What is Recurrent Ankle Sprain?

Ankle sprains are some of the most common repeat injuries in the lower body. Roughly 40% of people who sprain their ankle end up having long-term symptoms, which include pain, swelling, a loose feeling in the joint, and repeated sprains a year after the initial injury. On top of this, about 20% of people who have an acute (sudden and severe) sprain end up with chronic (long-term) ankle instability. Ankle sprains are common in both the general public and athletes.

The idea is that the injury may affect your body’s ability to sense where your ankle is (a sense called proprioception), which might make you more likely to sprain your ankle again. Therefore, a thorough discussion of your injury history and a comprehensive examination can guide doctors when dealing with repeated ankle instability, helping to reduce the chance of further complications.

What Causes Recurrent Ankle Sprain?

Ankle sprains that occur repeatedly are complex injuries that can be caused by various factors. One major cause is having a previous ankle sprain, which can predict up to 61% of future ankle sprains. The most common way to sprain your ankle is by accidentally twisting it, where your body puts too much force on your foot. This type of injury often harms the anterior talofibular ligament, a ligament in the ankle.

During an initial ankle sprain, the ankle ligaments get microscopic tears because of the stress, which weakens the ligament. There are a few things that could make ankle sprains happen again:

Poor balance (diminished postural control)
Difficulty sensing movement or position (impaired proprioception)
Loss of muscle strength
Loosened ligaments (ligamentous laxity), as seen in conditions like Ehlers-Danlos syndrome, Marfan syndrome, and Turner’s syndrome
Decreased range of motion in the ankle joint
High-arched feet (cavus foot-type)

If an individual has poor proprioception (sense of self-movement and body position) before an injury, the ankle has a higher risk of getting hurt again. To avoid injuries, it’s crucial to maintain the ankle joint’s stability. This relies heavily on the body’s ability to correctly perceive its own movement and position of the ankle joint. When passive and dynamic parts that provide stability to our body, like the joint capsule and muscles, are weakened, there’s an increased risk of recurring sprains.

Risk Factors and Frequency for Recurrent Ankle Sprain

Acute ankle sprains is a common injury in the United States with two million cases reported every year. These sprains are one of the top reasons people visit the emergency department or primary care providers following an injury to the lower leg. Around 2.15 people out of every 1000 in the U.S. experiences this injury each year, according to emergency department data.

Age is not a reliable predictor of more frequent ankle sprains. However, several studies do show that the average age of people with these sprains is approximately 26 years, with the highest occurrence seen in the 10 to 19 years age range. These sprains are also more common in people younger than 24 years. The rate of ankle sprains is higher in adolescents (1.94 per 1000 people) than in adults (0.72 per 1000 people). This could be due to factors related to physical, cognitive, and neurological development in younger people.

Investigations have found that males have a slightly higher annual incidence rate of ankle sprains (2.20 per 1000 people) as compared to females (2.10 per 1000 people).
In the age group of 15 to 24, males have a higher tendency to sustain this injury than females.
However, females aged 30 and above suffer more sprains than males of the same age group.
Racial differences also exist with African Americans and Caucasians reporting higher incidences of ankle sprains than Hispanics.
African American males specifically have a considerably higher incidence of ankle sprains than Hispanic males.

Nearly half of all reported ankle sprains are related to sports activities. The most common sports associated with these injuries are basketball (41.1% of cases), football (9.3% of cases), and soccer (7.9% of cases). Military service members also report a higher occurrence of ankle sprains when compared to the general civilian population.

Signs and Symptoms of Recurrent Ankle Sprain

Patients with a recurring ankle sprain should be evaluated completely, with details of their injury history, including how they got their previous sprains. The goal is to find any ongoing weakened ligaments.

Initial checks should look for obvious dislocations or imbalances. Next, attention should be given to the ankle’s tenderness by feeling the ligaments, specifically the inside of the ankle and the fibula length.

Swelling and bruising may be seen at the time of the exam, but not in all cases.
The ankle’s range of motion should be compared with the opposite ankle.
It’s normal to have 10 degrees of movement pulling the foot upward with a straight knee, and 20 degrees with a bent knee.
The same comparison procedure should be done for the joint just below the ankle.
Muscle strength should be assessed for important movements like pushing down, pulling up, turning inward, and turning outward.
Neurovascular status should also be checked.

