At the Foot and Ankle Center of Washington we are experts in conservative treatment of ankle sprains and weak ankles. We firmly believe that most people can be treated successfully without surgery. We have a throughout treatment guide specifically designed to rehabilitate even some of the weakest ankles. Be sure to see our Ankle Instability page, and our Ankle Sprains page before you consider surgery. 

If your ankle continues to feel unstable even with our conservative treatment plan, we understand that surgery may become your best option.

We have over 20 years of experience treating chronic ankle sprains and weak ankles surgically, and we will always put your best interest first. 


What specifically is causing my lateral ankle sprains/weak ankles?

In the human body there are many different tissues holding your bones and joints together. One of the strongest types of tissue holding your body together is called a ligament. Ligaments hold one bone to the next bone, and there are a huge number of them around each and every one of your joints.

 In your ankle there are many ligaments that each need to be tight and strong to keep your ankle functioning properly. Each ligament has a name and some are known to be weaker than others. When you have chronic ankle sprains caused by weak ankles, the most common ligament to cause trouble is called the Anterior Talofibular Ligament (a.k.a. ATFL) and the second most common is the Calcaneofibular Ligament (a.k.a. CFL). The ligaments  can be stretched, inflamed, partially or completely torn. There are multiple other ligaments around the outside of your ankle that hold the joint together and keep the ankle strong.

Although the ATFL and CFL are the most commonly injured, any number of the nearby ligaments can also be damaged.

When these ligaments are injured repeatedly and don’t heal properly they allow for the ankle joint to move in ways that can lead to damage. The cartilage, bones, and soft tissue that makes up your ankle joint will likely become inflamed with repeated injury, leading to stretching and eventual scarring around your ankle. 

Each of these things, ligament injury, cartilage injury, bone injury, and diffuse soft tissue injury can contribute to chronic ankle sprains, weak ankles and ankle pain. Each of them is addressed in a different way, and at the Foot and Ankle Center of Washington we are experts at determining what surgery you need to correct each individual component of your pain. 


Before Your Surgery:


Why do I need surgery?

If you’ve already failed conservative treatment that means the tissues around your ankle may be too weak, torn, or scarred to hold your ankle in place. Without surgery these tissues may never repair themselves and you will continue to have ankle sprains and experience pain.

Loose ligaments and soft tissues can allow for improper wear on your joints over time. Fixing the chronic ankle instability with a soft tissue procedure is easier to heal and less painful in the long run than trying to correct years of injury to the joints. 

What happens if I don’t have surgery?

If you choose not to have surgery, your chronically weak ankle(s) can be braced using firm shoes, or custom made ankle foot orthosis and strengthened with ankle exercises. We can help you determine which option is best for you, and we can guide you in finding the correct solution for you. 

If you choose not to have the surgery and you don’t support your ankle in some way, you will continue to sprain your ankle and you may even eventually end up breaking your ankle. There is a possibility that you could damage the cartilage and joints in your ankle joint which is very difficult to heal once damaged. 

Am I a good candidate for ankle stabilization surgery?

A good candidate for ankle stabilization is someone who has tried conservative treatment for several months, including strengthening exercises, custom orthotics and shoe modification with no relief. This includes individuals who suffer from repeated ankle sprains, making daily activities difficult, and individuals who tend to roll their ankles frequently due to having weak ligaments. 


During Your Surgery


While there are several variations to an ankle stabilization procedure. Choosing between procedures is based on what structures are weak in your ankle, the severity of the injury, and your surgeon’s preference. Deciding which procedure to perform requires a physical exam from a skilled doctor and possibly additional imaging studies like an MRI. The most common procedure is called a Brostrom procedure and it includes several key steps listed below. 

  • In the lateral ankle stabilization surgery the first thing your surgeon will do is position your foot so that they have the best possible view of the outside of your ankle. Then they will make a cut in the skin and dissect down to the damaged ligaments. The size of the cut can vary depending on which combination of procedures you personally need performed. 
  • The doctor will inspect your ligaments for tears, scarring and thinning. If the ligament is intact it will be cut, and tightened by sewing it back together in a new shorter and stronger position. If the ligament is already ruptured it will be cleaned, and sewn together in the stronger shorter position. 
    • Two ligaments in the ankle can be addressed this way, one is the ATFL discussed above, and the second is the Calcaneofibular Ligament (a.k.a. CFL). Both can be repaired, however, both do not always need repair. Certain tests before your surgery can help determine which, if not both, need repair. 
  • Your doctor may use strong thread/suture attached to small metal bone anchors to strengthen your ligaments even more by reinforcing them. The bone anchors may be made of metal, or multiple other materials. The purpose of the thread and anchors is to brace your own ligaments while they heal, and provide stability. The two anchors will be placed into your bone, and the strong thread will be tightened between the two anchors over top of the repaired ligaments. This is a very popular technique used by surgeons to strengthen the outside of your ankle. 
  • Once the ligaments are tightened and reinforced the tissue around the outside of your ankle is sewn back together carefully to bring additional stability to the repair. The skin incision is closed with stitches and a bandage is placed over the top. 
  • You will have a custom made splint around your ankle for the first week after surgery, possibly longer. The splint will prevent you from moving your ankle, which allows the stitches to heal. 

For severe weak ankles or Brostrom procedure revision:

In the rare circumstance that you have a severely weak ankle with little to no ligament left to repair, we may consider doing a more advanced procedure.

