Ankle Sprains

An ankle sprain is a common injury and usually results when the ankle is twisted, or inverted. The term "sprain" signifies injury to the soft tissues, usually the ligaments, of the ankle.

Anatomy

A ligament is made up of multiple strands of tissue - similar to a nylon rope. A sprain results in tearing of the ligaments. The tear can be a complete tear of all the strands of the ligament or a partial tear, where a portion of the strands of the ligament are torn. The ligament is weakened by the injury - how much depends on the degree of the tear. The lateral ligaments are by far the most commonly injured ligaments in a typical inversion injury of the ankle.

On the lateral side of the ankle there are three ligaments that make up the lateral ligament complex. These include the anterior talofibular ligament (ATF), the calcaneofibular ligament (CF) and the posterior talofibular ligament (PTF). The very common inversion injury to the ankle usually injures the anterior talofibular ligament and the calcaneofibular ligament. The ATF ligament keeps the ankle from sliding forward and the CF ligament keeps the ankle from rolling over on its side.

Symptoms

Initially the ankle is swollen, painful, and may turn echymotic (bruised). The bruising, and the initial swelling, is due to ruptured blood vessels from the tearing of the soft tissues. Most of the initial swelling is actually bleeding into the surrounding tissues. This initial swelling due to bleeding then increases due to edema fluid leaking into the tissues as well over the next 24 hours.

Diagnosis

The diagnosis of an ankle sprain is usually made by examination of the ankle and xrays to make sure that there is no fracture of the ankle. If there is a complete rupture of the ligaments suspected, your doctor may order stress xrays as well. These xrays are taken while someone twists or "stresses" the ligaments.

Medical Treatment

Treatment begins initially by:

controlling swelling

controlling pain

controlling weight bearing

Elevation will help control the swelling

Gentle compression and ice will control swelling

Mild pain relievers will help with the pain

Crutches will prevent weight bearing.

Casts have fallen out of favor, and as treatment progresses, early weight bearing has been shown to be beneficial. Braces that can be worn to support the ankle - but still allow weight bearing are the most popular treatment method today. Healing of the ligaments usually takes about 6 weeks. The swelling may be present for several months. A physical therapist may be suggested to help you regain full function of your injured ankle.

Ankle Instability

In a small number of cases, the ligaments will not heal back as strong as normal. This results in an ankle that is unstable and has a tendency to give away, or twist again very easily. Ankle instability can lead to an ankle that is sore and painful, sometimes swollen, and untrustworthy on rough terrain. If your ankle ligaments do not heal back adequately following an ankle sprain there are several things that may be suggested by your doctor.

A physical therapy program (see below) may help strengthen the muscles around the ankle to help make the ankle more reliable. The therapy is also necessary to "retrain" the proprioceptive nerves around the ankle that have been torn with the ligament. These nerves are important in telling our brains how to use the muscles to allow the joints to properly function. An ankle brace may also help control some of the instability and prevent the ankle from giving way.

Surgery

If all these simple measures fail, surgery may be suggested to reconstruct the ligaments that have been torn. Surgery involves making an incision on the side of the ankle. A portion of the tendon called the peroneus brevis is used to reconstruct the lateral ligaments.

A drill hole is made in the fibula, near the attachment the original ligament. A second drill hole is made in the area where the ligaments attached to the talus. The tendon graft is then woven these holes to recreate the ligament complex.

After surgery, you will usually be placed in a cast or brace for about 6 weeks to allow the tendon reconstruction to heal. Following removal of the cast, physical therapy will be required to regain full use of the ankle.

Rehabilitation

Whether you have had an ankle sprain that did not require surgery or whether you are recovering form surgical reconstruction of the ankle ligaments you will probably benefit from physical therapy. Your physical therapist will evaluate your foot and ankle on your first visit to therapy. This will enable your therapist to locate the sore tissue and to develop a treatment plan.

The outside ligaments of the ankle are hurt most often in an ankle sprain. This is because most ankle sprains are from an inward twist (an inversion injury). When this happens, the force from the twist may also compress the tissues on the medial, or inside, of the ankle. This can be a source of pain and inflammation on the inside area of the ankle. A grade of I, II, or III is usually given depending on whether you had a slight sprain (I), significant tearing and bleeding (II), or a complete rupture of the tendon (III).

Acute Treatment

Treatment may vary depending on which grade sprain you've had. In each case, the first line of treatment is to calm the inflammation and halt the swelling. The RICE principle can help address each of these needs.

Rest: A brace or splint will keep the ankle in a safe position, helping you avoid more strain to the sore area. In severe cases, you may require a pair of crutches to limit weight through the foot.

Ice: Cold therapy in the form of ice towels, bags, or wraps can aid in slowing the inflammatory process and in limiting pain. Apply as directed by your therapist.

