Subtle Signs & Symptoms of Ankle Instability

Subtle signs of ankle instability may not always be obvious sprains or injuries where your ankle “rolls over.” Sometimes the symptoms are mild, like feeling off balance, slight swelling after activity, or a moment where your ankle just doesn’t feel quite right. If you find yourself dealing with repeated ankle injuries or pain, understanding what ankle instability looks like can help you spot the signs and symptoms early and avoid further damage to your joint.

Tracking these symptoms and getting your ankle checked early can allow for specific treatment and increase ankle stability.

How Does Ankle Laxity Occur?

With repeat ankle sprains comes stretching of the ligaments that stabilize your ankle joint. When these ligaments have been stretched beyond their normal capacity, even if your ankle feels “normal” again, there are small alterations that take place:

• Passive support through the ligaments becomes lax

• Sensory-motor disruption occurs causing abnormal joint position sense

• An individual may alter their gait pattern in order to unload the ankle joint.

Because of these issues individuals with ankle laxity can experience subtle “giving-way” of the ankle, particularly when on uneven ground. Repetition of ankle sprains can also lead to inhibition of your peroneal muscles around your ankle which causes more risk for reoccurrence.

Mechanical vs. Functional Ankle Instability

Medical professionals divide ankle instability into two categories: mechanical and functional.

Mechanical ankle instability is caused by…

• Objective lateral ankle ligamentous laxity

Patients with mechanical instability typically have:

• Increased translation during an anterior drawer exam

• Increased talar tilt

• Ligamentous laxity noted on stress imaging

If conservative management and rehabilitation do not improve your instability, surgical intervention to stabilize your ankle may be recommended.

Functional ankle instability is caused by…

• Subjectively swollen ligaments but normal structural stability.

Patients with functional instability typically experience:

• Occasional ankle “giving way”

• Poor balance/coordination

• Decreased ability to stabilize ankle quickly

Retraining balance and strengthening your peroneal muscles can help regain ankle stability if you fall into this category.

The Role of Ligamentous Attenuation in Ankle Instability

Repeated microtrauma to ankle ligaments causes attenuation. Ligamentous attenuation is when your ligament fibers become stretched out and unable to effectively return to their normal configuration.

This leads to a decrease in tensile strength of your ligaments and increases laxity of your joint. Increased motion in your ankle joint over time can overload your cartilage and soft tissues surrounding your ankle which can cause further ankle instability.

Because attenuation also affects your proprioceptive fibers within your ligaments…

Your brain has a decreased ability to recognize where your ankle is positioned while in motion.

Subjective Feelings Associated with Ankle Instability

Instability can cause odd feelings in your ankle, typically before you experience more obvious pain.

You may feel…

• Like your ankle is not where you think it is for a split second

• Pins-and-needles in your ankle joint

• Light numbness after standing or walking for long periods of time

• Anxiety when trying to make sharp cuts or change directions quickly

These subtle symptoms may cause you to become more “camera-minded” to watch where you place your feet.

Episodes of Ankle Giving Way

Those who suffer from ankle instability will often experience occasional episodes of their ankle giving way.

This typically happens when…

• Walking on an uneven surface

• Going down stairs

• Changing your speed quickly

Even if your ankle doesn’t completely roll over, these instances may cause you to limp or guard your steps.

Apprehension With Certain Movements

If you experience ankle instability you may feel apprehensive when moving in certain ways.

For example…

• Cutting to the left or right

• Pivoting quickly on your foot

• Doing side lunges

You may experience…

• Shorter steps

• Reluctance before changing directions

• Looking down at your feet more often

Typically, these are adaptive body movements our brains choose without us even realizing it.

Physical Signs of Ankle Instability

Physical signs of ankle instability can appear to be mild but may be persistent.

Treating Post-Activity Synovitis

Sometimes after standing or walking for long periods of time, your ankle may feel…

• Warm to the touch

• Mildly swollen

• Stiff for an extended period of time

If you experience regular bouts of mild inflammation in your ankle, your joints may be getting irritated due to repeated instability.

Tenderness Along Your Lateral Ligaments

Have you ever noticed that along your outside ankle you feel tender to the touch?

Perhaps only mild swelling but with tenderness along your ligaments near your ankle joint?

These can also be signs of ankle instability.

Compensations for Ankle Instability

The human body is smart. If one thing isn’t working properly, it typically finds a way to compensate.

