Considerations for Performing Ankle Lateral Ligament Repair in Athletes

Masato Takao, MD, PhD, JAPAN

ISAKOS eNewsletters   Current Perspective 2025   Not yet rated

Introduction

Although lateral ankle instability is common sports injury, its pathogenesis, diagnosis, and treatment remain controversial. At the ISAKOS conference held in Munich in June 2025, we participated as faculty in the session entitled “Meet the Expert: Chronic Lateral Ankle Ligament injuries” and thoroughly enjoyed the discussion between the faculty and participants from around the world. One concern throughout this fantastic session was the reluctance that the participants seemed to have toward the surgical treatment of lateral ankle ligament injuries, especially in elite athletes. We discussed cases in which conservative treatment of lateral ankle instability in top athletes resulted in worsening symptoms or osteochondral lesions of the talus, but few of the participants suggested that surgery should be performed in the early stage following the injury.

In the present article, we explore the reasons behind the hesitation to perform lateral ankle ligament repair in athletes.

Figure 1. Chairmen and faculties in the session entitled “Meet the Expert: Chronic Lateral Ankle Ligament injuries”

Negative Impacts of CLAI

Ankle sprains are among the most common injuries among athletes, and lateral ankle sprains account for 90% of all ankle sprains. Most doctors have recommended non-surgical treatment for acute rupture of the lateral ligaments of the ankle. However, non-surgical treatment can sometimes fail, and symptomatic chronic lateral ankle instability (CLAI) develops in approximately 20% of patients after an inversion sprain of the lateral ankle ligaments. Persistent CLAI may cause osteochondral lesions of the talar dome and subsequently may result in osteoarthritis of the ankle. It also has been reported that the peroneal tendon, which is the dynamic stabilizer on the lateral side of the ankle joint, gradually weakens, leading to subluxation and rupture of the tendon at the sharp edge of the posterolateral tip of the fibula in patients with CLAI. Furthermore, CLAI negatively affects not only the plantar flexion of the ankle but also the extensor strength of the hip and knee by affecting sensorimotor control at both the spinal and supraspinal levels. As a result, it has been suggested that the performance of athletes is reduced. Therefore, if non-surgical treatment fails and lateral instability of the ankle remains persistent, then surgical repair or reconstruction should be performed in order to maintain the lateral stability of the ankle and prevent subsequent disorders such as osteochondral lesions of the talar dome and osteoarthritis of the ankle.

Recent Evolution of Surgical Techniques for CLAI

Direct anatomical repair of the lateral ligaments of the ankle was originally described by Broström in 1966, and this popular technique continues to be the gold standard procedure for the treatment of lateral ankle instability. Although patients tend to report subjective satisfaction with this procedure, several problems remain. One notable issue is its invasiveness, which requires at least a 4-cm-long incision with significant dissection and soft-tissue debridement that may cause superficial nerve disorders. Furthermore, the development and use of a less-invasive technique is thought to allow a faster return to sports activities.

While arthroscopic surgery for other joints evolved quickly after the development of suture anchors, the arthroscopic procedure for suturing the residual ankle lateral ligament has been developed by top surgeons in this field. In 2009, Corte-Real and Moreira modified the Broström technique into a simple and reproducible arthroscopic procedure using suture anchors. The Ankle Instability Group (AIG), which was established in 2013 by top surgeons in this field as a research group specializing in ankle instability, also has contributed to the development of this field.¹ The AIG consists of core members from Argentina, Belgium, Brazil, Canada, China, Egypt, France, Japan, Korea, Portugal, Singapore, Spain, United Kingdom, and the United States. The aims of the AIG are (1) to facilitate the most scientifically rigorous international discussion for ankle instability (completely independent of scientific societies and commercial companies), (2) to invite the greatest number of experts around the world, and (3) to support young foot and ankle surgeons who will further develop the field in the future. The AIG group has dedicated a vast number of resources to address the shortcomings of current treatment in lateral ankle instability, which has led to seven major publications on the topic in specialist journals around the world.

The all-inside arthroscopic procedure, first reported by Vega in 2013, uses a knotless anchor and was considered to be the least-invasive arthroscopic repair technique at that time. A suture anchor procedure with a lasso-loop stitch technique, first described in 2015, was subsequently modified into the lasso-loop self-cinching stitch technique.² This procedure is currently considered to be the least-invasive option, as every step—including placement of the suture anchor at the ATFL attachment to the lateral malleolus, securement of the anchor to the residual tissue, and knot tying—is performed arthroscopically through a single portal. Since the all-inside arthroscopic procedure enables the ligament to be sutured in a direct arthroscopic view, it can be performed anatomically. An all-inside suture anchor procedure with a modified lasso-loop stitch technique that offers strong initial strength and allows for accelerated rehabilitation is described below.

