FAQ’S

WILL OAT WORK FOR A SEVERE ANKLE INJURY FOR A POST-MENOPAUSAL WOMAN?

Q: After a very severe ankle injury, I found out I have a hole in the ankle bone that goes clear down to through the cartilage to the bone. The surgeon is recommending something called an OAT procedure. At age 55 (and being a post-menopausal woman), will this work for me? I don’t heal as well as I used to.

A: Holes referred to as “defects” in cartilage that go clear down to the bone can be treated with the technique you mentioned: osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (usually from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same person’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In a recent study from Korea, surgeons used a second arthroscopic examination a year later to evaluate the results of this procedure used on the talus (ankle bone). It is rare that a second-look arthroscopic exam is possible so the results of this study are important. Quality of bone and cartilage graft were evaluated using the second arthroscopy instead of MRI in order to get a better look at the results.

Using an analysis of many patient variables, the researchers were able to determine the most important factors affecting the final results. They investigated the role of age, gender, body mass index (BMI), duration of symptoms, severity (depth and size) and location of lesion, and presence of bone cysts as predictive factors of outcomes. They also looked at results based on patient satisfaction, pain, function, and activity level.

Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. Age was not a statistically significant factor. The most important variable in the result of the OAT procedure was actually a surgical effect. The surgeon must restore the joint surface smoothly, evenly, and anatomically accurately.

Impingement (pinching) of the surrounding soft tissues must be avoided. The graft shape and size must match the defect as closely as possible. And the graft must be covered over carefully with a patch to prevent “uncovered” areas. It seems that any gaps or uncovered spots quickly fill in with fibrous cartilage. The result is an unstable defect area.

The authors of this particular study suggest longer-term studies (beyond the one-year mark) in order to evaluate changes and look for influencing factors that might not show up in the first 12-months. They also commented that their study was fairly small in terms of number of patients (52 ankles). Therefore the study should be repeated with a larger number of subjects before accepting these results as the final word on the subject.

But it does offer some evidence that your age and potentially your postmenopausal status may not make a difference. These are good questions to ask your surgeon before having this procedure. Reparative surgery is important in this condition to avoid premature arthritic changes that can cause a chronically painful and unstable ankle.

Reference: Yong Sang Kim, MD, et al. Factors Associated with the Clinical Outcomes of the Osteochondral Autograft Transfer System in Osteochondral Lesions of the Talus. Second-Look Arthroscopic Evaluation. In The American Journal of Sports Medicine. December 2012. Vol. 40. No. 12. Pp. 2709-2719.

IS IT NORMAL AFTER ANKLE SURGERY 5 YEARS AGO THAT I CAN’T STAND ON MY LEFT LEG WITHOUT FALLING OVER?

Q: I just noticed yesterday when I was playing Simon Says with my five-year-old that I can no longer stand on my left leg without falling over. I did have surgery on that side two years ago for a badly sprained ankle. But I went through Physical Therapy and everything seemed fine back then. Is this normal? Should I be worried?

A: What you are describing might be something referred to as functional instability. More formal testing would be needed to know for sure — and to advise you what to do. Functional instability just means the ankle holds up for you during daily activities. It doesn’t give out when standing, walking, or otherwise challenged (e.g., on hills or uneven surfaces). But when you try to balance on it, there are some obvious deficits that show up.

One of the problems may be a lack of normal proprioception. This refers to the joint’s sense of its own position. Receptors in the joint that signal the brain where the joint is and when a shift in position occurs aren’t firing properly. The signals may be absent, delayed, or too weak to allow the joint to stay stable under stress or challenge.

One thing you can try is to stand on the other (uninjred) leg and see if this is a general balance problem or just specific to the post-surgical side. In either case, some remedial work is advised to prevent future injuries or reinjuries.

Your Physical Therapist is the best one to re-evaluate you and set up a plan for functional rehabilitation. The therapist has the advantage of reviewing your discharge notes to see what the status of your balance was at that time and compare it to now. This may help you understand what happened, what is going on now, and what to do about it. You are fortunate that a simple children’s game brought this to your attention now. Simon says: you can do something about it!

Reference: John G. Kennedy, MD, MCh, MMSc, FRCS (Orth), et al. Anatomic Lateral Ligament Reconstruction in the Ankle. In The American Journal of Sports Medicine. October 2012. Vol. 40. No. 10. Pp. 2309-2317.

TELL ME ABOUT END-STAGE ARTHRITIS IN MY LEFT ANKLE.

Q: I have what’s called end-stage arthritis in my left ankle. It really affects my walking. Even getting around the house can be a real chore some days. I try not to let this get me down but I have to admit it does put a damper on my life. Do other people feel this way too? Or am I just having a pity party for myself?

A: Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. So say researchers at the VA Medical Center in Seattle Washington. Researchers from the Mechanical Engineering and Orthopaedics and Sports Medicine centers at the University of Washington also assisted in bringing this information to us in a recent study.

They studied 37 patients (men and women) who were expected to have ankle surgery for severe arthritis classified as end-stage arthritis. All patients in the study had failed to achieve pain control or improved function with conservative (nonoperative) care. Surgery to either fuse the ankle or replace it was scheduled.

The purpose of the study was to measure the impact of this type of ankle arthritis on function referred to as impairment of function. They used several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements were compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems.

The question they asked was: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions were answered by this study. But the researchers at least got a start on evaluating which tests and measures provide the most information about function and activity limitations. And they began to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients (just like you have experienced).

Analysis of the data showed that everyone had decreased ankle motion and power compared to the unaffected side. Average walking speed, number of steps taken each day, and length of steps were less than those of normal (control) adults. These measures were also correlated with physical function. Just moving around a room took more energy, more steps, and more time compared with normal, healthy adults. Those patients who had better physical function also had less pain and a better mental attitude.

It’s likely you will see yourself in some of these results: loss of function, increased pain, and decreased motion do tend to reduce quality of life and affect mental (and physical) health. There may still be some help that could improve your situation.

If you haven’t already tried Physical Therapy that is usually the first-line of treatment. Surgeons recommend giving this type of conservative care a good three to six months’ trial before throwing in the towel. Surgery is an option and some patients are better candidates than others. Your surgeon will be able to evaluate you and guide you through this process.

Reference: Ava D. Segal, MS, et al. Functional Limitations Associated with End-Stage Ankle Arthritis. In The Journal of Bone and Joint Surgery. May 2, 2012. Vol. 94. No. 9. Pp. 777-783.

DOES ARTHRITIS IN AN ANKLE GET WORSE OR TIME OR SHOULD I HAVE SURGERY?

Q: I have arthritis in one ankle from a bad break I got when I was a wild and wooley 20-something. Now I’m paying for it in my 40s. Is there any way to tell if I’m getting worse over time and when I should have surgery? I want to put it off for as long as possible.

A: Severe ankle arthritis is less common than hip or knee arthritis but just as disabling. It is possible to take baseline measurements and to measure the impact of ankle arthritis on function. Limitations in function during daily activities is referred to as impairment of function.

There are several different ways to assess function including counting the number of steps taken each day, step length, walking speed, and ankle motion. These measurements can be compared to normal, healthy adults of the same age and sex (male or female) who did not have any ankle problems or to your other ankle if it isn’t damaged. It might be better to use adult controls instead of your unaffected ankle because if your walking (gait) pattern is affected on one side, it’s likely there will be compensations on the other side even if it is normal and without injury.

Choosing between ankle fusion (called arthrodesis) and ankle replacement (arthroplasty) is always a challenge. Fusion limits pain because it stops ankle motion. But loss of ankle and foot motion causes changes or alterations in the walking (gait) pattern. That in itself can cause further problems later on. Ankle replacement restores ankle motion and takes the pressure and load off the other nearby joints. But long-term studies of ankle replacement are not showing outstanding results at this time.

The question then becomes: is function affected by end-stage ankle arthritis? If so, how can we measure the amount of disability? At what point do the results of these tests suggest surgery is the best treatment? And finally, which type of surgery is best: fusion or replacement?

Not all of these questions have been answered yet. But researchers have at least gotten a start on evaluating which tests and measures provide the most information about function and activity limitations. And they are beginning to see how the effects of end-stage ankle arthritis impact health and quality of life for these patients.

Average walking speed, number of steps taken each day, and length of steps can be correlated with physical function. These tests can help identify problems with ankle motion and function. It is likely that these same measures could be used in future studies. They can be used to determine when treatment should begin and what type should be provided.

Right now, that information isn’t available to help you make your decision. Your surgeon will be the best one to advise you about the use of conservative (nonoperative) care. He or she will also guide you as to when to consider surgery and what type of surgery is best for you.

Reference: Ava D. Segal, MS, et al. Functional Limitations Associated with End-Stage Ankle Arthritis. In The Journal of Bone and Joint Surgery. May 2, 2012. Vol. 94. No. 9. Pp. 777-783.

WILL MY INSURANCE COMPANY PAY FOR SPECIAL INJECTIONS FOR ANKLE ARTHRITIS?

Q: I had some special injections to my knee for arthritis that helped smooth things out and improve pain and motion. It was expensive but my insurance company paid for it (well they paid the usual 80 per cent). I asked about having the same treatment for my ankle arthritis and they flat refused to pay. What’s up with that? Can I fight it?

A: It sounds like maybe you had a series of injections using hyaluronic acid. Hyaluronic acid is a substance naturally found in the body in small quantities. It seems to have a role in the multiplication of normal, healthy cartilage cells. Used as an injection into the joint, it is designed to rebuild the protective joint cartilage.

Fifteen years ago, the Food and Drug Administration (FDA) approved the use of an injection of hyaluronic acid for knee arthritis. It has been used ever since for the effective relief of arthritis pain in some carefully selected patients.

Now surgeons are turning their attention to the possible use of this same injection for ankle arthritis. Although it has not yet been approved for this type of use by the FDA, studies are starting to trickle in. From what has been reported so far, there isn’t a clear benefit to these injections for the ankle. In fact, according to one random controlled trial, hyaluronic acid didn’t work any better than a placebo injection using saline (salt) solution.

The question comes up: why do hyaluronic acid injections seem to work so well for some patients with knee osteoarthritis but patients with ankle arthritis don’t’t get the same benefit? It’s possible that because most ankle arthritis is the result of trauma (and knee arthritis is not), there is a difference in the response to hyaluronic acid. Ankle cartilage is also a lot stiffer, denser, and less elastic compared with knee cartilage. Maybe that makes a difference.

Until there is enough evidence that hyaluronic acid is an effective treatment for ankle arthritis, it is unlikely that insurance companies will reimburse for its use. With the high cost of this product, further study is needed to find new types of nonsurgical treatment for ankle osteoarthritis that are cost effective and economical.

Reference: Henry DeGroot III, MD, et al. Intra-Articular Injection of Hyaluronic Acid is Not Superior to Saline Solution Injection for Ankle Arthritis. In The Journal of Bone and Joint Surgery. January 2012. Vol. 94A. No. 1. Pp. 2-8.

WHAT DO PATIENTS SAY ABOUT ANKLE JOINT REPLACEMENT?

Q: I have the most painful ankle in the world. In fact, I’m literally ready to have the surgeon just cut the foot off. I can’t walk much less run. Can’t ride my horse anymore. Can’t keep up with my grandkids. I asked about a joint replacement but the surgeon put me off. Said it was too ‘experimental.’ I know people are getting them. What do other patients say about their results? If it’s good, I’m going to find someone to do the surgery anyway.

A: Surgeons agree that a total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, it is a reasonable approach for some patients and is still considered an acceptable alternative to ankle fusion (or amputation).

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn’t a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) also remains a problem.

And studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It’s a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

Patients are selected carefully for this procedure. Your surgeon may have some specific reasons why he or she thinks you are not a good candidate. But it’s also possible your surgeon doesn’t do this type of surgery.

It may be a good idea to find a surgeon who does perform total ankle replacements on more than an occasional basis and get a second opinion. You may get the same answer in which case it would be good to explore your options for better pain management so that you can become more functional. It’s possible there are some conservative treatment approaches that could really help.

Reference: James A. Nunley, MD, et al. Intermediate to Long-Term Outcomes of the STAR Total Ankle Replacement: The Patient Perspective. In The Journal of Bone and Joint Surgery. January 4, 2012. Vol. 94A. No. 1. Pp. 43-48

AM I A GOOD CANDIDATE FOR ANKLE REPLACEMENT SURGERY?

Q: I’m trying to find some information on ankle replacement surgery. I’ve seen two surgeons who both think I’m a pretty good candidate for this type of surgery. I’ve talked with two other patients who seem very happy with their results. What’s the general word on the street about doing this? I know it’s a fairly new-ish procedure and that it hasn’t been perfected yet. What do you think I should know?

A: There is one recent study from Duke Medical Center that may have the answers you are looking for. In this study, one surgeon from Duke University Medical Center shares the results of 82 patients who received the STAR total ankle replacement.

