Chronic Ankle Instability: Difference between revisions

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== Clinically Relevant Anatomy<br>  ==
== Clinically Relevant Anatomy<br>  ==


Ankle sprain is a common athletic injury. Two million lateral ankle sprains occur annually in the United States, <ref name="Ivins">Ivins D. Acute ankle sprain: an update. Am Fam Physician 2006 Nov 15;74(10):1714-1720.</ref> affecting the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and/or the posterior talofibular ligament (PTFL). The literature reflects a high rate of persistent disability and recurrence.<ref name="Richie" />&nbsp;<ref name="Kaminski" />&nbsp;<ref name="Delahunt" /> <ref name="Hertel 2002" /> <ref name="Sefton" /> <ref name="Holmes 2009" /> <ref name="deVries">de Vries Jasper S, Krips R, Sierevelt Inger N, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. 2011(8).</ref> <ref name="vanRijn">van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 2008 Apr;121(4):324-331.e6.</ref> <ref name="Olmsted">Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the Star Excursion Balance Tests in Detecting Reach Deficits in Subjects With Chronic Ankle Instability. J Athl Train 2002 Dec;37(4):501-506.</ref> <ref name="safran">Safran MR, Benedetti RS, Bartolozzi AR,3rd, Mandelbaum BR. Lateral ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc 1999 Jul;31(7 Suppl):S429-37.</ref> <ref name="vanRijn2011">van Rijn RM, Willemsen SP, Verhagen AP, Koes BW, Bierma-Zeinstra SM. Explanatory variables for adult patients' self-reported recovery after acute lateral ankle sprain. Phys Ther 2011 Jan;91(1):77-84.</ref> <ref name="kiers">Kiers H, Brumagne S, van Dieen J, van der Wees P, Vanhees L. Ankle proprioception is not targeted by exercises on an unstable surface. Eur J Appl Physiol 2011 Aug 21.</ref> <ref name="yeung">Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994 Jun;28(2):112-116.</ref>  
[[Ankle_Sprain|Ankle sprain]] is a common athletic injury and About 20% of acute ankle sprain patients develop chronic ankle instability<ref name="Al-Mohrej">Al-Mohrej OA, Al-Kenani NS. Chronic ankle instability: Current perspectives. Avicenna journal of medicine. 2016 Oct;6(4):103.</ref>. Two million lateral ankle sprains occur annually in the United States, <ref name="Ivins">Ivins D. Acute ankle sprain: an update. Am Fam Physician 2006 Nov 15;74(10):1714-1720.</ref> affecting the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and/or the posterior talofibular ligament (PTFL). The literature reflects a high rate of persistent disability and recurrence.<ref name="Richie" />&nbsp;<ref name="Kaminski" />&nbsp;<ref name="Delahunt" /> <ref name="Hertel 2002" /> <ref name="Sefton" /> <ref name="Holmes 2009" /> <ref name="deVries">de Vries Jasper S, Krips R, Sierevelt Inger N, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. 2011(8).</ref> <ref name="vanRijn">van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 2008 Apr;121(4):324-331.e6.</ref> <ref name="Olmsted">Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the Star Excursion Balance Tests in Detecting Reach Deficits in Subjects With Chronic Ankle Instability. J Athl Train 2002 Dec;37(4):501-506.</ref> <ref name="safran">Safran MR, Benedetti RS, Bartolozzi AR,3rd, Mandelbaum BR. Lateral ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc 1999 Jul;31(7 Suppl):S429-37.</ref> <ref name="vanRijn2011">van Rijn RM, Willemsen SP, Verhagen AP, Koes BW, Bierma-Zeinstra SM. Explanatory variables for adult patients' self-reported recovery after acute lateral ankle sprain. Phys Ther 2011 Jan;91(1):77-84.</ref> <ref name="kiers">Kiers H, Brumagne S, van Dieen J, van der Wees P, Vanhees L. Ankle proprioception is not targeted by exercises on an unstable surface. Eur J Appl Physiol 2011 Aug 21.</ref> <ref name="yeung">Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994 Jun;28(2):112-116.</ref>  


