Br_j Sports Med 1997;31:1 1-20

Ankle ligament injuries

Per A F H Renstr6m, Lars Konradsen

Injuries to the ligaments of the ankle are oftencalled "low ankle sprains". If the tibiofibularligament or the syndesmosis is injured it iscalled a "high ankle sprain".

Inversion sprains with injury to the lateralligaments of the ankle/foot complex are by farthe most common. They occur with anestimated frequency of one injury per 10 000people per day, amounting to about 27 000injuries each day in the United States.' 2Although many injuries are treated outsidemedical establishments, 7-10% of those whoare visiting the emergency departments of thehospitals in Scandinavia have sprained ankles.3Ankle injuries are the most common injuries

in sports and recreational activity.i"12 For thisreason, probably, these injuries tend to occurprimarily to young people.'3 The sprainedankle also remains the most common injuryregardless of whether the sport is primarily anupper or a lower extremity sport. Garrick7noted that injuries to the ankle accounted for53% of injuries occurring during basketballand for 31% of those occurring during soccer.Reviewing 41 soccer teams, Ekstrand andTropp'4 found ankle sprains to account for 17 to21% ofthe injuries. The "high ankle sprain" usu-ally occurs as the result of an eversion injury incombination with fractures or lesions to thedeltoid ligament. Isolated syndesmosis injuriesoccur in 3% of the cases. This article will dealmainly with the lateral ligament complex.

Department ofOrthopaedics andRehabilitation,McClureMusculoskeletalResearch Center, TheUniversity ofVermont,Stafford Hall 428B,Burlington, Vermont05405-0084 USAP A F H Renstr6m

Department ofOrthopaedics,Gentofte Hospital,University ofCopenhagen,Copenhagen, DenmarkL Konradsen

Correspondence to:Dr Renstrom.

Accepted for publication17 December 1996

Ankle biomechanicsThe passive stability of the ankle is the respon-sibility of the ligaments and the bony con-

straints of the ankle joint, while the active sta-bility depends on muscular support. The talushas no muscular insertion. Active motiondepends on the long foot muscles inserting intoother tarsal or metatarsal bones. Dorsiflexionand inversion are effected by the extensor hal-lucis longus and the anterior tibial muscles.Dorsiflexion and eversion are guided by theperoneus tertius muscles and extensor digito-rum longus and brevis muscles. Plantar flexionand eversion are effected by the peroneus lon-gus and brevis muscles. Plantar flexion andinversion are regulated by the flexor hallucislongus, the flexor digitorum, and the posteriortibial muscles.'5The ligaments of the ankle can be divided

into the lateral group, the medial group, andthe ligaments of the syndesmosis.The lateral ankle ligament complex is

traditionally considered to consist of theanterior talofibular (ATFL), the calcaneofibu-lar (CFL), and the posterior talofibular(PTFL) ligaments. However, in inversion thesubtalar ligaments, especially the cervical

ligament, the interosseous ligament, and theligaments spanning the calcaneocuboid and thetalonavicular joints, also have to be considered.Many studies have been done on talotibial

ligaments to gain insight into how theyfunction together to stabilise the joint. Of thetalotibial ligaments, the ATFL is a thin 6-10mm wide, 20 mm long, and 2 mm thick'6 weakligament, being essentially a thickening of theanterior ankle joint capsule. It passes from thedistal anterior origin of the lateral malleolus tothe talus in front of the proximal part of thelateral articular surface. In neutral position itsdirection is parallel to a long axis of the footand in full plantar flexion it is more parallelwith the tibia (fig 1). The CFL is a 20-25 mmlong rounded ligament with a diameter of 6-8mm.'6 It is an extra-articular ligament closelyassociated with the peroneal tendon sheath. Itruns obliquely downwards and backwards tobe attached to the lateral surface of thecalcaneus. There is a great variety in itsdirection and in its attachment sites."' Arupture to this ligament will also cause arupture of the tendon sheath, and occasionallyalso damage the peroneal tendons.The ATFL acts as a primary restraint against

plantar flexion, as well as internal rotation ofthe foot.'7 In strain studies Renstrom et al"found that the strain of the ATFL significantlyincreases with increasing plantar flexion. In theneutral position the ligament is relaxed.'9The CFL does not have an independent role

in talotibial joint stability, but acts instead as aguide for the axis of subtalar motion.'7 In dorsi-flexion the ligament has increased strain.'8 In anormal standing position the ligaments remainrelaxed.The lateral talocalcaneal (LTCL) extends

from the talus to the calcaneus and blends itsfibres with CFL and ATFL fibres. The exactincidence of injury to this ligament is notknown. Transecting the subtalar ligamentsresults in very limited increase in motion whenmeasured in degrees, but as they have very lim-ited motion in the first place the increase afterrupture is about 40%.2° The incidence of rup-ture here is also unknown.The PTFL connects the posterolateral tu-

bercle of the talus to the medial aspect of thelateral malleolus. The PTFL has an averagediameter of 6 mm. In plantar flexion and in theneutral position the ligament is relaxed,whereas in dorsiflexion the ligament istensed.'5 The clinical significance of PTFLinjuries is somewhat unclear, but it is not com-monly damaged. The ATFL, CFL, and PTFLligaments function as a unit for the talotibialcomplex, though one may resist a specificmotion depending upon foot position.2'

