Chronic ankle sprain and instability | Conservative care and surgery
Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
Chronic ankle sprain and instability treatment
In this article, we will discuss chronic ankle sprain treatment, the problems of diagnosing ankle sprains, and long-term problems of ankle instability. We will discuss non-surgical options as well as surgical options for the treatment.
Highlights of this article:
- Treatment of ankle instability by treating damaged and injured ligaments.
- Ankle taping and bracing as inappropriate for long-term recovery.
- Surgical discussion – Chronic Lateral Ankle Instability
- Injection treatments. Are they effective for non-surgical repair?
- My ankle is always giving out
- “Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries.”
- Many patients 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.”
- The overall quality of the existing lateral ankle ligament sprains Clinical Practice Guidelines are poor and the majority are out of date.
- You may get conservative care non-surgical treatments that are accelerating your need for surgery and are simply not helping.
- Fear and frustration in college-age athletes with ankle sprain going through rehabilitation.
- Are Fear and frustration cured with an ankle brace, an ankle sleeve, or a roll of tape?
- “(Ankle Sprain) treatment is always the same and usually it is ineffective.”
- Doctors are not sure if ankle sprains ever really heal – a “new sprain’ is probably just an old sprain that never healed.
- There is not much evidence for the aggressive treatment of ankle strain in the athletic population.
- An ankle that never heals is forever unstable. This is where the surgical recommendation comes in.
- Who will need the surgery and who will not? This may be determined by the level of ankle instability.
- Surgical recommendations and the challenges of surgery.
- “The procedures of reconstruction surgery for chronic lateral ankle instability.”
- Anterior talofibular ligament injury and calcaneofibular ligament injury.
- Early dynamic training, electrotherapy, and hydrotherapy.
- When the tendon attachments of the ankle are damaged.
- Chronic ankle instability – is more than treating one ligament – it is treating the whole ankle joint.
- Injections for ankle instability and degenerative ankle problems.
- Ankle Instability and Prolotherapy.
- PRP Ankle Injection Research on ankle sprain.
- PRP and high ankle sprain
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:
- The different types of injections for ankle osteoarthritis pain
- Alternatives to ankle replacement surgery and ankle fusion
- Does ankle impingement require surgery? Improving range of motion without surgery
My ankle is always giving out
Many of our patients with chronic ankle instability complain of their ankles “giving way”, having a constant or permanent swelling, obvious pain, decreased range of motion or excessive motion from joint laxity, and recurring sprains.
They have been told by their doctors that if left untreated, ankle instability leads to cartilage deterioration with resultant degenerative arthritis. If the chronically sprained ankle ligaments do not heal, joint instability occurs and the end result is arthritis with ankle fusion or ankle joint replacement surgery an ultimate outcome. If surgery is not the choice the patient wants to make then they have to come up with a just live with it strategy until such time that there will be no other choice but surgery.
Unfortunately, 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. For one, taking pain medications increases pain sensitivity, requiring the patient to use the medication more frequently and at higher doses over time. This phenomenon is known as “Opioid-Induced Hyperalgesia.”
“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, 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.
Failure after strict rehabilitation may be an indication of surgery.
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 is 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, you are now exploring surgical and non-surgical options.
At our center, we usually do not see patients who have just “twisted” an ankle. We usually see patients who have twisted their ankle many times and with each twist, their ankle gets weaker and weaker and more unstable. 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 walk.
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 sprain now requires an x-ray
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.
This is why many times 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 on 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.
Let’s first look at an August 2019 study. 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. (2)
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, 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, 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.
Here is the research to back that up:
In 2005, a study in the British Journal of Sports Medicine (3) 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 seven 2020 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 2020 use this study as evidence.
The overall quality of the existing lateral ankle ligament sprains Clinical Practice Guidelines are poor and the majority are out of date.
Before you think that this is old research, look at a 2019 study that also cites this paper from 14 years prior. Has anything changed that much? Published August 31, 2019, in the journal BioMed Central Musculoskeletal Disorders (4) by researchers led by the Australian National University.
