What are the potential sequelae and management options for a patient with a history of remote medial and lateral ankle ligament sprains?

Sequelae of Remote Medial and Lateral Ankle Ligament Sprains

Patients with a history of remote medial and lateral ankle ligament sprains face a 5-40% risk of developing chronic ankle instability (CAI) characterized by recurrent sprains, persistent pain, functional instability, and potential progression to ankle osteoarthritis. 1, 2

Long-Term Sequelae

Chronic Ankle Instability (CAI)

• Up to 40% of individuals who sustain a lateral ankle sprain develop CAI, defined as symptoms persisting beyond 12 months including recurrent sprains, episodes of giving way, pain, swelling, limited motion, weakness, and diminished function 2
• After 1 year, 5-33% of patients continue experiencing pain and instability complaints, while 3-34% suffer recurrent sprains 1
• Clinical signs of anterior impingement develop in 25% of patients, with 82% showing radiographic confirmation 1

Mechanical vs. Functional Instability

• Mechanical instability results from demonstrable ligament laxity and altered joint biomechanics, affecting both lateral stability and rotational ankle stability 3
• Functional instability can occur without demonstrable mechanical laxity and is primarily caused by impaired proprioception following the initial injury 3, 4
• Combined medial and lateral ligament involvement creates rotational instability of the talus in the ankle mortise, manifesting as the ankle "giving way" medially when walking on uneven ground or downhill 5

Biomechanical Alterations

• Lateral ankle ligaments play a critical role in transferring movement between leg and foot; their injury disrupts normal ankle mechanics throughout the entire ankle complex 3, 4
• Persistent deficiencies include altered hip joint kinematics, impaired dynamic postural control, and reduced ankle dorsiflexion range of motion 1
• Limited dorsal flexion and reduced proprioception are established risk factors for recurrent injury 1

Progressive Joint Degeneration

• Recurrent ankle sprains increase the risk for subsequent development of osteoarthritis as a long-term sequela 1, 6
• Chronic medial instability may progress to valgus and pronation deformity of the foot 5

Management Algorithm

Initial Assessment of Remote Injuries

• Evaluate current pain level, physical workload, and sports participation level, as these negatively influence recovery and increase recurrence risk 1, 7
• Assess for subjective instability (history of giving way is more diagnostically important than physical examination findings) 3
• Perform anterior drawer test optimally 4-5 days after any acute exacerbation (84% sensitivity, 96% specificity for ligament laxity) 7, 8
• Test for limited dorsiflexion and proprioceptive deficits 1, 7
• For medial instability, look for pain in the anteromedial ankle gutter, valgus/pronation foot deformity correctable by posterior tibial muscle activation, and pain during dorsiflexion 5

First-Line Treatment: Comprehensive Conservative Management

Supervised exercise therapy combined with functional support is the most effective treatment for chronic ankle instability and should be attempted for all patients before considering surgery. 1, 7

Exercise Therapy Protocol

• Implement supervised proprioception and balance training using ankle disk/wobble board exercises 7
• Begin with active dorsiflexion and plantarflexion exercises (3 sets of 10 repetitions), progressing to resistance band exercises in all four directions (3 sets of 10 repetitions) 7
• Include single-leg stance exercises on both stable and unstable surfaces 7
• Strengthen ankle AND hip muscles (hip kinematics are altered in CAI) 1, 7
• Incorporate coordination exercises and functional training specific to the patient's sport or activity demands 7
• Continue the full 4-6 week program even after pain subsides to prevent recurrent injury 7

Functional Support

• Use semirigid or lace-up ankle supports rather than elastic bandages or compression stockings for superior outcomes 7, 9
• Apply functional support for 4-6 weeks during activities to provide stability while allowing movement 7, 9
• Ankle braces show the greatest effects compared to other functional supports in reducing recurrent injuries 9

Manual Therapy

• Combine manual joint mobilization with exercise therapy for superior outcomes compared to exercise therapy alone 1, 7
• Manual mobilization provides short-term increases in ankle dorsiflexion range of motion and decreases pain 1, 7
• Address hypomobility in all joints affected by the original injury, not just the lateral ligaments 4

Second-Line Treatment: Surgical Intervention

Reserve surgical therapy exclusively for patients who have failed comprehensive exercise-based physiotherapy after adequate trial (typically 3-6 months). 1, 7

Surgical Indications

• Persistent mechanical instability with demonstrable ligament laxity despite completed conservative rehabilitation 1, 7
• Continued functional limitations affecting daily activities or sports participation after exhaustive conservative treatment 1
• Professional athletes may be considered for earlier surgical intervention to ensure quicker return to play 1

Surgical Outcomes

• Surgery is superior for decreasing recurrent ankle sprain prevalence, which is important given the osteoarthritis risk 1, 7
• More recent evidence shows significantly better outcomes for ankle activity recovery and instability resolution with surgical treatment 1
• However, 60-70% of individuals respond well to non-surgical programs, making universal surgical treatment unnecessary overtreatment 1
• Surgical complications include longer recovery times, higher incidences of ankle stiffness, and impaired ankle mobility 1
• For combined medial and lateral instability, reconstruction of all involved ligaments at both the medial and lateral ankle is mandatory 5

Prognostic Factors Requiring Attention

• High-level sports participation is an unfavorable prognostic factor for residual complaints 1
• Increased BMI, greater body height, and young male gender increase CAI risk 1
• Inability to complete jumping and landing within 2 weeks after initial injury predicts CAI development 1
• Acute postural balance impairments persisting after the sprain contribute to CAI 1

Critical Pitfalls to Avoid

• Never rely solely on compression bandages without proper functional support (less effective than semirigid braces) 7, 9
• Avoid prolonged immobilization beyond 10 days as it leads to muscle atrophy, joint stiffness, and worse outcomes 1, 9
• Do not discontinue exercises once pain subsides; incomplete rehabilitation dramatically increases recurrence risk 7
• Never neglect proprioceptive training, as impaired proprioception is a major cause of functional instability even without mechanical laxity 3, 4
• Do not treat lateral ankle sprains as isolated ligament injuries; assess and address dysfunction throughout the entire ankle complex 4
• Avoid passive treatment alone; any support device must be combined with active exercise therapy 9
• Do not rush return to full activities before adequate rehabilitation completion 7, 8
• Ultrasound, laser therapy, and electrotherapy have no proven effectiveness and should not be used 1, 8