How to Manage Chronic Ankle Instability After a Sprain

By Gary Feldman, DPM, FACFAS — Podiatric Medicine & Surgery, Maryland Orthopedic Specialists

You rolled your ankle months ago. The initial swelling went down and the bruising faded, but something still does not feel right. Your ankle gives way when you step off a curb, feels wobbly during a run, or aches after a long day on your feet. If this sounds familiar, you may be dealing with chronic ankle instability — and you are far from alone. As a foot and ankle specialist, I see this condition regularly in my practice, and the good news is that effective treatment options exist at every stage.

What Is Chronic Ankle Instability?

Chronic ankle instability (CAI) is defined as a condition in which a person continues to experience repeated episodes of ankle “giving way,” recurrent sprains, and persistent symptoms such as pain, swelling, and diminished function for more than 12 months after an initial lateral ankle sprain [1]. Lateral ankle sprains are among the most common musculoskeletal injuries in sport and physical activity, and it is estimated that up to 40 percent of people who suffer a first-time sprain will go on to develop chronic instability [1,2].

The underlying problem is twofold. First, there is often mechanical instability — the ligaments on the outside of the ankle, particularly the anterior talofibular ligament (ATFL), become stretched or torn and do not heal at their original tension. Second, there is functional instability — deficits in proprioception (your body’s sense of where your ankle is in space), neuromuscular control, and balance that develop after injury and persist if not specifically addressed [1,7].

Risk Factors

Not everyone who sprains an ankle develops chronic instability, but certain factors increase the likelihood:

  • History of multiple ankle sprains. Each subsequent sprain further damages the ligaments and worsens neuromuscular deficits [2,6].
  • Inadequate rehabilitation after the initial injury. Returning to activity before restoring full strength, range of motion, and proprioception is one of the most common contributors [4].
  • Participation in high-risk sports. Basketball, soccer, volleyball, and running involve rapid changes of direction and landing mechanics that place significant valgus and inversion stress on the ankle [2,5].
  • Hindfoot malalignment. A subtle cavus (high-arched) foot or varus heel alignment increases lateral ankle loading and predisposes to recurrent sprains [3].
  • Proprioceptive deficits. Research has shown that individuals with CAI demonstrate measurable deficits in joint position sense compared with healthy controls, contributing to the cycle of repeated injury [7].
  • Generalized ligamentous laxity. Some patients have naturally looser ligaments throughout their body, which makes the ankle more vulnerable after a sprain.

How Is Chronic Ankle Instability Diagnosed?

In my practice, diagnosis begins with a detailed conversation about your injury history — how many sprains you have had, whether your ankle gives way during everyday activities, and what symptoms persist. I also ask about any previous treatment or rehabilitation you may have completed.

The physical examination includes palpation of the lateral ligaments, the anterior drawer test (which assesses translation of the talus relative to the tibia), and the talar tilt test (which evaluates inversion laxity). Validated patient-reported questionnaires, such as the Cumberland Ankle Instability Tool (CAIT), help quantify the degree of perceived instability and functional limitation [3,6].

Imaging typically starts with weight-bearing X-rays to assess alignment and rule out fractures or arthritis. Stress radiographs can reveal abnormal talar tilt or anterior translation. MRI may be ordered to evaluate the integrity of the ligaments, the condition of the cartilage, and whether associated injuries such as peroneal tendon tears or osteochondral lesions are present [3,9].

Treatment Options

One of the most important messages I share with patients is that the majority of people with chronic ankle instability improve significantly with nonsurgical treatment. Surgery is reserved for those who do not respond to a thorough conservative program.

Conservative (Nonsurgical) Treatment

A structured rehabilitation program is the foundation of care for chronic ankle instability.

The key components include:

  • Proprioceptive and balance training. Exercises such as single-leg stance on unstable surfaces, wobble board drills, and the Star Excursion Balance Test progression are specifically designed to retrain the neuromuscular pathways that were disrupted by injury. Systematic reviews have confirmed that balance training is the single most effective standalone intervention for improving function in CAI [5,7].
  • Strengthening. Targeted strengthening of the peroneal muscles (the primary dynamic stabilizers of the lateral ankle), along with the calf complex, tibialis anterior, and hip stabilizers, helps restore the muscular support that protects the joint.
  • Range-of-motion restoration. Ankle dorsiflexion restriction is common after sprains and contributes to altered gait and compensatory movement patterns. Joint mobilization and stretching are used to restore full motion [4,5].
  • External support. Bracing or taping during sport can reduce the risk of re-injury while rehabilitation progresses. While external support is not a cure on its own, it serves as a valuable adjunct, particularly during the return-to-sport phase [5].
  • Activity modification and gradual return to sport. A stepwise progression from controlled rehabilitation exercises to sport-specific drills helps ensure the ankle is ready for the demands of competition.

Surgical Treatment

When a comprehensive conservative program of at least three to six months has not adequately resolved symptoms, surgical intervention may be recommended. The modified Brostrom procedure — a direct anatomic repair of the stretched or torn ATFL, often reinforced with the inferior extensor retinaculum (the Gould modification) — remains the gold standard. This technique has a long track record of restoring stability while preserving ankle motion [8,9].

