• Skip to main content
  • Skip to primary sidebar
  • Skip to footer
  • General Ortho
  • Procedures
  • Spine
  • Upper Limb
  • Lower Limb
  • Pain
  • Trauma
  • Tumors
  • Newsletter/Updates
  • About Us
  • Contact Us

Bone and Spine

Orthopedic health, conditions and treatment

Chronic Ankle Instability Causes and Treatment

By Dr Arun Pal Singh

In this article
    • Relevant anatomy
    • Causes of Chronic Ankle Instability
    • Types of Chronic Ankle Instability
      • Mechanical instability clinically
      • Functional instability
    • Clinical Presentation
    • Differential Diagnoses
    • Imaging
      • X-rays
      • MRI
      • Arthroscopy
    • Treatment of Chronic Ankle Instability
      • Non-operative Treatment
      • Operative Treatment
      • Anatomic Repair
      • Nonanatomic reconstructions, or check-rein procedures
      • Anatomic Reconstruction
    • Complications
    • Recurrence
    • References

Chronic ankle instability has is seen in about 20% of people who suffer from acute ankle sprains. It often causes recurrent sprains.

About 80% of acute ankle sprains reach full recovery with initial non-operative management, rest develop chronic symptoms resulting in chronic ankle instability.

[Please go through Acute ankle sprains to get a better perspective of this article ]

In few patients, there may be predisposing factors which may cause or maintain chronic ankle instability like the presence of hindfoot varus and a plantarflexed first metatarsal head. These factors produce early operative failure if not corrected at the time of surgery.

Relevant anatomy

Main ligaments injured in the ankle sprain are lateral ligaments which are anterior tibiofibular and calcaneofibular ligament.

[Read Anatomy of ankle joint ]

[Read more on ligaments involved in ankle sprains]

 

Lateral-Ligament-of-the-Ankle-Joint
Image Credit: Teach Me Anatomy

Causes of Chronic Ankle Instability

The exact etiology of recurrent ankle sprains is unknown

Following factors are thought to contribute

  • Lengthening of ligaments due to intervening scar tissue healing in a lengthened position
    • Scar tissue filling in the gap between the torn, separated ends.
  • The inherent weakness of the scar.
  • Persistent peroneal weakness.
  • Unrecognized disruption of the distal tibiofibular ligament
  • Loss of proprioception in the foot
    • Disrupted mechanoreceptors and their afferent nerve fibers
  • Dysfunction of the peroneal nerve
  • Impingement of the capsular scar tissue in the talofibular joint
  • Hereditary hypermobility of joints

Types of Chronic Ankle Instability

Mechanical instability clinically

Mechanical instability is characterized by abnormal ankle mobility, assessed using manual stress application by the anterior drawer and the talar tilt tests.

Functional instability

It is the subjective feeling rather than objective finding. The patient feels the ankle giving way during either physical activity or during common activities of daily living.

Just to differentiate, functional instability movement is the one which is independent of voluntary control, even if the physiological range of motion is not always exceeded.

Clinical Presentation

The main complaint usually is intermittent giving out of the ankle, mostly with physical activity but in quite a number of cases in daily living too.

There would be a past history of acute ankle sprains, often more than one.

The patient is often apprehensive of uneven surfaces where the walking is difficult. Even a mild exacerbation can lead to short-term dysfunction.

There is no pain or dysfunction between episodes.

In some cases, there could be hindfoot varus visible on examination [its one of the factors for recurrent sprains].  Otherwise, the ankle would be normal on examination.

The patient should be examined for general ligamentous laxity.  The hindfoot motion should be recorded and peroneal muscle strength should be tested.

Provocative tests like anterior drawer or talar tilt may reveal instability in mechanical stability cases.

Provocative tests are described in Ankle Sprains article.

Abnormal proprioreception may be revealed by modified Romberg test.

Differential Diagnoses

Consider other common causes of pain that occurs/persists after the ankle sprain. There could be missed injuries to

  • Anterior process of the calcaneus
  • Lateral or posterior process of the talus
  • The base of the 5th metatarsal
  • Osteochondral lesion
  • Injuries to the peroneal tendons
  • Injury to the syndesmosis

Imaging

X-rays

AP, lateral and mortise views are useful to rule out bony injury or degenerative changes. Stress x-rays can be useful to find talar tilt and anterior talar translation.

