CME ARTICLE

Multidirectional Instability of the Ankle:

Surgical Reconstruction
Andrew Dodd, MD, FRCSC* and Timothy R. Daniels, MD, FRCSCwz

to manage chronic lateral ankle instability have been described

Abstract: Lateral ligamentous instability of the ankle is common,
and numerous surgical techniques have been described to repair or
reconstruct the lateral ligaments. Medial-sided ankle instability has
become increasingly appreciated in recent years. Many patients present
with multidirectional ankle instability and need both medial and lateral
ligament reconstructions. We describe a surgical technique for man-
aging patients with multidirectional instability of the ankle using
hamstring autograft and readily available surgical instruments.
Level of Evidence: Diagnostic Level V. See Instructions for Authors
for a complete description of levels of evidence.
Key Words: lateral ankle instability, medial ankle instability,
multidirectional instability, surgical reconstruction, recurrent
instability
(Tech Foot & Ankle 2017;16: 46–52)
LEARNING OBJECTIVES
After participating in this CME activity, participants should be
able to:
(1) Recognize patients that are at risk of multidirectional
instability of the ankle.
(2) Evaluate patients for medial-sided instability of the ankle.
(3) Perform a surgical reconstruction for patients with multi-
directional instability of the ankle.
HISTORICAL PERSPECTIVE
Ligamentous injury to the ankle in the form of an ankle sprain
is extremely common.1–6 Most patients with acute ligamentous
injuries to the ankle suffer lateral ankle sprains, and can be
managed nonoperatively.2–4 A small portion of patients goes
on to develop chronic, recurrent ankle instability. The vast
majority of chronic ankle instability patients suffer from
lateral-sided ankle instability.2,7 Numerous surgical techniques
and include anatomic repair, tenodesis procedures, and
anatomic reconstruction with tendon grafts.2–4,6–8 Excellent
results have been reported with various anatomic reconstruc-
tion methods.6
More recently, chronic medial-sided ankle instability has
become increasingly appreciated.7,9–12 This has led to the
development of deltoid ligament reconstruction techniques to
address chronic deltoid insufficiency.7,9–11,13–15 In a large
series investigating chronic medial-sided ankle instability,
Hintermann et al found that upon surgical exploration, 100%
of patients had an insufficient anterior talofibular ligament
(ATFL), and over 80% had an insufficient calcaneofibular
ligament (CFL) in addition to their deltoid ligament dis-
ruption.7 These patients, therefore, should be considered to
have multidirectional instability (MDI) of the ankle.
To successfully manage MDI of the ankle, both lateral-
sided and medial-sided ligament reconstructions must be per-
formed. Previously described anatomic reconstruction methods
of the medial and lateral ankle ligaments often include the use of
free tendon graft with fixation into bone tunnels with interfer-
ence screws.3,6,8 Given the small size of talus, bone stock
becomes an issue when considering multiple tunnels entering
from both sides of the bone. The amount of graft tissue needed
can also be an issue if one were to perform independent medial
and lateral ligament reconstructions simultaneously.
To address these challenges, the senior author has
developed a method of simultaneous medial and lateral liga-
ment reconstruction for patients with MDI of the ankle. This
technique uses methods similar to previously described medial
and lateral ligament reconstructions, and readily available
surgical instruments and implants. The principle advantage to
this technique is its use of hamstrings autograft or allograft
tendon utilizing medial bone tunnels through both the talus and
calcaneus for deltoid reconstruction with exit points

