We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Chronic Ankle Instability
From WikiSM
Contents
Other Names
- Chronic Lateral Ankle Instability (CLAI)
- Recurrent ankle sprain
Background
- This page refers to chronic instability of the Ankle Joint
- Often termed 'Chronic Lateral Ankle Instability (CLAI)'
History
Epidemiology
- Ankle injuries account for 10-30% of all sports injuries[1]
- Prevalence
Pathophysiology
- General
- Vast majority of cases associated with preceding lateral ankle sprain(s) with failure to recover at least 6 weeks after injury
- Ankle can not maintain mechanical, functional performance
- Injury to ATFL and CFL play critical role in generating CLAI[3]
- Can be difficult to distinguish ankle instability from subtalar instability
- Definition
- Functional instability
- Depends on patient generated reports or complaints without a clear anatomical deficit
- Characterized by impaired proprioception, diminished neuromuscular control, compromised strength, decreased postural control, tight Achilles tendon and weak peroneal muscles[5]
- No clinical or radiographic evidence of instability
- Mechanical instability
- Instability identified on physical examination and radiographic evaluation
- Characterized by objective ligament laxity
- Mixed instability
- Most cases of CLAI likely a combination of both mechanical and functional instability
- Rotational ankle instability (RAI)
- Some CLAI patients have a partial deltoid injury
- Described as a combination of lesions in the medial (anterior deltoid ligament) and lateral ligament complex
- Increase in talar rotation due to deltoid "open book" tear of the most anterior component
Associated Conditions
- Lateral Ankle Sprain
- About 20% of acute ankle sprains go on to develop chronic ankle instability (need citation)
- Medial Ankle Sprain
- Sinus tarsi Syndrome
- Associated with ankle sprains[6]
- Osteochondral Defect of the talus
- The mechanism of instability is not well understood
- Peroneal Tendinopathy
- Subtalar Instability
Pathoanatomy
Risk Factors
- History of Lateral Ankle Sprain
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
Clinical Features
- History
- History of recurrent ankle sprains or severe inversion injury
- They may describe the ankle as rolling or giving way
- Often avoid provocative activities (weight bearing, exercise, uneven surfaces)
- Associated symptoms in include pain, swelling, occasionally locking
- Physical Exam: Physical Exam Ankle
- There may be swelling aroound the lateral ankle
- Tenderness at the ligamentous attachments of ATFL, CFL, etc
- Evaluate for Hindfoot Varus, midfoot cavus
- Special Tests
- Anterior Drawer Test Ankle: translate distal tibia posteriorly to evaluate for laxity
- Anterolateral Drawer Test Ankle: The patient's foot is in 10-15° of plantar flexion, translates the rear foot anteriorly
- Talar Tilt Test: Passively evert while palpating lateral talus
- Rhombergs Test: may be used to assess proprioception of the joint
- Peek-a-Boo Sign
- Coleman Block Test
Evaluation
Radiographs
- Standard Radiographs Ankle
- Stress Radiographs Ankle
- Performed while performing either an anterior drawer (AD) or talar tilt (TT) stress to the joint
- AD: anterior translation of 10 mm or at least a 5-mm side-to-side difference when comparing the injured and uninjured ankles
- TT: absolute TT of more than 10° or at least a 5° difference between ankles has been reported to correlate with ankle instability
- When compared to cadaveric measurements using an Optotrak 3D sensor system, stress views underestimate displacement and angular values[7]
- Instability on TT appears to correlate with MRI findings (need citation)
MRI
- Reliable, validated for surgical decision making[8]
- Sensitivity for identifying ATFL abnormality
- Anticipates perioperative surgical technique in 90% of patients (repair or reconstruction)
- Jolman et al retrospective analysis of MRI for CLAI[9]
- Sensitivity: 82.6%
- Specificity: 53.3%
Ultrasound
- Dynamic ultrasound can be used to evaluate ligaments, joint
- Cho et al compared preoperative dynamic US to stress XR, MRI in 28 patients who underwent arthroscopic repair[10]
