Chronic ankle sprain and instability

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Many of our patients with chronic ankle instability complain of their ankles “giving way” and having constant or permanent swelling, obvious pain, decreased range of motion, or excessive motion from joint laxity. Most will recite a history of chronic ankle sprains, they will note that their ankles are getting “weaker and wear.” They are seeking treatment because they have been told by their doctors that if left untreated, their chronic ankle instability leads to cartilage deterioration with resultant degenerative arthritis with ankle fusion or ankle joint replacement surgery an ultimate outcome.

When we see these patients, they usually walk in, sometimes barely, with chronic ankle pain and a clear problem of maintaining a normal gait or walking. These people know that over-the-counter painkillers or prescription opioids are usually considered the first line of treatment in treating the ankle problem. While taking a prescription pain reliever sounds like common sense for a person in pain the direct effects are doing more harm than good.

When they sit on the examination table, familiar stories emerge of treatments that have not helped; this is what we hear, sound familiar to you?

My ankle is more swollen now than it was when I first hurt myself despite all the treatments I am doing

I came in because the last ankle sprain was bad. It happened weeks ago. My ankle is more swollen now than it was when I first hurt myself despite all the things I am doing for it. I stand all day at work and when I get home, I ice it. I am taking painkillers and anti-inflammatories. My doctor wants to send me for massage therapy. I have had that before, it did not really help. I am wearing copper ankle sleeves and have magnets in my shoes. I have tried everything except long-term immobilization which I cannot do because I have to work.

Every ankle sprain is now taking 6 months to heal

I came in because every ankle sprain is now taking 6 months to heal and I know it is not even healing. With every sprain, I am sent to get an X-ray or an MRI to see if anything is broken. I have been advised that I should use crutches or a cane for a few weeks and take the anti-inflammatories when I need them. I should ICE if I have to and get a better ankle brace. All the typical stuff.

I have had an ankle sprain since I was a teenager

  • I have had ankle sprains since I was a teenager more than 30 years ago. As I get older, the ankle sprains get worse. The last one was really bad. It is why I am here. I stopped working out my legs and running for 3 months. When I tried to run again, the pain was back. I went to a specialist and he told me my running days were over. The more running I do the more damage I am doing. I do not want to give up running.

I have been in physical therapy forever

  • I am here because I do not know what to do, I have been doing physical therapy “forever,” and it does not help. I am trying to exercise, mostly walking and doing some stretching. The doctor keeps telling me the same thing over and over Rest, Ice, Compression, Elevate – mostly Ice. Sometimes Anti-inflammatories and some pain medications. When I complain that these treatments are not helping, my doctor tells me, “We can consider surgery.” I do not want surgery.

Part 1: What causes chronic ankle instability

  • “Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries.”
  • Poorer ankle symptoms, pain, and ankle-related quality of life after 3-15 years.
  • A patient will report that they had suffered numerous ankle sprains and did not seek medical attention because “the treatment is always the same and usually doesn’t help.”
  • Doctors are not sure if ankle sprains ever really heal – a “new sprain’ is probably just an old sprain that never healed.
  • The deltoid ligament’s role in chronic instability.
  • Lateral ankle instability: Damage to the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament.
  • The overall quality of the existing lateral ankle ligament sprains Clinical Practice Guidelines are poor and the majority are out of date.
  • A discussion of Subtalar joint instability – a wandering talus.
  • Peroneal tendon pathology and chronic ankle instability.
  • Distal tibialis anterior tendinopathy.

Part 2: There is not much evidence for the aggressive treatment of ankle sprain in the athletic population

  • Therapy to address sprinting and change of direction may help ankle instability in athletes.
  • Chronic ankle instability in athletes – is more than treating one ligament it is treating the whole ankle joint.
  • Chronic ankle sprains in elite college football players entering the National Football League. Are they getting surgeries they do not need?

Part 3: Perceived instability – Fear of Injury.

  • Fear and frustration in college-age athletes going through rehabilitation.

Part 4: Treatments

  • The old treatments of RICE are outdated.
  • Are Fear and frustration cured with an ankle brace, an ankle sleeve, or a roll of tape?
  • Whole body vibration.
  • Balance training and Pilates.
  • Prolotherapy

Part 5: Chronic ankle instability surgery

Part 6 Chronic ankle instability and degenerative joint breakdown in the ankle


What causes chronic ankle instability?


In the image above, ankle ligament instability symptoms are described as ankle popping, loss of motion, ankle pain, arch cramping, referral foot and toe pain, crunching or cracking noise, numbness in toes, and loss of muscle strength.

“Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries.”

A paper was published in the journal Foot & Ankle International, in December 2020. (1) Its introduction provides a brief yet detailed summary of the current state of affairs in the treatment of chronic ankle instability.

“Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases.” What are the special cases? The authors suggest that failure of conservative care and physical rehabilitation would be an indication of surgery.

Below we will further discuss the surgical options that may have been presented to you. The authors here note: “Several operative options are available, including anatomic repair (fixing the existing damaged tissue), anatomic reconstruction (replacing the damaged existing tissue with a graft), and tenodesis (tendon transfer) procedures. The anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.”

In summary, in December 2020, your ankle was this way because it was undertreated or badly treated. Try conservative care first, then move on to various surgeries.

If you are reading this article, you have already been through conservative care, it did not help, and you are now exploring surgical and non-surgical options.

An ankle that never heals is forever unstable.

If you are reading this article, it is very likely that you have, for the most part, failed conservative treatment and you are looking for answers about an ankle that never heals.

In the Journal of Orthopaedics & Traumatology, Surgery & Research, (2) Orthopedist researchers say not everyone with chronic ankle instability will need surgery, however, in the course of providing conservative management of chronic ankle sprains, it is difficult to determine which of those patients will fail the treatment and will eventually need surgery.

  • “Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. “

Poorer ankle symptoms, pain, and ankle-related quality of life after 3-15 years.

A December 2023 report in the journal Annals of Medicine (3) writes: “Individuals with time-loss ankle sprains often experience residual symptoms and chronic ankle instability years after injury. Up to 90% of post-traumatic ankle osteoarthritis cases are associated with severe ankle sprain.” In this paper, doctors at the Doisy College of Health Sciences, Saint Louis University, and the University of Calgary examined  50 young adults (average age, 23 years) with a 3-to 15-year history of a youth-sport related ‘significant ankle sprain’ that disrupted youth sport participation. The researchers found that among the patients with a history of a more severe ankle sprain, those which sidelined the athlete with a loss of more than four weeks from sports participation at the time of injury “is independently associated with poorer ankle symptoms, pain, and ankle-related quality of life after 3-15 years. ” What the researchers here are saying is that people who had these severe ankle sprains will have ankle issues later in life and something will need to be done to prevent those outcomes. But what?

 

A patient will report that they had suffered numerous ankle sprains and did not seek medical attention because “the treatment is always the same and usually doesn’t help.”