Some special tests can help determine the status of the ankle ligaments:

The Anterior drawer test evaluates the ligament at the front of the ankle, with a positive result indicated by a “dimple” sign.
The Talar tilt test looks for abnormal movement and checks the integrity of the CFL ligament at the ankle’s side.
The Kleiger external rotation test can identify possible injuries to the deltoid ligament (on the inside of the ankle) or the syndesmosis ligament (between the two lower leg bones).

When it comes to classifying the severity of the sprain:

Grade 1 is mild, with minor stretching and tearing that doesn’t affect joint stability. There may be mild swelling, but no effect on function. Patients may still be able to support their weight.
Grade II sprains involve a partial tear, usually of the ATFL. It presents with moderate to severe swelling, bruising, and a slight to noticeable effect on joint stability, which could lead to difficulty in bearing weight.
Grade III sprains signal a complete ligament tear and moderate to severe joint instability. They typically show immediate swelling, bruising, and significant instability at the ankle joint.

Testing for Recurrent Ankle Sprain

X-rays can be used to check if there is a bone break, which is found in about 15% of all ankle sprains. The X-rays should include weight-bearing views to assess the ankle from different angles. Other specific positions can also help with the diagnosis, but may not be needed for a simple ankle sprain.

The Ottawa Ankle Rules are used to decide if you need an x-ray, with the aim of reducing unnecessary radiation exposure. According to these rules, X-rays are necessary if any of these conditions are met:

You have pain in the ankle and can’t take four steps both right after the injury and in the emergency room.
You feel pain in a specific area around the ankle (the malleolar zone), and this area is tender when touched. This can be at the back half (the last 6 cm) of the outer ankle bone (the fibula) or at the tip of the outer bump of the ankle (the lateral malleolus).
You feel pain in the malleolar zone and have tenderness at the back half (the last 6 cm) of the inner ankle bone (the tibia) or at the tip of the inner bump of the ankle (the medial malleolus).

A Magnetic Resonance Imaging scan (MRI) is really helpful to look at any damage on soft tissues around the ankle. It’s usually done to plan surgery to fix a damaged ligament. On an MRI, healthy ligaments appear as thin, clear lines. With a new injury, swelling can be seen on the MRI as brighter areas within the ligament. An old injury may show the ligament as thicker and irregular with no visible swelling, changes in the bone marrow, or bleeding. Different parts of the ligaments are best seen in varying positions and slices, and thin slices (3 mm or less) provide the most accurate view of the ligaments.

Treatment Options for Recurrent Ankle Sprain

If you’ve sprained your ankle, most of the time, a simple, conservative approach can put you on the path to recovery. This course of action usually involves an ankle brace and doesn’t require surgery. That being said, if you’ve had multiple ankle sprains, you might need surgery to prevent it from happening again, but this only occurs after all non-surgical options have been tried.

A common treatment plan for ankle sprains is PRICE therapy. PRICE stands for Protection, Rest, Ice, Compression, and Elevation. Even though we don’t have definitive scientific proof that PRICE therapy is the best way forward, it’s often helpful in relieving pain and helping you regain your strength and flexibility.

Along with PRICE therapy, you can also use nonsteroidal anti-inflammatory drugs (or NSAIDs for short) to relieve pain. These can come as creams to rub on your ankle or pills to swallow. And if you’re worried about having a fracture, you should know that recent studies show that NSAIDs won’t hinder healing, as was previously thought.

Another effective treatment to consider is called Neuromuscular training therapy. This therapy includes exercises that improve your balance and awareness of your body’s positioning. To do this, you might be asked to stand on a balance board or your injured leg while doing activities. A review of multiple studies with over 3,000 participants found that this kind of training can significantly reduce the chance of spraining your ankle again, especially in athletes.

Some experts recommend immobilizing your ankle and not putting weight on it for up to two weeks, but others say that immobilizing it for up to 10 days could help with managing pain and swelling.