Compression: An elastic wrap or an air-type brace can compress the sore area, keeping the swelling to a minimum.

Elevation: Keep your ankle elevated above the level of your heart. This will help drain the extra fluid (edema) back into the lymph system.

Other treatment choices may be used to further limit pain and inflammation. Examples include contrast baths with hot and cold applications, cold whirlpool, or electrical stimulation.

Early Healing Phase

Range of Motion Exercises: As healing gets underway, it is important to begin a series of movement exercises for range of motion (ROM). At first, you'll work on bending and straightening the ankle. Later, diagonal motions can be used.

Strength Progression: Next, you'll begin a strengthening progression for the muscles around the ankle. Emphasis should be placed on the muscles that pull the foot up and out (evertors), up (dorsiflexors), and that raise the heel (plantarflexors). Isometrics may be chosen in the early stages of rehabilitation. These are strengthening exercises in which the muscles are working but the joint stays stationary. They allow you to exercise with the ankle at different angles, helping you stay away from painful positions of the ankle. These exercises provide the benefit of reducing overall pain and swelling. They also help the muscles remember what they're supposed to be doing.

Early resisted exercises: Some types of equipment are helpful in reducing the effects of gravity, allowing you to begin strengthening without causing pain. One example is the sled. It can be set at lower angles at first and then gradually progressed over the course of physical therapy as pain eases. Therapeutic band, pulleys, or isokinetic device may be used to apply progressive resistance to the muscles around the ankle.

Balance exercises: These exercises are especially important following a ligament injury. Healthy ligaments send information to the central nervous system about the position of a joint. That's partly why when we close our eyes we know precisely where our limbs are positioned. Once a ligament has been injured, these receptors are unable to receive and send the needed information to the brain. This increases the possibility of injury in the future. Balance exercises help restore this position sense by heightening the sensitivity in the remaining intact receptors. Examples of these types of exercises involve standing and walking on uneven or very soft surfaces, single leg balance, mini trampoline balance, and progressive agilities.

The structure of your foot is complex, consisting of bones, muscles, tendons, and other soft tissues. Of the 26 bones in your foot, 19 are toe bones (phalanges) and metatarsal bones (the long bones in the midfoot). Fractures of the toe and metatarsal bones are common and require evaluation by a specialist. A foot and ankle surgeon should be seen for proper diagnosis and treatment, even if initial treatment has been received in an emergency room.

What is a Fracture?

A fracture is a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.

Traumatic Fractures

Traumatic fractures (also called acute fractures) are caused by a direct blow or impact-like seriously stubbing your toe. Traumatic fractures can be displaced or nondisplaced. If the fracture is displaced, the bone is broken in such a way that it has changed in position (dislocated). Treatment of a traumatic fracture depends on the location and extent of the break and whether it is displaced. Surgery is sometimes required.

Signs and symptoms of a traumatic fracture include:

You may hear a sound at the time of the break.

Pinpoint pain" (pain at the place of impact) at the time the fracture occurs and perhaps for a few hours later, but often the pain goes away after several hours.

Deviation (misshapen or abnormal appearance) of the toe.

Bruising and swelling the next day.

It is not true that "if you can walk on it, it's not broken."

Evaluation by the foot and ankle surgeon is always recommended.

Stress Fractures
Stress fractures are tiny, hairline breaks that are usually caused by repetitive stress. Stress fractures often afflict athletes who, for example, too rapidly increase their running mileage. Or they may be caused by an abnormal foot structure, deformities, or osteoporosis. Improper footwear may also lead to stress fractures. Stress fractures should not be ignored, because they will come back unless properly treated. Symptoms of stress fractures include:
Pain with or after normal activity

Pain that goes away when resting and then returns when standing or during activity

Pinpoint pain" (pain at the site of the fracture) when touched

Swelling, but no bruising

Is it a Fracture, or a Sprain?

Sprains and fractures have similar symptoms, although sometimes with a sprain, the whole area hurts rather than just one point. Your foot and ankle surgeon will be able to diagnose which you have and provide appropriate treatment. Certain sprains or dislocations can be severely disabling. Without proper treatment they can lead to crippling arthritis.

Consequences of Improper Treatment
Some people say that "the doctor can't do anything for a broken bone in the foot." This is usually not true. In fact, if a fractured toe or metatarsal bone is not treated correctly, serious complications may develop. For example:

A deformity in the bony architecture which may limit the ability to move the foot or cause difficulty in fitting shoes.

Arthritis, which may be caused by a fracture in a joint (the juncture where two bones meet), or may be a result of angular deformities that develop when a displaced fracture is severe or hasn't been properly corrected.

Chronic pain and long-term dysfunction.

Non-union, or failure to heal, can lead to subsequent surgery or chronic pain.