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Figure 1 (A) Anterior talofibular (at]) ligament runs parallel to the axis of the foot whenthe foot is in neutral position. Cf = calcaneofibular ligament. (B) When the foot is inplantarflexion, the anterior talofibular ligament assumes a course parallel to the axis of thetibia and fibula.

Through the full range of motion the ATFLand CFL act in synergy22"2 (fig 1). As the footplantar flexes, the strain in the ATFL increaseswhile the strain in the CFL decreases.'8 Shybutet a125 measured ankle ligament loads directlyby using implanted buckle transducers. Theresults indicated that ligament loads remainlow within the functional range of motion (10degrees of dorsiflexion to 20 degrees of plantarflexion). This supports the concept that ankleligaments act as kinematic guides rather thanprimary restraints during normal activity.

Stormont et al26 studied the stabilisingcapacity of the ligaments and articular surfacein the ankle with and without physiologicalloading. With loading, the results indicatedthat the articular surface becomes an impor-tant stabiliser, accounting for 30% of stabilityin rotation and 100% of stability in inversion.Without loading, the results indicated that theprimary and secondary ligamentous con-

straints vary with testing modes and ankleposition.

Mechanism of injuryThe extent of tissue damage that will occur

with the trauma depends not only on themechanism and magnitude of the forces thatact on the ankle but also on the position of thefoot and ankle during the trauma.'5The most common mechanism causing

lateral ligament injuries is a situation where theankle goes into a combination of plantarflexion and inversion. The ATFL tears first fol-lowed by rupture of the anterolateral capsule.With further inversion, the CFL will beruptured followed by variable injury to thePTFL and the anterior part of the deltoid liga-ments.27With weight bearing, the articular surface

can provide 30% of stability in rotation, and100% stability in inversion.26 This ability is a

function not only of the axial load but also ofthe close packed position.28 Ankle destabilisa-tion thus occurs during loading and unloading,but the joint is stable once it is fully loaded.

Frequency of lesions caused by inversionsprainsOwing to the ATFL's vulnerable position inplantar flexion, it is the most commonlyruptured ligament in a lateral anklesprain..323 29-34 In 1964 Brostrdm'6 surgicallyexplored 105 sprained ankles and found anisolated ATFL tear present in about two thirdsof the cases. The second most common injurywas a combined rupture of the ATFL andCFL, occurring in about 20 to 25% of thecases.'3 1634 Other isolated ligamentous injuriesare relatively uncommon.'316 The PTFL, forinstance, is a very strong ligament and is rarelyinjured except in severe ankle trauma.2935Ligamentous lesions after acute inversion

sprains cannot, however, be seen in such a lim-ited scope. Thus Brostr6m'3 noted that in agroup of 321 patients with acute ankle sprains,19% had signs of injury to the bifurcate or thedorsal calcaneocuboid ligaments, or both.Gerner-Smidt36 in a combined study of chil-dren and adults found that 22% of the patientssustained lesions to the talonavicular or thecalcaneocuboid ligaments, or both, andHolmer et alP7 found clinical evidence ofisolated calcaneocuboid/calcaneocervical ortalonavicular ligament lesions in 15-25% ofinversion injuries. Meyer et ar' evaluated 40patients with acute ankle sprains (it is notmentioned, but they must have been consid-ered clinically grade II to III) with subtalararthrograms.39 Apart from lesions to the lateraltibiotalar joint ligaments, 17 patients (43%)showed contrast leaks into the sinus tarsi, sug-gesting interosseous ligament rupture. Some ofthese patients were operated on and the cervi-cal ligament was often found to be severed too.

