1. ANKLE INSTABILITY AND ASSOCIATED PATHOLOGIES Brian A. Weatherby, MD Assistant Professor University of South Carolina School of Medicine Greenville Hospital System University Medical Center

2. 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

3. Case Presentation Physical Exam –PROM Ankle (comparison)  Limited DF Pain at extreme DF –PROM Subtalar & Transverse Tarsal (comparison)  WNL

4. Case Presentation Physical Exam: –+ Anterior Drawer Exam (comparison) Reproduction of Pain  Intra-articular Pathology

5. Case Presentation Physical Exam: –+ Talar Tilt (comparison)

6. Case Presentation Physical Exam –TTP over antero-lateral ankle joint TTP over antero-medial joint (intra-articular?)

7. Case Presentation Physical Exam –+ Single Leg Squat Test

8. Case Presentation Physical Exam –NO Posterior Impingement

9. Case Presentation Physical Exam –NO Cavus Foot deformity –NO Generalized Ligamentous Laxity

14. 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

15. Anatomy

16. Anatomy/Biomechanics

17. 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

18. Initial Treatment Bracing Orthotics (Cavus Foot)

19. 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

20. 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)

21. Surgical Repair Brostrom-Evans –Girard et al., FAI 1999 > 250 lbs > 10 years instability Ligamentous Laxity Heavy laborer

22. 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

23. 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

24. 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 ????

25. 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

26. Associated Pathology Okuda et al., AJSM 2002 –63% chondral lesions Hintermann et al., AJSM 2005 –66% chondral lesions ANKLE ARTHROSCOPY  VITAL ADJUNCT PROCEDURE

27. Associated Pathology Tarsal Coalition  Resection/Arthrodesis Dislocating Peroneal Tendons  Repair

28. Associated Pathology Cavovarus Foot –Subtle Cavus Foot  Correction Ligamentous Laxity  Augmented repair

29. 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