“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 the 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.
You may get non-surgical treatments that are accelerating your need for surgery or are simply not helping.
Here is a 2019 study that cited the 2005 research reporting on chronic ankle sprains in elite college football players entering the National Football League.
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,(5) 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.
Back to the 2005 study, the researchers 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.”
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 in why your ankle never heals. You are not alone.
A study published in the Journal of Sport Rehabilitation (6) 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.”
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, which 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.
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 (7) They 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.
Caring Medical comment:
- Short-term, ankle bandages and tape are to be used with caution.
- A Long-term recommendation to keep the tape and bandage on because there is little else that can be offered is not a long-term solution.
- In our opinion, external structural support needs to be replaced by rebuilding the internal structures of the ankle with simple Prolotherapy injections. We will cover this below.
“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, put into a soft cast if necessary
- Ice, lots of ice to get the swelling down
- Anti-inflammatory medications
- Usually, the typical conservative care route is then followed:
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.
There is not much evidence for the aggressive treatment of ankle strain in the athletic population
A paper published in 2022 in the Journal of sport rehabilitation (29) assessed the effectiveness of treatment following and acute ankle sprain. Noting that acute lateral ankle sprain, if treated poorly, can result in chronic ankle issues, such as instability. In this paper “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.
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. (8)
- 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 or 3rd, or 4th ankle sprain event. The REST, ICE, 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.
An ankle that never heals is forever unstable. This is where the surgical recommendation comes in
In the journal of Orthopaedics & Traumatology, Surgery & Research, (9) 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. “
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.
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 (10) who 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 of 2016, the Australian team published their intent to examine the problems of ankle instability in the medical journal Systematic Reviews (11) 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. (12)
- 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 stabilizer, the accelerators, and the strength of bone to bone interactions. Tendons are the stabilizer, 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.
With a focus on the ankle ligaments, here are the surgical recommendations and the challenges of 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 to 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 w will discuss below.
Whenever we discuss surgery, it is important to bring in a surgical opinion.
In the Journal of Orthopaedic Surgery and Research, June 2018 (13) 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 seeks 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.
- (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains.
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
A February 2022 paper published in the Orthopaedic Journal of Sports Medicine (25) 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.
Early dynamic training, electrotherapy, and hydrotherapy.
A 2022 study in the Journal of Sport Rehabilitation (26) discussed the prevention of an acute ankle sprain moving towards chronic ankle sprain and ankle instability. They wrote: “Acute lateral ankle sprain is a common injury in athletes and is often associated with decreased athletic performance and, if treated poorly, can result in chronic ankle issues, such as instability. Physical performance demands, such as cutting, hopping, and landing, involved with certain sport participation suggests that the rehabilitation needs of an athlete after lateral ankle sprain may differ from those of the general population.”
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).
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. (7) Even in lateral ankle ligament ruptures causing gross mechanical instability early mobilization resulted in a better early functional result. (8)
What are we seeing in this image?
The caption reads: “Ultrasound showing tear in the anterior talofibular ligament of the right ankle.” What this image is illustration 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.
“The procedures of reconstruction surgery for chronic lateral ankle instability.”
In October 2021, specialists writing in The Journal of foot and ankle surgery (14) 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.”
Anterior talofibular ligament injury and calcaneofibular ligament injury.
A May 2020 paper published in the Orthopaedic Journal of Sports Medicine (15) 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.
Summary. The ankle is a unit. 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 tendon attachments
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 (16) 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.
Chronic ankle instability – 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, (17) Doctors 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 (18) looked at 98 patients with chronic, persistent ankle sprains. The problem of a single ligament causing ankle sprains and instability have 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 rapidly move towards ankle instability and degenerative ankle disease. At this point, the surgical options go from ligament reconstruction to the possibility of ankle fusion.
As a side note, one curious symptom and one that should clearly point to chronic ankle instability and should be explored in patients with chronic knee instability and hip instability are Dynamic balance problems related to the ankle.
