You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE Recurrent Ankle SprainsArticle Last Updated: Feb 15, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Joseph R Bozzelle, Jr, MD, Director, Rehabilitation Services, Crowley Rehabilitation Hospital, Doctors Hospital of Opelousas, Southwest Medical Center Joseph R Bozzelle, Jr, is a member of the following medical societies: Louisiana State Medical Society Coauthor(s): Stephen Kishner, MD, Residency Program Director, Professor of Clinical Medicine, Department of Medicine, Section of Physical Medicine and Rehabilitation, Louisiana State University School of Medicine; James Monroe Laborde, MD, MS, Clinical Assistant Professor, Department of Orthopedics, Tulane Medical School; Adjunct Assistant Professor, Department of Biomedical Engineering, Tulane University; Consulting Staff, Department of Orthopedic Surgery, Louisiana State University Health Sciences Center Editors: John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director Designate, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: recurrent ankle instability, chronic ankle sprain, chronic ankle instability, subtalar instability, functional ankle instability, chronic medial ligament instability, mechanical ankle instability INTRODUCTIONSection 2 of 12
  Ankle sprains, especially of the lateral ligaments, are extremely common injuries in the athletic population. Despite the vast amount of research in this area, recurrences remain common. The recurrence rate for lateral ankle sprains has been reported to be as high as 80%.1 In one study, 75% of the ankle sprains in professional soccer players were in ankles with previous sprains or instability.2 In another study, the incidence of developing chronic ankle instability was 20-40% of those who had previously sustained an acute ankle sprain.3 Neuromuscular and proprioceptive deficits are thought to be related to chronic ankle instability, including functional and mechanical insufficiencies.4 This article focuses on recurrent sprains, with emphasis on the lateral ligaments. This article also discusses medial instability, subtalar instability, and syndesmotic instability. Conservative treatment is explored, as well as surgical options for refractory or severe cases. ProblemMechanical instability (MI) relates to the laxity of the ankle joint that is caused by structural damage to the connective tissue that supports that joint. Functional instability (FI) refers to the recurrence of joint instability and the sensation of an unstable joint because of neuromuscular deficits, as opposed to structural deficits. For example, delayed activation of the peroneal muscles (everters such as the peroneus longus and brevis) that are innervated by the superficial peroneal nerve in response to sudden inversion perturbations has been hypothesized as a cause of FI following a lateral ankle sprain. Hertel and Valderrabano et al believe there is a distinct relationship between FI and MI in those patients with recurrent ankle sprains.1, 3 Many studies demonstrate that MI is related to various proprioceptive changes, resulting in an accompanying FI. As a joint develops MI, proprioceptive changes may occur, resulting in alterations in those defense mechanisms that prevent injury. The result is a joint that continues to be stressed beyond its physical limitations, leading to MI and FI of the joint.1, 3 Note, however, that not all patients who develop MI develop FI. These are exceptional cases. FrequencyWith respect to grade III ankle sprains, the average duration of disability has been reported to range from 4.5 to 26 weeks, and only 25-60% of patients are symptom free 1-4 years after injury. Staples noted that 42% of those with grade III lateral sprains treated nonoperatively were still symptomatic at follow-up, but severe disability was uncommon.5 Others have reported a 20-40% incidence of residual FI after conservative treatment of grade III lateral sprains. Brand et al evaluated athletes at the United States Naval Academy.6 The authors found that 10% of the incoming freshmen described functional ankle instability, and 17% of those who were studied reported a functionally unstable or "trick" ankle. In the study, FI was defined as frequent sprains, difficulty running on uneven surfaces, and difficulty cutting or jumping. Despite these findings, it was unclear from the study what proportion of symptomatic instability resulted from tibiotalar laxity versus subtalar instability. Although no incidence studies concerning subtalar instability appear to exist in the literature, Larsen claimed that subtalar instability may occur in 10-25% of individuals who have chronic functional ankle instability.7 Chronic ankle instability in this study was defined as recurrent giving-way for at least 6 months despite adequate nonsurgical therapy.8 Isolated sprains of the medial ankle ligaments are unusual. Deltoid ligament injuries typically occur in association with lateral ligamentous or bony injury.9 Syndesmotic sprains have an estimated incidence of 10% of all ankle sprains. In a study at the United States Military Academy, Hopkinson et al reported an incidence of 1%.10 In another study, calcification of the distal tibiofibular syndesmosis was found in 32% of professional football players attending training camp, which suggests a higher incidence.11 The probable reason for the discrepancy between the 2 studies is that radiographic stress views are necessary for the diagnosis of instability, and these are not routinely performed. EtiologyThe exact etiology of recurrent ankle sprains is unknown. However, many factors may play a role, such as the following:
