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Lateral Ankle Pathology. Brent Ricks DPM . Overview. Anatomy Clinical presentation Ankle Sprain classification Conservative treatment Surgical treatment Conclusion. Anatomy 8,11. Anterior Talofibular Ligament

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lateral ankle pathology

Lateral Ankle Pathology

Brent Ricks DPM

  • Anatomy
  • Clinical presentation
  • Ankle Sprain classification
  • Conservative treatment
  • Surgical treatment
  • Conclusion

anatomy 8 11
  • Anterior Talofibular Ligament
    • Intracapsular 10mm proximal from the Fibular tip
    • Controls anterior movement of Talus
    • Most important stabilizer for inversion
    • Anatomically weakest of the three lateral ankle ligaments Involved three times more than the CFL
  • Calcaneofibular ligament
    • Most important stabilizer of STJ
    • Extracapsular deep to Peroneals
  • Posterior Talofibular ligament
    • Intracapsular
    • Rarely injured
  • Peroneal tendons

clinical presentation 8 10 11 12 15
Clinical Presentation8,10,11,12,15
  • Subjective
  • 85% acute ankle sprains are plantarflexion inversion
  • 10-40% of Acute ankle sprains will continue to chronic ankle instability
  • Pain, weakness, crepitus, instability, swelling, stiffness
  • Objective
  • Rearfoot varus, plantar flexed first ray, Cavus foot
  • Peroneal tear and or strength deficit
  • STJ instability in 10-75%
  • Tibiofibular syndesmosis
    • Injured 1-18% in ankle sprains, most commonly seen in collision sports
    • Pain in anteriolateral ankle with increased pain with dorsiflexion
    • Frick test; Hold foot in neutral and externally rotate the foot on a fixed leg. Pain over the syndesmosis (recreates the mechanism of injury)
    • Squeeze Tibia and Fibula together at midpoint of calf. Pain is at distal Tib-Fib syndesmosis
  • Anterior Drawer
    • Suction or Sulcus sign over ATFL
    • 10mm bil or 3mm difference
  • Talar Tilt (CFL)
    • 9 degree absolute, 3 difference
  • Talar dome lesions/Ankle arthritis
    • (20/30, 8/28)

ankle sprain classification 2
Ankle Sprain Classification2
  • Grade 1- Little swelling and tenderness, minimal or no functional loss, no mechanical joint instability
  • Grade 2- Moderate pain, swelling over the involved structures, loss of some joint motion with mild to moderate joint instability
  • Grade 3- complete ligament rupture with marked swelling, hemorrhage and tenderness, loss of function, joint motion and instability

conservative treatment 2 3 4 5 9
Conservative treatment2,3,4,5,9
  • RICE until swelling and pain resolves then ankle mobilization and early weight bearing
    • Cryotherapy with in 36 hours returned to full activity in 13.2 days vs. 30.4 days beginning after 36 hours
  • Taping effectiveness decreases 40% after 10min of exercise, no significant support after 60 min.
  • Taping helps minimize motion, if previously injured more than to an uninjured ankle, within 30 min window
  • Ankle braces demonstrate no significance with those who had a previous injury in high school volleyball.
    • A rigid brace in previously uninjured females may help

conservative treatment 1 2
Conservative Treatment1,2
  • PT
    • Grade 1-2- A functional program should start immediately (3 weeks after injury to maximize collagen content)
    • Unilateral stance on a soft surface for kinesthetic awareness
    • Agility ladder for timing coordination
    • Tilt board for proprioceptive and Peroneal strengthening to improve functional instability (giving out)
    • Plyometric exercises (eccentric loading immediately followed by concentric contraction) are more effective in increasing functional performance than strength training
      • Complex series of hops and jumps
    • Strength training
      • Inversion, eversion, dorsiflexion, plantarflexion against resistance; Heel rise/ toe rise; towel curl, marble pick up
    • Activities without PT monitoring resulted in less effectiveness and were performed correctly 50% of the time

conservative treatment 6 7
Conservative Treatment6,7
  • Orthotics
  • Pt with chronic ankle instability have lateral foot biased weight distribution in walking and barefoot running
  • Any medial ground reactive force should be avoided.
    • High arched Pt that flattens with weight bearing should get maximum arch fill on cast
  • Oblique valgus post
    • Reduce PTF and CFL tension
    • 3 degrees for Pt with Calcaneous aligned under leg, more for pes cavus
  • Valgus forefoot post
  • Cuboid pad to decrease ATFL tension
  • Lateral clip

surgical treatment 8 11
Surgical Treatment8,11
  • Brostrom-Gould
    • Midsubstance repair
    • Incorporation of inferior extensor retinaculum
    • Mild to moderate instability
    • 85-95% effective in treating chronic instability
    • Superior to tenodesis for functional outcomes,r:0,s:0&tx=90&ty=67


Kang SK et al. Long-Term Results After Modified Brostrom Procedure Without Calcaneofibular Ligament Reconstruction. Foot and Ankle International. 2011 (32) 153-157

  • 26/30 male patients
  • Average age 23
  • 80% high level or amateur athletes
  • 6 months conservative treatment with more than 15mm anterior drawer
  • ATFL repair at anterior fibular border with extensor retinaculum anchor to periosteum.
  • Short leg cast 4 weeks
  • Air Cast ankle brace 2 weeks
  • At 4 weeks gentle ROM
  • PT at 6 weeks
  • Full weightbearing when full ankle ROM reached