From the *Clinical Fellow, Division of Orthopaedic Surgery, St. Michael’s Hospital and the University of Toronto, Toronto, ON; wHead, Division of
Orthopaedic Surgery, St. Michael’s Hospital, Toronto, ON; and zProfessor, the University of Toronto, Toronto, ON, Canada.
The authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no
relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.
Address correspondence and reprint requests to Andrew Dodd, MD, FRCSC, Division of Orthopaedic Surgery, St Michael’s Hospital and the University of
Toronto, 800-55 Queen Street East, Toronto, ON, Canada M5C 1R6. E-mail: andrewedodd@gmail.com.
INSTRUCTIONS FOR OBTAINING AMA PRA CATEGORY 1 CREDITTM
Techniques in Foot & Ankle Surgery includes CME-certified content that is designed to meet the educational needs of its readers. This activity is available for
credit through February 28, 2018.
Earn CME credit by completing a quiz about this article. You may read the article here, on the TFAS website, or in the TFAS iPad app, and then complete the
quiz, answering at least 80 percent of the questions correctly to earn CME credit. The cost of the CME exam is $10. The payment covers processing and
certificate fees. If you wish to submit the test by mail, send the completed quiz with a check or money order for the $10.00 processing fee to the
Lippincott CME Institute, Inc., Wolters Kluwer Health, Two Commerce Square, 2001 Market Street, 3rd Floor, Philadelphia, PA 19103. Only the first
entry will be considered for credit, and must be postmarked by the expiration date. Answer sheets will be graded and certificates will be mailed to each
participant within 6 to 8 weeks of participation.
Need CME STAT? Visit http://cme.lww.com for immediate results, other CME activities, and your personalized CME planner tool.
Accreditation Statement
Lippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians.
Credit Designation Statement
Lippincott Continuing Medical Education Institute, Inc., designates this journal-based CME activity for a maximum of 1 (one) AMA PRA Category 1
CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.

46 | www.techfootankle.com Techniques in Foot & Ankle Surgery  Volume 16, Number 1, March 2017

Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.

