Journal List > J Korean Foot Ankle Soc > v.22(2) > 1096553

Ha, Kim, and Gwak: Diagnosis and Comorbidity of Chronic Ankle Instability


Ankle sprains are among the most common injuries sustained during athletic activities and daily life. Acute ankle sprain is usually managed conservatively with functional rehabilitation but the failure of conservative treatment leads to the development of chronic ankle instability. The development of repetitive ankle sprains and persistent symptoms after injury has been termed chronic ankle instability. Acute ankle sprains and chronic ankle instability require a careful evaluation to detect other comorbidities, such as subtalar instability, osteochondral defect, peroneal tendinopathy, tarsal coalition, os trigonum, flexor hallucis longus tendinitis, calcaneus anterior process fracture, and neural injuries. For the successful treatment of acute ankle sprains and chronic ankle instability, the treatment of comorbidity lesions should be performed first.

Figures and Tables

Figure 1

(A, B) Partial tear of anterior talofibular (ATFL): diffuse internal hypoechoic area with swelling (arrows). (C, D) Complete tear of ATFL: hypoechoic gap in ligament (hematoma), wavy free ends (arrows). LM: lateral malleolus.

Figure 2

(A) Normal anterior talofibular (ATFL) magnetic resonance imaging (MRI) T2 axial view (arrow). (B) Torn ATFL MRI T2 axial view (arrow).

Figure 3

(A) Anterior drawer test. (B) Suction sign (arrow).

Figure 4

Ankle varus stress view (A, C) and anterior drawer test (B, D) were performed with Telos device at 20 N.



Financial support None.

Conflict of interest None.


1. Al-Mohrej OA, Al-Kenani NS. Acute ankle sprain: conservative or surgical approach? EFORT Open Rev. 2017; 1:34–44.
2. Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010; 18:557–569.
3. Cass JR, Settles H. Ankle instability: in vitro kinematics in response to axial load. Foot Ankle Int. 1994; 15:134–140.
4. Rasmussen O. Stability of the ankle joint. Analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand Suppl. 1985; 211:1–75.
5. Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966; 132:551–565.
6. Balduini FC, Tetzlaff J. Historical perspectives on injuries of the ligaments of the ankle. Clin Sports Med. 1982; 1:3–12.
7. Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. Br J Sports Med. 1994; 28:112–116.
8. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008; 121:324–331.e6.
9. Clanton TO. Athletic injuries to the soft tissues of the foot and ankle. In : Coughlin MJ, Mann RA, editors. Surgery of the foot and ankle. 7th ed. St. Louis: Mosby;1999. p. 1090–1209.
10. Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E. Lateral and syndesmotic ankle sprain injuries: a narrative literature review. J Chiropr Med. 2011; 10:204–219.
11. Rubin G, Morris W. The talar-tilt angle and the fibular collateral ligaments: a method for the determination of talar tilt. Bone J Surg. 1960; 42:311–326.
12. Fujii T, Luo ZP, Kitaoka HB, An KN. The manual stress test may not be sufficient to differentiate ankle ligament injuries. Clin Biomech (Bristol, Avon). 2000; 15:619–623.
13. Cha SD, Kim HS, Chung ST, Yoo JH, Park JH, Kim JH, et al. Intra-articular lesions in chronic lateral ankle instability: comparison of arthroscopy with magnetic resonance imaging findings. Clin Orthop Surg. 2012; 4:293–299.
14. Milz P, Milz S, Steinborn M, Mittlmeier T, Putz R, Reiser M. Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients. Acta Orthop Scand. 1998; 69:51–55.
15. Fuller EA. Center of pressure and its theoretical relationship to foot pathology. J Am Podiatr Med Assoc. 1999; 89:278–291.
16. Hubbard TJ, Kramer LC, Denegar CR, Hertel J. Contributing factors to chronic ankle instability. Foot Ankle Int. 2007; 28:343–354.
17. Ryan L. Mechanical stability, muscle strength and proprioception in the functionally unstable ankle. Aust J Physiother. 1994; 40:41–47.
18. Tropp H, Odenrick P. Postural control in single-limb stance. J Orthop Res. 1988; 6:833–839.
19. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am. 1955; 37-A:1237–1243.
20. Mologne TS, Ferkel RD. Arthroscopic treatment of osteochondral lesions of the distal tibia. Foot Ankle Int. 2007; 28:865–872.
21. Odak S, Ahluwalia R, Shivarathre DG, Mahmood A, Blucher N, Hennessy M, et al. Arthroscopic evaluation of impingement and osteochondral lesions in chronic lateral ankle instability. Foot Ankle Int. 2015; 36:1045–1049.
22. Nicholas R, Hadley J, Paul C, James P. “Snowboarder's fracture”: fracture of the lateral process of the talus. J Am Board Fam Pract. 1994; 7:130–133.
23. Nitz AJ, Dobner JJ, Kersey D. Nerve injury and grades II and III ankle sprains. Am J Sports Med. 1985; 13:177–182.
24. Chu IT, Park HW, Kim CK. Neural Injuries in Ankle Sprain. J Korean Foot Ankle Soc. 2006; 10:247–249.
25. Helgeson K. Examination and intervention for sinus tarsi syndrome. N Am J Sports Phys Ther. 2009; 4:29–37.
26. Aynardi M, Pedowitz DI, Raikin SM. Subtalar instability. Foot Ankle Clin. 2015; 20:243–252.
27. Heckman DS, Gluck GS, Parekh SG. Tendon disorders of the foot and ankle, part 1: peroneal tendon disorders. Am J Sports Med. 2009; 37:614–625.
28. Snyder RB, Lipscomb AB, Johnston RK. The relationship of tarsal coalitions to ankle sprains in athletes. Am J Sports Med. 1981; 9:313–317.
29. O'rahilly R. A survey of carpal and tarsal anomalies. J Bone Joint Surg AM. 1953; 35-A:626–642.
30. Lee KT, Kim JB, Park YU, Jegal H, Chon JG, Lee JG. Ultrasonographic evaluation of flexor hallucis longus tenosynovitis in sports players. Korean J Sports Med. 2013; 31:51–54.

Duckhee Kim

Similar articles