Ankle Sprain-They Are Not So Simple
Ankle sprain is the most common injuries for athletes. Anyone who has played a sport is likely to have experienced this type of injury. Also known as ankle instability, or a lateral ankle ligament tear, it occurs when someone awkwardly plants the foot. When this happens, the foot is turned inward and is occasionally followed by a “popping” sound. Walking is difficult and the foot shows immediate swelling. During this time, there is extreme pain.
Diagnosing an Ankle Sprain Injury
While most of these injuries are dismissively treated by primary care providers, Orthopaedic surgeons with interest in the foot and ankle commonly say, “there is no such thing as a common ankle sprain.”
Since the ankle sprain is a condition manifested by instability of the joint, Dr. Sanders performs a careful physical exam on the ankle by palpating and stressing the ligaments, along with the Achilles tendon. Following this, he decides whether or not further testing is necessary. If so, the patient will receive a Telos Stress X-ray. This low-cost exam uses the Telos Stress Device to apply stress to the ligaments of both ankles under X-ray. A comparison between the normal and abnormal ankle X-rays using digital technology will then allow Dr. Sanders to determine if there is a significant difference between the two ankles.
This low cost examination has a great advantage over an MRI. On MRI, a stretched out and incompetent ligament can appear normal. Only stress, such as applied to the foot and ankle when weight bearing, or a stress X-ray, will allow for a quantitative evaluation of pathological laxity.
Other concurrent pathological conditions can exist. These include two conditions that predispose to ankle sprains, and two that results from chronic repetitive ankle sprain. A contracture of the gastrocnemius muscle may be present such that the foot cannot be dorsiflexed (toes toward the nose) as much with the knee extended as with the knee flexed. This cause the foot to be kept in a plantar flexed position, making it easier for the foot to turn in. The other common condition is a high arched or cavus foot. In these cases the tuberosity of the heel is often deviated medially such that high tension forces, likely to cause ligament damage are transmitted to the lateral ankle ligaments with weight bearing.
An osteochondral lesions of the talus is a common result of chronic ankle instability and occurs in 40% of patients with recurrent sprains. This is characterized by damage to the cartilage of the talus (first foot bone) caused by repeated shear forces absorbed by the articular cartilage (gristle) as the talus starts to dislocate. The second, somewhat less common, concurrent injury occurring with an ankle sprain is a tear or dislocation of the peroneal tendons. These tendons reside behind the fibula and can be stretched, torn, or dislocated during lateral ankle injuries. Patients with these problems complain of pain behind their fibula and also feelings of instability. They must be examined as part of the initial evaluation. If they are dislocatable, then they require early surgical fixation. When these conditions exist, treatment of the ankle injury must be performed in conjunction with treatment of the underlying and associated condition, if a successful result is to be anticipated.
A variant of the ankle sprain is the “High Ankle Sprain.” This is an injury to the syndesmotic ligaments which hold the tibia to the fibula and maintain the talus (first foot bone) is its proper place. This injury occurs when the athlete’s body rotates away from the fixed weight bearing foot. It is distinguished from the more common ankle sprain by an excessive amount of pain and swelling. On exam, there is tenderness when the two lower leg bones (tibia and fibula) are compressed together. X-rays, and sometimes stress X-rays or MRIs are necessary to determine if the bones are stable in their proper relationship. We have had success using a poor man’s test of the syndesmotic ligaments. If an athlete is unable to walk on the injured leg, and we suspect this injury, we tightly wrap tape around the leg just above the ankle. If the bones are spread apart, and the tape temporarily holds them together, the athlete will be relieved of pain and can walk normally. If the syndesmotic ligaments are torn and unstable, with evidence that the bones are spreading apart, surgical treatment is necessary to stabilize the ankle. Afterward, a period of time in a cast or walker is necessary. Despite the sensationalism seen in some professional football players, the recovery from this injury is a slow and steady one, not a sprint.
Initial Treatment of a New Ankle Sprain
A system referred to as “RICE” is used and includes Rest, Ice, Compression, and Elevation. The best instrument for achieving both ice and compression is the Cryo/Cuff®. Therefore, patients are encouraged to immediately begin using a Cryo/Cuff®, while keeping the ankle elevated. Following several days of elevation, patients are told to begin walking, with or without crutches – though crutches are discouraged. Patients are then put in a special brace called an Air-Stirrup Ankle Brace, which can be placed over a sock and worn with a high top tennis shoe. This brace provides support and compression for the injured ankle within the shoe, allowing athletes to begin exercising, and regaining strength more quickly.
