Volume 20, Issue 3 (September 2022)                   Iranian Rehabilitation Journal 2022, 20(3): 287-296 | Back to browse issues page


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Bahramizadeh M, Khaliliyan H. Efficacy of Different Types of Foot Orthoses on Postural Control in Subjects With Lateral Ankle Sprain: A Systematic Review. Iranian Rehabilitation Journal 2022; 20 (3) :287-296
URL: http://irj.uswr.ac.ir/article-1-1627-en.html
1- Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
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1. Introduction
The ankle joint is one of the most common sites of damage to the musculoskeletal system of the human body [1] and sprains account for 25% of injuries in this area [2]. Ankle sprains are often caused by repeated movements of jumping on the ground and running at high speed [3]. This happens especially if the movements are accompanied by a change of direction. This can be considered one of the most common injuries during sports and recreational activities. Among the types of ankle sprains, lateral (inversion) sprains account for 85%, medial (eversion) sprains for 5%, and syndesmosis sprains for 10% of the injuries [4].
The ankle joint is surrounded by different ligaments that connect the bones. This fibrous connective tissue stabilizes the joint and limits its range of motion. If additional stress is applied to the joint, it causes the ligaments to stretch and if the stress is beyond the tolerance of the ligaments, the joint will be damaged or sprained [5]. At the time of the lateral ankle sprain, the ankle is in plantar flexion. Supine torque is applied to the foot and external rotational force is applied to the leg [6, 7]. After a lateral ankle sprain, there is usually pain and disability because of the possible damage to the ligament structures, nerves, and muscle-tendon parts [8]. It is estimated that in 36% to 85% of cases, complete recovery from these complications takes up to 3 years [9]. Residual signs of instability and recurrent ankle sprains that last for more than one year are defined as a chronic ankle sprains or instability [10, 11]. More than 70% of people suffer from an acute sprain. These patients show signs of chronic ankle instability over time [9]. Common symptoms of this complication include a feeling of giving away, ligament laxity, edema, weakness, pain, and decreased proprioception in the ankle joint during activity. These complications can cause significant biomechanical changes in the gait. Long-term complications include osteoarthritis and osteochondral in the talus dome [12, 13].
Chronic ankle instability is a complex phenomenon associated with various disorders. The two main disorders are mechanical and functional instability. Mechanical instability occurs because of the structural changes in the ligaments shortly after the initial injury. This type of instability increases the range of motion in both the talocrural and subtalar joints [14]. In this case, the foot contacts with the ground in an inverted position during rapid movements. A large amount of inversion torque is created in the subtalar joint and the probability of recurrence of sprain increases [15, 16]; however, functional instability is associated with impairment in sensorimotor control and proprioception [17]. In other words, lateral ankle sprain destroys the integrity of the ligament structure, and the mechanical receptors in the joint capsule, tendons, and ligaments around the joint that are a part of the somatosensory system suffer. Nerve fibers combine the information from the receptors with information received from the visual and vestibular sensory systems and after being transmitted to the central nervous system, this information is used for postural control [18].Postural control is a method in which the central nervous system uses the sensory information of other systems to produce the motor output needed to maintain proper posture. The visual, vestibular, and somatosensory systems are the main systems involved in controlling posture [19]. Postural control is the basis of all daily activities [20]. Decreased ability to maintain balance and postural control is a major risk factor for the recurrence of lateral ankle sprain and it is the focus of most researchers to evaluate the effects of orthoses for patients with a lateral ankle sprain. Accordingly, balance and postural control restoration are the basis of acute or chronic lateral ankle sprain rehabilitation programs [12].
Given the high incidence of lateral ankle sprains and subsequent chronic instability, various conservative treatments have been proposed for this complication. Acute sprains can be managed with rest, ice, compression, elevation (RICE) and nonsteroidal anti-inflammatory drugs, followed by functional rehabilitation exercises, taping, and orthoses. As the use of orthoses reduces the time and effort required for treatment, it can provide better results [6].
Common orthoses prescribed to these patients are ankle supports and foot orthoses (FOs). Over the years, FOs have been used by specialists to treat acute and chronic ankle injuries in athletes. Satisfaction with these devices is reported to be 70% to 80% [21]. Compared to ankle orthoses, FOs are used because of their adjustability, reasonable price, ease of use, and comfort.
In this review study, we searched for different types of FOs whose effect is on postural control in people with a lateral ankle sprain. We also sought to determine the most effective FO in this field.
2. Materials and Methods
Articles were selected using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method. 
Eligibility criteria
In this study, the inclusion criteria were level 2 or higher studies (the level of evidence was estimated based on the center of evidence-based medicine definition, which is related to the study design) that evaluated the effects of FOs on postural control in adults (18 years old or older) with acute or chronic lateral ankle sprain (Table 1). The exclusion criteria were studies that did not show postural control as an outcome measure; participants who had sprains because of an underlying disease, such ::::::as char::::::cot; and participants who used tapping, ankle support, or a combination of ankle and foot orthoses as an intervention.



