Ankle Instability

dr. Syarif Hidayatullah, Sp.OT, M.Kes

Ankle Anatomy
 Distal fibula and distal
tibia form a bony
mortise that allows talar
dorsiflexion and
plantarflexion
 Talar body is wider
anterior than posterior
which leads to less
stability with
plantarflexion and
internal rotation
 Foot and Ankle Joints
 Complex hinge of bone
and ligaments
 Complex joint motion
 Prone to circulatory
disturbances
 Dorsum of the foot has
thin skin with tendons
rather than muscles
 Following injury may lead
to foot pain, stiffness and
fracture disease
 Medial Collateral Ligaments
 Superficial
 Superficial talotibial,
naviculotibial, and
calcaneotibial fibers

 Deep
 Deep anterior talotibial
and posterior talotibial
fibers from posterior
colliculus to talus
 Strongest portion of the
Deltoid ligament
 Lateral Collateral Ligaments
 Anterior Talofibular
Ligament
First injured in lateral sprain
with plantarflexed ankle
 Calcaneofibular Ligament
Strongest lateral ligament
First injured in lateral sprain
with dorsiflexed ankle
 Posterior Talofibular
Ligament
Syndesmosis
 Anterior inferior
tibiofibular ligament
 Posterior inferior
tibiofibular ligament
 Transverse
tibiofibular ligament
 Interosseous
membrane
Ankle Stability
 4 factors
lateral malleolus, lateral ligament
medial malleolus, medial ligament
anterior sydesmotic ligament
posterior syndesmotic ligament
 Anatomy
 Tendons
 Achilles Tendon
 Posterior Tibial Tendon
 FDL and FHL
 Tibialis Anterior tendon
 Vessels
 Saphenous vein
anteriorly
 Posterior tibial artery
 Nerves
 Tibial nerve posteriorly
Anatomy
 Tendons
Peroneus Brevis
Peroneus Longus
 Nerves
Superficial
peroneal nerve
Sural nerve
Anatomy
 Extensor retinaculum
 Tendons
Tibialis Anterior
EHL
EDL
 Dorsalis Pedis Artery
 Deep Peroneal Nerve
 Classification
 Weber
 Lauge-Hansen
Weber Classification
 Type A fracture
located at or below
the syndesmosis
 Type B fracture
located at the
syndesmosis
 Type C fracture
above the
syndesmosis
 Weber Classification
 “the higher the fibular fracture, the more
extensive the damage to the tibiofibular
ligaments; and the greater the damage,
the greater the danger of ankle mortise
insufficiency”
 Basic Principles
 Exact restoration of anatomy
 closed or surgical methods acceptable
 unstable fractures better treated by
surgery
 stable internal fixation allows early
ambulation
Ankle Sprains
 Most common ligamentous injury
 One sprain per day per 10,000 people
 40% will have intermittent chronic
problems
 More common on the lateral aspect of
the ankle
Ankle Sprains
 Most common
mechanism of ankle
injury is inversion
stress with
plantarflexion
 May lead to ankle
fracture, sprain, or
syndesmotic injury
 Abduction or adduction
are other mechanisms
Ankle Sprain
 History
Description of the injury
Position of the ankle during the injury
Able to continue to play or bear weight
Previous injury
Site of injury
Physical Exam
Inspection
Deformity, ecchymosis, swelling, perfusion
ROM (normal)
 30 to 50 degrees plantar flexion
 20 degrees dorsiflexion
 25 degrees inversion and eversion
 15 degrees of adduction
 30 degrees of abduction
Palpation
-individual ligaments (MCL,LCL, syndesmotic) and tendons
-the joints above and below the ankle
-important: proximal fibula (“Maisonneuve fracture”) and the
base of the fifth metatarsal ("dancer's fracture").
Special Tests

