- Don’t ignore pain of sprained ankle
- The Long-Term Effects of Ankle Sprains
- Ankle Sprains & Chronic Pain
- Peroneal tendon tear
- Osteochondral defect of the talus
- Chronic instability
- What are the Long Term Effects of Ankle Sprains?
- Ignoring a sprained ankle can become a bigger pain later in life
- Not just a sprain: 4 foot and ankle injuries you may be missing
Don’t ignore pain of sprained ankle
WABC-TV—NEW YORK—May 23, 2008
It’s a common injury — getting a sprained ankle.
But how do you know the difference between a serious case and a mild one?
Many people misjudge the severity and end up NOT getting the proper treatment.
The proper treatment for most ankle sprains is just ice and rest over a couple days.
But there are times when the pain persists. Though there’s a tendency among many weekend athletes to just ignore it, the result can be cartilage damage, bone damage and arthritis down the line.
Bob Fohngho, 25, has been a basketball player going way back. He had a bad sprain four years ago. His reaction is typical for many athletes and weekend warriors.
“It’s probably mentality that it’s just a sprain and that I could still walk on it and run on it,” basketball player Bob Fohngho said. “I really didn’t think I had to go to the doctor for it.”
But it left his ankle weakened and he re-sprained it again and again until he had an MRI.
“Here, you can see he has developed a cyst,” Dr. John Kennedy at Hospital for Special Surgery said. “The cartilage that lines the joint has fallen into the cyst.”
Dr. John Kennedy says that as the ankle twists, the most common sprains involve a stretching and tearing of a ligament, and cartilage damage from pressure between two bones.
He says most sprains just need two days of ice and rest.
“If they still have pain a week later, that’s when they should go to the primary care MD to have the next step to go to the physical therapist,” Dr. John Kennedy said.
If pain persists, an orthopedist should take a look.
Bob needed surgery to get him back on the court. He’s learned not to ignore what some would call… just a sprain.
If it hurts, that’s not a normal body feeling so you should definitely go see your doctor.
The operation that Dr. Kennedy did for Bob used transplanted cartilage and stem cells to replace the damaged area of his ankle bone.
How many of us ignore sprains?
A recent study found that a third of ankle sprain sufferers were still having pain a year later and at three years, 25% were still in pain.
This story originally appeared on 7online.com.
For more information regarding Bob Fohngho’s treatment at Hospital for Special Surgery and the results of ignoring ankle injuries, read Ignoring a sprained ankle can become a bigger pain later in life.
The Long-Term Effects of Ankle Sprains
Ankle sprains are among the most common of diagnoses seen by physical therapists. Most of us have regrettably experienced this painful injury through playing sports that require jumping, quick movements, and frequent changes in direction. Soccer, football, ultimate frisbee, basketball, and volleyball are all good examples of popular sports that often result in sprains. I will also see in the clinic sedentary patients who simply mis-stepped off a curb, stair, or an uneven surface.
What most people do not realize is that ankle sprains can have nagging consequences that can be seen years after the initial injury. Today we will address two effects that are worth your attention.
The first problem resulting from the ankle sprain involves the ligaments that are “stretched out” from the sudden and often violent turning of the ankle past its normal range of motion. These ligaments resemble the plastic that surrounds a six-pack of beer. Once they are stretched out, they will never return to their original shapes. We are left with an ankle that is less stable, especially in the direction that the sprain occurred.
To add fuel to the fire, the sprained ligaments lose the ability to efficiently communicate with your brain. The result is decreased coordination of the ankle. Watch someone who recently sprained his or her ankle attempt to balance on his or her leg: you will see a general lack of balance and coordination that is reflective of this phenomenon.
A second clinical problem seen long after the initial ankle sprain is chronic stiffness. Months, and even years after the injury, it is common to see a loss of ankle dorsiflexion. (Dorsiflexion is the direction that the ankle moves if you were to attempt to bring your toes closer to your face while standing or lying down). This loss of range in the ankle has a domino effect: normal walking becomes compromised, and muscles higher in the leg and pelvis lose efficiency and strength. This can lead to other problems such as lower back pain and hip bursitis.
