Bhalekar Anand Chandrakant

Bhalekar Anand Chandrakant

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION
1 / Name of the candidate
And Address /
BHALEKAR ANAND CHANDRAKANT
SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, PANDESHWAR,
MANGALORE-575001.
2 /

Name of the Institute

/ SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, MANGALORE.
3 /

Course of study and Subject

/ Master of Physiotherapy (MPT)
2 years Degree Course.
“Musculoskeletal disorder and Sports
physiotherapy”
4 /

Date of Admission

To course / 18 – 01 – 2010
5 /

Title of the topic

/ CORRELATION OF FOOT POSTURE INDEX WITH RISK FACTORS FOR LATERAL ANKLE SPRAIN IN ACTIVE ADULTS.
6
7.
8 / Brief resume of the intended work:
6.1Need for the study:
An inversion ankle sprain denotes an acute injury of the lateral ligaments of the ankle complex and is referred as a lateral ankle sprain (LAS).¹Lateral ankle sprains are one of the most common injuries among athletes as well as in other active adults in community.²According to Brooks et al,the incidence of lateral ankle sprain is approximately 1 per 10000 people per day.³
Many LASs resolve with a conservative treatment approach,whereas others have persistent pain, weakness, other symptoms of instability, and recurrent sprains.4-6
Chronic ankle instability (CAI) is a term that is presently used to denote the occurrence of subsequent repeated episodes of lateral ankle sprain following first episode of LAS.⁴,⁵It is classified as Functional and Mechanical based on possible cause of instability.7A reported 31% to 40% of these individuals with ankle sprains develop chronic ankle instability (CAI).8-¹¹
CAI yields to ankle instability and the presence of residual symptoms such as pain, swelling,‘‘giving way,’’ and loss of motion occurring long after an initial LAS(about 6 months) affecting activities of daily life.7
Initially acute episode of LAS gives rise to CAI; and this CAI in future yields to new recurrent episodes of LAS with or without severe insult to ankle joint.4-5 This forms vicious cycle of LAS and CAI,occurring one after another,leading to increasing level of ankle disability.This explains the strong cause-effect relationship between LAS and CAI.Following are the Risk factors for LAS :
1. DecreasedAnkle Dorsiflexion ROM12-14
2. Increased Postural sway14,15
3.Increased First Metatarso-phalangeal joint extension ROM16
4.Increased Non-weight bearing calcaneal eversion ROM 17,18
These risk factors for LAS do possess high degree of clinical importance,as potential tool to prevent future LAS and,to prevent vicious cycle of LAS-CAI in high risk individuals.
But,assessment of risk factors for LAS needs specific equipment,need active participation of subjects,demand good understanding of commands by subjects,impractical to use for studies with large sample size,and also affected by various extraneous factors.These limitations in assessing risk factors for LAS,alleviatetheir potential of utility in clinical practice and research.Hence,a single measure of assessment which will substitute all these risk factors for LAS is strongly required.
Variations in foot posture influence the function of the lower limb and may therefore play a role in predisposition to injury.19-22Malalignments in structure of the forefoot, midfoot, and rearfoot are thought to lead to compensatory motion at ankle complex, which may ultimately result in injury.19
Postural stability is affected by foot type under both static and dynamic conditions.These differences appear to be related to structural differences as opposedto differences in peripheral input.23
Foot Posture Index (FPI) is a diagnostic clinical tool used to classify foot postures as Pronated,Neutral(normal),and Supinated foot based on the 6 obsevational criteria ,with score ranging from –12 to +12.24
FPI is easy, quick, affordable, valid & reliable clinical measure of foot-posture which also have standardized guidelines of administration, gives quantifiable data and can be conveniently used in large sample size studies.24-²6If foot postures Index found to be co-related with risk factors for lateral ankle sprain, FPI can be used alone as quick screening tool by clinicians and sports PT for prevention of future injuries as substitute to risk factors for LAS.
There exist few studies on effect of foot type/posture on ankle sprain; among them some study reported positive co-relation between foot posture and LAS, while others reported as no significant co-relation between same.
Most of the studies were done on military/ Sports population. No study had been done in community dwelling active adults and no published studies are available in Indian population regarding foot postures and risk factors for LAS.
So,the purpose of this study is to find out co-relation between Foot Posture Index and risk factors for LAS in community dwelling active adults.
6.2Review of Literature:
  1. Keenan et al. (2007)²6 performed Rasch analysis of baseline FPI(foot Posture Index) scores from studies conductedduring the development of the instrument and reported that the finalized 6-item instrument showed good metric properties, including good individual item fit and good overall fit to the model, along with a lack of differential item functioning.
  2. Willems et al. (2005)16did prospective study on Intrinsic risk factors for inversion ankle sprains in females and reported that risk of ankle sprain increased by about 3% per degree of range of the first Metatarso-phalangeal joint. Thus a subject with 2 standard deviations (30˚) more Metatarso-phalangeal joint extension would have 2.5 times the risk of a person with average Metatarso-phalangeal ranges.
  3. Beynnon et al. (2001)17 did prospective study on risk factors for lateral ankle sprain in college athletes .They evaluated calcaneal range of motion and found that women with increased calcaneal eversion range of motion in the open chain were significantly more likely to suffer an LAS.