This procedure involves taking a graft tendon, and using it to reconstruct your ATFL and CFL ligaments. This procedure is significantly more complicated than the Brostrom procedure described above. An additional incision behind your ankle bone on the outside of your ankle will be required. The additional incision may be straight, or curved and can be 3-5cm long. The tendon graft is anchored in 2 places, one anchor in the calcaneus (heel bone) and one in the talus. Your surgeon skillfully recreates the ATFL and CFL ligaments using the tendon graft, tightening each newly constructed ligament independently to support your ankle. 

In some cases it will be necessary to move your heel bone over to limit the inward position of your heel.  If this more advanced procedure is necessary, your doctor will discuss exactly what they plan to do before the surgery. Every person is different, and your procedure may not follow exactly the protocol listed above. 


FAQ


What are the risks of surgery?

There are several common risks with surgery which are detailed well on our Pre Surgical Preparation page. In addition to these general risks, there are a few specific risks associated with the ankle stabilization surgery that you should be aware of. 

First and foremost, the risk of needing a second surgery with an ankle stabilization procedure is higher than some other common foot surgeries. This is because your ligaments, while sewn together in a tighter position during the surgery, have the potential to loosen again over time. We do everything possible to avoid these potential complications by providing you with the knowledge and material to recover completely before returning to activity. 

Second, there is a minor risk of over-tightening the ligaments of the ankle. You may feel like your ankle is unusually tight after ankle stabilization surgery, this is normal and may require some adjusting. 

There is a risk of injury to a specific nerve that runs down the top of your foot near the surgical site. This nerve provides feeling to part of the top of your foot, and if damaged may result in loss of sensation to part of the top of your foot. This is very rare, and at the Foot and Ankle Center of Washington we take many extra precautions to protect that nerve. 

The best way to avoid complications is to follow your doctor’s orders carefully after surgery, and report any sudden or painful changes in your ankle. Picking a skilled surgeon with extensive experience in sports medicine and ankle stabilization always helps reduce your risk of complications. 

What are the benefits of surgery?

The main goal of a successful ankle stabilization surgery is to reduce pain from chronic sprained ankles and possible future arthritis or injury. Ankle stabilization surgery with appropriate rehabilitation can allow you to return to your favorite shoe gear and activities. Everyone’s surgical experience is different, and your recovery and results may vary. We have many years of experience producing good results with safe recoveries. 

With the correct surgeon and post operative physical therapy, many individuals return to walking, running and even sports activities after the ankle stabilization surgery. 

When can I return to walking and driving after a Brostrom surgery?

You will be fully non-weight bearing for 2-4 weeks. That means you will not be able to walk, or stand without either crutches or a knee scooter. At 2-4 weeks after surgey you can start transitioning to weight bearing. This involves gradually placing increasing amounts of your body weight on the ankle. By 6 weeks you will likely be fully weight bearing and able to walk. All surgical results vary, and it can take longer to recover for some individuals. 

If we operate on the right foot, you will not be able to drive for several weeks. You will be wearing a surgical boot for 4-6 weeks after the surgery, which prevents you from driving. If we operate on the left ankle you may be able to drive much sooner, because the surgical boot will not be in the way of an automatic car’s pedals. We advise patients to avoid driving until you feel you can safely make an emergency stop. 

When can I return to sports after a Brostrom surgery?

With the proper physical therapy many athletic patients are able to slowly return to activity at the 12 week mark after surgery. If the surgery is more complex and involves additional bone anchors and tendon grafts, this may be significantly longer. 

While most people begin to return to activity at 8 weeks, it can take up to a year to retrain the ankle and fully return to normal after an ankle stabilization procedure. Close adherence to your surgeon’s recovery plan and attending physical therapy are key for the most speedy recovery. 

Will I need another surgery?

The Brostrom ankle stabilization surgery is a very good and reliable surgery for stabilizing a chronically weak ankle. A study published in 2017 looked at the outcomes of 669 Brostrom procedures and found the need for a second operation was only 1.2% on average 8.4 years after their Brostrom procedures. Now, it’s important to note that each ankle is different, and your ankle may be more severely injured than others, making a reoperation more likely. At the Foot and Ankle Center of Washington we’ve had immense success with the Brostrom procedure, and a very similar reoperation rate.

In the circumstance you have an unstable CF ligament or you do need a second operation, we would likely move on to the tendon graft procedure described above. 


I need an ankle stabilization surgery, what next?

If you’ve met with an experienced foot and ankle surgeon, and decided together that it’s time to pursue surgery, the next step is preparing for that surgery. We have a very informative Pre-Surgical Planning page specifically designed to help you navigate this next step. 

At the Foot and Ankle Center of Washington our experienced foot and ankle surgeon Dr.Hale will guide you through the preoperative process, details of the operation and post operative recovery. 

If you would like to avoid surgery at this time Dr.Huppin and Dr.Hale both focus on taking the most cosnervative treatment options possible first. Please make an appointment with either of our highly qualified foot and ankle specialists to assess your unique foot pain and every option available to you. 

Medical References:

  1. So E, Preston N, Holmes T. Intermediate- to Long-Term Longevity and Incidence of Revision of the Modified Broström-Gould Procedure for Lateral Ankle Ligament Repair: A Systematic Review. J Foot Ankle Surg. 2017;56(5):1076‐1080. doi:10.1053/j.jfas.2017.05.018

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