FOOT AND ANKLE

Ankle instability: ankle. Freeman introduced the term “functional instability” for a
group of patients who complain of giving way but do not have

presentation and abnormal mobility of the ankle. It is thought that functional

instability occurs due to proprioceptive or neuromuscular deficits,

management or because of poor postural control. Proprioceptive deficits can

arise as a consequence of damage to proprioceptive fibres in the
joint capsule and ankle ligaments. Neuromuscular deficits can
M Hossain
arise due to damage to the peroneal muscles. These types of
R Thomas functional deficits result in impaired neuromuscular recruitment,
and affected patients are likely to benefit from an appropriate
physiotherapy regimen. Patients who demonstrate abnormal
Abstract
ankle joint mobility on clinical examination or under stress radi-
The ankle joint is akin to a mortise. Damage to this mortise joint with
ography are said to have “mechanical instability”. Although
injury to either the medial, lateral or syndesmotic complex can result in
conceptually it is nice to be able to classify patients with CAI into
chronic ankle instability. In this article we discuss the management of
two different classes the reality is that the complete spectrum of
ankle instability, most commonly arising from injuries to the lateral liga-
CAI often includes an overlap in presentation3 (Figure 1).
ment complex. Chronic ankle instability may develop from an inversion-
type ankle sprain, usually affecting the anterior talo-fibular ligament
Relevant anatomy (Figure 2)
(ATFL). Most affected patients improve with conservative management
following this injury, but up to 30% of patients can develop debilitating Lateral collateral ligament complex
chronic ankle symptoms. In assessing ankle instability it is important to This ligament complex comprises the Anterior talo-fibular liga-
differentiate between patients with functional instability and those with ment (ATFL), posterior talo-fibular ligament (PTFL) and the
mechanical instability. Clinical assessment is the cornerstone of diag- calcaneofibular ligament (CFL).
nosis, although stress views performed under anaesthesia (including
the contralateral ankle for comparison) are useful. MRI is helpful in the ATFL: the ATFL is essentially a discrete thickening of the ankle
assessment of soft tissue and cartilage injury. Short periods of immobili- joint capsule. It is a flat quadrilateral structure that originates
sation and physiotherapy are the mainstay of acute treatment. Patients from the antero-inferior margin of lateral malleolus and runs
with functional instability may benefit from peroneal strengthening and antero-medially to be inserted on to the talar body just anterior to
proprioceptive rehabilitation. Surgery is recommended for patients with the lateral malleolar articular surface and is about 0.5e1 cm
mechanical instability who fail conservative treatment. Anatomical liga- wide. Although the ligament is depicted as a single band in most
ment repair has the best results. Non-anatomic ligament reconstruction illustrations, Sarrafian described the ATFL as having two distinct
is reserved for revision cases although primary ligament reconstruction bands, later corroborated by Golano P et al.4 It is the weakest of
may have a role in selected cases. the three ligaments but can undergo great deformation before
Keywords ankle instability; anterior talo-fibular ligament; Brostrom failure.
repair; functional instability; mechanical instability
PTFL: the PTFL originates from the malleolar fossa on the medial
surface of the lateral malleolus and travels horizontally to be
Introduction inserted on to the postero-lateral talus, coming under tension in
dorsiflexion. It is very strong and is rarely injured.
Ankle sprains are among the most common sporting injuries. It is
estimated that around 5000 ankle sprains occur every day in the
UK.1 Although most of these patients get better with conservative
treatment, a significant number continue to have long term
problems with pain, swelling and chronic ankle instability.2
It is important to appreciate, when a patient presents with
complaints of the ankle giving way, that he or she may have
anatomical abnormalities that predispose to chronic ankle insta-
bility (CAI). It is also useful to emphasise that not all patients who
complain of ankle instability have objective signs of an unstable

M Hossain PG Cert MSc (Orth Eng) MSc (Oxon) FRCSGlasg (Tr and Orth) Senior Foot
and Ankle Fellow, Cardiff Regional foot and ankle unit, University
Hospital of Llandough, Llandough, UK. Conflicts of interest: none
declared.