Chondral or osteochondral lesions of thetalar dome have been noted by Taga et al'0 in89% and by van Dijk'` in 66% of acuteinversion injuries. In 1991 Grana"4 foundchondral lesions in 80% and osteochondrallesions in 6.5% of acute ankle injuries. Lesionsto peroneal tendons ranging from total tendonrupture or insertion site fracture to longitudi-nal slits occur, and the tendon injuries areoften overlooked.42 Injury to the superficial anddeep peroneal nerves ranging from the rarecondition of complete nerve palsy4344 to, whatseems to be much more common, discreteconduction velocity changes have beennoted.4546 In rarer cases fractures to the cuboid,the anterior process of the calcaneus, and thelateral process of the talus have been diagnosedafter an inversion injury.4749

Grading lateral ligament injuryClinically, sprains of the lateral ankle have beenclassified in three groups based on severity.4 Agrade I injury involves stretch of the ligamentwithout macroscopic tearing, little swelling ortenderness, slight or no functional loss, and nomechanical instability of the joint. A grade IIinjury is a partial macroscopic tear of the liga-ment with moderate pain, swelling, andtenderness over the affected structures. Someloss of motion and mild or moderate instability

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of the joint occurs. In a grade III injury, there iscomplete rupture of the ligament with severeswelling, haemorrhage, and tenderness. Thereis loss of ability to bear weight on the foot, lim-ited function, and considerable abnormalmotion and instability of the joint. An im-proved and validated classification of anklesprains is needed. The terms mentioned abovewere validated by Lindenfeld50 and found to bequite subjective. Others prefer to classify lateralligament injuries as single or double ligamenttears. A single injury would imply lesions toonly the ATFL, a double injury would affectboth the ATFL and the CFL. The distinctionin clinical terms is difficult here also.

DiagnosisDiagnosing the extent of an acute lateralligament injury is not considered very accuratebecause of pain, swelling, and muscle tender-ness.'5 In the first few days after injury localpalpational pain is often diffuse, with no maxi-mal point of tenderness.' 5152 The extent ofswelling does not depend only on the magni-tude of the ligamental injury but also on theinitial treatment. Extensive swelling is a predic-tor of ligament rupture, but the positivepredictive value has been found to be only60-70%.5 The characteristic haematomasuggesting ligament rupture usually does notdevelop during the first few days, and jointrange of motion is mainly determined by theseverity of pain and does not differ betweensimple sprains and ligament rupture.5455 Fur-thermore, the interobserver variation of theacute examination concerning tenderness,swelling, discoloration, and the anterior drawersign is considerable.56 The anterior drawer signseems to be a good predictor of lateral ligamentdisruption. Brostrom30 found that the anteriordrawer sign was positive in all of 239 patientswith ligament rupture. His examination was,however, done with general or local anaesthe-sia. Without anaesthesia he could only elicit apositive drawer sign in two patients. Based onthese results van Dijk57 suggests that thephysical examination should be delayedfour to five days after the initial injury.The specificity and sensitivity of delayed physi-cal examination for the presence or absence ofa rupture to the ATFL were found to be 84%and 96% respectively, and the delayed examin-ation, done by observers of varying degrees ofexperience, gave information of ligament qual-ity that equalled that of arthrography. Afterfour to five days a combination of tenderness atthe level of the anterior talofibular ligament,lateral haematoma discoloration, and a positivedrawer sign indicated a ligament lesion in 95%of the cases. A negative drawer test and theabsence of discoloration always indicated anintact ligament.

Radiographs to exclude fractures are sug-gested according to the Ottowa strategy forankle injury.58 Plain radiographs are taken ifthere is bone tenderness at the tip or posterioraspect of the lateral malleolus, at the tip orposterior aspect of the medial malleolus, at the

navicular tuberosity or at the base of the fifthmetatarsal, or if the patient is unable to bearweight immediately after injury and at the ini-tial examination. With these rules the authorscould reduce the use of radiographs from 80%to 63% of the injuries.

Treatment of lateral ligament lesionsTREATMENT OF GRADE I AND II SPRAINS

In the presence of a grade I or grade II injury itis universally agreed that recovery is fast withnon-operative management and the prognosisis good.455'5 Jackson et at5 found that earlymobilisation resulted in a disability of eightdays for a grade I and 15 days for a grade IIinjury. Functional treatment includingearly motion and use of ankle support andearly weight bearing is today the acceptedtreatment for grade I and II ankle sprains.

TREATMENT OF GRADE III SPRAINS

In the case of grade III lateral ligament lesionsthe treatment of choice that is, whether tooperate, to immobilise in a cast, or to allowearly controlled mobilisation, is more contro-versial. The key consideration being thequestion of whether ligament healing withadequate tension can be achieved equally wellwith early controlled mobilisation as withdirect visualisation and suturing.