Diagnosis, treatment, and prevention of future ankle sprains can be tricky. Leading sports medicine researchers routinely write about the problem of helping patients with chronic ankle sprains. Most studies acknowledge that it is difficult to even know if these patients are getting the right treatments. We are going to bounce around twenty years of research to show that treating a chronic ankle instability problem is a chronic problem for medicine.

If a patient can be identified with a proper ankle diagnosis, they may get the proper treatment

Let’s look at an August 2019 study from Erasmus MC University Medical Center Rotterdam. Here the researchers tried to help doctors by categorizing people like you into subcategories of an ankle sprain. Why? Because if a patient can be identified with a proper ankle diagnosis, they may get the proper treatment. The following results will probably not surprise you but it may suggest why you may have been receiving the “same old treatments that do not help.” This research was published in the Journal of Science and Medicine in Sport / Sports Medicine Australia. (4)

 

Mechanical instability patients, Perceived instability patients, and patients with recurrent sprains.

In this study, the doctors examined 206 patients who visited their general practitioner with a lateral ankle sprain 6-12 months prior to participating in the study.

  • The patients completed a questionnaire, and had a physical examination, radiography, and magnetic resonance imaging.
  • Then the patients were classified into the three recognized subgroups of chronic ankle instability:
    • mechanical instability patients (recurrent sprain, weakness, and instability thought to be caused by damage shown on imaging testing).
    • perceived instability patients – Patients who report hypermobility, weakness, and a “giving way sensation.”
    • and patients with recurrent sprains.

What’s the difference between patients? Where would you fit in?

  • A total of 192 participants were classified into the three subgroups of chronic ankle instability.
    • Of these participants, 153 participants were classified into subgroups and 39 could not be classified.
    • With the overlap between the subgroups and patients falling into more than one subgroup,
      • 59 were classified as having mechanical instability.
      • 145 having perceived instability
      • 30 have recurrent sprains.
    • The patients reporting only recurrent sprains or perceived instability were more often sports participants.
    • Participants with mechanical instability more often had tenderness on palpation of the anterior talofibular ligament, and showed developing or developed osteoarthritis in the talonavicular joint (where the ankle and foot meet) on X-ray.

What was the conclusion of this study?

  • Putting patients into the three recognized subgroups of chronic ankle instability may not be useful in helping patients.

What does this mean to you?

  • Based on the classification of the type of ankle patient you are, you may get surgery that will not help you. You may get non-surgical treatments that are accelerating your need for surgery.

Doctors are not sure if ankle sprains ever really heal – a “new sprain’ is probably just an old sprain that never healed

In the British Journal of Sports Medicine, researchers say that a new ankle injury is not always a new or acute one, but one that can be identified as an old, chronic injury with an increase in symptoms. (5)

Learning point:

  • A “new” ankle sprain may be an old ankle injury that went undetected and never healed.

The researchers of this study pointed out a scenario that we have seen frequently and many of the readers of this article can identify with:

  • An athlete/patient comes into a care center with an acute ankle injury.
    • In the medical history at the examination, it comes out that the patient had a previous ankle injury but did not seek medical attention for it.
    • The patient reports that before this “acute” injury that caused them to seek medical help this time, they did have ankle pain.

The problem of treatment:

  • Since this is a “first time,” to the doctor with this injury, they may treat it as a “new injury,” despite the patient telling of a previous injury.
    • Doctors then would go to “first time,” treatment protocols that would not be as effective for a 2nd, 3rd, or 4th ankle sprain event. The REST, ICE, and anti-inflammatory treatments.
    • Further, if this was a 2nd or 3rd or 4th ankle sprain event, and the patient reported no pain between these injuries and his/her appearance in the doctor’s office that day, this would again be treated as a “new injury,” the REST, ICE, anti-inflammatory treatments would be first recommended.

The researchers suggested to doctors that these “new injuries,” should not be treated as new injuries but rather as gradual wear and tear overuse injuries. An old injury that never really healed and appropriate treatment should be explored for a chronic injury.

In our experience, this is a major reason why patients tell us “the treatment is always the same and usually ineffective.” Later in this article, we will document our own research suggesting the treatment of patients with wear and tear and overuse ankle sprain injuries.

The deltoid ligament’s role in chronic instability

The deltoid ligament is a strong, dense triangle-shaped ligament on the inner (medial) ankle. It provides a counterbalance to the less strong outer ankle ligaments which are more prone to damage in injury. These are the anterior talofibular (ATFL), the calcaneofibular (CFL), and posterior talofibular (PTFL).

 

Isolated deltoid injuries are considered very rare and most happen when your ankle rolls outward or in combination with a high ankle sprain. As pointed out in a May 2023 paper in the Journal of Orthopaedic Surgery: (6) “When a prompt diagnosis is not formulated, ligament tears can remain untreated, and chronic ankle instability can result after acute lateral or medial ankle sprain. When the medial ligament complex (MLC), in particular the anterior fascicle of the deltoid ligament (tibiotalar joint stabilizer), is involved, rotational ankle instability can develop.”

Management in the acute phase of deltoid injury  remains a subject of debate

Also pointed out in a May 2023 paper in the Journal of Orthopaedic Surgery: (7) In the acute setting, deltoid insufficiency often coincides with multi-ligament injury to the ankle joint; syndesmosis injury, or ankle fractures. Management in the acute phase remains a subject of debate. Some orthopedic surgeons have a tendency towards repair, whereas most trauma surgeons often treat the deltoid nonoperatively. In the chronic setting, the ligament complex is often elongated (stretched) as a result of prolonged strain.

Diagnosis of deltoid injury remains a subject of debate

A February 2024 study in the journal Foot and ankle surgery (8) acknowledges: “There is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse. (In other words, the surgery is not often done).

Lateral ankle instability: Damage to the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament

In the updated 2024 medical publication Stat Pearls (9), the problems of lateral ankle instability and the progression to ankle osteoarthritis is observed this way:

“Lateral ankle instability is a complex condition that can, at times, prove difficult to evaluate and treat for general practitioners. The difficulty in evaluation and treatment is due in part to the ankle complex being composed of three joints: talocrural, subtalar, and tibiofibular syndesmosis. All three joints function in conjunction to allow complex motions of the ankle joint. The main contributors to the stability of the ankle joint are the articular surfaces, the ligamentous complex, and the musculature – which allows for the dynamic stabilization of the joints.”

The ligamentous complex – the ligament function

  • The anterior talofibular ligament’s (ATFL), primary function is to resist inversion in plantar flexion (your foot bends too far forward or downward will twist to the inside) and to prevent the talus from moving forward or away from the mortise contributing to problems of “widening of the ankle mortise.”
  • The primary functions of the calcaneofibular ligament (CFL)  are to resist inversion in neutral and dorsiflexed positions (prevents your foot from bending too far back) and also restrains subtalar inversion (your ankle from rolling over to the outside), which limits talar tilt (the outward roll of the ankle)within the mortise.
  • The posterior talofibular ligament is seen as a secondary ligament to support the function of the anterior talofibular ligament and the calcaneofibular ligament.

