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Dr. Joseph N. Daniel Clinical Associate Professor of Orthopaedic Surgery Foot and Ankle Service, The Rothman Institute Thomas Jefferson University Hospital Philadelphia, PA Diagnosis and Treatment of Ankle Instability

Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

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Page 1: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Dr. Joseph N. Daniel

Clinical Associate Professor of Orthopaedic Surgery

Foot and Ankle Service, The Rothman Institute

Thomas Jefferson University Hospital

Philadelphia, PA

Diagnosis and Treatment of

Ankle Instability

Page 2: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Disclosure

Wright Medical

Page 3: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Objectives

• Differential Diagnosis

• Incidence

• Anatomy

• Mechanisms of Injury

• Clinical Examination

• Imaging

• Treatment Options / Timing of Surgery

• Complications

Page 4: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Differential Diagnosis of Laterally Based Ankle Pain

• Fractures

– avulsion fracture distal fibula

– lateral process talus fracture

– anterior process calcaneus fracture

– cuboid fracture

– 5th MT base fracture

Page 5: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Differential Diagnosis of Laterally Based Ankle Pain

• Ligament Injuries

– ATFL

– CFL

– PTFL

– syndesmosis injury

• AITFL

– lateral talocalcaneal ligament

Page 6: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Differential Diagnosis of Laterally Based Ankle Pain

• Tendon Injuries

– Peroneus Brevis / Peroneus Longus

• inflammation

• intra-substance tears

• complete ruptures

Page 7: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Differential Diagnosis of Laterally Based Ankle Pain

• Osteochondral Pathology

– ankle

– subtalar

Page 8: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Differential Diagnosis of Laterally Based Ankle Pain

• Neural Injuries

– superficial peroneal nn

– sural nn

Page 9: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Incidence

• Most common orthopaedic injury

• 30,000 acute ankle sprains daily in USA

• Chronic ankle instability much less common

• Multiple factors involved in evolution of lateral ankle

instability

– varus heel

– generalized ligamentous laxity

– peroneal muscle weakness

– repetitive axial and inversion loads

Page 10: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Incidence

• M > F ?

• Avg age:

Page 11: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Anatomy and Biomechanics

• Ankle Joint

– complex of bony anatomy + soft tissue structures

• ligaments

• capsule

• retinaculum

Page 12: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Anatomy and Biomechanics

• Ligaments

– anterior talofibular ligament (ATFL)

– calcaneofibular ligament (CFL)

– posterior talofibular ligament (PTFL)

– cervical ligament (CL)

– interosseous ligament (IL)

Page 13: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Anatomy and Biomechanics

• Ligaments

– distal tibiofibular syndesmotic ligament complex

• anterior tibiofibular ligament

• posterior tibiofibular ligament

• transverse tibiofibular ligament

• interosseous ligament

Page 14: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Anatomy and Biomechanics

• Capsule

• Inferior Extensor Retinaculum

Page 15: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Mechanisms of Injury

• Twisting Injury

– PF + I

• daily activity

• sporting events

– basketball

– soccer

– football

– volleyball

Page 16: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

History / Clinical Examinaiton

• Accurate Description of MOI

– important to determine if additional pathology exists

• Initial Examination

– best if performed immediately

– usually seen 24-48 hrs later

Page 17: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

History / Clinical Examination

• Initial Examination

• swelling

• pain (VAS)

• ability to WB and push-off injured part

• palpation all bony landmarks

– both malleoli

– lateral process talus

– anterior process calcaneus

– cuboid

– 5th MT base

Page 18: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

History / Clinical Examination

• Initial Examination

• PROM / AROM ankle, subtalar joints

• palpation of ATFL, CFL, peroneal tendons (? subluxation;

dislocation), sinus tarsi, deltoid ligament, distal

syndesmotic ligaments

• anterior drawer (internal + external)

• talar tilt (?)

Page 19: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Radiographs

• WB (assumed WB) AP, lateral, Morise views ankle

• WB (assumed WB) AP, lateral, oblique views foot

Page 20: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Types of Instability

• Mechanical

– ROM beyond normal

• Functional

– feeling of impending instability or frank episode

Page 21: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Classification

• First Degree

– partial or complete rupture ATFL

• Second Degree

– complete rupture ATFL + partial or complete rupture CFL

• Third Degree

– complete rupture ATFL, CFL + partial or complete rupture

PTFL

Page 22: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Treatment

• Based on degree of injury + presence of any

associated injuries

Page 23: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Treatment

• Grade I / Grade II:

– RICE

– air cast or lace up ankle splint

– with edema, cam boot

– functional rehab P.T. protocol

– RTA 2-3 wks

Page 24: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Treatment

• Grade II / Grade III:

• same; controversial

• functional rehab P.T. protocol

• surgery:

– ankle arthroscopy + synovectomy +/- excision loose

bodies+/- abrasion chondroplasty + Brostrom-Gould

lateral ankle ligament complex reconstruction

• RTA up to 12 wks

Page 25: Diagnosis and Treatment of Ankle Instability · •30,000 acute ankle sprains daily in USA •Chronic ankle instability much less common •Multiple factors involved in evolution

Thank you

“BE ASHAMED TO DIE UNTIL YOU HAVE DONE SOMETHING GOOD

FOR MANKIND”Dr. Vernon Johnson, American Pastor during the Revolutionary War