Correlation of anxiety and depression with ankle function in chronic ankle instability patients and analysis of risk factors

Abstract

BACKGROUND

Psychological comorbidities, such as anxiety and depression, in patients with chronic ankle instability (CAI) may impede ankle function improvement, although the precise nature of this association warrants further investigation.

AIM

To analyze the correlation of anxiety and depression with ankle function in patients with CAI and discussing the risk factors.

METHODS

This study included 116 patients with CAI, who were admitted to our hospital from July 2022 to July 2024. Anxiety and depression states of patients were assessed with the self-rating anxiety scale (SAS) and self-rating depression scale (SDS), respectively, and their ankle joint function was assessed with the ankle-hindfoot function score of the American Orthopedic Foot and Ankle Society. Further, the ankle function of patients with CAI with different anxiety and depression states was discussed. Furthermore, the Pearson correlation coefficient was used to analyze the correlation of anxiety and depression with ankle joint function in such patients. Univariate and multivariate analyses were conducted to investigate the factors affecting ankle joint function in patients with CAI.

RESULTS

Among the 116 patients with CAI, 97, 13, 5, and 1 cases demonstrated none, mild, moderate, and severe anxiety, whereas 95, 15, 6, and 0 cases showed none, mild, moderate, and severe depression, respectively. The average ankle joint function score was 74.82 ± 6.93 points. The ankle joint function in patients with CAI presented a significant downward tendency as the degree of anxiety and depression increased. Correlation analysis revealed that both the SAS and SDS scores of patients with CAI were significantly negatively correlated with the ankle joint function score. Univariate and multivariate analyses indicated that the risk factors affecting patients’ ankle joint function included early functional rehabilitation, visual analog scale, and SDS.

CONCLUSION

A substantial number of patients with CAI suffer from anxiety and depression, and these negative emotions, to a certain extent, harm the smooth rehabilitation of ankle joint function.

Key Words: Chronic ankle instability; Anxiety and depression; Ankle function; Correlation analysis; Risk factors

Core Tip: The incidence of chronic ankle instability (CAI) reaches up to 53%, with nearly half of affected patients reporting negative emotions such as anxiety and depression. These psychological factors have negatively affected both treatment efficacy and functional recovery of the ankle. This study involved 116 patients with CAI and revealed that approximately 20.0% demonstrated varying severity of anxiety and depressive symptoms. Statistical analysis revealed a significant inverse correlation between the severity of patients’ anxiety/depression symptoms and their ankle functional outcomes. The study further determined three independent risk factors impairing ankle functional recovery: (1) Inadequate early functional exercise; (2) Increased pain levels as measured by the visual analog scale; and (3) Higher scores on the self-rating depression scale. These results indicate that clinical management should incorporate comprehensive psychological assessment and targeted interventions to optimize functional outcomes. Further, implementing early rehabilitation exercises and effective pain management strategies may help mitigate psychological distress while facilitating ankle function restoration.

INTRODUCTION

Chronic ankle instability (CAI) represents a pathological manifestation of residual symptoms after severe ankle sprains and ranks among the most prevalent sports-related injuries[1,2]. Epidemiological statistics indicate that at least 2 million cases of acute ankle sprains are reported annually in the United States alone, with half of these individuals not engaged in sports activities[3,4]. This condition causes a limited range of motion, secondary tissue damage, restricted bone movement, and post-traumatic osteoarthritis, which systematically impairs proprioception, balance, and motor patterns, and may cause bilateral muscle weakness and H-reflex alterations[5]. A wide array of treatment options are available for CAI. These include first-line conservative therapies, such as neuromuscular rehabilitation, balance training, and non-steroidal anti-inflammatory drugs, as well as minimally invasive treatments, including arthroscopic surgery, steroid injections, and platelet-rich plasma injections[6]. However, a significant number of patients with CAI may experience negative emotions, including anxiety, depression, and even fear, both regarding the disease itself and the treatment process[7]. Allen et al[8] included 280 patients with CAI and revealed that 46.4% of the participants demonstrated adverse mental symptoms such as anxiety, depression, and post-traumatic stress disorder. These negative emotional states may be associated with factors such as persistent pain due to disease, functional limitations, sleep disturbances, unfulfilled high expectations regarding treatment, or fear of surgical procedures[9-11]. Moreover, Allen et al[12] revealed that compared with patients without psychiatric disorders, those with CAI accompanied by psychiatric diagnoses, such as anxiety and depression, demonstrate relatively lower improvement effects in postoperative foot-ankle outcomes and foot-ankle abilities.

