Ankle sprains most commonly injure the superior fascicle of the anterior talofibular ligament, often initiating a cascade of biomechanical changes termed the “domino effect.” Chronic ankle instability can lead to both intra-articular and extra-articular alterations, which may become symptomatic, sometimes even without overt instability symptoms. Accurate clinical examination is crucial, as standard imaging may miss ligament injuries. Management of ankle instability is essential before addressing secondary changes. While surgical treatment is recommended after failed conservative therapy, most secondary muscle–tendon issues do not require surgery, and some impingements resolve naturally following stabilization of the ankle joint.