Ankle Instability

Advisor : Aj. Jirun Apinun

R3 Kanitsorn Pakdeethitipaibul
Reference
Lateral ligamentous complex (Ankle)
Lateral ligamentous complex (Subtalar)
Medial ligamentous complex
Biomechanic (Lateral)
• Joint stabilizing function of the ligament is most critical in unloaded
ankle joint
• Dorsiflexion -> ATFL is loose, CFL is taut
• Plantarflexion -> ATFL is taut, CFL is loose
• ATFL : Resticting internal rotation and anterior translation
(platarflexed) of Talus
• CFL : prohibits adduction
• PTFL : Prevents external rotation (Dorsiflexed)
Biomechanic (Medial)
• Ligaments take more role in unloaded ankle and when plantar
flexion
• Tibiocalcaneal ligament (TCL) : Prohibits eversion and abduction
• Deep posterior tibiotalar ligament (dPTTL) : Resist external rotation
when the foot is dorsiflexed
• Division of both deep and superficial Deltiod à Anterior instability
does not increase
• Deep Deltiod : greatest restraint against lateral translation
Lateral ankle injury
• Ankle sprains are one of the most common injuries in sports
• Vast majority of the ankle sprains are Lateral inversion injuries (85%)
• Fall down the stairs, a misstep off a curb, landing on another person’s
foot
• All situations, the ankle is plantar-flexed and not fully-loaded
Lateral ankle injury
• The most common ligament disruption by far involves the ATFL
(Midsubstance)
• The second most common injury is a combination rupture of the ATFL
and CFL (additionally injured in more severe sprains)
• The PTFL (stronger) is usually completely torn only in severe sprains
or dislocations.
Clinical evaluation
• Popping or tearing sensation in the ankle and occasionally an audible
noise
• While running, cutting, landing from jump
• Swelling and pain
• Difficulty weight bearing
• Complete tear two or more ligaments
• History of multiple ankle sprains
• Joint instability may be presented in Complete ligament tears
Clinical evaluation
• Swelling and tenderness over the affected ligaments.
• Frey et al. :
• Found that physical examination was 100% accurate in the diagnosis of grade
III ligament injuries
• only 25% accurate in the diagnosis of grade II injuries compared with MRI
findings.
Anterior drawer test
• Often elicits pain in patients with an
ATFL injury
Suction sign
• In a relaxed patient with a complete
ATFL tear, anterior subluxation of the
talus may be appreciated
• usually apparent at the anterolateral
joint
Inversion stress
• Induces pain or demonstrates instability in patients with
calcaneofibular disruption.
• It usually is not possible to perform this maneuver in the acutely
injured patient without some type of anesthesia.
 Radiologic evaluation
• Plain Radiograph (Ankle AP, Lat., Mortise)
Stress Film
Talar Tilt
• Inversion force is applied.
• Anesthesia?
• Foot position?
• Knee position?
• Normal value ?
• Author prefer (Mann 9th) : foot in relaxed plantar flexion, the knee
slightly bent, and without the use of a foot-holding apparatus.
• 15 degrees as our cutoff for the talar tilt angle and consider this to
indicate a high probability of a complete tear of the ATFL
Stress Film
Anterior Drawer Test
• Primarily evaluates the ATFL with the foot in relaxed plantar flexion
• Performed while the ankle is undergoing an anterior displacement
stress.
• When the anterior translation is greater than 5 mm, we consider the
ATFL ruptured.
MRI
• If clinically suspect but physical
exam and plain film are not
definitive
• MRI is the imaging method of
choice.
• Grading the extent of
ligamentous injury
• Can also detect other
pathology
• 100% sens. for Dx ATFL and CFL
tear
Classification (Clinically oriented)
• Jack et al.
• Grade I : Mild, sprain intra-ligamentous tear with minimal swelling
and tenderness, no instability
• Grade II : moderate, sprain is an incomplete tear of the ligament with
mild to moderate instability and considerable pain, swelling,
tenderness, and loss of motion
• Grade III : complete ruptures of the ligament(s) associated with
instability of the joint and marked swelling, pain, tenderness, and loss
of motion
Dose not correspond to the clinical situation or the surgical finding in
every situation
Treatment (Acute sprain)
• Conservative -> Mainstay of management
• conservative approach is associated with good or excellent results.
Cast immobilization
• For 6 weeks in this dorsiflexed position promotes optimum stability
• Prolong cast -> “cast disease,” with muscle atrophy, stiffness, and loss
of bone density. à Controversy in the competitive athlete
• Reserving delayed surgical repair for those who have persistent
symptoms.
Treatment (Acute sprain)
Functional treatment
• RICE Protocol
• progressive weight-bearing is allowed, Use Crutch if needed
• mobilization in a lace-up ankle brace, stirrup brace, or
walking boot or with taping.
Treatment (Acute sprain)
• ROM Exercise
• Muscle strengthening :
• peroneal and ankle dorsiflexor strengthening,
and Achilles tendon stretching.
• Proprioceptive training

