Were you told you have just an “ankle sprain” but it is not getting better? Read more to see if you may have one of the other injuries that can occur when you roll your ankle.
Intro and basic ankle anatomy: Ankle sprains (aka a rolled ankle, inversion ankle injuries) usually implies rolling of the ankle so the foot turns in compared to the leg and this injures tissues on the outer side of the ankle. This injury is very common in almost any sport and even occurs in non-sporting activities when walking on uneven terrain. When this happens the person usually falls, feels immediate pain on the outside part of the ankle (lateral) and may or may not be able to put weight back on the leg. Over the next few hours, swelling and bruising develops and they may still not be able to put weight on their injured ankle. Over the next few days most people employ protection, rest, ice, compression, elevation (the PRICE principles) and the pain and swelling may improve. The bruising usually changes to all sorts of pretty colors and the actual bruising (just blood under the skin) may follow gravity and settle down closer to the bottom of the foot away from where it hurts. Below is a diagram of ankle/foot bones and ankle ligaments for reference so you can see where they are when I speak about each boney injury later in the blog. The main bones to focus on are the lateral malleolus (bottom of the fibula bone on the outside of the ankle), medial malleolus (inside of the ankle, bottom of the tibia bone), talus (foot portion of the ankle joint), calcaneus (heel bone, connects to talus and rest of foot bones), base of the fifth metatarsal (where peroneus brevis muscle attaches, boney spot on outside part of the foot touching the ground).
Picture A is looking at the outside (lateral part) of the ankle, picture B is looking at the ankle from the back. The main lateral (outside of ankle) ligaments involved in ankle sprains are named for the two bones they connect and are involved in ankle sprains usually in the following order 1) Anterior talofibular ligament (ATFL) (L1 in figure), 2) Calcaneofibular ligament (CFL) (L2 in figure), and rarely 3) Posterior talofibular ligament (PTFL) (L3 in figure).
Initial evaluation: The Ottawa ankle rules were developed to help doctors decide which ankle sprains need to have an x-ray and which ankle sprains do not need an x-ray. X-rays may catch a bone fracture but most ankle sprains do not have bone injury. They state that anyone with pain in the malleolar zones (purple area in diagram below), pain at points A, B, C or D, or inability to bear weight immediately following injury and when seen in ER/Urgent Care/Clinic should get an x-ray. If you can bear weight after the injury, don’t have boney pain at the spots noted in the diagram then you don’t need x-rays since you have had just a mild sprain and there is pretty much 0% chance of a fracture using the Ottawa ankle guidelines.
Basic Treatment for ankle ligament sprain: If there is no fracture seen on initial x-rays you likely just have sprained or torn the ligaments, although it is possible that another injury was missed on the initial x-ray. Grade I sprain is a stretch of the ATFL and maybe the CFL, Grade II sprains are partial tears of the ATFL and maybe the CFL, Grade III sprain is complete tear of at least the ATFL, CFL and possibly the PTFL. The severity of the injury affects the length of time before you can put weight on the ankle, the instability that may be present after you heal and the length of time it will take to get you back playing your sport.
After being evaluated by a sports medicine physician, you can continue to use the PRICE principles for a few days +/- limiting weight-bearing (crutches) if needed. It is important to begin physical therapy soon after injury to work on reducing swelling, receive pain relieving treatments, maintain range of motion (alphabet exercises) and work on muscle strengthening to help stabilize your ankle for the future. As you begin to place more weight on your ankle you can begin to work on balance (aka proprioception) because this is crucial in your ability to return to your sport and prevent future ankle sprains. The balance training is usually what is forgotten in the rehab process because at this stage the pain is better or gone, however leaving balance training out leads to chronic ankle instability and repeat ankle sprain injuries. There is a gradual progression of activity in your rehab program before you can return to full unrestricted play in your sport. You may be advised to use an ankle sports brace or special taping for games to prevent re-injuring of that ankle.
If there is only a ligament injury and there is chronic ankle instability for longer than 12 months a surgery could be considered, but this scenario is rare. Prior to considering surgery for chronic ankle instability, you should also consider trying platelet rich plasma (PRP, see separate blog on this topic) injection to allow your body to heal itself without going under the knife.
What is a “high ankle sprain”?
Occasionally, the talus bone twists and pushes the tibia and fibula (lower leg bones) apart causing a tear of the connective tissue between the tibia and fibula in the calf area. This is called a “high ankle sprain” (aka a syndesmosis injury). This injury may occur along with other injuries to the ankle but is important to diagnosis this since the syndesmosis usually needs a longer time to heal, around 6-8 weeks. There are certain findings on exam and on x-ray that will show that you have injured the syndesmosis.
So you did your PT, can walk without a limp but still have some pain 6-12 weeks after your injury. What might be going on?
If all you have injured is your ligaments, then most people improve with conservative treatment over a period of 3-6 weeks. If you had a Grade II-III tear without bone fracture you may be having symptoms of chronic ankle instability and could be a candidate for platelet rich plasma (PRP) treatment, see separate blog on the topic. Briefly, PRP involves drawing some of your own blood, removing everything but the growth factors in the platelets, concentrating them and injecting them back into your torn ligament. This attracts stem cells that begin healing damaged tissue and could stabilize your ankle and resolve your pain.
Other things that may cause chronic ankle pain after an ankle injury include things like sinus tarsi syndrome, anterior or posterior ankle impingement, arthritis or a fracture that was not seen on the original x-rays.
