Return to Play Following

A n k l e Sp r a i n an d L a t e r a l
Ligament Reconstruction
Scott B. Shawen, MDa,b,*, Theodora Dworak, MD
c
,
Robert B. Anderson, MDb

KEYWORDS
 Return to play  Ankle sprain  Ankle stabilization surgery  Ankle instability
 Syndesmosis injury

KEY POINTS
 Ankle sprains are the most common musculoskeletal injury in athletes.
 Treatment should consist of activity modification and pain control with transition to early
range of motion and functional rehabilitation to allow for quicker return to function and
decreased reinjury rates.
 Patients with functional or mechanical instability that do not improve with rehabilitation or
preventative measures should be considered for operative reconstruction of the lateral lig-
aments to prevent chronic degeneration, dysfunction, or deformity.
 Concurrent findings, such as osteochondral injury, peroneal tendon injury, loose bodies,
impingement, and tarsal coalition, should be considered in patients with continued ankle
pain. Advanced imaging with MRI and arthroscopy are tools to further evaluate these con-
current injuries.
 Athletes should return to play only after range of motion and strength of the injured ex-
tremity has returned. Athletes with history of prior ankle sprain should be prophylactically
treated with either taping or bracing during participation in sport to prevent further and re-
petitive injury.

INTRODUCTION

Ankle sprains and lateral ankle instability are exceedingly common injuries. However,
the incidence of injury varies depending on the activity level of the studied population.
These injuries occur most often during axial loading of the foot with inversion stress
and a plantar-flexed foot.1 Subsequent repeat ankle sprain or improper rehabilitation

The views expressed in this article are those of the author and do not reflect the official policy
of the Department of Army/Navy/Air Force, Department of Defense, or US Government.
a
Uniformed Services University of the Health Sciences, Bethesda, MD, USA; b OrthoCarolina
Foot & Ankle Institute, 2001 Vail Avenue, Suite 200B, Charlotte, NC 28207, USA;
c
Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901
Rockville Pike, Bethesda, MD 20889, USA
* Corresponding author.
E-mail address: scott.b.shawen@gmail.com

Clin Sports Med - (2016) -–-

http://dx.doi.org/10.1016/j.csm.2016.05.012 sportsmed.theclinics.com
0278-5919/16/$ – see front matter Published by Elsevier Inc.
2 Shawen et al

following initial injury can result in lateral ankle instability in up to 20% of patients.2–4
Instability is either functional or mechanical in nature. Functional lateral ankle insta-
bility is often subjective without physical laxity of the joint and is a result of deficits
in proprioception, postural control, or muscle strength.3 Mechanical lateral ankle
instability results as a structural deficiency in the surrounding ligaments of the ankle
leading to increased laxity and unnecessary motion about the joint.3 Both mechanical
and functional ankle instability, if improperly managed, can put athletes at risk of
further injury. Injury to the syndesmosis, sometimes referred to as high ankle sprain,
is an additional form of ankle instability that is often more severe in extent and
outcome.5 Disruption of the anatomic structures of the syndesmosis can also lead
to mechanical ankle instability, pain, and delayed recovery.
With the frequency of ankle sprains, lateral ligament instability, and syndesmotic in-
juries, it is essential to understand the underlying cause and risk factors for these con-
ditions. Greater understanding allows for proper prevention, diagnoses, and treatment
of athletes with these conditions. Appropriate initial treatment is critical to returning
athletes to sport and preventing long-term morbidity. This article investigates the
epidemiology, anatomy, diagnosis, and management of patients with ankles sprains
and lateral ankle injuries.

