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Chronic Ankle Sprain

What Is A Chronic Ankle Sprain?

Chronic ankle sprain is the failure of an ankle to recover following an acute ankle sprain injury. Most acute injuries heal within 4 to 6 weeks.

The injured ligaments could be on the outside of the ankle (lateral), the inside (medial) or both.

As instability (feeling of weakness and sense of giving way) is typically the main complaint, it is also known as chronic ankle instability.


Stability to the joints is derived by two mechanisms:

  • Dynamic stability – muscle contraction across joints help to stabilise the joints
  • Static stability – ligaments and the shape of the bones help provide stability

Dynamic stability is the most important of the two during normal function and activities of daily living. It is only when dynamic stability fails, do the ligaments then come under tension. Poor dynamic control – which is weakness in core stability; gluteus medius, quadriceps, hamstring and peroneal muscle can predispose to ankle instability. Ankle proprioception: sense position, location, orientation and movement of the ankle is vital for ankle stability.


Instability can be subdivided into:

  • True mechanical instability – the ligaments are lax and not functioning properly, and there may be damage within the joint (cartilage, scarring, inflammation etc)
  • Functional instability – there is no anatomical abnormality but a lack of adequate proprioception and dynamic stability (neuromuscular control)

Many patients have an element of both mechanical and functional instability.


Medial aspect of foot and ankle illustrating the 2 main medial ligaments, Deltoid and the Spring ligament

Medial aspect of foot and ankle illustrating the 2 main medial ligaments, Deltoid and the Spring ligament

Lateral aspect of foot and ankle illustrating the 3 lateral ligaments. ATFL is the most commonly injured ligament in the ankle

Lateral aspect of foot and ankle illustrating the 3 lateral ligaments. ATFL is the most commonly injured ligament in the ankle

What Can Cause It?

A failure of the ankle ligaments to heal properly or a lack of effective rehabilitation following an injury are the most common causes of chronic ankle sprain.

However a number of other conditions can also cause a chronic ankle sprain or prevent a full recovery, and these need to be investigated and treated in addition to any damaged ankle ligaments:

What Are The Symptoms?

Patients typically complain of instability, a sense of ankle weakness or giving way when trying to twist and turn quickly while running or playing sports.

Patients may have a sense of weakness or actually find that their ankle gives way frequently and unpredictably.

The main symptoms of chronic ankle sprains are:

  • A sense of ankle weakness and giving way
  • Ankle pain preventing sports and interfering with normal activities
  • True ankle instability
  • Stiffness
  • Swelling

Clinical examination

Your foot and ankle surgeon will assess you for generalised hypermobility which has a bearing on healing and treatment.

Examination of the ankle will focus on the site of pain and site of tenderness.

The anterior drawer test will also assess the degree of ligamentous laxity. Stress tests in inversion (turning in) and eversion (turning out) will also be performed.

Examination will also focus on confirming/excluding the presence of associated conditions as discussed above.

What Investigations May Be Required?

Investigations help confirm the diagnosis, grade the severity of the condition, help confirm or rule out any co-existing condition and where applicable, aid in pre operative planning.


Plain radiograph (x-ray)

Weight bearing plain radiographs are a quick and effective way of assessing stability and damage within the ankle joint such as arthritis.

Stress radiographs may also be taken. This involves turning the ankle in or out (depending on whether the lateral or medial ligaments are affected) and comparing with the contralateral normal ankle. Increased opening of the joint may indicate ankle instability.


MRI

MRI provides excellent high definition static images. This is a routine investigation in all patients with chronic ankle sprains as it provides detailed information of the hindfoot and not only confirms the diagnosis but also helps confirm/exclude any other pathology within or outside the ankle joint.

MRI is particularly useful in assessing:

  • Cartilage loss – arthritis
  • Cartilage and bone damage – osteochondral lesions
  • Reactive bone changes – bone bruising
  • Effusion – swelling in the joint
  • Synovitis – inflammation in the joint
  • Ligament damage 
  • Peroneal tendon problems – tenosynovitis, tendon tears
  • Scarring within the joint
  • Any other pathology
MRI of the ankle revealing a torn ATFL lateral ligament

MRI of the ankle revealing a torn ATFL lateral ligament

 


CT

CT images give excellent information on bone structure and is superior to plain radiography in that respect. In suspected cases of a missed fracture this test may be requested.

