Review of Post-Operative Rehabilitation Protocols Following Ankle Lateral Collateral Ligament Repair in Adults

Michael Apostolides, MD, MSc, MRCS; Mina Mazin Al-Janabi, MBBS iBSc, MRCS; Crispin Southgate, FRCS (T&O); Baljinder Singh Dhinsa, FRCSEd (T&O), MSc, MFSTEd

Special Issue: Ankle Fractures

Foot Ankle Stud. 2023; 5(1): 1028.

Review of Post-Operative Rehabilitation Protocols Following Ankle Lateral Collateral Ligament Repair in Adults

Michael Apostolides, MD, MSc, MRCS¹; Mina Mazin Al-Janabi, MBBS iBSc, MRCS²; Crispin Southgate, FRCS (T&O)³; Baljinder Singh Dhinsa, FRCSEd (T&O), MSc, MFSTEd³

¹East Sussex Healthcare NHS Trust, UK

²Princess Alexandra Hospitals NHS Trust, UK

³East Kent Hospitals University NHS Foundation Trust, UK

*Corresponding author: Michael Apostolides East Sussex Healthcare NHS Trust, The Ridge , St. Leonards-on-Sea, East Sussex, TN37 7PT, UK. Tel: +44 7473250592 Email: michael.apostolides1@nhs.net; michaelapostolides88@gmail.com

Received: July 13, 2023 Accepted: August 16, 2023 Published: August 23, 2023

Abstract

Ankle sprains are very common injuries and are usually managed non-operatively. With poor rehabilitation, 20% of ankle sprains may develop chronic instability, which often necessitates surgical intervention. Rehabilitation after such procedures is focused on regaining the function of the ankle while keeping a stable joint. Post-operative rehabilitation and weight-bearing status varies greatly among surgeons. Our aim is to review the existing most recent literature that investigates post-operative outcomes following different rehabilitation protocols in patients with Chronic Lateral Ankle Instability (CLAI).

We performed a literature search from 2002 to 2022, through Medline/Pubmed databases using the terms ‘ankle lateral ligament’, ‘repair’, ‘reconstruction’ and ‘post-operative rehabilitation’. A gray literature search was also performed using the Google Scholar search engine. Studies that described post-operative rehabilitation protocols following CLAI surgery were included.

25 studies with 1045 patients describing rehabilitation protocols following repair/reconstruction of CLAI were included. Most studies used the Broström procedure or modification of it. In 82% of cases patients were immobilised in a cast from day 1 post-operatively for two weeks and were kept non-weight-bearing in 64% during the same time. A boot or brace was kept up to 6 weeks in 82%. Full weight-bearing was recommended either at the very start following surgery (32%), or after four weeks from surgery (36%). Early range of movement exercises started after week 2, with muscle strengthening, proprioception, and balance between week 2 and 6. Return to sports is usually between 2-4 months.

In conclusion, post-operative rehabilitation protocols following CLAI surgery vary considerably. We attempted to quantify the studies that provide enough information on this subject and create a post-operative rehabilitation protocol following anatomic repair/reconstruction for CLAI.

Keywords: Chronic lateral ankle instability; Modified broström-gould; Post-operative rehabilitation

Introduction

Emergency Departments are inundated with musculoskeletal trauma, with up to 50% resulting from ligamentous injuries [1]. Amongst these, 40% involve the ankle, the lateral ankle ligamentous complex injuries being the most prevalent within the sporting community and the general population [2]. The Anterior Talofibular (ATFL) and Calcaneofibular Ligaments (CFL) are the ones that are most commonly injured [2]. Management of these ankle sprains is mostly conservative, but it is reported that, with poor rehabilitation, up to 20% can result in chronic instability [3]. This may manifest as frequent ‘giving-way’ of the ankle while weightbearing, or inability to return to sports due to the lack of objective stability, for more than 6 weeks from injury. While most acute ankle sprains can be managed conservatively, Chronic Lateral Ankle Instability (CLAI) may require operative management, when conservative measures fail [3,4].