Figure 2. Left image: Before tightening the knot. The red arrow indicates that the anterior talofibular ligament (ATFL) stump is hanging down and away from the distal end of the anterior inferior tibiofibular ligament (AITFL). Right image: After tightening the knot. The blue arrow indicates that the stump of the ATFL has been moved to its normal attachment and sutured, making the stump of the ATFL continuous with the distal end of the AITFL.

Accelerated Rehabilitation After All-Inside Arthroscopic Repair

The efficacy of early motion for soft- tissue healing has been clarified in previous studies. Animal models have demonstrated a range of biomechanical and physiological mechanisms that support the use of early active mobilization after soft-tissue injury. Early functional loading and controlled movement after injury have been reported to improve the strength of soft tissues. Early mobilization has been reported to result in a significant increase in the expression of sensory neuropeptide receptors from 8 to 17 days after injury, which is similar to the increase in extracellular matrix mRNA expression. Another report revealed that the morphology of fibroblasts quickly changes in response to cyclic stretching and that the expression of genes related to the mechanotransduction pathway, especially during the resting period after the end of stretching, is subsequently upregulated. Because previous studies have shown that lasso-loop stitches exhibit a strong knot strength, accelerated rehabilitation is allowed after surgical procedures performed with that technique.

For patients who undergo an arthroscopic ligament repair using modified lasso-loop stitch, an elastic bandage is applied for 2 days after surgery. Depending on the severity of pain, full weight-bearing may be allowed as soon as the first day after surgery. Jogging and proprioceptive training are allowed 2 weeks postoperatively, and a return to sports without external fixation is allowed for 5 weeks postoperatively. The detailed rehabilitation protocol is shown in Table 1.

Table 1. Detailed Rehabilitation Protocol

To ensure safe and effective accelerated rehabilitation, all staff involved must accurately understand the patient's condition and agree on the best approach. Physicians, physical therapists, nurses, and nursing assistants at the Clinical and Research Institute for Foot and Ankle Surgery (CARIFAS) hold rehabilitation conferences four times a week for all patients undergoing rehabilitation, facilitating safe and efficient accelerated rehabilitation.

Clinical Results of Concurrent Surgery with Accelerated Rehabilitation After Modified Lasso-Loop Stitch Arthroscopic Ankle Stabilization

In one study, the subjective clinical assessment score, SAFE-Q, achieved nearly perfect scores in all categories 1 year after surgery, representing a significant improvement over the preoperative scores.³ The average times between surgery and unsupported walking, jogging, and return to full athletic activities were 1.6 ± 2.5, 16.9 ± 3.7, and 42.4 ± 19.3 days, respectively.³ There were no significant differences in clinical scores or return to activity between patients who had undergone unilateral surgery and those who had undergone simultaneous bilateral surgery,³ patients who had undergone ankle lateral ligament repair alone and those who had undergone simultaneous posterior ankle impingement surgery,⁴ and skeletally mature and immature patients.⁵

Conclusion

With recent advances in arthroscopic surgery for CLAI and accelerated postoperative rehabilitation, athletes are now able to return to sports early after surgery. Although it is assumed that the surgeon performing the surgery has excellent skills, accurately evaluates the patient’s condition after surgery, and shares information with all medical staff, we recommend that doctors should not hesitate to perform arthroscopic ligament repair for CLAI, even in athletes, to prevent complications caused by residual CLAI and to improve sports performance.

References

1. Takao M, Guillo S. Recent development of arthroscopic repair of the ankle lateral ligament. ISAKOS Newsletter. 2024 volume I.
2. Takao M. Arthroscopic all inside ATFL repair. 231-236. Helder Pereira, Stephane Guillo, Mark Glazebrook, Masato Takao, James Calder, Niek van Dijk, Jon Karlsson (Editors). Lateral Ankle Instability. An International Approach by the Ankle Instability Group. ESSKA Book, Springer, 2021
3. Takao M, Inokuchi R, Jujo Y, Iwashita K, Okugura K, Mori Y, Hayashi K, Komesu K, Glazebrook M; Ankle Instability Group. Clinical outcomes of concurrent surgery with weight bearing after modified lasso-loop stitch arthroscopic ankle stabilization. Knee Surg Sports Traumatol Arthrosc. 2021 Jun; 29(6): 2006-2014.
4. Takao M, Jujo Y, Iwashita K, Inagawa M, Chua EN, Lee KJ, Watanabe T, Shimozono Y, Ozeki S. Effect of simultaneous bilateral surgery or simultaneous arthroscopic ankle lateral ligament repair in hindfoot endoscopic surgery for posterior ankle impingement syndrome in athletes. Foot Ankle Surg. 2024 Aug;30(6):510-515.
5. Takao M, Jujo Y, Iwashita K, Inagawa M, Chua EN, Lee KJ, Watanabe T, Shimozono Y. Arthroscopic Modified Lasso-Loop Stitch Technique for Chronic Lateral Ankle Instability in Skeletally Immature vs Mature Patients. Foot Ankle Int. 2024 Apr;45(4):373-382.

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