In two studies from University College Dublin, patients who suffered from an acute ankle sprain were followed and tested for problems of balance. Not only were their injured ankles tested but also the same side knees and hips. At 6 months follow up (19) and one-year follow (20) after a single ankle sprain event, patients showed a reduced balance that created stress on the entire limb side, hip, knee, and ankle included.
Injections for ankle instability and degenerative ankle problems
In February 2021, leading Italian and Swiss researchers publishing in the journal International Orthopaedics (21) attempted to offer evidence supporting the safety and effectiveness of intra-articular injective treatments for ankle lesions ranging from osteochondral lesions of the talus to osteoarthritis. They explored previously published research on:
- Hyaluronic acid injections
- Platelet-rich plasma (PRP)
- Saline injections
- Methylprednisolone (steroid)
- Botulinum toxin type A
- Mesenchymal stem cells and
In all the injection research there were no severe adverse events were reported.
- For osteochondral lesions of the talus, a comparison was possible between Hyaluronic acid injections and PRP showing no significant difference.
- For ankle osteoarthritis, a significant difference favoring Hyaluronic acid (HA) injections versus saline were documented at six months. The GRADE level of evidence was very low.
However, the conclusion of this research could not offer a definitive recommendation because there is not enough evidence in the research to support the use of one injection treatment over another.
Ankle Instability and Prolotherapy
This section will deal with the question, How do WE treat chronic ankle sprains and instability?
In this video, Danielle R. Steilen-Matias, MMS, PA-C demonstrates treatment to the lateral ankle
The treatment begins immediately in the video
This is comprehensive Prolotherapy, meaning there are a lot of injections. The patient getting the injections in this video is comfortable and tolerates the treatment well. The patient in this video is having the lateral or outer ankle treated.
- The injections are given at the ligament attachment to the bone. This helps stimulate healing and strengthening of the ankle ligaments.
- At 0:48 the importance of treating the lateral ligaments of the ankle, the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament.
- The patient is not sedated in any way, once treatment begins patients are surprised that it is not as painful as it looks. We do offer various pre-treatment medications to help the patient including IV sedation. Especially for those with a fear of needles.
- This patient came to see us for an old ankle sprain injury causing chronic ankle instability and pain with running and lower body activities.
- On his first physical exam, he had some ligament laxity, a lot of tenderness, and instability in his ankle. At that visit, we treated the lateral side. This is a follow-up treatment.
- Depending on the severity of the ankle sprain, it could take 3 to 8 treatments to affect a repair.
Caring Medical’s first line of treatment for chronic ankle pain and ankle instability is Prolotherapy. In treating with Regenerative Injection Techniques (RIT), i.e., Prolotherapy, a comprehensive approach must be taken. This means treating the whole ankle, not just a single injection at a single site in the joint, as some physicians attempt to do. The comprehensive problem of ankle instability requires comprehensive treatment. Here’s what current research reveals about ankle instability and injury and how a doctor should consider treatment:
Writing in the medical journal Practical Pain Management, (22) we reported on 19 patients surveyed following Prolotherapy ankle treatments. These patients said they had less pain, stiffness, crepitating, depressed and anxious thoughts, medication usage, as well as improved range of motion, walking ability, sleep, and exercise ability.
Of these 19 patients:
- Patients reported an average of 3.3 years (40 months) of pain and on average saw more than three doctors before receiving Prolotherapy.
- The average patient was taking at least one pain medication.
- Sixty-three percent (12) stated that the consensus of their medical doctor(s) was that there were no other treatment options for their chronic pain.
- Eleven percent (2) stated that the only other treatment option for their chronic ankle pain was surgery.
- Patients received an average of 4.4 Prolotherapy treatments per ankle.
- The average time of follow-up after their last Prolotherapy session was 21 months.
- Patients were asked to rate their pain and stiffness levels on a scale of 1 to 10 on a visual analog scale (VAS) with 1 being no pain/stiffness and 10 being severe crippling pain/stiffness.
- The 19 ankles had an average starting pain level of 7.9 and stiffness of 5.4.
