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Lateral ligament reconstruction

115 citationsUpdated Oct 2026

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Overview

Lateral ligament reconstruction addresses chronic lateral ankle instability through anatomic repair or reconstruction, techniques that have demonstrated high success rates and reduced joint morbidity [1]. The primary surgical options include anatomic ligament repair with reinforcement and anatomic ligament reconstruction [2]. For patients with severe chronic instability, allograft reconstruction is a valid treatment option that yields satisfying outcomes [3]. While lateral ankle ligament reconstruction is a relatively stable treatment for chronic instability [4], the current recommendation favors open anatomic repair and reconstructions [29]. Surgical management encompasses anatomic direct repair, anatomic reconstruction using autograft or allograft, and arthroscopic repair [31].

Clinical outcomes are favorable across various approaches. Satisfactory results can be achieved through both arthroscopic and percutaneous anatomic ligament reconstruction [5]. Arthroscopic lateral ligament repair yields favorable short-term clinical outcomes [15, 22], and when feasible, it produces similarly favorable outcomes compared to open repair [33]. Open and arthroscopic ligament repair produced excellent comparable clinical outcomes at five-year follow-up [23]. Anatomic allograft reconstruction also produced similarly favorable outcomes compared to lateral ankle repair, including high patient satisfaction, high function and activity levels, and no revision surgeries in either cohort [74].

Specific indications and technique variations influence the choice of procedure. If disruption of the lateral ligaments is noted at operation, repair is indicated as it markedly increases the chances for a stable ankle [6]. A simple non-augmented repair is acceptable with a high success rate for selected individuals with good indications [26]. Lateral ligament augmentation demonstrates superior mechanical stability and functional outcomes compared to the modified Broström repair [45]. Anatomic reconstruction seems to give the best results, but may be more invasive than anatomic repair [36]. Other surgical options include reconstruction using the anterior half of the peroneus longus tendon for attenuated or deficient ligaments [17] and endoscopic ligament reconstruction, which is a safe procedure producing good clinical results with minimal complications [20]. Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes [32].

Anatomy & Pathophysiology

Ligament Anatomy and Injury Mechanisms

The most common mechanism of injury to the ankle ligaments is inversion of the foot [71]. With an inversion mechanism, the anterior talofibular ligament (ATFL) is the first or only ligament to sustain injury [71]. Specifically, forced plantar flexion and inversion injures the ATFL first, followed by the calcaneofibular ligament [115]. A total rupture of the lateral ligaments involves the calcaneofibular ligament and the posterior talofibular ligaments [71]. Anatomically, the ATFL inferior fascicle is connected to the calcaneofibular ligament, while the superior fascicle is an intra-articular structure [158]. The intra-articular position of an injured ATFL superior fascicle is thought to impair healing, similar to the resynovialization process of a ruptured anterior cruciate ligament remnant in the knee [158]. Conversely, an eversion injury causes damage to the deltoid ligaments [71], and hyperdorsiflexion trauma might cause an injury to the syndesmotic ligaments [71]. The accessory anteroinferior tibiofibular ligament is a normal anatomical finding that could lead to anterolateral impingement in cases with coexistent ankle instability [131].

Pathophysiology of Chronic Instability

Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments [71]. The dynamic congruency of the joint, which is influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability [85]. Three-dimensional talar shape seems not a factor in chronic mechanical ankle instability [85]. Histologically, apoptosis occurs in the ATFL of patients with chronic lateral ankle instability [187]. Neurologically, the number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction in patients with chronic ankle joint instability [108]. Patients with chronic ankle instability had longer electromechanical delay times in neutral but not when the ankle was placed in inversion [106].

Kinematic alterations extend beyond the ankle. Alterations of kinematics in athletes with chronic ankle instability were found not only at the ankle but also at hip joints during the side-cutting movement [90]. Individuals with chronic ankle instability demonstrated reduced sagittal plane motions at the hip, knee, and ankle joints, and reduced capacity of the stance limb to avail of its supporting base [98]. The chronic ankle instability, coper, and control groups displayed different ankle joint coupling patterns and coordination variability during a walking gait cycle [113]. Athletes with chronic ankle instability demonstrated dynamic stability deficits, and the direction of the jump can affect dynamic postural stability in the sagittal and frontal planes [132]. Single-leg drop landing movement strategies in participants with chronic ankle instability are altered compared with lateral ankle sprain copers, which may be responsible for the increased risk of injury during landing manoeuvres [134]. Further investigations are required to clarify the characteristic foot and ankle malalignment in chronic ankle instability to facilitate the development of efficient interventions [96].

Biomechanical and Radiographic Characteristics

The ATFL–posterior talofibular ligament angle decreases after ankle lateral stabilization surgery [28]. Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space [92]. Ultrasound can reliably measure the medial clear space of the ankle while doing dynamic stress manoeuvres [103]. The MLPP system is capable of measuring ATFL strain patterns and may be used to determine the relationship between limb position and ATFL strain patterns [118]. Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [109].

Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [129]. Sectioning of the deltoid ligament resulted in a 43% increase in tibiotalar contact area while peak pressures increased 30% [137]. Sectioning of the deltoid ligament alone results in valgus tilt of the talus and therefore chronic instability, which may lead to tibiotalar arthrosis [137].

Classification

Surgical Intervention Taxonomy: The literature identifies 80 different surgical interventions and variants for chronic lateral ankle instability, reflecting a lack of consensus for technical management [12]. These procedures are categorized into three main types: tightening of the ligament and capsular tissue, tightening associated with reconstruction, and tendon grafts using all or part of the tendon [12].

Anatomic vs. Tenodesis Outcomes: Anatomic lateral ligament reconstruction using allograft yields excellent clinical outcomes and accurate tunnel positioning confirmed by 3D-CT [16]. In comparative studies, significantly more patients in the anatomic reconstruction group achieved an excellent or good result according to the scale developed by Good et al. compared to the tenodesis group [34]. While there were no significant differences between the anatomic reconstruction and tenodesis groups in terms of Karlsson score values [34], seven patients in the tenodesis group graded their functional outcome as fair or poor due to reduced push-off power during sports [34]. Additionally, three patients in the tenodesis group suffered from recurrent giving way, resulting in fair or poor grades [34]. In the anatomic reconstruction group, five patients graded their outcome as fair or poor, with three citing limited dorsiflexion and two citing recurrent swelling and giving way [34].

Graft Source Variants: Lateral ligament reconstruction with allograft is a valid treatment option for patients with severe chronic lateral ankle instability [3]. Specific autograft options include the anterior half of the peroneus longus tendon [24], the long extensor tendon of the fourth toe [150], and the plantaris tendon, which permits anatomical reconstruction while avoiding sacrifice of the dynamic effect of the peroneus brevis muscle [38]. The modified Brostrom procedure with a semi-single ligament reconstruction provides as much initial stability as the two ligaments reconstruction procedure [40].

Other Considerations: Reconstruction of the unstable lateral ligament complex has a high rate of success [1]. Short and intermediate term results for lateral ligament reconstruction are good or very good in between 80 and 95% of cases [12]. An excellent or good result was achieved in 132 ankles, all of which had improved mechanical stability as measured radiographically [8]. Postural control is improved by reconstructing the lateral ligaments [43], and MRI assessment suggests an evolution in graft properties supporting the possibility of creating a viable ligament [42]. The ATFL–PTFL angle decreases after ankle lateral stabilization surgery [28].

Regarding the Castaing peroneus brevis plasty, Karlsson scores were significantly poorer principally due to "pain" and "residual instability" components [18]. The mean Karlsson score at 20 years' follow-up for this technique was 80/100 [18]. There was no difference in joint mobility or osteoarthritis between Castaing peroneus brevis plasty and other techniques at long-term follow-up [18]. Radiologic residual laxity showed greater varus with isolated direct repair [18], with a positive correlation between varus laxity pre-operatively and at follow-up in patients with isolated direct repair [18]. Degree of osteoarthritis was independent of technique but correlated with poorer functional scores [18]. Little real osteoarthritis was observed, with grades 2 and 3 representing only 3% of the series as a whole [18]. Patients with greater osteoarthritis showed significantly greater radiologic varus laxity at follow-up [18].

When treating chronic lateral ankle instability, surgeons should consider ligament quality [67]. Restoring the CFL plays a relevant role in lateral ligament repair, however sufficient time for ligament healing should be allowed before inversion stresses are applied [13]. Operative management of serious injury to the fibular collateral ligament of the ankle is satisfactory [7]. Reconstruction of the late injury to the fibular collateral ligament is best accomplished by the tenodesis of Watson-Jones, utilizing the peroneus brevis tendon as replacement tissue [7]. Improvement in the early treatment of the severe injury to the fibular collateral ligament can be assured by primary repair [7]. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures, though acute repair may give better results in professional athletes [27].

The anterior talofibular ligament is the most frequently ruptured and most important component of the lateral ligaments of the ankle [152]. The superior fascicle of the ATFL is anatomically and functionally distinct from the inferior ATFL fascicle, which shares features with the CFL to form the lateral fibulotalocalcaneal ligament (LFTCL) complex [151].

Clinical Presentation

Chronic ankle instability is defined by ongoing symptoms of at least 6 months, including recurrent sprains, pain, and impairments with perceived instability during sportive activity [93]. A detailed history of the patient's complaints is required to help differentiate between instability due to recurrent ligament injury and functional instability not related to increased ligament laxity [60]. Patients with chronic lateral ankle instability may exhibit functional deficits including maximal isokinetic strength measurements, posture, and gait control impairments [93].

Physical examination must include an assessment for generalised ligamentous laxity and of overall lower extremity alignment, particularly hindfoot varus malalignment [60]. Hindfoot varus malalignment, if not addressed at the time of surgery, may result in a high likelihood of failure of surgical repair or reconstruction [60]. The range of motion (passive and active) of the ankle and subtalar joints is noted during clinical assessment [60]. Gastrocnemius tightness is assessed during the physical examination for lateral ligament instability [60].

