Peroneal Reaction Time Instability of The Ankle in Treated Functional
Peroneal Reaction Time Instability of The Ankle in Treated Functional
Peroneal Reaction Time Instability of The Ankle in Treated Functional
Summary
Peroneal reaction time was measured in two groups of patients with
either acute or chronic unilateral instability of the ankle, both before
and after treatment. Group A consisted of patients with chronic
functional instability who were treated with surgical stabilization
while Group B contained patients with acute functional instability
who were treated with proprioceptive exercises. Statistical analysis
of the electromyographic recordings taken from peroneus longus
muscles of these patients showed longer mean peroneal reaction
time before conservative or surgical treatment in both groups
(P<0.001). Group A patients showed no statistical difference in mean
peroneal reaction time before and after surgical stabilization;
however eight out of 10 patients in this group were satisfied with
the surgical outcome of functional instability. Group B patients
showed mean peroneal reaction time to have improved (P<0.001)
following proprioceptive exercises and all of them had satisfactory
outcome of treatment. Our study demonstrates that peroneal
reaction time is prolonged in patients with acute or chronic
unilateral functional instability suggesting disruption of the reflex
pathway between ankle and spinal cord. Surgical stabilization
improves symptoms of chronic functional instability but no
significant change in the peroneal reaction time is demonstrated
while proprioceptive exercises improve patients' symptoms of acute
functional instability as well as peroneal reaction time. We discuss
the possible causes of variations in peroneal reaction time before
and after treatment in functional instability of the ankle.
men and 45% in women. Football had the next highest through a spinal pathway following afferent nerve
frequency with 13.2% of all injuries involving the fibre injury. They also discounted that any
ankle. supraspinal or central mechanism was involved in
While there is a debate as to the best initial the production of abnormal peroneal reaction time.
treatment for an acute complete tear of lateral The aim of this prospective study was to evaluate
ligament complex of ankle, persistent functional the preoperative and postoperative peroneal reaction
instability of the ankle develops in ~20% of the time in patients with unilateral chronic functional
patients regardless of whether the initial treatment instability of the ankle and compare it to their
is surgical or conservative [6-11]. recovery status in terms of symptoms and function
Functional instability, a subjective complaint, is the after the operation. It was also of interest to see how
commonest residual disability [12-16] and is peroneal reaction time responded in patients with
described'as a sensation of the ankle 'giving way' acute unilateral functional instability following the
and a tendency for frequent recurrent spraining. use of proprioceptive exercises as this appears not
Functional instability is different from mechanical to have been previously reported.
instability, which is abnormally increased mobility
of the ankle and indicates a lesion of the passive
Materials and methods
stabilizers of the ankle, primarily the ligaments.
Freeman et al. [13] suggested that functional Two groups of 10 patients were selected. Group A
instability of the ankle is secondary to joint de- included patients with unilateral chronic functional
afferentiation and motor incoordination with instability of the ankle that were treated surgically.
interference of the reflexes that depend on articular Group B consisted of patients with unilateral acute
mechanoreceptors. The hypothesis is well supported functional instability of the ankle that were treated
by studies showing the presence of mechanoreceptors with proprioceptive exercises. The experiment was
in the ligaments of the human ankles and other joints approved by the ethical committee of Liverpool John
[17, 18]. Moores University. All subjects gave their informed
Konradsen et al. [19] suggested that the loss of consent to participate in the study.
afferent input from the torn ligaments may render Group A included eight men and two women, the
the ankle susceptible to undetected inversion mean age was 26.5 years (range 16-34 years), seven
positions and therefore causing repeated injuries. patients had ankle instability on the right and three
Functional instability of the ankle joint is a complex on the left side (Table 1). The contralateral ankles
syndrome, in which different mechanical, functional were normal and stable in all cases. All of them had
and neuromuscular factors are probably involved history of inversion injury to the ankle of more than
[20]. Staples [14] discussed four possible causes of 6 months and had received conservative treatment
functional instability, which are: (1) peroneal in the form of rest, elevation of the ankle, ice
weakness; (2) mechanical instability; (3) tibiofibular application and dorsiflexion/plantarflexion exercises
sprains and (4) proprioceptive defects. of the ankle joint once the pain settled. Two of them
The measurement of the reflex time of the peroneus (patients 3 and 6) received proprioceptive exercises
muscle group contraction in response to the inversion to the injured ankles approximately 3 months after
of the ankle is one way of obtaining information the initial injury to the ankle for the symptoms of
about functional instability. Konradsen and Raven ankle giving way but failed to complete the
[21] and Karlsson et al. [20] measured reaction time physiotherapy course. All the patients were unable
from electromyographic (EMG) recordings of the to participate in recreational or sports activities. None
peroneal muscle group by calculating the time of them had any functional instability of the ankle
interval from the onset of inversion of the ankle on the injured side in the past. Examination of the
to the first electromyographic response, which was bilateral subtalar joints in all patients showed pain-
called as peroneal reaction time. This time interval free symmetrical range of movements and the
was found to be longer in patients with functional position of the heel on standing and sitting postures
instability compared to normal subjects and was revealed no abnormality. Rest of the examination of
described as secondary to abnormal stretch reflexes ankle and foot on both sides was normal. These
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patients were diagnosed to have chronic functional planterflexion exercises started once swelling and
instability on the basis of history of inversion injury pain settled. They were mobilized non-weight
to the ankle of more than 6 months, pain over the bearing to full weight bearing according to the
lateral ligament complex, feeling of ankle giving severity of pain. However all of them developed
way, positive anterior drawer test on examination symptoms of recurrent pain and the ankle giving
as described by Marder [22] and demonstration of way over the following 6-8 weeks. They were
significant talar tilt and anterior translation of talus subsequently referred for proprioceptive exercises on
[23] on stress views of the ankle under general a wobble board under the supervision of a senior
anaesthesia performed by one consultant orthopaedic physiotherapist once diagnosis of acute functional
surgeon. None of the patient's symptoms suggested instability was made. The programme for
causes other than lateral ligament injury in the ankle. proprioceptive exercises lasted for average 6 weeks.
