Hi, my name is Brian Lau and I'd like to thank AFSN for the opportunity to present on ankle instability. So here's our outline today, and we'll go over really quickly in the background, anatomy and the history, because we have a lot to cover in just 10 minutes, and so kind of highlight key points that I want to emphasize on those things, then we'll talk about treatment options as well as the medial and the high ankle sprain. Ankle sprains are very common, very common injuries in sports related injuries, and also as demonstrated here in our NCAA data, showing that basketball is most common, but can be really throughout any sport, and ankle sprains being very, very common to that. Here's an anatomy slide, again, not to go over each of the different structures and stuff, but just want to highlight that there are distinct structures, and then make sure you know where these are, and palpate these, because this can dictate, you know, making sure you're not missing any injuries, and also dictate your treatments. Etiologies, there's an inversion and eversion, they are all considered ankle sprains, but they can lead to different patterns of injury and can change the way you treat these. So inversions being more commonly resulting lateral side, and eversion can cause medial side, as demonstrated up here, but also be more likely to get a high ankle sprain injury. So physically and acutely, making sure you're following the Ottawa rules and palpating the different areas, medial, lateral, and aeolus, the base of the foot, interprostate, and cartenius, and the nomenclin, make sure there are no tendons there, if there are, make sure you can x-ray, make sure you're not missing any fractures. These are the don't miss fractures, again, these are just demonstrations that we just mentioned, but these are treated differently, so make sure you look at these specific areas on any kind of radiographs, make sure that you're treating these a little bit more conservatively and a little bit longer, as they are fractures, not just osteosteoarthritis. Physical exam, anterior dorsal tilt, make sure you're testing these to see how the stability of those ligaments are, but in acute setting, often pain locations are more important, so knowing where the anatomy is, knowing where you're palpating, can tell you what things are injured, is it the medial side, stenosis, is it ATFL, is it CFL, ATFL, make sure you're palpating those areas in addition to the Ottawa rules to help you diagnose what type of ankle sprain or condition it has. Are they able to ambulate, and do they have prior injuries, and that can tell you kind of, you know, are they loose because they are acutely injured or more chronically injured. Predisposing factors, maybe not acutely in the sidelines, but in some acute setting, you want to make sure you evaluate these. Now, you look from the front, you can see they can look very much the same, but from the back, you can see this has a little more varus, which can predispose people to lateral sided injuries, so if you do see this, whether you treat them conservatively or operatively, you want to make sure you include an orthotic to help correct this alignment and prevent a re-injury. Imaging, standard radiographs are going to be most commonly used, will allow fracture and incombinant injuries. Advanced imaging for high level athletes, if you're worried about the medial side or high level side, or if they're chronically recurrent. Conservative management, mainstay, short time of immobilization, and then early functional rehabilitation. Here's a clinical systematic review, which demonstrates that functional rehab is better for all those different factors there, sport, work, subjectiveness, and also satisfaction. And gain, rather than long periods of immobilization. And what is that function we have is including not just range of motion, but balance and proprioception, so you want to make sure you incorporate these and prescribing these when you talk about rehab from ankle instability. When do you operate on these? Acutely, if it's open or it's a loose injury, potentially, if it's a recurrent injury. And then if you have some common injuries, so making sure you have that physical exam to, you know, have the knowledge of whether or not an MRI for the injuries and need to identify that common injury. Traditionally, it's going to be three months of conservative treatment before operative management. What is surgery? So make sure to always include arthroscopy. So even if the MRI is negative, a lot of times you can get small conjural injuries that can't be identified, you want to make sure you find those early on. And therefore, you can still treat while it's still small, clearly you're carrying small loose bodies and might be fractured small conjural injuries and also give you a sense of if someone's going to take a little bit longer to recover because maybe they have a conjunctivitis to it as well. And then you're going to do standard brow stringing for bowel modification, and we're getting those ligaments back up and adding the retinacular mass for support. And I use the knotless sutures to kind of decrease suture stack kind of irritation because of the area is so thin. Time to re-support after surgery is going to be about four and a half months, more granular than that, two months of personal training, four months again, back to team training. So it's not just going to be a few weeks. You want to make sure you advise these patients as well. Augmentation is getting a lot of attention nowadays. This is not artificial tissue, it's a suture-based kind of thing that's added on top to act like a seatbelt, prevent it from first sliding out. And when they do it, it's increased laxity, so it's hypermobile. So you're going to envision surgery or potentially even high lip demand or high-level athletes. This is time zero data showing that internal brace can add additional structural strength to your construct, even stronger than the intact ATFL, you can actually get confidence to rehab quicker. Clinical data here, early clinical data 2018 was demonstrated in this cohort group that it was safe and effective, minimal over-constraint with only a degree of dorsal flexion. More recently in 2023, demonstrating from a recent FAI paper, no difference in functional outcomes. This might give you an indication that there's no reason to do it. In this cohort, in their internal brace group, they let their patients begin their rehab process at two weeks versus six weeks of their standard group. So at five years, even if that early rehab, they found that there were similar