Chronic ankle sprain and instability treatment
Ross Hauser, MD
In this article Dr. Hauser discusses chronic ankle sprain treatment, the problems of diagnosing ankle sprains and long-term non-surgical options including the use of Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy.
Highlights of this article:
- Ankle instability caused by injured ligaments
- Ankle taping and bracing are not long-term options
- Ankle fusion may not meet patient expectations
- Prolotherapy shown to be effective non-surgical repair
Chronic ankle instability symptoms
Many of our patients with chronic ankle instability complain of the ankle “giving way”, constant or permanent swelling, obvious pain, decreased range of motion or excessive motion from joint laxity, and recurring sprains. Left untreated, ankle instability leads to cartilage deterioration with resultant degenerative arthritis. If a ligament does not heal, joint instability occurs and the end-result is arthritis with good prospects for fusion or joint replacement surgery.
The most common type of ankle sprain is an inversion injury, turning the ankle inward, injuring or tearing the ligaments on the lateral side of the ankle, usually the anterior talofibular and the tibiofibular ligaments. The inside of the ankle is held together by a group of ligaments called the deltoid ligament. This ligament is injured from turning the foot outward, as can happen when falling down stairs or mis-stepping. Once an ankle is sprained, the injury may take a few weeks to many months to fully heal. The injured ankle often remains a little weaker and less stable than the uninjured one.
Chronic ankle pain – Ankle Instability Treatment
Unfortunately, over-the-counter painkillers or prescription opioids are usually considered the first line of treatment in treating the ankle problem. While taking a prescription pain reliever sounds like common sense for a person in pain the direct effects are doing more harm than good. For one, taking pain medications increases pain sensitivity, requiring the patient to use the medication more frequently and at higher doses over time. This phenomenon is known as “Opioid-Induced Hyperalgesia (OIH)” and medical professionals are increasingly beginning to recognize that continued use of opioids will increase pain.
At Caring Medical we do not prescribe any narcotic medications to treat chronic ankle pain simply because of the overwhelming evidence that reveals how narcotics suppress healing and actually exacerbate pain. Further, pain relief is not a reliable sign that a ligament as healed; perfect function is the sign.
A joint that is strong, without swelling or signs of weakness, is a better measure. Caring Medical’s first line of treatment for Chronic ankle pain – ankle instability is Prolotherapy, a type of regenerative injection therapy. In treating with Regenerative Injection Techniques (RIT), i.e., Prolotherapy, Platelet Rich Plasma Therapy, Stem Cell Prolotherapy, a comprehensive approach must be taken. This means treating the whole ankle, not just a single injection at a single site in the joint, as some physicians attempt to do. The comprehensive problem of ankle instability requires a comprehensive treatment. Here’s what current research reveals about ankle instability and injury and how a doctor should consider treatment:
Doctors and patients should be advised that the initial diagnosis of an ‘ankle sprain’ is not always correct. Prolonged pain, swelling and disability that limits the activity and remains tubborn to treat following an ankle injury are not typical of an ankle sprain and should alert the clinician of the possibility of an alternative or an associated diagnosis.
There are several conditions that can be misdiagnosed as an ankle sprain and those include:
- ankle syndesmosis (ligament) injuries,
- sinus tarsi syndrome (a wear and tear condition resulting in hypermobility mostly seen in athletes),
- ankle and hind foot fractures,
- osteochondral lesions (cartilage problems),
- posterior tibialis and peroneal tendons abnormalities,
- spring ligament damage, impingement syndromes and reflex sympathetic dystrophy.1
More serious options for continued ankle pain:
When the athlete returns to the doctor with complaints of continued pain, the next step will probably be either stronger NSAIDs or cortisone shots to the ankle. Cortisone has been shown to further degenerate the injured ligaments in joints, leading the athlete on the fast track to osteoarthritis. When the cortisone shots don’t work and leave the patient with pain, the words “ankle fusion,” “arthroscopy,” and “joint replacement” are often mentioned.
Ankle surgeries often do not cure the injury
An ankle fusion is a type of surgery commonly suggested for a degenerative ankle joint. An ankle fusion makes the shinbone grow together with the bone directly under it, called the talus. The boney bumps on either side of the ankle are removed so the surgeon can get into the joint. The joint surfaces are commonly removed, and sometimes reshaped. The joint is then corrected and secured with two or three screws. It is usually necessary to add extra bone to the ankle fusion. After an ankle fusion, patients are told that they can usually walk normally, but that they will be experiencing a lot of pain after surgery.
Arthroscopy cuts and shaves away tissue. This should only be used if the patient is experiencing pain with pinching sensations and blocking. If it is used on someone whose ankle is already degenerative it makes the problem worse and more painful. Joint replacement is exactly what it sounds like: the surgeon removes the degenerative joint and replaces it with a prosthetic.
It may seem surprising, but athletes often have ankle pain after surgery! Unfortunately conservative treatments like Prolotherapy are overlooked when, in fact, “conservative treatment of patients with CAI must be the first-line therapy. Surgical treatment must be indicated only when conservative treatment fails.”2
But in other research, it seems that the best way to treat chronic ankle instability is to replace the ligament with a tendon from the deep thigh area!3 We have to ask why replace a ligament that can be repaired and weaken another area and call this the best way?
In our research we have shown that comprehensive Prolotherapy used on patients who had an average duration of three years four months of unresolved ankle pain and who were twenty-one months out from their last Prolotherapy session was shown in this observational study to improve their quality of life.
Prolotherapy research on Ankle Instability Treatment
Writing in the medical journal Practical PAIN MANAGEMENT, we reported that patients surveyed said they had less pain, stiffness, crepitating, depressed and anxious thoughts, medication usage, as well as improved range of motion, walking ability, sleep and exercise ability. Overall average pain levels dropped from 7.9 on a 10-point VAS scale before treatment to a 1.6 level after treatment.
This study included patients who were told by their medical doctor(s) there were no other treatment options for their unresolved ankle pain or that they needed surgery. Ninety percent of the participants experienced 50% or more pain relief. Prolotherapy helped the patients make significant improvement in stiffness, range of motion, exercise ability, activities of daily living and walking ability, as well as decreasing their levels of anxiety and depression. Prolotherapy helped all patients on pain medications reduce the amount of medications taken.5
For significant deterioration, we may recommend to patients a more aggressive approach incorporating Platelet Rich Plasma and Stem Cell Therapy injections. Each case is unique and requires an assessment by our Prolotherapist.
1. Persistent ankle pain following a sprain: a review of imaging.Mansour R, Jibri Z, Kamath S, Mukherjee K, Ostlere S. Emerg Radiol. 2011 Jun;18(3):211-25. Epub 2011 Mar 5.
2. Rodriguez-Merchan EC. Chronic ankle instability: diagnosis and treatment. Arch Orthop Trauma Surg. 2012 Feb;132(2):211-9. Epub 2011 Nov 5.
4. Zhang L, Li ZY, Liu JS, Sun J, Ma J, Zhang S, Liu XH. [Clinical results of anatomical reconstruction of the lateral ligaments for chronic ankle instability]. Zhongguo Gu Shang. 2012 Nov;25(11):886-90.
5. Hauser RA, Hauser, MA, Cukla J. Dextrose Prolotherapy Injections for Chronic Ankle Pain Practical PAIN MANAGEMENT, January/February 2010 p 70-76.