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Sprained Ankle

If a sprained ankle is left untreated, if you engage in activities too soon after spraining your ankle or if you sprain your ankle repeatedly, you may experience the following complications:

  • Chronic pain
  • Chronic ankle joint instability
  • Early-onset arthritis in that joint

During the physical exam, your doctor will check for points of tenderness. He or she will move the joint in a variety of ways to check your range of motion and to see if any particular position or movement causes pain.

If the injury is severe, your doctor may recommend one or more of the following imaging scans to rule out a broken bone or to more precisely evaluate the soft tissue damage:

  • X-ray. During an X-ray, a small amount of radiation passes through your body to produce images of your internal structures. This test is good for evaluating bones, but is less effective at visualizing soft tissues. Tiny cracks or stress fractures in bones may not show up, especially at first, on regular X-rays.
  • Bone scan. For a bone scan, a technician will inject a small amount of radioactive material into an intravenous line. The radioactive material is attracted to your bones, especially the parts of your bones that have been damaged. Damaged areas show up as bright spots on an image taken by a scanner. Bone scans are good at detecting stress fractures.
  • Computerized tomography (CT). CT scans are useful because they can reveal more detail about the bones of the joint. CT scans take X-rays from many different angles and combine them to make cross-sectional images of internal structures of your body.
  • Magnetic resonance imaging (MRI). MRIs use radio waves and a strong magnetic field to produce detailed images of internal structures. This technology is exceptionally good at visualizing soft tissue injuries.

Treatment for a sprained ankle depends on the severity of your injury. Many people simply treat their injury at home.

Medications
In most cases, over-the-counter pain relievers — such as ibuprofen are enough to handle the pain caused by a sprained ankle.

Therapy
A few days after your injury, after the swelling has gone down, you may want to see a physical therapist and start performing exercises to restore your ankle’s range of motion, strength, flexibility and balance.

Balance and stability training is especially important to retrain the ankle muscles to work together to support the joint. These exercises may involve various degrees of balance challenge, such as standing on one leg.

If you sprained your ankle while exercising or participating in a sport, talk to your doctor about when you can begin your activity again. You may need to wear an ankle brace or wrap your ankle to protect it from re-injury.

Surgical and other procedures
If your ankle joint is unstable, your doctor may refer you to a joint specialist for evaluation. You may need a cast or walking boot to immobilize your joint so that it can heal properly. In rare cases of severe ligament tears, or if you are an elite athlete, you may need surgery to repair the damage.

For immediate self-care of an ankle sprain, try the R.I.C.E. approach:

  • Rest. Avoid activities that cause pain, swelling or discomfort. But don’t avoid all physical activity. Instead, give yourself relative rest. With an ankle sprain, you can usually still exercise other muscles to prevent deconditioning. For example, you could use an exercise bicycle, working both your arms and the uninjured leg while resting the injured ankle on a footrest. That way you still exercise three limbs and keep up your cardiovascular conditioning.
  • Ice. Even if you’re seeking medical help, ice the area immediately. Use an ice pack or slush bath for 15 to 20 minutes and repeat every two to three hours while you’re awake, for the first 48 to 72 hours. Cold reduces pain, swelling and inflammation in injured muscles, joints and connective tissues. It also may slow bleeding if a tear has occurred. If the area turns white, stop treatment immediately. This could indicate a cold injury. If you have vascular disease, diabetes or decreased sensation, talk with your doctor before applying ice.
  • Compression. To help stop swelling, compress the ankle with an elastic bandage until the swelling stops. Don’t wrap it too tightly or you may hinder circulation. Begin wrapping at the end farthest from your heart. Loosen the wrap if the pain increases, if the area becomes numb or if swelling occurs below the wrapped area.
  • Elevation. To reduce swelling, elevate your ankle above the level of your heart, especially at night. Gravity helps reduce swelling by draining excess fluid.

Prevention

Take the following steps to help prevent a sprained ankle:

  • Warm up before you exercise or play sports.
  • Be careful when walking, running or working on an uneven surface.
  • Wear shoes that fit well and are made for your activity.
  • Don’t wear high-heeled shoes.
  • Don’t play sports or participate in activities for which you are not conditioned.
  • Maintain good muscle strength and flexibility.
  • Practice stability training, including balance exercises.

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Don’t Ignore Ankle Sprained

Ankle sprain is a common injury in Singapore athletes as well as the active adult. Most of the time, the ankle heals with a little care (rest, taping, ice). But one rare complication of lateral ankle sprains is a condition called peroneal tendon instability.

