Sports Medicine

, Volume 29, Issue 5, pp 361–371 | Cite as

Functional Instability Following Lateral Ankle Sprain

Injury Clinic

Abstract

Lateral ankle sprain (LAS) is an extremely common athletic injury. Despite extensive clinical and basic science research, the recurrence rate remains high. Functional instability (FI) following LAS is hypothesised to predispose individuals to reinjury because of neuromuscular deficits which result following injury. This paper provides an overview of the potential causes of FI which may manifest themselves clinically. The theoretical explanations of FI are discussed, as are implications for assessment and treatment of FI following LAS.

When LAS occurs, structural damage not only occurs to the ligamentous tissue, but also to the nervous and musculotendinous tissue around the ankle complex. While injury to the ligaments may result in laxity of the joints of the ankle complex, neuromuscular deficits are also likely to occur due to the injury to the nervous and musculotendinous tissue. These neuromuscular deficits may be manifested as impaired balance, reduced joint position sense, slower firing of the peroneal muscles to inversion perturbation of the ankle, slowed nerve conduction velocity, impaired cutaneous sensation, strength deficits and decreased dorsiflexion range of motion. Additionally, the abnormal formation of scar tissue after injury may lead to sinus tarsi syndrome or anterolateral impingement syndrome, which may also lead to FI of the ankle complex.

Assessment of patients with LAS must address not only joint laxity and swelling, but should include examination for neuromuscular deficits as well. The treatment and rehabilitation goals must also address restoration of neuromuscular function, as well as restoration of mechanical stability to the injured joints.

