9%). Six studies

(2.6%) did not describe the population investigated.

2.1 Demographic Data

A total of 227 epidemiology studies were includ-

The nature of study was identified to be prospective

(75.3%) or retrospective (18.9%). Thirteen studies

ed. Some studies reported injury epidemiology in

(5.7%) did not describe the study nature. Most stud-

two or more countries and thus made the total count

ies (49.8%) had a patient number of 101–500. The

to 255. Most studies were conducted in Europe

total patient number of sports injuries was 201 600

(45.5%), North America (30.2%) and Australasia

(11.8%). Only a few studies were from Asia (4.3%),

and the number of ankle injuries included was

South America (2.0%) and Africa (0.4%). Distribu-

32 509.

Sports Med 2007; 37 (1)

Ankle Injury and Ankle Sprain in Sports

2.2 Prevalence of Ankle Injuries in

Different Sports

Table II. The period of study, population investigated, nature of

study and patient number of the studies included in this review

Demographic

No. of studies

The total number of sports included in the analy-

sis is 70. The weighted percentage of the most

common injured body sites are shown in table III.

Among these 70 sports, the ankle ranked the most

popular injured body site in most studies (24 sports,

34.3%), followed by knee (14 sports, 20.0%), head

(8 sports, 11.4%), trunk (6 sports, 8.6%) and hand (6

sports, 8.6%). Figure 1 shows the weighted percent-

age of ankle injury in all of the 70 included sports.

Ankle injury was most common in aeroball (80.0%),

wall climbing (60.0%), indoor volleyball (45.6%),

mountaineering (40.0%), netball (39.8%), and field

events in track and field (39.2%).

Period of study

Pre-1980

1981–5

1986–90

1991–5

1996–2000

2001–5

N/A

Total

286 a

Population

team

public

event

school

military

2.3 Prevalence of Ankle Sprains in

Different Sports

N/A

Total

227

Information about the ankle injury was available

in 43 sports, and is shown in table IV. Ankle sprain

was the most common injury (33 sports, 76.7%),

followed by fracture (7 sports, 16.3%). Figure 2

shows the weighted percentage of ankle sprains in

the 43 included sports. In some sports, all of the

reported ankle injuries were ankle sprains (100%).

These sports included Australian football, field

hockey, handball, orienteering, scooter and squash.

In addition to these six sports, ankle sprain percent-

age was also >80% in indoor volleyball, American

football, martial arts, basketball, aeroball, ultimate

frisbee, flag football, cheerleading, indoor soccer,

ice hockey, lacrosse, badminton and netball.

Nature of study

prospective

171

retrospective

N/A

Total

227

No. of patients

1–100 52

101–500 113

501–1000 25

1001–2000 13

2001–5000 13

5001–10 000 10

>10 000 1

Total 227

a Total count exceeds the number of studies as some studies

reported epidemiology findings in more than one period of

time.

N/A = data not available.

2.4 Prevalence of Ankle Injury and Ankle

Sprains in Different Countries

2.5 Incidence of Ankle Injuries

Epidemiology data in general sports were availa-

ble in eight countries as shown in table V. In gener- The incidence of ankle injuries are shown in table

al, the knee was the most injured site (16–27%), VI. In terms of incidence per 1000 person-hour,

followed by the ankle (11.2–20.8%), with an excep- hurling and camogie had the highest general inci-

tion that the hand was most injured site in Sweden dence (32.88), followed by rugby (8.14), soccer

(19.8%) and Holland (21.8%). Information regard- (6.52), basketball (5.20) and triathlon (4.70). During

ing the type of ankle injury was available in three games, the incidence was highest in soccer (34.83),

countries (US, Holland and Hong Kong) and and followed by rugby (14.00), American football

showed that sprains were the most common type of (13.80) and indoor soccer (11.68). In training, soc-

ankle injury (33.0–73.0%).

cer showed the highest incidence rate (2.74). In

Sports Med 2007; 37 (1)

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