Chronic ATFL Injury (Missed Ankle Sprain)
1️ The Most Common Hidden Cause
The Anterior Talofibular Ligament (ATFL) is the most commonly injured ligament in ankle sprains.
However, many patients:
- Do not seek treatment
- Resume activity too early
- Receive incomplete rehabilitation
Over time, this leads to chronic ankle instability.
2️ Symptoms
- Recurrent ankle “giving way”
- Pain on the outer (lateral) side of the ankle
- Difficulty walking on uneven surfaces
- Mild swelling after activity
Patients often say “I never had a major injury”, but on deeper questioning, there’s usually a
minor twist months or years ago. I encounter this scenario quite often.
3️ Diagnosis
- Clinical tests (anterior drawer, talar tilt)
- MRI to assess ligament integrity
4️ Management
Non-surgical:
- Physiotherapy (proprioception + strengthening)
- Bracing
Surgical:
- Ligament repair/reconstruction (e.g., Brostrom procedure/Modified Brostrom procedure)
- 👉 If untreated, chronic instability can lead to cartilage damage and early arthritis.
For more information regarding chronic ATFL injury do read my blog on website titled “Ankle
sprain that never healed-When do I need surgery?”
Osteochondral Lesions of the Talus (OLT)
The “Silent Cartilage Injury”
Osteochondral lesions involve damage to the cartilage and underlying bone of the talus. These may occur after:
- Minor ankle sprains
- Repetitive microtrauma
- Undiagnosed injuries
- Reduced vascularity
In my clinical practice I often see chronic instability due to missed ankle sprains as the most common cause of OLT lesions
Symptoms
- Deep ankle pain
- Pain during weight-bearing
- Catching or locking sensation
Why It’s Often Missed
- X-rays are usually normal
- Pain is vague and poorly localized
- Symptoms mimic simple sprain
Diagnosis
- MRI (gold standard)
- CT scan for bony involvement
Management
Early stage:
- Activity modification
- Immobilization
Advanced cases:
- Arthroscopic debridement and microfracture
- Osteochondral grafting
- Treating the underlying cause
👉 Important: Delayed diagnosis can lead to progressive joint degeneration.
Tendon Pathology Around the Ankle
Tendons play a crucial role in ankle stability. Chronic overuse or subtle biomechanical issues can lead to tendinitis, tendinosis, or tendon tears.
Common Tendons Involved:
✔ Peroneal Tendons (Lateral Ankle)
Severe pain with the first few steps after waking up. Typically reduces after sometime.
- Pain behind the lateral malleolus
- Worse on walking or running
- May have snapping sensation
Often associated with chronic instability or cavus foot. Peroneal tendon pathologies are often seen after an acute episode of trauma or in track athletes
✔ Posterior Tibial Tendon (Medial Ankle)
- Pain on the inner side of the ankle
- Progressive flattening of the foot
- Difficulty standing on toes
This can lead to adult-acquired flatfoot deformity. I encounter these patients quite commonly in routine OPD. A thorough evaluation is paramount to address the underlying pathology.
✔ Achilles Tendon
- Posterior ankle pain
- Morning stiffness
- Pain during activity
Often seen in sedentary individuals who suddenly increase activity or after an episode of trauma.
✔ Diagnosis
- Clinical examination
- Ultrasound or MRI
Management: Highly individualized and depends on proper Foot and Ankle evaluation. Management may range from:
- Activity modification
- Physiotherapy
- Orthotics
- PRP in select cases
- Surgery for tears or failed conservative care
Ankle Impingement Syndromes
✔ When Tissue Gets “Pinched”
Ankle impingement occurs when soft tissue or bone gets trapped within the joint during movement.
