In a patient three months after a Broström‑Gould lateral ankle ligament repair who sustains a grade 1 ankle sprain and has generalized joint hypermobility with a persistent ‘dirty’ sensation in the ankle, how should the injury be managed?

Management of Post-Broström-Gould Grade 1 Sprain in a Patient with Generalized Joint Hypermobility

In a patient three months post-Broström-Gould repair who sustains a grade 1 sprain and has generalized joint hypermobility with persistent subjective instability, immediately apply a semi-rigid or lace-up ankle brace for 4–6 weeks, initiate supervised exercise therapy within 48–72 hours focusing on proprioception and neuromuscular control, and obtain stress radiographs of both ankles to assess mechanical stability before considering revision surgery. 1, 2

Immediate Mechanical Support and Protection

• Apply a semi-rigid or lace-up ankle brace immediately and continue for 4–6 weeks; this is superior to elastic bandages and provides functional stability while allowing protected movement. 1
• The brace protects the healing ligament repair while preventing excessive stress that could compromise the surgical reconstruction. 1
• Avoid rigid immobilization beyond 10 days if used for acute pain control, as prolonged immobilization leads to decreased range of motion, chronic pain, and joint instability without demonstrated benefit. 1

Early Supervised Rehabilitation (Critical for Hypermobility)

• Initiate supervised physical therapy within 48–72 hours of the re-injury; this has Level 1 evidence for reducing recurrent sprains by approximately 63% and is particularly crucial in patients with generalized joint hypermobility who have inherent ligamentous laxity. 1, 3
• The rehabilitation program must be supervised rather than home-based, as supervised protocols produce superior outcomes in patients with joint hypermobility who require specialized neuromuscular retraining. 1, 4

Specific Exercise Protocol for Post-Surgical Hypermobile Patients

• Proprioception training is the cornerstone of rehabilitation in hypermobile patients and should include ankle disk/wobble board exercises progressing from stable to unstable surfaces. 3
• Begin with active dorsiflexion and plantarflexion exercises (3 sets of 10 repetitions), then progress to resistance band exercises in all four directions (3 sets of 10 repetitions). 3
• Include single-leg stance exercises on both stable and unstable surfaces to restore dynamic postural control, which is commonly impaired in patients with chronic ankle instability. 3
• Hip strengthening and coordination exercises are essential, as altered hip joint kinematics are persistent deficiencies in patients with chronic ankle instability. 3
• Progress to sport-specific functional drills only after achieving adequate proprioceptive control and strength. 1

Assessment of Mechanical Stability

• Obtain stress radiographs (varus talar tilt and anterior drawer views) of both ankles at 3–5 days post-injury once swelling subsides to accurately assess whether the surgical repair remains mechanically intact. 1, 2
• The critical decision point is whether the contralateral uninjured ankle shows normal stress test parameters; if the contralateral ankle demonstrates normal varus talar tilt and anterior talar translation, the modified Broström procedure can succeed even in patients with generalized joint hypermobility. 2
• If stress radiographs show mechanical instability exceeding the contralateral side, this suggests failure of the surgical repair and warrants orthopedic referral for consideration of revision surgery or augmentation. 2
• The "dirty" or "not clean" sensation reported by the patient may represent either subjective functional instability (proprioceptive deficit without mechanical laxity) or true mechanical instability (ligament repair failure); stress radiographs distinguish between these two entities. 3, 2

Pain Management

• Topical NSAIDs (with or without menthol gel) are first-line for pain control, as they reduce pain, improve physical function, and increase treatment satisfaction. 1
• If topical therapy is insufficient, prescribe oral NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) to reduce pain and swelling and accelerate return to activity. 1
• Avoid opioids, as they cause significantly more adverse effects without superior pain relief compared to NSAIDs. 1