Techniques in Foot & Ankle Surgery  Volume 16, Number 1, March 2017
corresponding to the origin of the CFL and talar insertion site
of the ATFL. The lateral arms are then used for reconstruction
of the lateral ankle ligaments, with the option of syndesmotic
reconstruction if required.
INDICATIONS AND CONTRAINDICATIONS
Patients presenting with MDI of the ankle often have a variety
of presenting symptoms. Complaints can include the sensation
of the ankle giving way, or the inability to trust the ankle,
particularly on uneven or sloped terrain. Occasionally, the
primary complaint can be persistent lateral ankle pain with
activity or an inability to reliably pivot on the affected
extremity during sports. Patients usually report a history of a
single, significant ankle injury, or multiple recurrent ankle
sprains. These symptoms are consistent with isolated lateral
ankle instability and can be difficult to differentiate; a high
index of suspicion is required. Some of the patients we have
seen with MDI of the ankle present with persistent problems
following lateral ligamentous reconstruction. In the authors’
opinion, MDI may be an underrecognized cause for failed
lateral ankle ligament reconstructive surgery. Nonathletic
patients with MDI can present with ill-defined diffuse
fatigue-type pain after extended periods of walking or standing
that can be difficult to describe.
A thorough, focused foot and ankle examination is neces-
sary to diagnose medial instability of the ankle. It is important for
the physician to understand that deltoid ligament insufficiency
results in transverse plane instability as opposed to the coronal/
sagittal plane instability as with isolated lateral ankle ligament
insufficiency. Excessive external rotation and flexion of the talus
occurs with forward flexion of the tibia on the planted foot. In a
closed kinetic chain this presents clinically as increased internal
rotation of the tibia and valgus orientation of the hindfoot as the
patient flexes forward on the planted foot. Special attention is
paid to the standing alignment of the hindfoot, where a valgus
orientation is noted on the affected side. The valgus of the
hindfoot is different than what is observed in a typical pes planus
deformity. The valgus is starting at a high level (ankle joint), thus
the calcaneus is not in as much valgus and excessive forefoot
abduction (too many toes sign) is not as evident. The patient is
capable of performing a normal single-limb heel raise with the
calcaneus inverting as they rise up on their toes. This is because
the tibialis posterior (TP) tendon is still capable of inverting and
locking the chopart joints, resulting in normal function of the
gastroc-soleus complex. Assessment of motor power of the
muscles about the ankle is important; this ensures that appro-
priate rehabilitation and strengthening of the dynamic stabilizers
has been performed. In the senior authors’ experience, however,
this condition is rarely managed satisfactorily with nonoperative
treatment. Tests for lateral-sided instability include a varus stress
(CFL) and the anterior-drawer test (ATFL), both of which should
be compared with the contralateral limb.4 The authors have
found that an anterior-drawer, external-rotation test can often
demonstrate the rotatory instability of the ankle that results from
chronic deltoid attenuation. To perform this test the examiner
stabilizes the tibia with one hand and grasps the posteromedial
aspect of the hindfoot with the other. The hindfoot is then pulled
anteriorly and externally rotated. The thumb of the inferior hand
is placed on the medial aspect of the talar neck, just anterior to
the medial malleolus, to aid in assessing the degree of external
rotation of the talus (Fig. 1). This can reproduce the patients’
pain and excessive external rotation of the talus can be appre-
ciated, particularly when compared with the other side (in uni-
lateral cases).
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Surgical Reconstruction Ankle MDI
FIGURE 1. Hand positioning for the anterior-drawer, external-
rotation test. The thumb is placed on the medial talar neck just
anterior to the medial malleolus (*). This helps to assess the
degree of external rotation of the talus.
PREOPERATIVE PLANNING
The hindfoot alignment view x-ray is helpful in identifying a
valgus or lateral position of the calcaneus on the affected side.
Typically, the anteroposterior and lateral ankle views are not
very helpful in the diagnosis of instability; however, they
should be reviewed to exclude other pathology. The physician
should pay close attention to the syndesmosis. Even with a
valgus stress view, opening of the medial joint space is usually
negligible or not apparent. Magnetic resonance imaging (MRI)
is helpful in confirming the diagnosis of deltoid ligament
insufficiency. We routinely order an MRI when we suspect
MDI of the ankle to assess the medial ligament complex.
TECHNIQUE
(1) The patient is positioned supine on the operating room
table. We use a deflatable beanbag to bump up the hip on
the operative limb, so that the foot remains in neutral
rotation at rest. This gives adequate access to both the
medial and lateral aspects of the limb. A thigh tourniquet
is placed as high as possible, and prepping and draping is
done to a point well above the knee to facilitate hamstring
graft harvest.
(2) The medial approach to the foot is used to access the
medial malleolus, calcaneus, and talus. A skin incision is
made following the course of the TP tendon, from B2 cm
above the tip of the malleolus to the navicular (Fig. 2A).
The incision is deepened to the TP tendon sheath, which
is incised. The tendon is retracted dorsally and the flexor
digitorum longus tendon is dissected out deep and inferior
to the TP. Both tendons are retracted dorsally and the
dissection is carried out down to the sustentaculum tali of
the calcaneum. Careful, sharp dissection of soft tissues
off of the sustentaculum tali (Fig. 3) will allow visual-
ization of the entry point for the calcaneal bone tunnel
just inferior and posterior to the sustentaculum tali. Soft
tissues are then cleared of the medial talar neck in
preparation for the talar bone tunnel.
(3) A lateral approach to the fibula and lateral ankle
ligaments is performed. The skin incision is centered on
the fibula, B5 cm above the tip of the fibula. This is
carried distally, angling slightly anterior to approximate a
www.techfootankle.com | 47