Related eMedicine topics: PathophysiologyIn lateral sprains, the most commonly injured ligament is the anterior talofibular ligament (ATFL). The disruption typically occurs mid substance, but bony avulsions of the talus and fibula have been reported. The second most common injury is a combination rupture of the ATFL and the calcaneofibular ligament (CFL), usually mid substance. Isolated tears of the CFL are rare and may play a role in subtalar instability.9 In medial sprains, deltoid ligament rupture can occur after pronation-eversion, internal rotation, forced plantarflexion, or forced dorsiflexion. Usually, in forced abduction injuries, rupture of the superficial deltoid ligament occurs first, followed by the deep ligament. The deep deltoid ligament has been shown to have the highest load to failure compared with the lateral complex.9 (See the Relevant Anatomy section for a detailed description of the pertinent anatomy.) In syndesmotic sprains, most clinicians agree that the most predominant causative force is external rotation. This injury can occur with abduction, but that process would be accompanied by failure of the deltoid ligament and the medial malleolus. Persistent external rotation can tear the interosseus ligament and membrane in addition to the AITF ligament. The posteroinferior tibiofibular (PITF) ligament is usually preserved.9 O'Donoghue et al suggested that, in athletes, syndesmotic sprains are the result of hyperdorsiflexion of the ankle.15 Note, however, that no study has been able to produce a purely ligamentous injury to the syndesmosis with an externally applied force. In subtalar injuries, high-energy supination trauma to the ankle and hindfoot causes injury. The most frequently injured ligaments in these cases are the calcaneofibular, followed by the lateral talocalcaneal, then the cervical interosseus, and finally, the talocalcaneal. These injuries typically occur with lateral ankle joint instability, although isolated injuries have been reported.
Pisani described a mechanism that causes injuries to the IOL that was occurring in triple jumpers and basketball players.16 The injury results from a sudden impact and deceleration of the calcaneus, with inertial progression of movement of the talus. ClinicalWhen obtaining a history, ask the patient about the mechanism of injury, as well as why, when, where, and how it occurred. Often, however, the patient's account of the mechanism does not correlate with the structures that have been damaged. Patients often report twisting the foot. The time of onset of swelling is important. Patients may hear a pop at the time of the injury. Also, patients should be asked about their past ankle injuries, their goals regarding functional results, the level and intensity of their sports and activity, and their medical history. Chronic medial ligament instability is uncommon, but it produces discomfort on the medial side of the ankle and is associated with slight valgus and abduction of the ankle with each step. Patients with subtalar instability may report giving-way symptoms of the foot during activity and a history of recurrent instability, pain, swelling, and stiffness. The symptoms are often vague, and distinguishing between subtalar and tibiotalar instability is difficult. Patients may also have pain over the sinus tarsi or deep pain in the subtalar area. This sinus tarsi syndrome can be a component of subtalar instability, with tenderness to palpation over the sinus tarsi and pain upon forced inversion of the foot. Increased internal rotation of the calcaneus is also a common finding, and excessive distal displacement of the calcaneus may occur in relation to the talus compared with the normal side. Subtalar instability should be regarded as contributing to the patient's symptoms, especially in a high-energy injury. On physical examination, one should look for areas of tenderness and swelling. Areas of point tenderness should especially be identified so that a ligamentous correlation can be established. Ecchymosis may be present. Note, however, that blood usually settles along the medial or lateral aspects of the heels. Thus, the location of the ecchymosis may not correlate with the location of the injury. Also, active range of motion must be assessed because Achilles tendon ruptures can mimic ankle sprains. In lateral sprains, passive inversion should reproduce the symptoms. Plantarflexion should also exacerbate the symptoms because this motion stretches the ATFL to its maximum. As with all limb injuries, the neurovascular status of the limb