Evolution in Surgical Management of Ankle Instability in Athletes

Brian C. Lau, MD; Alexej Barg, MD; C. Thomas Haytmanek, MD; Kirk McCullough, MD; Annunziato Amendola, MD


J Am Acad Orthop Surg. 2021;29(1):e5-e13. 

In This Article

Time to Return to Sport

Frequently, the only question that athletes consider when contemplating surgical treatment for ankle instability is how long it will take to return to play. In a systematic review of 20 articles evaluating 489 athletes were reviewed and a weighted mean time to return to play was 4.7 months.[43] Although that is a useful response to the athlete's question, the review is limited because it included studies with varying surgical techniques and rehabilitation protocols.

Some studies have separated times to return to activity more distinctly. For example, Lee et al[44] evaluated 66 athletes (soccer, basketball, ballet/gymnastics, and martial arts) after open transosseous Broström repair. The author's rehabilitation protocol began with 4 weeks of immobilization and 6 weeks of limited weight-bearing. At 6 weeks, formal therapy was initiated. Their athletes returned to personal training at 1.9 months and returned to team training at 3.9 months. The return-to-full-play rate was 83.3% at 4 months and 100% at 8 months postoperatively.[44]

Different criteria are used to determine progression of rehabilitation and return to play. After operation, athletes generally return to running on level ground once their ankle strength is 90% of their uninjured contralateral limb. Cutting and jumping may resume when balance and proprioception have been adequately restored.[45] Return to play can be considered when an athlete meets three criteria: (1) no longer experiences pain or swelling or instability, (2) demonstrates painless normal ankle range of motion and strength, and (3) has restored neuromuscular control through relevant sport-specific functional tests. Once cleared to return to play, it is also recommended that ankle bracing treatment or taping be used during athletic activities for at least 6 months postoperatively, a practice that has been associated with a 70% decrease in recurrent ankle sprains.[45]

Reports on return to play after surgical procedure for ankle instability vary widely but an average of 4.7 months can be expected. Return to training may begin as early as 2 months. At 8 months, most athletes can expect to have returned to play. There remains no consensus on specific return-to-play criteria but generally should include painless range of motion, no recurrent mechanical or subjective instability and an objective-criteria for sport-specific activity.