Dodd and Daniels Techniques in Foot & Ankle Surgery
FIGURE 2. A, Landmarking the medial incision, coursing over the
medial malleolus (%). B, Landmarking the lateral incision,
coursing over the tip of the lateral malleolus (%).
line that is halfway between the ATFL and CFL
(Fig. 2B). The incision is deepened, proximally to the
periosteum of the fibula, and distally to the ankle capsule.
A full-thickness fasciocutaneous flap is elevated posteri-
orly to expose the peroneal tendons. The superior per-
oneal retinaculum is incised, and the peroneal tendons are
retracted posteriorly. The ankle capsule, along with the
ATFL and CFL, are then dissected free of the distal fibula
as 1 large flap (Fig. 4), as when performing a primary
lateral ligament repair. The insertion point of the ATFL
on the talus and the CFL on the calcaneus are marked for
future bone tunnel placement.
(4) The hamstring tendons are harvested from the ipsilateral
limb. A 4-cm oblique incision is made in the skin at the
level of the hamstring tendons insertion into the medial
tibia, which is usually readily palpable. Dissection is carried
down to the fascia overlying the tendons, which is incised.
The semitendinosis and gracilis tendons are isolated, and
adhesions to surrounding tissues are resected. A tendon
stripper is then used to obtain the maximum length of
tendon possible. Distally, the tendons are elevated off of the
tibia with a small flap of periosteum. The tendons are left
attached to each other at their distal ends. At the distal end
of the graft, the 2 tendons are stitched together with a heavy
whipstitch, leaving the ends of the suture long to use to pass
the graft. Each tendon is prepared independently with a
heavy whipstitch, again leaving the tails of the suture long
for tendon passing. The end result is a Y-shaped graft with
suture extending from each limb. Each limb of the graft is
then sized. Alternatively, hamstring allograft can also be
used if available.
48 | www.techfootankle.com Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 16, Number 1, March 2017
FIGURE 3. Medial exposure demonstrates the sustentaculum tali
(%), FDL (retracted), and TP tendon (’). FDL indicates flexor
digitorum longus; TP, tibialis posterior.
(5) A guidewire is inserted into the medial malleolus for
preparation of a bone tunnel. The guidewire enters at the
tip of the medial malleolus, and exits at the anterolateral
tibia (Fig. 5). The position is checked fluoroscopically.
Ensure the medial shoulder of the ankle joint is not vio-
lated. A cannulated drill (4.0 mm) is passed over the
guidewire to facilitate suture passing. An acorn drill
corresponding to the size of the doubled end (base of the
Y) of the graft is then drilled B5 cm into the medial
malleolus. The doubled end of the graft is passed into the
tunnel, and fixed there with a bioabsorbable interference
screw. The graft should be solidly fixed into the medial
malleolus with 2 tails of the graft free (Fig. 6).
(6) The calcaneal bone tunnel is now created. The entry point of
the tunnel is just inferior to the sustentaculum tali, at its
posterior border. The exit point of the tunnel is at the
insertion point of the CFL on the lateral calcaneus. The
guidewire is inserted in this path and its position is checked
visually and fluoroscopically (Fig. 7). Ensure the subtalar
joint is not violated. An acorn drill corresponding to the size
of 1 limb of the tendon graft is then drilled over the guide-
wire starting medially, and exiting the lateral calcaneal wall,
creating a bone tunnel through the width of the calcaneus.
One of the free tendon grafts is passed through this tunnel,
exiting at the CFL footprint on the lateral calcaneus. Ensure
the graft is passed deep to the TP and flexor digitorum
longus tendons.
(7) The talar bone tunnel is now created. The entry point is at
the medial talar neck, at the midway point between the
dorsal and plantar aspects of the neck. The exit point is at
the anterolateral talar neck, at the insertion point of the
ATFL. A guidewire is inserted in this path and its position
FIGURE 4. Lateral exposure demonstrates the distal fibula (%)
and the lateral ankle ligaments (in forceps).
Techniques in Foot & Ankle Surgery  Volume 16, Number 1, March 2017
FIGURE 5. Position of the guidewire in the medial malleolus for
first bone tunnel.
is checked visually and fluoroscopically (Fig. 8). Careful
attention is paid to ensure the guidewire does not penetrate
the dorsal cortex of the talus as this will result in an intra-
articular graft placement. An acorn drill corresponding to
the size of the final limb of the graft is drilled over the
guidewire to exit the lateral talar neck, creating a tunnel
through the width of the talar neck. The free tendon is then
passed through this tunnel.
(8) The medial-sided ligament reconstruction is tensioned.
The foot is held in neutral dorsiflexion/plantarflexion,
with slight internal rotation and adduction. The tendon
grafts are tensioned from the lateral side, and bioabsorb-
able interference screws are placed from medial to lateral
in the calcaneal and talar bone tunnels.
(9) A fibular bone tunnel for the CFL reconstruction is
created. A guidewire is placed at the fibular origin of the
CFL, and drilled retrograde out the anterior fibular cortex.
Its position is confirmed visually and fluoroscopically.
The appropriate-sized acorn drill is used to drill a tunnel
through the fibula. The tendon graft that exits the
calcaneus at the CFL insertion point is passed through
the fibular bone tunnel (Fig. 9).
(10) The native ATFL and CFL are now repaired back down to
the distal fibula with a suture anchor, using the same
technique used for primary ankle ligament repair. The foot
is held in dorsiflexion and eversion when tensioning the
repair. The suture anchor is additionally used to fix the
ATFL limb of the tendon graft down to the fibula at this
point (Fig. 10). With the tendon tensioned, it is secured to
FIGURE 6. The graft (%) has been fixed in the medial malleolar
bone tunnel (arrow) with an interference screw. Tibialis posterior
(’) is coursing beneath the medial malleolus.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Surgical Reconstruction Ankle MDI
FIGURE 7. Guidewire for calcaneal tunnel has been inserted just
distal to, and at the posterior aspect of the sustentaculum tali
(%). Inset demonstrates fluoroscopic view of the guidewire in
place, exiting at the calcaneal insertion of the CFL. CFL indicates
