SLR - August 2014 - Keith Bortniker

Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes.

Reference:  Wataru M, Takao M, Yamada K and Matsushita T.  Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes.  The American Journal of Sports Medicine.  Vol. 42, No. 6.  1441-1446; June 2014.

Scientific Literature Review

Reviewed By: Keith Bortniker, DPM
Residency Program: Montefiore Medical Center

Podiatric Relevance: Lateral ligamentous reconstructive surgery often provides ligamentous stability to the ankle joint for patients with chronic lateral ankle instability, especially in the athlete patient population. In this particular patient group, early range of motion and return to function is extremely important, and often dictates return to sport. As such, this cohort analysis is important to assess the effectiveness of early rehabilitation with mobilization. We often strive to provide our patients with early range of motion and prompt return to function without causing harm. 

Methods: This study is a cohort analysis by the surgeons at Teikyo University School of Medicine in Tokyo, Japan. In a 4 year period, there were 69 athletes assessed who had an inversion sprain during their sport and had symptoms of chronic ankle pain/instability for more than six months. Diagnosis of talocrural instability was made with talar tilt angle greater than 5 degrees compared to the contralateral limb and anterior talar displacement greater than 6mm by the anterior drawer test. Inclusion criteria for the study included instability of the talocrural joint on stress radiography; stability of the subtalar joint with intact calcaneo-fibular ligament (i.e. talar tilt less than 10 degrees); no concomitance diagnosed on MRI; no prior surgery on the affected ankle; healthy contralateral ankle; and no response to nonoperative therapy greater than three months. A total of 33 patients (23 male and 10 female) were divided into two groups: the first group underwent an ATF ligament reconstruction with postoperative immobilization. The second group underwent an ATF ligament reconstruction with postoperative accelerated rehabilitation without immobilization. Group 1 comprised 15 patients while group 2 comprised 18 patients. The surgical procedure performed in both groups was an ATF ligament reconstruction using a gracilis tendon autograft from the ipsilateral knee followed by interference anchoring system. In group 1, the post-operative course was initiated with four weeks non-weightbearing with a short leg cast, followed by four weeks in a soft ankle orthosis. Protected weightbearing was initiated at two weeks post-operatively and full weightbearing at four weeks. Once the short leg cast was removed, strengthening and range of motion exercises were initiated with the guidance of a physical therapist. Proprioceptive training and sport-specific drills were implemented at six-seven weeks post-operatively. In group 2, a soft ankle orthosis was applied immediately post-operatively and ankle range of motion and strengthening exercises were initiated with a physical therapist two days post-operatively. The patients were able to weightbear as tolerated immediately post-operatively. Then, at 2-3 weeks post-operatively, sport-specific drills were initiated. In both groups, patients started jogging once pain-free weightbearing was achieved. Return to full training and pre-injury sport activities was initiated when sport-specific drills were achieved without difficulty. 

Results: Clinical outcomes were compared between groups pre-operatively and at two years post-op. There was no statistical significance between the study groups in regards to Karlsson-Peterson ankle function score, talar tilt angle and anterior talar displacement. However, the study determined one variable to be statistically significant between group 1 and 2. The mean return to previous athletic activities in group 1 was 18.5 weeks post-operatively and in group 2 was 13.4 weeks post-operatively. There was a statistically significant decrease in time to return to athletic activity in group 2 compared to group 1. This measure was the sole statistically significant data between the two treatment groups.

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