Abstract
Lateral ankle sprains are one of the most common athletic injuries. Even more concerning is the high recurrence rate after an initial sprain. The development of repetitive ankle sprains and persistent symptoms after injury has been termed chronic ankle instability (CAI). One of the purported causes of CAI is mechanical ankle instability (MAI).
MAI results in abnormal ankle mechanics. Both hypermobility and hypomo-bility may change a joint’s axis of rotation and result in abnormal joint mechanics. The role of hypermobility, or laxity, has been examined extensively in the literature, but more recently the role of hypomobility has also been examined. There may be a relationship between the two, with implications at the talocrural, subtalar, and inferior tibiofibular joints.
Assessment and treatment should focus on both hypermobility and hypomobil-ity and although injury may seem to be isolated to the talocrural joint, the inferior tibiofibular and subtalar joints should also be thoroughly examined.
Similar content being viewed by others
References
McKay GD, Goldie PA, Payne WR, et al. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001; 35: 103–108
Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train 2002; 37: 364–375
Freeman MAR. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br 1965b; 47: 669–677
Tropp H, Odenrick P, Gillquist J. Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Med 1985; 6: 180–182
Wilkerson GB, Nitz AJ. Dynamic ankle stability: mechanical and neuromuscular interrelationships. J Sport Rehab 1994; 3: 43–57
Denegar CR, Miller SJ. Can chronic ankle instability be prevented? Rethinking management of lateral ankle sprains. J Athl Train 2002; 37: 430–435
Brostrom L. Sprained ankles I: anatomic lesions on recent sprains. Acta Chir Scand 1964; 128: 483–495
Rubin G, Witten M. The subtalar joint and symptoms of turning over on the ankle: a new method of evaluation using tomography. Am J Orthop 1962; 4: 16–19
Hertel J, Denegar CR, Monroe MM, et al. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc 1999; 31: 1501–1508
Meyer JM, Garcia J, Hoffmeyer P, et al. The subtalar sprain: a roentgenographic study. Clin Orthop 1986; 226: 169–173
Perry J. Anatomy and biomechanics of the hindfoot. Clin Orthop 1983; 177: 9–15
Vildadot A, Lorenzo JC, Salazar J, et al. The subtalar joint: embryology and morphology. Foot Ankle 1984; 5: 54–66
Inman VT. The joints of the ankle. Baltimore (MD): Williams & Wilkins, 1976
Lundberg A, Goldie I, Kalin B, et al. Kinematics of the ankle/foot complex: plantar flexion and dorsiflexion. Foot Ankle 1989; 9: 194–200
Leardini A, O’Connor JJ, Catani F, et al. The role of the passive structures in the mobility and stability of the human ankle joint: a literature review. Foot Ankle Int 2000; 21: 602–615
Soavi R, Girolami M, Loreti I, et al. The mobility of the proximal tibiofibular joint: a roentgen steroephotogrammetric analysis on six cadaver specimens. Foot Ankle Int 2000; 21: 336–342
Panjabi MM. The stabilizing system of the spine, part I: function, dysfunction, adaptation, and enhancement. J Spinal Disord 1992; 5: 383–389
Panjabi MM. The stabilizing system of the spine, part II: neutral zone and instability hypothesis. J Spinal Disord 1992; 5: 390–397
Konradsen L, Magnusson P. Increased inversion angle replication error in functional ankle instability. Knee Surg Sports Traumatol Arthrosc 2000; 8: 246–251
Myers JB, Riemann BL, Hwang JH, et al. Effect of peripheral afferent alteration of the lateral ankle ligaments on dynamic stability. Am J Sports Med 2003; 31: 498–506
Bullock-Saxton JE, Janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip extension. Int J Sports Med 1994; 15: 330–334
Beckman SM, Buchanan TS. Ankle inversion injury and hypermobility: effect on hip and ankle muscle electromy-ography onset latency. Arch Phys Med Rehabil 1995; 76: 1138–1143
Lentell GB, Bass 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: 206–215