CT is particularly useful in the following cases:

  • 3D image reconstruction
  • Detecting small and complex fracture patterns
  • Pre operative planning
  • Evaluating the joint in the presence of surgical hardware ie screws & plates
  • Assessing adjacent joints for presence of arthritis
  • Assessing bone healing (fusion)

Can The Problem Get Worse?

The natural history of chronic ankle instability is not fully understood.

Repetitive ankle sprains do increase the risk of damage to the ankle joint (osteochondral lesion) and peroneal tendons.

Non-Operative Treatment Options

Non-operative management for chronic ankle stability aims at improving ankle stability and alleviating any pain.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. New training regime and exercise program coupled with a comprehensive physiotherapy program (see below).


Footwear modification

Wearing above-ankle sturdy walking boots will provide greater stability to the ankle joint.


Brace

An ankle brace can provide increased stability to the ankle joint and is useful in individuals participating in sports and exercise that places their ankle at risk.


Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort and swelling in the ankle.


Physiotherapy

The aim of physiotherapy is to improve dynamic stability, core stability (balance) and ankle proprioception.

Improving Dynamic stability – involves strengthening the muscles of the lower limb: gluteus medius muscle, hamstrings, quadriceps and crucially the peroneal muscles.

Injections For Chronic Ankle Sprain

In some patients after an ankle sprain, a number of problems can occur that cause pain and hamper effective rehabilitation. These include synovitis (inflammation in the lining of the joint) and excessive scarring and inflammation of the damaged ligaments for example. As inflammation is a key factor in these conditions a steroid injection can help reduce the inflammation and relieve symptoms.


Image guided steroid and local anaesthetic injection

This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.

The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.

Steroids reduce inflammation and ease pain when injected directly into an inflamed joint. 

We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of methylprednisolone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.

The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.

Injections are not repeated less than at 6 monthly intervals and generally not more than twice.

Please read here for more information regarding injections and possible complications.

A - Placement of fine needle in ankle joint, B - Radio-opaque dye confirms needle is in the joint

A – Placement of fine needle in ankle joint B – Radio-opaque dye confirms needle is in the ankle joint

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

A variety of surgical options exist for patients with chronic ankle sprains. Surgery needs to be tailored to the individual and the underlying cause of the chronic instability. One or more procedures may need to be undertaken, either combined in one sitting or as a staged procedure depending on the underlying problem(s).


Ankle arthroscopy and debridement

Arthroscopy allows for not only direct visualisation of the joint surfaces (diagnostic) but also treatment as well, such as:

  • Removal of debris from the joint
  • Removal of loose bodies
  • Removal of inflamed tissue
  • Removal of unstable joint surfaces.
  • Removal of anterior ankle excess bone growth (osteophtyes)
  • Removal of excess scar tissue

The operation is carried out via keyhole surgery. It is performed under a short general anaesthetic as a day case procedure.

During this operation water is used to inflate the ankle joint. Inevitably some fluid leaks into the soft tissues causing swelling of the ankle, as a result some patients who require reconstruction of their ligaments may have to have a second operation at a later date.


Ankle lateral ligament reconstruction (anatomical repair)

In patients with stretched and lax lateral ligaments the Modified Brostrom Gould procedure can be carried out.  This operation is done as a day case procedure under a general anaesthetic.

A small incision is made on the outer aspect of the ankle, anterior to the distal end of the fibula. The stretched ATFL and CFL ligaments are divided and tightened and secured to the distal end of the fibula using a special surgical device called bone anchors.

This operation has excellent outcomes in terms of restoration of stability, pain relief and return to full activity in 85-90% of patients.

As the operation involves using the native ligament, this operation is also described as an anatomical repair. In some patients the native tissue is of poor quality and the repair fails. If this occurs then a non anatomical repair is carried out.

An anatomical repair is always the first choice because:

  1. It has a good success rate (85-90%)
  2. It is the most “natural” repair as the bodies own tissue is used
  3. A small wound and early recovery are possible

Ankle lateral ligament reconstruction (non anatomical repair)

Patients who have had a failed Brostrom anatomical repair or re-injured their ankle having had a previous repair are candidates for this procedure. The operation involves using artificial ligament to augment/reconstruct the lateral ligaments. A larger dissection is required and recovery can take longer. The operation is undertaken as a day case procedure and under a general anaesthetic.


