Ankle Sprains: Avoiding the Route to Chronic Pain
Updated: 49 minutes ago
Ankle sprains are among the most common musculoskeletal injuries, particularly in sports and recreational activities. Most involve the lateral ligaments on the outside of the ankle and occur when the foot rolls inward during an inversion injury. Although many ankle sprains recover well, they should not always be dismissed as minor injuries.
For some people, pain, stiffness, weakness, instability, or recurrent sprains can persist long after the initial injury. Repeated ankle sprains and chronic ankle instability may also contribute to longer-term changes in joint function and an increased risk of ankle osteoarthritis.
Successful rehabilitation therefore involves more than simply waiting for an injured ligament to heal. It requires restoring mobility, strength, balance, proprioception, and confidence in movement while identifying other factors that may be contributing to persistent symptoms or instability.
Article Index:
Ligamentous Architecture
The stability of the ankle’s outer side depends on three main ligaments: the Anterior Talofibular Ligament (ATFL), the Calcaneofibular Ligament (CFL), and the Posterior Talofibular Ligament (PTFL).
In an inversion sprain, where the ankle twists inward, the ATFL is typically the first to be injured. Ligaments are named for the bones they connect—in this case; the ATFL connects the talus bone in the ankle to the fibula, a critical bone in the lower leg. The ATFL’s primary role is to prevent the talus from shifting forward, helping to keep the ankle stable.
Ligament Injuries in Severe Ankle Sprains
The Calcaneofibular Ligament (CFL), which connects the heel bone (calcaneus) to the fibula, may also be injured in a severe ankle sprain. It is generally stronger than the ATFL.
Movements in which the foot is pointed downward (plantar flexion) and rolls inward (inversion) can damage both the ATFL and CFL, leading to significant ankle instability.
The Posterior Talofibular Ligament (PTFL), the strongest ligament in the lateral ankle complex, is rarely injured unless there’s a complete ankle dislocation.
A more severe type of sprain, known as a 'High Ankle Sprain,' involves the syndesmotic ligament complex. This injury tears the ligament and connective tissue between the tibia and fibula, often requiring surgical intervention.
The Kinetic Chain of Ankle Sprains
Ankle sprains affect more than just ligaments—they impact connective tissues, tendons, muscles, and nerves. Understanding the complexity of these injuries, especially lateral and high ankle sprains, is key to effective treatment and prevention.
Tendons: During an inversion sprain, the Peroneal Tendon is often affected. As healing progresses, this tendon may shift from its normal position, leading to subluxation, a partial dislocation. Proper realignment during recovery is crucial for optimal healing.
Muscles: The Peroneus Brevis and Peroneus Longus muscles are commonly involved in ankle sprains. Lateral sprains can cause longitudinal tears in the Peroneus Brevis, while the Peroneus Longus may show altered activation due to muscle constraints from ankle instability. If these issues aren’t addressed, re-injury is likely. These muscles play a critical role in rolling the foot outward at the tarsal joint and flexing the foot downward at the ankle.
Retinaculum: Think of the retinaculum as a strong belt of connective tissue that keeps the peroneal tendons securely in place. A tear in this 'belt' can cause a snapping sensation in the outer ankle. In severe cases, retinaculum tears may not heal with manual therapy alone and could require surgical intervention.
Understanding the anatomy of these injuries is crucial for creating a comprehensive treatment plan for ankle sprains. This holistic approach aids in healing and lowers the risk of future sprains.
Ankle and Foot Examinations
Diagnosing and treating ankle sprains requires a thorough examination of the ankle and foot, using three key tests: orthopedic, neurological, and vascular.
Orthopedic tests focus on bones, muscles, and ligaments to pinpoint specific areas that need attention.
Neurological tests assess nerve function to rule out any nerve-related issues.
Vascular assessments ensure proper blood circulation, which is vital for healing.
We've created a series of demonstration videos to illustrate the importance of these exams in managing ankle sprains and related conditions. These visual guides deepen your understanding of these essential evaluation processes.
Effective Ankle and Foot Examination
This video uses orthopedic tests to evaluate some of the most common ankle and foot conditions we see in clinical practice. These conditions include Ankle Sprains (inversion sprain), Cuboid Syndrome, Talar Dome Lesions, 5th Metatarsal Fracture, Syndesmosis damage, Achilles Tendon Tendinopathy, Morton's Neuroma, 2nd Metatarsal Stress Fracture, Plantar Fasciitis, and Bunions.
