Proprioception of the Ankle

Introduction

Skin sensors and musculoskeletal sensors including nerve fibers and Golgi nerve organs (GTOs) are the main sensors that regulate the relative level of motor and muscle activity.[1] They respond to touch vibration pressure and stretch their skin changing length a function of muscle and tendon strength. Skeletal muscle length and tension are controlled through proprioception in order to coordinate motor control.[2] This article will focus on ankle proprioception and how it can be used in the rehabilitation of ankle injuries.

Sensory receptors

Nerve Pathway

What Is Proprioception?

Proprioception is a fundamental change in the sensory range of touch that affects the perception of joint movement (kinesthesia) and joint position (sensitivity to joint position).[3] When neurological changes occur, sensory nerves are supplied by the joint nerves and tendons of the cutaneous tissue proprioceptive feedback to the central nervous system (CNS) via physiological mechanisms. The route taken depends on the type of signal being transmitted. Communication and proprioceptive information via the posterior column-medial lemniscal pathway reaches the CNS. Muscles of the spinal cord pathways carry information about pain and inflammation. In addition, the visual and vestibular centers provide afferent information to the central nervous system about body position and balance.[3]

Proprioception is governed by body receptors.[4] Because it is directly connected to the brain through nerves an individual who is visually impaired is aware of his or her bodily functions.[4] If there is a change in the longitudinal joint position or speed of movement of the ankle The CNS uses this information to coordinate movement and perform gait.[4]

Mechanoreceptors, thermoreceptors, and nociceptors are all cutaneous sensory receptors. There are six skin mechanoreceptors: Merkel discs Meissner corpuscles Pacinian corpuscles Ruffini endings and C-fiber low threshold mechanoreceptors. Hair follicles also belong to this group and are responsible for Detect light touch. Meissner bodies are located in the dermal papillae and detect subtle touch and vibration. High frequency vibrations and touch are also responsible for the Pacinian corpuscles located in the dermis. Ruffini bodies detect stress from stretch skin. The basal epidermis is home to the Merkel discs responsible for detecting structure and texture. Finally, the C Fiber LTM detects light touch. [5]

The brain receives strong proprioceptive messages through receptors located in the muscles. These receptors are called muscle spindles. [6] Muscle spindles are considered the most important proprioceptors. They are activated by muscle stretch and exhibit high sensitivity Small and rapid changes in muscle length. This mechanical stretch sensation is transmitted to the spinal cord via the dorsal root ganglia, and the central nervous system receives this information via afferent nerve fibers. [1]

Proprioception and Ageing

Several studies have found that aging negatively affects muscle spindles and their neural pathways, resulting in decreased sensitivity and sharpness. [4]

In a study by Skinner et al.[7] found that older subjects had significantly worse proprioception in response to passive movements compared to the younger group.[7] Kaplan et al[8] observed age-related changes in proprioception and confirmed a decrease in proprioception during older individuals compared to younger ones.

At the peripheral level the age-related decline in proprioception involves changes in spindle muscle formation and function as well as deficits in the processing of sensory input.[9] The structural changes include a decrease in the total number of nerve fibers and nuclear chains threads per spindle and the thickness of the spindle capsule.[9] Processing deficit is characterized by myelin abnormalities axonal atrophy and decreased nerve conduction velocity.[9] Decreased proprioception is caused by the following changes in the central nervous system:

• Progressive loss of dendrite structure in the motor cortex[9].
• Loss of muscle and nerve mass[9].
• Neurochemical changes in the brain[9]

Intrinsic foot muscles

Proprioception and Muscles of the Foot

Panjabi was the first to propose the theory of core stability.[10] It describes the functional dependencies between the passive (skeletal and joint systems) active (muscles and tendons) and neural (sensory receptors) subsystems responsible for spinal movement and stability. The same is true the concept applied to the ankle and foot was introduced by McKeon in 2013.[11] The concept of the foot muscles describes the role of the muscles of the foot. It is a functional connection of the plantar intrinsic muscles to both sides of the foot. [11] .

The foot active subsystem:

• Offers local dynamic support
• Senses foot position
• Provides postural control
• Actively controls balance in standing position
• Controls foot position on uneven terrain
• It facilitates greater recruitment of muscles when additional loads are applied[4]

Researchers continue to investigate the role of foot structures in proprioception. The contents are supposed to provide immediate sensory information when there is a change in foot alignment.[11] Furthermore it has been stated that these muscles respond well to training and sensitivity to deformation can be changed.[11] Muscles in the body are vulnerable to fatigue and according to Hiemstra et al[12], muscle fatigue can adversely affect sense of joint position at different locations in different lower extremities.

Visual / Vestibular System and Proprioception

The vestibular system is an important accessory sensory system essential to our cognitive perception of movement and orientation in space.[13]

Vision plays an important role in the ability to feel one’s body in space. It is necessary for precision of movement[14] but not necessary for one to understand body ownership.[4] The vestibular system regulates head movement.[13] This is fundamentally emotional schedule as:

• The posture of the head greatly influences the human body.[4] Small head movements can cause postural and sensory instability.[13]
• Findings suggest that abnormal head position alters muscle function and proprioception.[4]
• The rapid movement of the head by compensatory eye movements contributes to proprioception and posture.[4]

Proprioception and Ankle Injury

When trauma occurs to nerves it can disrupt the afferent connection of nerve cells that carry sensory information from the body part to the brain. This can lead to proprioceptive deficits.[15] Several studies investigated the relationship between toes proprioception does not ankle resists: .