Therefore, we hypothesized a certain correlation between the anxiety and depression status of patients with CAI and ankle joint function. An in-depth analysis of the risk factors affecting ankle joint function recovery in patients was conducted, to optimize the management strategies for ankle joint function restoration in such patients. Previous studies have primarily focused on the following aspects: (1) The correlation between anxiety/depression and pain or quality of life in patients with chronic ankle disorders; (2) The association of pain catastrophizing, body mass index, and depressive symptoms with pain severity in patients with orthopedic foot/ankle at tertiary referral centers; or (3) The effects of clinical interventions on function, mood, and quality of life in patients with CAI[13-15]. In contrast, our study demonstrates several novel contributions. First, by conducting an in-depth exploration of the bidirectional association between psychological factors and functional outcomes, we help determine the independent influence of mental state on ankle functional recovery addressing a gap in previous research that predominantly emphasized biomechanical factors while neglecting psychological aspects. Second, the independent risk factors identified through our multivariate analysis provide a foundation for targeted intervention strategies, offering direct evidence for establishing integrated treatment protocols.

MATERIALS AND METHODS

General information

In this research, the study cohort included 116 patients with CAI, who were admitted to The People’s Hospital of Pingyang from July 2022 to July 2024. The inclusion and exclusion criteria are detailed as follows.

Inclusion criteria: (1) CAI diagnosis confirmed through clinical and radiological examinations[16]; (2) Complete ligament rupture or absorption demonstrated by ultrasound and magnetic resonance imaging examinations, with ligament rupture or absorption observed during the surgical procedure, and grades 2-3 mechanical laxity of the ankle joint in the clinical anterior drawer test[17]; (3) A talar tilt angle difference of 10° in laxity between the two ankle joints and an absolute talar tilt angle difference of 15° indicated by the X-ray assessment; (4) Presence of functional impairments including ankle pain and gait disturbances; and (5) A history of ankle injury with a disease duration of no < 6 months.

Exclusion criteria: (1) Negative results in the talar tilt test and anterior drawer test; (2) History of invasive treatments such as surgery or minimally invasive procedures; (3) Incomplete recovery from a previous fracture on the affected side; (4) Co-existing rheumatoid arthritis, degenerative arthritis, or calcaneofibular ligament rupture; (5) Previous or current use of anti-anxiety or anti-depression medications; and (6) Presence of other diseases that may affect the recovery of ankle joint function, such as diabetes and neuromuscular atrophy.

Detection indicators

The self-rating depression scale (SDS) and the self-rating anxiety scale (SAS) were used to assess patients’ depressive and anxious emotions, respectively[18]. Both the SDS and SAS assessments consist of 20 items, adopting a 4-level scoring system. The higher the score, the more severe the degree of depression and anxiety of the patient. Specifically, an SDS score of < 50 is considered as no anxiety, 50-59 as mild anxiety, 60-69 as moderate anxiety, and ≥ 70 as severe anxiety. Further, a SAS score of < 53 is considered as no depression, 53-62 as mild depression, 63-72 as moderate depression, and ≥ 73 as severe depression.

The ankle-hindfoot function score of the American Orthopedic Foot and Ankle Society (AOFAS)[19] was used to assess patients’ ankle joint function from pain (40 points), function (50 points), and alignment (10 points) domains, with a total score of 100 points. Higher scores indicate better ankle function recovery. A score of < 70 indicates poor recovery, 70-79 indicates fair recovery, 80-89 indicates good recovery, and 90-100 indicates excellent recovery.

Statistical analysis

Statistical Package for the Social Sciences version 23.0 was used for data analysis. Categorical data were presented in the format of the number of cases (percentage), and the χ² test was adopted for inter-group comparison. Quantitative data were expressed as mean ± SD and one-way analysis of variance was applied for analyzing the quantitative data among multiple groups. The Pearson correlation coefficient was used to analyze the correlation of anxiety and depression with the ankle joint function of patients with CAI. Binary logistic regression was employed to analyze the factors affecting ankle joint function recovery in these patients. A P value of < 0.05 signified a statistically significant difference.

