prevalence and impact of chronic musculoskeletal ankle disorders in the community

att

J

1801

ORIGINAL ARTICLE

Prevalence and Impact of Chronic Musculoskeletal AnkleDisorders in the CommunityClaire E. Hiller, PhD, Elizabeth J. Nightingale, PhD, Jacqueline Raymond, PhD, Sharon L. Kilbreath, PhD,
Joshua Burns, PhD, Deborah A. Black, PhD, Kathryn M. Refshauge, PhD
swa

p

a

ooqep

ABSTRACT. Hiller CE, Nightingale EJ, Raymond J, Kil-breath SL, Burns J, Black DA, Refshauge KM. Prevalence andimpact of chronic musculoskeletal ankle disorders in the com-munity. Arch Phys Med Rehabil 2012;93:1801-7.

Objective: To determine the point prevalence of chronicmusculoskeletal ankle disorders in the community.

Design: Cross-sectional stratified (metropolitan vs regional)random sample.

Setting: General community.Participants: Population-based computer-aided telephone

survey of people (N�2078) aged 18 to 65 years in New SouthWales, Australia. Of those contacted, 751 participants provideddata.

Interventions: Not applicable.Main Outcome Measures: Point prevalence for no history of

ankle injury or chronic ankle problems (no ankle problems),history of ankle injury without residual problems, and chronicankle disorders. Chronic musculoskeletal ankle disorders dueto ankle sprain, fracture, arthritis, or other disorder comparedby chi-square test for the presence of pain, weakness, givingway, swelling and instability, activity limitation, and healthcare use in the past year.

Results: There were 231 (30.8%) participants with no ankleproblems, 342 (45.5%) with a history of ankle injury but nochronic problems, and 178 (23.7%) with chronic ankle disor-ders. The major component of chronic ankle disorders wasmusculoskeletal disorders (n�147, 19.6% of the total sample),most of which were due to ankle injury (n�117, 15.6% of thetotal). There was no difference among the arthritis, fracture,sprain, and other groups in the prevalence of the specificcomplaints, or health care use. Significantly more participantswith arthritis had to limit activity than in the sprain group(Chi-square test, P�.035).

Conclusions: Chronic musculoskeletal ankle disorders affectedlmost 20% of the Australian community. The majority were dueo a previous ankle injury, and most people had to limit or changeheir physical activity because of the ankle disorder.

Key Words: Ankle injuries; Chronic limitation of activity;oint instability; Joint pain; Prevalence; Rehabilitation.

From the Faculty of Health Sciences, University of Sydney, Sydney (Hiller,Nightingale, Raymond, Kilbreath, Burns, Black, Refshauge); and Institute for Neu-roscience and Muscle Research, The Children’s Hospital at Westmead, Sydney(Burns), Australia.

Presented in part to the American College of Sports Medicine, June 5, 2010,Baltimore, MD, and International Foot and Ankle Biomechanics Congress, September16, 2010, Seattle, WA.

No commercial party having a direct financial interest in the results of the researchsupporting this article has or will confer a benefit on the authors or on any organi-zation with which the authors are associated.

Correspondence to Claire Hiller, PhD, Faculty of Health Sciences, The Universityof Sydney, 75 East St Lidcombe, NSW 2141, Australia, e-mail: [email protected]. Reprints are not available from the author.

In-press corrected proof published online on Jun 8, 2012, at www.archives-pmr.org.

0003-9993/12/9310-00379$36.00/0http://dx.doi.org/10.1016/j.apmr.2012.04.023

© 2012 by the American Congress of RehabilitationMedicine

CHRONIC MUSCULOSKELETAL conditions constitute aglobal health problem that is likely to increase as the

average life span increases. The contribution of chronic ankledisorders to this global problem is unknown. Chronic ankleconditions may be linked to the high incidence of ankle injurysuch as ankle sprain and fracture, injuries that are often thoughtto fully recover. The ankle was the most common site of injuryin 24 of 70 sports, and ankle sprain was the major specificinjury in 33 of 43 sports reviewed.1 Furthermore, 22% of allports injuries presenting to a hospital emergency departmentere ankle injuries, with a ratio of 8 ankle sprains for each

nkle fracture.2 From the general community, presentations tohospital emergency were between 2.23 and 74,5 ankle sprainsper year per 1000 population and 1.1/1000 person-years forankle fracture.6 Because most people do not seek hospitaltreatment for ankle sprain, the true incidence is likely to behigher.7-9

Long-term consequences of ankle injury are varied. Residualproblems after ankle fracture include pain, decreased range ofmotion, and impaired function.10 Approximately 25% of peo-le have poor to fair self-reported outcomes at 2,11 5,10 and

