Ankle Sprains & Chronic Ankle Instability
Let’s meet the Ankle Joint:
The ankle joint plays a very important role in gait and propelling the body forward when it flexes downward and pushes off the ground. A significant amount of force and pressure are imparted upon this joint with each step. The ankle joint has a complex construct that takes on these forces while having most of its motion in a flexion direction while having rigidity in and side-to-side and rotation motion. It has a mortise type anatomy that makes it more complex than the hip or knee joints. The bones that make up the ankle joint are: the Talus (anklebone), the Lateral Malleolus of the Fibula (outer leg bone), the Tibial Plafond (leg bone), and the Medial Malleolus of the Tibia (inner leg bone). The normal ankle joint should be able to have a total range of motion of about 70 degrees (20 upward flexion and 50 downward flexion) for normal function. The ankle joint does not tilt inward and outward. That is the job of the joint below the ankle called the subtalar joint.
What is an Ankle Sprain?
A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle.
Ligaments hold the ankle bones and joint in the proper position. These ligaments protect and keep the ankle joint from abnormal movements, twisting, turning, and rolling. When the ankle is forced into one of these positions, ligaments surrounding the joint can become injured. Ligaments are elastic structures that usually stretch within their limits, and then go back to their normal positions. When an ankle ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers.
If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also cause damage to the ankle joint surface (cartilage) leading to and osteochondral defect (small loss of ankle cartilage) to ankle joint arthritis. The peroneal tendons on the outer side of the ankle can become injured or tear after one sprain or multiple sprains.
There is a complex and strong set of ligaments on the inner side of the ankle, that are rarely injured. There are 3 main supporting ligaments on the outer side of the ankle. In the event of a forced internal rotation of the ankle, 1 or 2 or 3 of these ligaments can stretch, tear, or rupture. The most common type of sprain is an internal or lateral ankle sprain.
In some cases with excessive forces, the ankle bones can break (ankle fracture) when the bones hit one another as they are twisting.
Multiple sprains of the same ankle can lead to an unstable (ankle instability) and chronic pain. Chronic lateral ankle instability often requires surgery.
What are the symptoms of an Ankle Sprain?
When excessive force is applied to the ankle’s soft tissue structures, the patient may hear or feel a “pop” as the ligaments tear. The first signs are a shooting and searing pain on the outer side of the ankle. There will be some degree of immediate swelling, sometimes the size of a tennis ball. There can be little or significant bruising of the skin around the ankle, heel, and even the toes. Some patients will not be able to place any pressure on the ankle. It is important to note that the patient may still be able to walk even if there is a fracture of the bone. It is for this reason that an ankle sprain should not be ignored.
What Causes an Ankle Sprain?
Ankle sprains occur when the ankle twists, rolls, or turns beyond its normal motions, and a significant force is transmitted upon landing. The ankle can sprain if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range while in the abnormal position.
If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. The patient may lose their balance or may fall and be unable to stand on the foot. High-heeled shoes can lead to an ankle sprain.
Patients with a very high arched foot type (pes cavus) tend to walk on the outer edge of the foot and therefore have a higher incidence of ankle sprains or chronic ankle instability.
Ankle sprains can occur during sport and physical activity or even with simple walking. They occur equally among men and women, young and old, the athlete or the weekend warrior.
How is an Ankle Sprain Diagnosed?
Diagnosis is achieved by the clinical examination and x-rays of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s ankle and its stability. There will be an evaluation of the quality and strength of the ankle ligaments and tendons that cross the ankle. Digital radiographs (x-rays) of the ankle will be obtained in the office and reviewed with the patient to check for any fractures or dislocations. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated problems. Depending on the severity of the sprain, an MRI may needed to evaluate the ligaments and other tissues.
Ankle sprains are given a grade associated with the severity of the injury to the ligaments:
Grade 1 Sprain
Slight stretching and some damage to the fibers of the ligament.
Grade 2 Sprain
Partial tearing of the ligament. When the ankle joint is examined and it has increased motion in certain directions, abnormal looseness (laxity) of the ankle is measured.
Grade 3 Sprain
Complete tear of the ligament. When the ankle joint is examined and it has increased motion in certain directions, significant instability of the ankle is measured.