Stability testing relies on specific maneuvers to identify ligamentous deficiency. The anterior drawer test and hindfoot inversion tests are used to assess for lateral ligament laxity [60]. Clinical examination for chronic ankle instability includes the anterior talar drawer and talar tilt test [93]. Clinical suspicion of lateral ligament injury is scored on a four-grade scale ranging from Grade 0 (intact ligament) to Grade 3 (complete discontinuity with loss of integrity) [46]. Clinical suspicion is considered positive when scored Grade 3 [46]. Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury [116].

Diagnostics and treatment for lateral ligament instability should consider the deltoid ligament complex, especially the transverse calcaneonavicular ligament [102]. Operative procedures that only focus on part of the pathology should be approached with caution until assessment of a patient with ankle instability defines all deficiencies [58]. Surgical treatment for chronic lateral ankle instability is recommended when patients exhibit symptoms after 3 to 6 months of nonsurgical treatment and physical examination reveals tenderness [87].

Investigations

Plain radiography: Stress radiographs demonstrate 8 to 10 degrees of increased tilt of the talus in the ankle mortise compared with the normal ankle in the presence of mechanical instability [57]. Radiographic measurements show excellent agreement among reviewers and across trials, suggesting clinical reproducibility and surgical utility for defined parameters [178]. However, stress radiography is unreliable for distinguishing between intact and single-ligament disruption or between sequential transection models [73].

MRI: Preoperative MRI is a reliable and valid decision-making tool for selecting the surgical stabilization technique in patients with chronic lateral ankle instability [160]. Magnetic resonance imaging plays an increasingly important role in diagnosing foot and ankle abnormalities and planning surgical treatment [167]. Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI [177]. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination [177]. Adding the oblique axial-coronal plane to the MRI scanning protocol improves the diagnostic accuracy of ATFL injury [168]. A transformer-based multilabel deep learning model detects lateral and medial collateral ligament injuries based on MRI and outperforms CNN-based models [164].

CT: CT and MRI are excellent imaging modalities that help the timely diagnosis and appropriate treatment for combined impingement with circumferential lesions [174].

Other Considerations: Point-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries [179]. Pre-operative 3.0-T MRI demonstrates excellent accuracy in the diagnosis of syndesmotic ligament tears and allows for the visualization of relevant individual syndesmosis structures [144]. MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time [157]. The oblique axial magnetic resonance imaging scan revealed that the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles were 76.5 and 41.2%, respectively [161]. About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement [153]. More than half of athletes referred for MRI after suffering an acute ankle sprain had evidence of any lateral ligament injury without syndesmotic involvement [153]. Ligament injuries produce significant changes in the response of the ankle and subtalar joints to load as detected by the 3D stress MRI technique [155]. MRI assessment of tendon graft after lateral ankle ligament reconstruction suggests an evolution in graft properties and supports the possibility of creating a viable ligament [42]. The authors of a letter argue that their previous study using the SNQA protocol on MRI in 20 patients had already described early postoperative ligamentization at 3 months [41].

Treatment

Non-Operative

Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes [68]. The only satisfactory non-operative treatment for injuries of the fibular collateral ligaments of the ankle is immobilization in plaster for at least six weeks [148].

Operative

Indications: Reconstruction of the unstable lateral ligament complex using various operative techniques has a high rate of success [1]. Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, this systematic review helps reassure clinicians of their current practices [75].

Surgical Approach / Technique: The Broström procedure is the gold standard when anatomic reconstruction of the lateral ankle ligaments is attempted [163]. Anatomic stabilization techniques provide superior results in terms of functional outcome in patients suffering from chronic ankle instability compared to non-anatomic techniques [36]. The modified Broström procedure with a semi-single ligament reconstruction can provide as much initial stability as the two ligaments reconstruction procedure [40]. Restoring the calcaneofibular ligament plays a relevant role in lateral ligament repair, however sufficient time for ligament healing should be allowed before inversion stresses are applied [13]. Arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term [15]. Arthroscopic repair of the lateral ankle ligament, when feasible, produces similarly favorable outcomes compared with open lateral ankle repair [33]. The arthroscopic Broström procedure is a viable alternative to the open procedure, allowing the surgeon to address both lateral ligament instability and associated intra-articular pathologies without extensive dissection [101]. Lateral ligament augmentation demonstrates superior mechanical stability and functional outcomes compared to the modified Broström repair in treating chronic lateral ankle instability [45].

Implant Selection: Ligament reconstruction may offer superior results when there is a high preoperative ATFL-SNR [10]. Use of the LARS in this manner is a viable option in patients for whom the MBG procedure is relatively contraindicated [149]. Carbon fibre reinforcement for chronic lateral ankle instability has the advantage of preservation of inversion, maintenance of peroneal function and simplicity of insertion; in addition the implant does not stretch so the result will not deteriorate with time [79].

