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Ankle Instability

Causes, Symptoms, Treatments, & Other Resources

Ankle injuries can be excruciating and can occur with sports or simple activities like stepping off the curb incorrectly, and the most common ankle injuries are to the ligaments.  What are the four ligaments in the ankle?  What are loose ankle ligaments?  What causes chronic instability?  How do you treat weak ankles?  Let’s dig in.

What Are the 4 Ligaments of the Ankle?

Ligaments are thick bands of connective tissue that connect one bone to another.  The ankle ligaments function to stabilize the joint and limit excessive bending and rotation.  The deltoid ligament is a triangular-shaped complex located on the inside aspect (medial) of the ankle (1).  The outside aspect (lateral) of the ankle has three principal ligaments:  Anterior Talofibular (ATF), Posterior Talofibular (PTF), and Calcaneal Fibular ligament (CF).  The ATF is the weakest lateral ankle ligament and is the most commonly injured in lateral ankle sprains (2).

Loose Ankle Ligaments: What Causes Chronic Ankle Instability?

The ankle is susceptible to injury.  It is the most injured joint in sports and accounts for 10-30% of all sports injuries (3).  A sprain (aka twisting the ankle) is when one or more of the ligaments is stretched or torn.  Pain, swelling, and bruising are common.  Sprains are classified into grades 1, 2, or 3 based upon the severity of the injury.  Simple tasks like stepping off the curb or sports can lead to ankle sprains.  Ligaments stabilize the ankle joint and when sprained can lead to ankle instability.  When acute ankle sprains are not identified, treated, and allowed to heal chronic ankle instability can occur.  20% of acute ankle sprains develop into chronic ankle instability (4).  Chronic instability is serious as it is associated with loss of cartilage, tendon injury, and instability of the foot joints.

What are the Symptoms & Why Is It A Big Deal?

Chronic ankle instability can occur when acute sprains are not identified, treated, and allowed to heal.  Chronic instability can lead to loose ankle ligaments, loss of joint cartilage, and tendon injury. 

Ankle Pain After Walking

More than any other joint, our ankles bear the burden of all of our body weight. The ankles aren’t large weight-bearing joints, like our hips or knees; comparatively speaking, the ankles are rather small for the tasks they are assigned to do. If the ankles are normal and healthy and there isn’t a weight issue placing excess stress on the ankles, the ankles can typically bear the forces of walking, running, hiking, and so on quite well. However, when the ankles are weak or carrying too much weight, any additional forces placed upon them—even something as simple as walking—can create problems. Do your ankles get sore after walking? What about foot and ankle pain after hiking? If so, it’s a good idea to proactively address it now, before it gets worse, rather than resigning yourself to it and decreasing or stopping the activities you enjoy. We’ll explain more in a moment, but first let’s take a closer look at the structure of the ankle.

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Ankle Pain When Running

There are multiple causes of ankle pain while running. The six major causes are: Stress Fracture A stress fracture is a small crack in the bone due to overuse and repeated impact. They are a common cause of pain in runners, accounting for up to 16% of injuries. The shin bone (tibia) is the most commonly affected bone accounting for approximately 40 % of stress fractures. Pain is the most common symptom. Plantar Fasciitis. The plantar fascia is the thick connective tissue that extends from your heel to your toes. Plantar fasciitis is the inflammation of the plantar fascia and is the most…

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Outside Ankle Pain

We often see patients with outside ankle pain who have no idea how it happened; they just know their ankle suddenly started hurting. One patient was a classic example of this. As an athletic hockey and Lacrosse player, however, it’s highly possible he experienced sprains and other ankle injuries, even minor ones, over the years, and these, rather than one big traumatic episode, could have been the catalyst to his sudden outside ankle pain. Outside ankle pain can be treated without surgery by an interventional orthopedics physician. Loose or torn ligaments usually can be treated nonsurgically with ultrasound-guided high-dose platelet-rich plasma (PRP) injections…

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How Do You Test for Ankle Instability?

