eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Recurrent Ankle Sprains: Treatment

Author: Joseph R Bozzelle, Jr, MD, Director, Rehabilitation Services, Crowley Rehabilitation Hospital, Doctors Hospital of Opelousas, Southwest Medical Center
Coauthor(s): Stephen Kishner, MD, MHA, Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans; James Monroe Laborde, MD, MS, Clinical Assistant Professor, Department of Orthopedics, Tulane Medical School; Adjunct Assistant Professor, Department of Biomedical Engineering, Tulane University; Adjunct Assistant Professor, Department of Physical Medicine and Rehabilitation, Louisiana State University Medical School; Consulting Staff, Department of Orthopedic Surgery, Louisiana State University Health Sciences Center
Contributor Information and Disclosures

Updated: Feb 15, 2008

Treatment

Medical Therapy

For recurrent sprains that involve the medial ligaments, slight modifications to the conservative treatment of lateral sprains are used. These include ankle stirrup bracing, casting, and orthoses (in addition to physical therapy). Once again, if these measures are unsuccessful, surgical intervention is necessary.

In syndesmotic injuries, when a diastasis has been present for longer than 3 months, significant arthritic changes have probably begun. Diastasis refers to any loosening in the attachment of the fibula to the tibia at the inferior tibiofibular joint. In most cases, arthroscopic evaluation of the ankle joint is helpful to determine the best course of management. Surgical options are discussed below (See Surgical therapy).

Chronic instability of the subtalar joint frequently requires surgical intervention. Despite this, the treatment is initially nonsurgical and is similar to the conservative management of recurrent or chronic lateral ankle instability. This includes peroneal strengthening, proprioceptive training, Achilles tendon stretching, and the use of a brace. Taping of the ankle by an athletic trainer can be of benefit, especially when a subtalar sling modification is incorporated.

Surgical Therapy

Broström described a repair that reapproximates the ruptured ligaments and restores true normal anatomy of the ankle.³¹ Some clinicians noted this procedure to be hazardous because finding healthy margins of the ruptured ligament tissue was difficult. Gould et al described a modified Broström procedure that allowed for reinforcement of the repair, limited inversion (reducing the likelihood for injury), and helped to correct the subtalar component to the instability.³² This modified procedure allowed restoration of the normal anatomy and preserved normal ankle motion with less surgical exposure. The incision is performed from an anterolateral approach, paralleling the fibula border, and starting from the level of the plafond distally to the level of the peroneal tendons. Dissection is then carried down to the capsule. If no obvious ATFL rupture is present, the capsule and ligaments are divided a few millimeters and imbricated.

The peroneal sheath is then opened to determine the quality of the CFL. If the CFL is stretched, it can be divided and imbricated. If this ligament is ruptured, a distal avulsion from the calcaneus can be reattached with a suture anchor. A proximal avulsion can be reattached with sutures through drill holes in the fibula.

For mid-substance tears, determine whether the remnant can be imbricated. If it cannot, some surgeons have used the PTFL by releasing it from its talar insertion and swinging it distally to insert at the calcaneal insertion site of the CFL. The most important thing to consider here is that there is no anterior displacement force on the ankle while the sutures are being tied. A bump is usually placed under the calf. Stability is checked before closure. Further stability (and possibly proprioception) is provided to the subtalar area by imbrication of the inferior extensor retinaculum to the periosteum over the fibula. Once the skin is closed (usually with subcuticular stitching), a U-shaped splint and a posterior splint or walking boot are applied.

Other procedures, as mentioned above, are mainly tenodesis procedures. Four have been extensively used and described in the literature: the Watson-Jones, Evans, Larsen, and Chrisman-Snook procedures. These procedures focus on harvesting all or part of the peroneus brevis and then rerouting the tendon through various bone tunnels, thereby creating a tenodesis of the ankle or reconstructing the ATFL or CFL. Indications for these augmented types of reconstruction are as follows:

• The ATFL and CFL are so disrupted and frayed that they cannot be repaired primarily.
• Hypermobility of the subtalar joint is present.
• The patient has had previously unsuccessful reconstruction of the ankle.

The technique for the overall approach for each of these procedures is essentially the same. A longitudinal incision is made running just posteriorly to the prominence of the lateral malleolus. The incision is then extended to allow harvesting of the peroneus brevis tendon. Before harvesting the tendon, the joint is inspected and debrided if necessary. Occasionally, the ATFL and/or CFL are avulsed from the fibula with a piece of bone. This so-called os subfibulare should be excised.

Maintain the integrity of the superior peroneal retinaculum upon exposure of the peroneus brevis tendon. The anterior third of the tendon is isolated distally and split from the distal position to the musculoskeletal junction. This tendon portion is transected at its proximal aspect. A drill hole is made through the distal fibula, and the split portion of the peroneus brevis is passed through this hole. The tendon is tensioned with the foot in mild plantarflexion and eversion.

The Evans procedure provides stability that is a result of the ATFL and CFL but not anatomically or mechanically. The peroneus brevis tendon is anchored to the fibula, indirectly limiting inversion of the ankle and anterior talar translation, while also limiting motion of the subtalar joint.

The Watson-Jones procedure reconstructs the ATFL but not the CFL. This technique makes use of the Evans tenodesis. One important addition, however, is that the peroneus brevis graft is routed anteriorly through the talar neck to reconstruct the ATFL.

Larsen rerouted the peroneus brevis tendon from the fifth metatarsal base into the fibula and then back down into the calcaneus.⁷ The proximal part of the tendon was sutured to the peroneus longus.

