Five-Month Patient Results Following Ankle Ligament Reconstruction

We present the case of a female patient in her early 20’s who was seen for follow up after 5 months of rehabilitation following surgical procedures to address instability in both the medial and lateral sides of her right ankle. This patient reported achieving an excellent outcome, and her subjective sense of significant improvement after rehabilitation was aligned with her physical exam and radiographic evaluation. This case documents the improvements made by the patient during the rehabilitation process and outlines essential steps to be performed by the practitioner in the clinical examination and radiographic follow up after surgery for ankle instability.

Medial ankle instability; lateral ankle instability; Brostrom-Gould procedure; ankle arthroscopy; deltoid ligament repair.

This patient presented for follow up after 5 months of rehabilitation following surgical procedures to address instability in both the medial and lateral sides of her ankle. Her lateral instability was addressed using peroneal tendoscopy, which confirmed and further elucidated the extent of her injury, as well as the Brostrom-Gould procedure to provide lateral stabilization. Her ankle arthroscopy also identified injury to the medial ankle ligament complex, and subsequently open repair of the deltoid ligament was performed to provide medial stabilization. This case documents the improvements made by the patient during the rehabilitation process, and outlines essential steps to be performed by the practitioner in the clinical examination and radiographic follow up after surgery for ankle instability. 

The patient noted significantly improved stability on both sides of the ankle where reconstruction was performed. She described her initial progress as slow during the first few months, but she has since regained near full range of motion, with no residual concerns except for some degree of stiffness, which continued to improve at the time of follow up. She anticipated a return to college softball in the near future with no limitations.

The postoperative rehabilitation exercises performed by the patient included a series of progressive activities. Initially, the patient was immobilized and non-weight bearing for 3 weeks, focusing on pain and edema control. From weeks 3 to 6, the patient progressed to full weight bearing in a walking boot, with a focus on gentle dorsiflexion and good gait mechanics. Between weeks 6 to 12, the patient transitioned from the boot to an aircast, gradually increasing exercise intensity and focusing on achieving full range of motion. From months 3 to 5, the patient progressed from the aircast to an ASO lace-up ankle brace, gradually returning to athletic activities based on functional status. Throughout this period, the patient avoided certain movements, such as inversion, eversion, and plantar flexion beyond resting position, and no running, jumping, or ballistic activities were allowed for 5 months.

The physical examination began with inspection of the ankle, which identified three small incisions used for peroneal tendoscopy that was employed as a diagnostic and therapeutic measure. Also present were incisions over the lateral aspect of the ankle where the Brostrom-Gould procedure was performed and medially for open repair of the medial ligamentous complex. Range of motion testing was performed including dorsiflexion and plantarflexion, demonstrating well-maintained range of motion with near equivalence to the contralateral side. Approximately 10 degrees of dorsiflexion and 30–40 degrees of plantarflexion was observed. Palpation of the ankle joint revealed minimal stiffness on the operated ankle compared to the contralateral side. The anterior drawer test, as well as inversion and eversion tests were performed at about 20 degrees of dorsiflexion, which revealed no obvious laxity in the ankle joint. The patient was able to stand independently and stand on her toes on the operated foot with no reported or apparent instability. The described examination was performed 5 months after the surgery.

Radiographic evaluation of the ankle included an anteroposterior view of the ankle in a standing position. The ankle showed good maintenance of the joint space, with proper alignment of the talus directly beneath the tibia. A titanium suture anchor used during repair of the medial ligament complex was evident on the plain film. A mortise view involving 15–20 degrees of internal rotation of the ankle demonstrated good joint space preservation, proper alignment, and no evidence of arthritis. A lateral view demonstrated no encroachment of the suture anchor onto the cartilage of the subchondral bone.

This patient achieved an excellent outcome at five months following ankle reconstruction and medial and lateral stabilization. Her subjective sense of significant improvement after rehabilitation was aligned with her physical exam and radiographic evaluation, and she was expected to achieve an excellent outcome and return to athletics that year. 

Physical examination of patients with suspected medial ankle instability should begin with bilateral inspection of the ankles in standing, walking, and sitting position.^1,2  Any swelling, hematoma, malalignment, deformity, or scars, as well as asymmetrical planovalgus and abductus upon weight-bearing should be identified and documented by the practitioner. Palpation of the medial and lateral ligaments and joint spaces in addition to the syndesmosis and posterior tibial, peroneal, and Achilles tendons should be performed to assess for gross abnormalities. Of note, tenderness in the medial gutter overlying the deltoid ligament is commonly seen with injury. Tenderness along the posterior tibial tendon may indicate associated posterior tibial tendon insufficiency, which often co-occurs in the setting of medial ankle instability. Eversion and external rotation stress tests can assess stability of the deep and superficial deltoid ligaments, and the anterior drawer test may be used to diagnose anteromedial subluxation.

An important pearl from this case is highlighting the importance of surgical diagnostic confirmation of ankle instability, particularly medial ankle instability. For lateral instability, clinical examination and imaging results are often sufficient to support definitive diagnosis, but for medial instability, while these tools are helpful, full confirmation with arthroscopy is nearly always required. Orthopaedic surgeons as well as sports medicine practitioners, physical therapists, and physical medicine rehabilitation specialists, should be aware that concern for medial instability should lead to referral to a surgeon for arthroscopic confirmation. 

Lateral ankle injuries often present with swelling and ecchymosis, which may or may not persist in chronic cases.³ Palpation of the entire fibula should be performed in addition to areas required to meet Ottawa ankle criteria. Additional physical exam tests should include determination of current weight-bearing ability, as well as special tests including the squeeze test, the external rotation stress test, the anterior drawer test, and the talar tilt test. Of note, these special tests are often clinically helpful but have not been studied extensively.³ Plain radiographs are sufficient for the diagnosis of concomitant fractures in acute ankle sprains.³ Patient selection for radiography in acute injuries should be made in association with the Ottawa ankle rules.⁹ Ankle sprains with persistent pain up to 8 weeks following initial presentation may benefit from MRI to detect soft tissue injury, suspected syndesmosis, or talar dome fractures.^3,4 Peroneal tendoscopy may be performed in refractory cases as a supplementary diagnostic for lateral instability.

As part of the rehabilitation for procedures addressing ankle instability, proprioceptive training may be an acceptable therapeutic modality for patients with chronic lateral ankle instability before surgery. There is evidence to suggest that strength and balance exercises contribute to improved ankle strength, range of motion, and perceived ankle stability in comparison to usual care.^5–7 A systematic review of seven trials involving 3726 participants identified a statistically significant decrease in ankle sprain incidence in patients who had undergone proprioceptive training (RR=0.65, 95% CI 0.55–0.77), including patients with a history of ankle sprain (RR=0.64, 95% CI 0.51–0.81).⁸ One study assessing a 6-week proprioceptive training program in 70 athletes with chronic ankle instability reported no significant difference in pain scores between intervention and control groups; however, further study is warranted as most studies have not identified pain as a primary outcome.⁹ As such, proprioceptive training may have preventive or therapeutic benefit in patients with or at risk for lateral ankle injury.³

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.