4.McGuine et al. (2000)15did study on High SchoolBasketball Players to check, whether balance as predictor of Ankle sprain and concluded that preseason balance measurement (postural sway) served as a predictor of ankle sprain susceptibility.

  1. Watsonet al. (1999)27conducted study on Ankle sprains in players of the field-games such as,Gaelic football and hurling.In their study they characterized postural sway with a practical approach,for the purpose of convenience that involved measurement of the duration of time a subject could maintain a single-leg stance without touching down to recover balance. Those who could maintain a single-leg stance for at least 15 seconds were considered to have normal posture, while those who touched down to regain balance within the 15-second test were considered to have abnormal posture. Ankle sprains affected more subjects with abnormal posture than with normal posture
  2. Pope et al. (1998)¹2conducted study on effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on risk of selected injuries, such as Ankle sprain, in 1093 male Army recruits undertaking 2 weeks of intensive training and concluded that that subjects with the most inflexible ankles (34˚ of dorsiflexion range) had nearly five times the risk of suffering an ankle sprain as subjects with average flexibility (45˚of dorsiflexion range).
  3. Baumhauer et al. (1995)1³conducted a prospective study on 145 college-aged athletes to examine injury risk factors and determine if an abnormality in any one or a combination of factors identifies an individual, or an ankle, at risk for subsequent inversion ankle injury and reported that Ankles with greater plantar flexion strength and a smaller dorsiflexion-to-plantar flexion ratio also had a higher incidence of inversion ankle sprains.
  1. Konradsen et al. (19991)28did study on postural sway in patients with CAI , and reported significantly altered postural sway(as measured by average distance from the mean center of pressure position) in patients with functional ankle instability
  2. Freeman et al. (1965)8conducted study onINSTABILITY OF THE FOOT AFFER INJURIES TO THE LATERAL LIGAMENT OF THE ANKLE in Forty-two previously asymptomatic patients presenting witha recent rupture of the lateral ligament of the ankle, and twentysimilar patients with a simple sprain of this ligament and reported pathological processwhich is usually responsible for functional instability of thefoot after a lateral ligament injury and concluded 31% to 40% of incidence of residual symptoms and development of chronic ankle instability (CAI) after LAS .
6.3Objective of the study:
To find out correlation between Foot Posture Index and risk factors for LAS in community dwelling active adults.
6.4Hypothesis:
Experimental hypothesis:
There will be correlation of FPI with risk factors for LAS in active adults.
Null hypothesis:
There will beno correlation of FPI with risk factors for LAS in active adults.
Material and Methods:
7.1Source of data:
30 Individuals with abnormal foot postures (Pes planus and Pes cavus)will be selected from Mumbai, Maharashtra based on inclusion and exclusion criteria.
Sampling: Purposive sampling
7.2Method of collection of data:
30 Subjects will be selected from the volunteers after screening them for inclusion and exclusion criteria. Those who fulfil inclusion criteria will be included for study. Selected participantswill be asked to givewritten consent stating voluntary acceptance to participate in this study. Subjects will be explained about the testing procedures. Participants then will be assessed by FPI and they will be classified into 2 groups, i.e. Pes cavus and Pes planus, based on score of FPI.
Then the biomechanical parameters like ankle dorsiflexion ROM, Postural sway, Metatarso-phalangeal extension ROM, non-weight bearing Calcaneal eversion ROMwill be measured according to the standard measurement protocols for all the subjects in the both the groups.
Description of Testing Procedure:
1.The Foot Posture Index:FPI rates weight-bearing foot posture(in bilateral stance) according to series of clinical observational criteria24as follows :
1.Talar head palpation
2. Supra and infra lateral malleolar curvature.
3.Calcaneal frontal plane position
4.Prominence in the region of the Talo-navicular joint
