ANKLE INSTABILITY

QUESTIONS AND ANSWERS

Key Contributors to Ankle Sprain Risk

• Prior Injuries: A history of significant ankle sprains can make your ankle more susceptible to future injury. Previous sprains often indicate weakened or compromised structures within the ankle.
• Ankle Instability: Many experience a sensation of their ankle rolling inward too easily. This instability often stems from weakened ligaments or previous injuries, increasing the risk of a sprain.
• Bone Alignment: The alignment of the hindfoot plays a crucial role. If your heel tends to slope inward, it shifts your balance, making ankle rolls more probable.
• Ligament Laxity: Loose ligaments, known medically as ligamentous laxity, mean less support for your joints. This condition allows for excessive movement and can lead to instability.
• Activity Level: Engaging in high-impact sports, such as basketball or volleyball, demands quick changes in direction and sudden stops, elevating the risk of twisting or spraining an ankle.

By proactively addressing these risk factors, whether through physical therapy, appropriate footwear, or exercise adjustments, you can significantly reduce the likelihood of suffering from an ankle sprain.

Chronic ankle instability generally develops after an ankle sprain that has not healed or rehabilitated properly. As a result, when you sprain your ankle, the connective tissues are stretched or torn. Also, it affects your ability to balance. Proper rehabilitation is vital to retain the strength of the muscles around the ankle and also heal the tissues in the ankle that impact the balance. Avoiding so may result in recurrent ankle sprains, often leading to chronic ankle instability. Moreover, every subsequent sprain further weakens the ligaments, causing instability. As a result, it increases the chances of developing other problems.

Understanding Ankle Instability: Pure vs. Functional

When it comes to ankle instability, it’s crucial to distinguish between two main types: pure ankle instability and functional ankle instability.

Pure Ankle Instability

• Definition: This condition refers to a genuinely unstable ankle, where the joint itself is loose and lacks support.
• Cause: It often results from weakened or damaged ligaments, leading to a “floppy” ankle that can easily twist or roll.
• Treatment Focus: Surgical intervention may be necessary to reconstruct the ligaments on the outer (lateral) side of the ankle, aimed at restoring stability.

Functional Ankle Instability

• Definition: Unlike pure instability, the ankle joint remains structurally stable, but the individual feels as if the ankle is unstable.
• Cause: This sensation of instability often stems from internal issues within the ankle joint. Potential culprits include talar osteochondral lesions, ankle impingement, or arthritis.
• Treatment Focus: The goal here is to pinpoint and manage the source of pain or discomfort, which can vary from addressing physical joint issues to physical therapy exercises.

Key Difference in Treatment

• Pure instability calls for reconstructive strategies, mainly targeting the ligaments.
• Functional instability requires a diagnostic approach to alleviate internal joint problems and manage pain.

Understanding this distinction is essential for effective treatment and recovery, ensuring each condition receives the appropriate care tailored to its specific needs.

Ankle Instability Diagnosis 

When it comes to evaluating and diagnosing your condition, the foot and ankle surgeon might ask you about any ankle injuries and instability you may have experienced before. Then the doctor will carefully examine your ankle to find tender areas, instability, or signs of swelling. Often they recommend X-rays or other imaging tests to further evaluate the ankle.

Physical Examination Process

• Gait and Hindfoot Assessment: The examination begins by observing your gait and assessing the hindfoot for any abnormalities, such as hindfoot varus, where the heel curves inward towards the body’s midline.
• Diagnostic Tests:
  • Anterior Drawer Test: This test checks for increased inversion laxity, which can indicate instability.
  • Lateral Stress Test: A positive result here can confirm the presence of instability.
• Comparative Analysis: These tests are done in comparison to your opposite ankle, providing a clearer picture of any discrepancies or issues.
• Pain Localization: If you experience chronic pain, the doctor will use palpation to localize it, helping to identify issues with specific anatomical structures in the area.

Together, these steps and tests allow the doctor to make a comprehensive evaluation of your ankle, ensuring that any underlying issues are accurately identified and addressed.

Imaging Tests 

X-Rays – When it comes to the evaluation of ankle instability, X-rays are the starting point. Weight-bearing ankle x-rays help evaluate the ankle joint itself. The ankle joint mortise should be symmetrical.

Stress Radiography – Doctors also recommend stress x-rays in patients with suspected ankle instability. Stressing the heel towards the midline when an x-ray or fluoroscopic imaging can help figure out how much the outside part of the ankle joint opens up. Doctors compare this measurement to the opposite ankle. Also, it will help ensure whether the instability is coming from the ankle joint, the subtalar joint, or both.

MRIs – MRIs do not help diagnose instability. Ankle Instability is a clinical diagnosis depending on history, evaluation, and stress radiographs. However, doctors may suggest an MRI for patients with chronic pain. MRI is a sensitive test that helps identify intra-articular abnormalities as a talar osteochondral injury or extra-articular sources of pain like tendonitis or scarring of the restraining ligaments.

