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Ankle Instability (Ankle Giving Way) Treatment in Singapore

What is Ankle Instability?

Ankle Instability is characterised by the feeling of ankle ready to give way.

If you would like an appointment / review with our specialist to treat ankle instability in Singapore, the best way is to call +65 6664 8135 or click here to book an appointment at the clinic. If you would like to speak to one of our clinicians first then please contact feedback2@bone.com.sg or SMS/WhatsApp to +65 6664 8135

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Basics
Description
  • Recurrent ankle sprains occurring primarily from an inversion stress on a plantarflexed ankle, which lead to chronic ankle pain and instability
  • Divided into 2 types:
    • Functional instability:
      • Pain causes ankle to be unstable.
      • Feeling of ankle giving way
      • Neuromuscular deficit
    • True mechanical instability:
      • Frank insufficiency of ligaments
      • Physiologic ROM is exceeded.
      • Positive anterior drawer or talar tilt test
General Prevention
  • Treat initial ankle sprains aggressively using:
    • Activity modification
    • Bracing
    • Functional rehabilitation program
Epidemiology
Incidence
  • Ankle sprains account for as many as 40% of all athletic injuries .
  • 27,000 ankle sprains occur each day in the United States.
  • Symptomatic ankle instability will develop in up to 20% of patients after an inversion sprain of the lateral ankle ligaments.
Prevalence
High in soccer and basketball players
Risk Factors
  • History of previous sprain (most common risk factor)
  • Connective-tissue disorders
  • Cavovarus foot alignment
Etiology
  • Complex causes of functional instability:
    • Neural: Proprioception, reflexes, muscle reaction time
    • Muscular: Strength, power, endurance
    • Mechanical: Lateral ligamentous laxity
  • Ankle sprains cause sequential disruption of:
    • Anterolateral joint capsule
    • ATFL
    • CFL
  • Primary static restraints to ankle inversion injury:
    • ATFL:
      • Most commonly injured ankle ligament
      • Primary restraint to inversion with ankle plantarflexed
      • Torn in inversion, plantarflexion, and internal rotation
    • CFL:
      • Stabilizes ankle and subtalar joints
      • Resists inversion with ankle dorsiflexed
      • Tears in inversion and dorsiflexion
  • Primary dynamic restraints:
    • Peroneal tendons
  • Key anatomy:
    • ATFL:
      • Originates 1 cm proximal to tip of lateral malleolus
      • Inserts into talus 18 mm superior to subtalar joint, coursing anteriorly at a 90° angle to fibula
      • 7 mm wide, 10 mm long
      • Intimately associated with joint capsule
    • CFL:
      • Originates adjacent to the ATFL, 8 mm proximal to tip of fibula
      • Courses at a 30° angle to the fibula, heading posteriorly and distally to insert on the calcaneus 13 mm distal to subtalar joint
      • Extracapsular: Floor of peroneal sheath
    • Posterior talofibular ligament: Rarely injured except with ankle dislocations
Associated Conditions
Connective-tissue disorders: Ehlers-Danlos
 
Diagnosis
  • Must differentiate functional from mechanical instability.
  • 30% of simple ankle sprains result in residual symptoms with peroneal weakness (functional instability).
Signs and Symptoms
Recurrent ankle pain and swelling
 
