ANKLE INSTABILITY

Anatomy
Ankle is a hinge-like joint
Between distal ends of the tibia and fibula
and upward projecting talus

Ankle Ligaments
Lateral Ankle ligaments:
- Anterior talofibular ligament (ATFL)
- Posterior talofibular ligament (PTFL)
- Calcaneofibular ligament (CFL)

Medial ankle ligament:

- Deltoid Ligament

Distal tibiofibular Ligaments: (Syndesmosis)

- Anterior TFL (DATFL)
- Posterior TFL (DPTFL)
- Inferior Transverse Ligament
- Interosseous Membrane

ATFL
A thickening of ankle capsule
Extends from anterior edge of distal part of fibula to talar neck
Strain in ATFL:
- Minimum in dorsiflexion & neutral
- Increases as ankle is moved progressively through plantarflexion
Primary restraint to anterior shift
Inversion & internal rotation moments applied to ankle increase strain
in ATFL

CFL
A round ligament that spans ankle & subtalar joints
Obliquely from inferior tip of distal part of fibula to insert on midlateral part of calcaneus
Strain increases as ankle is moved from plantarflexion to
dorsiflexion
Greatest strain occurring when inversion moment is applied
with ankle in dorsiflexion
Primary restraint to tilt
CFL has major role in stabilization of subtalar joint

Deltoid Ligament
Consists of deep & superficial components
Superficial portion has a broad, fan-shaped attachment to
navicular, sustentaculum tali, & posterior part of talus
Deep fibers connect medial malleolus to medial border of talus
Deep portion resists external rotation of talus
Superficial component resists abduction of talus

Ankle Movements
Ankle joint (Sagittal plan)
Plantar flexion --Dorsal flexion ---

Subtalar joint (Coronal plan)

Eversion
Inversion

Lateral ligaments injury

 97% of all ankle ligament ruptures occur on

antero-lateral side
Mechanism:
- inversion Injury
- anterior talofibular ligament most common
- Injury to calcaneofibular ligament occurs in more severe
injuries
- Disruption of posterior talofibular ligament is rare

Clinical finding:
- pain and swelling at lateral aspect of ankle

 Physical Examination:
- Tenderness at just distal and slightly anterior to lateral malleolus
- Passive inversion of the ankle is extremely painful

Radiology:
Indication: 1) pain around the malleolus
2) inability to weight bear on the ankle immediately
after the injury or in ED
3) bone tenderness at the posterior edge or tip of
the medial or lateral malleolus or the base of the
fifth metatarsal bone
Views: AP, Lateral, Mortis (30 degree oblique)

 Other investigation:
- MRI
- CT scan

Re-examination:
- Inability to weight bear > 1/52
- persistent pain > 6/52

Special Tests
Talar Tilt Test:
- Ankle in neutral position (10-20 degree of plantarflexion)
- Stabilizes the medial aspect of tibia by grasping the leg with
one hand above the ankle
- Other hand force the heel into maximum inversion
- The range of movement can be estimated clinically and
compared with normal ankle.
- The exact degree of talar tilt can also be measured by x-rays,
which should be taken with mortise view: 15 degrees of talar
tilt or 5 degrees more than in the normal ankle is abnormal
- Inversion laxity suggests injury to both the CFL and AFTL

 Anterior Drawer Test:

- The patient should be sitting with the knee flexed to 90
degrees and the ankle in 10 degrees of plantarflexion.
- The lower leg is stabilized with one hand
- Other hand forces the patients heel forward under the tibia
- In a positive test the talus can be felt sliding forward
(subluxation of talus anteriorly from beneath tibia)
- The position of the talus is verified by lateral x-rays; anterior
displacement of 10 mm (or 5 mm more than on the normal side)
- Abnormal indicate injury of ATFL

Treatment Ligament Injury

Conservative:
- RICE (rest, ice, compression, elevation) for 1-3/52
- PRICER (protection, rest, ice, compression, elevation, rehabilitation)
- NSAIDs

Operative:

- Disruption of both medial & lateral ligamentous structures

- Bony avulsion
- Residual complaints of ankle pain and stiffness
- Sensation of instability or giving way
- Intermittent swelling are suggestive of cartilage damage

Deltoid Ligament Injury

 Usually associated with:

- Fracture of the distal end of the fibula
- With syndesmotic injuries (tearing of the distal tibiofibular ligaments)
- Both

Mechanism:
- pronation trauma

Clinical Finding:
- tenderness over ligament
- pain over medial gutter and anterior fibula

 Investigation:
- x-ray: mortise view (Widening of medial joint space > 4mm)
- MRI

Treatment:
- Conservative: cast below knee for 8/52
- ORIF

Syndesmosis Injury

 Can cause partial or complete separation of the

tibiofibular joint (diastasis)
Partial diastasis due to DATFL injury alone
(External rotation)
Complete diastasis due to DATFL and DPTFL
(abduction trauma)

 Clinical finding:
- pain at the front of the ankle
- Positive squeeze test

Investigation:
- X-ray: tibiofibular joint is separated and the ankle mortise is
widened

 Treatment:
- Partial diastasis: strapping the ankle firmly for 23 weeks

- Complete diastasis: ORIF