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Pediatric Orthopedic Surgeons treating bladder exstrophy

ANKLE INSTABILITY

The ankle is made up of multiple bones, muscles, and connective tissues (ligaments) that work together to provide stability and support and prevent excessive movements. When the ligaments supporting the sides of the ankle are injured, often from repeated ankle sprains, they are stretched out and weakened, which can cause ankle instability, a condition characterized by frequent “giving way” or a rolling of the ankle.

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Ankle Instability

Ankle sprains are a common injury in children. In a condition like chronic ankle instability, there is a recurring giving way of the outer (lateral) side of the ankle. And it often occurs due to repeated ankle sprains. Usually, the collapse occurs while walking or doing other activities, and sometimes, even when you’re just standing. Not only children but also athletes often experience this type of ankle problem.

Symptoms 

Children with chronic ankle instability often complain of:

  • A repeated twisting or turning of the ankle, especially while walking or running on uneven surfaces or while participating in sports
  • Continuing swelling and discomfort
  • Tenderness or pain
  • Wobbly or unstable ankle

Causes

Ankle InstabilityAnkles comprise three bones and ligaments. The ligaments prevent the ankle joint from moving around too much. Ankle instability is generally the result of injured lateral [outside] ankle ligaments. And it usually causes strain or stretch, or in more severe cases, can even cause a sprain or tear in the ligaments. It often causes ankle instability. Also, the patient becomes more prone to getting frequent ankle sprains, even with minor twists or turns. 

QUESTIONS AND ANSWERS

What is Ankle Instability?

Ankle instability refers to a condition where the ankle joint fails or feels unstable during weight-bearing activities. The condition can occur when caused by repeated ankle sprains that lead to stretched or torn ligaments, reducing the ankle’s ability to support and stabilize the foot.

What are the Symptoms of ankle Instability?

The common symptoms of ankle instability include a recurrent feeling of the ankle “giving way,” especially on uneven surfaces or during physical activity. Ankle pain, swelling, and tenderness may occur, particularly after activity or following an ankle injury. Individuals with ankle instability may find it challenging to participate in sports or daily activities due to concerns about ankle stability.

How is Ankle Instability Treated?

The treatment for ankle instability may depend on the severity of the condition and its impact on the individual’s daily life. Doctors consider non-surgical treatments first and may include rest, ice, compression, and elevation (RICE therapy), physical therapy to strengthen the ankle and improve balance, and the use of ankle braces or supports during activities. In cases of persistent or severe instability, doctors may recommend surgery to repair or reconstruct the damaged ligaments and restore stability to the ankle joint. Our doctors will implement the appropriate treatment approach after a thorough evaluation,

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.

Schedule an appointment today to treat your child for an Ankle Instability Condition

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.

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. If a Brostrom procedure is done when the ligaments are considerably deficient or mechanical abnormalities (ex. high arched foot) are left uncorrected, failure can occur. Even though surgery is highly successful, patients involved in high-risk activities may still experience re-spraining their ankles.

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

Call 214-556-0590 to make an appointment.

Comprehensive services for children from birth through adolescence at five convenient locations: Arlington, Dallas, Flower Mound, Frisco and McKinney.