ORTHOPODE
Chronic lateral instability of the ankle
Repeated ankle sprains, accidents caused by instability, unease in walking on irregular ground, the feeling of the ankle being “not sure”, losing confidence and gradually restricting activities so as to avoid spraining the ankle are frequent reasons for consulting a specialist ankle surgeon.
We shall therefore deal with this issue as clearly and comprehensibly as we can. But, before getting on to instability, we should first explain what elements enable a normal ankle to be stable.
Factors of stability of normal ankle
Quelles sont les causes de l’arthrose de la cheville ?
I/ “Passive” factors: i.e., the kind that are not improved by functional rehabilitation by a physiotherapist
1°) Bone elements
a) Congruence between bone parts: how they “fit” and are embedded
The distal tibia, with the medial malleolus, and the distal fibula (lateral malleolus) compose the “bimalleolar mortice”, inside which the talar dome is naturally stabilized. This congruence is the first element in normal ankle stability.
b) Anatomic axis of the ankle
In a normal ankle, the contact point of the heel with the ground is somewhat off the tibial axis. This is a further element of ankle stability, and always needs looking at in analyzing the pathology and its causes.
Anatomic specimen, showing the heel contact point, positioned normally outside the prolongation of the axis of the tibia.
Normal X-ray image, showing a normal axis, between 5° and 10°.
Pathological X-ray image, showing an axis at 1°, outside the normal range.
The ankle needs to be stable, but also mobile, to allow normal propulsion and also effective shock absorption. Mobility with stability: here is the challenge.
2°) The ligament system
The second “passive” stabilization system comprises the “stays”: the ligament system, which needs to be healthy and balanced.
This shows the crucial importance of X-ray assessment under weight-bearing (i.e., standing) ahead of any diagnosis and treatment. This simple, relatively inexpensive and easily accessible examination is the only one that can be made with the ankle in its functioning position: i.e., standing. Your specialist will glean a lot of information from it: joint impingement, joint gap, ligament imbalance, malalignment, etc.
Pathological X-ray shows a loss of normal alignment, and osteoarthritis lesions due to repeated sprain.
II/ Active” stability factors
This is a matter of the muscle-tendon system; the main parts involved in stabilizing the ankle are the long and short peroneal muscles, the tendons of which turn behind and below the malleolus.
Image of the peroneal tendons’ course
There can be functional instability without associated ligament lesions: some people have unstable ankles that give way, with repeated sprains, although their ligaments are perfectly healthy.
This always needs screening for, as treatment is different: functional proprioceptive rehabilitation usually succeeds in stabilizing the ankle in these cases – with no need to operate on healthy ligaments! We shall see below what physiotherapists can achieve, and their state-of-the-art “connected” tools, enabling new methods of rehabilitation, with objective measurement methods to monitor the patient’s progress in performing the exercises. In some cases, however, we can only admit that rehabilitation has failed, especially when the exercises themselves trigger pain that prevents rehabilitation being effective.
Intraoperative image of peroneal tendon tear causing instability of functional origin
This introduction to the stable ankle and the elements ensuring its stability helps us understand how a particular ankle may have come to be unstable, and that identifying the cause or causes is an indispensable step in determining treatment.
Diagnosis of instability
Quelles sont les manifestations de l’arthrose de la cheville ?
1/CLINICAL ASPECTS
1°) The interview:
The concept of instability can come up only in consultation: it is a symptom, and the definition covers a range of specific complaints of varying severity. There may be apprehension: the patient feels his or her ankle is not stable, solid, reliable; they cannot trust it and fear it will “give way”. There may be very brief episodes where it does indeed give way, not necessarily painfully, and sometimes only on irregular or sloping ground or on pebbles or the kerbside. There may also be real repeated sprains. Patients may have to give up sports (team sports or racket sports) or else change their sporting activity.
Pain may be the presenting symptom. It may be intermittent, occurring only in case of sprain or accident, or be more recurrent, during sports activity, or even during simple everyday activity. The cause will always have to be looked for: in the joint, the tendons, the ligaments, etc.
2°) Clinical examination:
The clinical examination is indispensable! No complementary exams can replace a good “programmed” clinical examination: i.e., one which follows a well-laid track of observation, palpation, passive and active tests, covering the joints and muscle-tendon structures and screening for ligament laxity.