Nonoperative management is the initial approach for treating CLAI, with physiotherapy, orthotic devices, and proprioceptive training. However, in persistent instability or failure of conservative measures for more than 3 to 6 months, operative management can be considered [5]; this includes anatomic ligament repair or reconstruction and non-anatomic reconstruction techniques [6]. The Broström technique, first described in 1966, offers anatomic repair of the ATFL and CFL, and is considered the gold standard [2]. There have been many modifications to this technique, as well as arthroscopic variants [5].

The recovery period after such procedure is between 3 and 6 months [2]. Rehabilitation protocols are essential to allow for patients to regain their range of motion in the ankle [5]. However, the optimum length of rehabilitation as well as the main concept of early versus late mobilization is still controversial [5]. Some surgeons are protective of the repair/reconstruction and keep ankles immobilized in a cast for up to 6 weeks. While this protects the repair, it can also lead to decreased ankle motion and muscle atrophy, making the overall rehabilitation process more challenging (and not conducive for a return to sports) [2]. Others allow early mobilization of the ankle, but this also comes with risks of complications, especially wound-related [2]. Confidence in the reconstruction of the ligamentous structures has improved with the use of anchors and polyethylene suture material; however the orthopaedic dogma of postoperative immobilization remains. Our aim was to perform a narrative review of the most recent literature describing postoperative rehabilitation protocols after surgical management of CLAI.

Methods

A literature search was performed via Pubmed/Medline databases using the terms ‘ankle’, ‘lateral collateral ligament’, ‘repair’, ‘reconstruction’ and ‘post-operative rehabilitation’, for studies that investigated different rehabilitation protocols in patients with CLAI from 2002 to 2022. A gray literature search was also performed using the Google Scholar search engine. We felt that a 20-year period is a good representation of the published literature on this subject, given that the number of studies published on CLAI has significantly increased since 2014. Articles included in this review were studies describing their post-operative rehabilitation protocols following CLAI surgery, comparative or case series. If the description was incomplete, or the authors failed to provide timings for the rehabilitation period, the study was excluded.

Protocols were categorized based on the type of surgery: anatomic repair or reconstruction, and non-anatomic reconstruction (Figure 1). We recorded the type and length of immobilization, weight-bearing status and type of exercises allowed with physiotherapy, including time frames, and the complications reported. We lastly looked for aim to return to work and sport. Using the evidence, we attempted to create a standardized rehabilitation protocol based on type of repair/reconstruction performed.

Figure 1: Search strategy (2002-2022) and included studies.


    

    

    Figure 1: Search strategy (2002-2022) and included studies.

Results

Initial search identified 4554 articles. Following removal of unrelated research, duplicates, and studies not providing enough information on post-operative rehabilitation protocols, we included 25 studies (Figure 1). 22 studies described anatomic repair or reconstruction techniques and 3 studies non-anatomic reconstruction methods. Table 1 shows in detail each study, along with the number of patients included, the surgical technique used, rehabilitation protocol and complications. In the anatomic repair/reconstruction group, there were 929 patients in total, compared to 116 in the non-anatomic reconstruction group. Most studies in the anatomic group described a variation of the Broström procedure, with or without arthroscopy (15/22, 68%). 2 studies used the Karlsson procedure (9%), 4 studies described arthroscopic reconstruction techniques (18%) and 1 study Arthroscopic Lateral Ligament Repair (ALLR) (4.5%). In the non-anatomic group, there were three different techniques described: modified Watson-Jones, fibular periosteal flap, and a split peroneus brevis graft. We looked at the rehabilitation protocols separately for anatomic and non-anatomic reconstruction groups. Specifically, we looked at the type and length of immobilization along with the weight-bearing status. Secondly, the timing of exercises and type of exercises and the overall length of rehabilitation required to return to sporting activities.

Table 1: Studies providing post-operative rehabilitation protocols (2002–2022) following CLAI surgery.