It is easy to see why then when you walk, your foot turns inwards causing pain, there is pain when walking up and down steps, when driving, if it is your right ankle, you have dull throbbing pain when stepping on gas or brakes. Your weakened ligaments are allowing for your talus to bang against the mortise causing loss of cartilage, pain, and the development of bone spurs.

The various risk factors for the development of bone spurs in the ankle.

A May 2020 paper published in the Orthopaedic Journal of Sports Medicine (1o) outlined the various risk factors for the development of bone spurs in the ankle. Among them were injuries to the Anterior talofibular ligament [ATFL] and the calcaneofibular ligament. Injuries to these ligaments were significantly associated with the presence of lateral osteochondral lesions (bone-on-bone situation developing on that side of the ankle). Further patients with BOTH Anterior talofibular ligament [ATFL] injury and calcaneofibular ligament [CFL] injuries were significantly more likely to develop bone spurs than were patients with single-ligament injuries.

A message to take home is that bone spurs develop because of ligament injury. A comprehensive full-ankle approach to treating ligaments may be a valid way to prevent the development of bone spurs. Surgical repair of one ligament, while successful for many, will not be successful for all. At our clinic, we help patients like this with dextrose or platelet injections into the ankle to strengthen and support the ankle ligament complex.

The overall quality of the existing lateral ankle ligament sprains Clinical Practice Guidelines are poor and the majority are out of date.

In 2019 researchers questioned the use of and the application of guidelines that doctors should be using to treat acute ankle sprains. This was published in the journal BioMed Central Musculoskeletal Disorders (11) by researchers led by the Australian National University. Concerns are still current in 2024 as we will see in the supportive research.

“Acute lateral ankle ligament sprains are a common injury seen by many different clinicians. Knowledge translation advocates that clinicians use Clinical Practice Guidelines to aid clinical decision-making and apply evidence-based treatment. The quality and consistency of recommendations from these Clinical Practice Guidelines are currently unknown.” (Note: This is 2019 talking). . . The overall quality of the existing lateral ankle ligament sprains clinical practice guidelines are poor and the majority are out of date.”

Here are the latest Clinical Practice Guidelines presented by the American Academy of Orthopaedic Surgeons

  • Almost all ankle sprains can be treated without surgery. Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately.

A three-phase program guides treatment for all ankle sprains—from mild to severe:

  • Phase 1 includes resting, protecting the ankle, and reducing the swelling.
  • Phase 2 includes restoring range of motion, strength, and flexibility.
  • Phase 3 includes maintenance exercises and the gradual return to activities that do not require turning or twisting the ankle. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities)—such as tennis, basketball, or football.
  • This three-phase treatment program may take just 2 weeks to complete for minor sprains or up to 6 to 12 weeks for more severe injuries.

Recommendations also include:

  • The RICE protocol. Rest, Ice, Compression, Elevate
  • Medication. Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Physical therapy.

Despite the fact that acute ankle sprains are among the most commonly seen injuries in the emergency department, a standardized protocol for its management has not been established.

In July 2022, an international team of clinicians writing in the journal Frontiers in Medicine (12) wrote: “Despite the fact that acute ankle sprains are among the most commonly seen injuries in the emergency department, a standardized protocol for its management has not been established. Furthermore, the (variety) of interventions and outcomes examined in this (study examining previous research), and the range in quality of these studies make it difficult to propose a standard algorithm for acute ankle sprain management.

Based on this umbrella review, non-surgical treatment is effective in managing acute ankle sprains, and functional treatment (mobilized ankle as opposed to immobilization) seems to be superior when compared to immobilization. Moreover, paracetamol and opioids are as effective as NSAIDs in reducing pain, thus they represent an alternative treatment option. Manipulative and exercise therapy could be also recommended, especially during the initial recovery phase, to prevent reinjury, and to restore dorsiflexion (the ability to point your toes upward).

A discussion of Subtalar joint instability – a wandering talus.

The subtalar joint is the joint of the heel and the talus. Subtalar joint instability has been defined as the talus bone being tilted in relationship to the heel. However, there is great controversy as to whether subtalar joint instability is a real diagnosis or if it is simply a description of lateral ankle instability. In other words is it a problem of the talus tilting in relationship to the heel or is it a ligament problem? If so, which ligaments? Is it a talocalcaneal interosseous ligament problem that is holding the heel to the talus or is it a breakdown of the other ligaments described above? Is it all the ligaments?

A February 2020 paper asked the question: Does subtalar instability really exist? Writing in the journal Foot and ankle surgery (13) researchers wrote: “Subtalar joint instability is considered as a potential source of chronic lateral hindfoot (the talus to heel) instability. However, clinical diagnosis of subtalar joint instability is still challenging.” In their review the researchers assessed the consistency of doctors using the diagnosis “subtalar instability” or other diagnostic terms to describe foot/ankle instability.

Why is this important? It is important to understand the extent of the foot problem. Why is your talus tilted or wandering? What ligaments should a doctor suspect?

What they found was doctors using a diagnosis of subtalar joint instability amid a degree of confusion. They also found that “complaints of instability can be related to subtalar ligament injuries and an abnormally increased motion of the subtalar joint. (It could be all the ligaments) Stress radiographs should be interpreted with caution and should not have the status of a reference test. (In other words, an MRI may NOT show or identify what is the true cause of the problem it may miss something less obvious.)

Regardless of the diagnostic terms, all signs point to ligament damage.

An August 2021 paper in the Orthopedic Journal of Sports Medicine (14) describes it this way: “Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability.”

Peroneal tendon pathology and chronic ankle instability

This section summarizes our article: A missed peroneal tendon injury: Is this the cause of inappropriate surgery and continued foot and ankle pain?

When reviewing the current and recent medical literature on helping people with chronic ankle instability and pain before or FOLLOWING corrective elective surgery, we see research that focuses on a peroneal tendon injury.

A November 2021 study published in The Journal of Foot and Ankle Surgery (15) offered this summary of Peroneal tendon pathology and chronic ankle instability:

Peroneal tendon pathology is commonly associated with chronic lateral ankle instability. Foot and ankle surgeons often rely on preoperative magnetic resonance imaging (MRI) for the identification of related pathology and surgical planning in these patients. The purpose of this study was to assess the ability of preoperative MRI to accurately detect peroneal tendon pathology in patients with chronic lateral ankle instability.

Explanatory notes: The researchers here show that Peroneal tendon pathology or injury is common in chronic ankle instability, but it is not often detected unless you are in the middle of the surgery. Here is what they observed:

  • Peroneal tendon pathology was identified intraoperatively in (92.7%) patients and on MRI in 40 (48.8%) patients.  (Note over 40% of Peroneal tendon injury that may contribute to chronic ankle instability was missed on an MRI.)
  • The most commonly identified pathologies were Peroneal tenosynovitis, Peroneal tendinopathy, and Peroneal longitudinal split/tear, with the peroneus brevis tendon being most commonly involved.
  • “While MRI is a helpful study for evaluation of co-pathologies and surgical planning in patients with lateral ankle instability, procedural selection should not be solely based on MRI results, and the peroneal tendons should be evaluated intraoperatively in patients undergoing arthroscopic procedures for lateral ankle instability.”