- Ending pain and stiffness levels were 1.6 and 1.5 respectively
- Ninety-five percent reported a starting pain level of 6 or greater, while none had a starting pain level of four or less.
- After Prolotherapy, none had a pain level of 6 or greater, and 90% of patients reported at least a 50% reduction in pain.
- One-hundred percent of patients stated their pain and stiffness were better after Prolotherapy.
- Over 78% reported that pain and stiffness since their last session had not returned.
In regard to the quality of life issues prior to receiving Prolotherapy:
- 74% noted problems with walking, but only 37% experienced compromised walking after.
- In regard to exercise ability before Prolotherapy, only 47% could exercise longer than 30 minutes, but after Prolotherapy, this increased to 90%.
- To a simple yes or no question, “Has Prolotherapy changed your life for the better,” all of the patients treated answered “yes.” This question was included in many of our studies because when it comes down to the point of any medical treatment, we feel this is the point. It’s not “Is my x-ray better?” but rather, how has your life changed for the better.
What are we seeing in this image? A good candidate for Prolotherapy.
In this x-ray, we see a very good candidate for Prolotherapy treatments to the ankle. The patient has some mild loss of cartilage in her ankle and a mildly limited range of motion. For this reason, she was rated as a good candidate for Prolotherapy. She is not an excellent candidate due to the loss of cartilage and range of motion.
For significant deterioration, we may recommend to patients a more aggressive approach incorporating Platelet Rich Plasma and bone marrow aspirate stem cell treatments.
In the medical journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, Caring Medical published our findings on seven patients receiving combined bone marrow aspirate stem cell treatments. Patient case 1 represented an ankle case.
A 59-year-old female patient came into our office with right ankle pain following a lateral sprain. The patient reported she could barely walk without severe ankle pain.
The patient had unsuccessful treatment with cortisone injections and was being recommended for an ankle fusion based on X-ray and MRI findings that suggested osteoarthritis, avascular necrosis of the talus, and synovitis. Please see our published research on bone marrow aspirate injections into the talus and the case history of regenerative repair.
The patient received four bone marrow/dextrose treatments over a period of eight months.
- At the second treatment, the patient reported the ability to stand for long periods and walk for half a mile without pain.
- At the third treatment, she reported an improved range of motion, less frequent pain, and the ability to take two-mile walks on hilly, uneven ground, although steep climbs still induced pain.
PRP Ankle Injection Research on ankle sprain
Throughout this article, we reinforce the message that damage to the ankle may require more than rest or ice or immobilization. It may take more than a single treatment of anything and it may be unrealistic for patients to think that one treatment or injection of anything with getting them back on their feet quicker or better. This is the case with Platelet Rich Plasma therapy as well. When exploring this treatment that utilizes your blood platelets injected into the site of injury, patients should be aware that in many cases, a single one-time “shot,” will not be a successful treatment. We offer PRP with Prolotherapy in many patients.
A September 2019 study in the journal Foot and Ankle Surgery (23) evaluated the effect of Platelet-Rich Plasma (PRP) therapy in patients with acute lateral ankle sprain treated with rigid immobilization.
In this study, (Twenty-one) Patients with first-time grade II lateral ankle sprain clinically diagnosed were evaluated. A rigid immobilization was placed in all patients for ten days. In the PRP treatment experiment group application of PRP over the anterior talofibular ligament was performed. Standard pain and disability scoring evaluations were given at 3, 5, 8, and 24 weeks of the follow-up period.
The results of this study show: “The (PRP treated) experimental group presented the highest reduction in pain and better functional scores than the control group at 8 weeks. At the end of the follow-up period, the results of both groups were similar. A similar evolution was observed in patients treated with rigid immobilization with or without PRP after 24 weeks.
Here we have research again that shows one treatment is usually not a good treatment. While early indications show PRP was effective, at 24 weeks the single PRP treatment and immobilization results were about the same. This helps reinforce the idea that PRP is usually not as effective as a single, “magic bullet,” injection. The treatment needs to be repeated as part of a comprehensive program. You can ask about our program below.
