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While ankle instability and sensation of snapping frequently occur together, these are two completely different structural and functional foot and ankle problems. They do occur secondary to similar injuries and should be rehabilitated concurrently to achieve best outcomes.

“Ms. Bit Unsteady used to be into gymnastics but had to quit the sport 10 years ago due to repeat ankle sprains resulting in longer and longer periods required to achieve recovery. Eventually, her ankle became perpetually swollen and painful and required constant taping and elastic tape use. Now, she is in her late 20s and the memory and much of the pain of old ankle trauma has faded. Of course, Ms. Unsteady has not engaged in much physical activity since her gymnastic days. It’s summer now and her friends have invited her to go on a day hiking trip. Since Ms. Unsteady does not go hiking regularly, she decides to wear her old sneakers to the trip. She figures that they still have pretty good threads and should give her enough stability. Hiking shoes are much too expensive, she ponders. Everything goes well and she is enjoying first 2 miles of the hike. At this point, the group gets to a shallow stream that they have to cross and Ms. Unsteady is engaged in a lively conversation with her friend about trees, the air, and the wonder of being outdoors. As she steps to cross the stream, her foot lands on a slippery rock and suddenly and forcefully turns in. As she starts to fall, her friend catches her! She sits down on a nearby log and takes off her shoe. The outside of her injured ankle looks very familiar, as her mind go back to injuries of her gymnastic days. The outside of her ankle is swollen and very tender to touch with some bruising forming around the outside of the heel. Thankfully, group leader has an ice pack and some elastic bandages. After 20 minutes of icing, compression and elevation, Ms. Unsteady is able to place weight on her injured ankle but is now unable to complete the hike. She hobbles back to the car and must return home. The following morning, she notices that her ankle is even more swollen and decides to visit her local urgent care center to make sure she does not have a fracture. The doctor at urgent care center is friendly enough. She runs a quick foot and ankle x ray and comforts Ms. Unsteady with good news. No fracture was found on x ray and she is told that she can walk as much as her pain allows.

While Ms. Unsteady is happy with the news, she is still very much concerned as her pain continues being severe and the ankle continues to be swollen 2 weeks after the injury. As she walks, she feels a snapping sensation on the outside of her ankle. She wonders what else could be wrong with her ankle?”

There are several structures responsible for support and stability of the ankle.

These structures are lateral ankle ligaments (keep ankle attached to the foot) and peroneal tendons (pull the foot/heel out when walking on uneven terrain). These structures work together and are most frequently injured during severe ankle sprains.

First, lets discuss the snapping sensation and peroneal tendon issues. Peroneal muscles start on the outside of the leg and travel towards the ankle at which point peroneal tendons start. There are two peroneal muscles/tendons: peroneus longus and peroneus brevis. You probably guessed based on their names that one is longer than the other. While both evert the foot, it is really peroneus brevis that is responsible for most of the eversion.

Sometimes these tendons get damaged due to single traumatic episode, but they can also undergo weakening and scarring from chronic injury. If these tendons stretch out or tear, one may lose the ability, or at least have diminished ability, to evert the heel resulting in excessive heel/foot inversion moment or rolling inward. This will make the foot weak and will force it in the direction of chronic inversion resulting in predisposition to repeat sprains. In addition to injury to tendons themselves, there is a thin belt of tissue holding the tendons in place behind lateral malleolus in their designated groove on the outside of the ankle. Lateral malleolus is a bony rounded structure that protrudes on the outside of the ankle. This belt of stabilizing tissue is called peroneal retinaculum. If the ankle rolls forcefully enough and frequently enough, this structure may become partially or even completely torn resulting in tendons popping out of their grove with ankle motion. As tendons continue to pop in and out of the groove and get forced and shredded over the bone, they get irreversibly injured. This is called tendon subluxation. To resolve and repair the injury, tendons must be repaired and then placed back into their respective grooves behind lateral malleolus. This must be followed by repairing of peroneal retinaculum to keep tendons in place. This can only be accomplished with surgery.

However, surgery is not always needed with peroneal tendon injuries!

