Current Concepts In Treating Chronic Ankle Instability

Bob Baravarian, DPM

   Chronic ankle instability can be a common and often debilitating problem resulting from multiple moderate ankle sprains or a single severe ankle sprain. The subsequent residual symptoms associated with chronic ankle instability may lead to multiple additional ankle sprains and possible secondary conditions such as arthritis, synovitis or tendon irritation/tear.

   In our practice, chronic ankle instability is one of the most common presentations and we have noted a triad of common problems associated with patients who have chronic ankle instability. These patients have often had multiple sprains with difficulty playing sports and chronic lateral ankle pain. Patients will often relate a single severe sprain or multiple periods of moderate sprain with activity.

   The triad we often note in our practice consists of ankle instability secondary to lateral ankle ligament tear, synovitis and possible scar tissue formation in the ankle with or without exostosis formation, and peroneal tendon tear. These findings are not always present together but often seem to be related to ankle instability cases. Over a period of over 100 cases, we have noted that most of these patients have had ankle instability for an extended period of time of over six months.

   Patients also relate multiple moderate sprains or one severe sprain that resulted in the onset of pain and swelling about the ankle. Patients also relate not having had proper treatment for the original ankle sprain at the time of the initial injury or injuries, and this led to chronic pain and instability. In order to understand the underlying problem, one needs to understand the cause of the problem.

   Emergency room technicians often render treatment with an Ace wrap and pain medications with no form of formal bracing or physical therapy. Patients will relate that the ankle never quite recovered from the initial injury and, over a period of months to years, the ankle has been getting more swollen and painful. They may also note that the ankle feels unstable. Often, there is also chronic inversion of the ankle with even normal activity due to the lack of proper proprioception and ligament laxity.

What To Look For In The Physical Exam

The symptoms related to the triad of problems range from edema and pain in the ankle to posterior fibular pain to just a feeling of instability. However, what is most common is a sense of a chronic ache about the lateral ankle and lateral gutter with extended walking or sports. With extended periods of chronic instability, the patient may also note spurring of the anterior ankle with a grinding feeling.

   The physical exam often shows a swollen ankle, especially in the lateral gutter and anterior lateral ankle. There is a positive anterior drawer test and an additional talar tilt may be present as well. Physicians may also note crepitus in the anterior ankle with range of motion due to anterior spurring. The lateral ankle exam often misses the posterior and distal fibular region.

   In cases of peroneal tendon tear, there may or may not be a weakness of the peroneal tendons. In most cases, peroneal tendon weakness is hard to diagnose. However, there may be chronic pain along the peroneal tendons with increased pain to pressure especially on the distal posterior fibula and just distal to the tip of the fibula along the peroneal tendons.

What Diagnostic Imaging Can Reveal

Diagnostic studies require plain film radiographs for a check of osteochondral lesions, bone spurs and possible avulsion fractures about the ankle. One must also check the position of the talus within the ankle mortise. Radiographs are of little use in the assessment of the ligament and tendon structures. We most commonly use magnetic resonance imaging (MRI) for an adequate check of the ankle.

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