Every ankle sprain patient that I see is given at minimum two exercises to perform in order to combat the above mentioned problems. The first is single leg balance training with the shoes off. The muscles supporting the ankle and foot need to be retrained in order to provide the maximum amount of stability. I typically will ask the patient to attempt to balance on the affected leg with the knee slightly unlocked until the ankle is fatigued. Once this is mastered I will progress patients to balance on a foam pad, pillow, or BOSU ball.
Secondly I have patients learn to perform a calf-stlye stretch to regain any lost dorsiflexion. The patient faces the wall with the sprained ankle placed about two to three feet from the wall. The toes are pointed toward the wall, the knees are slightly bent, and the hands are placed on the wall. The patient is asked to lean forwards until a gentle stretch is felt in the top portion of the ankle. Ten to fifteen seconds of gentle stretch is advised. This stretch may be familiar to runners.
Take a minute to look at how well your ankle moves. Does one ankle have less range and coordination than the other? Did you ever sprain that ankle? If so, it is in your best interest to do something about it.
Ankle Sprains & Chronic Pain
By Robert C. Olson, D.P.M.
It is estimated that 25,000 people sprain their ankle every day in the United States. Approximately 85% of these injuries are a rolling in or inversion of the ankle. Typically the ligaments on the outside of the ankle are stretched or torn. Sprains can be divided into 3 levels or grades of injury, which correlate with the level of ligament damage, based on clinical exam. Grade II and III injuries consist of partial or complete tearing of the ligaments. Treatment begins with RICE (rest, ice, compression, elevation) and includes immobilization in grade II and III injuries to allow healing, followed by rehabilitation to prevent repeat sprains. Often patients are told to begin activity too early or don’t seek treatment at all. Twenty to thirty percent of patients suffer long-term effects from their injury. This is generally chronic pain along the outside of the ankle. The four most common causes of pain following an ankle injury are: Impingement, peroneal tendon tear, osteochondral defect of the talus, and ankle instability.
When the ankle ligaments are damaged the joint capsule or lining of the ankle may also be torn. This tearing may lead to scarring within the ankle that gets pinched between the leg bone and foot bone of the ankle during walking or activity. This causes pain along the front of the ankle, which may come and go with certain activities. Magnetic resonance imaging (MRI) is a test that may aid in the diagnosis of this problem, but the scarred tissue isn’t always seen clearly. Steroid injections will often give temporary relief, but generally ankle arthroscopy or a “scope” is done to remove the abnormal soft tissue and allow return to activity.
Peroneal tendon tear
There are two tendons that run behind the fibula or outside ankle bone called the peroneus brevis and peroneus longus. When the ankle turns inward as in a typical ankle sprain the peroneus brevis can be pressed against the fibula causing it to tear or split like a hot dog. If detected early these tears may heal with 5-6 weeks of immobilization, if not they may cause chronic pain along the back of the ankle. This diagnosis is typically made based on clinical findings, but an MRI may aid in the diagnosis. In most patients who have had a tear for several weeks or months it is difficult to get them to heal with a cast or cast boot. These patients often require surgical repair of the torn tendon.
Osteochondral defect of the talus
The talus is the foot bone of the ankle. This injury is a broken piece of cartilage, which may be attached to a small piece of underlying bone from the talus. These injuries most commonly affect the outside of the ankle. Patients with these injuries complain of a pain deep within their ankle. They may also have some catching and painful clicking or popping with activity. If the piece of bone is very thin it may not be visible on x-ray. MRI of the ankle will typically show this pathology. Unless the attached piece of bone is very thick, these broken pieces of cartilage and bone need to be removed from the ankle. This can typically be done through the scope, occasionally the ankle joints needs to be opened for removal.
Instability of the ankle can be divided into mechanical and functional instability. With functional instability the ligaments are not stretched and the ankle is stable on exam. The patient however has the feeling of giving way. This can be caused by the above-mentioned problems or by instability from improper muscle function. This is treated with physical therapy for rehabilitation and retraining of the ankle. Mechanical instability on the other hand is due to improper healing or stretching of the ankle ligaments that cause the ankle to be unstable or lax, leading to true giving way of the ankle. This can be controlled in some patients with bracing, but often times surgical repair or reconstruction of the ankle ligaments is necessary.