EPIDEMIOLOGY AND RISK FACTORS

The incidence rate of ankle sprains is 2.15 per 1000 person-years in the general pop-
ulation of the United States.6 However, incidence rates increase with exposure to
sport occurring at a rate of 3.4 injuries per 1000 athlete exposures in the National
Basketball Association and 2.06 per 1000 athlete-hours in soccer players.7,8 Similarly,
lateral ankle sprain and syndesmotic sprain are the most common foot and ankle in-
juries in collegiate football players occurring in 31% and 15% of players, respec-
tively.9 Although ankle injury is more common in collision sports, ankle sprains are
frequently reported as the most common injury regardless of the type of athletic
exposure.7–12
The incidence of ankle sprains also varies with demographics. Ankle sprains are
more common in younger age groups, 15 to 19 years of age, and specifically males.6
Some studies have shown an increased incidence in female athletes, whereas others
demonstrate increased incidence in males.6,13 The true difference in gender may be
sport specific. Several studies have shown increased frequency of ankle sprains in fe-
male basketball players compared with their male counterparts or when compared
with their female colleagues who participate in other sports, such as lacrosse, field
hockey, volleyball, and soccer.14–16
Multiple studies have attempted to identify specific anatomic and physical risk fac-
tors for ankles sprains and chronic ankle instability. There is evidence to suggest
increased frequency of ankle sprains in athletes with increasing body mass index
and lower physical activity.17,18 Some authors suggest athletes with muscle imbal-
ances have an increased risk for ankle instability, whereas others have found signifi-
cant risk with how the calcaneus moves during gait.17,18 Poor postural stability has
also been identified as a possible risk factor.19
Previous authors support the theory that some of these risks can be modified,
whereas others are fundamental to the athlete and cannot be changed. Modifiable
risk factors for ankle sprains include body mass index; use of preventative therapies,
such as braces or tape; strengthening; participation in sport; player positions; and
even playing surfaces and equipment.9,13,20,21 Nonmodifiable risk factors include de-
mographic factors, such as age, gender, and race, and anatomic factors, such as limb
 Ankle Sprain and Lateral Ligament Reconstruction 3

alignment, anatomic variation, and joint laxity.13,18,19 However, the true relevance of
these risk factors, modifiable or not, are difficult to discern because large systematic
reviews evaluating such factors have poor consensus.22,23
Identifying risk factors and demographic contributions for syndesmosis injury in ath-
letes has been more difficult with limited studies showing significance for specific risk
factors. However, vertical jump distance and balance may play a role.12 Additionally, in
football, player position has been shown to have different rates of ankle injury.9

PATHOANATOMY

Unlike other joints in the body the tibiotalar joint is inherently stable given the comple-
menting structures of the medial malleolus of the tibia and the medial shoulder of the
talus. This structural stability continues on the lateral side with lateral malleolus of
the fibula; however, the fibula is able to change positions to accommodate motion
of the talus during ankle movement.24 The boney constraints of the medial and lateral
aspects of the ankle joint provide significant stability in the coronal plane attributing to
the predominant motion of the tibiotalar joint being plantar and dorsiflexion in the
sagittal plane.
The relationship of the fibula to the tibia is maintained by the ligamentous structures
of the syndesmosis. These ligamentous structures include the anterior inferior tibiofib-
ular ligament, posterior inferior tibiofibular ligament, inferior transverse ligament, inter-
osseous ligament, and interosseous membrane. These structures allow for an
increase in the intermalleolar distance during the swing phase of gait to accommodate
for the dorsiflexion and clearance of the foot, and the distance decreases during the
stance phase to provide stability to the ankle joint.24 Recurrent injury to the syndesmo-
sis in professional athletes has been reported to result in tibiofibular synostosis and/or
heterotopic ossification leading to pain with impact activities and restricted range of
motion.12,24
The surrounding ligamentous support of the ankle joint is also crucial to adding sta-
bility to the joint. The anterior talofibular ligament (ATFL) prevents anterior translation
of the talus relative to the tibia and is often the first structure injured during an ankle
sprain.25 The calcaneofibular ligament (CFL) resists inversion of talus relative to the
tibia but also provides stability to the subtalar joint; it is the second structure injured
during an ankle sprain.25 The posterior talofibular ligament prevents posterior transla-
tion of the talus relative to the tibia when the ankle is in neutral plantar flexion, but is
rarely injured during inversion injury to the ankle.26
The superior aspect of the anterior lateral joint capsule is often overlooked as a
structure that provides stability to the ankle. However, cadaveric studies have demon-
strated that disruption of the anterior lateral joint capsule results in 18% of joint
displacement in grade I ankle sprains and up to 33% of displacement in grade III in-
juries.25 Similarly, the stabilization provided by the capsule is even more critical in
chronic lateral ligament laxity.27
The musculature surrounding the ankle joint provides active stability to the ankle
joint during motion. Specifically peroneus longus and brevis assist with counteracting
inversion forces during injury. Injury to the peroneal tendons in patients with chronic
ankle instability is thought to be the result of repetitive compression of the tendons
along the posterior aspect of the fibula.28 In addition, there is a risk of tendon sublux-
ation given the orientation of fibers of the CFL and superior peroneal retinaculum.
The histology of acutely injured lateral ankle ligaments is not unlike other areas of
anatomy. Broström and Sundelin27 reported a predominance of hemorrhage and
fibrous exudate exists immediately following injury, which is replaced by granulocytic
4 Shawen et al