Again, let us stress that chronic ankle instability is a problem of the whole ankle joint and not the isolated tear. When there is an isolated tear the whole ankle reacts by altering movement and by adding swelling to help support itself.

Distal tibialis anterior tendinopathy

A November 2023 paper in the journal Foot and Ankle International (16)  assessed treatment outcomes in patients with distal tibialis anterior tendinopathy. The researchers of this study write: “Current clinical practice is mainly guided by case reports and small retrospective case series; little consensus exists on which treatment protocol is most effective. This study aims to assess a conservative treatment for distal tibialis anterior tendinopathy consisting of PRP (injections) and walking cast immobilization.

  • Eighteen patients (average age 65) received leukocyte-poor PRP Methods: Ultrasound leukocyte-poor PRP injection was given around the tibialis anterior tendon insertion. Walking cast immobilization was used for 3 weeks after infiltration, followed by eccentric exercises of the distal tibialis anterior tendon and gastrocnemius-soleus muscle complex stretching.
  • The researchers found significant clinical improvement in pain, function, and disability.
  • Two (11%) patients chose operative treatment because of persisting symptoms.

Part 2: There is not much evidence for the aggressive treatment of ankle sprain in the athletic population


A paper published in 2022 in the Journal of Sport Rehabilitation (17) assessed the effectiveness of treatment following an acute ankle sprain. Noting that acute lateral ankle sprain, if treated poorly, can result in chronic ankle issues, such as instability the authors wrote: “Early dynamic training (progressive balancing exercises to build muscle strength) after acute lateral ankle sprain in athletes results in a shorter time to return to sport, increased functional performance, and decreased self-reported reinjury. The results of this scoping review support an early functional and dynamic rehabilitation approach when compared to passive (manual or physical therapy that is less demanding and focuses more on non-weight bearing as opposed to weight-bearing) interventions for athletes returning to sport after acute lateral ankle sprain. Despite existing research on rehabilitation of lateral ankle sprain in the general population, a lack of evidence exists related to athletes seeking to return to sport.” In other words, there is not much evidence for the aggressive treatment of ankle strain in the athletic population.

Therapy to address sprinting and change of direction may help ankle instability in athletes

A May 2022 study from Indian and Australian researchers (18) suggested that doctors: “Chronic ankle instability in athletic populations appears to be highly associated with declines in functional performance and to a somewhat lesser extent, ankle range of motion, strength and muscle endurance measures. This may suggest that optimal rehabilitation for athletes with Chronic ankle instability may require a greater focus on improving sprinting speed and change of direction ability in the mid to latter stages of rehabilitation, with regular assessments of these functional performance tests necessary to guide the progression and overload of this training.”

It is well understood that an athlete will need a more aggressive treatment program than those not engaged in athletics or for that matter, a person who does physically demanding work and needs to get back on the job.

Returning to this study: The researchers examined three treatment methods early dynamic training (specific ankle exercises to improve strength and balance), electrotherapy (such as transcutaneous electrical nerve stimulation (TENS)), and hydrotherapy (treating with water immersion).

Conclusions: Early dynamic training after an acute lateral ankle sprain in athletes results in a shorter time to return to sport, increased functional performance, and decreased self-reported reinjury. The results of this scoping review support an early functional and dynamic rehabilitation approach when compared to passive interventions for athletes returning to sport after lateral ankle sprain (Such as RICE, Rest, Ice, Compression, Elevation).

Chronic ankle instability in athletes – is more than treating one ligament it is treating the whole ankle joint

In this section of our article, we will present non-surgical options and the research behind them in repairing ligaments and tendon damage that may be occurring in the whole ankle. Surgery can be a successful remedy for some patients. However, surgery can be limited in what it can fix at a single surgery and surgery, despite “claims of minimally invasive,” still requires a long rehabilitation afterward. Ankle ligament reconstructive surgery is no different.

In the Journal of Physical Therapy Science(19Doctors at South Korea’s Sport Science Institute, Incheon National University looked at male soccer players and found the complexity of the problem needed to be solved by addressing the entire ankle joint and not simply a ligament tear or chronic ligament weakness.

Here are their findings:

  • Over 70% of patients who experience ankle sprains report additional symptoms resembling chronic ankle instability, such as re-injury or ankle function abnormalities.
  • Chronic ankle instability has been connected to reduced muscle strength and proprioception (ankle joint function as a whole) which interferes with postural control.
  • It is presumed that chronic ankle instability is caused by complex functional deterioration. It is not a simple solution.
  • Correcting ankle structure and muscle-strengthening exercises are important for the rehabilitation of ankle instability. (In other words, the ankle needs to be repaired and strengthened – the obvious goal of anyone suffering from chronic ankle instability).

A study from Dutch doctors published in the International Journal of Sports Medicine (20looked at 98 patients with chronic, persistent ankle sprains. The problem of a single ligament causing ankle sprains and instability has now become a problem of total ankle joint destruction in these patients.

  • MRI revealed signs of developing ankle osteoarthritis (cartilage loss and osteophytes (bone spurs)),
  • Bone marrow edema is seen in the talocrural joint where the tibia, fibula, and talus meet (TCJ) in 40% of the patients and in the talonavicular joint (TNJ) in 49% of the patients.

Chronic ankle sprains in elite college football players entering the National Football League. Are they getting surgeries they do not need?

That study from doctors at Tulane University School of Medicine,  Steadman Philippon Research Institute,  Drexel University College of Medicine, Harvard Medical School, and the New England Patriots, found that prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine (pre-draft player workouts). The purpose of the study which was published in the Orthopaedic Journal of Sports Medicine,(21) was to try to determine ways to prevent recurrent ankle sprains.

Here is what the NFL research said: “Our injury profile was fairly consistent with the existing literature on ankle injuries. Ligamentous (ligament) sprains were the most common diagnosis, making up 86.0% of all ankle injuries.” 

Let’s remember that number – 86% of ankle injuries are ligament sprains.

In 2005, a study in the British Journal of Sports Medicine (22) discussed the long-term outcomes of inversion ankle injuries. (The most common type of ankle sprain is the “rolled” or “twisted” ankle, inversion injury, turning the ankle inward, injuring or tearing the ligaments on the lateral (outer) side of the ankle, usually the anterior talofibular and the tibiofibular ligaments.)

This 2005  study was cited by over a dozen 2023 published studies to validate the findings on the problems of identifying and treating ankle sprains and preventing these ankle sprains from becoming long-term problems. So here we have a 2005 study that suggests that you may get surgery that will not help you. You may get non-surgical treatments that are accelerating your need for surgery or are simply not helping. Researchers in 2023 use this study as evidence.

The researchers in 2005 addressed the same problem NFL teams were trying to avoid in 2018:

“Most patients who sustained an inversion ankle injury at sport and who were subsequently referred to a sports medicine clinic had persistent symptoms for at least two years after their injury.”

