Ankle Sprain Not Healing? What Else It Could Be

If your ankle still hurts long after a sprain, you are not being dramatic, and you are not alone. A sprain that “never quite got better” is one of the most common reasons people are referred for a surgical opinion. This article explains why some sprains linger, what else can be going on, how the cause is sorted out, and when surgery comes into the picture. For a general guide to pain and swelling around the ankle, see ankle pain and swelling.

What “not healing” can look like

Most people recover from a sprain, but in some, complaints continue.^[3] Reasons to have the ankle looked at again include:

• pain or swelling that persists for weeks, or that comes back with activity
• the ankle rolling or giving way, especially on uneven ground or in sport
• a feeling that the ankle is weak or cannot be trusted^[4]
• deep pain in the joint, clicking, catching or a locking sensation^[5]
• pain on the outer side of the ankle that lingers, or snapping behind the outer ankle bone^[6]

There is no single deadline, and the ligaments are only one of several structures that can be hurt in a sprain. An international consensus of ankle specialists notes that sprains and chronic instability carry a broad burden: reduced activity, and earlier arthritis in the ankle after injury.^[7]

The usual explanations

A sprain that never fully recovered: chronic ankle instability

A common cause is a sprain that was not fully rehabilitated. Repeated sprains can progressively weaken the ligaments on the outer side of the ankle, and the ankle starts to give way.^[8,4] This is chronic ankle instability, described in more detail in our guide to chronic ankle instability.

An injury to the cartilage

Up to 75% of osteochondral lesions of the talus, which are injuries to the cartilage on top of the ankle bone and the bone under it, follow trauma such as a sprain or fracture.^[9] They cause deep ankle pain with weight-bearing, clicking or catching and swelling, and they can continue for months after a sprain that seemed to have healed.^[5] See osteochondral lesions of the talus. Some settle without surgery, but in one systematic review only about 45% of people treated without surgery had a good result.^[10]

A peroneal tendon injury

The peroneal tendons run behind the outer ankle bone and help keep the ankle stable. They are easy to miss and can feel like a sprain, and lingering outer-ankle pain should make you think of them.^[1,2] See peroneal tendon injuries.

Other joint problems

Chronic ankle pain that X-rays have not explained can come from soft tissue pinched inside the joint (impingement), arthritis, a high-arched foot that tilts the heel inward, or a bony connection between foot bones.^[11] These can occur together with looseness of the ligaments, which is why treating only the ligaments sometimes disappoints.

An injury that was missed

The ankle rules used after an injury are very sensitive for ruling out a fracture, but they are not perfect and they are not designed to find every problem.^[12] Stress fractures and bone bruises can be missed on X-rays, which is why MRI is used when pain persists.^[13]

How the cause is sorted out

• History. How the ankle was first injured, how it was treated, how often it gives way and what triggers it.
• Examination. Tenderness, swelling, how loose the ankle is when stressed, alignment, calf tightness, strength and balance.^[4]
• Weight-bearing X-rays to check the bones, the joint and the alignment of the foot.
• MRI when symptoms do not match the examination, or the ankle is still painful despite rehabilitation. It can help tell impingement, a cartilage lesion and a tendon injury apart.^[11]

See foot and ankle imaging for what each test can and cannot show, and what to expect at your visit.

What treatment usually looks like

Treatment begins with rehabilitation, supervised whenever possible. Clinical guidelines prefer supervised exercise to passive treatments, and after an acute ligament injury they recommend a brace or tape combined with exercise.^[14] An overview of systematic reviews found strong evidence for bracing and moderate evidence for balance and coordination training in preventing another sprain.^[15] Exercise-based rehabilitation after a first sprain lowered the chance of re-injury at 12 months (odds ratio 0.60).^[16]

If a specific problem is found, treatment is aimed at it: protection and therapy for a cartilage lesion, rest and rehabilitation for a tendon injury, and so on. See non-surgical treatment.

When surgery is considered

Surgery is generally considered when the ankle keeps giving way despite months of rehabilitation.^[8,4] The most common operation is an anatomic repair of the outer ankle ligaments, and it has good long-term results: in a systematic review of 669 procedures, the revision rate was 1.2% after an average follow-up of 8.4 years.^[17] Reviews with at least ten years of follow-up found better function and less later arthritis after anatomic repair than after older, non-anatomic operations.^[18] Randomized trials are few and small, so conclusions about which technique is best are limited.^[19] Repair alone may not be enough when another problem, such as a cartilage lesion or a peroneal tear, is present; those are addressed at the same time or in a plan of their own. See ankle ligament reconstruction.

What you can do in the meantime

• Get the ankle assessed rather than waiting for it to improve on its own.
• Keep moving, with support, and follow a strengthening and balance program.
• Use a brace for sport or uneven ground if you have been advised to.^[15]
• Avoid pushing through repeated giving way, since each new sprain can add to the problem.^[8]

If you are also weighing a future operation, how to prepare for foot and ankle surgery may help.

Common questions

How long should a sprain take to heal?

It depends on how severe the sprain was: sprains range from mild stretching to a complete tear.^[8] If pain, swelling or giving way continue for weeks despite sensible care, get it evaluated instead of waiting.

Do I need an MRI?

Not always. MRI is considered when ongoing pain is not explained by the examination and X-rays, or when the ankle has not improved with rehabilitation.^[11]

Can a brace solve it?

Bracing has strong evidence for preventing another sprain, but whether it is enough depends on what is causing the problem.^[15]

Do I need surgery if my ankle keeps giving way?

Not at first. Supervised rehabilitation and bracing come first, and surgery is for ankles that keep giving way after a well-tried program.^[14,4]

Could this lead to arthritis?

Sprains and chronic instability have been linked to earlier arthritis in the ankle, which is one reason persistent problems deserve attention.^[7]

The bottom line

A sprain that has not healed is a symptom to explain, not a diagnosis. Instability is the most common answer, but cartilage, tendon and joint problems can look identical from the outside. A careful evaluation finds the cause, and rehabilitation comes first.