infiltration, mononuclear cells, and fibroblast a few days following injury. Chronically
lax ligaments, even though previously injured, are able to remodel into parallel
collagen bundles not unlike normal ligamentous structure.27 This is in contrast to
the degeneration that occurs in chronically injured tendons, such as the Achilles.

PATIENT EVALUATION

Critical to the treatment of ankle sprains and lateral ankle instability is patient evalua-
tion through history and physical examination. Patients often present with difficulty
weight bearing, lateral ankle pain, swelling, and ecchymosis.29 Clinicians should differ-
entiate a first-time ankle sprain from recurrent injury and discuss the mechanism of
injury. Patients often report the sensation of their ankle giving way or describe multiple
episodes of instability.3 Symptoms of instability should also be discussed to determine
functional from mechanical instability because treatment varies.3 Patient level of func-
tion and athletic participation may also affect treatment and rehabilitation.
The physical examination is fundamental in the evaluation of patients with ankle
sprains and lateral ankle instability. As with any patient with foot or ankle symptoms,
evaluation of the hind foot alignment for planovalgus or cavovarus deformity should
not be overlooked. Patients with a cavus deformity are more likely to develop attenu-
ated lateral ligaments and subsequent lateral ankle instability.30 These patients should
be addressed with caution because the underlying cause of the ankle problem is likely
from their malalignment and traditional soft tissue reconstruction options are likely to
fail. The ability to weight bear following injury and the specific anatomic location of
pain on examination can assist with determining the need for imaging using the
Ottawa ankle rules.29 Range of motion and gait are used to discern the acuity and
severity of the injury at the time of evaluation.
Provocative tests for determining functional from mechanical instability include talar
tilt, anterior drawer, squeeze, and external rotation stress tests. These tests may be
less useful in the acute setting because of guarding on the patient’s part. Talar tilt eval-
uates the integrity of the CFL and is performed with inversion stress to the lateral
ankle.1 Anterior drawer evaluates ATFL and is performed by directing and anterior
force to the talus while stabilizing the tibia.31 It is likely to be positive in patients
with chronic injury as evident by the suction sign.1,2 Anterior lateral drawer test is per-
formed similarly to the traditional test only it allows for rotation of the talus about the
intact medial ankle ligaments. It may identify the more subtle injury to the ATFL
because detection of incompetence of that structure is not limited by the deltoid.31
Squeeze test is used if there is suspicion for a syndesmotic injury; patients report ankle
pain with squeezing of the fibula against the tibia at the mid-calf level.5 External rota-
tion stress test also evaluates the syndesmosis; the proximal tibia is stabilized and an
external rotational force is applied to the foot and is considered positive if patients
complain of pain.1,5

IMAGING

Should history and physical examination prompt further evaluation with imaging, clini-
cians should start with weight bearing standard three-view radiographs of the ankle
and foot.29 Additional anteroposterior and lateral radiographs of the leg are also critical
to rule out syndesmotic injury or a high fibula fracture.5 Although most patients with
ankle sprains are likely to have normal radiographs, they should be used to rule out
fracture or dislocation in the acute setting, and a tarsal coalition often associated
with recurrent ankle sprains.29,32 Stress radiographs or fluoroscopic imaging evalu-
ating talar tilt and anterior talar translation can help evaluate the integrity of the lateral
 Ankle Sprain and Lateral Ligament Reconstruction 5