Other Considerations: All-arthroscopic technique for anatomic reconstruction for chronic lateral ankle instability leads to good clinical results [53]. This hybrid anatomic lateral ligament reconstruction technique using a peroneus longus autograft to substitute the native ATFL provides an alternative to anatomic reconstruction when direct repair is not possible [107]. Symptomatic chronic lateral ankle instability could be successfully managed with an easy and effective surgical reconstruction method [49]. The current reconstruction method led to a satisfactory clinical and functional midterm outcome shown by a numeric scale [80]. MRI assessment suggests an evolution in graft properties after lateral ankle ligament reconstruction and supports the possibility of creating a viable ligament [42]. An excellent or good result was achieved in 132 ankles, all of which had improved mechanical stability as measured radiographically, following reconstruction of the lateral ligaments for chronic lateral instability [8].

Revision: Revision lateral ankle ligament reconstruction improves symptoms, but outcomes reflect the revision context rather than indicating the procedure is inferior [21]. Over a 5-year follow-up period, primary modified Broström procedure produced better pain relief and functional recovery than revision to lateral ankle ligament reconstruction, despite a higher frequency of intra-articular lesions [25]. Surgical resection of the distal fascicle of the anterior inferior tibiofibular ligament and ligament reconstruction, when necessary, resulted in significant symptom improvement for anterolateral ankle impingement [54].

Complications

Nerve Injury: The immediate danger of lateral ligamentoplasty procedures includes neurological injury to the superficial terminal branches of the sural nerve and the superficial fibular nerve [12]. The intermediate dorsal cutaneous branch of the superficial peroneal nerve crosses the inferior extensor retinaculum and is the primary structure at risk during arthroscopic repair [173]. In a study of arthroscopic all-inside anterior talofibular ligament repair, 2 patients in the inferior extensor retinaculum reinforcement group experienced superficial peroneal nerve injuries, with symptoms subsiding by 3 months [165]. In a study comparing arthroscopic all-inside anterior talofibular ligament repair with and without inferior extensor retinacular reinforcement, one patient in each group presented with neuralgia of the superficial peroneal nerve that improved over time without treatment [173]. In a series of anatomic reconstruction with semitendinosus allograft, one patient experienced superficial peroneal neurapraxia that resolved and a sural nerve injury that did not recover [184]. In the same series, one patient experienced sural neurapraxia that resolved [184]. In a study of arthroscopic allograft reconstruction for chronic lateral ankle instability, 9.1% of patients experienced minor neurologic complications [81]. In a study of anatomic repair for anterior talofibular ligament injury, no patient had superficial peroneal nerve injury [171].

Wound and Soft Tissue Complications: The immediate danger of lateral ligamentoplasty procedures includes cutaneous complications, necessitating the avoidance of extensive subcutaneous detachment and conservation of the inframalleolar fat pad [12]. In a study of arthroscopic all-inside anterior talofibular ligament repair, one patient in the no-inferior extensor retinaculum reinforcement group presented with an abscess requiring local incision and drainage [173]. In a series of anatomic reconstruction with semitendinosus allograft, one patient developed a local wound infection with skin slough, which resolved with oral antibiotics and local wound care [184].

Hardware and Suture Complications: In a study of arthroscopic all-inside anterior talofibular ligament repair, one patient in the inferior extensor retinaculum reinforcement group had suture knot irritation around the acAL portal, which improved after knot excision under local anesthesia [165]. In a study comparing arthroscopic all-inside anterior talofibular ligament repair with and without inferior extensor retinacular reinforcement, two patients in the inferior extensor retinaculum reinforcement group had knot irritation causing mild discomfort [173]. In a study of anatomic repair for anterior talofibular ligament injury, no patient had knot reaction [171].

Recurrence and Instability: In a study of arthroscopic all-inside anterior talofibular ligament repair, 8.1% of patients in the repair group and 6.7% of patients in the repair with inferior extensor retinaculum augmentation group had anterior talofibular ligament retear on MRI, all of whom had recurrent chronic ankle instability with functional discomfort [165]. In a study of anatomic repair for anterior talofibular ligament injury, 6 patients (15.4%) suffered recurrent sprain after return to sport [171]. In a study of sports activity levels after surgical treatment for chronic anterolateral ankle instability, 3 patients in the tenodesis group suffered from recurrent giving way and graded their outcome as fair or poor [34]. In the same study, 2 patients in the anatomic reconstruction group graded their outcome as fair or poor because of recurrent swelling and giving way [34]. The presence of one or more risk factors for recurrence of instability after lateral ankle ligament repair should influence the surgical strategy to mitigate the risk of treatment failure [202].

Functional Limitations: In a study of anatomic repair for anterior talofibular ligament injury, 8 patients (25%) had range of motion deficiency with a feeling of ankle stiffness, including 5 patients with 5–10 degrees of dorsiflexion limitation and 3 patients with 5–10 degrees of inversion limitation [171]. In a study of sports activity levels after surgical treatment for chronic anterolateral ankle instability, 7 patients in the tenodesis group graded their functional outcome as fair or poor because they experienced reduced push-off power in the operated ankle while performing sports [34]. In the same study, 5 patients in the tenodesis group graded their functional outcome as fair or poor because they complained of limited dorsiflexion [34]. In the same study, 3 patients in the anatomic reconstruction group graded their functional outcome as fair or poor because of limited dorsiflexion [34]. In a long-term review of ligamentoplasty using the peroneus brevis, reduced tibiotalar dorsiflexion significantly reduced the number of good and very good results and was the only apparent cause of poor results [126]. In a study of arthroscopic allograft reconstruction for chronic lateral ankle instability, patients successfully returned to preinjury occupations within 5 months and sports within 9 months [81].

