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WHAT IS ANKLE INSTABILITY?

Patients with ankle instability report that their ankle feels “weak” or “turns in” on them frequently. They also report that their ankle constantly twists and that they have repeated ankle sprains. In more mild cases, the episodes of ankle instability are brought on by higher activity demands such as running on uneven surfaces or playing sports that involve cutting and pivoting movements. In more severe cases, ankle instability episodes can occur with minimal provocation and in routine situations such as walking on flat, even surfaces.

ANKLE INSTABILITY The above picture shows an illustration of a left ankle twisting inwards, resulting in partial tears to the ligaments on the outside part of the ankle. The most commonly torn ligament is the anterior talofibular ligament (ATFL) – the ligament that connects your fibula to your talus.

WHAT CAN CAUSE ANKLE INSTABILITY?

There are many causes of ankle instability. In most cases, ankle instability develops after previous injuries. The classic scenario consists of a patient who had previous ankle sprains. When one has an ankle sprain, there is a partial tear of the ligaments on the outside part of your ankle (the same side as the little toe). As the ankle twists inwards, the ligament can stretch and tear. Most people make a full recovery. But sometimes, the ligament does not heal properly and/or is weak. This can lead to a situation in which a patient continues to have an unstable ankle.

Other causes of ankle instability can include:

  • Injuries to the joint (such as an osteochondral injury to the talus – a “divot” in the cartilage/bone that can lead to instability
  • Ligamentous laxity (some patients can have loose ligament at baseline)
  • Weakness around the ankle
  • Abnormal shape of the foot/ankle – for example, patients with very high arches (cavovarus foot deformity) can put more load on the outside part of the foot that can lead to overloading of the ligaments on the outside part of the ankle.

HOW DO I KNOW IF I HAVE ANKLE INSTABILITY?

The first step in determining if you have ankle instability is for an orthopedic surgeon to listen to your story. Patients with ankle instability most commonly report that their ankle feels weak and that they have repeated episodes of ankle sprains or their ankle twisting. Patients often have pain along their ankle as well.

A good examination of your ankle is also important. One simple test is called the anterior drawer test. The examiner grabs your heel and draws it forward. This is compared to the other, injured ankle. When the ligaments on the outside part of your ankle are healthy and functioning, there should not be excessive movement of your ankle forward when the examiner draws your ankle forward. A “positive” test (excessive forward movement of your ankle) indicates that the ligaments are not functioning normally.

DO I NEED ANY IMAGING STUDIES?

X-ray’s should be obtained to make sure there are no other injuries or issues with the ankle. For example, some patients with ankle instability can have injuries to the cartilage and bone of their ankle joint.

With repeated sprains, the cartilage/bone of your talus and collide with that of your tibia. This can lead to tears in the cartilage or divots in the cartilage/bone.

Sometimes, a MRI of the ankle may be necessary to evaluate the ligaments themselves and the cartilage. X-ray’s do a great job of providing information with regards to the bone itself, but do not show the soft tissues (such as cartilage and ligaments).

WHAT ARE MY TREATMENT OPTIONS?

There are both non-surgical and surgical treatment approaches to ankle instability.

As a general rule-of-thumb, non-surgical treatment strategies should be exhausted before going forward with surgery.

Non-surgical treatment strategies include: bracing, medications, injections, and physical therapy.

If you have ongoing instability despite trying non-surgical treatment strategies, if may be reasonable to consider surgery. The modified Broström procedure is the gold-standard treatment for ankle instability. This procedure involves reconstructing or “tightening” the ligaments on the outside part of your ankle so that your ankle is no longer loose or unstable.

Generally, an ankle arthroscopy procedure (placing a camera inside of the ankle to assess for other injuries and cleaning out scar tissue) is recommended given that a significant proportion of patients with ankle instability have other problems within the ankle joint.

WHAT IS MINIMALLY INVASIVE ANKLE INSTABILITY SURGERY?

Dr. Anthony Yi offers a minimally invasive approach to treating ankle instability that involves 3 small incisions (up to 5 mm in length). The ligament can be reconstructed using special instruments and a camera to look at the inside of the joint. Studies support this technique as a safe and effective way to treat ankle instability. The more traditional method involves much larger open incision on the outside part of your ankle. The benefits of the minimally invasive method include: smaller incision (and using the same incisions that are already being used for the ankle arthroscopy procedure), less pain, less narcotic pain medication use, excellent results, and the potential for earlier weight bearing and earlier rehabilitation.

Dr. Anthony Yi would be happy to talk to you about your options for treating ankle instability.