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Tuesday, June 6, 2023

Alterations in Hip Muscle Function Following Severe Ankle Sprain

Brent Brookbush

Brent Brookbush


Research Review: Alterations in Hip Muscle Function Following Severe Ankle Sprain

By Jinny McGivern, PT, DPT, CFMT, Certified Yoga Instructor

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Bullock-Saxton, J. E. (1994). Local sensation changes and altered hip muscle function following severe ankle sprain. Physical therapy74(1), 17-28. ABSTRACT

Why is this relevant?:

There has been significant growth in the amount of discussion and research published regarding the concept “regional interdependence”. This study provides further evidence of how an injury in one body segment can result in compensation at another segment by demonstrating a relationship between the foot/ankle complex and the hip. Further, it explores this relationship between altered sensory input (perception of vibration) after a history of ankle sprains, and the subsequent motor output (EMG Activity) of the lower extremity. While more research is needed to determine if these compensations set the stage for subsequent injuries, this study provides a foundation of correlation between two segments.

Image courtesy of https://en.wikipedia.org/wiki/Sprained_ankle

Study Summary

Study DesignDescriptive comparative study
Level of EvidenceIII - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies.
Subject DemographicsTwo groups of individuals were recruited from the Australian Defense Force.  One group of 20 subjects, the Injured Group (INJ), reported a history of unilateral ankle sprain.  The control group of 11 subjects reported no history of lateral ankle sprain (CON).
  • Age:
    • INJ - 10% aged 18-20 yrs; 50% 21-25 yrs; 30% 25-30 yrs; 10%  31-35 yrs.
    • CON - 9% aged 18-20 yrs; 46% 21-25 yrs; 36 % 25-30 yrs; 9% 31-35 yrs.

  • Gender: Male
  • Characteristics:
    • INJ - 45% sedentary occupations (drivers or admin positions), 55% Active (light-heavy field work)
    • CON - 36% sedentary occupations (drivers or admin positions), 63% Active (light-heavy field work)

  • Inclusion Criteria: INJ group - history of grade II or III unilateral lateral ankle sprain (must have caused swelling and discomfort with walking); right side must be dominant side for activities such as kicking; treatment of ankle sprain must have included immobilization period.
  • Exclusion Criteria: INJ group - significant injury to ankle other joint or bone of the lower limb; history of "clumsiness" (history of sensory or motor dysfunction not related to injury or intellectual impairment); any neurological conditions/deficits.
Outcome MeasuresSensory Perception
  • Perception of vibration at various frequencies for the (R) and (L) sides of the CON group and the injured (inj side) and uninjured side (uninj side) of the INJ group:
    • 100Hz:
    • 150Hz
    • 200Hz
    • 250Hz

  • Comparisons were made between both limbs of the CON group with both limbs of the INJ group.
  • Comparisons were made between limbs within each group.

Motor Output

  • Timing of EMG activity of the Gluteus Maximus, Erector Spinae (right and left sides) and Biceps Femoris during a prone hip extension activity
    • Timing of muscles firing prior to the lift of the leg (O-H) - within and between groups
    • The time difference between firing of 1st muscle to firing of 4th muscle - between groups

ResultsSensory Perception
  •  Perception of vibration at various frequencies:
    • 100Hz:
      • CON: (R side) .399, (L side) .395
      • INJ: (inj side) .867, (uninj side) .824

    • 150Hz
      • CON (R side) .317, (L side) .299
      • INJ: (inj side) 1.400, (uninj side) .918

    • 200Hz
      • CON (R) side .495, (L) side 1.051
      • INJ (inj side) 2.243, (uninj side) 1.273

    • 250Hz
      • CON (R) side .978, (L) side 1.664
      • INJ (inj side) 3.924, (uninj) 2.324

  • Vibration sense was decreased in both limbs of the INJ group as compared to both limbs of the CON group
  • The INJ group required significantly more sensory input before vibration was sensed in the inj side at 150Hz, 200Hz & 250Hz.
  • The CON group only demonstrated significant differences in sensory perception at 200 Hz.

Motor Output

EMG analysis of the timing of Erector Spinae, Biceps Femoris and Gluteus Maximus:

  • Onset of muscle activity:
    • All muscles fired prior to the lift of the leg.
    • Onset of Gluteus Maximus firing was significantly later for the INJ group as compared to the CON group (both limbs were combined for each group) (p<.001).
    • There were no significant differences in onset timing for  the Erector Spinae or Biceps Femoris between the two groups.
    • There was a significant side to side difference within the CON group for onset of Gluteus Maximus and Biceps Femoris firing between right ("skill" side) and left ("stance" side) - the "stance" side was found to fire significantly earlier.
    • There were no significant side to side differences between injured and uninjured limbs of INJ group for any of the timing of the muscles observed (indicating both limbs demonstrated delayed onset of Gluteus Maximus as compared with CON group).
    • The uninjured limb demonstrated significantly delayed activation of Gluteus Maximus when compared with both limbs of the CON group.

  • Time span between activation of 1st muscle and 4th muscles
    • The INJ group demonstrated a significantly longer time period between the activation of the 1st and 4th muscles. (CON group = .306 s from 1st to 4th muscle; INJ group = .527s; INJ group's time was 72% longer than CON).

There was a positive correlation between decreased vibration perception at 250 Hz and later onset of Gluteus Maximus contraction in the INJ group.

Conclusions This research demonstrates that ankle injuries can have lasting impairments reaching up the kinectic chain to proximal segments such as the hip.
Conclusions of the Researchers This research demonstrates a correlation between local changes in sensory perception at the ankle, and proximal alterations in the timing of Gluteus Maximus activation during prone hip extension.