Following an acute ankle sprain, deficits in postural control, proprioception, muscle reaction time and strength typically occur, <ref name="Genthon">Genthon N, Bouvat E, Banihachemi JJ, Bergeau J, Abdellaoui A, Rougier PR. Lateral ankle sprain alters postural control in bipedal stance: part 2 sensorial and mechanical effects induced by wearing an ankle orthosis. Scand J Med Sci Sports 2010 Apr;20(2):255-261.</ref> <ref name="Akbari">Akbari M, Karimi H, Farahini H, Faghihzadeh S. Balance problems after unilateral lateral ankle sprains. J Rehabil Res Dev 2006 Nov-Dec;43(7):819-824.</ref> <ref name="Sefton">Sefton JM, Hicks-Little CA, Hubbard TJ, Clemens MG, Yengo CM, Koceja DM, et al. Sensorimotor function as a predictor of chronic ankle instability. Clin Biomech (Bristol, Avon) 2009 Jun;24(5):451-458.</ref> <ref name="McKeon">McKeon PO, Hertel J. Systematic review of postural control and lateral ankle instability, part I: can deficits be detected with instrumented testing. J Athl Train 2008 May-Jun;43(3):293-304.</ref> <ref name="Hertel 2001">Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL. Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 2001 Jul;82(7):1000-1003.</ref> <ref name="Holme">Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999 Apr;9(2):104-109.</ref> <ref name="Leanderson">Leanderson J, Bergqvist M, Rolf C, Westblad P, Wigelius-Roovers S, Wredmark T. Early influence of an ankle sprain on objective measures of ankle joint function. A prospective randomised study of ankle brace treatment. 1999;7(1):51-8-51-8.</ref> <ref name="Evans">Evans T, Hertel J, Sebastianelli W. Bilateral deficits in postural control following lateral ankle sprain. Foot Ankle Int 2004 Nov;25(11):833-839.</ref> <ref name="Goldie">Goldie PA, Evans OM, Bach TM. Postural control following inversion injuries of the ankle. Arch Phys Med Rehabil 1994 Sep;75(9):969-975.</ref> <ref name="Wikstrom">Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Balance capabilities after lateral ankle trauma and intervention: a meta-analysis. Med Sci Sports Exerc 2009 Jun;41(6):1287-1295.</ref> <ref name="Munn">Munn J, Sullivan SJ, Schneiders AG. Evidence of sensorimotor deficits in functional ankle instability: a systematic review with meta-analysis. J Sci Med Sport 2010 Jan;13(1):2-12.</ref> <ref name="Kernozek">Kernozek TW, Greany JF, Anderson DR, Van Heel D, Youngdahl RL, Benesh BG, et al. The effect of immersion cryotherapy on medial-lateral postural sway variability in individuals with a lateral ankle sprain. Physiother Res Int 2008 Jun;13(2):107-118.</ref> <ref name="Urguden">Urguden M, Kizilay F, Sekban H, Samanci N, Ozkaynak S, Ozdemir H. Evaluation of the lateral instability of the ankle by inversion simulation device and assessment of the rehabilitation program. Acta Orthop Traumatol Turc 2010;44(5):365-377.</ref> <ref name="Willems">Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Proprioception and Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability. J Athl Train 2002 Dec;37(4):487-493.</ref> <ref name="Konradsen">Konradsen L, Olesen S, Hansen HM. Ankle sensorimotor control and eversion strength after acute ankle inversion injuries. Am J Sports Med 1998 Jan-Feb;26(1):72-77.</ref> <ref name="Glencross">Glencross D, Thornton E. Position sense following joint injury. J Sports Med Phys Fitness 1981 Mar;21(1):23-27.</ref> <ref name="Refshauge">Refshauge KM, Kilbreath SL, Raymond J. Deficits in detection of inversion and eversion movements among subjects with recurrent ankle sprains. J Orthop Sports Phys Ther 2003 Apr;33(4):166-73; discussion 173-6.</ref> <ref name="Garn">Garn SN, Newton RA. Kinesthetic awareness in subjects with multiple ankle sprains. Phys Ther 1988 Nov;68(11):1667-1671.</ref> <ref name="Lentell">Lentell G, Baas B, Lopez D, McGuire L, Sarrels M, Snyder P. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther 1995 Apr;21(4):206-215.</ref> <ref name="Richie">Richie DH,Jr. Functional instability of the ankle and the role of neuromuscular control: a comprehensive review. J Foot Ankle Surg 2001 Jul-Aug;40(4):240-251.</ref> <ref name="Cingel">van Cingel RE, Kleinrensink G, Uitterlinden EJ, Rooijens PP, Mulder PG, Aufdemkampe G, et al. Repeated ankle sprains and delayed neuromuscular response: acceleration time parameters. J Orthop Sports Phys Ther 2006 Feb;36(2):72-79.</ref> <ref name="Kaminski">Kaminski TW, Hartsell HD. Factors Contributing to Chronic Ankle Instability: A Strength Perspective. J Athl Train 2002 Dec;37(4):394-405.</ref> <ref name="Delahunt">Delahunt E. Peroneal reflex contribution to the development of functional instability of the ankle joint. Physical Therapy in Sport 2007;8(2):98-104.</ref> <ref name="Hertel 2000" /> which can lead to chronic ankle instability (CAI).<ref name="Hertel 2000">Hertel J. Functional instability following lateral ankle sprain. Sports Med 2000 May;29(5):361-371.</ref>&nbsp;<ref name="Hertel 2002">Hertel J. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train 2002 Dec;37(4):364-375.</ref> CAI includes mechanical instability (motion exceeds normal physiological limits) and functional instability (objectively stable with subjective feelings of instability related to sensorimotor or neuromuscular deficits).<ref name="Richie" />&nbsp;<ref name="Kaminski" />&nbsp;<ref name="Delahunt" /> <ref name="Hertel 2000" /> <ref name="Hertel 2002" /> <ref name="Hubbard">Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int 2007 Mar;28(3):343-354.</ref> <ref name="Sefton 2011">Sefton JM, Yarar C, Hicks-Little CA, Berry JW, Cordova ML. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther 2011 Feb;41(2):81-89.</ref> <ref name="Holmes 2009">Holmes A, Delahunt E. Treatment of common deficits associated with chronic ankle instability. Sports Med 2009;39(3):207-224.</ref> <br>  