Information sources
Articles were searched in PubMed, Scopus, Web of Sciences, and Google Scholar databases in all languages. The search period was from 1990 to 2022.
Search strategy
The search strategy was based on the population intervention comparison outcome (PICO) method by selecting the keywords and constructing the search terms with the help of “OR”, “AND”, and “NOT” operators (Figure 1). Synonyms for the keywords were also obtained from the MEDLINE database.




Study selection
The review strategy was to review the title and abstracts to check the existence of inclusion and exclusion criteria. Studies with the following items in the title or abstract were eligible: (1) participants were adults with an acute or chronic lateral ankle sprain, (2) the intervention included FOs, (3) the outcome measures were all the variables that according to the documents could be attributed to the concept of postural control, (4) statistical analyses were reported, and (5) the full text of the article was available. First, the title and introduction of the articles were reviewed and then the full text of the articles was reviewed separately by two reviewers more than once in terms of the existence of inclusion criteria. In case of disagreement between the two reviewers, the final decision was made after discussion and then the articles were assessed in terms of quality.
Quality assessment
Non-full-text, non-peer-reviewed and non-experimental studies did not enter the study. The selected papers were checked following the standards for reporting diagnostic accuracy statements and then entered into review. This checklist consists of 30 sections (scores 0 to 30) and was developed to contribute to the completeness of reporting of diagnostic accuracy studies. The guiding principle of standards for reporting diagnostic accuracy development was to select items that, when reported, would help readers judge the likelihood of study bias, evaluate the application of the study findings, and validate the conclusions and recommendations.

3. Results
In the initial search, 48 articles were found, 20 of which were deleted after eliminating duplicates and reviewing the keywords, titles, and abstracts. After further evaluation of the articles by reviewing the full text, 8 articles were identified as irrelevant and 10 articles fully met the inclusion criteria (Figure 2). Study designs included randomized controlled trials and repeated-measure studies that included within- and or between-group comparisons.



Characteristics of participants
The number of participants in each study ranged from 15 to 49. A total of 284 people participated in these studies, of which 51 were healthy (control group), 37 patients (3 studies) were in the acute phase, and 196 patients were in the chronic phase (7 studies). The mean age of all participants was 21.6.
Types of interventions
The types of FOs used in these studies included custom molded FOs that are made with impression and keep the subtalar joints in neutral (semirigid or rigid with deep heel cup) [6, 22-24] and prefabricated (semirigid, deep 
heel cup, medially posted, laterally posted, neutral textured, and laterally posted with heel wedge) [21-23, 25-30]. Also, in one study a custom molded with textured surface FO was used [22]. Semirigid custom-molded FOs were made of Aquaplast T and rigid types were made of polypropylene. In some of these studies, the control group used flat FOs with different shoes. 
Study outcomes
The variables that were measured in these studies and attributed to the concept of postural control included the center of pressure (COP) displacement and velocity, time out of balance, and reaching the distance of the star excursion balance test (SEBT).
seven studies measured COP displacement as the primary outcome and the force plate systems were the most common measuring device [6, 14, 25, 26, 30]. Two of these studies used the SEBT [22, 24], and one measured the number and amount of time that a person lost balance via a digital balance evaluator [18].
Some studies have examined a type of FOs on postural control in subjects with a lateral ankle sprain [6, 29, 30]and other studies compared the effects of different types of FOs in this population [22, 23, 25-27, 30]. Most measurements were performed with shoes. All shoes used in these studies were low-top to prevent the effect of high collars on postural control.
Center of pressure displacement and velocity
In this regard, 6 studies evaluated the effects of prefabricated semirigid (cm, between sessions 1 and 3; P=0.02), textured (P=0.03 in one study and P=0.04 in another study) with 4 degrees of medial wedge (path length, mm: P=0.027), lateral wedge (P=0.004), and custom molded (P=0.029) FOs on reduction of COP displacement and all reported positive results on postural control [21, 25, 26, 28-30]. One study compared the effects of 5 types of rear FOs, one of those was custom molded and the other four were prefabricated (medially posted, laterally posted, neutral textured, laterally posted with heel wedge) on the length and velocity of postural sway. They examined COP in the frontal and sagittal planes and found FOs to be ineffective in controlling posture, regardless of the types of orthoses [27].