Lower Limb Neuro Examination
The lower limb neurological examination is part of the overall neurological examination process and assesses the motor and sensory neurons that supply the lower limbs. This assessment helps detect any impairment of the nervous system and is used both as a screening and an investigative tool.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is valuable for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. This video reviews some common procedures we perform in daily clinical practice.
Imaging
Most ankle sprains can be assessed through a careful history and physical examination and do not routinely require imaging. Imaging becomes important when a fracture, significant ligament or tendon injury, cartilage injury, or another condition is suspected, or when symptoms are not progressing as expected.
X-rays may be recommended when a fracture is suspected. Clinical decision tools such as the Ottawa Ankle Rules can help determine when X-rays are appropriate.
Ultrasound can provide dynamic, real-time imaging of ligaments, tendons, and other soft tissues and may be useful when a specific soft-tissue injury is suspected.
MRI provides detailed imaging of ligaments, tendons, cartilage, bone, and other structures. It is generally considered when symptoms persist, the diagnosis remains uncertain, or a more significant injury is suspected.
Imaging should be guided by the clinical examination and the individual circumstances of the injury rather than used routinely for every ankle sprain.
The Acute Stage
The first hours and days after an ankle sprain are important, but the goal is not simply to eliminate swelling or completely rest the ankle. The priority is to protect the injured tissues while gradually restoring comfortable movement and weight bearing as the injury allows.
More severe injuries, significant swelling, inability to bear weight, obvious deformity, or substantial tenderness over specific bones may require further assessment to rule out a fracture or more serious injury.
Protect, Support, and Keep Moving
Protection: Immediately after an ankle sprain, temporarily reducing activities that significantly increase pain can help protect the injured tissues. Crutches, taping, or an ankle brace may be useful depending on the severity of the injury.
Weight Bearing: Prolonged avoidance of weight bearing is generally not recommended for uncomplicated ankle sprains. Gradually begin putting weight through the ankle as tolerated, using appropriate support when necessary. More severe sprains may require a short period of greater protection or immobilization.
Compression and Elevation: Compression and elevation can be useful for managing swelling, particularly during the early stages of recovery. Swelling is a normal part of the body's response to injury, so the goal is not necessarily to eliminate it completely but to manage excessive swelling and discomfort.
Ice: Ice can provide short-term pain relief and may help some people manage swelling. However, it should be viewed primarily as a symptom-management strategy rather than something that has been proven to accelerate tissue healing.
Begin Movement Early
As pain allows, begin restoring comfortable ankle movement rather than waiting for the injury to completely settle. Gentle ankle movements, such as ankle circles or drawing the alphabet with your foot, can be a useful starting point. Exercise should then progressively address range of motion, strength, balance, proprioception, and eventually the functional demands of everyday activities or sport.
The key is progressive loading. Protect the ankle when necessary, but gradually give it the movement and activity it needs to recover.
Ankle Exercises - Acute Injury
This video demonstrates gentle ankle mobility exercises that can be introduced during the early stages of recovery when appropriate. The exercises are designed to restore comfortable movement and provide a starting point for progression into strengthening, balance, proprioception, and functional rehabilitation.
Manual Therapy and Ankle Sprain Rehabilitation
Manual therapy can be used as part of a broader rehabilitation program following an ankle sprain. Depending on the individual and stage of recovery, techniques directed at the ankle, foot, and surrounding tissues may help reduce pain and improve joint mobility and range of motion, particularly when combined with exercise and progressive rehabilitation.
Manual therapy should not be viewed as a replacement for rehabilitation. Restoring strength, balance, proprioception, mobility, and the ability to progressively load the ankle are important components of recovery and reducing the risk of recurrent injury.
The following videos demonstrate how we use Motion Specific Release (MSR) as part of an integrated approach to ankle sprain rehabilitation. MSR may include joint mobilization and manipulation, soft-tissue and fascial techniques, neurodynamic approaches, and exercise, selected according to the individual's examination findings and stage of recovery.
Rehab Ankle Sprains - Exercise and Treatment
Without proper treatment and rehabilitation, a severely injured ankle may not fully heal, leading to instability. This instability can result in chronic pain, recurrent sprains, gait imbalances, osteoarthritis, and ongoing dysfunction. In this video, Dr. Brian Abelson and Miki Burton RMT demonstrate effective methods for addressing this common issue.
MSR - 7 Point Ankle & Foot Mobilization
Enhancing joint mobility is crucial for effectively addressing the entire kinetic chain, especially after an ankle sprain. In this video, Dr. Abelson demonstrates powerful MSR techniques specifically designed to improve ankle and foot mobility, which is key to a full recovery and preventing future injuries.