ankle ligaments. According to Lee and colleagues,33 disruption of the posterior talo-
fibular ligament is likely to be the only significant variable contributing to anterior talar
translation; talar tilt on stress radiographs is affected by not only the integrity to the
ATFL but also age and gender of the patient. Given the variability of stress views to
the degree of ligamentous injury many authors question their clinical utility. However,
knowledge of the extent of the lateral ankle instability on preoperative radiographs
(particularly when asymmetric) provides assistance with anatomic reconstruction via
intraoperative radiographic evaluation and can assist with radiographic evaluation
postoperatively.34
Because radiographs are often of minimal benefit in patients with lateral ankle insta-
bility, MRI is frequently prescribed. MRI should be reserved for patients with chronic
lateral ankle instability who fail a course of initial conservative treatment or who
have unexplained pain in association with the ligament disorder. Although MRI of
the ankle has excellent intraobserver reliability and positive predictive value for injury
to the ATLF, its sensitivity is low for imaging, between 76% and 84%.35 These limita-
tions continue when evaluating for concomitant injuries of the ankle. Although MRI
may identify associated pathology, such as osteochondral lesions, peroneal tendon
tears, and loose bodies, the sensitivity of identifying such is still lower than with
arthroscopy.36,37 Clinicians should be systematic in evaluating the ankle joint during
arthroscopy so as not to overlook these subtle concomitant injuries.
Ultrasound has recently become more widely used in the evaluation of musculoskel-
etal injuries. This modality can demonstrate increased elongation of the ATFL with an
anterior drawer applied.38 Similarly, syndesmotic injuries can also be evaluated with
ultrasound techniques. Injury of the interosseous membrane is suspected if there is
disruption of the normal linear hyperechoic structure between the tibia and fibula.5 Un-
fortunately, ultrasound remains operator dependent with difficulty in reproducibility
and interpretation.

PREVENTATIVE TREATMENT

Preventative treatment of ankle sprains and subsequent lateral ankle instability begins
with identifying modifiable risk factors. Deficiencies in balance are addressed with sin-
gle limb balance training and neuromuscluar control.39,40 This training seems to be
most useful at decreasing rates of ankle injury in patients that are at increased risk
of injury, such as those with increased body mass index or those with history of pre-
vious injury.39,40 Addressing deficiencies in ankle range of motion and muscle strength
of the lower extremity has lower levels of evidence for injury prevention, but can easily
be added to an athlete’s training.39
Some authors have advocated the use of bracing to prevent ankle sprains. These
braces provide additional lateral and medial mechanical support.15 Although bracing
had been shown to be useful in selective sports it is probably most useful in patients
with recurrent ankle sprains rather than prophylaxis.10,39
Similar to bracing is the practice of taping. Taping is thought to assist the athlete by
making up for the deficit in proprioception following the initial ankle injury. Although
experimental models have difficulty validating this theory,41 taping has proved to be
effective in decreasing ankle injury in patients with previous injury and should be
considered as preventative treatment.10,39

NONPHARMACOLOGIC TREATMENT

First time ankle sprains should be treated similarly to other musculoskeletal injuries us-
ing the PRICE acronym: protection, rest, ice, compression, and elevation.39 Following
6 Shawen et al

improvement of initial symptoms, patients should progress to weight bearing as toler-

ated. Early range of motion has been shown to have improved functional outcomes
and has equal pain scores compared with those treated with prolonged periods of
immobilization.42,43 An elastic compression wrap with an air stirrup type of brace
can allow for a return to baseline walking speed faster than treatment with a brace
or wrap alone.44 Patients with low-grade syndesmotic injuries should be immobilized
and institute protected weight bearing for a longer period of time, perhaps 3 to
4 weeks, as compared with athletes with a simple low-grade inversion ankle sprain.45
Physical therapy and rehabilitation are critical in preventing functional instability and
decreasing a patient’s risk for recurrent injury. Supervised physical therapy has better
outcomes with regard to strength and proprioception for ankle sprains in the short
term; however, improvement in reinjury rates and long-term functional results are
similar to home therapy plans.46 Consideration should be given to an evaluation
with MRI for those patients with protracted functional instability or pain.

