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Dr. Joseph N. Daniel
Clinical Associate Professor of Orthopaedic Surgery
Foot and Ankle Service, The Rothman Institute
Thomas Jefferson University Hospital
Philadelphia, PA
Diagnosis and Treatment of
Ankle Instability
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Disclosure
Wright Medical
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Objectives
• Differential Diagnosis
• Incidence
• Anatomy
• Mechanisms of Injury
• Clinical Examination
• Imaging
• Treatment Options / Timing of Surgery
• Complications
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Differential Diagnosis of Laterally Based Ankle Pain
• Fractures
– avulsion fracture distal fibula
– lateral process talus fracture
– anterior process calcaneus fracture
– cuboid fracture
– 5th MT base fracture
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Differential Diagnosis of Laterally Based Ankle Pain
• Ligament Injuries
– ATFL
– CFL
– PTFL
– syndesmosis injury
• AITFL
– lateral talocalcaneal ligament
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Differential Diagnosis of Laterally Based Ankle Pain
• Tendon Injuries
– Peroneus Brevis / Peroneus Longus
• inflammation
• intra-substance tears
• complete ruptures
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Differential Diagnosis of Laterally Based Ankle Pain
• Osteochondral Pathology
– ankle
– subtalar
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Differential Diagnosis of Laterally Based Ankle Pain
• Neural Injuries
– superficial peroneal nn
– sural nn
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Incidence
• Most common orthopaedic injury
• 30,000 acute ankle sprains daily in USA
• Chronic ankle instability much less common
• Multiple factors involved in evolution of lateral ankle
instability
– varus heel
– generalized ligamentous laxity
– peroneal muscle weakness
– repetitive axial and inversion loads
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Incidence
• M > F ?
• Avg age:
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Anatomy and Biomechanics
• Ankle Joint
– complex of bony anatomy + soft tissue structures
• ligaments
• capsule
• retinaculum
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Anatomy and Biomechanics
• Ligaments
– anterior talofibular ligament (ATFL)
– calcaneofibular ligament (CFL)
– posterior talofibular ligament (PTFL)
– cervical ligament (CL)
– interosseous ligament (IL)
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Anatomy and Biomechanics
• Ligaments
– distal tibiofibular syndesmotic ligament complex
• anterior tibiofibular ligament
• posterior tibiofibular ligament
• transverse tibiofibular ligament
• interosseous ligament
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Anatomy and Biomechanics
• Capsule
• Inferior Extensor Retinaculum
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Mechanisms of Injury
• Twisting Injury
– PF + I
• daily activity
• sporting events
– basketball
– soccer
– football
– volleyball
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History / Clinical Examinaiton
• Accurate Description of MOI
– important to determine if additional pathology exists
• Initial Examination
– best if performed immediately
– usually seen 24-48 hrs later
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History / Clinical Examination
• Initial Examination
• swelling
• pain (VAS)
• ability to WB and push-off injured part
• palpation all bony landmarks
– both malleoli
– lateral process talus
– anterior process calcaneus
– cuboid
– 5th MT base
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History / Clinical Examination
• Initial Examination
• PROM / AROM ankle, subtalar joints
• palpation of ATFL, CFL, peroneal tendons (? subluxation;
dislocation), sinus tarsi, deltoid ligament, distal
syndesmotic ligaments
• anterior drawer (internal + external)
• talar tilt (?)
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Radiographs
• WB (assumed WB) AP, lateral, Morise views ankle
• WB (assumed WB) AP, lateral, oblique views foot
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Types of Instability
• Mechanical
– ROM beyond normal
• Functional
– feeling of impending instability or frank episode
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Classification
• First Degree
– partial or complete rupture ATFL
• Second Degree
– complete rupture ATFL + partial or complete rupture CFL
• Third Degree
– complete rupture ATFL, CFL + partial or complete rupture
PTFL
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Treatment
• Based on degree of injury + presence of any
associated injuries
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Treatment
• Grade I / Grade II:
– RICE
– air cast or lace up ankle splint
– with edema, cam boot
– functional rehab P.T. protocol
– RTA 2-3 wks
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Treatment
• Grade II / Grade III:
• same; controversial
• functional rehab P.T. protocol
• surgery:
– ankle arthroscopy + synovectomy +/- excision loose
bodies+/- abrasion chondroplasty + Brostrom-Gould
lateral ankle ligament complex reconstruction
• RTA up to 12 wks
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Thank you
“BE ASHAMED TO DIE UNTIL YOU HAVE DONE SOMETHING GOOD
FOR MANKIND”Dr. Vernon Johnson, American Pastor during the Revolutionary War