Chronic Ankle Instability
May 6, 2022
According to statistics from the Federal Office for Accidents (2015), almost every 4th sports injury, as well as almost every 6th injury occurring at home and during leisure activities, affects the ankle joint area [4]. Therefore, injuries to the upper ankle joint certainly rank among the most common sports injuries in sports traumatology [1–3].
In most cases, this involves a supination trauma. In this injury, the foot tilts inward over three axes of movement. In technical jargon, this is referred to as plantar flexion, adduction, and inversion of the foot. Due to the significant stretching of the outer (lateral) ligament complex of the ankle, it is often overstretched and thus injured. There is a risk that this acute injury may later develop into chronic ankle instability.
Learn more about the structure and anatomy of the ankle joint and the mechanisms of injury in our first blog "Acute Supination Trauma, Ligament Injuries of the Foot".
The therapy and symptoms can vary greatly between acute supination trauma and chronic ankle instability. In this article, we focus on chronic instability.
Chronification
The consequences of an acute supination trauma often become apparent over time. On the one hand, the overstretched ligament structures no longer sufficiently support joint stability, and on the other hand, signals from the stretch receptors for proprioceptive muscle control are not triggered in time. Due to muscle overload, this can lead to chronic ankle instability from an acute supination trauma in 20-40% of cases [1,3].
Chronic Foot Joint Instability
Chronic foot joint instability is characterized by recurrent supination traumas, persistent pain in the upper ankle, difficulties under load, a subjective feeling of instability, or difficulties walking (especially on uneven terrain) [1,5].
This instability can manifest mechanically and/or functionally.
Mechanical instability includes pathological ligament insufficiencies and limitations occurring after capsule-ligament injuries (e.g., due to scarring, poor wound healing), as well as limited range of motion in dorsal extension (pulling the toes toward you).
Functional instability is apparent through muscle deficits and a subjective feeling of instability. This is partly due to a deterioration in proprioceptive neuromuscular potential, leading to reduced joint control [1,6]. This was already researched in a study in 1965: it was found that frequent ligament injuries to the ankle lead to a deficit in perception, which affects surrounding muscles (reduced proprioceptive neuromuscular potential) [7].
Consequences of Chronic Ankle Instability
In 55% of cases, chronic ankle instability is the main cause of ligamentous post-traumatic osteoarthritis[8]. A retrospective study from 2019 shows that individuals with chronic ankle instability, due to repetitive supination traumas, are more likely to develop an osteochondral lesion of the talus earlier [9]. This means that the bone, which connects the lower leg to the foot, prematurely develops arthritis, manifesting as pain under load, swelling, and limited mobility of the ankle joint. To prevent these consequences as much as possible, adequate treatment during the acute phase is recommended. Otherwise, efficient treatment of chronic ankle instability is of great importance.
Therapy and Treatment of Chronic Ankle Instability
The therapeutic treatment is based on mechanical and functional aspects. This means improving both mobility and motor control.
During the treatment of mechanical instability, all joints of the foot, as well as the lower extremity, are tested for mobility. The discovered limitations are then improved through active and passive mobilization to restore the correct dynamic biomechanics of the ankle joint [10].
This can be achieved through manual techniques in osteopathy and physiotherapy.
Particularly in chronic ankle instability, however, functional, active therapy and treatment should clearly take precedence!
The goal of this is to perform all activities smoothly, to overcome the fear of poor movement, and to regain confidence in the joint. It mainly involves active exercises and training forms, where coordination, balance, strength, endurance, and speed are trained. A continuous buildup is crucial; this means starting with simple static exercises before increasing the difficulty level with dynamic and more complex exercises. Another important point is to eventually perform non-cyclic, sport-specific exercises to prepare the joint for real conditions during sport or daily life [11].
Conclusion
Do not underestimate injuries from a supination trauma to the foot. Especially if you often twist your ankle, do not take it lightly! Because an acute supination trauma can lead to chronic ankle instability, even if the injury initially seems quite harmless! Have it checked and consider appropriate treatment to prevent long-term damage or pain.
Premature arthritis in the ankle joint is a possible long-term consequence in over half of the cases resulting from an acute supination injury or chronic ankle instability of the foot.
Even if you have twisted your ankle for years and have loose ligaments, it is never too late to receive support with tailored therapy!
If you need us, we are here for you!
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References
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Leumann A, Tsaknis R, Wiewiorski M, Valderrabano
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7. The etiology and prevention of functional instability of the foot.pdf.
8. Ligamentous Posttraumatic Ankle Osteoarthritis.
Valderrabano V, Hintermann B, Horisberger M, Fung TS.
Am J Sports Med. April 1, 2006;34(4):612–20.
Ikoma K, Kido M, Maki M, Imai K, Hara Y, Ikeda R, et al.
Journal of Orthopaedic Science 2020 Jan;25(1):178-182. doi: 10.1016/j.jos.2019.02.003. Epub 2019 Feb 21
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11. acute_ankle_sprain_KNGF-Guideline.pdf.
