Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 2-10, March 2010

When Is Ankle Arthroscopy Indicated in Ankle Instability?

  • Annunziato Amendola, MD

      Affiliations

    • Corresponding Author InformationAddress reprint requests to Annunziato Amendola, MD, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242
    • ,
  • Davide E. Bonasia, MD

University of Iowa Sports Medicine, Iowa City, IA

Article Outline

Ankle sprains are among the most common injuries encountered in work and sport, with well over 2 million individuals experiencing ankle ligament trauma each year in the United States. Although most of these respond well to conservative management, acute ankle sprains are frequently associated with pathology resulting in chronic symptoms, including pain and instability, which persist beyond the expected recovery period. Although it is generally accepted that arthroscopy can be very helpful in the diagnosis and treatment of many ankle injuries and joint disorders, there is still some controversy regarding specific indications and effectiveness for its use. Given that these therapeutic and diagnostic indications are still being defined, the purpose of this article was to review the use and indications of arthroscopy or periarticular endoscopy as an adjunct to treating ankle instability at the time of open ligamentous stabilization. Ankle arthroscopy before lateral ligaments reconstruction will aid the surgeon in assessing for additional damage while conferring minimal additional time or morbidity. Surgically amenable lesions (ie, chondral lesions, loose bodies, associated instabilities, synovitis, impingements, ossicles, and peroneal tendon pathologies) can then be addressed, and the patient can be more accurately counseled regarding the condition of his ankle. Although it is likely that preoperative arthroscopy will improve outcomes in surgically stabilized ankles, there is a lack of controlled prospective studies that can truly assess its efficacy.

Keywords: ankle instability, arthroscopy, ankle sprains, pain and instability

 

Ankle sprains are among the most common injuries encountered in work and sport, with more than 2 million individuals experiencing ankle ligament trauma each year in the United States.1 Although most of these respond well to conservative management,2 acute ankle sprains are frequently associated with pathology resulting in chronic symptoms, including pain and instability, which persist beyond the expected recovery period. In a survey of 84 high school varsity basketball players, Smith et al3 reported that >70% had experienced an ankle sprain in their athletic lifetime. Fifty percent of these reported chronic symptoms after an acute sprain, with 15% noting a performance deficit because of the dysfunction. Similarly, Staples4 found 41% of patients with lateral ankle sprains continued to experience symptoms ranging from mild soreness to severe disability at long-term follow-up. The most common causes of disability after chronic ankle sprains in addition to the excessive laxity are the associated pathologies that develop with the recurrent episodes of giving way or inversion sprains. These may include intra-articular pathology (chondral lesions, loose bodies, ossicles, synovitis, and arthrosis), impingement lesions (anterior and anterolateral), and other instabilities other than lateral (subtalar, syndesmotic, and medial). These conditions are often associated with chronic ankle pain in addition to the ankle laxity.

Therefore, when dealing with athletes with chronic ankle instability, it is important to conduct a thorough evaluation and assess all the causes of pain and instability before embarking on a treatment plan. Although it is generally accepted that arthroscopy can be very helpful in the diagnosis and treatment of many ankle injuries and joint disorders, there is still some controversy regarding specific indications and effectiveness for its use. Given that these therapeutic and diagnostic indications are still being defined, the purpose of this article was to review the use and indications of arthroscopy or periarticular endoscopy as an adjunct to treating ankle instability at the time of open ligamentous stabilization.

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Lateral Ankle Instability and Associated Instabilities: Indications for Stabilization 

Chronic Lateral Ankle Instability 

Chronic lateral ankle instability must be thoroughly evaluated to determine whether true mechanical instability due to ligamentous laxity exists. This is differentiated from functional instability related to muscular weakness or pain inhibition reflexes from associated injury. If pain is is not present between sprains, true mechanical instability may be the primary problem. Stress radiographs are controversial because of the large variability in physiological values and the lack of correlation with clinical symptoms. Initial treatment for all patients, regardless of the duration of the instability, involves a therapy program of peroneal muscle strengthening and proprioceptive training, combined with the use of a lace-up brace for high-risk activities. This regimen is effective in 90% of patients. The remaining patients are candidates for operative stabilization. If pain is present between instability episodes and an associated lesion has been identified, it may be an option to treat this cause before considering surgical stabilization of the ankle or to treat it concurrently. If no clear associated lesion is identified, arthroscopy is carried out immediately preceding the lateral repair. The preferred technique is the Gould modification of the Broström procedure, an anatomical shortening and reinsertion of the anterior talofibular ligament (ATFL) and calcaneo-fibular ligament (CFL), reinforced with the inferior extensor retinaculum and distal fibular periosteum. Ninety percent good or excellent results have been reported with this procedure.