PHARMACOLOGIC TREATMENT OPTIONS

In addition to nonpharmacologic treatment, pharmacologic treatment assists with

pain control, inflammation, and swelling. These medications should be used in
conjunction with nonpharmacologic treatments. Nonsteroidal anti-inflammatory drugs
in the form of cyclooxygenase inhibitors or specific cyclooxygenase-2 inhibitors, such
as celecoxib are more effective than placebo at treating pain in patients with lateral
ankle sprain.47 Topical nonsteroidal anti-inflammatory drugs, such as diclofenac
diethylamine 2.32% gel, have also been shown to be safe and effective for ankle
sprains.48 Acetaminophen extended release is as useful as ibuprofen with minimal
side effects.49 New treatments with platelet-rich plasma injections have shown mini-
mal improvement in randomized studies and are likely of limited use in lateral ankle
sprains.50

SURGICAL TREATMENT

An acute ankle sprain is not a typical indication for surgical intervention because im-
mediate reconstruction or repair of the lateral ligaments has not shown to provide any
improvement in long-term functional outcomes.51 On the contrary, those patients that
develop chronic instability are unlikely to have improvement in their symptoms without
surgical intervention.4 The increased risk for developing posttraumatic arthritis in
these patients is suggested but remains in question.4 It is our belief that patients
who have failed formal rehabilitation of prior ankle sprains and have evidence for me-
chanical instability benefit from lateral ligament reconstruction.
Surgical treatment of lateral ankle instability varies depending on the specific type of
lateral ligament reconstruction. The goal is to provide a stable ankle no matter what
procedure is performed. Broström2 described his technique for direct repair of the
lateral ankle ligaments (ATFL only) with suture in 1966. Gould augmented this tech-
nique in 1980 with advancement of the extensor retinaculum and the procedure has
been further modified by repairing both the ATFL and CFL back to the fibula using
bone tunnels or suture anchors.52,53 The modified Broström-Gould procedure pro-
vides an anatomic reconstruction of the lateral ligaments and is the most widely used.
The Broström-Gould techniques may fail to provide adequate stability in those pa-
tients found to have poor soft tissue envelope because of chronic injury or underlying
cavovarus. Therefore additional reconstruction techniques have been described and
often use modifications of the local anatomy to provide stability (Fig. 1). For example,
Evans54 described in 1953 a transposition of the peroneus brevis tendon through a
 Ankle Sprain and Lateral Ligament Reconstruction 7

Fig. 1. Augmented reconstructions. (A) The Evans reconstruction uses a tenodesis of the per-
oneus brevis tendon to the fibula. (B) The Watson-Jones procedure reconstructs the ATFL in
addition to tenodesis of the peroneus brevis tendon. (C) The Chrisman-Snook procedure
uses a split peroneus brevis tendon to reconstruct the ATFL and CFL. (D) The procedure
developed by Colville also uses a split peroneus brevis tendon to reconstruct the ATFL and
CFL in an anatomic fashion without limiting subtalar motion. (E) The Anderson procedure
uses the plantaris tendon to anatomically reconstruct both lateral ligaments without
limiting subtalar motion. (F) The Sjølin technique uses periosteal flaps to augment an
anatomic repair. (From Colville MR. Surgical treatment of the unstable ankle. J Am Acad Or-
thop Surg 1998;6:374; with permission.)

bone tunnel in the distal fibula followed by reattachment of the tendon to its remaining
distal portion. Today this procedure is more commonly done, as described by Girard
and colleagues,55 using an anterior slip of the peroneus brevis as a checkrein, there-
fore avoiding complete disruption of the tendon and preserving most tendon function
(Fig. 2). Similarly, the original Chrisman-Snook procedure or its modifications use an
anterior slip of the peroneus brevis or allograft tendon grafts. In addition to rerouting

Fig. 2. The end-to-end repair of the calcaneofibular and anterior talofibular ligaments is
achieved with nonabsorbable suture. The split tendon is rerouted through a drill hole in
the distal fibula and is secured at both ends. (From Girard P, Anderson RB, Davis WH,
et al. Clinical evaluation of the modified Broström-Evans procedure to restore ankle stability.
Foot Ankle Int 1999;20(4):246–52.)
8 Shawen et al

