Outcomes and Return to Sports Following the Ankle Lateral Ligament Reconstruction in Professional Athletes: A Systematic Review of the Literature

Abstract

Introduction

The literature on the early reconstruction of severe acute lateral ligament injuries in professional athletes suggests earlier rehabilitation and reduced incidence of recurrent instability. Predicted time to return to training and sports is important to both the athlete and the club and has not previously been reported.

Aims and Objectives

The primary aim was to establish the best treatment options available for lateral ligament injury in professional athletes and assess the average time to return to physical training and return to play (RTP). Secondary aims were to find out the rate of return to the pre-injury level of competitive sports and the reasons for delayed recovery.

Materials and Methods

We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management, and treatment outcomes. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases were performed. Studies conducted between Jan 2000 and Dec 2020 with articles reporting the ankle lateral ligament reconstruction in professional athletes were included.

Main Results

After initial screening, 982 articles were identified, of which, 10 articles evaluating 343 athletes met the criteria and were included for final review. The combined mean age was 23 years with an average follow-up of 58.4 months. After surgery 308 (89%) returned to their pre-injury level of sports, 7 (2%) patients returned to a lower-level sport while the remaining 28 (9%) never returned to play.

Conclusion

Our results provide a guide to predict the expected time to return to play (RTP) after surgical repair of lateral ligament injuries along with associated injuries leading to delayed rehabilitation. Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle with a mean time of 16 weeks to return to sports. The available studies vary considerably in their metrics used for measuring patient-reported outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-021-00532-0.

Introduction

Ankle sprains are among the most common injuries in high-demand athletes with most cases involving the lateral ligamentous complex [1–4]. These injuries have been reported to be most symptomatic in high-demand athletes in whom ankle instability causes significant functional disability [5]. The stability of the ankle joint is provided by three groups of ligaments: the lateral ligaments, the tibiofibular syndesmosis, and the medial ligaments. The lateral ligaments comprise the anterior talofibular, the calcaneofibular, and the posterior talofibular ligaments, the latter being the strongest of the three [6, 7].

When it comes to professional athletes (competitive athletes), a common question that the treating clinician faces is the duration of rehabilitation and return to pre-injury status. The average time to return to sports among the general population is unrealistic to be applied to a professional athlete because of the expected physical and financial attachments to their club. However, it is also unrealistic to expect a “black or white” answer as the return to pre-injury status is a natural and time-dependent process. Nevertheless, the decision about the initiation of the rehabilitation program is important because any undue delay can jeopardize not only the injured personnel but also the affiliated club [8].

Most patients will improve after a period of initial rest, physical therapy, and gradual functional rehabilitation. However, it has been noted in previous studies that as many as 20% of patients develop chronic symptomatic ankle instability [9–11]. Conservative treatment of ankle ligament injuries does not always result in anatomical and functional healing of the injury itself or resolve the instability, and it may eventually contribute to secondary osteoarthritis. Chronic ankle instability is one of the most common residual problems after such injuries [12, 13]. If conservative treatments fail to provide satisfactory function and stability, operative treatment is usually considered.

In a meta-analysis of 7 randomized controlled trials [14] on surgical treatment of chronic lateral ankle instability, the authors suggested that, given the lack of statistical significance and poor methodology employed in these trials, no conclusion could be drawn regarding the best method of treatment.

Historically, an estimated 50–80 surgical techniques for lateral ligament reconstruction have been described in the literature [5, 15–17]. These can be divided into 2 major categories: anatomic repairs and nonanatomic augmented reconstructions. Anatomical repairs are derived from the procedure initially described by Brostrom in 1966 [18]. Commonly employed modifications to this technique were described by Gould et al. in 1980 [19] and by Karlsson et al. in 1988 [20]. Nonanatomic reconstructions were originally described by Elmslie in 1934 [21] and subsequently by Evans in 1953 [22], Watson-Jones in 1955 [23], and Chrisman and Snook in 1969 [24, 25].

