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Chronic ankle instability

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What you're feeling¶

The main sign of chronic ankle instability is a feeling that your ankle might give way. This often happens when you walk on uneven ground or play sport. Many people with this problem also keep rolling the ankle inwards, over and over.

The pain sits on the outside of your ankle, along the bony ridge below the ankle knob. It tends to flare when you walk on slopes, gravel or grass, or when you change direction quickly during activity. The ankle may also look puffy around the joint line rather than badly bruised or swollen, because this is a long-standing problem rather than a fresh injury. Some people notice mild swelling that lingers after activity.

Over time, the repeated rolling can affect how well you sense where your foot is. This makes the ankle feel less steady on stairs, on ladders, or when you step off a kerb without looking down. Simple tasks can become harder: standing at the bench to cook, walking the dog on a nature strip, or getting through a shopping centre without watching every step. For active people and athletes this can be very limiting, and for others it still gets in the way of daily life.

These symptoms often start after an ankle sprain that never fully settled. About one in three people still have ankle symptoms after a bad sprain, and many have lasting changes in the joint. You may also notice your knee on that side feels less healthy, because the two joints work together when you move.

If any of this sounds familiar, it is worth having your ankle checked. Your surgeon can examine the outside of your ankle and look at scans to see which ligaments are loose and whether anything else inside the joint is involved.

What's actually happening¶

Your ankle joint is held together by strong straps called ligaments. On the outside of the ankle there are three of them, and they stop the joint from tipping inwards. The one at the front is the weakest of the three, which is why it is the one that tears most often when you roll your ankle.

When you first sprain your ankle, one or more of these straps gets stretched or torn. In most people they heal and tighten up again. In about one in three people they stay loose. A loose strap cannot hold the joint snugly in place, so the ankle keeps tipping inwards during activity. That is the giving way you feel.

There is a second part to the problem. Your ankle also relies on nerves to sense where your foot is and to react quickly if it starts to roll. After repeated sprains this sensing system becomes dulled, so the muscles do not tighten in time to catch the joint. The two problems feed each other: a loose joint confuses the nerves, and slow reactions let the joint roll again.

The result is a cycle. Each new roll stretches the ligaments a little more and dulls the sensing a little further. Over time the ankle can also develop stiffness or alignment changes in the heel and midfoot that make rolling more likely in the first place.

This is why the symptoms you read about above keep coming back. The looseness causes the rolling, and the dulled sensing explains why the ankle feels unsteady on stairs or uneven ground even when it is not actively giving way. Some people also notice swelling that lingers, because the joint surfaces are being stressed each time it rolls.

The good news is that both parts of the problem can be worked on. Exercises can retrain the sensing and strengthen the muscles that steady the joint. If the ligaments remain too loose despite this, surgery can tighten them again.

What we can do about it¶

Dr Kieran Hirpara, an orthopaedic surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your ankle, and arrange scans where they are needed to work out which ligaments are loose and whether anything else in the joint is involved.

Because this is a long-standing problem, we usually start with non-operative care. Physiotherapy is the mainstay. It strengthens the muscles on the outside of your ankle and retrains your balance, so your foot reacts faster when the ankle starts to roll. We may also add a brace or taping to hold the ankle steady during activity, and an insole with a wedge along the outer edge if your heel sits tilted inwards. Give this a fair trial before thinking about surgery, as it takes weeks of consistent work for the exercises to change how your ankle behaves.

When these measures have not settled things, surgery may be the next step. The usual operation tightens the stretched ligaments on the outside of your ankle and reinforces them with nearby tissue, so the joint is held snugly again. If the ligament tissue itself is too worn, a tendon graft can be used to rebuild it instead. Some of these repairs can be done through small incisions using a camera inside the joint, which can also let us check for and treat other problems within the ankle at the same sitting. We will talk through which option fits your ankle, your tissue quality and your activity goals, and decide together whether surgery is right for you.

What to expect¶

Chronic ankle instability rarely settles on its own. The looseness and the dulled sensing that cause the giving way tend to persist, and the symptoms often come and go with activity rather than disappearing. Some people find their ankle copes for months, then rolls again on uneven ground or during sport. Without treatment, the cycle of rolling and re-spraining can continue, and the repeated stress on the joint can lead to lasting changes over time.

With the right care, most people see real improvement. Exercises that strengthen the ankle and retrain balance can settle symptoms for many people, especially when started early and done consistently. If these measures are not enough, surgery can tighten the loose ligaments and restore stability. People who have this surgery often regain a steady, pain-free ankle that holds up during daily activity and sport, and the repaired ligaments protect the joint from further wear in the years that follow.

Recovery takes patience. Whether you are managed with exercises or with surgery, the ankle needs weeks of consistent work to regain its strength and steadiness. Some people notice their ankle feels more reliable within a few months, while for others it takes longer before they trust it on stairs, slopes or uneven ground. The rehabilitation program you follow matters as much as the treatment itself, so it is worth committing to the full program rather than stopping once the ankle feels better.

It is also honest to say that not every ankle returns to how it was before the first sprain. Some people keep mild symptoms even after treatment, and a small number continue to find the ankle less steady than they would like. The outlook is generally better when the problem is addressed early rather than after years of repeated rolling. If your symptoms have lasted more than a few months despite proper exercises and support, it is worth discussing your options with your surgeon so you can decide on the path that suits your ankle and your activity goals.

When to see someone¶

See your GP if your ankle keeps giving way or rolling inwards, especially on uneven ground or during sport, and it has not settled after a few months of proper exercises and support. Ask for a specialist review if the outside of your ankle stays painful or puffy, if you keep spraining the same ankle over and over, or if the joint feels unsteady on stairs, slopes or kerbs even when it is not actively rolling. These are signs the ligaments may still be loose and worth assessing before further rolling wears the joint. There is no emergency here, but the sooner the ankle is checked, the better the options.

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