• Nonathletic patients :
• Walking boot, soft cast, or plaster
immobilization
• switch to taping or the stirrup brace after 7 to
21 days.
Surgical repair (Acute injury)
“Controversial topic”
• Some studies suggest surgical repairment leads to :
• ✓ Lower incidence of residual pain
• ✓ Reduce symptoms of giving-way
• ✓ Lower incidence of recurrent sprains
• Indication for acute repairment is limited to :
• Recurrent sprains previously failed with conservative
• Concurrent ankle pathology requiring surgical treatment
• Injury in high-performance athlete (Controversy)
Chronic lateral instability
 Pathology
Functional instability Mechanical instability
• Feeling or sensation of the ankle • Instability is found on physical
being unstable with no change exam with increased range of
in structure. motion about the ankle beyond
• Recurrent ankle sprains physiologic ranges
• Benefits from proprioception • Most commonly a result of
training and strength training ligamentous support disruption
that help stabilize the ankle
during ambulation.
Not all patients with mechanical instability have
functional stability
Clinical evaluation

History Physical finding

• Previous sprain • Tenderness over affected
• Complaints of functional ligaments
instability • Instability and/or pain+guarding
with stress test
• May associated with peroneal
weakness
• Positive modified Rhomberg test
Radiograph
• Weight bearing ankle films to R/O :
• Arthritis
• Occult fracture
• Displaced fibular ossicle
• Other bone pathology
Conservative Treatment
Correction of the deficits in proprioception, strength, and flexibility

Ankle support Physical therapy

• Lower heels • Ankle ROM exercise

• Stiffer soles • Strengthening
• Lateral heel wedge • Proprioceptive exercise
• AFO