There is scarce literature available to provide a predicted time frame for professional athletes to return to their pre-injury level of competitive physical fitness. The primary aim of this review article is to assess the average time to return to physical training and return to play (RTP) following ankle lateral ligament reconstruction in professional athletes. The secondary aims are to assess the rate of return to the pre-injury level of competitive sports, performance level at the final follow-up, and identify the reasons for delayed recovery.

Methodology

Search Strategy

A literature search was conducted through the databases including PubMed (MEDLINE), Ovid, Cochrane Library (Cochrane Systematic Reviews and Cochrane Bone, Joint, and Muscle Trauma Group), Embase, ScienceDirect, Google Scholar, and ISI Web of Knowledge. Articles published from Jan 2000 to Dec 2020 were included and the search was limited to articles available in the English language only.

Search Terminologies

The National Library of Medicine’s (NLM) Medical Subject Headings (MeSH) terms were selected and used along with text words. MeSH terms used ‘Lateral ligament’, ‘Ankle ‘and ‘Ankle lateral ligament reconstruction’ provided a consistent way to retrieve information where different terms had been used by authors for the same concept. The terminologies used included ‘Ankle lateral ligament reconstruction’ OR ‘Reconstructive ankle procedures’ OR ‘Brostrom Gould repair in athletes’ AND ‘Ankle injuries in professional athletes’ AND ‘Return to sports in professional athletes.

Inclusion Criteria

All types of articles reporting the ankle lateral ligament reconstruction in elite athletes were included. In the first phase, the abstracts of the relevant articles were reviewed. In the second phase, after applying the exclusion criteria, full texts of the selected articles were obtained from electronic databases and in hard copy format where needed. Figure 1 represents the PRISMA flow diagram of the methodology used. Two authors (PG and ST) were involved in the literature search, with no disagreement between the two authors in final inclusion.

Fig. 1.

Flow diagram of search methodology

Exclusion Criteria

Articles reporting the outcomes of ankle lateral ligament reconstruction in adults other than professional athletes were excluded and also studies without an exact statement of time to return to sport. Any articles not available in the English language were excluded. Duplicate articles were excluded.

Quality Appraisal

The PICO method (Population, Intervention, Comparison, and Outcome), CASP tools (Critical Appraisal Skills Programme), and MINORS (Methodological Index for Non-randomized Studies) were used to critically appraise the quality of selected studies and analyze their results.

Results

After the initial search and screening, in the first phase, 982 articles were identified from the searched databases. In the second phase, 10 articles were selected for final inclusion, which fulfilled the inclusion criteria. The included studies comprised 3 prospective studies and 7 retrospective studies. Ten studies had a total of 431 operated patients, out of which 343 were followed up for results 88 patients were lost to follow-up. The studies were conducted between the years 1990 and 2017. The combined mean age of the patients was 23 years among all the studies, the youngest patient being 13 years old, and the oldest 65 years old in different studies. The average duration of follow-up was 58.4 months (range 28–149).

Among all the followed-up patients, 308 (90%) returned to their pre-injury level of sports, and 7 (2%) patients returned to a lower-level sport. The remaining 28 (8%) were not able to return to sports. Overall, both the frequency and quality of RTP criteria and reporting were very low. There was a wide variation in the functional assessment of patients among different studies. The functional scores used in 9 out of 10 studies included Tegners scores, Karlsson scores, Visual Analogue Scale (VAS) score, American Orthopaedic Foot and Ankle Society Scales (AOFAS) score, SF-12 Score, and Foot and Ankle Outcome Score (FAOS). Post-operative assessment of range of motion, calf atrophy, talar tilt angle, and anterior drawer test was recorded in 7 out of 10 studies. Post-operative complications occurred in 68 (19.8%) patients (Table 1). The demographics of the individual studies are presented in Table 2.

Table 1.

List of post-operative complications

Superficial infections treated by oral antibiotics	9
Superficial numbness that resolved in 6 months	24
Ankle stiffness	18
Ankle Instability	7
Re-rupture	3
Peroneal nerve complications requiring Decompression	3
Complex Regional Pain Syndrome (CRPS)	2
Push-lock anchor breakage intraoperatively	2

Table 2.

