Chronic Lateral Ankle Instability
Ligament injuries anywhere in the body are much more serious than muscle injuries. Muscles have a tremendous blood supply and heal very quickly. Even if the muscle injury does not completely heal, the only symptom that you would notice would be weakness in the muscle. With some exercise, even that symptom would resolve. This is not the case with ligaments.
Ligament injuries are different because most of them do not totally heal. Even if the pain resolves, the ligament will not be as strong as it was prior to the injury. Since ligaments stabilize the joints, by definition ligament injury produces a loose joint. If the ligament never heals, chronic joint looseness or instability will result.
The symptoms of chronic ankle instability are feelings of the joint giving way, swelling, pain, decreased range of motion or excessive motion, and recurring sprains. The pain is usually chronic or recurrent. Other symptoms include complaints of increased symptoms after walking or sports, and recurrent sprains.
Any athlete who reports ankle swelling and/or has ligament injury in a joint should consider Prolotherapy as a necessary treatment.
If the ankle instability is not treated, cartilage deterioration with resultant degenerative arthritis develops. This sequence of events occurs everywhere in the body. If a ligament does not heal, instability of the joint occurs and the end-result is arthritis with good prospects for fusion or joint replacement surgery. Prolotherapy at any stage in the arthritis process can stop it. Even after arthritis occurs, Prolotherapy is still the treatment of choice.
Studies on injured ligaments show that at least one year is required before healing has been completed or the total amount of healing occurs. (Andriacchi, T. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: AAOS; 1987; 103-108.)
Injured ligaments do not entirely regenerate. Rather, they repair with scar tissue. Repair and regeneration begin at 48 hours to 72 hours post-injury, and continue maximally for six weeks. This is one of the reasons Prolotherapy injections are given every six weeks to maximize the time of proliferation (cell growth) of the new ligament tissue. From six weeks to 12 months the ligament tissue remodels, contracts, and gains tensile strength. After 12 months the ligament and scar tissue generally matures and achieves 50 to 70 percent strength of the original ligament. (Andriacchi, T. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: AAOS; 1987; 103-108.) Do you understand the magnitude of this statement? On average, ligaments only heal to 50 to 70 percent strength when they are injured. This is why Prolotherapy should be done just about every time a ligament is injured. Pain relief is not a reliable sign that a ligament has healed; perfect function is the sign.
A joint that is strong, without swelling or signs of weakness, is a better measure. On physical examination the injured ligament should be able to withstand at least four pounds of pressure applied to it without demonstrating tenderness. We use a dolorimeter (an insturument used to measure pain tolerance) in our office in Oak Park, Illinois to test this. Many people in the sports medicine field feel that the ligament must be protected to promote maximal repair. They then only obtain 50 to 70 percent of the original strength after all is said and done. (Andriacchi, T. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: AAOS; 1987; 103-108.)
Athletes, you should heal ankle sprains, otherwise up to 42 percent of them may end up leaving your ankles with long-term instability. In those subjects with documented looseness, the majority of athletes have significant symptoms including swelling, pain, weakness, and of course crepitation (cracking noises). Ankle instability is significant because if it is not treated, degenerative ankle arthritis results.
The area most affected in the foot is the subtalar joint (a joint slightly below your ankle) because of unresolved ligament laxity. This is the part of the foot that becomes degenerated.
The traditional treatments for unresolved ankle pain are arthroscopy and/or ankle fusion. Both of these, in our opinion, are not the best options when compared to Prolotherapy. Athletes with chronic ankle pain are generally divided into three groups: those with ligament laxity (instability), impingements (tissue, such as synovium, causing the ankle not to move well), and degenerative arthritis.
The instability group is at the early stage in the development of degenerative arthritis. As it turns out, arthroscopy treatment for ligament laxity and degenerative arthritis is terrible. In one study arthroscopic surgery produced only 33 percent positive results for unstable ankles. This was better than another study which noted that operative ankle arthroscopy at one-year follow-up showed only 12 percent good or excellent results on people with degenerative arthritis of the ankle. Forty-three percent of the people proceeded to have ankle fusions! (Martin, D. Operative ankle arthroscopy. Long-term follow-up. American Journal of Sports Medicine. 1989; 17:16-23.) Other studies have documented poor result with arthritic ankles, especially in people with knee arthritis and obesity. (Amendola, A. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy. 1996; 12:565-573.; Japour, C. Ankle arthroscopy: follow-up study of 33 ankles effect of physical therapy and obesity. Journal of Foot and Ankle. 1996; 35:199-209.)
Arthroscopy does nothing to repair or regenerate the injured tissue. Arthroscopy is good for cutting and shaving. The arthroscopy should be used to cut or shave the tissue that is blocking the motion for an athlete with a long history of typical anterior ankle pain without instability but with pinching sensations, impingement, blocking, or a feeling of unsteadiness, combined with a certain restriction of movement. Arthroscopy is very successful in these cases.
There is, however, a much more conservative approach. Prolotherapy doctors are trained to do joint injections with Prolotherapy. If a joint requires flushing, this can be done by injecting saline into the joint and removing the fluid. This is a much quicker procedure than arthroscopy and will often accomplish the same breaking up of scar tissue in the involved joint. We have successfully performed this procedure in the shoulder, knee, and ankle joints, as have other Prolotherapy doctors.
Athletes should also consider the fact that arthroscopy is not without complications. Complication rates range from around 15 to 17 percent and can be quite serious, including reflex sympathetic dystrophy, wound infections, permanent nerve damage, and various fistulas.(Feder, K. Ankle arthroscopy: review and long-term results. Foot and Ankle. 1992; 13:382-385.;Barber, F. Complications of ankle arthroscopy. Foot and Ankle. 1990; 10:263-266.)
If an ankle is unstable, has had poor arthroscopic results including arthritis, or a catching sensation is felt, then the joint should be flushed (as an option.)
Arthroscopy of the ankle should play no role in the care and treatment of the athlete, unless all other treatments have failed, including Prolotherapy.
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