FAQ 37-2: Global Foot and Ankle Instability: A Multi-Directional Problem

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Editorial

Foot and ankle instability is a multi-directional or “global” clinical problem, that frequently extends beyond isolated lateral ligament insufficiency. This edition of Foot and Ankle Quarterly presents a pattern-based framework for evaluating and treating instability of the lateral ankle, medial ankle, syndesmosis, subtalar joint, midfoot, peroneal tendons and global hindfoot alignment.

Chronic instability should be differentiated into mechanical and functional/neurogenic components, recognizing that ligamentous injury on its own does not independently establish clinically meaningful instability. Comprehensive assessment incorporates patient history, dynamic examination, neurologic sensory examination, weight-bearing radiographs, stress testing when indicated, MRI for soft-tissue and intra-articular pathology, and weight-bearing CT when three-dimensional loaded alignment or subtle instability is suspected. Treatment begins with structural rehabilitation addressing strength, proprioception, balance and neuromuscular control. When surgery is indicated, procedure selection should be guided by the complete instability pattern, tissue quality, patient demands and associated pathology, rather than an isolated MRI finding. The modern goal is not simply to tighten the anterior talofibular ligament, but to restore a stable, functional, three-dimensional foot and ankle while correcting the mechanical and functional/neurological contributors to recurrent instability.

As Guest Editor for this issue, I have brought in experts from across the trauma/sports injury space to provide valuable insights on this pathology, and I would like to also acknowledge and thank my residents, Dr. Empryss Tolliver (PGY-3) and Dr. Ahmad Alforookh (PGY-2) for their research and assistance in preparing our Feature Article.

Narendra Rajnikant Patel, DPM, FACFAS

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Foot and Ankle Quarterly (FAQ) is a unique program designed to help today’s podiatric physician manage an ever-increasing flow of information. After completing the Foot and Ankle Quarterly, Volume 37 program, the learner should be better able to: develop and refine a perspective on current treatment recommendations, updates, and advances pertinent to podiatric practice; evaluate the implications of the learned information as it pertains to the diagnosis and treatment of podiatric disorders and societal issues and barriers, and; apply current trends, standards, and best practices into learner’s own practice.

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Article Authors and Lecturers

  • Ahmad Alforookh (1. Data Trace Publishing Co.)
  • Marque Allen (n.)
  • Hozaifa M. Anjum (n.)
  • Brian Burgess (n.)
  • WooYoung Chun (n.)
  • Jeff Dikis (1. Data Trace Publishing Co.)
  • Ersta Ferryanto (n.)
  • Mark Mendeszoon (n.)
  • Narendra R. Patel (1. Data Trace Publishing Co.)
  • Lauren L. Schnack (n.)
  • Empryss Tolliver (n.)

FAQ Journal Planning Committee

  • Chrissy Wesolowski (n.)
  • Lauren Molander (n.)
  • Stephanie Wu, DPM, MSc (n.)

Foot and Ankle Quarterly
37-1 Contributors

Guest Editor

Narendra Rajnikant Patel, DPM, FACFAS
Faculty Attending Surgeon, Fellowship Trainer for Complex Deformity Correction and Microsurgical Limb Reconstruction, Ascension St. Joseph, Chicago, IL; Chief of Podiatric Foot and Ankle Surgery, Ascencion Alexian Brothers, Elk Grove Village, IL; Faulty Lecturer, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL

Contributors

Ahmad Alforookh, DPM, PGY-2
Resident, Podiatric Medicine and Surgical Residency Program (PMSR/RRA), Ascension St. Joseph Hospital, Chicago, IL

Marque Allen DPM
Fellowship Director, Sport Medicine Associates of San Antonio, TX

Hozaifa M. Anjum, DPM, AACFAS
Fellow, Foot & Ankle Surgery, Illinois Bone & Joint Institute, Joliet, IL

Brian Burgess, DPM, FACFAS
Fellowship Director, Illinois Bone and Joint Institute, Joliet / New Lenox, IL

 WooYoung Chun, DPM
Foot and Ankle Fellow, Sport Medicine Associates of San Antonio, TX

Jeff Dikis, DPM
Podiatric Surgeon and Partner, McFarland Clinic, Ankeny, IA

Ersta Ferryanto, DPM
Podiatric Surgeon, Weil Foot and Ankle Institute, Chicago, IL

Mark J. Mendeszoon, DPM, FACFAS, FACPM
Downtown Physicians, New York, NY; Past Fellowship Director, Advanced Foot and Ankle Surgery and Sports Medicine Fellowship

Lauren L. Schnack, DPM, MS, FACFAS, FACPM
Associate Professor, Fellowship Trained Podiatric Surgeon, Department of Podiatric Medicine and Surgery, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL

Empryss Tolliver, DPM, MA, PGY-3
Chief Resident, Podiatric Medicine and Surgical Residency Program (PMSR/RRA), Ascension St. Joseph, Chicago, IL


37-2 In This Issue

  • FEATURE ARTICLE: Global Foot and Ankle Instability: More than an ATFL Repair
    Narendra Rajnikant Patel, DPM, FACFAS, Empryss Tolliver, DPM, MA and Ahmad Alforookh, DPM
  • CONDENSATIONS and COMMENTARIES
    • Lateral Subtalar Joint Capsuloligamentous Instability: A Review and Proposed Repair Technique
      Commentary by Ersta Ferryanto, DPM
    • Chronic Medial Ankle Instability Medial Drive-Through Sign and Surgical Repair Technique
      Commentary by Marque Allen, DPM and WooYoung Chun, DPM
    • Open Brostrom for Lateral Ligament Stabilization
      Commentary by Ersta Ferryanto, DPM
    • Prospective Observational Study of Midtarsal Joint Sprain: Epidemiological and Ultrasonographic Analysis
      Commentary by Narendra Rajnikant Patel, DPM, FACFAS
    • Functional Instability of the Ankle and the Role of Neuromuscular Control: A Comprehensive Review
      Commentary by Lauren L. Schnack, DPM, MS, AACFAS, FACPM
    • Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed
      Commentary by Mark J. Mendeszoon, DPM, FACFAS, FACPM
    • Syndesmosis and Deltoid Ligament Injuries in the Athlete
      Commentary by Jeff Dikis, DPM
    • The Biomechanical Role of the Deltoid Ligament on Ankle Stability: Injury, Repair, and Augmentation
      Commentary by Jeff Dikis, DPM
    • Combined Arthroscopic All-Inside Repair of Lateral and Medial Ankle Ligaments is an Effective Treatment for Rotational Ankle Instability
      Commentary by Brian Burgess, DPM, FACFAS and Hozaifa M. Anjum, DPM, AACFAS
    • The “All-Inside” Arthroscopic Broström Procedure with Additional Suture Anchor Augmentation: A Prospective Study of 45 Consecutive Patients
      Commentary by Brian Burgess, DPM, FACFAS and Hozaifa M. Anjum, DPM, AACFAS
  • AUDIO LECTURE 1: Evaluating Syndesmotic and Deltoid Ankle Injuries
    Jeff Dikis, DPM
  • AUDIO LECTURE 2: Neurogenic Ankle Instability: A New Perspective on Functional Ankle Sprains
    Narendra Rajnikant Patel, DPM, FACFAS
  • CME Questionnaire