What is chronic ankle ligament sprain (also known as chronic ankle instability)?

A series of ligaments stabilise the outer (lateral) part of the ankle. These ligaments are frequently damaged as a result of tripping, twisting the ankle, or a tackle in football. When these ligaments are torn, the ankle becomes unstable, which can lead to more ligament sprains and pain. Nearly half of all ankle ligament sprain patients experience long-term ankle discomfort and instability.

What are the symptoms of chronic ankle ligament sprain?

The following are signs and symptoms of a chronic ankle ligament sprain:
  • A history of a terrible incident of some significance
  • Several ankle injuries over a period of time
  • After an accident, there is swelling and bruising on the outside of the foot and ankle.
  • Walking causes cracking noises from the ankle.
  • Stiffness in the ankles
  • Inflammation of the lateral malleolus (the large bony bump on the outside of the ankle)

What other conditions can present as chronic ankle ligament sprain

A chronic ankle ligament sprain can also be caused by the following conditions:
  • Osteoarthritis of the ankle
  • Sinus tarsi syndrome 
  • Osteoarthritis of the midfoot
Chronic ankle ligament sprain vs Ankle ligament sprain
The location of symptoms can also aid in distinguishing between these illnesses. In contrast to ankle osteoarthritis (OA), which affects the top of the foot as well as the outer and inner sides of the ankle, a chronic ankle ligament sprain is felt mostly on the outside of the ankle.
Ankle osteoarthritis (OA) is a frequent ailment among the elderly, affecting both men and women. It might emerge suddenly after a trauma, but it usually develops gradually over time. Ankle osteoarthritis pain is frequently coupled with growing stiffness and a change in the form of the ankle joint. A twisted ankle is more usually connected with a chronic ankle ligament sprain. It affects both men and women equally, but is significantly more prevalent in the younger sporting/active population.
Anatomy of ankle
The ankle is a complicated region made up of three different joints that perform the following functions (see diagram below):
  • The tibia, fibula, and talus bones form the talocrural joint (the actual ankle joint – blue arrow below). It controls dorsiflexion (the upward movement of your foot) and plantarflexion (the downward movement of your foot) (pointing your foot towards the ground).
  • The tibia and fibula bones form the inferior tibiofibular joint (red circle below), which is crucial for stabilising the lower shin and ankle.
  • The talus and calcaneus bones create the subtalar joint (green circle below), which is responsible for inversion (turning your ankle in) and eversion (turning your ankle out) (turning your ankle out).

Ligaments are fibrous bands of tissue that link bones to form joints. They are short and strong. The purpose of a ligament is to provide mechanical support to the joint, thereby enhancing its strength and stability (Singh et al., 2016). They are meant to resist and control excessive movement at the joint by being structurally stiff (Hauser et al., 2011). Proprioceptive cells are also rich in ligaments (cells used to provide sense of awareness of body position, increasing balance and stability). When a ligament is injured, it affects balance and joint stability. An irregular transition of force through the joint surface is caused by a loss of balance and stability, which increases the risk of osteoarthritis (Hauser et al., 2011).

Ligaments of the ankle
The ankle ligaments are separated into three categories. The lateral ligaments (the ligaments on the outside of the ankle) will be discussed extensively in this blog. The high ankle ligaments and the medial ligaments (placed on the inside of the ankle) (ligaments stabilising the tibia and fibula of the shin).

The lateral ligaments 

The following are the three lateral ankle ligaments:

  • The anterior talofibular ligament is a ligament that connects the lower jaw to the upper jaw (ATFL). The lateral malleolus of the fibula (a prominent bony protrusion at the end of the fibula) is connected to the talus bone of the ankle via this ligament.
  • The calcaneofibular ligament is a ligament that connects the calcaneus to the fibul (CFL). The calcaneous (heel bone) is connected to the tip of the lateral malleolus of the fibula via this ligament.
  • The posterior talofibular ligament is a ligament that connects the lower jaw to the upper jaw (PTFL). This ligament connects the talus’s posterior (back) facet to the fibula’s lateral malleolus.

Injury to the lateral ankle ligaments is surprisingly prevalent. In England alone, 630,890 ankle injury sprains were reported in 2009, according to a big national study (Woodman et al., 2013).

