Chronic Ankle Instability: It may not be just an ankle sprain anymore

Intro 

      Ankle sprains are one of the most common recurrent injuries in sporting activities1-21 leading to a healthcare burden of three11,22 to four1 billion dollars annually. Forty to seventy percent of people with recurrent ankle sprains are likely to develop Chronic Ankle Instability (CAI)2,4,8,11,13-17,19,22,23. Despite efforts to restore strength and function after initial injury18,20, these patients also deal with excessive ligament laxity1,4,7,8,13,16,17, loss of proprioception1,2, decreased range of motion(ROM)1,2,4,5,11-14,16,18,19, recurrent swelling1,4,7,9,12,16,17,19, pain with activity1,4,6,7,9,12,16,17,19, decreased balance1,2,10,12,18,22,, feeling of “giving way”1,2,3,6,7,9,10,12-19,22,, and ankle osteoarthritis (OA)1,3,7,11,18,23. Debatably, the worst side effect in these patients is the development of osteoarthritis up to a decade sooner than those with primary joint OA11,22, leading to self-reported disability scores significantly lower than the general population5,13,16,22. The associated disability scores are also equal to or lower than patients with end-stage kidney disease, chronic heart failure, and Parkinson’s disease22. Thus, as clinicians, we need efficient methods for treating the initial ankle sprain before it develops into chronic ankle instability.  

 

Pathophysiology of chronic ankle pain 

Chronic ankle instability can be broken down into two main components: mechanical instability and functional instability2,4,6,14,16,17,22.   

 

      Mechanical instability relates to the damaged sensory receptors in the ligaments and joint capsule surrounding the ankle2,6,8,10,18. This damage interrupts afferent information input8,10,14 from the proprioceptors5,16, somatosensors5, and mechanoreceptors5 of the ankle joint10,24. Disruption in afferent information alters patients’ ability to detect early joint-loading10, as well as static and dynamic postural control10,19,24. Additionally, restricted dorsiflexion (DF) in the joint due to anterior talar displacement and restricted posterior talar glide interrupts the arthrokinematics of the joint1,5,6,14,16. These disturbances hinder information from entering the dorsal horn of the spinal cord, synapsing with interneurons before traveling to higher levels in the central nervous system (CNS) were sensory information is directed to the brain stem and motor cortex24. The afferent information received by the CNS can be used for feedback10,25 (detecting changes in joint position) or feedforward (joint adjustment in anticipation of movement) purposes24,25. This is especially important when unexpected perturbations or environmental factors change the normal motor pattern24. Proprioception is the fastest and most accurate input; the motor cortex requires afferent information to decide how to adjust muscle length, tension, and joint position to react to the change in movement24. When an injury is present, the information does not get transmitted fast enough or is even non-existent24, leading to compensations that can override mechanical instability and falsely return patients to pre-injury function22. 

 

      Functional joint stability is defined as maintaining joint homeostasis during bodily movements24. One of the current theories of functional compensation involves muscle stiffness over a joint24,25. When muscle ligaments, joint ligaments, and capsular structures18 are loose, multiple factors lead to increased reflexive neural activation of the structures, causing increased muscle and joint stiffness24. Stiffer structures may help resist sudden joint movement through reducing the new force, thus decreasing the potential for secondary injury24,25.  The second compensation stiffer muscles help with is that stiff muscles can transfer commands to muscle spindles faster due to their increased activity level24. This compensates for some of the normally impaired lag time during the start of activity24. Finally, higher motor control centers have been found to alter movement and muscle activation patterns at, proximal, and distal to the joint to maintain postural control24. This demonstrates the importance of making sure mechanical instabilities are addressed to avoid functional compensations that can lead to chronic ankle instability.  

 

Diagnosis 

      Clinicians should first obtain a detailed patient history25 including mechanism of injury, specific details on the ankle pain, when the feeling of instability occurs, mechanical symptoms, how the injury has impacted activity level, any previous sprains, previous treatment effectiveness, and a complete neurovascular exam of lower extremities6. It is also important to consider comorbidities, specifically BMI, that can contribute to ankle instability6.  

 

      Although not required, imaging can aid the diagnosis6. Radiographs of the anteroposterior, lateral, and mortise are most common6. Less common are instrumented stress radiographs or stress ultrasounds to complement manual testing of the AFTL/CFL ligaments. MRIs can be used before pursuing surgical routes but are not typically required during initial assessment6.  