Kang SK et al. Long-Term Results After Modified Brostrom Procedure Without Calcaneofibular Ligament Reconstruction. Foot and Ankle International. 2011 (32) 153-157

  • Follow up 10.6 years
  • Excellent (asymptomatic, full activities)
    • 12/30 patients
  • Good (some symptoms, full activity)
    • 16/30 patients
  • Fair (symptomatic not fully functioning)
    • 2/30 patients (re-injured)
  • No statistical difference in ROM in contralateral ankle
  • Anterior Drawer
    • Grade 0 (<5mm) - 13
    • Grade 1 (5-10mm) - 13
    • Grade 2 (10-15mm) - 4

surgical treatment 8 111
Surgical Treatment8,11
  • Chrisman-Snook
    • Split Peroneous Brevis does not result in loss of eversion strength
    • 80% good to excellent results
    • Indications
      • Failed Brostrom, significant instability, Morbidly obese, STJ instability
    • Non-weight bearing 4 weeks followed by protected weight bearing as tolerated
    • Non-weight bearing 1 week. CAM boot with advancement of weight bearing until 6th week. Light exercise until 3months out.
    • Free Semitendinosus allograft anchored to the lateral Talar neck
    • Gracilis tendon autograft

Watson Jones


Klammer et al. Percutaneous Lateral Ankle Stabilization: An Anatomical Investigation. Foot and Ankle International. 2011 (32)
  • Cadavaric study, 11 feet, Gracilis graft
  • 5mm incision at the anterior margin of the Fibula 10-15mm proximal of the Fibular tip
  • Guide wire into the Talar neck used to guide the bone tunnel
  • Tendon graft inserted and secures with absorbable interference screw
  • Fibular tunnel then created at the same level
  • Second incision made at the posterior Fibular tunnel and graft passed
  • 3rd incision at the insertion of CFL, Posterior and superior to Peroneal tubrical, and tunnel through Calcaneous made
  • Tendon passed and secured
  • Medial Calcaneal Branch of the Tibial nerve hit 2/11. No other nerovascular structures were compromised

surgical treatment 9
Surgical Treatment9
  • Peroneal Repair
  • Brevis more commonly involved
    • Less than 50% of tendon torn
      • primary repair, debridement, tubularization
    • More than 50% torn
      • Tendon grafting
      • Side to side anastomosis
    • Tendonosis
      • Debridement
      • Topaz, PRP, etc

  • RICE with immobilization and NSAID, PT
  • Orthosis and braces
  • Consider all structures of lateral ankle, best viewed with MRI
  • Brostrom Gould for ATF and CFL repair and augmentation
  • If that fails, STJ instability, obesity; Tenodesis
  • Hawson ST. Physical Therapy and Rehabilitation of the Foot and Ankle in the Athlete. Clin Podiatr Med Surg. 2011; 189-201
  • Ismail MM; Ibrahim MM; Youssef EF; El Shorbagy KM. Plyometric Training Versus Resistive Exercises After Acute Lateral Ankle Sprain. Foot and Ankle International. 2010; (31) 523-530
  • Frey C; Feder KS; Sleight J. Prophylactic Ankle Brace use in High School Volleyball Palyers: A Prospective Study. Foot and Ankle International. 2010; (31) 296-300
  • Hubbard TJ; Cordova M. Effect of Ankle Taping on Mechanical Laxity in Chronic Ankle Instability. Foot and Ankle International 2010; (31) 499-504
  • Lyrtzis C; Natsis K; Papadopoulos C; Noussios G; Papathanasiou E. Efficacy of Paracetamol Versus Diclofenac for Grade 2 Ankle sprins. Foot and Ankle International. 2011; (32) 501-575
  • Morrison KE; Hudson DJ; Davis IS; Richards JG; Royer TD; Dierks TA; Kaminski TW. Plantar Pressure During Runnig in Subjects with Chronic Ankle Instability. Foot and Ankle International. 2010 (31) 994-1000
  • Rosenbloom KB. Pathology-Designed Custum Molded Foot Orthoses. Clin Podiatr Med Surg. 2011 (28) 171-187
  • Hentges MJ; Lee MS. Chronic Ankle and Subtalar Loint Instability in the Athlete. Clin Podiatr Med Surg. 2011 (28) 87-104
  • Franson J; Baravarian B. Lateral Ankle Triad: The triple Injury of Ankle Synovitis, Lateral Ankle Instability, and Peroneal Tendon Tear. Clin Podiatr Med Surg. 2011 (28) 105-115
  • Soomekh DJ. New Technology and Techniques in the Treatment of Foot and Ankle Injuries. Clin Podiatr Med Surg. 2011 (28) 19-41
  • Schenck RC; Coughlin MJ. Lateral Ankle Instability and Revision Surgery Alternatives in the Athlete. Foot Ankle Clin N AM. 2009 (14) 205-214
  • Lee KT; Park YU; Kim JS; Kim JB; Kim KC; Kang SK. Long-Term Results After Modified Brostrom Procdure Without Calcaneofibular Ligamnet Reconstruction. Foot and Ankle International. 2011 (32) 153-157
  • Klammer G; Schlewitz G; Stauffer C, Vich M; Espinosa N. Percutaneous Lateral Ankle Stabilization: An Anattomical Investigation. Foot and Ankle International. 2011 (32) 66-70
  • Irwin TA; Anderson RB; Davis WH; Cohen BE. Effect of Ankle Arthritis on the Clinical Outcome of Lateral Ankle Ligament Reconstruction in Cavovarus Feet. Foot and Ankle International. 2010. (31) 941-948