When the ankle is subjected to an unanticipated, high-velocity trauma including inversion and plantarflexion, lateral ankle ligament sprains occur (see below image). A lateral ankle injury that results in a “twisted ankle” is common:

  • I tripped over a curb.
  • Usually during a bad tackle while playing football.
  • In high heels, stumbling.
  • Running on cobblestones is a unique experience.

The following are some of the most common signs of a lateral ankle injury:

  • Ankle twisting or rolling as a result of a sudden stressful occurrence.
  • You may hear a popping or cracking sound coming from your ankle.
  • Swelling that occurs right away. With severe sprains, this can be significant, and it often happens overnight, resulting in a big egg-shaped swelling over the lateral ankle.
  •  Bruising can cover the entire ankle and extend into the foot in cases of substantial lateral ankle ligament injury (see below image)
  • Stiffness is frequently linked to inflammation, and it is exacerbated by lengthy periods of rest, such as sitting at a desk or waking up. Movement can help to ease stiffness.
  • The ATFL ligament, which is situated in front of the lateral malleolus, causes pain.

Statistics on lateral ankle ligament injuries:

  • The ATFL is the weakest and most vulnerable of the three lateral ligaments of the ankle (Singh et al., 2016). 2017 (Li et al.).
  • A lateral ligament injury to the ankle has been linked to a 70% recurrence risk (Hubbard and Hertle et al., 2006).
  • 10% of individuals with lateral ankle sprains do not respond to conservative treatment (Lee et al., 2017).
  • 40 percent of patients with lateral ankle ligament injuries report chronic pain that interferes with everyday activities (pain that lasts more than 12 weeks) (Golano et al., 2016).
  • Patients with chronic lateral ankle sprains have been shown to have sprains of both the ATFL and the CFL in 20% of cases (Golano et al., 2016).
    How do we diagnose lateral ankle ligament sprain?


 A clinical examination and diagnostic imaging are used to identify lateral ankle ligament sprains. A highly experienced physiotherapist should do the clinical assessment, which involves an interview and a physical examination.The purpose of the interview is to learn how your pain began, whether this is your first ankle injury, if you have had any past leg injuries or pathologies (from the hip to big toe), and what aggravates or relieves your symptoms.
The physical examination consists of the following components:
  • A thorough examination of the foot and ankle is performed to check for edoema and bruises.
  • Your ankle and foot will be examined structurally (including assessing the quality of the arch of your foot).
  • Range of motion of the foot and ankle joints. When analysing lateral ankle ligament sprains, inversion and eversion are particularly important.
  • Strengthening of the calf muscles. Is it possible for you to do a heel raise?
  • Testing for balance. Are you able to stand on one leg and keep your balance?
  • Palpation (feeling) of the ankle joint and soft tissues around it. This is used to pinpoint the source of your discomfort. It can be excruciating, but it aids in the formulation of a diagnosis.
  • If necessary, functional tests such as walking, single-leg balance, hopping, and running may be performed.
As previously stated, lateral ankle ligament sprains have been proven in up to 40% of instances to become chronic and persistent (Golano et al., 2016). As a result, it’s vital to get a prompt and precise diagnosis so that the most effective treatment may be chosen for you.
Other ankle diseases are frequently linked to lateral ankle ligament sprains, which might lead to recurrent sprains or prolong your symptoms. Diagnostic imaging is needed to determine the presence of ankle pathology and the severity of the injury (partial or full ligament ruptures can be visualised as well as the surrounding soft tissues).

The following ankle diseases can cause lateral ankle ligament sprains:

