What are effective therapies for managing recurrent ankle sprain injuries in patients with joint hypermobility due to hypermobile Ehlers-Danlos syndrome (EDS)?

Management of Recurrent Ankle Sprains in Hypermobile EDS

Patients with hypermobile EDS and recurrent ankle sprains require aggressive functional rehabilitation centered on proprioceptive training and semi-rigid ankle bracing, as their underlying ligament laxity and proprioceptive deficits make them particularly vulnerable to chronic ankle instability. 1, 2

Core Treatment Strategy

Functional Support (Mandatory)

• Use a semi-rigid ankle brace continuously during all weight-bearing activities for at least 3-6 months. 1, 3, 4
• Semi-rigid braces are superior to elastic bandages and tape for patients with inherent ligament laxity, providing mechanical stability that hypermobile EDS patients cannot generate through ligamentous structures alone. 1, 4
• Continue prophylactic bracing indefinitely during sports and high-risk activities, as functional support reduces recurrent sprains by 70% (RR 0.30,95% CI 0.21 to 0.43). 4, 5
• Avoid elastic bandages entirely—they provide insufficient support for hypermobile joints. 4

Exercise Therapy Protocol (Essential)

Begin supervised exercise therapy immediately, focusing specifically on proprioceptive retraining rather than just strength. 1, 2

The exercise program must address the fundamental problem in hypermobile EDS: proprioceptive inaccuracy confounds the relationship between muscle strength and function. 2

Specific Exercise Components:

• Proprioceptive exercises are the highest priority—single-leg balance progressions, perturbation training, and movement detection exercises targeting joint position sense. 1, 2
• Neuromuscular control training emphasizing quality of movement over strength alone, as muscle strength without proprioceptive control does not reduce activity limitations in hypermobile EDS. 2
• Coordination exercises integrating visual feedback and closed-chain activities. 1
• Strength training for ankle eversion and dorsiflexion, but only after establishing proprioceptive control. 1, 2
• Sport-specific functional activities once basic proprioception is restored. 1, 3

Supervised training is mandatory—unsupervised programs show inferior outcomes in chronic ankle instability. 4

Balance and coordination training reduces recurrent sprains by 38% (RR 0.62,95% CI 0.51 to 0.76), which is critical given that hypermobile EDS patients have baseline proprioceptive deficits. 1, 5, 2

Manual Therapy Adjunct

• Add manual joint mobilization techniques only in combination with exercise therapy to enhance dorsiflexion range and reduce pain. 1, 3
• Manual therapy alone is insufficient and should never be the primary treatment. 1

Pain Management

• Use NSAIDs for short-term pain control during acute exacerbations if not contraindicated. 1, 3
• Consider acetaminophen as an alternative with potentially fewer side effects. 4
• Neuropathic modulators may be considered for chronic pain, though 47% of EDS patients report adverse effects. 6

Addressing EDS-Specific Risk Factors

Critical Prognostic Factors to Monitor

Hypermobile EDS patients face compounded risk due to inherent ligament laxity (identified as a negative prognostic factor at 8 weeks post-sprain). 1

Monitor these specific indicators of poor prognosis: 1

• Inability to complete jumping and landing within 2 weeks predicts chronic ankle instability
• Persistent postural balance impairments at 8 weeks indicate need for intensified rehabilitation
• Deficiencies in dynamic postural control
• Altered hip joint kinematics

Workload Modification

• Reduce physical workload during rehabilitation, as higher workload increases recurrent sprain risk (RR 1.09) and ankle instability (RR 1.16). 1
• Address BMI if elevated, as this is an independent risk factor for poor outcomes. 1

Occupational Therapy and Bracing

Occupational therapy with joint protection strategies shows 70% improvement rates in EDS patients and should be integrated early. 6

This addresses activity limitations through adaptive techniques and appropriate bracing for daily activities. 6

When to Consider Surgery

Surgery should be reserved only for: 1, 3, 4

• Professional athletes requiring rapid return to competition
• Patients who fail comprehensive functional rehabilitation after 6-8 weeks

Important caveat: Even with surgery showing some benefit (RR 0.72 for preventing recurrent sprains), 60-70% of patients respond to conservative treatment, and hypermobile EDS patients may have compromised tissue quality that limits surgical success. 4

Return to Activity Timeline

• Sedentary work: 2-4 weeks with functional support. 3, 4
• Physically demanding work: 6-8 weeks minimum, with <10kg lifting restrictions for 3-6 weeks. 3
• Sports participation: Begin supervised sport-specific exercises at 3-4 weeks, full return at 6-8 weeks only after passing functional testing. 3, 5
• Continue prophylactic bracing during all sports indefinitely. 3, 5

Critical Pitfalls in Hypermobile EDS

Avoid These Common Errors:

• Never immobilize beyond 10 days—this worsens outcomes and increases stiffness, particularly problematic in EDS patients who already have altered collagen. 1, 3, 4
• Do not rely on RICE protocol alone—insufficient evidence supports this as standalone treatment. 1, 4, 5
• Avoid focusing solely on strength training without proprioceptive work—this is the most critical error in hypermobile EDS, as proprioceptive inaccuracy confounds the strength-function relationship. 2
• Do not allow premature return to sports without completing proprioceptive training—this dramatically increases recurrence risk in already-vulnerable hypermobile joints. 3, 5
• Never use continuous 24-hour bracing—this causes muscle weakness; brace only during weight-bearing activities. 4

Evidence Limitations

The evidence base for hypermobile EDS-specific rehabilitation is extremely limited, with only one poor-quality cohort study and no RCTs specifically addressing this population. 7, 8 However, the general ankle sprain guidelines from the British Journal of Sports Medicine provide level 1-2 evidence that can be adapted for hypermobile EDS patients, with particular emphasis on proprioceptive training given the documented proprioceptive deficits in this population. 1, 2