R Thomas BSc (Hons) FRCS (Tr and Orth) FFSEM(UK) Consultant Orthopaedic
Surgeon, Cardiff Regional foot and ankle unit, University Hospital of
Llandough, Llandough, UK. Conflicts of interest: none declared. Figure 1 Interplay of factors in chronic ankle instability.

ORTHOPAEDICS AND TRAUMA 29:2 145 Ó 2014 Elsevier Ltd. All rights reserved.
 FOOT AND ANKLE
Figure 2 Anatomy of the ankle: lateral ligaments and the anterior inferior
tibio-fibular ligament.
CFL: the CFL is a distinct structure. It is not a capsular thickening
but is extra-capsular. It is in close proximity to the peroneal
tendons. During surgical exploration these tendons act as a
landmark for the CFL. It is found immediately deep to, and runs
at right angles to, the peroneal tendons. The CFL originates from
the tip of the fibula and runs downwards and backwards to
attach to a tubercle situated on the postero-lateral surface of
calcaneus. It’s footprint on the calcaneus is around 3 cm poste-
rior and superior to the peroneal tubercle. There is some varia-
tion in its proximal attachment. Instead of attaching proximally
to the tip of the fibula, the CFL can be attached to the ATFL or
have attachments to both fibula and ATFL.
Syndesmosis complex
The ankle syndesmosis is formed between the distal tibia and
fibula. The stability of this complex is maintained by the anterior
tibio-fibular ligament, posterior tibio-fibular ligament and inter-
osseous tibio-fibular ligament. Stability of the syndesmosis is
also provided by the inferior margin of the interosseous mem-
brane. The anterior tibio-fibular ligament is directed inferior and
laterally from the anterior tubercle of the distal tibia to the
anterior margin of the lateral malleolus. The lower fascicle of the
anterior tibio-fibular ligament (AITFL) is frequently damaged in
ankle sprains and can consequently produce anterolateral ankle
impingement. The pathologic lesion can be seen at ankle
arthroscopy as a thick hyalinised “meniscoid” lesion.
Biomechanics
ATFL
The ATFL is horizontal in the neutral position of the ankle.
Therefore, as a restraint, it is ineffective in a neutral or dorsi-
flexed position. The ATFL becomes more vertical in ankle plantar
flexion in line with the fibula and becomes a true collateral lig-
ament in this position. The ligament is therefore stressed in the
plantar flexed ankle and is most prone to injury in this position.
Indeed, it is the main stabiliser of the ankle in plantar flexion
ORTHOPAEDICS AND TRAUMA 29:2
against anterior translation, varus tilt and internal rotation of the
talus.
CFL
The CFL is angulated posteriorly in the neutral position of the
ankle but becomes more vertical in ankle dorsiflexion and in this
position acts as a true collateral ligament. It spans both the ankle
and the subtalar joints. The CFL resists ankle inversion with the
ankle in neutral to dorsiflexion and is an important stabiliser of
the subtalar joint. It is relaxed in a valgus ankle and stressed in a
varus position.
It is therefore apparent that throughout the arc of ankle mo-
tion either the ATFL or the CFL acts as a true collateral ligament
of the ankle (ATFL in plantarflexion and CFL in dorsiflexion).
There is a window in this range of movement where neither of
the two ligaments is able to support the ankle. The mean normal
angle between the two ligaments is 105
(range 70
e140
). If the
angle between the two ligaments is increased then the window of
instability also enlarges. Individuals with such an anatomical
variation may be more prone to develop ankle instability.
Practice point 1
C ATFL stabilises the ankle in PF
C CFL stabilises the ankle in DF
C ATFL is the weakest of the lateral ligaments and is the most
frequently injured
C Individuals who have widely spaced ATFL and CFL may be more
prone to chronic ankle instability
C Varus hindfoot and tight tendo Achilles both predispose to ankle
instability
Anatomic factors predisposing to ankle instability
Varus hindfoot
A varus hindfoot predisposes to ankle instability. Inversion of the
subtalar joint locks the transverse tarsal joint and reduces the
ability of the ankle to dissipate stress. In a normal ankle, on heel
strike, the centre of pressure of the foot lies lateral to the subtalar
joint axis. This results in the Ground Reaction Force (GRF) pro-
ducing pronation torque in a normal ankle. However, if the
hindfoot is in varus this produces a supinating torque because of
the medially placed centre of pressure. This torque stresses the
ATFL.
Tight tendo Achilles
Tightness of the Achilles tendon limits ankle dorsiflexion and
also results in the ATFL being stressed for a longer period of the
gait cycle.
Pathomechanics of ankle sprain