must be assessed. This assessment consists of palpation of the dorsalis pedis and posterior tibial arterial pulses and testing for sensation, especially over the sural nerve distribution. Sural nerve and peroneal nerve palsies, although rare, are complications of a lateral ligamentous injury. Electromyographic examinations of individuals with severe ankle sprains have shown that 80% of these patients have some degree of peroneal nerve injury. The anterior drawer test is performed to test the stability of the ATFL. The examiner attempts to translate the foot anteriorly with respect to the leg by gripping the heel. The foot should be in 10º of plantarflexion. This takes any slack out of the tendon being tested and removes any bony stability that would give a false-negative test result. The patient's knee must be flexed to relax the gastrocsoleus complex, and the examiner must support the foot perpendicular to the leg. The inversion stress maneuver, also known as the talar tilt test, is an attempt to assess the CFL integrity. In many cases this is difficult, if not impossible, to perform secondary to patient pain and swelling. The patient should lie supine or on the side, with the foot relaxed. The gastrocnemius must also be relaxed by flexion of the knee. The talus is then tilted from side to side into adduction and abduction. The findings should be compared with the contralateral side. The prone anterior drawer test is another test for ligamentous instability. The patient must lie prone with the feet extending over the end of the examining table. The examiner then pushes the heel steadily forward with one hand. A positive test result consists of excessive anterior movement and a dimpling of the skin on both sides of the Achilles tendon. The Kleiger test can demonstrate the integrity of the deltoid ligament. The patient sits with the knee flexed to 90º. The foot must be relaxed and not bearing weight. The foot is gently grasped and rotated laterally. A positive test result occurs when the patient has pain medially and laterally. The talus may displace from the medial malleolus, indicating a tear of the deltoid ligament. In patients with suspected syndesmotic injuries, pain in the area of the syndesmosis can be elicited if the fibula is squeezed at the mid calf. Note that pain should not be felt at the site of the pressure, but rather in the lower leg. The anterior drawer and talar tilt tests should produce negative results. The most revealing test is external rotation of the affected foot while holding the leg stabilized, with the knee flexed at 90º (also known as the Kleiger test, mentioned above). In syndesmotic injuries, this test produces pain at the syndesmosis. INDICATIONSSection 3 of 12
See Medical therapy. RELEVANT ANATOMYSection 4 of 12
Lateral ligament anatomy and biomechanics The lateral complex of ligaments has 3 components: the ATFL, the CFL, and the posterior talofibular ligament (PTFL) (see Image 1). When referring to the subtalar joint, the lateral complex has 5 structures: the CFL, the inferior extensor retinaculum (IER), the lateral talocalcaneal ligament (LTCL), the CL, and the interosseus talocalcaneal ligament. Note that the CFL spans both the tibiotalar and talocalcaneal joints. In addition to the general anatomy of the ankle, note the biomechanical function of each component in stabilizing the joint. In dorsiflexion, the ATFL is loose and the CFL is taut. This is reversed in plantarflexion; the ATFL is taut and the CFL is loose. The PTFL is maximally stressed in dorsiflexion. Biomechanical studies by Attarian et al in 1985 demonstrated that the ATFL has a lower load to failure than the CFL.17 The maximum load to failure of the CFL is roughly 2-3.5 times greater than that for the ATFL. On the other hand, the ATFL can undergo the greatest amount of deformation (strain) before failure and allows for internal rotation of the talus during plantarflexion in contrast to the CFL and PTFL. The ATFL primarily restricts internal rotation of the talus in the mortise. When in plantarflexion, the ATFL also inhibits adduction. The CFL prevents adduction and acts virtually independently in neutral and in dorsiflexed positions. The PTFL inhibits external rotation with the ankle in dorsiflexion. Note that medial ligaments are the primary restrictors of dorsiflexion and that the PTFL only assists in this function. The short fibers of the PTFL can also restrict internal rotation after the ATFL has been ruptured. After disruption of the CFL, the PTFL inhibits adduction with the ankle in dorsiflexion. During forced dorsiflexion, the PTFL can rupture. With forced internal rotation, ATFL rupture is followed by injury to the PTFL. Extreme external rotation disrupts the deep deltoid ligament on the medial side. Adduction in neutral and dorsiflexed positions can disrupt the CFL. In plantarflexion, the ATFL can be injured. Medial ligament anatomy and biomechanics The deltoid ligament is divided into 2 portions: the superficial and deep deltoid ligaments (see Image 2). The superficial deltoid ligament originates from the anterior colliculus (an