  

    Study

    Surgery

    Patient N

    Immobilization

    Weight-bearing*

    Physiotherapy (exercises allowed)

    Return to sports

    Complications (N)

  

  

    Anatomic Repair / Reconstruction

  

  

    Teramoto et al (2022) [7]

    Arthroscopic Lateral Ligament Repair (ALLR)

    22

    

      Day 0-3: Fibreglass    backslab

      Day 4 – Week 3: Ankle    brace during day & fibreglass backslab at night

    

    

      Day 0-3: Non-WB

      After day 3: FWB

    

    

      Day 3 – Week 3: Ankle    dorsi-flexion, walking, squats, foot intrinsic muscle training

      Week 3-4: Ankle    plantar flexion & dorsi-flexion strengthening

      Week 4: Jogging

      Week 6: Competitive    sport training

    

    8 weeks

    Not stated

  

  

    Yang et al (2022) [8]

    Arthroscopic vs Open Anatomic Reconstruction

    Arthr.: 10


      Open: 10

    

      Week 0-4: Ankle boot

      After week 4: high    ankle shoes

    

    

      From day 1: partial    WB

      From week 4: FWB

    

    

      From week 2: ROM    exercises

    

    4 months

    

      Superficial wound    infection (1)

      Stitch abscess (1)

      Transient sural    paraesthesia (1)

    

  

  

    Martin et al (2021) [9]

    Open modified Broström

    93

    

      Week 0-2: Cast

      Week 3-4: Walking    boot

      After week 4: ankle    lace-up brace

    

    

      Week 0-2: Partial WB

      Week 2-: WBAT

    

    

      Week 2: home    resistant band strengthening

      Week 4: stationary    biking, water therapy

      Week 4-6: treadmill,    elliptical training, proprioception, heel raises

      Week 6: jumping

    

    100 days

    

      Cellulitis (1)

      SPN#    hyperesthesia (2)

    

  

  

    Baraza et al (2017) [10]

    Open modified Broström-Gould

    21

    

      Week 0-6: Cast

      From week 6:    malleolar splint

    

    

      Week 0-6: Non-WB

      From week 6: FWB

    

    

      From week 6: gentle    ROM exercise

    

    Not stated

    

      Persistent ankle pain    requiring re-operation (3)

    

  

  

    Jiang et al (2017) [11]

    Open modified Broström-Gould +/- Arthroscopy for OCL8

    34 (+ arthr.)


      36 (- arthr.)

    Both groups

      

        Week 0-3: Splint

        Week 4-6: Ankle brace

      

    Group A (+ arthr.)

      

        Week 0-6: Non-WB

        Week 7-8: Partial WB

        Week 9-12: FWB

      

      Group B (- arthr.)

      

        Week 0-4: Non-WB

        Week 5-6: FWB

      

    Group A

      

        Week 2-6: daily full    range continuous passive motion, no varus (from week 5) or internal rotation

      

      Group B

      

        Week 3: daily full    range continuous passive motion, no varus (from week 5) or internal rotation

      

    Group A

      

        4-6 months

      

      Group B

      

        3-4 months

      

    

      Continuous ankle    instability (6 – 3 each group)

    

  

  

    Jeong et al (2016) [12]

    Open modified Broström

    45

    

      Week 0-4: Cast

      Week 5-6: Ankle    orthosis

    

    

      Week 0-6: Non-WB

      From week 6: Partial    WB

    

    

      From week 4: Gentle    ROM exercises

      From week 6: peroneal    muscle strengthening + proprioception exercises

      After 3 months: light    exercises

    

    Not stated

    None

  

  

    Russo et al (2016) [13]

    Open modified Broström-Gould

    18

    

      Day 1: ankle brace

    

    

      Day 1-14: very light    WB

      From day 15:    increasing partial WB

    

    

      From day 15:    flexion-extension exercises, peroneal muscle strengthening, proprioception

      From 3 months:    running

    

    4 months

    None

  

  

    Acevedo et al (2015) [14]

    Arthroscopic Broström

    93

    

      Week 0-2: Cast

      Week 3-4: Walking    boot

      Week 5-12: lace-up    ankle brace

    

    

      Week 0-2: Non-WB

      Week 3-4: WB as    tolerated

      Week 5-6: FWB

    

    

