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Ankle Sprains and Instability
Standard Ankle Sprain
An ankle sprain is an injury to the ligaments that stabilize the ankle and prevent it from rolling or giving way. The ligament damage can be as mild as stretching the tissue or as severe as completely tearing the tissue. Fortunately, most patients who have an ankle sprain recover with rest, ice, compression, elevation, anti-inflammatories, and bracing. Once the acute pain begins to resolve, physical therapy can may help to strengthen the ankle and improve balance and proprioception for prevention of future sprains. Many patients with complete tears of their ankle ligaments recover completely and are able to resume normal activities without the need for surgical intervention.
High Ankle Sprain
High ankle sprains are less common and may take a little bit longer to recover from. A high ankle sprain refers to an injury of the syndesmosis. The term 'syndesmosis' is used to refer to the distal tibiofibular joint at the top ('high' portion) of the ankle. Here the small fibula bone rests in a trough recessed into the larger tibia bone. The fibula and tibia are held together at the syndesmosis by multiple ligaments known as the distal tibiofibular ligaments or the syndesmotic ligaments. Injury to this area is commonly referred to as a 'high-ankle sprain'. It is very important to restore and maintain the relationship between the tibia and fibula at the syndesmosis, and this relationship is often disrupted with ankle sprains or ankle fractures. Sometimes arthroscopy is used to evaluate for injury and to aid in the repair of syndesmosis injuries.
The recovery from ankle instability surgery is variable and dependent on patient characteristics as well as surgical findings. The surgery is generally done on an outpatient basis. You will be discharged with a prescription for pain medicine to help control your pain. Many patients choose to have a nerve block placed prior to discharge to help decrease any discomfort. Much of the time immediately after surgery is spent resting and elevating your leg to decrease swelling. We generally recommend you keep your leg elevated as much as possible during the first week after surgery. The ankle is usually immobilized for 2-6 weeks to promote healing. Crutches, a walker, or a rolling knee scooter can be utilized to aid with mobilization during the first 6 weeks. Typically, between 4-6 weeks following surgery, the cast is changed to a walking boot. Patients wear the boot for about 6 weeks as they gradually transition back to full weight bearing and begin range of motion exercises. Typical office visits are at 2 weeks, 6 weeks, 12 weeks, and then less frequently. Physical Therapy is an important component of recovery from chronic ankle instability surgery and is usually commenced at 6 weeks.
If you have attempted conservative treatment for chronic ankle sprains, but you continue to have pain and giving way, then you may benefit from an operation. Your work-up prior to surgery will include a physical exam, x-rays, and sometimes an MRI to evaluate the tendons, the ligaments, and the articular cartilage. A CT scan is also sometimes necessary to help measure the size of an OCD.
In individuals with a long history of sprains, additional portions of the ankle can become damaged including the articular cartilage and the peroneal tendons. For this reason, simultaneous to ligament repairs, the surgeon may perform additional procedures including ankle arthroscopy to remove inflammatory scar tissue and to address any damage to your articular cartilage. This may include removing loose pieces of cartilage or bone (loose bodies) or addressing cartilage defects (osteochondral defects- OCD). Drilling an OCD to stimulate healing is a procedure known as 'microfracture'. In patients who have already attempted microfracture, or who have a very large OCD, then other alternatives can be recommended to restore the cartilage defect. Some of these cartilage products approved by the FDA in the United States are BioCartilage (Arthrex, Naples, FL), Cartiform (Arthrex, Naples, FL) and DeNovo (Zimmer Warsaw, IN). These products are generally only approved by insurance companies for very large defects or after other procedures such as microfracture have been attempted. Individuals with recurrent sprains also can develop concomitant peroneal tendon tears (see peroneal tendons). These tears can cause pain on the side of the foot or in the ankle behind the fibula bone. Tears may limit tendon function and strength, which is important for preventing future ankle sprains. For this reason, the peroneal tendons may be evaluated and repaired if necessary at the time of an ankle ligament repair surgery.
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