Reaching the distance of star excursion balance test 
A month-long study examined the use of custom-molded FOs on the reach distances of the SEBT and reported an increase in these distances (P=0.023) [24]. A comparative study states that among the three types of custom molded with textured, custom molded, and prefabricated FOs, the first is the most effective type in improving the reach distances (P=0.001) [22].
Time out of balance
One study compared custom and prefabricated FOs by measuring the time that participants are out of balance. The study found that only custom-molded FOs are effective in decreasing this time (P=0.013) [23]. A summary of all the studies is provided in Table 1.
4. Discussion
FOs are complex biomechanical interventions due to variances in materials, manufacturing methods, design, individual preferences, and rates of adherence [31]. Nine out of the 10 studies that examined the effects of FOs on postural control in subjects with lateral ankle sprain found FOs to be effective in improving postural control [6, 21-25, 28-30]. Hertel reported that orthoses do not affect improving balance in subjects with chronic ankle instability and the proven effects of these orthoses in the rehabilitation process of these people are because of their effects on another variable. Although Hertel used more complex systems for its experiments, the posts it used on the FOs tested were not customized, unlike previous research [27].
Prefabricated FOs seem to improve postural control in mentioned patients; however, comparative studies have found that custom-molded FOs that are adapted to specific biomechanics are more effective [22, 23]. Chang tested the prefabricated FO with 4 degrees medial wedge on postural control and found positive results. He stated this was because of the increased range of motion of the ankle joint in these individuals. This is while previous studies have shown positive results from the lateral wedge in the treatment of patients with a lateral ankle sprain and no accurate information is available as to which of these two types of wedges is more effective [25].
All subjects with acute or chronic lateral ankle sprain use compensatory strategies to maintain balance. These strategies can put more pressure on the first metatarsophalangeal joint and fingers. Placing custom orthoses in shoes allows more contact area for the foot, put the subtalar joint in a neutral position, uniform the pressure distribution, and provides a more stable base of support. These FOs also provide mechanical support by controlling the movements of the heel to the toes. These types of orthoses, if made with a deep heel cup, can better support the subtalar joint in the single limb support, improve the integrity of the subtalar joint, provide a better biomechanical condition for the joint, and improve postural control in patients with a lateral ankle sprain [22].
It should be noted that custom molded FOs are made to affect mechanical instability in people with a lateral ankle sprain, but as mentioned, a range of posture disorders in this population are related to sensorimotor problems, and since in the absence of input data from the mechanical receptors of the lateral ankle ligaments, the sensorimotor system automatically changes the input source to the mechanical receptors on the plantar surface of the foot [32]. Therefore, it seems that adding texture tissue to the FOs increases sensory feedback by stimulating the tactile receptors of the plantar region of the foot [33]. In this regard, Patrick and Jamali have expressed positive results from the effect of texture tissue FO and considered it necessary to study various types of textural material on measures of postural control in this group [28, 30].
Abassi stated that because people with chronic ankle instability have both mechanical and functional instability, making interventions aimed at affecting both types of instability can improve the rehabilitation results of these people. In this regard, she and her colleagues made a custom FO with a textured surface for the first time, and after examining its effect on dynamic postural control and comparing it with different types of prefabricated and custom mold FOs, they introduced it as a better option [22].
5. Conclusion
FOs are effective in controlling posture in the rehabilitation process of individuals with acute sprain and chronic instability. Custom mold FOs that are made by impression, keep the subtalar joint in neutral, and have a deep heel cup to maintain proper heel position seems to have better results than prefabricated FOs. Recent studies emphasize that because these individuals have both mechanical and functional instabilities, the design of rehabilitation interventions to improve both types of instability, such as custom FO with a textured surface, has better results in improving postural control in this group; however, only three studies evaluated FOs made to alter sensory input and it seems that the design of cross-sectional studies in this area is required.
For future research, we suggest comparative studies to determine which types of medial or lateral wedges work best in improving postural control in these individuals. Also, by reviewing available studies, we found that it is not clear how many degrees of the wedge is more effective in improving postural control and no attention has been paid to the study of medial and lateral arch supports in these people. As most studies on the impact of FOs in the community of people with lateral ankle sprains have been made for mechanical purposes, we also suggest that future studies focus on FOs designed to alter sensory input.
Since this study is a review, it shows the existing data on the usage of FOs for improving postural control in people with an acute or chronic lateral ankle sprain. It is necessary to continue studies of this research segment to find out the most appropriate FO as well as standardized tests and evaluations of postural control for a better comparison.
Ethical Considerations
Compliance with ethical guidelines

This is a review article with no human or animal sample.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Authors' contributions
All authors contributed equally to preparing this article.
Conflict of interest
The authors declared no conflict of interest.


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Article type: Reviews | Subject: Orthosis and Prosthesis
Received: 2022/03/13 | Accepted: 2022/06/20 | Published: 2022/09/19

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