The Chrisman-Snook procedure, most commonly used for subtalar instability, involves using half of the longitudinally divided peroneus brevis tendon to substitute or reconstruct the calcaneofibular ligament. In this procedure, the peroneus brevis graft is brought through the fibula from anterior to posterior to reconstruct the ATFL. It is then brought posterior and inferiorly to the calcaneus in a weave pattern to reconstruct the CFL. The Chrisman-Snook procedure, although technically demanding, has been repeatedly demonstrated to produce satisfactory stability to those patients who have a talotibial and combined talotibial and talocalcaneal instability.

These procedures vary greatly in the ability to correct subtalar instability. A review of the literature shows that the Watson-Jones procedure is associated with subjective instability 20-90% of the time, and the Evans procedure, 20-33%. Also, with the Evans procedure, a persistent anterior drawer sign is found in 45-60% of patients. In the Chrisman-Snook procedure, 13-30% of patients had subjective persistent instability. Decreased inversion is common with all these procedures. Each procedure employs a specific weave pattern, referring to the manner in which the peroneus brevis tendon is routed through the drill holes.

Triligamentous reconstruction uses half of the peroneus brevis tendon to substitute for the ATFL, CFL, and CL. This procedure efficiently addresses both talotibial and talocalcaneal instability. Despite this success, triligamentous reconstruction is a very technically demanding procedure.

The surgical treatment decision for chronic medial instability revolves around whether the tissues are of good or bad quality. If the tissues are of good quality, a direct reattachment can be performed. If the tissues are of poor quality, a free flexor digitorum longus graft can be used that goes from the tibia into the talus or navicular to reconstruct the deltoid ligament.

For syndesmotic sprains, surgical treatment depends on whether any arthritic change is present. If the articular surface is destroyed on both sides of the joint, tibiotalar arthrodesis or arthroplasty is necessary. In patients with diastasis without significant tibiotalar arthritis, late reduction of the syndesmosis and reconstruction of the ligaments are recommended.

Follow-up

For direct ligament repair procedures such as the modified Broström procedures, follow-up care depends on whether the patient is an athlete. Patients who are athletes are placed in a short-leg splint or walking boot with the foot in neutral dorsiflexion and slight eversion. The patient can bear weight as tolerated, and use of the walking boot is continued for 3-4 weeks. At 4 weeks, the patient can start dorsiflexion and eversion movements, and then the patient is placed in an ankle stirrup brace.

Achilles tendon stretching and active inversion also begins at 4 weeks. During this time, proprioception training and resistive exercise with rubber tubing can be initiated. The patient is then allowed to progress from walking to straight-line running. Rehabilitation can proceed as tolerated, provided that no pain or swelling is present. Activity can progress from figure-8 running in progressively smaller loops to, ultimately, cutting. The athlete is then allowed to resume sports-specific activity, with return to competition once each task of the sport can be completed without pain or swelling. Patients are instructed to use protective taping and/or bracing for 6 months after the repair.

For nonathletes, according to Coughlin and Mann, 10-12 weeks of protection is recommended, with the first 6 weeks in a cast and the second 6 weeks in a removable brace or walking boot.³³

For reconstruction procedures such as the Watson-Jones, Chrisman-Snook, Evans, and Larsen, patients are placed in a U-shaped splint and posterior splint or walking boot. The ankle is then protected for 12 weeks, with a walking boot used for 6 weeks and a pneumatic stirrup brace for the second 6 weeks. After 2 weeks, gentle dorsiflexion and eversion are started. At 4 weeks, peroneal strengthening from the neutral position and Achilles exercises are implemented.

Active inversion, plantarflexion, and proprioceptive training are started at 6-8 weeks. Following this period, the athlete is allowed to progress from walking, to jogging, to running, to figure-8 running, to cutting, and then to sports-specific tasks. The ankle must then be taped or braced for 6 months after the reconstruction.

For medial ankle surgery, the associated injuries usually dictate postoperative management. Because deltoid ligament injuries can be associated with fractures or avulsions, the ankle is generally splinted and kept non–weight bearing for the first 7-10 days. Then, the patient is placed in a boot or cast and kept non–weight bearing for another 3 weeks. The patient spends the final 2-4 weeks in a walking boot or cast. Patients should wear a stirrup brace during sports activities for the first 6 months after the injury(ies) has(have) occurred.

Complications

The most frequently encountered problem after surgical repair of the lateral ankle ligaments is trauma to the sural and superficial peroneal nerves. The incidence of hypersensitivity or hyposensitivity ranges from 7-19%. This is with or without accompanying dysesthesias. Wound problems and infection, postoperative stiffness, deep venous thrombosis, and wound necrosis have been reported after surgery.

Another frequent sequela of recurrent ankle sprains is chronic anterolateral ankle impingement. This is a result of a thickened and scarred joint capsule. Wolin et al reported that recurrent pain and swelling after injury to the lateral ligaments without instability in patients with a history of previous ankle sprains was due to hyalinized connective tissue arising from the anteroinferior portion of the talofibular joint capsule.³⁴ The authors postulated that the symptoms were the result of this connective tissue becoming pinched in the talofibular joint with motion. This belief was reinforced by the authors' report that in 9 patients such symptoms were alleviated after removal of the pinched connective tissue, which was referred to as meniscoid tissue.

Bassett et al noted chronic pain in 7 patients due to talar impingement by a distal fascicle of the AITF ligament.³⁵ Through anatomic and clinical studies, the investigators found that a distal fascicle of the AITF ligament is parallel and distal to the ATFL. This anatomic variant was noted in 10 of 11 cadaveric specimens and in 7 patients (observed during arthroscopy). Bassett et al further noted that this structure becomes symptomatic after ankle sprains because of the increased laxity of the lateral aspect of the ankle due to an incompetent ATFL — which allows the anterolateral talar dome to extrude anteriorly with dorsiflexion. This, in turn, allows the talar dome to contact the distal fascicle of the anteroinferior distal tibiofibular ligament with greater pressure and friction.

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