Louwerens JWK, Ginai AZ, Van Linge B, et al. Stress radiography of the talocrural and subtalar joints. Foot Ankle Int 1995; 16: 148–155
Karlsson J, Bergsten T, Peterson L, et al. Radiographic evaluation of ankle joint stability. Clin J Sport Med 1991; 1: 166–175
Ryan L. Mechanical instability, muscle strength and proprioception in the functionally unstable ankle. Aust J Physiother 1994; 40: 41–47
Zell BK, Shereff MJ, Greenspan A, et al. Combined ankle and subtalar instability. Bull Hosp Jt Dis Orthop Inst 1986; 46: 37–46
Cass JR, Morrey BF, Chao EYS. Three-dimential kinematics of ankle instability following serial sectioning of lateral collateral ligaments. Foot Ankle 1984; 5: 142–149
Martin RB, Burr DB, Sharkey NA. Skeletal tissue mechanics. 1st ed. New York (NY): Springer-Verlag, 1998
Clanton TO. Instability of the subtalar joint. Orthop Clin North Am 1989; 20: 583–592
Ishii T, Miyagawa S, Fukubayashi T, et al. Subtalar stress radiography using dorsiflexion and supination. J Bone Jt Surg 1996; 78B: 56–60
van Hellemondt FJ, Louwerens JWK, Subrandu ES, et al. Stress radiography and stress examination of the talocrural and sub-talar joint on helical computed tomography. Foot Ankle Int 1997; 18: 482–488
Yamamoto H, Kazuyoshi Y, Ogiuchi T, et al. Subtalar instability following lateral ligament injuries of the ankle. Injury 1998; 29: 265–268
Kato T. The diagnosis and treatment of instability of the subtalar joint. J Bone Jt Surg Br 1995; 77B: 400–406
Brostrom L. Sprained ankles III: clinical observations in recent ligament ruptures. Acta Chir Scand 1965; 103: 560–569
Zwipp H, Rammelt S, Grass R. Ligamentous injuries about the ankle and subtalar joints. Clin Podiatr Med Surg 2002; 19: 195–229
Sammarco GJ, Burnstein AH, Frankel VH. Biomechanics of the ankle: a kinematic study. Orthop Clin North Am 1973; 4: 75–96
Meadows JTS. Orthopedic differential diagnosis in physical therapy: a case study approach. New York (NY): McGraw-Hill, 1999: 114–115
Tabrizi P, McIntyre WMJ, Quesnel MB, et al. Limited dorsiflexion predisposes to injuries of the ankle in children. J Bone Jt Surg Br 2000; 82B: 1103–1106
Appelberg B, Hulliger M, Johansson H, et al. Excitation of dynamic fusimotor neurons of the cat triceps surae by contralateral joint afferents. Brain Res 1979; 160: 529–532
Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther 2002; 32: 166–173
Green T, Refshauge K, Crosbie J, et al. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther 2001; 81: 984–994
Mulligan BR. Manual therapy: NAGS, SNAGS, MWMS etc. Wellington: Plane View Services Ltd, 1995
Hetherington B. Lateral ligament strains of the ankle: do they exist? Man Ther 1996; 1: 274–275
Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Man Ther 1999; 4: 19–24
Mavi A, Yildirim H, Gunes H, et al. The fibular incisura of the tibia with recurrent sprained ankle on magnetic resonance imaging. Saudi Med J 2002; 23: 845–849
Ebraheim NA, Lu J, Yang H, et al. The fibular incisure of the tibia: a cadaver study. Foot Ankle Int 1998; 19: 318–321
Berkowitz CM, Kim DH. Fibular position in relation to lateral ankle instability. Foot Ankle Int 2004; 25: 318–321
Eren OT, Kucukkaya M, Kabukcuoglu Y, et al. The role of a posteriorly positioned fibula in ankle sprain. Am J Sports Med 2003; 31: 995–998
Scranton PE, McDermott JE, Rogers JV. The relationship between chronic ankle instability and variations in mortise anatomy and impingement spurs. Foot Ankle Int 2000; 21: 657–664
Tohyama H, Beynnon BD, Renstrom PA, et al. Biomechanical analysis of the ankle anterior drawer test for anterior talofibu-lar ligament injuries. J Orthop Res 1995; 13: 609–614
Bahr R, Pena F, Shine J, et al. Mechanics of the anterior drawer and talar tilt test. Acta Orthop Scand 1997; 68: 435–441
van Dijk C, Lim L, Bossuyt P, et al. Physical examination is sufficient for the diagnosis of sprained ankles. J Bone Jt Surg Br 1996; 78: 958–962
Blanshard K, Finaly D, Scott D, et al. A radiological analysis of lateral ligament injuries of the ankle. Clin Radiol 1986; 37: 247–251