1412 years postfracture. Following ankle sprain, a systematicreview reported that 15% to 64% of the people had not recov-ered in 3 years.13 Residual problems included pain, chronicnkle instability, and recurrent sprain.13 Daily life is apprecia-

bly impacted; for example, 15% of the people with instabilityafter ankle sprain returned to work with some impairment, 6%were unable to maintain any occupational activity,14 while 72%of the people were unable to maintain their previous activitylevel.15 The longer-term consequence of ankle fracture, sprain,steochondrosis, and cartilage damage is posttraumatic anklesteoarthritis.16 Ankle osteoarthritis can result in very pooruality of life.17 Among patients presenting for surgery fornd-stage ankle osteoarthritis, 70% to 85% of the cases wereosttraumatic.16,18-20

While we have some information on ankle injury inci-dence, the prevalence of ongoing problems following injuryis unknown in the general community. Follow-up studieshave been undertaken only in either specific sportinggroups1 or in people presenting to a medical facility.3,4

Anecdotal evidence suggests that these ongoing problemsare self-managed and these disorders are therefore not in-cluded in health care statistics.

Taken together, these observations suggest a high preva-lence of chronic ankle disorders that potentially have asignificant, adverse impact on health and quality of life. We,therefore, aimed to determine the point prevalence ofchronic musculoskeletal ankle disorders in the general com-munity and investigate the impact of these disorders and
health care use.
Arch Phys Med Rehabil Vol 93, October 2012

mailto:[email protected]

mailto:[email protected]

http://www.archives-pmr.org

http://dx.doi.org/10.1016/j.apmr.2012.04.023

S

pcptwcvit

N

P

spotfihvbsiSc

I

selllcwaisa“

laitPoPcwc

aitowqab

S

TpS(rr(7Sfew(Paa

1802 CHRONIC MUSCULOSKELETAL ANKLE DISORDERS, Hiller

A

METHODS

amplingThe sample was drawn from eligible residents in a defined

opulation that was broadly representative of the Australianommunity. Data were collected by computer-assisted tele-hone interviews from a random sample of known landlineelephone numbers of residents in New South Wales—the stateith the largest population (7.1 million, 2009) in Australia. We

hose to stratify according to domicile, that is, metropolitanersus regional. We did not stratify for sex or age because theres no evidence for differences between sexes or for age youngerhan 65 years. Our findings support this decision.

Metropolitan was defined as the Sydney, Wollongong, andewcastle areas as determined by the sample postcode.

articipantsEligible participants were aged 18 to 64 years and could

peak English. Age was restricted to distinguish between therimary effects of aging and the secondary effects from injuryr other disease on ankle status. The person who answered theelephone was invited to participate in the study. If they did nott the age criteria they were asked whether there was anotherousehold member who did. Only 1 participant was inter-iewed from each contact number. Once a participant agreed toe interviewed, he/she was read a comprehensive informationtatement and verbal consent was obtained and recorded. Eth-cs approval for the study was obtained from the University ofydney Human Research Ethics Committee. Interviews wereonducted in July and August 2009.

nterviewThe interview, modified from a pilot version, consisted of a

eries of structured questions with a mix of closed and open-nded items. After the participant characteristics were estab-ished (age and sex), participants were asked “Do you have anyong-term problems with your ankles, lasting or expected toast more than 6 months?” Participants who answered “yes”ontinued to the main survey. Participants who answered “no”ere asked whether they had ever injured their ankles and

bout the type of injury, medical attention sought, time sincenjury, and activity that caused the injury. At the end of theurvey, participants were asked to confirm whether they hadny problems now because of the injury and if they answeredyes” were redirected to the main survey (appendix 1).

Participants who indicated that they had chronic ankle prob-ems were asked whether the problem was due to an injury,rthritis, or other condition. Participants who indicated annjury were asked about the type of injury, length of time sincehe injury, and medical attention sought at the time of injury.articipants who indicated arthritis were asked about the typef arthritis and whether a doctor had diagnosed the arthritis.articipants who reported that the chronic problem was notaused by injury or arthritis were asked the cause. If the causeas not musculoskeletal in origin, such as ankle swelling from

ardiovascular disease, the interview concluded at this point.Participants completing the remainder of the survey were

sked questions including the presence of any of the followingn or around the ankle: pain, weakness, swelling, feeling ofheir ankle giving way, feeling of ankle instability, and anyther problem. Participants who included pain as a problemere asked about its frequency and severity. Participants wereuestioned about the duration of the chronic problem. Twoctivity questions were asked; what activity they had to limit
ecause of their ankle problem, and what activity they most
rch Phys Med Rehabil Vol 93, October 2012

wanted to undertake but were unable to because of their ankleproblem. Final questions included health care use for the ankleproblem in the past year.