MRI

MRI is more useful than that in the acute setting.

Ligament injury is seen on MRI as swelling, discontinuity of fibers or a  wavy ligament etc.

Moreover, MRI is quite helpful in revealing other causes of ankle pain if any. [see the list in arthroscopy]

Arthroscopy

The exact role of arthroscopy is not defined but it can be used to look for other causes that can contribute to pain and dysfunction. These include

  • Osteochondral (OCD) lesions of the talus
  • Impingement
  • Loose bodies
  • Painful ossicles
  • Adhesions
  • Chondromalacia

Treatment of Chronic Ankle Instability

Non-operative Treatment

This consists of functional rehabilitation by strengthening exercises, exercise for proprioception and balancing exercises.

The treatment is continued for 2-3 months. The likelihood of success is decreased with mechanical instability, peroneal weakness, or proprioceptive deficits.

Six weeks of aggressive physical therapy is recommended.

Orthotics can be useful during the rehabilitation process. Bracing may also provide additional support for the chronically unstable ankle.

Operative Treatment

The patients who do not benefit from non-operative treatment should be considered for surgery.

The goal of surgery is to restore the native anatomy of the injured ligaments,[ length, direction, tightness] in order to restore the correct kinematics [anatomic reconstruction] or substitute the injured ligaments [tenodesis].

Some amount of joint stiffness may occur with all the procedures.

Indication for surgical treatment are

  • persistent symptomatic mechanical instability
  • Failed functional rehabilitation.

Contraindications  to surgery are

  • Pain without instability
  • Peripheral vascular disease
  • Peripheral neuropathy
  • inability to comply with a postoperative regimen.

Over 80 surgical procedures have been described for chronic lateral ankle instability

Surgical Procedures divided into three categories

  • Anatomic repair
  • Nonanatomic, or check-rein reconstruction
  • Anatomic reconstruction with graft

There are a number of procedures described in each category. Only the commonly done or representative procedures are mentioned.

Anatomic Repair

End to end repair in chronic ankle instability
Anatomical repair if ligaments in chronic ankle instability, Image Credit: PMC Open Access

Modified Brostrom procedure includes repair of bone tunnel repair of the anterior tibiofibular ligament and calcaneofibular ligament. Most of the patients [85%] achieve good outcomes.

Increased failure rates are reported in persons with long-standing instability, poor tissue quality, history of the previous repair, generalized ligamentous laxity, and cavovarus foot deformity.

Nonanatomic reconstructions, or check-rein procedures

Modified Watson-Jones routes the peroneal brevis tendon obliquely through the distal fibula in an anterior-distal to posterior-proximal fashion

Chrisman-Snook reconstruction[modification of  Elmslie procedure] splits the  peroneus brevis tendon and transferred through the fibula and into the calcaneus, thus providing a more anatomic reconstruction

Nonanatomic reconstructions yield mixed results. Issues observed in long-term follow-up are subjective instability, nonphysiologic kinematics, and diminishing clinical outcome scores.

Anatomic Reconstruction

Anatomic reconstruction can be achieved using free autograft or allograft tendon.

The indications are poor tissue quality or revision surgery. The use of free autograft or allograft spares peroneal function or strength.

For reconstruction, the graft is placed into the anatomic origins and insertions of the anterior tibiofibular and calcaneofibular ligaments.

The autograft can be obtained from the gracilis, semitendinosus, fascia lata, palmaris, plantaris, and patella tendons.

The use of allograft, though save from donor-site morbidity, but there is a risk of disease transmission.

Anatomic reconstructions are excellent procedures for high demand ankles with chronic instability.

Postoperative Protocol

The splint is removed at 2 weeks postoperatively and is switched to a removable ankle brace in order to begin gentle range of motion exercises.

Passive inversion stretching is avoided for 6 weeks.

Physical therapy is then started and includes

  • Active and passive range of motion
  • Gait training
  • Strengthening of ankle muscles
  • Proprioceptive training

A return to full activity can be expected at 3 to 6 months.

Complications

  • Wound complications occur
  • Paresthesias
  • Neuroma formation
  • Late recurrent instability due to chronic attritional injuries.

Recurrence

Acute recurrence is often due to acute reinjury. Late recurrence is due to attritional injuries.

Risk factors for failure and recurrent instability after the operative procedure are

  • Ligamentous laxity
  • Longstanding instability
  • High functional demand
  • Cavovarus foot.