References

  1. 1.
    Smith RW, Reischl SF. Treatment of ankle sprains in young athletes. Am J Sports Med 1986; 14: 465–71PubMedGoogle Scholar
  2. 2.
    Yeung MS, Chan K, So CH, et al. An epidemiological survey on ankle sprain. Br J Sports Med 1994; 28: 112–6PubMedGoogle Scholar
  3. 3.
    Freeman MAR. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br 1965; 47: 678–85PubMedGoogle Scholar
  4. 4.
    Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 1965; 47: 669–77PubMedGoogle Scholar
  5. 5.
    Lephart SM, Pincivero DM, Rozzi SL. Proprioception of the ankle and knee. Sports Med 1998; 25: 149–55PubMedGoogle Scholar
  6. 6.
    Garrick JG, Requa RK. The epidemiology of foot and ankle injuries in sports. Clin Sports Med 1988; 7: 29–36PubMedGoogle Scholar
  7. 7.
    Viladot A, Lorenzo JC, Salazar J, et al. The subtalar joint: embryology and morphology. Foot Ankle 1984; 5: 54–66PubMedGoogle Scholar
  8. 8.
    Michelson JD, Hutchins C. Mechanoreceptors in human ankle ligaments. J Bone Joint Surg Br 1995; 77: 219–24PubMedGoogle Scholar
  9. 9.
    Takebayashi T, Yamashita T, Minaki Y, et al. Mechanosensitive afferent units in the lateral ligament of the ankle. J Bone Joint Surg Br 1997; 79: 490–3PubMedGoogle Scholar
  10. 10.
    Norkin CC, Levangie PK. Joint structure and function: a comprehensive analysis. Philadelphia (PA): FA Davis, 1992Google Scholar
  11. 11.
    Lephart SM, Pincivero DM, Giroldo JL, et al. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med 1997; 25: 130–7PubMedGoogle Scholar
  12. 12.
    Tropp H, Odenrick P, Gillquist J. Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Med 1985; 6: 180–2PubMedGoogle Scholar
  13. 13.
    De Simoni C, Wetz HH, Zanetti M, et al. Clinical examination and magnetic resonance imaging in the assessment of ankle sprains treated with an orthosis. Foot Ankle Int 1996; 17: 177–82PubMedGoogle Scholar
  14. 14.
    Karlsson J, Andreasson GO. The effect of external ankle support in chronic lateral ankle joint instability: an electromyographic study. Am J Sports Med 1992; 20: 257–61PubMedGoogle Scholar
  15. 15.
    Lentell G, Baas B, Lopez D, et al. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther 1995; 21: 206–15PubMedGoogle Scholar
  16. 16.
    Isakov E, Mizrahi J. Is balance impaired by recurrent sprained ankle? Br J Sports Med 1997; 31: 65–7PubMedGoogle Scholar
  17. 17.
    Bernier JN, Perrin DH, Rijke A. Effect of unilateral functional instability of the ankle on postural sway and inversion and eversion strength. J Athletic Training 1997; 32: 226–32Google Scholar
  18. 18.
    Konradsen L, Olesen S, Hansen HM. Ankle sensorimotor control and eversion strength after acute ankle inversion injuries. Am J Sports Med 1998; 26: 72–7PubMedGoogle Scholar
  19. 19.
    Wilkerson GB, Nitz AJ. Dynamic ankle stability: mechanical and neuromuscular interrelationships. J Sport Rehabil 1994; 3: 43–57Google Scholar
  20. 20.
    Tropp H, Odenrick P. Postural control in single-limb stance. J Orthop Res 1988; 6: 833–9PubMedGoogle Scholar
  21. 21.
    Garn SN, Newton RA. Kinesthetic awareness in subjects with multiple ankle sprains. Phys Ther 1988; 68: 1667–71PubMedGoogle Scholar
  22. 22.
    Gauffin H, Tropp H, Odenrick P. Effect of ankle disk training on postural control in patients with functional instability of the ankle joint. Int J Sports Med 1988; 9: 141–4PubMedGoogle Scholar
  23. 23.
    Friden T, Zatterstrom R, Lindstrand A, et al. A stabilometric technique for evaluation of lower limb instabilities. Am J Sports Med 1989; 17: 118–22PubMedGoogle Scholar
  24. 24.
    Lentell GL, Katzmann LL, Walters MR. The relationship between muscle function and ankle instability. J Orthop Sports Phys Ther 1990; 11: 605–11PubMedGoogle Scholar
