Lateral Ankle Pathology
Brent Ricks DPM
Overview
► Anatomy
► Clinical
presentation
► Ankle Sprain
classification
► Conservative treatment
► Surgical treatment
► Conclusion
http://www.sliceofscifi.com/2008/03/25/oh-yeah-they-know-were-here/
8,11
Anatomy
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Anterior Talofibular Ligament
 Intracapsular 10mm proximal from
the Fibular tip
 Controls anterior movement of
Talus
 Most important stabilizer for
inversion
 Anatomically weakest of the three
lateral ankle ligaments Involved
three times more than the CFL
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Calcaneofibular ligament
 Most important stabilizer of STJ
 Extracapsular deep to Peroneals
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Posterior Talofibular ligament
 Intracapsular
 Rarely injured
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Peroneal tendons
http://www.bodyassist.com/content.php?page=tapeanankle
Clinical
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Subjective
85% acute ankle sprains are plantarflexion inversion
10-40% of Acute ankle sprains will continue to
chronic ankle instability
Pain, weakness, crepitus, instability, swelling, stiffness
Objective
Rearfoot varus, plantar flexed first ray, Cavus foot
Peroneal tear and or strength deficit
STJ instability in 10-75%
Tibiofibular syndesmosis
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8,10,11,12,15
Presentation
Injured 1-18% in ankle sprains, most commonly seen in
collision sports
Pain in anteriolateral ankle with increased pain with
dorsiflexion
Frick test; Hold foot in neutral and externally rotate the
foot on a fixed leg. Pain over the syndesmosis (recreates
the mechanism of injury)
Squeeze Tibia and Fibula together at midpoint of calf.
Pain is at distal Tib-Fib syndesmosis
http://www.tabers.com/tabersonline/ub/view/Tabers/1
43062/29/ANTERIOR_DRAWER_TEST
Anterior Drawer
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Suction or Sulcus sign over ATFL
10mm bil or 3mm difference
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9 degree absolute, 3 difference
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(20/30, 8/28)
Talar Tilt (CFL)
Talar dome lesions/Ankle arthritis
http://ajs.sagepub.com/content/36/6/1143.abstract
Ankle Sprain
Grade 1- Little swelling and
tenderness, minimal or no
functional loss, no
mechanical joint instability
► Grade 2- Moderate pain,
swelling over the involved
structures, loss of some joint
motion with mild to moderate
joint instability
► Grade 3- complete ligament
rupture with marked
swelling, hemorrhage and
tenderness, loss of function,
joint motion and instability
2
Classification
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http://www.ankleandfootnorthwest.com/ankle-sprain.html
http://www.atlantisfootandankle.com/ankle-sprain-instability.aspx
Conservative
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2,3,4,5,9
treatment
RICE until swelling and pain resolves
then ankle mobilization and early
weight bearing
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Cryotherapy with in 36 hours returned to
full activity in 13.2 days vs. 30.4 days
beginning after 36 hours
NSAIDS
Taping effectiveness decreases 40%
after 10min of exercise, no significant
support after 60 min.
► Taping helps minimize motion, if
previously injured more than to an
uninjured ankle, within 30 min window
► Ankle braces demonstrate no
significance with those who had a
previous injury in high school volleyball.
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A rigid brace in previously uninjured
females may help
http://www.countrforce.com/sportanklebrace.html
http://www.ehow.com/video_9595_tape-sprained-ankle.html
Conservative
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PT
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Grade 1-2- A functional program should
start immediately (3 weeks after injury to
maximize collagen content)
Unilateral stance on a soft surface for
kinesthetic awareness
Agility ladder for timing coordination
Tilt board for proprioceptive and
Peroneal strengthening to improve
functional instability (giving out)
Plyometric exercises (eccentric loading
immediately followed by concentric
contraction) are more effective in
increasing functional performance than
strength training
► Complex series of hops and jumps
Strength training
► Inversion, eversion, dorsiflexion,
plantarflexion against resistance;
Heel rise/ toe rise; towel curl,
marble pick up
Activities without PT monitoring resulted
in less effectiveness and were performed
correctly 50% of the time
1,2
Treatment
http://www.uksoccershop.com/p-17410/power-speed-parachute.html
http://www.extraedgetraining.com/blog/2010/0
4/under-rated-training-equipment/
http://www.sgwoodworksllc.com/Products-2.html
Conservative
6,7
Treatment
Orthotics
Pt with chronic ankle instability have
lateral foot biased weight distribution in
walking and barefoot running
► Any medial ground reactive force should
be avoided.