  • These two studies, separated by 13 years should give you an understanding as to why, your chronic ankle problem is just that, a chronic problem.
    • Ice does not repair ligaments
    • Braces do not repair ligaments
    • Tape does not repair ligaments
    • Anti-inflammatories do not repair ligaments
    • Painkillers do not repair ligaments

Back to the NFL study. What was the recommendation for treatment? This is what was published:

“Because treatment decisions are individually varied and surgical data were not available for all players, it is difficult to recommend any specific procedure for certain injuries.”

 


Part 3: Perceived Instability – Fear of Injury


Perceived instability is the thought that your ankle is unstable whether it is no not. A December 2022 paper in the Journal of Athletic Training (23) found that:

  • Physically active individuals with chronic ankle instability had lower levels of sports performance when pain catastrophizing and injury-related fear were present.
  • Clinicians should begin to identify these factors in patients with chronic ankle instability and explore intervention strategies for reducing injury-related fear and pain, which may assist in improving function and disability.

Fear and frustration in college-age athletes going through rehabilitation

If you are reading this article to this point, it is likely that you have had some fear and frustration about why your ankle never heals. You are not alone.

A study published in the Journal of Sport Rehabilitation (24) from American researchers at Still University and Old Dominion University wrote:

“Collegiate athletes with any history of ankle sprain exhibited elevated levels of fear compared to healthy controls. These findings suggest that ankle sprains, in general, may elevate injury-related fear but those with a history of recurrent sprains appear to be more vulnerable. Accordingly, fear should be addressed during rehabilitation.”

Doctors in Belgium published a July 2023 study in the journal Sports Medicine (25) which examined patient outcome data in assessing structural and functional brain adaptations related to lateral ankle sprains and chronic ankle instability. The researchers write: “Patients with chronic ankle instability experience persistent ankle dysfunctions and detrimental long-term sequelae (symptoms and recurrence). . .  Changes at the brain level are put forward to explain these undesirable consequences and high recurrence rates partially.  These adaptations correlate with clinical outcomes (e.g. patients’ self-reported function and different clinical assessments) and might contribute to the persisting dysfunctions, increased re-injury risk, and long-term sequelae (symptoms) seen in these patients.” The doctors recommend rehabilitation programs that  integrate sensorimotor and motor control strategies to cope with neuroplasticity (the brain’s adaption and changes) related to ligamentous ankle injuries.”

Physical therapy will not be a long-lasting solution to a chronic ankle sprain

Rehabilitation focuses on balance and strength training. There is no question these exercises can help. Yet, chronic ankle instability remains a critical problem. For balance and strength training to be most effective, the therapy must rely on resistance to build muscle. The muscle relies on strong tendons to hold itself to the bone. If the tendons are weak, the resistance is lower.  Muscles also rely on ligaments to hold the bones together so the tendons are in a maximum position to help the muscles get maximum resistance. If the ligaments and tendons are not addressed in physical therapy or any conservative treatments which we will discuss next, the physical therapy will not be a long-lasting solution to a chronic ankle sprain. In the section below on Prolotherapy, we will address the problems of ligaments and tendons.


Part 4: Treatments: “The treatment is always the same and usually it is ineffective.”


Sometimes when we ask a patient, how many times they have sprained their ankle, they will report that they really do not know. The patients will be able to review with us their medical history for ankle sprains as simply:

  • Scenario 1: Most times I did not go “get it checked out.” They (the ankle sprains) happen all the time. I know what to do for it.”
    • Usually, the typical conservative care route is then followed:
      • Rest, get off the ankle as best you can
      • Immobilize, get the ankle taped up, braced up, and put into a soft cast if necessary
      • Ice, lots of ice to get the swelling down
      • Anti-inflammatory medications

The patients will usually be able to describe numerous occasions where they enacted their own self-care using any combination of these treatment protocols.

  • Scenario 2: I go to the doctor or emergency room or walk-in immediate care center when the ankle sprain is really bad.
    • Here an examination of the ankle to rule out Grade Three complete rupture of ankle ligament and possible ankle dislocation should be performed. In a severe ankle injury, peroneal tendon subluxation, the popping out of the two tendons on the outer side of the ankle should be discussed. Some of these patients were later recommended for surgery which we will discuss below.

The old treatments of RICE are outdated


An August 2022 study published in the Journal of Clinical Medicine (26) writes: “Old conservative protocols, RICE (i.e., rest, ice, compression and elevation) and POLICE (i.e., protection, optimal loading, ice, compression, and elevation), were developed from existing data at the time that has now been partially refuted. Newer protocols such as PEACE (i.e., protection, elevation, avoiding anti-inflammatory, compression, and education) and LOVE (i.e., load, optimism, vascularization, and exercise focus on education, vascularization, early loading, and exercise. Therefore, new protocols have focused on active treatment such as exercise, while suggesting a de-emphasis on passive inflammatory control treatments.

As a side note: What the researchers are saying is that treating ankle sprain with movement or stimulation is better than passive Rest, Ice, Immobilization, and Elevation) We have practiced the same idea of the MEAT protocol (Movement Exercise Analgesia Treatment) for nearly thirty years. To demonstrate here are two studies from the early 1990s. An early mobilized group of patients with lateral ankle sprains had less pain and returned to full capacity quicker compared to the immobilized group. (27) Even in lateral ankle ligament ruptures causing gross mechanical instability early mobilization resulted in a better early functional result. (28)

Are Fear and frustration cured with an ankle brace, an ankle sleeve, or a roll of tape?

A team of physical therapists in Spain has published a study (April 2018) in the journal Disability and Rehabilitation (29They wanted to report on their findings surrounding the immediate and prolonged (one week) effects of elastic bandage on balance control in subjects with chronic ankle instability.

  • Twenty-eight individuals: 14 were randomly assigned to the elastic bandage group (7 men, 7 women) and 14 were assigned to the non-standardized tape (typical white adhesive tape) group (9 men, 5 women).
  • This study did not observe differences between the elastic bandage group and the non-standardized tape group during the follow-up in the majority of measurements.
    • The elastic bandage of the ankle joint has no advantage as compared to the non-standardized tape.
    • The effects of the bandages could be due to a greater subjective sense of security. It is important to be prudent with the use of bandages since a greater sense of safety could also bring with it a greater risk of injury.
    • The application of the bandage on subjects with chronic ankle instability should be prolonged and used alongside other physiotherapy treatments.

A February 2020 paper in the journal Clinical Orthopaedics and Related Research (30) suggests that moderate-level research demonstrates “that external supports of any type were no more effective than controls in improving dynamic postural control in patients with at least one ankle sprain and residual functional or mechanical deficits. Therefore, implementing those tools (braces or other compression)as a standalone treatment does not appear to be a viable strategy for the primary management of ankle instability.”

Whole body vibration

Using a machine that creates vibration, the idea is that the vibration strengthens your muscles by forcing rapid contracting and relaxation.

