Sprained Ankle Still Hurts after 3 Weeks/Months/Years: Why and How to Treat?

Ankle Sprain, Twisted Ankle, Torn Ligament: What Is It?

In everyday language, we sometimes say that we have “twisted” or “sprained” our ankle. “Twisted ankle,” “sprained ankle,” “torn ligament in ankle” and “ankle sprain” are synonymous expressions.

An ankle sprain is an injury to one or more ligaments of the ankle joint due to sudden stretching.

The ligaments of the ankle are thick bands of tissue that connect the bones together and hold them in place. Just as a piece of fabric is composed of textile fibers, ligaments are composed of ligamentous fibers.

In the case of an ankle sprain, the injury can range from the rupture of a few ligament fibers to the complete tear of one or more ligaments of the ankle.

Immediate Pain after Ankle Sprain: Why?

The ligament injury will create numerous microscopic debris of ligaments. These are small fragments of the torn ligament fibers in your ankle.

These pieces will become immersed in the liquid part of the ankle ligament. They will then come into contact with various chemical substances present in the fluid, resulting in a chemical reaction: the inflammatory response [1].

The inflammatory response leads to the production of new chemical compounds. These compounds will activate and sensitize specific sensors present in the ankle ligament called nociceptors. It is these sensors that transmit the sensation of pain to the brain.

This pain that occurs immediately after an ankle sprain is called acute pain. If the pain persists beyond a certain duration, it is referred to as chronic pain.

The immediate pain after the sprain is normal and serves a purpose. It forces you to rest your ankle for a while, allowing your body to organize itself for optimal ligament healing.

When Will my Sprained Ankle Stop Hurting?

The available studies on the duration of pain after ankle sprains indicate that [2]:

• Pain decreases rapidly within the first 2 weeks following the injury.
• Up to 2 out of 3 individuals will no longer experience pain after one year.
• Up to 9 out of 10 individuals will no longer experience pain after three years.

An ankle sprain can vary in severity. Three levels of severity are distinguished:

• Grade 1: Partial ligament injury that does not affect ankle stability (the ligament still holds the bones together well).
• Grade 2: Partial ligament injury that affects ankle stability (the ligament no longer holds the bones together well).
• Grade 3: Complete ligament tear.

Surprisingly, the severity of the sprain does not determine how long the pain will last over time [2].

Key takeaway: 2 out of 3 individuals will no longer experience pain after one year, and 9 out of 10 after three years.

You are not alone in questioning the duration of this pain. These phrases are searched on Google dozens of times every day in United-States alone:

• sprained ankle still hurts after 2 weeks (it is quite usual!)
• sprained ankle still hurst after 3 weeks (it is also quite usual!)
• spraine akle still hurts after 3 months (this is the case for more than 2 out of 3 people)
• sprained ankle still hurst after 6 months (this is the case for more than 2 out of 3 people)
• sprained ankle still hurst after 1 year (this is the case for 2 out of 3 people)
• sprained ankle still hurst 3 years later (it is something well-known, even if it is rare).

Ankle Still Hurt after My Ankle Sprain: How to Explain It?

Indeed, the pain that occurs immediately after an ankle sprain is a normal and useful phenomenon. Therefore, it is not surprising that it may last for a certain period of time. But how long exactly?

When Should I Be Concerned about Chronic Pain?

When a ligament is injured, one can imagine that the pain will disappear once it has completely healed. This leads us to ask: how long does it take for a ligament to heal? Based on current scientific knowledge, this duration could range from 6 weeks to 3 months [3].

Now we can go back to our initial question and specify it: why can ankle still hurts after a sprai beyond the 6-week to 3-month range?

First of all, as long as we are within this range, it is still possible that complete healing has not yet occurred. After 3 months, this possibility becomes uncertain, and other potential causes need to be considered.

Key takeaway: Before 3 months, there is no need to worry. The ligament may not have completely healed yet.

Possible Causes of Chronic Pain after Ankle Sprain

There are over a dozen reasons that can explain why akle still hurts after a twisted ankle. These causes can be categorized into two groups:

1. Local causes: One or more anatomical abnormalities have developed in your ankle, in addition to the initial ligament injury.
2. Neurological causes: Your nervous system has become dysfunctional in its pain management.

Now let’s examine each of these categories.

Local Causes

Other anatomical injuries related to the sprain may have gone unnoticed or developed later. In individuals experiencing chronic ankle pain following a sprain, the following conditions can be found [4-5]:

1. In 6 to 9 out of 10 individuals, one or more anomalies within the ankle joint, such as:
   • Lesions of cartilage and its attachment to the bone (osteochondral lesions).
   • Presence of an unexpected fragment within the joint (articular loose body), such as a piece of cartilage.
   • Hypertrophied synovial membrane.
   • Inflammatory synovial membrane.
   • Bone overgrowth (osteophyte).
2. In nearly 8 out of 10 individuals, abnormalities of a tendon in the ankle muscles (fibular muscles), including:
   • Inflammation of the synovial sheath of the tendon (tenosynovitis).
   • Tendon body fissure.
   • Thinning of the fibular retinaculum (a fibrous structure that holds the tendons against the bone while allowing them to slide).
3. In nearly 8 to 9 individuals, injury to a nerve in the ankle (fibular nerve or tibial nerve).

In summary, there are numerous possible local causes that can explain the persistence of your pain. The diagnosis and treatment of each of these conditions require specific expertise (ideally). Just for osteochondral lesions, there are at least ten therapeutic options described in the scientific literature [6-8].

Neurological Causes

Your nervous system (including your brain and spinal cord) can become dysfunctional in its pain management, referred to as central sensitization. This can explain why ankle still hurt after an ankle injury.

