Ankle Instability


Ankle sprains are common injuries accounting for up to 40% of all athletic injuries. It has been estimated that 75% of ankle sprains involve the lateral ligamentous complex. More than 23,000 ankle sprains occur per day in the United States affecting both males and females at approximately the same rates. Previous studies demonstrate that ankle sprains account for up to 53% of basketball injuries and 29% of soccer injuries. Most injuries respond well to conservative treatment with physical therapy emphasizing proprioceptive training, restoration of motion, and strengthening of the supporting musculature. Unfortunately, up to 34% of patients will resprain their ankle and up to 33% of ankle sprains will develop mechanical instability (MI) or functional instability (FI) that may ultimately lead to chronic ankle instability. Previous studies have demonstrated associated intra-articular pathology in upward 93% of patients with ankle instability, with up to 78% of patients developing posttraumatic arthritis. , Therefore proper diagnosis and management is critical in order to prevent long-term sequelae of ankle instability.


The lateral ligament complex of the ankle is composed of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL) ( Fig. 13.1 ).

Fig. 13.1

Lateral Ankle Ligament Complex.

ATFL , anterior talofibular ligament; CFL , calcaneofibular ligament; PTFL , posterior talofibular ligament.

The ATFL, which is the weakest of the three ligaments, originates 10 mm proximal to the tip of the fibula and inserts onto the lateral talar neck just distal to the articular surface. The CFL is an extra-articular ligament originating on the distal tip of the fibula and inserting onto the calcaneus 13 mm distal to the subtalar joint. The CFL forms the floor of the peroneal tendon sheath. The PTFL is the strongest of the lateral ligaments and extends from the posterior border of the distal fibula to the posterolateral tubercle of the talus.

The ATFL functions as the primary restraint to inversion in plantar flexion and resists anterolateral translation of the talus. It is the most commonly injured ligament in lateral ankle sprains. The CFL is the primary restraint to subtalar inversion in neutral and dorsiflexed positions. Although the PTFL limits posterior talar displacement, it does not play an integral role in ankle stability when both the ATFL and CFL are intact.

The most common mechanism of injury to the lateral ankle ligament complex involves excessive supination of the rearfoot about an externally rotated lower leg after contact with the ground. Plantar flexion during injury increases the likelihood of injury. The ATFL is typically the first ligament injured during an ankle sprain. Attarian et al. conducted a biomechanical study evaluating 20 human cadaver ankles and performed cyclic loading of each isolated bone-ligament-bone preparation, constant velocity load-deflection tests at varying deflection rates, and extremely rapid load to failure tests. The authors demonstrated that maximum load to failure for the CFL was 2–3.5 times greater than that for the ATFL, further supporting the increased rate of injury to the ATFL when compared with the CFL. The CFL is involved in 50%–75% of ankle sprains, whereas the PTFL is involved in less than 10% of all ankle sprains.

Risk Factors

Several studies have examined the relationship between intrinsic and extrinsic risk factors for ankle sprains. Extrinsic risk factors include training errors, type of sport, type of equipment, level of competition, and environmental conditions. Intrinsic risk factors include age, gender, weight, aerobic fitness, alignment, strength, range of motion, proprioception, joint laxity, and foot morphology. McKay et al. conducted a study evaluating the risk of ankle sprain in elite and recreational male and female basketball players and demonstrated an increased risk in patients who had a history of ankle injury and in patients who failed to stretch before games. Insufficient rehabilitation and earlier perceived healing of the injury may contribute to this increased risk. Baumhauer et al. demonstrated that individuals with a muscle strength imbalance and a smaller dorsiflexion-to-plantar flexion ratio had a higher incidence of ankle sprain. Willems et al. performed a prospective study evaluating risk factors for inversion ankle sprains in collegiate physical education female students aged 17–26 years. The authors identified several risk factors including less accurate passive joint inversion position sense, less postural control, and higher extension range of motion at the first metatarsophalangeal joint. Sport activities that involve running, jumping, and cutting movements place athletes at an increased risk for inversion sprains. Previous studies have demonstrated that ankle sprains most commonly occur in basketball, football, and soccer.

Clinical Presentation

Patients with acute ankle ligament injuries typically present with lateral ankle pain and swelling, and they often describe a sensation of “rolling over” his or her ankle. Patients may be unable to bear weight on the affected extremity during the initial presentation. In cases of chronic instability, patients report experiencing recurrent ankle sprains and describe a sensation of the ankle “giving way.”