Following an acute ankle sprain, deficits in postural control, proprioception, muscle reaction time and strength typically occur, <ref name="Genthon">Genthon N, Bouvat E, Banihachemi JJ, Bergeau J, Abdellaoui A, Rougier PR. Lateral ankle sprain alters postural control in bipedal stance: part 2 sensorial and mechanical effects induced by wearing an ankle orthosis. Scand J Med Sci Sports 2010 Apr;20(2):255-261.</ref> <ref name="Akbari">Akbari M, Karimi H, Farahini H, Faghihzadeh S. Balance problems after unilateral lateral ankle sprains. J Rehabil Res Dev 2006 Nov-Dec;43(7):819-824.</ref> <ref name="Sefton">Sefton JM, Hicks-Little CA, Hubbard TJ, Clemens MG, Yengo CM, Koceja DM, et al. Sensorimotor function as a predictor of chronic ankle instability. Clin Biomech (Bristol, Avon) 2009 Jun;24(5):451-458.</ref> <ref name="McKeon">McKeon PO, Hertel J. Systematic review of postural control and lateral ankle instability, part I: can deficits be detected with instrumented testing. J Athl Train 2008 May-Jun;43(3):293-304.</ref> <ref name="Hertel 2001">Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL. Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 2001 Jul;82(7):1000-1003.</ref> <ref name="Holme">Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999 Apr;9(2):104-109.</ref> <ref name="Leanderson">Leanderson J, Bergqvist M, Rolf C, Westblad P, Wigelius-Roovers S, Wredmark T. Early influence of an ankle sprain on objective measures of ankle joint function. A prospective randomised study of ankle brace treatment. 1999;7(1):51-8-51-8.</ref> <ref name="Evans">Evans T, Hertel J, Sebastianelli W. Bilateral deficits in postural control following lateral ankle sprain. Foot Ankle Int 2004 Nov;25(11):833-839.</ref> <ref name="Goldie">Goldie PA, Evans OM, Bach TM. Postural control following inversion injuries of the ankle. Arch Phys Med Rehabil 1994 Sep;75(9):969-975.</ref> <ref name="Wikstrom">Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Balance capabilities after lateral ankle trauma and intervention: a meta-analysis. Med Sci Sports Exerc 2009 Jun;41(6):1287-1295.</ref> <ref name="Munn">Munn J, Sullivan SJ, Schneiders AG. Evidence of sensorimotor deficits in functional ankle instability: a systematic review with meta-analysis. J Sci Med Sport 2010 Jan;13(1):2-12.</ref> <ref name="Kernozek">Kernozek TW, Greany JF, Anderson DR, Van Heel D, Youngdahl RL, Benesh BG, et al. The effect of immersion cryotherapy on medial-lateral postural sway variability in individuals with a lateral ankle sprain. Physiother Res Int 2008 Jun;13(2):107-118.</ref> <ref name="Urguden">Urguden M, Kizilay F, Sekban H, Samanci N, Ozkaynak S, Ozdemir H. Evaluation of the lateral instability of the ankle by inversion simulation device and assessment of the rehabilitation program. Acta Orthop Traumatol Turc 2010;44(5):365-377.</ref> <ref name="Willems">Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Proprioception and Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability. J Athl Train 2002 Dec;37(4):487-493.</ref> <ref name="Konradsen">Konradsen L, Olesen S, Hansen HM. Ankle sensorimotor control and eversion strength after acute ankle inversion injuries. Am J Sports Med 1998 Jan-Feb;26(1):72-77.</ref> <ref name="Glencross">Glencross D, Thornton E. Position sense following joint injury. J Sports Med Phys Fitness 1981 Mar;21(1):23-27.</ref> <ref name="Refshauge">Refshauge KM, Kilbreath SL, Raymond J. Deficits in detection of inversion and eversion movements among subjects with recurrent ankle sprains. J Orthop Sports Phys Ther 2003 Apr;33(4):166-73; discussion 173-6.</ref> <ref name="Garn">Garn SN, Newton RA. Kinesthetic awareness in subjects with multiple ankle sprains. Phys Ther 1988 Nov;68(11):1667-1671.</ref> <ref name="Lentell">Lentell G, Baas B, Lopez D, McGuire L, Sarrels M, Snyder P. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther 1995 Apr;21(4):206-215.</ref> <ref name="Richie">Richie DH,Jr. Functional instability of the ankle and the role of neuromuscular control: a comprehensive review. J Foot Ankle Surg 2001 Jul-Aug;40(4):240-251.</ref> <ref name="Cingel">van Cingel RE, Kleinrensink G, Uitterlinden EJ, Rooijens PP, Mulder PG, Aufdemkampe G, et al. Repeated ankle sprains and delayed neuromuscular response: acceleration time parameters. J Orthop Sports Phys Ther 2006 Feb;36(2):72-79.</ref> <ref name="Kaminski">Kaminski TW, Hartsell HD. Factors Contributing to Chronic Ankle Instability: A Strength Perspective. J Athl Train 2002 Dec;37(4):394-405.</ref> <ref name="Delahunt">Delahunt E. Peroneal reflex contribution to the development of functional instability of the ankle joint. Physical Therapy in Sport 2007;8(2):98-104.</ref> <ref name="Hertel 2000" /> which can lead to chronic ankle instability (CAI).<ref name="Hertel 2000">Hertel J. Functional instability following lateral ankle sprain. Sports Med 2000 May;29(5):361-371.</ref>&nbsp;<ref name="Hertel 2002">Hertel J. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train 2002 Dec;37(4):364-375.</ref> CAI includes mechanical instability (motion exceeds normal physiological limits) and functional instability (objectively stable with subjective feelings of instability related to sensorimotor or neuromuscular deficits).<ref name="Richie" />&nbsp;<ref name="Kaminski" />&nbsp;<ref name="Delahunt" /> <ref name="Hertel 2000" /> <ref name="Hertel 2002" /> <ref name="Hubbard">Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int 2007 Mar;28(3):343-354.</ref> <ref name="Sefton 2011">Sefton JM, Yarar C, Hicks-Little CA, Berry JW, Cordova ML. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther 2011 Feb;41(2):81-89.</ref> <ref name="Holmes 2009">Holmes A, Delahunt E. Treatment of common deficits associated with chronic ankle instability. Sports Med 2009;39(3):207-224.</ref> <br>  
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'''1. Proprioception'''  
'''1. Proprioception'''  