This surgeon performed all of the procedures himself using the Scandinavian Total Ankle Replacement (STAR) over a 10-year-period of time. The STAR prosthesis has been in use since the early 1980s with good results. It remains one of the most widely used ankle implants.

Since the 1970s when the first ankle replacement was attempted, the implants have been redesigned and improved. These second generation implants have led to better results but patients still report less than perfect results.

Most patients experience improved motion and function. Walking is improved but restoring running isn’t a likely result for most patients. Residual pain remains a problem. Infection (skin and deep joint) can also develop causing some difficulties.

Studies show that up to one-third of all patients experience a failed surgery. Failure usually means the implant has to be removed for some reason. Implant loosening, fracture of the implant itself, and subsidence (implant sinks down into the bone) are common reasons for implant removal or revision.

Surgeons pay attention to longevity as well. It’s a major surgical procedure and one for which the hope is long-lasting results without the need for further surgical interventions. The hope is that the implant will last 10 to 15 years at least. Studies with second generation implants are just beginning to report long-term results.

The surgeon who conducted this study was particularly interested in knowing how the patients viewed the results. Measurements were taken before surgery and compared to the same measurements after surgery. Pain, ankle motion, and function were the main areas assessed. Patients’ satisfaction with the results and self-reported quality of life were important means of determining patient reaction to the outcomes.

After analyzing all the data, he found there were improvements in all areas measured but especially in patient quality of life and satisfaction. Everyone was followed for at least two years and some patients were in the study for almost 10 years. This is probably one of the most comprehensive, long-term studies of patient perceived outcomes currently available.

The surgeon reminds the reader that these are self-reported results for a particular ankle implant (the STAR prosthesis). The more objective measures (number of patients requiring further surgery, number of failed implants, and implant survival rate) were also favorable. There was a revision rate of four per cent early on that increased over time. The survival rate was 88.5 per cent after 10 years.

It should help you to know that surgeons agree total ankle replacement is a complex, challenging procedure. It is prone to many complications that often require further (revision) surgeries. However, as this study showed, it is a reasonable approach for some patients. And is still considered an acceptable alternative to ankle fusion (or amputation). As the patients in this study report, function and quality of life are improved. Patient satisfaction is ranked high enough to make this a procedure worth considering.

Reference: James A. Nunley, MD, et al. Intermediate to Long-Term Outcomes of the STAR Total Ankle Replacement: The Patient Perspective. In The Journal of Bone and Joint Surgery. January 4, 2012. Vol. 94A. No. 1. Pp. 43-48.

IS THERE ANYTHING ELSE THAT CAN BE DOWN FOR THE OUTSIDE EDGE OF MY ANKLE SPRAIN?

Q: O geez. I sprained the outside edge of my left ankle two months ago and it never healed right. Clicking, popping, pain, etc. Finally saw an orthopedist. Said I need surgery because the tendon is popping in and out of the groove. Yikes. Is there anything else that can be done?

A: You may have an unusual lateral ankle sprain with a condition called peroneal tendon instability. A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.

When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation such as you mentioned.

Conservative (nonoperative) care is only possible when the unstable tendons can reposition inside the retromalleolar groove. A cast or boot placed on the lower leg will give the tendon a chance to heal. If conservative care is unable to achieve a stable gliding tendon or if the tendon displacement is unstable from the start, then surgery is necessary.

There are several different surgical options to consider. The fibrous protective sheath (retinaculum) can be reinforced or reconstructed. The groove can be reshaped (deepened) and rebuilt. The surgeon will probably suggest some additional imaging studies to determine the extent of the damage and the best way to surgically treat it. If you are still uncertain about the need for surgery, you always have the option of seeking a second opinion. There is nothing wrong with asking questions and seeking further advice.

Reference: Markus Walther, MD, PhD, et al. Peroneal Tendon Instability: Diagnosis and Authors’ Recommended Treatment. In Current Orthopaedic Practice. March/April 2012. Vol. 23. No. 2. Pp. 80-85.

WHAT’S UNUSUAL ABOUT THE TENDONS NOT STAYING IN THE GROOVE AS A RESULT OF AN ANKLE SPRAIN?

Q: I sprained my ankle doing a stupid move on my motorcycle. It never seemed to heal so I finally went in for help. They discovered the tendons along the outside of my leg aren’t staying in the groove where they are supposed to be. The doc said it was unusual but I didn’t catch what was unusual and why mine aren’t staying where they are supposed to. Can you help explain this to me?

A:  Ankle sprain is a common injury in athletes as well as the active adult. Most of the time, the ankle heals with a little care (rest, taping, ice). But one rare complication of lateral ankle sprains is a condition called peroneal tendon instability. It sounds like this may be what you are experiencing.

A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.

When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. Traumatic displacement of the peroneal tendons is a rare but painful complication of some lateral ankle sprains. Some people have a naturally shallow groove, which contributes to the likelihood of tendon displacement after ankle sprain.

The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation. Swelling may mask the symptoms of tendon displacement at first. It’s only weeks to months later when the painful symptoms don’t go away that the additional tendon damage is recognized. Early MRIs may not show peroneal tendon instability, especially if the tendon pops in and out of the groove spontaneously. Dynamic ultrasound tests are the best diagnostic tests because they will reveal the movement of the unstable tendon.

Reference: Markus Walther, MD, PhD, et al. Peroneal Tendon Instability: Diagnosis and Authors’ Recommended Treatment. In Current Orthopaedic Practice. March/April 2012. Vol. 23. No. 2. Pp. 80-85.

SHOULD ATHLETES WEAR ANKLE BRACE TO PREVENT SPRAINS

This may be the first study to look at preventing ankle sprains (and other leg injuries) by wearing a soft, lace-up ankle brace. Ankle sprains may seem like a minor problem but they put many athletes on the bench every year. And the effects can catch up with you much later in life. Chronic ankle stability, decreased physical activity, and ankle osteoarthritis head the list of potential long-term effects of ankle sprain.

Can a simple lace-up ankle brace really prevent ankle sprains? To find out, a group of researchers from the University of Wisconsin (Madison) enrolled 1460 high school athletes in this study. All participants were basketball players. The study included males and females involved in high school basketball during the 2009-2010 season.

The athletes were randomly divided into two groups. One group received the ankle brace. The other group was the control group (no brace). Athletes in the brace group wore the McDavid Ultralight 195 brace during any conditioning session, practice, or game throughout the season. This particular brace was chosen because it happens to be one that is used by many high school and college-level athletes.

Number and severity of all injuries affecting the lower extremity were recorded. This included ankle sprains, other ankle injuries, as well as knee injuries. An injury was defined as any event that caused the athlete to quit playing for 24 hours (or more). Severity of the injury was determined by the number of days the athletes couldn’t practice of play basketball in competition because of the injury.

There were a number of other variables that the athletic trainers involved in the study kept track of. For example, player compliance with wearing the brace was recorded. The use of tape in addition to bracing was noted. Type of shoes (low, mid- or high-top) was included as well. As it turned out, everyone wore the same type of court shoes (mid-tops).

There were a total of 265 injuries (all types). About 16 per cent of the entire group was affected. Most of the injuries were acute, traumatic (rather than slow and gradual). Basketball requires frequent stops, starts, turns, and cutting movements that increase the risk of acute injuries (especially of the knee and ankle). But handling the ball also lends itself to wrist, hand, and finger injuries. And falls resulting in head injuries (concussions) are also common.

Of course the real interest is in knowing how many of the injuries occurred to athletes wearing the lace-up ankle brace compared with those who did not wear a brace. As you might expect, the braced group did have fewer injuries. But the brace did not reduce the severity of the ankle injuries. Bracing did not prevent knee injuries either. The number of acute knee injuries was similar between the two groups.

What do the results of this large study really tell us? Wearing a lace-up ankle brace is effective in reducing ankle injuries in high school basketball players regardless of age, sex (male or female), or body mass index (body weight for size). The protective effect of this simple device also helps athletes who have already had a previous ankle injury from reinjuring that ankle again. This is good news since ankle reinjury is a common problem in athletes.

The authors conclude by saying that future research is needed. First, to repeat these same results in athletes of all kinds. Then, to compare various bracing options to find the one with the best protective effects. Comparing bracing with and without a neuromuscular training program is also called for. And they plan on taking a closer look at the trend for other types of injuries of the lower extremity (leg) observed in this study.

Reference: Timothy A. McGuine, PhD, ATC, et al. The Effect of Lace-Up Ankle Braces on Injury Rates in High School Basketball Players. In The American Journal of Sports Medicine. September 2011. Vol. 39. No. 9. Pp. 1840-1848.

ARE JOINT SPRAINS HEREDITARY?

Joint laxity or looseness is one factor that might contribute to chronic joint injuries or sprains. And that’s something you can be born with. Inherited conditions (e.g., Marfan’s syndrome) involving collagen fibers that make up the soft tissues are a more remote possibility.

But there are other possible factors contributing to chronic joint injury such as impaired balance, problems with proprioception (joint sense of position) or muscle imbalances/weakness. Usually there is a reason behind the reason.

In other words, a specific reason why someone might have muscle weakness or impaired proprioception. Before starting on they exercise program, it’s wise to look for all possible avenues to restore a normal, natural balance of muscle strength, motor control, movement, proprioception, and kinesthesia (awareness of movement).

You may not be able to solve this on your own. A visit to your primary care physician might be in order. He or she can direct you to someone more specific if needed (e.g., rheumatologist, orthopedic surgeon, neurologist). If there’s a problem with muscle insufficiency, altered motor control, or joint proprioception, a Physical Therapist can help you find the right rehab protocol and exercises to restore normal function.

Reference: Riann M. Palmieri-Smith, PhD, ATC, et al. Peroneal Activation Deficits in Persons with Functional Ankle Instability. In The American Journal of Sports Medicine. May 2009. Vol. 37. No. 5. Pp. 982-988

FUSION FOR PAINFUL OLD ANKLE INJURY

Q: Years ago, I broke and dislocated my right ankle. Everything healed nicely at the time. But, now the pain from arthritis has really gotten to me. The surgeon recommends fusion of the two main joints. I forgot to ask if I’ll need a brace or anything like that.

A: The type of fusion you are describing is called a tibiotalocalcaneal arthrodesis. Tibio-talo-calcaneal refers to the three bones that will be fused together. Essentially, your ankle and subtalar joint will be fused. Arthrodesis is the medical term for fusion.

There are various ways to surgically fuse these joints together. Screws, nails, and plates are possible options. These devices are used to hold the joint in place until the bone graft fills in and forms a solid fusion.

There will be a loss of ankle motion but bracing isn’t usually needed. The fusion provides the stability you need. But without movement at the ankle, you may need a good, supportive shoe. Shoe modifications can be made to accommodate any residual deformity that might be present.

Some patients require a high orthopedic shoe. Others may only need a heel raise or modification to the sole. Most (90 per cent or more) patients who have this type of fusion need some kind of shoe modification at least.

Reference: Ronald Boer, MRCSEd, et al. Tibiotalocalcaneal Arthrodesis Using a Reamed Retrograde Locking Nail. In Clinical Orthopaedics and Related Research. October 2007. No. 463. Pp.

ALTERNATIVE TO ANKLE FUSION FOR MARATHON ATHLETE

Q: X-rays of my right ankle show arthritis just on one side of the joint. I’d really like to keep training for a marathon but the pain is starting to get to me. I don’t think fusing the joint is such a good idea. Can something else be done to fix the problem?

A: Osteoarthritis that occurs as a result of a poorly aligned ankle is not uncommon. In most cases (70 to 80 per cent), trauma to the ankle is the original cause of the problem.

If conservative care doesn’t help, then surgery is often advised. The two most commonly used operations include ankle joint fusion or total ankle replacement (TAR). But there are some patients who could benefit from surgery to realign the joint instead.

The surgeon may be able to balance the uneven joint space. The operation is called realignment surgery. Too much tension on the tendons can be lessened. Angles between bones in the ankle can be changed. And the bone can be lengthened or shortened.

Shear forces can be reduced and shifted to be equal across the joint. Any deformity in the midfoot, forefoot, or hindfoot may be reduced. If realignment surgery is not successful, then a fusion or TAR can still be done.

The realignment approach has made it possible for some patients to continue participating in sports activities. Running long distances, including marathons, has been done by patients who have had this operation.

Reference: Geert I. Pagenstert, MD, et al. Realignment Surgery as Alternative Treatment of Varus and Valgus Ankle Osteoarthritis. In Clinical Orthopaedics and Related Research. September 2007. Vol. 462. Pp. 156-168.

MOTION PROBLEM AFTER REMOVAL OF ANKLE CAST

Q: Wow! I broke my ankle six weeks ago, and when they took the cast off, I could barely move my foot and ankle. Is this common?

A: Your experience is very common. In fact, this is more likely to happen than not happen. When joints are immobilized (can’t move) in a cast, the muscle fibers start to shorten. Injury to the bone and surrounding tissue may change the way the soft tissues work and move. This can also delay return to normal motion.

