Identification of predictive factors influencing return to sport in patients following lateral ankle ligament surgery: A prospective cohort study

Abstract

Objective

Ankle sprains, particularly lateral inversion injuries, commonly lead to chronic instability and often require surgical interventions; however, 25% of patients fail to return to sport (RTS) because of persistent physical or psychological barriers. This study aimed to identify demographic, surgical, rehabilitation, functional, and psychological factors influencing RTS in patients following lateral ankle ligament surgery.

Methods

This was a single-center prospective cohort study that included 132 patients (aged 28.23 ± 5.93 years) who underwent lateral ankle ligament surgery at the Fourth Medical Center of PLA General Hospital. The data included demographics, surgical type, rehabilitation information, functional outcomes and psychological readiness. Statistical analyses included univariate/multivariate logistic regression and receiver operating characteristic (ROC) curves to identify factors and optimal cutoffs for RTS.

Results

The RTS rate was 52.27% (69/132), with a mean return time of 172 days. Compared with reconstruction, repair surgery demonstrated superior RTS rates (56.3% vs. 30.0%). The American Orthopedic Foot and Ankle Society (AOFAS) score73.5 (AUC = 0.92; sensitivity: 0.884, specificity: 0.587), visual analog scale (VAS) score≤3.5 (AUC = 0.78), and Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) score≥62.9 (AUC = 0.64) emerged as critical thresholds. Multivariate analysis revealed three independent predictors influencing RTS timing: surgical repair type (p = 0.005), psychological readiness (p < 0.001), and inpatient rehabilitation (p = 0.031).

Conclusions

In this study, successful RTS hinges on repair techniques, functional recovery (AOFAS score ≥ 73.5), pain reduction (VAS score ≤ 3.5), and psychological readiness (ALR-RSI score ≥ 62.9). Clinicians should prioritize individualized, milestone-driven programs to optimize outcomes and reduce delayed recovery.

Keywords

Ankle lateral ligament return to sport predictive factors

Introduction

Ankle sprains are among the most frequently occurring musculoskeletal injuries, with research indicating that the incidence of ankle sprains within the general population is 11.88%.¹ Ankle sprains are also significantly associated with athletic activities, representing between 16% and 40% of all injuries incurred in sports,² particularly in sports such as football³ and basketball.⁴ Among all ankle sprains, lateral inversion sprains are the most common, accounting for approximately 85%⁵ of all sprains. Approximately 40% of individuals who sustain lateral inversion sprain are estimated to develop a condition known as chronic ankle instability (CAI).⁶ For people who have failed nonoperative treatment or have sport demands, lateral ankle stabilization procedures are advised.

There is an increasing body of evidence indicating that surgical treatment of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) through the Broström procedure and its modifications reliably produces favorable results.^7–10 Unfortunately, many postsurgical patients continue to face a range of problems, such as instability and stiffness,¹¹ and approximately 25% of patients cannot return to sport (RTS).¹² This situation will persistently influence their professional and personal lives, possibly leading to certain socioeconomic challenges. Identifying specific factors that influence RTS could significantly enhance postoperative rehabilitation protocols and clinical decision-making, enabling more personalized patient management.

The process of RTS is one that necessitates the completion of a series of stages, each of which requires patients to be adequately prepared, both physically and psychologically.¹³ A recent systematic review by Li et al. reported RTS rates of 95% to any sport, 83% to preinjury level, and 87% to competitive sport following anatomic lateral ankle stabilization surgery.¹⁴ Nonetheless, there is significant variability in the definitions of RTS across various studies. Previous investigations have identified various factors potentially influencing RTS outcomes, including the patient's sex, the treatment approach employed, the presence of strength impairments, other physical alterations and other psychological factors.^14–16 Despite these efforts, most studies have focused on these factors in separately, and few have integrated the multidimensional aspects of RTS following lateral ankle ligament surgery.