RESULTS

Anxiety and depression status in patients with CAI

Anxiety and depression status assessment of the 116 patients with CAI revealed an average SAS score of 35.46 ± 14.09 points and a mean SDS score of 40.96 ± 12.14 points. None, mild, moderate, and severe anxiety accounted for 83.62%, 11.21%, 4.31%, and 0.86% of the cases; whereas, none, mild, moderate, and severe depression were 81.90%, 12.93%, 5.17%, and 0.00%, respectively (Figure 1 and Table 1).

Figure 1 Patients’ anxiety, depression, and ankle joint function. SAS: Self-rating anxiety scale; SDS: Self-rating depression scale; AOFAS: American Orthopedic Foot and Ankle Society.

Table 1 The anxiety and depression status of chronic ankle instability patients, n (%).

Indicators	None	Mild	Moderate	Severe
SAS (points)	97 (83.62)	13 (11.21)	5 (4.31)	1 (0.86)
SDS (points)	95 (81.90)	15 (12.93)	6 (5.17)	0 (0.00)

SAS: Self-rating anxiety scale; SDS: Self-rating depression scale.

Ankle joint function of patients with CAI

The average AOFAS ankle-hindfoot function score among the 116 patients with CAI was 74.82 ± 6.93 points. Patients rated as excellent, good, fair, and poor in terms of ankle function accounted for 24.14%, 50.86%, 24.14%, and 0.86%, respectively (Figure 1 and Table 2).

Table 2 Ankle function in patients with chronic ankle instability, n (%).

Indicators	Excellent	Good	Fair	Poor
AOFAS ankle-hindfoot function score	28 (24.14)	59 (50.86)	28 (24.14)	1 (0.86)

AOFAS: American Orthopedic Foot and Ankle Society.

Ankle function of patients with CAI with different anxiety and depression states

The AOFAS ankle-hindfoot function scores of patients with CAI demonstrated a significant downward trend with the increasing severity of SAS and SDS (P < 0.05). Table 3 shows specific results.

Table 3 Ankle function of chronic ankle instability patients with different anxiety and depression states, mean ± SD.

Indicators		AOFAS ankle-hindfoot function score	F value	P value
SAS (points)	None	75.24 ± 6.93	3.537	0.032
	Mild	72.62 ± 5.74
	Moderate	67.80 ± 4.76
	Severe
SDS (points)	None	75.66 ± 6.57	6.179	0.003
	Mild	72.80 ± 7.20
	Moderate	66.50 ± 6.12
	Severe

The data were tested using one-way analysis of variance. SAS: Self-rating anxiety scale; SDS: Self-rating depression scale; AOFAS: American Orthopedic Foot and Ankle Society.

Correlation analysis between anxiety and depression and ankle function in patients with CAI

Pearson correlation analysis revealed that both the SAS and SDS scores of patients with CAI were significantly negatively correlated with the AOFAS ankle-hindfoot function score (r = -0.335, P < 0.001; r = -0.437, P < 0.001, Table 4).

Table 4 Correlation analysis between anxiety and depression and ankle function in patients with chronic ankle instability.

Indicators	AOFAS ankle-hindfoot function score
	r value	P value
SAS (points)	-0.335	< 0.001
SDS (points)	-0.437	< 0.001

The Pearson correlation coefficient was used for data testing. SAS: Self-rating anxiety scale; SDS: Self-rating depression scale; AOFAS: American Orthopedic Foot and Ankle Society.

Risk factors of ankle function recovery in patients with CAI

Univariate analysis of the factors affecting ankle joint function recovery in patients with CAI revealed that factors, such as gender and age, exhibited no significant correlation with ankle joint function recovery in these patients (P > 0.05). In contrast, early functional rehabilitation, visual analogue scale (VAS), Pittsburgh sleep quality index (PSQI), SAS, and SDS were intimately associated with ankle joint function recovery in patients with CAI (P < 0.05). The Binary logistic regression analysis revealed the lack of early functional rehabilitation (P = 0.042), high VAS (P = 0.018), and high SDS (P = 0.026) as all risk factors affecting the recovery of ankle joint function in patients with CAI (Tables 5 and 6).