Loss of dorsiflexion (moving the toes up toward the face) is called a plantar flexion contracture. Three out of every four people have this type of contracture when the cast comes off. In fact, 22 percent of those people still have a contracture two years later.

Physical Therapists are working to find the best way to treat this problem. Right now it looks like exercise is enough. Adding stretching exercises doesn’t appear to help.

Reference: Anne M. Moseley, PhD, et al. Passive Stretching Does Not Enhance Outcomes in Patients
with Plantarflexion Contracure after Cast Immobilization for Ankle Fracture: A Randomized Controlled Trial. In Archives of Physical Medicine and Rehabilitation. June 2005. Vol. 86. No. 6. Pp. 1118-1126.

MOTION PROBLEM AFTER REMOVAL OF ANKLE CAST

Q: Wow! I broke my ankle six weeks ago, and when they took the cast off, I could barely move my foot and ankle. Is this common?

A: Your experience is very common. In fact, this is more likely to happen than not happen. When joints are immobilized (can’t move) in a cast, the muscle fibers start to shorten. Injury to the bone and surrounding tissue may change the way the soft tissues work and move. This can also delay return to normal motion.

Loss of dorsiflexion (moving the toes up toward the face) is called a plantar flexion contracture. Three out of every four people have this type of contracture when the cast comes off. In fact, 22 percent of those people still have a contracture two years later.

Physical Therapists are working to find the best way to treat this problem. Right now it looks like exercise is enough. Adding stretching exercises doesn’t appear to help.

Reference: Anne M. Moseley, PhD, et al. Passive Stretching Does Not Enhance Outcomes in Patients
with Plantarflexion Contracure after Cast Immobilization for Ankle Fracture: A Randomized Controlled Trial. In Archives of Physical Medicine and Rehabilitation. June 2005. Vol. 86. No. 6. Pp. 1118-1126.

WHY ARE X-RAYS TAKEN FOR A SPRAIN?

Q: Why is it necessary to have X-rays taken after a sprained ankle? Can’t the doctor just examine the foot and see what’s wrong?

A: In some cases, it is possible to look for signs of ankle injury such as swelling, bruising, tenderness, and decreased motion. The doctor may also use other tests such as squeezing the bones together or moving one part of the foot by itself. Usually ankle pain prevents a thorough examination. Even with a good exam, it is not possible to use signs and symptoms to tell the difference between a torn ligament and a bone fracture.

An X-ray can show if any bones are broken. A new procedure using an arthroscope allows doctors to see inside the ankle joint. An arthroscope is a tiny TV camera that can be placed inside the ankle to see the bones and ligaments directly. This makes it possible to see and identify any structures that are torn or broken.

Better technology makes it possible for doctors to make the right diagnosis. Accurate diagnosis helps them determine the best possible treatment.

WHY ARE X-RAYS TAKEN FOR A SPRAIN?

Q: Why is it necessary to have X-rays taken after a sprained ankle? Can’t the doctor just examine the foot and see what’s wrong?

A: In some cases, it is possible to look for signs of ankle injury such as swelling, bruising, tenderness, and decreased motion. The doctor may also use other tests such as squeezing the bones together or moving one part of the foot by itself. Usually ankle pain prevents a thorough examination. Even with a good exam, it is not possible to use signs and symptoms to tell the difference between a torn ligament and a bone fracture.

An X-ray can show if any bones are broken. A new procedure using an arthroscope allows doctors to see inside the ankle joint. An arthroscope is a tiny TV camera that can be placed inside the ankle to see the bones and ligaments directly. This makes it possible to see and identify any structures that are torn or broken.

Better technology makes it possible for doctors to make the right diagnosis. Accurate diagnosis helps them determine the best possible treatment.

ANKLE SPRAIN SWELLING AND FUNCTION

Q: When it comes to ankle sprains, how much is swelling related to ankle function?

A: According to a recent study, not much. Twenty-nine patients with new ankle sprains were in the study. The authors found that a measure of ankle swelling wasn’t related to patients’ ability to do sports and daily activities. Swelling also wasn’t related to whether or not patients could put weight on their hurt ankles.

The authors believe that patients’ own reports are the best gauge of ankle function. This makes sense given the number of personal factors that go into how patients recover from injuries.

DIFFERENCE BETWEEN ANKLE TAKEDOWN AND ANKLE ARTHRODESIS

Q: What’s the difference between an ankle takedown and an ankle arthrodesis? My husband’s surgeon used both these words when talking about an operation for his severe ankle arthritis.

A:  Arthrodesis is the fusion of a joint. Bone graft is used most often around the joint to hold it together and keep it from moving. As the bone fills in around the bone chips used in the graft, a fusion occurs.

A takedown is used to convert a fused joint into a moveable joint again. A special joint implant is used to restore ankle motion. The most successful of these devices is the Agility total ankle made in the United States.

A takedown operation is fairly new in the United States. There are problems with arthrodesis or takedown. Doctors are working to find ways to improve both operations as they each have their place for different patients.

Reference: Justin Greisberg, MD, et al. Takedown of Ankle Fusion and Conversion to Total Ankle
Replacement. In Clinical Orthopaedics and Related Research. July 2004. Vol. 424. Pp. 80-88.

BEST TREATMENT FOR TRIPLANAR ANKLE FRACTURE

Q: What’s the best treatment for a triplanar ankle fracture?

A: Triplanar ankle fractures occur in children between the ages of 10 and 16. Boys are affected more often between 13 to 15 years and girls between 12 and 14 years. The difference has to do with when the growth plates close (sooner in girls than boys).

Triplanar refers to three directions or orientations of fracture. These include the sagittal (front-to-back) plane, transverse (side-to-side) plane, and frontal (top-to-bottom) plane.

The location and degree of damage depends in part on the status of the growth plates. Since these growth areas don’t close all at the same time, some areas are at greater risk for fracture than others.

Treatment is determined based on two things: fracture reduction and joint incongruity. Reduction refers to how well the bones can be matched back up to their normal alignment. Surgery is usually needed to pull the bones back down into place.

If this can be done without an open incision by using traction, then it is referred to as a closed reduction. This procedure is done under general anesthesia. Then the patient is put in a long leg cast while the ankle heals.

If the fracture remains displaced by more than three millimeters, then the surgeon will likely use an open reduction. The standard procedure involves making as many incisions as needed to correct the alignment. Metal plates, screws, wires, and/or pins are used to hold everything in place once the bone fragments are realigned as close to normal as possible.

More recently, surgeons have started using arthroscopic surgery. The scope allows the surgeon to see inside the joint. This makes it possible to get better alignment and fixation. Surgical trauma is less with this method. Direct visualization allows for more accurate joint congruity.

Reference: Kent A. Schnetzler, MD, MS, and Daniel Hoernschemeyer, MD. The Pediatric Triplane Ankle Fracture. In Journal of the American Academy of Orthopaedic Surgeons. December 2007. Vol. 15. No. 12. Pp. 738-747.

BALLET DANCER ANKLE PROBLEM

Q: What’s a “cuboid syndrome?” My daughter is a ballet dancer and off her feet with this problem. What can be done to treat it?

A: The cuboid bone is a small, cube-shaped bone in the foot. It’s actually part of the ankle. It connects with the heel bone in the back and the long bones of the last two toes on the outside of the foot.

Cuboid syndrome refers to a painful foot from a disruption of the cuboid bone. This can occur from overuse or injury. The injury is usually a fast, forceful motion of the foot and ankle downward (plantar flexion) and inward (inversion).

Treatment can include using a pad under the cuboid bone or taping the foot and ankle. A chiropractor or Physical Therapist trained in joint manipulation can also perform a manipulation called the cuboid whip. This maneuver helps realign the bones and restore full pain free motion.

Reference: Jason Jennings, DPT, SCS, ATC, MTC, CSCS, and George J. Davies, PT, DPT, MEd, SCS, ATC, LAT, CSCS, FAPTA. Treatment of Cuboid Syndrome Secondary to Lateral Ankle Sprains: A Case Series. In Journal of Orthopaedic & Sports Physical Therapy. July 2005. Vol. 35. No. 7. Pp. 409-415

SURGERY FOR ANKLE WITH CHRONIC SPRAINS

Q: What kinds of surgical techniques are used to stabilize an ankle with chronic sprains?

A: There are many surgical techniques, but they basically fall into two groups. One is anatomic reconstruction. With this technique, surgeons use the original ankle ligaments to repair the ankle. The other technique is called tenodesis. In this procedure, surgeons reconstruct the ankle ligament using tendon from elsewhere in the body, such as the lower leg. Surgeons attach the transplanted tissue to bones in the ankle joint.

Researchers evaluated the results of both kinds of surgery in a group of athletes. For these patients, anatomic reconstruction resulted in better ankle movement and stability. It also led to fewer degenerative changes in the joint. Compared to tenodesis, anatomic reconstruction more often gave a good or excellent result. For athletes and other active patients, researchers think anatomic reconstruction is the method of choice.

PREVENTING FOOTBALL RELATED ANKLE SPRAINS

I’m a high school football coach. We seem to have a high number of ankle sprains putting our players on the bench. Is this typical? What can we do about it?

Studies show that ankle injuries in sports accounts for 10 to 30 percent of all athletic injuries. Basketball players seem to have the highest incidence of ankle sprains when compared with soccer and football players. Basketball players are also more likely to resprain their ankles.

Physical Therapists and athletic trainers are studying the problem. They are looking for risk factors for ankle sprains. Once these are identified, then training can be geared toward preventing ankle injuries.

Several studies using force plate technology have been able to show that decreased standing balance is linked with ankle sprains. Being overweight is a risk factor for male athletes. Overweight athletes who have sprained their ankles at least once before have an even greater risk of reinjury. A high body mass index (BMI) in football linemen has been linked with an increased risk of leg injuries.

For now it looks like improving one-legged standing balance can make a difference. Weight loss in football players may reduce ankle injuries but could increase injury to other parts of the body. More study is needed on this topic.Malachy P. McHugh, PhD, et al. Risk Factors for Noncontact Ankle Sprains in High School Athletes. In The American Journal of Sports Medicine. March 2006. Vol. 34. No. 3. Pp. 464-470

VOLLEYBALL ATHLETE WITH WEAK ANKLES

I’m a college-level volleyball player with weak ankles. I trained extra to prevent ankle injuries and ended up hurting my knee. Am I just prone to injury no matter what I do?

Some people do seem more likely to get injured than others. This could be related to an overactive nervous system, lax ligaments, or poor joint position sense. There may not be an easily identifiable link, or there may be more than one factor involved.

In your case, it may be that training for the ankles worked well. You didn’t injure your ankles and they were able to with withstand outside forces. It’s possible the knee joint was stressed instead. When the ankles are strong, forces from the ground up through the
foot and ankle are transferred to the knee instead. Injury can occur here if this is the weakest link.

It may be best to keep training for improved ankle strength and improving the joint’s sense of position (called proprioception). An overall program to include ankle, knee, and hip may be best for you. If you need help, seek out the assistance of a Physical Therapist or athletic trainer.Evert Verhagen, et al. The Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains. In The American Journal of Sports Medicine. August/September 2004. Vol. 32. No. 6. Pp. 1385-1393.

BENEFITS OF ANKLE FUSION FOR ARTHRITIS

I’m 43-years old and planning to have my left ankle fused because of severe arthritis from an old injury. What can I expect down the road after this operation?

Ankle fusion has become a more popular way to treat end-stage arthritis in younger adults. It’s a way to save the ankle and preserve some function. The operation is called a salvage procedure.

Long-term, functional outcomes of ankle fusion aren’t known yet. Studies are underway that will be following patients for many years and reporting results. A recent report of intermediate results has been published. Patients were followed for an average of three to four years. Results were compared between the fusion group and a healthy (control) group of adults who didn’t have a history of ankle problems or pain.

The researchers report most of the patients were satisfied with the results and would do it again if they had to. Pain relief was the number one advantage to this operation. Although they could still walk without crutches, cane, or other assistive devices, their gait was slower with shorter steps than adults in the control group.

There’s also a good chance you may develop arthritis in the other joints of the foot and ankle. Your surgeon will monitor for this. Additional surgery may be needed sometime further down the road.Rhys Thomas, FRCS (ORTH), et al. Gait Analysis and Functional Outcomes Following Ankle Arthrodesis for Isolated Ankle Arthritis. In The Journal of Bone and Joint Surgery. March 2006. Vol. 88-A. No. 3. Pp. 526-535

CAUSE OF ANKLE ARTHRITIS IN 40 YEAR OLD

I’m 42-years old and suddenly I’ve developed a bad case of arthritis in my left ankle. What can cause this to happen?

Osteoarthritis of the ankle can occur as a result of the natural aging process and biologic changes that cause joint changes. This is called primary osteoarthritis (OA).