It can be:
- Anterior impingement (common in athletes)
- Posterior impingement (common in dancers, footballers)
✔ Causes
- Repetitive microtrauma
- Scar tissue formation after minor injuries
- Bony spurs
✔ CausesSymptoms
- Pain at extreme ranges of motion
- Pain while squatting, climbing stairs, or running
- Localized tenderness
✔ Diagnosis
✔ Management
Conservative:
- Rest
- NSAIDs
- Physiotherapy
Surgical:
- Arthroscopic decompression
- Open decompression
I see patients coming to the clinic with the classical pain at extreme range of motion. However, not every bony spur needs to be removed. Depending on the underlying cause a bony spur can sometimes be a protective mechanism.
Ankle Arthritis
Not Just a Disease of Old Age
Unlike knee arthritis, ankle arthritis often occurs due to:
- Previous injuries
- Chronic instability
- Cartilage damage
Symptoms
- Persistent deep ankle pain
- Stiffness, especially in the morning
- Reduced range of motion
- Pain during walking
Diagnosis
Early stage:
- Activity modification
- Weight loss management
- Physiotherapy: Strengthening exercises
- Injections (Visco supplementation, corticosteroids, PRP may be tried)
Advanced stage:
- •Arthroscopy ankle fusion
- Open ankle fusion
- Ankle replacement
Ankle fusion results in loss of movement
at the ankle joint. However, with dedicated physiotherapy
and rehabilitation, most patients regain a comfortable,
confident gait as the surrounding joints gradually compensate
for lost motion. It remains the gold standard treatment
advanced ankle arthritis, valued for its reliability, durability,
and consistently strong outcomes. Today, arthroscopic ankle fusion
increasingly preferred in suitable patients due to its minimally
invasive approach when compared with traditional open surgery.
Ankle replacement is a more recent advancement in Foot and Ankle
surgery and continues to gain prominence because it preserves joint
movement while relieving pain. Modern-generation implants have
demonstrated substantial improvements, with reduced wear rates,
enhanced design, and improved longevity compared with earlier models.
The decision between ankle fusion and ankle replacement is highly
individualised. It depends on several important factors, including age,
medical co-morbidities, activity demands, bone quality, and the
patient’s functional goals and expectations. A carefully tailored
consultation is essential to determine the most appropriate treatment
pathway.
Key Takeaways
- Persistent ankle pain without injury is not normal and should not be ignored
- Many cases are due to missed or untreated minor injuries
- Early diagnosis can prevent long-term complications like arthritis
- MRI plays a crucial role in identifying hidden causes
- Treatment is patient specific after careful evaluation of the underlying cause.
Frequently Asked Questions
1) Can ankle pain occur without any injury?
Yes. Many cases are due to microtrauma, overuse, or undiagnosed minor injuries.
2) What is the most common cause?
Chronic ligament injury (especially ATFL) is the most common hidden cause.
3) Is MRI necessary?
MRI is often essential to detect soft tissue injuries and cartilage damage.
4) Can this lead to arthritis?
Yes, untreated conditions like instability or osteochondral lesions can lead to early arthritis.
5) When should I see a specialist?
If pain persists beyond 6 weeks or affects daily activities.
6) Can persistent ankle pain occur due to medical conditions?
Yes. Rheumatoid arthritis, gout or other inflammatory arthropathies may present with ankle pain. Laboratory evaluation to rule them out is necessary.
7) Do I need surgery for my persistent ankle pain?
The choice between conservative management and surgery depends on the chronicity and underlying cause. One should get properly evaluated by a Foot and Ankle Specialist to know the exact cause of pain or discomfort.
8) How long can I wait before surgery?
The answer depends on the underlying cause and chronicity. Early intervention may prevent future morbidity and disease progression.
If you or your patient is dealing with ankle pain that just won’t go away—even without a
clear injury—it’s important to look deeper. Conditions like ligament instability, cartilage
damage, or tendon pathology often remain hidden until properly evaluated.
A timely diagnosis not only relieves pain but also prevents long-term joint damage and disability.
If you are a patient from Thane, Mumbai or Navi Mumbai schedule a consultation with Dr
Vivek Maurya for comprehensive foot and ankle evaluation and evidence-based treatment.
