By Dr Ryan du Sart - Orthopaedic Surgeon | South West WA

Most people can name the first time they rolled their ankle. Far fewer can name the fifth. By then it has stopped feeling like an injury and started feeling like a personal quirk, the ankle that goes on gravel, the one you strap before footy, the one you think about on a ladder.

That pattern has a name. It is called chronic ankle instability, and it is one of the more commonly overlooked orthopaedic problems in adults who stay active.

Why one bad sprain can turn into many

The ligaments on the outside of the ankle, particularly the anterior talofibular ligament and the calcaneofibular ligament, work like guide ropes. They hold the joint in line when the foot lands on an uneven surface.

When those ligaments tear, they do not always heal back to their original length. They can heal long and slack. The rope is still attached, but there is slack in it. The ankle then has a little more movement than it should, and each unexpected step on a rut, a kerb or a football boot has a bit more room to go wrong.

This is why the second sprain often takes less force than the first, and the third less again.

Signs it is instability, not just a weak ankle

Instability tends to show itself in patterns rather than in one dramatic moment. Common signs include:

• The ankle rolling on flat ground or minor uneven surfaces
• A sense that the joint gives way or cannot be trusted
• Ongoing swelling or aching after activity, long after the original injury
• Avoiding certain surfaces, sports or footwear without really deciding to
• Relying on strapping or a brace to feel confident

Persistent pain at the front or inside of the ankle can also point to associated damage to the joint surface, which sometimes accompanies repeated sprains.

Why it is worth assessing rather than managing

Repeat sprains are not only inconvenient. Each episode places abnormal load through the cartilage of the ankle joint, and over time that load can contribute to post-traumatic ankle arthritis. Assessment is about protecting the joint you have, not simply settling the current episode.

An orthopaedic assessment usually involves a discussion of your injury history, an examination of ankle movement and stability, and imaging where it is useful. X-rays can show bony changes, and MRI can show ligament quality and any damage to the cartilage surface.

Treatment starts before surgery

For many people, structured non-operative care resolves the problem. That typically means physiotherapy focused on strength and balance retraining, activity modification for a period, and bracing or taping during higher risk activity. Proprioception work matters here, since instability is partly a control issue and not purely a structural one.

Surgery is considered when the instability persists despite that work, when the ligaments are damaged beyond what conservative care can address, or where there are signs the joint itself is being affected.

What ankle ligament reconstruction involves

The procedure aims to restore normal ligament tension rather than simply patch the damage. Through an incision on the outer ankle, the damaged ligaments are identified, shortened back to their anatomical position and reattached to the fibula using strong sutures and bone anchors. Where a ligament is too weak to repair, a tendon from around the ankle or foot can be used to reconstruct it. Dr du Sart discusses this possibility before surgery rather than during it.

Ankle arthroscopy, or keyhole inspection of the joint, is sometimes performed at the same time to address bone spurs, loose fragments or cartilage damage found alongside the instability.

Recovery in realistic terms

Recovery is staged and requires patience. The first two weeks generally involve elevation and no weight through the operated foot, with crutches or a knee scooter for mobility. A cast is typically used for the first two weeks, followed by a CAM boot with partial weight bearing through to around five weeks. Physiotherapy usually begins at the two week mark and continues well beyond the boot coming off.

Return to work depends on the job. Standing and walking roles commonly need six to eight weeks, and physically demanding work can take considerably longer. Return to sport is generally discussed in months rather than weeks. Driving timeframes differ depending on whether the left or right ankle was operated on and the type of vehicle.

These are general timeframes only. Your own recovery depends on the extent of the injury, the work done, and how rehabilitation progresses.

Getting an ankle assessed

Dr Ryan du Sart is an orthopaedic surgeon consulting regularly in Bunbury and Busselton, with a special interest in foot and ankle surgery. Referrals are made through your GP, who can assess the ankle, arrange imaging where appropriate, and refer on if a specialist opinion is warranted.

If your ankle has rolled more than once and you have started planning around it, that is worth a conversation.

For personalised advice about ankle instability, speak with your orthopaedic specialist.