Transcript ANKLE INSTABILITY AND ASSOCIATED PATHOLOGIES

ANKLE INSTABILITY AND
ASSOCIATED PATHOLOGIES
Brian A. Weatherby, MD
Assistant Professor
University of South Carolina School of Medicine
Greenville Hospital System University Medical Center
Case Presentation
• 16 y/o Female Cheerleader
– Multiple twisting injuries to ankle while
stunting/tumbling
– Tx = RICE, PT, bracing, taping
– CANNOT perform 2° to pain with impact
loading & repeated instability (in brace)
• Recent onset of pain and “pinching” with walking
Case Presentation
• Physical Exam
– PROM Ankle (comparison)  Limited DF
• Pain at extreme DF
– PROM Subtalar & Transverse Tarsal
(comparison) WNL
Case Presentation
• Physical Exam:
– + Anterior Drawer Exam (comparison)
• Reproduction of Pain  Intra-articular Pathology
Case Presentation
• Physical Exam:
– + Talar Tilt (comparison)
Case Presentation
• Physical Exam
– TTP over antero-lateral ankle joint
• TTP over antero-medial joint (intra-articular?)
Case Presentation
• Physical Exam
– + Single Leg Squat Test
Case Presentation
• Physical Exam
– NO Posterior Impingement
Case Presentation
• Physical Exam
– NO Cavus Foot deformity
– NO Generalized Ligamentous Laxity
Ankle Sprains
• Incidence = 1 in
10,000 persons per day
– 21% of athletic injuries
 ankle
– 45% of those 
basketball
– Majority = Inversion &
PF
• 15-20%  Pain &
Dysfunction
Anatomy
Anatomy/Biomechanics
Initial Treatment
• Functional Rehabilitation Protocol
– Renstrom et al. Sports Med 1999
• “Functional treatment produced no more
sequelae than casting with or without
surgical repair. Secondary surgical repair,
even years after an injury, has results
comparable to those of primary repair.”
– Pihlajamaki et al. JBJS 2011
• Return to pre-injury level same for FRP
& Surgery
• Surgery did ↓ re-injury but had ↑
incidence of arthritic changes
Initial Treatment
• Bracing
• Orthotics (Cavus Foot)
Surgical Indications
• Failed APPROPRIATE non-op treatment
– Persistent instability/recurrent Gr II/III sprain
– Activity related pain > 3 months
• Correlate with MRI findings
• Instability episodes with ADL’s
• Continuous bracing not possible
(work/skin)
• NOT isolated pain
– OCD
– Loose body
– Impingement
Surgical Repair
• Brostrom-Gould Technique (Modified Brostrom)
– Hamilton et al., FAI 1993
• 96% good to excellent
– Lee et al., FAI 2011
• 94% good to excellent (w/out CFL)
Surgical Repair
• Brostrom-Evans
– Girard et al., FAI 1999
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•
•
> 250 lbs
> 10 years instability
Ligamentous Laxity
Heavy laborer
Associated Pathology
• Soft Tissue
Impingement
– Wolin et al (1950)
• “mensicoid lesion”
– Ferkel et al (1990)
• “meniscoid tissue” =
hyaline cartilage with
degenerative change
and fibrosis
• Synovial hyperplasia,
subsynovial capillary
proliferation
Associated Pathology
• Soft Tissue
Impingement
– Bassett et al (1990)
• Fibrotic thickening of
the inferior slip of
AITFL
• Chronic rubbing may
result in
chondromalacia on
talus
Associated Pathology
• Osseous
– Osteochondral Defect of Talus
(postero-medial)
– Bony Impingement
– Loose Bodies
Repetitive Subluxation Episodes
(coronal & sagittal)Micro
Trauma to bone/chondral surface
Inflammatory Rxn/Insult ????
Associated Pathology
• Taga et al., AJSM 1993
– 95% intra-articular pathology
• Komenda & Ferkel, AJSM
1999
– 93% intra-articular pathology
• Choi et al., AJSM 2008
– 96% intra-articular pathology
Associated Pathology
• Okuda et al., AJSM 2002
– 63% chondral lesions
• Hintermann et al., AJSM
2005
– 66% chondral lesions
ANKLE ARTHROSCOPY 
VITAL ADJUNCT
PROCEDURE
Associated Pathology
• Tarsal Coalition
Resection/Arthrodesis
• Dislocating Peroneal
Tendons
Repair
Associated Pathology
• Cavovarus Foot
– Subtle Cavus Foot
 Correction
• Ligamentous Laxity
Augmented repair
Summary
• Chronic ankle instability WILL develop in a
certain # of athletes sustaining sprains
• Mainstay in treatment is FRP & bracing
• ALWAYS be aware of, recognize, and
address associated pathologies
• Ankle Ligament Reconstruction + Ankle
arthroscopy is the GOLD STANDARD for
surgical treatment