General Complication Rates: The reported complication rates for arthroscopic lateral ankle repair vary widely from 0% to 29%, including nerve pain, knot irritation, delayed wound-healing, and deep vein thrombosis [173]. In a study of immediate weightbearing after augmented modified Broström reconstruction, most patients achieved excellent functional outcomes by 6 weeks with minimal complications [72]. In a study of surgical fibular tendon stabilisation by isolated re-tensioning of the superior fibular retinaculum, the technique is associated with a very low complication rate [82].

Recovery

Light activity (weeks): Most patients achieve excellent functional outcomes by 6 weeks following immediate weightbearing after augmented modified Broström reconstruction, with minimal complications and high satisfaction [72]. Immediate weightbearing is a safe and practical postoperative rehabilitation method that can be applied after arthroscopic lateral ankle ligament repair [139]. An accelerated rehabilitation pathway after modified Broström repair is supported by findings indicating safety and efficacy in both athletic and general populations [145].

Full activity (months): Patients with chronic lateral ankle instability who underwent arthroscopic allograft reconstruction successfully returned to preinjury occupations within 5 months and sports within 9 months [81]. All 30 patients with chronic lateral ligament instability returned to normal sporting activity, including National Championships and Olympic representation [59]. Good patient-reported outcomes as well as excellent return to sport and return to work rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for chronic lateral ankle instability [69]. Most patients achieved return to sport before 1 year following immediate weightbearing after augmented modified Broström reconstruction [72]. All patients were able to return to their normal occupations after operation [172].

Rehabilitation protocol: Immediate weightbearing is a safe and practical postoperative rehabilitation method that can be applied after arthroscopic lateral ankle ligament repair [139]. An accelerated rehabilitation pathway after modified Broström repair is supported by findings indicating safety and efficacy in both athletic and general populations [145].

Functional milestones: Patients undergoing arthroscopic allograft reconstruction showed excellent clinical outcomes with 100% achieving minimal clinically important difference in scores at minimum 24-month follow-up [81]. Arthroscopic autologous tendon reconstruction yields superior ligament integrity and functional recovery compared with allograft reconstruction [156].

Other Considerations: Lateral ligament reconstruction with allograft leads to satisfying outcomes and reduced joint morbidity in patients with severe chronic lateral ankle instability [3]. Revision anatomical reconstruction of the lateral ligaments of the ankle augmented with suture tape provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up [83]. The literature identifies a clear deficiency in consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair [47]. The ALR-RSI is a valid, reproducible scale with which to identify patients who are ready to resume the same sport after ankle ligament reconstruction [147]. Distal rupture near the talar or calcaneal end was associated with delayed return-to-sport and inferior performance in resuming pre-injury sports level [191]. There is fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities [193].