5.Congruence of medial longitudinal arch
6. Abduction/adduction of the forefoot on the rearfoot.
Each of the above criteria will be scored, ranging from -2 to +2 based on predetermined reference values. Finally scores of all 6 criteria will be added, which will yield to final score for foot posture.24
Interpretation: Based on final score foot posture will be classified as follows:24
0 to +5 -----Normal
0 to –12 ---Pes planus
+6 to +12---Pes cavus
2.Balance measurement
a)Single Leg Stance Test
“Single leg balance test”will be used to assess the static balance of participants.Participants will be asked to stand on one leg, place their arms across their chest with their hands touching their shoulders and do not let their legs touch each other.They will be instructed to look straight ahead with their eyes open and focus on an object about 3 feet in front of them.Total 3 trials will be taken with eyes open.Same procedure will be repeated with closed eyes.27,29,³0
b)Modified Star Excursion Balance Test (MSEBT)
Dynamic balance will be assessed by “Modified Star Excursion balance test”, which includes only 3 of total 8 reach direction components used in original Star Excursion Balance Test¹8.The participant will stand on 1 leg in the center of a grid, with the most distal aspect of the great toe at the starting line.While maintaining single-leg stance, the participant will be asked to reach with the free limb in the anterior,posteromedial, and posterolateral directions in relation to the stance foot.The maximal reach distance will be measured by marking the tape measure with erasable ink at the point where the most distal part of the foot reached.The greatest of 3 trials for each reach direction will be used for analysis of the reach distance in each direction.31,32
3.Ankle Dorsiflexion ROM12,13,14:will be evaluated by standard Goniometry procedures by using Universal Goniometer.
4.First Meta-tarso-phalangeal Joint extension ROM16: will be evaluated by standard Goniometry procedures by using Universal Goniometer.
5. Non-weight bearing calcaneal eversion ROM17,18: will be evaluated by standard Goniometry procedures by using Universal Goniometer.
Materials to be used:
  1. Adhesive tape31
  2. Measure tape31
  3. Marker31
  4. Protractor31
  5. Stop-watch31
  6. Standard Goniometer.12,14
  7. Pen and papers.
INCLUSION CRITERIA:
  1. Age group 18 to 59 years33
  2. Both male and female
  3. Can perform one-leg standing without any support independently for at least 15 seconds.27
EXCLUSION CRITERIA:
  1. Incidence of ankle sprain in past 3 weeks.
  2. Any neurological deficit or other injury to leg that may interfere with proprioceptive acuity.
  3. Recent history of lower limb fractures.
  4. Musculoskeletal deformities of Foot and ankle otherthan Pes planus & Pes cavus.
  5. Gross swelling near Ankle and foot.
  6. Severe pain in foot and ankle.
  7. Visual or vestibular impairments.
STUDY DESIGN: Correlational study.
SATISTICAL ANALYSIS:
  1. Karl Pearsoncoefficient of correlation.
  2. ANOVA.
7.3. Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
Yes. This study intends to investigate the various biomechanical factors in healthy adults.
7.4. Has ethical clearance been obtained from your institution in case of 7.3?
YES. Consent has been taken from the institute ethical clearance committee.
List of references:
  1. Katherine E. Morrison,Thomas W. Kaminski. Foot Characteristics in Association with Inversion Ankle Injury 2007;42(1):135-42.
  2. Osman Tugrul Eren,Metin Kucukkaya,Yavuz Kabukcuoglu. The Role of a Posteriorly Positioned Fibula in Ankle Sprain THE AMERICAN JOURNAL OF SPORTS MEDICINE, 2003;31(6):995-8.
  3. Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. BMJ. 1981;282:606-7.
  4. Fallat L,Grimm DJ,Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg. 1998;37:280-5.
  5. Yeung MS, Chan KM, So CH et al. An epidemiological survey on ankle sprain. Br J Sports Med. 1994;28:112-6.
  6. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37:364-75.
  7. Valderrabano V, Leumann A, Pagenstert G. Chronic ankle instability in sports -- a review for sports physicians Sportverletz Sportschaden. 2006 Dec;20(4):177-83.
  8. Freeman MAR. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br. 1965;47:678-85.