• Payne et al.[16] found that ankle proprioception can predict ankle injury in college basketball players.
• Fu et al[17] found that a group of basketball players with poor ankle proprioception exhibited multiple muscle activations and a higher risk of ankle injury during sport-related activities.
• A systematic review by Witchalls et al.[18] showed that ankle proprioception is associated with ankle injury.
• In a systematic review and meta-analysis Xhu et al.[19] found that patients with chronic ankle instability had impaired motor skills and joint position perception compared with healthy subjects.
• Studies of chronic ankle instability have shown increased thresholds of mechanoreceptors and decreased proprioceptive acuity.[4]

Individuals with chronic ankle instability develop cognitive impairment characterized by increased mechanoreceptors and decreased proprioceptive acuity.[4] It is suggested that cognitive approaches should be included in the treatment of these disorders.

Proprioception Retraining

When an injury happens, it affects more than just muscles. Residual effects of injury include impaired proprioception with balanced loss of sensation of body position and joint position and changes in muscle spindle function.[20] These changes in proprioception must be conscious ahosiesie denam:

• External manipulation
• Sensory integration therapies targeting proprioceptive input[4].

The basic principles when providing proprioception retraining are as follows:

• Start simple and slow
• Provide good instructions
• Do not threaten the patient
• Tasks should not cause more than minor pain
• Offer a reward[4]

Intrinsics Foot Muscle Exercise

Intrinsics Foot Muscle Exercise

Short Foot Exercises

The elasticity of the foot muscles is important for the efficient biomechanical function of the musculoskeletal system of the lower extremity.[21] Balance training to improve ankle proprioception and increase strength in the leg is referred to as short leg exercise (SFE). The ultimate value of. SFE is the development of a dynamic equilibrium position.[22] The SFE training includes exercises that pull the first metatarsal head toward the calcaneus. There should be no twisting of the toes. [23] .

Benefits of including short foot exercises in the early stages of proprioceptive training after an ankle injury include:

• Stimulates neural circuits in the soles of the feet
• Improve posture and core stability
• Improvement in proprioception

According to Lee et al. [23] SFE training in patients with chronic ankle instability improves proprioception and homeostasis. They found that this training was more effective than standard proprioceptive motor training. The authors further conclude that SFE Starting earlier can promote a quicker return to daily life and physical activity. [twenty three]

Here are the guidelines from SFE:

• Weeks 1-4: Seated position with feet on stability trainer and hips, knees and ankles flexed 90º to stabilize body [23]
• Weeks 5-8: Stand 2 feet
• Weeks 5–9: single-leg stance
• SFE hold 5 seconds; 12 repetitions per session with 2 minutes rest between sets[23]
• Performed three sets, 3 times a week

You can find out more about strengthening the intrinsic muscles of the foot here.

Foot Massage

Sensory Targeted Ankle Rehabilitation Strategies

The Sensory Targeted Ankle Rehabilitation Strategy (STARS) consists of three interventions: joint mobilization reflexology and calf triceps stretch. [24] The treatment protocol consisted of six five-minute sessions of each component of STARS over a two-week period. Research shows that foot massage and joint mobility provide the best outcomes in terms of sensorimotor function in patients with chronic ankle instability. [24] Feldbrugge and colleagues [25] suggested that joint mobility and calf extension can improve ankle dorsiflexion and self-reported functional performance Chronic ankle instability. [25]

Joint mobilisation

[26]

Plantar massage

• Consists of a combination of petrissage and effleurage, covering the entire sole of the foot [4]
• Not specific to time spent or location of massage with either technique [4]
• One study found that reflexology prior to rehab exercises increased the effectiveness of the treatment by 30%[4]

[27][28]

Triceps surae (calf muscles) stretching

[29]

Textured surface

External Devices

The following techniques / devices can be used to stimulate cutaneous proprioceptive signals:

• Textured insoles:
  • According to Corbin et al.[30] textured insoles increase afferent information to the central nervous system to provide improved postural control in bilateral posture.
  • Steinberg et al[31] have found that the use of textured insoles in male dancers improved their dynamic balance posture indicating a beneficial effect on foot proprioception.
• Kinesio taping method:
  • A study by Halseth et al.[32] demonstrated that the Kinesio taping technique does not appear to enhance proprioception in healthy individuals.
  • A systematic review by Wilson and Bialocerkowski[33] provides recommendations for the use of a Kinesio taping technique in clinical practice to prevent hindfoot injuries due to its positive effects on proprioception muscle endurance and functional performance . . . .
• Training application in clinical practice: balance half ball wobble board multi-station training on 12 different BOSU Swiss balls:[34]
  • No improvement in ankle function / stability[4].
  • It may be necessary to start later in the rehabilitation process[4]
  • It can freeze the patient because the skills required are too demanding[4].
  • According to Donovan et al.[35] the introduction of destabilizing devices during a 4-week rehabilitation program improved dorsiflexion during the stance phase of gait but had no effect on improving frontal plane motion.

External Supports

Outside intervention is no better than rehabilitation as a stand-alone treatment. The final restoration plan should include the following:

• Integrated closed-chain dynamic regeneration processes[4]
• Fixed and stable foot placement in a labeled position with verbal cues provided by a supervising therapist[4]
• Visual information (mirrors) with external support[4].

Network meta-analysis by Tsikopoulos et al.[36] concluded that external supports (taping bracing insoles with a combination of insoles and bracing) provided no benefit in improving active posture in individuals with ankle fractures. The authors suggest that using external support as a standalone option in rehabilitation for ankle instability does not make it optimal and that a combination of rehabilitation and external intervention may be more effective.[36]

Tests for Proprioception

• The Balance Error Scoring System (BESS) description and testing protocol can be found here.