October 14, 2019

Overlooked Causes of Chronic Ankle Pain

By Alexander Lambert II, MD


Ongoing pain in the ankle joint is a common complaint in orthopaedics practices, and properly diagnosing the root cause can be challenging. One frequently overlooked factor is an ankle sprain, whether fairly recent or dating back a decade or longer. 

By definition, a sprain involves some degree of tearing in a ligament, ranging from just a few fibers to the entire band of connective tissue. The vast majority are fairly minor and heal properly with rest, ice and possibly a temporary brace. 

However, a good number of these injuries are undertreated. People may not realize the extent of the damage or seek any treatment; many also return to regular activity too quickly. Physicians also tend to miss high ankle sprains involving the ligament between the tibia and fibula. 

Even if a tear in an affected ligament fully heals, it can do so in a stretched position that causes long-term laxity in the ankle. In those cases, tendons surrounding the joint often are forced to act as secondary stabilizers. 

Over time, that chronic strain can lead to persistent tendinitis, which many physicians correctly diagnose and treat without realizing it is actually a secondary condition, with a damaged ligament the primary issue. Therefore, the tendinitis temporarily resolves with rest and anti-inflammatories but recurs once the patient returns to exercise. 

In cases of chronic ankle pain, patients often have no problems with daily activities but begin to notice symptoms after starting a new or more strenuous workout routine, particularly one with cutting moves, jumping, climbing or running on uneven surfaces. In fact, I have encountered patients who don’t even remember the initial ankle sprain because it occurred years ago. 

Unfortunately, MRI is not a good test for determining ankle instability. Images can reveal tendinitis, but miss evidence of sprains occurring more than six months prior to the study. A ligament may appear intact and normal but actually have healed elongated. 

If tendinitis proves persistent and X-rays rule out causes such as osteochondral defects or stress fractures, a physician must carefully check for subtle laxity in the ankle. That requires stressing ankle ligaments in different positions when the patient is fully relaxed and hasn’t tensed in anticipation of a maneuver. This can require two or three repeat assessments. 

If a sprain injury is the cause of chronic pain, treatment options include activity modification, ankle bracing for certain activities, and physical therapy to return balance and strength to the joint. A smaller group of patients benefit from surgery to reconstruct the impacted ligament. 

Of course, ensuring that a sprain heals correctly in the first place is the best solution. With a more significant injury, patients may need anywhere from six weeks to three months of recovery time. That patience may potentially prevent years of ankle problems in the future.

Alexander Lambert II, MD is an orthopaedic sports medicine specialist for Hampton Roads Orthopaedics Spine & Sports Medicine, based in the Williamsburg office. He also is a team physician for the College of William & Mary. hrosm.com