Demographics of individual studies

Author	Year published	Type of study	Study period	Total No of patients	No of patients followed up	Males	Females	Mean age (years)	Mean follow up	Return to play (n)	Surgical procedure
Xinning Li [41]	2009	Retrospective	1998–2001	62	52	25	27	19.6	29 Months	49	Variant of the Gould-modified Broström procedure
Dennis Kramer [43]	2011	Retrospective	1997–2006	67	43	9	34	19.7	52 Months	35	Modified Chrisman and Snook procedure
Federico Morelli [42]	2011	Retrospective	1990–2004	28	14	6	8	22.7	128 Months	12	Modified Watson-Jones technique
John G kennedy [51]	2012	Retrospective	2007–2011	57	57	39	18	28	32 Months	41	Hybrid technique using peroneus longus tendon
Feancesco Bezzano [44]	2013	Retrospective	2004–2009	40	40	27	13	24.5	36 Months	38	Reconstruction with fibular periosteal flap
William James White [45]	2015	Prospective	2009–2015	42	42	37	5	22	44 Months	42	Modified Brostrom operation
Byung -KI Cho [46]	2015	Prospective	2008–2010	24	24	17	7	23.1	24 Months	23	Modified Brostrom operation using suture bridge
Adriano Russo [47]	2016	Retrospective	2000–2005	22	18	11	7	21.5	149 months	18	Bostrom Gould procedure
Gianluca Sperati [48]	2019	Prospective	2011–2017	35	35	23	12	31	54.2 Months	35	Hemicasting ligamentoplasty
Kyungtai Lee [49]	2019	Retrospective	2011–2013	54	18	9	9	19.3	28 Months	18	Modified Brostrom operation

Discussion

There is an extensive amount of literature describing techniques and outcomes for lateral ankle ligament repair and reconstruction among the general population. Professional athletes are a discrete group who are eager to return to sports as quickly as possible due to higher than the usual expectations. They are more susceptible to re-injury after returning to sports and are likely to test the quality of the surgical repair. Recovery progression after the injury or surgery in a professional athlete may be different from that of a recreational sports person. One might assume that, because of the very high levels of expected performance, the professional athlete may take longer to return to a pre-injury level than the average person. However, better access to expert aftercare by dedicated physical therapists and different levels of motivation often means that high-performance athletes are observed to rehabilitate more quickly [8].

A recent meta-analysis [26] showed an advantage of surgery over conservative treatment in four domains: return to pre-injury level, rate of recurrence, chronic pain, and subjective or functional instability, which is the reason why surgical treatment is mostly used in such patients. In high-demand patients, reducing these complications is of paramount importance especially for professional athletes. A study by Li et al. [27] stressed three key points: return to pre-injury level, need to use specific criteria to evaluate the outcomes, and reduction of comorbidities such as reduced subtalar motion and the possible deterioration of function.

White et al. [11] reported an early resumption of athletic activity after surgical treatment of lateral ligament injury. Based on club medical records, the median time to return to training for athletes was 63 days (range 49–152 days) and the median time to play was 77 days (range 56–178 days). The timings reflected the judgment that the athletes were physically fit and available for the team selection. 'The authors in this study reported that the median time to full training was significantly different between athletes with isolated lateral ligament injuries and those with other associated injuries. Hence, the athletes should be made aware that the associated injuries may delay their return to training due to delayed recovery.

Krips et al. [28] compared anatomical versus non-anatomical repair for lateral instability in high-demand athletes and found that anatomical repair resulted in significantly less restricted ankle range of motion (ROM) in dorsiflexion (3 vs 15 patients) and more athletes returned to their previous activity levels compared with the tenodesis group. The number of patients rated ‘good’ or ‘excellent’ by the scoring system of Good et al. was significantly higher (36 vs 21 patients respectively) in the anatomical repair group.