Facial Expansion: MSR Foot Pain Protocol
This video demonstrates how fascial expansions are incorporated into the MSR approach for ankle and foot conditions. The procedure combines concepts from fascial anatomy and kinetic-chain relationships with selected principles and points traditionally used in acupuncture and Traditional Chinese Medicine, including ST44, LV3, LV2, K3, and B60.
Within MSR, these techniques may be combined with joint mobilization or manipulation, myofascial techniques, and functional exercise according to the individual's examination findings. The goal is to reduce pain, improve mobility, and restore function as part of a broader rehabilitation program.
Nerve Entrapments and Ankle Sprains
An ankle sprain, particularly a lateral inversion sprain, can sometimes affect nearby peripheral nerves. Traction, compression, or irritation of a nerve may contribute to symptoms such as pain, burning, tingling, numbness, or altered sensation that persist beyond the initial injury.
Superficial Peroneal Nerve: The superficial peroneal nerve can be vulnerable to traction during an inversion ankle sprain. When examination findings suggest nerve involvement, treatment may include neurodynamic techniques, manual therapy, and exercise as part of the overall rehabilitation program.
Recognizing possible nerve involvement is particularly important when symptoms do not follow the expected course of a typical ankle sprain.
Peroneal Nerve Mobilization:
In this video, Dr. Mylonas demonstrates MSR techniques used when addressing suspected peroneal nerve involvement following an ankle sprain. These techniques are intended to improve neural mobility and are incorporated into a broader rehabilitation approach when clinically appropriate.
Treatment Frequency
Treatment and rehabilitation following an ankle sprain should be based on the severity of the injury, examination findings, functional limitations, individual goals, and response to care, rather than a predetermined number of appointments.
Mild ankle sprains may require only a short period of professional care followed by progressive self-managed rehabilitation. More significant injuries may require a longer period of treatment, rehabilitation, and reassessment before returning to unrestricted activity or sport.
When manual therapy is used, its frequency should also be adjusted according to the individual's response. If a patient is not progressing as expected, the treatment plan should be reassessed rather than simply continuing the same approach.
When Is Surgery Necessary?
Most lateral ankle sprains are managed without surgery. Surgical consultation may be considered for certain severe injuries, associated fractures or tendon injuries, significant mechanical instability, or persistent symptoms and instability that have not responded adequately to appropriate conservative management.
Following surgery, rehabilitation is individualized and generally progresses from protection and restoration of movement toward progressive weight bearing, strengthening, balance, proprioception, and eventually the functional or sport-specific demands of the individual.
Exercise
After the acute phase of a lateral ankle sprain, it's crucial to begin a comprehensive rehabilitation program. This should include three key components: flexibility and mobility, muscle strengthening, and balance and proprioception training. Each is vital for a full recovery and preventing future injuries.
Flexibility and Mobility: Regaining the ankle’s range of motion is essential for restoring normal function. This involves targeted stretching exercises tailored to the severity of the injury.
Strengthening: Strengthening the muscles around the ankle provides crucial support and stability, helping to prevent future sprains. Exercises will be personalized to your specific needs.
Balance and Proprioception Training: After an ankle sprain, it is key to retrain your body’s awareness of position and movement (proprioception). Balance exercises help restore this awareness, reducing the risk of re-injury.
These exercises are examples of what might be included in your rehabilitation plan, but the exact routine will be customized to fit your individual needs and injury severity.
Rehab Ankle Sprains - Exercise and Treatment
Without appropriate treatment and rehabilitation, a severely injured ankle may not fully heal and could lose its stability. This loss of stability could, in turn, result in chronic ankle pain, recurrent sprains, gait imbalances, osteoarthritis, and a path of ongoing dysfunction. In this video, Dr. Brian Abelson and Miki Burton RMT show you effective ways of addressing this common condition. (Exercises start at Time Code 08:45)
Improve Your Balance - Exercises for Beginners
Balance exercises are essential for recovering from ankle sprains and enhancing sports performance. These exercises help stabilize the ankle during functional movements, reducing the risk of re-injury. Incorporating basic balance exercises into your rehabilitation program can significantly improve stability and prevent future sprains.
Improve Your Balance - Advanced Exercise
Advanced balance exercises are valuable for all ages, particularly for those recovering from ankle sprains. These exercises enhance your ability to control and stabilize your body, reducing the risk of re-injury and improving sports performance. This routine is designed to build on the beginner series, which should be completed for several weeks before advancing.