Non-anatomical reconstructions that sacrifice all or part of the peroneus brevis tendon to provide a tenodesis effect across the ankle and subtalar joints have been popular in the past. Concerns regarding the loss of the dynamic stabilizing effect of the peroneus brevis and overtightening of the subtalar joint have contributed to their decrease in popularity. Tenodesis procedures that attempt to anatomically replace the ATFL and CFL5 appear to have better functional and radiologic success compared with those that do not replicate the course of the native ligaments. Recalcitrant inversion injury in the presence of a varus hind foot may warrant consideration of supramalleolar or calcaneal osteotomy. More recently, anatomical reconstruction using autogenous or allogenic tissue has received some attention,6, 7 but no controlled trials have been published.

Chronic Subtalar Instability 

Chronic subtalar instability is believed to be associated with lateral mechanical instability in 10%-25% of patients. The structures considered most important in stabilizing the subtalar joint are the extensor retinaculum, CFL, the lateral talocalcaneal ligament, the interosseous talocalcaneal ligament, and the cervical ligament. The mechanism of injury involves supination with the ankle in dorsiflexion or simply the continuation of the arc of injury in a standard inversion ankle sprain. Chronic repetitive stress on the ligaments due to jumping has also been proposed. Controversy continues to surround the diagnosis as positive stress radiographs do not correlate with symptoms. Magnetic resonance imaging (MRI) has recently been shown to be accurate in displaying ligamentous injury of the subtalar joint. Initial treatment is the same rehabilitation protocol as for lateral instability. Operative treatment involves reconstructing the relevant anatomy or performing the extensor retinacular advancement (Gould modification) at the time of lateral ankle ligament stabilization.

Medial (Deltoid) Instability 

Medial (deltoid) instability has also received significant attention in the recent past. This can occur alone or in conjunction with lateral instability to cause excessive rotatory instability of the talus within the mortise. This may be associated with a history of trauma, valgus hind foot, or posterior tibialis tendon dysfunction. Although limited data are available in the published data regarding medial ankle instability in patients with lateral ankle instability, it is common to observe an associated lesion of the deltoid ligament (6%-40%). Similarly, a high incidence of lateral ligaments lesions (77%)8 is detectable in chronic medial instability. Hintermann et al8 stated that this phenomenon is probably due to repetitive rotatory shift of the talus within the medial ankle mortise, provoking overuse and attenuation of the lateral ankle ligaments. Nevertheless, the authors raised the doubt that the “primum movens” of combined medial and lateral instability can be the lateral insufficiency. Another interesting datum regarding medial ankle instability is the high association with chondral lesions (100%).9

The diagnosis is often underestimated,9 and arthroscopy has an important role in confirming the diagnosis. The clinical relevance of medial ligament insufficiency is not exactly known and the wide tendency is to not treat it surgically, as in deltoid disruptions associated with ankle fractures.10, 11 The only study reporting results on medial ankle stabilization is the one by Hintermann et al.8 The authors treated 52 consecutive ankles with medial ankle instability. The surgical technique involved an arthroscopic diagnostic procedure before an open medial repair with anchors and with augmentation (plantaris tendon graft), if the tissue quality was poor. Additional lateral ligaments shortening and reinsertion were performed if an associated lateral instability was detected. At an average of 4.43 years after surgery, the clinical result was considered good or excellent in 46 cases (90%), fair in 4 cases (8%), and poor in 1 case (2%).

