Is Prehabilitation Effective on Modified Broström Procedure for Chronic Lateral Ankle Instability?

Abstract

Category: Sports; Ankle Introduction/Purpose: The clinical features of chronic lateral ankle instability (CLAI) consist of mechanical and functional instability. Mechanical instability can be identified by physical examination of the injured anterior talofibular ligament laxity and can be treated with surgical ligament repair. Functional instability is more related to the patient's subjective symptoms due to decreased muscle strength, range of motion (ROM), coordination, and proprioception. In a previous report, ankle instability recurred in 16% after the modified Broström procedure (MBP) despite postoperative rehabilitation. Functional instability should be treated along with mechanical instability. We hypothesized that applying preoperative physiotherapy (prehabilitation) to patients with CLAI would improve postoperative functional recovery. We designed and performed a structured prehabilitation protocol for CLAI patients scheduled for MBP and investigated postoperative effects. Methods: Between March 2021 and December 2022, 28 patients were prospectively enrolled. Patients were randomly assigned to prehabilitation group (P) or non-prehabilitation group (N). Fourteen patients were enrolled in group P, and they started a 4-week prehabilitation protocol that continued the physiotherapy until 6 weeks postoperatively. Group N included 14 patients who received the same protocol of physiotherapy only for 6 weeks after surgery. The physiotherapy protocol consisted of peroneal muscle strengthening using Thera-band, gastro-soleus stretching, bipedal calf raises, single limb stance, step down with single limb, and box hop/quadrant hop. Outcome measurement was performed 1 day before MBP, 4 weeks and 6 weeks after surgery. The visual analogue scale, AOFAS ankle hindfoot scale, Karlsson scale, Foot and Ankle Ability Measure (FAAM-activities of daily living: ADL and FAAM-sports), Lower Extremity Functional Scale (LEFS), and ankle ROM were investigated. All data were statistically analyzed. Results: The mean ages were 27.0 ± 8.46(P), 29.7 ± 7.54(N), and there were 4 (28.6%, P) and 6 (42.9%, N) males. There were no statistical differences between the two groups in age and gender distribution. As shown in the attached table comparing clinical outcomes between the two groups, AOFAS ankle hindfoot scale, Karlsson scale, FAAM-ADL, and LEFS 1 day before MBP were statistically significantly higher in group P than in group N. Compared to group N, group P improved ankle inversion and eversion 1 day before MBP (p < 0.05 each). Although there was no statistical significance, the mean of Karlsson scale, FAAM-ADL subscale, FAAM-sports subscale, and LEFS were all maintained higher in group P than in group N from before MBP to 6 weeks after surgery. Conclusion: Our findings demonstrated the importance of functional recovery along with mechanical stability in the treatment of CLAI. Functional scores tended to be maintained higher in group P than in group N from preoperative to postoperative follow-up period. However, the number of participants included in our study was relatively small at 28. Larger studies with long-time follow- up will be needed. In conclusion, a structured prehabilitation may improve functional recovery when performing MBP for CLAI.