More often in the case of ankle OA, there has been an injury or previous trauma of some kind. This could be an ankle sprain, joint infection, or fracture. Do you recall anything like that in your past? It could have happened years ago.

Anything that can disrupt the stability of the ankle can result in OA. Over time the structures bear the load of your weight unevenly long enough that the cartilage wears away or even tears. You can end up with OA. OA of this kind is called secondary OA.

Most people with stage 2 or 3 OA of the ankle once played sports either competitively or for recreation. Ankle sprains during active play are the most common event linked with OA years later.Masato Takao, MD, PhD, et al. Reconstruction of Lateral Ligament with Arthroscopic Drilling for Treatment of Early-Stage Osteoarthritis in Unstable Ankles. In The Journal of Arthroscopic and Related Surgery. October 2006. Vol. 22. No. 10. Pp. 119-1125

COMMON ATHLETIC ANKLE INJURIES

I’m 17 years old (a girl) and very athletic. I made it through high school injury-free. I know girls are more likely to injure their ACLs. Are there other injuries we should watch out for?

Yes — ankle sprains. According to a recent study from the University of Vermont high school and college female athletes are more likely to sprain their ankles compared with men in the same sport.

Other sports were also studied including soccer, lacrosse, and field hockey. First-time ankle sprains occurred about once in every 1000 days of play (practice and games).

Researchers are trying to identify risk factors to help athletes avoid such injuries. More studies are needed before specific recommendations can be made.Bruce D. Beynnon, PhD, et al. First-Time Inversion Ankle Ligament Trauma. The Effects of Sex, Level of Competition, and Sport on the Incidence of Injury. In American Journal of Sports Medicine. October 2005. Vol. 33. No. 10. Pp. 1485-1491.

ALTERNATIVE TO CAST FOR GRADE III ANKLE SPRAIN

I went to the emergency department for what turned out to be a Grade III ankle sprain. The doctor advised using a cast for a week to 10 days before switching to an ankle brace. I have a newspaper route and can’t afford to let the cast slow me down. What are my options?

Ligament injuries of the ankle can be graded as I, II, or III. The higher the number, the more severe is the injury. Grade II and III are often treated with casting for anywhere from 10 days to four weeks.

A recent study from the University of Vermont compared the results of Grades I – III ankle sprains using different treatment methods. Treatment options included an Air-Stirrup brace, Air-Stirrup brace combined with an elastic wrap, or a walking-cast for 10 days. Elastic wrap was used after the cast came off.

Using the Air-Stirrup brace with elastic wrap reduced the recovery time by half. Almost a week’s time was shaved off recovery with this method. If your sprain is severe enough to require a cast, ask about using a walking cast. This can help you get around your paper route more easily.

Be aware that switching to an elastic wrap after the cast comes off may also speed up your recovery time. It will still take longer to get back to ‘normal’ compared to a Grade I or II injury.

In this same study, some patients with grade III sprains treated with an Air-Stirrup (instead of a cast) did quite well. They were able to get back to full activity within three weeks’ time. This may be another option for you.Bruce D. Beynnon, PhD, et al. A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains. In The American Journal of Sports Medicine. September 2006. Vol. 34. No. 9. Pp. 1401-1412.

WHAT IS ANKLE FRACTURE WITH A SYNDESMOTIC INJURY?

I was in our state high school rodeo finals last weekend. I injured my ankle big time during the calf roping event. Had to have surgery with two pins through my ankle. Doc says it’s an ankle fracture with a syndesmotic injury. Can you explain what that means?

The syndesmosis refers to the ligaments and connective tissue that hold the bottom of the two lower leg bones together. These two bones are the tibia (your shin bone) and the fibula. The fibula is next to the tibia along the outside of the leg.

The syndesmosis is made up of a total of four ligaments and a band of tissue between the two bones. This band is called the interosseous membrane.

The syndesmosis can be sprained or ruptured. There may or may not be a bone fracture at the same time. Severe injuries with bone fracture and/or syndesmotic rupture requires surgery. The goal is to realign the bones and stabilize the joint. The hope is to restore normal movement and function.Charalampos Zalavras, MD, PhD, and David Thordarson, MD. Ankle Syndesmotic Injury. In Journal of the American Academy of Orthopaedic Surgeons. June 2007. Vol. 15. No. 6. Pp. 330-339.

MUSCLES TO STRENGTHEN AFTER SPRAIN

I was coming down off the bleachers at a basketball game and missed the last step. My foot twisted in and I sprained my ankle. Do I need to strengthen all the muscles around the ankle or just the ones I sprained?

The type of sprain you are describing is called an inversion injury. It’s likely that you sprained a ligament inside the joint, not the muscle around the ankle. Ligaments can’t be strengthened with exercises. Instead, the muscles around the ankle are improved. In this way, the muscles can help protect the weakened joint.

Ankle rehab does include muscle strengthening, along with other exercises, as well. Stretching to keep flexible and exercises to help the joint sense what position it’s in are important parts of the program. In the past, exercises focused on muscles along the outside of the lower leg.

A new study by Physical Therapists in Australia has challenged this method. They found that weakness of the muscles along the inside of the ankle (called invertors) is the real problem. Exercises after an inversion ankle sprain should focus on the invertors.Joanne Munn, et al. Eccentric Muscle Strength in Functional Ankle Instability. In Medicine & Science in Sports & Exercise. February 2003. Vol. 35. No. 2. Pp. 245-250.

TREATMENT FOR TORN LIGAMENT

I was coming down from a lay up during a basketball game two days ago. When I landed, my foot rolled in and I tore a ligament on the outside of my ankle. Will I need surgery to fix this problem, or are there things I can do to avoid surgery?

Most doctors in the United States would not do surgery right away. In rare cases, such as with an elite athlete, surgery may be done immediately. Because surgery carries higher risks and costs, most doctors rely on nonsurgical treatments first. These treatments commonly include a period of rest, along with the use of an ankle brace. Cold treatments, anti-inflammatory medication, and a compression wrap with elevation of the sore limb are generally helpful for the pain and swelling. If you start to get relief and can gradually get back to activities without having extra swelling or unsteadiness in the ankle, you most likely will not need surgery. 
A recent study comparing types of treatment for this condition showed that people who had surgery experienced fewer problems over a longer time period. However, because the surgery is costly and has greater risks, it is usually only done only if other types of treatment haven’t improved stability in the injured ankle.

HOW ACCURATE ARE X-RAYS FOR TWISTED ANKLE?

I twisted my ankle when I missed the last step of our stairway. The doctor took X-rays and said it was not broken. How accurate are X-rays for this kind of injury?

Examining the ankle using X-rays has been standard in the medical world. This method is very accurate for diagnosing bone fractures. Because of the complexity of the ankle structure, several different views on X-rays are usually needed. X-rays are not always able to show damage to the surrounding ligaments. However, with the progress in optical technology, arthroscopic examination of the ankle is now possible.

The arthroscope is a tiny camera that can be inserted into the ankle joint to see if there are any broken bones or torn ligaments. One set of ligaments, called the ankle syndesmosis, joins the two lower leg bones together. X-rays are about 50 to 64 percent accurate in showing if the syndesmosis has been damaged. By comparison, ankle arthroscopy is 100 percent accurate. This new method is sometimes necessary for correct diagnosis of soft tissue damage that occurs with ankle injuries.

SHOULD I SEEK TREATMENT FOR ANKLE SWELLING FROM OLD INJURY?

I tweaked an old ankle injury ice skating last night. There’s quite a bit of swelling along the outside ankle bone. I know the swelling will go down on its own. Is there any real reason to get treatment for this?

Rest, ice, compression, and elevation is still the standard home treatment applied for mild to moderate ankle sprains. With severe sprains, immobilization with an air cast may be advised. The goal of treatment is to reduce swelling and speed recovery.

Many studies have shown that edema or swelling from inflammation can slow down healing. In fact, the rate of recovery is directly linked to the amount of swelling at the site of the injury. The more swelling there is, the slower the recovery rate.

Swelling also inhibits the muscle reflexes around the ankle. These responses are needed to prevent further injury or reinjury. Tiny receptors in the joint that measure ankle motion and direction can be damaged by edema. The sense of joint position called proprioception may not return to normal without treatment.

If you’ve injured this ankle before, you may need some outside help to get back to normal. A Physical Therapist can show you some exercises to help recover strength, coordination, and proprioception. Most often, a home program can be followed with minimal supervision for four to six weeks.

Ivy O. W. Man, et al. Effect of Neuromuscular Electrical Stimulation on Ankle Swelling in the Early Period After Ankle Sprain. In Physical Therapy. January 2007. Vol. 87. No. 1. Pp. 53-65.

WHY DO X-RAYS SOMETIMES MISS FRACTURES?

I took up snowboarding last year after years of downhill skiing without injury. My first time out, I landed on my left foot and hurt myself. At first the doctor didn’t think anything was broken because the X-ray was negative. I went back to the doctor when it didn’t get better. They found a piece of bone had broken off the talus bone in the ankle. Why didn’t the X-ray show this?

X-rays are only two-dimensional pictures of bones. They can’t always “see” everything that’s going on in the ankle joint. The talus is a bone sandwiched in between two other bones (the heel and the tibia forming the lower leg bone).

The talus has two bumps on the back of the bone. These are the medial and lateral processes. X-rays only show four out of 10 cases (40 percent) where the lateral process of the talus is broken off.

When this fracture goes unnoticed, patients may be treated for an ankle sprain. They don’t get better and end up back in the doctor’s office with chronic pain and swelling. Further imaging is needed to get to the bottom of the problem.

Vincent A. Fowble, MD, et al. Fracture of the Lateral Process of the Talus: A Report of 2 Cases. In The American Journal of Orthopedics. October 2004. Vol. 33. No. 10. Pp. 522-525.

USING VIDEO TO EXPLAIN ANKLE SURGERY TO PATIENT

I took my father to the clinic for his preop visit. He’s going to have ankle surgery. They showed us a videotape of the operation. I wonder how much older folks like Dad really get out of this. Wouldn’t it be better if the nurse or doctor explained everything?

Using videotaped presentations before surgery is a fairly new idea in the world of health care. The advantage is that the information is consistent and complete. Nothing important is left out or forgotten. Older adults can control the volume on the TV so they can hear everything. They are less likely to ask a nurse or doctor to speak up.

A recent study was done comparing patient understanding and retention of preop information. Patients were divided into two groups. One group got the standard verbal information. The second group watched a videotape with information about risks, benefits, and other treatment options.

Everyone answered some questions in a survey given right after getting the information. They also filled out the same survey again 10 weeks later.

It turns out the videotape group had better understanding and recall of the material. Patients with less education did especially well compared to patients in the verbal group. You can probably reinforce the information you thought was important just by talking with your father about the video.Wen Chao, MD, and Mark S. Mizel, MD. What’s New in Foot and Ankle Surgery. In The Journal of Bone and Joint Surgery. April 2006. Vol. 88-A. No. 4. Pp. 909-922.

STILL HAVE PROBLEMS WITH OLD ANKLE LIGAMENT SPRAIN

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.

TREATMENT OPTIONS FOR ATHLETE’S DAMAGED ANKLE

I sprained my right ankle at least a dozen times during high school and college sports. Now I can hardly walk without it giving way. Is there anything that can be done about this?

There are several treatment options depending on the condition of the ankle joint and soft tissues around the joint. First a program of specific ankle exercises may help. The goal is to increase joint stability through increased muscle strength.

Second a treatment called prolotherapy may work for you. Sometimes this is called
sclerotherapy or reconstructive therapy. A doctor with special training injects an agent into the ankle. Scar tissue forms around the soft tissues to help form
stronger bonds where the torn ligaments normally hold the ankle stable.

Finally if these methods fail, surgery may be needed. In the past, ankle fusion was the only operation possible. Now the joint can actually be replaced. Total ankle replacement (TAR) can be used in the case of ankle instability. A severe ankle sprain or repeated injury such as you described can cause such problems. Ask your doctor which treatment would be best for you.

J. Chris Coetzee, MD, FRCSC, and Michael D. Castro, DO. Accurate Measurement of Ankle Range of Motion after Total Ankle Arthroplasty. In Clinical Orthopaedics and Related Research. July 2004. No. 424. Pp. 27-31

HOW DOES R.I.C.E. RELATE TO TREATMENT OF ANKLE INJURY?

I sprained my ankle, and my buddy said something about “rice.” Is this a special diet or what?

RICE stands for rest, ice, compression, and elevation. It’s a recipe to reduce pain and swelling and get you back on your feet.

RICE has four important ingredients. First, take rest seriously. Avoid activities that cause any ankle pain. Second, put a bag of crushed ice on your ankle for at least 20 minutes, two to four times a day. Third, compress the sprain by wrapping it with a stiff sports tape or ACE wrap. A Physical Therapist can show you a good wrapping technique. Finally, keep your foot lifted and supported above the level of your heart for at least two to four hours a day. 

