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Ankle Sprains Can Sometimes Create Serious Complications

Accidentally rolling your ankle and suffering an ankle sprain can be a painful and debilitating experience. Acute ankle sprains are one of the most common musculoskeletal injuries leading to emergency room visits, with upwards of two million people being affected in the United States every year.

Routine sprains typically respond quickly to rest, ice, compression, and elevation. Guarded weight-bearing in an ankle brace or utilization of a cast boot for two to three weeks usually gets the patient back on track.

Up to 40% of patients will experience more chronic pain and instability and may require further advanced treatments. The key is to obtain a quick thorough exam immediately following your injury. X-rays and evaluation are standard at the initial visit. 

Typically, ankle sprains are associated with injury to the lateral ligamentous structures of the ankle. In more severe injuries, tearing of the peroneal tendon may occur as well as damage to the cartilage of the ankle bone, or talus. Severe injuries may also include tearing of the deltoid ligament along the medial ankle, as well as small avulsion fractures about the ankle resulting from the ligamentous tissue pulling off portions of bone from the ankle joint.

When a patient has sustained an ankle sprain and does not see improvement with pain or instability after two to three weeks of conservative care consisting of rest, ice, compression, elevation and bracing, further evaluation and imaging may be needed.

MRI is the most specific definitive modality to help evaluate the extent of damage to the ligaments and tendons, and is also quite helpful in evaluating subchondral cyst formation deep into the ankle bone that can occur with cartilage damage. The MRI helps determine “functional” versus “mechanical” instability and will help direct the next steps in treatment.

Some patients may, at this point, respond well to a one-month course of physical therapy to rehabilitate the damaged lateral ankle ligaments. Once patients have completed physical therapy and are pain-free and can perform a single leg hop 10 times to the affected ankle, they can at that time return to pre-injury activities.

Patients who fail physical therapy and have positive MRI findings of structural damage to ligaments, tendons and/or cartilage will need to be surgically repaired if the condition is affecting the patient’s way of life or function. These patients are considered to have mechanical instability and can be very successfully corrected utilizing advanced surgical techniques.

The surgical procedure focuses on stabilizing the ankle by repairing the torn ligamentous structures. Typically, surgical repair of the peroneal tendon along with evaluation and a “cleaning out” of the ankle joint is also performed. These patients are routinely casted and remain non-weight-bearing for up to six weeks. This course is then followed by immobilization in a boot and physical therapy for up to one month. The majority of patients return to pre-injury status or sports within four months.

New advances in foot and ankle surgery now allow us to treat subchondral cysts of the ankle with fluoroscopy-guided minimally invasive techniques utilizing bone substitutes that are introduced through a needle or trochar. 

This new technique eliminates the need for  large incisions as well as the need to cut through bone, thereby allowing the patient to go back to work or sport within weeks as opposed to months or even a year.

High ankle sprains are somewhat different and are usually seen in the injured athlete. These injuries occur when inter-osseous ligaments between the tibia and fibula are disrupted, destabilizing  the ankle joint. The public has become much more aware of these types of injuries recently due to the high volume of such injuries seen in high-end professional athletes, usually as a result of a significant football injury. These high ankle sprains typically require surgical stabilization immediately. 

The procedure requires a small plate along the fibula that incorporates two suture buttons passed through the tibia thereby stabilizing the “syndesmosis” or tibiofibular articulation. This outpatient procedure is performed with the use of intraoperative fluoroscopic imaging and has an excellent success rate. Rehabilitation after a period of casting and non-weight-bearing is required.

Some patients endure chronic pain and instability for years, that ultimately leads to joint  destruction and deformity. Unfortunately, these patients will then require either a total joint replacement or ankle fusion, both of which can take several  months  to a year to heal.

If you or someone you know has suffered an ankle sprain and are continuing to have pain and/or instability, please feel free to contact us at WVU Medicine Wheeling Hospital for an examination today.

Dr. Hofbauer is Director of the WVU Medicine Wheeling Hospital Foot and Ankle Advanced Surgical Fellowship Program

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