Professor Bill Ribbans – The Athletic Ankle. When do Lax Ligaments Need Surgery? – Injury Rehab Network

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Professor Bill Ribbans was the expert guest speaker at the May event of the Injury Rehab Network with BASRaT. Over 300 people joined live for the online event where Bill provided a fascinating insight into ankle injuries, rehabilitation, and surgery.


With over 40 years of experience in sports medicine, Bill has worked as Chief Medical Officer and Honorary Surgeon for many sports organisations with a specialism in foot and ankle surgery. Bill has recently retired as an Orthopaedic Surgeon, completing his final surgery in May 2021. Professor Ribbans will continue to work in sports medicine as an Orthopaedic Physician and Sports Physician.

Bill has recently published a book Knife in the Fast Lane which provides insight into the history of sports medicine from Bill’s unique perspective as a surgeon. Bill shares his experiences and learning from working in elite and professional sport with athletes, coaches and the many professionals and individuals involved in aiming for peak performance. Proceeds from the book are supporting Prostate Cancer UK.

Bill’s presentation ‘The Athletic Ankle. When do lax ligaments need surgery?’ investigated ankle injuries, their diagnosis and treatment.

The Athletic Ankle

Professor Ribbans began with a summary of the ‘Athletic Ankle’ including the following ligaments which were discussed in detail during the presentation:

  • Lateral ligament (low ankle)
  • Syndesmosis ligament (high ankle)
  • Medial ligament (deltoid)
  • Spring ligament

Ankle Injuries in Sport

Bill presented data about injuries in sport, showing that ankle injuries are the number one injury in 24 out of 70 sports. Lateral ligament injuries account for 75% of ankle injuries. 40% of athletic injuries are ankle injuries.

Recovery and rehabilitation from ankle injuries are complex. Professor Ribbans provided some key points for sports rehabilitators to consider:

  • The initial inflammatory response usually lasts 7-10 days.
  • The proliferative phase can take from 6-8 weeks.
  • Remodelling and maturation can take anywhere from 6 weeks to one year.

The recovery process leads to full remodelled scar tissue (not new ligament tissue).

Sports Rehabilitators can support effective recovery by minimising bleeding and swelling, protecting and avoiding re-injury, and promoting type 1 collagen growth which is critical for a good recovery. Bill noted that it is often over a year before full strength is regained.

An Unsung Hero From 1966

Dr Lennart Broström pioneered a technique for the anatomical repair of lateral ankle ligaments in 1966. This technique is still the foundation for many surgical procedures for ankle injuries and is often reinforced with an internal brace.

Ankle Injuries and Surgery

Professor Ribbans has assessed the chance of a sprained ankle needing surgery in the UK. There are around 1.8m ankle sprains each year with 300,000 people attending A&E with an ankle injury and 270,000 people with chronic symptoms.

Approximately 2,500 surgical procedures are performed on ankle injuries each year. This equates to around 6% of all severe lateral ankle ligament injuries and around a one in 700 chance of surgery from any grade of injury.

Ankle Injury Rehabilitation

Bill discussed best practice for ankle injury rehabilitation including:

  1. A phased functional programme with RICE.
  2. Use of a semi-rigid brace to provide support and prevent re-injury.
  3. Balance exercises and proprioceptive training to develop postural control.

Professionals need to assess the need for functional management versus acute surgery.

Ankle Surgery

Bill described different surgical techniques and when surgery is advisable. Acute surgery is required for open injuries, avulsion fractures and dislocations. Autograft and Allograft surgeries may be required for torn ligaments. Anatomical repair is common including the Broström technique plus a synthetic internal brace with bone anchors and/ or an allograft. Evidence suggests that athletes require between 11-15 weeks on average before they can return to sport after an acute repair.

Assessment of Ankle Injuries

Professor Ribbans presented a range of techniques that can be used to assess ankle injuries. Dorsiflexion and external rotation tests are reliable.

MRI and CT scans can be useful for assessing damage to both ligaments and bones.

Ankle Injury

Problem Ankle Injuries

High ankle sprains are difficult to assess, and Bill described how an arthroscopy is an effective way to complete an assessment. Surgery may include screws, suture buttons and an internal brace. The tightrope can be used for surgery on broken ankles.

Medial and Deltoid Spring Ligament Injuries

Professor Ribbans discussed the less common and often harder to assess and treat medical and deltoid spring ligament injuries. These are often combination injuries with management options including repair of torn ligament and the Broström technique.

The spring ligament is topical with lots of current research and discussion. Bill described how the spring ligament is effectively a hammock under the mid-foot. Isolated spring ligament injuries can be distinguished from tibialis posterior dysfunction by asking the patient to re-create their fallen medial longitudinal arch by contracting the TP tendon. In an isolated spring ligament injury this will still be possible. Complete tears to the spring ligament will require surgery.


Bill kindly took the time to answer questions from the group as follows:

Question 1 – When is an arthroscopy required?
Answer – When assessments are inconclusive.

Question 2 – Can anchors or an internal brace be too tight?
Answer – Anchors are required to give support, not rigid stability and therefore should not be too tight as this could affect the range of movement and cause pain.

Question 3 – A patient has had the Broström technique and is struggling with a range of movement – is this common?
Answer – The internal brace may be too tight. The brace is often relatively tight initially as it will stretch over time but should not be too tight.

Question 4 – How can sports rehabilitators test to differentiate for deltoid and spring ligament injuries?
Answer – With the deltoid ligament there is often pain at the medial malleolus and with the spring ligament, pain is likely to be underneath the foot. Stress testing is usually the best way to assess these types of injury.

Question 5 – What are the main cause of pain associated with a high ankle sprain to the peroneal retinaculum?
Answer – Pain can be caused by swelling or a split in tendons.

Question 6 – How common are talus fractures?
Answer – Talus fractures are uncommon as they are usually only caused by a significant impact. These can also be avulsion fractures which are also rare.

Learn More

Professor Ribbans book, Knife in the Fast Lane provides insight into the history of sports medicine from Bill’s unique perspective as a surgeon.

Information about research from Professor Bill Ribbans is available on Research Gate.

Follow Professor Bill Ribbans

Keep up to date with the latest from Professor Bill Ribbans on his website and on Instagram.

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