Ankle Instability: What To Do When Standard Rehab Isn’t Enough

It can be daunting when a patient walks through the door after yet another ankle sprain, despite having done everything right in their rehab. It can leave you wondering what else can you do for this patient?

They’ve ticked off calf raises, evertor strength, balance work, and dorsiflexion range, yet the ankle still feels unreliable. These cases are challenging because the usual boxes appear checked, but the patient still isn’t anywhere near happy.

Dr Chris Bleakley presents an excellent Case Study on exactly this: how he assessed and managed a netballer with lateral ankle instability. This blog offers a little insight into those first steps in managing complex ankle cases like these, hopefully bringing more clarity to those tricky initial appointments.

If you want to see exactly how an expert physio assesses and manages ankle instability, watch Dr Chris Bleakley’s full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

The case

A 16-year-old female netball player with a history of supination injuries and repeated episodes of giving way. Her previous management followed a familiar pathway: controlling cardinal signs with ice and compression, progressing through multimodal rehabilitation including mobility, postural control, eversion and calf strengthening, and returning to play within 4–6 weeks using bracing and taping.

At initial assessment, six weeks after her most recent injury, she had already returned to netball but did not trust the ankle. Her primary complaint was instability and weakness affecting confidence, along with some stiffness.

Ruling out other contributors

Chris first considered differential diagnoses. Watch him describe some of the key clinical tests he used in this video from his Case Study:

Do they need an MRI?

Imaging decisions were based on clinical reasoning. In this case, Chris deemed an MRI valuable because:

• It was her third injury in a short timeframe
• Netball involves high agility demands
• There’s known prevalence of osteochondral lesions in recurrent sprains
• The patient was considering surgery

MRI findings showed a full-thickness ATFL tear, high-grade CFL involvement, moderate effusion in the talocrural joint, and mild reactive tenosynovitis within the peroneal and tibialis posterior tendon sheaths, aligning well with Chris’ objective exam.

Deciding between surgery and rehabilitation

While surgery can have good outcomes for ankle instability, high-quality comparisons to rehab remain limited and treatment decisions should be made based on a range of patient-related factors. Chris uses four key components for shared treatment decision-making:

1. Number of impairments identified clinically
2. Prognostic factors
3. Demands of the sport
4. Psychosocial considerations

See Chris explain his assessment of the patient’s impairments in this clip from his Case Study:

Alongside the clinical assessment, Chris also likes to get a global rating from the patient, asking them to rate their perceived function out of 100. This provides a broader perspective.

In this case, a thorough review of all four components led to the decision that further rehab still held value, as there were still modifiable factors amenable to rehabilitation, so a non-surgical route was chosen.

Finding what typical rehab missed

So what do you do for the ankle that’s done everything?

On paper, the patient had completed a solid rehab program: single-leg balance, plantarflexion and eversion strengthening, progressive loading. But Chris reframed the issue from “more strength” to “different qualities of movement.”

One example was calf raises; while the patient’s plantarflexion strength and endurance were adequate, Chris noticed a common deficit in quality which needed to be addressed, watch him explain in this video from his Case Study:

Another interesting example was the patient’s proprioceptive training. She’d done plenty of single-leg balance work, which is great, but Chris identified the need for open-chain proprioceptive work. Although it might seem less functional or even regressive, Chris notes its utility in delivering fresh afferent input to a chronically unstable ankle. These are just a few examples of how Chris draws on his years of experience to identify the key gaps in this case.

Wrapping up

Patients with recurrent ankle instability often arrive with a decent foundation of knowledge and rehab experience. But they’re looking for that next layer, the guidance that bridges the gap between functional and confident.

This is where we need to move beyond generic ankle sprain rehab, and instead, identify the gaps in their specific rehab.

Chris provides a comprehensive breakdown of this case and how he guided this patient back to netball with full confidence in her ankle. Watch his full Case Study here.