Patient Guide · Foot & Ankle Surgeon · London & North London
My Ankle Sprain Still Hurts Months Later: What’s Going On?
An evidence-based guide to why an ankle sprain can still hurt months later — covering the normal recovery timeline, chronic ankle instability, and the injuries a “simple sprain” can sometimes hide — written by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore.
Recovery from an ankle sprain carries on improving for a full year, so being sore at three months is normal. What matters is the overall direction of travel — and knowing when a lack of progress means something else is going on.
In short
Still having symptoms months after a sprain is common, and things carry on getting better for a full year. When researchers combined 15 studies of people having their first sprain on the outside of the ankle, pain was still present in 48.6% at 3 months, 21.5% at 6 months and 6.7% at 12 months. The feeling of the ankle giving way improved in the same way: 37.9%, then 16.1%, then 8.1%.
So being sore at three months is normal. Being no better at six months is not, and if nothing has changed by twelve months, something else is going on.
Roughly 1 in 6 people sprain the same ankle again within a year, and each new sprain makes the next one more likely.
This matters in the long run. An unstable ankle that is left untreated can lead to ankle arthritis — among people with a long-standing unstable ankle, 37% had cartilage damage and 31% had bone spurs, and the risk rose sharply once symptoms had been there for five years or more.
The normal recovery curve — and why it is longer than you were told
Most people are told an ankle sprain takes six weeks. In reality, recovery carries on for much longer. The best evidence comes from a review that combined 15 studies of people who had never injured the ankle before and were having their first sprain on the outside of the ankle.
| 3 months | 6 months | 12 months | |
|---|---|---|---|
| Still had pain | 48.6% | 21.5% | 6.7% |
| Felt the ankle might give way | 37.9% | 16.1% | 8.1% |
| Sprained it again within the year | — | — | 15.8% |
Two things follow from this.
First, some reassurance. If you are three months in and still aching after a long day, about half of people are in the same position. That is normal recovery, not a sign that something has gone wrong.
Second, the numbers keep falling all the way to twelve months. The researchers concluded that this is a reason to carry on with treatment that does not involve surgery for longer before considering an operation — because a good number of people who still have symptoms at six months settle on their own.
That is helpful in both directions: it stops people panicking at three months, and it stops them being rushed into surgery at six.
When to stop waiting
Look at the overall direction of travel rather than how you feel on one particular day. Some practical guides:
- Not clearly better by 3 months — worth having a proper assessment, particularly if all you have had so far is an X-ray in A&E
- Still limited at 6 months — a scan is reasonable, and the diagnosis should be looked at again
- No change at 12 months — this is no longer a sprain that is healing. Something specific is going on and needs to be found
- At any stage: the ankle repeatedly gives way, locks or catches, swells after doing very little, or hurts somewhere different from where it hurt at the start
That last point is worth emphasising. Pain that has moved — from the outside of the ankle to the front, or deep inside the joint — means something, rather than being a random change.
What it might actually be
Chronic ankle instability
The ligaments healed, but longer and looser than before. The ankle feels unreliable on uneven ground, in the dark, or when you are tired, and rolls over very easily.
There are two parts to this, and they need telling apart because the treatment is different. Mechanical instability means the ligaments really are loose, which can be shown by examining the ankle and by scans taken while the ankle is stressed. Functional instability is the feeling of giving way when the ligaments are not actually loose — a problem with balance, reaction time and proprioception, the nerve feedback that tells your brain where your foot is. Many people have both. Functional instability improves with rehabilitation exercises; mechanical instability may need surgery to rebuild the ligaments.
A cartilage and bone injury inside the joint (an osteochondral lesion of the talus)
An injury to the cartilage and bone on the top of the talus, the bone that sits inside the ankle joint. It happens at the moment of the sprain and does not show up on ordinary X-rays.
The pattern is fairly typical: deep pain inside the joint rather than over the ligaments, aching after activity, sometimes catching or clicking, and swelling that keeps coming back. This is one of the diagnoses most often missed in a sprain that will not settle, and it needs an MRI or CT scan to see.
Peroneal tendon injury
The two peroneal tendons run behind the bony bump on the outside of the ankle and are often injured along with the ligaments. They can split along their length or slip out of the groove they normally sit in.
