COMPLICATIONS OF ANKLE SPRAINS
Augustine A. Bollo, D.P.M.
An ankle sprain is a common sports, and non-sport related
injury which can occur in most age groups usually ranging from young adolescence
to adulthood. The mechanism of injury usually involves excessive inward twisting
of the ankle, which causes a stretching and strain on the outside ankle
ligaments and capsular structure. This usually results in pain and swelling on
the outside of the ankle. The usual healing time of an ankle sprain with basic
treatment modalities (Rest, Ice, Compression, Elevation
and an elastic ankle support) is usually three to four weeks with no
complications. Although the ankle may be tender to touch, one should not have
difficulty walking after four to six weeks at the latest. When one experiences
continued difficulty walking, and/or pain after the normal healing time for an
ankle sprain, usually a more significant injury was present at the initial
incident. This may be for several reasons, such as professional neglect of
treatment, misdiagnosis of initial injury, inappropriate treatment of initial
injury, and/or too quick return to previous activities (i.e. sports, work).
Many other conditions may occur with an "ankle sprain type
injury", which often go undetected. These can often lead to delayed or long term
complications with the ankle. Some common injuries involved with and "ankle
sprain type injury" are as follows: Tear or rupture of the outside ankle
ligament(s), an occult fracture of the outside or inside ankle bones,
peri-tendinous (tendons around the ankle area) injury, bone contusion, and/or
nerve injuries (neuropraxia). All of these conditions may occur alone or in
combination. Initial treatment of these conditions requires immediate attention
which includes, X-rays and on some occasions an MRI. An X-ray helps detect
obvious fractures of the ankle, however in some incidences an MRI is necessary
to detect hidden fractures inside the ankle joint which may include the
cartilage, as well as soft tissue trauma to the ankle. Initial symptoms usually
include significant swelling and pain with stiffness of the joint and difficulty
walking. Treatment for all of these conditions usually includes initial
immobilization either in a removable or non-removable cast, physical therapy,
and sometimes anti-inflammatory medications. These conditions usually take at
least 6-8 weeks to heal and sometimes longer. When these conditions are not
initially detected by the patient or physician, delayed healing and/or
complications from the injury may occur. Some common symptoms often include
prolonged pain, swelling, ankle stiffness, ankle weakness, and/or continued
difficulty walking. Some common complications of ankle "ankle sprain type
injuries" with or without appropriate treatment may include:
- Synovitis (inflammation of the joint lining.
- Persistent swelling of the ankle.
- Ankle instability.
- Nerve entrapment.
1. ANKLE SYNOVITIS:
Synovitis is inflammation of the inner
lining of the
ankle joint capsule. This may occur with or without appropriate treatment of
the initial ankle injury. Commonly, when one injures the outside ankle
ligaments, the joint capsule is also injured which causes an inflammatory
response within the ankle joint. This inflammation may be generalized within
the ankle, or sometimes localized which can cause one to experience an
impingement of tissue within the ankle. This is usually detected with
clinical evaluation, intra-articular anesthetic injections, and/or an MRI.
Instability of the ankle may also cause continued abnormal motion in the
ankle causing a chronic inflammatory response as well. Symptoms usually
involve low grade swelling to the ankle, pain with certain weight bearing or
non-weight bearing movements of the ankle, and sometimes the symptoms are
vague and only present with an increase in activities such as running or
walking. Treatment initially involves immobilization in a cast or ankle
brace. Often times, anti-inflammatory medications are utilized, as well as
physical therapy modalities. Intra-articular injections of cortisone may
relieve pain and decrease swelling within the ankle joint. When symptoms
persist after conservative treatments have failed, ankle
resolves this condition. This is an operative procedure with minimal
incisions in which inflammatory tissue is removed from the inside of the
ankle joint. Recovery from ankle arthroscopy alone is usually quick healing,
and one can usually get back into a tennis shoe within two to four days
after the procedure, and usually the pain one had before the surgery is
resolved. Often times, physical therapy is used postoperatively to
facilitate a decrease in swelling and to increase the strength of the ankle.