  25. 25.
    Orteza LC, Vogelbach WD, Denegar CR. The effect of molded orthotics on balance and pain while jogging following inversion ankle sprain. J Athletic Training 1992; 27: 80–4Google Scholar
  26. 26.
    Cornwall MW, Murrell PM. Postural sway following inversion sprain of the ankle. J Am Pediatric Med Assoc 1991; 81: 243–7Google Scholar
  27. 27.
    Golomer E, Dupui P, Bessou P. Spectral frequency analysis of dynamic balance in healthy and injured athletes. Arch Int Physiol Biomech Biophys 1994; 102: 225–9Google Scholar
  28. 28.
    Leanderson J, Wykman A, Eriksson E. Ankle sprain and postural sway in basketball players. Knee Surg Sports Traumatol Arthrosc 1993; 1: 203–5PubMedGoogle Scholar
  29. 29.
    Goldie PA, Evans OM, Bach TM. Postural control following inversion injuries of the ankle. Arch Phys Med Rehab 1994; 75: 969–75Google Scholar
  30. 30.
    Forkin DM, Koczur C, Battle R, et al. Evaluation of kinesthetic deficits indicative of balance control in gymnasts with unilateral chronic ankle sprains. J Orthop Sports Phys Ther 1996; 23: 245–50PubMedGoogle Scholar
  31. 31.
    Guskiewicz KM, Perrin DH. Effect of orthotics on postural sway following inversion ankle sprain. J Orthop Sports Phys Ther 1996; 23: 326–31PubMedGoogle Scholar
  32. 32.
    Leanderson J, Eriksson E, Nilsson C. Proprioception in classical ballet dancers: a prospective study of the influence of an ankle sprain on proprioception in the ankle joint. Am J Sports Med 1996; 24: 370–4PubMedGoogle Scholar
  33. 33.
    Perrin PP, Bene MC, Perrin CA, et al. Ankle trauma significantly impairs postural control: a study in basketball players and controls. Int J Sports Med 1997; 18: 387–92PubMedGoogle Scholar
  34. 34.
    Guskiewicz KM, Perrin DH. Research and clinical applications of assessing balance. J Sport Rehabil 1996; 5: 45–63Google Scholar
  35. 35.
    Tropp H, Eckstrand J, Gillquist J. Factors affecting stabiliometry recordings of single limb stance. Am J Sports Med 1984; 12: 185–8PubMedGoogle Scholar
  36. 36.
    Tropp H, Eckstrand J, Gillquist J. Stabilometry in functional instability of the ankle and its value in predicting injury. Med Sci Sports Exer 1984; 16: 64–6Google Scholar
  37. 37.
    Pinstaar A, Brynhildsen J, Tropp H. Postural corrections after standardized perturbations of single leg stance: effect of training and orthotic devices in patients with ankle instability. Br J Sports Med 1996; 30: 151–5Google Scholar
  38. 38.
    DeCarlo MS, Talbot RW. Evaluation of ankle proprioception following injection of the anterior talofibular ligament. J Orthop Sports Phys Ther 1986; 8: 70–6Google Scholar
  39. 39.
    Hertel JN, Guskiewicz KM, Kahler DM, et al. Effect of lateral ankle joint anesthesia on center of balance, postural sway, and joint position sense. J Sport Rehabil 1996; 5: 111–9Google Scholar
  40. 40.
    Glencross D, Thornton E. Position sense following joint injury. J Sports Med Phys Fitness 1981; 21: 23–7PubMedGoogle Scholar
  41. 41.
    Gross MT. Effects of recurrent lateral ankle sprains on active and passive judgement of joint position. Phys Ther 1987; 67: 1505–9PubMedGoogle Scholar
  42. 42.
    Payne KA, Berg K, Latin RW. Ankle injuries and ankle strength, flexibility, and proprioception in college basketball players. J Athletic Training 1997; 32: 221–5Google Scholar
  43. 43.
    Brunt RL, Anderson JC, Huntsman B, et al. Postural responses to lateral perturbation in healthy subjects and ankle sprain patients. Med Sci Sports Exer 1992; 24: 171–6Google Scholar
  44. 44.
    Konradsen L, Voight M, Hejsgaard C. Ankle inversion injuries: the role of the dynamic defense mechanism. Am J Sports Med 1997; 25: 54–8PubMedGoogle Scholar
  45. 45.
