Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery

Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study was to analyze and assess the variability across different rehabilitation protocols for patients undergoing either lateral ankle ligament repair, reconstruction, and suture tape augmentation.

Using a web-based search for published rehabilitation protocols after lateral ankle ligament repair, reconstruction, and suture tape augmentation, a total of 26 protocols were found. Inclusion criteria were protocols for post-operative care after an ankle ligament surgery (repair, reconstruction, or suture tape augmentation). Protocols for multi-ligament surgeries and non-operative care were excluded. A scoring rubric was created to analyze different inclusion, exclusion, and timing of protocols such as weight-bearing, range of motion (ROM), immobilization with brace, single leg exercises, return to running, and return to sport (RTS). Protocols inclusion of different recommendations was recorded along with the time frame that activities were suggested in each protocol.

Twenty-six protocols were analyzed. There was variability across rehabilitation protocols for lateral ankle ligament operative patients especially in the type of immobilizing brace, time to partial and full weigh bearing, time to plantar flexion, dorsiflexion, eversion and inversion movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement between protocols. All (12/12) repair, internal brace, and unspecified protocols and 86% (12/14) of reconstruction protocols recommended no ROM immediately postoperatively. Eighty-six percent (6/7) of repair and 78% (11/14) of reconstruction protocols recommended no weight-bearing immediately after surgery, making post-operative ROM and weight-bearing status the most consistent aspects across protocols. Five protocols allowed post-operative weight-bearing in a cast to keep ROM restricted. Sixty-six percent (2/3) of suture tape augmentation protocols allowed full weight-bearing immediately post-operatively. Suture tape augmentation protocols generally allowed rehabilitation to occur on a quicker time-line with full weight-bearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3) protocols. RTS was consistent in repair protocols (100% at week 12-16) but varied more in reconstruction.

There is significant variability in the post-operative protocols after surgery for ankle instability. ROM was highly variable across protocols and did not always match-up with supporting literature for early mobilization of the ankle. Return to sport was most likely to correlate between protocols and the literature. Weight-bearing was consistent between most protocols but requires further research to determine the best practice. Overall, the variability between programs demonstrated the need for standardization of rehabilitation protocols.