A July 2023 paper in the BMC Sports Science, Medicine, and Rehabilitation (31) wrote: “There has been increasing evidence to suggest that plastic changes in the brain (or neuroplasticity, the brain and nerve networks adaptability to changes, such as ankle weakness) after the initial injury play an important role in chronic ankle instability. One method to treat chronic ankle instability, whole-body vibration has been found to be beneficial for treating the sensorimotor deficits (detrimental changes that affect the muscles among other issues) accompanying chronic ankle instability.”

A November 2023 paper in the Annals of Medicine and Surgery (32) assessed the use of whole-body vibration for the prevention of chronic ankle sprains and instability. Balance problems have been significantly associated with the risk of recurring sprains as static and dynamic balance are crucial components of ankle stability. Also, ankle muscle activity and strength play a significant role.

In reviewing previously published research, seven studies of 288 patients revealed that the patients with whole vibration treatments showed improvements in the posterolateral, posteromedial, and medial directions, respectively. There were also promising results on improvements in muscle activity, strength, and proprioception sense (the direction to move muscles) measurements.

Balance training and Pilates

A February 2022 paper in the Journal of Foot and Ankle Research (33) found that “Three months’ of supervised balance training could effectively improve postural control and muscle strength of chronic ankle instability cases with grade III ligament injury, although these improvements would partially decrease over time. Additional strength exercises for dorsiflexion and eversion should be supplemented from 6 months.”

An October 2022 study in the International Journal of Environmental Research and Public Health (34) compared Pilates training with traditional balance training (BT) in patients with chronic ankle instability. Fifty-one college football players with chronic ankle instability, divided into Pilates training and balance training groups, were included in the study. The groups performed Pilates training or balance training training as assigned, three times per week for 6 weeks. There were considerable improvements in both the Pilates training and balance training groups after training. The authors conclude that their findings suggest that ankle strength, balance, and core stability should be comprehensively evaluated and targeted in chronic ankle instability rehabilitation programs.

Prolotherapy

In 2010, our research team published findings in the journal Practical Pain Management (35) on the use of dextrose prolotherapy injections. We found these injections to “be very effective in eliminating pain and stiffness and improving the range of motion and quality of life in this group of patients with unresolved ankle pain. This included the subgroup of patients told by their doctors that there were no other treatment options for their pain or that surgery was their only option.”

We go on to explain that prolotherapy involves injections into all of the various ankle ligaments that stabilize the part of the ankle where the person is experiencing symptoms. “For lateral ankle pain, this involves the ligaments of the lateral ankle complex, including the anterior talofibular, calcaneofibular, and posterior talofibular. For anterior ankle pain that is higher, the syndesmotic ligament complex is injected. The ligaments involved include the anterior tibiofibular, posterior tibiofibular, and the distal interosseus membrane between the tibia and fibula. For medial ankle pain, the deltoid ligament with its complex of very strong thick ligaments is injected. Prolotherapy gets at both the superficial and deep deltoid ligaments including the posterior tibiotalar and anterior tibiotalar ligaments.”

How it works

“Prolotherapy is the injection of a solution for the purpose of tightening and strengthening weak tendons, ligaments, or joint capsules. Prolotherapy works by stimulating the body to repair these soft tissue structures. . . One explanation for the lack of response of chronic ankle pain sufferers to traditional conservative therapies is that their underlying problem, ligament laxity, is not being addressed.  . . Since prolotherapy is given at the ligament/ bone interface, it presumably stimulated ankle ligament repair in this patient population, causing a marked decrease in pain and improvement in patient’s quality of life.”

Neurofascial (treating nerve inflammation) prolotherapy

The concept of inflammation on the nerve causing pain and even degeneration of tissues has been documented in articles in the 1950s and 1960s by Dr. George Hackett, the person who coined the term Prolotherapy. He noted that inflammation neuritis and other antidromic impulses (nerve impulses that are traveling in the wrong direction and cause confusion) are transmitted to blood vessels in nerves and surrounding tissues stimulating a release of excess neurohumoral mediator substance (the nerves are over-reacting as in panic) which cause a neurovascular vasdilation-edema-sterile inflammation neuritis (immune breakdown which contributes to radiating nerve pain). This neurogenic inflammation can also lead to ligament weakness and bone decalcification.

Patients with chronic ankle ligament injury entered this uncontrolled before-after study based on eligibility criteria. Patients who consented to participate in the study filled out the prepared questionnaire containing demographic data, the Cumberland ankle instability tool (CAIT), and the Visual Analogue Scale (VAS). The initial CAIT score of less than 25 indicated functional instability following an ankle sprain. Patients underwent neurofascial prolotherapy with dextrose 12.5%. Two injections within one month were done. The CAIT was completed one, three, and six months after the intervention.

In a February 2022 study (36) published in the journal Anesthesiology and Pain Medicine, twenty-five patients with chronic ankle ligament injuries were treated with neurofascial prolotherapy. The patients in this study were 20 to 75 years old with a history of ankle sprain or injury whose magnetic resonance imaging confirmed ligamentous injury, with no pain and disability improvement after conservative treatments.

The outcomes “indicated that neurofascial prolotherapy significantly improves pain and functional instability in chronic ankle ligament injury. The (pain and disability scores) decreased significantly after one month, and this trend continued till the sixth month after the intervention.”


Part 5: Chronic ankle instability surgery


In the patients we see, they have at some point considered surgical intervention for their chronic ankle instability because they are basically done with treatments that are not effective. The reason they have not jumped right into surgery is because of its risks and the possibility that it will not help. But clearly, surgery does address ligament and tendon problems. These problems can also be addressed in a non-surgical manner as we have discussed.

Whenever we discuss surgery, it is important to bring in a surgical opinion.

In the Journal of Orthopaedic Surgery and Research, June 2018 (37) a team of medical university orthopedic surgeons presented their findings to the medical community:

  • “There is limited evidence to support anyone surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still get some conclusions:
    • (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains.
      • The goal of ankle tenodesis is to provide stability to the ankle by moving a weakened tendon to another place on the bone. The cost of this procedure is that you now have a much more limited range of motion in your ankle. This surgery has fallen out of favor. As a side note, The American Orthopaedic Foot & Ankle Society website tells physicians “Tenodesis stabilization restricts laxity and pathologic motion but ignores the underlying ligamentous pathology causing the instability.” Simply you cannot treat the tendons without addressing the problem of the ankle ligaments.
    • (2) Non-anatomic reconstruction (the use of allograft (donated tendon) autograft (your tendon) or tenodesis to replicate the motion and stability abnormally increased inversion stiffness at the subtalar level as compared with anatomic repairment (Surgical repair of the ligaments)
    • (3) Multiple types of modified Brostrom procedures could acquire good clinical results.
      • modified Brostrom procedures are a group of surgical procedures that seek to stabilize the ankle by repairing the anterior talofibular ligament. The main stabilizer ligament of the outer ankle. Brostrom procedure and its variants are the most popular surgery for ankle instability. But as stated above, there is limited evidence to support anyone surgical technique over another surgical technique for chronic lateral ankle instability.