If the ankle is kept from excess inversion ordorsal or plantar flexion the strain in the lateralligaments remains low,'8 allowing for adequatehealing conditions without elongation withinthis range of guided motion. With the develop-ment of lower extremity magnetic resonanceimaging scanning, studies have visualised thattotal ligament (grade III) ruptures do heal withligamental continuity if there is early mobilisa-tion. There is thus experimental evidence sup-porting ankle ligament healing in the presenceof early mobilising treatment.

Clinically many uncontrolled, non-randomised studies have shown mechanicalstability and satisfactory subjective results afterboth operative and conservative treatment. Ofthe many papers available, only 12 could beconsidered prospective and randomised30 55 60-69when a comparison between operative andconservative treatments was performed byKannus and Renstr6m.35 Six of these consid-ered the three treatment groups in question:operation, immobilising and early mobilisingmodalities30 62 63 65 66 69 and the results and con-clusions based on these reports will bementioned in the following. Duration of followup ranged from six months to 3.8 years, whichis considered adequate time to identify persist-ent disability. Results were evaluated usingselected outcome parameters. Return to workor physical activity was reported in four of thestudies that included three treatment modali-ties.30 6166 69 They concluded that return to workwas two to four times faster after functionaltreatment than after operation or immobilisa-tion in a cast. Return to pre-injury level ofactivity was found to be faster after conserva-tive treatment than after operative treatment infour cases.6 62 66 69 The opposite was found in

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three studies.0 55 63 and no difference was foundin the remaining five.

Pain, swelling, or stiffness with activity couldbe evaluated in four of the studies involvingthree treatment groups.62636669 The studiesfailed to show any differences. In the threestudies that included three therapy groups andincluded mobility of the ankle,306669 mobilitywas found to be superior after functional treat-ment compared with the other two methods.

Better mechanical stability has been the pri-mary argument for operation. Assessment ofmechanical stability calls for an objectivemeasurement with the evaluation of talar tiltand anterior drawer on stress radiographs.Based on five studies evaluating the threedifferent treatments,62 65 66 68 69 equal stabilityresults were found.

Functional instability is not a well definedentity but designates repeated inversion inju-ries that are either unprovoked or the result ofvery little provocation. Functional instabilityseems to be a late disability in 15 to 60% of lat-eral ligament injuries depending on the defini-tion applied. In the studies that reported onfunctional instability'062666971 opinions di-verged, but no one treatment seemed superiorto the others in minimising the chances of lateinstability. The scientific basis for treatingchronic functional instability is discussed laterin this review.The review of Kannus and Renstrom35

concludes that functional treatment is thetreatment of choice when treating gradeIII acute lesions of the lateral ligaments.Recent comparative studies do not change thisview. Konradsen et af2 and Eiff et al3concluded that in first time lateral anklesprains, although both immobilisation andearly mobilisation prevent late residual prob-lems and ankle instability, early mobilisationallows early return to work and, possibly, ismore comfortable for patients. In a recent pro-spective study comparing surgery with func-tional treatment in ankle ligament tears Kaik-konen and coworkers74 found that earlymobilisation gave better results than surgeryplus mobilisation in treatment of completetears of lateral ligaments of the ankle. Ninemonths after injury excellent to good scoreswere achieved in 87% of the functionallytreated patients and 60% of the surgicallytreated patients respectively. In a meta-analytical article Schrier75 found functionaltreatment was superior to immobilisation incasts, reducing both ankle instability and thecost of treatment.Sommer and Schreiber76 considered the

cost-benefit aspects by comparing immobilisa-tion in a plaster cast followed by immobilisa-tion with a brace, with early mobilisation usinga brace only. Early functional therapy proved tobe the treatment with the least direct costs.Leanderson and Wredmark77 in a study of 73patients with grade II and III sprains treatedwith either early mobilisation or immobilisa-tion found that the socioeconomic savings werepotentially significant with ankle brace treat-ment. Nationally, the potential yearly savings inSweden using this treatment were estimated to

be eight million American dollars. The treat-ment of choice thus remains functional treat-ment.

If acute surgery is considered necessary theindications could according to Leach andSchepsis78 be (a) a history of momentarytalocrural dislocation with complete ligamen-tous disruption, (b) a major clinical anteriordrawer sign, (c) 10 degrees more tilt on theaffected side with stress inversion testing, (d)clinical or radiographic suspicion of tears inboth the ATFL and CFL, and (e) osteochon-dral fracture. Most techniques described forrepair of acute ligament injuries are similar tothat of Brostr6m.'0 The results after acute sur-gery are in general very good with return tosport in 10 to 12 weeks. This must still becompared with the three to six weeks afterfunctional treatment.