It has been proposed that on landing from a height the ankle
assumes the natural loose-packed position of inversion and
plantar flexion.2 Therefore, synchronous firing of the evertors
and dorsiflexors are necessary to stabilise the ankle. Ankle
sprains occur when this mechanism is disrupted. It has also been
146 Ó 2014 Elsevier Ltd. All rights reserved.
 FOOT AND ANKLE
observed that the dominant ankle is more prone to injury than
the non-dominant side.
Clinical features
Patients may present with pain, swelling, giving way, activity
limitation etc. It is important to elicit in the history how long ago
the first acute event occurred, what treatment was offered, how
frequently the ankle gives way and what are the precipitating
factors. Pain at rest, between episodes of giving way, may sug-
gest underlying chondral injury.
Clinical examination
Look: examination commences with the patient standing with
both knees exposed to allow lower limb assessment. As dis-
cussed earlier, subtle varus of the foot is a known risk factor for
ankle instability (Figure 3). This requires a subjective assess-
ment, as there is no evidence-based guideline regarding what
constitutes the threshold for diagnosis of a “subtle varus
ankle”. Normal hindfoot alignment is few degrees of valgus.
Assessing gait also gives an opportunity to observe whether the
peroneal tendons dislocate during gait. Some patients with
complaints of ankle instability actually have peroneal insta-
bility that gives a perception of the ankle giving way. The site
and size of any swelling is also noted. Swelling can be present
over the lateral malleolus, lateral gutter, peroneal tendons or
the ankle joint. If pain is present it is useful to ask patients if
they can identify the site of pain with a single finger. Patients
with chronic ankle instability frequently have concomitant
injury and the site of pain they identify may be indicative of
this. Muscular and proprioceptive control of the leg is assessed
by asking the patient to stand on one leg at a time with eyes
open and then with them closed. Patients who are unable to
remain steady on their ankle with the eyes closed have a pro-
prioceptive deficit.
Feel: the site of tenderness is the key to differential diagnosis. A
torn ATFL is tender just anterior and superior to the tip of fibula.
Tenderness present more superiorly over the ankle joint would
suggest a possible syndesmosis injury. Tenderness over the
lateral gutter and lateral talar dome that is exacerbated with
Figure 3 Subtle hindfoot varus: this patient presented with a complaint of
recurrent stumble on his right ankle.
ORTHOPAEDICS AND TRAUMA 29:2
ankle dorsiflexion represents a positive impingement test. This
could be due to a meniscoid lesion from injury to the AITFL as
described above. Tenderness over the talar dome that is worse on
palpation but not on dorsiflexion might be due to an osteo-
chondral injury. Tenderness posterior to the fibula suggest
peroneal tendon pathology. Peroneal tendons are frequently
injured in ankle sprains. If the peroneal tendons are unstable
there may be obvious prominence at the back of the fibula or this
may be brought about by resisted eversion with the ankle.
Move: the range of movement of the ankle should be ascertained
and the strength of the peroneal muscles tested. Tests for
generalised joint laxity (Beighton score) should also be per-
formed to rule out systemic instability.
Silfverskiold test e tightness in gastrocnemius muscles and
tendo Achilles should be sought by assessing ankle range of
motion with the knees extended and flexed. If ankle dorsiflexion
is limited on knee extension but improved on knee flexion this
suggests gastrocnemius tightness. Alternatively, if ankle dorsi-
flexion is limited on knee extension but not improved on knee
flexion, this suggests that the tendo Achilles may be tight.
Anterior draw test e this test (Figure 4) evaluates the ATFL.
The patient needs to be relaxed, seated with the knee flexed and
the ankle plantar flexed around 10e20
. One of the examiner’s
hands stabilises the tibia and, with the other hand, the foot is
pulled forwards. An alternative way to perform this test is to
stabilise the heel on the bed with one hand and pull tibia for-
wards with the other hand. The test should be compared with
the contralateral ankle. Although different grades of positivity
are described, the inter- and intra-observer reliability are likely
to be low. A recent consensus statement has therefore recom-
mended that positive tests be described as stable, unstable or
unstable with a sulcus sign.5 A sulcus sign is present when a
Figure 4 Anterior drawer test.
147 Ó 2014 Elsevier Ltd. All rights reserved.
 FOOT AND ANKLE