anterior bony prominence) of the medial malleolus. The tibionavicular portion inserts onto the tarsal navicular and is the most anterior part. The tibiocalcaneal portion begins at the anterior colliculus and inserts onto the sustentaculum tali. The final component of the superficial deltoid is the posterior tibiotalar ligament (PTTL). The deep deltoid ligament originates from the intercollicular groove and the posterior colliculus. It is shorter and thicker than the superficial portion and is contiguous with the medial capsule of the ankle joint and the medial portion of the IOL. It is divided into the anterior tibiotalar ligament and the PTTL. Biomechanically, the deltoid ligament primarily prevents abduction. After division of both components of the deltoid ligament, anterior instability of the ankle does not increase. Once the lateral ligaments are cut, the deltoid ligament acts as a secondary restraint against anterior translation. The fibular ligament primarily inhibits lateral translation of the talus. The deep deltoid provides the greatest restraint against lateral translation. In order to tilt the talus in valgus within the mortise, both the superficial and deep deltoid ligaments must be completely ruptured. Syndesmosis The syndesmosis of the ankle refers to the membrane connecting the tibia to the fibula. The tibia and fibula are connected throughout their lengths by an interosseous membrane. However, 3 definable ligaments are found at the ankle: the AITF ligament, the PITF ligament, and the interosseous ligament. The AITF is the most commonly injured ligament in syndesmotic sprains. The PITF has 2 components: a deep portion (called the transverse tibiofibular ligament) and a superficial portion. The interosseous ligament is the shortest of the tibiofibular interconnections and is considered the primary bond between the tibia and fibula. Superiorly, the interosseous ligament is contiguous with the interosseous membrane, which provides some additional strength to the syndesmosis. Biomechanically, a certain amount of motion is allowed in all planes with respect to the distal ends of the tibia and fibula. When the ankle goes from full plantarflexion to full dorsiflexion, the distance between the lateral and medial malleoli increases by approximately 1.5 mm. Rotation of the tibia on the talus can also occur while a person is walking. This rotation can be as much as 5-6°. Ogilvie-Harris and Reed experimentally demonstrated the importance of the syndesmotic ligaments to ankle stability.18 By sectioning the ligaments, the authors concluded that the AITF ligament provides approximately 35% of ankle stability; the deep PITF, 33%; the interosseous PITF, 22%; and the superficial PITF, 9%. Rasmussen demonstrated that the ligaments of the syndesmosis play little role in the stability of the ankle as long as the other ligamentous structures are intact.19 Furthermore, no study exists in which a purely ligamentous injury to the syndesmosis has been produced through externally applied stress (namely, external rotation and abduction). Subtalar joint and ligament anatomy and biomechanics The subtalar joint can be divided into anterior and posterior articulations that are separated by the sinus tarsi and the tarsal canal (see Image 3). The anterior subtalar joint (talonavicular) is formed by the anterior portion of the talus, the posterior surface of the navicular, the anterior part of the calcaneus, and the calcaneonavicular ligament and the fibrous capsule. The posterior talocalcaneal portion is formed by the posterior facet of the inferior surface of the talus and the corresponding posterior facet of the calcaneus. From a biomechanical standpoint, the motion of the talocalcaneal joint is flexion-supination-adduction or extension-pronation-abduction. The motion occurs via talar ovoid surfaces moving over calcaneal ovoid surfaces. Sectioning studies by Kjaersgaard-Andersen et al showed that sectioning the CL resulted in a 10% increase in rotation, and sectioning of the IOL produced a 21% increase in rotation.21 In earlier studies, the same authors found a 77% increase in adduction at the talocalcaneal joint after sectioning the CFL.22 The authors' findings emphasize the importance of the CFL in providing lateral stability to the subtalar joint. This is contrary to a study by Cass et al that demonstrated no such influence on subtalar motion.23 The discrepancy among the studies may be explained by the variability of orientation of the CFL. Trouilloud et al identified 3 primary anatomic variants, as follows24:
CONTRAINDICATIONSSection 5 of 12
