Blog 1: Ankle Sprains: Why Most Athletes Never Recover
Part 1: What Actually Happens When You Sprain Your Ankle, and Why Most People Never Fully Recover
Welcome to Ankle Sprains and Chronic Instability!
This is a four part series written by Dr. Keirstyn, owner and chiropractor at Endurance Therapeutics, on one of the most common and most undertreated injuries in sport. The lateral ankle sprain is the single most frequent acute injury across almost every sport globally. It is also one of the injuries most likely to be dismissed, inadequately rehabilitated, and left to become a chronic problem that limits athletes for years.
If you have ever rolled your ankle, been told to ice it and rest, and then returned to sport still feeling like the ankle is not quite right, this series is for you.
What Is Actually Happening When You Roll Your Ankle
A lateral ankle sprain occurs when the foot rolls inward, forcing the ankle into inversion beyond its normal range of motion. This places excessive tensile force through the lateral ligament complex on the outside of the ankle. The three ligaments most commonly involved are the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament, in order of how frequently they are injured.
The anterior talofibular ligament is the most commonly injured of the three because it is the primary restraint against inversion when the ankle is in plantarflexion, which is exactly the position the foot is in when the ankle rolls during running, landing, or changing direction. It is a relatively small ligament with a limited blood supply, which is one of the reasons ankle sprains take longer to heal than athletes expect.
Sprains are graded by severity:
Grade 1:
Stretching of the ligament fibres without significant tearing. Mild swelling and tenderness, minimal functional limitation. Return to sport typically within one to two weeks with proper management.
Grade 2:
Partial tearing of one or more ligaments. Moderate swelling and bruising, some instability of the joint, meaningful functional limitation. Return to sport typically three to six weeks with proper rehabilitation.
Grade 3:
Complete rupture of one or more ligaments. Significant swelling, bruising, and instability. Depending on severity, return to sport may take six to twelve weeks or longer, and surgical consultation may be warranted in some cases.
Grade is not always predictable from the initial presentation. Some significant partial tears swell less than minor sprains depending on the location of the injury and the individual's inflammatory response. When in doubt, proper assessment matters more than self-grading.
What Else Gets Injured in an Ankle Sprain
This is the part most athletes and even many clinicians overlook. A lateral ankle sprain is rarely just a ligament injury. The inversion mechanism that damages the lateral ligaments also commonly involves:
Peroneal tendons: the peroneal muscles run along the outside of the ankle and are the primary dynamic stabilizers of the lateral ankle. During an inversion sprain, the peroneals contract eccentrically to resist the inversion force. This can result in peroneal tendon strain, subluxation, or in severe cases avulsion of the peroneal tendons from their attachment at the fibula.
Proprioceptive nerve endings: the lateral ankle ligaments are densely populated with mechanoreceptors — nerve endings that provide the brain with information about joint position and movement. When the ligaments are damaged, these mechanoreceptors are also damaged. The result is impaired proprioception, which is the body's awareness of where the ankle is in space. This is one of the primary drivers of chronic instability and the reason why simply waiting for pain to resolve is insufficient rehabilitation.
Bone bruising and osteochondral lesions: the inversion mechanism can also cause the talus to impact the lateral wall of the ankle mortise, resulting in bone bruising or cartilage damage. These lesions are frequently missed on standard X-ray but are visible on MRI and can cause persistent ankle pain and limitation long after the ligament injury has healed.
Sinus tarsi syndrome: the sinus tarsi is a small canal on the outside of the ankle between the talus and calcaneus. It contains proprioceptive nerve endings and fat tissue. It is frequently involved in lateral ankle sprains and when irritated causes a deep, aching lateral ankle pain that persists well beyond the initial injury.
Why Most People Never Fully Recover
The standard management of ankle sprains in most sporting contexts is RICE (rest, ice, compression, elevation) followed by return to sport once the pain has subsided. This approach addresses the acute inflammatory response but does almost nothing to address the proprioceptive deficit, the peroneal weakness, and the mechanical changes to the ankle that make the next sprain more likely than the first.
Research consistently shows that up to 40 percent of ankle sprains progress to chronic ankle instability, characterized by recurrent sprains, persistent feelings of giving way, and reduced confidence in the ankle during sport and daily activity. The athletes most likely to develop chronic instability are those who return to sport based on pain resolution alone rather than completing a full rehabilitation programme that restores proprioception, strength, and neuromuscular control.
The pain goes away. The deficits do not. That is why the ankle keeps rolling.
Up Next: Chronic Ankle Instability
In Part 2 of Ankle Sprains and Chronic Instability we go deep on what chronic instability actually is, what is happening in the ankle that makes it keep giving way, and why the standard approach of taping and hoping is not a solution. See you there.
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An ankle sprain that did not fully rehabilitate is one of the most fixable problems I see in the clinic. If your ankle has not felt right since a sprain, or if it keeps rolling on you, reach out to book an assessment at Endurance Therapeutics. There is almost always more that can be done.
📍 Endurance Therapeutics | Oakville, Ontario
📞 905-288-7161