Proprioception has been described as a product of sensory information gathered to the central neural system by mechanoreceptors located in the joint-capsule, ligaments, muscles, tendons, and skin.[9] Trauma to ligamentous tissues that contains mechanoreceptors may result in partial differentiation, which can lead to proprioceptive deficits and will subsequently contribute to CAI.[10,11] Studies have shown decreased proprioceptive abilities in patients with chronically unstable ankles. [6,12,13]<br>  
Proprioception has been described as a product of sensory information gathered to the central neural system by mechanoreceptors located in the joint-capsule, ligaments, muscles, tendons, and skin. Trauma to ligamentous tissues that contains mechanoreceptors may result in partial differentiation, which can lead to proprioceptive deficits and will subsequently contribute to CA. &nbsp;Studies have shown decreased proprioceptive abilities in patients with chronically unstable ankles..&nbsp;<br>  


'''2. Muscle weakness'''
'''2. Muscle weakness''' Next to the sensorimotor deficits, researchers have suggested weakness of the peroneal muscles to be related to chronic ankle instability. &nbsp;Deficits in evertor strength would reduce the ability of these muscles to resist inversion and return the foot to a neutral position and thereby prevent inversion sprain. Not concentric, but eccentric evertor weakness has been demonstrated in patients suffering from chronic ankle instability. &nbsp;Other researchers have shown concentric invertor strength deficits in patients with CAI. They had 2 explanations for the inversion weakness. Firstly it could be the result of selective reflex inhibition of the ankle invertors’ ability to start moving in the direction of initial injury. A second cause could be deep peroneal nerve dysfunction as a result of overstretching the peroneal nerve. Another theory they speculated is that the motor neuron pool associated with invertor muscle function has become less excitable by a lateral ankle sprain, whereas the motor neuron pool associated with evertor function is not affected that much.<br>  
Next to the sensorimotor deficits, researchers have suggested weakness of the peroneal muscles to be related to chronic ankle instability.[14] Deficits in evertor strength would reduce the ability of these muscles to resist inversion and return the foot to a neutral position and thereby prevent inversion sprain. Not concentric[15,16], but eccentric evertor weakness has been demonstrated in patients suffering from chronic ankle instability. [17,18,19] Other researchers have shown concentric invertor strength deficits in patients with CAI. They had 2 explanations for the inversion weakness. Firstly it could be the result of selective reflex inhibition of the ankle invertors’ ability to start moving in the direction of initial injury. A second cause could be deep peroneal nerve dysfunction as a result of overstretching the peroneal nerve. Another theory they speculated is that the motor neuron pool associated with invertor muscle function has become less excitable by a lateral ankle sprain, whereas the motor neuron pool associated with evertor function is not affected that much.<br>  


== Clinical Presentation  ==
== Clinical Presentation  ==


A patient with chronic ankle instability mainly complains about “giving out of the ankle“ and has a past history of at least two or three severe ankle sprains. A patient with CAI often is insecure on uneven surfaces and complains having difficulties with it.  
Clinically, the history of patients with chronic ankle instability reveals past recurrent ankle sprains and severe inversion injury. They take special precautions against weight bearing, strenuous activities, and walking on rugged surfaces.


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


On physical examination the hindfoot motion should be recorded and peroneal muscle strength should be tested. Signs of ligamentous laxity need to be checked. Stability tests like the anterior drawer and talar tilt test should be performed.[6] In patients with chronic ankle instability, proprioception is often abnormal; 86% of patients with grade III ankle sprains has peroneal nerve and 83% has tibial nerve stretch injury.[7] To test proprioception the modified Romberg test can be used: the patient stands on the non-affected ankle with open eyes and then with closed eyes and this is repeated with the injured ankle.  
Mechanical ankle instability is induced by ligament laxity; while functional ankle instability is caused by postural control deficits, neuromuscular deficits, muscle weakness, and proprioceptive deficits. &nbsp;The chronic ankle instability selection criteria have recently been updated by the International Ankle Consortium<ref>Gribble PA, Delahunt E, Bleakley CM, Caulfield B, Docherty CL, Fong DT, et al. Selection criteria for patients with chronic ankle instability in controlled research: A position statement of the International Ankle Consortium. J Athl Train. 2014;49:121–7.</ref> and there may be seven subsets, including mechanical instability interaction, frequency of multiple sprains, and perceived instability<ref name="Al-Mohrej " />.