The problems discussed above are certainly not the only causes for ankle pain, however they are the four most common causes for pain following what may otherwise may thought of as “just an ankle sprain.” Although these problems are common they don’t need to be considered normal or expected.
Sprains are just the worst as anyone who has had one can tell you. A sprain isn’t just an inconvenience now, it can have lasting implications.
How does a sprain happen?
An ankle sprain happens when you rapidly shift your movement. When you do that your ankle rolls inward or outward damaging the ligaments by stretching and/or tearing them. A sprain can be mild, giving you some pain, swelling and stiffness but the ability to walk easily. A moderate sprain can include swelling, bruising and tenderness and pain when walking. A severe ankle sprain will make your ankle unstable, swollen, bruised and you will be unable to walk. No matter the severity of the sprain there are long term issues that come from any sprain.
One aspect is the loss of motion and it’s consequences
The loss of motion will cause changes in how you move when walking. They may be slight, but the muscles in your butt on the side where the sprain happened will have a more difficult time contracting. This is because your heel leaves the ground a fraction of a second earlier than it should. It’s called dorsiflexion and it can lead to lower back pain or issues in the hip like bursitis.
Another issue is the damage to the ligaments themselves
Ligaments are kind of like a hard plastic. They can stretch some, but once overstretched they can’t go back to their original length. It doesn’t sound like a big deal until you remember what ligaments are there to do: provide support to the ankle joint. Once the ligament is overstretched they can’t provide the same amount of support. This means that the likelihood of re-injury is higher in the injured ankle. The ligaments also send messages to the brain about where, meaning what position, your ankle is positioned. Again this means that re-injury is more likely since your brain won’t get the message about where the ankle is when walking on uneven surfaces.
Your best option
So what can you do? Get physical therapy when you have a sprain. Your future mobility depends on it.
What are the Long Term Effects of Ankle Sprains?
Historically, ankle sprains have been grossly undertreated. This has resulted in long-term misery and disability and pain for many people. Every week in our office we have someone come in with ankle pain that has resulted from inadequate treatment of an ankle sprain that occurred years ago. Many people treat ankle sprains themselves just by staying off the foot, and using an Ace wrap. For most ankle sprains that are bad enough to cause pain and is grossly inadequate. The new standard of care for moderately severe ankle sprain is now about 2 weeks in a cast followed by about 6-8 weeks with a very restrictive brace and then 6-8 months with a less restrictive brace during at risk activities. The reason for this is because the ligaments can then be allowed time to heal in a shortened (normal) length.
With activity, even normal walking, the ankle ligaments are stretched and if they have been partially ruptured or completely torn, this activity of walking in the early stages of recovery creates a situation where the ankle ligaments become too loose and do not adequately support the joint. This may or may not be immediately painful. However, in the long run, the ankle joint starts to hurt because it is not functioning in a normal way. The ankle joint slips too far and is unstable. Sometimes, patients’ complaint of severe instability even have new sprains when walking on a flat surface or stepping on a pebble. Having your ankle sprain managed correctly and early will greatly increase your chance of not having long-term pain and discomfort from an ankle sprain.
If you already have an unstable ankle from a previous ankle sprain, there is still hope. Usually, these could be treated with a fairly minimally invasive surgery that can restore the ligamentous integrity of your ankle joint.
If you have sprained your ankle don’t put off seeking treatment. The longer you wait, the longer you’ll spend healing. Contact the Next Step Foot & Ankle Clinic here in Pleasanton, Texas for more information or an appointment by calling (830) 569-3338 or using our online request form. Let us help you on the path of healing.
The first time I sprained my ankle, it was quickly followed by a stress fracture and weeks of hobbling around. And for months after my ankle injuries finally healed, while swearing that everything was better, it seemed like I could constantly feel new injuries coming on—weaknesses I was susceptible to because of that ankle.
It turns out I wasn’t imagining things.
Though many of us have been taught that you can shake off a twisted ankle, that’s not really true. Studies are now finding that the ankle is, quite literally, the foundation of an athlete. An injury to your ankle can have long-lasting consequences.
