Ankle Sprains / Chronic Lateral Ankle Instability
Ankle sprains are the most common musculoskeletal injury in athletes and active adults, accounting for roughly two million emergency department visits annually in the United States. While most acute sprains resolve with conservative care, up to 40% of patients develop chronic lateral ankle instability — persistent pain, repeated giving-way, and diminished confidence on uneven terrain. At Maryland Orthopedic Specialists, we treat the full spectrum: from acute Grade I injuries managed with targeted rehabilitation to chronic instability requiring surgical ligament reconstruction. Early, appropriate care is the best protection against years of recurrent sprains and progressive ankle arthritis.
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What is ankle sprains / chronic lateral ankle instability?
The lateral ligament complex is the most vulnerable structure in the ankle, injured when the foot rolls inward (inversion) and plantarflexes under body weight. Three ligaments comprise this complex: - Anterior talofibular ligament (ATFL): The weakest and most frequently injured ligament, torn in approximately 85% of ankle sprains.
The lateral ligament complex is the most vulnerable structure in the ankle, injured when the foot rolls inward (inversion) and plantarflexes under body weight. Three ligaments comprise this complex:
- Anterior talofibular ligament (ATFL): The weakest and most frequently injured ligament, torn in approximately 85% of ankle sprains. It resists anterior drawer of the talus and internal rotation.
- Calcaneofibular ligament (CFL): Resists inversion in the neutral and dorsiflexed position; injured in moderate to severe sprains.
- Posterior talofibular ligament (PTFL): The strongest; rarely torn except in frank dislocations.
Grading
- Grade I: Stretching of ligament fibers without macroscopic tear. Minimal swelling, no mechanical instability. Weight-bearing is painful but possible.
- Grade II: Partial tear with moderate swelling, bruising, and some functional instability. Tender directly over the ATFL/CFL.
- Grade III: Complete rupture of at least the ATFL, often the CFL as well. Significant swelling, ecchymosis, and inability to bear weight; positive anterior drawer and talar tilt tests.
Ottawa Ankle Rules
The Ottawa Rules guide radiograph decision-making and carry ~99% sensitivity for ruling out fracture. X-ray is indicated if there is bony tenderness at the posterior 6 cm or tip of either malleolus, or at the base of the 5th metatarsal or navicular, AND inability to bear weight immediately after injury and in the ED/clinic. If Ottawa criteria are negative, fracture is effectively excluded.
Chronic Lateral Ankle Instability (CLAI)
When ligament healing is inadequate — due to incomplete rehabilitation, recurrent injury, or underlying anatomical factors (hindfoot varus, ligamentous laxity) — the ankle develops functional and/or mechanical instability. Criteria for CLAI include recurrent giving-way or apprehension episodes for more than 12 months, affecting sport, work, or daily activities. The ATFL and CFL remain attenuated and nonfunctional; dynamic stabilizers (peroneals, proprioceptors) are also impaired.
Treatment options
Most ankle sprains heal well with early protected movement, physical therapy, and time.
Acute Sprain Management
Rest, ice, compression, and elevation in the first 48 hours reduce swelling and pain. Early gentle movement within pain limits helps the ankle recover faster than keeping it completely still. A lace-up brace during activity reduces the risk of re-spraining the same ankle.
Physical Therapy
Balance and strengthening exercises for the ankle and surrounding muscles are the most important steps to a full recovery and preventing future sprains; a physical therapist will guide your progression.
Ankle Ligament Reconstruction (Broström Procedure)
Anatomic repair of the anterior talofibular and calcaneofibular ligaments using the patient's own tissue, reinforced with the inferior extensor retinaculum (Gould modification) for added mechanical strength. Arthroscopic-assisted technique available.
Click for more Surgical ProcedureAnkle Arthroscopy
Minimally invasive joint scope to treat intra-articular ankle pathology — osteochondral lesions, anterior bony impingement, and synovitis — through small portals with same-day discharge at our ambulatory surgery center.
Click for moreFrequently Asked Questions
I sprained my ankle years ago and it keeps "giving way." Is surgery my only option?
What is the Broström-Gould procedure and will I have hardware?
Can an ankle sprain cause arthritis?
What's the difference between a sprain and a fracture?
How long does recovery take after the Broström-Gould ligament reconstruction?
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References
- Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine. 2018;52(15):956. doi:10.1136/bjsports-2017-098106
- Krips R, de Vries J, van Dijk CN. Ankle instability. Foot & Ankle Clinics. 2006;11(2):311–329. doi:10.1016/j.fcl.2006.02.003
- Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. American Journal of Sports Medicine. 2017;45(1):201–209. doi:10.1177/0363546516660980
- Gribble PA, Bleakley CM, Caulfield BM, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine. 2016;50(24):1496–1505. doi:10.1136/bjsports-2016-096189
- Maffulli N, Ferran NA. Management of acute and chronic ankle instability. Journal of the American Academy of Orthopaedic Surgeons. 2008;16(10):608–615. doi:10.5435/00124635-200810000-00006