Table of Contents
This article is the companion to the JoMI articles:
- Deltoid Ligament Repair
by Eric Bluman, MD, PhD
- Brostrum-Gould for Lateral Ankle Instability
by Eric Bluman, MD, PhD
- Peroneal Tendon Debridement
by Eric Bluman, MD, PhD
We present the case of a patient who was seen for follow-up after 5 months of rehabilitation following surgical procedures to address instability in both the medial and lateral sides of her ankle. This patient reported achieving an excellent outcome, and her subjective sense of significant improvement after rehabilitation was aligned with her physical exam and radiographic evaluation. This case documents the improvements made by the patient during the rehabilitation process and outlines essential steps to be performed by the practitioner in the clinical examination and radiographic follow-up after surgery for ankle instability.
medial ankle instability; lateral ankle instability; Brostrom-Gould procedure; ankle arthroscopy; deltoid ligament repair
This patient presented for follow-up after 5 months of rehabilitation following surgical procedures to address instability in both the medial and lateral sides of her ankle. Her lateral instability was addressed using peroneal tendoscopy, which confirmed and further elucidated the extent of her injury, as well as the Brostrom-Gould procedure to provide lateral stabilization. Her ankle arthroscopy also identified injury to the medial ankle ligament complex, and subsequently open repair of the deltoid ligament was performed to provide medial stabilization. This case documents the improvements made by the patient during the rehabilitation process, and outlines essential steps to be performed by the practitioner in the clinical examination and radiographic follow-up after surgery for ankle instability.
The patient noted significantly improved stability on both sides of the ankle where reconstruction was performed. She described her initial progress as slow during the first few months, but she has since regained near full range of motion, with no residual concerns except for some degree of stiffness, which continued to improve at the time of follow-up. She anticipated a return to college softball in the near future with no limitations.
Physical examination began with inspection of the ankle, which identified three small incisions used for peroneal tendoscopy that was employed as a diagnostic and therapeutic measure. Also present were incisions over the lateral aspect of the ankle where the Brostrom-Gould procedure was performed and medially for open repair of the medial ligamentous complex. Range of motion testing was performed including dorsiflexion and plantarflexion, demonstrating well-maintained range of motion with near equivalence to the contralateral side. Approximately 10 degrees of dorsiflexion and 30–40 degrees of plantarflexion was observed. Palpation of the ankle joint revealed minimal stiffness on the operated ankle compared to the contralateral side. The anterior drawer test and inversion and eversion revealed no obvious laxity in the ankle joint. The patient was able to stand independently and stand on her toes on the operated foot with no reported or apparent instability.
Radiographic evaluation of the ankle included an anteroposterior view of the ankle in a standing position. The ankle showed good maintenance of the joint space, with proper alignment of the talus directly beneath the tibia. A titanium suture anchor used during repair of the medial ligament complex was evident on the plain film. A mortise view involving 15–20 degrees of internal rotation of the ankle demonstrated good joint space preservation, proper alignment, and no evidence of arthritis. A lateral view demonstrated no encroachment of the suture anchor onto the cartilage of the subchondral bone.
This patient achieved an excellent outcome at five months following ankle reconstruction and medial and lateral stabilization. Her subjective sense of significant improvement after rehabilitation was aligned with her physical exam and radiographic evaluation, and she was expected to achieve an excellent outcome and return to athletics that year.
Physical examination of patients with suspected medial ankle instability should begin with bilateral inspection of the ankles in standing, walking, and sitting position.1, 2 Any swelling, hematoma, malalignment, deformity, or scars, as well as asymmetrical planovalgus and abductus upon weight-bearing should be identified and documented by the practitioner. Palpation of the medial and lateral ligaments and joint spaces in addition to the syndesmosis and posterior tibial, peroneal, and Achilles tendons should be performed to assess for gross abnormalities. Of note, tenderness in the medial gutter overlying the deltoid ligament is commonly seen with injury. Tenderness along the posterior tibial tendon may indicate associated posterior tibial tendon insufficiency, which often co-occurs in the setting of medial ankle instability. Eversion and external rotation stress tests can assess stability of the deep and superficial deltoid ligaments, and the anterior drawer test may be used to diagnose anteromedial subluxation.