 

Physical exams should, at minimum, include: 

• Formal gait assessment: checking bony alignment, arch height, heel alignment, and performing bilateral ankle and foot comparisons6,26 

• Ankle Range of Motion (ROM) and strength assessments: With CAI it is common to have decreased DF ROM and deficits in joint strength5,6,26 
• Integrity of joint ligaments, structures, and mobility: checking for hypo and hyper mobility, particularly anterior joint laxity and decreased posterior talar glide1,5,6,14,16,26 
• Formal assessment of postural balance to help track performance and assess potential proprioception deficiencies5,6 

 

Treatment 

      There is no current consensus as to the best surgical procedure for CAI2. Surgery is reserved for patients who have failed conservative treatment due to having significant disability6. When surgery is required, the main goal is to re-tension the lateral aspect of the ankle to correct biomechanical instability and address any intraarticular disease6. The most common procedures include the Broström procedure, Gould modification of the Broström procedure, and Chriman-Snook Repair6.  

 

      With no consensus on surgery available, conservative treatment is the preferred choice2,6. However, there are a variety of treatments available1,2,7,18 with no agreement as to which one is most effective7,17,20. Following is a summary of current research relating to treatment options for CAI. 

 

• Joint Mobilization: Eleven articles were found1-3,5,7,14-16,19,27,28 that include level A15,16 , level B16, and level C7 research. The majority of these articles demonstrate increases in ankle DF ROM1,2,3,5,14-16,19,28, higher scores in Star Excursion Balance Tests (SEBT)1,2,5,16,19, and improved self-reported outcome measures1,2,5,15,28. Mulligan Mobilizations with Movement were also found to be more effective than Maitland Mobilizations16,28.  

 

• Joint Manipulation: Six articles were found 4,17,18,20,21,29. Weerasekara reported mobilizations are better than manipulations28. Three studies demonstrated that manipulations help to improve foot loading21, functional testing (speed test time, hop test, and Y-balance)4, and DF ROM20. Other findings stated fascia manipulation could be effective in preventing injuries17, manipulation of the proximal or distal tibiofibular joints had no significant effect18, and manipulation of asymptomatic ankles had no significant effect29. 

 

• Massage: Six articles were found3,7-10,23 that included level B7 research. Massage was found to improve static balance3,8,9,23, balance with eyes open8, self-reported outcome measures9, and DF ROM9. Research did not show significant improvements in balance with eyes closed7,8. Patients with CAI demonstrated greater light touch thresholds on the plantar aspect of their feet that can be addressed through clinician or self-applied plantar massage10. 

 

• Balance Training: Three articles were found7,10,13 that included level A7 research. Balance training demonstrated improvements in ankle/foot postural control10,13 and light touch proprioception10. The research recommended that balance training programs need to be progressively more challenging to have the largest impact on patient outcomes7. 

 

• Strength Training: Three articles were found3,7,19 that include level B7 research. Strength training was noted as effective at improving ankle strength3,7,19. However, strength training was suggested to not be as important as training the timing of muscle activation during activity7.  

 

• Dry Needling (DN): One article was found11 that included level B11 research. DN of the peroneus longus, for multiple treatments, demonstrated a greater effect on self-reported patient outcome measures compared to exercise11. 

 

• Multimodal: One article was found7 that included level B7 research. It reported improvements in self-reported patient outcome measures when following a progressive balance program7. 

 

• Taping: One article was found12. Mulligan distal fibular taping has been shown to decrease pain at rest and with dynamic activity and improve DFROM and dynamic balance12. 

 

      Upon review of the literature, no single article seems to hold the answer to the best course of treatment. Some articles suggest that a combination of the above options may be the best approach2-6,8,13,15,18,19,26,28. Further research is needed to determine how to best treat CAI.  

 

Conclusion  

      Chronic ankle instability is a complex injury that clinicians must be able to successfully treat. As highly trained clinicians, we have the skills and knowledge16,23 to treat this multifactoral problem. However, as a community, we must push for further research to determine which approaches are meaningful for our patients.   

 

Jessika Volz PT, DPT, ATC, FAAOMPT 

Assistant Athletic Trainer and Physical Therapist 

Real Salt Lake  

jessika.volz@rsl.com 

 

References 

 

1. Cruz-Díaz, D., Vega, R. L., Osuna-Pérez M. C., Hila-Contreras, F., & Martínez-Amat, A. (2015). Effects of Joint Mobilization on Chronic Ankle Instability: A Randomized Controlled Trial. Disability and Rehabilitation, 37. (7), 601-610. Doi: 10.3109/09638288.2014.935877 

 

2. Shi, X., Han, J., Witchalls, J., Waddington, G., & Adams, R. (2019). Does Treatment Duration of Manual Therapy Influence Functional Outcomes for Individuals with Chronic Ankle Instability: A Systematic Review with Meta-analysis? Musculoskeletal Science and Practice, 40. 87-95. Doi: 10.1016/j.msksp.2019.01.015 

 

3. McKeon, P. O., & Donovan, L. (2019). A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift. Journal of Athletic Training, 54. (6), 628-638. Doi: 10.4085/1062-6050-474-17 