Table 5 Univariate analysis of factors influencing ankle joint function recovery in patients with chronic ankle instability, n (%).

Indicators	Excellent and good (n = 87)	Non-excellent or good (n = 29)	χ2 value	P value
Sex			1.943	0.163
Male	41 (47.13)	18 (62.07)
Female	46 (52.87)	11 (37.93)
Age (years)			0.945	0.331
< 40	51 (58.62)	14 (48.28)
≥ 40	36 (41.38)	15 (51.72)
Early functional rehabilitation			4.369	0.037
With	58 (66.67)	13 (44.83)
Without	29 (33.33)	16 (55.17)
VAS (points)			5.432	0.020
< 3	60 (68.97)	13 (44.83)
≥ 3	27 (31.03)	16 (55.17)
PSQI (points)			4.603	0.032
< 5	50 (57.47)	10 (34.48)
≥ 5	37 (42.53)	19 (65.52)
SAS (points)			4.603	0.032
< 35 56	47 (54.02)	9 (31.03)
≥ 35 60	40 (45.98)	20 (68.97)
SDS (points)			5.671	0.017
< 40 50	43 (49.43)	7 (24.14)
≥ 40 66	44 (50.57)	22 (75.86)

χ² analysis was performed for data testing. VAS: Visual analogue scale; PSQI: Pittsburgh sleep quality index; SAS: Self-rating anxiety scale; SDS: Self-rating depression scale.

Table 6 Bivariate logistic regression analysis of factors influencing ankle joint function recovery in patients with chronic ankle instability.

Variable	β	SE	Wald	P value	Exp (β)	95%CI
Early functional rehabilitation	1.033	0.509	4.118	0.042	2.809	1.036-7.618
VAS (points)	1.224	0.519	5.558	0.018	3.402	1.229-9.415
PSQI (points)	0.909	0.498	3.328	0.068	2.481	0.935-6.588
SAS (points)	0.993	0.508	3.828	0.050	2.699	0.998-7.298
SDS (points)	1.179	0.528	4.987	0.026	3.251	1.155-9.149

Binary logistic regression analysis was conducted for data testing. VAS: Visual analogue scale; PSQI: Pittsburgh sleep quality index; SAS: Self-rating anxiety scale; SDS: Self-rating depression scale; CI: Confidence interval.

DISCUSSION

The prevalence risk of CAI ranges from 7% to 53% and can even be increased to 76% in patients with ankle sprain histories[20]. Further, the recurrence risk of CAI is substantial and potentially associated with proprioceptive deficits and increased ligament laxity[21]. To verify the potential correlation of anxiety and depression with ankle joint function in patients with CAI and investigate the factors affecting ankle function recovery, is study included 116 patients with CAI.

First, we identified that the average scores of the SAS and the SDS in patients with CAI in this study cohort were 35.46 ± 14.09 and 40.96 ± 12.14, respectively, with nearly 20.0% of the cases presenting varying degrees of anxiety and depressive symptoms. Apart from the adverse symptoms of the disease itself that cause daily activity limitations and quality of life deterioration in patients with CAI, other factors, such as the high uncertainty of prognosis resulting from the treatment regimens they undergo, the loss of self-identity due to functional limitations, and the restrictions on normal social interactions may all contribute to the development of different degrees of anxiety and depressive symptoms[22,23]. Further, the AOFAS ankle-hindfoot function score of the patients was 74.82 ± 6.93 points, with the excellent-good rate accounting for 75.0% and the non-excellent-good rate for 25.0%. Furthermore, as the severity of SAS and SDS symptoms in patients with CAI increased, the AOFAS ankle-hindfoot function score demonstrated a significant decreasing trend, indicating that negative emotions exert certain negative effects on the ankle joint function of these patients. Everhart et al[24] indicated that positive reframing as a coping mechanism among patients with postoperative knee surgery, to some degree, facilitates postoperative functional recovery and improves postoperative satisfaction, indicating the significance and benefits of positive mental coping for postoperative functional recovery. Lee and Park[25] reported a moderate correlation between emotional variations and functional outcomes during the postoperative rehabilitation process of collegiate athletes, indicating that positive psychological alterations are beneficial to postoperative rehabilitation to a certain extent, which is congruent with our observations. Further, Ostir et al[26] demonstrated a significant association between positive emotions and functional recovery after a stroke, specifically, positive emotions contribute to functional status restoration after a stroke, providing evidence in support of our results.