Once a patient is deemed a candidate for surgery based on their injury, a preoperative history should be taken and a physical examination should be performed. In patients with collagen vascular diseases, direct ligament repair procedures, such as the Broström procedure, are contraindicated. Patients with bleeding disorders, infection, or a history of heart disease, pulmonary disease, renal disease or liver disease, or those who are on blood thinners, require further workup and even clearance by appropriate specialists before it can be determined whether surgery is contraindicated in these cases. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyFor recurrent lateral ankle sprains, treatment should begin with a trial of conservative therapy for approximately 2-3 months. The treatment goals include the patient regaining full strength in the affected ankle, being provided protective support as needed, and returning to activity participation. These goals are accomplished through range-of-motion and strength exercises, sports-specific functional progression, weight-bearing multidirectional balance exercises, and protective support as needed.26 For recurrent sprains that involve the medial ligaments, slight modifications to the conservative treatment of lateral sprains are used. These include ankle stirrup bracing, casting, and orthoses (in addition to physical therapy). Once again, if these measures are unsuccessful, surgical intervention is necessary. In syndesmotic injuries, when a diastasis has been present for longer than 3 months, significant arthritic changes have probably begun. Diastasis refers to any loosening in the attachment of the fibula to the tibia at the inferior tibiofibular joint. In most cases, arthroscopic evaluation of the ankle joint is helpful to determine the best course of management. Surgical options are discussed below (See Surgical therapy). Chronic instability of the subtalar joint frequently requires surgical intervention. Despite this, the treatment is initially nonsurgical and is similar to the conservative management of recurrent or chronic lateral ankle instability. This includes peroneal strengthening, proprioceptive training, Achilles tendon stretching, and the use of a brace. Taping of the ankle by an athletic trainer can be of benefit, especially when a subtalar sling modification is incorporated. Surgical therapyAccording to a review by Safran, Zachazewski, and Benedetti, more than 20 different delayed surgical procedures are available for chronic ankle instability and sprains.30 Most of these procedures are reconstructive in nature and frequently involve tenodesis between the lateral malleolus and calcaneus, talar head, and/or the fifth metatarsal. All of these procedures use the peroneus brevis and/or longus, Achilles tendon, or fascia lata. None really restore the true ankle anatomy. Broström described a repair that reapproximates the ruptured ligaments and restores true normal anatomy of the ankle.31 Some clinicians noted this procedure to be hazardous because finding healthy margins of the ruptured ligament tissue was difficult. Gould et al described a modified Broström procedure that allowed for reinforcement of the repair, limited inversion (reducing the likelihood for injury), and helped to correct the subtalar component to the instability.32 This modified procedure allowed restoration of the normal anatomy and preserved normal ankle motion with less surgical exposure. The incision is performed from an anterolateral approach, paralleling the fibula border, and starting from the level of the plafond distally to the level of the peroneal tendons. Dissection is then carried down to the capsule. If no obvious ATFL rupture is present, the capsule and ligaments are divided a few millimeters and imbricated. The peroneal sheath is then opened to determine the quality of the CFL. If the CFL is stretched, it can be divided and imbricated. If this ligament is ruptured, a distal avulsion from the calcaneus can be reattached with a suture anchor. A proximal avulsion can be reattached with sutures through drill holes in the fibula. Other procedures, as mentioned above, are mainly tenodesis procedures. Four have been extensively used and described in the literature: the Watson-Jones, Evans, Larsen, and Chrisman-Snook procedures. These procedures focus on harvesting all or part of the peroneus brevis and then rerouting the tendon through various bone tunnels, thereby creating a tenodesis of the ankle or reconstructing the ATFL or CFL. Indications for these augmented types of reconstruction are as follows:
The technique for the overall approach for each of these procedures is essentially the same. A longitudinal incision is made running just posteriorly to the prominence of the lateral malleolus. The incision is then extended to allow harvesting of the peroneus brevis tendon. Before harvesting the tendon, the joint is inspected and debrided if necessary. Occasionally, the ATFL and/or CFL are avulsed from the fibula with a piece of bone. This so-called os subfibulare should be excised. The Evans procedure provides stability that is a result of the ATFL and CFL but not anatomically or mechanically. The peroneus brevis tendon is anchored to the fibula, indirectly limiting inversion of the ankle and anterior talar translation, while also limiting motion of the subtalar joint. The Watson-Jones procedure reconstructs the ATFL but not the CFL. This technique makes use of the Evans tenodesis. One important addition, however, is that the peroneus brevis graft is routed anteriorly through the talar neck to reconstruct the