Key Evidence

• [L5] Reconstruction of the unstable lateral ligament complex with use of a variety of operative techniques has had a high rate of success. [1] (10.2106/00004623-199407000-00021)
• [Paper] Anatomic ligament repair with reinforcement or anatomic ligament reconstruction are the two recommended options for lateral ligament reconstruction. [2] (10.1016/j.otsr.2016.06.026)
• [L4] Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability, leading to satisfying outcomes and reduced joint morbidity. [3] (10.1007/s00402-013-1911-6)
• [L1] Reconstruction of the lateral ankle ligament is a relatively stable treatment for chronic ankle instability. [4] (10.1016/j.injury.2020.05.031)
• [L3] Satisfactory clinical outcomes can be achieved through both arthroscopic and percutaneous anatomic ligament reconstruction. [5] (10.1186/s13018-024-05251-4)
• [L4] If disruption of the lateral ligaments is noted at operation, repair is indicated as it markedly increases the chances for a stable ankle. [6] (10.2106/00004623-198971090-00018)
• [L4] [7] (10.2106/00004623-195436040-00014)
• [L4] An excellent or good result was achieved in 132 ankles, all of which had improved mechanical stability as measured radiographically. [8] (10.2106/00004623-198870040-00015)
• [L3] However, ligament reconstruction may offer superior results when there is a high preoperative ATFL-SNR. [10] (10.1177/03635465251383564)
• [Paper] [12] (10.1016/j.otsr.2010.04.005)
• [L5] Restoring the CFL plays a relevant role in lateral ligament repair, however sufficient time for ligament healing should be allowed before inversion stresses are applied. [13] (10.1016/j.arthro.2017.04.065)
• [L4] The current systematic review demonstrated that arthroscopic lateral ankle ligament repair yields favorable clinical outcomes in the short term. [15] (10.1016/j.arthro.2018.02.034)
• [L4] Anatomic lateral ligament reconstruction using allograft led to excellent clinical outcomes and accurate tunnel positioning as confirmed by 3D-CT. [16] (10.1016/j.otsr.2018.10.008)
• [L4] Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments. [17] (10.1007/s00167-014-3072-8)
• [L4] [18] (10.1016/j.otsr.2010.04.004)
• [L2] Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure that produces good clinical results with minimal complications. [20] (10.1007/s00167-019-05793-9)
• [Paper] The editorial commentary concludes that revision lateral ankle ligament reconstruction (LALR) improves symptoms but outcomes reflect the revision context rather than indicating the procedure is inferior. [21] (10.1002/arj.70376)
• [L5] ALALR can produce favorable clinical outcomes in the short term, and it is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care in the future. [22] (10.1016/j.arthro.2018.05.001)
• [L3] Open and arthroscopic ligament repair produced excellent comparable clinical outcomes at 5 years follow-up. [23] (10.1007/s00167-023-07621-7)
• [L4] Lateral ligament reconstruction using the AHPLT may be a good surgical option for the treatment of chronic ankle instability. [24] (10.1177/0363546516675167)
• [L3] Over a 5-year follow-up period, primary MBP produced better pain relief and functional recovery than revision to lateral ankle ligament reconstruction (LALR), despite a higher frequency of intra-articular lesions. [25] (10.1002/arj.70354)
• [L5] A simple non-augmented repair is acceptable with a high success rate for selected individuals with good indications. [26] (10.1177/2325967124s00376)
• [L4] Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures, though acute repair may give better results in professional athletes. [27] (10.1007/s00167-012-2252-7)
• [L3] The ATFL–PTFL angle decreases after ankle lateral stabilization surgery. [28] (10.1007/s00167-020-06174-3)
• [L5] The current recommendation is for open anatomic repair/reconstructions. [29] (10.1016/j.csm.2020.07.004)
• [L4] Surgical procedures for managing chronic lateral ankle instability include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. [31] (10.5435/jaaos-d-16-00623)
• [L3] Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes. [32] (10.1016/j.otsr.2018.09.005)
• [L3] When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. [33] (10.1177/0363546517698675)
• [L3] [34] (10.1177/03635465020300010801)
• [L4] Anatomic reconstruction seems to give the best results, but may be more invasive than anatomic repair. [36] (10.1007/s00167-017-4730-4)
• [L4] The use of the plantaris tendon permits an anatomical reconstruction of the lateral ligaments while avoiding sacrifice of the dynamic effect of the peroneus brevis muscle. [38] (10.2106/00004623-198567060-00016)
• [L5] The modified Brostrom procedure with a semi-single ligament reconstruction can provide as much initial stability as the two ligaments reconstruction procedure. [40] (10.1007/s00167-008-0557-3)
• [L5] The authors of the letter argue that their previous study using the SNQA protocol on MRI in 20 patients had already described early postoperative ligamentization at 3 months. [41] (10.1177/03635465241255939)
• [L3] This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament. [42] (10.1177/03635465231225487)
• [L4] Postural control was improved by reconstructing the lateral ligaments. [43] (10.1007/s00167-015-3660-2)
• [L1] Lateral ligament augmentation demonstrates superior mechanical stability and functional outcomes compared to the modified Broström repair in treating CLAI. [45] (10.1186/s13018-025-06637-8)
• [L3] [46] (10.1002/ksa.12079)
• [L4] The review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair. [47] (10.1136/jisakos-2016-000064)
• [L4] Symptomatic chronic lateral ankle instability could be successfully managed with this easy and effective surgical reconstruction method. [49] (10.1016/j.injury.2003.09.035)
• [L4] All-arthroscopic technique for anatomic reconstruction for chronic lateral ankle instability leads to good clinical results. [53] (10.1016/j.arthro.2017.08.159)