      Week 2-4: gentle ROM    avoiding inversion

      Week 4-6: Plantar and    dorsi-flexion

      Week 6+: peroneal    muscle strengthening, balance, stationary bike, proprioception

    

    3-6 months

    

      Post-operative neuritis    (5)

    

  

  

    Cho et al (2015) [15]

    Open modified Broström

    24

    

      Week 0-3: Cast

      After week 3: elastic    ankle bandage

    

    

      Week 0-3: Non-WB

      Week 4: Partial WB

      After week 5: FWB

    

    

      From week 3: ROM    exercises

      From week 4: peroneal    muscle strengthening, proprioception training

      From week 6: running

    

    8 weeks

    

      SPN damage (1)

      Wound infection (1)

    

  

  

    Cho et al (2015) [16]

    Open modified Broström


      [suture bridge vs. suture anchor repair]

    45

    

      Week 0-3: Cast

      After week 3: elastic    ankle bandage

    

    

      Week 0-3: Non-WB

      Week 4: Partial WB

      After week 5: FWB

    

    

      From week 3: ROM    exercises

      From week 4: peroneal    muscle strengthening, proprioception training

      From week 6: running

    

    3 months

    

      Wound infection (1)

      Skin irritation (3)

    

  

  

    Iawo et al (2014) [17]

    Open modified Broström

    10

    

      Week 0-4: Cast

    

    

      Week 0-2: Non-WB

      Week 3-4: Partial WB

      From week 5: FWB

    

    

      From week 4: ROM    (plantar flexion and dorsi-flexion) + muscle strength exercises

      From 2 months:    inversion, eversion, balance

      From 3 months:    functional training (running, jumping)

    

    Not stated

    Not stated

  

  

    Petrera et al (2014) [18]

    Open modified Broström

    49

    

      Day 0 – week 6:    Pneumatic walking boot

    

    

      From day 0: FWB

    

    

      0-3 weeks: ROM, hip    & knee strengthening, limited plantar (0-20°) & dorsi-flexion (0-10°)    in NWB mode

      3-6 weeks: progress    with active ROM but avoid inversion

      From 6 weeks:    progress ROM and include inversion, proprioception. gait training, swimming,    biking

      From 3 months:    sports-specific training, running, plyometrics

    

    When full pain-free ankle ROM. >90% ankle strength of contralateral    ankle, pass sports-specific tests

    

      Superficial infection    (2)

      SPN paraesthesia (1)

      Residual instability    (3)

    

  

  

    Buerer et al (2013) [19]

    Open modified Broström-Gould

    41

    

      Week 0-4: Cast

      Week 4-8: ankle    splint (day + night)

      Week 8-12: ankle    splint (only night)

    

    

      From day 0: FWB

    

    

      From week 5: ankle    tonification

      Week 7:    proprioception & coordination training

    

    

      One plane sports: 7    weeks

      Pivot sports: 13    weeks

    

    

      SPN transient    paraesthesia (2)

      SPN persistent    hypoesthesia (2)

      Persistent    instability (1)

    

  

  

    Burn et al (2013) [20]

    Open modified Broström-Gould

    41

    

      Week 0-4: Cast

      Week 4-8: ankle    splint (day + night)

      Week 8-10: ankle    splint (only night)

    

    

      From day 0: FWB

    

    

      From week 5: ankle    exercises in sagittal plane

      Week 7:    proprioception & coordination training

    

    

      One plane sports: 7    weeks

      Pivot sports: 13    weeks

    

    Not stated

  

  

    Cho et al (2012) [21]

    Open modified Broström

    40

    

      Week 0-4: Cast

      After week 4: elastic    ankle bandage

    

    

      Week 0-4: Non-WB

      Week 5-6: Partial WB

      After week 6: FWB

    

    

      From week 4: ROM    exercises

      From week 6: peroneal    muscle strengthening, proprioception training

      From week 12: running

    

    Not stated

    

      Wound infection (2)

      SPN damage (1)

      Persistent ankle pain    (1)

    

  

  

    Li et al (2009) [22]

    Open modified Broström

    52

    

      Week 0-4: Cast

      Week 4-6: Ankle    Support Orthosis

    

    

