Effect of Q-angle, Lateral Distal Tibial Angle and Proximal Muscle Torque on Ankle Injury
Condition: Ankle; Injury, Superficial, Multiple (With Foot)
MeSH terms: Wounds and Injuries; Ankle Injuries
Study type: Observational [Patient Registry]

Summary: 
      This study was undertaken to examine the effect of Q angle, lateral distal tibial angle
      (LDTA), and lower extremity isometric muscle torque on ankle sprain. Among 40 participants
      with ankle sprain, Q angle and LDTA measurements in both extremities were performed using
      X-ray images, while the muscle strength in gluteus maximus, gluteus medius, and quadriceps
      femoris were determined with hand held dynamometer, and the muscle torque was estimated by
      multiplying these values with the distance to the joint center. The obtained data were
      analyzed by separation analysis. No significant relationship was found between the Q angle
      and ankle sprain (p> 0.05). A strong positive correlation was found between LDTA and ankle
      sprain (p = 0.01). A strong negative correlation was found between quadriceps femoris muscle
      strength, gluteus medius muscle strength and gluteus maximus muscle strength with ankle
      sprain (p <0.001, p = 0.001, p <0.001, respectively). A strong negative relationship was
      found between quadriceps, gluteus medius and gluteus maximus muscle torques with ankle sprain
      (p <0.001, p = 0.011, p = 0.002, respectively). As suggested by the discrimination analysis,
      independent variables that contributed most to ankle injury included the gluteus maximus
      muscle torque (MAXIMUSTORQ) (.906), gluteus medius muscle torque (MEDIUSTORQ) (. 494),
      lateral distal tibial angle (.436) and quadriceps femoris muscle. torque (QUADRTORQ) (. 341),
      respectively. In conclusion, strengthening the quadriceps femoris, gluteus medius and gluteus
      maximus muscles may be suggested as an effective strategy to prevent ankle sprain. It may be
      helpful to pay attention to individuals with high LDTA to prevent ankle sprains.
    

Detailed description: 
      Ankle sprain is the most common type of ankle injury, comprising nearly 80% of all injuries
      affecting this area. Among these, 77% consists of sprains involving the lateral ankle (1). In
      sedentary individuals, the reported incidence is 5.2 to 6 per 1000 persons (2). Although the
      reported risk factors for ankle sprain include asymmetric tension in the flexor muscles of
      the ankle, increased body mass index (BMI), increased bodyweight, and younger age, definitive
      data is lacking (2).

      The alignment of the pelvis, knee, and ankle has attracted significant research interest as a
      potential risk factor for lower extremity injury. Also, the quadriceps angle (Q angle) was
      reported to be an indicator for the biomechanical functions of the lower extremity,
      reflecting the effect of the quadriceps mechanisms on the knee, as well as providing
      information on patellar movements within the trochlear sulcus and on the functions of the
      thigh muscles (3). Q angle is measured as the narrow angle between the line that connects the
      anterior superior iliac spine (ASIS) to mid-patella and the line that connects the tibial
      tubercle with the center of patella (3, 4). Currently, no consensus exists regarding the
      normal value of the Q angle. While the American Orthopedics Society considers 10 degrees
      normal and 15 to 20 degrees as pathologic, the normal values reported by Schulthies et al.
      for males and females are 10 to 14 degrees, and 14.5 to 17 degrees, respectively (5). Several
      studies suggested that Q angle may actually represent an independent risk factor associated
      with increased risk of ankle sprain (4, 5). It has been proposed that individuals with knee
      valgus and a Q value exceeding 15 degrees have an increased risk of lower extremity injury.
      Also, a positive correlation between ankle sprain and Q angle was reported among recreational
      basketball players (3). On the other hand, no direct correlations were found between these
      two parameters in a study involving 45 professional athletes (4).

      Another parameter that can be utilized to evaluate the alignment disorders of the lower
      extremity is the lateral distal tibial angle (LTDA). The average angle between the distal
      tibial joint orientation line and the anatomical and mechanical axis of the tibia is 89
      degrees. This angle is referred to as LDTA (Figure 1). An angle of less than 86 degrees and
      more than 92 degrees indicate the presence of valgus and varus deformities, respectively (6).
      To the best of our knowledge, no previous studies have examined the association between LDTA
      and ankle sprain. It is plausible to assume that pathological LDTA, which is one of the
      alignment parameters of the lower extremity, may increase the predisposition to varus or
      valgus sprains. Therefore, our study was based on the hypothesis that LDTA may have an effect
      on the occurrence of ankle sprain, and thus it represents an intriguing research parameter.
      Also, when proximal muscle strength is assessed in people with chronic ankle imbalance, lack
      of muscle strength may be another potential risk factor for injury risk (9). This latter was
      particularly evident in studies that showed that the abductor muscle defects may lead to poor
      balance and neuromuscular adaptations in the ankle, therefore, contributing to increased
      inversion moments, increased activation, and earlier activation of the ankle evertors. When
      compared with athletes without injury, those with injury had weaker pelvic abduction and
      pelvic external rotation strength. In contrast, a prospective study by McHugh and colleagues
      concluded that the pelvic abductor, flexor or adductor strength had no role in predicting the
      future risk of ankle sprain (10).

      Therefore, the published literature on the potential effects of Q angle on ankle sprain is
      controversial. On the other hand, literature data on the role of LDTA and proximal muscle
      strength on injury risk is also far from being clear. The primary objective of our study was
      to examine whether Q angle, LDTA, and knee and pelvic muscular torque were associated with
      ankle sprain. The secondary objective was to determine the parameter that had the most
      prominent impact on ankle injury risk.
    

Intervention name(s): x-ray examination
Intervention type(s): Diagnostic Test
Intervention description(s): A total of 40 individuals who underwent an axial x-ray examination of the lower extremity following ankle sprain were included.
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Individuals with a lower limb ankle sprain
      
Keywords: ankle injury, muscle strength, torque, knee, lower extremity