Syndesmotic Instability 

Syndesmotic instability usually occurs with a disruption of the distal tibiofibular syndesmosis and is a common finding in chronic lateral instabilities, with an incidence ranging from 7% to 29%. The treatment of syndesmotic instability regardless of the involvement of lateral ligaments is still controversial.12 Current indications for surgical treatment of acute syndesmosis injuries include frank diastasis of the syndesmosis or diastasis on stress radiographs.13 In these cases, surgical treatment should include reduction and trans-syndesmotic fixation with 1 or 2 metallic screws.13 Arthroscopic evidence of syndesmotic instability is another indication for operative treatment. Nevertheless, when there are no radiographic signs of syndesmotic diastasis, the treatment of choice is controversial. Ogilvie-Harris et al14 treated 9 patients with syndesmotic instability and normal radiographs. The diagnosis was made clinically and confirmed arthroscopically. The treatment involved an arthroscopic removal of the torn portions of the interosseous ligament and posterior-inferior tibiofibular ligament along with a debridement of the chondral damage if present. No screw fixation was performed. Seven patients were completely satisfied with the result and only 2 were partially satisfied. The authors concluded that the pain was caused by the intra-articular disruption, not by biomechanical laxity, and that arthroscopic debridement was sufficient in these patients. Similar results and conclusions were reported by Han et al15 in their 20-patient series with arthroscopic diagnosis and treatment of chronic syndesmosis injuries.

By contrast, Wolf and Amendola16 advocate the use of percutaneous fixation. A total of 14 athletically active patients underwent arthroscopic debridement at the level of the anterior-inferior tibiofibular ligament (to allow adequate visualization of the syndesmosis) and percutaneous trans-syndesmotic fixation with arthroscopic demonstration of syndesmotic instability. Three patients required additional lateral ligament reconstruction (Broström). Two of 14 patients (14%) had an excellent result, 10 of 14 (71%) had a good result, and 2 of 14 (14%) had a fair result (according to Edwards and DeLee scale17). Schuberth et al18 at 24-month minimum follow-up reported excellent results in 6 patients with latent syndesmotic instability, treated with arthroscopic debridement and percutaneous fixation (Figs. 1 and 2).

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  • Figure 1. 

    Syndesmotic instability. (A) Normal preoperative radiograph. (B,C) Disruption of the anterior tibiofibular ligament. (D) Anterior tibiofibular ligament remnant after arthroscopic debridement.

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Associated Pathology at Time of Ankle Stabilization: Need for Arthroscopy 

Intra-articular Pathology 

Intra-articular pathology is a common finding in chronic ankle instability. The accuracy of arthroscopy in diagnosing ankle pathologies associated with lateral instability has been reported by many authors. A recent investigation by Hinterman et al19 demonstrated the sensitivity of arthroscopy in diagnosing abnormalities in the chronically unstable ankle. In their study, 148 patients with chronic ankle instability (greater than 6 months) underwent arthroscopic evaluation. All structural changes were noted and compared with the original diagnosis as assessed by standardized physical examination and imaging. Arthroscopy demonstrated that more than 50% of the cases had cartilage lesions of the talus, whereas the preoperative diagnosis was made in only 4% of the patients. Arthroscopic examination also revealed cartilage lesions of the tibial pilon (8%), medial malleolus (11%), and lateral malleolus (2.5%) that were not identified preoperatively. Furthermore, arthroscopic examination provided a more sensitive means to diagnose medial and rotational instability as well as visualize synovitis. Similar findings were seen in Kibler's20 study of 44 patients (46 ankles) who underwent a modified Broström procedure to repair the ATFL and the CFL in chronically symptomatic ankles. Arthroscopy identified intra-articular pathology in 38 (83%) of the 46 ankles. Preoperative diagnosis of intra-articular pathologies based on physical examination was made in only 28 (60%) cases.

Takao et al21 reported the results of 14 patients with apparent functional ankle instability. All subjects had no clinically demonstrable lateral instability and underwent standard stress radiography, MRI, ankle arthroscopy, and anatomical reconstruction of ATFL. Arthroscopic assessment revealed 3 cases with scar tissue and no ligamentous structure, 9 cases with partial ligament tears and scar tissue on the disrupted ATFL fiber, and 2 cases of abnormal course of the ligament at the fibular or talar attachment. MRI revealed the following: 5 cases of discontinuity of the ATFL, 2 cases of narrowing of the ATFL, 4 cases of high-intensity lesion in the ATFL, and 3 normal cases. The authors concluded that both MRI and arthroscopy are excellent tools in the diagnosis of ankle disorders, with arthroscopy being more accurate in detecting small lesions.