      Week 0-2: Non-WB

      Week 3-4: increasing    to FWB

    

    

      From week 4: ROM    exercises

      Week 6-8:    strengthening & proprioception training

      Week 8-12:    plyometrics

    

    16 weeks

    

      Re-rupture (3)

      Wound infection    (several)

    

  

  

    Brodsky et al (2005) [23]

    Open modified Broström-Gould

    73

    

      Week 0-4: Cast

      After week 4: Walking    boot

    

    

      Week 0-4: Non-WB

      After week 4: Partial    WB – increasing to FWB

    

    

      From week 4: Passive    dorsi-flexion & plantar flexion

      Week 8: Peroneal    muscle strengthening, proprioception & balance training

    

    10-12 weeks

    

      Superficial ulcer    from cast (1)

      Reflex sympathetic    dystrophy (1)

      Tibial sesamoiditis    (1)

    

  

  

    Schmidt et al (2005) [24]

    Karlsson procedure

    32

    

      Week 0-3: Cast

      Week 3-6: Air stirrup

    

    

      Week 0-3: -

      Week 3-6: FWB

    

    

      From day 3:    Dorsi-flexion & plantar flexion

      From week 3: Motion,    coordination, balance, proprioceptive training

    

    Not stated

    

      Prolonged wound healing    (1)

      Major instability (1)

    

  

  

    Jarvela et al (2002) [25]

    Karlsson procedure / primary repair

    32

    

      Week 0-4: Cast

    

    

      From week 0: FWB

    

    

      From week 4: ROM    & isometric peroneal strengthening exercises

    

    2-3 months

    

      Persistent    instability (2)

    

  

  

    Matsui et al (2016) [26]

    Arthroscopic anatomic reconstruction / Open repair

    37

    

      Several days:    Compressive bandage and ankle splint

      Up to 6-8 weeks: soft    ankle brace

    

    

      From day 1: FWB

    

    

      From day 1: active    ankle ROM†

      Week 1-2: exercises    to restore ROM and strength

      Week 2-3: treadmill,    sport-specific drills, balance training

    

    6 weeks

    

      SPN paraesthesia (3)

      Wound irritation (3)

    

  

  

    Trichine et al (2018) [27]

    Anatomic reconstruction

    38

    

      45 days: Cast

    

    

      0-15 days: NWB

      15-30 days: WB

    

    

      Week 6: ankle    tonification in sagittal plane

      Week 8: coordination,    proprioception

    

    

      One-plane sports: 8    weeks

      Pivot sports: 14    weeks

    

    

      Delay in wound    healing (3)

      Transient SPN    paraesthesia (2)

    

  

  

    Miyamoto et al (2014) [28]

    Anatomic Reconstruction using autograft

    Group I: 15


      Group A: 18

    Group I

      

        Week 0-4: Cast

        Week 4-8: Orthosis

      

      Group A

      

        Week 0-8: Orthosis

      

    Group I

      

        Week 0-2: Non-WB

        Week 3-4: partial WB

        From week 5: FWB

      

      Group A

      

        From week 0: FWB

      

    Group I

      

        From week 4: ROM    & strengthening exercises

        Week 6-7: Balance,    treadmill, sports drills

      

      Group A

      

        From week 2: ROM    & strengthening exercises

        Week 2-3: Balance,    treadmill, sports drills

      

    When patients felt confident and had no difficulties with sports    drills

    None

  

  

    Non-anatomic Reconstruction

    

    

    

    

    

    

    

  

  

    Ramdass et al (2019) [29]

    Anatomic vs non-anatomic reconstruction

    An.: 26


      Non-An.: 36

    

      Week 0-4: Cast

      Week 4-8: Ankle boot

    

    

      Week 0-4: Non-WB

      Week 4-8: protected    WB

    

    

      From week 2: ROM    exercises

      From week 8-12:    physiotherapy

      From week 10-12:    protected physical activity

    

    Not stated

    

      Sural neuroma (1)

      Transient sural    neuralgia (1)

      CRPSa (1)

      Ankle arthritis (4)

      Migration of anchor    (1)

    

  

  