outcomes. So potentially that time to return to sport, if important, internal brace can help with that. Calls for residual instability. So even with our techniques, up to 35% of the time, we can have residual problems and instability, most common from a missed concomitant injury, which can be medial or high ankle sprains. So how common is this? And you know, ankle sprains are not very common on their own, but can be very common for concomitant lateral sided injury. So it's probably seen you and you have not necessarily seen it. So 72% of cases have some sort of deltoid injury. So they're going to have, make sure you feel the medial side of, on your exam, you know, look at that side. I forget any additional imaging to make sure that there isn't any kind of signal on that side. And then when you do your arthroscopy, you can do the drive-through test, which is using that shaver, pushing it through the medial gutter. And if it goes through the telogen, the medial deltoid structures are insufficient when that may need a repair. How do you do that? It's going to be like a brachial on the medial side, use suture anchors and using the sutures to re-fin the deep or superficial deltoid. Again, I use not less anchors. High ankle sprains. Again, this slide is an anatomy slide, just again, showing that there are distinct structures osteoarthritis, as well as AITFL and PITFL, which are components of the synesthemosis. And depending on where that injury is shown and incorporates, can indicate how much force and the severity of that injury. If it's all the way around, or if it goes further up. High ankle sprains occur from eversion, just like the medial sprains we just talked about, they can cause later, longer time to return to play. And so you want to make sure you don't miss this. Now, when to operate on this is going to depend a lot on your physical exam. So things I like to do acutely is make sure you find that pain location as associated in the second image here. Does the pain go in the synesthemosis? Does it involve the AITFL? So if you're feeling a little bit harder in your AITFL or AITFL, there's a pain in there, there's a pain to squeeze test. The heel rise I find is a very good dynamic test to see if there's any pain of this. And that can be incorporated with something called the tape test. So if they can't do heel rise at all, that indicates there's a severe injury and may need surgery. A tape test, if they are able to do it, but they're painful with it, you know, you're not sure it's a synesthesmosis, they can have them do the heel rise test without taping and then tape it up. And if the pain improves or they even do more repetitions, I can tell you that stabilizing that synesthesmosis will probably be helpful because it's injured. Again, other radiographic signs, you can see the widening of the measurements you can see here. Here's an MRI chronometer, you can see it's called the lambda sign, which shows that the fluid is extravasating up to synesthesmosis, which indicates an injury as well. Conservative management is going to be, again, most commonly used, and it's going to be very similar to your proprioception and balance and strength as you would for an isolated ligament. Now, when to operate on these, how do you decide if they go early? Okay, so again, if they have this, no fractures, but soft tissue injuries, and they're unable to ambulate, or I'm going to heel rise, I told you that's obviously a very significant soft tissue injury. If they have tenderness on your exam was higher than five centimeters from the joint line, again, indicating that this force is propagated very approximate. Imaging, if you see an x-ray that's widening on there, clear-cut sign that the synesthesmosis has propagated further up and may need surgery. MRI, you're going to see if that injury is not just there, but if it's where it's involved. Is it circumferential? Is it involved posteriorly as well as anteriorly? Again, severity of injury, kind of a circle concept. Synesthmosis injury, again, similar to the physical exam, but now you see this fluid that's traveling higher than five centimeters, again, indicating a higher injury. Traditional-wise, just otherwise in three months, if it's, these are some, if you're treating higher-level athletes. Again, MRI finds an injury that's circumferential, okay? So you can see, is it circumferential injuries? This may be an indication for early surgery. Higher propagation of that injury, greater than five centimeters may be a good sign, indication for early rehab in these higher-level athletes. So what does that look like? Is it arthroscopy? You know, you can use screws or suture buttons or what's called an AITFL reconstruction, which is an axillary AITFL. This is what we recommend, again, arthroscopy every time. Again, this is a drive-through sign, that shaver through the lateral side, now producing a synesthmosis, demonstrating that that's disrupted and needs to be fixed. You can also look for isolated AITFL injuries. Suture button fixation is probably, I would recommend more commonly, especially in high-level athletes and athletes in general. Screw fixation demonstrates 21.7% malar reduction, you're forcing and fixing the deposition when suture buttons allow these to find their own bone, when you're trying to tighten them down. No difference in clinical outcomes. Functional, clinical studies show that suture buttons have higher functional scores, screws have higher intensity of OA, systematically re-demonstrating similar findings, less malar reduction, better PROs, less removal and irritation. AITFL, again, if you find that it's just the isolated AITFL that's becoming very popular nowadays, it's doing either primary repair, I've done these several times, and there's an evolution of just the AITFL, or doing an internal brace directly here, rather than putting suture buttons up high, and that can be helpful as well. So make sure you're palpating that and knowing that as a distinct structure. Again, ankle sprains are very common, don't miss the fractures, counter-reconstructive management mainstay, check that line for orthotics. Medium to high ankle sprains, make sure you don't miss them. Indications for early operative fixation, common injuries, high-level patients, look for the inability to do the heel rise, the ambulation, that tape test, circumferentially involved on the MRI or extension period in 5-7 years, or it's recurrent. These are my references, and thanks again for your time, and thank you to AOSSM.

Brian Lau

ankle instability

lateral ankle sprains

high ankle sprains

sports-related injuries