Acute treatment protocolBIOLOGICAL BACKGROUNDIn the post-injury phases of an acute severeankle injury, an ideal treatment and rehabilita-tion programme should fulfil four require-ments'5:1 The RICE principle: rest, ice (cold),

compression, and elevation aims to minimisehaemorrhage, swelling, inflammation, cellu-lar metabolism, and pain in order to offer thebest possible conditions for the healingprocess.s780

2 Protection of the injured ligaments duringthe first one to three weeks is required. Inthis phase of healing (the proliferationphase), protective ankle support is followedby undisturbed fibroblast invasion of theinjured area, which leads to undisturbedproliferation and production of collagenfibres. Mobilisation too early in inversionleads to more prolonged type III collagenformation with weaker healing tissue thanduring optimal immobilisation.8"8' Protec-tion is also needed to prevent secondaryinjuries and early distension and lengtheningof the injured ligaments.

3 About three weeks after the injury thematuration phase of the collagen and theformation of final scar tissue begins."8'- Inthis phase the injured ligaments needcontrolled mobilisation, and perhaps evenmore importantly, the ankle itselfmust avoidthe deleterious effects of immobilisation onjoint cartilage, bone, muscles, tendons, andligaments.8 8390 Controlled stretching ofmuscles and movement of the joint enhancethe orientation of collagen fibres parallelwith the stress lines (that is, the normal col-lagen fibres of the ligaments), and they canprevent the atrophy caused by immobilisa-tion.8°82 Repeated exercises will also increasethe mechanical and structural properties ofthe ligaments.9'

4 About four to eight weeks after the injurythe new collagen fibres begin to withstandalmost normal stress, and the goal for reha-bilitation is rapid recovery and full return towork and sports.

If treated according to the guidelines men-tioned above, each component of the ankle is

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ready for a gradually increasing mobilisationand rehabilitation programme, keeping inmind that final maturation and remodelling ofthe injured ligaments takes a long time-fromsix to 12 months.

Residual disability after inversion injuryInadequate rehabilitation is the primary causeof residual disability after ankle sprains. Manyathletes return to sports before they are fullyrehabilitated and therefore they are oftensubjected to reinjury or additional injury.Examination may show loss of range ofmotion, especially limited dorsiflexion, andatrophy of lower leg muscles.

Residual disability after ankle inversioninjury can be divided into primarily instabilityproblems and pain-giving entities.

CHRONIC ANKLE INSTABILITYChronic ankle instability can be subdividedinto mechanical, functional, and subtalar insta-bility and the sinus tarsi syndrome.

Mechanical instabilityMechanical instability is characterised by anklemobility beyond the physiological range ofmotion, which is identified on the basis of apositive anterior drawer or talar tilt test, orboth.92 The radiographic criteria for mechani-cal instability vary. Most authors agree, how-ever, that mechanical instability is presentwhen there is more than 10 mm of anteriortranslation on one side or the side-to-sidedifference is over 3 mm or the talar tilt is morethan 9 degrees on one side, or the side-to-sidedifference is more than 3 degrees.93 Puremechanical instability of the ankle is seldomthe sole independent reason for the develop-ment of late symptoms. Mann et al, showedthat 81% of patients with radiographicallydocumented instability experienced recurrentsprains.94

Functional instabilityFunctional instability is the chronic disabilityafter an ankle inversion injury that can beattributed to lateral ankle ligament deficiencyand is characterised by "giving way" problems.Forty eight per cent of patients with an acutefirst time sprain have recurrent sprains and26% report frequent sprains.94 The definitionof the symptom is ambiguous and the patho-genesis is unclear. It does not seem to bedependent on the grade of the initial injury69nor does it correlate with the degree of initialmechanical instability.6' 64 69-95 No histologicalligamentous changes except scarring have beenfound in chronic ankle disability.30As anatomical studies showed the presence

of mechanoreceptors in joint ligaments andcapsule, and clinical studies showed decreasedpostural control in patients with functionalinstability, Freeman et al suggested that func-tional instability was due to motor incoordina-tion secondary to a proprioceptive disorder.96Postural control was later measured objectivelyusing stabilometry by Tropp95 who, like Free-man, found increased postural sway in subjectswith functionally unstable ankles. It is, how-

ever, clear that functional instability is acomplex syndrome where mechanical, proprio-ceptive, and muscular disabilities either aloneor in combination are at fault. Known factorsinclude mechanically insufficient ligaments,peroneal muscle weakness,95 subtalar instabil-ity,97 and proprioceptive deficit.996Although increased postural swaying has

been used as a measure for a proprioceptivedeficit, there is no direct causal connectionbetween swaying with an increased amplitudewhen balancing on one foot and sustainingrecurrent inversion injuries. Rather it seemsreasonable to assume that a common andsuperior deficit is responsible for bothdisabilities. The nature of such a disabilityremains unclear. The latency of the peronealmuscles has been found to be significantlyslower in functionally unstable ankles bysome98.'00 but not by others.10'-'03 An increasederror in detecting ankle inversion movement orin matching ankle inversion angles has againbeen found by some'04-'06 but not by others.'07There is, however, evidence that (a) a proprio-ceptive deficit may result after an acute ankleinversion injury,46 70 108 (b) proprioceptive de-fects measured in different ways are seen insubjects with functional instability, and (c)models exist that may explain how measurablekinaesthetic deficits may cause an increasedfrequency of ankle inversion injuries (Konrad-sen et al, unpublished data).