• [L4] Surgical resection of the DF-AITFL and ligament reconstruction, when necessary, resulted in significant symptom improvement. [54] (10.1177/23259671241275959)
• [L5] Operative procedures that only focus on part of the pathology should be approached with caution until assessment of a patient with ankle instability defines all deficiencies. [58] (10.2106/jbjs.21.00726)
• [L4] All 30 patients with chronic lateral ligament instability returned to normal sporting activity, including National Championships and Olympic representation. [59] (10.1016/0020-1383(88)90073-3)
• [L5] [60] (10.1007/s00167-015-3789-z)
• [L4] Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. [67] (10.1007/s00167-022-07211-z)
• [L5] Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes. [68] (10.5435/00124635-200810000-00006)
• [L4] Good patient-reported outcomes as well as excellent RTS and RTW rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for CLAI. [69] (10.1007/s00167-022-06937-0)
• [L5] [71] (10.1007/s00167-010-1100-x)
• [L4] Most patients achieved excellent functional outcomes by 6 weeks, with minimal complications, high satisfaction, and return to sport before 1 year. [72] (10.1177/23259671251389196)
• [L5] Stress radiography did not distinguish between intact and single-ligament disruption and was unreliable in distinguishing between sequential transection models. [73] (10.1016/j.arthro.2016.11.008)
• [L3] When compared with lateral ankle repair, anatomic allograft reconstruction produced similarly favorable outcomes, including high patient satisfaction, high function and activity levels, and no revision surgeries in either cohort. [74] (10.1177/0363546515627817)
• [L2] Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, this systematic review helps reassure clinicians of their current practices. [75] (10.1136/jisakos-2018-000265)
• [L4] They have the advantage of preservation of inversion, maintenance of peroneal function and simplicity of insertion; in addition the implant does not stretch so the result will not deteriorate with time. [79] (10.1016/0020-1383(88)90169-6)
• [L4] The current reconstruction method led to a satisfactory clinical and functional midterm outcome shown by a numeric scale. [80] (10.1097/01.blo.0000128645.84131.af)
• [L4] Patients with CLAI who underwent arthroscopic allograft reconstruction successfully returned to preinjury occupations within 5 months and sports within 9 months, showing excellent clinical outcomes with 100% achieving minimal clinically important difference in scores at minimum 24-month follow-up, though 9.1% experienced minor neurologic complications. [81] (10.1016/j.arthro.2025.01.037)
• [L4] This simple and reproducible technique is associated with a very low complication rate and with excellent functional and anatomical outcomes. [82] (10.1016/j.otsr.2016.12.004)
• [L4] This technique provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up. [83] (10.1302/0301-620x.99b9.bjj-2017-0144.r1)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. [85] (10.1186/s12891-025-09458-2)
• [L1] [87] (10.1177/2325967119873852)
• [L3] Alterations of kinematics in athletes with chronic ankle instability were found not only at the ankle but also at hip joints during the side-cutting movement. [90] (10.1007/s00167-015-3745-y)
• [L4] Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. [92] (10.2106/jbjs.i.00084)
• [L4] [93] (10.1186/s13018-020-01847-8)
• [L1] Further investigations are required to clarify the characteristic foot and ankle malalignment in CAI to facilitate the development of efficient interventions. [96] (10.1186/s12891-021-04537-6)
• [L3] This was attested to reduced sagittal plane motions at the hip, knee and ankle joints, and reduced capacity of the stance limb to avail of its supporting base. [98] (10.1007/s00167-015-3744-z)
• [Paper] The arthroscopic Brostrom procedure is a viable alternative to the open procedure, allowing the surgeon to address both lateral ligament instability and associated intra-articular pathologies without extensive dissection. [101] (10.1016/j.eats.2016.03.003)
• [L5] Diagnostics and treatment for lateral ligament instability should consider the deltoid ligament complex, especially the TCL. [102] (10.1007/s00167-013-2708-4)
• [L3] Ultrasound can reliably measure the medial clear space of the ankle while doing dynamic stress manoeuvres. [103] (10.5435/jaaos-d-20-00597)
• [L3] Patients with chronic ankle instability had longer electromechanical delay times in neutral but not when the ankle was placed in inversion. [106] (10.1007/s00167-016-4243-6)
• [L4] This hybrid anatomic lateral ligament reconstruction technique using a peroneus longus autograft to substitute the native ATFL provides an alternative to anatomic reconstruction when direct repair is not possible. [107] (10.1177/0363546512455397)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [108] (10.1177/03635465231217490)
• [L2] Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. [109] (10.1016/j.jisako.2024.100361)
• [L3] The CAI, coper, and control groups displayed different ankle joint coupling patterns and coordination variability during a walking gait cycle. [113] (10.1177/23259671221139482)
• [Paper] The most common mechanism of injury to the lateral ankle ligaments occurs from a forced plantar flexion and inversion of the ankle, where the ATFL is injured first, followed by the CFL. [115] (10.1016/s0278-5919(03)00095-4)
• [L1] Ultrasound manifested high diagnostic accuracy in diagnosing chronic lateral ankle ligament injury. [116] (10.1186/s13018-018-0811-4)
• [L5] The MLPP system is capable of measuring ATFL strain patterns; thus, this system may be used to effectively determine the relationship between limb position and ATFL ankle ligament strain patterns. [118] (10.1186/s12891-021-04058-2)
• [Paper] [126] (10.1016/j.otsr.2013.12.003)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [129] (10.2106/00004623-199607000-00006)
• [L5] Although it reflects a normal anatomical finding, it could lead to anterolateral impingement in cases with coexistent ankle instability. [131] (10.1177/0095399703258697)
• [L3] Athletes with chronic ankle instability demonstrated dynamic stability deficits, and the direction of the jump can affect dynamic postural stability in the sagittal and frontal planes. [132] (10.1186/s12891-025-09307-2)
• [L3] These alterations may be responsible for the increased risk of injury experienced by individuals with CAI during landing manoeuvres. [134] (10.1007/s00167-015-3852-9)
• [L1] Immediate weightbearing is a safe and practical postoperative rehabilitation method that can be applied after arthroscopic lateral ankle ligament repair. [139] (10.1177/03635465241289946)
• [L2] Pre-operative 3.0-T MRI demonstrated excellent accuracy in the diagnosis of syndesmotic ligament tears and allowed for the visualization of relevant individual syndesmosis structures. [144] (10.1007/s00167-014-3399-1)
• [L4] These findings support the safety and efficacy of an accelerated rehabilitation pathway after modified Broström repair and justify its use in both athletic and general populations. [145] (10.1177/2325967126s00318)
• [L4] The ALR-RSI is a valid, reproducible scale with which to identify patients who are ready to resume the same sport after ankle ligament reconstruction. [147] (10.1177/2325967121s00010)
• [L4] The only satisfactory non-operative treatment is immobilization in plaster for at least six weeks. [148] (10.2106/00004623-196143020-00011)
• [L2] Use of the LARS in this manner is a viable option in patients for whom the MBG procedure is relatively contraindicated. [149] (10.1177/23259671221093968)
• [L4] Anatomic reconstruction of the lateral ankle ligaments using the long extensor tendon of the fourth toe appears to be an effective surgical option for chronic insufficiency of the lateral ankle ligament. [150] (10.1177/0363546510388882)
• [L5] The superior fascicle of the ATFL is anatomically and functionally distinct from the inferior ATFL fascicle, which shares features with the CFL to form the lateral fibulotalocalcaneal ligament (LFTCL) complex. [151] (10.1007/s00167-018-5188-8)
• [L4] The anterior talofibular ligament is the most frequently ruptured and most important component of the lateral ligaments of the ankle. [152] (10.2106/00004623-194931020-00013)
• [L3] About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement, while more than half had evidence of any lateral ligament injury without syndesmotic involvement. [153] (10.1177/0363546514529643)
• [L5] Ligament injuries produced significant changes in the response of the ankle and subtalar joints to load as detected by the 3D stress MRI technique. [155] (10.1016/j.orthres.2005.02.001)
• [L3] Arthroscopic autologous tendon reconstruction yields superior ligament integrity and functional recovery compared with allograft reconstruction. [156] (10.1186/s12891-025-09323-2)
• [L3] MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. [157] (10.1007/s00167-019-05581-5)
• [L5] [158] (10.1002/ksa.12538)
• [L3] Preoperative MRI is a reliable and valid decision making tool for the choice of surgical stabilization technique in patients with chronic lateral ankle instability. [160] (10.1016/j.arthro.2017.04.066)
• [L4] The oblique axial magnetic resonance imaging scan revealed that the prevalence of transverse ligament and posterior inferior tibiofibular ligament injuries in syndesmosis-injured ankles were 76.5 and 41.2%, respectively. [161] (10.1186/s12891-022-05220-0)
• [Paper] [163] (10.1016/j.csm.2015.06.004)
• [L4] The transformer-based model was able to detect lateral and medial collateral ligament injuries based on MRI and outperformed CNN-based models, demonstrating a promising performance in diagnosing CAI, especially patients with RCAI. [164] (10.1016/j.arthro.2024.05.027)
• [L3] [165] (10.1177/03635465211008097)
• [L5] Magnetic resonance imaging of the foot and ankle is playing an increasingly important role in the diagnosis of a wide range of foot and ankle abnormalities and the planning for their surgical treatment. [167] (10.5435/00124635-200105000-00005)
• [L5] The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury. [168] (10.1186/s13018-019-1102-4)
• [L3] [171] (10.1007/s00167-023-07658-8)
• [L4] All patients were able to return to their normal occupations after operation. [172] (10.1016/0020-1383(75)90065-0)
• [L1] [173] (10.2106/jbjs.20.01696)
• [Case_report] We suggest CT and MRI as excellent imaging modalities that can help the timely diagnosis and appropriate treatment for this combined impingement with circumferential lesions. [174] (10.1186/s12891-020-03584-9)
• [L3] Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. [177] (10.1007/s00167-022-07275-x)
• [L5] Radiographic measurements demonstrated excellent agreement among reviewers and across trials suggesting clinical reproducibility and surgical utility of the defined parameters. [178] (10.1177/2325967115s00041)
• [L3] Point-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. [179] (10.1016/j.injury.2017.07.015)
• [L4] [184] (10.1177/0363546515593942)
• [L5] [187] (10.1097/corr.0000000000002404)
• [L3] Distal rupture near the talar or calcaneal end was associated with delayed return-to-sport and inferior performance in resuming pre-injury sports level. [191] (10.1186/s12891-022-05260-6)
• [L1] There is, however, fair evidence showing a worse clinical outcome score in the combined ruptures, as well as a decreased return to full sports activities. [193] (10.1007/s00167-021-06610-y)
• [L4] The presence of one or more of these risk factors should influence the surgical strategy to mitigate the risk of treatment failure. [202] (10.1016/j.jisako.2025.100420)

See Also

• Chronic ankle instability
• Lateral ankle ligament injury
• Syndesmotic injury
• Ankle impingement

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[145] Paper 61. Immediate Weight Bearing after Modified-Brostrom Reconstruction: A Retrospective Review of an Accelerated Rehab Protocol. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00318

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