calcaneofibular ligament.
the fibula with the suture anchor and reinforced with mul-
tiple sutures into the periosteum and native ATFL/capsule.
(11) With the foot in the plantigrade position, the CFL graft is
tensioned and fixed in place with a bioabsorbable
interference screw. The residual tendon end is repaired
to the ATFL tendon graft.
(12) Wounds are irrigated thoroughly and layered closure is
performed. A well-padded posterior below-knee splint
with stirrups is applied. The patient is instructed to be
non–weight-bearing.
COMPLICATIONS
The senior author has performed this procedure in 6 patients at
the time of writing, and thus far no complications have been
encountered. Complications that may occur with this surgery
include, but are not limited to:
FIGURE 8. Fluoroscopic view of the talar guidewire entering the
medial talar neck and exiting at the insertion of the ATFL laterally.
ATFL indicates anterior talofibular ligament.
www.techfootankle.com | 49
Dodd and Daniels
FIGURE 9. Lateral view demonstrating the CFL graft (%) passing
through the fibular (F) bone tunnel. ATFL graft (A) is seen also. Inset
demonstrates fluoroscopic view of fibular guidewire. ATFL indicates
anterior talofibular ligament; CFL, calcaneofibular ligament.
 Wound complications (dehiscence, infection).
 Infection (superficial or deep).
 Fracture through bone tunnels.
 Intra-articular penetration of bone tunnels/graft (ankle/
subtalar joints).
These complications can be avoided by appropriate soft
tissue handling, careful attention to bone tunnel placement, and
liberal use of fluoroscopy intraoperatively. Graft length has not
been problematic in our experience thus far. Approximately
15 cm of graft is needed for each limb of the reconstruction.
We have not encountered a patient whose hamstring tendons
are too short to proceed. If this was to occur, or the tendons
were to be prematurely truncated, allograft reconstruction
should be considered.
POSTOPERATIVE MANAGEMENT
Immediately postoperatively the patient is placed into a well-
padded posterior splint with stirrups, with the ankle in the
plantigrade position. The patient is instructed to be non–
weight-bearing. Two weeks postoperatively sutures are
removed and a below-knee fiberglass cast is placed on the
limb, with continued non–weight-bearing. At the 6-week
postoperative visit, the fiberglass cast is removed and a
removable cast-boot is used. Range-of-motion exercises begin
and the patient begins weight-bearing in the cast-boot. Formal
physical therapy begins at 12 weeks’ postoperative, at which
time the cast-boot is weaned. Return to sport and recreational
activities can begin once adequate strength and proprioception
return, usually around 4 to 6 months postoperatively.
FIGURE 10. The ATFL graft (%) is sutured down to the fibula
with the suture anchor that was used to repair the native ATFL.
ATFL indicates anterior talofibular ligament.
50 | www.techfootankle.com Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Techniques in Foot & Ankle Surgery  Volume 16, Number 1, March 2017
OUTCOMES
The senior author has performed this procedure in 6 patients at
the time of writing. Although clinical results are early, both
surgeon and patients are satisfied with the procedure thus far.
There have been no significant complications and no patient
has complained of recurrent instability. Those patients who are
far enough out from surgery to be allowed to return to full
activity have responded that they would be willing to undergo
the same treatment again based on their current results
(Fig. 10).
FUTURE OF THE TECHNIQUE
Current techniques of deltoid ligament reconstruction do not
completely restore the function of both the superficial and deep
deltoid ligament. Further exploration into the ideal method of
deltoid ligament reconstruction is important, and may warrant
modifications to this surgical technique.
REFERENCES
1. Beumer A, van Hemert WL, Swierstra BA, et al. A biomechanical
evaluation of the tibiofibular and tibiotalar ligaments of the ankle. Foot
Ankle Int. 2003;24:426–429.
2. Colville MR. Surgical treatment of the unstable ankle. J Am Acad
Orthop Surg. 1998;6:368–377.
3. Coughlin MJ, Schenck RC Jr, Grebing BR, et al. Comprehensive
reconstruction of the lateral ankle for chronic instability using a free
gracilis graft. Foot Ankle Int. 2004;25:231–241.
4. Maffulli N, Ferran NA. Management of acute and chronic ankle
instability. J Am Acad Orthop Surg. 2008;16:608–615.
5. Morelli F, Perugia D, Vadala A, et al. Modified Watson-Jones
technique for chronic lateral ankle instability in athletes: clinical and
radiological mid- to long-term follow-up. Foot Ankle Surg.
2011;17:247–251.
6. Pijnenburg AC, Van Dijk CN, Bossuyt PM, et al. Treatment of ruptures
of the lateral ankle ligaments: a meta-analysis. J Bone Joint Surg Am.
2000;82:761–773.
7. Hintermann B, Valderrabano V, Boss A, et al. Medial ankle instability:
an exploratory, prospective study of fifty-two cases. Am J Sports Med.
2004;32:183–190.
8. Ibrahim SA, Hamido F, Al Misfer AK, et al. Anatomical reconstruction
of the lateral ligaments using Gracillis tendon in chronic ankle
instability; a new technique. Foot Ankle Surg. 2011;17:239–246.
9. Deland JT, de Asla RJ, Segal A. Reconstruction of the chronically
failed deltoid ligament: a new technique. Foot Ankle Int.
2004;25:795–799.
10. Haddad SL, Dedhia S, Ren Y, et al. Deltoid ligament reconstruction: a
novel technique with biomechanical analysis. Foot Ankle Int.
2010;31:639–651.
11. Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries:
diagnosis and management. Foot Ankle Clin. 2006;11:625–637.
12. Savage-Elliott I, Murawski CD, Smyth NA, et al. The deltoid ligament:
an in-depth review of anatomy, function, and treatment strategies. Knee
Surg Sports Traumatol Arthrosc. 2013;21:1316–1327.
13. Buchhorn T, Sabeti-Aschraf M, Dlaska CE, et al. Combined medial
and lateral anatomic ligament reconstruction for chronic rotational
instability of the ankle. Foot Ankle Int. 2011;32:1122–1126.
14. Ellis SJ, Williams BR, Wagshul AD, et al. Deltoid ligament
reconstruction with peroneus longus autograft in flatfoot deformity.
Foot Ankle Int. 2010;31:781–789.
15. Jeng CL, Bluman EM, Myerson MS. Minimally invasive deltoid
ligament reconstruction for stage IV flatfoot deformity. Foot Ankle Int.
2011;32:21–30.
Techniques in Foot & Ankle Surgery  Volume 16, Number 1, March 2017 Surgical Reconstruction Ankle MDI