ATFL. Larsen rerouted the peroneus brevis tendon from the fifth metatarsal base into the fibula and then back down into the calcaneus.7 The proximal part of the tendon was sutured to the peroneus longus. The Chrisman-Snook procedure, most commonly used for subtalar instability, involves using half of the longitudinally divided peroneus brevis tendon to substitute or reconstruct the calcaneofibular ligament. In this procedure, the peroneus brevis graft is brought through the fibula from anterior to posterior to reconstruct the ATFL. It is then brought posterior and inferiorly to the calcaneus in a weave pattern to reconstruct the CFL. The Chrisman-Snook procedure, although technically demanding, has been repeatedly demonstrated to produce satisfactory stability to those patients who have a talotibial and combined talotibial and talocalcaneal instability. These procedures vary greatly in the ability to correct subtalar instability. A review of the literature shows that the Watson-Jones procedure is associated with subjective instability 20-90% of the time, and the Evans procedure, 20-33%. Also, with the Evans procedure, a persistent anterior drawer sign is found in 45-60% of patients. In the Chrisman-Snook procedure, 13-30% of patients had subjective persistent instability. Decreased inversion is common with all these procedures. Each procedure employs a specific weave pattern, referring to the manner in which the peroneus brevis tendon is routed through the drill holes. Triligamentous reconstruction uses half of the peroneus brevis tendon to substitute for the ATFL, CFL, and CL. This procedure efficiently addresses both talotibial and talocalcaneal instability. Despite this success, triligamentous reconstruction is a very technically demanding procedure. The surgical treatment decision for chronic medial instability revolves around whether the tissues are of good or bad quality. If the tissues are of good quality, a direct reattachment can be performed. If the tissues are of poor quality, a free flexor digitorum longus graft can be used that goes from the tibia into the talus or navicular to reconstruct the deltoid ligament. For syndesmotic sprains, surgical treatment depends on whether any arthritic change is present. If the articular surface is destroyed on both sides of the joint, tibiotalar arthrodesis or arthroplasty is necessary. In patients with diastasis without significant tibiotalar arthritis, late reduction of the syndesmosis and reconstruction of the ligaments are recommended. Follow-upFor direct ligament repair procedures such as the modified Broström procedures, follow-up care depends on whether the patient is an athlete. Patients who are athletes are placed in a short-leg splint or walking boot with the foot in neutral dorsiflexion and slight eversion. The patient can bear weight as tolerated, and use of the walking boot is continued for 3-4 weeks. At 4 weeks, the patient can start dorsiflexion and eversion movements, and then the patient is placed in an ankle stirrup brace. For nonathletes, according to Coughlin and Mann, 10-12 weeks of protection is recommended, with the first 6 weeks in a cast and the second 6 weeks in a removable brace or walking boot.33 For reconstruction procedures such as the Watson-Jones, Chrisman-Snook, Evans, and Larsen, patients are placed in a U-shaped splint and posterior splint or walking boot. The ankle is then protected for 12 weeks, with a walking boot used for 6 weeks and a pneumatic stirrup brace for the second 6 weeks. After 2 weeks, gentle dorsiflexion and eversion are started. At 4 weeks, peroneal strengthening from the neutral position and Achilles exercises are implemented. For medial ankle surgery, the associated injuries usually dictate postoperative management. Because deltoid ligament injuries can be associated with fractures or avulsions, the ankle is generally splinted and kept non–weight bearing for the first 7-10 days. Then, the patient is placed in a boot or cast and kept non–weight bearing for another 3 weeks. The patient spends the final 2-4 weeks in a walking boot or cast. Patients should wear a stirrup brace during sports activities for the first 6 months after the injury(ies) has(have) occurred. COMPLICATIONSSection 8 of 12
The most frequently encountered problem after surgical repair of the lateral ankle ligaments is trauma to the sural and superficial peroneal nerves. The incidence of hypersensitivity or hyposensitivity ranges from 7-19%. This is with or without accompanying dysesthesias. Wound problems and infection, postoperative stiffness, deep venous thrombosis, and wound necrosis have been reported after surgery. Another frequent sequela of recurrent ankle sprains is chronic anterolateral ankle impingement. This is a result of a thickened and scarred joint capsule. Wolin et al reported that recurrent pain and swelling after injury to the lateral ligaments without instability in patients with a history of previous ankle sprains was due to hyalinized connective tissue arising from the anteroinferior portion of the talofibular joint capsule.34 The authors postulated that