Lee et al. [29] reported excellent long-term results at a mean of 10.6 years following modified Brostrom operation (MBO) without calcaneofibular ligament reconstruction, with 28 of the 30 (93%) patients returning to their pre-injury levels. Several good-quality studies have compared the 2 principal methods of treatment and concluded that anatomic reconstruction has the least number of complications and appears to restore kinematics and proprioceptive function in comparison to Check rein procedures, which were regarded as more technically demanding with higher complication rates [27, 28, 30].

Bell et al. [31] reported long-term results obtained when using this method to repair the calcaneofibular ligament in a sizeable active-duty military population. The results in these patients at 26.3 years follow-up were found to be ‘excellent’ or ‘good’ in 91% of cases. Corte-Real et al. [32] reported encouraging results with a low incidence of major and minor complications. Nery et al. [33] stated that the arthroscopic assisted Brostrom-Gould technique could be a viable alternative to the gold-standard Brostrom-Gould procedure, as it allows a simultaneous treatment of intra-articular lesions. Wainright et al. [34] recently reported improved ankle joint kinematics in unstable ankles after modified Brostrom-Gould repair with a significant decrease in anterior translation and internal rotation of the talus. Cadaveric studies have shown greater mechanical stability obtained with the modified Brostrom technique as opposed to Watson-Jones and Chrisman-Snook reconstructions [35, 36].

Generalized laxity is associated with recurrent instability after ankle ligament reconstruction [37, 38]. Direct repair of the ligaments in patients with generalized joint hypermobility presents a significant risk for mechanical failure of the procedure [38]. Gross ligamentous laxity (Beighton score > 4) was suggested as a possible indicator of increased risk of recurrent injury [39]. A more recent study reported that MBO may be successful in patients with chronic ankle instability and generalized laxity [40].

Li et al. [41] reported on athletes who underwent modified Brostrom repair using suture anchors and were allowed to return to play after 16 weeks of rehabilitation. However, the authors did not mention the type of sports. All the patients were operated on by a single senior surgeon and the study did not have any selection bias. The authors reported a complication rate of 17% in their study.

Morelli et al. [42] reported that following the modified Watson–Jones technique, 12 (86%) resumed pre-injury sports activity after a mean follow-up of 6 months (range 4–8 months). Eleven patients sustained injuries during sports, of which 6 (43%) were professional athletes (Soccer: 3, Tennis: 2, Basketball: 1). No correlations were found between the scores from the AOFAS rating scale and the duration of follow-up or between the clinical results and the radiographic changes (p > 0.05).

Kramer et al. [43] reported the outcomes of 38 athletes involved in various competitive sports including soccer, basketball, dancing, swimming, figure skating, football, field hockey, wrestling, lacrosse, softball, horseback riding, volleyball, kickboxing, and track sports. All these patients underwent Chrisman Snook procedure with a mean follow-up of 4.4 years. Return to sports data was available for 35 of the 38 athletes. Of these, 28 (80%) returned to their pre-injury sports at a median time of 6 months postoperatively. The range of motion was compared with the contralateral ankle using paired t-tests.

Banezzo et al. [44] reported on 40 patients who underwent nonanatomic reconstruction with fibular periosteal flap including 30 professional athletes and 10 high school or college level athletes (Basketball, Volleyball, Soccer, and Track and field). All patients were evaluated using the method introduced by Zwipp et al., which included both subjective and objective parameters. Thirty-eight (95%) returned to their pre-injury level and 2 returned to a lower-level sport after their rehabilitation. White et al. [45] reported the outcomes of modified Brostrom repair in 42 elite athletes with a median return to play of 77 days (range 56–178). Forty patients (95%) reported being very satisfied and two were partly satisfied. This study was a single surgeon series and patients with previous ankle injuries were not excluded.

Cho et al. [46] reported a modified Brostrom procedure using the suture bridge technique of ligament re-attachment in high-demand athletes achieved satisfactory results in 22 patients (91.7%). Patients included 10 track, 6 basketball, 5 soccer, and 3 taekwondo athletes. Clinical evaluation included the Karlsson score, the Sefton grading system, and the period to return to exercise. Functional assessment of the return to exercise was as follows: 8.4 weeks for jogging, 9.2 weeks for standing on one leg, 10.5 Weeks for jumping, 10.6 weeks for uneven surface walking, and 11.2 weeks for going downstairs, 12.5 weeks for spurt running.