Surgery can work for some people. One of the appeals of the arthroscopic Brostrom procedure is that it is an “outpatient,” or same-day surgery.  But as many have learned, same-day surgery can mean months of rehabilitation. Typical rehabilitation of this procedure can include:

  • Immobilization for weeks or months
  • The problem of managing swelling with anti-inflammatory medications
  • Sleeping with a splint for weeks on end.
  • Months of therapy and treatment

Same-day surgery simply means a smaller incision, the rehab remains the same.

More on the modified Brostrom procedures – many patients do not return to their pre-injury activity level

A February 2022 paper published in the Orthopaedic Journal of Sports Medicine (38) writes that “despite marked improvements in stability after lateral ankle ligament repair (surgery), many patients do not return to their pre-injury activity level. There are few studies addressing athletes’ assessment of their ability to return to play after lateral ankle ligament reconstruction for recurrent instability.”

To answer this question the researchers sought to determine the rate of return to the preinjury activity level among physically active patients after the modified Broström procedure for recurrent lateral ankle instability.

Included in this study were patients who had undergone a primary modified Broström procedure by a single surgeon over a 6-year period and had a minimum of 24 months of follow-up.

  • Of the 41 in this study who participated in a telephone interview, results indicated that 22 (54%) returned to their prior level of activity (returners). The mean age of returners was 27.2 years; for nonreturners, the mean age was 27.1 years.
  • Most patients (36/41; 88%) were satisfied with the surgery and the overall outcome.
  • Of the 19 nonreturners, 7 (37%) noted ankle-related reasons for not returning (pain: 57%; residual instability: 29%; decreased range of motion: 14%), and 12 (63%) cited non-ankle-related reasons.
  • Conclusion: A high patient satisfaction rate was reported after the modified Broström procedure for recurrent lateral ankle instability. The majority of patients who did not return to their pre-injury level cited a non-ankle-related factor as the reason for not returning to sport. This was especially true for the higher-level athletes.

The key is fixing the instability before the instability creates significant bone damage.

Hopefully, you are at a stage where the damage to your ankle is not irreversible. If you have chronic instability but a good range of motion in your ankle, we believe we can help you avoid future surgery and strengthen your ankle. The key is fixing the instability before the instability creates significant bone damage.

In December 2016, the Journal of British Sports Medicine (39published the Executive Committee of the International Ankle Consortium position paper on the progression of ankle instability caused by chronic ankle sprains to disabling full-blown osteoarthritis and the need for ankle surgery or fusion. These are the treatment guidelines doctors follow today.

That position paper which was compiled by researchers from the University of Kentucky, University College Dublin, UK National Centre for Sport and Exercise Medicine, the University of Delaware, University of North Carolina, among many other medical universities stated:

  • “This 2016 position paper with recommendations for information implementation and continued research based on the paradigm that lateral ankle sprain and the development of chronic ankle instability, serve as a conduit to a significant global healthcare burden.
  • We intend our recommendations to serve as a mechanism to promote efforts to improve the prevention and early management of lateral ankle sprain.
  • We believe this will reduce the prevalence of chronic ankle instability and associated sequelae that have led to the broader public health burdens of decreased physical activity and early onset ankle joint post-traumatic osteoarthritis. Ultimately, this can contribute to healthier lifestyles and the promotion of physical activity.”

Simply: People are at high risk of developing ankle osteoarthritis. It is a big problem.

My ankle is getting worse and worse.

Many of you reading this article have had ankle problems for a long time. Some of you are thinking if it were only my ankle I could probably deal with it. But it is not only your ankle, it is your knee, your foot, your hip, and low back pain too. Some of you are probably waking up in the morning, unsure how much weight to put on your foot or ankle because some mornings you can get right out of bed, other mornings you get up and reach for the wall because there is pain and instability and you need to catch your breath before you fall back onto the bed. Those are the mornings you probably tell yourself or your spouse, “I need to do something about this before it gets worse.” Then again, you may have been saying this for years.

Who will need the surgery and who will not? This may be determined by the level of ankle instability.

Ankle instability may not show up after the first acute ankle sprain and there is no consensus on how to tell if a patient will have instability in the future, this much is the consensus in the medical community. But what is the progression from an ankle sprain to ankle instability, can this be documented to offer some idea?

This was addressed by an Irish research team writing in the American Journal of Sports Medicine (40who among other findings found that patients who could not properly jump or land 2 weeks after their first lateral ankle sprain were high-risk candidates for chronic ankle instability.

Unfortunately, literature examining chronic ankle instability is often conflicting and confusing to patients. The Irish researchers were able to identify jumping and landing ability and non-reported ankle pain up to 6 months as being high-risk factors for ankle instability, but they were not the only factors.

University researchers in Australia also tackled this problem of identifying the risk factors for ankle instability. In June 2016, the Australian team published their intent to examine the problems of ankle instability in the medical journal Systematic Reviews (41) and correlate available research into a clearer understanding of key factors… This was what they said:

  • “Ankle sprains are a significant clinical problem. Researchers have identified a multitude of factors contributing to the presence of recurrent ankle sprains including deficits in balance, postural control, kinematics, muscle activity, strength, range of motion, ligament laxity, and bone/joint characteristics.

Unfortunately, the literature examining the presence of these factors in chronic ankle instability is conflicting.

  • As a result, researchers have attempted to integrate this evidence using systematic reviews to reach conclusions; however, readers are now faced with an increasing number of systematic review findings that are also conflicting. The overall aim of this review is to critically appraise the methodological quality of previous systematic reviews and pool this evidence to identify contributing factors to chronic ankle instability.”

In 2017, at the completion of their review, the researchers published their findings in the journal, Sports Medicine. (42)

  • Remarkably, only 17% of primary studies measured a clearly defined chronic ankle instability population.
    • COMMENT: In other words, research on chronic ankle instability in nearly 5 out of 6 studies, never clearly defined if the patients in the study actually had chronic ankle instability and to what levels.
  • “Evidence from previous systematic reviews does not accurately reflect the chronic ankle instability population. For the treatment of non-specific ankle instability, clinicians should focus on dynamic balance, reaction time, and strength deficits; however, these findings may not be translated to the chronic ankle instability population.”
    • COMMENT: In other words, you may not be getting the treatment you need for ligament deficiency. The ligaments are the stabilizers, the accelerators, and the strength of bone-to-bone interactions. Tendons are the stabilizers, the accelerators, and the strength of muscle-to-bone interactions.
    • In our opinion, you need a treatment that strengthens and rebuilds your tendons and ligaments.

Are surgeons even addressing Lateral ankle sprain?

Building on these findings is a July 2021 paper published in the journal BioMed Central Musculoskeletal Disorders. (43) What the researchers of this study wanted to know is if surgeons were using the current treatment criteria for patients with a lateral ankle sprain. To test how surgeons were treating this problem a questionnaire survey was conducted among Japanese orthopedic surgeons.  The survey was composed of 12 questions that were developed with consideration of the recommendations in the current clinical practice guidelines published by the Dutch orthopaedic society. The questions in this study were focused on the diagnosis, conservative treatment, rehabilitation, and the criteria for returning to sports.