“What we’re realizing is it’s a much more serious injury,” says Mike Turner, an associate professor at University of North Carolina, Charlotte. Turner and his wife, Tricia Hubbard-Turner, have authored a number of recent studies on the long-lasting effects of ankle injuries.
“It’s not a one-off. There are significant consequences,” adds Tim McGuine, a senior scientist at the University of Wisconsin School of Medicine and Public Health. A study of college-age athletes who had suffered multiple ankle sprains in the past found that they were markedly less physically active than their peers, even taking fewer steps over the course over a day. It’s almost like their brains simply didn’t want to over-stress those historically hurt ankles.
The issue is two-fold. We’re only starting to understand the long-term consequences of these mobility-impacting injuries, says McGuine. Similar effects are being seen with recurring knee issues and their long-lasting impacts. The second problem is that the ankle is so fundamental to the entire body’s operation, especially in running. It’s weight-bearing, and the constant force on your ankle makes it hard for the joint to heal. That’s why Turner and his wife have made the ankle a focus of so much study. “She would say the ankle’s the most important joint in the body,” he admits.
RELATED: 6 Injury-Reducing Exercises For Runners
According to Turner, even after ankle injuries start to heal, your brain begins to re-wire neurally and your body compensates in ways you may or may not realize. “You end up running differently, walking differently,” he explains. Video analysis has shown those changes can be fairly significant.
It doesn’t take a ton of research to realize an ankle injury can result in a whole new set of injuries. Researchers are finding that even these “small” injuries—ankle sprains, twists, fractures—can result in significant drops in a person’s quality of life even a year later, per all measures on standard surveys. People find that it’s slightly harder to walk up stairs or do activities that require ankle mobility. Subconsciously, they even avoid things that might cause another twisted ankle.
That’s because a twisted ankle isn’t as small an injury as we may think.
When you badly roll your ankle or sprain it, you’re essentially tearing or stretching the ligaments, which causes scar tissue to form, says McGuine. Scar tissue, in turn, affects your mechanics and functionality. Different studies have found re-injury rates between 40 and 70 percent, and many people struggle with long-term ankle instability for months or even years.
But, says Turner, it’s not yet clear what makes someone more prone to long-term ankle instability or even to ankle sprains in the first place. The vast majority of sprains are caused by people rolling their ankles out—as opposed to in—and very few ankle injuries are actual bone fractures.
What is clear is what you can do about it once it happens. Let it heal, says Turner, as in, don’t try to shake it off or run through it. Go to a sports-focused physical therapist or doctor who can watch how your whole mechanical chain works and make recommendations, says McGuine.
There are also a number of exercises that have been shown to improve ankle strength and mobility. The problem, however, says McGuine, is that a lot of ankle rehabilitation exercises or strengthening exercises—such as calf raises or pulling a band in and out with your foot—tend to move in straight lines or just two to three planes of motion. “But ankle injuries don’t happen in a straight line,” he explains.
RELATED: How To Rehab A Sprained Ankle
Instead, balancing exercises and exercises that work the muscles in the bottom of the foot are more effective. These can be fairly low-tech, McGuine says, such as balancing on one foot with your eyes closed. Then, progress to standing on an uneven surface—even something as simple as a pillow—because it forces your ankle and foot to compensate. Finally, you can try one-legged knee bends.
There’s also some evidence that bracing or getting your ankle taped by a trained professional can help stabilize it and prevent re-injury, says McGuine, but that doesn’t really address the fundamental underlying issues.
“If you don’t do your exercises for 5 to 10 minutes per day, then all the bracing in the world isn’t going to help,” says McGuine.
Ignoring a sprained ankle can become a bigger pain later in life
NEW YORK—May 23, 2008
A sprained ankle: a major inconvenience for active Americans and an injury that is often overlooked by those who experience them.
While one in every 10 visits to the emergency room is for a sprained ankle, most falsely believe that it is a mild injury that needs mild treatment, if any at all. Big mistake, says John G. Kennedy, M.D., foot and ankle orthopedic surgeon at Hospital for Special Surgery in New York City, who warns athletes that improper treatment of an ankle sprain can lead to serious problems down the road.