An important pearl from this case is highlighting the importance of surgical diagnostic confirmation of ankle instability, particularly medial ankle instability. For lateral instability, clinical examination and imaging results are often sufficient to support definitive diagnosis, but for medial instability, while these tools are helpful, full confirmation with arthroscopy is nearly always required. Orthopedic surgeons as well as sports medicine practitioners, physical therapists, and physical medicine rehabilitation specialists, should be aware that concern for medial instability should lead to referral to a surgeon for arthroscopic confirmation.
Lateral ankle injuries often present with swelling and ecchymosis, which may or may not persist in chronic cases.3 Palpation of the entire fibula should be performed in addition to areas required to meet Ottawa ankle criteria. Additional physical exam tests should include determination of current weight-bearing ability, as well as special tests including the squeeze test, the external rotation stress test, the anterior drawer test, and the talar tilt test. Of note, these special tests are often clinically helpful but have not been studied extensively.3 Plain radiographs are sufficient for the diagnosis of concomitant fractures in acute ankle sprains.3 Patient selection for radiography in acute injuries should be made in association with the Ottawa ankle rules.9 Ankle sprains with persistent pain up to 8 weeks following initial presentation may benefit from MRI to detect soft tissue injury, suspected syndesmosis, or talar dome fractures.3, 4 Peroneal tendoscopy may be performed in refractory cases as a supplementary diagnostic for lateral instability.
As part of the rehabilitation for procedures addressing ankle instability, proprioceptive training may be an acceptable therapeutic modality for patients with chronic lateral ankle instability before surgery. There is evidence to suggest that strength and balance exercises contribute to improved ankle strength, range of motion, and perceived ankle stability in comparison to usual care.5–7 A systematic review of seven trials involving 3726 participants identified a statistically significant decrease in ankle sprain incidence in patients who had undergone proprioceptive training (RR=0.65, 95% CI 0.55–0.77), including patients with a history of ankle sprain (RR=0.64, 95% CI 0.51–0.81).8 One study assessing a 6-week proprioceptive training program in 70 athletes with chronic ankle instability reported no significant difference in pain scores between intervention and control groups; however, further study is warranted as most studies have not identified pain as a primary outcome.9 As such, proprioceptive training may have preventive or therapeutic benefit in patients with or at risk for lateral ankle injury.3
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1. Alshalawi S, Galhoum AE, Alrashidi Y, et al. Medial Ankle Instability: The Deltoid Dilemma. Foot Ankle Clin. 2018;23(4):639-657. doi:10.1016/j.fcl.2018.07.008
2. Hintermann B. Medial ankle instability. Foot Ankle Clin. 2003;8(4):723-738. doi:10.1016/S1083-7515(03)00147-5
3. Maughan KL. Ankle Sprain. In: Post T, ed. UpToDate. ; 2020.
4. Nikken JJ, Oei EHG, Ginai AZ, et al. Acute ankle trauma: Value of a short dedicated extremity MR imaging examination in prediction of need for treatment. Radiology. 2005;234(1):134-142. doi:10.1148/radiol.2341031060
5. Faizullin I, Faizullina E. Effects of balance training on post-sprained ankle joint instability. Int J Risk Saf Med. 2016;27(s1):S99-S101. doi:10.3233/jrs-150707
6. Hall EA, Docherty CL, Simon J, Kingma JJ, Klossner JC. Strength-training protocols to improve deficits in participants with chronic ankle instability: A randomized controlled trial. J Athl Train. 2015;50(1):36-44. doi:10.4085/1062-6050-49.3.71
7. Van Ochten JM, Van Middelkoop M, Meuffels D, Bierma-Zeinstra SMA. Chronic complaints after ankle sprains: A systematic review on effectiveness of treatments. J Orthop Sports Phys Ther. 2014;44(11):862-871. doi:10.2519/jospt.2014.5221
8. Schiftan GS, Ross LA, Hahne AJ. The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis. J Sci Med Sport. 2015;18(3):238-244. doi:10.1016/j.jsams.2014.04.005
9. Cruz-Diaz D, Lomas-Vega R, Osuna-Pérez MC, Contreras FH, Martínez-Amat A. Effects of 6 Weeks of Balance Training on Chronic Ankle Instability in Athletes: A Randomized Controlled Trial. Int J Sports Med. 2014;36(9):754-760. doi:10.1055/s-0034-1398645
Hi. My name is Eric Bluman. This is my patient Kyra Benavent, and she's back for a five-month visit after a surgery that we performed for stabilizing her ankle. stabilizing her ankle.
