Chronic Ankle Instability

Original Editor - Lieselot Vanderhoeven

Top Contributors - Rachael Lowe, Laura Ritchie, Kim Jackson, Lieselot Vanderhoeven, Admin, Mariam Hashem, Simisola Ajeyalemi, Khloud Shreif, George Prudden, Tarina van der Stockt, WikiSysop, Wanda van Niekerk, Jess Bell, Pinar Kisacik, Olajumoke Ogunleye, 127.0.0.1 and Heba El Saeid  

Clinically Relevant Anatomy
[edit | edit source]

Ankle sprain is a common athletic injury. Two million lateral ankle sprains occur annually in the United States, [1] 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.[2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14]

Following an acute ankle sprain, deficits in postural control, proprioception, muscle reaction time and strength typically occur, [15] [16] [6] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [2] [33] [3] [4] [34] which can lead to chronic ankle instability (CAI).[34] [5] 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).[2] [3] [4] [34] [5] [35] [36] [7]

Mechanism of Injury / Pathological Process
[edit | edit source]

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.[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]

2. Muscle weakness 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.

Clinical Presentation[edit | edit source]

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.

Diagnostic Procedures[edit | edit source]

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.


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]

Outcome Measures[edit | edit source]

Patient Report[edit | edit source]

Objective/Physical Tests[edit | edit source]

Management / Interventions
[edit | edit source]

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. 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.
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. 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]  

2. Isokinetic exercise


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.

Differential Diagnosis
[edit | edit source]

add text here relating to the differential diagnosis of this condition

Key Evidence[edit | edit source]

add text here relating to key evidence with regards to any of the above headings

Resources
[edit | edit source]

add appropriate resources here

Case Studies[edit | edit source]

add links to case studies here (case studies should be added on new pages using the case study template)

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

Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10

References[edit | edit source]

  1. ↑ Ivins D. Acute ankle sprain: an update. Am Fam Physician 2006 Nov 15;74(10):1714-1720.
  2. ↑ 2.0 2.1 2.2 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.
  3. ↑ 3.0 3.1 3.2 Kaminski TW, Hartsell HD. Factors Contributing to Chronic Ankle Instability: A Strength Perspective. J Athl Train 2002 Dec;37(4):394-405.
  4. ↑ 4.0 4.1 4.2 Delahunt E. Peroneal reflex contribution to the development of functional instability of the ankle joint. Physical Therapy in Sport 2007;8(2):98-104.
  5. ↑ 5.0 5.1 5.2 Hertel J. Functional Anatomy, Pathomechanics, and Pathophysiology of Lateral Ankle Instability. J Athl Train 2002 Dec;37(4):364-375.
  6. ↑ 6.0 6.1 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.
  7. ↑ 7.0 7.1 Holmes A, Delahunt E. Treatment of common deficits associated with chronic ankle instability. Sports Med 2009;39(3):207-224.
  8. ↑ de Vries Jasper S, Krips R, Sierevelt Inger N, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. 2011(8).
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med 1994 Jun;28(2):112-116.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ Evans T, Hertel J, Sebastianelli W. Bilateral deficits in postural control following lateral ankle sprain. Foot Ankle Int 2004 Nov;25(11):833-839.
  22. ↑ Goldie PA, Evans OM, Bach TM. Postural control following inversion injuries of the ankle. Arch Phys Med Rehabil 1994 Sep;75(9):969-975.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 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.
  26. ↑ 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.
  27. ↑ 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.
  28. ↑ 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.
  29. ↑ Glencross D, Thornton E. Position sense following joint injury. J Sports Med Phys Fitness 1981 Mar;21(1):23-27.
  30. ↑ 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.
  31. ↑ Garn SN, Newton RA. Kinesthetic awareness in subjects with multiple ankle sprains. Phys Ther 1988 Nov;68(11):1667-1671.
  32. ↑ 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.
  33. ↑ 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.
  34. ↑ 34.0 34.1 34.2 Hertel J. Functional instability following lateral ankle sprain. Sports Med 2000 May;29(5):361-371.
  35. ↑ Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int 2007 Mar;28(3):343-354.
  36. ↑ 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.
Retrieved from "https://www.physio-pedia.com/index.php?title=Chronic_Ankle_Instability&oldid=164133"