Lateralising calcaneal osteotomy

In patients with recurrent instability or failed ligament reconstruction surgery due to a turned in heel (varus hindfoot), realigning the heel can improve the biomechanics of the lower limb and reduce the risk of instability and enhance any surgical repair of the ligaments.

The operation involves cutting the heel bone, realigning it and fixing it with one or more screws. The operation is done under general anaesthetic.


Ankle medial ligament reconstruction

Please read ankle medial ligament injury for more details regarding surgical reconstruction.


Spring ligament reconstruction

Please read spring ligament injury for more details regarding surgical reconstruction.

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Worsening pain
  • Continued instability
  • Increasing instability
  • Increasing deformity
  • Damage to the ankle joint (osteochondral injury)

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • Need for further surgery (revision or further treatment)
  • Persistent pain
  • Complex regional pain syndrome
  • Nerve injury
  • Wound healing problems

Potential specific complications of ankle arthroscopy and debridement include:

  • Portal site sensitivity
  • Numbness across top (dorsum) of foot – typically temporary

Potential specific complications of ankle lateral ligament reconstruction:

  • Failure of surgery and persistent instability

Potential specific complications of lateralising calcaneal osteotomy:

  • Non union
  • Symptomatic metalwork requiring removal

Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

All surgical procedures for chronic ankle sprain will be carried out under a general anaesthetic.

Following ankle arthroscopy and debridement

You will have a small waterproof dressing applied to the front of the ankle to cover the arthroscopy portal sites and a bandage applied. It is advised not to remove this bandage for 48 hours and certainly not to remove the underlying dressings covering the wounds until reviewed by Mr Malik at the 2 week post operative check up. For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.

Weight bearing status will really depend on how much has been done in side the ankle. Most patients are touch weight bearing for 48 hours and then weight bear as tolerate after that with or without the use of crutches. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence ankle range of motion exercises as soon as possible after the operation to prevent stiffness. Activities can be gradually increased as pain allows.

In addition following an ankle lateral ligament reconstruction and/or lateralising calcaneal osteotomy – 

You will have a backslab applied post operatively for two weeks.

A picture of a backslab

A picture of a backslab

Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.

You will be non weight bearing for approximately 2 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.

A picture demonstrating high foot and ankle elevation after surgery

A picture demonstrating high foot and ankle elevation after surgery

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection.

Following ankle arthroscopy and debridement

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.  If completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.

A referral to physiotherapy will be made at this stage. This is the earliest you may return to work.

In addition following an ankle lateral ligament reconstruction and/or lateralising calcaneal osteotomy – 

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your ankle will most likely be placed in a walking boot for 4 weeks. Short trips can be made outside, within limits of pain and swelling.

Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.


Six weeks post operatively

Following ankle arthroscopy and debridement

Significant improvement in swelling and pain. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.

In addition following an ankle lateral ligament reconstruction and/or lateralising calcaneal osteotomy – 

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.

After removal of the walking boot you will require the use of an ankle brace particularly when participating in certain activities Your physiotherapist will guide you.


Three months post operatively

Following ankle arthroscopy and debridement

Final clinical examination. Discharge if satisfactory.


Six months post operatively

Following an ankle lateral ligament reconstruction or lateralising calcaneal osteotomy – 

Final clinical examination. Discharge if satisfactory. Stable ankle.

FAQs

How long does the operation take?

This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.

The time given below is only a guide to the actual surgical time.

For an ankle arthroscopy and debridement

Up to 60 minutes.

For an ankle lateral ligament reconstruction

Up to 60 minutes.

For a lateralising calcaneal ostetomy

Up to 45 minutes.


When can I drive?

For an ankle arthroscopy and debridement – 

Most patients are able to drive after two weeks. Please see guidance below.

For an ankle lateral ligament reconstruction/ lateralising calcaneal osteotomy – 

Not for at least 6 weeks post surgery (if the right foot has been operated on).

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.


When can I return to work?

Following ankle arthroscopy and debridement – 

Most patients are able to return to work within 10 to 14 days.

For an ankle lateral ligament reconstruction/ lateralising calcaneal osteotomy – 

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.


What should the final outcome be?

Following an ankle arthroscopy and debridement – 

Excellent pain relief and return to sports by 3 to 6 months. Failure of this outcome warrants further investigation and possible treatment.

For an ankle lateral ligament reconstruction/ lateralising calcaneal osteotomy – 

Excellent pain relief, stability in the ankle and return to full activities of daily living. In some cases return to sport.

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