- 100% of patients had a lax, wavy ATFL
- Affected ATFL stretched to an average of 2.8 ± 0.3 cm under stress compared with only 2.3 ± 0.2 cm on the unaffected side
- The authors could identify no significant difference in ATFL resting length between the injured and uninjured sides (P = 0.777)
Classification
- Not applicable
Management
Nonoperative
- Indications
- Majority of cases initially
- Especially true for cases that are thought to be primarily functional
- Physical Therapy
- Emphasis on neuromuscular and proprioceptive training
- Neuromuscular training found to be effective in short term, unknown in long term[11]
- Ankle Orthotics
Operative
- Indications
- Failure of conservative measures
- Significant mechanical instability
- Technique
- Gould modification of Brostrom anatomic reconstruction
- Tendon transfer and tenodesis (Watson-Jones, Chrisman-Snook, Colville, Evans)
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications and Prognosis
Prognosis
- Nonoperative management
- Patients with functional CLAI benefit more than mechanical CLAI with nonoperative management
- Approximately 50% of athletes with functional CLAI will improve with conservative therapy (need citation)
- Delay in surgical intervention
- Initial conservative management delaying surgical intervention has not been associated with adverse outcomes (need citation)
- Anatomic repair
- Good or excellent results in 85% of patients[12]
- Predictors of poor surgical outcome
- Poor tissue[13]
- Long-standing ankle instability
- Cavovarus foot deformity
- Ligamentous laxity
Complications
- Postoperative
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ Hølmer P, Søndergaard L, Konradsen L, Nielsen PT, Jørgensen LN. Epidemiology of sprains in the lateral ankle and foot. Foot Ankle Int. 1994;15:72–4.
- ↑ 2.0 2.1 Lin, Chiao-I., et al. "The epidemiology of chronic ankle instability with perceived ankle instability-a systematic review." Journal of Foot and Ankle Research 14.1 (2021): 1-11.
- ↑ Bonnel F, Toullec E, Mabit C, Tourné Y, SOFCOT: Chronic ankle instability: Biomechanics and pathomechanics of ligaments injury and associated lesions. Orthop Traumatol Surg Res 2010;96:424-432.
- ↑ Espinosa N, Smerek J, Kadakia AR, Myerson MS. Operative management of ankle instability: reconstruction with open and percutaneous methods. Foot Ankle Clin. 2006;11:547-65.
- ↑ Coughlin MJ, Schenck RC, Jr, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004;25:231–41.
- ↑ Helgeson K. Examination and intervention for sinus tarsi syndrome. N Am J Sports Phys Ther. 2009;4:29–37.
- ↑ Hoffman E, Paller D, Koruprolu S, et al.: Accuracy of plain radiographs versus 3D analysis of ankle stress test. Foot Ankle Int 2011;32:994-999.
- ↑ Morvan A, Klouche S, Thes A, Hardy P, Bauer T: Reliability and validity of preoperative MRI for surgical decision making in chronic lateral ankle instability. Eur J Orthop Surg Traumatol 2018;28:713-719.
- ↑ Jolman S, Robbins J, Lewis L, Wilkes M, Ryan P: Comparison of magnetic resonance imaging and stress radiographs in the evaluation of chronic lateral ankle instability. Foot Ankle Int 2017;38:397-404.
- ↑ Cho JH, Lee DH, Song HK, Bang JY, Lee KT, Park YU: Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test, stress radiography, magnetic resonance imaging, and arthroscopy. Knee Surg Sports Traumatol Arthrosc 2016;24:1022-1028.
- ↑ de Vries, Jasper S., et al. "Interventions for treating chronic ankle instability." Cochrane Database of Systematic Reviews 8 (2011).
- ↑ Bell SJ, Mologne TS, Sitler DF, Cox JS. Twenty-six-year results after Broström procedure for chronic lateral ankle instability. Am J Sports Med. 2006;34:975–8.
- ↑ Nakata K, Shino K, Horibe S, Natsu-Ume T, Mae T, Ochi T. Reconstruction of the lateral ligaments of the ankle using solvent-dried and gamma-irradiated allogeneic fascia lata. J Bone Joint Surg Br. 2000;82:579–82.
- ↑ 14.0 14.1 Sammarco VJ. Complications of lateral ankle ligament reconstruction. Clin Orthop Relat Res. 2001;391:123–32.
Created by:
John Kiel on 7 July 2019 08:14:28
Authors:
Last edited:
3 October 2022 23:48:16
Categories: