Bilateral flatfoot before Surgery and  Bilateral flatfoot after Surgery
Ankle Arthroscopy and Subtalar Arthroscopy
Ankle Arthritis in Rhuematoid patient and Ankle Replacement in Rhuematoid Arthritis
Diabetic foot before Surgery and Diabetic foot after Surgery
Claw toe deformity in Rhuematoid patient and Claw toe deformity in Rhuematoid patient after surgery
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Ankle Sprain


What is an ankle sprain?

An ankle sprain is damage to ligaments of the ankle as a result of twisting injury. Most commonly lateral ligaments are injured after inversion injury. It causes pain and swelling around the outside of the ankle as shown in the picture.

 
Swelling and bruising following ankle sprain
 
     

It is a very common injury and approximately 25000 sprains happen every day in USA. Most of us actually remember twisting their ankle once in a while. The severity of the ankle sprain depends upon whether the ligaments are just stretched, partially torn, or completely torn as well as the number of ligaments damaged. Sprain can result from losing balance on an uneven ground or from a fall or a direct blow.

Most of the time one can manage to get up and get going but the sprain could be more severe; your ankle might swell and it might hurt too much to stand on it. If it's a severe sprain, you might have felt a "pop" when the injury happened.

Plain X-rays are indicated if you are not able to weight bear after sprain or if there is pain and tenderness over bones to exclude a fracture.
Treatment of an ankle sprain. How to cure ankle sprain?

Treating your sprained ankle properly may prevent you of chronic pain and instability. For a mild sprain, follow the R.I.C.E. guidelines: 

1. Rest your ankle by not walking on it.  
2. Ice it to keep the swelling down.  
3. Compressive bandages immobilize and support your injury.  
4. Elevate your ankle above your heart level for 48 hours.  
5. The swelling usually goes down within a few days.  
     
     

Most ankle sprains settle with the above regimen. If the pain and swelling has not settled by 10 days then an x-ray and referral to physiotherapy should be considered.

Continued symptoms at six weeks warrant specialist evaluation and possibly an MRI or CT scan to exclude any other associated injuries. An MRI in the early stages is not that helpful as there will be distortion from the soft tissue swelling and has little input in the management plan.

A severe sprain puts you at risk for permanent ankle instability. Surgery may rarely be needed to repair the damage, especially in competitive athletes. For severe ankle sprains, your doctor may also consider treating you with a short leg cast for 2-3 weeks or a walking boot.

Most of ankle sprains heal with the above treatment and does not need any further treatment. In some rare cases ankle continues to give way and stay painful even months after injury. Such people are likely to develop Ankle Instability.

Ankle Instability

Ankle instability is a condition characterised by the ankle ‘giving way’ or feeling wobbly and unreliable, particularly on uneven surfaces. There are two main ligaments that support the ankle. The outer ligaments, known as the lateral ligaments, have three components which stop the ankle from rolling and sliding forward. These ligaments are attached to the fibula (small bone next to the shin bone) and the talus (the ankle bone) and calcaneus (heel bone).

An ankle sprain stretches and tears these ligaments and if the sprain doesn’t heal properly, ankle instability can develop.

Signs and Symptoms of ankle instability

1.
Pain and tenderness usually on the outer side of the ankle. The pain may be so intense that you have difficulty walking or participating in sports. In some cases, the pain is a constant, dull ache.
 
2.
Difficulty walking on uneven ground or in high heels.
 
3.
A feeling of giving way (instability)
 
4.
Repeated ankle sprains
 

Causes of Ankle Instability

1.
The most common cause for a persistently painful ankle is incomplete healing after an ankle sprain. You may experience additional ankle injuries. Other causes of chronic ankle pain include:
2.
Peroneal injury leading to torn or inflamed peroneal tendon.
3.
Ankle Arthritis.
4.
A break (osteochondral fracture-OCD) in one of the bones that make up the ankle joint
5.
An inflammation of the joint lining (synovium)
6.
It is also associated with high arched foot (cavus foot)

Diagnosis

Diagnosis is made upon the history, clinical examination and investigations. An xray is important to rule out underlying fracture. Definitive diagnosis of instability can be made by doing stress xray or MRI scan.

On stress x-ray the unstable ankle opens up on the outside when inversion strain is put on the ankle.(see picture). This is because of the lax and stretched outside ligaments. This can be compared to other side if it is normal.

 
Stress test for ankle instability
 
     

Treatment

Treatment should be personalized to your individual needs. Most instability patients respond to an intense programme of ankle muscles and peroneal strengthening exercises.
Conservative treatments include:

1.
Anti-inflammatory medications such as aspirin or ibuprofen to reduce pain swelling
2.
Physical therapy, including tilt-board exercises, directed at strengthening the muscles, restoring range of motion, and increasing your perception of joint position
3.
An ankle brace or other support

If there is continuing pain and instability despite physiotherapy surgical repair of the chronically loose ankle ligaments can be performed.

There are many different techniques used to stabilize the ankle. The one I most commonly use is the Brostrom-Gould lateral ligament reconstruction. In this operation the lax ligaments are first taken them off the bone. They are then secured with a special stitch and advanced and reattached by drill holes into a bony channel made on the fibula bone. At the same time I use another local structure called the extensor retinaculum to reinforce the repair.

Case Diary

Case 1

This patient presented with recurrent giving way and pain in his right ankle after an inversion injury during a match of Badminton. His ankle kept giving way and became painful whenever he went back playing. Reconstruction of his lax ankle ligaments and ligament tear using anchor sutures (Brostrom-Gould repair) helped him return back to sports.

 
Brostrum reconstruction of Ankle
 
     

Case 2

What can happen if ankle keeps giving way and is not treated?

If you ignore the instability symptoms everytime your ankle gives way you do some damage to the articular surface and over period of time you can develop arthritis in your ankle. Arthrtis can severely affect your walking ability and if so happens you need a much bigger surgery like fusion or ankle replacement or corrective osteotomy.

 
Varus osteoarthritis following untreated ankle instability