Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

In the patients we see, they have at some point considered surgical intervention for their chronic ankle instability because they are basically done with treatments that are not effective. The reason they have not jumped right into surgery is because of its risks and the possibility that it will not help. But clearly, surgery does address ligament and tendon problems. These problems can also be addressed in a non-surgical manner.

My ankle is getting worse and worse.

Many of you reading this article have had ankle problems for a long time. Some of you are thinking that if it were only my ankle, I could probably deal with it. But it is not only your ankle, it is your knee, your foot, your hip, and your low back pain, too. Some of you are probably waking up in the morning, unsure how much weight to put on your foot or ankle because some mornings you can get right out of bed, other mornings you get up and reach for the wall because there is pain and instability, and you need to catch your breath before you fall back onto the bed. Those are the mornings you probably tell yourself or your spouse, “I need to do something about this before it gets worse.” Then again, you may have been saying this for years.

Whenever we discuss surgery, it is important to bring in a surgical opinion.

In the Journal of Orthopaedic Surgery and Research, June 2018 (1), a team of medical university orthopedic surgeons presented their findings to the medical community:

• “There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still draw some conclusions:
  • (1) There are limitations to the use of dynamic tenodesis, which has obtained poor clinical satisfaction and more subsequent sprains.
    • The goal of ankle tenodesis is to provide stability to the ankle by moving a weakened tendon to another place on the bone. The cost of this procedure is that you now have a much more limited range of motion in your ankle. This surgery has fallen out of favor. As a side note, the American Orthopaedic Foot & Ankle Society website tells physicians, “Tenodesis stabilization restricts laxity and pathologic motion but ignores the underlying ligamentous pathology causing the instability.” Simply, you cannot treat the tendons without addressing the problem of the ankle ligaments.
  • (2) Non-anatomic reconstruction (the use of allograft (donated tendon), autograft (your tendon), or tenodesis to replicate the motion and stability abnormally increased inversion stiffness at the subtalar level as compared with anatomic repairment (Surgical repair of the ligaments)
  • (3) Multiple types of modified Brostrom procedures could achieve good clinical results.
    • Modified Brostrom procedures are a group of surgical procedures that seek to stabilize the ankle by repairing the anterior talofibular ligament. The main stabilizer ligament of the outer ankle. Brostrom procedure and its variants are the most popular surgery for ankle instability. But as stated above, there is limited evidence to support one surgical technique over another surgical technique for chronic lateral ankle instability.

Surgery can work for some people. One of the appeals of the arthroscopic Brostrom procedure is that it is an “outpatient,” or same-day surgery.  But as many have learned, same-day surgery can mean months of rehabilitation. Typical rehabilitation of this procedure can include:

• Immobilization for weeks or months
• The problem of managing swelling with anti-inflammatory medications
• Sleeping with a splint for weeks on end.
• Months of therapy and treatment

Same-day surgery simply means a smaller incision; the rehab remains the same.

More on the modified Brostrom procedures – many patients do not return to their pre-injury activity level

A February 2022 paper published in the Orthopaedic Journal of Sports Medicine (2) writes that “despite marked improvements in stability after lateral ankle ligament repair (surgery), many patients do not return to their pre-injury activity level. There are few studies addressing athletes’ assessment of their ability to return to play after lateral ankle ligament reconstruction for recurrent instability.”

To answer this question, the researchers sought to determine the rate of return to the preinjury activity level among physically active patients after the modified Broström procedure for recurrent lateral ankle instability.

Included in this study were patients who had undergone a primary modified Broström procedure by a single surgeon over a 6-year period and had a minimum of 24 months of follow-up.

