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ANKLE INSTABILITY AND ASSOCIATED PATHOLOGIES. Brian A. Weatherby, MD Assistant Professor University of South Carolina School of Medicine Greenville Hospital System University Medical Center. Case Presentation. 16 y/o Female Cheerleader

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ankle instability and associated pathologies

ANKLE INSTABILITY AND ASSOCIATED PATHOLOGIES

Brian A. Weatherby, MD

Assistant Professor

University of South Carolina School of Medicine

Greenville Hospital System University Medical Center

case presentation
Case Presentation
  • 16 y/o Female Cheerleader
    • Multiple twisting injuries to ankle while stunting/tumbling
    • Tx = RICE, PT, bracing, taping
    • CANNOT perform 2° to pain with impact loading & repeated instability (in brace)
      • Recent onset of pain and “pinching” with walking
case presentation1
Case Presentation
  • Physical Exam
    • PROM Ankle (comparison)  Limited DF
      • Pain at extreme DF
    • PROM Subtalar & Transverse Tarsal (comparison) WNL
case presentation2
Case Presentation
  • Physical Exam:
    • + Anterior Drawer Exam (comparison)
      • Reproduction of Pain  Intra-articular Pathology
case presentation3
Case Presentation
  • Physical Exam:
    • + Talar Tilt (comparison)
case presentation4
Case Presentation
  • Physical Exam
    • TTP over antero-lateral ankle joint
      • TTP over antero-medial joint (intra-articular?)
case presentation5
Case Presentation
  • Physical Exam
    • + Single Leg Squat Test
case presentation6
Case Presentation
  • Physical Exam
    • NO Posterior Impingement
case presentation7
Case Presentation
  • Physical Exam
    • NO Cavus Foot deformity
    • NO Generalized Ligamentous Laxity
ankle sprains
Ankle Sprains
  • Incidence = 1 in 10,000 persons per day
    • 21% of athletic injuries  ankle
    • 45% of those  basketball
    • Majority = Inversion & PF
  • 15-20%  Pain & Dysfunction
slide17

Initial Treatment

  • Functional Rehabilitation Protocol
    • Renstrom et al. Sports Med 1999
      • “Functional treatment produced no more sequelae than casting with or without surgical repair. Secondary surgical repair, even years after an injury, has results comparable to those of primary repair.”
    • Pihlajamaki et al. JBJS 2011
      • Return to pre-injury level same for FRP & Surgery
      • Surgery did ↓ re-injury but had ↑ incidence of arthritic changes
initial treatment
Initial Treatment
  • Bracing
  • Orthotics (Cavus Foot)
surgical indications
Surgical Indications
  • Failed APPROPRIATE non-op treatment
    • Persistent instability/recurrent Gr II/III sprain
    • Activity related pain > 3 months
      • Correlate with MRI findings
  • Instability episodes with ADL’s
  • Continuous bracing not possible (work/skin)
  • NOT isolated pain
    • OCD
    • Loose body
    • Impingement
surgical repair
Surgical Repair
  • Brostrom-Gould Technique (Modified Brostrom)
    • Hamilton et al., FAI 1993
      • 96% good to excellent
    • Lee et al., FAI 2011
      • 94% good to excellent (w/out CFL)
surgical repair1
Surgical Repair
  • Brostrom-Evans
    • Girard et al., FAI 1999
      • > 250 lbs
      • > 10 years instability
      • Ligamentous Laxity
      • Heavy laborer
associated pathology
Associated Pathology
  • Soft Tissue Impingement
  • Wolin et al (1950)
    • “mensicoid lesion”
  • Ferkel et al (1990)
    • “meniscoid tissue” = hyaline cartilage with degenerative change and fibrosis
    • Synovial hyperplasia, subsynovial capillary proliferation
associated pathology1
Associated Pathology
  • Soft Tissue Impingement
    • Bassett et al (1990)
      • Fibrotic thickening of the inferior slip of AITFL
      • Chronic rubbing may result in chondromalacia on talus
associated pathology2
Associated Pathology
  • Osseous
    • Osteochondral Defect of Talus (postero-medial)
    • Bony Impingement
    • Loose Bodies

Repetitive Subluxation Episodes (coronal & sagittal)Micro Trauma to bone/chondral surface Inflammatory Rxn/Insult ????

associated pathology3
Associated Pathology
  • Taga et al., AJSM 1993
    • 95% intra-articular pathology
  • Komenda & Ferkel, AJSM 1999
    • 93% intra-articular pathology
  • Choi et al., AJSM 2008
    • 96% intra-articular pathology
associated pathology4
Associated Pathology
  • Okuda et al., AJSM 2002
    • 63% chondral lesions
  • Hintermann et al., AJSM 2005
    • 66% chondral lesions

ANKLE ARTHROSCOPY  VITAL ADJUNCT PROCEDURE

associated pathology5
Associated Pathology
  • Tarsal Coalition

Resection/Arthrodesis

  • Dislocating Peroneal Tendons

Repair

associated pathology6
Associated Pathology
  • Cavovarus Foot
    • Subtle Cavus Foot

 Correction

  • Ligamentous Laxity

Augmented repair

summary
Summary
  • Chronic ankle instability WILL develop in a certain # of athletes sustaining sprains
  • Mainstay in treatment is FRP & bracing
  • ALWAYS be aware of, recognize, and address associated pathologies
  • Ankle Ligament Reconstruction + Ankle arthroscopy is the GOLD STANDARD for surgical treatment