Research is ongoing to explain why and how some individuals develop this type of dysfunction while others do not [9]. A thorough understanding of this phenomenon is crucial for:

• Identifying whether chronic pain is truly caused by central sensitization (as opposed to an undetected or improperly treated local anomaly).
• Discovering genuinely effective strategies for treating this type of chronic pain.

It is worth noting that, in principle, persistent pain following an ankle sprain can arise from both a local anomaly and central sensitization.

Key takeaway: There are over 10 possible causes that can explain why ankle still hurt after an ankle sprain, and they can potentially coexist.

What to Do if Ankle Still Hurt after Ankle Sprain?

If your ankle still hurt beyond 3 months after your sprain, you have two problems to address:

1. Finding an effective treatment (if available).
2. Living with the pain in the meantime.

Let’s delve into each of these problems.

Finding an Effective Treatment

Ideally, you need a treatment that:

• Permanently eliminates your pain.
• Carries minimal risk of side effects.
• Is cost-effective.

Increasing your chances of finding such a treatment involves:

1. Finding a specialist in the management of persistent pain following an ankle sprain.
2. Undergoing necessary diagnostic examinations to accurately identify the causes of your pain (if possible given current knowledge).
3. Receiving the required treatment (if available).
4. Potentially enduring the associated recovery period, such as partial immobilization and post-surgery rehabilitation.
5. Assessing the immediate result at the end of the treatment.
6. Potentially returning to step 1 or 2 if the immediate post-treatment result is unsatisfactory.
7. Evaluating the long-term result after a few months.
8. Potentially restarting from step 1 or 2 in case of pain recurrence.

You have probably understood that all these steps require time, energy, and come with no certainty of the outcome.

Even the first step of finding a specialist is already a significant challenge.

Indeed, there are dozens of possible causes for chronic pain after an ankle sprain. To confidently identify the main cause of your pain, it requires true expertise.

This expertise includes a good understanding of the relevant international scientific literature in order to:

• First, confidently pinpoint the main cause of your pain (if the state of knowledge allows it).
• Then, guide you towards the best available therapeutic option to treat that cause.

How to find such a specialist? Unfortunately, I don’t know.

However, what I do know is that the more informed you are about the topic, the better equipped you will be to identify such a specialist. In this regard, reading this blog post is an excellent starting point!

I also know that sometimes it may be wise not to allocate too much time and energy to this quest. While not giving up hope for definitive relief, it can be wise to preserve your strength for other activities.

Indeed, while waiting to find the potential miraculous treatment or providential specialist, life must go on. You need to tame your pain, to deal with chronic pain.

How to Deal with Chronic Pain?

While waiting to find a satisfactory treatment for your chronic ankle pain, you have to live with it and deal it. What does this involve in practical terms? I propose a pain management strategy based on three principles:

1. First, analyze the real impact of your pain on your daily life.
2. Then, set smart goals to improve the situation.
3. Finally, establish a pain journal to track your progress.

This approach I propose is not specific to chronic ankle pain. It is suitable for a wide range of chronic pain conditions. I discuss it further in my blog post dedicated to managing chronic pain (coming soon in English).

***

Here’s what I wanted to tell you about this! I wish you a very good recovery! Do you have any comments or questions? Your comments are welcome 🙂 !

You may also like:

• Recovery Time after Twisted Ankle
• Swelling after Ankle Sprain: How Long Does it Last?

 📚 SOURCES

[1] Basbaum, A. I., Bautista, D. M., Scherrer, G., & Julius, D. (2009). Cellular and molecular mechanisms of pain. Cell, 139(2), 267–284. https://doi.org/10.1016/j.cell.2009.09.028

[2] van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008 Apr;121(4):324-331.e6. doi: 10.1016/j.amjmed.2007.11.018. PMID: 18374692.

[3] Hubbard -Turner, Tricia & Hicks-Little, Charlie. (2008). Ankle Ligament Healing After an Acute Ankle Sprain: An Evidence-Based Approach. Journal of athletic training. 43. 523-9. 10.4085/1062-6050-43.5.523.

[4] Ahn, Byung-Hyun, and Byung-Ki Cho. “Persistent Pain After Operative Treatment for Chronic Lateral Ankle Instability.” Orthopedic research and reviews vol. 13 47-56. 19 Apr. 2021, doi:10.2147/ORR.S299409

[5] Pina, Matthew & Messina, James & Geaney, Lauren. (2021). Persistent Nerve Injury and CRPS After Ankle Sprains. Techniques in Foot & Ankle Surgery. Publish Ahead of Print. 10.1097/BTF.0000000000000314.

[6] Badekas, T., Takvorian, M., & Souras, N. (2013). Treatment principles for osteochondral lesions in foot and ankle. International orthopaedics, 37(9), 1697–1706. https://doi.org/10.1007/s00264-013-2076-1

[7] Guimarães JB, da Cruz IAN, Nery C, Silva FD, Ormond Filho AG, Carneiro BC, Nico MAC. Osteochondral lesions of the talar dome: an up-to-date approach to multimodality imaging and surgical techniques. Skeletal Radiol. 2021 Nov;50(11):2151-2168. doi: 10.1007/s00256-021-03823-7. Epub 2021 Jun 15. PMID: 34129065.

[8] Boffa, A., Previtali, D., Di Laura Frattura, G. et al. Evidence on ankle injections for osteochondral lesions and osteoarthritis: a systematic review and meta-analysis. International Orthopaedics (SICOT) 45, 509–523 (2021). https://doi.org/10.1007/s00264-020-04689-5

[9] Barroso J, Branco P, Apkarian AV. Brain mechanisms of chronic pain: critical role of translational approach. Transl Res. 2021 Jun 25:S1931-5244(21)00144-4. doi: 10.1016/j.trsl.2021.06.004. Epub ahead of print. PMID: 34182187.