What is the appropriate management for a patient with a history of weak ankles and repeated falls, whose current ankle strength and stability are uncertain?

Management of Weak Ankles and Recurrent Falls

For patients with a history of weak ankles and recurrent falls, a thorough ankle assessment by the PCP is necessary, followed by referral to physical therapy if significant weakness is found, and consideration of lace-up ankle braces for interim support to prevent falls.

Initial Assessment

• The PCP should evaluate the patient's ankles for persistent weakness or instability, as these are significant risk factors for recurrent falls 1
• Assessment should include:
  • Anterior drawer test to detect excessive anterior displacement of the talus (84% sensitivity, 96% specificity) 2
  • Evaluation of dorsiflexion range of motion, as limited dorsiflexion increases risk of ankle instability 1
  • Assessment of proprioception and balance, which are critical factors in ankle stability 1, 2
• Document the patient's current level of pain, workload, and specific exercise activities, as these factors influence recovery and risk of recurrent injury 1, 2

Diagnostic Considerations

• If clinical suspicion for fracture exists, use the Ottawa Ankle Rules to determine need for imaging 1
• For patients with persistent ankle instability without recent trauma, consider:
  • Functional ankle instability (proprioceptive deficits) vs. mechanical ankle instability (ligamentous laxity) 3
  • Possible occult injuries that may have been missed on initial evaluation 1

Treatment Recommendations

For Significant Ankle Weakness

• If significant ankle weakness is found on examination, refer the patient to physical therapy for a supervised exercise program and provide a lace-up ankle brace for interim support to reduce fall risk 1
• Physical therapy should focus on:
  • Proprioceptive training using ankle disk/wobble board exercises 1, 2
  • Strengthening exercises for ankle and hip muscles 2, 4
  • Balance training on stable and unstable surfaces 2, 4
  • Functional exercises specific to the patient's daily activities 1, 2

Ankle Support Options

• Lace-up ankle braces are superior to elastic bandages or tape for providing stability while allowing movement 1, 2
• Semirigid or lace-up ankle supports have been shown to decrease the risk of recurrent ankle injury, especially in patients with a history of recurrent sprains 1, 2
• Functional support should be used for 4-6 weeks during activities to provide stability while allowing movement 2

Monitoring and Follow-up

• Reassess ankle strength and stability after 4-6 weeks of therapy 1, 2
• Consider using validated assessment tools such as:
  • Foot and Ankle Ability Measure (FAAM) for functional assessment 5, 6
  • Time-in-balance test (significant if ≤25.89 seconds) or foot-lift test (significant if ≥5 lifts) to quantify instability 4
• Monitor for improvement in balance and reduction in fall frequency 1

Common Pitfalls to Avoid

• Discontinuing exercises once pain subsides increases risk of recurrent injury; complete the full 4-6 week program 2
• Relying solely on compression bandages without proper functional support is less effective 1, 2
• Neglecting proprioceptive training increases risk of developing chronic ankle instability 2, 7
• Failing to address both mechanical and functional components of ankle instability 3, 7