Kyra tell - talk to me about how - how you've been - how you’ve felt since the surgery. Since the surgery, the first couple of months were definitely a little difficult, but it's gotten so much better in the past eight weeks. I've gained pretty much full range of motion. I can do whatever I want so much better than before the surgery. So you’re glad that we did the surgery? Yes. And it - it helped you? Yeah. Okay.
Do you have any residual problem? There’s no residual problems right now. There's a little bit of stiffness, but you said that was expected, so. So yeah, that - that - that can happen after these type of surgeries, and sometimes, it's a little bit of a trade-off. You know, you've got instability, and in order to get rid of the instability, we actually give you a little bit of stiffness. In terms of the range of motion of the ankle, how close is it to your - your well or non-operated side? I'd say this one being a 100%, this is probably at 85 right now. 85. Do you think it's continuing to get better? Yeah, definitely - everyday. Okay.
Do you have anything that you can't do that you'd like to do? No. No. Any plans for the future with this? What are you - what are you planning on - on doing activity wise with your ankle? Well, I would like to continue to play softball cuz I had to stop doing that for a while, so I'm hoping this summer I can train and get back to where I was. And what - what level softball do you play? Well I am a college athlete, so. So you’re gonna be playing at the college level, NCAA. Hopefully the D1 level. Yeah. Good.
Alright, any other comments or insight or things that surprised you about the process of the surgery? Things that were unexpected or - or - or either welcome or not unwelcome surprises? I don’t think so. It was pretty straightforward. Recovery period was long as expected, but it's a very good result and I'm very happy. Okay, great.
Let me - let me tell them a little bit about what we did just to sort of recap, and then we'll go through a physical exam, okay? Okay. Kyra’s complaint was that she had instability and pain in her ankle, and it was present not only in the ankle joint, but she also had problems with the peroneal tendons. And we diagnosed that with a combination of clinical examination, her history, of course, and - and some imaging studies.
We use the surgery not only for treatment but also to shore up our diagnosis. And we started out doing - addressing her peroneals - her peroneal tendons, and we did a peroneal tendoscopy, which is a relatively new type of surgery that is minimally invasive and allows us to go in and not only confirm diagnoses but also treat mild to moderate problems of the - of the peroneal tendons. And we did that using four different small incisions to - to place the cameras and the instruments. Following that, we - we did a ankle arthroscopy, and that was also diagnostic as well as for treatment. We cleared out a lot of internal derangements in her ankle, and we also confirm that the medial ligaments were - were damaged. And indeed, they - we saw that - we saw proof that that was happening from the arthroscopy. At that point we converted from a minimally invasive arthro - arthroscopic method to an open method and did both a medial ligament reconstruction and a lateral ankle reconstruction. And now we're going actually take a look at - at Kyra’s ankle and - and show you what was done.
So here we’re looking at the lateral side of Kyra's ankle, and if you can see, there are some small incisions that are here. And we actually can only see three of them here. Then these are what were used for the peroneal tendoscopy, and we were able to clear out a good length of the pathology and - and - and take care of all her problems through these very small incisions. Here is the incision that we used for the lateral ankle ligament repair, which is commonly called the Brostrom-Gould procedure, and this addressed both the anterior talofibular ligament as well as the calcaneofibular ligament and gave her good stability in - in through this area. On the anterior portion of the front of the ankle, there were two portals created - one here and one here - and that allowed us to go in and both diagnose and treat any internal problems of the joint. And again, that helped us confirm some instability over the medial ligamentous complex. And what you can see here is a incision that we used to do the direct open repair there.
