Ankle Instability (Ankle Giving Way) Treatment in Singapore

• 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

• Treat initial ankle sprains aggressively using:
  • Activity modification
  • Bracing
  • Functional rehabilitation program

Epidemiology

• History of previous sprain (most common risk factor)
• Connective-tissue disorders
• Cavovarus foot alignment

• 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

Tests

• 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

• 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.

Special Therapy

• 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.

• High success rate regardless of anatomic repair or tenodesis procedure
• Predictors of poor outcome after surgery:
  • 10 years of symptoms
  • Ankle osteoarthritis
  • Joint hypermobility

• 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.

Patient Teaching

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