    Konradsen L, Ravn JB. Ankle instability caused by prolonged peroneal reaction time. Acta Orthop Scand 1990; 61: 388–90PubMedGoogle Scholar
  46. 46.
    Lofvenberg R, Karrholm J, Sundelin G, et al. Prolonged reaction time in patients with chronic lateral instability of the ankle. Am J Sports Med 1995; 23: 414–7PubMedGoogle Scholar
  47. 47.
    Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports Phys Ther 1995; 21: 317–27PubMedGoogle Scholar
  48. 48.
    Isakov E, Mizrahi J, Solzi P, et al. Response of the peroneal muscles to sudden inversion stress during standing. Int J Sport Biomech 1986; 2: 100–6Google Scholar
  49. 49.
    Larsen E, Lund PM. Peroneal muscle function in chronically unstable ankles: a prospective preoperative and postoperative electromyographic study. Clin Orthop 1991; 272: 219–26PubMedGoogle Scholar
  50. 50.
    Johnson MB, Johnson CL. Electromyographic response of peroneal muscles in surgical and nonsurgical injured ankles during sudden inversion. J Orthop Sports Phys Ther 1993; 18: 497–501PubMedGoogle Scholar
  51. 51.
    Ebig M, Lephart SM, Burdett RG, et al. The effect of sudden inversion stress on EMG activity of the peroneal and tibialis anterior muscles in the chronically unstable ankle. J Orthop Sports Phys Ther 1997; 26: 73–7PubMedGoogle Scholar
  52. 52.
    Sheth P, Yu B, Laskowski ER, et al. Ankle disk training influences reaction times of selected muscles in a simulated ankle sprain. Am J Sports Med 1997; 25: 538–43PubMedGoogle Scholar
  53. 53.
    Lynch SA, Eklund U, Gottlieb D, et al. Electromyographic latency changes in the ankle musculature during inversion. Am J Sports Med 1996; 24: 362–9PubMedGoogle Scholar
  54. 54.
    Hyslop GH. Injuries to the deep and superficial peroneal nerves complicating ankle sprain. Am J Surg 1951; 51: 436–8Google Scholar
  55. 55.
    MacIver DA, Letts RM. Paralysis of the peroneal nerve in association with a plantar flexion inversion injury of the ankle. Med Serv J Can 1966; 22: 285–7PubMedGoogle Scholar
  56. 56.
    Nobel W. Peroneal palsy due to haematoma in the common peroneal nerve sheath after distal torsional fractures and inversion ankle sprains. J Bone Joint Surg Am 1966; 48: 1484–95PubMedGoogle Scholar
  57. 57.
    Sidey JD. Weak ankles: a study of common peroneal nerve entrapment neuropathy. BMJ 1969; 3: 623–9PubMedGoogle Scholar
  58. 58.
    Meals RA. Peroneal nerve palsy complicating ankle sprain: report of two cases and review of the literature. J Bone Joint Surg Am 1977; 59: 966–8PubMedGoogle Scholar
  59. 59.
    Streib EW. Traction injury of the peroneal nerve caused by minor athletic trauma: electromyographic studies. Arch Neurol 1983; 40: 62–3PubMedGoogle Scholar
  60. 60.
    Connolly TJ, Fitzgibbons TC, Weber LE. Injury to the peroneal nerve after ankle sprain: a case report. Nebr Med J 1990; 75: 6–7PubMedGoogle Scholar
  61. 61.
    Stoff MD, Greene AF. Common peroneal nerve palsy following inversion ankle injury: a report of 2 cases. Phys Ther 1982; 62: 1463–4PubMedGoogle Scholar
  62. 62.
    Nitz AJ, Dobner JJ, Kersey D. Nerve injury and grades II and III ankle sprains. Am J Sports Med 1985; 13: 177–82PubMedGoogle Scholar
  63. 63.
    Kleinrensink GJ, Stoeckart R, Meulstee J, et al. Lowered motor conduction velocity of the peroneal nerve after inversion trauma. Med Sci Sports Exer 1994; 26: 877–83Google Scholar
  64. 64.
    Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther 1994; 74: 23–34Google Scholar
  65. 65.
    Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am 1955; 37: 1237–43PubMedGoogle Scholar
  66. 66.
    Tropp H. Pronator weakness in functional instability of the ankle joint. Int J Sports Med 1986; 7: 291–4PubMedGoogle Scholar
  67. 67.
