Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

When One Sprain Turns Into Many

A single ankle sprain is one of the most common musculoskeletal injuries, affecting millions of Americans annually. Most acute ankle sprains heal within 4–6 weeks with appropriate care and return to full activity without long-term consequences. But for roughly 20–40% of people who sprain an ankle, recovery is never complete: they develop chronic ankle instability — a condition defined by persistent feelings of giving way, recurrent sprains from minimal provocation, and ongoing pain or discomfort that does not resolve with conservative measures.

Chronic ankle instability is not simply a matter of weak ligaments. It involves a complex combination of mechanical and functional deficits that reinforce each other, explaining why simple exercises alone are often insufficient to fully restore stability. At Balance Foot & Ankle in Howell and Bloomfield Township, Michigan, Dr. Tom Biernacki DPM and Dr. Carl Jay DPM provide comprehensive evaluation and treatment of chronic ankle instability, from advanced rehabilitation to lateral ligament reconstruction when needed.

Why Ankle Ligaments Don’t Always Heal Properly

The lateral ankle ligament complex — comprising the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) — is the primary stabilizer against ankle inversion and forward displacement of the talus. The ATFL is the most commonly injured, followed by the CFL. During acute lateral ankle sprains, these ligaments can be stretched, partially torn, or completely ruptured.

When an ankle sprain heals incompletely, it may be because the ligament healed in a lengthened position, leaving more laxity in the joint than was present before injury. This mechanical laxity allows abnormal motion — the talus can tilt or shift forward within the ankle mortise beyond normal limits, creating the mechanical ankle instability component.

But ligament laxity alone does not fully explain chronic ankle instability. Many individuals with demonstrable ligamentous laxity on examination have no functional complaints, while others with normal-appearing ligaments on MRI have disabling instability. This paradox is explained by the functional component: impaired neuromuscular control and proprioception. The ligaments contain mechanoreceptors — sensory nerve endings that detect joint position, speed, and direction of movement and signal the muscles to respond protectively. When these receptors are damaged or the neural pathways are disrupted by injury, the protective muscular responses are delayed or reduced, and the joint gives way before muscles can react.

Evaluating Chronic Ankle Instability

Diagnosis begins with a careful history — how many times has the ankle given way, under what circumstances, and what activities are limited — and physical examination. The anterior drawer test assesses ATFL integrity by pulling the heel forward relative to the tibia; excessive anterior translation indicates ATFL laxity. The talar tilt test assesses CFL integrity by inverting the heel; excessive tilting indicates CFL damage. Both tests are compared to the uninjured side for reference.

Stress X-rays can quantify the degree of talar tilt and anterior translation with objective measurements. MRI provides detailed information about the degree of ligament damage and associated injuries — osteochondral lesions of the talus, peroneal tendon tears, and loose bodies are commonly found alongside chronic ligament insufficiency and significantly affect treatment planning. Many patients with chronic instability have unrecognized osteochondral lesions that contribute to ongoing pain and must be addressed for full recovery.

Physical Therapy and Rehabilitation

Structured rehabilitation is the cornerstone of conservative treatment for chronic ankle instability and is effective in a majority of patients. Rehabilitation targets both the mechanical and neuromuscular components of instability. Proprioceptive training — balance exercises on unstable surfaces (balance boards, foam pads, BOSU balls), single-leg stance activities, and sport-specific challenges — stimulates mechanoreceptor function and retrains the neuromuscular responses that protect the ankle from unexpected perturbations.

Peroneal muscle strengthening directly addresses one of the key dynamic stabilizers of the lateral ankle. The peroneals provide eversion resistance that limits inversion sprains, but they often become inhibited after injury. Resistance band exercises, eccentric strengthening, and progressive loading exercises restore peroneal strength and reaction time. Proprioceptive taping and bracing during rehabilitation provide external mechanical support while neuromuscular function is being restored.

Surgical Ligament Reconstruction

When comprehensive rehabilitation lasting 3–6 months fails to restore functional stability, or when significant mechanical laxity is present on stress testing, surgical ligament reconstruction is highly effective. The Broström-Gould procedure is the standard anatomic repair: the stretched or torn ATFL and CFL are shortened and re-imbricated back to their anatomic attachments, tightening the lateral ligament complex to its proper tension. The inferior extensor retinaculum is incorporated into the repair (the “Gould modification”) to augment tissue quality and add proprioceptive input.

The Broström-Gould procedure has excellent published outcomes, with high rates of patient satisfaction and return to sport or activity. It is typically performed as outpatient surgery, followed by a period of immobilization, then progressive rehabilitation over 3–4 months. For patients with generalized ligamentous hyperlaxity, revision cases, or very high mechanical demands, augmentation with allograft or autograft tendon tissue may be added to enhance construct strength.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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When to See a Podiatrist for Ankle Instability

Chronic ankle instability — the feeling that your ankle keeps giving way — is treatable with proper rehabilitation and, when needed, surgical stabilization. Dr. Tom Biernacki at Balance Foot & Ankle offers both conservative and surgical management for chronic ankle instability.

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Clinical References

1. Hertel J. “Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability.” Journal of Athletic Training. 2002;37(4):364-375.
2. Krips R, et al. “Long-term outcome of the modified Brostrom procedure for chronic lateral ankle instability.” Foot and Ankle International. 2001;22(8):624-628.
3. Hintermann B, et al. “An anatomic study of the lateral ankle ligaments.” Foot and Ankle International. 2002;23(5):420-424.