AnalysisAssuming a prevalence of 15%21 and a margin of error of .03

with 95% confidence intervals, a minimum sample size of 545was required. We assumed that 4 calls would be required toachieve 1 completed interview; that is, approximately 2180calls would be required to yield 545 responses.

Descriptive statistics on the prevalence rates, impact, and useof health care were calculated. The total sample was classifiedinto 4 subgroups: participants with no history of ankle injuryand no chronic disorders, participants with a history of ankleinjury but no chronic disorders, participants with ankle prob-lems of nonmusculoskeletal origin, and participants withchronic musculoskeletal ankle disorders. Comparison betweenthese 4 groups was conducted using analysis of variance withpost hoc Tukey’s alpha for age distribution and chi-square testfor sex frequency. The total sample and the chronic musculo-skeletal ankle disorder group were divided into age bands forcomparison with the Australian Bureau of Statistics 10-yearage bands. The exception was the 18 to 24 years band.

The group with chronic musculoskeletal ankle disorders wasfurther classified into specific diagnostic groupings for addi-tional analysis. These groupings included arthritis, fracture,sprain, and “other” musculoskeletal disorders. Chi-square orFisher exact test was used to compare activity level and healthcare use among these specific groups. Responses for the activ-ity questions were collated into categories; for example, allspecifically named sports were placed under the umbrella term“sport.” All statistics were analyzed using SPSS version 17.0.a

RESULTS

ampleWe contacted 2078 residences resulting in 751 responses.

he response rate of 36.1% was consistent with current tele-hone survey trends.22 Age was 46.0�12.5 years (mean �D), but the sample was skewed toward the older age groupsAustralian Bureau of Statistics [2009] mean for same ageange�40.2y). The median age was 48 years (interquartileange 37–57y). Most participants resided in metropolitan areas73%), reflecting the New South Wales distribution (2009:3.9%). There were more women (n�504) than men (n�247).ex proportions for the total sample did not differ significantlyrom the chronic musculoskeletal disorders group, or withinach age band. However, there was a higher proportion of menith a history of ankle injury but without chronic disorders

140 men [41%] and 202 women [59%], �2�6.31, df�1,�.012) and a lower proportion of men who had no history ofnkle injury and had no chronic ankle disorders (55 men [24%]nd 176 women [76%]: �2�6.42, df�1, P�.011).

Prevalence of Chronic Ankle DisordersThe overall prevalence of chronic ankle disorders was 23.7%

(n�178) (table 1). Of these, the majority were due to muscu-loskeletal disorders (n�147). Injury was the cause of mostmusculoskeletal disorders (n�121) followed by arthritis(n�30). Nonmusculoskeletal ankle problems (n�31) includedswelling due to cardiovascular or systemic disease, foot prob-lems, and referred pain.

History of Ankle InjuryA history of ankle injury was reported by 459 participants

(61.1% of the total sample), with ankle sprain being the most

N(*

1803CHRONIC MUSCULOSKELETAL ANKLE DISORDERS, Hiller

common injury (n�219). One quarter of the participants witha history of ankle injury reported ongoing problems (n�117).

Impact of Chronic Musculoskeletal Ankle DisordersOf the participants with chronic musculoskeletal ankle dis-

orders, the majority reported problems lasting longer than 10years (n�73 of 147, 49.7%) (table 2). Pain was the mostcommon complaint (n�108, see table 2) followed by weakness(n�105) and instability (n�89). There was no difference in theprevalence of specific complaints between the groups. Mostpeople (64.6%) (table 3) limited or modified some physicalactivity because of the ankle problem, and a similar proportionnominated an important activity they wanted to do, but wereunable, because of their ankle problem (table 4). The mostfrequently described activity for both questions was sport. Thearthritis group had to limit activity significantly more than thesprain group (24 in the arthritis group [80%], 34 in the spraingroup [55%]: �2�4.47, df�1, P�.035).

There was no difference among the groups for either ques-tion relating to health resource use. The majority of participantshad not sought assistance from any health practitioner in the

Table 2: Impact of Chronic M

VariableArthritis(n�30)

Fracture(n�26)

Age (y) 54.5�8.5* 45.6�13Sex (males:females) 8:22 8:18Symptoms

Pain 24 (80) 20 (76.9Weakness 23 (76.7) 18 (69.2Swelling 16 (53.3) 16 (61.5Giving way 18 (60.0) 11 (42.3Instability 21 (70.0) 17 (65.4Other 8 (26.7) 6 (23.1

Duration�1y 2 (6.7) 01–5y 8 (26.7) 8 (30.85–10y 7 (23.3) 5 (19.2�10y 13 (43.3) 13 (50)

PainAlways 2 (8.3) 1 (3.8)Often 5 (16.7) 4 (15.4Occasionally 17 (56.7) 15 (57.7Severe 5 (16.7) 3 (11.5Moderate 16 (53.3) 8 (30.8Mild 3 (10.0) 9 (34.6

OTE. Values are mean � SD or n (%) or as otherwise indicated.