Grade 4 sSprain
Tearing of the ligaments with Fracture of the bone.
How to Prevent an Ankle Sprain?
The best way to prevent ankle sprains is to maintain good strength, muscle balance and flexibility.
- Warm-up before doing exercises and vigorous activities.
- Pay attention to walking, running or working surfaces.
- Wear good shoes with appropriate support.
- Pay attention to your body’s warning signs to slow down when you feel pain or fatigue.
- Use an ankle brace when performing activities with lateral motions.
- Custom Molded Orthotics
How is an Ankle Sprain treated?
Dr. Soomekh educates that early diagnosis and treatment of an ankle sprain is the key to successful treatment, faster recovery and painless lifestyle. Patients that sustain an ankle sprain and “walk it off” or postpone treatment are more likely to incur chronic pain and loss of function.
Conservative Treatment for Ankle Sprains:
Conservative treatments rely on their ability to stabilize the ankle and reduce pain and swelling. The ankle should be stabilized using an assistive devise. Low-grade sprains will benefit from the use of an ankle lace up brace. Moderate to severe may benefit from a walking boot to keep the ankle from further injury during the healing process. Some patients may need to be assisted by the use of crutches for the first few days after the injury.
Pain and significant swelling will usually last two days to three days. During the first 2 weeks it is recommended to use ice therapy and non-steroidal anti-inflammatories (NSAID’s) to reduce the pain and swelling.
The healing process takes about four weeks to eight weeks. It may be recommended to begin early flexion range of motion to prevent stiffness of the ankle. Motion may also aid in being able to sense position, location, orientation and movement of the ankle (proprioception). Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately. Even if an ankle has a chronic tear, it can still be highly functional because overlying tendons help with stability and motion.
Grade 1 Sprain
For a Grade 1 sprain, use R.I.C.E (rest, ice, compression and elevation):
- Rest your ankle by not walking on it or and using a brace.
- Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction.
- Compression dressings, bandages or ace-wraps immobilize and support the injured ankle.
- Elevate your ankle above your heart level for 48 hours.
Grade 2 Sprain
For a Grade 2 sprain, the RICE guidelines can also be used. A walking boot device may be advised to immobilize or splint the ankle.
Grade 3 Sprian
A Grade 3 sprain can be associated with permanent instability. Surgery is rarely needed unless left untreated. A short leg cast or a waling boot may be used for two weeks to three weeks.
Physical therapy and rehabilitation will be used to help to decrease pain and swelling and to prevent chronic ankle problems. This therapy is an integral part of reducing pain and increasing function and activity. Ultrasound and electrical stimulation may also be used as needed to help with pain and swelling. At first, rehabilitation exercises may involve active range of motion or controlled movements of the ankle joint without resistance. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Lower extremity exercises and endurance activities are added as tolerated. Proprioception training is very important, as poor proprioception is a major cause of repeat sprain and an unstable ankle joint. At the time the pain has significantly reduced, other exercises may be added, such as agility drills. The goal is to increase strength and range of motion as balance improves over time.
Ankle sprains do not heal quickly. They can take several months to allow the patient to feel confident in the strength of the ankle. When patients begin activity too soon, this can lead to more sprains while the old sprain had not fully healed. This can lead to chronic ankle instability that often needs to be corrected surgically.
Platelet Rich Plasma Therapy for Ankle Sprains:
Platelet-rich-plasma (PRP) can be used as a treatment option for ankle sprains that have not healed. The introduction of a high concentration of platelets can “jump-start” the ligaments to begin healing by increasing blood flow, converting the chronic injury into an acute inflammatory one leading to an influx of inflammatory healing cells to the ligament. It is a relatively non-invasive method using the patient’s own healing potential. Dr. Soomekh offers PRP therapy in the office setting. Click here for our details on PRP therapy.
The patient’s blood will be drawn from their arm. The blood will then be placed in a centrifuge in order to obtain the highest concentration of platelets available. The area of the ligaments is anesthetized. Dr. Soomekh will use precision ultrasound guidance to deliver the PRP by injection into the ankle ligaments. The patient can return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the ligaments during the healing period. Some patients may benefit from a second or third PRP therapy depending on their progress.