  • Impingement of the ankle. A bony protrusion on the talus bone or a soft tissue mass within the ankle joint might develop as a result of previous ankle trauma. This can become impinged (pinched), causing joint pain and instability, as well as an increased risk of lateral ankle ligament sprains.
  • Sinus tarsi syndrome is a condition that affects the feet.
  • Osteoarthritis of the ankle joint
  • Ankle fractures from the past
Options for diagnostic imaging include:
Ultrasound imaging of the musculoskeletal system for diagnostic purposes
Swelling and inflammation associated with a lateral ankle sprain can be assessed with diagnostic musculoskeletal ultrasound imaging. It can examine the lateral ankle ligaments dynamically during movement and visualise the amount of the ligamentous injury (Singh et al., 2016). If there is a partial or total ligament tear, the scan will reveal it. Diagnostic musculoskeletal ultrasound imaging has been shown to be a highly effective and appropriate imaging tool for assessing lateral ankle ligament sprains (Cho et al., 2016), and is capable of visualising swelling and inflammation (a condition known as synovitis) associated with lateral ankle ligament injury (Cho et al., 2016).
 Magnetic resonance imaging (MRI) 
An MRI may be requested if your physician suspects you have hurt your ankle joint or the talus bone. Diagnostic ultrasonography imaging can offer all of the information needed to diagnose a lateral ankle ligament injury (specifically an injury called an osteochondral defect). This procedure is often difficult for claustrophobic patients. In comparison to an ultrasound scan, an MRI scan is more expensive and time-consuming. MRI pictures are made up of a succession of images that combine to form a highly detailed 3D image that allows you to see your injury and make an accurate diagnosis. Ankle impingement, sinus tarsi syndrome, and joint diseases in the foot and ankle are frequently assessed with MRI.

How do we treat lateral ankle ligament sprain?

The following are examples of physiotherapy interventions used to treat a lateral ankle ligament sprain:
  • Advice on how to change your activities.
  • Increase ankle proprioception with balance and stability exercises.
  • Stretching exercises for the ankle joint.
  • Exercises to strengthen the ankles, such as calf lifts.
  • Support and treat symptoms with ankle bracing or physiotherapy taping.
  • To promote ankle joint movement and help you manage your pain and symptoms, your clinician may employ soft tissue massage techniques or ankle joint manipulations.
Here are a few pointers you might want to try for yourself:
  • Make sure you’re not exacerbating your problems. Avoid running, jumping, or walking on uneven ground.
  • Use an ankle brace. This will support the ankle and reduce motions that could aggravate your discomfort.
  • Heel lifts and other calf strengthening exercises can help strengthen and stabilise your ankle muscles. As shown in the figure below.
  • Standing on one leg is a good exercise. Balance training is a vital part of maintaining ankle stability and will help you feel better.
  • Pain can be relieved with over-the-counter oral medications like paracetamol or ibuprofen, or a topical anti-inflammatory gel like Voltarol. Before taking any drug, consult your pharmacist.

What if conservative management isn’t successful?

As previously stated, 10% of individuals with lateral ankle ligament sprains do not improve despite conservative treatment. If this is the case, injectable treatment can be a good option for you.

Corticosteroid injection guided by ultrasound

If your symptoms have persisted for more than three months, are interfering with your sleep, or are preventing you from finishing your physiotherapy rehabilitation, an ultrasound guided corticosteroid injection may be beneficial. After an ankle sprain,’synovitis’ or lateral ‘gutter’ impingement is the most common cause of chronic ankle pain.

Corticosteroid is an injected anti-inflammatory drug that is commonly used to treat pain and inflammation caused by musculoskeletal injuries. A corticosteroid injection provides pain relief for a period of time, giving you a ‘window of opportunity’ to effectively rehabilitate your ankle. According to studies, using a combination of corticosteroids and physiotherapy improves outcomes dramatically. A regimen of rehabilitation should begin within two weeks following a corticosteroid injection, according to Joint Injections.

All injection procedures are carried out at Joint Injections under ultrasound monitoring. Patients have reported that ultrasound-guided injections are less uncomfortable and better tolerated. They have less post-injection problems and are much more accurate than Landmark guided injections in terms of targeting the intended target.

An ultrasound machine is used to guide a needle directly to the source of your symptoms during an ultrasound-guided injection. To improve comfort during the treatment, corticosteroid injections are frequently mixed with a short-acting local anaesthetic.

Sinus tarsi syndrome is a condition that Joint Injections physicians are quite familiar with assessing and treating. Fully qualified independent prescribers, physiotherapists, musculoskeletal sonographers, and injectable therapists make up our highly skilled team. During your first appointment, your physician will give you an accurate diagnosis, prescribe the best medication for you, and perform an ultrasound-guided injection all in one session. You don’t need a referral from your doctor. You can self-refer to our same-day service at any time

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all foot and ankle disorders. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.