Table 1: Prevalence of Ankle Conditions

Group n (%)

No chronic ankle disorder or history of ankle injury 231 (30.8)History of ankle injury but no chronic disorders 342 (45.5)Nonmusculoskeletal ankle disorders 31 (4.1)Chronic musculoskeletal ankle disorder 147 (19.6)

Sprain 62 (8.3)Arthritis 30 (4.0)Fracture 26 (3.7)Other 29 (3.6)

NOTE. Percentages are of the total population sample (n�751).

Tukey’s � P�.003).Significant difference between the arthritis group and the fracture, spra

last year (table 5). The family doctor was the most commonsource of care. Most participants undertook some form ofself-management (n�107, 72.8%) (table 6), commonly usingheat (n�42) or medication (n�40). Use of ankle supports wasalso common: brace, tape, or a bandage was used by 47participants.

Of particular interest, 35.5% (163 of 459) of the participantswith ankle injury did not consult a health practitioner at thetime of injury, that is, 41.8% (143 of 342) of the participantswithout chronic problems and 17.1% (20 of 117) of the par-ticipants with chronic problems.

DISCUSSIONThree quarter of the participants in this community-based

survey had either injured an ankle in the past or had chronicankle problems. The majority who injured an ankle recoveredfully; however, 1 in 5 reported a chronic problem.

Of those with a chronic musculoskeletal ankle disorder,almost 80% were due to an injury and more than 60% of thesepeople had modified their physical activity. The most commonsymptoms were occasional moderate pain and weakness.Health care consultation at the time of ankle injury was under-taken by 64.5% of the people and health care consultationamong those with chronic musculoskeletal ankle disorders by44.2% in the past year. The majority of the participants withchronic musculoskeletal ankle disorders used a self-manage-ment strategy, commonly involving some type of ankle sup-port, heat, and medication.

Prevalence of Chronic Musculoskeletal Ankle DisordersWe were able to locate 1 other community-based study of

the prevalence of foot and ankle disorders, but that studyinvestigated community-dwelling people older than 65 years.21

It was found that 14.9% of that sample had ankle joint pain onmost days over the last 4 weeks,21 a similar prevalence to that

uloskeletal Ankle Disorders

Sprain(n�62)

Other(n�29)

Total(n�147)

44.9�12.1 46.4�12.2 47.6�12.317:45 8:21 41:106

43 (72.6) 21 (72.4) 108 (73.5)48 (77.4) 17 (58.6) 106 (72.1)29 (46.8) 16 (55.2) 77 (52.4)31 (50.0) 14 (48.3) 74 (50.3)41 (66.1) 10 (34.5) 89 (60.5)5 (8.1) 9 (31.0) 28 (19.0)

11 (17.7) 3 (10.3) 16 (10.9)15 (24.2) 7 (24.1) 38 (25.9)4 (6.5) 3 (10.3) 20 (13.6)

32 (51.6) 16 (55.2) 73 (49.7)

5 (8.1) 2 (6.9) 10 (6.8)6 (9.7) 6 (20.7) 21 (14.3)

32 (51.6) 13 (44.8) 77 (52.4)4 (6.5) 0 12 (8.2)

18 (29.0) 15 (51.7) 57 (38.8)21 (33.9) 6 (20.7) 39 (26.5)

usc

.5

))))))

))

)))))

in, and other groups.


fi(

asaOfr

b

N* : Doe

t (�2


A

found in our study (108 of 751, 14.4%). However our study didnot include acute pain or pain due to conditions other thanmusculoskeletal problems. The only community-based surveyin Australia examined foot but not ankle problems.23

Few other community-based musculoskeletal surveys reportspecifically on the ankle. A Netherlands random populationsample of musculoskeletal pain in people older than 25 yearsfound the 12-month prevalence of ankle pain to be 9.2%.Chronic ankle pain, defined as current pain lasting more than 3months, was reported by 3.5% of the survey sample.24 Similar

gures have been reported for “self-reported” ankle symptoms4.3%)25 and ankle “joint problems” (4.1%)26 in large surveys

from the United States and United Kingdom, respectively. In asurvey of 991 people entering an Australian fitness program,8% of the men and 4% of the women reported ankle pain ordiscomfort during daily activities.27

This survey’s higher rate of chronic problems may be due tothe comprehensive ankle symptoms included, the initial inter-view question, or the further questioning of people with ahistory of ankle injury. A number of participants (n�32, 4% ofthe total sample) who initially said that they did not have achronic ankle problem remembered problems after questioningabout an ankle injury.