So I'm gonna just put Kyra’s ankle through a range of motion and some - some physical examination here to - to demonstrate what we've done and to show that her range of motion really has been maintained in a - in a nice fashion. So the first thing we'll do is just do some dorsiflexion and plantarflexion maneuvers. You can see that she's probably got about 10 degrees of dorsiflexion, and I don't know - I'd say 35 or 40 degrees of plantar flexion through the ankle. And that's really good, and what I'm gonna do is compare it to the other side now. We’ll do it independently, and then we'll do it in tandem. You can see that it's very very close, and let me have Kyra do it actively. So go ahead and dorsiflex. Bring them up. Great. And down. It’s very close to symmetric. It's very nice. And - and move your feet in and out together. So that's - that's really nice. Both ankles are supple. There’s very little stiffness in this operative side.
And the other thing that I'm going to do here is a test for stability, and I'm gonna make sure that this is nice and stable. And that's - again, you can see that there's no real laxity to the ankle, and it’s not causing her any pain. Kyra, let me have your stand up.
So now we got Kyra standing up, and we're gonna see what kind of strength and motion she's got in her ankle, functionally, when - again, from a standing position. So Kyra go - go ahead and come up on your toes while - okay, and back down. Do that a few times. Good. Alright. Now, are you strong enough to - to come up r - on your right ankle alone? Yeah. Okay, go ahead. Great - yeah, absolutely. Good. Great.
So - obviously, so what you're telling us has been sorta proven. You can feel like you have good stability and good strength, and you’re not gonna - you don’t feel like you're gonna tip over when you do that. No, it feels very good. Okay. Great.
Here we have the latest radiographs of Kyra's, and these are from about a month ago now, showing the results from a radiographic perspective. And you can see, this is a anteropa - posterior view of her ankle in a standing position, and it's important to note - you know, she's got good maintenance of the joints space here. The talus here is well aligned below the tibia, and you can see right here, this is really the only hardware that we placed despite the extensive nature of - of the surgery that we did. This is a suture anchor made out of titanium that's placed into the tibia that we used to anchor the repair of the medial ligament complex. And so this is - that's really the only abnormality or not natural thing that we see on this - on this x-ray. The mortise view, which is a slightly internally rotated view, shows us much of the same. There’s no evidence of any arthritis, she's got good joint space preservation, and the alignment of the ankle is good. And - and this is echoed even further with her lateral view. Here you can see the - the anchor right here. You can see it's well above the joint line, and it doesn't even - doesn't encroach on the - on the cartilage of the subchondral bone. So all really good things for Kyra.
The surgical on video that's available is really germane for orthopedic surgeons who treat any sort of foot and ankle pathology. It's also very important for family medicine docs who have a specialization or concentrate on sports medicine injuries as well as people such as physical medicine and rehabilitation specialists and physical therapists, and this is especially important when you're talking about medial ankle instability. It's something that we're not always keyed into as clinicians. In terms of medial ankle instability, radiographs can appear quite normal as in this patient's. The diagnosis is suggested by the history as well as a phys - physical examination but really isn't cemented until you’re able to do an arthroscopy and - and prove its presence from a - from a surgical perspective. In the arthroscopic images that you can see in - during the operative video, you can clearly see the instability that’s present on the medial side. And this is really in distinction to what we see on the lateral ankle ligament instability where the clinical examination as well as the physical and - and - and on occasion the radiographs can provide you with a proof positive diagnosis and - and arthroscopic confirmation is usually not necessary. Diagnosing medial ankle instability really does incorporate the surgical confirmation of it, and it's important for physical therapists, physical medicine rehabilitation specialists, and orthopedic surgeons to realize that it's important to look for these things - but it really needs full confirmation using arthroscopy.