These options are seldom

acceptable on a long-term basis for
the athlete
Surgical Treatment
• Indication : young to middle- aged active patients who have failed a
well-designed non- operative treatment program.
• Anterior Drawer test : > 1 cm (or a side-to-side difference >3 mm)
• Talar Tilt : > 15 degrees (or a side-to-side difference of >10 degrees)
• The symptoms and signs are most critical.
• Contraindication : Other causes of instability
• collagen diseases
• Tarsal coalitions,
• Neuromuscular diseases
• Functional instability
Surgical Option
• Ligament repair / augmentation
• Non-anatomic reconstruction
• Anatomic reconstruction
It seems advisable to arthroscope the ankle prior to the reconstruction
• Concurrent pathology should also be addressed at the time of surgery,
e.g. :
- Intra-articular pathology
- Peroneal tendinopathy
- Tarsal coalition
- Hindfoot varus alignment
Ligament repair
• The anterior talofibular and
calcaneofibular ligaments are
inspected
• Torn or Avulsed —> Repair
• Intact but laxity —> Imbrication
• Bröstrom-Gould procedure
• Improve tibiotalar joint
kinematics → decreasing anterior
translation of the talus as well as
internal rotation
Non-anatomic reconstruction
Watson-jones Evans Chrisman-snook
Non-anatomic reconstruction
• Tenodesis procedures
• commonly used the peroneal tendons to stabilize the lateral ankle
and subtalar joints.
• Required harvesting all or part of the peroneus brevis or longus
tendon
• Attempted to restore stability through restraint of inversion and
anterior translation
• Restricted subtalar motion, Arthritic change
Anatomic ligament reconstruction
Syndesmotic Injury
Overview
• Diastasis : “Any loosening in the attachment of the fibula to the Tibia
at the inferior tibiofibular joint”
• Associated disruption of syndesmosis occur in 10-18 % in all type of
ankle sprain
• Associated disruption of syndesmosis occur in 23 % in all ankle
fracture required operative fixation
• Associated with important morbidity and delayed return to sports
Anatomy
Biomechanics
• Ankle motion is allowed in all three planes
• Rotation of the ankle is also possible through the syndesmosis
• Tibia can rotate on the talus approximately 5 to 6 degrees.
• Average of 2.4 mm of distal migration of the fibula occurs during the
stance phase of the gait cycle.
Mechanism of injury
• Ankle external rotation + hyperdorsiflexion (Most common)
• Activities
• Sports e.g. Football, soccer
• Low-energy trauma e.g. falling stairs
• Damage to syndesmotic ligaments may occur:
• Isolation (uncommon)
• With associated fracture : SER, PER
Clinical Evaluation
History Physical examination
• localized anterolateral ankle pain • Squeeze test
located over the anterior “Clinically, we have not found the
syndesmosis of the ankle squeeze test to be particularly
reliable for diagnosing acute
syndesmosis injury.”
• Shuck test or Cotton test
• External Rotation test
“The most reliable test for a
syndesmosis injury”
• One-legged hop test
Clinical Evaluation
Clinical tests show conflicting results
• Some present unsatisfactory predictive positive values and low
sensitivity
• Others show highly significant relation between clinical and MRI
findings
• If there is clinical suspicion à Additional imaging
Radiographic Evaluation
• 10% to 50% of syndesmosis injuries have a bony
avulsion.
• From the anterior of the posterior tubercle of Tibia
• Normal Parameter
• Medial clear space : < 4 mm (Too variable)
• Tibio-Fibular overlap : > 6 mm on AP, > 1 mm on Mortise view
• Tibio-Fibular clear space : < 6 mm on AP and Mortise
• Tibiofibular clear space was the most accurate means of
determining diastasis.
• Stress Radiograph : Interpretation can be inconclusive
à MRI
 CT scan
• Syndesmotic disruption sensitivity to 2 mm with
CT, whereas routine radiographic views could not
define a diastasis until the separation reached 4
mm.
• Axial CT images give the most precise view of the
reduction of the syndesmosis
• Done without stress or weight bearing ->
Limiting to some degree
MRI
• Very sensitive in terms of diagnosis, particularly in the acute
setting
• Finding
• Ligament discontinuity
• Wavy or curved
• Failure to visualize the ligament
Arthroscopy
• Able to perform stress test under
Direct visualization
• “Indispensable for the accurate
diagnosis of a tear of the tibiofibular
syndesmosis”
• Excellent diagnostic and therapeutic
solution
ESSKA-AFAS classification (2016)
Acute lesion
• Stable : AITFL lesion with a competent deltoid ligament
• Unstable : combines with deltoid ligament lesion
• Latent diastasis : combines the AITFL rupture with or without IOL
and deltoid ligament rupture
• Frank diastasis : All syndesmotic and deltoid ligament ruptured
Classification
• Edwards and DeLee
Treatment (Acute Injury)
Sprain Without Diastasis (Type 1)
• Symptomatic, Wt. bearing as tolerate
• Syndesmotic injury almost doubles the time to return to play
compared with a severe lateral ankle sprain
• Residual symptoms are not uncommon
Treatment (Acute Injury)
Latent Diastasis (Type 2)
• Do not require surgery if the reduction of the fibula is anatomic (as
confirmed by CT or MRI)
• Non-weight bearing cast for 3 – 4 weeks
Treatment (Acute Injury)
Frank Diastasis Without Fracture (Type 3)
• Surgical stabilization (as soon as the soft tissue envelope allows)
• A screw or endobutton placed 2 – 3 cm above joint line
• A screw
• 3.5 mm or 4.5 mm Fully threaded cortical screw
• 3-4 cortices
• Endobutton
• Physiologic motion
• at least as strong as screws
Fixation option
• Controversial point
• Screws (Rigid fixation)
• Gold standard for a decades
• Screw loosening or breakage
• Removal à Recurrence instability
• Endobutton (Dynamic fixation)
• Physiologic movement
• Reducing risk of breakage and implant removal
• Clinical outcomes appear to be better at two and five years for
suture-button
Treatment (Subacute Injury)
No guidelines exist for the treatment of syndesmotic problems in the
subacute period
• As little as 1 mm of lateral displacement in the fibula à reduce the
available tibiotalar contact area in weight bearing by 42%
• If frank diastasis is present, one must critically assess the tibiofibular
articulation for osteochondral changes
Treatment (Subacute Injury)
• Syndesmotic screw or suture endobutton and the remnants of the
AITF ligament are repaired
• If the ligaments are inadequate for late repair -> autograft or allograft
for AITFL and ITFL reconstruction
Treatment (Chronic Injury)
• MRI and arthroscopic evaluation of the ankle joint are important to
determine the best course of management
• Articular surface damage
• tibiotalar arthrodesis or arthroplasty
• joint appears salvageable
• reconstruct the syndesmosis or to stabilize it.

