How should I evaluate and manage a 30-year-old man with chronic intermittent ankle swelling and pain worsened by prolonged standing or walking, secondary to repeated football-related ankle trauma over the past 3–4 years?

Chronic Post-Traumatic Ankle Pain and Swelling: Evaluation and Management

Start with plain ankle radiographs (anteroposterior, lateral, and mortise views) to evaluate for post-traumatic osteoarthritis, osteochondral lesions, osteophytes, or ossific fragments from prior ligamentous injuries, then proceed to MRI if radiographs are normal or to further characterize soft-tissue pathology identified on x-ray. 1

Initial Diagnostic Workup

Begin with standard three-view ankle radiographs as the first-line imaging study for chronic ankle pain following repetitive trauma. 1 This will identify:

• Post-traumatic osteoarthritis from repetitive microtrauma 1
• Osteochondral lesions of the talar dome (though radiographs miss 41% of these) 1
• Anterior tibial or talar osteophytes causing anterior impingement 1, 2
• Ossific fragments indicating chronic ligamentous injury or retinaculum avulsion 1
• Periostitis adjacent to chronic tenosynovitis 1

Key clinical examination findings to document:

• Tenderness location (anterolateral suggests impingement; lateral suggests chronic instability) 3, 4
• Anterior drawer test for chronic lateral ligament laxity 1, 5
• Range of motion, particularly dorsiflexion restriction (suggests anterior impingement) 3, 2, 4
• Swelling pattern and timing relative to activity 4

When Radiographs Are Normal or Show Minimal Changes

Proceed to MRI without contrast as the next study, which has 96% sensitivity for osteochondral abnormalities and 93-97% accuracy for ligament tears. 1 MRI will identify:

• Osteochondral lesions missed on radiographs (41% of cases) 1
• Chronic ligament tears: anterior talofibular (77-92% accuracy), calcaneofibular (88-92% accuracy), deltoid (96% sensitivity) 1
• Anterior or anterolateral impingement from soft-tissue scarring, meniscoid lesions, or synovitis 1, 3, 2
• Tendon pathology including peroneal or tibialis posterior tendinosis 1
• Bone marrow edema suggesting occult stress injury 1

Common Pathologies in Chronic Post-Traumatic Ankle Pain

Based on arthroscopic studies of 100 patients with chronic ankle pain after sprains, 95% fall into three categories: 6

1. Chronic instability (lateral ligament or syndesmotic) 6, 5
2. Impingement syndromes (anterior or anterolateral) 6, 3, 2
3. Articular lesions (chondral or osteochondral defects) 6

The remaining 5% have nonspecific synovitis or early osteoarthritis. 6

Management Algorithm

Conservative Treatment (First-Line for All Patients)

Supervised exercise-based rehabilitation programs are strongly preferred over passive modalities as they stimulate recovery of functional joint stability. 1, 7 This should include:

• Proprioceptive training with ankle disk exercises to address functional instability 1
• Progressive strengthening of peroneal and tibialis muscles 1, 5
• Range of motion exercises particularly for dorsiflexion 2
• Functional activity progression 1, 7

Use semirigid or lace-up ankle braces during activities to prevent recurrent injury and reduce symptoms. 1, 7 These reduce recurrence risk by approximately 50% in patients with prior sprains. 1

NSAIDs may be used cautiously for pain and swelling control, but be aware they may suppress natural healing processes and should not be used long-term. 1, 7

When Conservative Treatment Fails After 6 Months

Consider diagnostic and therapeutic arthroscopy if symptoms persist despite comprehensive rehabilitation. 6, 3 Arthroscopic outcomes show:

• Syndesmotic instability treatment: significant improvement 6
• Anterior/anterolateral impingement debridement: significant improvement in two-thirds of patients 6, 3
• Osteochondral lesion excision with abrasion: successful in stable ankles 6
• Chronic lateral instability: requires open ligament reconstruction, not arthroscopic treatment 6

Surgery should be reserved for cases unresponsive to thorough exercise-based treatment. 1

Diagnostic Injection for Unclear Pain Source

If radiographs show multiple degenerative sites and the pain source is unclear, consider fluoroscopy- or ultrasound-guided diagnostic anesthetic injection to identify which joint is symptomatic before surgical planning. 1 This is particularly useful when:

• Multiple joints show degenerative changes 1
• Symptoms don't clearly localize on examination 1
• Surgical intervention is being considered 1

Critical Pitfalls to Avoid

Do not assume this is "just a chronic sprain" without imaging evaluation, as 20-40% of ankle sprains develop chronic complications requiring specific treatment. 4 The most common causes of persistent symptoms are:

• Incomplete rehabilitation (most common) 4
• Undiagnosed osteochondral lesions 6, 4
• Chronic ligamentous instability 6, 4, 5
• Anterior impingement from osteophytes or soft tissue 3, 2
• Occult syndesmotic injury 6, 4

Delayed examination 4-5 days post-acute injury optimizes ligament assessment, but this patient is 3-4 years out, so immediate examination is appropriate. 1, 7

Patients with recurrent ankle sprains have the highest risk of chronic instability - the most common predisposition to ankle sprain is having had a previous sprain. 5 This patient's history of repetitive football trauma places him at very high risk for chronic mechanical and functional instability requiring specific intervention beyond simple rest.