<br>MRI is most useful for chronic ankle instability. Ligament injury can be seen on MRI as swelling, discontinuity of fibers, a lax or wavy ligament, or non-visualization. The ankle should be in neutral or slight plantar flexion to help align ATFL and CFL. Limitations of MRI are cost, time, availability, motion artifact, and being unable to accurately predict chronic sequelae following acute injury.[8]<br>  
On physical examination the hindfoot motion should be recorded and peroneal muscle strength should be tested. Signs of ligamentous laxity need to be checked. Stability tests like the anterior drawer and talar tilt test should be performed. In patients with chronic ankle instability, proprioception is often abnormal; 86% of patients with grade III ankle sprains has peroneal nerve and 83% has tibial nerve stretch injury. &nbsp;To test proprioception the modified Romberg test can be used: the patient stands on the non-affected ankle with open eyes and then with closed eyes and this is repeated with the injured ankle.
 
MRI is most useful for chronic ankle instability. Ligament injury can be seen on MRI as swelling, discontinuity of fibers, a lax or wavy ligament, or non-visualization. The ankle should be in neutral or slight plantar flexion to help align ATFL and CFL. Limitations of MRI are cost, time, availability, motion artifact, and being unable to accurately predict chronic sequelae following acute injury.<br>  
 
== Associated lesions ==
 
Chronic ankle instability is often associated with lesions that evolve from contributory factors. They do not necessarily occur with chronic ankle instability, and if any, not all these lesions occur together. Associated lesions that may accompany chronic ankle instability are chronic regional pain syndrome, neuropraxia, sinus tarsi syndrome, tendon disorders such as peroneal tendinopathy, dislocation or subluxation, impingement syndromes, fractures such as anterior calcaneal process, fibula and lateral talar process, loose bodies, and osteochondral lesion of talar dome or distal tibia<ref name="Al-Mohrej" />.
 
Al-Mohrej<ref name="Al-Mohrej" /> describes the following lesions as frequently present with chronic ankle instability:
 
=== Sinus Tarsi Syndrome ===
 
[[Sinus_Tarsi_Syndrome|Sinus tarsi syndrome]] is common among basketball and volleyball players, dancers, and overweight people. It is also common among patients with flatfoot and hyperpronation deformities. It consists of pain and tenderness of the sinus tarsi; that is, the lateral side of the hindfoot. It may occur following a single or series of ankle sprains.[18] It is diagnosed by exclusion although magnetic resonance imaging could show evidence of the inflammation. Sinus tarsi syndrome is treated by primary repair of the sinus tarsi ligaments, augmentation by tendon, or both
 
=== Osteochondral Defects ===
 
Osteochondral defects (OCD) are injuries to the talus. They may include cartilage layers blistering and in-the-bone cyst-like lesions or even bone layers and cartilage fracture. OCD may occur as a result of one traumatic injury or recurrent trauma. OCD display swelling, ankle joint instability, and long pain. The exact mechanism of both pain and instability is not fully understood. Treatment is ideally operative depending on the nature, size, and location of the lesions.
 
=== Peroneal Tendinopathy ===
 
[[Peroneal_Tendonitis|Peroneal tendinopathy]]&nbsp;is chronic inflammation of the peroneal tendon resulting in weakness of the active ankle stabilizers. This happens when a person performs a repetitive activity that annoys the tendon over a long period. In addition, poor and rapid training and poor shoe-wear may cause peroneal tendinosis. People who have a hindfoot varus posture are more likely to experience peroneal tendinosis. Most cases of peroneal tendinosis are treated conservatively although surgical debridement and stimulation of healing either open or tendoscopically are gaining popularity.
 
=== Subtalar Instability ===
 
Subtalar instability is an incidence whose etiology is still not known. It seems to be underdiagnosed. It can have the symptoms of the chronic ankle instability. Clinically, the patients with subtalar instability have increased inward rotation. It is treated by a tendon transfer or tenodesis procedure such as Chrisman–Snook or alternatively by an anatomic ligament reconstruction.


== Outcome Measures  ==
== Outcome Measures  ==
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== Management / Interventions<br>  ==
== Management / Interventions<br>  ==


Since research has shown that repetitive ankle joint injuries cause neurosensorial, proprioceptive and mechanical impairments, exercises that increase proprioception, balance and functional capacity are routinely performed after an ankle joint injury in addition to strengthening the muscles.
Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention.&nbsp;Before conducting any surgical procedure, nonsurgical management is highly recommended for patients with chronic ankle instability. During the rehabilitation stage, neuromuscular and proprioceptive training should be provided as well as orthitics if indicated.
 
<br>
 
'''1. Balance training'''
 
Problems found in patients with CAI are the decreased postural control and joint position awareness and the increased instability. Changes in sensorimotor system function are thought to be on the origin of these problems. <br>Balance training is an important part of the current rehabilitation protocols for CAI. The effects of&nbsp; balance training on the sensorimotor deficits typical for CAI, including postural control, dynamic balance, joint position sense and segmental spinal reflexes, have been determined. After 6 weeks of balance training, participants with CAI demonstrated better dynamic balance performance in the anterior medial, medial, and poste¬rior medial directions, ankle inversion joint position sense, and motoneuron pool excitability, compared to a healthy control group that did not com¬plete the training. These results suggest that balance training may lead to a reduc¬tion in the incidence of repeated injury. The level of evidence of this study was 2B. [20] &nbsp;  
 
'''2. Isokinetic exercise'''
 
'''<br>'''To strengthen the muscles, isokinetic exercise is used. A research[21], with an evidence level of 3A, tried to determine the influence of isokinetic exercise on proprioceptive, functional and strength deficits in athletes with chronic ankle instability. Since these researchers didn’t found any deficits in eccentric invertor and evertor muscle strength, the isokinetic exercise program of the ankle joint was only performed in the concentric mode. Each exercise session was carried out with three settings of 15 repetitions at 120°/s. These sessions were repeated three times a week and lasted for 6 weeks. The isokinetic exercise program had a positive effect on the functional ability, muscle strength and proprioception of the ankle.<br>
 