Therefore, this study aimed to comprehensively evaluate the demographic, surgical, functional, and psychological factors influencing RTS following lateral ankle ligament surgery, and to establish evidence-based predictive thresholds. The findings are expected to offer valuable insights for developing individualized RTS protocols and establish a foundation for future prospective studies in this field.

Methods

Design and participants

The study was a single-center prospective cohort study, and its reporting conforms to STROBE guidelines.¹⁷ The research process was conducted following the Declaration of Helsinki. This investigation took place at one hospital in the Fourth Medical Center of PLA General Hospital and received approval from Medical Ethics Committee of Chinese PLA General Hospital (approval number: 2023KY152-KS001, date of approval: September 28, 2023). We consecutively enrolled all eligible patients who underwent lateral ankle ligament surgery at the Fourth Medical Center of PLA General Hospital between October 2023 and July 2024. The choice of surgical approach was based on the surgeon and the patients’ conditions. Surgery was performed by the same team of experienced and fellowship-trained foot and ankle surgeons in the same department, with a consistent surgical approach. The inclusion criteria were patients aged 18 to 50 years who underwent their first unilateral lateral ankle ligament surgery, 3 months to 2 years postoperatively, and regular participation in physical activity prior to injury. The exclusion criteria were ankle fractures, medial ankle ligament injuries, and injuries or disorders of other joints that may affect functional performance. All participants provided written informed consent, and the patient identifiers were rigorously de-identified to ensure complete anonymity throughout the study. In this study, a sample size of 10 times the variable was needed.

Assessment

The primary outcome was RTS after lateral ankle ligament surgery, including RTS, as well as the timing of RTS. The RTS criteria in this study were defined as patients’ resumption of participation in their defined sport, with this stage deemed a successful RTS outcome on the basis of individual satisfaction.¹⁸

Demographic information

Patient’s sex, age, height, weight, and body mass index (BMI) at the time of surgery were recorded from medical records. The Tegner activity scale,¹⁹ which ranges from 1 to 10 (where 1 represents walking on a flat surface and 10 indicates participation at an elite level), was employed to evaluate levels of physical activity.

Surgical information

The time intervals between injury and surgery, whether combined with other types of ankle injuries (arthritis, ankle impingement, cartilage damage, etc.), the number of other combined ankle injuries, and the type of surgery (repair or reconstruction) were also recorded from medical records.

Rehabilitation information

Data regarding the patient's history of preoperative rehabilitation, inpatient rehabilitation, duration of inpatient rehabilitation, and home rehabilitation were gathered by reviewing medical records and conducting telephone inquiries.

Physical function

The American Orthopedic Foot and Ankle Society (AOFAS) scale was used to evaluate the patient's postoperative physical function.²⁰ The AOFAS scale comprises three distinct subscales: pain, function, and alignment. The maximum achievable score on this scale is 100 points, with higher scores indicating fewer ankle limitations and better function. Additionally, the intensity of pain experienced by the patients was assessed via the visual analog scale (VAS), which is scored from 0 to 10, with higher scores indicating a greater degree of pain.

Psychological readiness

Patients completed the Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) scale assessment. This 12-item instrument was specifically developed to evaluate psychological readiness for RTS following lateral ankle ligament surgery and has been shown to be reliable and valid in the population.²¹ The scale encompasses three domains: emotions, confidence, and risk appraisal. The scores from each domain are aggregated and averaged, yielding a total score that ranges from 0 to 100. Elevated scores reflect a higher level of psychological readiness.

The data collection and subsequent analysis were conducted by two independent individuals, neither of whom were involved in the trial nor aware of its design and objectives.

Statistical analysis

The statistical analyses were conducted via the Statistical Package for the Social Sciences (SPSS) Version 27.0 (IBM Corp., Armonk, NY).

Data normality was assessed using Kolmogorov–Smirnov and Levene tests. Continuous variables are presented as mean ± SD, categorical variables as n(%).Group comparisons employed t-tests and ×2 tests or Fisher's exact tests, with p < 0.05 considered significant.

Predictors of RTS were identified through logistic regression followed by ROC analysis to determine optimal cutoff values.