Stick with RICE until you can walk easily, without pain. Certain Physical Therapy techniques such as joint mobilization, a light movement of the joint surfaces in the ankle, can help you reach an even faster recovery. Ask your Physical Therapist for details.

USE HEAT OR ICE FOR SPRAINED ANKLE?

I sprained my ankle two weeks ago. I have been using ice and keeping the ankle wrapped with an ace wrap. When can I use heat instead of ice?

For most injuries, ice is recommended during the first 24 to 48 hours. This helps reduce the pain and swelling that are part of the inflammatory stage of healing.

You can switch to heat when the ankle swelling goes away. The area should not be red or hot to the touch. By this time, the progress with ice has come to a halt. No further improvement in symptoms occurs after using ice.

Heat can be applied for 15 to 20 minutes, depending on the type of heat used. Extreme caution is advised when using a heating pad at home. Never fall asleep with the heating pad on. This can cause skin burns, increased tissue swelling, and delayed healing.

WHY DOES ANKLE STILL FEEL WEAK MONTHS AFTER SPRAIN?

I sprained my ankle six months ago. It still feels like the ankle could give out from under me at any time. Why is that?

Muscle strength is important in holding a joint steady or stable. But, there are other factors as well. For example, the joint must be able to sense what position it’s in at all times. This helps the body adjust itself over the ankle and keeps us from losing our balance.

The sense of joint position is called proprioception. Most ankle rehab programs include exercises for proprioception. A new study also reported that the muscles that pull the foot and ankle inward (called invertors) are weak after an ankle sprain.

Exercises for ankle sprain usually focus on the muscles along the outside of the ankle called the evertors. However, it may be that weakness of the invertors is the real problem. Consult a Physical Therapist if you haven’t been in an ankle rehab program. The therapist can set you up with a program to restore normal ankle function.Joanne Munn, et al. Eccentric Muscle Strength in Functional Ankle Instability. In Medicine & Science in Sports & Exercise. February 2003. Vol. 35. No. 2. Pp. 245-250.

HOW TO SPEED HEALING OF SPRAINED ANKLE

I sprained my ankle pretty good when I stepped down off the curb wrong. I’ve got a big walking trip to Europe planned in three weeks. Is there any way I can speed up the recovery process?

There may be! According to the results from a recent study of acute ankle sprains, short-term recovery time was greatly reduced with the use of an Air-Stirrup brace. Results were best when the Air-Stirrup was combined with an Ace elastic wrap.

An ankle sprain rehab program is also a good idea. The first phase tries to reduce the swelling and minimize the trauma. Crutches, ice, elevation, and exercises are used during the first week after injury.

Exercises are designed to restore motion and prevent fluid from building up around the area of injury and inflammation. Usually a Physical Therapist guides the patient through the process. Exercises may include toe curls, ankle rolls, walking, swimming, and biking on a stationary bike.

Balance training and agility skills along with strength training are the final phase of the program. You may not reach this phase of treatment before your trip. But the combined use of an ankle brace and elastic wrap should reduce your recovery time in the early phase by half.

Bruce D. Beynnon, PhD, et al. A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains. In The American Journal of Sports Medicine. September 2006. Vol. 34. No. 9. Pp. 1401-1412

WHY IS IT IMPORTANT TO REDUCE SWELLING OF SPRAINED ANKLE?

I sprained my ankle over the weekend and ended up in the emergency room for treatment. The nurses and doctors spent the whole time telling me how to get the swelling down. This may sound dumb, but why is that so important?

There are some who say, “swelling is the greatest enemy of healing.” Early treatment for any acute sprain or injury is to limit painful swelling that occurs with inflammation. Holding off swelling altogether or at least reducing it may also improve joint function.

There may be some research to call this assumption into question. A recent study of ankle and foot swelling early after injury showed no link between ankle swelling and ankle function. There may be some long-term benefits of limiting ankle swelling. Less swelling may mean less joint damage. Less swelling may also mean return to normal function sooner for the nearby muscles.Ivy O. W. Man, and Matthew C. Morrissey. Relationship Between Ankle-Foot Swelling and Self-Assessed Function after Ankle Sprain. In Medicine & Science in Sports & Exercise. March 2005. Vol. 37. No. 3. Pp. 360-363

WILL SPRAINED ANKLE BECOME ARTHRITIC?

I sprained my ankle last summer. After a few months it seemed to go back to normal. Will I get arthritis in this ankle later?

A grade II or moderate sprain causes partial tearing of a ligament. The patient has bruising, pain, and swelling. A person with a moderate sprain usually has some trouble
putting weight on the foot, and there’s some loss of function.

Patients who have a grade III or severe sprain completely tear or rupture a ligament. Pain, swelling, and bruising are usually severe. The patient can’t put any weight on the joint. An X-ray is usually taken to rule out a broken bone. MRIs tell if the ligament is torn partially or completely.

The long-term outcome of your ankle sprain depends on how severe it was and how it was treated. A broken ankle is more likely to lead to arthritis, especially if it’s not stabilized with treatment. It sounds like your symptoms are getting better over time. That’s a good sign that you will recover without further problems.Todd O. McKinley, MD, et al. Incongruity Versus Instability in the Etiology of
Posttraumatic Arthritis. In Clinical Orthopaedics & Related Research. June 2004.Vol. 423. Pp. 44-51.

WHAT IS THE RICE METHOD?

I sprained my ankle at a track meet. My coach wants me to see a Physical Therapist, but I say I can ice and wrap my ankle on my own. Is Physical Therapy worth my time?

You’re on the right track by using ice and a wrap for your ankle. Rest, ice, compression, and elevation–known as the RICE method–can reduce pain and swelling in your ankle and help get you back up to speed.

Your coach has a point, too. Research suggests that Physical Therapy helps ankle sprains heal faster than RICE alone. In a recent study, patients who had Physical Therapy had less pain and more ankle movement than patients who only had RICE. The therapy these patients received included specialized hands-on movement of the ankle joint. This technique, known as joint mobilization, may speed healing by improving movement in the ankle. 

Fortunately, the body has natural healing mechanisms, and your ankle will probably heal eventually, with or without help. But if you’re serious about getting back on the track faster, guided treatment with a Physical Therapist is your best bet

ANKLE SPRAIN MAKING JOINT FEEL UNSTABLE

I sprained my ankle and have a lot of swelling and pain. Why does the joint feel unstable, and what can I do to make it better?

This unsteady feeling in your ankle may start to improve once the swelling and pain subside. Swelling can put pressure on the nerve sensors that are responsible for your sense of joint position. Also, pain can keep muscles from doing their job of protecting the joint. The effects of swelling and pain may combine to make your ankle feel unstable. 

However, it is possible the ankle could feel unsteady even after the swelling and pain have gone away. This usually involves injury of the nerve sensors. The injury can be caused either by the trauma of the sprain itself or the pressure from the swelling.

You may need to do special training exercises, called proprioception exercises, to improve the joint’s stability. These types of exercises are a lot like doing balance training. Examples include balancing on one leg with your eyes open and then closed, walking on uneven or soft surfaces, and practicing on a special balance board. If your ankle keeps feeling unsteady, you may need the help of a Physical Therapist who will design a program that will probably include these types of exercises.

DOES ANKLE SPRAIN LEAD TO ARTHRITIS?

I saw a report in a sports magazine that says ankle sprains lead to arthritis years later. How long does it take and what happens?

A recent study from the Human Performance Lab at the University of Calgary in Canada reports a latency (delay) period of 30 years between severe ankle sprain and ankle osteoarthritis (OA).

Younger patients develop arthritis sooner than older adults. Patients with single episodes of ankle sprain also develop OA as much as 10 years before adults with chronic, recurring sprains. The reason for this remains unknown at this time.

It appears that the type of injury and side of the ankle injured have something to do with the development of arthritis later. Lateral ankle sprains along the outside of the leg are more likely to cause malalignment of the ankle and uneven wear on the joint.

The amount of damage at the time of the injury is another factor. Severe ligament tears lead to higher shear forces on the joint cartilage. The result may be damage to the cartilage in addition to the ligament injury.

Without strong ligaments to hold the ankle bones in place, instability occurs. Uneven or excess motion in any direction on either side of the joint comes with an unstable joint. A slow but steady amount of damage to the first layer of joint cartilage later leads to the start of osteoarthritis.Victor Valderrabano, MD, et al. Ligamentous Posttraumatic Ankle Osteoarthritis. In The American Journal of Sports Medicine. April 2006. Vol. 34. No. 4. Pp. 612-620.

WHAT IS COLD THERAPY FOR ANKLE SPRAIN?

I recently sprained my ankle. The information I received suggested “cold therapy” as a form of treatment for the first 24 hours. What does this mean, and how do I use it?

Cold therapy, sometimes called cryotherapy, can be applied in several ways. Usually it depends on the body part involved. A bag of crushed ice wrapped in a towel is easily applied to the knee or ankle. A commercially made cold pack works better for the back or neck.

Ice massage is an easy way to cool a small area of tissue, like an injured ankle ligament. Freeze water in a paper cup. Tear the top off   the cup, exposing the ice. Hold the cup to protect your fingers from the cold while applying the ice to your ankle in a circular motion. This cools the area without causing frostbite.

Studies show that cold therapy cools the skin and upper layer of tissue quickly–within eight minutes. It usually takes 12 to 15 minutes of cold therapy to decrease pain and muscle spasms. More than 30 minutes of cold therapy can cause frostbite and nerve damage. The recommended time for cold therapy is around 15 to 20 minutes.

NEED THE CAST IF THERE’S A SCREW IN PLACE?

I recently injured my lower leg and ankle in a motorcycle accident. There’s a screw now holding the lower leg bones together while they heal. I have to wear a cast for six weeks. Why do I need the cast if there’s a screw in place?

The two lower leg bones (tibia and fibula) have a fibrous sheath between them called the syndesmosis. It’s designed to hold the two bones together while allowing the motion needed for normal ankle movement.

Screw fixation holds the area together and doesn’t allow motion while it’s healing. If you don’t wear a cast, and if you do put weight on that foot and leg, the screw may come loose or even break.

Doctors are especially concerned about patients who are overweight or who have brittle (osteoporotic) bones. These factors increase the risk of screw failure. A new way to repair this injury is under investigation.

Doctors in Ireland are trying a flexible, plastic suture material. It holds the two bones
together while itself being held in place by buttons on the outside of each leg bone. The patient still wears a cast but can put weight on the leg sooner and get the cast off sooner. If studies show it’s safe, the suture-button may become the standard way to treat a syndesmosis problem.

Brian Thornes, FRCSI, et al. Suture-Button Syndesmosis Fixation. In Clinical
Orthopaedics and Related Research
. February 2005. Vol. 431. Pp. 207-212

ANKLE TWINGES WITH CERTAIN MOVEMENTS

I notice my left ankle “twinges” with certain movements like when I walk on a slanted surface or step down off a curb. Does this mean I am spraining my ankle over and over? I sprained it really badly about a year ago.

Your ankle is designed to recognize even the tiniest movement and let your brain know what’s happening. Then your brain tells the joint how to adjust its speed and direction. This process is called proprioception.

Damage to the joint capsule and/or surrounding tendons or muscles from a sprain can also damage your proprioception. The twinges you feel may occur because of a delayed message relay system, a weak muscle around the joint, or both. Recurrent ankle sprains result in pain, swelling, and loss of motion.

The “twinges” may be a signal that your proprioception isn’t working well. This puts you at risk for another ankle sprain. Current thinking is that a rehab program can help restore joint proprioception and prevent another injury.Arienne de Jong, MSc, et al. Performance in Different Proprioceptive Tests Does Not Correlate in Ankles with Recurrent Sprain. In Archives of Physical Medicine and Rehabilitation. November 2005. Vol. 86. No. 11. Pp. 2101-2105.

SNOWBOARDERS RISK FOR ANKLE INJURIES

I just took up snowboarding. Are my ankles likely to get hurt?

Snowboarders are at a moderate risk for ankle injuries, especially once they get into aerial maneuvers. When coming down from a jump, your foot flexes upward at a sharp angle, and your ankle takes the pressure of the landing. Add to this the tendency of the foot to point outward while landing, and you have a recipe for a broken ankle. Keeping the foot straight ahead provides a safer landing.

You’ll lower your risk of injury if you practice good technique and don’t push yourself beyond your skill level. Watch for boots and bindings that better protect the ankles in the coming years

SECOND SURGERY TO REMOVE SCREWS

I just saw an X-ray of the huge screw the doctor put in my son’s ankle. It’s for a torn ligament between the two lower leg bones. We’ve been told a second operation will be needed. This one will take it out when everything’s healed. Is there any way to avoid this second surgery?

Metal plates and screws are often used to hold bones together during healing after an injury. There are some problems with this. As you noted, a second operation is needed to
remove the hardware after healing takes place.

