Prolonged recovery after an ankle sprain

Details about common ankle sprains and their treatment can be found on these pages (click the link). As stated in that text, usual recovery after this injury takes on average between 3 and 6 weeks with appropriate physiotherapy. However, in some patients, symptoms after trauma may persist far beyond this time frame, and then it is time for an additional detailed examination, possible additional diagnostics, and a different approach to both diagnosis and treatment. Here I present the most common reasons for prolonged recovery after ankle sprains.

Peroneal tendon strain
Two tendons (peroneus longus and brevis) pass behind the lateral malleolus (outer ankle bone), run along the outer side of the foot, with one attaching to the fifth metatarsal bone (on the outer edge of the foot), and the other passing along the plantar side of the foot and attaching to the first metatarsal bone. During typical ankle sprains, the ligamentous system protects these tendons from injury, but in stronger or repeated sprains, when the ligaments are damaged or ruptured, especially in combination with generalized joint laxity, these two tendons become the only defensive mechanism left. In such situations, they may be injured either in the form of a strain with accompanying swelling and inflammation or in the form of partial or complete ruptures.

Although complete ruptures themselves are rare, inflammation and minor damage are not. They present as swelling and tenderness around the lateral malleolus, slightly posterior to the attachment of the ATFL, the ligament typically injured in these traumas. Additionally, careful stretching tests and isometric tests will confirm suspicion, and ultrasound examination will show the extent of damage and inflammation. Treatment is specific, lasts from several weeks up to three months, rarely requires orthopedic interventions, and the prognosis is good. Unfortunately, this type of injury rarely heals on its own and, if unrecognized, can cause symptoms for months or even years.

Medial collateral ligament injury
Almost all ankle sprains are inversion sprains (twisting inward), but not all. A small percentage are eversion sprains (twisting outward). In these, injury to the medial collateral ligament complex of the ankle regularly occurs. This connective structure is complex, very strong, and plays an important role in maintaining the shape of the longitudinal arch of the foot as well as in stabilizing the joint below the ankle (the subtalar joint). As a rule, its injuries heal more slowly, cause greater pain, and return to sports activities is more difficult.

During the initial examination, it is important to establish an accurate diagnosis and educate the patient about what to expect and over what time period. It is not unusual for treatment of this injury to last up to 6 months.

Bone contusions
Every ankle sprain leads to bone-to-bone impact. Which bones exactly and to what extent depends, of course, on the type, severity, and number of injuries. In some patients, this impact also produces bone inflammation, which is visible only on magnetic resonance imaging. Although MRI has become more accessible in recent years and its cost has decreased in both relative and absolute terms, it is still unnecessary to indicate this examination after every ankle sprain.

However, if swelling and pain after a sprain do not follow the expected curve of improvement, and tests and ultrasound of tendons and other soft-tissue structures do not indicate a clear cause of prolonged intense symptoms, then it is time for MRI. If imaging shows bone marrow edema due to contusion, it is time for specific and individualized physiotherapy aimed at stimulating bone healing. In rare cases, unloading walking with two forearm crutches can accelerate recovery, which is highly individual in duration. Prognosis and final outcomes are generally good.

Sprain of small foot joints
When we say ankle sprain, we generally think of twisting of the junction between the lower leg and the foot, that is, the talocrural joint. However, most ankle sprains also involve sprains of the small joints of the foot. If they are minor, they can heal spontaneously while the primary injury is being treated and therefore receive little attention. In some patients, they are the dominant problem and require special attention.

Since the role of these small joints is maintenance of the foot arches and shock absorption, more significant damage to their ligamentous structures, bone contusions, or tendon strains creates an environment for slow and prolonged recovery, with which the patient must be familiar. They are also, as an unrecognized additional problem, one of the most common causes of prolonged pain, symptoms, and difficult return to sports activities. Therefore, detailed and careful examination and diagnostics are of great importance in their recognition and treatment.

Inflammation and damage of the tibialis posterior tendon
This tendon passes behind the medial malleolus (inner ankle bone) and attaches to the bones of the medial arch of the foot. It has three functions – maintenance of arch height, inversion movement of the foot, and shock absorption during walking and running.

There are two mechanisms of its injury. One is acute, during eversion sprains, when strain is possible. The other is chronic, during repeated sprains, when the complex shock-absorbing mechanism of the foot is impaired and the tendon is exposed to constant increased eccentric load. This tendon is the second strongest in the foot, immediately after the Achilles tendon. Diagnosis is made by a combination of thorough physical examination and ultrasound. Treatment is direct through reduction of inflammation and improvement of its elastic properties, combined with indirect treatment, which includes correction of insufficient shock absorption locally and globally, and, if necessary, the use of appropriate orthopedic insoles for the same purpose. Sometimes shockwave therapy is also indicated.