== Differential Diagnosis<br>  ==
 
add text here relating to the differential diagnosis of this condition<br>
 
== Key Evidence  ==


add text here relating to key evidence with regards to any of the above headings<br>  
Since research has shown that repetitive ankle joint injuries cause neurosensorial, proprioceptive and mechanical impairments, exercises that increase proprioception, balance and functional capacity are routinely performed after an ankle joint injury in addition to strengthening the muscles.<br>  


== Resources <br>  ==
'''1. Proprioception'''


add appropriate resources here
Problems found in patients with CAI are the decreased postural control and joint position awareness and the increased instability. Changes in sensorimotor system function are thought to be on the origin of these problems. Balance training is an important part of the current rehabilitation protocols for CAI. The effects of&nbsp; balance training on the sensorimotor deficits typical for CAI, including postural control, dynamic balance, joint position sense and segmental spinal reflexes, have been determined. &nbsp; &nbsp;


== Case Studies  ==
'''2. Progressive loading'''


add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
Isokinetic muscle strengthening has been shown to have a positive effect on the functional ability, muscle strength and proprioception of the ankle.<br>


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==

Revision as of 15:06, 17 March 2017

Original Editor - Lieselot Vanderhoeven

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Clinically Relevant Anatomy
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Ankle sprain is a common athletic injury and About 20% of acute ankle sprain patients develop chronic ankle instability[1]. Two million lateral ankle sprains occur annually in the United States, [2] affecting the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and/or the posterior talofibular ligament (PTFL). The literature reflects a high rate of persistent disability and recurrence.[3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]

Following an acute ankle sprain, deficits in postural control, proprioception, muscle reaction time and strength typically occur, [16] [17] [7] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [3] [34] [4] [5] [35] which can lead to chronic ankle instability (CAI).[35] [6] CAI includes mechanical instability (motion exceeds normal physiological limits) and functional instability (objectively stable with subjective feelings of instability related to sensorimotor or neuromuscular deficits).[3] [4] [5] [35] [6] [36] [37] [8]

Mechanism of Injury / Pathological Process
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The main causes of chronic ankle instability that have been found are: decreased proprioceptive abilities because of a loss of mechanoreceptors and decreased muscle strength of invertor and evertor muscles.

1. Proprioception

Proprioception has been described as a product of sensory information gathered to the central neural system by mechanoreceptors located in the joint-capsule, ligaments, muscles, tendons, and skin. Trauma to ligamentous tissues that contains mechanoreceptors may result in partial differentiation, which can lead to proprioceptive deficits and will subsequently contribute to CA.  Studies have shown decreased proprioceptive abilities in patients with chronically unstable ankles.. 

2. Muscle weakness Next to the sensorimotor deficits, researchers have suggested weakness of the peroneal muscles to be related to chronic ankle instability.  Deficits in evertor strength would reduce the ability of these muscles to resist inversion and return the foot to a neutral position and thereby prevent inversion sprain. Not concentric, but eccentric evertor weakness has been demonstrated in patients suffering from chronic ankle instability.  Other researchers have shown concentric invertor strength deficits in patients with CAI. They had 2 explanations for the inversion weakness. Firstly it could be the result of selective reflex inhibition of the ankle invertors’ ability to start moving in the direction of initial injury. A second cause could be deep peroneal nerve dysfunction as a result of overstretching the peroneal nerve. Another theory they speculated is that the motor neuron pool associated with invertor muscle function has become less excitable by a lateral ankle sprain, whereas the motor neuron pool associated with evertor function is not affected that much.

Clinical Presentation[edit | edit source]

Clinically, the history of patients with chronic ankle instability reveals past recurrent ankle sprains and severe inversion injury. They take special precautions against weight bearing, strenuous activities, and walking on rugged surfaces.

Diagnostic Procedures[edit | edit source]

Mechanical ankle instability is induced by ligament laxity; while functional ankle instability is caused by postural control deficits, neuromuscular deficits, muscle weakness, and proprioceptive deficits.  The chronic ankle instability selection criteria have recently been updated by the International Ankle Consortium[38] and there may be seven subsets, including mechanical instability interaction, frequency of multiple sprains, and perceived instability[1].

On physical examination the hindfoot motion should be recorded and peroneal muscle strength should be tested. Signs of ligamentous laxity need to be checked. Stability tests like the anterior drawer and talar tilt test should be performed. In patients with chronic ankle instability, proprioception is often abnormal; 86% of patients with grade III ankle sprains has peroneal nerve and 83% has tibial nerve stretch injury.  To test proprioception the modified Romberg test can be used: the patient stands on the non-affected ankle with open eyes and then with closed eyes and this is repeated with the injured ankle.

MRI is most useful for chronic ankle instability. Ligament injury can be seen on MRI as swelling, discontinuity of fibers, a lax or wavy ligament, or non-visualization. The ankle should be in neutral or slight plantar flexion to help align ATFL and CFL. Limitations of MRI are cost, time, availability, motion artifact, and being unable to accurately predict chronic sequelae following acute injury.