Sinus Tarsi Syndrome: There is a small cave like opening (aka sinus) on the outside of your foot between the talus and calcaneus bones. If pain is produced when this is pushed on, as well as when the ankle is turned in (inverted), a cortisone injection that relieves the pain is both diagnostic and therapeutic.
Anterior impingement: Usually seen in soccer, high jump, running, basketball, volleyball or ballet dancers because they repeated plantar flex (toes pointed down) the ankle and cause soft tissue or boney growth in the front of the ankle. They may also have a history of repeated ankle sprains. Pain is in the front of the ankle and reproduced with dorsiflexion (toes pointed up) with limited movement.
Posterior impingement: Can be from overuse (such as ballet dancers and running) or from trauma of forcing the ankle into a plantar flexed (toes pointing down) position. Trauma may cause injury or fracture to the back part of the talus. Some people have an extra bone back there, called an os trigonum, and this bone can be irritated or torn away from the talus. Posterior impingement causes pain just in front and on either side of the Achilles tendon, and pain is increased with forced plantar flexion.
Ankle Arthritis: This can be seen on x-ray and usually only develops if there is chronic instability of the ankle over a long period of time. Stiffness in the morning, decreased range of motion, pain after exercise or walking all day are some of the symptoms.
Osteochondral injuries: The “dome” or joint surface of the talar bone is covered in cartilage to help the ankle joint glide smoothly. Sometimes, in about 10-20% of ankle sprains, a “bruise” can develop in the inner or outer sides of the talar dome. These are called Osteochondral lesions because they involve the cartilage (chondral) and the bone (osteo) immediately beneath. Depending on the grade of injury this may require prolonged time on crutches, and if severe, surgery to reattach a piece of the cartilage to restore a smooth joint surface and hopefully decrease the chances of arthritis later in life.
Occasionally in younger people (10-30yo) a similar problem may develop without any trauma or injury, called Osteochondritis dissecans (aka OCD lesion). This is from a decrease in blood supply to the small area of bone and cartilage and we are not sure why this occurs. OCD may also happen in the knee or elbow in some patients.
Other fractures that may have been missed: These may include fractures of the lateral talar process, posterior talar process and anterior process of the calcaneus. These are commonly missed because initially the x-rays may be normal and the pain may be where everyone with an ankle sprain hurts, over or near the stretched/torn ligaments. So the x-rays and the physical exam may not be helpful initially. After the rest of the ankle pain and swelling has resolved, it becomes easier to localize the exact area of remaining pain over one of these boney areas. Repeat x-rays may show the fractures or an MRI might be needed to find them. Treatment varies depending on many factors but generally having a fracture takes longer to heal than just ligament injuries.
Injuries to the 5thmetatarsal: The most common injury to the 5th metatarsal (the bone in the foot that connects to the little toe) occurs with an ankle sprain when the peroneus brevis muscle pulls off a piece of the base (blue area in image). These fractures typically heal with a cast or walking boot for 4-6 weeks. It is important to make sure that the fracture seen on x-ray does not represent a “Jones Fracture” (green area in image). A Jones fracture is in a particular spot where blood supply is poor and about 25% of the time a Jones fracture will not heal even when placed in a cast. There are certain indications for these Jones fractures to be surgically fixed to prevent chronic pain from a non-union.
Besides the bones, cartilage and ligaments the tendons may be injured with an ankle sprain. Major tendons around the ankle include: the Achilles in the back, anterior tibialis (AT), extensor hallucis longus (EHL) and extensor digiti longus (EDL) in the front, peroneus longus (PL) and brevis (PB) on the outside and the posterior tibialis (PT), flexor digitorum longus (FDL) and flexor hallucis longus (FHL) on the inside of the ankle. Most commonly the peroneus brevis is torn or inflamed at the lateral malleolus or pulls a piece of bone off the base of the 5th metatarsal (see above). The peroneus longus can also be torn or inflamed at the lateral malleolus or as it goes under the cuboid bone. Occasionally, the covering that holds the peroneus tendons behind the lateral malleolus (the retinaculum) can be loose or torn and the tendons can snap back and forth out of their normal grooves, this snapping sensation is felt by the patient and can causes further stress/friction on the tendons. Although the other ankle tendons are commonly injured they are not related to ankle sprains.
Other possibilities: Occasionally a nerve can be pinched or scar tissue pushes on a nerve and causes chronic pain, numbness/tingling in the foot/toes. Also, the lining of the joint (the synovium) may become inflamed, synovitis, and may benefit from a cortisone injections if severe enough. Rarely, things like gout, pseudogout or infection can cause ankle joint pain, swelling and redness but this is usually not associated with an ankle injury onset.
Work-up for chronic pain after ankle sprain? You probably need to be seen by someone who specializes in sports medicine, not necessarily a surgeon but someone with extra training in musculoskeletal medicine. After they examine you they might send you for repeat x-rays or special x-ray views, MRI or perform a diagnostic ultrasound to find out what is wrong. Treatment may range from surgery, crutches, therapy, or injections depending on what might be wrong. Sometimes these difficult cases take a long time to heal and may involve some trial and error even in experienced hands.
At Stark Sports Medicine we offer a complete range of non-surgical options for musculoskeletal injuries from highly trained therapists and sports chiropractic care to cutting-edge PRP injections and diagnostic musculoskeletal ultrasound. So if you’ve injured yourself today, have been living with chronic musculoskeletal pain or want a non-surgical second opinion give us a call at Stark Sports Medicine to arrange your initial evaluation. 949-722-7070.Mike Gruba, MD Rehab Director Stark Sports Medicine Group 17524 Von Karman Ave Irvine, CA 92614 949-722-7070
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