Even before the screw is taken out there’s a risk that it could loosen or break beforefull ligament healing occurs. Scientists are trying to use new materials to make a bioabsorbable screw. It could be left in place, and it will slowly break down and get
absorbed by the body.

There’s still the problem of infection and bone breakdown around the screw, even the bioabsorbable type. More studies are underway looking for other ways to repair this injury while minimizing additional problems.Brian Thornes, FRCSI, et al. Suture-Button Syndesmosis Fixation. In Clinical
Orthopaedics and Related Research
. February 2005. Vol. 431. Pp. 207-212.

STIFFNESS AFTER ANKLE CAST REMOVED

I have had a cast on my ankle for four weeks for a bone fracture. Now that the cast is off, I’m slowly (very slowly) getting my motion back. I can see how immobilizing the joint can cause stiffness but why is it taking so long to get over?

There are two reasons why stiffness seems to last a long time after casting a joint for a fracture. First there’s the joint itself. After injury, the repair processes can be damaged and slow to return to normal.

At the same time, animal studies have shown us that muscles shorten up when joints are immobilized. The tendons shorten up and the cartilage in and around the joint becomes unable to slide and glide.

Exercise seems to be the best solution to this problem. Studies haven’t shown that one type of exercise is better than another. In fact, a recent study from Australia showed that patients who exercised without stretching did just as well as those who exercised with stretching.

Give yourself at least four to six weeks to regain your full motion. Check with your doctor if you have any questions or concerns.Anne M. Moseley, PhD, et al. Passive Stretching Does Not Enhance Outcomes in Patients
with Plantarflexion Contracure after Cast Immobilization for Ankle Fracture: A Randomized Controlled Trial. In Archives of Physical Medicine and Rehabilitation. June 2005.
Vol. 86. No. 6. Pp. 1118-1126.

HOW CAN DIABETIC IMPROVE SENSATION IN ANKLES?

I have diabetes with some loss of sensation in my feet. Because of this, I have to be very careful to protect my feet and avoid injuries. Is it possible to compensate for this by improving sensation in my ankles?

The ankle’s ability to sense its own position while moving or standing is called proprioception. The positioning of the feet and ankles is very important for people with diabetes as this can help prevent injuries. Scientists suspect that proprioception is changed in people with diabetes, but not much information is available on this topic.

Studies of healthy adult volunteers have shown that fatigue can alter ankle proprioception. Tests of muscle fatigue and joint position in people with diabetes have not been done. Until more information is available, you may want to try a program of exercises to improve ankle proprioception. Physical Therapists typically prescribe these exercises after ankle injury and can help you in this area.digg_url = ‘http://www.eorthopod.com/public/patient_education/912/i_have_diabetes_with_some_loss_of_sensation_in_my.html’; digg_title = “I have diabetes with some loss of sensation in my feet. Because of this, I have to be very careful to protect my feet and avoid injuries. Is it possible to compensate for this by improving sensation in my ankles?”; digg_bodytext = “The ankle\’s ability to sense its own position while moving or standing is called proprioception. The positioning of the feet and ankles is very important for people with diabetes as this can help prevent injuries. Scientists suspect that proprioception is changed in people with diabetes, but not much information is available on this topic. \r”; digg_skin = ‘standard’;

ANKLE REPLACEMENTS IN CHARCOT’S DISEASE

I have Charcot’s disease from diabetes in my ankles. Would I be able to get the new ankle replacements I’ve heard are out now?

Neuropathy or loss of normal nerve function is a common problem in chronic diabetes. The hands and feet are affected most often. Patients report symptoms that range from mild tingling, burning, or numbness to a complete loss of sensation. Loss of sensation in the feet is a serious problem. It puts the patient at risk for trauma and joint destruction.

Over time, degeneration of the stress-bearing portion of the ankle causes Charcot’s disease. Sometimes this condition is called Charcot’s arthropathy or neuropathic arthropathy.

Treatment is important to preserve the bones of the foot and ankle function. Treatment begins with reduction of weight bearing. Joint protection is also important in conservative care. Surgical fusion can be done if all else fails but joint replacement is not advised in this condition.

For best results, patients with diabetes who have peripheral neuropathy, poor skin quality or poor circulation, and deficient bone stock don’t qualify for total ankle replacement.

Victor Valderrabano, MD, et al. Sports and Recreation Activity of Ankle Arthritis Patients Before and After Total Ankle Replacement. In The American Journal of Sports Medicine. June 2006. Vol. 34. No. 6. Pp. 993-999

HOW WILL A PLASTIC ANKLE BRACE HELP ME WALK?

I have ankle osteoarthritis. My doctor thinks I should get a plastic brace for my foot and ankle. How is this going to help me walk better?

Pain in any joint from arthritis can slow a person down and increase their overall fatigue. The major goal of bracing is to keep the joint in good position and control motion. The result should be to reduce pain and fatigue.

The type of brace can make a difference. Most of today’s bracing is with a rigid plastic called polypropylene. If the brace supports the calf, ankle, and foot, then it’s called an ankle-foot orthosis. Some orthoses start midcalf and support the hindfoot. Others support the hindfoot and the forefoot.

Studies show that wearing an orthosis gives better control over the ankle than just wearing a pair of standard shoes. With a good brace, deformity of the ankle can be corrected for arthritis patients.

With the right orthosis, you may be painfree longer each day. This would allow you to walk further. You may also be able to manage more difficult surfaces such as uneven slopes or ramps. Try to get an orthoses that restricts motion of the painful joint but still allows motion in the rest of the foot. Your doctor or the orthotist (person who makes orthoses) will help you with this.Yu-Chi Huang, MD, et al. Effects of Ankle-Foot Orthoses on Ankle and Foot Kinematics in Patients with Subtalar Osteoarthritis. In Archives of Physical Medicine and Rehabilitation. August 2006. Vol. 87. No. 8. Pp. 1131-1136

WHAT IS AN ACCESSORY LIGAMENT?

I had arthroscopic surgery on my ankle to find the cause of my chronic ankle pain. The doctor said there was an accessory ligament causing the problem. What’s an “accessory ligament?”

In human anatomy, accessory usually means an extra helper. The tissue may be like the main structure. An accessory ligament is usually in addition to the primary ligament. It’s not always present in every human.

A recent study from the University of Athens in Greece reported an accessory ligament. It was an accessory to the anterior inferior tibiofibular ligament (AITFL). The accessory is located just below the main ligament. It’s a separate structure with a
dividing wall between the two ligaments. This partition was made of fat and fibrous tissue.

Researchers report this ligament can get pinched up against a bone in the ankle. This happens most often after an ankle sprain. Surgery may be needed to remove or repair damaged tissue from this injury before symptoms will go away. In a small study of 24 cadavers, 22 of the ankles had this extra ligament. It’s not usually a problem until the ankle is injured or sprained.Constantinos E. Nikolopoulos, MD, et al. The Accessory Anteroinferior Tibiofibular Ligament as a Cause of Talar Impingement: A Cadaveric Study. In The American Journal
of Sports Medicine
. March/April 2004. Vol. 32. No. 2. Pp. 389-395

TENNIS AFTER TOTAL ANKLE REPLACEMENT (TAR)

I had a total ankle replacement about six months ago. I’d like to get back on the tennis courts now. Are there any guidelines I should follow?

You should contact your orthopedic surgeon to ask this question. He or she will have a better idea what you can and can’t do based on the type of implant and surgery done.

Research comparing active patients before and after total ankle replacement (TAR) offer a few suggestions. More studies are needed in this area. For now, some general guidelines include:Increased use may mean increased wear of the polyethylene parts; loosening can occur.A full Physical Therapy rehab program is advised before jumping into sports activities.X-rays must show good bone stock and no signs of implant loosening.Orthopedic surgeon must approve activity level, rate, and type of sport; a support brace may be needed.Avoid quick stops and high-impact activities.Let pain be your guide; any pain or discomfort must be reported to the surgeon as soon as possible.

Victor Valderrabano, MD, et al. Sports and Recreation Activity of Ankle Arthritis Patients Before and After Total Ankle Replacement. In The American Journal of Sports Medicine. June 2006. Vol. 34. No. 6. Pp. 993-999.

ATHLETE’S WEAK ANKLE AFTER SEVERE SPRAIN

I had a severe ankle sprain during a tennis match last year. The ankle feels unsteady to me, like I can’t trust it. It also rolls in without warning. Why is this, and what can be done for it?

Ankle sprains are notorious for happening again once you’ve had one. When the ankle is first hurt, the sprained ligament gets stretched or torn, and the area swells. This can cause the ankle to feel unsteady and roll inward occasionally. This condition is called “give-way” and happens when the ligaments don’t support the joint. This is a sign that the nerve sensors that give a sense of position, called “joint sense,” have been harmed. Once injured, they don’t recover. The loss of position sense puts the joint at further risk of injury.

Proprioceptive exercises help retrain the sense of joint position, by getting the other sensors in the area to do the work of the damaged sensors. These exercises are similar to balance training. Examples include balancing on one leg with your eyes open and then closed, walking on uneven or soft surfaces, and practicing on a special balance board. If the problem continues, you may need the help of a Physical Therapist who will design a program that includes these kinds of exercises.

SPEED RECOVERY AFTER MAJOR ANKLE SPRAIN

I had a major ankle sprain after falling from a ladder. So far, my doctor and therapist have had me keep it wrapped, iced, and elevated. Is there anything else I can do to speed up my recovery?

It sounds like you are on the right track with the treatments you describe. Continue to follow the advice of your doctor and therapist.

Research suggests that patients who’ve had major ankle sprains may benefit from doing special training of their healthy ankles. Disk training has been used to rehabilitate ankle sprains. Now there is evidence that these benefits may actually cross over to the other side. Researchers studied patients who worked only their sore ankles on the disk. A circular platform with a small sphere under it, the disk looks a bit like a spaceship. Patients place their feet on it and work the ankle by tilting the disk in various positions.

The study showed that disk training quickened the response of muscles around the ankle at the moment the ankle started to sprain. The main shin muscle, the anterior tibialis muscle, showed the greatest improvement. Surprisingly, this muscle got faster on the other leg, too–the one that wasn’t worked on the disk.
This certainly raises the question whether patients with severe ankle sprains might benefit by starting disk treatments right away on their uninjured ankles. Be sure to talk with your health provider before experimenting with this type of treatment.

RECURRENT ANKLE SPRAIN

I had a bad ankle sprain last year. Since then, I keep twisting my ankle for no apparent reason. Why is this, and what can I do to prevent it from happening?

People who sprain their ankles sometimes find the ankle continues to give out without warning. Many times, the ankle gives out and actually sprains again, a condition called recurrent ankle sprain. The tiny sensors within the joints, muscles, and ligaments of the ankle are often injured in the initial injury. These sensors normally give the body a sense of joint position. Damage to these sensors puts the ankle at risk for additional sprains.

An effective treatment for ankle sprains is disk training. A circular platform with a small sphere under it, the disk looks a bit like a spaceship. Patients place their feet on it and work the ankle by tilting the disk in various positions.

Doctors and therapists have used this type of training with success. Patients doing this kind of exercise often show improved balance and decreased ankle pain. The disk improves mobility in the ankle joint and responsiveness in the muscles that support the ankle. Disk training appears to be an excellent way to protect against future ankle sprains

WHAT IS SURAL NERVE INJURY?

Have you ever heard of a sural nerve injury? Our 15-year-old daughter is an equestrian rider. She got bucked off a horse and her foot was stuck in the stirrup. Now she has numbness and tingling in her ankle and foot. The diagnosis is sural nerve injury. What does that mean? Will she get better?

The sural nerve (also known as the short saphenous nerve) is a sensory nerve, which means it conveys sensory messages. Damage or compression of the sural nerve can result in burning pain and diminished sensation or loss of sensation (numbness).

This nerve passes down from the back of the knee along the outside of the lower leg. It’s located along the surface of the lower one-third of the leg. It passes along the outer bone of the ankle, just behind the malleolus (ankle bone). Then it goes along the outside edge of the heel to the base of the fifth (baby) toe.

Injury usually occurs along the superficial portion where it is closer to the skin and more likely to be crushed or compressed. It supplies the skin and soft tissues along the lower third of the lower leg with sensory function. Tingling, burning pain, or loss of sensation anywhere along this pathway suggests a sural nerve injury.

Vijay Jotwani, MD, et al. Cutaneous Sural Nerve Injury After Lateral Ankle Sprain: A Case Report. In The Journal of Musculoskeletal Medicine. March 2008. vol. 25. No. 3. Pp. 126-128.

ANKLE SURGERY RECOVERY FOR DIABETICS

I brought Mother home from the hospital last night. She has diabetes and she broke her ankle requiring surgery. The nurses gave us a long list of Dos and Don’ts. They were very firm in telling us we had to follow the instructions exactly. My sister and I have been taking care of Mother all our lives. What is all the fuss about?