An Integrated Approach to Ankle Sprain Rehabilitation
An ankle sprain should not always be viewed simply as an injured ligament. Depending on the severity and mechanism of injury, it may affect joint mobility, muscle function, balance, proprioception, neural structures, and movement throughout the lower extremity. Assessment should therefore consider both the injured tissues and the functional consequences of the injury.
Thorough Assessment: A clinical examination should identify the structures involved, determine the severity of the injury, assess functional limitations, and screen for findings that may require imaging or referral. Depending on the presentation, assessment may also include joint mobility, muscle function, balance, biomechanics, and possible peripheral nerve involvement.
Individualized Treatment: Treatment should be guided by examination findings rather than a predetermined protocol. Within MSR, manual therapy may include joint mobilization or manipulation, myofascial and fascial techniques, and neurodynamic approaches when clinically appropriate. These interventions are used as part of a broader rehabilitation strategy rather than as a replacement for exercise and progressive loading.
Progressive Rehabilitation: Rehabilitation should progressively restore mobility, strength, balance, proprioception, and the capacity to tolerate the demands of daily activity, work, or sport. The program should evolve as function improves and the demands placed on the ankle increase.
Regular Reassessment: Recovery does not always follow a predictable timeline. Pain, mobility, stability, function, and progress toward the patient's goals should be reassessed throughout care. If recovery is not progressing as expected, reconsider the diagnosis, look for contributing factors that may have been missed, modify the treatment or rehabilitation plan, and refer for further investigation when appropriate.
Ultimately, the goal is not simply to reduce ankle pain. It is to restore function, reduce the risk of recurrent injury, and help the individual return confidently to the activities that matter to them.
References:
Martin RL, Davenport TE, Fraser JJ, Sawdon-Bea J, Carcia CR, Carroll LA, Kivlan BR, Carreira D. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.
Wagemans J, Bleakley C, Taeymans J, Schurz AP, Kuppens K, Baur H, Vissers D. Exercise-based rehabilitation reduces reinjury following acute lateral ankle sprain: A systematic review update with meta-analysis. PLoS ONE. 2022;17(2):e0262023. doi:10.1371/journal.pone.0262023.
Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury: A systematic review and meta-analysis of prospective epidemiological studies. Sports Medicine. 2014;44(1):123-140.
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.
Thompson C, Schabrun S, Romero R, Bialocerkowski A, Marshall P. Factors contributing to chronic ankle instability: A systematic review and meta-analysis of systematic reviews. Sports Medicine. 2020;50(1):67-80.
Fong DT, Chan YY, Mok KM, Yung PS, Chan KM. Understanding acute ankle ligamentous sprain injury in sports. BMC Sports Science, Medicine and Rehabilitation. 2009;1:14.
Gomes YE, Chau M, Banwell HA, Causby RS. Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: A systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2022;23:885. doi:10.1186/s12891-022-05831-7.
Salminen I, Schroderus N, Takatalo J. Effectiveness of manual therapy with and without exercise in chronic ankle instability for pain, mobility, and function: A systematic review and meta-analysis. Disability and Rehabilitation. 2026;48(17):5465-5480. doi:10.1080/09638288.2026.2620954.
Shi X, Han J, Witchalls J, Waddington G, Adams R. Does treatment duration of manual therapy influence functional outcomes for individuals with chronic ankle instability: A systematic review with meta-analysis? Musculoskeletal Science and Practice. 2019;40:87-95. doi:10.1016/j.msksp.2019.01.015.
Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training. 2002;37(4):364-375.
Han K, Ricard MD, Fellingham GW. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. Journal of Sport Rehabilitation. 2021;30(1):14-20.
Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. Journal of Bone and Joint Surgery American. 2010;92(13):2279-2284.
Disclaimer:
The information provided on this website, including articles, videos, exercises, and other educational materials, is intended for general educational purposes and should not be considered a substitute for individualized assessment, diagnosis, or treatment by a qualified healthcare professional.
Musculoskeletal conditions vary considerably from person to person. An exercise, treatment, or technique that is appropriate for one person may not be appropriate for another. If you have pain, neurological symptoms, an injury, or concerns about your health, consult an appropriately qualified healthcare professional.
MSR manual treatment procedures intended for healthcare practitioners should only be performed by professionals with the appropriate training, qualifications, and scope of practice. Members of the public should not attempt professional manual treatment procedures based solely on information presented on this website.
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DR. BRIAN ABELSON, DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
Dr. Abelson is the Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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