Subtalar instabilityThe incidence of subtalar sprains is unknown,but it is widely accepted that most subtalarligamentous injuries occur in combination withinjuries of the lateral ligaments of the ankle (fig2). Subtalar instability is estimated to bepresent in about 10% of patients with lateralankle instability. The symptoms of chronicsubtalar instability include giving way episodesduring activity and a feeling of instability whenwalking on uneven ground. These symptomsmay coincide with chronic talocrural instabilityand therefore careful clinical examination isnecessary. Localised tenderness on palpationover the subtalar joint is suggestive of a sub-talar sprain. The diagnosis can be verified withsubtalar arthrography38 or a subtalar stress viewor stress tomography.

Functional treatment similar to the regimenused for lateral sprains is the treatment ofchoice. Surgery with non-anatomical proce-dures has been described.'09110 Anatomicalrepairs, however, show equally good re-sults.97 "'I

Sinus tarsi syndromeThe sinus tarsi syndrome is often accompaniedby a feeling of instability and giving way of theankle. Seventy per cent of the patients will haveexperienced a severe inversion sprain.92 If thecalcaneofibular ligament is torn the interos-seous talocalcaneal ligament occupying thesinus will often also be sprained. This sprainwill cause synovitis in the sinus tarsi with ratherlocalised pain. The diagnosis can be madebased on a complaint ofpain and tenderness ofthe sinus tarsi combined with the giving way

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Figure 2 Forceful inversion of the hindfoot in neutralflexion. Tearing of the calcaneofibular, the cervical, and theinterosseous ligaments. (From MeyerJM, Garcia J7,Hoffmeyer 1P Fritchy D. The subtalar sprain. Aroentgenographic study. Clin Orthop 1988;226:169-73.)

feeling. The pain and the giving way feeling canusually be relieved by local injections of anaes-thetic and corticosteroids. Excision of tissuefilling the sinus tarsi can give good results ifconservative treatment fails.

TREATMENT OF CHRONIC INSTABILITY

RehabilitationWith the uncertain pathogenesis of functionalankle instability the elements of treatment pro-tocols will rest primarily on personal experi-ences and not so much on scientific data.Before deciding upon surgical treatment, a wellplanned rehabilitation programme based onperoneal muscle strengthening and coordina-tion training should be carried out. Regainingmuscle strength is primarily achieved byincreasing neural activation through function-ally oriented training and dynamometer train-ing. '12 In functional training the patient isrequired to activate his/her musculature innormally occurring activities. Dynamic stabil-ity, including proprioceptive information,motor control, and appropriate muscle forcedevelopment, will be enforced by the training.Treatment of the proprioceptive ankle deficit

consists of a progressive series of coordinationexercises to re-educate the ankle. Tropp95found a significant improvement in balanceduring single limb stance in subjects with afunctionally unstable ankle after six weeks ofbalance board exercises (fig 3). The samegroup reported a decrease in the frequency ofinversion injuries and ankle giving way feelingswhen compared with an untrained controlgroup with unstable ankles. Tropp9" also foundthat the subjects in question showed a changein their strategy of single limb stance, goingfrom a broken chain strategy before training tothe normal inverted pendulum strategy aftercompleted training. So it may well be, assuggested by Glencross and Thornton,'04 that

Figure 3 Tilt board training is an excellent way to returnneuromuscular control to the injured ankle.

rehabilitation was as much a relearning pro-gramme as it was a physical recovery afterinjury. Often the injured subjects themselveshave a clear feeling of a perception/proprioception deficit in the ankle joint area-they cannot "feel" the ankle as they used to.When this feeling returns it seems to coincidewith complete rehabilitation. Leanderson etal'08 found that return of single limb balance tonormal values coincided with a subjective feel-ing of full rehabilitation in dancers. It can,however, be argued that in this group balanceduring single limb stance was as much aspecific functional test as an unspecific test forankle proprioception.

