Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options?

Abstract

This paper purpose is to suggest an in-depth approach to diagnose the causes and lesions associated with and consecutive to chronic ankle instability due to ankle collateral ligament laxity. The different therapeutic and medicosurgical options adapted to this diagnostic approach are identified. The diagnostic aim is to precisely locate the ligamentous injuries of the tibiofibular, subtalar, talar and calcanean system, to identify the predisposing factors such as the hindfoot morphology, and any lesions associated with chronicity: anterolateral impingement, fibular injury, osteochondral lesions of the talus dome and early osteoarthritis. Clinical tools are used in particular to identify areas of pain and for comparative analysis of mobility and laxity (ligament testing). There are also radiological tests, weight-bearing plain X-ray (stress X-ray), (alignment of the hind foot, with a Meary view [metal wire circling the heel], arthrosis), dynamic images to confirm and quantify laxity (manually, with a Telos device, with patient-controlled varus) and also more sophisticated techniques (ultrasound, CT arthrogramm, gadolinium enhanced MRI, MR arthrogramm) to identify ligament, tendon and cartilage damages. They are adapted to the lesions which have been identified in the diagnostic work-up: conservative first, to treat proprioceptive deficits (a new neuromuscular reprogramming technique which emphasizes muscle preactivation) and any static disorders (plantar orthotics); then surgical, to repair any collateral ligament (or sometimes subtalar) injury with three types of procedures: tightening the capsuloligamentous structures, ligament reconstruction with reinforcement (using the fibrous periosteum, the frondiform ligament (of Retzius) or tendinous reconstruction with the plantaris muscle, the peroneus tertius or even the calcanean tendon) and tendon tansfer procedures using all or part of the peroneus brevis (whole peroneus brevis and half peroneus brevis procedures). Any additional surgical procedures which may be indicated based on the results of the diagnostic work-up are performed at the same time as primary surgery when possible as needed (medial complex repair, calcaneal realignment osteotomies, talus osteochondral injuries debridment or fixation, anterior and posterior impingement suppression, tendon tears repair). The goal of this diagnostic and therapeutic approach is to stop the progression of laxity and to protect the ankle against degenerative arthritis, which is the main risk in these chronic conditions.

Avaliação do torque de resistência passiva em atletas femininas com entorse de tornozelo

“…The injury recurrence presents records above 70% among athletes 7,9,10 .Ankle sprains can be prevented; however, prevention of these injuries will only be possible if the risk factors were identified 2,10,11 . The possible risk factors include: alterations in the foot position 8,12 , deficit in proprioception 2,4,10,11,13,14 , laxity in the lateral ligamentous complex 4,15,16 and muscular weakness 4,9,13 . Better understanding on the sprain injury mechanism will possibly help the health professional, including physiotherapists, to plan an objective and efficient treatment.…”

“…After the sprain occurrence, the ankle ligaments and the articular capsule may become lax and increase articular instability 7,12,13,15 , which favors the recurrence of sprains in inversion. The drawer examination and talar inclination techniques are used to identify ankle articular instability 7,12,15 .…”

“…The drawer examination and talar inclination techniques are used to identify ankle articular instability 7,12,15 . However, the use of these techniques has been questioned, since they involve manual tests and only provide subjective information on the ligamentous laxity.…”

“…However, the use of these techniques has been questioned, since they involve manual tests and only provide subjective information on the ligamentous laxity. The stress radiographic exam in inversion has been traditionally used to quantify the ligament laxity through evaluation of the talus dislocation, but it is an indirect techinque 7,12,15 . Objective evaluation of ligamentous laxity may be performed through the accurate measurement of the passive resistance of the capsule ligamentuss tructures generated by the passive movements of ankle maximal inversion and eversion 16,17 .…”

“…Since ankle sprains can be caused by capsule and ligaments laxity, these structures are able to support only light tension during the extreme movements of the tibiotalar joint 7,12,18 ; therefore, the passive torque may be decreased at the end of the ankle inversion and eversion range of motion. Thus, individuals without ankle sprain history will possibly present higher passive torque than individuals who have suffered sprains.…”