A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.

When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation.

Swelling may mask the symptoms of tendon displacement at first. It’s only weeks to months later when the painful symptoms don’t go away that the additional tendon damage is recognized. Early MRIs may not show peroneal tendon instability, especially if the tendon pops in and out of the groove spontaneously.

A relaxed tendon is more likely to remain in the groove. Any active movement of the ankle will force the tendon out of its protective tunnel. If the ankle is relaxed and the tendon is repositioned correctly at the time of the imaging study, then diagnosis can be delayed. Dynamic ultrasound tests are the best diagnostic tests because they will reveal the movement of the unstable tendon.

Since this problem is rare, not much is known about the best way to treat it. Conservative (nonoperative) care is only possible when the unstable tendons can reposition inside the retromalleolar groove. A cast or boot placed on the lower leg will give the tendon a chance to heal.

If conservative care is unable to achieve a stable gliding tendon or if the tendon displacement is unstable from the start, then surgery is necessary. There are several different surgical options to consider. The fibrous protective sheath (retinaculum) can be reinforced or reconstructed. The groove can be reshaped (deepened) and rebuilt. The surgeon must be careful not to destroy or disrupt the smooth gliding surface of the bone that helps form the retromalleolar groove.

The retinaculum is repaired or reconstructed depending on the severity of the damage. Incision shape, drill holes, suture type and placement, and method for protecting the groove surface are discussed. Photos of each step in the surgical procedure are provided.

In summary, traumatic displacement of the peroneal tendons is a rare but painful complication of some lateral ankle sprains. Pain and swelling may mask the presence of this problem at the time of the injury with a delayed diagnosis. A careful examination with tenderness palpated over the torn retinaculum is the best way to accurately identify the injury. Treatment is usually surgical with the surgeon’s own preferred treatment presented.

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About Ankle Injury

1: Is it possible for the ankle to wear out?

Yes. However, it is not easy for this to happen as the ankle cartilage is extremely resistant. There is usually a cause, like a previous severe fracture, recurrent sprains or an infection of the ankle joint.

2: Can I ignore a sprained ankle and allow it to heal on its own?

No. A typical ankle sprain is usually one where there is an isolated tear of the anterior talofibular ligament (ATFL).

The consequences are loss of strength in turning the ankle outwards and proprioception, or the sense of body position awareness.

Patients will find that their ankles are ‘clumsy’ and weak, even for weeks after the swelling has gone down. They tend to have recurrent sprains.

Strengthening and balance exercises are needed to regain ankle stability and prevent future sprains.

A sprained ankle can also comprise injuries apart from the ATFL tear – some of these can be serious and you will need to see a doctor to exclude these injuries.

3: Is Tui Na, a form of Chinese massage, an effective way of treating sprained ankles?

When we do deep massage over the torn ligament or manipulate the joint – like in Tui Na – we may increase the bleeding in the area and separate the torn edges further, reducing the chances of the ligament regaining its integrity.

In ankle sprains, we need to address the instability by doing active balance and strengthening exercises, since position awareness and strength are not derived from Tui Na.

4: If I have injured my ankle, what activities should I avoid and for how long?

First, it is best to have your ankle injury examined and treated. All sporting activities should be avoided until the injury heals.

Sprains: It depends if the injury is acute or chronic. If acute, it is best to rest, ice, compress and elevate the ankle before undergoing physiotherapy. For chronic sprains, physiotherapy is recommended.

If patients improve with physiotherapy, then they can gradually go back to doing sports.

If there is no improvement, surgical repair of the ligaments is recommended.

Fractures: Surgical treatment is usually recommended, followed by physiotherapy. It may take about six months to a year before you can resume sporting activities.

Ankle arthritis: Activity levels are dictated by the pain experienced by patients. If the pain is mild, they are advised to limit activities to low impact sports, like swimming or cycling.

However, if the pain is severe or bothersome, it is recommended that patients undergo surgery.

5: What if my ankle still hurts a month after I injured it?

Then it is unlikely to be a simple isolated ATFL tear and you need to see your doctor. Most isolated ATFL tears feel much better within two weeks.

6: I have injured my ankle more than once. What are the consequences?

Repeat injuries to the ankle typically leave it in poorer condition and predisposes it to arthritis.

It is therefore recommended that the ankle injury be diagnosed and given the appropriate treatment.

7: I have ankle arthritis. Can I go for ankle replacement surgery?

