By M. Jordan Brassell, DPM
Although treating ankle sprains often is as simple as following the well-known Rest, Ice, Compression and Elevation (R.I.C.E.) protocol, not all cases are so straightforward.
Most patients who seek medical care for a suspected sprain already have tried R.I.C.E. and anti-inflammatory medications for at least several days but still suffer from lingering pain, tenderness, swelling, bruising and/or limited range of motion.
At that point, therefore, physicians likely should delve deeper to determine what exactly is damaged inside the ankle joint. A “sprain” could not only involve a partial or total tear of one or more ligaments, but a bone contusion, occult fracture, tendon dislocation, cartilage loss or injury, or even nerve traction injuries.
Ankle injuries that are incorrectly diagnosed and treated as only sprains will leave patients at much higher risk for chronic joint weakness and instability – and thus more susceptible to repeated injuries that can lead to painful conditions, such as earlier-onset arthritis, ankle instability and soft tissue impingement.
There are an estimated one to two million ankle injuries annually in the United States, approximately 85 percent of them ankle sprains. That isn’t surprising given the foot and ankle’s high-impact location and complex anatomy, with dozens of bones, ligaments, tendons, muscles, and cartilage packed into a tight space.
Whenever the ankle rolls, twists or turns awkwardly, ligaments and surrounding muscle, tendon, and neurovascular structures can stretch well beyond their normal range of motion. Resulting ankle sprains are graded from mild to severe, from sprains and microtears in tissues to partial or full-thickness tears of one or multiple ligaments.
The most commonly affected ligament is the anterior talofibular ligament, or ATFL, which runs along the antero-lateral aspect of the ankle joint. If repeatedly damaged, the ATFL or other connective tissues can become permanently more elastic and susceptible to re-injury.
Complicating matters is that severe ankle sprains can have similar symptoms to fractures of the tibia, fibula or talus, especially hairline or occult fractures. Patients with unresolved pain from a “sprain” would likely benefit from an MRI to visualize bone damage and edema that may not appear on X-ray and to determine the structural health of all soft tissues.
Many of these patients also are good physical therapy candidates, especially those who have worn an immobilizing brace or boot for two or more weeks. Therapists aim to build muscle strength in and around the joint for stability and also may integrate specialized treatment for patients to help re-teach proprioceptors, as their response may have been diminished.
Finally, while the vast majority of ankle sprains do eventually resolve with conservative treatments, patients with chronic issues have multiple surgical options. Those span from direct repairs and ligament augmentations to cartilage transplants; procedures often can be done arthroscopically and as minimally invasive surgeries to minimize damage and speed recovery.
All patients should be aware that if their ankle pain, swelling and other symptoms continue after a short period on a R.I.C.E. regimen, they should consider seeking advice from an orthopaedic specialist to protect the long-term health of their joints.
Dr. Brassell is a podiatrist with Hampton Roads Orthopaedics Spine & Sports Medicine, specializing in foot and ankle surgery and sports medicine. He sees patients in HROSM’s Newport News and Yorktown offices. hrosm.com