Patients with ankle instability and hindfoot varus deformity should be treated with a concurrent calcaneal osteotomy with lateral ankle ligament reconstruction.

Proprioceptive-based therapy is often a preferable option to revision surgery.

References

  • Van Dijk CN, Verhagen RA, Tol JL. Arthroscopy for problems after ankle fracture. J Bone Joint Surg Br. 1997;79(2):280–284.
  • Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis. 2011;69(1):17–26.
  • Caprio A, Oliva F, Treia F, Maffulli N. Reconstruction of the lateral ankle ligaments with allograft in patients with chronic ankle instability. Foot Ankle Clin. 2006;11(3):597–605.
  • Colville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg. 1998;6:368–377.
Spread the Knowledge
  • 6
    Shares
  •  
    6
    Shares
  • 1
  • 5
  •  
  •  
  •  

Filed Under: Foot Ankle

About Dr Arun Pal Singh

Arun Pal Singh is an orthopedic and trauma surgeon, founder and chief editor of this website. He works in Kanwar Bone and Spine Clinic, Dasuya, Hoshiarpur, Punjab.

This website is an effort to educate and support people and medical personnel on orthopedic issues and musculoskeletal health.

You can follow him on Facebook, Linkedin and Twitter

Primary Sidebar

tuberculosis of ankle joint

Tuberculosis of Ankle

Tuberculosis of ankle joint is relatively uncommon. The incidence of ankle tuberculosis is less than 5 percent of all osteoarticular tuberculosis. Pathophysiology The mycobacteriaereachs the ankle joint viathe bloodstream. The initial focus may start in the synovium, especially in children, or as an erosion in the distal end of tibia, malleoli or talus. Rarely tuberculosis […]

Calluses in hand

Interesting Names for Common Calluses

Callus is hyperkeratotic thickening due to repetitive friction. Presentation of calluses and corns are discussed here. In this article, I am writing about the commonly used terms for different types of calluses. These are vernacular terms and are interesting to note as they try to convey the etiology. Jeweler’s callus or  Cherry Pitter’s thumb or […]

complications-of-bone-grafting

Bone Grafts – Types, Mechanism, Techniques and Complications

Bone grafts are used to repair and rebuild diseased bones in your hips, knees, spine, and sometimes other bones and joints. A bone graft transplants bone tissue. Grafts can also repair bone loss caused by some types of fractures or cancers. Once your body accepts the bone graft, it provides a framework for the growth […]

Ankle sprain of second degree, image in PD from W

Ankle Sprain Causes, Symptoms and Treatment

Ankle sprain accounts for up to 40% of all athletic injuries and is most commonly seen in athletes participating in basketball, soccer, running, and ballet/dance. The ankle sprain is usually caused by an inversion-type twisting injury. About eighty percent of acute ankle sprains recover completely, 20% develop mechanical or functional instability resulting in chronic ankle […]

Elbow joint bones

Elbow Joint Anatomy and Significance

The elbow joint is made up of three bones, the humerus, ulna, and radius. Elbow joint connects the proper arm to the forearm. It is a  synovial joint structurally but functionally is a hinge joint. Elbow joint allows flexion and extension. There are actually three joints at the elbow. Humeroulnar joint – Hinge joint formed […]

Epidural streoid injections

Epidural Steroid Injection Procedure

Epidural steroid injection, as the name implies, is a technique of injecting a steroid into the epidural space for relieving pain in the neck, arm, back, and leg, caused by inflamed spinal nerves due to spinal stenosis or disc herniation.   An epidural steroid injection typically includes both a corticosteroid like methyl-prednisolone, dexamethasone or other […]

Cold Abscess Causes, Presentation and Treatment

The term cold abscess refers to an abscess [An Abscess is a collection of liquefied tissue(pus) in the body] where typical signs of abscess [warmth, redness, tenderness,] are absent. The prefix cold indicates that the abscess is not hot because that is the usual case. Thus a cold abscess is not accompanied by the classical […]

Browse Articles

Footer

Pages

  • About
    • Policies
    • Contact Us

Featured Article

What is Evidence Based Orthopedics?

Evidence-based orthopedics is the application of principles of evidence-based medicine to the field of orthopedics. Because each of the medical … [Read More...] about What is Evidence Based Orthopedics?

Search Articles

© Copyright: BoneAndSpine.com