Well, thanks, Brian. Again, I think the treatment of ankle instability is evolving like the treatment of everything else. And I think this is a really good symposium to kind of get the update on some of the changes in thought process. So this talk doesn't really have any conflicts, these are my disclosures. So I think when you approach, you know, ankle instability, again, it's important to go over this because I find this is the most common thing that I see in my clinic is patients who've had ankle instability symptoms, have surgery, and they continue to be problematic. And you kind of go back to square one and you try and figure out why things aren't working and why they're having problems. And I think this is really important. You kind of have to examine the whole ankle and look at other associated injuries or problems that happen at the time of the sprain or recurrent sprains. And so, again, take a very thorough, systematic approach and think of all the potential areas, you know, anatomically that could be affected that are causing some of the symptoms. And it may be including ankle instability. Again, a lot of people have done a lot of work over the years. It's hard to go through everything. This was Nick Van Dyke's PhD thesis. He looked at 40 acute ankle sprains and tried to assess what happens at the time of ankle injuries and published several papers on this cohort of 40 acute ankle sprains, including arthroscopic findings in this group, and found that two-thirds of them are chondral injuries at the time of the ankle sprain, and you can see how that happens. So again, you know, be aware of that and be conscious of that, that this may be one of the things that happens. The other thing that's happened over the years is ankle impingement that occurs with recurrent stress on the ankle. So this is a typical stress X-ray of, well, a stress condition of, this is an NBA basketball player who's 25 years old, and look at his ankle. He's got both anterior and posterior spurring, medial and lateral spurring from the chronic stresses on the ankle. And I think that's one of the things that's evolved over the last few years is that maybe this is a sign of chronic ankle instability, and they're trying to stabilize the ankle. And this is just one paper from the ankle instability group, which I'm not part of, that looked at ankle instability and arthroscopic findings, and really kind of making it, trying to make a correlation that if you have ankle impingement, soft tissue or bony impingement, that you should be thinking that they may have chronic ankle instability. Other associated problems with chronic ankle sprains are, you know, tendinopathies, in particular, the perineal tendons. This is a perineal tendoscopy. And I think if you're trying to make a diagnosis, obviously, imaging is good, ultrasound, MRI, but sometimes when it's really vague, this was a teenager and had chronic lateral ankle symptoms, and she has a tear of her perineus brevis tendon there, and you can see that in this perineal tendoscopy, and then we made a small incision and repaired the tear. There you can see the tear in the tendon. Syndesmotic sprains or partial syndesmotic sprains often accompany ankle sprains because they're very close together, the two ligaments. You can see the distal fibers of the tip-fib ligament and the ATFL. So if you're spraining your ATFL, you're probably going to injure a few fibers of your tip-fib ligament, and that may cause some chronic symptoms. And then deltoid injuries has become another well-known issue that may cause chronic problems. Even in patients who've had lateral ankle repair may have chronic deltoid instability. So it's important to understand the anatomy, and again, it's always important to emphasize this. This is a cadaveric dissection, and you can see the distal tip-fib fibers from the syndesmotic ligament, ATFL. If you remove the perineal tendons, you can see the ATFL and the CFL is deep to the perineal tendons. So again, all these structures are close. The distal fascicle of the syndesmotic ligament, the ATFL, CFL, perineal tendons, and then the extensor retinaculum is sitting right here, which you can use to augment your brostrom repair. And again, the deltoid has become important as well as a reason for failure of lateral ankle stabilization and understanding that deltoid injuries can occur at the same time. They're very difficult to assess, much more difficult than the lateral side. And so again, understand all the potential structures that are injured. Again, this is an external rotation injury where you injure your syndesmotic ligament and injure your deltoid. But again, it's important to understand that the deltoid and the syndesmosis may be part of the whole complex of ankle instability. So when you look at the treatment of ankle instability, there's lots of literature and lots of evidence-based publications that repairing the lateral ligaments for ankle instability are successful. However, there is a significant element of deltoid injury. This was