the tendon through the distal fibula, it is routed through a second bone tunnel in the
calcaneus to recreate the CFL. In the original description the tendon is further sutured
back to itself near the anterolateral ankle.56
There are several other procedures described to address lateral ankle instability.
Given the dynamic stability the peroneal tendons provide, there is a theoretical reason
to avoid violating them during reconstruction. As such, authors have described using
extensor tendon from the fourth toe or semitendinosus allograft.57,58 As an option to
soft tissue augmentation the repair can also use suture tape with reported good re-
sults.59 Patients who have lateral ankle instability in the setting of moderate-severe
varus malalignment may benefit from supramalleolar or lateralizing calcaneal osteot-
omies, in addition to a more robust and augmented soft tissue reconstruction.60
Unstable syndesmotic injuries have traditionally been treated with rigid internal stabi-
lization to achieve and maintain anatomic alignment, thus allowing for proper healing
while preventing further injury. There has been controversy surrounding the type, size,
and extent of screw fixation. Cadaveric studies have failed to show any significant differ-
ence between 3.5-mm and 4.5-mm screws or quadricortical versus tricortical fixation.61
Furthermore, the syndesmosis is a true and functional joint, with inherent motion occur-
ring between the fibula and tibia. As a result, implant removal has been advocated before
returning the athlete to full activity to avoid the potential complications of screw
breakage.45 However, more recent clinical data refute this assumption, showing no cor-
relation between screw breakage and pain.62 To avoid this situation and to provide more
physiologic, flexible fixation, there is a recent trend to treat these injuries with a modified
suture button construct. Studies have shown little difference between modified suture
construct for syndesmotic fixation versus screw fixation in a cadaveric model.63 How-
ever, location of the fixation does seem to be important because there is increased
displacement if fixation is placed too close to the tibial plafond.64

SURGICAL OUTCOMES, REHABILITATION, AND RETURN TO PLAY

Surgical outcomes for lateral ligament reconstruction are favorable. Maffulli and col-
leagues65 published long-term results on athletes following a Broström procedure
and found 58% were able to return to their preinjury level of sport, 16% were still
competing but at a lower level, and 26% had discontinued sport participation but
were still physically active. Similarly, long-term results of arthroscopic-assisted Bros-
tröm-Gould are also positive. In Nery and colleagues’s66 cohort of 38 patients, only
two patients had low functional scores. There was no difference in functional score be-
tween patients that had microfracture for osteochondral lesions at the time of surgery
and those who had lateral ligament reconstruction alone after a follow-up of 9.8 years.
Return to play following syndesmosis ankle injury is often longer and of greater vari-
ability compared with lateral ankle sprains.5 However, the outcome for patients under-
going treatment with greater than 1 year of syndesmotic instability are promising. Ryan
and Rodriguez67 showed that at 2 years follow-up 11 of 14 patients were able to return
to their preinjury level of competition after treatment with arthroscopic debridement of
the syndesmosis and fixation. As expected, the more severe the syndesmotic injury,
the longer a player is unable to play. Miller and colleagues5 found a positive correlation
between the height of the syndesmotic injury and the number of days to return to play
with the average time out of football being 15.5 days.

COMPLICATIONS

Although serious complications for lateral ligament reconstructions are rare, no

surgery is without risk. Complications include infection, osteoarthritis, neuroma,
 Ankle Sprain and Lateral Ligament Reconstruction 9

disathesias, and recurrence of instabilty.2 Complications for operatively treated syn-

desmosis injuries are similar to lateral ligament reconstruction. However, unique to
syndesmotic operative treatment is obtaining an accurate reduction of the joint, which
is difficult to evaluate intraoperatively, especially with fluoroscopy.68 As a result, mal-
reduction of the syndesmosis has been reported in up to 52% of cases. Even evalu-
ation of the reduction on computed tomography can be inconsistent depending on the
method of measurements used.68,69 In the end, the morbidity of having a malreduced
syndesmosis is questioned because implants are routinely removed or break allowing
the fibula to return to its original anatomic location.

SUMMARY

Ankle sprains are an exceedingly common injury in an athletic population. Modifiable

risk factors for injury need to be identified and addressed before engaging in athletic
activity. Acute ankle injury treatment includes activity modification and pain control
with focus on returning to weight bearing and range of motion when symptoms allow.
Physical therapy focusing on strengthening and proprioception is the mainstay of re-
covery. When patients return to baseline, it is recommended that they return to the
athletic field with external support in the form of a brace or tape apparatus to prevent
further injury. Athletes with dysfunction that fail to respond to physical therapy or have
recurrent injuries are indicated for lateral ligament reconstruction.

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