  • Among the respondents, 95.3% did not consider the Ottawa Ankle Rules in the decision to perform plain radiography for patients. (The Ottawa Ankle Rules were developed to help doctors who should and who did not need an X-ray to rule out bone break or fracture).
  • Rehabilitation following lateral ankle sprain was performed in 58.9% of patients.
  • Eighty-five (65.9%) of the surgeons used only one factor as the criterion for returning to sports. The absence of pain was the most frequently used criterion (45.7%). No objective criteria were used for the return to sports decision in athletes with a lateral ankle sprain.

So what does this mean in your search for comparisons for what are the best injections for ankle pain? Doctors may not be addressing ligament instability as the cause of your ankle problems, instead, they may be looking for end-stage evidence, the loss of cartilage, the bone spurs, the loss of range of motion, and the chronic pain. In a patient’s desire to relieve their ankle pain with injections, an examination of ankle instability and the impact on acceleration osteoarthritis should be undertaken.

“The procedures of reconstruction surgery for chronic lateral ankle instability.”

In October 2021, specialists writing in The Journal of Foot and Ankle Surgery (44) evaluated “the procedures of reconstruction surgery for chronic lateral ankle instability.” In this study, the doctors compared single anterior talofibular ligament reconstruction to simultaneous reconstructions of the anterior talofibular and calcaneofibular ligaments. As we will see, the surgeons of this study call for more ligament repair than isolation simply on the anterior talofibular ligament.

How was the study conducted?

  • 14 consecutive patients diagnosed with chronic lateral ankle instability underwent arthroscopic anterior talofibular ligament reconstruction with or without calcaneofibular ligament reconstruction after conservative treatment.
    • Seven patients underwent single anterior talofibular ligament reconstruction (group AT),
    • and 7 patients underwent simultaneous reconstructions of the anterior talofibular ligament and calcaneofibular ligament (group AC).
    • Patients’ pain and function significantly improved in all patients 1 year postoperatively.
  • Long-term outcomes: While the initial one-year success was good. The researchers found “that although the clinical outcomes after the anterior talofibular ligament reconstruction with or without the calcaneofibular ligament reconstruction for chronic lateral ankle instability were good, instability of the talar tilt angle at 1 year postoperatively in patients who underwent single anterior talofibular ligament reconstruction was greater than that in patients who underwent simultaneous anterior talofibular and calcaneofibular ligament reconstructions.”

Part 6 Summary


Ligament treatment is the key to stopping the progression of ankle osteoarthritis

Below is a video of Dynamic Digital Radiographs. These dynamic tests allow us a visual to assist in analyzing ankle pain and instability symptoms during normal movement of the ankle joint. Seeing how the ankle moves and at what point of the movement the patient exepreinces pain can help guide us through realistic assessment of the patient’s problems and guide treatments accordingly.

For many people, it is easy to understand that they have a loose ankle or an ankle that feels like it is giving way. They have problems walking, their ankle makes a lot of crunching, cracking, and popping noises, some have chronic swelling that never goes away, and their ankle hurt all the time. What is not always as easily understood when all they hear at the doctor’s office is “cartilage, cartilage, cartilage,” is that they have damaged, weakened ankle ligaments. “Cartilage, cartilage, cartilage,” is a problem of damaged ligaments.

A June 2019 study (45) from Army-Baylor University, which used the above 2016 study as one of their references offered these guidelines:

  • “Individuals who sustain an acute lateral ankle sprain may not receive timely formal rehabilitation and are at an increased risk to have subsequent sprains which can lead to chronic pain and instability. Attention to essential factors for ligament protection and healing while preserving ankle movement may result in a more stable yet mobile ankle offering improved outcomes.

The recommendations above are for the early management of lateral ankle sprain as the best way to avoid surgery. Recently, doctors from Rutgers University in New Jersey published their findings in the Journal of Orthopaedic Research (46) that listed the top five common athletic injuries as high-risk factors for developing osteoarthritis, among the top 5 HIGH-RISK injuries.

  • Chronic Ankle Instability.

What are we seeing in this image?

The caption reads: “Ultrasound showing a tear in the anterior talofibular ligament of the right ankle.” What this image illustrates is the accompanying chronic synovial effusion in the joint. The effusion or swelling in the ankle attempts to provide a “water brace” to stabilize itself. Surgery is seen as a way to correct the problem and provide stabilization.

My ankle is getting worse and worse – can’t I slow this down or should I just wait until the surgery is available?

Many of you reading this article have had ankle problems for a long time. Some of you are thinking if it were only my ankle I could probably deal with it. But it is not only your ankle, it is your knee, your foot, your hip, and low back pain too. Some of you are probably waking up in the morning, unsure how much weight to put on your foot or ankle because some mornings you can get right out of bed, other mornings you get up and reach for the wall because there is pain and instability and you need to catch your breath before you fall back onto the bed. Those are the mornings you probably tell yourself or your spouse, “I need to do something about this before it gets worse.” Then again, you may have been saying this for years.

So just how fast is your ankle going bad? How much do the other joints hurting impact your ankle?

Here is what doctors at the University of North Carolina are finding out. It is a study from December 2020. (47) The point of research like this is not to try to convince someone that they are getting worse, you probably don’t need much of that type of convincing, it is the doctors suggesting to other doctors how they may be able to help or make suggestions to people with ankle pain how to treat this problem. Here are the learning points:

  • The doctors were trying to determine the incidence and progression of ankle osteoarthritis and associated risk factors in patients who had some type of traumatic ankle injury previously and those who did not.
  • They talked to and collected data from 541 participants who had standardized MRIs and scans in 2013-2015 and then again 2 – 5 years later to see how their ankles were doing.

The findings:

  • Among ankles without a previous traumatic ankle injury, 28% developed or worsened radiologically (MRI or scan follow up) degenerative wear and tear type injury of the 2 – 5 year follow up period.
    • The imaging testing showed a little more than 1 in 4 people had radiological evidence of a worsening ankle.
  • However, more than that, 37% had worsening standard testing Foot and Ankle Outcome Score (FAOS) symptoms (pain, quality of life, functionality, sports activity), and 7% had worsening self-reported pain, aching, and stiffness.
  • There was a connection between worsening symptoms with higher weight and other joint problems.

Among ankles with some type of traumatic ankle injury previously:

  • 4% had progressive degeneration on MRI or scan
  • However 35% had worsening Foot and Ankle Outcome Score (FAOS) symptoms (pain, quality of life, functionality, sports activity), and 9% had worsening self-reported pain, aching, and stiffness.

So what should the doctors who read this study suggest to their patients to slow down degenerative progression? 

  • Stop smoking
  • Lose weight
  • Avoid activities where it will make your ankle worse

When these things don’t work, then there is conservative care with anti-inflammatories, pain medications, ankle braces, physical therapy, cortisone injections, and then surgery.

This article is part of a series of articles on our website that deal with the problems and challenges of an ankle injury. These articles include:

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