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

Understanding Chronic Lateral Ankle Instability

Chronic lateral ankle instability develops when the ligaments on the outside of the ankle fail to heal properly after one or more ankle sprains. The anterior talofibular ligament (ATFL) is the most commonly damaged, followed by the calcaneofibular ligament (CFL). When these ligaments remain stretched or torn, the ankle loses its natural restraint system and becomes prone to giving way during walking, running, and pivoting activities.

Approximately 20-30% of patients who sustain a lateral ankle sprain develop chronic instability despite appropriate initial treatment. Risk factors include severe initial injury, multiple sprains, hypermobility, high body mass index, and premature return to activity before complete ligament healing. Athletes in cutting and pivoting sports face the highest recurrence rates.

The functional consequences extend beyond ankle sprains. Chronic instability alters gait mechanics, increases the risk of ankle cartilage damage (osteochondral lesions), accelerates ankle arthritis, and reduces confidence during physical activity. Many patients unconsciously limit their activity level, leading to deconditioning and secondary musculoskeletal problems.

When Surgery Becomes Necessary

Surgical reconstruction is considered after 3-6 months of failed conservative treatment including physical therapy, ankle bracing, proprioceptive training, and activity modification. The specific criteria include persistent giving-way episodes despite rehabilitation, functional instability that limits desired activities, positive anterior drawer and talar tilt tests on examination, and MRI evidence of ligament attenuation or complete tear.

Pre-surgical imaging includes weight-bearing ankle X-rays to assess joint alignment and stress radiographs to quantify ligament laxity. MRI evaluates ligament quality, identifies concurrent osteochondral lesions or peroneal tendon pathology, and helps determine whether the remaining ligament tissue is adequate for direct repair versus requiring augmentation.

Patients who benefit most from the Brostrom-Gould procedure include those with moderate instability, adequate remaining ligament tissue, normal to mildly increased body weight, and realistic recovery expectations. Patients with severe laxity, ligament absence, generalized hypermobility, or high BMI may require augmented reconstruction techniques using tendon grafts.

The Brostrom-Gould Surgical Technique

The original Brostrom procedure, described in 1966, involves direct repair of the attenuated ATFL and CFL by shortening and reattaching the ligaments to the fibula. The Gould modification, added in 1980, reinforces this repair by incorporating the inferior extensor retinaculum—a strong tissue band overlying the repaired ligaments—as an additional layer of support.

Modern techniques use suture anchors drilled into the distal fibula to create secure fixation points for the ligament repair. The surgeon identifies the torn or stretched ATFL, shortens it to appropriate tension, and reattaches it to the fibula with suture anchors. The CFL is repaired similarly if damaged. The retinaculum is then advanced over the repair and secured, creating a double-layer reconstruction.

The procedure is typically performed through a 4-5 centimeter incision over the lateral ankle or arthroscopically through small portals. Arthroscopic Brostrom repair has gained popularity, offering smaller incisions, less soft tissue disruption, and the ability to simultaneously evaluate and treat intra-articular pathology such as osteochondral lesions, loose bodies, and synovitis.

Arthroscopic Versus Open Brostrom Repair

Arthroscopic Brostrom repair uses 2-3 small portals around the ankle to visualize and repair the ligaments from inside the joint. Advantages include direct visualization of the ankle joint to address concurrent cartilage damage, smaller incisions with less surgical scarring, reduced post-operative pain, and potentially faster early recovery milestones.

Open Brostrom repair provides direct access to the ligament structures and allows more precise tissue handling, particularly in revision cases or when ligament quality is poor. Some surgeons prefer the open approach for patients with significant ligament degeneration that requires more extensive tissue mobilization and repair.

Clinical outcome studies show equivalent long-term stability rates between arthroscopic and open techniques—both achieve approximately 90-95% patient satisfaction. The choice between approaches depends on surgeon experience, concurrent pathology requiring arthroscopic treatment, and patient-specific anatomic factors. Both approaches use the same Gould retinacular reinforcement principle.

Recovery and Rehabilitation Protocol

Weeks 1-2: The ankle is immobilized in a posterior splint with strict non-weight bearing. Elevation above heart level and ice therapy minimize swelling. Gentle toe and knee range-of-motion exercises maintain circulation. Sutures are removed at 10-14 days if incision healing is adequate.

Weeks 3-6: Transition to a walking boot with progressive weight bearing as tolerated. Ankle range-of-motion exercises begin under physical therapy guidance, starting with gentle dorsiflexion and plantarflexion. Inversion is restricted during this phase to protect the healing ligament repair. Stationary cycling and upper body exercises maintain cardiovascular fitness.

Weeks 6-12: Progressive strengthening, proprioceptive training, and balance exercises intensify. The walking boot is discontinued when gait is normalized, typically by week 8. Sport-specific training begins at week 10. Return to full activity including cutting, pivoting, and competitive sport occurs between weeks 12-16, guided by functional testing criteria.

Expected Outcomes and Success Rates

Published literature reports 85-95% good to excellent outcomes following Brostrom-Gould reconstruction, with long-term stability maintained in over 90% of patients at 10-year follow-up. Patient satisfaction correlates strongly with adherence to the rehabilitation protocol and realistic activity expectations during early recovery.