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Oblique valgus post
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High arched Pt that flattens with weight
bearing should get maximum arch fill on
cast
http://www.wecreatewellness.com/orthotics/
Reduce PTF and CFL tension
3 degrees for Pt with Calcaneous aligned
under leg, more for pes cavus
Valgus forefoot post
Cuboid pad to decrease ATFL tension
Lateral clip
http://www.sportsinjuryclinic.net/cybertherapist/general/pronate.htm
Surgical
8,11
Treatment
► Brostrom-Gould
 Midsubstance repair
 Incorporation of inferior
extensor retinaculum
 Mild to moderate
instability
 85-95% effective in
treating chronic
instability
 Superior to tenodesis
for functional outcomes
http://www.google.com/imgres?q=brostrom+ligament+repair&um=1&hl=en&qscrl=1&nord=1&rlz=1T4DKUS_enUS274
US275&biw=1427&bih=827&tbm=isch&tbnid=8yoHzXkjf8HzBM:&imgrefurl=http://www.medscape.com/viewarticle/5357
15_2&docid=xDV28YmYCTczaM&w=550&h=577&ei=DudGTqb2BKIsgKWyoSSCA&zoom=1&iact=rc&dur=78&page=1&tbnh=156&tbnw=149&start=0&ndsp=24&ved=1t:429,r:0,s:0&tx=9
0&ty=67
Kang SK et al. Long-Term Results After Modified Brostrom Procedure Without
Calcaneofibular Ligament Reconstruction. Foot and Ankle International. 2011 (32) 153-157
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26/30 male patients
Average age 23
80% high level or amateur athletes
6 months conservative treatment
with more than 15mm anterior
drawer
ATFL repair at anterior fibular
border with extensor retinaculum
anchor to periosteum.
Short leg cast 4 weeks
Air Cast ankle brace 2 weeks
At 4 weeks gentle ROM
PT at 6 weeks
Full weightbearing when full ankle
ROM reached
http://www.myfootshop.com/detail.asp?condition=ankle%20sprain
Kang SK et al. Long-Term Results After Modified Brostrom Procedure Without
Calcaneofibular Ligament Reconstruction. Foot and Ankle International. 2011 (32)
153-157
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Follow up 10.6 years
Excellent (asymptomatic, full
activities)
 12/30 patients
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Good
(some symptoms, full activity)
 16/30 patients
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Fair
(symptomatic not fully functioning)
 2/30 patients (re-injured)
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No statistical difference in ROM
in contralateral ankle
Anterior Drawer
 Grade 0 (<5mm) - 13
 Grade 1 (5-10mm) - 13
 Grade 2 (10-15mm) - 4
http://blog.syracuse.com/sports/2011/07/us_womens_soccer_team_has_hist.html
Surgical
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8,11
Treatment
Chrisman-Snook
 Split Peroneous Brevis does not
result in loss of eversion strength
 80% good to excellent results
 Indications
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Failed Brostrom, significant
instability, Morbidly obese, STJ
instability
 Non-weight bearing 4 weeks
followed by protected weight
bearing as tolerated
 Non-weight bearing 1 week. CAM
boot with advancement of weight
bearing until 6th week. Light
exercise until 3months out.
