A 32-year-old female recreational runner presents to physical therapy with a 3-month history of lateral ankle pain following an inversion sprain. She reports persistent swelling, instability during single-leg balance, and difficulty with cutting maneuvers. On examination, there is a positive anterior drawer test with 8 mm of translation compared to 3 mm on the contralateral side, and a talar tilt test showing 12 degrees of inversion laxity. Strength testing reveals 4/5 peroneal strength, and proprioception is impaired. Which of the following interventions is most supported by evidence for initial management in this patient with chronic ankle instability?
A) Immediate surgical reconstruction of the anterior talofibular ligament B) A 4-week program of progressive balance and proprioceptive training combined with peroneal strengthening C) Long-term use of a rigid ankle orthosis during all activities D) Corticosteroid injection into the ankle joint followed by rest
Answer
B) A 4-week program of progressive balance and proprioceptive training combined with peroneal strengthening
Explanation
This question assesses knowledge of evidence-based management for chronic lateral ankle instability (CAI), a common orthopaedic condition in physical therapy. The patient’s history of an inversion sprain, positive ligamentous laxity tests (anterior drawer and talar tilt), peroneal weakness, and proprioceptive deficits are classic signs of CAI, which often persists after acute ankle sprains due to neuromuscular impairments rather than solely mechanical instability.
- Option B (Correct): High-quality evidence from systematic reviews (e.g., from the Journal of Orthopaedic & Sports Physical Therapy) supports neuromuscular training, including balance exercises (e.g., on unstable surfaces), proprioceptive drills (e.g., single-leg stance with perturbations), and targeted strengthening of the evertors (peroneals) as the first-line intervention for CAI. A structured 4-6 week program has been shown to improve dynamic stability, reduce recurrence rates, and enhance functional outcomes like the Foot and Ankle Ability Measure (FAAM) scores without the need for invasive procedures initially.
- Option A (Incorrect): Surgical reconstruction (e.g., Broström procedure) is typically reserved for cases refractory to conservative management or with severe mechanical instability and functional limitations after 3-6 months of rehab. It’s not indicated as initial management per clinical practice guidelines from the Orthopaedic Section of the APTA.
- Option C (Incorrect): While bracing can provide short-term stability, long-term rigid orthosis use is not recommended as it may lead to dependency and does not address underlying neuromuscular deficits. Evidence favors functional taping or semi-rigid braces as adjuncts to rehab, not as standalone or long-term solutions.
- Option D (Incorrect): Corticosteroid injections are not evidence-based for CAI and may weaken ligaments further. Rest alone does not resolve proprioceptive or strength impairments; active rehabilitation is essential.
This approach aligns with the biopsychosocial model in PT, emphasizing patient education on activity modification and gradual return to sport.
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