Image courtesy of https://en.wikipedia.org/wiki/Gluteus_maximus_muscle

Review & Commentary:

Many features of this study contributed to a strong methodology. The authors developed a research method that provided information on multiple integrated attributes of how the lower extremity compensates following an ankle sprain. Because their hypothesis was related to compensation patterns throughout the lower extremity, the authors elected to observe both limbs in injured and uninjured subjects. Studies will often use the contralateral, uninjured lower extremity as a control for the injured side; however, this study demonstrates that both limbs may be affected post unilateral ankle sprain. The authors selected vibration as their sensation of choice, citing that optimal perception of vibration requires efficient function of superficial and deep peripheral receptors, as well the somatosensory cortex. The authors hypothesize that during an inversion sprain, local receptors in the joint capsule and ligaments of the ankle are compromised altering perception in the INJ group. Note, confirmation of where in the afferent pathway these impairments occur is outside the scope of this particular study. Vibration was described as an easy sensation to control the dosage of; using graded intensities (Hz) with each subject. The sequence of frequencies tested was randomized. Interestingly, the authors chose to observe muscle timing, as opposed to muscle strength for their EMG analysis; providing information about neuromuscular coordination. Repeatability studies were performed for the methods used to record vibration perception, as well as muscle activity, indicating these methods would be appropriate for other researchers to repeat and confirm findings. The authors implemented excellent standardization procedures and thoroughly described the details of their setup for measuring vibration and hip muscle activity.

This research has its limitations. It had a relatively small sample size, and the two groups of subjects were not matched in size (the INJ group was twice the size of the CON group). When describing the sample, the authors reported varying levels of activity of the INJ & CON groups; however, it does not appear that they analyzed whether there were significant differences in activity levels between groups. When assessing vibration sensation, the subjects were positioned in a non-weight bearing position. It would be beneficial for future research to investigate the individual's ability to sense vibration in standing and other dynamic weight bearing postures to more closely replicate the conditions in which sprains actually occur. The authors utilized surface EMG to measure activity of the hip muscles. Surface EMG measurements are vulnerable to interfering cross talk from proximal muscles; however, the authors reported following previously determined protocols for reducing this type of interference. The authors did not measure hip extension ROM, but required all subjects to perform 15 degrees of hip extension during measurements of hip muscle activity. It is possible, and perhaps likely, that subjects with limited range of motion compensated with altered recruitment strategies during these measurements. The authors observed the relationship between altered sensation at the ankle and altered movement strategy at the hip (Biceps Femoris  and Gluteus Maximus ) and lower trunk (Erector Spinae ). Future research should investigate if there are also altered strategy in the muscles that make up the Intrinsic Stabilization Subsystem, specifically the Transverse Abdomninis , Multifidi and Pelvic Floor. Terada et al. (2016) recently reported that the diaphragm demonstrates altered activity in those with chronic ankle instability. When applying the results of this study, it is important to keep in mind that this research was performed on men of a specific age range with a specific pathology; the results may not be applicable to all populations.

It is interesting to note that inclusion criteria for the INJ group was a period of ankle immobilization following injury. This begs the question, was it the ankle injury that resulted in the changes in sensory input or the period of immobilization that played a larger role in changing lower limb movement patterns? Future research should investigate the role of immobilization on changes in sensory perception following ankle sprain, as this may have implications for the acute care management of this type of injury.

Why is this study important?

This study provides further evidence to support the concept of "regional interdependence". Specifically, this study demonstrates that ankle sprain results in altered sensation, and also altered muscle recruitment patterns of the hip including latent firing of the gluteus maximu s.

How does it affect practice?

This research is evidence of a relationship between movement impairment of the ankle and hip. Following ankle injury, assessment and appropriate intervention of the hip is likely optimal for recovery. This research also demonstrates that altered strength is only one indicator of dysfunction, and that impairment may also result in altered muscle recruitment patterns. This implies that corrective/therapeutic interventions should not only address strength deficits, but attempt to address muscle recruitment patterns of the entire dysfunctional segment - i.g. ankle sprain would include interventions for both under-active and over-active muscles of the entire lower extremity.

How does it relate to Brookbush Institute Content?

This research supports the Brookbush Institute's view that Lower Extremity Dysfunction (LED) will likely result in latent firing/under-activity of the gluteus maximus, even in cases where LED is the result of acute ankle pathology. Further, this study demonstrates that addressing gluteus maximus dysfunction with hip extension alone is likely not sufficient, and that further consideration needs to be given to compensation and recruitment strategy. Specifically, the Brookbush Institute addresses "over-active" muscles with release techniques , joint hypomobility with joint mobilizations , short muscles with lengthening techniques , and under-active muscles with activation techniques before integration into multi-joint movement patterns, functional tasks and activities of daily living. Activation techniques may be further divided into isolated activation and reactive activation techniques; designed to increase motor unit recruitment and enhance activation timing. The videos below are examples of a circuit of isolated and reactive activation techniques for the Gluteus Maximus.

Gluteus Maximus Isolated Activation

VA and Gluteus Maximus Activation and Progressions

Gluteus Maximus Reactive Activation

Gluteus Maximus Reactive Activation Progressions


Terada, M., Kosik, K. B., McCann, R. S., & Gribble, P. A. (2016). Diaphragm Contractility in Individuals with Chronic Ankle Instability. Medicine and science in sports and exercise.

© 2016 Brent Brookbush

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