The more I study the ankle, the more I find it to be a phenomenally complex joint. And I also see the ankle to be a very vulnerable joint to both short term injury and long term disability. Let’s take a look at both the short term issues (weeks) associated with ankle injuries and the long term disability.
Most ankle injuries are inversion sprains. Inversion refers to the position of the sole of one foot facing the sole of the other foot. So when we speak of an ankle sprain, we’re usually referring to an injury to the lateral ankle due to inversion. Another way to look at a sprain is to think of the leg staying in a fixed position while the foot (at the ankle) is forced into inversion.
How do we treat the acute ankle sprain? First, an x-ray is usually in order.
The x-ray is used to screen for a number of different fracture patterns associated with inversion injuries. If the x-ray shows no indication of fracture, we proceed with the time tested use of RICE; rest, ice, compression and elevation. What’s the best method of compression? I’m not a big fan of stirrup braces that you usually see dispensed from an ER or Urgent Care Center. My preference is to use an elastic compression device. Once cleared for fracture and RICE has been explained to the patient, we’ll suggest a follow-up visit in 6 weeks if the ankle is still hurting.
Why would the ankle still hurt at 6 weeks post sprain? There’s a number of different issue that could be contributing to ongoing pain. These issues include a bone contusion, ligament injury, tendon injury, cartilage injury, high ankle sprain or soft tissue injury to the joint. A high ankle sprain is an injury to the ligament that holds the bones of the leg together just above the ankle (called the anterior inferior tibial fibular ligament). Treatment at 6 weeks post ankle sprain will include follow-up plain x-rays and an MRI. Plain x-rays are used to re-evaluate the ankle for fracture. Often we’ll see an area of fracture that is healing that was not seen in the original post-injury films. MRI is used to determine the extent of soft tissue injury and is invaluable at this stage of treatment.
And what if the MRI picks up an injury? Treatment will depend upon the nature of the injury and the goals of the patient. The professional athlete will be treated more aggressively than would be a retiree. Treatment may be conservative to include casting, continued rest, bracing or physical
therapy. Treatment may also be surgical and address issues such as ligamentous laxity, cartilage damage, tendon damage of bone injury. Fortunately, most of the surgical methods described can be performed arthroscopically. Arthroscopic, or small incision surgery enables patients to return to activities much sooner.
And what’s the long term prognosis post ankle sprain? In most cases good. Sure, a single instance of injury can be enough to cause severe damage, but in most cases, the problems arise with recurrent sprains. If left untreated, recurrent sprains will result in early ankle arthritis. Treatment for recurrent sprains usually requires a stabilization surgery to insure longevity of the ankle joint.
Jeffrey Oster, DPM