ANKLE SPRAIN AND LIGAMENT INJURY
DR. GITLIN HAS LECTURED ON ANKLE LIGAMENT INJURY AND REPAIR SINCE 2002 AND HAS EXTENSIVE INTEREST AND EXPERIENCE ON THE TOPIC OF THE ANKLE SPRAIN THAT ‘JUST 'DOES NOT HEAL’. HERE IS SOME INFORMATION FOR YOU BEFORE YOU GET TO A SPECIALIST.
OVERVIEW OF THE COMMON ANKLE SPRAIN
An ankle sprain is one of the most common injuries sustained, it’s estimated that there are about 3 million ankle sprains occurring every year in the United States!!!!! That’s almost 9000 sprains every day and that’s considered an underestimate since most people never report the injury. In other words everyone has had one or more ankle sprains. In many cases its a simple twist with the ankle rolling inwards. An interesting statistic - 45 % of all athletic injuries involve the ankle!!!
Why does it usually roll inwards?
The bones in the back of the foot have evolved in such a way that it’s easier to turn the foot inward to face the other foot. Even though the injury is referred to as an ankle sprain, the actual injury involves a few other joints.
THE ANATOMY OF THE ANKLE JOINT
There are two joints of importance when it comes to understanding the ankle sprain. On is the obvious : ankle joint. The other is the subtalar joint. The function of the ankle joint makes the foot go up and down. The subtalar joint’ function is to allow the back of the foot to invert and evert which means to tilt in and out. These two joints work together.
Ligamants hold the joints together, they are very strong, but some are stronger than others, the ones on the inside of the ankle are thicker and shorter and stronger. The ones on the outside of the ankle are the ones that get injured most often in a lateral ankle sprain. (lateral just means outside of the ankle in doctor talk).
The two ligaments of most importance you can see in the diagram here. They are called the Anterior Talofibular ligament (ATFL) and the Calcaneofibular Ligament (CFL) . There is one more called the posterior talofibular ligamant but it is rarely injured and generally not discussed. The ATFL is injured first becasue of the position ofthe ankle while it twists and if it twists past a. certain point the CFL will be damaged next.
When discussing ankle sprains the two main tendons on the outside of the ankle can also be damaged.We will discuss these peroneal tendons later.
SEEING THE DOCTOR WHEN IT FIRST HAPPENS
When sprain occurs the most important thing to do is RICE - rest, ice, compression, elevation. And many sprains are minor and heal uneventfully BUT morerecent medical research shows that there is NO simple ankle sprain. There is significant damage to the ligaments even in a small sprain and that 75 % of all sprains lead to instability of the ankle joint in the future. That is significant because instability over a long period of time causes arthritis of the ankle joint. Also this lingering instability causes ‘Chronic Ankle Sprains’ meaning that once the ligamnts are strectched out the ankle keeps inverting more often on uneven ground.
Because of this new research we try to over treat even some of the simplest of ankle sprains with immobilization in a cast and physical therapy.
When you see a doctor they will assign a GRADE to the sprain. Grade 1 ,2 or 3, with 3 being the worst. It works like this: a grade 1 sprain is no torn ligaments, just stretched out. Grade 2 is a torn anterior talofibular ligament and a grade 3 is both the ATFL and CFL ligaments torn.
THE PAIN DOES NOT GO AWAY
Even with the best treatment sometimes the tenderness at the outside of the ankle doesnt completely go away. In other cases pain does go away but returns a few months later. Patients often come in with swelling in the lateral ankle and often can feel a clicking in the ankle. This can be a sign that there is cartilage loose in the joint. This needs to be dealt with quickly, usually an MRI is ordered so provide the correct diagnosis and arthroscopic surgery may be indicated. These injuries are often called osteochondral lesions (OCD). Thats damage to the cartilage and the bone underneath. This can easioly occur in severe ankle sprains because when the ankle bones tilt, they hit each other and any thin surfaces can be cracked. They are also called Talar dome fractures because its usually an injury to a ankle bone called the talus. Leaving a broken peice of cartilage to float aound a joint is dangerous since it can scratch and damage the whold surface of the joint- where there is enough damage thats called = ARTHRITIS. For information on arthritis procedures we do specific to this click here
THE LIGAMANT REPAIR - BROSTRUM GOULD PROCEDURE
When a patient complains of recurrent ankle sprains or pain when walking surgery may be considered. the first line procedure many surgeons use is called the Bostrum-Gould. This is illustrated in the picture, you can see how the ligmants retightened up and stitched tight. There are other structures of tissue in the foot that are also used in the repair to strengthen the ATFL ligament.
In some cases where a Brostrum procedure was already attempted and failed or in situations where the ligamants are too torn up to be stiched up. Other procedures are done that completely replace the CFL and ATFL ligaments. You can see these illustrated as well, here tendons are harvested and rerouted in a way to replace the ligaments. There are new medical devices that replace the ligamants with polymers. We prefer to use the patients own tissues; even though the surgery is slightly more technical the results are better in general. Common names for this type of procedure is the Chrisman-Snook.
PERONEAL GROOVE DEEPENING
This procedure is not so common and most doctors are not well trained in the correct method of it. Here is a diagram of a shallow groove in A, in diagram B you can see bone being cut away to deepen the bone behind the bone called the fibula. The furthest end of this bone makes up the lateral ankle joint. tp where the ankle ligaments attach. The two major tendons in the lateral ankle sit in a groove in that area. The groove has some depth to it, a few millimeters which is very important. But a certain portion of people dont have a groove or even a bulge instead of the groove! Normally this may not cause any problems at all but after an ankle sprain the structures (retinaculum) holding the peroneal tendons in the groove can tear and then the depth of that groove start to matter. If the groove is deep the tendons wont jump out when the ankle is moving. Otherwise, if the groove is not there the tendons will jump out and cause pain or even worse get torn up over time. SELF TEST: if you rotate your ankle around in circles while using your hand to feel the outside of the ankle; and you feel something jumping in and out it may be these tendons subluxing. They will pop in and out of the groove depending on the position of the ankle.
BTW this groove is called the peroneal groove of the fibula, since its a groove where the peroneal tendons sit.
THE PERONEAL TENDONS - BREVIS AND LONGUS
Click the peroneal tendon button to learn more and see surgical photos and explanation of how we address peroneal tendon problems.
There is one more very important issue to consider when we perform repairs of an old ankle sprain. Something called the’ low lying peroneus brevis muscle belly’. In this area of the lateral ankle the peroneal tendons live right next to each other in a tunnel of tissue. If you do a google search of this you will find that its considered rare! It is not rare, we very often see it during surgery. In this diagram you can see a red arow and yellow line, if the peroneus brevis muscle extends past this line it is considered low lying. The problem with this is that it crowds the two tendons that normally sit in that area and creates inflammation which is very painful in this tight area. The muscle needs to be debulked which is a simple procedure yet it gives much relief to the patient.
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