Pain sits behind and below the outer ankle bone rather than in front of it, and there is often a snapping feeling. This is easily mistaken for ligament pain that is still settling.
A missed fracture
Several small fractures are well known for being missed on the first X-ray after a “sprain”: the front of the heel bone (the anterior process of the calcaneus), the outer corner of the talus (the lateral process), the base of the fifth metatarsal on the outer edge of the foot, and the navicular on the inner side. The clue is pain in one exact spot over a bone, rather than pain spread over an area.
A high ankle sprain (syndesmosis injury)
An injury to the ligaments that hold the two shin bones, the tibia and fibula, together just above the ankle. The pain is higher up than in a usual sprain, is worse when you push off or twist, and takes a good deal longer to settle. It is often missed at first, and it is treated differently from an ordinary sprain on the outside of the ankle.
Nerve irritation
One of the nerves, the superficial peroneal nerve, crosses this area and can be stretched during the injury or caught in scar tissue afterwards. This gives burning or tingling pain, and sometimes a patch of numbness or altered feeling on the top of the foot — which feels different from ordinary pain.
Simple loss of strength and fitness (deconditioning)
Sometimes nothing is damaged and the calf and outer ankle muscles have simply never been built back up. This is common, often overlooked and completely fixable, and it is why doing proper rehabilitation exercises matters more than most people are told.
Why this matters more than it seems
An ankle that keeps giving way is not just an inconvenience. Each episode does a little more damage to the surface of the joint.
In a study of 1,169 people whose ankle had been unstable for a long time, 37% had cartilage and bone injuries inside the joint and 31% had bony spurs. The risk was clearly higher in those who had had symptoms for five years or longer, and higher still where both of the main ligaments on the outside of the ankle were injured.
This links directly to something covered elsewhere on this site. Unlike the hip and knee, most severe ankle arthritis follows an injury — and in people who develop severe ankle arthritis after breaking the ankle, the gap between the injury and the arthritis averages around 21 years. The damage builds up quietly over decades.
What a proper assessment involves
- Your history — how the original injury happened, how many episodes you have had since, what brings it on, and exactly where the pain is now
- Examination — testing how loose the ligaments are, but also checking the peroneal tendons, how flexible the calf is, the shape of your foot (a high arch that turns inwards makes repeat sprains more likely and changes the treatment) and your balance standing on one leg
- Weight-bearing X-rays, taken standing up — to check how the bones line up and to look for spurs or fractures that were missed
- MRI scan — the main test where a cartilage, tendon or bone injury is suspected
- Weight-bearing CT, a scan taken standing up — where the alignment is in question, because the position of the back of the foot under your body weight drives repeated instability and cannot be measured properly lying down
- In some cases, an injection to pinpoint where the pain is coming from, or a keyhole look inside the joint (arthroscopy)
Treatment: rehabilitation first
A structured rehabilitation programme is the foundation, and it deserves a proper try — usually three months of consistent work — before surgery is discussed.
- Balance training — standing on one leg, building up to wobbly surfaces and to the movements of your sport. This tackles functional instability directly
- Strengthening the peroneal muscles — the muscles that actively stop the ankle rolling over
- Calf strength and flexibility
- A step-by-step return to sport, rather than going back on a fixed date
Other measures
- Shoes — supportive shoes with a firm heel; be careful with very soft, thick-soled running shoes if your ankle tends to roll
- An insole (orthotic) where the shape of your foot is part of the problem
- Taping as a short-term alternative to a brace
- Bracing is highly effective when playing sport
When surgery is considered
Surgery is for ankles with genuine mechanical instability — ligaments that really are loose — which have not improved after at least three to six months of proper rehabilitation. As the recovery figures above show, it is often worth waiting closer to the longer end of that range.
The most common operation is a repair of the ligaments on the outside of the ankle (a Bröström-type procedure), which tightens and reattaches the stretched ligaments, often backed up with nearby tissue. Where the tissue is poor, or an earlier repair has not worked, the ligaments can be rebuilt using a piece of tendon (a graft).
Keyhole surgery (arthroscopy) is often done at the same time, both to look inside the joint and to treat anything that is found — because in an ankle that has been unstable for a long time, there is often something to treat.