Prevalence of Specific ConditionsComparison of our results for ankle arthritis and chronic

problems following ankle sprain and fracture is problematic

Table 3: Activities Limited by Participants

ActivityArthritis(n�30)

Fracture(n�26)

No 6 (20.0)† 8 (30.8)Sport 0 5 (19.2)Run 4 (13.3) 3 (11.3)Walk long distances 6 (20.0) 0Walk 9 (30.0) 2 (7.7)Uneven ground 0 4 (15.4)Stairs 3 (10.0) 0Other 2 (6.7) 4 (15.4)

OTE. Values are n (%).One main response was taken for the open-ended survey question

†Difference between arthritis and sprain group significantly differen

Table 4: Priority Activity That Participants With Ch


Fract(n�

None 4 (13.3)† 8 (30Sport 1 (3.3) 7 (26Run 5 (16.7) 5 (19Walk 6 (20.0) 1 (3.Walk long distances 3 (10.0) 1 (3.Bushwalk (rough terrain) 3 (10.0) 2 (7.Dance 1 (3.3) 0Stairs 4 (13.3) 0ADL 2 0Exercise 1 (3.3) 0Other 0 2 (7.

NOTE. Values are n (%).Abbreviation: ADL, activities of daily living.*The response was taken for the open-ended survey question: What
ankle problem?†Difference between arthritis and sprain groups significantly different (Fi

due to the lack of community-based surveys. Only 2 stud-ies18,28 provide evidence concerning the relative prevalence ofnkle osteoarthritis; however, participants were patients pre-enting to rheumatology clinics. These studies found the prev-lence of ankle osteoarthritis to be 4%28 and 8%18 of patients.ur study, which was drawn from a very different population,

ound the prevalence rate to be 4%, but the confirmed diagnosisate was 2.8%.

The rate of chronic problems following ankle sprain haseen investigated in a systematic review13 of the clinical

course of ankle sprain. This review found that 15% to 64%of the people did not recover from the ankle sprain within 3years. Our study supported this review as 47% of the peoplein the community had experienced an ankle sprain and ofthese 17.5% had not recovered, the majority with symptomspersisting for more than 10 years after injury. Prevalence ofankle fractures in the community has been reported as1.9/1000 person-years in people older than 35 years. In ourstudy, 7.7% of the community reported a history of anklefracture and of these 45% had chronic problems. As we hadno medical classification of the fractures, this rate cannot bedirectly compared. However, a systematic review of long-term outcomes (more than 4 years) after surgically treatedankle fractures found that 20% of optimally reduced anklefractures did not have a “good to excellent” long-termoutcome.29

Chronic Musculoskeletal Ankle Disorders*

Sprain(n�62)

Other(n�29)

Overall(n�147)

28 (45.2) 10 (34.5) 52 (35.4)11 (17.7) 4 (13.8) 20 (13.6)4 (6.5) 3 (10.3) 14 (9.5)7 (11.3) 6 (20.7) 19 (12.9)4 (6.5) 1 (3.4) 16 (10.9)3 (4.8) 2 (6.9) 9 (6.1)

0 2 (6.9) 5 (3.4)5 (8.1) 1 (3.4) 12 (8.2)

s your ankle problem limit your physical activity? In what way?test, P�.035).

Musculoskeletal Ankle Disorders Wanted to Do*

Sprain(n�62)

Other(n�29)

Overall(n�147)

28 (45.2) 12 (41.4) 52 (35.4)12 (19.4) 4 (13.8) 24 (16.3)7 (11.3) 3 (10.3) 20 (13.6)4 (6.5) 5 (17.2) 16 (10.9)3 (4.8) 1 (3.4) 8 (5.4)1 (1.6) 0 6 (4.1)2 (3.2) 2 (6.9) 5 (3.4)

0 1 (3.4) 5 (3.4)2 (3.2) 0 4 (2.7)2 (3.2) 0 3 (2.0)1 (1.6) 1 (3.4) 4 (2.7)

most important activity to you that you cannot do because of your

With

ronic

ure26)

.8)

.9)

.2)8)8)6)

6)

is the

sher exact test, P�.003).

i

cippsIth

tpms

ftpcct

N*


Impact of Chronic Musculoskeletal Ankle DisordersWe were particularly interested in the impact of chronic

ankle disorders in terms of symptoms, activity, and the differ-ence among the groups. There was no significant differenceamong the groups in the frequency of ankle pain, weakness,swelling, giving way, or instability. However, the severity ofchronic pain varied from being mostly mild following anklesprain and fracture to moderate in the ankle arthritis group.

