Porter & Schon: Baxter's The Foot and Ankle in Sport, 2nd ed.

Section 3 - Anatomic Disorders in Sports

Chapter 12 - Nonsurgical treatment of acute and chronic ankle instability

Jon Karlsson,
Mikael Sansone






Acute ligament injuries



Chronic ankle joint instability











Ligament injuries to the lateral ankle ligaments are the most common sports-related injuries. It is estimated that these injuries account for approximately 25% of all sports-related injuries, and the incidence has been shown to be approximately 5600 injuries daily in the United Kingdom and 23,000 in the United States. There are three different strategies in terms of treatment alternatives, that is, cast immobilization, surgical treatment, and functional treatment. Despite the extremely high number of injuries, there are only a few well-conducted studies, and even though many or even most authors advocate early mobilization, there is little scientific evidence to support it. The best studies are summarized in three Cochrane reviews. All three reviews concluded that more high-quality studies are needed.


Acute Ligament Injuries

It has been shown in several studies that early diagnosis, functional treatment, and rehabilitation are the keys to prevention of chronic lateral ligament instability of the ankle. [0010] [0020] [0030] The on-field treatment of fresh ruptures is well known, for example, the rest, ice, compression, and elevation (RICE) principle. The most vulnerable of the lateral ligaments is the anterior talofibular ligament (ATFL; Fig. 12-1, A ), followed by a combined rupture of this ligament and the calcaneofibular ligament (CFL; Fig. 12-1, B ). Other injuries, such as injuries to the medial deltoid ligament are much less frequent and occur with a frequency of less than 10% of all injuries. [0020] [0030] The mechanism of injury to the lateral ligaments is most commonly a plantarflexion inversion injury from landing ( Fig. 12-2 ). Prevention of ligament injuries has gained much attention recently, because it has been shown that approximately 75% of all injuries are recurrences and may thus potentially be prevented, provided a sound protocol is used. [0040] [0050] [0060] Prevention by either coordination training using balance boards or by external support can significantly reduce the number of ligament injuries. Ankle tape and/or functional splinting, proficiently completed by the use of a stirrup splint ( Fig. 12-3 ) is preferred by many athletes. It also has been shown that there is hardly any place for surgical repair after acute ligament ruptures. [0070] [0080] After the recommended treatment using a rehabilitation program with functional treatment, active range of motion exercises, coordination training, peroneal strengthening, and early weight bearing, the functional results are reported as excellent or good in approximately 80% to 90%, whereas 10% to 20% of patients develop secondary symptoms of chronic instability and/or pain. [0090] [0100] Despite this, the treatment of acute lateral ankle ligament injuries is still controversial; some authors have recommended that these injuries be treated with early mobilization, whereas others recommend cast or brace immobilization for 3 to 6 weeks or even early surgical repair. However, even though there is substantial evidence to suggest that early mobilization with active rehabilitation probably is the treatment of choice, there are only a few randomized, controlled studies comparing different treatment modalities.[11] In a recent meta-analysis it was shown that no treatment of lateral ankle ligament ruptures led to an increased number of residual symptoms.[12] Surgical treatment produced better results than functional treatment; however, functional treatment was found to be superior to cast immobilization for 6 weeks. The authors pointed out that surgical treatment was associated with higher costs, as well as increased risk of complications, such as disturbance of wound healing, nerve damage, and possibly infections. In one Cochrane review, it has been shown that functional treatment appears to be the favorable strategy for treating acute ankle ligament injuries when compared with immobilization.[13]Concerning surgical versus nonsurgical treatment for acute injuries of the ligament complex, there is insufficient scientific evidence from randomized, controlled studies to determine the relative effectiveness of surgical and conservative treatment of these injuries, as concluded in a second Cochrane review.[14] This might imply that surgical treatment is not necessarily superior. It also is obvious that in case of failed conservative treatment, late reconstructive procedures can be performed with satisfactory results, even several years after the initial injury. The extent of injury, that is, being grade I, II, or III, might play a role. Two prospective, randomized studies have evaluated the effect of early range of motion training, full early weight bearing, combined with either an ankle stirrup brace or specially designed compression pads. Both studies showed that early functional treatment resulted in significantly shorter sick leave and facilitated earlier return to sports, without the risk of inferior functional results in the long term. One Cochrane review compared different functional treatment strategies for the treatment of acute ankle ligament injuries.[15] It was shown that the use of elastic bandage was correlated with fewer complications than tape but was associated with slower return to work and sport. Semirigid ankle braces produced less ankle laxity than elastic bandages. Lace-up ankle support was more effective in reducing swelling in the short term compared with semirigid braces, elastic bandage, and tape. Thus either semirigid brace or lace-up support probably is preferred.



Figure 12-1  Anterior talofibular ligament (ATFL) (A) and calcaneofibular ligament (CFL) (B). Note ATFL (A) over probe and peroneal tendons running posterior to fibula. Note CFL under probe with peroneal tendons removed.




Figure 12-2  Mechanism of injury for lateral ankle ligament sprain. Position at time of landing is plantarflexion and inversion.




