The Blackburn Foot and Ankle Hyperbook

Evidence based education in foot and ankle surgery

Ankle instability and chronic ligament injurie

Ankle ligament injuries are common:

about 10% of all A+E attendances incidence of about 5/1000/year(Holmer et al 1994), which su 300,000 per year in the UK or about 800 per day

Many ankle injuries occur in young people during sports: the mean Holmers series was 24y and nearly half were sport s-related. Smith (1986) found that half of a series of 84 college basketball players h ankle injuries.

Some of those who suffer a sprained ankle develop recurring compl Verhagen et al (1995) followed up 577 patients treated by taping o reconstruction for 6.5 years. 18% had pain and about 40% had rec sprains or feelings of instability. Munk et al (1995) studied 79 patie years after ankle sprains treated by various methods: 20% had per instability and 5% had pain.

Anatomy and biomechanics

The ankle is a modified hinge joint between the tibial plafond, medi malleoli proximally and the talus distally. The inferior tibiofibular an

joints are also intimately related to ankle function. The ankle joint c reinforced by the anterior talofibular (ATFL), calcaneofibular (CFL) a talofibular ligaments (PTFL) laterally, and by the deltoid ligament m which the deep tibiotalar part (DTTL) is the most important for ankl There are also anterior (AITFL), interosseous and posterior ligamen inferior tibiofibular joint and a posterior transverse band, the poster intermalleolar ligament. The subtalar joint is stabilised by the latera interosseous and cervical talocalcaneal ligaments, and by the calcan superficial deltoid ligaments and the inferior extensor retinaclum, w both ankle and subtalar joints.

The ankle dorsiflexes and plantarflexes through an axis that passes tips of the malleoli. As the lateral malleolus is longer and more post the medial, the axis is not quite parallel to either the ground or the plane. In addition, the instant axis of rotation of the ankle moves fr to moment. Hence, as the ankle dorsiflexes, it rotates externally an The talus is also wider anteriorly than posteriorly, so the lateral ma rotate externally by about 11deg in the course of full dorsiflexion. D the syndesmosis may interfere with ankle dorsiflexion or make it pa rotation of the ankle (and proximal limb) in relation to a fixed foot a are accommodated by the rotation of the subtalar joint. Stiffness of joint interferes with ankle movement and smooth gait.

When weight is borne through the ankle, the talus is compressed u bony mortise, and the shape of the bones produces stability. There no sense to prevent patients weightbearing on the ankle unless the significant defect in the tibial plafond. Without axial loading, the AT main stabiliser against anterior, varus and internal rotation stresses plantarflexion and the CFL in neutral. With increasing dorsiflexion, t of the inferior tibiofibular joint probably play an increasing part in s role of the deltoid ligament and particularly the DTTL in protecting a valgus and external rotation stresses is only beginning to be unders role of the posterior structures has had little study, probably becaus displacement and forced dorsiflexion is an uncommon mechanism o injury.

Chronic ankle instability

As Munk and Verhagen showed, a significant proportion of patients chronic symptoms after an ankle ligament injury:

giving way repeated sprains pain stiffness locking swelling

The amount of disability form such symptoms has not been studied many ankle injuries occur during sport, difficulty in returning to spo common complaint.