Russo et al. [47] reported long-term results of the Brostrom Gould procedure for chronic lateral ankle instability. All the 18 patients returned to pre-injury level sports with a follow-up of 10–15 years and ‘excellent’ results in 94.5% of the cases and ‘good’ in the remaining 5.5%. Sperati et al. [48] reported on 35 patients with competitive non-professional level sports operated with Hemi–Castaing procedure with an average follow-up of 54.2 months. All these patients returned to their pre-injury level of sports between 80 and 100 days.

Lee et al. [49] reported on 18 patients, all of whom returned to the pre-injury level of activities without any surgical complications following modified Brostrom repair. The mean length of time to return to personal training postoperatively was 1.9 ± 1.2 months (range 1–6 months), return to team training was 2.9 ± 1.0 months (range 1–6 months), and return to play was 3.9 ± 1.4 months (range 2–7 months). RTP was 4 months in 15 patients and 7 months in the remaining 3 patients. RTP was reported to be satisfactory with almost 90% of the patients returning to the same level of sports after surgical treatment. This was reported to be most noticeable with the anatomic repairs using modified Brostrom repair [40, 42–44, 50, 51]. The outcomes of the Chrisman Snook technique using a peroneus brevis graft were considered less successful with 13.8% of patients requiring re-operations.

Most of the reviewed studies had a clear detailed postoperative regime, which did not vary considerably. It included non-weight bearing in plaster for 3–6 weeks followed by physiotherapy. There was a variation of the physiotherapy protocols in different studies. There was no difference between male and female athletes with regards to recovery, complications, or return to sports. The most noticeable complication was re-rupture. Li et al. [41] reported 3 re-ruptures in their series. Superficial peroneal nerve was reported to be the most at risk; however, all the sensory nerve injuries were reported to have recovered at a maximum of 6 months.

All the studies had a minimum of 2 years of follow-up. There is no randomized controlled trial to compare two or more different techniques, likewise, there was no control group in any of the included studies. Some studies excluded patients with concomitant injuries such as osteochondral defects (OCD) while others addressed it with arthroscopy at the time of surgery [51].

All the studies included patients with chronic instability in professional athletes and failed conservative measures without any selection bias. Patients with other concomitant injuries were excluded. Seven out of 10 studies had approval from their local hospital review board. All the studies included consecutively treated patients in their specified period without any bias. None of the studies was funded, hence avoiding publication bias and funding bias.

Limitations

All the studies had single surgeon-operated patients, but there was no randomization performed to avoid selection bias. Three studies reported that patients with associated injuries took longer to return to play, suggestive of confounding bias. Data analysis for outcome measures showed an observational bias as there was no uniformity in all the studies. In past studies, AOFAS scores were used as an assessment tool, but in recent years its validity is questioned [52]. Most of the studies had data interpretation bias, as they were not specific about the different stages of training but reported only the endpoint of return to play, not sport-specific data. Our series contain heterogeneity and, included only English language studies between Jan 2000 and Dec 2020.

Conclusion

The results of this systematic review may act as a guide to predict the expected time to return to training and sports after surgical repair of lateral ligament injuries and the influence of the associated injuries leading to a delayed rehabilitation. Modified Brostrom procedure using a suture anchor was observed to provide satisfactory clinical outcomes in high-demand athletes with lateral ligament instability. Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle and expected return to sports at a mean of 16 weeks with a return to pre-injury level of the sport in 89% of elite athletes. Despite the return to the same level of competition, the club and the athlete should be made aware that associated injuries may delay return to sport, and symptoms may persist or recur. This review warrants a need for further high-level studies, which are sports-specific and injury-specific to assess return to play duration in professional athletes.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

The authors are responsible for the correctness of the statements provided in the manuscript. PROSPERO Systematic review Registration number—272923.

Funding

The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support were received.

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent

For this type of study formal consent is not required.