The correlation analysis indicates that both the SAS and SDS scores of patients demonstrated a significant negative correlation with the AOFAS ankle-hindfoot function score, reaffirming that negative emotions are, to a certain extent, prejudicial to the smooth rehabilitation of the ankle joint function in patients with CAI. Qi et al[27] revealed that negative emotions in patients after total knee arthroplasty presented a significant negative correlation with knee joint function and quality of life, which is analogous to our results. Similarly, the adoption of optimal lifestyle behaviors and positive emotions has been more favorable for low-back pain recovery[28].

Our univariate analysis revealed that early functional rehabilitation, VAS, PSQI, SAS, and SDS were closely correlated with ankle joint function recovery in patients with CAI. Multivariate analysis further revealed that the lack of early functional rehabilitation, high VAS, and high SDS were all risk factors affecting the excellent recovery of ankle joint function in patients with CAI. Based on the aforementioned results, we propose a comprehensive, three-pronged clinical intervention strategy for patients with CAI. (1) Early functional rehabilitation optimization: A multidisciplinary approach should be used to develop a structured, phased recovery plan. Initial rehabilitation should emphasize joint mobility exercises (e.g., ankle pumps, resistance band training), progressively advancing to balance training (e.g., single-leg stance, Bosu ball exercises), and functional movement drills (e.g., jump stabilization exercises). The integration of wearable technology (e.g., pressure-sensitive insoles) facilitates real-time monitoring of joint loading, ensuring proper form and preventing overtraining while improving patient compliance; (2) Personalized pain management for patients with high VAS scores: A tailored combination of pharmacological and non-pharmacological interventions should be implemented according to individual patient needs. Treatment options may include non-steroidal anti-inflammatory drugs combined with localized thermotherapy/cryotherapy, physiotherapies (e.g., pulsed radiofrequency therapy, extracorporeal shockwave therapy), or cognitive-behavioral pain management techniques; and (3) Structured psychological support for patients with high SDS scores: Patients demonstrating increased depression scores should receive targeted psychosocial interventions, including group-based psychoeducation highlighting the mind-body connection in chronic conditions. Evidence-based approaches, such as mindfulness-based stress reduction and relaxation training (e.g., diaphragmatic breathing, progressive muscle relaxation), should be incorporated. Individualized cognitive-behavioral therapy or counseling should be made available for cases of moderate-to-severe depression.

Several promising research directions warrant further investigation. First, a deeper investigation of the specific mechanisms by which anxiety and depression impair ankle function-particularly the role of inflammatory markers (e.g., interleukin-6), cortisol levels, and their association with muscle atrophy-would provide critical information about the underlying pathophysiology and inform clinical interventions. Second, randomized controlled trials comparing conventional management with a combined approach of early functional rehabilitation and psychological intervention could identify long-term therapeutic benefits, thereby validating more effective clinical protocols. Finally, the development of digital therapeutics, such as artificial intelligence-driven rehabilitation applications capable of remote monitoring and adaptive adjustment of treatment plans based on real-time pain and psychological assessments, may significantly improve precision in clinical management strategies. These directions hold significant potential for advancing both mechanistic understanding and practical therapeutic approaches in this field.

CONCLUSION

To sum up, this study reveals a significant negative correlation between the anxiety and depression status of patients with CAI and their ankle joint function. Hence, the more severe the degree of anxiety-depression status of the patient, the greater the possible negative impact on ankle joint function recovery. Further, risk factors affecting ankle joint function recovery involve the lack of early functional rehabilitation, high VAS, and high SDS. Strengthening early functional rehabilitation, pain management, and psychological management in patients with CAI can, to a certain extent, contribute to the smooth recovery of ankle joint function.