Ankle Instability – Chronic and Recurrent Treated at Mercy

Ankle sprains are among the most common orthopedic injuries that occur. Sprained ankles can happen during athletics but also during standard daily activities such as walking.

The vast majority of patients have successful healing of the ankle following a sprain, with good return of stability and the ability to resume their prior activities including running and sports. 

Chronic Ankle Instability

A small percentage of patients, however, may have continued symptoms of instability or "giving way" of the ankle which can lead to difficulty with athletics and even routine activities. 

Chronic ankle instability can be caused by:

• Underlying conditions - may cause a higher likelihood of experiencing ongoing sprains and instability of the ankle
• Genetic factors - inadequate or weaker ligament tissue may increase the chances of repeated sprains
• Mechanical factors - such as foot alignment problems which can cause repeated injuries

Running, jumping or cutting sports (such as soccer, basketball, volleyball) can also lead to repeated injuries of the ankle. Repeated sprains can lead to other injuries such as torn tendons or cartilage damage in the ankle joint itself.

It is unknown if female athletes are more at risk due to underlying anatomic or hormonal differences, such has been seen with ACL ligament injuries in the knee.

Symptoms of Ankle Instability

Patients with instability of the ankle may experience:

• Difficulty walking on uneven surfaces or terrain (which can cause them to roll the ankle)
• Difficulty tolerating high-heeled shoes, putting the ankle at risk of repeat sprains
• Severe pain at the time of a sprain, but little discomfort between episodes
• A "giving way" of the ankle 
• Difficulty with activities or sports
• A feeling the ankle is loose or unsteady and can’t be trusted while walking
• A sensation that the ankle catches or locks

Diagnosis of Ankle Instability

Individuals with instability of the ankle are first questioned about activities or episodes that put their ankle at risk. It is helpful to know how many sprains the patient has had previously and what treatments they have already tried. 

Upon physical examination, the surgeon will assess: 

• The overall position or alignment of the foot which may reveal an underlying mechanical issue
• The motion of the ankle and foot 
• The ligaments of the ankle to see if they feel loose compared to the opposite leg
• The ankle joint and surrounding tendon structures
• The strength of the tendons to identify any subtle weakness that may indicate a tendon tear

The doctor may also request:

• X-rays of the foot to examine the underlying mechanical alignment
• Standing X-rays of the ankle to assess the overall alignment of the joint and identify any bone problems such as loose pieces or arthritis from the prior sprains
• Stress X-rays of the ankle to visualize the degree of looseness of the joint
• MRI to identify injury of the ankle ligaments and loose bodies in the ankle joint, cartilage damage or tendon injuries from the repeated sprains

Non-Surgical Treatment for Ankle Instability

In most cases, patients with chronic instability of the ankle are initially treated with non-surgical methods including:

• Taping or bracing of the ankle -- especially during sports activities -- which may provide some stability and allow the individual to continue to participate
• The use of a hightop work boot to provide stability for workers to continue to perform their occupational duties
• Physical therapy - focusing heavily on restoring the strength of the muscles around the ankle and retraining for balance and coordination
• The use of anti-inflammatory medications and ice after certain activities 

Surgical Treatment for Ankle Instability

If patients have ongoing symptoms despite attempts at bracing or rehabilitation, surgery may be recommended. 

In most cases, surgical tightening of the loose ankle ligaments can be performed with very high success rates. Research studies have shown excellent return to sports in most patients who undergo such surgery. The studies have also shown very long-term durability of this type of surgery.  

It is important that any associated conditions or injuries be fixed at the same time as the ligament surgery, including:

• Removal of loose debris in the ankle joint
• Addressing cartilage damage or cysts in the ankle from the sprains
• Repairing torn tendons to assist in restoring strength

Surgery has to be considered carefully in athletes so as to allow sufficient time for recovery and rehabilitation prior to the start of the next athletic season. Likewise, workers with ankle instability that prohibits them from performing their job may need surgery to allow them to successfully return to work.

Advanced Surgeries

Research is ongoing to determine the effectiveness of minimally invasive techniques to tighten the ankle ligaments compared to the more traditional open method. 

In cases where the standard surgery has failed or in patients with extremely poor ligament tissue, more advanced surgical techniques may become necessary. These often involve use of cadaver (allograft) tissue to strengthen the patient’s own ligaments. This surgery is more complex and requires a surgeon who is experienced and skilled in these techniques. 

Rehabilitation and recovery following this type of surgery is a bit longer than the standard surgery, but still offers good results allowing many patients to return to sports and work activities successfully. The surgeon may also recommend combining other procedures along with ligament repair to improve foot alignment and repair tendon tears.