“Athletes, especially male athletes, have been told by countless coaches and trainers to ‘suck it up’ and put some ice on an ankle sprain,” says Dr. Kennedy. “Those are the types of patients I see 10-15 years down the road in my office, who have formed large cysts, known as osteochondral lesions, in their ankles. Their next stop is typically the operating table to have cartilage restored.”
Case in point – basketball has been a constant in Queens resident Bob Fohngho’s life since he was 8. Throughout his career, the 25-year-old suffered several ankle sprains as a result of awkward landings. Typically, his coaches told him to wrap the ankle in ice and elevate it for a day or so. Trainers cautioned that his injured ankle needed more rest, but Bob did not want to let his team or coaches down and decided it was “good enough” to play on. As years progressed, his passion for basketball never waned. However, he experienced a great deal of pain in his injured ankle when he was not active.
Frustrated, Bob went to several doctors to find out why he was still in pain, but x-ray after x-ray showed no problems with the ankle. He finally turned to Dr. Kennedy, who suggested an MRI to get a better look at the injured ankle. The MRI showed that Bob, in fact, had an osteochondral lesion.
“Nearly 45 percent of the time, osteochondral lesions do not show up on normal x-rays,” said Dr. Kennedy. “To the active male, a negative x-ray result gives them temporary solace and false confidence that they can get ‘back in the game.’ Once the pain comes back, it plays on the psyche of the athlete – they feel the pain, but the x-ray showed no problems. They do not know what to do.”
In Bob’s case, Dr. Kennedy presented the best option as a surgical procedure that would remove the cyst and replace it with undamaged cartilage from an area above his knee cap. This procedure, known as Osteochondral Autologous Transfer System (OATS), uses a device that resembles an apple corer to remove the lesion and then bore a hole into the damaged ankle. Dr. Kennedy chose the OATS procedure because of the large size of Bob’s lesion. In instances where the cyst is smaller, doctors would use a less invasive known as microdrilling. This type of procedure is usually recommended for patients under 50 years of age. Dr. Kennedy then removed healthy cartilage from his knee and used it to fill the hole in his ankle. A plate and two screws were put in place to stabilize the ankle.
Immediately following surgery, Bob was put in a below-the-knee cast for two weeks and was then put into a removable boot for roughly five weeks. After the cast was removed, Bob began intensive physical therapy. Dr. Kennedy noted that a patient like Bob, who is an athlete and wants to go back to sports, is motivated and takes rehabilitation with great verve, which results in speedier and stronger recoveries. There is a gradual molding process for the new cartilage in the ankle and exercises focus more on range of motion, rather than the ability to bear weight on the ankle. Once a patient exhibits a more fluid range of motion, the focus then shifts toward weight-bearing exercises.
Fifteen months following his surgery, Bob runs at full speed, experiences no more pain in his ankle, and plays in two competitive basketball leagues. “This experience has not only allowed me to get back on the basketball court but has boosted my confidence at my job as well,” said Bob, who was recently promoted to department supervisor of the GYN unit at Memorial Sloan-Kettering Hospital in New York. One thing is now certain for Bob – he will no longer ignore a sprained ankle.
I sprained the ligaments on the outside of my ankle four months ago and still have pain, stiffness, and swelling whenever I use the ankle. Could there be something else going on in the ankle that is keeping me from getting better?
Minor ankle sprains usually heal within two to four weeks. If the ligaments were badly strained or actually torn, the healing period may be longer. Persistent problems this long after an injury may signal an underlying problem such as a talar dome fracture.
The talar dome is made of two two small bones on the top of the talus, or ankle bone. When the ankle turns inward during a sprain, the lower leg bones can squeeze against the talar dome.
In just over 6 percent of ankle sprains, the pressure can chip the talar dome. If the chip loosens, and gets in the way of movement it can cause the joint to “lock up.” This kind of fracture is often overlooked during a routine ankle sprain examination. If normal activities continue to cause pain, stiffness, and swelling long after the initial sprain, doctors usually suspect a problem with the talar dome.
The fracture doesn’t always show up clearly on X-ray, so a CAT scan or even a bone scan may be required. If the bone scan shows a problem, an MRI will often be recommended because it gives doctors the information they need in order to choose the best type of treatment. You should alert your doctor to the problems you’ve described.
