Chronic ankle sprain and instability | Conservative care and surgery

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Chronic ankle sprain and instability treatment

In this article, we will discuss chronic ankle sprain treatment, the problems of diagnosing ankle sprains, and long-term problems of ankle instability. We will discuss non-surgical options as well as surgical options for the treatment.

Highlights of this article:

Summary outline:

This article is part of a series of articles on our website that deal with the problems and challenges of an ankle injury. These articles include:

My ankle is always giving out

Many of our patients with chronic ankle instability complain of their ankles “giving way”, having a constant or permanent swelling, obvious pain, decreased range of motion or excessive motion from joint laxity, and recurring sprains.

They have been told by their doctors that if left untreated, ankle instability leads to cartilage deterioration with resultant degenerative arthritis. If the chronically sprained ankle ligaments do not heal, joint instability occurs and the end result is arthritis with ankle fusion or ankle joint replacement surgery an ultimate outcome. If surgery is not the choice the patient wants to make then they have to come up with a just live with it strategy until such time that there will be no other choice but surgery.

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.”

“Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries.”

A paper was published in the journal Foot & Ankle International, December 2020. (1) Its introduction provides a brief yet detailed summary of the current state of affairs in the treatment of chronic ankle instability.

“Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases.

Failure after strict rehabilitation may be an indication of surgery.

Several operative options are available, including anatomic repair (fixing the existing damaged tissue), anatomic reconstruction (replacing the damaged existing tissue with a graft), and tenodesis (tendon transfer) procedures.

The anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability.

Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.”

In summary, in December 2020, your ankle is this way because it was undertreated or badly treated. Try conservative care first, then move on to various surgeries.

If you are reading this article, you have already been through conservative care, it did not help, you are now exploring surgical and non-surgical options.

At our center, we usually do not see patients who have just “twisted” an ankle. We usually see patients who have twisted their ankle many times and with each twist, their ankle gets weaker and weaker and more unstable. When we see these patients, they usually walk in, sometimes barely, with chronic ankle pain and a clear problem of maintaining a normal gait or walk.

When they sit on the examination table, familiar stories emerge of treatments that have not helped; this is what we hear, sound familiar to you?

My ankle is more swollen now than it was when I first hurt myself despite all the treatments I am doing

I came in because the last ankle sprain was bad. It happened weeks ago. My ankle is more swollen now than it was when I first hurt myself despite all the things I am doing for it. I stand all day at work and when I get home, I ice it. I am taking painkillers and anti-inflammatories. My doctor wants to send me for massage therapy. I have had that before, it did not really help. I am wearing copper ankle sleeves and have magnets in my shoes. I have tried everything except long-term immobilization which I cannot do because I have to work.

Every sprain now requires an x-ray

I came in because every ankle sprain is now taking 6 months to heal and I know it is not even healing. With every sprain, I am sent to get an x-ray or an MRI to see if anything is broken. I have been advised that I should use crutches or a cane for a few weeks and take the anti-inflammatories when I need them. I should ICE if I have to and get a better ankle brace. All the typical stuff.

This is why many times a patient will report that they had suffered numerous ankle sprains and did not seek medical attention because “the treatment is always the same and usually doesn’t help.”

Diagnosis, treatment, and prevention of future ankle sprains can be tricky. Leading sports medicine researchers routinely write on the problem of helping patients with chronic ankle sprains. Most studies acknowledge that it is difficult to even know if these patients are getting the right treatments.

Let’s first look at an August 2019 study. Here the researchers tried to help doctors by categorizing people like you into subcategories of an ankle sprain. Why? Because if a patient can be identified with a proper ankle diagnosis, they may get the proper treatment. The following results will probably not surprise you but it may suggest why you may have been receiving the “same old treatments that do not help.”

This research was published in the Journal of Science and Medicine in Sport / Sports Medicine Australia. (2)

In this study, the doctors examined 206 patients who visited their general practitioner with a lateral ankle sprain 6-12 months prior to participating in the study.

What’s the difference between patients? Where would you fit in?

What was the conclusion of this study?

What does this mean to you?

Here is the research to back that up:

In 2005, a study in the British Journal of Sports Medicine (3) discussed the long-term outcomes of inversion ankle injuries. (The most common type of ankle sprain is the “rolled” or “twisted” ankle, inversion injury, turning the ankle inward, injuring or tearing the ligaments on the lateral (outer) side of the ankle, usually the anterior talofibular and the tibiofibular ligaments.)