For patients with generalized ligament laxity, long-standing instability, or a failed prior repair, anatomic reconstruction using a tendon graft (autograft or allograft) may be considered. While the recovery timeline is typically longer, reconstruction can provide excellent stability in appropriately selected patients [8].

Arthroscopic techniques for both repair and reconstruction have gained popularity in recent years, offering potential benefits including smaller incisions, reduced soft-tissue disruption, and the ability to address intra-articular pathology such as cartilage damage at the same time [9].

Prevention

Prevention of chronic ankle instability begins with proper management of the very first ankle sprain.

Here is what I recommend:

  • Complete your rehabilitation. Even when the pain resolves, your proprioception, strength, and balance may not have fully recovered. A structured rehab program supervised by a physical therapist is essential.
  • Incorporate balance training into your routine. Proprioceptive exercises should be part of ongoing training for any athlete in a high-risk sport — not just a response to injury [5,7].
  • Wear appropriate footwear and consider bracing. Ankle braces have been shown to reduce re-injury rates in athletes returning to sport after a sprain.
  • Strengthen the entire lower kinetic chain. Weakness at the hip and core can alter landing mechanics and increase stress on the ankle.
  • Listen to your body. Persistent ankle discomfort, swelling, or a sense of instability after a sprain is a signal that further evaluation is warranted — not something to push through.

When to See a Specialist

If you have experienced two or more ankle sprains in the same ankle, feel your ankle give way during walking or athletic activity, have persistent pain or swelling that has not resolved with rest, or feel less confident in your ankle during sport, it is time to see a specialist. Early evaluation and targeted rehabilitation can break the cycle of recurrent sprains and prevent the long-term consequences of untreated instability, including cartilage damage and early-onset ankle arthritis.

At Maryland Orthopedic Specialists, we take a thorough, conservative-first approach to chronic ankle instability. Whether the answer is a personalized rehabilitation program, bracing, or surgery, we will build a treatment plan tailored to your goals and your sport.

If you are dealing with recurring ankle sprains or instability, I encourage you to schedule a consultation at Maryland Orthopedic Specialists, (301) 515-0900, mdorthospecialists.com.

Disclaimer This blog post is intended for patient education purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional regarding your individual condition and treatment options.

References

1. Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train. 2019;54(6):572-588. DOI: 10.4085/1062-6050-344-18. https://pmc.ncbi.nlm.nih.gov/articles/PMC6602403/

2. Wikstrom EA, Herzog MM, Marshall SW, Kerr ZY. Epidemiology of Ankle Sprains and Chronic Ankle Instability. J Athl Train. 2019;54(6):603-610. DOI: 10.4085/1062-6050-447-17. https://pmc.ncbi.nlm.nih.gov/articles/PMC6602402/

3. Sarcon AK, Heyrani N, Giza E, Kreulen C. Lateral Ankle Sprain and Chronic Ankle Instability. Foot Ankle Orthop. 2019;4(2):2473011419846938. DOI: 10.1177/2473011419846938. https://pmc.ncbi.nlm.nih.gov/articles/PMC8696766/

4. Dhillon MS, Patel S, Baburaj V. Ankle Sprain and Chronic Lateral Ankle Instability: Optimizing Conservative Treatment. Foot Ankle Clin. 2023;28(1):1-17. DOI: 10.1016/j.fcl.2022.12.006. https://linkinghub.elsevier.com/retrieve/pii/S1083751522001541

5. Ferjancic S, Kozinc Z. Epidemiology, Risk Factors and Conservative Treatment of Chronic Ankle Instability: A Review of Systematic Reviews. Kinesiologia Slovenica. 2023;29(3):101-118. DOI: 10.52165/kinsi.29.3.101-118. http://journals.uni-lj.si/kinsi/article/view/15198

6. Lin CI, Houtenbos S, Lu YH, Mayer F, Wippert P. The Epidemiology of Chronic Ankle Instability with Perceived Ankle Instability — A Systematic Review. J Foot Ankle Res. 2021;14:41. DOI: 10.1186/s13047-021-00480-w. https://pmc.ncbi.nlm.nih.gov/articles/PMC8161930/

7. Xue X, Ma T, Li Q, Song Y, Hua Y. Chronic Ankle Instability Is Associated with Proprioception Deficits: A Systematic Review and Meta-Analysis. J Sport Health Sci. 2021;10(2):182-191. DOI: 10.1016/j.jshs.2020.09.014. https://pmc.ncbi.nlm.nih.gov/articles/PMC7987558/

8. Camacho LD, Roward ZT, Deng Y, Latt LD. Surgical Management of Lateral Ankle Instability in Athletes. J Athl Train. 2019;54(6):639-649. DOI: 10.4085/1062-6050-348-18. https://pmc.ncbi.nlm.nih.gov/articles/PMC6602388/

9. Zhu W, Yang Y, Wu Y. Recent Advances in the Management of Chronic Ankle Instability. Chin J Traumatol. 2024;27(6):311-319. DOI: 10.1016/j.cjtee.2024.07.011. https://pmc.ncbi.nlm.nih.gov/articles/PMC11840320/