Overall, the majority of participants with chronic musculo-skeletal ankle disorders limited or modified their activity, withsignificantly more participants with arthritis (80%) experienc-ing limitations than those with ankle sprain (55%). In addition,significantly more participants with arthritis nominated activi-ties they wished to do, but were unable, compared with peoplewith problems following ankle sprain. This is consistent withprevious reports on the impact of osteoarthritis on quality oflife.17 However, it is of interest that symptoms and activitympacts are similar after ankle fracture and ankle sprain.

There is a strong indication that acute ankle injury andhronic musculoskeletal ankle disorders are underrepresentedn health care statistics. Health care was sought by 64.5% of thearticipants at the time of ankle injury. Only 44% of thearticipants with a chronic musculoskeletal ankle disorderought help over the past year from a health care practitioner.nterestingly, there was no difference among the arthritis, frac-ure, and sprain groups for the frequency of consultation withealth care practitioners. While help from health care practi-

Table 5: Health Care Sought Within the Past Year for P


Fracture(n�26)

None 15 (50) 14 (53.8)Family doctor 12 (40.0) 2 (7.7)Specialist 5 (16.7) 1 (3.8)Physiotherapist 1 (3.3) 6 (23.1)Chiropractor 0 (0.0) 1 (3.8)Chemist 2 (6.7) 5 (19.2)Other 2 (6.7) 3 (11.5)

OTE. Values are n (%).There was no significant difference between groups (�2 test).

Table 6: Self-Management for Participants


Fracture(n�26)

Nothing 7 (23.3) 7 (26.9Heat 11 (36.7) 10 (33.3Brace 4 (13.3) 4 (15.4Medication (OC) 13 (43.3) 3 (11.5Ice 5 (16.7) 5 (19.2Tape 1 (3.3) 0Exercise 5 (16.7) 5 (19.2Medication (script) 7 (23.3) 1 (3.8)Complementary 2 (6.7) 1 (3.8)Massage 1 (3.3) 1 (3.8)Elevation 1 (3.3) 1 (3.8)Bandage 0 1 (3.8)Orthotics 1 (3.3) 1 (3.8)Other 3 (10.0) 1 (3.8)

NOTE. Values are n (%).
Abbreviations: OC, over the counter; script, prescription.*There was no significant difference between groups.
ioners was sought by less than half the participants, mostarticipants had developed a self-management strategy. Theain strategies involved heat applied using various methods,

ome type of ankle support, and medication.A higher proportion of participants with chronic disorders

ollowing ankle injury sought health care consultation at theime of injury (82.9%) than did those without (58.2%). It isossible that people with more severe injuries seek health careonsultations and that these injuries are more likely to result inhronic symptoms. However, this has not been demonstrated inhe case of ankle sprain.13

ImplicationsChronic musculoskeletal ankle disorders impact daily life,

and these results raise interesting rehabilitation questions. It isunclear whether financial or education barriers, or an attitudethat the injury was “minor,” kept people from consulting ahealth care practitioner at the time of injury. It may be that apublic health campaign would inform people of current besttreatment practice and thus reduce chronic problems. However,current best practice may not be as effective as previouslythought with people not consulting health care practitioners,not because they have recovered but because it is ineffective.Future research into whether best practice reduces chronicproblems compared with self-care, and whether the severity ofinjury should be the criterion for clinicians to refer people forfurther rehabilitation, would be useful. Furthermore, decreased

ipants With Chronic Musculoskeletal Ankle Disorders*

Sprain(n�62)

Other(n�29)

Overall(n�147)

39 (62.9) 14 (48.3) 82 (55.8)10 (16.1) 4 (13.8) 28 (19.0)

6 (9.7) 4 (13.8) 16 (10.9)8 (12.9) 5 (17.2) 20 (13.6)3 (4.8) 2 (6.9) 6 (4.1)5 (8.1) 3 (10.3) 15 (10.2)5 (8.1) 5 (17.2) 15 (10.2)

Chronic Musculoskeletal Ankle Disorders*

Sprain(n�62)

Other(n�29)

Overall(n�147)

21 (33.9) 5 (17.2) 40 (27.2)11 (17.7) 10 (34.5) 42 (28.6)13 (21.0) 21 (72.4) 26 (17.7)7 (11.3) 8 (27.6) 31 (21.1)7 (11.3) 0 17 (11.6)

12 (19.4) 2 (6.9) 15 (10.2)5 (8.1) 0 15 (10.2)1 (1.6) 0 9 (6.1)4 (6.5) 2 (6.9) 9 (6.1)4 (6.5) 3 (10.3) 9 (6.1)

0 4 (13.8) 6 (4.1)1 (1.6) 4 (13.8) 6 (4.1)

0 2 (6.9) 4 (2.7)1 (1.6) 2 (6.9) 7 (4.8)

artic

With

)))))

)



A

physical activity is likely to adversely affect health status:obesity and diabetes are major health problems, and it is notknown what contribution chronic ankle disorders have on theirdevelopment.

