Chronic Ankle Instability: What's Going On and How Can I Treat It?

Introduction:

Chronic ankle instability (CAI) poses a significant challenge for elite athletes, impacting performance and increasing the risk of recurrent injuries. In this blog, we will delve into the intricate anatomy and function of the ankle joint complex, identify the key ligaments involved, and explore management strategies supported by research. 

Anatomy and Function of the Ankle Joint Complex:

The ankle joint is a remarkable complex, comprising three main joints: the talocrural joint (Tibia, Fibula & Talus), the subtalar joint (Talus & Calcaneus), and the inferior tibiofibular joint( Tibia & Fibula). The talocrural joint is responsible for dorsiflexion and plantarflexion. The subtalar joint allows for inversion and eversion. The inferior tibiofibular joint facilitates stability during weight-bearing activities.

Ligaments Involved in Ankle Stability:

An intricate network of ligaments provides stability to the ankle joint complex. The lateral ligament complex, consisting of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), is particularly susceptible to injuries leading to chronic instability. Hertel et al. (2019) and Gribble et al. (2021), emphasise the importance of understanding ligamentous contributions to ankle stability. These ligaments play a crucial role in preventing excessive ranges of motion.

Chronic Ankle Instability: Causes and Consequences:

CAI, is multifactorial, often arises from repeated ankle sprains, combined with poor early stage management, often due to the pressures of return to function/sport. In elite athletes, who subject their ankles to high levels of stress, poor early stage management can lead to improper healing, either non union or elongation of the ligaments. This can be a significantly contributing factor to persistent instability. Biomechanical abnormalities (Feger et al., 2017) and proprioceptive or strength deficits in supporting muscles, further contribute to the development of CAI.

Management Strategies:

Implementing evidence-based rehabilitation protocols is so important in managing CAI, but what does this mean? A study by Hiller et al. (2018) underscores the efficacy of structured rehabilitation in reducing the recurrence of ankle injuries in athletes. Proprioceptive training, strengthening exercises, and neuromuscular control drills, all get quoted in the doctrine, but what do they actually mean? Effectively all programs should include a combination of skill enhancement (“neuromuscular control/proprioception) and Strengthening of supporting muscles, the muscles that work concomitantly with the ruptured, weakened, lengthened ligaments.    

Bracing and External Support:

The use of external support, such as ankle braces, has gained traction in elite sports. Cho et al. (2020) conducted a comprehensive review supporting the role of prophylactic bracing in reducing the risk of recurrent ankle injuries. Customised braces provide mechanical support while allowing sufficient ankle mobility for athletic performance. At the top end of elite performance, often they can strengthen and practice strategies to reduce the impact of CAI, due to their ability to schedule this into their training. Surgery can have a lengthy recovery timeframe and may ultimately have a negative impact on performance. So their decision to use braces is based often on time constraints and financial implications, surgery may be considered for the off season.  

Biomechanical Analysis:

Employing advanced biomechanical analysis tools, such as three-dimensional motion analysis and force plate systems, aids in identifying and correcting faulty movement patterns. Research by Delahunt et al. (2022) highlights the significance of biomechanical assessments in tailoring individualised interventions for athletes with CAI. But this is costly and requires specialised equipment, technical skill to use and analyse results, often only found at university or research specialist centres. Your local running shop isn’t exactly what we’re talking about here. 

Surgical Interventions:

In cases where conservative measures fall short, surgical interventions may be considered. Arthroscopic procedures to address ligamentous laxity and anatomical reconstructions have shown promising results (Wang et al., 2021). Surgical interventions should be approached judiciously, considering the athlete's specific needs and performance goals. In the amateur athlete personal, professional and health related goals should be factored into the process. A clear explanation of the implications of surgery, timeframes and impact on work etc should all be discussed. 

Conclusion:

Chronic ankle instability remains a significant concern for elite athletes, necessitating a comprehensive and multidimensional approach. Understanding the intricate anatomy, identifying ligamentous involvement, and implementing evidence-based management strategies are crucial for optimising outcomes. The integration of recent research findings ensures that athletes receive the most current and effective care, promoting long-term ankle health and performance. As the field of sports medicine continues to evolve, ongoing research will further refine our understanding and refine our strategies for managing chronic ankle instability in athletes.

References:

Hertel, J., Corbett, R. O., & An, H. (2019). An updated model of chronic ankle instability. Journal of Athletic Training, 54(6), 572-588.

Gribble, P. A., Delahunt, E., & Bleakley, C. (2021). 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, 51(9), 469-479.

Feger, M. A., Donovan, L., Hart, J. M., & Hertel, J. (2017). Lower extremity muscle activation in patients with or without chronic ankle instability during walking. Journal of Athletic Training, 52(3), 227-236.

Hiller, C. E., Nightingale, E. J., Lin, C. W., Coughlan, G. F., & Caulfield, B. (2018). Factors associated with work-related ankle sprain injury: A case-control study. Journal of Science and Medicine in Sport, 21(2), 119-123.

Cho, B. K., Park, J. K., & Choi, S. M. (2020). Effect of prophylactic ankle bracing on ankle and knee biomechanics in female basketball athletes: A randomised control study. Journal of Sports Science & Medicine, 19(3), 444-452.

Delahunt, E., & Bleakley, C. M. (2022). Individualised neuromuscular control training to prevent ankle sprain in athletes: The paradigm shift toward a personalised approach. Physical Therapy in Sport, 51, 79-85.

Wang, X., Ma, T., Liu, C., & Han, J. (2021). Surgical management of chronic ankle instability: A systematic review and network meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 29(3), 822-832.