    Benazzo et al (2013) [30]

    Non-anatomic reconstruction with fibular periosteal flap

    40

    

      Week 0-6: Cast

    

    

      Week 0-3: Non-WB

      From week 3: FWB

    

    

      From week 6: ROM    exercises

      From Day 50:    Proprioception training, muscle strengthening

      From Day 65:    Eccentric muscle strengthening

    

    4 months

    

      Superficial wound    infection (1)

    

  

  

    Morelli et al (2010) [31]

    Modified Watson-Jones

    14

    

      Week 0-4: Cast

    

    

      Week 0-2: Non-WB

      From week 2: FWB

    

    

      From week 4: ROM    exercises

    

    Mean 6 months

    

      Delay in wound    healing (2)

      Transient SPN    paraesthesia (3)

    

  

  

    *Weight-bearing status abbreviations: FWB (Full    Weight-Bearing), WBAT (Weight-Bearing As tolerated), Non-WB    (Non-Weight-Bearing)


      #SPN: Superficial Peroneal Nerve


      8OCL: Osteochondral Lesion


      †ROM: Range of Movement


      aCRPS:    Complex Regional Pain Syndrome






Table 1: Studies providing post-operative rehabilitation protocols (2002–2022) following CLAI surgery.

Rehabilitation protocols for the anatomic repair/reconstruction studies are detailed in table 1 and illustrated in figure 2. Almost 82% of studies immobilized patients in a below knee cast from day 1 post-operatively for two weeks. During the same time, patients were kept non-weight-bearing for the first two weeks in 64% of studies, as seen in figure 3B. 72.7% of protocols suggested keeping the cast for an additional week, and 45.4% for four weeks in total. Only two studies recommended keeping the cast for six weeks in total (9%). There were some studies that placed patients in a walking boot, an elastic brace, or a combination of the two from immediately post-operatively. Overall, a type of boot or brace was kept up to 6 weeks in 82% and 8 weeks in 41% of studies. In terms of full weight-bearing, there were two highlight periods in which authors recommended – at the very start following surgery, on day 1 (32%), or after four weeks from surgery (36%) (Figure 2B).

Figure 2: Bubble plots showing post-operative rehabilitation protocols for anatomic repair or reconstruction of CLAI. Size of the bubble proportional to the number of studies describing the rehabilitation strategy, i.e. the bigger the bubble, the more studies describe the strategy (weeks are shown in the x axis). (a) Immobilisation techniques as described in weeks, (b). Weight-bearing status per week, (c). Rehabilitation, physiotherapy exercises and return to sports. POP: Plaster Of Paris, NWB: Non-Weight-Bearing, PWB: Partial Weight-Bearing, FWB: Full Weight-Bearing, ROM: Range Of Movement.


    

    

    Figure 2: Bubble plots showing post-operative rehabilitation protocols for anatomic repair or reconstruction of CLAI. Size of the bubble proportional to the number of studies describing the rehabilitation strategy, i.e. the bigger the bubble, the more studies describe the strategy (weeks are shown in the x axis). (a) Immobilisation techniques as described in weeks, (b). Weight-bearing status per week, (c). Rehabilitation, physiotherapy exercises and return to sports.

POP: Plaster Of Paris, NWB: Non-Weight-Bearing, PWB: Partial Weight-Bearing, FWB: Full Weight-Bearing, ROM: Range Of Movement.

Figure 3: Post-operative rehabilitation strategies for non-anatomic reconstruction of CLAI. (a). Immobilization techniques, (b). Weight-bearing status per week, (c). Rehabilitation and physiotherapy per week (bars and not indicative of length of physiotherapy or exercises, but rather the start). POP: Plaster Of Paris, NWB: Non-Weight-Bearing, FWB: Full Weight-Bearing, ROM: Range Of Movement.


    

    

    Figure 3: Post-operative rehabilitation strategies for non-anatomic reconstruction of CLAI. (a). Immobilization techniques, (b). Weight-bearing status per week, (c). Rehabilitation and physiotherapy per week (bars and not indicative of length of physiotherapy or exercises, but rather the start).

