Chronic ankle sprain and instability treatment
In this article Ross Hauser, MD 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
- Prolotherapy injection treatments shown to be effective for non-surgical repair.
Chronic ankle sprains and instability
Chronic ankle sprains can be tricky to diagnose and treat. Ankle instability may not show up after the first acute ankle sprain and there is no consensus on how to tell if a patient will have instability in the future.1 Unfortunately, literature examining chronic ankle instability is conflicting and confusing to patients.2
New research make this clear.
- In Germany, doctors say because of their frequency, the simple sprain with uneventful healing (an ankle sprain that has seemingly healed) should be monitored to prevent it from becoming a potentially complicated sprain which is at risk of transition to chronic ankle instability.3
I agree there. What I do not agree with is many cases is the recommendation to surgery should ankle instability develop.
- Conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. As you will see below chronic ankle instability is a whole joint problem and not one isolated to a single ligament element.For a full discussion please see my article on various ankle surgery options.
Let’s do a medical equation and combine the research of two studies. Above the German doctors said the simple ankle sprain that looks like it healed should be monitored to prevent it from becoming a potentially complicated sprain which is at risk of transition to chronic ankle instability. In the British Journal of Sports Medicine researchers said says that a new ankle injury is not always a new or acute one, but one that can be identified as an old chronic injury with an increase in symptoms.4
Researchers are showing that doctors should be aware that chronic ankle instability can be a problem of an injury that never heals.
We get a good idea who has instability or is at risk for chronic ankle sprain when we see a patient who feels that their ankle is “giving way”, have constant swelling, obvious pain, decreased range of motion or excessive motion from ankle instability. They often ask what is causing their “weak ankles,” the continued “popping,”and “clicking” sound they hear. The patients know the ankle is not right.
A good summary of chronic ankle instability
In new research surrounding male soccer players doctors had this to say:
- Over 70% of patients who experience ankle sprains report additional symptoms resembling chronic ankle instability, such as re-injury or ankle function abnormalities.
- Chronic ankle instability has been connected to reduced muscle strength and proprioception (ankle joint function as a whole) which interferes with postural control.
- It is presumed that Chronic ankle instability is caused by complex functional deterioration. It is not a simple solution
- Correcting ankle structure and muscle strengthening exercises are important for the rehabilitation of ankle instability. (In other words the ankle needs to be repaired and strengthened – the obvious goal of anyone suffering with chronic ankle instability).5
Knee, Hip, Ankle and Balance problems
In two studies from Ireland, patients who suffered from an acute ankle sprain were followed and tested for problems of balance. Not only were their injured ankles tested but also the same side knees and hips. At 6 months follow up and one-year follow up after a single ankle sprain event, patients showed reduced balance that created stress on the entire limb side, hip, knee, and ankle included.6,7
The first ankle sprain
The most common type of ankle sprain is from a “rolled ankle” 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. Many times a patient will report that they simply “twisted” their ankle without realizing the structural damage that could have been done.
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.
Ankle sprains are either undertreated or overtreated. . . This is an injury that doctors should be acutely aware of and successfully able to evaluate and treat. 8
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 ankle replacement surgery. Treated with stronger NSAIDs or cortisone shots can also lead the patient to surgery.
Cortisone has been shown to further degenerate the injured ligaments in joints, leading the patient towards osteoarthritis. Once diagnosed with osteoarthritis that is seemingly irreversible, the words “ankle fusion,” “ankle arthroscopy,” and “ankle joint replacement” are introduced into the consultation.
Ankle Instability and Prolotherapy
This section will deal with the question, How do you treat a sprained ankle?
Caring Medical’s first line of treatment for chronic ankle pain – ankle instability is Prolotherapy. In treating with Regenerative Injection Techniques (RIT), i.e., Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy, 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:
Writing in the medical journal Practical Pain Management, we reported on patients surveyed following Prolotherapy ankle treatments. These patients 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 significantly 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.9
For significant deterioration, we may recommend to patients a more aggressive approach incorporating Platelet Rich Plasma and Stem Cell Therapy injections.
PRP Ankle Injection Research on high ankle sprain
A less common but well known ankle injury is the “high ankle sprain.” This is damage to the ligaments that connect the shin bones tibia to the fibula. Because of the high impact stress at the tibia and fibula junction, the syndesmosis joint, the high ankle sprain is difficulty to heal.
In recent research doctors examined the success of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP). They further studied the issues of ankle instability and stability before and after the PRP ankle injections.
Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain.
Here are the results:
- Early diagnosis and treatment lead to shorter Return to Play
- Significantly less residual pain upon return to activity was found in the PRP group;
Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain.10
1. Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability: A Prospective Cohort Analysis. Am J Sports Med. 2016 Feb 24. pii: 0363546516628870.
2. Thompson C, Schabrun S, Romero R, Bialocerkowski A, Marshall P. Factors contributing to chronic ankle instability: a protocol for a systematic review of systematic reviews. Systematic Reviews. 2016;5:94.
3. Harrasser N, Eichelberg K, Pohlig F, Waizy H, Toepfer A, von Eisenhart-Rothe R. Lateral instability of the upper ankle joint]. Orthopade. 2016 Oct 13. German. PubMed PMID: 27738709.
4. Shrier I, Clarsen B, Verhagen E, Gordon K, Mellette J. Improving the accuracy of sports medicine surveillance: when is a subsequent event a new injury? Br J Sports Med. 2016 Jun 28. pii: bjsports-2016-096160.
5. Myrick KM. Clinical assessment and management of ankle sprains. Orthop Nurs. 2014 Sep-Oct;33(5):244-8. doi: 10.1097
6. Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Dynamic balance deficits in individuals with chronic ankle instability compared to ankle sprain copers 1 year after a first-time lateral ankle sprain injury. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1086-95. doi: 10.1007/s00167-015-3744-z. Epub 2015 Aug 8.
7. Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Dynamic Balance Deficits 6 Months Following First-Time Acute Lateral Ankle Sprain: A Laboratory Analysis. J Orthop Sports Phys Ther. 2015 Aug;45(8):626-33. doi: 10.2519/jospt.2015.5653. Epub 2015 Jun 24.
8. Kim K, Jeon K. Development of an efficient rehabilitation exercise program for functional recovery in chronic ankle instability. Journal of Physical Therapy Science. 2016;28(5):1443-1447. doi:10.1589/jpts.28.1443.
9. Hauser RA, Hauser, MA, Cukla J. Dextrose Prolotherapy Injections for Chronic Ankle Pain Practical PAIN MANAGEMENT, January/February 2010 p 70-76.
10. Laver L, Carmont MR, McConkey MO, Palmanovich E, Yaacobi E, Mann G, Nyska M, Kots E, Mei-Dan O. Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial. Knee Surg Sports Traumatol Arthrosc. 2015 Nov;23(11):3383-92.