This 2005  study was cited by seven 2020 published studies to validate the findings on the problems of identifying and treating ankle sprains and preventing these ankle sprains from becoming long-term problems. So here we have a 2005 study that suggests that you may get surgery that will not help you. You may get non-surgical treatments that are accelerating your need for surgery or are simply not helping. Researchers in 2020 use this study as evidence.

The overall quality of the existing lateral ankle ligament sprains Clinical Practice Guidelines are poor and the majority are out of date.

Before you think that this is old research, look at a 2019 study that also cites this paper from 14 years prior. Has anything changed that much? Published August 31, 2019, in the journal BioMed Central Musculoskeletal Disorders (4) by researchers led by the Australian National University.

“Acute lateral ankle ligament sprains are a common injury seen by many different clinicians. Knowledge translation advocates that clinicians use Clinical Practice Guidelines to aid clinical decision-making and apply the evidence-based treatment. The quality and consistency of recommendations from these Clinical Practice Guidelines are currently unknown.” (Note: This is 2019 talking). . . The overall quality of the existing lateral ankle ligament sprains clinical practice guidelines are poor and the majority are out of date.”

Here are the latest Clinical Practice Guidelines presented by the American Academy of Orthopaedic Surgeons

A three-phase program guides treatment for all ankle sprains—from mild to severe:

Recommendations also include:

You may get non-surgical treatments that are accelerating your need for surgery or are simply not helping.

Here is a 2019 study that cited the 2005 research reporting on chronic ankle sprains in elite college football players entering the National Football League.

That study from doctors at Tulane University School of Medicine,  Steadman Philippon Research Institute,  Drexel University College of Medicine, Harvard Medical School, and the New England Patriots, found that prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine (pre-draft player workouts). The purpose of the study which was published in the Orthopaedic Journal of Sports Medicine,(5) was to try to determine ways to prevent recurrent ankle sprains.

Here is what the NFL research said: “Our injury profile was fairly consistent with the existing literature on ankle injuries. Ligamentous (ligament) sprains were the most common diagnosis, making up 86.0% of all ankle injuries.” 

Let’s remember that number – 86% of ankle injuries are ligament sprains.

Back to the 2005 study, the researchers addressed the same problem NFL teams were trying to avoid in 2018:

“Most patients who sustained an inversion ankle injury at sport and who were subsequently referred to a sports medicine clinic had persistent symptoms for at least two years after their injury.”

Back to the NFL study. What was the recommendation for treatment? This is what was published:

“Because treatment decisions are individually varied and surgical data were not available for all players, it is difficult to recommend any specific procedure for certain injuries.”

Fear and frustration in college-age athletes going through rehabilitation

If you are reading this article to this point, it is likely that you have had some fear and frustration in why your ankle never heals. You are not alone.

A study published in the Journal of Sport Rehabilitation (6) from American researchers at Still University and Old Dominion University wrote:

“Collegiate athletes with any history of ankle sprain exhibited elevated levels of fear compared to healthy controls. These findings suggest that ankle sprains, in general, may elevate injury-related fear but those with a history of recurrent sprains appear to be more vulnerable. Accordingly, fear should be addressed during rehabilitation.”

Rehabilitation focuses on balance and strength training. There is no question these exercises can help. Yet, chronic ankle instability remains a critical problem. For balance and strength training to be most effective the therapy must rely on resistance to build muscle. The muscle relies on strong tendons to hold itself to the bone. If the tendons are weak, the resistance is lower.  Muscles also rely on ligaments to hold the bones together so the tendons are in a maximum position to help the muscles get maximum resistance. If the ligaments and tendons, which are not addressed in physical therapy or any conservative treatments which we will discuss next, the physical therapy will not be a long-lasting solution to a chronic ankle sprain. In the section below on Prolotherapy, we will address the problems of ligaments and tendons.

Are Fear and frustration cured with an ankle brace, an ankle sleeve, or a roll of tape?

A team of physical therapists in Spain has published a study (April 2018) in the journal Disability and Rehabilitation (7) They wanted to report on their findings surrounding the immediate and prolonged (one week) effects of elastic bandage on balance control in subjects with chronic ankle instability.

Caring Medical comment:

“The treatment is always the same and usually it is ineffective.”

Sometimes when we ask a patient, how many times they have sprained their ankle, they will report that they really do not know. The patients will be able to review with us their medical history for ankle sprains as simply:

The patients will usually be able to describe numerous occasions where they enacted their own self-care using any combination of these treatment protocols.