Martin DE, Kaplan PA, Kahler DM, et al. Retrospective evaluation of graded stress examination of the ankle. Clin Orthop 1996; 328: 165–170
Tohyama H, Yasuda K, Ohkoshi Y, et al. Anterior drawer test for acute anterior talofibular ligament injuries of the ankle. Am J Sports Med 2003; 31: 226–232
Frost SCL, Amendola A. Is stress radiography necessary in the diagnosis of acute or chronic ankle instability? Clin J Sports Med 1999; 9: 40–45
Broden B. Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol 1949; 31: 85–91
Kovaleski JE, Gurchiek LR, Heitman RJ, et al. Instrumented measurement of AP and inversion-eversion laxity of the normal ankle joint complex. Foot Ankle Int 1999; 20: 808–814
Hubbard TJ, Kovaleski JE, Kaminski TW. Reliability of in-tratester and intertester measurements derived from an instrumented ankle arthrometer. J Sport Rehabil 2003; 12: 208–220
Liu W, Siegler S, Techner L. Quantitative measurement of ankle passive flexibility using an arthrometer on sprained ankles. Clin Biomech 2001; 16: 237–244
Hubbard TJ, Kaminski TW, Vander Griend B, et al. Quantitative assessment of mechanical laxity in the functional unstable ankle. Med Sci Sports Exerc 2004; 36: 760–766
Kovaleski JE, Hollis JM, Heitman RJ, et al. Assessment of ankle-subtalar joint complex laxity using an instrumented ankle arthrometer: an experimental cadaveric investigation. J Athl Train 2002; 37: 467–474
Jerosch J, Hoffstetter I, Bork H, et al. The influence of orthoses on the proprioception of the ankle joint. Knee Surg Sports Traumatol Arthrosc 1995; 3: 39–46
Cordova ML, Ingersoll CD, Palmieri RM. Efficacy of prophylactic ankle support: an experimental perspective. J Athl Train 2002; 37: 446–457
Garrick JG, Requa RK. Role of external support in the prevention of ankle sprains. Med Sci Sports 1973; 5: 200–203
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: 601–606
Sitler M, Ryan J, Wheeler B, et al. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuires in basketball: a randomized clinical study at West Point. Am J Sports Med 1994; 22: 454–461
Wilkerson GB. Comparative biomechanical effects of the standard method of ankle taping and a taping method designed to enhance subtalar instability. Am J Sports Med 1991; 19: 588–595
Wilkerson GB, Kovaleski JE, Meyer M, et al. Effects of the subtalar sling ankle taping technique on combined talocrural-subtalar joint motions. Foot Ankle Int 2005; 26: 239–246
Baumhauer JF, O’Brien T. Surgical consideration in the treatment of ankle instability. J Athl Train 2002; 37: 458–462
Karlsson J, Bergsten T, Lansinger O, et al. Reconstruction of the lateral ligaments of the ankle for chronic ankle instability. J Bone Jt Surg Am 1988; 70: 581–588
Karlsson J, Bergsten T, Lansinger O, et al. Surgical treatment of chronic lateral instability of the ankle joint: a new procedure. Am J Sports Med 1989; 17: 268–273
Kaikkonen A, Lehtonen H, Kannus P, et al. Long-term functional outcome after surgery of chronic ankle instability: a 5-year follow-up of the modified Evans procedure. Scand J Med Sci Sports 1999; 9: 239–244
Hennrikus WL, Mapes RC, Lyons PM, et al. Outcomes of the Chrisman-Snook and modified-Brostrom procedures for chronic lateral ankle instability: a prospective, randomized comparison. Am J Sports Med 1996; 24: 400–404
Karlsson J, Bergsten T, Lansinger O, et al. Lateral ankle instability of the ankle treated by Evans procedure: a long-term clinical and radiological follow-up. J Bone Jt Surg Br 1988; 70: 476–480
Greenman PE. Principles of manual medicine. 2nd ed. Baltimore (MD): Williams & Wilkins, 1996: 43–49
Acknowledgements
No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Hubbard, T.J., Hertel, J. Mechanical Contributions to Chronic Lateral Ankle Instability. Sports Med 36, 263–277 (2006). https://doi.org/10.2165/00007256-200636030-00006
Published:
Issue Date:
DOI: https://doi.org/10.2165/00007256-200636030-00006