    Bush KW. Predicting ankle sprain. J Manual Manipulative Ther 1996; 4: 54–8Google Scholar
  68. 68.
    Wilkerson GB, Pinerola JJ, Caturano RW. Inverter vs. evertor peak torque and power deficiencies associated with lateral ankle ligament injury. J Orthop Sports Phys Ther 1997; 26: 78–86PubMedGoogle Scholar
  69. 69.
    Soderberg GL, Cook TM, Rider SC, et al. Electromyographic activity of selected leg musculature in subjects with normal and chronically sprained ankles performing on a BAPS board. Phys Ther 1991; 72: 514–22Google Scholar
  70. 70.
    Ryan L. Mechanical stability, muscle strength, and proprioception in the functionally unstable ankle. Aust J Physiother 1994; 40: 41–7Google Scholar
  71. 71.
    Ashton-Miller JA, Ottaviani RA, Hutchinson C, et al. What best protects the inverted weightbearing ankle against further inversion? Evertor muscle strength compares favorably with shoe height, athletic tape, and three orthoses. Am J Sports Med 1996; 24: 800–9PubMedGoogle Scholar
  72. 72.
    Kaminski TW, Perrin DH, Mattacola CG, et al. The reliability and validity of ankle inversion and eversion torque measurements from the Kin Com II isokinetic dynamometer. J Sport Rehabil 1995; 4: 210–8Google Scholar
  73. 73.
    Wiesler ER, Hunter DM, Martin DF, et al. Ankle flexibility and injury patterns in dancers. Am J Sports Med 1996; 24: 754–7PubMedGoogle Scholar
  74. 74.
    Wilson RW, Gieck JH, Gansneder BM, et al. Reliability and responsiveness of disablement measures following acute ankle sprains among athletes. J Orthop Sports Phys Ther 1998; 27: 348–55PubMedGoogle Scholar
  75. 75.
    Baumhauer JF, Alosa DM, Renstrom PAFH, et al. A prospective study of ankle injury risk factors. Am J Sports Med 1995; 23: 564–70PubMedGoogle Scholar
  76. 76.
    Meyer JM, Lagier R. Post-traumatic sinus tarsi syndrome: an anatomical and radiological study. Acta Orthop Scand 1977; 48: 121–8PubMedGoogle Scholar
  77. 77.
    Taillard W, Meyer JM, Garcia J, et al. The sinus tarsi syndrome. Int Orthop 1981; 5: 117–30PubMedGoogle Scholar
  78. 78.
    Lowy A, Schilero J, Kanat IO. Sinus tarsi syndrome: a postoperative analysis. J Foot Surg 1985; 24: 108–12PubMedGoogle Scholar
  79. 79.
    O’Conner D. Sinus tarsi syndrome: a clinical entity. J Bone Joint Surg Am 1958; 18: 231–3Google Scholar
  80. 80.
    Shear MS, Baitch SP, Shear DB. Sinus tarsi syndrome: the importance of biomechanically-based evaluation and treatment. Arch Phys Med Rehabil 1993; 74: 777–81PubMedGoogle Scholar
  81. 81.
    McCarroll JR, Schrader JW, Shelbourne KD, et al. Meniscoid lesions of the ankle in soccer players. Am J Sports Med 1987; 15: 255–7PubMedGoogle Scholar
  82. 82.
    Martin DF, Curl WW, Baker CL. Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 1989; 5: 110–4PubMedGoogle Scholar
  83. 83.
    Thein R, Eichenblat M. Arthroscopic treatment of sports-related synovitis of the ankle. Am J Sports Med 1992; 20: 496–8PubMedGoogle Scholar
  84. 84.
    Meislin RJ, Rose DJ, Parisien JS, et al. Arthroscopic treatment of synovial impingement of the ankle. Am J Sports Med 1993; 21: 186–9PubMedGoogle Scholar
  85. 85.
    Liu SH, Nuccion SL, Finerman G. Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. Am J Sports Med 1997; 25: 389–93PubMedGoogle Scholar
  86. 86.
    Wilkerson GB. Treatment of inversion ankle sprains through synchronous application of focal compression and cold. Athletic Training 1991; 26: 220–37Google Scholar
  87. 87.
    Bonnin M, Tavernier T, Bouysset M. Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 1997; 25: 699–703PubMedGoogle Scholar
  88. 88.
    Trettin DM, Browne JE. Osteoid osteoma of the tarsal cuboid presenting with recurrent ankle sprains in an adolescent: a case report. Foot Ankle Int 1995; 16: 30–3PubMedGoogle Scholar