Taga et al22 performed an arthroscopic investigation of ankles before lateral ligament reconstruction to look for associated cartilage lesions. Of the 22 patients with chronic ankle instability, chondral lesions were detected in 21 (95%). The articular surface of the medial tibial plafond was noted to be the most frequently and severely involved site with 7 (33%) of the ankles exhibiting grade 3 or 4 lesions at this location. This was similar to previous reports of medial degeneration after chronic lateral instability.23 Furthermore, given that the higher grade injuries were not noted radiographically, only arthroscopic evaluation could accurately diagnose the presence of associated chondral lesions. They suggested that arthroscopic evaluation should be performed to evaluate ankles with lateral ligament damage to aid patient counseling and direct further intervention.

Choi et al24 described 63 (96.9%) intra-articular lesions out of 65 cases of lateral ankle instability, of which 53 (81.5%) showed soft-tissue impingement as the most common associated lesion. Other associated intra-articular lesions included ossicles at the lateral malleolus (38.5%), syndesmosis widening (29.2%), and osteochondral lesion of the talus (23.1%).

Komenda and Ferkel25 in their series of 55 patients with lateral instability demonstrated intra-articular abnormalities in 93% of ankles before lateral ankle stabilization. However, the incidence of chondral injuries in this study was only 25% compared with 95% reported by Taga et al.22 Additional abnormalities, including loose bodies (22%), synovitis (69%), adhesions (15%), and osteophytes (11%) were discovered.

Ankle arthroscopy seems to be essential even when an open surgery is planned, for example, in lateral stabilization. Ferkel and Chams26 in their series of 21 patients with lateral ankle instability reported that arthroscopy showed 95% of intra-articular lesions, and only 20% of them could be noted during the following open procedure. In contrast, Ogilvie-Harris et al14 stated that in the ankles treated with lateral ligament reconstruction, the chondral lesions detected arthroscopically (23 out of 27 patients) could all have been treated during open surgery. Nevertheless, the authors concluded that arthroscopy was useful to confirm the abnormal talar tilt when the diagnosis of lateral instability was not certain.

In review of the published data, high rate of associated intra-articular lesions is evident along with the essential role that arthroscopy has in detecting them. Nevertheless, the types of lesions differ somewhat across studies, which may reflect the variety of anatomical lesions likely to produce chronic symptoms. Furthermore, there are still some debated issues about chondral defects (Fig. 3). Although other intra-articular disorders reported good results with arthroscopic treatment and seem to not affect the outcome of lateral reconstruction,14, 24, 25 it is still controversial whether chondral lesions correlate with poor results. Komenda and Ferkel25 in the previously cited study reported good or excellent results in 96% of cases, further suggesting a benefit for the use of arthroscopy in diagnosing and treating all intra-articular lesions at the time of ligament repair. Okuda et al27 reported a 63% rate of focal chondral lesion diagnosed arthroscopically in a 30-patient series. The lesions were located on the medial side of the tibial plafond in 13 ankles (43%), on the lateral side in 2 ankles (7%), on the lateral side of the talar dome in 3 ankles (10%), and on the medial side in 9 ankles (30%). The authors noticed no significant differences in the clinical and radiologic results between patients with and without chondral damages. Hence, they concluded that lateral stabilization can be successful regardless of the presence of focal chondral lesions in patients with chronic lateral ankle instability when preoperative weight-bearing radiographs of the ankle do not show any joint space narrowing. Nevertheless, long-term results of patients with chondral lesion are not yet known.

