Ankle Sprains

What is an ankle sprain? 

An ankle sprain is when an injury occurs to one or more of the ligaments of the ankle.  The ankle joint is comprised of three bones - the tibia, fibula, and talus.  The tibia is the largest bone of these.  All of these bones are connected by a complex arrangement of ligaments which provide inherent stability and allow this joint to function normally.  An ankle sprain can range from a simple overload of the ligament that heals within several days to the complete rupture of multiple ligaments and subsequent dislocation or subluxation of the ankle.

                                       

The severity of an ankle sprain is dependent upon whether the ligament is stretched, partially torn, or  completely torn, as well as the number and location of the ligaments that are affected. 
The most common ligaments ruptured are the anterior talofibular ligament (ATF) and calcaneofibular ligament (CF).


Etiology:

An ankle sprain is generally the result of a twisting type of motion to the ankle joint, or a direct blow that forces the ankle out of its normal anatomic alignment.  Ankle sprains can occur while doing virtually any activity although they are most common while playing sports or while wearing inappropriate shoes. 


Symptoms of an ankle sprain:
Symptoms usually include pain, swelling, and bruising.  Often times the ankle joint will become stiff from all the swelling and inflammation (the body's attempt to immobilize itself).  Also, pain deep within the ankle joint may present.  Walking may be difficult or impossible depending upon the severity of the sprain. 

Pain and swelling may be absent in people who have had previous ankle sprains.  The ankle may feel unstable and "floppy" when walking.  An ankle sprain always requires treatment.  If left untreated, the ankle may develop chronic ankle instability - a condition with persistent discomfort and a continual "giving way" of the ankle.  Additionally, a sprain may be accompanied by a more severe ankle injury such as an ankle fracture, or an osteochondral defect (damage to the cartilage within the ankle joint.) 

Treatment and Rehabilitation:
Immobilization is generally recommended until pain has subsided enough to begin physical therapy.  Therapy is started as soon as possible to promote healing and increase your range of motion.  Anti-inflammatory medications such as ibuprofen or naproxen are generally recommended initially.  Ice and compression are also used in the initial inflammatory stages of rehabilitation. 

Ankle sprain grading and treatment
Grade 1 - stretched ligament = lace up ankle brace
Grade 2 - partially torn ligament= aircast, transition to lace up ankle brace
Grade 3 - complete tear of ligament = CAM Walker until pain subsides, then aircast with PT, Lace up brace once back to activity. 

Lace up Ankle Brace



Aircast Ankle Brace


CAM Walker

Once you return to your sport or full activity it may still be recommended to utilize an ankle brace for stability, and to minimize chances for recurrence. This is generally recommended for 3 months with a complete tear doing normal day to day activities to prevent recurrence.  With sports, the lace up brace should be utilized for 6 months to prevent recurrence. 

Occasionally surgery is indicated.  Usually this is for the person who experiences subjective chronic instability of the ankle from multiple sprains or for sprains that did not heal as expected.  Additionally, cartilage damage within the ankle joint (an osteochondral defect) may need surgery.   

 

Initial Treatment:
This injury should be stabilized as soon as possible either by the emergency room or by a foot and ankle specialist.  Until you are able to be examined by a doctor, the “R.I.C.E.” method should be followed. This involves: 

• Rest. It is crucial to stay off the injured foot, since walking can cause further damage. Non-weightbearing with crutches or a walker is ideal. Generally, an ankle brace will be recommended to stabilize the ligaments initially (regardless of if you are able to bear weight), and then to be used while performing physical therapy. 
• Ice. To reduce swelling and pain, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
• Compression. Wrap the ankle in an elastic bandage or wear a compression stocking to prevent further swelling. An ACE bandage is often recommended as initial treatment.
• Elevation. Keep the foot elevated to reduce the swelling. It should be even with or slightly above the hip level.

Ankle pain and Arthroscopy

Ankle Pain:
 As a brief introduction,: The Ankle Joint (Talocrural Joint) is made up of 3 bones.  The Tibia and Fibula make up the lower leg and these bones are attached to the Talus by a series of ligaments.  Tendons are found all around the ankle joint and cause the foot to go up and down.  This is the action of the ankle joint: up (dorsiflexion), and down (plantarflexion). The up and down motion is what we mean when we say ankle pain.  There may also be pain with straight axial pressure, one may experience a "giving away" type feeling while standing or walking.

 
The ankle joint rarely sees arthritic changes from wear and tear like the knees and hips do.  Most often ankle arthritis will be a result of some traumatic injury remotely or acutely.  Arthritis is when the cartilage wears away and there is bone on bone.  Along with arthritis comes inflammation, and excess bone growth (bone spurs). 

Ankle fractures and ankle sprains are some of the most common causes of ankle pain and later, arthritis.  Ankle sprains (partial or complete), may have residual pain even months after the injury.  When a ligament is torn, there will be some bleeding into the joint which will later turn into scar tissue and usually have a chronic inflammatory component to it.  Often cortisone injections will alleviate some of the pain associated with inflammation and may help to break up some of the scar tissue.  If several injections have not provided adequate relief of symptoms, an MRI may be indicated to look for more significant causes of ankle pain.
OCD lesions (Osteochondral Defects) may be seen.  These are local areas of cartilage damage or arthritis.     

