This is a question that I received from my husband who sprained his ankle his freshmen year in college. My husband is now 51 and still has soreness in the ankle especially after running on grass or trails (surfaces that are uneven). He was helping coach our kids’ cross-country team and at one point had me run for him because his ankle was so sore. This is not ideal since several of the kids are faster than me. Anyway, let’s get back to the subject at hand. First let’s talk about my husband’s ankle sprain. It was a lateral ankle sprain that led to chronic ankle instability. The anatomy of such an injury will tell us why it is still so problematic years later.
What is a lateral ankle sprain?
This is one of the most common injuries in sports. My husband injured his when playing basketball with friends. My husband jumped for a rebound and landed on another player’s foot. He came down on the outside of his ankle with the foot pointing down. A lateral ankle sprain occurs when the ankle is plantarflexed and inverted meaning that it is pointing inward and down. The injury occurs as the outside ligaments of the ankle have to stretch. Ligaments attach bone to bone and function to add stability to joints. There are 3 small ligaments on the outside of the ankle and because of their size they are prone to tears.
How bad is this ankle?
So how easily you recover from an ankle sprain and how much 
residual pain you have is correlated to how bad you injured the ankle. There are 3 degrees of ankle sprain with 1st degrees being the least injured to 3rd degree being the most. There are several clues to figuring out how bad your ankle sprain is, and they are:
- Bruising
- Swelling
- Ability to walk
First degree ankle sprain – this is the type of sprain that has a little puffiness around the ankle especially around the knobby bone on the outside of the ankle (aka lateral malleolus). The ligaments have microscopic tears. If bruising is there, it is not much. A person should be able to walk but might limp for a few days after the injury.
Second degree ankle sprain – this degree of sprain has definite bruising and swelling which are both usually around the lateral malleolus (the bone on the outside of the ankle). The ligaments are partially torn but not completely torn. It would be very painful to walk for a week or two after the injury.
Third degree ankle sprain – there is significant bruising which could extend into the foot and up the lower leg. There will be a lot of swelling in the ankle and foot. It will look like your ankle swallowed a softball and your foot will probably not fit in most of your shoes. It will not be possible to walk or stand on that side. One of more of your lateral ankle ligaments are completely torn.
My husband’s ankle sprain was a grade 3 and he was on crutches for three months and in walking boot for several weeks after the crutches. After taking off the walking boot, he was given a stability brace and sent on his way. He never received physical therapy for the injury and was never given any instruction on how to recover past the initial swelling, bruising, and pain stage. He was never educated on the instability that could occur after such a severe sprain.
Chronic ankle instability (CAI)
Chronic ankle instability occurs when your ankle consistently “gives out” or “gives way”. Usually this is rolling to the outside. This occurs because the injured ligaments do not have a great blood supply and take a long time to heal. Also, once a ligament is torn, it will not have the same tensile strength as before the injury. Basically, the ankle will no longer be as stable especially after a 2nd or 3rd degree sprain.
So, my husband does not complain that his ankle “gives way” 
while running or jumping so could his issue still be chronic ankle instability. The answer is yes. He can have more laxity in the ankle joint as a result of the injury but not have so much instability that his ankle is constantly giving out. His ankle joint is moving around more than it should and causing inflammation in the surrounding structures. Also, because my husband is in his 50s and his injury was 30 years ago, so he might also be dealing with some arthritis from this injury.
What can be done now?
- Bracing – Since some of the structural stability of the ankle is now gone with the injury to the outer ligaments, stability is going to have to come from other areas. The first and easiest solution is to have an ankle brace. The brace will provide outside support to the ankle and prevent it from moving into the ranges of motion that are causing pain and difficulty. There are several different types of braces. It could be a stirrup brace or a general ankle stability brace. These braces are bulkier and are going to provide strong stability for the ankle. If you feel like that is overkill and you do not need that much support, you could use an ankle sleeve which would give compression to control swelling. The sleeve provides minimal stabilization for the ankle, and it will not prevent the ankle from giving way. So, if your ankle is very unstable and gives out regularly, you will probably want to wear a brace. Or if you are playing a sport like volleyball, basketball, or soccer where ankle sprains are more likely, you might want the support of a brace. If you are like my husband and have some soreness after running on uneven surfaces (aka grass) a sleeve might work.
- Strengthening – The other way to stabilize the ankle is to improve muscular strength, balance, and proprioception. When I refer to muscular strength, this means the muscles around the hip, knee, and ankle. All of these muscles work together to stabilize the leg and it is important that there is no weak link in the chain.
- Ankle -Start strengthening the ankle with some simple resistance band exercises in all the directions the ankle moves. You can also work on heel raises which are simply going up on your toes. Start heel raises using both feet. You might start by putting more weight through the uninjured leg and letting the injured foot come along for the ride. Slowly start putting more weight through the injured side as it becomes tolerable. Eventually working toward single leg heel raises on the injured leg. See the video below.
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- Hip and knee – Since you have injured the ligaments in your ankle, the ankle joint is not going to be as stable as it was, and the chances of re-strain have increased. By strengthening your hip, thigh, and lower leg, you can create more muscular stability to make up for the loss of ligamentous stability. Side lying leg lifts at the wall, side stepping with a resistance band, fire hydrants, squats, and lunges all are great exercises for strengthening the hips and knees. Using loop resistance bands for these exercises can add significant strength. See the video below.
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- Improved balance and proprioception are very important in preventing further sprains. If your balance is very poor begin balancing on the injured leg while holding onto a counter, then balancing without holding onto anything. Work up to balancing for 30 seconds to a minute. After you can stand on one leg without any difficulty, stand on a pillow or balance while closing your eyes. You can play around with tandem balance (one foot right in front of the other) and tandem walking (forwards and backwards).
- Balance and proprioception – Improved balance and proprioception are very important in preventing further sprains.
- If your balance is very poor, begin balancing on the injured leg while holding onto a counter. Progress to balancing without holding onto anything. Work up to balancing for 30 seconds to a minute. After you can stand on one leg without any difficulty, stand on a pillow or balance while closing your eyes. You can play around with tandem balance (one foot right in front of the other) and tandem walking (forwards and backwards).
- Proprioception is knowing the position of your body without having to look at it. For example, right now I know that my right foot is pointed with my toes in a slightly flexed position and my low back is slightly flexed. Knowing that your ankle is in a stable or unstable position without having to constantly look at it is important in preventing future injuries. A good way to improve proprioception is hopping. First start by hopping on two feet in all directions. Then proceed to hop with just one leg. Hop several times in a row on one foot or alternate between the two. Work on landing softly and with a sure footing.
If you have tried all of this and you are still having difficulty with your chosen activity, go see a physical therapist. There could be issues with the joints in your ankle and foot or other abnormal movement patterns that are better resolved in the clinic. If you don’t have a physical therapist, now is the time to get one. We are immeasurably helpful in helping people get back to doing the activities that give them joy!
In review
- Chronic ankle instability can occur after a bad ankle sprain.
- Use a brace or sleeve to aid in stability when being active.
- Strengthen the muscles around the ankle, knee, and hip to add extra muscular stability to the ankle.
- Improve proprioception and balance.
- Go to physical therapy to help with abnormal joint mobility, abnormal movement patterns, and pain.
If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.statpearls.com/articlelibrary/viewarticle/24090/