PRP and high ankle sprain
A less common but well-known ankle injury is the “high ankle sprain.” This is damage to the ligaments that connect the shin bones tibia to the fibula. Because of the high impact stress at the tibia and fibula junction, the syndesmosis joint, the high ankle sprain is difficult to heal.
In recent research, (24) doctors examined the success of platelet-rich plasma (PRP) into the injured anteroinferior tibiofibular ligaments (AITFL) in athletes on return to play (RTP). They further studied the issues of ankle instability and stability before and after the PRP ankle injections.
Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain.
Here are the results:
- Early diagnosis and treatment lead to shorter Return to Play
- Significantly less residual pain upon return to activity was found in the PRP group;
Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint, and less long-term residual pain.
A demonstration of Stem Cell Therapy and Prolotherapy
In our clinics, stem cell therapy, which are cells taken from the patient, NOT donated “stem cells,” are used in only the most advanced cases. This is not our “go-to,” treatment. In the same way, the joint degeneration does not occur overnight, one cannot expect the repair to be achieved overnight. In more advanced cases it can take more than 1 treatment to achieve treatment goals.
The treatment begins at 1:06 of the video
- When someone has very advanced osteoarthritis of a joint, like an ankle joint, we may use platelet-rich plasma combined with lipoaspirate (fat-derived stem cells). Very advanced osteoarthritis has a deficiency of cells in the joint, better understood as a deficiency of building material.
- In this video, fat-derived stem cells are drawn in a liposuction procedure from the buttocks of this patient.
- This procedure begins at 1:42 of the video. A very dilute anesthetic is injected into the area to numb the pain. The collected fat is then combined with Platelet Rich Plasma. and injected into the ankle.
- The ankle injections begin at 2:29. This patient is having numbing solutions to make the treatment more comfortable.
- The procedure is done very quickly.
- At 3:30 the stem cell/PRP combination is injected.
- Advanced degeneration is usually seen every few weeks for up to 4 to 6 visits.
Summary and contact us. Can we help you?
At Caring Medical we do not prescribe any narcotic medications to treat chronic ankle pain simply because of the overwhelming evidence that reveals how narcotics suppress healing and actually exacerbate pain. Further, pain relief is not a reliable sign that a ligament has healed; perfect function is the sign.
A joint that is strong, without swelling or signs of weakness, is a better measure. Caring Medical’s first line of treatment for Chronic ankle pain – ankle instability is Prolotherapy, a type of regenerative injection therapy. In treating with Regenerative Injection Techniques (RIT), i.e., Prolotherapy, Platelet Rich Plasma Therapy, Stem Cell Prolotherapy, a comprehensive approach must be taken. This means treating the whole ankle, not just a single injection at a single site in the joint, as some physicians attempt to do. The comprehensive problem of ankle instability requires comprehensive treatment. Here’s what current research reveals about ankle instability and injury and how a doctor should consider treatment:
Doctors and patients should be advised that the initial diagnosis of an ‘ankle sprain’ is not always correct. Prolonged pain, swelling, and disability that limits the activity and remains stubborn to treat following an ankle injury are not typical of an ankle sprain and should alert the clinician of the possibility of an alternative or an associated diagnosis.
There are several conditions that can be misdiagnosed as an ankle sprain and those include:
- ankle syndesmosis (ligament) injuries,
- sinus tarsi syndrome (a wear and tear condition resulting in hypermobility mostly seen in athletes),
- ankle and hindfoot fractures,
- osteochondral lesions (cartilage problems),
- posterior tibialis and peroneal tendons abnormalities,
- spring ligament damage, impingement syndromes, and reflex sympathetic dystrophy.1
Clearly, this type of chronic ankle problem cannot be treated with a single injection of PRP, Prolotherapy, or Stem Cell Therapy, this is a complicated problem needing a comprehensive plan.
In our research we have shown that comprehensive Prolotherapy used on patients who had an average duration of three years four months of unresolved ankle pain and who were twenty-one months out from their last Prolotherapy session was shown in this observational study to improve their quality of life.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your ankle problems. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated April 3, 2022