Very little scientific literature addresses the treatment of chronic

syndesmosis injuries
Medial ankle sprains
Overview
• Isolated injury are unusual
• Typically, deltoid ligament injuries occur in association with lateral
ligamentous or fibular injuries
• Chronic deltoid ligament insufficiency is rarely clinically significant,
though its prevalence is probably underestimated.
Anatomy
• Deltoid ligament : large, band-like structure originating from the
medial malleolus and inserting in numerous distal locations.
• Superficial : Originates from Anterior colliculus
• Tibionavicular ligament (TNL)
• Tibiospring ligament (TSL)
• Talocalcaneal ligament (TCL)
• Deep : originates from the intercollicular groove and the posterior
colliculus.
• Deep posterior tibiotalar ligament (dPTTL)
• Deep anterior tibiotalar ligament (dATTL)
Biomechanics
• ligaments take over a more dominant role in the unloaded ankle and
when the ankle is in plantar flexion.
• Tibiocalcaneal ligament (TCL) :
• primarily prohibits eversion and abduction
• The deep deltoid :
• functions to resist external rotation when the foot is dorsiflexed.
• greatest restraint against lateral translation
• Highest load to failure
• The greatest tibiotalar joint contact changes occur after sectioning
the tibiocalcaneal fibers
Clinical Evaluation
• Feeling of giving way
• Medial ankle joint pain
• Valgus and/or pronation deformity that is correctable with posterior
tibial muscle activation.
Plain Radiograph
• Small avulsion fragments at
the tip of the medial
malleolus
• Valgus AP stress radiograph
shows a talar tilt
• Stress radiograph (Gold
standard) : The most
accepted is > 4 mm

although the validity of the test has not been confirmed in medial instability
without an associated fibular fracture.
MRI
• Modality of choice
• Visualization of the
deltoid ligament
• Coronal and Axial
views
Classification
Classification
• No system is particularly useful for decision making in treatment
• The most practical classification —> Stable and anatomically
aligned or not?
• If not —> must be treated more aggressively with surgical
repair or cast immobilization and limited weight bearing
CONSERVATIVE TREATMENT
• If a fibular fracture or the syndesmosis is reduced and stabilized -> no
need to repair deltoid ligament
• (Although this remains controversy)
• Casting for 8 – 10 wks à Sufficient healing of the Deltoid lig.

Isolated Deltoid injury Gr. 1-2 Isolated Deltoid injury > Gr.2
• Functional management • Immobilization in cast or walking
• Pneumatic brace boot
• Walking boot • Progresses Wt. bearing as
tolerated
• 6 – 8 wks
SURGICAL TREATMENT
• Open repair : reserved for younger and more athletic patients with
obvious instability
• Direct repair
• Suture anchor
• NWB for 7 – 10 days
• Walking boot 2 – 4 wks , Progress to full weight bearing
Chronic Medial Ligament Instability
• Chronic isolated deltoid insufficiency is extremely uncommon
• Associated with cartilage damage
• Secondary chronic medial instability from PTTD VS Athletic injury

• Discomfort on medial side

• Increased heel valgus
• Eversion of the hind foot during stance or ambulation
Investigation
• Valgus stress radiograph
• Valgus instability
• Medial clear space widening
• Fibular fracture nonunion, malunion
• Does not allow the talus to sit in the mortise properly
• —> Deltoid healing in a lengthened position
• MRI is helpful to identify this pathology
• Arthroscopy
Treatment

Conservative Surgery
• Taping • Tissue are good -> Direct
• Ankle brace imbrication
• Casting • Tissue are inadequate ->
Autograft or allograft
• Physical therapy reconstruction
• Orthoses
Surgical management
• Hindfoot valgus and/or overpronation deformity
• Medial displacement calcaneal osteotomy
• and/or lateral column lengthening combined with the use of an allograft
reconstruction technique

“To date, the results of secondary repairs and reconstructions for the
deltoid ligament complex have not been as reliable as the standard
lateral side procedures, nor have they been subjected to critical long-
term follow-up.”
Thank you