Dalhosie University

Halifax Nova Scotia

Mark Glazebrook
MSc., PhD, MD, FRCS(C), Dip Sports Med
Associate Professor Dalhousie University
Queen Elizabeth II health sciences Center
Halifax, Nova Scotia

Foot and Ankle 1:52 PM

Functional Versus Mechanical Instability: Keys to Diagnosis,

Physical Examination and Radiological Evaluation
Mark Glazebrook MD PhD
 Mark Glazebrook Disclosure Statement

Mark Glazebrook has received something of value in the past 1 year (≥

$500.00) or served as a Journal reviewer from a commercial company or
institution related directly or indirectly to the subject of this presentation,
as noted below.
a = research/institutional support, b = misc. non-income support,
c = royalties, d = stock/options, e = consultant/employee
f = Journal reviewer

NAME: DISCLOSURE: COMPANY/SOURCE:

1. Glazebrook e Stryker Wright Inc.

2. Glazebrook a,e Ferring Inc.
3. Glazebrook a,e Cartiva Inc
4. Glazebrook ae Smith & Nephew
5. Glazebrook f Foot & Ankle International
6. Glazebrook f JBJS(A)
7. Glazebrook f The Bone & Joint Journal
8. Glazebrook f CORR
9. Glazebrook Past BOD Member AOFAS
10. Glazebrook President Elect/BOD Canadian Orthopedics
Association (COA)
 Acute Ankle Sprains

Inversion injury
Lateral 90%
Anterior talofibular ligament (ATFL 70%)
Calcaneofibular ligament (CFL 20%)
Syndesmotic (High sprain) injuries 10%
PTFL and deltoid (without #) - Rare
 Classification
Grade Ligament Injured Severity & Presentation

Grade 1 ATFL Mild :

O tear or change in length, no swelling.
Point tenderness
Mild functional loss

Grade 2 ATFL & CFL Moderate :

Partial ligament tear, with elongation.
Pain, localized swelling, tenderness.
Moderate functional loss
Grade 3 ATFL, CFL & PTFL Severe:
Complete ligamentous rupture, Marked
pain, swelling, tenderness,
Marked loss of Function ----Instability
 Injury to Ligaments

Grade 3 Severe :
• Complete disruption
• Obvious Laxity on
exam and
paradoxically less
tender
• Signal and structural
changes on MRI with
torn ends visible and
fluid filled gap
 Injury to Ligaments

Grade 3 Severe :
• Complete disruption
• Obvious Laxity on
Chronic Ankle Instability
exam and
(CAI)
paradoxically less
tender
• Signal and structural
changes on MRI with
torn ends visible and
fluid filled gap
 Ankle Instability
Mechanical Vs Functional
Mechanical (Abnormal movement talus in Mortise)
Pathological ligament laxity
Synovial changes
Degenerative conditions
Hind foot stiffness
Functional (Complaint of Giving way)
Impairments to proprioception Neuromuscular
Strength deficits around the ankle
Postural control deficits
Deformity(Hindfoot Varus)
Intraarticular Pathology (OCL & Impingement)
 Ankle Instability
Associated Conditions

Lateral Stress
Hindfoot Varus
Peroneal Tears
Peroneal Instability
Plantar Lateral Pain
Anterolateral Impingement
OCL
 Ankle Instability

Clinical Presentation
History:
Persistent pain
Recurrent giving way
Difficulties on uneven ground
Improved with ankle stabilizing orthosis (ASO)
Physical Exam: COMPARE TO CONTRALATERAL!
Anterolateral swelling &/or tenderness
Difficulty with SLS & Toe walking
Anterior Drawer Testing:
ATFL  Dorsiflexion
CFL  Plantarflexion (or Neutral to resist eversion)
 Imaging
• Stress views

Talar tilt angle 5 degrees greater than Anterior translation 5 mm greater than that
on the uninvolved side or an absolute on the uninvolved side or an absolute value
value of 10 degrees is indicative of of 9 mm is indicative of instability.
pathologic laxity
 Ankle Instability
• Ultrasound Griffith and Brockwell F&A Clinics 2006

Ultrasound showing (A) complete tear (discontinuity) of anterior talofibular

ligament (arrows) with (B) normal side (arrows) for comparison. (C)
Compete tear (no visualization) (arrows) of calcaneofibular ligament with
(D) normal side (arrows) for comparison. F, fibula; T, talus; C, calcaneum