Ankle replacement is generally suited for ankle arthritis patients who are above 50, do not do heavy manual work and are not overweight. It is not for the active, the young and manual workers who lift heavy loads. The ankle prosthesis is an artificial joint and can wear out with heavy usage.

8: Do I need to take supplements for ankle health?

No. Glucosamines have been recommended for joint health. However, there is no evidence that it helps in the ankle joint.

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Ankle Instability and Ankle Sprains

The ankle works in a systematic way. Movement is only supposed to be in one plane, in other words, up and down. We call this dorsiflexion and plantarflexion. The ankle joint is held in place securely by a group of bones that house the main anklebone (called the talus) inside a box-like effect. On the inside is the medial malleolus and on the outside the fibula.

Front of the ankle.
M= medial malleolus, L=lateral malleolus (fibula). The outside of the heel is pushed inwards to stress the joint. In the normal ankle, no tilting of the ankle should occur at all. Note the tilting of the talus in the ankle.

The inward and outward movements of the back of the foot do not actually occur in the ankle joint but occur in the joint underneath it called the subtalar joint. The muscle that pulls the foot inward (inversion) is slightly stronger than the muscles that pull the foot outward (eversion). When the foot lands in an awkward manner there is a tendency for the heel to roll inwards and create stress on the outside ligaments. If this stress is severe then a sprain of the ankle occurs. A sprain is actually a tear that occurs in the outer supportive ligaments of the ankle. As these ligaments are stretched, a critical point is reached beyond which ligaments do not return to their normal elastic function and a tear of the ligament occurs. Sprains can range from the relatively minor to those where the ligaments are completely torn and the ankle can be quite loose.

The acute sprain of the ankle is commonly associated with marked swelling and bruising on the outer side of the ankle. Rest of the ankle with immobilization of some sort is critical. The classic treatment for a sprain of the ankle is what we refer to as the Rice Program. It involves rest, ice, compression and elevation. This treatment is designed to decrease the inflammation and swelling of the ankle associated with the sprain. The Rice Program by itself will not heal the ligaments. In order for the ligaments to heal the ankle needs to be immobilized with either a cast or a boot. For minor sprains a brace can be applied to the ankle. Walking is permitted during this recovery process, allowing the ankle ligaments to heal.

Following this period of initial immobilization, strengthening exercises are essential to regain the balance of the ankle. It is critical that the tendons and muscles on the outside of the ankle (the peroneal tendons) are strengthened. This should be done initially in a supervised exercise program. If the ligaments have been severely torn, the ability to fine tune the ankle and prevent further sprains from occurring depends on the strength of the peroneal muscles. As the ankle turns repeatedly, the peroneal muscles weaken further. This weakens the ability to prevent recurring sprains. Patients with a high arch or a heel that is naturally turned in slightly are predisposed to sprains.

As a result of continued rolling, turning or instability of the ankle, the ability to fine tune the foot on uneven surfaces becomes limited. The ability to make rapid changes in the position of the foot on the ground surface is called proprioception. If this ability is diminished, the likelihood of a more severe ankle sprain occurring is increased. In recurring ankle sprains we call this chronic recurrent instability of the ankle. The ankle is at risk of developing other problems. These include bruising of the cartilage of the talus and bone spurs that develop around the front and sides of the ankle. These are all precursors of ultimate arthritis of the ankle.

These pictures illustrate a patient with chronic ankle instability. Note how loose the ankle is when it is turned slightly inwards. The ligaments are completely torn in this ankle and the likelihood of recurring sprains is very high.

The diagnosis of chronic recurrent instability is made through a careful examination of the ankle and X-rays that are taken while stress is applied to the ankle.

Here are two X-ray’s of a patient with chronic recurrent instability of the ankle. In both the right and the left ankle, an assistant is pushing on the outside of the foot (in the direction of the white arrow) while the XR is taken. The XR on the left is normal, while the one on the right demonstrates a loose (unstable) ankle.

Once the diagnosis of the extent and severity of the ankle instability is made then a treatment plan can be initiated. A strengthening program is helpful before proceeding with surgery. This is true even with patients who have had recurring sprains and chronic recurrent instability.

Fortunately, surgical repair of the chronically loose ankle ligaments can be performed. There are many different techniques used to stabilize the ankle. Some rely upon repairing the ligaments themselves by tightening them up. Others depend more on using a tendon behind the ankle (the peroneal tendon) or a tendon graft to tighten up the ankle completely. These operations are usually very successful. Individuals are able to return to all forms of athletic activity without risk of recurrent injury to the ankle.

Read more about Ankle Sprain

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