It’s wonderful that your mother is in good hands at home. Hospital staff don’t always know all the details about a patient’s home situation. And in the case of patients with diabetes, there are some very special concerns.

First of all, healing in this group can be very, very slow. Even with the best of care, the fracture may not heal. This can mean a nonunion or a malunion of the bones. Walking, balance, and coordination can be affected.

There is a serious risk of complications that could lead to amputation of the foot. In fact, complications among adult patients with diabetes and a fracture almost triple compared to someone without diabetes. And almost half of this group experiences some kind of problem during recovery.

There are several reasons for the delayed or non-healing response. Damage to the small blood vessels needed to supply the injured soft tissues and bone is common with chronic diabetes. This can keep oxygen and nutrients from reaching the healing area.

Likewise, high glucose levels over a long period of time can cause nerve injuries. Damage to the peripheral nerves can result in a loss of protective sensation in the feet. This, in turn, can lead to trauma, pressure ulcers, and even gangrene.

Strict adherence to the postoperative protocol is essential for a good result. Good communication with her primary care physician and other involved health care staff is vitally important during these next few months of recovery.

And to add one more Don’t to your list: Don’t hesitate to contact the nurse or doctor with any unusual changes that you see or concerns that you may have. Recognition of potential problems early in recovery can prevent more serious complications later.Saad B. Chaudhary, MD, MBA, et al. Complications of Ankle Fracture in Patients with Diabetes. In Journal of the American Academy of Orthopaedic Surgeons. March 2008. Vol. 16. No. 3. Pp. 159-170.

RESUMING HORSEBACK RIDING AFTER BROKEN ANKLE

I broke my ankle when I was thrown from my horse. I had to have surgery to pin the bones together. Now that the cast is off I’d like to go horseback riding again. Is this allowed?

You’ll want to check with your surgeon about this question. Returning to previous levels of activities like horseback riding may not be allowed until full healing has occurred. This is especially true if there are metal pins, screws, or plates in the joint.

Most expert riders agree a dorsiflexed ankle is important in riding. This means your toes
are pointing up and your heels are pressed down while in the stirrups. When the motion in the healing ankle is within five degrees of the other ankle, then activities like horseback riding may be allowed.

You may want to think about buying some breakaway or safety stirrups. If your horse falls, spooks, or throws you, the stirrups drop off the saddle. Your feet won’t get stuck in the stirrups while you get dragged around or crushed by the horse.Anne M. Moseley, PhD, et al. Passive Stretching Does Not Enhance Outcomes in Patients
with Plantarflexion Contracure after Cast Immobilization for Ankle Fracture: A Randomized Controlled Trial. In Archives of Physical Medicine and Rehabilitation. June 2005.
Vol. 86. No. 6. Pp. 1118-1126.

POST-INJURY ANKLE OSTEOARTHRITIS

I broke my ankle in a car accident several years ago. I was 23-years old at the time. Now I’m starting to notice some pain and stiffness in that ankle from time to time. I watched my Grandpa struggle with arthritis in both his ankles for years. Am I destined to have the same fate?

Ankle osteoarthritis (OA) isn’t as common as hip or knee OA so there aren’t as many studies on this topic to help answer this question. We do know that ankle OA is more common in people who have had a previous history of trauma.

It usually happens younger in life. Having this problem over a longer time period increases the chances of developing arthritis later. Arthritis linked with previous trauma or injury is called posttraumatic OA. If your grandfather had OA from aging, the condition would have been called degenerative OA.

Whether you have traumatic or degenerative OA, the symptoms and disability are similar. Early intervention may make a difference for you. It may be a good idea to see your orthopedic surgeon for a follow-up visit. Maintaining your motion and strength will help you stay active and may reduce your symptoms.

A short course of Physical Therapy to evaluate your ankle motion and set you up with a home program may be advised. Avoiding other musculoskeletal problems by staying active and fit will be of great benefit to your overall health and well-being.Charles L. Saltzman, MD, et al. Impact of Comorbitities on the Measurement of Health in Patients with Ankle Osteoarthritis. In The Journal of Bone and Joint Surgery. November 2006. Vol. 88-A. No. 11. Pp. 2366-2372.

ANKLE SUPPORT TO PREVENT ATHLETIC INJURIES

I am training on a trampoline for competition in gymnastic events. I’ve been told ankle injuries are common in this sport. I’d like to find some kind of ankle support to prevent this from happening. What do you recommend?

A dynamic program of ankle motion, strengthening, and improving proprioception (joint position sense) is always recommended first. In any barefoot sport that relies heavily on the foot and ankle, function, motion, strength, and stability are essential.

In trampoline and other gymnastic events, the ankle must respond to even the tiniest wobble or landing that isn’t right on. Previous ankle injuries, weak ankles, or less than normal joint motion can increase your risk of injury. Improving proprioception has been shown beneficial as well.

Once you have these key ingredients as part of your daily training program, you may not need any further support. But if you do, then experts suggest you may want to consider using a soft lace-up or velcro strap brace.

The semi-rigid aircast works well once you’ve sprained your ankle because it doesn’t allow you to plantar flex or point your toes. Any loss of plantar flexion when there’s no injury present will compromise your work on the trampoline. Should you find yourself with an ankle sprain, the Aircast is a good choice during the acute or early phase of healing.Eric Eils, PhD. Passive Stability Characteristics of Ankle Braces and Tape in Simulated Barefoot and Shod Conditions. In The American Journal of Sports Medicine. February 2007. Vol. 35. No. 2. Pp. 282-287

ANKLE SUPPORT TO PREVENT ATHLETIC INJURIES

I am training on a trampoline for competition in gymnastic events. I’ve been told ankle injuries are common in this sport. I’d like to find some kind of ankle support to prevent this from happening. What do you recommend?

A dynamic program of ankle motion, strengthening, and improving proprioception (joint position sense) is always recommended first. In any barefoot sport that relies heavily on the foot and ankle, function, motion, strength, and stability are essential.

In trampoline and other gymnastic events, the ankle must respond to even the tiniest wobble or landing that isn’t right on. Previous ankle injuries, weak ankles, or less than normal joint motion can increase your risk of injury. Improving proprioception has been shown beneficial as well.

Once you have these key ingredients as part of your daily training program, you may not need any further support. But if you do, then experts suggest you may want to consider using a soft lace-up or velcro strap brace.

The semi-rigid aircast works well once you’ve sprained your ankle because it doesn’t allow you to plantar flex or point your toes. Any loss of plantar flexion when there’s no injury present will compromise your work on the trampoline. Should you find yourself with an ankle sprain, the Aircast is a good choice during the acute or early phase of healing.Eric Eils, PhD. Passive Stability Characteristics of Ankle Braces and Tape in Simulated Barefoot and Shod Conditions. In The American Journal of Sports Medicine. February 2007. Vol. 35. No. 2. Pp. 282-287.

ARTHRITIC ANKLE SURGERY FOR SENIORS

I am not a young 62-year-old, if you know what I mean. But I’m still a little active. I don’t run marathons, but I do like to golf and dance once in a while. The problem is I’ve got a bum ankle from arthritis. Am I too old for some kind of surgery for this problem?

Ankle pain, decreased joint motion, and loss of function can be very disabling. Conservative care can help some individuals regain more normal joint action. If you have not had a rehab program of some kind, then that may be your first step to recovery.

But if painful and disabling symptoms persist after six months of rehab, then surgery may be advised. Ankle fusion is the most common operation for this type of problem. Joint motion is already limited by the pain and arthritic changes in the joint. By completely fusing the joint, the pain can be decreased or eliminated.

But if you want to preserve joint motion, then a total ankle replacement (TAR) may be right for you. TAR is a fairly new operation. Implant designs are still being changed and improved.

Patients receiving TARs tend to be young in general (younger than 65 years old). But this group of patients are still older than patients who have ankle fusions.

An orthopedic surgeon is the best one to advise you. A careful exam and assessment will guide the physician in planning the best plan of treatment for you.S. L. Haddad, MD, et al. Intermediate and Long-Term Outcomes of Total Ankle Arthroplasty and Ankle Arthrodesis. In The Journal of Bone and Joint Surgery. September 2007. Vol. 89-A. No. 9. Pp. 1899-1905.

DISK TRAINING TREATMENT FOR ANKLE SPRAIN

I am being treated for an ankle sprain. My Physical Therapist has me stand and work my ankle on a big round disk. How does this type of training help?

Disk training is an effective treatment for ankle sprains. The disk is a circular platform with a small sphere under it. People place their feet on it and work the ankle by tilting the disk in various positions.

Disk training can improve balance, ease ankle pain, and protect people from having repeated ankle sprains. A unique study also showed how this type of training quickens the response of muscles around the ankle. The main shin muscle, the anterior tibialis muscle, showed the greatest improvement. By getting the ankle muscles to respond faster in the event the ankle turns inward, the disk helps protect your ankle from being sprained again.

PREVENTING ANKLE SPRAINS CAUSED BY SNOWBOARDING

I am a snowboarder, and I’ve had a couple of painful ankle sprains. Should I do something about it?

Absolutely. What feels like a series of ankle sprains could actually be a break in the main ankle bone, called the talus. The fracture commonly involves a small bump on the outside of the talus. This kind of injury is common among snowboarders but hard to see on an average X-ray. Doctors can identify ankle fractures by X-raying the ankle at a specific angle and by using a CAT scan. The CAT scan provides a detailed X-ray that looks like “slices” of the bone tissue.
If left untreated, an ankle fracture can lead to bigger problems, such as ongoing pain, ankle arthritis, and the inability to do sports. Once your doctor identifies the problem, he or she can suggest ways to treat it. Whether you wind up having a cast or an operation, you’ll be better off in the long run if you tend to your ankle now

ATHLETE WRAPPING ANKLE SPRAIN FOR COMPETITION

I am a gymnast coming up on a big regional tournament. About two weeks ago, I sprained my ankle. My coach wants me to wear tape during the competition. I’m worried it will hold me back. What should I do?

Ankle sprain is one of the most common injuries among all kinds of athletes. And three-fourths of those who sprain their ankles once, do it again. Chronic ankle instability could really effect your performance as a gymnast.

You may want to wear some type of ankle support. If tape seems too restrictive, try using elastic wrap or a neoprene sleeve that fits over the foot and ankle. A recent study comparing different types of ankle taping showed taping does not impair function or performance.

It doesn’t improve performance either. But it gives the athlete a sense of stability and confidence needed during competition. And it may prevent re-injury, which is equally important.Kate Sawkins, et al. The Placebo Effect of Ankle Taping in Ankle Instability. In Medicine & Science in Sports & Exercise. May 2007. Vol. 39. No. 5. Pp. 781-787.

CAN AN ANKLE SPRAIN CAUSE PAIN IN THE KNEE?

I am a competitive runner. During my training for a marathon, I increased my mileage. Shortly after that, I twisted my ankle while running. My ankle doesn’t hurt, but my knee does. There’s a painful tenderness along the outside of the knee, just below the joint. Can an ankle sprain cause pain at the knee?

Yes. Anytime there’s an injury, problems can occur in the joint above or below that injury. It’s possible that you hurt your knee and your ankle at the same time. If the ankle injury is more painful or obvious, the other trauma may be missed for some time.

The force of the injury through the ankle can also put a twisting load on the joint just below the knee. This is the tibiofibular joint, the place where the two bones of the lower leg (tibia and fibula) meet.

Before continuing training, it would be a good idea to have this evaluated. There could be a bone fracture, torn ligament, or stretched nerve causing these symptoms. Treatment now may help prevent a worse injury later.

Jon K. Sekiya, MD, and John E. Kuhn, MD. Instability of the Proximal Tibiofibular Joint. In Journal of the American Academy of Orthopaedic Surgeons. March/April 2003. Vol. 11. No. 2. Pp. 120-128

BROKEN OR SPRAINED ANKLE?

How can you tell whether an ankle is broken or just sprained?

The foot and ankle are complex parts of the body. Sometimes it is impossible to tell what the injury is without an X-ray or other tests, such as a bone scan or MRI (magnetic resonance image). Computed tomography (CT scan) is also helpful for seeing if there is serious damage to a bone. If there is pain, swelling, tenderness to touch, redness, decreased motion, and inability to put weight on the foot, then a visit to the doctor is necessary.

When in doubt, you can use the RICE advice. These four letters stand for Rest, Ice, Compression, and Elevation.

  • Rest the sore ankle so it can begin healing.
  • Ice the ankle for 20 minutes every three to four hours.
  • Compress the joint with an elastic wrap or splint.
  • Elevate the sore and swollen limb for 24 hours.

If after 24 hours the symptoms are much improved and it is possible to put full weight on the ankle, a fracture is unlikely. If there is little or no change in how the ankle looks and feels, see your doctor.

ANKLE AMPUTATION FOR ARTHRITIS?

Have you ever heard of anyone having his or her foot amputated for arthritis? My grandma just had this done and it doesn’t make any sense to me.