These two initial procedures, interview and clinical examination, general allow precise diagnosis. Complementary examinations are intended to confirm this or that suspicion or to determine the origin of a problem that has been revealed.
2/PARACLINICAL EXAMINATIONS
1°) Radiographic assessment: This is the indispensable complementary examination, and is the only one that can be conducted with the patient standing upright. It screens for hindfoot malalignment (often, the heel being “too much in the middle”) or some abnormality in the foot in standing posture, but also for avulsion of the ligament attachments, cartilage lesions, etc.
2°) Ultrasound: Performed by a specialist, ultrasound is the most sensitive and specific examination. The probe provides reliable exploration of the ankle ligaments and also of the peroneal tendons, which lie just under the skin. Moreover, it can be a dynamic examination, with the radiologist twisting the ankle and observing the ligament structures as they stretch – or fail to.
3°) CT arthrography is the only examination that explores cartilage lesions, and is often an indispensable preoperative examination.
CT scan, showing advanced osteoarthritic lesions, with direct contact between the bones.
4°) MRI provides no direct information on cartilage and, if examination conditions are less than perfect (in terms of choosing slices), the ligaments may not be properly explored.
5°) EOS examination of the lower limbs is sometimes prescribed as a complementary examination to assess overall lower-limb alignment.
Treatment strategy
Quelles sont les manifestations de l’arthrose de la cheville ?
1°) Non-surgical treatment: functional proprioceptive rehabilitation with a physiotherapist
THIS IS INDISPENSABLE, before considering any surgical treatment. The physiotherapy is based on functional proprioceptive rehabilitation, to optimize neuromuscular programing. Various methods exist, some of which are classical, others innovative and specific to ankle rehabilitation.
In calcaneal varus, where the heel is shifted midward, compensatory orthopedic insoles can prove useful.
2°) Surgical treatments:
The most frequently used procedure worldwide is the “Bröstrom-Gould” procedure (cf. presentation by Dr Grisard: Revue de littérature Ligamento cheville on YouTube).
But other techniques have good reputations too, such as the extensor retinaculum procedure (cf. Ligamentoplastie au rétinaculum des extenseurs on YouTube), which has the advantage of stabilizing the underlying level, which is often involved in long-standing chronic lateral instability.
These techniques are performed under open surgery.
There are also arthroscopic equivalents, the results of which, however, are still under assessment (See presentation by Dr. Jean-Luc Grisard, “Académie de la cheville”, on YouTube)
In practice, the choice of technique is made on a case-by-case basis: a young woman with slight hyperlaxity practicing leisure sport is not going to want the same treatment as a judoka weighing 100 kg who takes part in competitions; the demand is not the same, the needs are not the same, and the surgical technique needs to be personalized.
I am going to be operated on by ankle ligament reconstruction: I have a few questions
Quelles sont les manifestations de l’arthrose de la cheville ?
Dr. Jean-Luc Grisard
Before the operation
An appointment with the anesthetist is mandatory. Except in case of emergency surgery, you need to see the anesthetist between 2 and 30 days before the operation. In this consultation, the anesthesia technique will be decided upon, depending on the requirements of surgery, your own preference, and also your state of health and personal risk factors.
Hospital admission
Admission: Unless you live particularly far away or have other difficulties, you will be admitted on the actual day of surgery.
Skin preparation:
- The Clinique du Parc Infection Risk Prevention Committee (Chair: Dr. Jean-Luc Grisard) strongly advises against hair removal: it has been proved that this only increases infection risk at the surgery site! Patients can have hair removed at least 1 week ahead or surgery, but never by shaving, which risks tiny cuts that get colonized by bacteria, increasing the risk of postoperative infection.
- You will take a shower, with mild unscented soap (Savon de Marseille, Sanex, etc.) in the evening and morning before surgery, washing your hair as well. Betadine and other antiseptics are no longer used in the Clinique du Parc, for skin preparation (shower) or for postoperative dressing, for a simple reason: our skin is covered by “resident” bacterial flora which contributes to healing, and antiseptics are actually harmful, as they kill off this flora.
- Remove any nail varnish, which is a “culture broth” for bacteria.
- Take off all rings, ear-rings and piercings, as these harbor bacteria.
Hospital stay: either 1 night in hospital, or outpatient “day-surgery” (same-day discharge).
