Chronic ankle pain – when acute ankle sprains don’t resolve

Chronic ankle pain - when acute ankle sprains don't resolve

Chronic ankle pain is frequently multifactorial

An acute lateral ankle sprain is the quintessential injury that presents for physio at our Randwick practice the Movement Centre. Most of us have experienced it. Rolling the ankle outward, the foot rolling under us into an inverted position. There is usually acute pain and swelling on the outer ankle. These injuries can range from innocuous twinges that we can run off, to significant injuries requiring immobilisation. Some even require surgery. In some cases, there can be a long window of re-injury, or lingering pain and swelling. Why is it that some people have lingering issues and chronic ankle pain after an ankle sprain?

Reasons for lingering issues and chronic ankle pain

There are many reasons that an acute ankle sprain can develop into chronic ankle pain or issues:
  • Obviously the severity of the injury can create long term issues.
  • Bigger injuries, trauma and significant acute pain can have lingering issues, more scar deposition and healing processes. Particularly if the ankle requires surgery or long periods of immobilisation.
  • Failure to adequately immobilise or protect an acute injury. This can lead to long-term issues with instability and reinjury.
  • Poor range of motion after injury.
  • Prolonged immobilisation, while sometimes necessary, can result in tightness in muscles and joints that can linger long after the injury has healed. Deficits in range of motion need to be restored effectively, especially before resuming high impact activities such as running.
  • Weakness around the ankle. As we unload injured ankles after an ankle sprain, the muscles of the foot and calf can become slightly weaker. As we reload the foot post-injury, these muscles must be strengthened and loaded gradually, to restore proper function to the foot.

The site of the injury is also important for long term outcomes

Bone injuries that involve the joint line or cartilage surface can require more protection and slower healing time frames. In ankle injuries we particularly need to pay attention to the cartilage lined talar dome. The talar dome is the soft, cartilage lined articulating surface where the foot meets the ankle. In forceful ankle sprains, the talar dome can be bruised. Bruising through the cartilage and subchondral bone takes time to heal. This is often overlooked in acute ankle sprains. There are many other non-structural issues for lingering pain and stiffness following an ankle injury.
  • The trauma of the initial injury, fear and uncertainty about reinjury, time away from sport and exercise can all have an impact.
  • There can be processes of central and peripheral sensitisation that can create neural wind-up of the pain response, resulting in lingering pain that doesn’t follow usual injury healing time frames.

Identifying lingering issues

To understand the causes, we need to review the initial mechanism of injury and the subsequent management. A thorough assessment is undertaken; and we look through all of the above-mentioned components to identify what may be contributing. This typically involves a discussion about the mechanism of the injury, and the acute management. We also want to know what rehab has been performed, and what return to sport has been achieved. A thorough objective assessment is then carried out. In this assessment we want to observe the function of the ankle, and the limitations. Objective assessment of a chronic ankle will often involve:
  • Sports specific test – running, jumping, hopping – aiming to replicate the patient’s activity and symptoms.
  • Strength assessment – particularly observing for any differences between the injured side and non-injured side.
  • Range of motion assessment – In ankles we have a focus on the dorsiflexion range – again looking for differences between sides and comparing to norms for the population.
  • Nerve and vascular assessment as necessary. In chronic conditions there can be underlying nerve irritation the the root of the problem.
  • Specific ligament, bone and soft-tissue testing.
  • With chronic conditions we also often include a scan of the whole limb and spine
The three main things we are looking for in chronic ankle pain conditions are:
  • Has range of motion been restored to pre-injury levels? And how close is it to the non-injured side?
  • Has strength and balance been restored to sports-specific requirements
  • Was something missed in the initial diagnosis? Structural damage, failure to heal, excessive laxity, nerve irritation etc.
Some examples of problems that contribute to chronic ankle pain include:
  • Sinus Tarsi Syndrome: pain in the lateral rear-foot that can linger following acute injury, especially with flat-foot type.
  • Peroneal tenosynovitis: Pain and swelling of the tendons behind the lateral malleolus (ankle bone). This results from inflammation of the sheath of the tendon – usually from repetitive use and instability.
  • Tibialis Posterior tendon issues: Pain generally along the inside of the ankle, worse with prolonged walking and flat shoes. This is generally the result of over-use and change in footwear or loading.
  • Chronic instability: Usually marked by recurrent inversion injuries, or loss of balance. This usually results from an ankle sprain that hasn’t healed adequately. While this condition can seem innocuous, repetitive inversion injuries can have long-term issues on the bone surfaces and surrounding tissues.
  • Achilles tendon issues: Stiffness and soreness in the Achilles – most often on first movement, initiating exercise, and after exercise – is a common symptom following ankle injury. This is particularly so when there has been a period of prolonged immobilisation.
  • Bunions, and other 1st Metatarsal and big toe issues: Issues here can result from altered movement patterns following ankle injury. If range and strength are not restored, our body can create adaptive movements that involve rolling over the inside of the big toe.
  • Cartilage damage, arthritic pain and stiffness:This is characterised by lingering stiffness and swelling in the joint. Repetitive injury can degrade the quality and quantity of the cartilage that lines the joint surfaces. While not directly painful in it’s own right, this process can contribute to lingering pain and swelling.

Key takeaway points in chronic ankle pain

We hate hearing patients say they have “bad ankles”. Or that they have chronic ankle pain. Or they suffer from repetitive ankle sprains. So often there is an answer to their problems. If you are experiencing lingering ankle pain, or stiffness and weakness issues preventing you from returning to the activities you love, come and see our team of physios and podiatrists. Movement Centre in Randwick is focused on finding the best possible outcome for each of our patients. We have a wide range of equipment and approaches to address the problems associated with chronic ankle pain outlined above.
Disclaimer: The Movement Centre provides this information as an educational service. The information contained on this website and in this blog is not intended to serve as or replace actual medical advice. Anyone seeking specific advice or assistance should consult their local Randwick Physio, general practitioner, medical specialist, or otherwise appropriately skilled practitioner.