Study LimitationsThere are issues with generalizing the results. First, although

it was a randomized survey across a major geographical area,the design depended on landline telephones to contact potentialparticipants. The use of landlines resulted in the recruitment ofa skewed sample of older women, people at home, and peoplewith landlines. One third of the calls were made outside work-ing hours and on weekends to minimize the skew away frompeople working, and this produced no difference in sex or agebetween the call hours. Future research stratified by age andsex, and including mobile phone contact, would provide moregeneralizable results. Second, participation by people withankle problems may have been more likely because the callwas initiated as a survey about ankles. However, there was nomention of injury to minimize this bias.

The response rate for this survey could be considered low;however, it is consistent with current response rates for ran-domized telephone surveys.22 We chose to restrict age becauseof difficulties in obtaining parental permission for children andthe desire to avoid confounding from age-related conditions.Overall, the results should be generalized with caution andpotentially overestimate the prevalence of problems.

CONCLUSIONSTo the best of our knowledge, this is the first study to survey

a community-dwelling sample to determine the prevalence andimpact of chronic musculoskeletal ankle disorders. This initialbroad screening survey demonstrates that chronic musculosk-eletal ankle disorders are highly prevalent, affecting almost 1 in5 Australians. Persisting ankle problems are particularly com-mon following ankle injury, suggesting a need for further workto quantify the impact, for example, by more specific determi-nation of activity limitations and participation restrictions.

APPENDIX 1: SURVEY QUESTIONS AND FLOW1. Do you have any long-term problems with your ankles?

That is, problems have lasted or are expected to lastmore than 6 months (eg, pain, weakness, swelling,arthritis, and gout).YES go to 8NO go to 2

2. Have you ever injured your ankles? For example,sprains, strains, fractures, broken bones, dislocations.YES go to 3NO END

3. What injuries have you had?Sprain of ligamentStrain of a muscleFracture or broken boneDislocationOther (Please specify) __________

4. Did you attend any of the following for treatment ofyour injury?Hospital emergency/casualtyDoctor (general practitioner or specialist)PhysiotherapistChiropractorOther (Please specify) __________

5. How long ago?6. Which of these best describes the activity that you were

doing when you received your/latest injury?


Sporting activitiesLeisure activitiesWork-related activityAttending school/college/universityDomestic activitiesOther (Please Specify) __________

7. Do you have any problems NOW because of the injury?YES go to 14NO END

8. Is your ankle problem due to an injury to your ankle?YES go to 14NO go to 9

9. Is your ankle problem due to arthritis?YES go to 11NO go to 10

10. What is your ankle problem due to?END if not musculoskeletalGo to 19 if musculoskeletal

11. What type of ankle arthritis do you have?12. Did a doctor tell you that you had arthritis?

YESNO—please specify whom

13. Is your arthritis due to a previous ankle injury?YES go to 14NO go to 16

14. Did the injury that is causing you problems occur in thelast month6 monthsyear1 to 5 years5 to 10 yearsMore than 10 years?

15. Was the injury due to one of the following?Sprain of ligamentStrain of a muscleFracture or broken boneDislocationOther (Please Specify) __________

16. Did you attend any of the following for the treatment ofyour injury?Hospital emergency/casualtyDoctor (general practitioner or specialist)PhysiotherapistChiropractorOther (Please Specify) __________

17. Is the injury a recurrence of a previous problem?18. Do you suffer from any of the following due to your

ankle problems?Pain in or around your ankleAnkle weaknessAnkle swellingA feeling of your ankle giving wayA feeling of ankle instabilityAny other ankle problem—Please specifyIf answered yes to pain go to 19.If not code 1 go to Q21.

19. Do you have pain in your ankle?AlwaysOftenOccasionally

20. Is the painSevereModerate
Mild


APPENDIX 1 (Cont’d): SURVEY QUESTIONS ANDFLOW

21. How long have you had problems with your ankle?Less than a year1 to 5 years5 to 10 yearsMore than 10 years

22. Does your ankle problem limit your physical activity?In what way?

23. What is the most important activity to you that youcannot do because of your ankle problem?

24. Have you sought help for your ankle problem (notinjury) in the past year fromHospital emergency/casualtyGeneral practitionerSpecialist doctorPhysiotherapistChiropractorChemist/pharmacistOther (Please specify) __________

25. Do you do anything to help with your ankle problem?

References1. Fong D-P, Hong Y, Chan L-K, Yung P-H, Chan K-M. A system-

atic review on ankle injury and ankle sprain in sports. Sports Med2007;37:73-94.

2. Boyce SH, Quigley MA. Review of sports injuries presenting toan accident and emergency department. Emerg Med J 2004;21:704-6.

3. Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJJr. The epidemiology of ankle sprains in the United States. J BoneJoint Surg Am 2010;92:2279-84.

4. Bridgman SA, Clement D, Downing A, Walley G, Phair I, Maf-fulli N. Population-based epidemiology of ankle sprains attendingaccident and emergency units in the West Midlands of England,and a survey of UK practice for severe ankle sprains. Emerg MedJ 2003;20:508-10.

5. Holmer P, Sondergaard L, Konradsen K, Nielsen PT, JorgensenLN. Epidemiology of sprains in the lateral ankle and foot. FootAnkle Int 1994;15:72-4.

6. Jensen SL, Andresen BK, Mencke S, Nielsen PT. Epidemiologyof ankle fractures: a prospective population-based study of 212cases in Aalborg, Denmark. Acta Orthop Scand 1998;69:48-50.

7. Bahr R, Holme I. Risk factors for sports injuries–a methodologicalapproach. Br J Sports Med 2003;37:384-92.

8. McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries inbasketball: injury rate and risk factors. Br J Sports Med 2001;35:103-8.

9. Schappert SM, Rechtsteiner EA. Ambulatory medical care utili-zation estimates for 2007. Vital Health Stat 13 2011:1-38.

10. Shah NH, Sundaram RO, Velusamy A, Braithwaite IJ. Five-yearfunctional outcome analysis of ankle fracture fixation. Injury2007;38:1308-12.

11. Lash N, Horne G, Fielden J, Devane P. Ankle fractures: functionaland lifestyle outcomes at 2 years. ANZ J Surg 2002;72:724-30.

12. Day GA, Swanson CE, Hulcombe BG. Operative treatment ofankle fractures: a minimum ten-year follow-up. Foot Ankle Int
2001;22:102-6.
13. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, KoesBW, Bierma-Zeinstra SM. What is the clinical course of acuteankle sprains? A systematic literature review. Am J Med 2008;121:324-31.

14. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up ofinversion trauma of the ankle. Arch Orthop Traum Surg 1995;114:92-6.

15. Konradsen L, Bech L, Ehrenbjeerg M, Nickelsen T. Seven yearsfollow-up after ankle inversion trauma. Scand J Med Sci Sports2002;12:129-35.

16. Valderrabano V, Horisberger M, Russell I, Dougall H, Hinter-mann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res2009;467:1800-6.

17. Glazebrook M, Daniels T, Younger A, et al. Comparison ofhealth-related quality of life between patients with end-stage ankleand hip arthrosis. J Bone Joint Surg Am 2008;90:499-505.

18. Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiologyof ankle arthritis: a report of a consecutive series of 639 patientsfrom a tertiary orthopaedic center. Iowa Orthop J 2005;25:44-6.

19. Valderrabano V, Hintermann B, Horisberger M, Fung TS. Liga-mentous posttraumatic ankle osteoarthritis. Am J Sports Med2006;34:612-20.

20. Valderrabano V, Pagenstert G, Horisberger M, Knupp M, Hinter-mann B. Sports and recreation activity of ankle arthritis patientsbefore and after total ankle replacement. Am J Sports Med 2006;34:993-9.

21. Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlayJB. Prevalence of foot and ankle conditions in a multiethniccommunity sample of older adults. Am J Epidemiol 2004;159:491-8.

22. Curtin R, Presser S, Singer E. Changes in telephone surveynonresponse over the past quarter century. Public Opinion Q2005;69:87-98.

23. Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and corre-lates of foot pain in a population-based study: the North WestAdelaide health study. J Foot Ankle Res 2008;1:2.

24. Picavet HS, Schouten JS. Musculoskeletal pain in the Nether-lands: prevalences, consequences and risk groups, the DMC(3)-study. Pain 2003;102:167-78.

25. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletalimpairments and associated disability. Am J Public Health 1984;74:574-9.

26. Badley EM, Tennant A. Changing profile of joint disorders withage: findings from a postal survey of the population of Calderdale.Ann Rheum Dis 1992;51:366-71.

27. Sedgwick AW, Smith DS, Davies MJ. Musculoskeletal status ofmen and women who entered a fitness programme. Med J Aust1988;148:385, 388-91.

28. Cushnaghan J, Dieppe P. Study of 500 patients with limb jointosteoarthritis, I: analysis by age, sex, and distribution of symp-tomatic joint sites. Ann Rheum Dis 1991;50:8-13.

29. Stufkens SA, van den Bekerom MP, Kerkhoffs GM, HintermannB, van Dijk CN. Long-term outcome after 1822 operativelytreated ankle fractures: a systematic review of the literature. Injury2011;42:119-27.

Suppliera. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.


prevalence and impact of chronic musculoskeletal ankle disorders in the community

Documents