Physical Examination

Physical examination may demonstrate localized tenderness directly over the ligament origin/insertion points. The anterior drawer test performed in 10–15 degrees of plantar flexion is considered positive for an ATFL tear when there is greater than 8 mm of forward translation on the lateral radiograph. The talar tilt test assesses for CFL integrity. The angle formed by the tibial plafond and talar dome is measured as inversion force is applied to the hindfoot. Angles greater than 5 degrees indicate CFL disruption. These test results should always be compared to those of the contralateral ankle. In addition to the standard tests, patients should also be evaluated for peroneal tendon pathology, deformity, and neurovascular compromise.


Standard radiographic assessment, including weight-bearing anteroposterior, lateral, and mortise views, is initially performed after acute ankle injury in order to rule out ankle fracture. The Ottawa Ankle Rules were described to determine which patients presenting with lateral ankle sprain symptoms warranted proper radiographic workup. The three rules include (1) bony tenderness at the base of the fifth metatarsal, (2) inability to bear weight, and (3) bony tenderness at the tip of the malleolus. Ultrasound can also be used to assess for ligamentous injury. Computed tomography and magnetic resonance imaging (MRI) are typically utilized only when associated injuries are suspected, including fracture, tendon pathology, osteochondral lesions or fractures, and other ligamentous injuries.

Grading of Lateral Ankle Sprains

Ankle sprains are typically graded as I (no tear), II (partial tear), or III (complete rupture). Lateral ankle ligament injury can also be classified by ligament involvement, including grade I (ATFL stretched), grade II (ATFL torn ± CFL tear), and grade III (ATFL, CFL torn ± capsular tear ± PTFL tear). Clinical grading is subjective and may be inaccurate depending on the amount of pain and swelling of the ankle, especially following an acute injury.

Concomitant Injuries

Lateral ankle sprains may be associated with concomitant intra-articular and extra-articular ankle injuries. Previous studies have demonstrated associated pathology including osteochondral defects, peroneal tendon injuries, deltoid ligament injury, intra-articular loose bodies, and fractures. The most common fractures include those of the fifth metatarsal base, anterior process of the calcaneus, and lateral/posterior process of the talus. Previous studies have reported high prevalence of peroneal weakness in individuals following lateral ankle sprain, with 66% of patients presenting with residual peroneal related symptoms.

Nonoperative Treatment

Early functional rehabilitation is the standard of care for acute lateral ankle sprains. Management typically includes rest, ice, compressions, and elevation (RICE); early range of motion; progressive weight-bearing; and physical therapy. Previous studies have recommended that therapy includes proprioception, range of motion, inversion/eversion strengthening, and peroneal strengthening and that exercises be continued for up to 12 weeks. Kerkhoffs et al. performed a meta-analysis of 2184 adult male and female patients evaluating immobilization versus early functional rehabilitation for the treatment of acute lateral ankle sprains. Early functional rehabilitation was defined as functional treatment with tape, bandages, or wraps that only supported the ankle joint. The authors reported higher return to sports/work, fewer symptoms, better range of motion, and higher patient satisfaction in patients treated with early functional rehabilitation. Surgical intervention is typically reserved for patients who present with persistent lateral ankle instability and pain after nonoperative interventions have failed.

Chronic Ankle Instability

It has been estimated that up to 20%–30% of patients with acute lateral ankle ligament rupture will develop chronic ankle instability. , Patients presenting with recurrent ankle sprains may have persistent ankle instability and pain due to MI or FI. MI results from anatomic changes leading to increased risk of ankle sprain. These include pathologic laxity, impaired kinematics, synovial changes, and osteoarthritis. FI is the presence of symptoms of “giving way,” which is typically attributed to impaired proprioception and sensation, postural control, and strength deficits. MRI can be helpful in these cases to evaluate for other causes of ankle pain, including tendon tears, chondral defects, and ligamentous injuries.

Operative Treatment

Patients who have failed conservative treatment typically require surgical intervention. Numerous surgical techniques for the treatment of chronic lateral ankle ligament instability have been described, along with various modifications of each procedure. Categories of techniques include nonanatomic tenodesis reconstruction, anatomic repair, and anatomic reconstruction. ,

Repair of mid-substance tears of the ATFL was first described by Brostrom ( Fig. 13.2 ) and was later modified to include repair of the CFL and incorporation of the inferior extensor retinaculum and lateral talocalcaneal ligament by Gould.

Aug 21, 2021 | Posted by in SPORT MEDICINE | Comments Off on Ankle Instability

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