CME QUESTIONS
(1) Failure of lateral ligament reconstruction surgery (recurrent instability) may be due to:
(a) Unrecognized multidirectional instability of the ankle.
(b) Prolonged immobilization of the ankle.
(c) Pes planovalgus deformity of the foot.
(d) Inadequate tibialis anterior strength.
(2) Patients with medial-sided ankle instability frequently have:
(a) Subtalar joint arthritis.
(b) Lateral-sided ankle instability.
(c) Equinus contracture of the ankle.
(d) Hallux rigidus.
(3) Medial-sided instability of the ankle can be assessed with which of the following examination maneuvers?
(a) Inversion stress-test of the ankle.
(b) Anterior-drawer test.
(c) Anterior-drawer, external-rotation test.
(d) Posterior-drawer test.
(4) Which imaging modality is most helpful in assessing multidirectional instability of the ankle?
(a) Ultrasound.
(b) Standing x-rays.
(c) CT scan.
(d) MRI.
(5) One can ensure adequate rehabilitation has been performed for ankle instability by assessing:
(a) Peroneal muscle-group motor power.
(b) Patient’s description of physiotherapy regiment.
(c) Ankle range of motion.
(d) Time from injury.

Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved. www.techfootankle.com | 51
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Dodd and Daniels Techniques in Foot & Ankle Surgery  Volume 16, Number 1, March 2017

52 | www.techfootankle.com Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.