Ankle Instability in the Hypermobile Patient: Ehlers-Danlos Syndrome and Generalized Laxity

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Chronic lateral ankle instability in patients with generalized ligamentous hypermobility — including Ehlers-Danlos syndrome (EDS) and hypermobility spectrum disorders (HSD) — presents a distinct clinical challenge because the standard Broström ligament reconstruction, which works reliably in the average patient, produces significantly higher failure rates in hypermobile patients. The structural deficiency is systemic rather than isolated to the injured ankle ligaments, requiring modification of surgical technique and rehabilitation to achieve lasting stability.

Recognizing Hypermobility

The Beighton score is the standard screening tool for generalized joint hypermobility: >6/9 points (in adults over 50, >4/9) suggests hypermobility. Key components relevant to foot and ankle: passive dorsiflexion of the little finger to 90 degrees, passive wrist dorsiflexion, knee hyperextension >10 degrees, and flat-handed floor touching with knees extended. Hypermobile EDS (hEDS) — the most common EDS subtype — requires a combination of Beighton score criteria, musculoskeletal symptoms, and exclusion of other connective tissue disorders. Many patients with recurrent ankle instability and hypermobility have never been formally diagnosed, and the evaluation of recurrent ankle instability should include Beighton scoring.

Why Standard Broström Fails

The standard Broström-Gould repair imbricated the native ATFL and CFL tissue, reattaching them to their fibular origin. In hypermobile patients, the repaired ligaments are inherently lax from connective tissue dysfunction — they stretch out and become incompetent again more rapidly than in patients with normal tissue quality. Published series of Broström repair in hypermobile patients show recurrence rates 2–3 times higher than in non-hypermobile patients at 5-year follow-up.

Augmented Reconstruction

Augmented Broström repairs using autograft (gracilis, semitendinosus) or synthetic ligament augmentation (InternalBrace — a suture tape construct providing load-sharing support while the repaired native ligaments heal) show substantially improved outcomes in hypermobile patients in early series. The augmentation provides the tensile strength that the native ligament tissue cannot reliably supply. Concurrent peroneal strengthening and neuromuscular rehabilitation — more intensive than standard post-Broström rehabilitation — is essential for optimizing dynamic stabilization. Dr. Biernacki at Balance Foot & Ankle evaluates ankle instability in hypermobile patients and discusses augmented reconstruction options. Call (810) 206-1402 at our Bloomfield Hills or Howell office.

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When to See a Podiatrist

Many foot conditions can be managed conservatively at home, but some require professional evaluation. See a podiatrist promptly if you experience:

• Pain that persists for more than 2 weeks despite rest
• Swelling, redness, or warmth that isn’t improving
• Numbness, tingling, or burning in the feet
• A wound or sore that is not healing within 2 weeks
• Any foot concern if you have diabetes or poor circulation
• Nail changes that suggest fungal infection or other problems

At Balance Foot & Ankle, our three board-certified podiatrists — Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin — provide comprehensive foot and ankle care at our Howell and Bloomfield Township offices. Most insurance plans are accepted.

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Patients with Ehlers-Danlos syndrome and generalized hypermobility face unique challenges with ankle instability. Our surgeons tailor treatment approaches for hypermobile patients.

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Clinical References

1. Tinkle BT, Bird HA, Grahame R, Lavallee M, Levy HP, Sillence D. The lack of clinical distinction between the hypermobility type of Ehlers-Danlos syndrome and the joint hypermobility syndrome. Am J Med Genet A. 2009;149A(11):2368-2370.
2. Grahame R. Joint hypermobility and genetic collagen disorders: are they related? Arch Dis Child. 1999;80(2):188-191.
3. Rombaut L, Malfait F, De Wandele I, et al. Medication, surgery, and physiotherapy among patients with the hypermobility type of Ehlers-Danlos syndrome. Arch Phys Med Rehabil. 2011;92(7):1106-1112.