What is a chronic ankle sprain?

Chronic Ankle Sprain: Definition and Management

A chronic ankle sprain is a condition resulting from inadequate treatment or healing of an acute ankle sprain, characterized by persistent symptoms including pain, decreased range of motion, joint instability, and recurrent episodes of the ankle "giving way," which can significantly impact quality of life and functional ability. 1, 2

Pathophysiology and Development

• Approximately 20% of acute ankle sprains progress to chronic ankle instability 2, 3
• Chronic ankle instability typically develops when:
  • Functional rehabilitation after acute sprain is inadequate
  • Initial injury was severe (complete ligament rupture)
  • Patient has a history of recurrent sprains
  • Proper healing time was not allowed before return to activities 1, 4

Clinical Presentation

• Persistent symptoms beyond expected healing time (2-6 weeks depending on severity)
• Recurrent episodes of ankle "giving way" (at least three episodes within 12 months) 5
• Decreased proprioception and neuromuscular control
• Compromised static and dynamic balance 5
• Potential mechanical laxity of the lateral ankle ligaments
• Functional deficits during activities, especially on uneven surfaces 6

Diagnostic Approach

• Physical examination should assess:

  • Ligament stability using varus stress test and anterior drawer test 2
  • Subtalar joint stability (commonly overlooked) 2
  • Proprioception deficits
  • Range of motion limitations
  • Balance and functional performance 5

• Imaging considerations:

  • Stress radiographs may be used but have limited sensitivity 6
  • MRI may be helpful to assess ligament integrity but has limitations in predicting mechanical properties of healing ligaments 6

Treatment Options

Conservative Management

• Functional rehabilitation is the first-line treatment approach:

  • Comprehensive exercise program focusing on:
    • Proprioceptive training (ankle disk exercises)
    • Balance training
    • Coordination exercises
    • Strengthening of peroneal muscles 4, 7

• External supports:

  • Semirigid supports or braces are superior to elastic bandages 1
  • Particularly beneficial for patients with history of recurrent sprains 1

• Manual therapy:

  • Joint mobilization combined with exercise therapy shows better outcomes than exercise alone 1
  • Can improve ankle dorsiflexion range of motion and decrease pain 1

Surgical Management

• Reserved for patients who fail conservative treatment

• Options include:

  • Anatomical repair (Brostrom-Gould procedure)
  • Ligament augmentation using tendon
  • Anatomical reconstruction (especially for revision cases or poor tissue quality) 3
  • Arthroscopic techniques are becoming more popular 2

• Surgical outcomes:

  • Surgery appears superior at decreasing recurrence rates 1
  • May have longer recovery times and risk of complications including ankle stiffness 1
  • Professional athletes may benefit from earlier surgical intervention for quicker return to play 1

Prevention Strategies

• Complete appropriate rehabilitation before returning to full activities 4
• Use of proper ankle supports, especially with history of previous sprains 4, 7
• Implementation of proprioceptive and balance training programs 4, 7
• Strong evidence supports bracing and moderate evidence supports neuromuscular training in preventing recurrence 7

Common Pitfalls and Considerations

• Failing to differentiate between functional and anatomical ankle instability 2
• Overlooking subtalar joint instability during assessment 2
• Returning to activities too soon before complete rehabilitation
• Not addressing proprioceptive deficits, which can persist even a year after injury 5
• Neglecting the need for long-term preventive strategies in patients with history of ankle sprains 4