Changing Normal Gait

As a result of ankle instability, you may…

• Take a shorter step with your injured leg

• Push less forcefully off your foot

• Turn your feet slightly outward

• Walk with a wider base of support

These adjustments can help you unload your ankle but may cause you to fatigue your hip, knee, or lower back.

Over-Compensating With Other Limbs

Similar to gait changes, some people who experience ankle instability may rely on the other leg for support when walking or standing.

It’s common for people to experience…

• Hip fatigue

• Knee pain

• Muscle imbalance

because of this compensation.

Balance Issues Related to Ankle Instability

Sprains can cause damage to the mechanoreceptors which help give us joint position sense.

Loss of Balance

Have you ever noticed yourself…

• Not being able to balance easily on one foot

• Feeling like you sway more when standing

• Feeling unstable when trying to stand on one foot with your eyes closed?

If you answered yes to any of these questions, you may have some balance deficits that are associated with ankle instability.

Slow Peroneal Muscle Response Time

Our peroneal muscles run along the outside of our legs and help protect our ankle from rolling forward. However, if you have ankle instability your peroneal muscles may take longer to fire.

This can cause a brief window of time where your ankle is susceptible to rolling.

Weight Shift to Injured Leg

A common compensation our bodies make with ankle instability is to…

Shift our weight to the opposite leg.

During your physical exam your doctor will pay close attention to your gait to identify any of these compensations.

Diagnosing Ankle Instability

Ankle instability is diagnosed through clinical history, physical exam, and sometimes imaging.

Physical Testing

A thorough examination of your ankle will include…

• Ligamentous palpation

• Range of motion testing

• Strength testing

• Balance testing

• Functional movement testing

Manual Stress Tests

Your provider will often perform provocative tests to evaluate the stability of your ankle joint.

Common tests include…

• Anterior drawer test: tests anterior talofibular ligament integrity

• Talar tilt test: tests calcaneofibular ligament integrity

Your provider will compare your injured ankle to your uninjured ankle in these tests to evaluate your overall laxity.

Although not always necessary, your doctor may obtain further imaging to confirm your diagnosis of ankle instability. These studies may include…

• Weight-bearing ankle x-rays

• MRI to identify any ligamentous or cartilage injury

• Stress imaging to quantify the amount of movement in your ankle joint

Doctors at Treasure Valley Foot & Ankle use these imaging modalities along with functional movement assessments to differentiate between structural ankle instability versus functional ankle instability.

When to see a Doctor for Ankle Instability

If you experience any of the following symptoms, it may be time to seek medical treatment.

• Frequent ankle rolls

• Swelling after standing or walking long periods of time

• Feel clumsy or off balanced when on uneven surfaces

• Unable to return to your previous activity level

• Have had multiple ankle sprains in a year’s time

Seeking medical treatment early allows for early intervention with things such as ankle strengthening, proprioceptive training, and bracing to help decrease your risk of re-injury.

Summary

Symptoms of ankle instability can be mild but recurrent and include…

• Reoccurring ankle rolls

• Mild swelling after standing/walking

• Decreased balance or coordination

• Tenderness down your lateral ankle ligaments

• Altered gait pattern

Spotting these symptoms early and getting an accurate diagnosis can allow for specific treatment to improve ankle stability.

Frequently Asked Questions

Q1: What are some subtle signs of ankle instability?

A: Some subtle signs you may have ankle instability include…

• Repeated ankle rolls

• Feeling clumsy or off balanced

• Mild swelling after prolonged activity

• Trouble balancing on uneven surfaces

• Inability to do things you used to

Q2: How can you tell if you have an unstable ankle?

A: You may have an unstable ankle if you experience repeated ankle sprains, feel like your ankle is going to give way when you walk or run, experience balance problems, and notice swelling after prolonged activity.

Q3: Can you have ankle instability without a severe sprain?

A: Yes. It is possible to have ankle instability with repeated ankle injuries or even without ever experiencing what you would consider a “bad” ankle sprain.

Q4: What happens if you have ankle instability? 

A: If you have ankle instability you may experience recurring ankle sprains, trouble balancing, and difficulty returning to your normal activity level.Balance and proprioception can be affected by ankle instability.

Q5: How do you fix ankle instability?

A: Ankle instability can be treated with physical therapy, bracing, proprioception training, and in some cases surgery to stabilize the ankle.

Simply icing your ankle and taking off of it may help with pain but will not fix the underlying problem of ankle instability.