There is not much evidence for the aggressive treatment of ankle strain in the athletic population

A paper published in 2022 in the Journal of sport rehabilitation (29) assessed the effectiveness of treatment following and acute ankle sprain. Noting that acute lateral ankle sprain, if treated poorly, can result in chronic ankle issues, such as instability. In this paper “early dynamic training (progressive balancing exercises to build muscle strength) after acute lateral ankle sprain in athletes results in a shorter time to return to sport, increased functional performance, and decreased self-reported reinjury. The results of this scoping review support an early functional and dynamic rehabilitation approach when compared to passive (manual or physical therapy that is less demanding and focuses more on non-weight bearing as opposed to weight-bearing) interventions for athletes returning to sport after acute lateral ankle sprain. Despite existing research on rehabilitation of lateral ankle sprain in the general population, a lack of evidence exists related to athletes seeking to return to sport.” In other words, there is not much evidence for the aggressive treatment of ankle strain in the athletic population.

Doctors are not sure if ankle sprains ever really heal – a “new sprain’ is probably just an old sprain that never healed

In the British Journal of Sports Medicine researchers say 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. (8)

Learning point:

The researchers of this study pointed out a scenario that we have seen frequently and many of the readers of this article can identify with:

The problem of treatment:

The researchers suggested to doctors that these “new injuries,” should not be treated as new injuries but rather as gradual wear and tear overuse injuries. An old injury that never really healed and appropriate treatment should be explored for a chronic injury.

In our experience, this is a major reason why patients tell us “the treatment is always the same and usually ineffective.” Later in this article, we will document our own research suggesting the treatment of patients with wear and tear and overuse ankle sprain injuries.

Ligaments and progressive collapsing foot deformity

Researchers at the University of Arizona published an April 2022 paper in the journal Clinical biomechanics (31) in which they wanted to test the importance and impact of ligament tears on joint contact mechanics in progressive collapsing foot deformity. Progressive collapsing foot deformity is a collective term to describe ankle instability of loss of ankle range of motion from osteoarthritis. The areas affected are the subtalar, transverse tarsal, naviculocuneiform (midfoot joint) and tarsometatarsal joints (Lisfranc joints), as well as gastrocnemius-soleus complex (the muscles that flex the ankle joint) contracture. The researchers write that patients who suffer from “longstanding progressive collapsing foot deformity often develop osteoarthritis of the ankle, midfoot, or hindfoot joints, which can be symptomatic or lead to fixed deformities that complicate treatment. The development of deformity is likely caused by ligament degeneration and tears.”

An ankle that never heals is forever unstable. This is where the surgical recommendation comes in

In the journal of Orthopaedics & Traumatology, Surgery & Research, (9) Orthopedist researchers say not everyone with chronic ankle instability will need surgery, however, in the course of providing conservative management of chronic ankle sprains, it is difficult to determine which of those patients will fail the treatment and will eventually need surgery.

If you are reading this article, it is very likely that you have, for the most part, failed conservative treatment and you are looking for answers.

Who will need the surgery and who will not? This may be determined by the level of ankle instability.

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, this much is the consensus in the medical community. But what is the progression from an ankle sprain to ankle instability, can this be documented to offer some idea?

This was addressed by an Irish research team writing in the American Journal of Sports Medicine (10) who among other findings found that patients who could not properly jump or land 2 weeks after their first lateral ankle sprain were high-risk candidates for chronic ankle instability.

Unfortunately, literature examining chronic ankle instability is often conflicting and confusing to patients. The Irish researchers were able to identify jumping and landing ability and non-reported ankle pain up to 6 months as being high-risk factors for ankle instability, but they were not the only factors.

University researchers in Australia also tackled this problem of identifying the risk factors for ankle instability. In June of 2016, the Australian team published their intent to examine the problems of ankle instability in the medical journal Systematic Reviews (11) and correlate available research into a clearer understanding of key factors… This was what they said:

Unfortunately, the literature examining the presence of these factors in chronic ankle instability is conflicting.

In 2017, at the completion of their review, the researchers published their findings in the journal, Sports Medicine. (12)

With a focus on the ankle ligaments, here are the surgical recommendations and the challenges of surgery

In the patients we see, they have at some point considered surgical intervention for their chronic ankle instability because they are basically done with treatments that are not effective. The reason they have not jumped right to surgery is because of its risks and the possibility that it will not help. But clearly, surgery does address ligament and tendon problems. These problems can also be addressed in a non-surgical manner as w will discuss below.

Whenever we discuss surgery, it is important to bring in a surgical opinion.