 

4. Kamali, F., Sinaei, E., & Bahadoriam, S. (2017). The Immediate Effect of Talocrural Joint Manipulation on Functional Performance of 15-40 Years Old Athletes with Chronic Ankle Instability: A Double-blind Randomized Clinical Trial. Journal of Bodywork & Movement Therapies, 20. (4), 830-834. Doi: 10.1016/j.jbmt.2017.01.010 

 

5. Hoch, M. C., Andreatta, R. D., Mullineaux, D. R., English, R. A., McKeon, J. M. M., Mattacola, C. G., & McKeon, P. O. (2012). Two-Week Joint Mobilization Intervention Improves Self-Reported Function, Range of Motion, and Dynamic Balance in Those With Chronic Ankle Instability. Journal of Orthopaedic Research, 30. (11), 1798-1804. Doi: 10.1002/jor.22150 

 

6. Gruskay, J. A., Brusalis, C. M., Heath, M. R., & Fabricant, P. D. (2019). Pediatric and Adolescent Ankle Instability: Diagnosis and Treatment Options. Current Opinion Pediatrics, 31. (1), 69-78. Doi:10.1097/MOP.0000000000000720 

 

7. Kosik, K. B., McCann, R. S., Terada, M., & Gribble, P. A. (2017). Therapeutic Interventions for Improving Self-Reported Function in Patients with Chronic Ankle Instability: A Systematic Review. British Journal of Sports Medicine, 51. (2), 105-112. Doi: 10.1136/bjsports-2016-096534 

 

8. LeClaire, J. E., & Wikstrom, E. A. (2012). Massage for Postural Control in Individuals With Chronic Ankle Instability. Athletic Training & Sports Health Care, 4. (5), 213-219. Doi:10.3928/19425864-20120731-02 

 

9. Jordan, J. A., Turner, M. J, Thomas, A., Wikstrom, E. A., & Hubbard-Turner. (2020). Effects of a 4-Week Instrumented Soft Tissue Mobilization and Sham Treatment as Rehabilitation Strategies for Chronic Ankle Instability. Athletic Training & Sports Health Care, 12. (1) 14-20. Doi: 110.3928/19425864-20190207-03 

 

10. Powell, M. R., Powden, C. J., Houston, M. N., & Hoch, M. C. (2014). Plantar Cutaneous Sensitivity and Balance in Individuals With and Without Chronic Ankle Instability. Clinical Journal of Sports Medicine, 24. (6), 490-496.  

 

11. Mullins, J. F., Nitz, A. J., & Hoch, M. C. (2019). The Effect of Dry Needling on Patient-Reported Outcomes in individuals With Chronic Ankle Instability: A Critically Appraised Topic. International Journal of Athletic Therapy and Training, 24. (5), Doi: 10.1123/ijatt.2018-0075 

 

12. Simsek, S., & Yagci, N. (2019). Acute Effects of Distal Fibular Taping Technique on Pain, Balance, and Forward Lunge Activities in Chronic Ankle Instability. Journal of Back and Musculoskeletal Rehabilitation, 32. (1), 15-20. Doi: 10.3233/BMR-181132 

 

13. Burcal, C. J., Trier, A. Y., & Wikstrom, E. A. (2017). Balance Training Versus Balance Training with STARS in Patients with Chronic Ankle Instability: A Randomized Controlled Trial. Journal of Sport Rehabilitation, 26. (5), 347-357. Doi: 10.1123/jsr.2016-0018 

 

14. Hoch, M. C., & McKeon, P. O. (2010). Joint Mobilization Improves Spatiotemporal Postural Control and Range of Motion in Those with Chronic Ankle Instability. Journal of Orthopaedic Research, 29. (3), 326-332. Doi: 10.1002/jor.21256  

 

15. Wikstrom, E. A., Bagherian, S., Cordero, N. B., & Song, K. (2019). Six Sessions of Anterior-to-Posterior Ankle Joint Mobilizations Improve Patient-Reported Outcomes in Patients With Chronic Ankle Instability: A Critically Appraised Topic. Journal of Sports Rehabilitation, 28. (4), 381-384.  

