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Evidence-Based Article
Why Does Ankle Pain Linger After a Sprain?
Understanding the Hidden Issues Behind “Simple” Ankle Injuries
Ankle sprains are one of the most common injuries in sports and everyday life. For many people, recovery is straightforward—rest, gradual movement, strengthening, and a return to activity. But for others, ankle pain never fully goes away.
This persistent pain and stiffness can develop even when someone follows medical advice, completes physical therapy, and performs common strengthening or balance exercises. When symptoms linger for months, the issue often progresses into chronic ankle instability (CAI) — a condition that affects movement, balance, and performance.
The truth is: exercise alone is not always enough. In many cases, lingering pain comes from joint mechanics that never fully recovered after the sprain.
What Happens Inside the Joint After an Ankle Sprain?
Research shows that ankle sprains can leave lasting structural and mechanical changes in the joint:
✔ 1. Bone Alignment Changes
Studies have found that people with CAI commonly show:
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Anterior displacement of the talus
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Increased internal rotation of the talus
When the talus sits forward or rotated, the ankle cannot flex properly—leading to stiffness, pain, and limited progress in rehab.
✔ 2. Altered Walking Mechanics
Both acute sprain and CAI patients often walk with:
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Increased rearfoot inversion (rolling outward)
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More persistent inversion during the stance phase in CAI
This altered gait pattern increases stress on the lateral ankle, making another sprain more likely.
✔ 3. Joint Stiffness and Restricted Dorsiflexion
Imaging studies show anterior shifts in the talus or fibula, which:
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Restrict dorsiflexion
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Create chronic tightness and pinching
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Affect squatting, running, jumping, and change of direction
These hidden joint restrictions are often the reason progress stalls, even with diligent strengthening and balance work.
Why Strength Exercises Alone Sometimes Aren’t Enough
Strengthening the muscles around the ankle is essential — but if the ankle joint itself is misaligned or stiff, the exercises cannot restore full function.
This is where manual therapy, particularly Mobilization with Movement (MWM), becomes a key missing piece.
Mobilization with Movement (MWM): The Evidence-Based Missing Link
MWM is a manual therapy technique that applies a gentle glide to the joint while the patient performs a movement. The goal is to restore proper joint mechanics during functional tasks like squatting, walking, or stepping.
✔ Strong research supports MWM for ankle sprains:
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Systematic review of 10 trials (419 patients):
MWM significantly improved pain and ankle range of motion compared to controls. -
Randomized controlled trials:
MWM outperformed placebo treatments and traditional mobilizations. -
Over 80% of patients show immediate improvement in weight-bearing dorsiflexion.
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Athlete case series:
Competitive athletes demonstrated immediate functional gains after MWM. -
Long-term outcomes:
Distal fibula MWM appears more effective than other manual therapies for restoring daily and sports function.
MWM works because it corrects the joint mechanics that exercises alone cannot change.
However, the exact technique depends on which part of the ankle is restricted—making skilled assessment by a physical therapist essential.
The Bottom Line: Why Your Ankle Pain May Still Be There
Lingering pain after an ankle sprain is extremely common — and often misunderstood.
Key reasons include:
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Joint malalignment that persists after the initial injury
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Restricted dorsiflexion due to anterior talus or fibula shift
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Altered walking mechanics that increase reinjury risk
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Exercises that strengthen muscles but do not address joint mechanics
If your ankle hasn’t improved despite “doing everything right,” it may be time to reconsider the approach.
A skilled physical therapist can assess joint movement, apply targeted mobilization techniques like MWM, and pair them with strengthening to restore full function.
< Recommendation by Our Experts>
✔ Don’t Assume Exercise Alone Will Fix It
If pain lingers after a sprain, underlying joint mechanics may be the real issue—not weak muscles.
✔ Consider Evidence-Based Mobilization Techniques
Techniques like MWM can immediately improve pain and dorsiflexion when properly applied.