Anterior Drawer
 Integrity of the Anterior Tibiafibular Ligament
 Grasp the heel with one hand and apply a posterior force to the
tibia with the other hand, while drawing the heel forward.
 Laxity is compared with the opposite (uninjured) ankle.
 Positive test: a difference of 2 mm subluxation compared with the
opposite side or a visible dimpling of the anterior skin of the
affected ankle (suction sign)
Squeeze Test
 Tests the integrity of the syndesmotic ligaments
 Examiner places his hand 6 to 8 inches below the knee and
squeezes the tibia and fibula together
 Positive test: results in pain in the ankle, which indicates injury of
the syndesmotic ligament
X-rays
X-rays
 Approx. 10-15% of all traumatic radiographs are of the ankle
 80% of all ankle injuries get an x-ray, fewer than 15% have a
significant fracture

Views
AP, lateral, mortise view (15-20 degrees of internal rotation)
 AP : malleoli, plafond, talar dome, lateral process of the talus
 Lateral : ant/post. tibial margins, talar neck, post. talar process
and Calcaneus
 Mortise : most important view, medial clear space should not
exceed 4mm
Xray Measurements
Ankle Sprain Classification
 Histologic Classification
Grade I – Ligamentous stretching without
macroscopic tearing
Grade II – Partial macroscopic tearing
Grade III – Complete ligamentous rupture
Ankle Sprain Classification
 Anatomic Classification
 Grade I – ATFL disruption
 Grade II – ATFL and CFL disruption
 Grade II – Complete ligamentous disruption

Clinical Grading
 Grade I
 Stress tests normal
 Grade II
 Increased pain swelling
 May have positive stress tests
 Grade III
 Severe pain swelling
 Positive stress tests
 Lateral Ankle Sprains
 Commonly missed diagnoses
– Peroneal tendon injuries
– Achilles injuries
– Fracture of :
 Lateral process of talus
 Anterior process of calcaneus
 Fifth metatarsal
 Lisfranc injuries
– Osteochondritis dessicans
Lateral Ankle Sprains
Lateral Process fracture of the Talus
 Lateral Ankle Sprains
 X-rays are based on careful physical exam
 MRI rarely indicated in the acute setting
 Consider stressing syndesmosis and lisfranc
joints if injury is suspected
Ankle Sprain Treatment
 RICE with ankle brace initially and protected
weight bearing for Grade I and II
 ROM exercises
 Peroneal strengthening and proprioceptive
training
 Bracing or taping for 4-6 weeks depending on
activity
 Return to sports when able to cut without pain
 Severe sprain may require up to 6 months of
protective bracing
Ankle Sprain Treatment
 Grade III sprain may require a walking
boot or a cast for 4 – 6 weeks
 Extended period of protective bracing
may be warranted
 Return to play criteria remain the same
 Need to be aware of possibility for
syndesmosis injury (high ankle sprain)
 Lateral Ankle Sprains
 Management surgical
– Acute surgical repair not supported by literature
– symptomatic chronic instability may require
surgical intervention
 Anatomic Brostrom repair favored over nonanatomic
rerouting procedures
 Medial Ankle Sprain
 5% ankle sprains
 Forced eversion
 Injury to deltoid
ligament
 May be associated with
syndesmotic injury
and/or Weber C fibula
fracture
 Medial Ankle Sprain
 Tenderness/swelling over deltoid
 External rotation test elicits pain in the deltoid
and possibly in syndesmosis
 Medial Ankle Sprain
 AP/LAT/OBLIQUE ankle x-rays to assess
mortise and syndesmosis
– Medial joint space widening
– Syndesmotic widening
– Presence fibula fracture
 Consider external rotation stress x-rays if
syndesmotic disruption is suspected
 Medial Ankle Sprain
 Management
– Stable (no talar subluxation)
 Similar to lateral sprains

– RICE, early wgt bearing, early ROM, functional brace,

functional rehab
– Unstable (talar subluxation)
 No talar subluxation is acceptable

 Anatomic reduction and surgical stabilization of

syndesmosis
Chronic Ankle Instability
 Continued instability or recurrent injury
despite rehabilitation and proprioceptive
training
 Protective Bracing vs. Surgical
treatments
Modified Brostrom procedure
Chrisman-Snook procedure
Modified Brostrom
 Repair of the ATFL
 Repair of the CFL
 Reefing of the
lateral extensor
retinaculum
 May be modified to
advance the
ligaments through
drill holes or use of
suture anchors
Nonanatomic Reconstructions