2. PERSISTENT SWELLING OF THE ANKLE:
Persistent swelling of the ankle may be caused by several conditions.
Most commonly, the ankle ligament being torn and not healing appropriately,
or a bone contusion in which the medial or inside aspect of the ankle has
been compressed during the injury causing inflammation within the bones of
the ankle itself. This may take two to three months to resolve, and at times
an MRI may be necessary to detect swelling within the bones of the ankle. On
rare occasions, one may experience a small fracture within the ankle and/or
a tear of the cartilage within the ankle, which may cause persistent pain,
swelling and stiffness within the ankle. This is detected with an MRI scan.
Treatments include immobilization in a non-removable or removable cast,
physical therapy, anti-inflammatory medications, and often times an intra-articular
injection of cortisone may be necessary. Often times, if there is a detected
cartilage tear or fracture within the ankle, operative measures are usually
necessary. This can usually be treated with ankle arthroscopy in which a
camera is placed within the joint in order to visualize and remove the torn
cartilage or fractured piece of bone within the ankle. The postoperative
course for this condition usually takes longer than simple Synovitis removal
from an ankle. One is usually immobilized in a removable cast and placed in
physical therapy for a course of one month. Of course, postoperative healing
may vary depending on the severity of the injury within the ankle joint. One
may me immobilized for a shorter or longer period of time.
3. LATERAL ANKLE INSTABILITY:
Lateral ankle instability occurs when a ligament on the
outside of the ankle has been injured and torn either partially or totally,
and the ligament has not healed in its anatomic position, and in fact has
healed in a stretched position causing the ankle to move in abnormal
positions causing weakening on the outside of the ankle. Symptoms usually
involve consistent weakening of the ankle. Patients often relate that their
ankle turns in on them on uneven surfaces or with certain movements. Other
symptoms related to instability include persistent low-grade swelling of the
ankle, as well as persistent low- grade pain within the ankle joint.
Aggressive conservative treatment is necessary for instability of the ankle.
This includes a combination of cast immobilization, physical therapy,
functional orthotic devices, and anti-inflammatory medications. When
aggressive conservative treatments have failed, and one still experiences
weakness and instability of the ankle, operative measures are often
necessary, which include stabilizing the outside of the ankle by tightening
the ankle ligament in combination with ankle arthroscopy in order to remove
inflammatory synovitis tissue within the ankle. Postoperatively, the patient
needs to be immobilized for a period of 6 weeks in order for the ligament to
heal in its anatomic position, followed by aggressive physical therapy for
strengthening and range of motion.
4. NERVE INJURIES:
Nerve injuries may occur with a significant twisting injury of the ankle,
and/or chronic swelling to the ankle causing pressure to the cutaneous
nerves surrounding the ankle. One often experiences burning pain, sometimes
difficulty sleeping at night with burning and radiating, sharp type
sensation either up, or more commonly into the foot and toes. This is
usually exacerbated by walking, but one may also have symptoms without
walking. These injuries need to be treated aggressively and immediately.
This usually involves immobilization of the area to prevent excessive stress
on the nerves, physical therapy to decrease swelling and pain, oral anti-inflammatory
and/or other nerve type medications to calm down the pain cycle to the
nervous system. When these symptoms persist, a nerve conduction
study is often necessary in order to objectively detect the extent of injury
to the nerves. These injuries may take two to three months to resolve, even
with aggressive conservative care. Surgical intervention is rarely
indicated, however in persistent cases with positive nerve studies, a
decompression or release of tissue surrounding nerves is may be performed in
these rare cases.
In summary, ankle sprains usually resolve uneventfully with no
complications. However, when inappropriate treatment or significant injury
has occurred, complications of an "ankle sprain type injury" may occur,
which do need to be treated immediately and aggressively in order to prevent
delayed or long term healing of these injuries. Again, the most common
symptoms of a complication from an ankle sprain include persistent pain,
swelling, stiffness, and/or weakness of the ankle.