Advanced Imaging if Symptoms Persist

• If pain persists beyond 1–3 weeks despite appropriate functional treatment (brace + supervised exercise), obtain a non-contrast MRI to assess for radiographically occult complications including osteochondral lesions, syndesmotic injury, peroneal tendon pathology, or incomplete healing of the ligament repair. 1
• MRI is the preferred advanced imaging modality when plain radiographs and stress views are normal or nondiagnostic but clinical symptoms persist. 1

Orthopedic Referral Criteria

• Immediate orthopedic referral is indicated if:

  • Stress radiographs demonstrate mechanical instability exceeding the contralateral ankle, suggesting surgical repair failure. 2
  • MRI reveals osteochondral injury, significant peroneal tendon pathology, or other structural complications. 1
  • The patient fails to improve after 6–8 weeks of appropriate functional treatment (brace + supervised exercise therapy). 1, 3

• Delayed orthopedic referral (after conservative trial) is appropriate if:

  • The patient develops recurrent sprains or functional instability after completing a supervised rehabilitation program, indicating chronic ankle instability. 3
  • Persistent subjective instability continues despite normal stress radiographs and completion of 4–6 weeks of supervised proprioceptive training. 3

Special Considerations for Generalized Joint Hypermobility

• Generalized joint hypermobility is NOT an absolute contraindication to the modified Broström procedure if the contralateral uninjured ankle demonstrates normal varus talar tilt and anterior talar translation on stress tests. 2
• In a study of 32 patients with chronic ankle instability and generalized joint hypermobility who underwent modified Broström procedure, the Karlsson-Peterson ankle score improved significantly from 63.6 to 90.4 at mean 27.4-month follow-up, with 26 of 32 patients satisfied or very satisfied. 2
• Nine patients sustained ankle sprains after surgery (6 mild), but only 3 had mechanical instability on stress radiographs, and none required reoperation. 2
• The key prognostic factor is the stability of the contralateral ankle, not the presence of generalized joint hypermobility per se. 2
• Patients with generalized joint hypermobility require more intensive and prolonged proprioceptive training than patients without hypermobility, as their inherent ligamentous laxity demands superior neuromuscular compensation. 4

Prevention of Chronic Ankle Instability

• Up to 40% of patients develop chronic ankle instability after ankle sprains, and 5–46% report long-term pain at 1–4 years. 3
• The most important modifiable risk factor is inadequate rehabilitation, particularly failure to start supervised exercise therapy within 48–72 hours and prolonged immobilization. 3
• Continue wearing the ankle brace during high-risk activities even after completing the 4–6 week rehabilitation program, as external ankle support reduces recurrent sprains by 47% in high-risk activities. 5
• Incorporate ongoing proprioceptive exercises into regular training activities indefinitely, as this has high cost-benefit ratios due to reduced recurrence rates. 1

Common Pitfalls in This Clinical Scenario

• Delaying supervised exercise therapy beyond 48–72 hours forfeits the proven reduction in recurrent sprains and is particularly detrimental in hypermobile patients who require specialized neuromuscular retraining. 1
• Assuming the "dirty" sensation represents surgical failure without obtaining stress radiographs; many patients with subjective instability have mechanically stable ankles and respond to proprioceptive training alone. 3, 2
• Prescribing unsupervised home exercise programs instead of supervised physical therapy; this results in inferior outcomes, especially in hypermobile patients who need expert guidance on neuromuscular control. 1
• Returning to full activities before completing 4–6 weeks of rehabilitation increases reinjury risk and may compromise the surgical repair. 1
• Neglecting to assess the contralateral ankle before concluding that hypermobility precludes successful conservative management or indicates surgical failure. 2

Return-to-Activity Timeline

• For this grade 1 sprain occurring 3 months post-surgery, expect return to sedentary work at 3–4 weeks with activity restrictions (no lifting >10 kg, limited standing on uneven surfaces). 1
• Full return to work and sports typically occurs at 6–8 weeks, depending on physiotherapy outcomes and the demands of the patient's activities. 1
• Do not clear the patient for unrestricted activity until stress radiographs confirm mechanical stability and the patient demonstrates adequate proprioceptive control on functional testing. 1, 2