Evolution in Surgical Management of Ankle Instability in Athletes

Brian C. Lau, MD; Alexej Barg, MD; C. Thomas Haytmanek, MD; Kirk McCullough, MD; Annunziato Amendola, MD


J Am Acad Orthop Surg. 2021;29(1):e5-e13. 

In This Article

Abstract and Introduction


Recent concepts are changing the management of ankle instability. These include concurrent medial and lateral instabilities, use of ankle arthroscopy, use of suture anchors, all-arthroscopic stabilization, synthetic augmentation, and early postoperative rehabilitation. Medial sided injuries occur in up to 72% of the lateral ankle sprains, and concomitant repair may provide greater stability. Suture anchors are equally as strong as transosseous tunnels, and the technique is simple, reproducible, and may decrease complications, but anchors do increase costs. Synthetic augmentation demonstrates greater strength than Broström alone in cadaver-based biomechanical testing. Although clinical studies of synthetic augmentation have demonstrated equivocal stability and pain compared with Broström alone, synthetic augmentation may expedite rehabilitation. All-arthroscopic ankle stabilization is gaining popularity with increasing publications. Early findings demonstrate comparable biomechanical and clinical data compared with open techniques. Early postoperative weight-bearing within 2 weeks seems to be safe and may shorten time to return to play. Surgeons may consider using these novel techniques in the management of lateral ankle instability.


Ankle injuries are a common problem in athletes and account for a up to a third of all injuries encountered during athletic competitions.[1] Most ankle injuries are categorized as sprains,[1] and although most ankle sprains recover without difficulty, about 20% of acute ankle sprains will develop into chronic ankle instability.[2]

Ankle instability refers to symptoms of persistent mechanical or perceived (functional) instability that may lead to recurrent ankle sprains. Mechanical instability is defined by physiological laxity of the lateral ankle ligamentous complex detectable on examination. Functional or perceived instability is characterized by a subjective feeling of giving way of the ankle. Mechanical and functional instabilities can occur independently but are not mutually exclusive and can occur concomitantly. For example, an athlete may not suffer a traumatic event leading to an ankle sprain but still have sensation that ankle is giving way during athletic activity. This may be associated with laxity on examination (concomitant mechanical and functional instabilities) but also may not have laxity on examination (isolated functional instability).

As our understanding of ankle instability has expanded, so has our management armamentarium. Over the past several years, a number of concepts have surfaced that may contribute to ankle stability and long-term management of ankle dysfunction in the athlete. The current review will highlight some of these concepts.