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1/3/21
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Ankle InstabilityKasey Miller, DPT, COMT, Fellow-in-Training
January 2021
About Me
IAOM-US
• Live in Kansas City, MO and work at Modern Physical Therapy• Went to KU Med for PT School and graduated in 2016• Introduced to IAOM during school and have been assistant faculty since
January 2018• Will complete my fellowship this summer
Objectives
� Understand the prevelance and complication of ankle instability
� Identify common types of ankle instability and mechanisms of injury
� Assess for ankle instability
� Organize a plan of care for ankle instability using evidence based approach
� Acknowledge preventative measures to avoid developing ankle instability
IAOM-US
� 50-70% of the people who sustain a lateral ankle sprain (LAS) develop chronic ankle instability
� Symptoms of chronic ankle instability demonstrate an onset as early as 6 to 12 months after initial injury
� Continuation of post-injury symptoms more than 6 months following the initial injury
Chronic Ankle Instability
Hiller CE, Kilbreath SL, Refshauge KM. Chronic ankle instability: evolution of the model. Journal of
athletic training. 2011 Mar;46(2):133-41
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Chronic Ankle Instability: Symptoms
Lingering Pain
Instability
Injury Recurrence
Balance Deficits
Persistent functional disability
Swelling
Giving Way
Impaired strength
Chronic Ankle Instability: Consequences
� Increased ligamentous laxity
� Proprioceptive deficits
� Activity limitations� Up to 72% of people are unable to return to prior level of function
� 85% of people develop problems in the contralateral ankle
Löfvenberg R, Kärrholm J, Lund B. The outcome of nonoperated patients with chronic lateral instability of
the ankle: a 20-year follow-up study. Foot & ankle international. 1994 Apr;15(4):165-9.
Type of Instabilities
Functional Instability
Mechanical Instability
Functional Instability
� Recurrent ankle sprains and frequent sensation of instability
� Examination Findings:� Normal motion
� (-) Ligament laxity testing
� Self-reported symptoms such as weakness and pain
� Injured ankle “feels different”
� Feeling of instability could be attributed to:� Muscle weakness
� Altered muscle recruitment patterns
� Decreased ROM
� Balance deficits
� Impaired proprioception and joint position sense
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Functional Instability Continued
� Those who performed coordination exercises during recovery demonstrated lower incidence of functional instability
� Potential Causes of CAI:� Changes in the motor component of sensorimotor control
� Impaired postural control
� Diminished ankle-eversion strength
� Alterations in motor control of proximal muscles
Functional instability represents the sensorimotor cause of persistent injury
Mechanical Instability
� Pathologic ligamentous laxity around the ankle-joint complex
� (+) Ligamentous laxity testing� Occurs in 30% of patients following the initial ankle sprain
Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Locomotive biomechanics in persons with
chronic ankle instability and lateral ankle sprain copers. Journal of science and medicine in sport. 2016 Jul
Mixture of instabilities
Mechanical Functional
Updated Model of Chronic Ankle Instability
8 Primary components 1. Primary Tissue Injury 2. Pathomechanical Impairments3. Sensory-Perceptual impairments4. Motor-behavioral impairments5. Personal Factors 6. Environmental factors7. Component interactions8. Spectrum of clinical Outcomes
IAOM-US
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IAOM-USHertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl
Train. 2019;54(6):572-588. doi:10.4085/1062-6050-344-18
Primary Tissue Injury
� For CAI to develop, patient must sustain an injury
� Lateral ankle sprains are most common pathology� Anterior talofibular ligament is most commonly injured ligament
� Calcaneofibular ligament is present in more severe ankle sprains
� Other potential injuries from inversion-internal-rotation mechanism of injury
� Fibular fracture
� Fifth metatarsal fracture
� Osteochondral lesion of talus
� High ankle sprain (Anterior inferior tibiofibular ligament and tibiofibular syndesmosis)*
� Subtalar joint instability*
Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train.