The operation:
The technique most often used in our department is the extensor retinaculum technique: this includes both ligament reconstruction and retinaculum reinforcement. See https://www.youtube.com/watch?v=T8U2d0D5_V4
Immobilization in boot cast: This protects the reconstruction that has been performed, facilitates good healing by preventing traction and skin stretching, and prevents the ankle stiffening in an “equinus” position during the period in which weight-bearing is not allowed (usually, 2 weeks).
The cast should be worn around the clock for the first 4 weeks: the dressing will not be changed, so as not to disturb healing; moreover, taking your foot out of the boot cast pulls on the skin, jeopardizing good healing. The sutures will be removed around 2 weeks after surgery.
Postoperative pain: In most cases, postoperative pain is moderate. The experience of pain depends on personal factors, psychological status (your morale: how you are feeling), preoperative pain (by memory effect), and any usual treatments. Pain management follows the guidelines of the Clinique du Parc Pain Committee (Comité de Lutte contre la Douleur: CLUD).
Autonomy:
A physiotherapist will come to see you in your hospital room to show you how to use crutches and start weight-bearing again, which is allowed as soon as you are discharged. He or she will teach you the self-rehabilitation exercises you need to practice regularly while still wearing the boot cast up until the end of the immobilization period.
THUS, you are encouraged to start walking with full weight-bearing from the actual day of surgery itself: at first, crutches are indispensable to keep your balance, limit pain and overcome your apprehension, but as the days go by you can take more and more of your weight on your foot, and do without the second crutch.
Discharge
Discharge is usually later in the day of the operation for outpatient surgery, or else at the end of the next morning.
On request, a transport ticket will be provided by the secretariat.
Once back home
Pain-killers (analgesics): if there is no intolerance, contraindications, allergy or drug interactions, you will be given a prescription for step-1 pain-killers that you should take systematically for the first 5 days after discharge, whether you are in pain or not: they are meant to prevent pain setting in. As well as these systematic drugs, you will be prescribed step-2 pain-killers to be taken on top of the step-1 analgesics if these are not enough.
Anticoagulation treatment: Anticoagulation treatment lasts 30-45 days, depending on your risk factors: history of phlebitis, overweight/obesity, etc. It comes in the form of subcutaneous injections, which most patients manage to do themselves.
Boot cast immobilization:
The boot cast is to be worn around the clock for 6 weeks, except during self-rehabilitation exercises.
| Weeks 1-2 | Day 15 | Weeks 3-4 | Weeks 5-6 | Weeks 7-12 | |
| BOOT | SUTURES | BOOT | BOOT | Walking without protection | |
| 24/24 | 24/24 | 24/24 | 24/24 | ||
| SELF-REHAB | |||||
| WEIGHT-BEARING | ALLOWED | FROM | THE DAY | OF | SURGERY |
Rest: It is essential to raise the foot up to heart level for the first 10 days: by combating swelling, you combat pain, promote good healing and allow quick recovery.
Rehabilitation: Rehabilitation starts 28 days after surgery. At first, it is self-rehabilitation, without a physiotherapist: once a day, you take your foot out of the boot and practice flexion-extension movements, along the axis of the ankle, without twisting. This is a good opportunity to have a shower.
The physiotherapist comes on the scene at 7 weeks. You get a prescription at discharge to contact a physiotherapist in advance.
Autonomy
Will I be able to put my foot on the ground? Will I need crutches? For how long?
Yes, crutches are obligatory until the first follow-up consultation. Then it is recommended that you progressively return to complete weight-bearing without restriction except for pain. Resuming weight-bearing prevents “neuromuscular deprograming”, helps recover ankle motion, reduces the risk of phlebitis, and keeps the muscle system in trim. This does not, however, mean going for walks: you need to limit the time you spend upright; there is always the problem of swelling, which you will need to fight against for a number of weeks.
And then?
Sick-leave: 6 weeks to 3-4 months, depending on your kind of work.
Rehabilitation with a physiotherapist: 30 sessions are prescribed from the outset.
Driving can be taken up again at the end of the 6th week, after giving up the boot cast.
Starting leisure and sports activities again
Walking, cycling, swimming: 6 weeks
Running: 3 months
“Racket” sports: 4 months
Team sports with pivoting (changing direction) and contact: 6 months
Treatments
The initial and adequate management of a trauma, which goes from the “simple” sprain to the fracture, simple or complex, is a fundamental element.
See treatments for osteoarthritis of the ankle