If the retinaculum is not split and tendons stay in their grooves, rehabilitation through conservative care may be attempted. This is particularly true if the tendons are not split and only inflamed within their sheaths. This condition of sheath inflammation without tendon substance damage is called tenosynovitis. When the tendons do get injured, they do not split and separate end to end but instead split along the length.

But how does one go about discovering what is actually injured?

It is important to be familiar with the exact normal location of these tendons and to start with palpating along the length of the tendons as they cross the ankle and travel into the foot. It is important to pay attention to exact areas of swelling, bruising and pain at lateral ankle. It is essential to ensure that there is no pain on palpation of the surrounding/nearby bone, as ankle sprains can be accompanied with ankle fractures. In our example, Ms. Unsteady got an x ray to verify absence of the fracture. One should rotate the ankle clockwise and counter-clockwise to see if the ankle pops on the outside. This may correlate with the tear of above described retinaculum. One should make sure that retinaculum tear and subluxation of tendons is not missed as diagnosis of ankle sprain only is made. Incomplete diagnosis (doc telling you it’s a simple sprain) is common reason for inability to achieve full recovery.

If the tear is suspected and surgery is considered, it is helpful to obtain an MRI of the injured ankle to establish how serious it is. MRI will help not only to identify exact area of the tear but also will help the surgeon decide on how to best repair the tendon(s) and, if needed, repair retinaculum and ankle ligaments. X ray only shoes bones and gives an idea on the health of joints. To see non bony structures, one has to get other imaging modalities like MRI (unless it is contraindicated). Ultrasound exam is the next best alternative but does not show the same level of detail.

So once you know what’s injured, how do you treat it?

As no surgeon can promise 100% guaranteed success with surgical intervention, I always recommend that non-surgical approach is considered first! This can be true even for those patients whose retinaculum is torn if they are willing to control their subluxation with the use of the brace….albeit forever.

For acute injuries, the tendons should be stabilized with an Ace wrap and should be iced several times per day with ice pack or cooling ankle wrap. This must be supplemented by elevation of the injured extremity as much as possible. Use of anti-inflammatory medications is optional but should be limited, as prolonged use can actually slow down tendon healing.

Depending on the amount swelling, one should consider first using tall “fracture” boot with compression pump. This will stabilize the tendons and will decrease the swelling.

The boot can be removed when sleeping and showering. Using a non-removable cast is another alternative. Over the next few weeks, the pain should be gradually improving. Once the swelling subsides, transition to stabilizing ankle brace should be made. Ankle brace should be designed in such a way as to prevent excessive inward and outward rolling. Aircast ankle stirrup brace, for example, has gel cushions built in. This brace can be held in the refrigerator overnight (not freezer!), which will then allow one to use it for stabilizing and cooling purposes. With the wearing of the brace, one can transition out of “fracture” boot and into a supportive stiff-soled shoes.

The recovery can be accelerated by engaging with physical therapist or certified professional trainer.

Rehabilitation of Peroneal tendons should include:

  • Peroneal tendon strengthening
  • Medial ankle ligament stretching,
  • Stability exercises,
  • Proprioception exercises,
  • Isometric and eccentric exercises

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Even for tendons that are dislocated out of peroneal groove and with a torn retinaculum, bracing that limits ankle motion can be attempted. This modality will, by design, restrict motion and will change how one walks! However, this may still be better for patients who are too high risk for surgery or who cannot take time off to undergo surgery and then extensive recovery required.

A gauntlet type brace should be considered first as it would allow for maximum stability. This brace, however, is usually custom made and can be expensive.

As an alternative, one can consider purchasing a stiff over the counter lace up ankle brace and combine its use with the wear of high top boots or hiking shoes to prevent foot from rolling.

If conservative non-surgical care fails to control the symptoms, surgical evaluation should be pursued.

One must, however, be prepared not only for benefits associated with surgery but also for potential risks and complications!

All these as well as conservative care should be thoroughly discussed with your foot and ankle surgeon to ensure best possible outcome post injury!

For another reason for ankle instability—chronic ankle ligament insufficiency—read our next post!

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Until next time….Happy running!