Treatment of Toe Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:
Rest. Sometimes rest is all that is needed to treat a traumatic fracture of the toe.
Splinting. The toe may be fitted with a splint to keep it in a fixed position.
Rigid or Stiff-Soled Shoe. Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned.
Buddy Taping." "Buddy taping" the fractured toe to another toe is sometimes appropriate, but in other cases it may be harmful.
Surgery. If the break is badly displaced or if the joint is affected, surgery may be necessary. Surgery often involves the use of fixation devices, such as pins.
Treatment of Metatarsal Fractures

Breaks in the metatarsal bones may be either stress or traumatic fractures. Certain kinds of fractures of the metatarsal bones present unique challenges.

For example, sometimes a fracture of the first metatarsal bone (behind the big toe) can lead to arthritis. Since the big toe is used so frequently and bears more weight than other toes, arthritis in that area can make it painful to walk, bend, or even stand.

Another type of break, called a Jones fracture, occurs at the base of the fifth metatarsal bone (behind the little toe). It is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments. Your foot and ankle surgeon is an expert in correctly identifying these conditions as well as other problems of the foot.

Treatment of metatarsal fractures depends on the type and extent of the fracture, and may include:
Rest. Sometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
Avoid the Offending Activity. Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.

Immobilization, Casting, or Rigid Shoe. A stiff-soled shoe or other form of immobilization may be used to protect the fractured bone while it is healing.

Surgery. Some traumatic fractures of the metatarsal bones require surgery, especially if the break is badly displaced.

Follow-Up Care. Your foot and ankle surgeon will provide instructions for care following surgical or non-surgical treatment. Physical therapy, exercises and rehabilitation may be included in a schedule for return to normal activities.
Stress Fracture / March Fracture

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WHAT'S THE PROBLEM?

Stress fractures are an injury to bone caused by unaccustomed stress from running, marching, or walking. They are often seen in military recruits or athletes as they increase their training. They may also be seen in people with hormonal imbalances or prior surgery that has altered the way their foot or ankle functions.

HOW DOES IT FEEL?

Stress fractures may feel like an ache in the foot or ankle or may feel like a sharp pain when a lot of stress is placed on the foot or you are doing heavy physical activity. You will also notice swelling around the site of the pain, but usually no bruising is present.

LET'S DO A TEST!

Your podiatrist will take an x-ray to determine if there is a break or crack in the bone. After several weeks a large calcium deposit or bone callus may be seen around the stress fracture. However, early on, when the pain starts, no change at all may be seen on x-ray. Your podiatrist may place a tuning fork on the area where he or she thinks a stress fracture may be located. This will result in pain being noted at a very distinct location. Finally, if doubt still exists about the diagnosis, a bone scan may be obtained, which shows increased bone production if a stress fracture is present. This test is the most sensitive for detecting a stress fracture, but in clear cases may be unnecessary. In people at high risk for stress fractures, such as military personnel in basic training, normal x-rays do not change treatment plans and people are treated as if they do have a stress fracture.
HOW DID THIS HAPPEN?

Bone is a living, breathing tissue that also has large amounts of minerals that provide strength. When increased stress is applied (sudden increases in exercise time or intensity) the bone responds by becoming stronger and denser where the extra stress is applied. If there is not enough time for that adaptation to occur, small micro cracks develop. In severe cases, these small cracks can result in a complete displaced fracture if treatment is not initiated. Bone fractures are most commonly thought of as resulting from acute injuries that happen all at once. Stress fractures are another type of fracture that occurs gradually, from repeated injury, over use or stress, over longer periods of time.

WHAT CAN I DO FOR IT?

Stop whatever exercise you are doing that has resulted in your foot or ankle pain. Stress fractures are not caused by an injury like an ankle sprain or bumping something with your foot, so if you cannot remember a precise injury that started the pain, you may self-treat with ice, over-the-counter pain medications, and comfortable shoes. If there is not a decrease in pain over several days, see your foot doctor.

WHAT WILL MY DOCTOR DO FOR IT?

After making the diagnosis of stress fracture, your doctor will tell you to decrease activity levels. You may either be instructed to wear athletic shoes or a stiff soled shoe, to reduce bending motions of your foot when you walk. Depending on the location and severity, your doctor may recommend a cast and crutches. As the pain becomes less intense, you may gradually resume your activity level.

CAN I PREVENT IT FROM HAPPENING AGAIN?

Never increase exercise levels too quickly; no more than a ten percent increase per week. Always wear good supportive shoes that will absorb and cushion all the stress caused by your activity. If your stress fracture was a result of a medical condition, closely follow your doctor's instructions to prevent a recurrence.

Dr. Craig Thomajan is a Podiatrist at Austin Foot and Ankle Specialist located in Austin, Texas. If you would like to learn more, please visit him on the web at Austin Foot and Ankle