Diagnosing and Managing Chronic Ankle Instability
The ankle joint consists of many bones, ligaments and tendons that plays an important role in maintaining its stability. Consequently, ankle instability happens if any of the related bones, tendons, or ligaments are compromised. The tibia and fibula are intimately joined by the interosseous membranes. These two bones also share connections with the ligamentous complexes of the foot so that any sprain on the ligaments can also potentially cause a distal fracture in the bones of the lower leg. Additionally, the tendons from the muscles of the lower leg—mainly the Achilles tendon and the peroneus longus and brevis, are closely associated with the bones of the foot. Injury to these tendons will likely result in ankle instability.
Mechanism of Ankle Instability
Due to the complexity of the ankle joint ad surrounding structures, any injury to the bones, tendons and ligaments can result in instability. For example, any impact on the heel of the foot from jumping from a higher to lower level will produce a vector of the force directed into the distal tibia. And this can cause fracture and dislocations of the tibia or fibula and cause ankle unsteadiness. Such an injury to the tibia causes an increase in contact stress between the tibia and talus and is an important pathomechanical factor in unstable joints.4 Additionally, the fibula may also have a profound effect on ankle stability.
Damage to the tendons and ligaments supporting the ankle joint can also cause ankle instability. Lateral ankle instability can cause laxity of the superior retinaculum which the ligaments wraps around the proximal ankle joint. This laxity can cause a peroneus brevis split and, in turn, this split results in chronic ankle instability.
Diagnosis of Ankle Instability
When a person present with ankle instability, the first step is to determine whether the injury demands emergency care. During first line of care, the physician should asses the history and etiology of the injury. Most of the ankle injury is ankle sprain and is usually ligamentous or may include bone fractures. With fractures, the person will experience bony tenderness on palpation of the posterior edge of the distal tibia and fibula, or on the medial and lateral malleolus. Inability to bear weight on the affected foot immediately after the injury are also the signs of fracture that requires immediate emergency care.
With ligament injury, the lateral ligamentous complex is more prone to damage due to the anatomical position of the ankle in plantarflexion and inversion. Because of this, most of the ankle sprain occurs while the ankle is in plantarflexion and inversion.
Physiotherapy Management for Ankle Instability
Once the diagnosis of ankle sprain is made, conservative management is always preferred. During the early stage of mild sprain, RICE protocol are usually implemented. For Grade 1 and Grade 2 ankle sprain, a form of immobilization using ankle brace will provide stability to the ankle and provides the ability to walk and climb stairs without further injuring the ankle. When ankle instability is due to compromised integrity of the tendons, management is aimed at correcting the cause of the pathology. Exercise therapy has been the mainstay of treatment to improve the outcome in cases of tendon laxity.
Early functional rehabilitation of the ankle should include range-of-motion exercises and isometric and isotonic strength-training exercises. In the intermediate stage of rehabilitation, a progression of proprioception-training exercises should be incorporated. Advanced rehabilitation should focus on sport-specific activities to prepare the athlete for return to competition. Although it is important to individualize each rehabilitation program, this well-structured template for ankle rehabilitation can be adapted as needed.
Many researchers have examined the effects of various training regimens on the characteristics of chronic ankle instability and the symptoms of acute ankle sprain. The available research regarding rehabilitation of ankle injuries and chronic ankle instability focuses on a wide variety of exercises and programs. Many experts have succeeded using a type of balance board to improve strength and balance measures in subjects with acute injury and CAI. Others have found that incorporating a variety of coordination-training exercises produces significant improvements in measures of strength and proprioception.
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