POP: Plaster Of Paris, NWB: Non-Weight-Bearing, FWB: Full Weight-Bearing, ROM: Range Of Movement.

In terms of exercises allowed, most authors would start range of movement in the sagittal plane after week 2, with muscle strengthening, proprioception, and balance between week 2 and 6, but mostly at week 6 (30%) (Figure 2C). Inversion is usually allowed after week 6. Few studies reported start of different light exercises such as jogging, swimming, and cycling – from the data collected, these can start between weeks 2-6, with more specific sports training after week 6. Return to sports varies considerably between studies and the type of sport and can be anything between 2 and 4 months (Figure 2C).

Rehabilitation protocols for the non-anatomic reconstruction studies are again detailed in table 1 and illustrated in Figure 3. All authors placed their patients in a cast post-operatively for a period of 4-6 weeks and kept them non-weight-bearing between 2-4 weeks (Figure 3A & 3B). Full weight-bearing was then recommended. There was limited information on specific exercises and timing, but range of movement was initiated early usually by week 4 (Figure 3C). Return to sports was suggested from 4 months post-operatively.

Post-operative complications were monitored and are shown in table 2. Three studies did not mention complications, whereas two studies from the anatomic group stated they had no post-operative complications. For the anatomic repair group, the most frequent complications were wound infection (1.7%), and injury to the superficial peroneal nerve which settled within a few months from surgery (1.4%). Ankle instability was reported in 1.5% of cases. For the non-anatomic reconstruction group, ankle arthritis and transient paresthesia along the superficial peroneal nerve were the two most common complications.

Discussion

The ankle is an intricate joint, comprised of the talocrural joint and the tibiofibular syndesmosis, as well as medial and lateral ligamentous complexes that provide static and dynamic stability. Due to the structure of the ankle – the medial malleolus being shorter than the lateral malleolus – the ankle tends to invert, thus making the lateral ligamentous complex more susceptible to injury [32]. The ATFL possess the lowest ultimate load of the three lateral ligaments, which makes it the weakest of the three and thus more likely to be involved in ankle sprains, followed by the CFL [33].

With poor rehabilitation, one in five patients sustaining an ankle sprain will develop chronic instability. There are certain risk factors which can predispose an individual to developing CLAI. Individuals who have a high BMI, generalized ligamentous laxity, females (due to increased laxity of ligaments of the ankle) or those with deformities such as hindfoot varus and midfoot cavus, are at an increased risk [3,5]. Furthermore, athletes who participate in jumping sports such as basketball are also theoretically at risk [34].

Patients with CLAI provide history of inversion injuries and recurrent ankle sprains, often with protected weight bearing [3]. When there is a failure of recovery over a period of 6 weeks and there is mechanical and functional under-performance, it is referred to as chronic ankle instability [35]. Mechanical instability is due to ligament laxity, whereas functional instability is caused by poor posture, neuromuscular and proprioceptive deficits; mechanical and functional instability often overlap [35].

CLAI management can be nonoperative or operative. Patients should ideally be trialed with a minimum of three months of physiotherapy before any operative repair is considered [34]. Although most patients who are managed conservatively will show improvement, those who remain symptomatic for more than six months can be considered for operative repair. The main focus of operative intervention is to improve stability of the ankle joint and to prevent complications including osteoarthritis. Techniques include anatomical repair or reconstruction and non-anatomical reconstruction [6]. The most widely used technique is the one described by Broström in 1964, of suture or transosseous reinsertion of the ATFL and CFL [6]. Since then, many modifications have been described, with or without arthroscopic assistance.

There is no standardized post-operative rehabilitation program following repair or reconstruction for CLAI [36]. Post-operatively, initially there is a period of immobilization which is usually in a cast for anything between 2 and 6 weeks, followed by immobilization in a walking boot, which is also variable. Weight-bearing is again a controversial topic, with some studies suggesting early full weight-bearing, while others advising against it. The restrain from allowing early mobilization and ROM is demonstrated in a systematic review comparing early versus delayed mobilization post-operative protocols for LCL repair [2]. In this study, authors reported higher complication rates and postoperative laxity in the early-mobilized group. However, it was also reported that the post-operative functional outcome, using the AOFAS and Karlsson scores in the early mobilized was improved, making the postoperative laxity finding perhaps not so clinically relevant [2]. The Chinese Society of Sports Medicine has reached a consensus statement, providing clinical guidelines for the operative management of CLCL instability. Among these, they recommend early ROM (mostly dorsiflexion) and partial weightbearing in a brace from day two after surgery, for patients undergoing anatomic repair or reconstruction [37].