In contrast, Takao et al28 described the results of 16 lateral ankle instabilities with moderate arthrosis (7 cases with stage 2 and 9 cases with stage 3 degeneration, according to Takakura classification). All patients underwent lateral stabilization and arthroscopic drilling of the cartilage lesions. The authors recommended the combined procedures only for stage 2 arthrosis. Similar results were reported by Taga et al22 in the previously described article, which stated that all the patients included in the study had sustained functional stability and improved mobility at 1 year follow-up. However, 4 of the patients with grade 3 or 4 lesions continued to experience medial ankle pain with activity. Physical examination of these patients revealed point tenderness at the antero-medial joint line corresponding to the location of the chondral lesions. The authors concluded that these symptomatic lesions may affect the final outcome of ankle stabilization procedures. Choi et al24 in a 65-case series evaluated the effect of associated lesions on the outcome of lateral ankle stabilization and concluded that arthroscopic diagnosis and treatment of intra-articular lesions is a safe and effective method. Nevertheless, the presence of any combination of associated intra-articular lesions resulted in a poor outcome. The strongest risk indicators for patients' dissatisfaction were syndesmosis widening, osteochondral lesions of the talus, and ossicles.

Another controversy in the published data is whether chondral lesions are correlated to the degree and the duration of ankle instability (Fig. 4). In the study by Taga et al,22 the severity and extent of cartilage lesions increased with the duration of symptoms but did not correlate with the number of ligaments involved. The authors concluded that even single ligament lesions should be treated to prevent further cartilage damage. In contrast, Hintermann et al19 showed no correlation between the severity and extent of cartilage lesions and the duration of ankle instability, but found an increased incidence of cartilage lesions in the presence of deltoid ligament rupture. Similar results were reported by Schäfer et al.9 Furthermore, Löfvenberg et al29 evaluated 37 patients with chronic ankle instability 20 years after the diagnosis and only 6 (16%) of them developed chondral degenerative changes.

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  • Figure 4. 

    Chondral lesion of the talar dome. (A) Chondral flap. (B) Debridement and curetting of the lesion, after flap's removal. (C) The lesion after the debridement.

Bony or Soft-Tissue Impingement 

Bony or soft-tissue impingement is associated with lateral ankle instabilities in 28%-81% of the cases. Of bony impingements, anterior impingement is more common (Fig. 5). Although anterior impingement (spurs on the anterior tibia and anterior neck of the talus) indicates a long-standing disorder of the ankle, sprains usually exacerbate the symptoms that may require surgery in previously asymptomatic patients.14 Ogilvie-Harris et al14 treated 11 patients with anterior impingement, which became symptomatic after multiple sprains. The patients complained of pain, stiffness, limp, and limitation of activities and not of substantial instability. The spurs were arthroscopically removed without any other combined procedure. The range of motion in dorsiflexion was significantly improved from an average of 0° dorsiflexion preoperatively to 10° postoperatively. Nine of the patients were completely satisfied, whereas 2 were only partially satisfied. Similar conclusions are reported by van Dijk,30 but only when anterior impingement is associated to initial chondral degeneration.

Another condition associated with ankle sprains and instability is the anterolateral impingement syndrome, which is a synovial thickening consistent with impingement in the anterolateral ankle gutter.14, 31 In these patients the pain is characteristically increased by plantar flexion of the ankle and a talar dome chondral lesion is often associated. Arthroscopy yields good results in treating this condition. Ferkel et al31 evaluated 31 patients with anterolateral impingements. Arthroscopic synovectomy and debridement of scar tissue from the lateral gutter was performed in all patients. The outcomes of more than a 2 year follow-up were excellent in 15 cases, good in 11, fair in 4, and poor in 1. Ogilvie-Harris et al14 treated arthroscopically 17 cases with anterolateral impingement. Thirteen patients were completely satisfied, 3 partially satisfied, and only 1 was dissatisfied with the results.

Loose Bodies and Avulsion Fractures 

Loose Bodies and avulsion fractures can commonly occur with recurrent sprains. Often avulsion injuries occur around the ankle (medial malleollus, fibular malleollus, medial and lateral wall of the talus, and postero medial talus). At the time of ankle stabilization, removing these loose bodies and unstable avulsions may be of benefit to prevent any discomfort when returning to play after stabilization (Fig. 6).