  89. 89.
    Montella BJ, O’Farrell DA, Furr WS, et al. Fibular osteochondroma presenting as chronic ankle sprain. Foot Ankle Int 1995; 16: 207–9PubMedGoogle Scholar
  90. 90.
    Toy BJ. Conservative treatment of bilateral sural nerve entrapment in an ice hockey player. J Athletic Training 1996; 31: 68–70Google Scholar
  91. 91.
    Bandy WD, Strong L, Roberts T, et al. False aneurysm: a complication following an inversion ankle sprain. A case report. J Orthop Sports Phys Ther 1996; 23: 272–9PubMedGoogle Scholar
  92. 92.
    Geppert MJ, Sobel M, Bohne HO. Lateral ankle instability as a cause of superior peroneal retinacular laxity: an anatomical and biomechanical study in cadaveric feet. Foot Ankle 1993; 14: 330–4PubMedGoogle Scholar
  93. 93.
    Taga I, Shino K, Inoue M, et al. Articular cartilage lesion in ankle with lateral ligament injury: an arthroscopic study. Am J Sports Med 1993; 21: 120–7PubMedGoogle Scholar
  94. 94.
    Hertel J, Denegar CR. A rehabilitation paradigm for restoring neuromuscular control following athletic injury. Athletic Ther Today 1998; 3 (5): 12–6Google Scholar
  95. 95.
    Worrell TW, Booher LD, Hench KM. Closed kinetic chain assessment following inversion ankle sprain. J Sport Rehabil 1994; 3: 197–203Google Scholar
  96. 96.
    Bunton EE, Pitney WA, Kane AW, et al. The role of limb torque, muscle action, and proprioception during closed kinetic chain rehabilitation of the lower extremity. J Athletic Training 1993; 28: 10–20Google Scholar
  97. 97.
    Tomaszewski D. T-band kicks ankle proprioception program. Athletic Training 1991; 26: 216–9Google Scholar
  98. 98.
    Wester JU, Jespersen SM, Nielsen KD, et al. Wobble board training after partial sprains of the lateral ligament of the ankle: a prospective randomized study. J Orthop Sports Phys Ther 1996; 23: 332–6PubMedGoogle Scholar
  99. 99.
    Bernier JN, Perrin DH. Effect of coordination training on proprioception of the functionally unstable ankle. J Orthop Sports Phys Ther 1998; 27; 264–75PubMedGoogle Scholar
  100. 100.
    Clanton TO. Instability of the subtalar joint. Orthop Clin North Am 1989; 20: 583–92PubMedGoogle Scholar
  101. 101.
    Surve I, Schwellnus MP, Noakes T, et al. A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the Sport-Stirrup orthosis. Am J Sports Med 1994; 22: 601–6PubMedGoogle Scholar
  102. 102.
    Sharpe SR, Knapik J, Jones B. Ankle braces effectively reduce recurrence of ankle sprains in female soccer players. J Athletic Training 1997; 32: 21–4Google Scholar
  103. 103.
    Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med 1985; 13: 259–62PubMedGoogle Scholar
  104. 104.
    Bennell KL, Goldie PA. The differential effects of external ankle support on postural control. J Orthop Sports Phys Ther 1994; 20: 287–95PubMedGoogle Scholar
  105. 105.
    Kinzey SJ, Ingersoll CD, Knight KL. The effects of selected ankle appliances on postural control. J Athletic Training 1997; 32: 300–3Google Scholar
  106. 106.
    Warner JJ, Lephart S, Fu FH. Role of proprioception in pathoetiology of shoulder instability. Clin Orthop 1996; 330: 35–9PubMedGoogle Scholar
  107. 107.
    Barrett DS, Cobb AG, Bentley G. Joint proprioception in normal, osteoarthritic, and replaced knees. J Bone Joint Surg Br 1991; 73: 53–6PubMedGoogle Scholar
  108. 108.
    Harter RA, Osternig LR, Singer KM. Knee joint proprioception following anterior cruciate ligament reconstruction. J Sport Rehabil 1992; 1: 103–10Google Scholar

Copyright information

© Adis International Limited 2000

Authors and Affiliations

  1. 1.Department of KinesiologyPennsylvania State UniversityUniversity ParkUSA

Personalised recommendations