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Lateral ankle sprains are one of the most common musculoskeletal injuries seen in primary care and physiotherapy practice.
Whether sustained during football, running, rugby, tennis or simply stepping awkwardly off a kerb, they account for a significant proportion of lower limb injuries presenting to GPs, First Contact Practitioners and musculoskeletal physiotherapists.
Fortunately, the majority recover uneventfully with appropriate rehabilitation.
However, studies suggest that up to 30-40% of patients continue to experience pain, instability or recurrent sprains, often months or even years after the original injury.
For the clinician, the challenge lies in recognising when a seemingly routine ankle sprain isn’t quite following the expected course.
The question becomes. is this simply a slow recovery, or is there another injury that has been missed?
Mr Ahmed Latif, Consultant Foot and Ankle Surgeon at London Bridge Orthopaedics, frequently sees patients who have undergone months of treatment for a diagnosis of “ankle sprain”, only for subsequent assessment to identify a different pathology.
“Persistent symptoms after an ankle sprain should never simply be accepted as part of the healing process. Most patients improve steadily over the first three months. If that isn’t happening, it’s important to reconsider the diagnosis rather than simply continuing the same treatment.”
A structured assessment can often identify these patients much earlier and prevent prolonged disability.
Around 85% of ankle sprains involve an inversion injury, typically affecting the lateral ligament complex.
The lateral ligament complex consists of:
The ATFL is by far the most commonly injured ligament due to its orientation and relatively low tensile strength during plantarflexion and inversion.
However, the force required to injure the lateral ligaments may also damage several adjacent structures simultaneously.
These include:
Consequently, what initially appears to be a simple Grade I or II ankle sprain may actually represent a far more complex injury.
The history often provides the biggest clue that something more significant has occurred.
Questions worth exploring include:
A straightforward inversion mechanism points towards lateral ligament injury.
External rotation of the foot, however, should immediately raise suspicion of a syndesmosis (“high ankle”) injury.
Similarly, an axial loading injury may increase the likelihood of an osteochondral lesion.
Although commonly associated with ligament rupture, an audible pop may also accompany peroneal tendon subluxation.
Patients unable to weight bear for several days often sustain more than a simple ligament injury.
Persistent symptoms often prove more valuable than the initial injury itself.
Ask specifically about:
Each of these symptoms points towards a different differential diagnosis.
Although ligament laxity should certainly be assessed, examination should extend well beyond anterior drawer testing.
A systematic assessment often prevents important pathology from being overlooked.
Look carefully for:
A subtle cavovarus foot is particularly important, as it predisposes patients to recurrent lateral ankle instability.
Pain directly over the ATFL remains common for several weeks.
However, tenderness elsewhere should prompt reconsideration.
Important areas include:
Deep anterior ankle pain may indicate an osteochondral lesion rather than persistent ligament injury.
Single-leg balance provides valuable information regarding proprioception.
Observe:
Poor neuromuscular control remains one of the strongest predictors of recurrent sprains.
Assesses ATFL integrity.
Best performed with slight plantarflexion.
Excessive anterior translation compared with the opposite side suggests instability.
Evaluates CFL injury.
Particularly useful when symptoms persist beyond the acute stage.
Pain over the syndesmosis during external rotation raises suspicion of a high ankle sprain.
These injuries typically recover much more slowly and frequently require orthopaedic review.
Compression of the tibia and fibula reproducing distal syndesmotic pain is another useful indicator.
Ask the patient to actively evert against resistance.
Pain, weakness or visible tendon subluxation should prompt further investigation.
These occur in up to 70% of significant ankle sprains but remain underdiagnosed.
Patients often report:
Plain radiographs frequently appear normal.
MRI is usually required for diagnosis.
Persistent lateral pain behind the fibula should not automatically be attributed to ligament injury.
Patients often describe:
Dynamic ultrasound is particularly valuable for diagnosis.
These injuries are commonly underestimated.
Recovery is considerably longer than routine lateral sprains.
Persistent pain above the ankle joint together with difficulty twisting or pivoting should raise suspicion.
Repeated inversion episodes despite rehabilitation may indicate mechanical instability.
Failure of comprehensive rehabilitation after 3-6 months should prompt an orthopaedic assessment.
Modern anatomical ligament reconstruction produces excellent outcomes in appropriately selected patients.
Although uncommon, clinicians should remain alert to features suggesting alternative pathology.
These include:
Persistent pain out of proportion to examination should also raise the possibility of Complex Regional Pain Syndrome (CRPS), particularly if accompanied by colour or temperature changes.
Plain radiographs remain the first-line investigation and should be guided by the Ottawa Ankle Rules.
However, normal X-rays do not exclude significant pathology.
MRI should be considered when:
Ultrasound offers excellent dynamic assessment of the peroneal tendons and lateral ligaments.
CT may occasionally be required for detailed assessment of osteochondral lesions or subtle fractures.
Referral to a foot and ankle specialist should be considered when patients demonstrate:
Early referral is particularly important in athletes and highly active individuals where delayed treatment may prolong recovery and increase the risk of secondary joint degeneration.
The majority of ankle sprains do not require surgery.
However, surgical management may be indicated in selected patients.
Common indications include:
Mr Latif explains:
“One of the biggest misconceptions is that surgery is only considered after years of symptoms. In reality, timely intervention in carefully selected patients – particularly athletes or those with mechanical instability – can restore function and reduce the risk of long-term joint damage.”
Persistent ankle pain following a sprain should never simply be labelled as a “slow recovery.” A detailed history, systematic examination and an understanding of commonly missed injuries can significantly improve diagnostic accuracy.
Perhaps the most important question to ask is not “Has the ligament healed?” but rather “Is the original diagnosis still the correct one?”
Recognising when recovery is deviating from the expected trajectory, and referring appropriately, can make a substantial difference to long-term outcomes, allowing patients to return to work, exercise and sport with confidence.
Fong, D.T. et al. (2007) ‘A systematic review on ankle injury’, Sports Medicine, 37(1), pp. 73–94.
Verhagen, R.A. et al. (1995) ‘Long-term prognosis of ankle sprains’, Journal of Bone and Joint Surgery, 77(2), pp. 262–266.
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