The physical examination must include an assessment of both ankles.  In a seated and relaxed position, the ankle is put through various stress tests to determine ligament laxity.  The anterior drawer test is used to assess the integrity of the ATF whereas the talar tilt assesses the CFL (5).  Performing and Interpreting these tests often times can be a challenge due to pain level, swelling, body size, and muscle spasm.  Is there another option that is available in the office? Yes.

Ultrasound Stress Test

Under ultrasound, the ankle ligaments are identified and stress is then applied to determine whether the ligaments are loose or partially torn.  The applied stress is similar to that one would experience while running and cutting.  An MRI is not capable of this evaluation as it is a static test with the patient remaining still.  This test is critical in the evaluation of ankle injuries.

To learn more about stress ultrasound for ankle ligament instability please click on the video below.

How Do You Treat Weak Ankles?

It depends on the type and severity of the injury. Conservative care is the initial treatment of choice for most injuries and involves physiotherapy, bracing or taping, and neuromuscular training (6).  Surgery is often recommended for those that fail conservative treatment.  Surgical options include repair or reconstruction of the damaged ligament or replacement with a graft.  Like all surgeries, complications can occur.   In one study complication rate was 29% and involved wound healing, nerve injuries, and blood clots (7).  Are there non-surgical regenerative options?  Yes as PRP and bone marrow concentrate (containing stem cells) are effective in the treatment of ankle ligaments injuries (8).   At the Centeno-Schultz Clinic, we have extensive experience in the treatment of loose ankle ligaments and chronic ankle instability utilizing precisely guided PRP and bone marrow concentrate (containing stem cells). Ligament healing occurs in three phases;  Inflammation, regeneration, and tissue remodeling.

To understand the phases of ligament healing and response to PRP and stem cell injections please watch the video below.

In Conclusion

Ligaments are thick bands of connective tissue that connect one bone to another.  The ankle ligaments provide critical support and stability.  There are four major ligaments in the ankle that are susceptible to injury. Chronic ankle instability can occur when acute sprains are not identified, treated, and allowed to heal.  Chronic instability can lead to loose ankle ligaments, loss of joint cartilage, and tendon injury.  Stress ultrasound provides an ideal and immediate evaluation of the ligament integrity in the office.  Surgery is often recommended when conservative treatment fails but has significant complications.  PRP and bone marrow concentrate containing stem cells are effective treatment options for loose ankle ligaments and chronic ankle stability and avoid the risks associated with surgery.

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Our Doctors Who Treat Ankle Instability

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. I have been a patient with severe pain and know firsthand the limitations of traditional orthopedic surgery. I am a co-founder of the Centeno-Schultz Clinic which was established in 2005. Being active is a central part of my life as I enjoy time skiing, biking, hiking, sailing with my family and 9 grandchildren.

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Matthew William Hyzy, D.O.

Doctor Hyzy is Board Certified in Physical Medicine and Rehabilitation (Physiatry) and fellowship-trained in Interventional Orthopedics and Spine. Dr. Hyzy is also clinical faculty at the University of Colorado School of Medicine in the Department of Physical Medicine and Rehabilitation; In addition, Dr. Hyzy is an Adjunct Clinical Assistant Professor at The Rocky Vista University College of Osteopathic Medicine. Dr. Hyzy also maintains an active hospital-based practice at Swedish Medical Center and Sky Ridge Medical Center. He is also recognized and qualified as an expert physician witness for medical-legal cases and Life Care Planning. He is published in the use of autologous solutions including…

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Mairin Jerome, MD

Mairin Jerome, MD

Dr. Mairin Jerome is a physiatrist with subspecialty fellowship training in Interventional Orthopedics and Regenerative Medicine. This subspecialty serves to fill the gap for patients who are interested in therapeutic options that lie between conservative treatment and surgery. Dr. Jerome uses regenerative medicine techniques, including prolotherapy and orthobiologics, via X-ray or ultrasound guidance to precisely deliver injections to areas of musculoskeletal injury or degeneration. Orthobiologics refers to tissue harvested typically from a person’s own body, such as platelets (platelet-rich plasma, PRP) or bone marrow, for use in treating painful musculoskeletal conditions. The goal is to stimulate the body’s healing mechanisms to improve pain, function, and decrease inflammation.