Figure 12-3  Ankle stirrup brace used in rehabilitation after acute and chronic lateral ankle instability.



It appears that early weight training, combined with range of motion training, is beneficial. The long-term prognosis likely is unaffected by early functional training. [0160] [0170] Studies have shown that the best external support is strong evertor muscles. Therefore a combination of isokinetic strength training with proprioception training is most favorable; this combination can shorten rehabilitation and serve as secondary prophylaxis.


Chronic Ankle Joint Instability

It has been shown in several studies that chronic lateral ankle joint instability may develop in approximately 10% to 30% of all patients who sustain an acute injury of the ligaments. [0180] [0190] [0200] The functional instability, irrespective of the mechanical laxity (indeed, there is no constant correlation between the functional instability and the laxity of the joint), does not always produce disability of such grade that surgical reconstruction is needed. Surgical reconstructions have been well described during the last 3 decades and are needed most often in athletes who participate in sports with high demands of stable ankle joints, such as soccer, volleyball, basketball, and all sports involving jumping, sidestepping, turning, and twisting. In the literature, more than 50 different surgical methods have been described to correct chronic ankle joint instability. [0040] [0090] [0100] [0190] The clinical diagnosis initially is based on a thorough clinical assessment, for instance, testing the anterior drawer sign ( Fig. 12-4 ) and the inversion (supination) test ( Fig. 12-5 ). Comparison always must be made with the contralateral ankle. It must be remembered, however, that functional instability is a complex syndrome, and there are several factors at play, such as increased laxity, proprioceptive deficit, and peroneal muscle weakness, either alone or most often in combination. Excessive laxity must be corrected with some kind of surgical procedure, but proprioceptive deficit and muscular weakness can and should be treated by rehabilitation.[20] In the acute phase the main objective is for pain relief, but soon after injury the treatment is aimed at restoring range of motion, and this should be done without any loss of proprioception.


Figure 12-4  Radiograph of ankle demonstrating the subluxation that occurs with an anterior drawer test for lateral ankle instability with anterior talofibular ligament (ATFL) ligamentous laxity.




Figure 12-5  Radiograph of ankle demonstrating the subluxation that occurs with a talar tilt test for lateral ankle instability with calcaneofibular ligament (CFL) ligamentous laxity.



The general principle is that early rehabilitation is the main goal. Immobilization probably should never be used, not even in case of grade III injury. There are several studies in the literature comparing immobilization and early mobilization, and none favor immobilization. In fact, immobilization may result in joint stiffness, muscle atrophy, and loss of proprioception. Some clinicians do use intermittent immobilization for the acute phase of recovery, allowing early mobilization also, but there is no literature documenting this approach.

Rehabilitation can be divided into four phases, that is, the initial phase, early rehabilitation, late rehabilitation, and functional phase. The length of each phase depends much on the individual process of healing. The initial phase is directed at reduction of swelling, most often with compression bandage but also with anti-inflammatory medication, short rest (maximum of 1 to 2 days), ice and elevation, that is, the RICE principle. Sometimes ultrasound and electrotherapy are added, but their effect has not been shown with any convincing evidence. In order not to lose neuromuscular coordination, gait training including early weight bearing and balance board training, is started as early as possible. The initial phase is for the most part the first week after injury. The second phase, that is, weeks 2 to 4, the early rehabilitation phase is aimed at restoring normal range of motion of the ankle with active exercises, and sometimes manual treatment and kinetotherapy are added. Sometimes, gentle passive movement of the ankle joint can be used to increase the range of motion in the sagittal plane. Stretching of the calf muscles also is important during this phase, especially to increase dorsiflexion. The tilt or balance board exercises ( Fig. 12-6 ) are used progressively during this phase, both in terms of time and intensity. The training is aimed first at balance on both legs, and thereafter on one leg (the injured one). Cryotherapy may be continued during this phase, as well as anti-inflammatory medication. During this phase, the athlete is allowed to return to sports activities, provided an external support is used, such as ankle tape or functional bracing.[16]


Figure 12-6  Balance board used in rehabilitation after acute and chronic lateral ankle instability.



The late rehabilitation phase usually is reached around week 5, and the weight-bearing exercises are increased. The main goal of this phase is training of muscular strength, endurance, and neuromuscular function. The final functional phase starts around week 9 and is aimed at return to full sports activity, including jumping, turning, and twisting. External support should be worn during the entire functional phase, and one of the main aims is to reduce the risk of recurrence of the ankle sprain. Supervised programs such as the one described and detailed in Table 12-1 , can be used both after first-time injury and in the case of chronic or recurrent ankle insufficiency.