Ankle instability
Every ankle sprain causes greater or lesser damage to the ligamentous system of the ankle. Repeated sprains increase this damage. After resolution of basic pain and healing of soft tissues, looseness or instability of the ankle may remain. It manifests as repeated minor or major sprains, or prolonged pain and swelling of the ankle without a subjective feeling of instability.

Diagnosis is established through clinical examination, medical history, and, if necessary, investigations such as magnetic resonance imaging. Minor instabilities respond well to conservative treatment (physiotherapy and exercises), given sufficient time to achieve therapeutic effect. Greater instabilities, especially those that do not respond to high-quality conservative treatment, require surgical stabilization.

Anterior and posterior ankle impingement
The body generally does not tolerate instability, especially of joints. The same applies to the ankle. If the ligamentous system is damaged to the extent that it does not prevent bone collision at end-range movements, these collisions will cause pain and inflammation of soft tissues, possibly bone inflammation, and ultimately formation of osteophytes, which are the cause of pain at specific locations, accompanied by swelling.

Diagnosis is established clinically, by ultrasound, X-ray imaging, and MRI. In mild to moderate cases, physiotherapy is the first-line treatment. In cases of larger osteophytes, surgical intervention is necessary, not only to remove the osteophytes but also to stabilize the ankle.

Poor mobility of small foot joints
Injured soft tissues can sometimes heal with extensive scarring, just as in some people skin heals with visible and large scars, unlike most in whom the scar is smaller. Furthermore, these scars can limit small joint movements in the foot, thereby reducing their shock-absorbing function during movement. Reduced shock absorption further overloads other soft tissues, especially tendons and ligaments, causing pain and inflammation in distant parts of the foot, toes, and lower leg.

This is also, based on our clinical experience, the most common cause of prolonged pain and slowed healing after ankle and foot trauma, more about which can be found on these pages. The hypothesis is established through clinical examination, and normal (desirable) mobility of small joints can be relatively easily restored with manual physiotherapy techniques (joint mobilizations and manipulations, soft tissue techniques, and mobilization with movement), accompanied by exercises. If it is uncomplicated joint hypomobility and the diagnosis is precise, therapeutic effect is achieved quickly.

Reactive achillodynia
Residual pain of the Achilles tendon after an ankle sprain, when all other pain and damage caused by the sprain have been resolved, is not uncommon. It is more frequent in cases that were immobilized for longer than 7 days. It is characterized by typical tenderness on palpation of the Achilles tendon itself, as well as pain during walking on toes or during running and jumping.

It is also typical that ultrasound findings are normal and do not indicate inflammation or damage. Differential diagnosis must exclude posterior impingement, whose symptoms overlap. The reasons for this condition are unclear. It is possible that it represents functional shortening of the tendon due to immobilization or irritation of the fat pad between the tendon and the heel bone caused by breakdown products of blood that leaked from damaged blood vessels. Manual therapy combined with eccentric exercises usually brings rapid relief.

OCD (osteochondritis dissecans)
With every ankle sprain, trauma to the cartilage and bones of the joint occurs. In rare cases, this can result in separation of a piece of cartilage and adjacent bone in the form of a loose body. Unlike a bone fracture, which is visible on X-ray immediately after trauma, this process develops slowly after trauma and is visible on imaging (MRI and X-ray) only weeks or months later. Unfortunately, there are no specific tests that would indicate possible development of OCD.

Suspicion is raised if pain and swelling of the joint, especially after physical activity, persist even after 6–8 weeks of persistent, specific, individualized, and comprehensive physiotherapy. At that point, orthopedic examination and MRI diagnostics are of great help. Treatment is slow and complex, and may include hyperbaric oxygen therapy, immobilization, unloading with crutches, and surgical intervention.

Combinations and other factors
We view an ankle sprain as a relatively insignificant trauma that resolves on its own or with minor help from physiotherapy. In about 80% of cases, this is true. However, the same statistics also say that every fifth sprain creates additional problems, either some of those described, their combination, or some very rare ones for which there was no space in this text.

Then awareness of their existence, skill in clinical examination, hypothesis formation and its verification either by therapeutic interventions or diagnostic procedures, followed by creation of an individualized protocol, becomes of great importance for full recovery. Sometimes an orthopedist is sufficient, sometimes a physiotherapist, but most often a collaborative approach is necessary in which multiple specialists from different fields participate in diagnosis and treatment.

At the end of this (too long) summary, I feel the need to say that it is always immensely regrettable when a patient presents with chronic ankle pain lasting a year, caused by simple hypomobility that can be easily corrected with one or two manipulations. It is an even greater misfortune when an initially simple problem becomes greatly complicated simply because it was not recognized in time and then requires complex and prolonged treatment that may include surgery.

The rule is simple: if all symptoms of an ankle sprain have not fully resolved within a maximum of 6–8 weeks, seek professional help. Also, if you see that the therapy you are undergoing does not bring results, and even the well-intentioned healthcare professional providing it does not have a clear idea what the problem is and within what time frame improvement is expected, ask for a second opinion.