the symptoms were the result of this connective tissue becoming pinched in the talofibular joint with motion. This belief was reinforced by the authors' report that in 9 patients such symptoms were alleviated after removal of the pinched connective tissue, which was referred to as meniscoid tissue. Bassett et al noted chronic pain in 7 patients due to talar impingement by a distal fascicle of the AITF ligament.35 Through anatomic and clinical studies, the investigators found that a distal fascicle of the AITF ligament is parallel and distal to the ATFL. This anatomic variant was noted in 10 of 11 cadaveric specimens and in 7 patients (observed during arthroscopy). Bassett et al further noted that this structure becomes symptomatic after ankle sprains because of the increased laxity of the lateral aspect of the ankle due to an incompetent ATFL—which allows the anterolateral talar dome to extrude anteriorly with dorsiflexion. This, in turn, allows the talar dome to contact the distal fascicle of the anteroinferior distal tibiofibular ligament with greater pressure and friction. OUTCOME AND PROGNOSISSection 9 of 12
If recurrent ankle sprains are treated early and appropriate rehabilitation is initiated, the prognosis is excellent with conservative treatment.36, 37, 38 The prognosis becomes even more important to consider for those who require surgical correction. Reconstructive procedures can vary significantly in their ability to correct any persistent instability. (See Surgical therapy for a discussion of the percentage ranges of persistent instability following each procedure.) With respect to chronic syndesmotic sprains, long-term outcome studies are few in number. In a study conducted at West Point, all patients who were studied returned to full duty without further problems. One of these patients was surgically treated, and all had full range of motion in the ankle.10 Edwards and DeLee studied 6 cases of patients with frank diastasis.39 In the 4- to 60-month follow-up period, one case of postoperative skin slough healed uneventfully, and one fixation device failed. Four cases had good results, and 2 had fair results in that the patients had residual mild ankle pain and restricted range of motion. Katznelson et al reported on 5 patients with subacute or chronic syndesmotic injury.40 Each was treated with operative stabilization and bone grafting to the tibiofibular joint, which formed a synostosis. By 10 weeks, all the affected ankles had achieved fusion with no complications. One patient developed traumatic osteoporosis that resolved in 6 months. This patient had mild loss of dorsiflexion. Results are also limited for subtalar instability because this condition is mostly recognized during surgery for chronic lateral ligamentous instability. Most of the available results are intermingled with the results of lateral ankle procedures. Chrisman and Snook had 3 patients with subtalar and ankle instability that were treated by their eponymous procedure.27 One patient had a failed Watson-Jones procedure with persistent instability. The 3 patients with subtalar instability had a 20º limitation of inversion compared with the opposite, normal side. These patients also had no symptoms of instability at 2-6 years of follow-up.8 FUTURE AND CONTROVERSIESSection 10 of 12
It is controversial whether arthroscopy is warranted in those patients with known instability who require reconstruction. Some investigators believe that the pathology can be addressed in an open fashion. Those who favor arthroscopy claim that this procedure provides a more detailed view of the ankle joint anatomy and provides ease in the identification of any additional pathology.41, 42 Another controversy that exists surrounds the value of stress radiography in the evaluation of a sprained ankle.28 Those who argue against radiography note that stress radiography does not reliably detect a difference between the injured and uninjured sides all of the time. They also note that laxity in the joint does not correlate with the patient's symptoms. Future ideas for the treatment of chronic ankle instability are promising. One novel idea is to transfer the peroneus tertius tendon so that it can act as a dynamic stabilizer. This procedure is thought to add to the proprioceptive stability of the ankle joint, and it is not technically complex, making it a desirable treatment. Despite the apparent advantages, however, long-term follow-up studies are lacking. A sample search of the literature resulted in 2 studies regarding the peroneus tertius tendon transfer procedure for the purpose of stabilizing the ankle.43, 44 Other studies investigated the use of this procedure for correction of drop foot deformities45 and for clawfoot deformities.46 Other procedures for lateral ligamentous reconstruction include using the medial one third of the Achilles tendon, the plantaris tendon, bovine collagen, and carbon-fiber prosthetic ligaments. Follow-up studies are inadequate for these procedures as well. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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