From the protocols that were included in this review, more than 80% suggested immobilization in a cast for two weeks with non-weight-bearing. This was then followed usually with a walking boot for four weeks, with initiation of weight-bearing after removal of cast. Patients were started on ROM exercises in the sagittal plane from 15 days following surgery, with inversion allowed after week six. Proprioception and balance exercises were also suggested to start early in the recovery period, between two and six weeks. Depending on the sport, patients were advised to return to sports between two and four months after surgery.

It is very important to understand the basic science of what we are trying to achieve with surgery in CLAI to make correct recommendations in probably an equally important phase of treatment, which is the rehabilitation. Anatomic repair in CLAI aims to restore the bone-ligament interface, a transitional zone which follows Wollf’s law [38]. It is well known that with stress deprivation, mechanical properties of both bone and ligament decrease [39]. Therefore, in order to achieve the optimum repair, some mechanical stimulus is required. If the mechanical environment is not desirable, instead of a bone-ligament transitional zone, there is formation of scar tissue [40].

Neuromuscular rehabilitation is key part of the recovery phase following surgery for CLAI. Both strengthening of the evertor group muscle as well as proprioception exercises are equally important with re-instituting the mechanical properties of the repair. Even with a short period of joint immobilization, functional deconditioning may occur [41]. Therefore, early controlled and supervised ROM is advisable. Proprioceptive training has been a major part of CLAI rehabilitation since Freeman’s publication in 1965 [42]. Its main aim is to reduce symptoms of giving way and reduce function deficits [43].

Based on the evidence presented, the collective presentation of rehabilitation protocols and taking into consideration the evidence-based approach from ESKKA-AFAS Ankle Instability group, the following rehabilitation protocol can be considered after CLAI surgery using anatomic repair (Table 3). In the first two weeks, patients may be immobilized in a cast and non-weight-bearing. After cast removal and inspection of the surgical wound, patients may be placed in a boot and allowed full weight-bearing with the boot on. Patients may be allowed to remove the boot for ROM exercises in the sagittal plane, and light evertor muscle group strengthening exercises may be initiated. If inversion/eversion exercises are to be allowed during this time, these should be supervised and controlled. After six weeks, patients may remove the walking boot and start the early rehabilitation phase, with muscle strengthening exercises of the whole lower limb, proprioception and balance and gait training. During the late rehabilitation phase, between weeks 8-12, the emphasis is on functional, unilateral fully weight-bearing exercises such as plyometrics and jogging. During this phase, functional tests can be used to identify patients ready to progress to the return-to-play phase, usually between 3-4 months post-surgery. Running and sports-specific drills can be started in this phase. Advanced functional tests as well as patients own views on ankle stability should be taken into consideration prior to allowing return-to-sports.

Conclusions

Post-operative rehabilitation protocols following CLAI surgery vary considerably among surgeons. It is very challenging to create a universal rehabilitation protocol based on evidence, simply because very few studies in the literature specifically test their post-operative protocol as their primary outcome measure. With this review article, we attempted to quantify the studies that provide enough information on this subject and create a post-operative rehabilitation protocol following anatomic repair/reconstruction for CLAI, based on basic science and the recommendations given by the ESKKA-AFAS Ankle Instability group. It is clear that this is an area where further high-quality research is required to provide an evidence-based answer.

Author Statements

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

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Citation: Apostolides M, Al-Janabi MM, Southgatec C, Dhinsac BS. Review of Post-Operative Rehabilitation Protocols Following Ankle Lateral Collateral Ligament Repair in Adults. Foot Ankle Stud. 2023; 5(1): 1028.

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