Osteochondral defects will often present with significant pain and disability.  Occasionally immobilization and rest will provide some relief of the symptoms associated with this pathology.  Often, surgical intervention will be needed to provide long lasting pain relief.  Generally the size of the lesion is predictive of how well the surgery will help to alleviate the pain.  The larger the lesion, the less effective the surgery.  An MRI will often give some idea of the size of the lesion but it may be larger in reality once the joint is visualized arthroscopically (microscopic camera that is inserted into the joint).

Lesions less than 10-12mm in diameter will usually do quite well after arthroscopic surgery.  You may be told to rest for a week or two after this surgery (no weight bearing).  For larger lesions, the surgery is less predictable and requires a longer period of rest (2-4 weeks non weight bearing).  During the surgery, the loose cartilage is debrided and small drill holes are placed in the bone beneath the cartilage.  This stimulates the body to produce fibrocartilage, which is similar to normal cartilage (hyaline cartilage).

Bunions, hammertoes, and neuromas are three of the most common foot issues.  Bunions, also known as hallux valgus, is more frequently seen in women than men but common for both.  Shoes that are ill-fitting generally play a role in making this issue worse but do not usually cause it.  Usually bunions are inherited.  Often a muscle imbalance will increase over time and the deformity may change even with appropriate shoes.  Appropriate shoes have a wide toe-box, adequate length (approx. a thumb thickness between the tip of the great toe and the end of the shoe), and are deep enough shoe to accommodate for any toe deformities.

In addition to wearing different shoes, what else can be done for bunions?
Conservative treatment for bunions is limited but there are several options that can be somewhat helpful.  Bunion splints can help to keep the great toe apart from the second toe and can slow the need for surgery.  Splints can also be used to keep an elevated second toe down.  The Darco splint is one that can help with both of these issues. Wearing this splint at night or while sitting around may provide enough relief to slow the need for surgery.  A cortisone injection into the joint may provide relief if there is an inflammatory component to the bunion or some arthritis.  Additionally, a topical anti-inflammatory patch or gel may provide some relief.  These include Flector Patch, or Voltaren gel.  Conservative treatment usually only provides relief for a short period of time, but is certainly worth trying prior to surgical intervention.

How much does bunion surgery hurt?
The amount of pain that one will have from bunion surgery is highly variable, but it is generally painful since bone work is often performed.  The medial bump is usually cut or chiseled away, and the metatarsal bone is usually cut so as to reorient the great toe joint.  At times, the proximal phalanx of the great toe is cut as well.  Bone cuts are usually stabilized with screws or wires.

In addition to the bone work that is done, there are many other things that factor into the amount of pain one will experience.  Some people are naturally more sensitive to any type of stimulus which will make this surgery more challenging.  Also, individuals taking pain medicine, anti-psychotics/anti-depressants, and sleeping pills will most likely need much stronger medicine after surgery and may benefit from a pain pump where local anesthesia is continually infiltrated around a large nerve for 3-7 days after surgery by a very thin catheter.



How long does it take to heal?
Generally the skin incision will heal in about 10-14 days, and the bone is healed in 6 weeks.  Most of the time you can walk immediately after bunion surgery in a bandage and surgical shoe.  The surgical shoe is usually used for 2 weeks until the bandage is no longer needed.  After 2 weeks you can usually return to a sneaker or running shoe.  After 6 weeks full excercise is generally allowed.  Full exercise means starting with a very low impact activity like a stationary bicycle, then progressing to more traumatic activity as tolerated.  Running and jumping should be the last activities attempted.  You need to increase activity in a stepwise fashion!

The soft tissue will take 3months to a year to loosen up.  The great toe joint will be stiff for quite some time.  If the incision is made dorsally (on the top of the joint), you will often have difficulty flexing the great toe down for some time or perhaps forever.  With a medial based incision, you will not have this difficulty and the scar will not be as visible.  You may need two separate incisions if it is done this way.  The second incision would be made in the webspace between the first and second toes to release a tendon which may be necessary depending on the deformity.

What are the most common complications?
Bunion surgery usually has a fairly high success rate but can be quite painful as mentioned above.  Infections can occur as with any surgery... frequently a pre-operative antibiotic is administered.  Wound healing issues can occur, especially in smokers. Smoking affects all small blood vessels which are critical for healing.  Not only will the skin and soft tissues have a much longer time healing or may not heal, the bone work will take 50-100% longer to heal than in a non-smoker.  The bone work may even go on to a non-union (where it never bonds back together as it is supposed to.). If you smoke, you should strongly consider stopping completely at least 14-23 days before the surgery to prevent these complications, or even not have the surgery.  A smoker who undergoes surgery is set up for failure or revision surgery.

There are specific post-op instructions which need to be adhered to in order to obtain the best result.  There will be restrictions in the type of foot wear needed (post-op shoe, sneakers, etc.), the amount of activity you are allowed, bathing.  These instructions are given so that the most predictable and best outcome is obtained.  If you deviate from these, healing and positional issues will occur that will give you less than a desired outcome or even beget revision surgery.

Often the surgical site will be stiff for an extensive amount of time, up to 6-12 months.  Full muscular strength after surgery usually takes 3-6 months. Although you are often able to bear weight immediately and results are predictable, there is a significant healing phase and you must be patient. The surgery usually takes 45-60 minutes but the healing is the difficult part.