 These procedures use the peroneal tendons to

reconstruct the lateral ligamentous complex
 Higher complication rates than Brostrom
 More restricted ankle and subtalar motion (Colville, JAAOS,
1998)
Syndesmosis Injury
 10% of ankle sprains
 Rupture of the interosseous
ligaments between the tibia
and fibula with or without
fibular fracture
 Medial malleolar fracture or
deltoid ligament rupture
 Persistent instability and gap
in the joint after bimalleolar
fixation
Syndesmosis Exam
 Squeeze Test
Squeeze the
syndesmosis
above the
anklepain
 Abduction-External
Rotation Stress Test
Further instability
with external
rotation (may be
shown with x-ray)
 Syndesmotic (High) Ankle Sprains
 AP/LAT/OBLIQUE ankle
x-rays
– Syndesmotic widening
– Medial joint space
widening
– Presence of fibula
fracture
 External rotation stress x-
rays
– Severe pain associated
with normal x-rays
 Must get tibia/fibula X-rays
to rule out high fibula
fracture
Syndesmosis Injury
 Classification
Type I – straight lateral talar subluxation
Type II – plastic deformation of the fibula
with Type I
Type III – posterior rotatory displacement of
the fibula and talus
Type IV – diastasis of the tibia and fibula
with superior displacement of the talus
Syndesmosis Injury
 Treatment
Non-displaced without fracture
○ May consider casting for 6 weeks (high ankle
sprain)
○ Surgical treatment with syndesmotic screws
Displaced
○ Surgical treatment with syndesmotic screws
Syndesmosis Injury
 Reduce the
syndesmosis with a
large clamp under
fluoro
 Place 1.5 cm proximal
to the plafond
 Place with 30 degrees
anterior angulation
 Do not use lag screw
technique
Syndesmosis Controversies
 Number of Screws
One vs. two, 3.5 mm screw vs. 4.5 mm
screw
 Number of Cortices
Three vs. four cortices
 Ankle position during placement
Classically dorsiflexion was advocated
Tornetta showed no difference with
plantarflexion
Syndesmosis Post-Op
 Place in a cast or removable boot NWB
 May consider screw removal after 3
months
 Weight bearing will break screws, but
does not cause clinical problems
 Premature weight bearing may break
screws and lead to syndesmosis
widening
Ankle Dislocations
 Isolated ankle
dislocation is rare
 Mechanism is forced
inversion that results in
a posteromedial
dislocation
 Anterolateral ligaments
damaged
 Commonly open 30 -
90%
 Rule out neurovascular
injury
 Tibiotalar Dislocations
 OTA classification
– Anterior
– posterior
 Tibiotalar Dislocations
 Management closed injury
– Check neurovascular status
– Prompt closed reduction
– Cast for 6 weeks in plantigrade position
– Results generally good
– Results not improved with acute ligament repair
– Late instability rare
 Tibiotalar Dislocations
 Management open injuries
– Consider stabilization with
ex-fix to facilitate care of
soft tissues
– Prognosis worse than
closed injuries
– Stabilize syndesmosis if
disrupted
– Immediate wound closure
if possible
Ankle Dislocations
 Post operative care
Open reduction may require ex fix or cast to
hold the repair in place
Long term instability is rare
May have development of arthosis over time
Peroneal Tendon Dislocation
 Peroneal tendons
course behind the
distal fibula
 The peroneus
brevis may have
degenerative
changes if the injury
is not identified in a
timely fashion
Peroneal Tendon Dislocation

 The peroneal
retinaculum may be
avulsed from the
fibula or calcaneus
or lifted up enough
to allow tendon
dislocation
 Peroneal Tendon Dislocation
 Forceful contraction of peroneals during
sudden dorsiflexion and inversion
 Usually cutting sport
 Frequently misdiagnosed as ankle sprain
 Peroneal Tendon Dislocation
 Tenderness/swelling retromalleolar area
 Active eversion may demonstrate subluxing
tendons
 X-rays may reveal a small avulsion fracture of
the posterior lateral malleolus
 MRI may reveal subluxed tendons
Peroneal Tendon Dislocation
 X-ray
May show avulsion of retinaculum from
fibula
 Conservative treatment
Casting in slight plantarflexion and inversion
for 6 weeks non weight bearing
Allows the retinaculum to heal if the tendons
can be reduced closed
Successful if the injury is identified early
Peroneal Tendon Dislocation