Return-to-sport rates exceed 90% for recreational athletes and 85% for competitive athletes. The average time to unrestricted sport participation is 4-6 months, though individual timelines vary. Athletes in high-demand sports like basketball, soccer, and tennis typically require the longer end of this range to achieve adequate neuromuscular control before competition.

Complications are uncommon but include superficial wound issues (3-5%), sural nerve irritation with temporary lateral foot numbness (5-8%), and recurrent instability (5-10%). Revision surgery for failed primary repair can be performed using tendon graft augmentation techniques with good salvage results.

Preventing Re-Injury After Surgery

Post-surgical ankle bracing during sport is recommended for the first 12 months to protect the healing ligament while neuromuscular control continues to improve. Lace-up ankle braces provide meaningful support without significantly restricting athletic performance. Many athletes continue bracing beyond 12 months during high-risk activities as a precaution.

Long-term proprioceptive training is the most important factor in preventing re-injury. Single-leg balance exercises on unstable surfaces, perturbation training, and sport-specific agility drills should continue as a maintenance program 2-3 times weekly indefinitely. Athletes who discontinue balance training show higher re-sprain rates.

Footwear selection plays a role in long-term ankle protection. High-top shoes provide minimal additional stability compared to low-tops—ankle braces are more effective. The key footwear features are a firm heel counter, appropriate traction for the sport surface, and accommodation for an orthotic insole if prescribed.

The Most Common Mistake We See

The biggest mistake patients make is assuming ankle instability will improve with time alone. Without structured rehabilitation—and in many cases surgical repair—chronically unstable ankles progressively damage the articular cartilage of the talus, leading to irreversible ankle arthritis. Each additional sprain causes incremental cartilage injury. Early surgical stabilization prevents this cascade and preserves the ankle joint for decades of active use.

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In-Office Treatment at Balance Foot & Ankle

Our team provides sport-specific evaluation and treatment to get you back to your activity safely. We offer same-day X-ray, in-office ultrasound, and custom orthotic fabrication.

Same-day appointments available. Call (810) 206-1402 or book online.

Frequently Asked Questions

How long after Brostrom surgery can I walk without a boot?

Most patients transition out of the walking boot at 6-8 weeks post-surgery when gait is comfortable and ankle strength is adequate. The transition is gradual—starting with short distances in supportive shoes and increasing over 1-2 weeks. Your surgeon and physical therapist guide this progression based on your specific healing rate.

Will I need physical therapy after Brostrom ankle surgery?

Yes. Physical therapy is essential for optimal outcomes and typically begins at week 3 with gentle range-of-motion exercises. Formal PT continues for 8-12 weeks, progressing through strength, balance, proprioception, and sport-specific phases. Patients who complete the full rehabilitation protocol achieve better stability outcomes than those who discontinue early.

Can the Brostrom repair fail?

Failure rates are approximately 5-10%. Risk factors include obesity, generalized ligament laxity, premature return to activity, and insufficient rehabilitation. If primary repair fails, revision surgery using tendon graft augmentation can restore stability with good results. Following the rehabilitation protocol closely minimizes failure risk.

Is the Brostrom procedure done under general anesthesia?

The procedure can be performed under general anesthesia, regional ankle block, or spinal anesthesia. Most patients receive an ankle nerve block that provides 12-18 hours of post-surgical pain relief combined with light sedation. This approach avoids general anesthesia side effects while ensuring a comfortable experience. Discuss options with your surgeon.

The Bottom Line

The Brostrom-Gould procedure provides reliable, long-lasting restoration of ankle stability for patients with chronic lateral ankle instability. Modern surgical techniques, whether open or arthroscopic, achieve excellent outcomes when combined with a structured rehabilitation program. Early surgical intervention prevents progressive cartilage damage and preserves ankle joint health for lifelong activity.

Sources

1. Vopat ML, et al. Brostrom-Gould Repair Versus Augmented Lateral Ankle Ligament Reconstruction: A Systematic Review and Meta-Analysis. Am J Sports Med. 2025;53(6):1567-1578.
2. Li H, et al. Arthroscopic Versus Open Brostrom Repair for Chronic Ankle Instability: Randomized Controlled Trial at 5-Year Follow-Up. Foot Ankle Int. 2024;45(12):1345-1354.
3. Guelfi M, et al. Long-Term Outcomes of Anatomic Lateral Ankle Ligament Repair: 10-Year Follow-Up Study. J Bone Joint Surg Am. 2025;107(8):712-720.
4. Song Y, et al. Return to Sport After Brostrom Procedure: Timing, Functional Criteria, and Reinjury Rates. Br J Sports Med. 2024;58(9):523-531.

Broström-Gould Ankle Ligament Surgery

Chronic ankle instability from repeated sprains can be permanently corrected with the Broström-Gould ligament repair. At Balance Foot & Ankle, Dr. Tom Biernacki performs this proven procedure to tighten and reinforce damaged lateral ankle ligaments, restoring stability for active lifestyles.

Learn About Our Ankle Instability Treatment → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Maffulli N, et al. The modified Broström procedure for chronic lateral ankle instability. Foot Ankle Surg. 2013;19(4):228-232.
2. Bell SJ, et al. A prospective evaluation of the Broström procedure for lateral ankle instability. Am J Sports Med. 2006;34(6):975-978.
3. Vuurberg G, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based guideline. Br J Sports Med. 2018;52(15):956.