dimple is seen in the lateral gutter on testing. It is not
commonly seen in practice.
An anterolateral draw test has also been described in the
literature that is claimed to be more sensitive and specific in
detecting ATFL injury but has not been clinically validated or
widely adopted.6
External rotation stress test e this test is performed to assess
for syndesmosis injury. The knee is flexed and the leg stabilized
with one hand, while the other hand externally rotates the foot. A
positive test reproduces pain over the syndesmosis. The external
rotation stress test has a low sensitivity but high specificity to
detect syndesmotic injury.7 This means that many injuries remain
undetected by this test but there are few false positive cases.

Practice point 2

Clinical examination check list:

Practice point 3
Look:
Classification of ankle instability
Lower limb alignment: rule out subtle cavus
Gait Grade Anatomic injury Clinical finding Imaging finding
Site and size of swelling
I ATFL/CFL partial  or þ drawer Drawer, Talar tilt
Peroneal instability
tear
Modified Romberg test
II ATFL tear þ drawer þDrawer, Talar tilt
Feel:
III ATFL þ CFL þ þ drawer þDrawer, þTalar tilt
Area of tenderness
Move:
ROM
Resisted eversion
Silfverskiold test Investigations
Anterior draw test
Although clinical examination is quite sensitive to detect grade III
Talar tilt test
injury it is less reliable in detecting less severe degrees of injury.
Beighton score
Appropriate investigations are useful diagnostic tools and help to
reinforce the clinical diagnosis.

Talar tilt test e this test (Figure 5) evaluates the CFL. With the
ankle plantigrade the hindfoot is tilted one way then the other to
assess for asymmetric movement. Palpation over the talar neck
helps to differentiate movement of the ankle from the subtalar
joint. It is often difficult to compare between sides. Tilting both
heels simultaneously with the patient prone may allow better
comparison between the two sides.
Radiology
Weight bearing AP, mortise and lateral views of the ankle are
standard images. Plain films may show syndesmotic injury,
osteochondral fracture of the talus or avulsion fracture of fibula
(Figure 6). An ossicle at the tip of the lateral malleolus is also

Figure 6 X-ray of ankle showing avulsion fracture of fibula suggestive of

peroneal instability, this patient presented with a complaint of ankle
Figure 5 Talar tilt test. instability.