Scarring of the anterior talofibular ligament (ATFL) is a common finding in most MRIs of the hindfoot, no matter whether or not patients have ankle instability.

Nonsurgical Treatment

The noninvasive treatment for chronic ankle instability commonly depends on the results of various tests and examinations. The nonsurgical treatment may include:

• Physical therapy – It involves various treatments and exercises that strengthen the ankle, enhance balance, improve range of motion and heal your muscles. While proceeding through rehabilitation, you may also get training that associates specifically with your activities or sport.
• Therapy to improve brain-ankle coordination or ankle proprioception – Doctors also recommend practicing aggressive therapy to improve Proprioception. Doing exercises such as standing on one foot with your eyes closed and later trying it on a soft surface with the eyes closed can be very advantageous in improving Proprioception. It can really improve your ankle stability.
• Assessment and treatment by a physical therapist- The patient may benefit from practicing strengthening and Proprioception training under the guidance and supervision of a trained physical therapist.
• Bracing – Some patients may also benefit from wearing an ankle brace that supports the ankle and prevents the ankle from turning and spraining.
• Medications – Doctors often recommend Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation.
• Prophylactic splinting of the ankle – Prophylactic ankle splinting by using an ankle lacer, ankle stirrup, or ankle taping can benefit patients who participate in high-risk activities.

Thus, proper rehabilitation, strengthening and proprioception training, splinting, or bracing can help most patients with ankle instability heal their ankle strain without any operation.

Surgery 

Doctors try to treat ankle instability without surgery whenever possible. They focus on strengthening the muscles that control the ankle joint, keeping patients away from high-risk activities. Also, they utilize a supportive brace or shoe to reduce the risk of returning ankle sprains. However, in some patients with severe conditions, non-operative treatment may not be helpful, and surgery is the only solution.

Surgery might be necessary to tighten up the ligaments that support the outside of the ankle. Or, sometimes, reconstructing these ligaments using a tendon graft may be required. The foot and ankle surgeon usually recommends surgery depending on the level of instability or when nonsurgical approaches do not respond. Surgery usually involves repairing or reconstructing the damaged ligament(s). The surgeon will select the best suitable surgical procedures depending on the types and severity of your case and your activity level. Quite obviously, the length of the recovery period will vary depending on the surgery.

Operative Treatments 

Broström procedure

Anatomically repairing the outside (lateral) ankle ligaments is a common way of surgically stabilizing the ankle. This procedure is called the Broström procedure. And it involves cutting off the stretched-out ligaments (ATFL and CFL) on the outside of the ankle and then fixing them in a tightened position.

Tendon Reconstruction Of The Lateral Ankle Ligaments

It is a more complex method that helps strengthen the stretched-out ligaments. Here, surgeons form a tendon graft through bones outside of the ankle. And this gives additional support to this part. There are many techniques for a free tendon graft. But it is often more suitable to replicate the normal anatomic alignment of the lateral ligaments. It helps minimize any alteration of natural ankle mechanics.

Closing Calcaneal Osteotomy 

It may be beneficial in realigning the hindfoot in patients who failed in the initial attempt of reconstructing the unstable ankle. Also, it helps patients with marked inward (varus) hindfoot alignment. It is usually performed by using a closing wedge calcaneal osteotomy. In this method, surgeons cut the heel bone on the outside and correct the alignment. Then they stabilize the bone with a screw.

An accurate ankle reconstruction surgery has a very high success rate in treating ankle instability. However, failure can occur if a Brostrom procedure is done when the ligaments are considerably deficient or mechanical abnormalities (e.g., high arched foot) are left uncorrected.

Despite the high success rate, it is crucial to note that even with successful surgery, patients involved in high-risk activities may still experience re-spraining their ankles. For optimal results, surgeons must assess and address any mechanical abnormalities during the procedure. Additionally, patients should be cautious post-surgery, especially if they plan to engage in activities that could stress the ankle further. Understanding these factors helps set realistic expectations and encourages proactive measures for a successful recovery.

Care at Home

Depending on your child’s sprained ankle, doctors may suggest care-at-home methods and exercises. You can take care of your child at home using first aid RICE (Rest, ice, compression, elevation) principles.  Ankle exercises such as ankle alphabet, foot circles, foot pushes, calf stretch, assisted calf stretch, etc. help.

Bottom Line 

If your child has chronic ankle instability, we urge you to consult with our highly experienced orthopedic doctors at one of our Medical City Children’s Orthopedics and Spine Specialist Offices in Arlington, Dallas, Flower Mound, Frisco, and McKinney, Texas. We are experts with ankles and children. And with proper treatment and care, we can help your child get back to his or her normal life.

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Footnote:

Foot Health Facts:  Ankle Instability