ANKLE INSTABILITY

People who get ankle instability are usually the people who have suffered an ankle sprain.  This can come in other types of injury, but this is the number one source of ankle instability.  What do I mean when I say ankle instability? For the most part, it is a chronic feeling that comes quite a bit after an ankle sprain where the ankle just never quite feels right.  The patient usually feels a limitation on how much weight they can put on their foot or how much stress or how much they can push off of their ankle.  A lot of times, this is not a significantly intense pain, but it is a cognizant way of the body saying there is something wrong.

For most people, the location of this instability is the outside ligament or tendon of the ankle joint.  It could be just underneath the fibular malleolus or the lateral bump that you can easily feel on the outside of your ankle.  For most people what has happened is that they have either torn the ATFL, which stands for anterior talofibular ligament, and/or the CFL, which is the calcaneofibular ligament.  If there is no tear in an ankle ligament, then possibly there is an injury to the peroneal brevis or peroneal tendon tear.

IMAGING

Imaging for ankle instability can initially be done with an x-ray.  Certain x-rays can stress the ligament and see if there is excessive movement or range of motion of the ankle joint.  Another thing an x-ray will show is other signs of possible other reasons for the pain.  This could be an osteochondral defect, which is really a fancy word to say that your cartilage has been injured, or there could be underlying bone spurs or ankle joint arthritis. However, when the x-rays come back normal, it still does not mean that there is not ankle instability.  Unfortunately, x-rays will only show bone or osseous structures. They do not show ligament damage or tendon tears.

A normal x-ray can often lead to further imaging of an MRI or of a CT scan. When looking specifically for ligaments, MRIs are very helpful to determine if there are any tears or what is called attenuation, which just means a stretched out ligament. With an MRI, you can better diagnose the actual injury to these ligaments and get to the bottom of what is creating this ankle instability.

TREATMENT

Often, when there is ankle instability, there is not very much conservatively that can correct this problem.  If the MRI were to come back and say that there is no ligament tear or tendon damage, then conservative treatment could be considered, especially if it has not been too long with this feeling of instability.  Some of the conservative treatment could be physical therapy or an ankle brace when playing sports.  Perhaps if not instability, an ankle scope would be beneficial or some type of steroid into the ankle joint could be helpful.  However, if it is a tear and it has been around for quite some time, and even if it isn’t a tear, you may still want to consider a procedure.  The reason why I mention that without a tear you might want to consider surgery is because the ligament still could have been stretched out and it still has overall that feeling of instability in the ankle joint, so surgery could tighten up the ankle ligament and make the patient overall feel a lot more stable with their foot.  If there is a diagnosed tear, then it could also be helpful to have the surgery as it will stabilize the ankle joint once more.

ANKLE INSTABILITY PROCEDURES

There are different ways to address chronic instability.  Some doctors will just suture the ligament back to itself. Some doctors will add a bone anchor to the attachment or repair.  Another recent technique is to add additional bridging to this repair.

What I am referring to is a type of procedure where the ligaments are still initially repaired through anchoring the ligament back to the fibular bone and then adding an additional 2 anchors to attach a very thick suture tape, which is really a very thick suture material, running from the fibula, which is the outer bone of the ankle, into the talus, which is the bottom part of the ankle.  Once this bridging takes place, it is shown to be twice as strong as the ankle was before the injury and much stronger than it would be without it.  Even with ankle repairs, they still are weaker than prior to the injury.  However, this bridging technique has been very successful in not only providing a stronger ankle but allowing the patient to feel stable again in their ankle with sports and to get back to their activities that they could not participate in beforehand.  If the ligament is all that is the problem, the patient could also get back on their feet rather quickly.  Of course, this is dependent on the surgery and the technique.  With the bridging technique, you can occasionally bring patients back on their foot in 2-3 weeks.