Chronic Ankle Instability – Part 1

Chronic ankle instability is a condition in which the ankle “gives out” frequently. The ankle either doesn’t give the right feedback to the brain or the motor response is not firing in a way to keep the ankle from rolling or spraining while you perform anything from sports to walking, but this instability can hamper even the simplest of tasks: standing. After multiple ankle sprains the ankle just doesn’t hold up and is quite simply weak.

Who is at risk?
Children are more at risk than adults1 and people who are more active in sports are obviously at a greater risk for ankle injury, and hence ankle instability. As mentioned in another post, those with ligamentous laxity are at a greater risk of injury and instability of the lateral ankle ligaments. The lateral ligaments are more commonly injured 2 with soccer, basketball, volleyball, and ballet leading to more injuries per participant.3 Lateral Ankle sprains are among one of the most common injuries treated by foot and ankle specialists.4

What are the lateral ankle ligaments anyway?
When talking about the lateral ligaments, one needs to know the difference between lateral and medial. The body is divided down the middle into medial (towards the midline) and lateral (away from midline).
Take for example, the right ankle has an inside and outside. The outside of the ankle is the lateral part of the ankle and the inside is the medial part of the ankle. This is “first lecture of anatomy” type terminology, but helps when a provider slips and isn’t as friendly with their terminology. The image below demonstrates the three ligaments or bands of tissue that connect bone to bone that make up the lateral ankle ligament complex.

ATFL

ATFL

Symptoms
Patients will typical say that their ankle is giving out, and is worse with activity. Those with ankle instability will also complain of difficulty walking on uneven surfaces. Lastly, the ability to perceive the position of the joint, proprioception, is also diminished.

Types of Chronic Ankle Instability
Chronic ankle instability can be a functional problem, a mechanical problem or a combination of the two.
Functional Instability stems from the lack of proper functioning of the muscles, nerves, ligaments and feedback systems that keep the ankle upright. These include issues with proprioception, neuromuscular or postural control deficits, muscle weakness, frequent sprains or simply perceived instability.

Mechanical instability stems from underlying issues in the bones and joints. Ligament laxity, rearfoot joint alignment, and a fibula that is in a poor position.

Conservative Treatment Options
RICE (Rest, Ice, Compression, Elevation) and anti-inflammatories (Motrin, Advil, Ibuprofen)
Strengthen lateral muscles of the leg and proprioceptive feedback with physical therapy
Supportive ankle brace
Lateral heel and sole wedge in shoe
Night splint

These treatments may take up to 6 months or longer depending on efficacy and rate of improvement. If conservative options fail, surgical options will need to be considered for improvement and hopefully resolution of symptoms.

References:

1. Mandarakas et al (2014). Systematic review of chronic ankle instability in children. Journal of Foot and Ankle Research 2014, 7:21
2. Pontell et al (2006) Sports Injuries in the Pediatric and Adolescent Foot and Ankle: Common Overuse and Acute Presentations. Clin Podiatr Med Surg 23 (2006) 209– 231
3. Attenborough et al (2014) Chronic Ankle Instability in Sporting Populations. Sports Med . 2014.
4. Mann 9th edition, Surgery of the Foot and Ankle, 2014

Images:
www.orthoanswer.org

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