Sometimes arthritis gets so bad the joint has to be fused so it doesn’t move any more. The surgeon takes bone chips from a donor bank or from the patient’s own pelvic bone and inserts them in and around the joint. New bone cells fill in forming a solid fusion.

Amputation after fusion occurs in up to 15 percent of all cases of ankle fusion. The reasons for this vary from patient to patient. Sometimes the bone doesn’t “take” and the joint doesn’t fuse. This is called a nonunion. In other cases bone infection eats away at enough bone that there’s a danger of gangrene. Amputation may be the only option to save the leg.

Believe it or not, many patients prefer amputation to the intense pain and suffering they’ve had with the arthritis. With a prosthetic device, they can walk again pain free. They report their improved quality of life was worth the loss of a foot.Nelson F. SooHoo, MD, and Gerald Kominski, PhD. Cost-Effectiveness Analysis of Total Ankle Arthroplasty. In The Journal of Bone and Joint Surgery. November 2004. Vol. 86-A. No. 11. Pp. 2446-2455

WHAT IS A HIGH ANKLE SPRAIN?

Have you ever heard of a high ankle sprain? My daughter hurt her ankle while playing hockey and this is what the doctors are calling it?

Most ankle sprains stretch or tear the ligaments along the outer (lateral) border of the ankle. Sometimes a medial (inside) ankle sprain occurs.

A “high” ankle sprain is used to describe an injury of the ligament that joins the two lower leg bones together. This ligament is called the syndesmosis ligament. The ligament is above the ankle, which is why it’s called a high sprain.

This type of injury occurs most often in hockey players and skiers. The foot and ankle get turned out or externally rotated. Since the foot is in a rigid skate or ski boot there’s no “give” and the ligament tears.

Rick W. Wright, MD, et al. Ankle Syndesmosis Sprains in National Hockey League Players. In American Journal of Sports Medicine. December 2004. Vol. 32. No. 8. Pp. 1941-1947.

PROBLEM WITH ANKLE RECONSTRUCTION

Four months ago, I had surgery to reconstruct my ankle. I had a worn and arthritic ankle joint on one side. I was trying to avoid having a fusion. But I’m no better off than before the surgery. Pain and loss of motion affect the way I walk. Even my balance is off. How long do I have to wait before going ahead with the fusion after all?

It sounds like you might have had realignment surgery to correct an asymmetrical (uneven) deformity. Sometimes realignment surgery works very well to restore the normal ankle position. Decreased pain and increased motion often result in improved function.

But when the procedure fails, then a second operation may be needed. The surgeon may be able to revise the original surgery. Two treatment options include total ankle replacement and ankle fusion.

The treatment decision is based on the position of the ankle bones. The surgeon will also look at the width of the joint space across the joint. It may be possible to measure the load placed on each side of the joint. A minor revision may be all that’s needed to unload the diseased (worn) joint area.

See your surgeon again before assuming a fusion is the next step. It’s possible that you might benefit from a rehab program. If not, a second revision operation may be possible.

The surgeon will do whatever is possible to postpone or avoid an ankle fusion or TAR. With reconstruction revision, fusion or TAR are still possible if needed later.Geert I. Pagenstert, MD, et al. Realignment Surgery as Alternative Treatment of Varus and Valgus Ankle Osteoarthritis. In Clinical Orthopaedics and Related Research. September 2007. Vol. 462. Pp. 156-168

REPEATED ANKLE SPRAINS

Every now and then my ankle gives way on me. I sprained it about two years ago. It feels like I’m respraining it a little bit each time this happens. Why does this happen?

When people report repeated ankle sprains, the condition is referred to as functional instability. You can walk on that foot, but as you described, every now and then without warning, the foot and ankle give way. This condition is the most common long-term problem after an ankle sprain injury.

Scientists aren’t exactly sure what causes this to happen. The obvious answer is that supporting ligaments damaged in the first injury aren’t holding the ankle in place. But there must be more to it than that, or the ankle would give way with every step you took.

There are a couple of theories to explain FI. The first is known as articular deafferentation. According to this theory, tiny receptors in the joint capsule and ligaments around the ankle are damaged. These are called mechanoreceptors.

Ankle stability depends on the muscles around the ankle to react quickly to sudden movements. Enough muscle tension is created to prevent the ankle from going too far in one direction of the other. The mechanoreceptors signal the muscles when the joint is in danger. The muscles respond to stabilize the joint. Damaged mechanoreceptors don’t allow a fast enough response and down you go!

Another idea is the feed-forward motor control theory. Recent research has shown that the body may react to certain positions and movements ahead of time based on past experience. So for example, when you go to take a step, the muscles contract to position and hold the ankle in just the right spot. The goal is to stabilize it and prevent injury.

After injury, the muscles may anticipate injury and start to contract too early. The intent is to protect the joint but the result is abnormal motor control and giving way of the joint. Sometimes this problem can be corrected with a fairly simple program of exercises and activities. A Physical Therapist can help you with this.Eamonn Delahunt, BSc, et al. Altered Neuromuscular Control and Ankle Joint Kinematics During Walking in Subjects with Functional Instability of the Ankle Joint. In The American Journal of Sports Medicine. December 2006. Vol. 34. No. 12. Pp. 1970-1976.

DOES ANKLE TAPING PREVENT INJURY?

Does ankle taping really work? I see many of my teammates using various methods of taping to keep from re-spraining their ankles. If it works, which type of taping is best?

Taping is a common way to support a joint, especially the ankle joint. The goal is to reduce the risk of re-injury and avoid another ankle sprain. But does it work? And if it does work, what’s the mechanism behind the effect?

Right now, all we have are theories about this. The general consensus is that taping does help prevent re-injury. There are two most likely explanations for this. First, tape gives the joint mechanical support. The tape keeps the ankle joint from moving too far in any one direction.

Second, it enhances proprioception. Proprioception is the sense of where the ankle is at any given moment. Proprioception allows the ankle to feel changes in the surface or slope of a surface. That way the ankle and foot can make necessary corrections to stay steady and balanced while walking or running.

A new theory has been proposed as a result of some recent research. It may be that ankle taping may have a placebo effect. Placebo means it doesn’t really have any effect, but the person thinks it does.

Under these conditions, the athlete performs with increased confidence. The athlete expects the tape to work, so it does. Studies show that taping doesn’t negatively effect performance. It’s likely that taping does prevent reinjury. It probably doesn’t really improve function.

All things considered, it’s still a good idea to use taping to prevent spraining the ankle again. The method of taping isn’t as important as the person’s belief that the taping is helping.Kate Sawkins, et al. The Placebo Effect of Ankle Taping in Ankle Instability. In Medicine & Science in Sports & Exercise. May 2007. Vol. 39. No. 5. Pp. 781-787.

HOW LONG AFTER SPRAIN BEFORE I CAN JUMP?

After spraining my ankle I notice I can step down off stairs or curbs but I still can’t jump across a puddle or other obstacles. How long does it take to get this skill back?

Acute ankle injury takes about four to six weeks to recover and heal. This means the pain and swelling are gone and you can put your full weight on that leg.

Moderate to severe ankle sprains often involve a torn ligament. Ligaments do not heal like muscles do. Once they are torn, scar tissue fills in. The elastic quality of the ligament is gone. The result can be changes in the joint’s sense of movement and position in space called proprioception.

Loss of proprioception may result in ankle instability. Changing position and keeping balance can be difficult. The skill may not come back without a rehab program to “reset” joint proprioception.

A Physical Therapist can test your ankle and let you know if rehab is needed. He or she can also set you up on a rehab program. With careful practice on your part, your ankle can be restored in several weeks to several months.Erik A. Wikstrom, MS, ATC/L, et al. Detection of Dynamic Stability Deficits in Subjects with Functional Ankle Instability. In Medicine & Science in Sports & Exercise. February 2005. Vol. 37. No. 2. Pp. 169-175

WEAK ANKLES AFTER PLAYING VOLLEYBALL

After playing volleyball for a few hours, my ankles feel wobbly and weak. What causes this? Is there something I can do about it?

This is actually a common experience for people who play basketball or volleyball. After intense activity, the ankle’s ability to sense its position may be impaired. This could explain the awkward or clumsy feeling some people have after exercise.

The ability of a joint to sense its position is called proprioception. It is possible to improve proprioception through a series of specific exercises. Physical Therapists typically use these exercises to rehabilitate people after injury. The same exercises could be used as part of an athletic training program.

PREVENTING ANKLE ARTHRITIS AFTER SPRAIN

About two years ago, I sprained my ankle big time. It never has healed properly. In fact, I think I may have resprained it several times just in the last few months. Now I’m worried that I’ll end up with arthritis in that joint. Can I do anything to prevent this from happening?

Ankle arthritis can be caused by trauma. A sprain that never completely heals properly can cause significant ankle instability and foot malalignment. Over time, this type of imbalance can lead to excessive joint wear and tear. Painful, debilitating post-traumatic arthritis may be the end result.

Now is a good time to address your concerns. An orthopedic evaluation may serve you well. X-rays of the ankle may be taken. This will show the joint spaces and articular surface of the joint. Any signs of joint space narrowing, uneven surfaces, or the presence of bone spurs may point to a diagnosis of arthritis.

Many people have significant signs of arthritic changes without symptoms, so doctors don’t put a lot of stock in X-ray results. They can provide some additional information not possible with a physical exam.

After taking a history and conducting a physical exam, the orthopedic surgeon will be able to advise you of your treatment options. A Physical Therapist can help identify areas of weakness and instability and plan an appropriate rehab program. Muscle strengthening is important but treatment will also address joint proprioception (sense of position) needed to prevent chronic reinjury.

If there is too much ligamentous damage, surgery may be needed. A conservative rehab program is advised before having surgery, so that’s the first step even for severely damaged soft tissue structures.Loretta B. Chou, MD, et al. Osteoarthritis of the Ankle: The Role of Arthroplasty. In Journal of the American Academy of Orthopaedic Surgeons. May 2008. Vol. 16. No. 5. Pp. 249-259

PAIN AND LOSS OF MOTION AFTER ANKLE REPLACEMENT

About 18 months ago I had a total ankle replacement for severe ankle arthritis. Everything seemed to be going good until last month. I started to have ankle pain and a loss of motion. It almost feels like the joint is jammed together. Is this possible?

You may be describing a situation called subsidence. The implant can actually sink down into the bone. This can cause the symptoms you are having. You may also feel like the leg on that side is shorter. Your pant legs may seem uneven or your waist may look lower on one side compared to the other.

Call your surgeon and report these problems. Early attention can make the difference between implant revision and removal.

Justin Greisberg, MD, et al. Takedown of Ankle Fusion and Conversion to Total Ankle
Replacement. In Clinical Orthopaedics and Related Research. July 2004. Vol. 424. Pp. 80-88.

ANKLE GIVING OUT AFTER SPRAIN

A year ago I sprained my right ankle. It doesn’t hurt but it gives out on me. What could be causing this? 

Ankle sprains can often lead to problems with an unstable ankle lasting months to years later. It usually happens when there’s weakness of the ankle muscles and a loss of proprioception.

Proprioception is the sense the joint has of its own position. Studies show ankle sprains result in damage to the receptors that signal the joint about its position. These receptors are located in the ligaments, muscles, and tendons. Injury to any of these structures can result in decreased proprioception.

A rehab program to restore muscle strength and proprioception can be helpful.Valter Santilli, MD, et al. Peroneus Longus Muscle Activation Pattern During Gait Cycle in Athletes Affected by Functional Ankle Instability. In American Journal of Sports Medicine. August 2005. Vol. 33. No. 8. Pp. 1183-1187

FRACTURE PAIN AND STIFFNESS RETURNING

A year ago I fractured my ankle and had a very slow recovery. Everything finally seemed to be working fine but now it’s starting to stiffen up and hurt quite a bit. Am I going to have problems like this for the rest of my life?

You may be experiencing the start of post-traumatic adhesive capsulitis. This is like having a frozen ankle (similar to a frozen shoulder). Scar tissue forms in and around the ankle. Fibrous bands try to replace any torn ligaments and stabilize the joint.

Unfortunately the body sometimes overdoes it and too much scar tissue and too many adhesions form. Loss of motion from the restrictive tissue sets up a pain cycle early on.

It’s best to make an appointment with your surgeon for some follow-up. You may need to resume some of your rehab exercises. The therapist can also mobilize the joint. This may break up some of the adhesions, restore the joint fluid, and ankle motion. If a short course of therapy doesn’t change the picture, then surgery may be needed.

The doctor may have to cut the joint capsule and possibly remove some of the fibrous scar tissue. This type of surgery can sometimes be done arthroscopically. This saves you from having large, painful incisions and more scar tissue later.Tun Hing Lui, MBBS (HK), FRCS, et al. The Arthroscopic Management of Frozen Ankle. In The Journal of Arthroscopic and Related Surgery. March 2006. Vol. 22. No. 3. Pp. 283-286.