2019;54(6):572-588. doi:10.4085/1062-6050-344-18
Considerations of the Subtalar Joint
• Subtalar joint instability appears to be more frequent than is generally assumed.• About 25% of the cases presenting with
combined injuries of the lateral ankle and the subtalar joint.
• In particular, the calcaneofibular ligament (CFL) bridges the subtalar joint and contributes essentially to subtalar joint stability
• Current imaging options do not reliably predict subtalar joint instability.
• Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging.
Mittlmeier T, Rammelt S. Update on Subtalar Joint Instability. Foot Ankle Clin. 2018; 23(3):397-413. Krähenbühl N, et al. Currently used imaging options cannot accurately predict subtalar joint instability. Knee Surg Sports Traumatol Arthrosc. 201; 27(9):2818-2830.
Medial talocalaneal
Cervical
Interosseous
Pathomechanical Impairments� Structural abnormalities to the ankle joint and surrounding
tissues that contribute to ankle dysfunction and CAI
� Pathologic Laxity (Mechanical Instability)� Loss of structural integrity of lateral ankle ligaments
� Talocrural joint laxity� Potential subtalar joint laxity
� (+) Ligament Laxity Tests
� Anterior drawer for ATFL � Inversion Stress Test (10 degrees PF + ADD+ inversion) for CFL
� Squeeze Test: Syndesmosis
� Arthrokinematic Restrictions� Restricted anterior-to-posterior glide of talus on tibia
� Anterior displacement of the talus on the distal tibia
� Osteokinematic Restrictions� Restricted DF
Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train . 2019;54(6):572-588. doi:10.4085/1062-6050-344-18
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Clinical Tip: Anterior Drawer
� Acute LAS: Pull talus anterior via calcaneus
IAOM-US
� Recurrent LAS: Push tibia posteriorly � ATFL: 10 degrees PF
� CFL: Neutral
Sensory-Perceptual Impairments� Conditions that the patient senses or feels about
the body, the injury, or the self
� Diminished Somatosensation� Damage to proprioceptors, ligaments and
possible nerve injury
� Increased proprioceptive errors
� Increased recurring ankle sprains
� Decreased cutaneous sensation
� Poor plantar sensation
� Pain
� Perceived Instability� May be perceived instability
� Cumberland Ankle Instability Tool
� Identification of Functional Ankle Instability
� Fear of movement
Screening Tools
Cumberland Ankle Instability Tool
• Self report frequency and circumstances of perceived instability episodes
• 9 Questions• 1 pain• 8 perceived instability
• Score of < 24/30 considered diagnosis criterion for functional ankle instability
Identification of Functional Ankle Instability
• 10 questions about history and perceived instability• >11/37 for diagnosis criterion
IAOM-US
Foot and Ankle Ability Measure (FAAM)
IAOM-US
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Motor-Behavior Impairments � Deficiencies and alterations in muscle
contractility, motion patterns, and physical activities
� Motor aspect of sensorimotor function
� Altered reflexes� Delayed reaction time of peroneal muscles
� Neuromuscular inhibition� Proximal muscles inhibited such as hamstrings
and quads
� Muscle Weakness� Hip abduction
� Eversion
� Plantar flexion/Dorsiflexion
� Balance Deficits
IAOM-US
Personal Factors
Demographics
Age
BMI
Sex
Medical History
Comorbid factors
Structural deficits due to previous injury
Physical Attributes
Strength and conditioning
Flexiblity
Foot morphotype
Psychological Profile
Self efficacy
Anxiety
IAOM-US
Environment Factors
Societal expectations
and home life
Sports Participation
Access to health care
facilities
Social support
networks
Work Environment
IAOM-US
Spectrum of Clinical Outcomes
IAOM-US
Chronic Ankle Instability
• 12 months removed from initial sprain
• Propensity for recurrent ankle sprains
• Frequency giving way episodesPersistent pain, swelling, weakness
• Pain• Swelling• Weakness
• Feeling unstable
• Changes the type of sport or physical activity they participate in
Coper
• 12 months removed from initial sprain and no recurrent ankle sprains
• minimal symptoms
• minimal deficits in self-reported function
• Full recovery
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IAOM-US
The Development of CAI
IAOM-US
• Advanced age• Neuromuscular control• Previous hx of trauma• Proximal stability• Etc.