The sample size calculation was based on the rule requiring 10 events per variable for analysis. With 14 primary predictor variables included in our study, a minimum sample size of 140 participants was needed. Our final 132 patients provided sufficient power to detect clinically significant differences at α = 0.05 level.

Univariate logistic regression analysis was employed to model the relationships between a range of predictor variables and the dependent variable, RTS. Subsequently, stepwise regression analyses were conducted for variables that were identified as significant in the univariate logistic regression analyses until the optimal model was derived. The predictor variables for RTS were identified on the basis of the logistic regression results. Receiver operating characteristic (ROC) curves were employed to analyze the predictive value of statistically significant variables, delineating the sensitivity and specificity of each predictor variable. The specificity was plotted as the horizontal coordinate, the sensitivity was plotted as the vertical coordinate, and the area under the curve (AUC) was calculated. The AUC was classified as follows: 0.5 to 0.69 was considered to be of some diagnostic value; 0.7 to 0.89 was considered to be of moderate diagnostic value; and greater than or equal to 0.9 was considered to be of high diagnostic value. The value of the variable exhibiting the highest sum of specificity and sensitivity was selected as the diagnostic threshold. The statistical analysis and presentation are consistent with the CHecklist for Statistical Assessment of Medical Papers (CHAMP) statement.²²

Results

In this study, data were collected from a cohort of 151 patients who underwent arthroscopic surgery of the lateral ankle ligaments. Of these, 14 patients were excluded: 8 patients presented with concomitant ankle fractures, 2 had associated medial ankle ligament injuries, and 4 presented with combined injuries or disorders of other joints. Additionally, complete data were unavailable for 5 patients. Consequently, the final analysis included a total of 132 participants, and all of their data were complete (Figure 1). Among these 132 patients, 69 returned to their preinjury sport level, resulting in a return rate of 52.27%. The average duration of RTS was 172 days, with a median of 100 days.

Figure 1.

Flow diagram.

There was a statistically significant difference in the VAS score, AOFAS score, and ALR-RSI score between patients in the RTS group and those in the non-RTS group. No statistically significant differences were observed in the remaining factors (Table 1).

Table 1.

Demographic and other data for participants who returned and did not return to preinjury sports.

Variables	Total (n = 132)	RTS (n = 69)	Non-RTS (n = 63)	p-Value
Sex, [n (%)]
Male	122	64 (52.5%)	58 (47.5%)	0.518
Female	10	3 (30.0%)	7 (70.0%)	0.518
Age （years, mean ± SD）	28.23 ± 5.93	27.78 ± 5.93	28.71 ± 5.93	0.369
BMI [kg/m², n (%)]
<18.5	4	1 (25.0%)	3 (75.0%)	0.080
18.5–23.9	52	27 (51.9%)	25 (48.1%)
24–27.9	66	39 (59.1%)	27 (40.9%)
≥28	10	2 (20.0%)	8 (80.0%)
Tegner （mean ± SD）	5.78 ± 2.17	5.93 ± 2.22	5.62 ± 2.12	0.416
Time between injury and surgery
≤3 months	37	18 (48.6%)	19 (51.4%)	0.550
3–6 months	26	16 (61.5%)	10 (38.5%)
6 months to 1 year	25	12 (48.0%)	13 (52.0%)
1–5 years	37	21 (56.8%)	16 (43.2%)
＞5 years	7	2 (28.6%)	5 (71.4%)
Combined ankle injuries
Yes	90	47 (52.2%)	43 (47.8%)	1.000
No	42	22 (52.4%)	20 (47.6%)	1.000
Number of combined ankle injuries (n)	1.39 ± 1.20	1.38 ± 1.13	1.41 ± 1.29	0.866
Type of surgery
Repair	112	63 (56.3%)	49 (43.8%)	0.054
Reconstruction	20	6 (30.0%)	14 (70.0%)	0.054
Preoperative rehabilitation
Yes	70	42 (60.0%)	28 (40.0%)	0.087
No	62	27 (43.5%)	35 (56.5%)	0.087
Inpatient rehabilitation
Yes	81	39 (48.1%)	42 (51.9%)	0.309
No	51	30 (58.8%)	21 (41.2%)	0.309
Home rehabilitation
Yes	83	47 (56.6%)	36 (43.4%)	0.261
No	49	22 (44.9%)	27 (55.1%)	0.261
AOFAS score	77.89 ± 15.38	84.78 ± 10.38	70.35 ± 16.46	<0.001
VAS	2.75 ± 2.18	2.12 ± 1.75	3.44 ± 2.39	<0.001
ALR-RSI score	51.16 ± 21.88	56.53 ± 21.3	45.26 ± 21.14	0.003