 

16. Vallandingham, R. A., Gaven, S. L., & Powden, C. J. (2019). Changes in Dorsiflexion and Dynamic Postural Control After Mobilization in Individuals with Chronic Ankle Instability: A Systematic Review and Meta-Analysis. Journal of Athletic Training, 54. (4), 403-417. Doi: 10.4085/1062-6050-380-17 

 

17. Brandolini, S., Lugaresi, G., Santagata, A., Ermolao, A., Zaccaria, M., Marchand, A., & STecco, A. (2019). Sport Injury Prevention in Individuals with Chronic Ankle Instability: Fascial Manipulation Versus Control Group: A Randomized Controlled Trial. Journal of Bodywork and Movement Therapies, 23. (3), 316-323. Doi: 10.1016/j.jbmt.2019.01.001 

 

18. Beazell, J. R., Grindstaff, T. L., Sauer, L. D., Magrum, E. M., Ingersoll, C. D., & Hertel, J. (2012). Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals With Chronic Ankle Instability. Journal of Orthopaedic & Sports Physical Therapy, 42. (2). Doi: 10.2519/jospt.2012.3729 

 

19. Cruz-Díaz, D., Hita-Contreras, F., Martínez-Amat, A., Aibar-Almazán, A., & Kim, K-M. (2020). Ankle-Joint Self-Mobilization and CrossFit Training in Patients with Chronic Ankle Instability: A Randomized Controlled Trial. Journal of Athletic Training, 55. (2), 159-168. Doi: 10.4085/1062-6050-181-18 

 

20. Whitman, J. M., Cleland, J. A., Mintken, P., Keirns, M., Bieniek, M. L., Albin, S. R. Magel, J., & McPoil, T. G. (2009). Predicting Short-Term Response to Thrust and Nonthrust Manipulation and Exercise in Patients Post Inversion Ankle Sprain. Journal of Orthopaedic & Sports Physical Therapy, 39. (3). Doi: 10.2519/jospt.2009.2940 

 

21. López Rodríguez, S., Fernandez de-las-Penas, C., Alburquerque-Sendin, F., Rodríguez-Blanco, C., & Palomeque-del-Cerro, L. (2007). Immediate Effects of Manipulation of the Talocrural Joint on Stabilometry and Baropodometry in Patients with Ankle Sprain. Journal of Manipulative and Physiological Therapeutics, 30. (3), 186-192. Doi: 10.1016/j.jmpt.2007.01.011 

 

22. Gribble, P. A., Delahunt, E., Bleakley, C., Caulfield, B., Docherty, C., Fourchet, F., Fong, D., Hertel, J., Hiller, C., Kaminski, T., McKeon, P., Refshauge, K., Van Der Wees, P., Vicenzino, B., Wikstrom, E. (2013). Selection Criteria for Patients with Chronic Ankle Instability in Controlled Research: A Position Statement of the International Ankle Consortium. Journal of Orthopaedic Sports Physical Therapy, 43. (8), 585-591. Doi: 10.2519/jospt.2013.0303 

 

23. Wikstrom, E. A., Song, K., Lea, A., & Brown, N. (2017). Comparative Effectiveness of Plantar-Massage Techniques on Postural Control in Those With Chronic Ankle Instability. Journal of Athletic Training, 52. (7), 629-635. Doi:10.4085/1062-6050-52.4.02 

 

24. Riemann, B. L., & Lephart, S. M. (2002). The Sensorimotor System, Part I. The Physiologic Basis of Functional Joint Stability. Journal of Athletic Training. 37. (1), 71-79.  

 

25. Riemann, B. L., & Lephart, S. M. (2002). The Sensorimotor System, Part II. The Role of Proprioception in Motor Control and Functional Joint Stability. Journal of Athletic Training. 37. (1), 80-84.  

 

26. Fraser, J. J., Feger, M. A., & Hertel, J. (2016). Clinical Commentary on Midfoot and Forefoot Involvement in Lateral Ankle Sprains and Chronic Ankle Instability. Part 2: Clinical Considerations. The International Journal of Sports Physical Therapy, 11. (7), 1191-1203.  

 

27. Hidalgo, B., Hall, T., Berwart, M., Biernaux, E., & Detrembleur, C. (2018). The Immediate Effects of Two Manual Therapy Techniques on Ankle Musculoarticular Stiffness and Dorsiflexion Range of Motion in People with Chronic Ankle Rigidity: A Randomized Clinical Trial. Journal of Back and Musculoskeletal Rehabilitation, 31. (3), 515-524. Doi: 10.3233/BMR-170963 

 

28. Weerasekara, I., Osmotherly, P. G., Snodgrass, S. J., Tessier, J., & Rivett, D. A. (2019). Effects of Mobilization with Movement (MWM) on Anatomical and Clinical Characteristics of Chronic Ankle Instability: A Randomised Controlled Trial Protocol. BMC Musculoskeletal Disorders, 20. (75). Doi: 10.1186/s12891-019-2447-x 

 

29. Fryer, G. S., Mudge, J. M, & McLaughlin, P. A. (2002). The Effect of Talocrural Joint Manipulation of Range of Motion at the Ankle. Journal of Manipulative and Physiological Therapeutics, 25. (6), 384-390. Doi: 10.1067/mmt.2002.126129