Recovery usually means wearing a boot for several weeks, physiotherapy starting early on, and a return to sports involving twisting and turning at around four to six months.
Frequently asked questions
How long should an ankle sprain take to heal?
Longer than most people expect. About half of people with a first sprain still have some pain at three months, but this falls to about one in five at six months and fewer than one in ten at a year. Look at the overall direction of travel rather than any single week.
Is it normal for my ankle to still hurt three months after a sprain?
Yes — about half of people are in that position, and most keep improving. What is not normal is having no improvement at all between three and six months.
Why does my ankle keep giving way?
Either the ligaments healed loose (mechanical instability), or your balance and reaction system has not recovered (functional instability), or both. The difference matters, because the first may need surgery and the second improves with rehabilitation exercises.
Do I need an MRI for an ankle sprain?
Not as a matter of routine. It becomes worthwhile if symptoms carry on beyond about three to six months, if the ankle catches, locks or swells again and again, or if the pain is deep in the joint rather than over the ligaments — all of which raise the possibility of a cartilage injury.
Should I wear an ankle brace?
If you play a sport with a lot of turning or jumping and you have sprained the ankle before, the evidence supports it. In one trial, wearing a brace during sport roughly halved the chance of spraining the ankle again compared with a home exercise programme.
Will repeated sprains cause arthritis?
An ankle that keeps giving way damages the joint surface over time. Among people with a long-standing unstable ankle, 37% had cartilage damage and 31% had bony spurs, and the risk rose sharply after five years of symptoms. Most severe ankle arthritis follows an injury, and it usually appears around two decades after the original injury.
Can I run on an unstable ankle?
Straight-line running on even surfaces is usually manageable. Trail running, court sports and anything involving sharp changes of direction carries a real risk of another episode, and each one increases the chance of the next.
Is surgery a guarantee?
No, but repair of the ligaments on the outside of the ankle is one of the more reliable operations in foot and ankle surgery for the right patients — meaning an ankle that is genuinely loose and has not improved with good rehabilitation.
Speak to a specialist
An ankle sprain that has not settled deserves a diagnosis rather than more waiting. Often the answer is reassurance and a properly structured rehabilitation programme. Sometimes it is a cartilage or tendon injury that has gone unnoticed — and finding it earlier makes it easier to treat.
Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital, Stanmore, and Honorary Associate Clinical Professor at UCL. He has a particular interest in sports injuries of the foot and ankle, including ankle instability, cartilage injuries and ligament reconstruction, with access to weight-bearing CT, MRI and arthroscopy. He sees patients across North and Central London.
- Telephone: 07547 395 270
- Email: secretary@matthewwelck.com
- Book a consultation: matthewwelck.com/appointments
Urgent same-day appointments are offered where possible.
References
- Michels F, Wastyn H, Pottel H, Stockmans F, Vereecke E, Matricali G. The presence of persistent symptoms 12 months following a first lateral ankle sprain: A systematic review and meta-analysis. Foot Ankle Surg. 2022;28(7):817–826. doi:10.1016/j.fas.2021.12.002
- Wang DY, Jiao C, Ao YF, et al. Risk Factors for Osteochondral Lesions and Osteophytes in Chronic Lateral Ankle Instability: A Case Series of 1169 Patients. Orthop J Sports Med. 2020;8(5):2325967120922821. doi:10.1177/2325967120922821
- Janssen KW, van Mechelen W, Verhagen EALM. Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomised controlled trial. Br J Sports Med. 2014;48(16):1235–1239. doi:10.1136/bjsports-2013-092947
- Janssen KW, Hendriks MRC, van Mechelen W, Verhagen E. The Cost-Effectiveness of Measures to Prevent Recurrent Ankle Sprains: Results of a 3-Arm Randomized Controlled Trial. Am J Sports Med. 2014;42(7):1534–1541. doi:10.1177/0363546514529642
- Horisberger M, Valderrabano V, Hintermann B. Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma. 2009;23(1):60–67. doi:10.1097/BOT.0b013e31818915d9
Study data above retrieved via PubMed. This article is provided for general information and patient education only. It is not a substitute for individual medical assessment, diagnosis or treatment by a qualified healthcare professional.
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