Intrinsic Factors
• Court conditions• Opposing players• Uncontrollable environment
Extrinsic Factors
The Development of CAI
IAOM-US
Sensorimotor Deficits Associated with CAI
� Ligamentous structural damage has more effects than anatomical restrictions
� Disrupt afferent-efferent communication
� Central control issues that manifest peripherally
� Doherty et al performed several tests at acute stage following LAS injury to analyze kinematics and kinetics
1. Star Excursion Balance Test (SEBT)
2. Maximum Hip-knee-ankle flexion-extension moments
3. Reach test (Anterior, PL, PM)
4. Landing and drop vertical
5. Gait analysis
6. Self-reported measures (Cumberland Ankle Instability Tool and
Foot and Ankle Ability Measure)
Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Sweeney K, Delahunt E. Inter-joint coordination strategies
during unilateral stance 6-months following first-time lateral ankle sprain. Clinical Biomechanics. 2015 Feb 1;30(2):129-35.
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Associated Deficits with CAI
Static Postural Control Deficits
Dynamic Postural Control Deficits
Gait Deficits
Deficits in Jumping and Landing Tasks
Associated Deficits with CAI
� Lose ankle strategy to maintain static balance
� Utilize hip strategy
� Increase in ROM at the hip joint but decreased ankle ROM
� Difficult for individual to utilize different components of the
kinetic chain individually and they became ”locked”
� Decreased stability with single leg stance
Static Postural Control
Deficits
Dynamic Postural
Control Deficits
Gait Deficits
Deficits in Jumping
and Landing Tasks
Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Sweeney K, Patterson MR, Delahunt E. Lower limb interjoint
postural coordination one year after first-time ankle sprain. Med Sci Sports Exerc. 2015 Mar 31;47(11):2398-405.
Associated Deficits with CAI
� Reduced hip-knee flexion moment and ankle dorsiflexion during star excursion balance test (SEBT)
� Reach distances were reduced in PL and PM directions
� SEBT deficits manifested bilateraly
� Highlight LAS and CAI is not exclusive to peripheral symptoms but
have central manifestations
Static Postural Control
Deficits
Dynamic Postural
Control Deficits
Gait Deficits
Deficits in Jumping
and Landing Tasks
Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Sweeney K, Patterson MR, Delahunt E. Lower limb interjoint
postural coordination one year after first-time ankle sprain. Med Sci Sports Exerc. 2015 Mar 31;47(11):2398-405.
Associated Deficits with CAI
� Reduction of push-off tendencies
� Decreased hip extension
� increased ankle displacement in the frontal plane
Static Postural Control Deficits
Dynamic Postural Control Deficits
Gait Deficits
Deficits in Jumping and Landing Tasks
Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Sweeney K, Patterson MR, Delahunt E. Lower limb interjoint
postural coordination one year after first-time ankle sprain. Med Sci Sports Exerc. 2015 Mar 31;47(11):2398-405.
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Associated Deficits with CAI
� Increase in hip flexion before initial contact (preparation for landing)
� Reduction in hip flexor activity after initial contact
� Hip stiffness and bilateral increased extension moments during landing
� Inter-limb asymmetries� Tendency to off-load injured limb and shift load to non-injured side
� Contralateral injury
Static Postural Control Deficits
Dynamic Postural Control Deficits
Gait Deficits
Deficits in Jumping and Landing Tasks
Doherty C, Bleakley C, Hertel J, Sweeney K, Caulfield B, Ryan J, Delahunt E. Lower extremity coordination and
symmetry patterns during a drop vertical jump task following acute ankle sprain. Human movement science. 2014 Dec 1;38:34-46. IAOM-US
Predicting Chronic Ankle Instability
Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery from a first-time lateral ankle sprain and the predictors of
chronic ankle instability: a prospective cohort analysis. The American journal of sports medicine. 2016 Apr;44(4):995-1003.