Special ~/ttention was paid to rule out any subtalar
joint pathology. Subsequently these patients had
Electromyographic studies
lateral ligament reconstruction, which was carried
out by modified Chrisman Snook procedure using Electromyographic (EMG) measurements were taken
split peroneus brevis tendon [24]. No attempt was from peroneus longus of the affected and
made during surgery to dissect out all the contralateral normal side in both groups before and
components of the lateral ligament complex of the after the surgical or conservative treatments. The
ankle. Postoperatively all patients had a below knee normal side was used as control. Patients were briefed
cast for 6 weeks following which they were referred about the testing method and a demonstration was
to physiotherapy department for mobilization made beforehand by one of the authors to familiarise
exercises to the ankle and subtalar joint. It was noted the procedure to the patients.
in the postoperative period that on average all A trap door able to tilt 30 ° in the coronal plane
patients had lost 10° of inversion in subtalar joints was made to simulate an ankle inversion effect. It
on the operated side at the end of the rehabilitation measured 20" in width, 17" in length and 8" in height.
programme compared to preoperative assessments The middle third part was hinged for tilting and
but did not complain of pain or walking difficulty designed to lock. The trap door was connected to
on plain or uneven surfaces. two sensors one of which was stimulated when lock
Group B included 10 male patients; the mean age of the hinge opened by manually pulling a support
was 24.8 years (range 20-28 years). Right and left slot and consequently tilting the trap door. The other
ankles were involved equally. Eight patients were sensor would activate when the door hit the 30 °
active sportsmen and seven of them had inversion restrainer.
injury while playing football (see Table 2). Their Patients had the hair over the belly of the peroneus
contralateral ankles were normal and stable. These longus shaved with a disposable razor after
parients were diagnosed as having acute lateral identification of its borders; and a small area on the
ligament injury on the basis of a history of recent bony anteromedial surface on the tibia for application
inversion injury to the ankle; pain, swelling and of surface electrodes. The skin was cleaned and dried
tenderness over the lateral ligament complex, pain with 70% sterile isopropyl alcohol wipe (Seton
on active inversion of the ankle and negative Pebbles Ltd, Oldham, UK). EMG signals were
radiographs for any fracture in and around the ankle recorded using surface electrodes (Nicolet, Nicolet
joint. No pathology was noted in the subtalar joint Biomedical Inc., Madison, WI, USA). Two electrodes
or other joints of the injured foot. No attempt was were centred over the peroneus longus belly 2 cm
made to carry out stress views under general apart and 3 cm distal to the head of fibula; the third
anaesthesia. Patients with any other associated injury electrode was used as neutral over the tibia.
to the same ankle and foot were excluded from the The subjects would stand with the affected foot on
study along with those who had previous ankle the hinged part and the other foot on another
injury to the same side. These patients were treated platform of the same height. The intermalleolar
conservatively with rest, elevation, ice application distance was set up at 25 cm for normal balance and
and compression bandage. Ankle dorsiflexion and axis of rotation of the trap door was adjusted just
treatment, while those who did receive patient's s y m p t o m s , no significant change in peroneal
p r o p r i o c e p t i v e exercises s h o w e d i m p r o v e m e n t s reaction time w a s o b s e r v e d in chronic cases.
clinically a n d electrophysiologically, in a short Patients with acute ankle sprains and p o o r peroneal
duration? reaction time at 6-8 w e e k s can h a v e significant
Third, p r o p r i o c e p t i v e exercises m a d e the p e r o n e a l improvement clinically and measurable
muscles m o r e sensitive to inversion signals f r o m i m p r o v e m e n t s in peroneal reaction time w i t h
ankle a n d allowed t h e m to r e s p o n d in a n o r m a l w a y proprioceptive exercises of the ankle.
as before the ankle injury rather than s h o w i n g the We m u s t stress that t w o g r o u p s of subjects w e r e
characteristic slow reflex response as seen in EMG not c o m p a r e d to each other in this s t u d y because of
recordings after the injury to the ankle. It m a y be, m a n y variables, w h i c h could not be controlled.
w h e n the afferent signals f r o m the ankle joint are There is n e e d for a further s t u d y to be carried out
disrupted, the brain and other cerebral higher centres to record peroneal reaction time in chronic unstable
quickly learn to replace this information w i t h that ankles following p r o p r i o c e p t i v e exercises to identify
f r o m the m e c h a n o r e c e p t o r s of the peroneal muscles a n y changes w h i c h m a y a c c o m p a n y the treatment.
a n d tendons for the precise j u d g e m e n t of position of
the ankle once the peroneal muscle c o m p l e x has b e e n
Statement of interest
r e - e d u c a t e d w i t h p r o p r i o c e p t i v e exercises. In other
w o r d s functional training preserves the nutrition a n d N o benefits in a n y f o r m h a v e been received or will
enhances the co-ordination of the p e r o n e a l be received f r o m a c o m m e r c i a l p a r t y related directly
m u s c u l a t u r e in stabilizing the ankle joint. or indirectly to the subject of this article.
The v i e w that the peroneal muscles are re-educated
is s t r e n g t h e n e d b y the fact that eight out of ten
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