Ankle Instability

Introduction

Regular or frequent giving way of the ankle or rolling over the ankle resulting in pain on the outer side of the ankle is known as ankle instability. This may result in frequent falls and difficulty walking over uneven ground or playing sport. It often develops after an injury, such as a sprained ankle. Chronic ankle pain can be caused by several other conditions.

Signs and symptoms

  • Pain: Usually on the outer side of the ankle. The pain may be so intense that you have difficulty walking or participating in sports. In some cases, the pain is a constant, dull ache.
  • Difficulty walking on uneven ground or in high heels
  • A feeling of giving way (instability)
  • Swelling
  • Stiffness
  • Tenderness
  • Repeated ankle sprains

Possible causes for chronic lateral ankle pain

The most common cause for a persistently painful ankle is incomplete healing after an ankle sprain. With ankle sprain, the connecting tissue (ligament) between the bones is stretched or torn. Without thorough and complete rehabilitation, the ligament or surrounding muscles may remain weak, resulting in recurrent instability. As a result, you may experience additional ankle injuries. Other causes of chronic ankle pain include:

  • An injury to the nerves that pass across the ankle. The nerves may be stretched, torn, injured by a direct blow, or pinched under pressure (entrapment).
  • A torn or inflamed tendon
  • Arthritis of the ankle joint
  • A fracture in one of the bones that make up the ankle joint (osteo-chondral fracture)
  • An inflammation of the joint lining (synovium)
  • The development of scar tissue in the ankle after a sprain.

Treatment

This will depend on the final diagnosis and should be personalised to your individual needs. Both conservative (non-operative) and surgical treatment methods may be used. Conservative treatments include:

  • Anti-inflammatory medications such as aspirin or ibuprofen to reduce swelling
  • Physical therapy, including tilt-board exercises, directed at strengthening the muscles, restoring range of motion, and increasing your perception of joint position
  • An ankle brace or other support

If condition requires it, or if conservative treatment doesn't bring relief, surgery may be recommended. Many surgical procedures can be done as a daycase. Some procedures use arthroscopic techniques; other require open surgery. Rehabilitation may take 6 to 10 weeks to ensure proper healing. Surgical treatment options include:

  • Removing (excising) loose fragments
  • Cleaning (debriding) the joint or joint surface: Arthroscopic surgery
  • Repairing or reconstructing the ligaments or transferring tendons :

Procedure

This procedure is performed through an incision on the outside (lateral) of the ankle. The incision is opened up down to the ankle joint. The anterior talofibular ligament is identified. This ligament is typically stretched out. The dissection is usually extended down to the tip of the fibula (prominent bone on the outside of the ankle) where the calcaneofibular ligament is identified. This ligament is also often scratched out. The anterior talofibular ligament is tightened. Cutting the ligament and repairing it in a tightened position with strong non-absorbable sutures do this. This may also be performed on the calcaneofibular ligament if this ligament is also loose. A “Gould’s modification” to the Broström procedure may be added by identifying the strong extensor retinaculum and incorporating this into the repair. Sometimes an additional augmentation of the repair is carried out by using non-absorbable tape (‘Internal brace’). Following the ligament repair the wound is then closed in a layered manner.

Recovery

Patients undergoing this type of surgery typically need a 6-week period where the ligaments are allowed to heal. During this time, patients are either non weight-bearing or putting only limited weight through the operated extremity. Patients are sometimes are allowed to place the ankle through a gentle range of motion in order to limit the stiffness. At approximately 6 weeks physical therapy is usually started. This program focuses on:

  • Regaining strength about the ankle
  • Regaining motion
  • Improving proprioception
  • Returning the gait to a more normal manner.

For a number of months after surgery, the repair is often protected with an ankle brace or equivalent. It is common for patients to take 4-6 months to be able to return to high-level activities.

Complications of the Surgery

Specific risks

  • Injury to the superficial peroneal nerve: This nerve is often in the wound. The nerve is usually identified and is not normally cut but retracted away from harm. During the retraction, the nerve can be irritated with too much tension. If this type of neuritis occurs, fairly aggressive therapy to desensitize this area is required.
  • Stretching out of the repair: The repaired ligament is often strong and creates increased stability of the ankle. However, it is not as strong as the original ligament and further ankle sprains will potentially stretch out this ligament. If revision of a Broström repair is required many surgeons will choose to perform a tendon reconstruction of the lateral ligaments.

General risk:

  • Infection
  • Wound healing problems
  • Nerve injury
  • Deep Vein Thrombosis (DVT)
  • Pulmonary Embolism (PE)
  • Continued Symptoms / Failure to resolve all of the symptoms

This procedure is designed to effectively treat ankle instability. The pain that originates from other sources such as the ankle joint itself will not necessarily be addressed with this procedure.

Prevention

Almost half of all people who sprain their ankle once will experience additional ankle sprains and chronic pain. You can help prevent chronic pain from developing by following these simple steps:

1. Follow your doctor's instructions carefully and complete the prescribed physical rehabilitation program.

2. Do not return to sporting activity until cleared by your physician.

3. When you do return to sports, use an ankle brace rather than taping the ankle. Bracing is more effective than taping in preventing ankle sprains.

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