Ankle injuries are prolific but not benign. Kerkhoffs et al1 present a consensus statement on the diagnosis and treatment of acute lateral ligament ruptures that will help us to treat the majority of our athletes in an evidence-based way. However, is it reasonable to assume that all these injuries and athletes are equal? Should we necessarily treat high-level athletes in a different way than recreational athletes or is the proposed simple functional treatment sufficient for all?

Historical perspective

Complete cast immobilisation was the treatment of choice until the sixties, when Freeman introduced the concept of using coordination exercises to reduce the proprioceptive deficit and symptoms of the ankle ‘giving way’.2 Primary surgical repair became treatment of choice from 1966, after the PhD research of Broström.3 While Broström reported lower rates of long-term complaints after surgical intervention, he still recommended functional treatment initially due to the quicker return to work and sports.

Quick wins or long-term success

In high-level athletes, goals are often set in the short term and only the upcoming game really counts. From daily clinical practice we know that it may be possible to bring our athletes back to the pitch within two weeks, even with complete ankle ligament ruptures. However, should we facilitate these quick wins and early return to the same level of sports or should we take our responsibility and prevent them from long-term sequelae?

Nowadays, the majority of athletes with acute lateral ankle ligament injuries are treated with functional rehabilitation, but in the long term this approach is associated with a higher percentage of objective ankle instability and potentially associated with more residual complaints and intra-articular pathology.4 ,5

Interestingly, and in contrast to the significantly higher percentage of acute anterior cruciate ligament surgeries, primary surgical repair has not been the treatment of choice for lateral ankle ligament injuries. Surgical repair is typically preserved for the 10–20% of the patients with secondary chronic lateral ankle ligament laxity and functional instability.6

Based on the presented evidence on this topic, and considering the cost effectiveness, the operative complications and the postoperative stiffness associated with surgical treatment, the current treatment of choice for most acute injuries would be functional treatment with close follow-up to identify patients with complaints of chronic lateral ankle ligament laxity or related symptoms.1 ,4 ,6

Previous practice

However, the majority of the evidence originates from trials in recreational athletes and was conducted at least 20 years ago. The evidence reflects previous practice, whereby postoperative prolonged cast immobilisation was the standard with subsequent delayed return to sports and associated stiffness. Furthermore, the current evidence on surgical treatment also originates predominantly from trials with multiple surgeons performing operative treatment. It is likely that the surgical results might be superior if performed by an experienced foot/ankle surgeon.7 To strengthen this hypothesis, results from a recent randamised controlled trial with small sample size, indicate that—although in terms of recovery to preinjury level, long-term results of primary surgical repair correspond with those of functional treatment—primary surgical repair appears to decrease the prevalence of re-injury.5 The intra-articular collateral damage is barely discussed in the literature. It can be argued that this collateral damage can be addressed better with a primary surgical approach than with functional treatment, but there are no published data to support this argument.

A new twist on the athlete's ankle twist

Hence, given the potential improvement in overall surgical outcomes if performed by an experienced foot/ankle surgeon and the increased quality of postoperative care, it can be debated whether the existing evidence is still applicable to contemporary management of high-level athletes with ankle sprains.

Considering the limited evidence, more than ever an individually directed treatment approach in high-level athletes is advocated. Dealing with high-level athletes implies that we can only partially rely on the available evidence from the literature since this is mostly based on ankle injuries in recreational athletes or non-athletic populations, not on high-level athletes. The time of the season, athletes’ expectations, sports specific ankle load, individual history (of chronic instability), stage of the career, time from trauma to diagnosis, collateral ankle joint damage and access to an expert surgeon are all features to take into account when considering best evidence and eminence-based treatment of lateral ankle ligament injuries in the high-level athlete.

In a financially driven professional sports world, the immediate priority is the upcoming game. The tension between this immediate priority and possible increased time loss after primary surgical repair is a significant factor in avoiding surgery. However, after functional treatment, recurrent lateral ankle ligament injuries9 due to an increased laxity4 can lead to significant time loss of play later in the career and even potentially career-ending intra-articular cartilage lesions and impingement8 symptoms. Together with the fact that short-term results after primary repair by an expert surgeon will most likely be better,7 we can no longer refuse the high-level athletes surgery on an individual basis. Nowadays the postoperative cast immobilisation has been abandoned, effectively equalising both duration and intensity of the rehabilitation program after functional and surgical treatment.

Some are more equal than others

With the current evidence and eminence-based clinical update on treatment of lateral ankle ligament injuries, the treatment for high-level athletes cannot be uniform and a more individualised approach is advocated. Hence, it seems that ‘all acute athletes’ ankle injuries are equal, but some are more equal than others’.