• Of the 41 in this study who participated in a telephone interview, results indicated that 22 (54%) returned to their prior level of activity (returners). The mean age of returners was 27.2 years; for nonreturners, the mean age was 27.1 years.
• Most patients (36/41; 88%) were satisfied with the surgery and the overall outcome.
• Of the 19 nonreturners, 7 (37%) noted ankle-related reasons for not returning (pain: 57%; residual instability: 29%; decreased range of motion: 14%), and 12 (63%) cited non-ankle-related reasons.
• Conclusion: A high patient satisfaction rate was reported after the modified Broström procedure for recurrent lateral ankle instability. The majority of patients who did not return to their pre-injury level cited a non-ankle-related factor as the reason for not returning to sport. This was especially true for the higher-level athletes.

A March 2025 study in the Journal of Experimental Orthopaedics (3) examined risk factors for failure of lateral ankle ligament surgery. Looking at previously published data from 762 patient histories, the researchers found:

• Eighty-nine patients (11%) had treatment failure as defined by recurrence of instability, with rates ranging from 5.7% to 28.5%.
• Six risk factors were
  • generalized joint laxity
  • high-level sports activities and
  • being female
  • varus hindfoot alignment
  • poor quality of the remnant lateral ligaments
  • intraoperative syndesmosis widening

The key is fixing the instability before the instability creates significant bone damage.

Hopefully, you are at a stage where the damage to your ankle is not irreversible. If you have chronic instability but a good range of motion in your ankle, we believe we can help you avoid future surgery and strengthen your ankle. The key is fixing the instability before the instability creates significant bone damage.

In December 2016, the Journal of British Sports Medicine (4) published the Executive Committee of the International Ankle Consortium position paper on the progression of ankle instability caused by chronic ankle sprains to disabling full-blown osteoarthritis and the need for ankle surgery or fusion. These are the treatment guidelines doctors follow today.

That position paper, which was compiled by researchers from the University of Kentucky, University College Dublin, UK National Center for Sport and Exercise Medicine, the University of Delaware, University of North Carolina, among many other medical universities, stated:

• “This 2016 position paper with recommendations for information implementation and continued research is based on the paradigm that lateral ankle sprain and the development of chronic ankle instability serve as a conduit to a significant global healthcare burden.
• We intend our recommendations to serve as a mechanism to promote efforts to improve the prevention and early management of lateral ankle sprain.
• We believe this will reduce the prevalence of chronic ankle instability and associated sequelae that have led to the broader public health burdens of decreased physical activity and early-onset ankle joint post-traumatic osteoarthritis. Ultimately, this can contribute to healthier lifestyles and the promotion of physical activity.”

Simply: People are at high risk of developing ankle osteoarthritis. It is a big problem.

Who will need the surgery and who will not? This may be determined by the level of ankle instability.

Ankle instability may not show up after the first acute ankle sprain, and there is no consensus on how to tell if a patient will have instability in the future. This much is the consensus in the medical community. But what is the progression from an ankle sprain to ankle instability? Can this be documented to offer some idea?

This was addressed by an Irish research team writing in the American Journal of Sports Medicine (5), who, among other findings, found that patients who could not properly jump or land 2 weeks after their first lateral ankle sprain were high-risk candidates for chronic ankle instability.

Unfortunately, literature examining chronic ankle instability is often conflicting and confusing to patients. The Irish researchers were able to identify jumping and landing ability and non-reported ankle pain up to 6 months as being high-risk factors for ankle instability, but they were not the only factors.

University researchers in Australia also tackled the problem of identifying the risk factors for ankle instability. In June 2016, the Australian team published their intent to examine the problems of ankle instability in the medical journal Systematic Reviews (6) and correlate available research into a clearer understanding of key factors… This was what they said:

• “Ankle sprains are a significant clinical problem. Researchers have identified a multitude of factors contributing to the presence of recurrent ankle sprains, including deficits in balance, postural control, kinematics, muscle activity, strength, range of motion, ligament laxity, and bone/joint characteristics.