W ill your patient develop
CAI after Lateral Ankle
Sprain?
Jumping and Landing
Unable to perform within
2 weeks following injury
Star Excursion Balance
Test
Poor dynamic control in
PL and PM directions
the Foot and Ankle Ability
Measure
Poorer self reported
function
IAOM-US
Four Pillars of Prevention After Initial Sprain
Protection of healing
structures
Evaluate all Joints
Affected by Injury
Correction of Hypomobility
Strategies to correct
hypermobility
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Protection of Healing Structures
Bracing
Kinesiotape
Transverse Friction
Pacing Program
Protection of Healing Structures: Bracing
� Bracing elicited more synchronous motion throughout gait
� Coordination variability decreased with bracing
� Greater pattern stability
� Bracing increases coordination patterns
� May work to guard against malalignment
� Push Brace is our favorite
� Care: Recurring
� Med: Acute or Secondary
Jagodinsky AE, W ilburn C, Moore N, Fox JW, Weimar W H. Ankle Bracing Alters Coordination and Coordination
Variability in Individuals W ith and W ithout Chronic Ankle Instability. J Sport Rehabil. 2020 Mar 4:1-8.
Protection of Healing Structures: Kinesiotape
� Swelling� Lymphatics
� Bruising
� Tenosynovitis
� Weaning off a brace
Jagodinsky AE, W ilburn C, Moore N, Fox JW, Weimar W H. Ankle Bracing Alters Coordination and Coordination
Variability in Individuals W ith and W ithout Chronic Ankle Instability. J Sport Rehabil. 2020 Mar 4:1-8.
Protection of Healing Structures: Transverse Friction
� Fibroblast proliferation
� Collagen Re-alignment
� Analgesic
� Micro lymphatic Drainage
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Transverse Friction Review
Ligament
• Start with 2/10 and progress once pain free• One direction
Tendinitis
• Start 2/10 and progress once pain free• One direction
Tenosynovitis
• Start extremely light and stay light• Tendon on slack• Perform tendon glides after tenderness is reduced
Tendinosis
• Start aggressive and stay aggressive• Both directions• Stimulate blood flow or jumpstart inflammatory response
Protection of Healing Structures: Pacing Program
▪ Acute/Inflammatory Pain increases for hours to 3-4 days▪ Proliferation After 4 days, pain levels off▪ Early remodeling 11 to 21 days▪ Late remodeling 3 to 6 weeks▪ Back to sports 8 to 12 weeks (with supportive device
for up to one year)
Hubbard T and Hicks-Little C. Ankle ligament healing after an acute ankle spring: An evidence-based approack. J Athletic Training. 2008; 43:523-529.
