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

Early Versus Delayed Weight-bearing and Rehabilitation

Historically, a period of immobilization, followed lower extremity surgical procedure because of concerns with tissue healing of the wound in an edematous limb and possible excessive wound exudate that may lead to increased infection rates. Postoperative protocols generally consist of an initial 2- to 6-week period of cast, splint, or boot immobilization to allow wound healing. Concern also exists that unprotected early mobilization may lead to increased stress on the repaired tissue leading to elongation of ligaments causing increased laxity and decreased stability.[36] Therefore, the consensus statement by the Ankle and Foot Associates Section of the European Society for Sports Traumatology, Knee Surgery and Arthroscopy recommended 10 to 14 days of immobilization and elevation of the limb until the wound heals after lateral ankle ligament repair.[37] The statement did note that studies that used immediate weight-bearing after ankle ligament repair did not report any increased wound complications.[37]

Several studies have evaluated whether this initial immobilization could be eliminated and expedite recovery. Karlsson et al[38] were the first to use an early weight-bearing protocol after lateral ankle stabilization in 1995 starting with 2 weeks of immobilization and eventually to immediate weight-bearing in 1999. They demonstrated that early mobilization after anatomic lateral ankle ligament reconstruction allowed for earlier return to sport and greater plantarflexion strength in comparison to patients who have are immobilized.[38] Others followed with attempts at earlier weight-bearing and rehabilitation. The 2011 Cochrane review of De Vries et al[39] evaluated randomized controlled studies and found that early mobilization (within 2 weeks of surgical procedure) allowed patients to return to work and sport at about 2 weeks and 3 weeks, respectively, earlier then delayed mobilization and rehabilitation (greater than 6 weeks postoperatively). In addition, a review by De Vries found that no difference exists between early and delayed mobilization regarding return to their former athletic level (2/35 versus 4/35).[39] Kim et al[40] reported on 155 ankles and found no difference in patient-reported outcomes or talar tilting on stress radiographs when early weight-bearing at 2 weeks postoperatively was used.

Petrera et al[41] conduted a trial of immediate full weight-bearing in a walking boot on the first postoperative day in a series of 55 patients after open suture anchor based Broström repair. They allowed immediate limited ankle range of motion (30° arc of motion) with no inversion or eversion. At the third week, formal physical therapy was initiated to allow active range of motion. At 6 weeks, the walking boot was discontinued, and therapy progressed to strengthening, proprioceptive exercises, fast-paced walking, or jogging. At 3 months, running and plyometric and sport-specific training were allowed. They reported a 94% return to play at the final follow-up but did not report the time necessary to return.[41] There were, however, two patients with a superficial infection (3.6%) that were treated successfully with oral antibiotics.[41]

Agrawal et al[42] reported on functional outcomes and return to sports on 71 patients who underwent absorbable suture open Broström repair with immediate full weight-bearing. Their protocol was full weight-bearing in a normal shoe from the day of surgical procedure. Physiotherapy started on postoperative day 1 with gentle range of motion, calf strengthening, and static peroneal exercises. At 3 to 4 weeks, proprioception, Theraband, and dynamic peroneal exercises were started. No boots, braces, or casts were used at any stage in the postoperative period. Agrawal's group reported improvements in FAOS and pain scales with a failure rate of 4% with three patients (traumatic rerupture). No superficial infections were noted, and 87% were able to return to sport. The time to return to sport was not reported.[42]

Although more research is required, clinical studies support early mobilization within 2 weeks, and possibly immediate weight-bearing after lateral ankle stabilization. Comparable patient-reported outcomes, risks of superficial infection, and maintenance of repair on stress radiographs exist compared with delayed rehabilitation. In addition, early rehabilitation may shorten return to play by 2 to 3 weeks.