Chronic Ankle Instability by Dr. Shawn Khademi

11 Jun 2020 All, Blog

Ankle sprains represent one of the most common musculoskeletal injuries seen in both athletes as well as the general population. Studies show that these types of injuries can even account for up to 40 percent of injuries in sports! Depending on the severity of the injury, ankle sprains are generally treated conservatively with a gradual return to activity as tolerated. However, what if there’s still pain several months later? What if the ankle still feels like it’ll “give out” at any moment? 

Patients with a history of recurring ankle sprains and chronic pain and discomfort often present to the office with confusion and disappointment that they are not healing in an appropriate period of time. They often rely on an over-the-counter ankle brace to at least give them some support in shoes and during activity. This is not a sustainable modality of treatment and certainly not something that patients would like to be in for the rest of their life. Oftentimes, if the original ankle injury was not rehabilitated properly or if a severe injury was not recognized early in the treatment course, this can unfortunately lead to chronic pain with instability.

The first step in treating chronic ankle instability is to assess the ankle radiographically to ensure that there are no obvious osteochondral defects within the ankle joint or other surrounding osseous injuries. A thorough physical examination will generally elicit tenderness in the lateral ankle complex and sometimes even within the peroneal tendons. Various exam maneuvers may or not may reveal clinical instability of the lateral ankle complex although patients will say that they feel unstable while walking, especially on uneven surfaces. 

An MRI is generally obtained at this time to truly assess the underlying soft tissue structures.  Unrecognized osseous injury in the ankle joint can be uncovered and tearing vs. attenuation of tendinous and ligamentous structures are intricately visualized. Definitive treatment varies from patient to patient, however, it is unlikely at this point that conservative treatment will improve pain long-term and lessen instability. A last ditch-effort in functional bracing and focused physical therapy can be utilized, however, patients need to understand that surgery may very well be inevitable if there is persistent pain and discomfort, especially with instability.

Depending on the underlying injury, surgical intervention can be tailored to best benefit the patient and allow for optimal recovery. Diagnostic ankle arthroscopy can usually be performed first which allows the surgeon to visualize the interior of the ankle joint with a camera and other instruments; this is all done through very small incisions. All inflammatory and scar tissue can be effectively debrided (i.e. cleaned up) with specialized instruments and any loose bony fragments can be removed. If there are osteochondral defects in the ankle joint, these can also be addressed at the same time per the discretion of the surgeon.

Repair of the damaged tendinous/ligamentous structures obviously depends on the patient’s clinical findings with correlation to MRI results. While this can sometimes be done arthroscopically depending on the surgeon, an open incision can give excellent visualization to the underlying damage and allow the surgeon to repair the torn ligaments/tendons and even tighten them using bone anchors inserted into the fibula. There are a variety of surgical techniques and types of suture/bone anchors that can be utilized—it is important to have a discussion with your surgeon regarding how he/she will repair the ankle and what this will mean in terms of recovery time.

After surgery, patients will generally be immobilized in a cast for approximately 4 weeks depending on the procedure performed. They will then transition to a walking boot and will proceed with focused physical therapy for the next 4-6 weeks. An ankle brace is typically utilized for the first 1-3 months as patients transition back to shoes and generally, they are able to progress into normal, strenuous activities between 3-6 months after surgery. This all depends on the type of surgery performed and how the patient progresses post-operatively and can absolutely vary from person to person. 

If you have problems with recurring ankle sprains and feel unstable while walking, make an appointment with our office by calling 847-639-5800 for evaluation and treatment options!

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