RTS: return to sport; BMI: body mass index; AOFAS: American Orthopedic Foot and Ankle Society; VAS: Visual Analog Scale; ALR-RSI: Ankle Ligament Reconstruction-Return to Sport after Injury.

The univariate regression analysis demonstrated that higher subjective ankle scores and increased psychological readiness were positively correlated with the likelihood of RTS. Conversely, higher pain levels were negatively correlated with this outcome. Additionally, repair surgery demonstrated a more favorable association with RTS (Table 2). Stepwise regression analyses were conducted on variables identified as significant in univariate logistic regression analyses. The results demonstrated that the type of surgery performed by the patient was a significant predictor of RTS, with a preference for repair surgery. The odds ratio (OR) value was 0.034 (range, 0.002–0.251), and the p-value was 0.005.

Table 2.

Univariate logistic regression to identify factors associated with RTS.

Variables	Regression coefficient	p-Value	Odds ratio (95% CI)
Age	−0.027	0.367	0.974 (0.917–1.032)
Sex	Reference: Female		1.711 (0.465–6.974)
Male	0.537	0.423	0.309 (0.015–2.589)
BMI	Reference: 18.5–23.9		1.337 (0.643–2.795)
<18.5	−1.176	0.322	0.232 (0.033–1.031)
24–27.9	0.291	0.437	0.736 (0.610–0.874)
≥28	−1.463	0.081	1.689 (0.615–4.787)
Time between injury and surgery	Reference: ≤ 3 months		1.385 (0.555–3.496)
3–6 months	0.524	0.314	0.422 (0.055–2.237)
6 months to 1 year	−0.026	0.960	0.994 (0.475–2.071)
1–5 years	0.326	0.485	0.975 (0.731–1.299)
＞5 years	−0.862	0.338	0.333 (0.111–0.896)
Combined ankle injuries	Reference: No		1.203 (0.502–2.942)
Yes	−0.006	0.986	1.944 (0.977–3.922)
Number of combined ankle injuries	−0.025	0.864	0.650 (0.318–1.314)
Type of surgery	Reference: Repair		1.602 (0.789–3.285)
Reconstruction	−1.099	0.036	1.068 (0.912–1.256)
Preoperative rehabilitation	Reference: No		1.085 (1.046–1.138)
Yes	0.665	0.060	0.885 (0.807–0.957)
Inpatient rehabilitation	Reference: No		1.102 (0.921–1.328)
Yes	−0.431	0.233	0.974 (0.917–1.032)
Home rehabilitation	Reference: No		1.711 (0.465–6.974)
Yes	0.471	0.194	0.309 (0.015–2.589)
Tegner	0.066	0.415	1.337 (0.643–2.795)
AOFAS score	0.079	<0.001	0.736 (0.610–0.874)
VAS	−0.306	0.001	0.974 (0.350–2.702)
ALR-RSI score	0.025	0.004	0.232 (0.033–1.031)

BMI: body mass index; AOFAS: American Orthopedic Foot and Ankle Society; VAS: Visual Analog Scale; ALR-RSI: Ankle Ligament Reconstruction-Return to Sport after Injury.