In summary, training proprioceptive func-tion through coordination exercises using uni-lateral balance boards, uniaxial and multiaxialteeter boards, and jumping ropes relies prima-rily on empirical data but produces veryfavourable results. Restitution of normal func-tion relies on the individual's subjective feelingof return to normal sensation. Full effect oftraining is achieved within 10-12 weeks asevaluated by postural sway.95About 50% of patients with functional insta-

bility will regain satisfactory functional stabilityafter such a programme."'

EXTERNAL SUPPORTWhen considering the mechanical effect of thedifferent external support modalities it isimportant to remember that even though theydo increase the resistance to inversion, theeffect cannot be compared with that of activeevertor muscles. Ashton-Miller et al'.' foundthat active evertor muscles, acting isometricallyon a 15 degrees inverted ankle, can providemore than three times the protection against

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further ankle inversion than tape or an orthosisworn inside a three-quarter-top shoe.

TapeThe primary purpose of taping is to provideincreased stiffness to the ankle and a semirigidand sometimes rigid splinting around it. Stud-ies have shown that taping the ankle preventsankle injuries. Garrick et al found that thecombination of taping prophylactically and theuse of high top shoes in basketball reduced thefrequency of ankle sprains.' 4a Lindenberger etall5 found that tape had a significant prophy-lactic effect in handball team players who werestudied prospectively for two full seasons. Sixtop level teams participated in the first year. Inthree teams the players wore tape and in theother three teams the players did not. Duringthe first season 13 ankle sprains occurred allin the non-taped group. In the second seasonnine teams participated. Twenty one anklesprains occurred and 20 of these were in thenon-taped group.

Contrary to this, several studies have shownthat tape loses as much as 50% of its support-ive effect after only 10 minutes of activeexercise"'-"8 and offers virtually no supportafter one hour."9 The mechanism behind theeffect of ankle taping thus remains unclear.However, tape does not only restrict extensivejoint motion but also enhances proprioceptivefeedback mechanism and shortens the recruit-ment time of the dynamic ankle stabilisers.'20Many athletes may have a skin reaction to

tape and therefore skin protection may beused. There seems to be no difference insupport between tape directly on the skin andtape with skin protections. Because of theseskin problems, tape is used mostly by top ath-letes and not by recreational athletes.

BracesThe use of ankle orthoses has increased overthe past decade. In contrast with tape themechanical effect of a brace does not wear offwith activity as shown by Shapiro et al.'2'Not many clinical trials have been per-

formed judging the effect of ankle bracing onthe frequency of ankle inversion injuries. In aretrospective trial Rovere et al'22 found a reduc-tion of sprains in football using a lace-on clothbrace. Tropp et al5 in a prospective studyshowed the effect of a semirigid ankle brace inreducing the frequency of injuries in soccerplayers, and in a prospective randomised studySitler et al'23 found that ankle stabilisers signifi-cantly reduced the frequency of ankle injuriesbut not their severity in a group of basketballplayers at West Point, New York. The resist-ance to an eversion moment seems to be thesame for ankle braces as that for newly appliedtape."4 Like tape, braces have been shown tohave a proprioceptive enhancing effect.'24There have been discussions about the effect

on performance of tape and braces. Insprinting a reduction in maximal speed hasbeen found by most,'25 but not by all.'26 Forvertical jumping most studies also show that abrace decreases ability...2.'2 Opinions aboutbracing compared with taping vary, with some

studies showing a smaller effect and others alarger detrimental effect of tape compared withbraces. It must be noted that most of the stud-ies were done on subjects with stable ankles.The use of an ankle brace or taping, orboth, is recommended as they both givesupport against ankle inversion when theevertor muscles are relaxed and increasethe maximal resistance to inversion withevertor muscles activated. They do seem tobe able to enhance proprioceptive awareness,and to decrease the frequency of inversioninjuries and decrease the severity of the injuriesin groups with functionally unstable ankles.

The role of shoesBiomechanical studies support the use of hightop shoes for ankle sprain prevention becausethey limit extreme range of motion, provideadditional proprioceptive input, and decreaseexternal stress on joints.'29 Clinical trials, how-ever, have not shown that the effect of this bio-mechanically improved stability translates intoa lower rate of ankle sprains in high top shoes.Further studies are needed.

