Why chronic ankle sprains do not heal

When new patients call in to make an appointment for their ankle injury, we ask, what is the nature of the injury. The response we often hear: “It won’t heal.”

Almost ten years ago, in 2013, this was the conservative care recommendations for the treatment of ankle sprains in athletes. (1) This may provide some evidence into the non-healing ankle epidemic:

  • Successful treatment in moderate to severe ankle sprains can achieved with individualized aggressive, non-operative measures. RICE (Rest, Ice, Compression, Elevation) therapy is the treatment of choice for the first 4-5 days to reduce pain and swelling. Initially, 10-14 days of immobilization in a below the knee cast/brace is beneficial followed by a period in a lace-up brace or functional taping reduces the risk of recurrent injury. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results.

Here is a typical patient we see in our office. History of chronic ankle sprains, weakness, laxity, loss of mobility, pain and swelling. Patient often rests, ices, wears tape or ankle braces. Reports need for varying degrees of anti-inflammatory and over-the-counter pain medications. Takes pain medications and anti-inflammatories prior to sports participation. Patient reports that that surgery has been recommended as their only option.

An estimated 40 percent of people who suffer from an ankle sprain will be left with long-term pain and weakness and up to 70%; will eventually develop osteoarthritis. The reason is because the majority of ankle injuries do not heal properly and respond poorly to the traditional methods of treatment. Such as the ones listed above.

There are three types of ankle sprain, separated into grades of severity. The first, a grade one sprain, is the least severe. This occurs when the ligaments are slightly stretched out, causing minimal tearing of the tissue fibers. This is the type of injury that doesn’t cause severe pain, and the victim can usually “walk it off” without permanent damage. A grade two sprain involves further tearing of the ligaments and can cause instability in the ankle joint. This type of sprain leads to a lot of swelling and tenderness, which makes it difficult to walk and move around. A grade three sprain is indicated by a complete tear of the ligaments, and will make itself known with extreme pain, swelling, and lack of function.

Sprinting and change of direction in chronic ankle instability

A May 2022 study (2) suggested: “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.”

Treating the athlete with Acute lateral ankle sprain

A May 2022 study (3) suggests that “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 Acute lateral ankle sprain may differ from those of the general population. . . .Early dynamic training 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 interventions for athletes returning to sport after  lateral ankle sprain. Despite existing research on rehabilitation of LAS in the general population, a lack of evidence exists related to athletes seeking to return to sport.”

High ankle sprain

A May 2022 paper (4) examined treatments for syndesmotic ankle sprains or “high ankle sprains.”  The researchers write: “The management of such injuries is controversial, with a paucity of evidence on treatment protocols with unpredictability regarding the time lost to participate in sports following injury.” This study reviewed data on 1133 patients and the return to play (RTP) time and examine the outcomes and complications of ankle syndesmotic sprains in this athletic population.

  • The overall return to play was 99%, the average time to return to play was 52 days
  •  Return to play for surgically treated patients was 71 days whereas it was 39 days for nonsurgically treated cases. A low incidence of recurrence and complications were reported.

1 van den Bekerom MP, Kerkhoffs GM, McCollum GA, Calder JD, van Dijk CN. Management of acute lateral ankle ligament injury in the athlete. Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc. 2012 Oct 30.
2 Jamsandekar MS, Patel VD, Prabhakar AJ, Eapen C, Keogh JW. Ability of functional performance assessments to discriminate athletes with and without chronic ankle instability: a case-control study. PeerJ. 2022 May 27;10:e13390.
3 Tee E, Melbourne J, Sattler L, Hing W. Evidence for Rehabilitation Interventions After Acute Lateral Ankle Sprains in Athletes: A Scoping Review. Journal of Sport Rehabilitation. 2022 Dec 30;1(aop):1-8.
4 Salameh M, Hantouly AT, Rayyan A, Dabbas J, Toubasi AA, Hartnett DA, Blankenhorn B. Return to Play After Isolated Syndesmotic Ligamentous Injury in Athletes: A Systematic Review and Meta-analysis. Foot & Ankle Orthopaedics. 2022 May;7(2):24730114221096482.


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