Regression analyses were conducted on a cohort of 69 patients who returned to the preinjury sport level, with the time taken to RTS. The findings from the stepwise regression indicated that the timing of the surgical procedure, the availability of hospital-based rehabilitation, and the ALR-RSI score were significant factors affecting the time taken to RTS (Table 3).

Table 3.

Results of multiple linear regression analyses with RTSS time as the dependent variable.

Variables	Regression coefficient	t-Value	p-Value
(Intercept)	−284.674	−2.930	0.005
Time between injury and surgery	Reference： ≤3 months
3–6 months	78.403	1.642	0.106
6 months to 1 year	2.660	0.050	0.961
1–5 years	123.973	2.724	0.008
＞5 years	−44.530	−0.405	0.687
Inpatient rehabilitation	−79.654	−2.208	0.031
ALR-RSI score	3.380	4.051	0.000

ALR-RSI: Ankle Ligament Reconstruction-Return to Sport after Injury.

ROC curves were established with variables that were significantly different via univariate logistic regression, and the AUC was calculated. The findings indicated that the AUCs of the VAS, AOFAS, and ALR-RSI scores exhibited a certain diagnostic utility. The VAS score exhibited a cutoff value of 3.5, with a specificity of 0.460 and a sensitivity of 0.783 (Figure 2). The AOFAS score demonstrated a cutoff value of 73.5, with a specificity of 0.587 and a sensitivity of 0.884 (Figure 3). Additionally, the ALR-RSI score had a cutoff value of 62.9, characterized by a specificity of 0.857 and a sensitivity of 0.478 (Figure 4).

Figure 2.

ROC curve for VAS.

Figure 3.

ROC curve for AOFAS.

Figure 4.

ROC curve for ALR-RSI.

Discussion

This study aimed to investigate the rate and timing of RTS following lateral ankle ligament surgery, as well as the factors influencing these outcomes. Our findings provide critical insights into the recovery process for patients undergoing surgical intervention for CAI and highlight both the challenges and predictors of successful RTS.

Return to sport rate and timing

Our results indicate that 52.27% of the participants successfully returned to their preinjury level of sport, with an average RTS time of 172 days (median: 100 days). This RTS rate and timing are consistent with previous studies, which reported ranges after lateral ankle ligament surgery, depending on various factors such as the type of surgery, patient demographics, and rehabilitation protocols.^23–29 The RTS rate in this study was slightly lower than that in the previous study,¹⁴ which may be related to the criteria used to determine RTS and the preinjury sport level of the study population. This discrepancy may reflect methodological differences, our study employed the RTS criteria requiring return to the identical preinjury sport with subjective satisfaction, whereas many included studies in the meta-analysis used less rigorous definitions. The median RTS time of 100 days, which may be slightly lower than the mean RTS time of 172 days, suggests that while many patients achieve RTS within a relatively short period, a significant proportion may still experience delayed recovery. This highlights the necessity for individualized rehabilitation that accounts for specific patient characteristics and the demands of their respective sports level.

Surgical technique and biomechanical implications

In our study, repair procedures involved the modified Broström technique with direct ligament repair, while reconstruction procedures utilized either autologous semitendinosus tendons or allogeneic tendons based on patient-specific factors. Compared with reconstruction, repair procedures demonstrated superior RTS rates (56.3% vs. 30.0%), which aligns with the findings of biomechanical studies showing that native ligament preservation enhances proprioception and dynamic stability.^8,23 The modified Broström technique, by preserving the original ligamentous anatomy, maintains the natural tension and feedback mechanisms for movements in sport. Reconstruction, often reserved for generalized laxity or failed repairs, may delay recovery because of graft incorporation and altered kinematics.^9,24 Our findings corroborate Li et al.'s 10-year follow-up, where anatomical repair yielded better functional outcomes than did reconstruction.⁸ It is important to emphasize that both surgical approaches can yield satisfactory clinical outcomes when applied to appropriate indications. Our clinical experience suggests that the decision between repair and reconstruction should consider not only the ligament condition but also the patient's sport-specific and RTS demands.