In 2017, at the completion of their review, the researchers published their findings in the journal Sports Medicine. (7)

• Remarkably, only 17% of primary studies measured a clearly defined chronic ankle instability population.
  • COMMENT: In other words, research on chronic ankle instability in nearly 5 out of 6 studies never clearly defined whether the patients in the study actually had chronic ankle instability, and to what levels.
• “Evidence from previous systematic reviews does not accurately reflect the chronic ankle instability population. For the treatment of non-specific ankle instability, clinicians should focus on dynamic balance, reaction time, and strength deficits; however, these findings may not be translated to the chronic ankle instability population.”
  • COMMENT: In other words, you may not be getting the treatment you need for ligament deficiency. The ligaments are the stabilizers, the accelerators, and the strength of bone-to-bone interactions. Tendons are the stabilizers, the accelerators, and the strength of muscle-to-bone interactions.
  • In our opinion, you need a treatment that strengthens and rebuilds your tendons and ligaments.

Are surgeons even addressing Lateral ankle sprain?

Building on these findings is a July 2021 paper published in the journal BioMed Central Musculoskeletal Disorders. (8) What the researchers of this study wanted to know was whether surgeons were using the current treatment criteria for patients with a lateral ankle sprain. To test how surgeons were treating this problem, a questionnaire survey was conducted among Japanese orthopedic surgeons.  The survey was composed of 12 questions that were developed with consideration of the recommendations in the current clinical practice guidelines published by the Dutch orthopaedic society. The questions in this study were focused on the diagnosis, conservative treatment, rehabilitation, and the criteria for returning to sports.

• Among the respondents, 95.3% did not consider the Ottawa Ankle Rules in the decision to perform plain radiography for patients. (The Ottawa Ankle Rules were developed to help doctors determine who should and who should not need an X-ray to rule out a bone break or fracture.)
• Rehabilitation following lateral ankle sprain was performed in 58.9% of patients.
• Eighty-five (65.9%) of the surgeons used only one factor as the criterion for returning to sports. The absence of pain was the most frequently used criterion (45.7%). No objective criteria were used for the return to sports decision in athletes with a lateral ankle sprain.

So what does this mean in your search for comparisons for what are the best injections for ankle pain? Doctors may not be addressing ligament instability as the cause of your ankle problems; instead, they may be looking for end-stage evidence, the loss of cartilage, the bone spurs, the loss of range of motion, and the chronic pain. In a patient’s desire to relieve their ankle pain with injections, an examination of ankle instability and the impact on accelerated osteoarthritis should be undertaken.

“The procedures of reconstruction surgery for chronic lateral ankle instability.”

In October 2021, specialists writing in The Journal of Foot and Ankle Surgery (9) evaluated “the procedures of reconstruction surgery for chronic lateral ankle instability.” In this study, the doctors compared single anterior talofibular ligament reconstruction to simultaneous reconstructions of the anterior talofibular and calcaneofibular ligaments. As we will see, the surgeons of this study call for more ligament repair than isolation simply on the anterior talofibular ligament.

How was the study conducted?

• 14 consecutive patients diagnosed with chronic lateral ankle instability underwent arthroscopic anterior talofibular ligament reconstruction with or without calcaneofibular ligament reconstruction after conservative treatment.
  • Seven patients underwent single anterior talofibular ligament reconstruction (group AT),
  • and 7 patients underwent simultaneous reconstructions of the anterior talofibular ligament and calcaneofibular ligament (group AC).
  • Patients’ pain and function significantly improved in all patients 1 year postoperatively.
• Long-term outcomes: While the initial one-year success was good. The researchers found “that although the clinical outcomes after the anterior talofibular ligament reconstruction with or without the calcaneofibular ligament reconstruction for chronic lateral ankle instability were good, instability of the talar tilt angle at 1 year postoperatively in patients who underwent single anterior talofibular ligament reconstruction was greater than that in patients who underwent simultaneous anterior talofibular and calcaneofibular ligament reconstructions.”

Chronic ankle sprain and instability injections and treatments

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