Ankle sprains: What helps against chronic ankle instability?

Strength and coordination exercises help in the treatment of chronic ankle instability. But surgery is sometimes a good idea too. People who already start rehabilitation exercises two or three weeks after surgery will probably be activated again before people who only start later.

People with a twisted ankle may develop chronic (prolonged) ankle instability. It is considered chronic if the ankle joint continues to yield too easily six months after the first sprain, or if the ankle twists again within six months after the first sprain. Unstable ankle joints can easily twist again. The joint remains unstable in approximately 10 to 20 of every 100 people who have a severe ankle sprain.

This type of instability can develop if the ligaments of the ankle are too stretched, or if they are torn and re-grow together too flexibly (mechanical instability).

The interactions between the bones of the ankle and the surrounding ligaments and muscles can also be altered. Our bodies are aware of their own movement and spatial orientation, known as proprioception. This also helps to coordinate the movements of the joints, to stabilize them through reflexes and to keep the body balanced. So, if an ankle feels permanently unstable, this could not only be caused by excess stretched ligaments, but also by a problem with proprioception or problems resulting with muscle coordination.

What treatment options are there?

There are several treatment options for chronic ankle instability: conservative treatment is first tested. This involves doing physiotherapy to strengthen the joint and, possibly, use an ankle brace to stabilize it.

A common physiotherapy approach is called neuromuscular training. Its objective is to improve the strength, stability and coordination of the ankle. Research has shown that neuromuscular training can improve stability and movement of the ankle in the first weeks. But there is not enough research on the long-term effectiveness of this treatment.

If the joint remains unstable despite training because the ligaments are too loose, surgery may be considered. One option is to shorten and tighten the ankle ligaments. Another option is to remove a tendon from the lower leg and use it as an external ligament in the ankle. The tendons and ligaments are made of similar tissue.

To go:

How can you get in shape again after surgery?

Ankle instability often leads to problems with muscle coordination. For this reason, exercises are always an important part of rehabilitation after surgery. It also helps to use an ankle brace during this time, to give external support to the ankle. The pressure exerted on the joint can help you recover a good feeling of muscle coordination.

People probably benefit from movement, strength and coordination exercises two to three weeks after surgery at the latest. Studies suggest that people who do this become more active before those who wear an ankle for six weeks and do not do any exercise during that time. The study participants who had begun to do exercises and strength training before were able to return to work about a week or two earlier.

They were also able to return to sports about three weeks before. But no benefits could be seen after approximately two years: the stability and flexibility of the ankle joints of the participants was the same in both groups.

However, many of these studies had few participants or were performed poorly. This means that your results should be interpreted with caution.

Which is better: physiotherapy or surgery?

There were no studies comparing surgery directly with physiotherapy or other treatments. For this reason, it is not possible to say who would benefit the most from surgery or how effective it is compared to non-surgical treatment (conservative).

It is also unclear how different surgical procedures compare to each other. There are only a few small studies on this, and they do not provide reliable results. One study examined a surgical procedure called "Chrisman Snook," in which the ligaments are strengthened with tendons that are taken from the foot or lower leg. Compared to other procedures, it led to more complications, including nerve damage.

In general, it is currently unclear whether surgery leads to faster recovery than strength and coordination training. But if the ankle remains unstable due to loose ligaments, surgery could be an option. Regardless of the treatment you choose: with a little patience, the twisted ankles usually become stable again.