Modified Broström-Gould Procedure: Lateral Ankle Ligament Reconstruction for Instability

Watch: Dr. Tom Biernacki, DPM

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

Anatomical Basis for the Broström-Gould Procedure

The lateral ankle ligament complex — consisting of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) — provides the passive restraint against excessive inversion and anterior translation of the talus within the ankle mortise. The ATFL is the most commonly injured ankle ligament and the primary target of lateral instability reconstruction; the CFL, which constrains the subtalar joint as well as the ankle, is addressed in patients with combined ankle-subtalar instability.

The Broström procedure — described by Lennart Broström in 1966 — directly repairs the attenuated lateral ligaments by imbrication (overlapping and suturing the elongated ligament tissue to reduce its effective length and restore normal tension). The Gould modification — added by E.H. Gould in 1980 — reinforces the repair by advancing the inferior extensor retinaculum over the repaired ATFL, providing an additional layer of support and adding proprioceptive benefit from this richly innervated structure.

Patient Selection and Preoperative Planning

Ideal candidates for Broström-Gould reconstruction are patients with mechanical lateral ankle instability — demonstrated by a positive anterior drawer test, positive talar tilt test, and positive stress radiographs — who have failed a structured 3–6 month functional rehabilitation program emphasizing peroneal strengthening and proprioceptive training. Patients should have sufficient native ligament tissue remaining for imbrication repair. Patients with generalized ligamentous laxity (Beighton hypermobility syndrome), previous failed reconstruction, morbid obesity, or severe hindfoot valgus may require augmented or modified techniques beyond standard Broström-Gould.

Preoperative MRI characterizes ATFL and CFL morphology (providing surgical planning information) and identifies associated pathology — osteochondral lesions, peroneal tendon tears, loose bodies — that requires concurrent treatment. Bilateral comparison stress radiographs document objective laxity.

Combined Arthroscopic and Open Technique

Many foot and ankle surgeons now perform ankle arthroscopy immediately before the open Broström-Gould reconstruction, using the same general anesthetic and surgical setting. Arthroscopic examination of the ankle identifies and treats: osteochondral lesions of the talar dome (which coexist with CAI in 20–25% of cases); anterolateral soft tissue impingement (Bassett’s lesion — a hypertrophied band of tissue that develops from chronic instability and impinges in the anterolateral joint); loose bodies; synovitis; and cartilage lesions that would be missed on preoperative MRI. Arthroscopic treatment immediately precedes the open ligament reconstruction, maximizing the benefit of a single anesthetic exposure.

Open Surgical Technique

Incision and Exposure

A curvilinear or J-shaped incision is made anteriorly and inferiorly to the lateral malleolus, centering over the ATFL origin on the fibular tip. The sural nerve — located posterior to the incision — and the superficial peroneal nerve branches — located anteriorly — must be identified and protected throughout. The peroneal tendon sheath is opened and the peroneal tendons are inspected for associated tears before proceeding with the ligament reconstruction.

Ligament Preparation

The ATFL is identified — typically a thin, elongated band of fibrous tissue remnant running from the anterior fibular tip to the talar neck. The ligament substance is divided in its mid-substance or at its fibular origin (depending on tissue quality), creating two limbs for imbrication. The CFL is similarly identified, running from the fibular tip to the calcaneus beneath the peroneal tendons; its repair is performed simultaneously for patients with subtalar component instability.

Imbrication and Repair

The ankle is held in neutral dorsiflexion and slight eversion (corrected alignment) while the ligament limbs are overlapped and sutured with multiple non-absorbable sutures in a pants-over-vest (imbrication) configuration. The sutures are placed to take up the slack in the attenuated ligament — recreating normal resting tension without overtightening, which would restrict normal range of motion. Suture anchors placed at the fibular attachment site provide secure fixation when the ligament tissue quality is insufficient for direct suture imbrication.

Gould Modification: Retinaculum Reinforcement

After completing the ligament imbrication, the inferior extensor retinaculum — the band of tissue running from the fibula to the lateral calcaneus — is mobilized and advanced superiorly to overlap the completed ligament repair. Two to four non-absorbable sutures secure the retinaculum to the fibula, providing reinforcement of the repair and recruiting this proprioceptively rich structure as an additional stabilizer.

Postoperative Rehabilitation

The repaired ankle is immobilized in a splint for 2 weeks to protect the suture lines during early healing. Transition to a CAM boot with partial weight-bearing begins at 2 weeks; full weight-bearing in the boot is achieved by 3–4 weeks. Physical therapy begins at 4 weeks: range of motion restoration, peroneal strengthening, and gradual proprioceptive retraining. Transition to a supportive lace-up ankle brace and regular footwear occurs at 6–8 weeks. Return to light jogging typically begins at 10–12 weeks; return to cutting activities and sport-specific training at 16 weeks; full return to competitive sport at 4–6 months.

Outcomes

The modified Broström-Gould procedure is one of the most successful orthopedic surgical procedures for its indication. Published series demonstrate 85–95% satisfactory outcomes with restoration of ankle stability, return to pre-injury activity levels, and high patient satisfaction. Long-term follow-up studies at 15–20 years show maintained stability in the majority of patients. Complications are uncommon — superficial wound issues, sural nerve irritation, and rare failure requiring revision occur in less than 5% of cases in experienced hands. For appropriately selected patients who have completed an adequate trial of functional rehabilitation, the Broström-Gould procedure offers an excellent and durable solution to chronic lateral ankle instability.

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Ankle Ligament Reconstruction in Michigan

The modified Broström-Gould procedure is the gold standard for chronic lateral ankle instability. Dr. Tom Biernacki performs this ligament reconstruction to restore ankle stability and prevent recurrent sprains at Balance Foot & Ankle.

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Clinical References

1. Broström L. “Sprained ankles. VI. Surgical treatment of chronic ligament ruptures.” Acta Chir Scand. 1966;132(5):551-565.
2. Gould N, et al. “Early and late repair of lateral ligament of the ankle.” Foot Ankle. 1980;1(2):84-89.
3. Bell SJ, et al. “Modified Broström procedure for lateral ankle instability: a long-term follow-up study.” Am J Sports Med. 2006;34(6):975-978.

In-Office Treatment at Balance Foot & Ankle

If home care isn’t resolving your your foot or ankle concern, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer same-day and next-day appointments at both our Howell and Bloomfield Hills offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.

Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.

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