ORTHOPAEDICS AND TRAUMA 29:2 148 Ó 2014 Elsevier Ltd. All rights reserved.
 FOOT AND ANKLE
Figure 7 EUA: anterior draw.
frequently found in CAI. The hindfoot alignment view is also
useful to assess hindfoot alignment although is not routinely
performed.5
Stress views
Stress views (Figures 7 and 8) allow objective assessment of
displacement under load. These views should be performed with
comparative views of the normal side. It is useful to understand that
there is no consensus in the published literature, or good evidence,
to indicate the true cut-off for a positive test. More than 4 mm
anterior displacement is considered positive in the anterior draw
test. Talar tilt is measured by drawing a line tangential to the
articular surfaces of the distal tibia and talus. The talar tilt angle is
formed by the convergence of these two lines. More than 6
differ-
ence between the two sides is considered positive and more than 15

difference indicative of injury to both the ATFL and the CFL.8
Figure 8 EUA: talar tilt.
ORTHOPAEDICS AND TRAUMA 29:2
Figure 9 MRI showing injury to ATFL.
Ultrasound
Ultrasound is useful in skilled hands, particularly to assess the
peroneal tendons, but has been made redundant by the wide-
spread availability of MRI scanning.
MRI
MRI (Figure 9) allows not only the assessment of the ATFL and
CFL but also of local tendons and bones. The diagnostic accuracy
of MRI has been widely investigated. The ATFL is best seen in
axial cuts at a level where the fibula appears as a comma shaped
structure. At this level the ATFL bridges the anterior margin of
distal tibia and fibula. High signal or disruption is suggestive of
injury.
Treatment
Conservative
All patients should have an initial trial of conservative treat-
ment.5 Treatment following acute ankle injury consists of rest,
elevation, ice packs and some form of ankle immobilisation for a
short period. There is evidence that any type of immobilisation:
such as taping, functional bracing, Aircast walker or short leg
cast may be more helpful than no support.9 Therefore patient
compliance and preference may be taken into account in
choosing a form of immobilisation. Once the acute episode has
resolved it is important to organize physiotherapy for appropriate
rehabilitation. This consists of proprioception training, peroneal
tendon strengthening, tendo Achilles stretching and balance
training. Proprioceptive training is imparted with the wobble
board and peroneal strengthening with Theraband exercises.
Data is available for short term efficacy following neuromuscular
rehab but long term follow up results are not known.10 Taping of
the ankle reduces mechanical instability and has also been pro-
posed as a prophylactic intervention, especially in athletes.11
Patients who fail to improve with conservative treatment may
benefit from surgical intervention.
149 Ó 2014 Elsevier Ltd. All rights reserved.
 FOOT AND ANKLE
Practice point 4
C Proprioceptive training and neuromuscular strengthening form
the cornerstone of conservative management
C Anatomical repair has the best results from surgery
C Surgery should also address associated problems such as pero-
neal tendon tear/instability, osteochondral lesion, impingement
lesion
C Non-anatomic repairs sacrifice peroneus brevis and also affect
subtalar joint kinematics
C Near anatomic allograft repair and arthroscopic anatomic repair
are new techniques that show promising results
Surgery
Surgery has been reserved for patients with chronic ankle
instability who fail conservative treatment. However, there have
been reports of acute surgical repair with the supposed benefits
of a reduced incidence of instability.12 It remains to be seen if
early surgery is better than functional rehab over the long term.
Arthroscopy: a number of studies have demonstrated that there
is a high incidence of intra-articular pathology in patients with
chronic ankle instability. Arthroscopy is therefore indicated
when surgery is planned. The majority of surgeons would
perform arthroscopy in the same sitting as ligament reconstruc-
tion. However, some choose to perform arthroscopy as an elec-
tive procedure prior to ligament reconstruction which follows at
a later date.13 Arthroscopy serves both diagnostic and thera-
peutic purposes. It helps to assess chondral injury and to treat
synovitis, impingement lesions and osteochondral lesions. Those
who prefer a staged approach to surgery have claimed that
treatment of soft tissue impingement and osteochondral lesions
may avoid the need for further surgery in some patients. Patients
with refractory functional instability may also benefit from
arthroscopic debridement.
