Stay Strong and Able With These Advanced Chronic Ankle Instability Treatments

An ankle sprain has been reported to be the most common athletic injury in the United States. A vast majority of ankle sprains involve the lateral ankle ligaments. In the acute setting, ankle sprains are treated with rest, ice, compression, and immobilization. As symptoms resolve, patients continue treatment through physical therapy and gradual return to activity.

Ankle Sprain Complications and Chronic Instability

The most common ankle sprain is of the lateral or outside part of the ankle.

A majority of these injuries heal without issue through these conservative measures. However, a percentage of these injuries do not heal well and patients develop chronic ankle instability or recurrent lateral ankle sprains. Individuals report a history of multiple ankle sprains or simply one incident in the past involving a severe ankle sprain.

Patients report instability with certain activities, uneven surfaces and generally a feeling of looseness to the ankle. Ankle instability can become a debilitating issue causing functional deficits, repeat injuries, arthritis, and even tendon injuries.

Diagnostic Chronic Ankle Instability

Patients often come to us following a recurrent injury or a prolonged period of inflammation and describe a history of events as previously stated. Patients demonstrate functional and/or mechanical instability upon evaluation. The physical exam shows tenderness throughout the lateral ankle joint and often swelling exists during times of inflammation. X-rays are performed which can show acute fractures, spurring of the ankle joint, intra-articular arthritic changes, and varying degrees of angular deformity to the ankle joint.

High Ankle Sprain Picture

An ankle sprain may cause tenderness and bruising around the ankle.

Mechanical instability is diagnosed using a manual stress testing of the ankle joint, which can also be done under radiographic examination. Ankle instability can also be caused by systemic conditions including Ehlers-Danlos syndrome and Marfan’s syndrome.

Structural deformities of the foot and ankle including ankle varus, calcaneal varus, and high arched feet can also lead to chronic ankle instability. MRIs are useful to further evaluate the ankle ligaments as well as associated causes of pain including tendon tears, inflammation, bony bruising, and chondral injuries.

Conservative and Surgical Treatment for Chronic Ankle Instability

Regardless of prior history, in an acute injury, conservative methods are prescribed. Early functional rehabilitation is utilized and is the key to conservative management. Conservative methods include RICE protocol, immobilization, progressive weight bearing, early range of motion and physical therapy.

RICE treatment for Ankle Sprain

Icing an ankle sprain can decrease the swelling, pain and bruising.

Surgical treatment is entertained following the failure of physical rehabilitation, proprioceptive training, strengthening, and bracing. Surgical patients fail conservative efforts and experience continued pain, edema, and symptomatic instability. In cases of chronic instability, long term bracing can be utilized to assist with daily ambulation and activity. However, it is difficult for the full spectrum of symptoms to resolve with conservative treatment and following the resolution of therapy the chronic instability results in continued pain and the return of symptoms.

The lateral ankle ligament repair is performed utilizing the Brostrom-Gould method. This surgical technique not only repairs the attenuated lateral ankle ligaments, but also provides additional support by mobilizing the extensor retinaculum. At University Foot and Ankle Institute we utilize the latest in surgical advancements and techniques in ligament repair including less invasive incisions, bone anchors, and the use of the InternalBrace when warranted.

Prior to ankle stabilization surgery, ankle arthroscopy is generally performed enabling treatment of intra-articular pathology including scar tissue, inflammation, and potentially arthritic or chondral changes.

Surgical repair is performed through a lateral ankle incision allowing visualization of the lateral ankle ligaments, extensor retinaculum, and the distal fibula. The retinaculum is carefully dissected and the lateral ankle capsule and ligaments are sharply dissected forming a soft tissue cuff for surgical repair. At this time the lateral joint is examined for any bony fragments which are removed. The distal fibula is further exposed and is roughened with a rongeur to assist with soft tissue adherence.

Bone anchors are then inserted into the distal fibula and suture is passed through the soft tissue cuff, the cuff is tightened, and surgical knots are performed. Certain repairs are performed in a double row fashion where the sutures can then be placed into additional anchors in the distal fibula. The soft tissue layers are then closed in a layered fashion prior to skin closure. The patient is placed in a splint or cast following surgery and is non weight bearing for three to four weeks.

In cases of severe ligamentous instability or chronic attenuation the InternalBrace can be utilized to augment the surgical repair. Surgical repair can also be performed with modified incisions to allow for repair of the adjacent peroneal tendons. Arthroscopic repair of lateral ankle instability is a developing method of surgical repair, however long term results are still being analyzed.

Following the initial period of non weight bearing the patient is placed in a removable boot and gradually advances weight bearing status. Functional rehabilitation follows which focuses on range of motion, proprioception, and strength training. The patient eventually transitions to an ankle brace prior to returning to normal activity.

In Summary

Acute lateral ankle sprains are significantly more common than chronic ankle instability; however the latter can lead to debilitating problems. Acute sprains should always be treated with conservative measures and physical therapy, however should symptoms persist surgical options are available to provide excellent long term outcomes.

If you are suffering from any of the symptoms we’ve discussed, you should see a foot and ankle specialist to have them take a closer look. The physicians at University Foot and Ankle Institute are here to help. Our nationally recognized podiatrists and foot and ankle specialists offer the most advanced foot and ankle care along with the highest success rates in the nation.

For more information or to schedule a consultation, please call (877) 736-6001 or visit us at www.footankleinstitute.com.

Dr. Ryan Carter

Dr. Ryan Carter

Dr. Ryan Carter was born and raised in St. Louis, Missouri. He received his bachelor’s degree in Biology at the University of Missouri, Columbia, where he played on the men’s lacrosse team and was captain during his senior year.

After receiving his medical degree at Midwestern University Arizona School of Podiatric Medicine, Dr. Carter then completed a three-year surgical residency at Kaiser Permanente in Santa Clara, California. During his residency, he received comprehensive training in all aspects of the foot and ankle. During his final year of residency he served as chief resident.

In his free time, Dr. Carter enjoys running and spending time with his 10 year old corgi Kobe.
Dr. Ryan Carter

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