Associated lesions[edit | edit source]

Chronic ankle instability is often associated with lesions that evolve from contributory factors. They do not necessarily occur with chronic ankle instability, and if any, not all these lesions occur together. Associated lesions that may accompany chronic ankle instability are chronic regional pain syndrome, neuropraxia, sinus tarsi syndrome, tendon disorders such as peroneal tendinopathy, dislocation or subluxation, impingement syndromes, fractures such as anterior calcaneal process, fibula and lateral talar process, loose bodies, and osteochondral lesion of talar dome or distal tibia[1].

Al-Mohrej[1] describes the following lesions as frequently present with chronic ankle instability:

Sinus Tarsi Syndrome[edit | edit source]

Sinus tarsi syndrome is common among basketball and volleyball players, dancers, and overweight people. It is also common among patients with flatfoot and hyperpronation deformities. It consists of pain and tenderness of the sinus tarsi; that is, the lateral side of the hindfoot. It may occur following a single or series of ankle sprains.[18] It is diagnosed by exclusion although magnetic resonance imaging could show evidence of the inflammation. Sinus tarsi syndrome is treated by primary repair of the sinus tarsi ligaments, augmentation by tendon, or both

Osteochondral Defects[edit | edit source]

Osteochondral defects (OCD) are injuries to the talus. They may include cartilage layers blistering and in-the-bone cyst-like lesions or even bone layers and cartilage fracture. OCD may occur as a result of one traumatic injury or recurrent trauma. OCD display swelling, ankle joint instability, and long pain. The exact mechanism of both pain and instability is not fully understood. Treatment is ideally operative depending on the nature, size, and location of the lesions.

Peroneal Tendinopathy[edit | edit source]

Peroneal tendinopathy is chronic inflammation of the peroneal tendon resulting in weakness of the active ankle stabilizers. This happens when a person performs a repetitive activity that annoys the tendon over a long period. In addition, poor and rapid training and poor shoe-wear may cause peroneal tendinosis. People who have a hindfoot varus posture are more likely to experience peroneal tendinosis. Most cases of peroneal tendinosis are treated conservatively although surgical debridement and stimulation of healing either open or tendoscopically are gaining popularity.

Subtalar Instability[edit | edit source]

Subtalar instability is an incidence whose etiology is still not known. It seems to be underdiagnosed. It can have the symptoms of the chronic ankle instability. Clinically, the patients with subtalar instability have increased inward rotation. It is treated by a tendon transfer or tenodesis procedure such as Chrisman–Snook or alternatively by an anatomic ligament reconstruction.

Outcome Measures[edit | edit source]

Patient Report[edit | edit source]

Objective/Physical Tests[edit | edit source]

Management / Interventions
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Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. Before conducting any surgical procedure, nonsurgical management is highly recommended for patients with chronic ankle instability. During the rehabilitation stage, neuromuscular and proprioceptive training should be provided as well as orthitics if indicated.

Since research has shown that repetitive ankle joint injuries cause neurosensorial, proprioceptive and mechanical impairments, exercises that increase proprioception, balance and functional capacity are routinely performed after an ankle joint injury in addition to strengthening the muscles.

1. Proprioception

Problems found in patients with CAI are the decreased postural control and joint position awareness and the increased instability. Changes in sensorimotor system function are thought to be on the origin of these problems. Balance training is an important part of the current rehabilitation protocols for CAI. The effects of  balance training on the sensorimotor deficits typical for CAI, including postural control, dynamic balance, joint position sense and segmental spinal reflexes, have been determined.    

2. Progressive loading

Isokinetic muscle strengthening has been shown to have a positive effect on the functional ability, muscle strength and proprioception of the ankle.