In the Journal of Orthopaedic Surgery and Research, June 2018 (13) a team of medical university orthopedic surgeons presented their findings to the medical community:

Surgery can work for some people. One of the appeals of the arthroscopic Brostrom procedure is that it is an “outpatient,” or same-day surgery.  But as many have learned, same-day surgery can mean months of rehabilitation. Typical rehabilitation of this procedure can include:

Same-day surgery simply means a smaller incision, the rehab remains the same.

More on the modified Brostrom procedures

A February 2022 paper published in the Orthopaedic Journal of Sports Medicine (25) writes that “despite marked improvements in stability after lateral ankle ligament repair (surgery), many patients do not return to their pre-injury activity level. There are few studies addressing athletes’ assessment of their ability to return to play after lateral ankle ligament reconstruction for recurrent instability.”

To answer this question the researchers sought to determine the rate of return to the preinjury activity level among physically active patients after the modified Broström procedure for recurrent lateral ankle instability.

Included in this study were patients who had undergone a primary modified Broström procedure by a single surgeon over a 6-year period and had a minimum of 24 months of follow-up.

Early dynamic training, electrotherapy, and hydrotherapy.

A 2022 study in the Journal of Sport Rehabilitation (26) discussed the prevention of an acute ankle sprain moving towards chronic ankle sprain and ankle instability. They wrote: “Acute lateral ankle sprain is a common injury in athletes and is often associated with decreased athletic performance and, if treated poorly, can result in chronic ankle issues, such as instability. Physical performance demands, such as cutting, hopping, and landing, involved with certain sport participation suggests that the rehabilitation needs of an athlete after lateral ankle sprain may differ from those of the general population.”

It is well understood that an athlete will need a more aggressive treatment program than those not engaged in athletics or for that matter, a person who does physically demanding work and needs to get back on the job.

Returning to this study: The researchers examined three treatment methods early dynamic training (specific ankle exercises to improve strength and balance), electrotherapy (such as transcutaneous electrical nerve stimulation (TENS)), and hydrotherapy (treating with water immersion).

Conclusions: Early dynamic training after an acute lateral ankle sprain in athletes results in a shorter time to return to sport, increased functional performance, and decreased self-reported reinjury. The results of this scoping review support an early functional and dynamic rehabilitation approach when compared to passive interventions for athletes returning to sport after lateral ankle sprain (Such as RICE, Rest, Ice, Compression, Elevation).

What the researchers are saying is that treating ankle sprain with movement or stimulation is better than passive Rest, Ice, Immobilization, and Elevation) We have practiced the same idea of the MEAT protocol (Movement Exercise Analgesia Treatment) for nearly thirty years. To demonstrate here are two studies from the early 1990s. An early mobilized group of patients with lateral ankle sprains had less pain and returned to full capacity quicker compared to the immobilized group. (7) Even in lateral ankle ligament ruptures causing gross mechanical instability early mobilization resulted in a better early functional result. (8)

Therapy to address sprinting and change of direction may help ankle instability in athletes

A May 2022 study from Indian and Australian researchers (30) suggested that doctors : “Chronic ankle instability in athletic populations appears to be highly associated with declines in functional performance and to a somewhat lesser extent, ankle range of motion, strength and muscle endurance measures. This may suggest that optimal rehabilitation for athletes with Chronic ankle instability may require a greater focus on improving sprinting speed and change of direction ability in the mid to latter stages of rehabilitation, with regular assessments of these functional performance tests necessary to guide the progression and overload of this training.”

What are we seeing in this image?

The caption reads: “Ultrasound showing tear in the anterior talofibular ligament of the right ankle.” What this image is illustration is the accompanying chronic synovial effusion in the joint. The effusion or swelling in the ankle attempts to provide a “water brace” to stabilize itself. Surgery is seen as a way to correct the problem and provide stabilization.

“The procedures of reconstruction surgery for chronic lateral ankle instability.”

In October 2021, specialists writing in The Journal of foot and ankle surgery (14) evaluated “the procedures of reconstruction surgery for chronic lateral ankle instability.” In this study, the doctors compared single anterior talofibular ligament reconstruction to simultaneous reconstructions of the anterior talofibular and calcaneofibular ligaments. As we will see, the surgeons of this study call for more ligament repair than isolation simply on the anterior talofibular ligament.

How was the study conducted?

Anterior talofibular ligament injury and calcaneofibular ligament injury. 