History
  • Recurrent sprains with minimal trauma
  • Subjective feeling of ankle giving way
  • Repeated episodes of instability with asymptomatic periods between episodes
Physical Exam
  • Assess hindfoot alignment.
  • Evaluate gait.
  • Neurovascular examination: Increased superficial peroneal nerve injuries in patients with recurrent ankle sprains
  • Palpate peroneal tendons.
  • Assess ankle ROM.
    • Crepitus and pain with ROM may be indicative of cartilaginous injury.
  • Assess subtalar motion.
    • Rigidity may suggest tarsal coalition.
  • Assess subtalar stability.
    • Assess CFL integrity.
    • Dorsiflex ankle and apply inversion force to calcaneus.
    • Medial translation of calcaneus is indicative of subtalar instability.
  • Evaluate for mechanical instability.
    • Anterior drawer test:
      • Evaluates ATFL
      • Position ankle in neutral and apply anterolateral force to heel.
      • Positive test: >10 mm of anterior translation on involved side, >3 mm of anterior translation greater than on uninvolved side; confirm with lateral stress radiograph.
    • Talar tilt test:
      • Evaluates CFL
      • Patient seated, ankle neutral
      • Apply inversion force to hindfoot and midfoot as a unit.
      • Do not allow forefoot to rotate medially.
      • Positive test: Talar tilt >9° total, talar tilt 3° more on involved than uninvolved side; confirm on stress mortise radiograph.
Tests
Imaging
  • Lateral and mortise radiographs:
    • Posttraumatic changes:
      • Tibial marginal osteophytes
      • Talar exostoses (at ATFL insertion)
      • Osteochondral lesions of talus
      • Os subfibulare
  • Mortise and lateral stress radiographs:
    • Anterior translation (assesses ATFL):
      • Measured on lateral stress radiograph
      • Perpendicular distance between posterior edge of tibial articular surface and talus
      • Anterior translation 5 mm more than other side or 10 mm absolute is indicative of mechanical instability.
    • Talar tilt (assesses CFL):
      • Measured on mortise stress view
      • Angle between tibial and talar surfaces
      • Talar tilt angle 3° more than the other side or 10° absolute is indicative of mechanical instability.
Differential Diagnosis
  • Ankle pain may be associated with ankle instability.
  • Other causes of ankle pain include (2,5):
    • Intra-articular fibrosis/synovitis
    • Talus OATS
    • Peroneal tendon tears
    • Peroneal tendon subluxation
    • Lateral process of talus fracture
Treatment
General Measures
  • Initial treatment for ankle instability is nonoperative.
    • RICE protocol
    • Ankle brace:
      • Moderate to severe sprains may be braced for 6 months to allow return to sports.
    • Functional rehabilitation
    • Residual lateral ankle pain and functional instability most often are secondary to inadequate rehabilitation.
Activity
  • Restrict sports until:
    • Rehabilitation program is completed.
    • Strength and ROM are normal.
    • Patient is able to perform sport-specific tasks (cutting, jumping).
  • Functional bracing or taping during return to athletics may help prevent recurrence.
    • Braces do not interfere with performance.
Special Therapy
Physical Therapy
  • Should emphasize:
    • ROM, concentric and eccentric muscle strengthening
    • Endurance training of peroneals
    • Proprioception
    • Tilt-board exercises
Surgery
  • Indications for surgery:
    • Persistent instability after a functional rehabilitation program
    • Extreme laxity
    • Recurrent sprains with normal activities
    • Instability with sports despite bracing/taping
  • Surgical techniques:
    • Anatomic repair:
      • Best results for patients with good-quality soft tissues
      • Benefits: Restores normal anatomy, preserves subtalar motion, preserves peroneals (dynamic stabilizers)
      • Contraindications: Connective-tissue disorder (Ehlers-Danlos), failed previous surgery, severely attenuated tissue (>10 years of instability)
      • Brostrom repair : Direct late repair, torn ends of ATFL shortened and repaired; sometimes CFL imbrication is necessary
      • Gould modification : Immobilization and reattachment of inferior extensor retinaculum to fibula after imbrication of ATFL and CFL; provides additional stability
      • Combination of Brostrom and Gould technique is the gold standard, with 90% success rate .
    • Reconstruction (Chrisman-Snook, Evans):
      • Indications: Patient with poor-quality soft tissue (ligaments are attenuated), salvage for a failed Brostrom procedure, obesity/high-demand patient
      • Benefits: Increased strength of repair
      • Problems: Nonanatomic reconstruction, loss of talocrural and subtalar motion, adjacent peroneal nerve injury
      • Chrisman-Snook reconstruction : Split peroneus brevis at its attachment to base of 5th metatarsal; harvest proximal portion of split peroneus brevis and weave it anterior to posterior through a drill hole in fibula; then weave it posterior to anterior through a calcaneal bone tunnel; suture it back to itself.
      • Evans reconstruction : Harvest proximal portion of peroneus brevis; weave it anterior to posterior through a fibular drill hole; does not address subtalar instability
    • Realignment procedures: Hindfoot varus calcaneal osteotomy can be performed in conjunction with repair or reconstruction.
Follow-up
  • Postoperatively:
    • Cast in eversion for 6 weeks
    • Then switch to removable brace
    • Physical therapy for 3 months
    • Protective brace for at least 6 months
Prognosis
  • High success rate regardless of anatomic repair or tenodesis procedure
  • Predictors of poor outcome after surgery:
    • 10 years of symptoms
    • Ankle osteoarthritis
    • Joint hypermobility
Complications
  • Highest percentage occur in nonanatomic reconstruction procedures
    • Loss of subtalar and talocrural motion
    • Peroneal nerve injury
    • Tendon failure: Tendons are stiffer and have less strain to failure than ligaments.
Miscellaneous
Codes
ICD9-CM
718.87 Ankle instability
 
Patient Teaching
Activity
Modify activities until appropriate rehabilitation program is completed.
 
Prevention
Brace may prevent recurrence during athletics.
 
FAQ
Q: Does the patient have functional or mechanical instability?
A: Check anterior drawer and talar tilt test to document presence or absence of mechanical instability.
 
Q: What are the initial treatment recommendations for a patient presenting with functional ankle instability?
A: Activity modification, ankle brace, functional rehabilitation program focusing on proprioception and endurance training of peroneals.
 
Q: What is the gold standard initial surgery for mechanical ankle instability in a healthy athlete?
A: An anatomic repair procedure such as the Brostrom repair with Gould modification.

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