 Surgery
ORIF retinacular
piece if possible
Repair retinaculum
if possible
Soft tissue
reconstruction with
sling for
retinaculum
Peroneal Tendon Dislocation
 Bone block surgeries
such as Kelly’s or
DuVries modification
 Debridement of
peroneus brevis may
be necessary if
degenerative
changes are present
and tenodesis
Peroneal Tendon Dislocation
 Surgery
Deepening of the
groove has become
more popular
 Post Operative Care
NWB for 6 weeks
Passive motion after
2 weeks
Strengthening after 6
weeks
 Posterior Tibial Tendon Rupture
 Anatomy
– Arises from posterior aspect intermuscular septum
– Inserts on tarsal bones
– Avascular zone posterior to medial malleolus
– High frictional load posterior to medial malleolus
 Posterior Tibial Tendon Rupture
 Function
– Inverter of hindfoot
– Locks transverse tarsal joint
– Maintains height longitudinal arch
– Maintains neutral position of hindfoot at 7-10
degrees
Posterior Tibial Tendon
 History
More commonly an attritional rupture over
time than an acute rupture
Patient may complain of flat foot and midfoot
pain
Sports with quick changes of direction may
put increased force on tendon
 Xray
Foot xray may show medial talar
displacement
Posterior Tibial Tendon
 Physical Exam
Hindfoot valgus and forefoot abduction that
give the “too many toes sign”
Pain in the midfoot and weakness in inversion
from an everted position
Late stages may demonstrate sinus tarsi pain
from impingement
Single heel rise - Lack of supination of the
foot and inversion of the heel while rising on
toes
Flexible vs. rigid deformity
Posterior Tibial Tendon
Lateral subtalar dislocation
Posterior Tibial Tendon
 Conservative Treatment
Rest and NSAIDS
Consider casting in recalcitrant cases
Shoe modification
Orthotics with medial wedges
Posterior Tibialis Reconstruction
 Surgery for the
flexible deformity
Reconstruction of the
posterior tibial
tendon with FDL or
FHL
Medial calcaneal
wedge osteotomy or
lateral column
lengthening through
the calcaneus
 Posterior Tibial Tendon Rupture
 Chronic rupture
– Develop gradually
– Women over 40
– Tenderness/swelling over tendon
– Forefoot abduction
– Hindfoot valgus
– Loss of height of arch
– “too many toes” sign
– Absent single heel raise
 Posterior Tibial Tendon Rupture
 Imaging
– Weightbearing radiographs
 Degree deformity

 Presence arthritis

 Assessment longitudinal arch

– MRI
 Method of choice in imaging posterior tibial tendon
 Posterior Tibial Tendon Rupture
 Chronic rupture
– Stage I
 Pain, weakness, no deformity

– Stage II
 Flexible flatfoot deformity
– Stage III
 Rigid flatfoot deformity

 Radiographic subluxation/arthritis
 Posterior Tibial Tendon Rupture
 Chronic rupture
– Stage I
 Pain, weakness, no deformity

– Stage II
 Flexible flatfoot deformity
– Stage III
 Rigid flatfoot deformity

 Radiographic subluxation/arthritis
 Posterior Tibial Tendon Rupture
 Management
– Chronic rupture
 Stage III

– Nonop (Ankle Foot Orthosis)

– Surgical arthrodesis (type depends on deformity and site of
arthritis)
• Subtalar
• Double
• Triple
 Posterior Tibial Tendon Rupture
 Management
– Chronic rupture
 Stage I

– Non operative (NSAID, arch support, AFO)

– Tenosynovectomy if symptoms persist
 Stage II
– nonop (medial wedge, arch support, or AFO)
– Surgical teraphy still controversial
– Reconstruction utilizing FDL or split anterior tibial tendon
– Deformity frequently recurs
– Calcaneal osteotomies hold promise
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