Evaluation of All Joints Affected by Injury
Talocrural Joint Syndesmosis
Subtalar Joint Hip
Knee Proximal Tib-Fib
Correction of Hypomobility
� Can lead to adjacent instability by altering the kinetic chain� Talocrural joint hypmobility may lead to subtalar instability
� Assess� Talocrural joint
� Subtalar joint
� Distal tibiofibular joint
� Proximal tibiofibular joint
� 1st MTP
� Limited Dorsiflexion is common� Anterior translation of talus on tibia
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Correction of Hypomobility
IAOM-US
Talocrural Traction
Talocrural Posterior glide
STJ Medial Glide
Correction of HypermobilityNeuromuscular
Control
Somatosensory Activation
• Proprioception• Balance
Fundamental Performance
Advanced Performance
Functional Advancement
SenmocorTM
Correction of HypermobilityNeuromuscular
Control
Somatosensory Activation
• Proprioception• Balance
Fundamental Performance
Advanced Performance
Functional Advancement
Correction of Hypermobility: Neuromuscular Control
IAOM-US
Neuromuscular Control
Somatosensory Activation
Fundamental Performance
Advanced Performance
Functional Advancement
� Unconscious efferent response to an afferent signal concerning joint stability
� Preparatory (anticipatory) and Reactive (reflexive) activation
� Pre-activating muscles � Short foot
� Pronation control
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Correction of Hypermobility: Somatosensory Activation
IAOM-US
Neuromuscular Control
Somatosensory Activation
Fundamental Performance
Advanced Performance
Functional Advancement � Reflex modulation
� Proprioception
� Balance management
� Postural Control
Correction of Hypermobility: Fundamental Performance
IAOM-US
Neuromuscular Control
Somatosensory Activation
Fundamental Performance
Advanced Performance
Functional Advancement
� Sagittal Plane Control� Flexion/Extension Correctives
� Frontal Plane Control� Abd/Add Correctives
� Transverse Plane Control � Rotational Correctives
Correction of Hypermobility: Advanced Performance
IAOM-US
Neuromuscular Control
Somatosensory Activation
Fundamental Performance
Advanced Performance
Functional Advancement
� Fundamental Movements with ankle stability
� Hinge
� Squat
� Lunge
� Push
� Pull
� Twist
� Ambulation
Correction of Hypermobility: Functional Advancement
IAOM-US
Neuromuscular Control
Somatosensory Activation
Fundamental Performance
Advanced Performance
Functional Advancement
� Agility Strategies
� Performance Training
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IAOM-US IAOM-US
Tests for Ankle Instability
TalocruralStress Test
Anterior Drawer
Syndesmosis
Squeeze Test
External Rotation Test
�Max PF + Inversion = ATFL
� 10 deg PF + Inversion = CFL
�DF + Inversion = PTFL
Tests for Ankle Instability: Stress Test
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▪ Anterior Drawer▪ 10 degrees PF: ATFL ▪ Neutral: CFL ▪ 15 degrees DF + Neutral: CFL
▪ DF Laxity < Neutral laxity = ATFL ▪ DF Laxity = Neutral laxity = CFL
JM Hollis, et al. Simulated Lateral Ankle Ligamentous Injury - Change in Ankle Stability. American Journal of Sports Medicine. 1995;23:672-677.
Tests for Ankle Instability: Anterior Drawer Tests for Anterior Instability: Squeeze Test
IAOM-US
IAOM-US
Tests for Ankle Instability: External Rotation Test
IAOM-US
Case Review
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Ankle-Foot Case: WHO
WHO:• 64-year-old female, retired high school teacher. • Daily activities include housework and volunteering
at the local senior center. • She generally enjoys traveling both within the
United States and internationally. • She notes that she has been able to ride her
stationary bicycle with minimal discomfort, and it actually seems to help her symptoms.
Photo by BBH Singapore on Unsplash
Ankle-Foot Case: WHAT & WHERE
WHAT:• Dull aching at the right ankle,
with warmth and swelling; burning pain at the distal foot.
WHERE:
• Patient places her hand at the anterolateral aspect of the ankle to indicate her aching pain, where it also feels swollen and warm.
• Pain in her foot is located at the dorsum and plantar aspect of the distal foot between the 2nd and 3rd metatarsal and refers proximally along the sole of the foot.
How does this apply to Instability?
• A previous history of ankle sprain may have led to• Laxity of the tibiofibular syndesmosis leading to increase
loads on the TCJ• Leading to early osteoarthritis of the TCJ
• Potential insufficiency of the anterior talofibular ligament leading to flat foot• Leading to Morton’s neuroma
• This is further complicated by the slight knee valgus due to early osteoarthrosis, promoting the hyperpronation, which can lead to a hypermobile 1st ray• And that can lead to increased load on the metatarsals,
and perpetuate the Morton’s neuroma
Treatment Ideas
IAOM-US
• TCJ• STJ• Midfoot• Knee • Hip
Joint Dysfunction
• Tib Post• Foot intrinsics
Muscle Dysfuncion
• Balance• Proprioception• Reflexes • Anticipatory
Sensorimotor Control