 Free Semitendinosus allograft
anchored to the lateral Talar neck
 Gracilis tendon autograft
http://www.lexikon-orthopaedie.com/pdx.pl?dv=0&id=01620
Watson Jones
Evans
Klammer et al. Percutaneous Lateral Ankle
Stabilization: An Anatomical Investigation. Foot and
Ankle International. 2011 (32)
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Cadavaric study, 11 feet, Gracilis graft
5mm incision at the anterior margin of
the Fibula 10-15mm proximal of the
Fibular tip
Guide wire into the Talar neck used to
guide the bone tunnel
Tendon graft inserted and secures with
absorbable interference screw
Fibular tunnel then created at the same
level
Second incision made at the posterior
Fibular tunnel and graft passed
3rd incision at the insertion of CFL,
Posterior and superior to Peroneal
tubrical, and tunnel through Calcaneous
made
Tendon passed and secured
Medial Calcaneal Branch of the Tibial
nerve hit 2/11. No other nerovascular
structures were compromised
http://www.auntminnieeurope.com/index.aspx?sec=sup&sub=mri&pag=dis&itemId=605243
Surgical
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9
Treatment
Peroneal Repair
Brevis more commonly
involved
 Less than 50% of tendon
torn
► primary
repair,
debridement, tubularization
 More than 50% torn
► Tendon
grafting
► Side to side anastomosis
http://radiographics.rsna.org/content/20/suppl_1/S153.full
 Tendonosis
► Debridement
► Topaz,
PRP, etc
http://www.footankleinstitute.com/peroneal-tendon-tear/
Conclusion
► RICE
with immobilization and NSAID, PT
► Orthosis and braces
► Consider all structures of lateral ankle, best
viewed with MRI
► Brostrom Gould for ATF and CFL repair and
augmentation
► If that fails, STJ instability, obesity;
Tenodesis
References
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Hawson ST. Physical Therapy and Rehabilitation of the Foot and Ankle in the Athlete. Clin Podiatr Med Surg. 2011; 189-201
Ismail MM; Ibrahim MM; Youssef EF; El Shorbagy KM. Plyometric Training Versus Resistive Exercises After Acute Lateral Ankle Sprain.
Foot and Ankle International. 2010; (31) 523-530
Frey C; Feder KS; Sleight J. Prophylactic Ankle Brace use in High School Volleyball Palyers: A Prospective Study. Foot and Ankle
International. 2010; (31) 296-300
Hubbard TJ; Cordova M. Effect of Ankle Taping on Mechanical Laxity in Chronic Ankle Instability. Foot and Ankle International 2010; (31)
499-504
Lyrtzis C; Natsis K; Papadopoulos C; Noussios G; Papathanasiou E. Efficacy of Paracetamol Versus Diclofenac for Grade 2 Ankle sprins.
Foot and Ankle International. 2011; (32) 501-575
Morrison KE; Hudson DJ; Davis IS; Richards JG; Royer TD; Dierks TA; Kaminski TW. Plantar Pressure During Runnig in Subjects with
Chronic Ankle Instability. Foot and Ankle International. 2010 (31) 994-1000
Rosenbloom KB. Pathology-Designed Custum Molded Foot Orthoses. Clin Podiatr Med Surg. 2011 (28) 171-187
Hentges MJ; Lee MS. Chronic Ankle and Subtalar Loint Instability in the Athlete. Clin Podiatr Med Surg. 2011 (28) 87-104
Franson J; Baravarian B. Lateral Ankle Triad: The triple Injury of Ankle Synovitis, Lateral Ankle Instability, and Peroneal Tendon Tear. Clin
Podiatr Med Surg. 2011 (28) 105-115
Soomekh DJ. New Technology and Techniques in the Treatment of Foot and Ankle Injuries. Clin Podiatr Med Surg. 2011 (28) 19-41
Schenck RC; Coughlin MJ. Lateral Ankle Instability and Revision Surgery Alternatives in the Athlete. Foot Ankle Clin N AM. 2009 (14) 205214
Lee KT; Park YU; Kim JS; Kim JB; Kim KC; Kang SK. Long-Term Results After Modified Brostrom Procdure Without Calcaneofibular
Ligamnet Reconstruction. Foot and Ankle International. 2011 (32) 153-157
Klammer G; Schlewitz G; Stauffer C, Vich M; Espinosa N. Percutaneous Lateral Ankle Stabilization: An Anattomical Investigation. Foot
and Ankle International. 2011 (32) 66-70
Irwin TA; Anderson RB; Davis WH; Cohen BE. Effect of Ankle Arthritis on the Clinical Outcome of Lateral Ankle Ligament Reconstruction
in Cavovarus Feet. Foot and Ankle International. 2010. (31) 941-948