Not just a sprain: 4 foot and ankle injuries you may be missing
• Treat a nondisplaced shaft fracture of the fifth metatarsal conservatively, with 6 to 8 weeks of immobilization with a protective orthosis. B
• Suspect a navicular fracture in patients who describe a gradual onset of vague, dorsal midfoot pain associated with athletic activity. C
• Order magnetic resonance imaging when you suspect osteochondritis dissecans, as radiographs are insensitive for identifying these lesions. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Ankle sprain, one of the more common injuries that primary care physicians evaluate, is usually managed with conservative treatment. Not uncommonly, however, lateral ankle sprain is diagnosed without consideration of a broader differential diagnosis.
Contributing to the problem is the fact that the clinical presentation of some fractures and tendon injuries is similar to that of a routine sprain. In some cases, the mechanism of injury—sprains are usually caused by excessive inversion of the ankle on a plantar-flexed foot—is similar, as well. What’s more, radiographs are often omitted or misinterpreted.
In the pages that follow, we highlight 4 commonly misdiagnosed injuries: fifth metatarsal fractures, navicular fractures, talar dome lesions, and peroneal tendon injuries. These injuries should be included in the differential diagnosis of an acute ankle injury—or a subacute foot or ankle injury that fails to respond as expected. Prompt recognition and appropriate treatment result in optimal outcomes. When foot and ankle fractures and tendon injuries are misdiagnosed (or simply missed) and do not receive adequate treatment, long-term morbidity, including frequent reinjury and disability, may result.1
Are x-rays needed? Turn to the Ottawa rules
Ankle sprains represent a disruption in a ligament supporting a joint, and result in pain, edema, and ecchymosis, and often affect a patient’s ability to bear weight. While uncomplicated sprains generally heal with conservative treatment, other common foot and ankle injuries may require a different approach.
The Ottawa foot and ankle rules are an evidence-based guide to the use of initial radiographs after acute ankle injury (TABLE 1).2-4 Pain—near the malleoli (for the ankle) or in the midfoot—is the key criterion, but x-rays are recommended only if at least one other specified criterion is also met. With a sensitivity of nearly 100%, the rules have been shown to reliably exclude, and diagnose, ankle and midfoot fractures in children >5 years and adults.2,5
Ottawa ankle and foot rules2-4
X-rays are required only if the patient has pain near the malleolus and one or more of the following:
- Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
- Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
- Inability to bear weight for 4 steps, both immediately after the injury and in the emergency department
X-rays are required only if the patient has pain in the midfoot and one or more of the following:
- Bone tenderness at the base of the fifth metatarsal
- Bone tenderness at the navicular bone
- Inability to bear weight for 4 steps, both immediately after the injury and in the emergency department
Fifth metatarsal fractures are easily missed
The mechanism of injury for a fifth metatarsal fracture is often similar to that of a lateral ankle sprain. In addition, isolated ankle radiographs may not adequately evaluate the fifth metatarsal, which increases the risk of misdiagnosis.6
3 types of fifth metatarsal fractures
Fifth metatarsal fractures involve one of the following:
- an avulsion fracture, caused by the pull of the plantar aponeurosis and the peroneus brevis tendon at the tuberosity of the bone
- a Jones fracture, at the base of the fourth and fifth metatarsal (FIGURE 1)
- a shaft fracture, distal to the fifth metatarsal joint in the proximal diaphysis.6-8
Jones fractures heal slowly
This 50-year-old patient presented with pain and swelling in the ankle and lateral foot shortly after an inversion ankle injury. A radiograph (A) taken at that time reveals a Jones fracture. The second radiograph (B) was taken 6 weeks later, after continued immobilization with no weight-bearing. Three months after the injury (C), the patient was clinically asymptomatic.
While avulsion fractures are generally the result of an inversion ankle injury, Jones fractures are usually caused by a large adductive force applied to the forefoot on a plantar-flexed ankle.6 Shaft fractures, also known as diaphyseal stress fractures, are overuse injuries from chronic overload, usually after a sudden increase in running or walking.9