In experienced hands, the accuracy of ultrasonography for

acute tears :

Anterior Talofibular Ligament (ATFL) ~ 95%

CalcaneoFibular Ligament (CFL) ~ 90%
Anterior Tibiofibular Ligament ~ 85%
 Ankle Instability
Imaging Studies Griffith and Brockwell F&A Clinics 2006

MRI demonstrate associated causes of ankle pain:

chondral injuries
bone bruising
stress fractures
associated tendon tears
chronically disrupted ligament
thickened, lax, wavy, discontinuous or
completely non-visualized
 Ankle Instability

TREATMENT
 Ankle Instability TREATMENT

Non Operative

RICE from Injury

Functional Rehabilitation
Peroneal Strengthening
Achilles Stretching
Proprioception
Bracing or High Top Shoe wear
Lateral Wedge Orthotic
Taping (Ineffective after ~10 min exercise)
 Ankle Instability TREATMENT

Operative

Open (Traditional) Vs Minimally Invasive (MIS)

Anatomic Repair
Non Anatomic Repair
Anatomic Reconstruction
Non Anatomic Reconstruction
 CAI: Open Operative Procedures
Anatomic Repair
+/- augmentation w
adjacent Extensor
retinaculum

Brostrom-Gould
 CAI: Open Operative Procedures
Anatomic Repair Ligament
+/- augmentation w Reconstruction
adjacent Extensor Partial or complete
retinaculum ligament
reconstruction

Brostrom-Gould

Watson Jones Evans Chrisman-Snook

 CAI:
OPEN Stabilization Outcomes
Level Level Level Level Level Grade of
Procedure Total
1 2 3 4 5 Recommendation

Open Anatomic Repair 0 6 4 7 4 21 B

Open Non-anatomic Repair 0 0 1 0 0 1 I

Open Anatomic Reconstruction 1 0 3 12 2 18 A

Open Non-anatomic Reconstruction 0 1 4 23 1 29 B

Internal Brace 0 0 1 1 0 2 I
Total 1 7 13 43 7 71

Conclusion:
OPEN ankle stabilization surgery provides good to excellent results
Less is Better!!
 Current Literature Available on
MIS stabilization Techniques

Current Evidence for Treatment of Ankle

Instability with MIS??

Minimally Invasive Surgical Treatment of Chronic Ankle Instability:

A Systematic Comprehensive Evidence Based Review of Current Literature
Kentaro Matsui, Bernard Burgesson, Masato Takao, James Stone, Stephane Guillo,
ESSKA AFAS Ankle Instability Group, and Mark Glazebrook
 Current Evidence MIS Approaches to
Ankle Stabilization.

Surgical Total Level Level Level Level Level Grade of For or

Technique Papers I II III IV V Recommendation Against

MIS Non A 0 0 0 0 0 0 I NA
Repair
MIS Non A 6 0 0 1 2 3 C For
Reconstruction

Arthroscopic 19 0 0 0 12 7 C For
Repair

Arthroscopic 6 0 0 0 1 5 C For
Reconstruction
 Current Evidence MIS Approaches to
Ankle Stabilization.

Surgical Total Level Level Level Level Level Grade of For or

Technique Papers I II III IV V Recommendation Against

MIS Non A 0 0 0 0 0 0 I NA
Limited Evidence to Support MIS for Rx of Ankle Instability!!
Repair
MIS Non A 6 0 0 1 2 3 C For
Further Studies Needed !!1
Reconstruction

Arthroscopic 19 0 0 0 12 7 C For
Repair

Arthroscopic 6 0 0 0 1 5 C For
Reconstruction
 Summary

• Ankle Sprains Common

• Clinical Diagnosis Best

• US &/or MRI best for diagnostic imaging

• Must differentiate Mechanical Vs Functional Instability

• Mechanical Instability Requires Ankle Stabilization

• Functional Instability requires Rx of different pathology

• Literature to support Open Surg CAI GOOD

• Literature to support MIS Surg CAI POOR (studies needed)

 THANK-YOU !!

Special Thanks
James Stone (USA)

MASATO TAKAO (Japan)

Kentaro Matsui (Japan)

Stephane Guillo (France)

Xavier Martin (Catalonia/Spain)

ESSKA-AFAS
Ankle Instability Group1