ANKLE INSTABILITY AND ASSOCIATED PATHOLOGIES

Brian A. Weatherby, MDAssistant Professor

University of South Carolina School of MedicineGreenville Hospital System University Medical Center

Case Presentation• 16 y/o Female Cheerleader

– Multiple twisting injuries to ankle while stunting/tumbling

– Tx = RICE, PT, bracing, taping

– CANNOT perform 2° to pain with impact loading & repeated instability (in brace)

• Recent onset of pain and “pinching” with walking

Case Presentation• Physical Exam

– PROM Ankle (comparison) Limited DF• Pain at extreme DF

– PROM Subtalar & Transverse Tarsal (comparison) WNL

Case Presentation• Physical Exam:

– + Anterior Drawer Exam (comparison)• Reproduction of Pain Intra-articular Pathology

Case Presentation

• Physical Exam:– + Talar Tilt (comparison)

Case Presentation

• Physical Exam– TTP over antero-lateral ankle joint

• TTP over antero-medial joint (intra-articular?)

Case Presentation• Physical Exam

– + Single Leg Squat Test

Case Presentation

• Physical Exam– NO Posterior Impingement

Case Presentation

• Physical Exam– NO Cavus Foot deformity– NO Generalized Ligamentous Laxity

Ankle Sprains

• Incidence = 1 in 10,000 persons per day– 21% of athletic injuries

ankle– 45% of those

basketball– Majority = Inversion &

PF

• 15-20% Pain & Dysfunction

Anatomy

Anatomy/Biomechanics

Initial Treatment

• Functional Rehabilitation Protocol– Renstrom et al. Sports Med 1999

• “Functional treatment produced no more sequelae than casting with or without surgical repair. Secondary surgical repair, even years after an injury, has results comparable to those of primary repair.”

– Pihlajamaki et al. JBJS 2011• Return to pre-injury level same for FRP

& Surgery

• Surgery did ↓ re-injury but had ↑ incidence of arthritic changes

Initial Treatment

• Bracing

• Orthotics (Cavus Foot)

Surgical Indications • Failed APPROPRIATE non-op treatment

– Persistent instability/recurrent Gr II/III sprain

– Activity related pain > 3 months• Correlate with MRI findings

• Instability episodes with ADL’s

• Continuous bracing not possible (work/skin)

• NOT isolated pain– OCD

– Loose body

– Impingement

Surgical Repair• Brostrom-Gould Technique (Modified Brostrom)

– Hamilton et al., FAI 1993• 96% good to excellent

– Lee et al., FAI 2011• 94% good to excellent (w/out CFL)

Surgical Repair

• Brostrom-Evans– Girard et al., FAI 1999

• > 250 lbs

• > 10 years instability

• Ligamentous Laxity

• Heavy laborer

Associated Pathology• Soft Tissue

Impingement– Wolin et al (1950)

• “mensicoid lesion”

– Ferkel et al (1990)• “meniscoid tissue” =

hyaline cartilage with degenerative change and fibrosis

• Synovial hyperplasia, subsynovial capillary proliferation

Associated Pathology

• Soft Tissue Impingement– Bassett et al (1990)

• Fibrotic thickening of the inferior slip of AITFL

• Chronic rubbing may result in chondromalacia on talus

Associated Pathology• Osseous

– Osteochondral Defect of Talus (postero-medial)

– Bony Impingement– Loose Bodies

Repetitive Subluxation Episodes (coronal & sagittal)Micro Trauma to bone/chondral surface Inflammatory Rxn/Insult ????

Associated Pathology

• Taga et al., AJSM 1993– 95% intra-articular pathology

• Komenda & Ferkel, AJSM 1999– 93% intra-articular pathology

• Choi et al., AJSM 2008– 96% intra-articular pathology

Associated Pathology• Okuda et al., AJSM 2002

– 63% chondral lesions

• Hintermann et al., AJSM 2005– 66% chondral lesions

ANKLE ARTHROSCOPY VITAL ADJUNCT PROCEDURE

Associated Pathology• Tarsal Coalition

Resection/Arthrodesis

• Dislocating Peroneal TendonsRepair

Associated Pathology• Cavovarus Foot

– Subtle Cavus Foot Correction

• Ligamentous Laxity

Augmented repair

Summary

• Chronic ankle instability WILL develop in a certain # of athletes sustaining sprains

• Mainstay in treatment is FRP & bracing

• ALWAYS be aware of, recognize, and address associated pathologies

• Ankle Ligament Reconstruction + Ankle arthroscopy is the GOLD STANDARD for surgical treatment