an MRI study done from Utah where they found that 72% of lateral ankle injuries may have a medial deltoid injury at the time of the initial injury. And this is from their study, again, showing the types of injuries that occurred in terms of the deltoid component. When you look at the outcome of surgical stabilization, and the next three speakers will be speaking more on that, there is a significant failure rate of just surgical stabilization. Again, this has been over the last 10 years or so. And maybe it's because the lateral stabilization has not addressed all the symptoms. So you need to assess the whole ankle, what are the associated injuries, and what's the medial contribution to the instability problems that you should address. So that's just an overview of assessing ankle instability in general. Once you've worked through that and you're left with a ankle that you feel has lateral chronic ankle instability, this is the way I think about it, having static or dynamic instability. And these are some of the other terms that are used. Functional instability, which is really from dynamic control. Mechanical instability, which is due to failure of static constraints. And then you may also have subtalar joint involvement. And again, it's a difficult area to assess. So functional instability is a loss of proprioceptive feedback, muscle weakness, muscular inhibition because of swelling, and joint dysfunction, as you can see there in a swollen ankle. And so my approach to ankle instability, I'm sure everybody here does the same thing. You need to make a clear diagnosis, in other words, make a complete evaluation, optimize the rehab program to treat the functional instability. And then if that fails, I think you can consider surgical treatment in this group of patients. How about imaging for diagnosis? Again, I think the clinical exam is the most important part of the evaluation. But we obviously do routine radiographs to look at the joints, look at the alignment, look for ankle impingement. Stress x-rays, I tend not to use stress x-rays in my practice. And then I do use a CT and MRI to assess the joint condition, the subtalar joint, assess the cartilage status so that you can figure out the treatment required. Weight-bearing CT has become an important entity over the last couple of years. This is a publication from Cesar Doneto looking at weight-bearing CT to assess ankle instability. This was a retrospective study that compared a large group of normals to a group of ankle sprains and basically concluded that various alignment on this weight-bearing CT, the various alignment was a significant predictor of chronic ankle instability. And again, we know that, and you can assess that on physical examination as well. Testing for stability, I think everybody's familiar with the anterior drawer test and the lateral tailored tilt test. And again, you can compare one side to the other and get a good feel on physical exam what each of these contributions are to the instability. Again, alignment, you should check the alignment in the clinic. Here you can see the looking from behind. You can see the peekaboo sign where you see the medial side of the foot is kind of peeking in because of the various alignment. And obviously, standing x-rays give you a better view as well. So, you should be looking for various alignment either from the forefoot or from the hindfoot as a cause of chronic ankle instability. And here's an example. This is a 16-year-old girl. You can see the hindfoot alignment on the hindfoot alignment view. And you can see that, you know, the lateral standing view looks a little bit high arched but not severe. There's the examination. Again, you can see the various hindfoot. And so, in this case, we did a stabilization and hindfoot realignment. And just briefly about surgery, I think this has really come a long way. You're going to hear about what, where we are with surgical treatment. I think we're all doing anatomic repairs and reconstructions either with free grafts or synthetic augmentation. And I think these other non-anatomic procedures are not really common these days. And again, this has been shown through lots of work. This is one of the original studies from Colville, again, showing that anatomic reconstructions are the best for ankle instability. I tend to do a Brostrom with the extensor augmentation here, the extensor retinaculum. And again, it's a very simple procedure. But I think the common questions are, should we be using synthetic augmentation? Should we be doing arthroscopy and arthroscopic augmentation at the time of surgery? And now arthroscopic Brostroms have become more popular. And again, the next speakers will speak on that. So ankle instability is common. I think a detailed evaluation and clinical examination is the most important part of it. There's a lot of evolving concepts that I hope we get to discuss at today's symposium. Thank you.

ankle instability

associated injuries

surgical treatment

diagnosis imaging

ankle stabilization techniques