What is the best treatment for chronic ankle instability?

Best Treatment for Chronic Ankle Instability

Supervised exercise therapy combined with functional support is the most effective treatment for chronic ankle instability, focusing on proprioception, strength, coordination, and functional training. 1

Initial Assessment

• Evaluate for mechanical versus functional instability to guide treatment approach 2
• Assess pain level, physical workload, and sports participation as these factors may negatively influence recovery 1
• Examine for limited dorsal flexion and reduced proprioception, which are risk factors for chronic ankle instability 1
• Consider using the anterior drawer test (84% sensitivity, 96% specificity) to assess ligament laxity, optimally performed 4-5 days post-injury 3

First-Line Treatment: Conservative Management

Functional Support

• Use semirigid or lace-up ankle supports rather than elastic bandages or tape for better outcomes 1
• Apply functional support for 4-6 weeks during activities to provide stability while allowing movement 4
• Avoid prolonged immobilization (>10 days) as it leads to poorer outcomes compared to functional rehabilitation 1

Exercise Therapy

• Implement supervised exercise therapy focusing on:
  • Proprioception and balance training (ankle disk/wobble board exercises) 1, 4
  • Strengthening of ankle and hip muscles 5
  • Coordination exercises 1
  • Functional training specific to patient's activities 1
• Begin with active dorsiflexion and plantarflexion exercises (3 sets of 10 repetitions) 4
• Progress to resistance band exercises in all four directions (3 sets of 10 repetitions) 4
• Include single-leg stance exercises on stable and unstable surfaces 4, 6

Manual Therapy

• Combine manual joint mobilization with exercise therapy for better outcomes than exercise therapy alone 1, 3
• Manual mobilization can provide short-term increases in ankle dorsiflexion range of motion and decrease pain 1

Second-Line Treatment: Surgical Intervention

• Reserve surgical therapy for patients who have not responded to comprehensive exercise-based physiotherapy 1, 3
• Surgery may be superior for decreasing the prevalence of recurrent ankle sprains 1
• Surgical treatment has shown better outcomes in terms of recovery of ankle activity and instability compared to functional treatment alone 1
• Be aware of potential complications including longer recovery times, ankle stiffness, and impaired ankle mobility following surgery 1

Treatment Selection Algorithm

1. For mild to moderate instability with primarily functional deficits:

   • Begin with 4-6 weeks of supervised exercise therapy and functional support 1, 4
   • Focus on foot and ankle muscle strengthening exercises which show highest probability of improvement 6
   • Include hip-strengthening exercises which have demonstrated positive effects on strength, balance, and function 5

2. For severe instability or cases with significant mechanical component:

   • Trial conservative management first for 8-12 weeks 3, 7
   • If no improvement after comprehensive rehabilitation, consider surgical referral 1, 7
   • Surgical options may be particularly beneficial for patients with recurrent sprains despite appropriate rehabilitation 1

3. For athletes or high-demand individuals:

   • Implement more intensive proprioceptive and balance training 8
   • Consider longer use of functional support during high-risk activities 4
   • Focus on sport-specific exercises in the later phases of rehabilitation 4

Common Pitfalls to Avoid

• Discontinuing exercises once pain subsides increases risk of recurrent injury; complete the full 4-6 week program 4
• Relying solely on compression bandages without proper functional support is less effective 1, 4
• Returning to full activities too quickly before adequate rehabilitation can lead to recurrent injury 3
• Neglecting proprioceptive training increases risk of developing chronic ankle instability 3
• Overlooking hip muscle strengthening, which plays an important role in ankle stability 5