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More Resources for Ankle Instability

  • How Long Does a Sprained Ankle Stay Swollen?

    It happened several weeks ago as you stepped off the curb.  Your doctor told you that you sprained your ankle.   What is an ankle sprain? What are the different types of ankle sprains?  How can I tell if I have an ankle sprain?  How long does a sprained ankle stay swollen?  Let’s dig in. What … Continued


  • Ankle Sore after Walking? What’s Wrong and How to Fix it

    Is your ankle sore after walking? Is it inflamed or painful? Dr. Centeno talks about what could be causing the issue. Transcript Ankle Sore after Walking? What’s Wrong Hi, this is Dr. Centeno.  There are many people who, after they go for a walk, have ankle soreness, or, after they go for a run. So, … Continued


  • A Common Ankle Ligament Tear w/ Dr. Pitts

    Dr. John Pitts talks about a common ankle ligament tear, what treatment options are available, and what to do if you would like to seek help for you ankle pain  Transcript Hi, everybody. This is Dr. John Pitts from Centeno-Schultz Clinic. Today, I like to talk about a torn ankle ligament. So what is a … Continued


  • Ligaments of the Ankle – A Tutorial with Dr. Schultz [VLOG]

    Dr. Schultz gives a tutorial on the ligaments of the ankle – what they are, what they support, and why you should care.  Transcript Hi everybody, this Dr. Schultz, thanks for checking in. Today, we’re going to be reviewing the ligaments of the ankle. This is really important, and I just want to take a … Continued


  • Brostrom Ankle Surgery: Reasons To Avoid This Surgery

    Ligaments are the thick connective bands of connective tissue that connect one bone to bone. There are three important ankle ligaments on the outside of the ankle that provide stabilize the joint.  Brostrom ankle surgery is a reconstruction of one or more lateral ankle ligaments. Dr. Schultz discusses the risks and rehabilitation of Brostrom ankle surgery and a new treatment that is an effective alternative to lateral ankle sugery.


  • Ankle Ligament Surgery: The Facts and Are there Better Options?

    Ankle ligaments are thick bands of connective tissue that provide support to the ankle joint and are susceptible to injury. Dr. Schultz discusses the different types of ankle ligament injuries, ankle ligament surgery, and nonsurgical alternative to treat ankle ligament injuries.



1.Crim J. Medial-sided Ankle Pain: Deltoid Ligament and Beyond. Magn Reson Imaging Clin N Am. 2017;25(1):63-77. DOI: 10.1016/j.mric.2016.08.003

2.Golanó P, Vega J, de Leeuw PA, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):557-69. DOI: 10.1007/s00167-010-1100-x.

3. Hølmer P, Søndergaard L, Konradsen L, Nielsen PT, Jørgensen LN. Epidemiology of sprains in the lateral ankle and foot. Foot Ankle Int. 1994;15(2):72-4. DOI: 10.1177/107110079401500204.

4.Al-Mohrej OA, Al-Kenani NS. Chronic ankle instability: Current perspectives. Avicenna J Med. 2016;6(4):103-8. doi: 10.4103/2231-0770.191446.

5.Lynch SA. Assessment of the Injured Ankle in the Athlete. J Athl Train. 2002;37(4):406-12.

6. .McCriskin BJ, Cameron KL, Orr JD, Waterman BR. Management and prevention of acute and chronic lateral ankle instability in athletic patient populations. World J Orthop. 2015;6(2):161-71. DOI: 10.5312/wjo.v6.i2.161

7. Corte-Real NM, Moreira RM. Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int. 2009;30(3):213-7. DOI: 10.3113/FAI.2009.0213.

8. Lai MWW, Sit RWS. Healing of Complete Tear of the Anterior Talofibular Ligament and Early Ankle Stabilization after Autologous Platelet Rich Plasma: a Case Report and Literature Review. Arch Bone Jt Surg. 2018;6(2):146-9.

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