What are the possible differentials and management options for chronic left ankle pain following a lateral ankle roll injury?

Differential Diagnoses for Chronic Left Ankle Pain Following Lateral Roll Injury

After a lateral ankle roll injury with pain persisting for 2 months, the most likely diagnoses are chronic lateral ligament injury (particularly anterior talofibular ligament), osteochondral lesions, peroneal tendon pathology, lateral ankle impingement, and sinus tarsi syndrome. 1

Primary Differential Diagnoses

Chronic Lateral Ligament Injury/Instability

• Most common cause of persistent pain after lateral ankle sprain, affecting up to 40% of patients who develop chronic ankle instability (CAI) 1
• At 1-4 years follow-up, 5-46% still experience pain, 3-34% have recurrent sprains, and 33-55% report instability 1
• Anterior talofibular ligament (ATFL) is most commonly injured, followed by calcaneofibular ligament (CFL) 1
• Patients complain of giving-way sensation, lateral ankle pain, and functional instability 2

Osteochondral Lesions

• Frequently associated with lateral ankle sprains and can cause persistent pain 1
• May present with deep ankle pain, catching, locking, or crepitation 2
• Often requires advanced imaging for diagnosis as plain radiographs may be normal 1

Peroneal Tendon Pathology

• Includes tendinopathy, partial tears, or subluxation/dislocation 1, 3
• Up to 34% of asymptomatic patients may have peroneus brevis tears, so clinical correlation is essential 1
• Pain typically located posterior and inferior to lateral malleolus 3
• Dynamic assessment may reveal tendon subluxation with ankle movements 1

Lateral Ankle Impingement

• Clinical signs present in 25% of patients with chronic ankle pain, with 82% radiographically confirmed 1
• Anterolateral impingement most common, caused by soft tissue or synovial hypertrophy 4, 5
• Pain with dorsiflexion and anterolateral tenderness on examination 2

Sinus Tarsi Syndrome

• Deep lateral ankle pain in the sinus tarsi region 3
• Often associated with subtalar joint instability 3
• Tenderness anterior and inferior to lateral malleolus 3

Other Important Considerations

• Syndesmotic injury: High ankle sprain with pain above the ankle joint, positive squeeze test 5, 2
• Stress fractures: Particularly of lateral malleolus, fifth metatarsal base, or navicular 1
• Inadequate rehabilitation: Most common cause of persistent symptoms 5, 2
• Reflex sympathetic dystrophy: Rare but important to recognize early; presents with discoloration, glossy skin, temperature changes 2

Diagnostic Approach

Initial Imaging

• Start with plain radiographs (AP, lateral, and mortise views) to evaluate for fractures, osteoarthritis, osteochondral lesions, or ossific fragments 1
• Radiographs may reveal evidence of prior trauma, calcified bodies, or periostitis adjacent to tenosynovitis 1

Advanced Imaging When Radiographs Are Normal or Nonspecific

MRI is the preferred next study for comprehensive evaluation of chronic ankle pain 1

MRI Diagnostic Accuracy:

• ATFL tears: 77-92% accuracy, with 97% accuracy in one study identifying exact injury location in 93% of cases 1
• CFL tears: 88-92% accuracy 1
• Deep deltoid ligament: 96% sensitivity, 98% specificity 1
• Syndesmotic injuries: 100% accuracy 1
• Tendon tears: >90% sensitivity for ankle tendon pathology 1
• Osteochondral lesions: Excellent visualization with 93-96% sensitivity 1

Alternative Imaging Options:

• Ultrasound: 91% accuracy for ATFL injuries, 63% accuracy for exact location; allows dynamic assessment of tendon subluxation and ligament laxity 1
• MR arthrography: Helpful for chronic ankle instability assessment 1
• Stress radiography: Lower accuracy (67%) compared to MRI, but can assess functional instability 1

Clinical Examination Pearls

Key Physical Findings to Assess:

• Anterior drawer test: Best performed 4-5 days post-injury with 84% sensitivity and 96% specificity for ligament rupture 1
• Palpation: Specific tenderness over ATFL, CFL, peroneal tendons, sinus tarsi, or syndesmosis 3, 2
• Range of motion: Reduced dorsiflexion suggests impingement or inadequate rehabilitation 2
• Swelling pattern: Diffuse versus localized helps narrow differential 2
• Instability testing: Assess for mechanical laxity versus functional instability 1

Prognostic Factors Indicating Poor Recovery

Address these factors early to prevent chronic instability: 1

• High pain levels at presentation
• High physical workload or competitive sports participation
• Inability to complete jumping/landing within 2 weeks
• Deficiencies in dynamic postural control
• Increased ligament laxity at 8 weeks post-injury
• Young male athletes with high BMI or greater body height 1

Common Pitfalls to Avoid

• Don't assume all chronic pain is simply "incomplete healing" - up to 40% develop CAI despite appropriate initial treatment, suggesting underlying structural pathology 1
• Don't rely solely on initial radiographs - many significant soft tissue injuries and osteochondral lesions are not visible on plain films 1
• Don't ignore peroneal tendon findings on MRI without clinical correlation - 34% of asymptomatic patients have tears, so positive predictive value is only 48% 1
• Don't delay MRI beyond 6-8 weeks if symptoms persist despite appropriate functional rehabilitation 1
• Don't overlook syndesmotic injury - often missed initially and requires different management than lateral ligament sprains 5, 2