Along with the immobilization, using external support like taping or bracing your ankle has been shown to be quite effective; these methods can reduce swelling and help you get back to your activities faster. Bracing on its own can even be helpful for up to a year after injury. It’s important to note that while bracing has shown some effectiveness in preventing another ankle sprain, it hasn’t been shown to prevent a first-time injury.

If you’ve had repeated ankle sprains and conservative treatments haven’t helped, you may need surgery. This is generally the last resort when we can’t tell if the problem is due to a mechanical issue or functional issue with your ankle.

The most common surgical procedure is called the Brostrom Gould procedure, where stitches or tissue anchors are used to repair the ligament in your ankle. There are other surgeries available that use tissue from your tendons to stabilize the ankle. But, these surgeries aren’t as common because they can be more complex and can lead to the ankle joint being too tight.

Alongside surgery, ankle arthroscopy (a procedure where a tiny camera is used to look inside your ankle) is often carried out. This is because other problems such as inflammation or bone and cartilage injuries can often be seen at the same time due to the original injury. One study found that a high proportion of patients with chronic ankle instability also had inflammation in their ankle joint. As a result, it’s important to get these problems diagnosed and treated quickly to prevent further injury.

When it comes to foot and ankle issues, there could be a variety of problems causing discomfort or pain. These might include:

Ankle fracture (a break in the bone)
Posterior tibial tendonitis (inflammation of the tendon in the back of the leg)
Osteochondral lesion of the talus (a condition affecting the bone and cartilage in the foot)
Neuromuscular disorders that affect the muscles and nerves in the foot
Superficial peroneal nerve neuralgia (pain due to damage or disease affecting a nerve in the leg)
Peroneal tendon tears (tears in the tendon running along the outside of the ankle)
Fractures in the anterior process of the calcaneus (front part of the heel bone)
Fractures at the base of the fifth metatarsal (the long bone on the outside of the foot that connects to the little toe)

What to expect with Recurrent Ankle Sprain

Most injuries, up to 85%, get better with non-surgical treatment. However, up to 20% may remain unstable, meaning they won’t heal properly on their own, and will need surgical intervention. A particular surgical procedure called the ‘Brostrom with Gould modification’ has shown remarkable success. It has a recorded success rate of up to 95%.

This procedure has proven to enhance the stability of the subtalar and ankle joint – two crucial parts of your foot that allow you to walk and balance – without affecting the other healthy tendons in the same area. For example, the peroneus brevis, another important ankle tendon, remains untouched unlike in other procedures like the Chrisman-Snook and Watson-Jones surgeries.

Possible Complications When Diagnosed with Recurrent Ankle Sprain

When someone sprains their ankle, they are more prone to spraining it again. Sometimes, repeated sprains can lead to long-lasting pain or a sensation of the ankle giving way. This happens in about 20 to 50% of people who’ve had an ankle sprain.

A well-known complication of multiple ankle sprains is Chronic Ankle Instability (CAI). This is believed to result from a weakening of the ankle’s ability to sense its position and from an increase in looseness in the ankle’s ligaments because of multiple sprains. As a consequence of CAI, an individual might find it harder to perform everyday activities, like walking or tasks at work. People who wind up with CAI have mostly had a history of numerous ankle sprains, and serious ‘rolled’ ankle injuries.

Main Points:

Repeated sprains can make you more prone to future ankle sprains
Chronic pain and a sensation of instability can result from recurring sprains
Chronic Ankle Instability (CAI) is a complication from repeat sprains
CAI can make everyday activities harder
People with a history of many sprains or severe injuries are more likely to develop CAI

Acute Ankle Sprain Deltoid and syndesmotic insufficiency demonstrated by medial
gutter widening.

Preventing Recurrent Ankle Sprain

The first line of treatment for this condition often involves methods that don’t involve surgery, such as physical therapy that includes training for better muscle and nerve functioning, and using braces. These non-surgical strategies are always tried first before considering surgery. If surgery becomes necessary, the results are generally very favorable. A particular type of surgery, known as the Brostrom procedure with Gould modification, has a high success rate of up to 95%, greatly bettering the overall function of the ankle.