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Al-Mohrej OA, Al-Kenani NS. Chronic ankle instability: Current perspectives. Avicenna journal of medicine. 2016 Oct;6(4):103.
  2. ↑ Ivins D. Acute ankle sprain: an update. Am Fam Physician 2006 Nov 15;74(10):1714-1720.
  3. ↑ 3.0 3.1 3.2 Richie DH,Jr. Functional instability of the ankle and the role of neuromuscular control: a comprehensive review. J Foot Ankle Surg 2001 Jul-Aug;40(4):240-251.
  4. ↑ 4.0 4.1 4.2 Kaminski TW, Hartsell HD. Factors Contributing to Chronic Ankle Instability: A Strength Perspective. J Athl Train 2002 Dec;37(4):394-405.
  5. ↑ 5.0 5.1 5.2 Delahunt E. Peroneal reflex contribution to the development of functional instability of the ankle joint. Physical Therapy in Sport 2007;8(2):98-104.
  6. ↑ 6.0 6.1 6.2 Hertel J. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train 2002 Dec;37(4):364-375.
  7. ↑ 7.0 7.1 Sefton JM, Hicks-Little CA, Hubbard TJ, Clemens MG, Yengo CM, Koceja DM, et al. Sensorimotor function as a predictor of chronic ankle instability. Clin Biomech (Bristol, Avon) 2009 Jun;24(5):451-458.
  8. ↑ 8.0 8.1 Holmes A, Delahunt E. Treatment of common deficits associated with chronic ankle instability. Sports Med 2009;39(3):207-224.
  9. ↑ de Vries Jasper S, Krips R, Sierevelt Inger N, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. 2011(8).
  10. ↑ van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 2008 Apr;121(4):324-331.e6.
  11. ↑ Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the Star Excursion Balance Tests in Detecting Reach Deficits in Subjects With Chronic Ankle Instability. J Athl Train 2002 Dec;37(4):501-506.
  12. ↑ Safran MR, Benedetti RS, Bartolozzi AR,3rd, Mandelbaum BR. Lateral ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc 1999 Jul;31(7 Suppl):S429-37.
  13. ↑ van Rijn RM, Willemsen SP, Verhagen AP, Koes BW, Bierma-Zeinstra SM. Explanatory variables for adult patients' self-reported recovery after acute lateral ankle sprain. Phys Ther 2011 Jan;91(1):77-84.
  14. ↑ Kiers H, Brumagne S, van Dieen J, van der Wees P, Vanhees L. Ankle proprioception is not targeted by exercises on an unstable surface. Eur J Appl Physiol 2011 Aug 21.
  15. ↑ Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994 Jun;28(2):112-116.
  16. ↑ Genthon N, Bouvat E, Banihachemi JJ, Bergeau J, Abdellaoui A, Rougier PR. Lateral ankle sprain alters postural control in bipedal stance: part 2 sensorial and mechanical effects induced by wearing an ankle orthosis. Scand J Med Sci Sports 2010 Apr;20(2):255-261.
  17. ↑ Akbari M, Karimi H, Farahini H, Faghihzadeh S. Balance problems after unilateral lateral ankle sprains. J Rehabil Res Dev 2006 Nov-Dec;43(7):819-824.
  18. ↑ McKeon PO, Hertel J. Systematic review of postural control and lateral ankle instability, part I: can deficits be detected with instrumented testing. J Athl Train 2008 May-Jun;43(3):293-304.
  19. ↑ Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL. Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 2001 Jul;82(7):1000-1003.
  20. ↑ Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999 Apr;9(2):104-109.
  21. ↑ Leanderson J, Bergqvist M, Rolf C, Westblad P, Wigelius-Roovers S, Wredmark T. Early influence of an ankle sprain on objective measures of ankle joint function. A prospective randomised study of ankle brace treatment. 1999;7(1):51-8-51-8.
  22. ↑ Evans T, Hertel J, Sebastianelli W. Bilateral deficits in postural control following lateral ankle sprain. Foot Ankle Int 2004 Nov;25(11):833-839.
  23. ↑ Goldie PA, Evans OM, Bach TM. Postural control following inversion injuries of the ankle. Arch Phys Med Rehabil 1994 Sep;75(9):969-975.
  24. ↑ Wikstrom EA, Naik S, Lodha N, Cauraugh JH. Balance capabilities after lateral ankle trauma and intervention: a meta-analysis. Med Sci Sports Exerc 2009 Jun;41(6):1287-1295.
  25. ↑ Munn J, Sullivan SJ, Schneiders AG. Evidence of sensorimotor deficits in functional ankle instability: a systematic review with meta-analysis. J Sci Med Sport 2010 Jan;13(1):2-12.
  26. ↑ Kernozek TW, Greany JF, Anderson DR, Van Heel D, Youngdahl RL, Benesh BG, et al. The effect of immersion cryotherapy on medial-lateral postural sway variability in individuals with a lateral ankle sprain. Physiother Res Int 2008 Jun;13(2):107-118.
  27. ↑ Urguden M, Kizilay F, Sekban H, Samanci N, Ozkaynak S, Ozdemir H. Evaluation of the lateral instability of the ankle by inversion simulation device and assessment of the rehabilitation program. Acta Orthop Traumatol Turc 2010;44(5):365-377.
  28. ↑ Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Proprioception and Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability. J Athl Train 2002 Dec;37(4):487-493.
  29. ↑ Konradsen L, Olesen S, Hansen HM. Ankle sensorimotor control and eversion strength after acute ankle inversion injuries. Am J Sports Med 1998 Jan-Feb;26(1):72-77.
  30. ↑ Glencross D, Thornton E. Position sense following joint injury. J Sports Med Phys Fitness 1981 Mar;21(1):23-27.
  31. ↑ Refshauge KM, Kilbreath SL, Raymond J. Deficits in detection of inversion and eversion movements among subjects with recurrent ankle sprains. J Orthop Sports Phys Ther 2003 Apr;33(4):166-73; discussion 173-6.
  32. ↑ Garn SN, Newton RA. Kinesthetic awareness in subjects with multiple ankle sprains. Phys Ther 1988 Nov;68(11):1667-1671.
  33. ↑ Lentell G, Baas B, Lopez D, McGuire L, Sarrels M, Snyder P. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther 1995 Apr;21(4):206-215.
  34. ↑ van Cingel RE, Kleinrensink G, Uitterlinden EJ, Rooijens PP, Mulder PG, Aufdemkampe G, et al. Repeated ankle sprains and delayed neuromuscular response: acceleration time parameters. J Orthop Sports Phys Ther 2006 Feb;36(2):72-79.
  35. ↑ 35.0 35.1 35.2 Hertel J. Functional instability following lateral ankle sprain. Sports Med 2000 May;29(5):361-371.
  36. ↑ Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int 2007 Mar;28(3):343-354.
  37. ↑ Sefton JM, Yarar C, Hicks-Little CA, Berry JW, Cordova ML. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther 2011 Feb;41(2):81-89.
  38. ↑ Gribble PA, Delahunt E, Bleakley CM, Caulfield B, Docherty CL, Fong DT, et al. Selection criteria for patients with chronic ankle instability in controlled research: A position statement of the International Ankle Consortium. J Athl Train. 2014;49:121–7.
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