Supportive treatment modalitiesPassive physical therapy modalities are oftenrecommended to promote healing in the earlyrehabilitation phase. The most commonly usedare ultrasound, temperature contrast baths,short waves, and various current treatmentsincluding dynamic or interference currenttherapy, or electrogalvanic stimulations. Ofthese different types of passive physicaltherapy, only cryotherapy has been proved tobe effective.130

Non-steroidal anti-inflammatory drugs havebeen studied in prospective randomised doubleblind trials, and found to be more effectivethan placebo for ankle tenderness, swelling,and pain, though the difference was notstriking and seemed to disappear during anextended follow up.3 130

In subjects with chronic post-injury swelling,moist heat packs, warm whirlpool baths,contrast baths, electrogalvanic stimulation, andintermittent pneumatic compression have beentried.4 Prospective randomised studies haveshown that only the last alternative has anindependent ability to reduce the amount ofswelling.131 132

Table 1 Classification of operative treatments for chronicankle ligament injury

Non-anatomical reconstruction

Non-anatomical reconstructionEndogenous

Peroneal tendonWatson-JonesEvansChrisman-Snook

OtherPlantarisPartial Achilles tendonFree autogenous graft

ExogenousCarbon fibreBovine xenograft

Anatomical repairDirect sutureImbrication and repair to boneLocal tissue augmentation

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J~~ K~Figure 4 Anatomical reconstruction of chronic ankle ligament instability. (A) Elongatedligaments are divided 3 to 5 mm from insertion of the fibula. (B) Bone surace of the distalend of the fibula is roughened to form a trough to promote ligament healing. Holes aredrilled through the distalfibula. (C) Mattress sutures are used to fix the distal stump of theligaments and the capsule to the fibula. The sutures are tightened while the foot is held indorsiflexion and eversion. (D) The proimal ends of the ligaments are imbricated over thedistal portion.

Surgery for chronic instabilityChronic ankle instability, as demonstrated bypain, recurrent giving way, and positive stresstests, is often treated surgically. A combinationof mechanical and functional instability is themost commonly reported indication for sur-gery. More than 50 procedures or modifica-tions have been described for treating chronicankle instability, and these can be looselygrouped as non-anatomical reconstructions oranatomical repairs (table 1).Non-anatomical reconstructions use other

structures or materials to substitute for theinjured ligaments. Structures commonly usedfor grafting are fascia late and the peroneusbrevis tendons in procedures such as Watson-Jones, Evans, and Chrisman-Snook. Numer-ous modifications of these classic procedureshave been described. The Chrisman-Snook'09modification of the Elmslie procedure is themost widely used non-anatomical reconstruc-tion. In four clinical series with a total of 100ankles, more than 90% of patients had good orexcellent results, and stability was more than95% of the normal ankle. Reported complica-tions included neuromas in 0 to 16% ofpatients, restricted dorsiflexion in about 20%,and restricted inversion to some degree in allpatients. An advantage of the Chrisman-Snookprocedure is that less lateral weakness isproduced because only half of the peroneusbrevis tendon is used for the graft. A criticismof the procedure has been that it results inrestricted subtalar motion. Furthermore,these tenodesis procedures are non-anatomical and do not restore normalbiomechanics."33 Although short term resultsare excellent, long term results may not be as

good. Thus Karlsson et a193 found that theEvans static tenodesis was satisfactory in fewerthan 50% of cases after a mean follow upperiod of 14 years.

Anatomical reconstructions, in which thetissues of the damaged ligaments are used,have become increasingly popular as they per-mit reconstruction without sacrificing any nor-mal tissue.3093 14 Brostrdm in 196630 reportedthat direct suture repair of chronic ankleligament injuries was possible even many yearsafter the initial injuries and that the ends of theligament could be found. Others reported thatthe elongated ligaments had healed encased ina fibrous scar tissue. Several authors havereported successful imbrication or shorteningand replantation of the ligaments to obtain amore anatomical reconstruction. We haveobtained good results with a modified Bros-trom technique (Peterson procedure) thatincludes shortening of the ligament, repairthrough bony tunnels, and imbrication withlocal tissue93 14 (fig 4). This anatomicaltechnique repairs both the ATFL and CFL.The non-anatomical reconstructions, exceptfor the Chrisman-Snook modification of theElmslie procedure, repair only the ATFL.Repair of the CFL is important, because insuf-ficiency of this ligament may be a factor in thedevelopment of subtalar instability. The post-operative treatment after an anatomical recon-struction is a splint for eight days to securewound healing and, thereafter, a removablewalking boot for five weeks. The patient startswith dorsiflexion and plantar flexion exercisesafter eight days or as early as possible out of theboot two to three times a day. Return to sportis usually possible in three months.Anatomical repair ofboth the ATFL and

the CFL through bony tunnels producesgood long term results and is recom-mended as the initial procedure in mostcases. If anatomical repair fails, a tenodesisprocedure, such as the Chrisman-Snook re-construction, is a good alternative. A non-anatomical reconstruction is also indicated inpatients with moderate arthritis or lax joints.

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