Table 12-1   -- Rehabilitation Program for Patients Who Have Chronic Instability of the Ankle

Week 1

Range of motion exercises (flexion-extension), for increased blood circulation

3 × 20 repetitions; 3 times/day


Weeks 2-4

Isometric contractions in flexion, extension, and pronation

3 × 10sec; relax for 2-6sec between each contraction

Foot exercises

3 minutes, 2 times/day

Roll a small ball under the foot back and forth and side to side

Wrinkle a towel

Pick up marbles and/or small rocks

Closed chain (weight bearing)

Balance and coordination training

3 × 20 repetitions

Bilateral toe raises

Walk on tiptoe

Jog in place and jog on a soft mattress

Walk along zigzag lines, back and forth, and side to side

The training should be increased from week to week by increasing the tempo and by turning 90/180 degrees

Walk with a surgical tube around the ankle, back and forth, and side to side

Stand on one leg (hold the balance), and when this is easily accomplished, then stand on one leg and flex and extend the knee

Hold for 10-30sec

Stand on one leg, with the eyes closed for 40sec

Increase the balance training by standing on a balance board, first on both feet and thereafter on one foot while flexing and extending the knee simultaneously. The knee should be kept over the ankle as much as possible

Stand on the balance board on one foot; roll a ball around the balance board with the other foot

Use 2-3 balance boards and try to walk from one to another, and keep the balance at the same time

Endurance and strength training

Training with a surgical tube—flexion, extension, and pronation; 3 × 20 repetitions

Increase the training after a while by shortening the surgical tube

Stretch the gastrocnemius and soleus muscles with straight and flexed knee

2 × 15-20sec

Weeks 5-8

Increased strength training:

2 × 20 repetitions

Toe raises in one leg

Step-ups on a box back and forth and from side to side

Step-ups using two boxes, 1m apart

Jog up and down with different steps in between the boxes

Use a weight shoe for heavy weight training of flexion, extension, and pronation

Week 9

Increased coordination training:

Walk on uneven surfaces

Use different kinds of jumps

Jog in intervals

Train with a ball

Weeks 10-12

Add to the program:

Turnings while jogging

Starts, stops, and rushes

Cone training

Slope training

Sports activity, individual and team training

Modified from Karlsson et al., 1991.

A modified program also can be successfully used after acute ligament injuries.




Before any decision is made on surgical treatment in the case of the chronically unstable ankle, a well-planned rehabilitation protocol (such as the one shown in the Table 12-1 ) should be carried out. This protocol is based on isokinetic strength training of the peroneal muscles and proprioceptive training. One study has shown that approximately 50% of patients with chronic ligament insufficiency will regain satisfactory functional stability after a 12-week program.[16] The obvious goal of the rehabilitation program is to decrease the muscle weakness, regain normal or near-normal proprioceptive function, and reestablish the protective reflexes. The last few weeks of the rehabilitation program should concentrate on sports activity. Patients with the highest grade of ligament laxity are those least likely to benefit from this protocol. The program is described in detail in Table 12-1 .



The best way to treat ligament injuries obviously would be to prevent them, and even though this is practically impossible, it is true that prevention can play a significant role. The two main methods that have been proven successful in clinical practice are proprioceptive training and external ankle support. There is, however, little scientific evidence to support the preventive effect of ankle taping. A few studies have shown that balance board training can reduce the risk of ankle ligament injuries, especially in those with previous injuries. [0210] [0220] [0230] However, the effect is either less pronounced or unknown in athletes with previously uninjured ligaments. [0180] [0240] This means that the question whether the first-time ligament injury can be prevented using proprioceptive training is still unanswered. The second measure is external ankle support, either ankle tape or brace. [0250] [0260] [0270] There is little evidence for the use of ankle tape, and the mechanism behind the function of ankle tape is not fully understood. It has been suggested that tape may reduce ankle laxity, limit the extremes of ankle motion, and/or shorten the reaction time of the peroneal muscles, thereby affecting the proprioceptive function of the ligaments and joint capsule around the ankle joint.[28] However, as the tape becomes loose after 15 to 30 minutes of use, it never has been proven how it really works. [0290] [0300] Despite this, ankle tape is extremely common and has been found empirically to be useful. There is more evidence for the use of ankle braces, especially the semirigid Air-stirrup brace. [0310] [0320] [0330] [0340] [0350] [0360] [0370]

Taken together, treating deficits of the proprioceptive system probably is the most important aspect of ankle rehabilitation after lateral sprains. Consideration of improvements in proprioception should be the most important when deciding on a rehabilitation protocol. Moreover, a combination of different exercises and modalities should always be a part of a thorough rehabilitation program. Ankle disk training and/or semirigid ankle brace appear to the effective cornerstones of treatment and prevention. [0380] [0390] [0400] [0410]



Ankle ligament injuries are common, time consuming, and expensive. Most of the injuries are to the lateral ligament complex, and the outcome may be satisfactory, even without treatment. However, nonsurgical treatment of acute ligament injuries may lead to shorter sick leave and faster return to sports activities without risking the functional outcome in the short term and medium term. Well-planned rehabilitation protocol has been shown repeatedly to produce satisfactory outcome in terms of functional stability and return to sports. Despite this, approximately 10% to 30% of all patients will suffer from sequels in the short term and medium term. The symptoms usually are pain and/or functional instability. Studies have shown that approximately 50% of all patients who have chronic ligament insufficiency will recover after having undergone a 12-week rehabilitation program based on strength and proprioceptive training. However, it should be borne in mind that even though rehabilitation programs may work well, prevention is the most important nonsurgical treatment.



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