Working out the ankle and stretching the heel cord are very important for the rapid recovery of an ankle sprain. By working the ankle in dorsi and plantar flexion, an athlete can begin practicing his sport once again. If the Air-Stirrup Ankle Brace is worn for the full four weeks, rarely is additional treatment required for a sprain. At least ninety five percent of acute ankle sprains are successfully treated with conservative rehabilitation and proper care.
Approximately 20 percent of people with sprained ankles have recovered with “residual laxity.” This occurs when the sprain is not properly treated. These patients are always subject to re-spraining the ankle with even the most minimal trauma. Patients who were not properly treated for the first sprain and continue to experience ongoing problems with the ankle are candidates for ankle reconstruction.
The first things to consider were mentioned above.
Other questions we ask include:
1.) Does the patient have a high arched, or cavus foot? If so, the reasons for the cavus foot must be determined, and the anatomic abnormality, usually identified by turning the heel bone, must be corrected.
2.) Does the patient have a contracture of the gastrocnemius? If so, the gastrocnemius tendons must be lengthened.
3.) Is there an osteochondral lesion of the talus? If so, then the lesions must be debrided and drilled.
4.) Are the peroneal tendons intact and stable inside their groove? If they are not, then they must be stabilized.
If these conditions exist and are ignored surgery is certain to fail. For this reason, we correct these problems all at the same time.
The surgical treatment Dr. Sanders utilizes is customized for the size and activity level of the individual patient. Both are time tested and accepted anatomic repair/reconstructions of the lateral ankle ligaments.
The procedure we perform on most sedentary people and recreational athletes is known as the Gould Modification of the Brostrom Repair. It is performed in the Day Surgery section of a hospital. In this procedure, Dr. Sanders, first regularly performs an arthroscopy of the ankle. Approximately 40% of patients have an associated injury to the articular cartilage that will need attention. The repair is actually quite simple. The residual stretched ankle ligaments are incised and over sewn, similarly to the manner in which a pair of pants are taken in.
Additionally, some strong tissue called the Inferior Extensor Retinaculum is sewn into the repair, further strengthening the construct. Commonly we use a synthetic augmentation that will cause the ankle repair to be as sturdy as the native ankle at time zero. This means that patients can tolerate accelerated rehabilitation with immediate active motion and weight bearing in an Air-Stirrup Ankle Brace and normal shoes. In patients with a high arch, meaning that the heel bone is crooked or turned inward on the congenital or developmental basis, this bony problem must be addressed by repositioning the heel so it is straight. Likewise, a contracted gastrocnemius muscle must be released when it is present.
In large sized individuals and competitive athletes, we perform an anatomic reconstruction of the ankle ligaments utilizing a soft tissue graft from the illiotibial band of the thigh, which is expendable tissue that will regenerate. An alternative tissue is a hamstring tendon, which can lead to strength deficit. An allograft tissue is also effective but adds an additional cost of $2000. Biomechanical studies on this method of reconstruction have shown that at time zero, the reconstruction is as sturdy as the native ligament. Because of this we can institute accelerated rehabilitation consisting of immediate active motion and weight bearing as tolerated.
At the Sanders Clinic, all foot and ankle surgery patients are given the benefit of multimodal analgesia. By attacking the pain through several different pathways, fewer narcotics are necessary, and subsequently, the negative side effects of narcotic use can be diminished or eliminated. These medications include an anti-inflammatory such as Meloxicam, a nonnarcotic analgesic such as Tramadol, acetaminophen, also known as Tylenol, and gabapentin – which calms down peripheral nerve pain. These medications are taken around the clock. The need for a Class 3 narcotic analgesic, such as hydrocodone, is drastically diminished, therefore fewer side effects such as nausea and/or constipation occur. Phenergan is prescribed to help with nausea. Taking two Tylenol every four hours is a good alternative.
And Tylenol PM (a preparation that includes benedryl) is encouraged over other medications in the event of sleep disturbance, which is common after such procedures. Ambien, which is also prescribed, is a stronger sleep aid.
In the first week, patients are encouraged to take it easy, for the most part, staying at home and off the leg – with hip and knee bent to 90 degrees and the foot maintained in the elevated position with folded sheets under the calf.
Rehabilitation, either self-directed or directed by a therapist continues for a period of three months. Typically, patients return to unrestricted sports wearing the Air-Stirrup Ankle Brace three months after surgical reconstruction.