Chronic ankle instability

[Thomas Jones]

Rip and Team:

I wondered if you had any insight and/or suggestions as to how best to manage ankle instability. I've sprained my right ankle 25+ times. Never the left. After the first few I had a surgery performed where the posterior talofibular ligament was re-attached and loose bodies removed within the joint. Promptly after completing the rehab and getting cleared for all activities, I sprained it again jogging out to the outfield in a beer league softball game. It is very unstable and is susceptible to spraining at just about any time -- although nowadays I recover very quickly. I'm now in my early 50s and I enjoy backpacking and hunting. Even with a brace and good boots I'm always at risk for more sprains, and have to be ridiculously cautious to avoid further sprains.

The physical therapists and MDs recommend a lot of single leg balance drills to improve proprioception -- I guess the theory is that if you sense you are off balance quickly, you won't have as bad a sprain. There some "strengthening" exercises with bands, but no real use of progressive overload methods.

I am able to squat, deadlift, etc. with no problems and my range of motion is good.

Thanks in advance for your time.

[Mark Rippetoe]

What are your lifts? Height? Bodyweight?

[Thomas Jones]

6'6". 255#. 54 y.o. I pull 325# x 5 and squat 275# for 3 reps.

I've pushed my weight over 270# in the past and only got fatter without any meaningful strength gains.

[Mark Rippetoe]

Has anyone imaged your ankle?

[Thomas Jones]

Yes. About 3 years ago I started down the path of another surgery. Xrays and MRI. Went so far as to schedule a surgery, but ultimately decided not to as the surgeon was less than enthusiastic that surgery would solve my woes. Something like, "Yeah, most of my patients see improved stability, but I can't promise you won't sprain it again and undo the work I do." He was on the fence about whether he'd have surgery done if he were the patient. It's not like I'm Steph Curry and make a living with my ankle. Ultimately, I had a hard time convincing myself that the three months on crutches, and three months of rehab would be worth it for a second time. I'd have to dig around at this point to locate that MRI report but happy to do so if you think it would be helpful.

[Mark Rippetoe]

This has to be the most frustrating forum on the boards. WHAT WAS THE DIAGNOSIS????

[Thomas Jones]

Ha! I was stalling because I don't recall the specifics nor have them handy. Will post again once I track down the report.

[Thomas Jones]

I was finally able to get the report (I won't bore you with the horseshit involved):

LIGAMENT: There is tearing of the anterior tablofibular ligament. The calcaneofibular ligament though still has identifiable fibers and at least is partially intact. The posterior talofibular ligament appears intact. The deltoid ligament superficial fibers appear intact. There may be some disruption of deep fibers. The anterior and posterior syndesmotic ligaments are present and slight mottled signal suggesting perhaps scarring from partial tearing.

TENDONS: Peroneous longus and brevis tendons appear intact. There is generous fluid though in the tendon sheath suggesting perhaps mild tenosynovitis. The anterior tibial tendon, posterior tibial tendon, digitorum longus tendon and flexor hallucis longus tendons appear intact. The Achilles tendon and plantar fascia appear unremarkable.

JOINTS: There is subtle but real osteochondral lesion of the talus involving the lateral talar dome. This area shows abnormal subcortical T2 hyperintensity which measures 10 mm anterior to posterior and 4 mm across. In addition to this abnormal T2 hyperintensity the articular plate is slightly depressed and there is loss of overlying articular cartilage. A free fragment is not seen. There is loss of artcular cartilage in the ankle joint overall with marginal osteophytes on both the margins of the talus and on the anterior tibial plafond. The distal fibula is deformed suggesting the patient may have had a prior fracture. The subtalar facet is quite angled and shows subchondral sclerosis. I am uncertain if this is degenerative or posttraumatic. There is a bony extension off the back of the talus which is united with the talus and not an accessory bone. This could represent hypertrophic new bone formation from trauma or posttraumatic deformity. The talonavicular joint shows sclerosis.

MARROW: There is edema adjacent to the subchondral lesion of the talus. No other marrow edema is seen just sclerosis as discussed above.

TARSAL SINUS: Tarsal sinus and ligaments appear unremarkable.

IMPRESSION:

1. Disruption of the anterior talofibular ligament and probably partial tearing of the calcaneofibular ligament. Both the anterior and posterior ligaments appear thickened and could be scarred from prior trauma and the deep fibers of the deltoid ligament are not well seen and likely there has been a chronic partial-thickness tear.

2. Osterochondral lesion of the talus.

3. Posttraumatic and degenerative changes of the ankle joint and subtalar joint.