Functional recovery and pain modulation

An AOFAS score ≥73.5 emerged as a robust predictor (AUC = 0.92) of RTS, reflecting the importance of restoring pain-free mobility and proprioception. Scores below this threshold may indicate residual deficits in dorsiflexion or subtalar motion, which are critical for sport-specific movements.^30,31 Notably, a VAS score >3.5 reduced the likelihood of RTS by 26%, emphasizing the need for targeted pain management, as in previous studies.¹⁵ Higher pain levels impede rehabilitation adherence, delaying recovery and reducing RTS rates (sensitivity 0.783, specificity 0.460). Severe pain reduces rehab adherence and RTS success, whereas moderate pain patients may still recover. Individualized pain management and structured reassessment plans, including timelines and milestones, are critical for RTS.³² Effective pain management and individualized rehabilitation programs that address both physical and psychological aspects are crucial for optimizing RTS outcomes.³³

Psychological readiness

The ALR-RSI threshold of 62.9 highlights psychological barriers in 43% of non-RTS patients, which is consistent with the ACL literature, where fear of reinjury reduces RTS rates.^34,35 Sigonney et al. validated the ALR-RSI's predictive value in ankle cohorts, linking low confidence to delayed RTS.³⁶ Previous studies revealed that the ALR-RSI score was a better predictor of returning to the same preinjury level after surgery.³⁷ Integrating psychological readiness assessments into rehabilitation protocols helps identify at-risk patients, enabling targeted mental health support to address recovery barriers and improve RTS success.

Limitations and future directions

This study has several limitations. First, the cohort was limited to a single center, which may affect the generalizability of the findings. Additionally, the reliance on self-reported measures for psychological readiness and physical activity levels may introduce bias. We are designing multicenter studies and objective measures of physical performance to validate these findings further. Moreover, we investigated the long-term outcomes of RTS, including the risk of reinjury and the ability to maintain activity levels.

Conclusion

In conclusion, this study suggests that return to preinjury sport levels following lateral ankle ligament surgery may be influenced by surgical technique, postoperative function, pain levels, and psychological readiness. These potentially modifiable factors could inform rehabilitation strategies addressing recovery. Based on our findings, we recommend RTS after an AOFAS score of ≥73.5, a VAS score of ≤3.5 and an ALR-RSI score of ≥62.9. Further validation through larger prospective studies is warranted to establish more definitive RTS criteria.

Footnotes

List of abbreviations

Acknowledgements

The authors have cited the scales used in this study and made best efforts to check if permissions were needed to use them.

ORCID iDs

Pengpeng Feng

Kunli Ding

Xiao Li

Ethical approval

This work received approval from the Medical Ethics Committee of the Chinese PLA General Hospital (approval number: 2023KY152-KS001, date of approval: September 28, 2023).

Authors’ contributions

Pengpeng Feng designed the study, coordinated rehabilitation protocols, collected clinical data, and contributed to manuscript drafting. Kunli Ding performed statistical analyses, interpreted results, and co-wrote the methodology and results sections. Shuxian Li assisted in functional outcome assessments, contributed to study design, and participated in manuscript preparation. Xiuxiu Shi supported data collection and rehabilitation tracking, assisted in statistical validation. Jiahang Li assisted in demographic/surgical data acquisition and preliminary analysis. Jige Dong supervised surgical interventions, provided clinical expertise, and critically revised the manuscript. Yu Wang oversaw advanced statistical modeling, validated analytical frameworks, and edited the final draft. Xiao Li led overall study conceptualization, secured funding, and finalized manuscript approval.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Key Research and Development Program of China, Beijing Nova Program, (grant number 2023YFC3604905, 20230484400).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

AI tools

No AI tools were used in this manuscript.

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Picot

Lopes

, et al. Indicators of return to sports at preinjury levels following surgery for chronic ankle instability: comparison of ALR-RSI, AOFAS, and Karlsson scores. Orthop J Sports Med 2025; 13: 23259671241302078.