  9. Staples OS. Result study of ruptures of lateral ligaments of the ankle.Clin Orthop. 1972;85:50–58.
  10. Bosien WR, Staples OS, Russell SW. Residual disability following acuteankle sprains. J Bone Joint Surg Am.1955;37:1237-43.
  11. Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br. 1965;47:678-85.
  12. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and preexercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother 1998;44:165-72.
  13. Baumhauer JF, Alosa DM, Renstrom AF et al.A prospective study of ankle injury risk factors. Am J Sports Med. 1995 Sep-Oct;23(5):564-70.
  14. M de Noronha, K M Refshauge, R D Herbert et al. Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain? Br J Sports Med 2006;40:824-28.
  15. McGuine, Greene, Thomas MD et al. Balance as a Predictor of Ankle Injuries in High School Basketball Players. Clinical Journal of Sport Medicine 2000;10 (4):239-44.
  16. Willems TM, Witvrouw E, Delbaere K et al. Intrinsic risk factors for inversion ankle sprains in females: a prospective study. Scand J Med Sci Sports 2005;15:336-45.
  17. Beynnon BD, Renstrom PA, Alosa DM et al. Ankle ligament injury risk factors: a prospective study of college athletes. J Orthop Res. 2001;19:213-20.
  18. Baumhauer JF, Alosa DM. A prospective study of ankle injury risk factors. Am J Sports Med 1995;23:564-70.
  19. Nigg BM, Cole GK, Nachbauer W. Effects of arch height of thefoot on angular motion of the lower extremities in running.J Biomech 1993,26:909-16.
  20. Nawoczenski DA, Saltzman CL, Cook TM. The effect of footstructure on the three-dimensional kinematic couplingbehavior of the leg and rearfoot. Phys Ther 1998,78:404-16.
  21. Dahle LK, Mueller M, Delitto A et al.Visual assessment offoot type and relationship of foot type to lower extremityinjury. J Orthop Sports Phys Ther 1991,14:70-4.
  22. Cowan DN, Jones BH, Robinson JR. Foot morphologic characteristicsand risk of exercise-related injury. Arch Fam Med 1993,2:773-7.
  23. Karen P. Cote, Michael E. Brunet II, Bruce M. Gansneder et al. Effects of Pronated and Supinated Foot Postures on Static and Dynamic Postural Stability. Journal of Athletic Training 2005;40(1):41-6.
  24. Anthony C. Redmond, Jack Crosbie, Robert A. Ouvrier Development and validation of a novel rating system for scoringStanding foot posture: The Foot Posture Index. Clinical Biomechanics 2006;21:89-98.
  25. Keenan A-M, Redmond AC, Horton M et al. The Foot Posture Index: Rasch analysis of a novel, foot-specific outcome measure. Arch Phys Med Rehabil 2007;88:88-93.
  26. Watson A W. Ankle sprains in players of the field-games Gaelic football and hurling. J Sports Med Phys Fitness. 1999;39:66-70.
  27. Konradsen L, Voigt M. Inversion injury biomechanics in functional ankle instability: a cadaver study of simulated gait. Scand J Med Sci Sports. 2002 Dec;12(6):329-36.
  28. COL Barbara A. Springer, COL Raul Marin, Tamara Cyhan et al. Normative Values for the Unipedal Stance Testwith Eyes Open and Closed. Journal of Geriatric Physical Therapy. Vol. 30;1:07.
  29. Trojian TH, McKeag DB. Single leg balance test to identify risk of ankle sprains.Br J Sports Med.2006;40:610-3.
  30. Phillip J. Plisky, Mitchell J. Rauh, Thomas W. Kaminskiet al. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High SchoolBasketball Players. J Orthop Sports Phys Ther 2006;36(12):911-9.
  31. Sawkins Kate, Refshauge Kathryn, Kilbreath Sharon et al. The placebo effect of ankle taping in ankle instability. Med Sci Sports Exerc. 2007 May;39(5):781-7.
  32. Anthony C Redmond, Yvonne Z Crane, Hylton B Menz.Normative values for the Foot Posture Index. Journal of Foot and Ankle Research 2008;1:6.

9 /
Signature of the candidate
10 /
Remarks of the guide
11 / 11.1 Guide’s name
Designation of the Guide
11.2 Signature
/
DR. KARTHIKEYAN G.
Associate Professor in Physiotherapy
11.3 Co-Guide (If Any)
Designation of co guide
11.4 Signature /
DR. SELVAMANI.K
Associate Professor in Physiotherapy
11.5 Head of the Department
Designation

11.6 Signature

/
DR.T.JOSELEY SUNDERRAJ PANDIAN
Associate Professor in Physiotherapy
and P.G Co-ordinator
12 /
12.1 Remarks of Chairman and Principal
12.2 Signature /
DR. RAMPRASAD M.
Principal and Associate
professor in physiotherapy

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