Chronic Lateral Ankle Instability:
If an ankle sprain is not recognized, or is not treated with the necessary attention and care, chronic problems of pain and instability may result. Patients that sustain many ankle sprains over short periods of time can end up with chronic pain and an unstable ankle. The ankle will feel loose and unstable. Patients will relate feeling insecure about the strength of the ankle and are cautious about how they use their “weak ankle.”
The Ankle Sprain Triad:
Some untreated ankle sprains, or those that have multiple sprains over time can develop added problems around the ankle joint. This leads to what can be called a “Tirad” of damage from ankle sprains:
- Chronic tearing and loosening of the ankle ligaments
- The cartilage of the ankle can become disrupted and develop losses of cartilage. Inflammation and scar tissue within the joint will develop increasing pain and disability.
- The peroneal tendons on the outside of the ankle can become damaged. Continued use of the damaged tendon can develop into tearing of the tendons. This leads to increased pain and disability.
As the ankle becomes more unstable, it can become misaligned in the joint, and begin to wear down the cartilage. Left untreated, an unstable ankle can lead to ankle arthritis. The tendons (peroneal tendons) that lie on the outer side of the ankle can become damaged and tear over time. In these chronic cases, surgery is often warranted.
Surgical Treatment for Lateral Ankle Instability:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when ankle instability becomes painful, contributes to more damage, daily activities become a struggle, and conservative treatments have failed, surgical repair may be indicated.
Is Ankle Surgery Painful?
Considering surgery can be intimidating. Ankle surgery including surgery to correct ankle instability is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain.
The goal of ankle instability surgery is to tighten the ankle ligaments, realign the ankle joint, clean out the ankle joint, repair any cartilage damage, repair any tendon damage, and allow a return to all activities. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
How do I Choose the Right Surgeon?
Dr. Soomekh has significant experience in every aspect of ankle surgery. He is able to choose the exacting correct procedure for each individual patient because he has innovated and perfected the techniques for ankle repair. He uses the most advanced equipment and materials available. He understands the importance of identifying any other underlying conditions that may be associated with the ankle instability, like any accompanying ankle cartilage damage or tendon damage (the Triad). Dr. Soomekh will use the information gained from the patient’s symptoms, age, activity level, lifestyle goals, the severity of the deformity, the clinical examination, the patient’s gait, x-rays, and MRI, to make a recommendation on the proper procedure.
Ankle arthroscopy is a minimally invasive procedure with two small incisions into the ankle joint, using a camera to visualize the joint. The other incision is used for instrumentation placed into the joint to perform the repair. The purpose of this procedure is to “clean out” the joint and buy the joint and promote new cartilage growth when possible. The earlier in the disease process that this procedure is performed, the more rewarding it will be for the patient.
Two small incisions are made on wither side of the front of the ankle joint. The camera is placed into the joint and a precise and systematic examination of the joint is performed. Any inflammation (synovitis), scar tissue, extra bone (spur), floating pieces of cartilage, and extra fibrous bands of tissue within the joint are removed. Areas of missing cartilage are stimulated to promote new growth of cartilage by varying methods. In some cases the stretched out ligaments can be “tightened” through the arthroscopy. While watching the camera, a special instrument is introduced into the joint that will “shrink” the ligaments, tightening them.
Lateral Ankle Stabilization:
In those cases where the ligaments are torn and loose, direct surgical repair of the ligaments may be needed. An incision is made on the outer side of the ankle over the ligaments. The 3 main ligaments are identified and inspected. Those that are torn or elongated are repaired. This is done by removing damaged ligament, and stitching the ligaments ends to one another in a tightened state. In some cases the ligaments need to anchored back to the bones. This is done by using state of the art anchoring materials, anchoring the ligaments back into the bone and into their anatomic position. This type repair will tighten and strengthen the ligaments, in most cases stronger than before. There are some instances where the ligaments are too weakened or destroyed to repair. For these patients donated human tendon is used to create new ankle ligaments. This tendon is routed through the bones of the ankle and heel to reinforce and strengthen the ankle. In the same setting, any damage to the peroneal tendons will be repaired.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top Ankle specialists and Ankle surgeons in the Los Angeles area.