Ligament repair: a number of repair techniques have been
described. Anatomical repair gives the best results and is indi-
cated in most patients.13 Anatomical repair of the existing ATFL
and CFL to bone was described by Brostrom but the modification
by Gould is currently most popular. Gould recommended rein-
forcement of the repair using inferior extensor retinaculum. The
availability of suture anchors allows direct insertion of ligament
ends onto the fibula rather than suturing together torn ligament
ends. Interestingly, anatomical repair is not only simple, it also
restores ankle kinematics to near normal compared to ligament
reconstruction techniques. Lately there has been interest in
arthroscopic lateral ligament repair. These techniques aim to
replicate arthroscopic Brostrom-Gould repair.14 This is still an
evolving field and although early results have been published
long term results are still awaited.
Ligament reconstruction: ligament reconstruction can be per-
formed using a number of options: native autografts, allografts or
synthetic implants. The majority of UK orthopaedic surgeons
would perform a revision anatomical repair for failure of a primary
anatomical repair and only attempt ligament reconstruction for
ORTHOPAEDICS AND TRAUMA 29:2
continuing instability.13 However, there may be a role for early
ligament reconstruction in patients with a high BMI, heavy manual
jobs, sportsmen or those with generalised ligament laxity who may
overstress the repaired ligament and are therefore at high risk of
failure of primary repair.5 Ligament reconstruction may affect
ankle kinematics but in these situations stability is preferred over
normal kinematics. Reconstruction is also indicated when there is
insufficient native ligament left for adequate repair. It has also
been suggested that ligament reconstruction rather than repair
should be chosen if arthroscopic assessment reveals the ATFL to
be highly irregular in appearance. The damaged ligament in this
case is likely to be composed of scar tissue rather than type I
collagen and as such may not be suitable for primary repair.5
Non-anatomic lateral ligament reconstruction has a long track
record. A number of procedures have been described. Watson-
Jones described re-routing of the peroneus brevis (PB) tendon
between the talus and the calcaneus. This was subsequently
modified by Evans, who preferred re-routing via the distal fibula.
Chrisman and Snook detached only a portion of PB, keeping its
distal attachment intact. The main criticism of non-anatomic
repairs is that these techniques restrict the movement of the
subtalar joint and also sacrifice the PB tendon, which is an
important lateral stabiliser of the ankle. Therefore some surgeons
have attempted near anatomic repair using allografts.15 Many
surgeons feel that in view of long term complications and
availability of modern fixation techniques non-anatomic recon-
struction using PB should now be avoided.5
Additional surgery: it is important to stress that if concomitant
pathologies are present they also need to be addressed for a
successful surgical outcome. For example, a fixed varus hindfoot
may need to be corrected with a calcaneal sliding osteotomy,
whilst a tight tendo Achilles or gastrocnemius may benefit from
appropriate release. If a fibular ossicle is found this also needs to
be addressed. Fixation should be attempted for large ossicles but
small fragments may be excised.5
Outcome measures
There has been a generally welcomed trend in orthopaedic sur-
gery to record patient specific outcome measures. Although there
are some outcome measures in use in foot and ankle surgery
there is currently no widely accepted and validated outcome
measure for patients with chronic ankle instability.5 It is there-
fore difficult to compare results across studies and to pool out-
comes for meta-analysis. The Foot and Ankle Outcome Score
(FAOS) has been validated in patients with lateral ligament
reconstruction. The Cumberland ankle instability tool (CAIT)16
has also been used.
Conclusion
CAI represents a spectrum of pathologies in and around the
ankle. Careful clinical assessment is required for successful
management. Most patients can be managed with conservative
treatment. A number of different surgical options are available
for those who fail conservative treatment. It is expected that
future trials will concentrate on developing validated patient
reported outcome measures so that objective evidence-based
treatment recommendations can be made. A
150 Ó 2014 Elsevier Ltd. All rights reserved.
 FOOT AND ANKLE
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