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Anatomy of the Ankle

Ankle sprains, if not treated early, can create chronic ankle instability; (weak ankle) which leads to difficulty in sports activities and frequent recurrent ankle sprains. The ankle is composed of the joint, formed by three bones called the tibia (lower leg bone) and the talus as well as the fibula and ligaments that surround the joint. The ankle ligaments support the joint and prevent excessive motion that may cause instability. There are two sets of ligaments in the ankle joint, the deltoid ligaments (found on the inside of the ankle joint on the same side as the big toe) and the lateral collateral ligaments (found on the outside of the ankle joint on the same side of the little toe). The weakest of the fore mentioned and most commonly injured ankle ligaments are the lateral collateral ligaments. It is commonly injured by "rolling the ankle" or turning the foot inward, which stretches the ligament and results in tearing or rupturing of the ligament.

Causes of Ankle Sprains

Stretching the ankle ligaments beyond their maximum ability causes ankle sprains. This results in tearing or rupturing. Stretching of the ankle ligaments can occur when missing a step on a curb or physical activity that results in turning the foot inward or outward. Certain factors can increase the likelihood that ankle sprains occur. Skeletal deformities of the foot where the heel is turned inward places the foot in a position that encourages the ankle to roll. Increased laxity and flimsiness of the ligaments will create a situation in some people where the supporting ligaments cannot stop the twisting motion, which leads to the ankle injury. Impaired proprioception, a condition where the body has difficulty sensing the position of the ankle and impaired muscular control of the ankle joint, can also lead to more frequent sprains. Additionally, the incidence of ankle sprains can also increase if there are loose bone fragments found in the ankle joint associated with arthritis.

Symptoms of Ankle Sprains

Ankle ligament injures are classified by grades from grade I to grade III. Each grade is treated differently and the classification enables the podiatrist to provide the best treatment for the patient. Grade I ankle ligament injuries do not involve ligament rupture and only have minor swelling and tenderness. Grade II injuries have partial rupture of the ligaments, with moderate tenderness, swelling and loss of motion. Grade III injuries include a complete rupture of the ligament, severe bruising, swelling, pain, and major loss of function and motion of the ankle joint. Patients with ankle instability complain of persistent pain, recurrent sprains, and repeated instances of the ankle giving way.

Diagnosing Ankle Sprains:

When visiting a podiatrist for evaluation of an ankle sprain, the doctor will ask if the patient can recall the position the foot was in when the injury occurred. This will allow the podiatrist to determine which ligament was most likely injured. Additionally, the podiatrist will perform a physical exam. The exam will include pushing along both sides of the ankle where the ligaments attach, as well as distracting and moving the ankle to determine which ligaments have been injured. The podiatrist will perform X-rays of the foot and ankle in order to determine if the ankle sprain is accompanied by a fracture. This may occur when the ligament has pulled off a bone fragment from the ankle and/or foot. Diagnostic ultrasound may be done to visualize the extent of the soft tissue injury.

Non-surgical Treatment for Ankle Sprains

Simple sprains can be treated non-surgically with: resting the foot and ankle, ice, compression, and elevation - especially during the first few days. Early weight bearing without crutches is encouraged if possible to prevent stiffness of the ankle joint. It is usually recommended to start range-of-motion exercises of the ankle followed by coordination training with balance boards and trampoline, as well as strengthening exercises. An external ankle brace or ankle taping may be used to control the motion of the joint to reduce symptoms of the sprain and to prevent additional injury during the healing phase. With more severe ligament injuries, treatment can consist of cast immobilization, rehabilitation and possible surgical repair.

Platelet Rich Plasma Treatment:

Also known as PRP, is another treatment method that can be used to treat this condition. The procedure can be performed in the office and takes about 45 minutes. This is performed by taking a small sample of blood from the patient. This blood is then processed and a concentrated smaller amount of blood is produced with a very high quantity of platelets. Then, using ultrasound to guide the needle to the exact location of the injury the platelet-rich compound is injected. When the platelets are placed at the injured area they release a growth factor that attracts the patients stem cells. These stem cells then infiltrate the area and form new tissue to aid in healing the injured tissue.

Surgical Treatment for Ankle Sprains

When nonsurgical treatment does not resolve the ankle sprain, surgical treatment is the next option. There are three main types of surgical repair of ankle ligaments:

1. Tendon reconstruction: uses tendons to function similarly to the ligaments and since the long-term outcome is not as successful as other procedures, it is commonly used as secondary procedures in repairing ankle injuries.

2. Anatomic repair of the ligaments: restores the original ligament attachment and length by shortening and stitching the rupture ligaments.

3. Anatomic reconstruction: uses tissue flaps and grafts to reinforce and strengthen the ankle ligaments. This type of procedure is commonly used if anatomic repair of the ligament cannot be performed due to weakness and damage to the ends of the original ligament, failure from previous repair, increased ligament slack, or longstanding ankle stability of greater than 10 years.

After surgery, it is usually expected that the patient will be in a weight-bearing cast for about 6 weeks, followed by physical therapy and range-of-motion exercises.

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