Peroneal Tendon Pathology 

Another condition that may be associated with chronic ankle instability is peroneal tendons pathology, even though the real incidence of this association is unknown. As the peroneal muscles act as lateral ankle stabilizers, more strain is placed on these tendons in chronic lateral instability resulting in hypertrophic tendinopathy, tenosynovitis, and, ultimately, in (partial) tendon tears.32 On physical examination, there is tenderness on palpation, edema, and increase of symptoms on active eversion against resistance.32

These conditions, along with adhesions, tendon ruptures, and exostosis, can be easily treated with tendoscopy (Fig. 7), when a proper conservative treatment fails. Endoscopic release in combination with synovectomy has several advantages: out-patient procedure, diminished pain, quick work and sports resumption and no need for a plaster cast.32

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  • Figure 7. 

    (A) Portals' positioning for tendoscopy and modified lateral approach for Broström procedure, including the portals. (B,C) Endoscopic images of the peroneal tendons.

In patients with recurrent dislocation of the peroneal tendons, the patient complains of lateral instability, giving way, lateral pain, and, occasionally, a snapping sensation.32 The dislocation can be reproduced by active eversion of the slightly dorsiflexed foot against resistance. When the location cannot be reproduced, the cause of the snap often remains unclear.32 Grade 1 and 2 injuries of the superior peroneal retinaculum accounts for more than 80% of peroneal instabilities.33 In these cases, the anatomical reattachment of the retinaculum is indicated.33 Lui33 described the endoscopic technique for superior retinaculum repair, using 3 suture anchors inserted in the fibula. This procedure seems to have the advantages of minimal invasive surgery, better cosmesis results, and less subjective tightness of peroneal tendons.33 An endoscopic approach can allow better assessment of retinaculum integrity, grading of the injury, detection of other pathology (eg, exostosis of the retro malleolar sulcus),33 and can also be easily converted to an open procedure.

In the patients with peroneal snap without a clinically evident dislocation over the lateral malleolus, the peroneal tendons are likely to snap over each other at the level of the tip of the lateral malleolus. The treatment of this condition is still debated. Resection of the peroneal brevis vincula and tenodesis has been proposed, but the results are still controversial.32

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Author's Current Approach to Lateral Ankle Instability and the Use of Arthroscopy 

Presently, once the decision to stabilize an ankle has been made, my preferred method is a modified Broström with a Gould modification. In patients with excessive laxity, failed Broström, augmentation with an allograft semitendinosus or Achilles, or autograft hamstring tendon may be used. In addition, an arthroscopic evaluation is conducted before the incision to confirm the status of the joint, remove any synovial impingement, any bony impingement, loose bodies, and if necessary confirm the syndesmosis is intact.34 Antero-medial and anterolateral portals are used. The anterolateral portal is incorporated into the Broström incision anteriorly. Swelling from fluid extravasation is present but usually of no impediment to identifying anatomy and carrying out the procedure.

In general if there is any pain associated with the choric instability, arthroscopy is recommended at the time of stabilization to deal with any of the associated pathologies as noted earlier in the text (Fig. 8).

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  • Figure 8. 

    Ankle arthroscopy associated with Broström procedure (A) Positioning of the anteromedial and anterolateral (AL) portals and approach to the lateral compartment, including the AL portal. (B) AL approach for Broström procedure.

Most commonly a modified Broström is performed as the procedure of choice, but a lateral reconstruction with autogenous or allograft transplantation can be used.

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Conclusions and Senior Author's Approach 

Chronic dysfunction after an ankle sprain or recurrent sprains is a common occurrence. Despite surgical restoration of objective stability, many of these ankles are likely to continue to be problematic. In addition, traditional approaches to repair damaged ligaments offer limited exposure to intra-articular structures. As the use of arthroscopy expands, previously undiagnosed articular lesions suggest etiologies for unsatisfactory outcomes. Ankle arthroscopy has progressed immensely over the past several decades as previous limitations give way to improved technology, experiences, and techniques. Its use before ankle ligament reconstruction will aid the surgeon in assessing for additional damage while conferring minimal additional time or morbidity. Surgically amenable lesions can then be addressed and the patients can be more accurately counseled regarding the condition of their ankle. Although it is likely that preoperative arthroscopy will improve outcomes in surgically stabilized ankles, controlled prospective studies are lacking to truly assess its efficacy.

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References 

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PII: S1060-1872(09)00137-3

doi:10.1053/j.otsm.2009.11.004

Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 2-10, March 2010

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