✔ Seek a Skilled Assessment
A physical therapist trained in manual therapy can identify joint restrictions and guide a personalized recovery plan.
< Reference >
- Kobayashi, Takumi, Yuta Koshino, and Takahiro Miki. “Abnormalities of Foot and Ankle Alignment in Individuals with Chronic Ankle Instability: A Systematic Review.” BMC Musculoskeletal Disorders 22, no. 1 (2021): 683. https://doi.org/10.1186/s12891-021-04537-6.
- Fraser, John J., Joseph M. Hart, Susan F. Saliba, Joseph S. Park, Marshall Tumperi, and Jay Hertel. “Multisegmented Ankle-Foot Kinematics during Gait Initiation in Ankle Sprains and Chronic Ankle Instability.” Clinical Biomechanics 68 (August 2019): 80–88. https://doi.org/10.1016/j.clinbiomech.2019.05.017.
- Nguyen, Anh Phong, Laurent Pitance, Philippe Mahaudens, et al. “Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial.” Journal of Manual & Manipulative Therapy 29, no. 6 (2021): 341–52. https://doi.org/10.1080/10669817.2021.1889165.
- ElMeligie, Mohamed M., Heba A. Abdeen, Hady Atef, Elena Marques-Sule, and Rania N. Karkosha. “The Effectiveness of Mulligan Mobilization with Movement (MWM) on Outcomes of Patients with Ankle Sprain: A Systematic Review and Meta-Analysis.” BMC Sports Science, Medicine and Rehabilitation 17, no. 1 (2025): 105. https://doi.org/10.1186/s13102-025-01121-6.
- Gogate, Neha, Kiran Satpute, and Toby Hall. “The Effectiveness of Mobilization with Movement on Pain, Balance and Function Following Acute and Sub Acute Inversion Ankle Sprain – A Randomized, Placebo Controlled Trial.” Physical Therapy in Sport 48 (March 2021): 91–100. https://doi.org/10.1016/j.ptsp.2020.12.016.
- Norouzi, Adeleh, Cyrus Taghizadeh Delkhoush, Majid Mirmohammadkhani, and Rasool Bagheri. “A Comparison of Mobilization and Mobilization with Movement on Pain and Range of Motion in People with Lateral Ankle Sprain: A Randomized Clinical Trial.” Journal of Bodywork and Movement Therapies 27 (July 2021): 654–60. https://doi.org/10.1016/j.jbmt.2021.05.006.
- Weerasekara, Ishanka, Hayley Deam, Nathan Bamborough, et al. “Effect of Mobilisation with Movement (MWM) on Clinical Outcomes in Lateral Ankle Sprains: A Systematic Review and Meta-Analysis.” The Foot 43 (June 2020): 101657. https://doi.org/10.1016/j.foot.2019.101657.
- May, James M., Alan Nasypany, Julie Paolino, Russell Baker, and Jeffrey Seegmiller. “Patient Outcomes Utilizing the Mulligan Concept of Mobilization With Movement to Treat Intercollegiate Patients Diagnosed With Lateral Ankle Sprain: An a Priori Case Series.” Journal of Sport Rehabilitation 26, no. 6 (2017): 486–96. https://doi.org/10.1123/jsr.2015-0204.
- Hudson, Robinetta, Russell T. Baker, James May, Don Reordan, and Alan Nasypany. “Novel Treatment of Lateral Ankle Sprains Using the Mulligan Concept: An Exploratory Case Series Analysis.” Journal of Manual & Manipulative Therapy 25, no. 5 (2017): 251–59. https://doi.org/10.1080/10669817.2017.1332557.
- Izaola-Azkona, Loitzun, Bill Vicenzino, Iratxe Olabarrieta-Eguia, Marc Saez, and Ion Lascurain-Aguirrebeña. “Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain.” Physical Therapy 101, no. 8 (2021): pzab111. https://doi.org/10.1093/ptj/pzab111.
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