A May 2020 paper published in the Orthopaedic Journal of Sports Medicine (15) outlined the various risk factors for the development of bone spurs in the ankle. Among them were injuries to the Anterior talofibular ligament [ATFL] and the calcaneofibular ligament. Injuries to these ligaments were significantly associated with the presence of lateral osteochondral lesions (bone on bone situation developing on that side of the ankle). Further patients with BOTH Anterior talofibular ligament [ATFL] injury and calcaneofibular ligament [CFL] injuries were significantly more likely to develop bone spurs than were patients with single-ligament injuries.

A message to take home is that bone spurs develop because of ligament injury. A comprehensive full ankle approach to treating ligaments may be a valid way to prevent the development of bone spurs.

Summary. The ankle is a unit. Surgical repair of one ligament, while successful for many, will not be successful for all. At our clinic, we help patients like this with dextrose or platelet injections into the ankle to strengthen and support the ankle ligament complex.

The tendon attachments

This section summarizes our article: A missed peroneal tendon injury: Is this the cause of inappropriate surgery and continued foot and ankle pain?

When reviewing the current and recent medical literature on helping people with chronic ankle instability and pain before or FOLLOWING corrective elective surgery, we see research that focuses on a peroneal tendon injury.

A November 2021 study published in The Journal of Foot and Ankle Surgery (16) offered this summary of Peroneal tendon pathology and chronic ankle instability:

Peroneal tendon pathology is commonly associated with chronic lateral ankle instability. Foot and ankle surgeons often rely on preoperative magnetic resonance imaging (MRI) for the identification of related pathology and surgical planning in these patients. The purpose of this study was to assess the ability of preoperative MRI to accurately detect peroneal tendon pathology in patients with chronic lateral ankle instability.

Explanatory notes: The researchers here show that Peroneal tendon pathology or injury is common in chronic ankle instability, but it is not often detected unless you are in the middle of the surgery. Here is what they observed:

Again, let us stress that chronic ankle instability is a problem of the whole ankle joint and not the isolated tear. When there is an isolated tear the whole ankle reacts by altering movement and by adding swelling to help support itself.

A discussion of Subtalar joint instability – a wandering talus.

The subtalar joint is the joint of the heel and the talus. Subtalar joint instability has been defined as the talus bone being tilted in relationship to the heel. But there is great controversy as to whether subtalar joint instability is a real diagnosis or if it is simply a description of lateral ankle instability. In other words is it a problem of the talus tilting in relation ship to the heel or is it a ligament problem? If so, which ligaments? Is it a talocalcaneal interosseous ligament problem that is holding the heel to the talus or it it breakdown of the other ligaments described above? Is it all the ligaments?

A February 2020 paper asked the question: Does subtalar instability really exist? Writing in the journal Foot and ankle surgery (32) researchers wrote: “Subtalar joint instability is considered as a potential source of chronic lateral hindfoot (the talus to heel) instability. However, clinical diagnosis of subtalar joint instability is still challenging.” In their review the researchers assessed the consistency of doctors using the diagnosis “subtalar instability” or other diagnostic terms to describe foot / ankle instability.

Why is this important? It is important to understand the extent of the foot problem. Why is your talus tilted or wandering? What ligaments should a doctor suspect?

What they found was doctors using a diagnosis of subtalar joint instability amid a degree of confusion. They also found that “complaints of instability can be related to subtalar ligaments injuries and an abnormally increased motion of the subtalar joint. (It could be all the ligaments) Stress radiographs should be interpreted with caution and should not have the status of a reference test. (In other words an MRI may NOT show or identify what is the true cause of the problem it may miss something less obvious.)

Regardless of the diagnostic terms, all signs point to ligament damage.

An August 2021 paper in the Orthopedic journal of sports medicine (33) describes it this way: “Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability.”

Chronic ankle instability – is more than treating one ligament it is treating the whole ankle joint

In this section of our article, we will present non-surgical options and the research behind them in repairing ligaments and tendon damage that may be occurring in the whole ankle. Surgery can be a successful remedy for some patients. However surgery can be limited in what it can fix at a single surgery and surgery, despite “claims of minimally invasive,” still requires a long rehabilitation afterward. Ankle ligament reconstructive surgery is no different.

In the Journal of Physical Therapy Science, (17) Doctors at South Korea’s Sport Science Institute, Incheon National University looked at male soccer players and found the complexity of the problem needed to be solved by addressing the entire ankle joint and not simply a ligament tear or chronic ligament weakness.

Here are their findings:

A study from Dutch doctors published in the International Journal of Sports Medicine (18) looked at 98 patients with chronic, persistent ankle sprains. The problem of a single ligament causing ankle sprains and instability have now become a problem of total ankle joint destruction in these patients.

Chronic ankle sprains rapidly move towards ankle instability and degenerative ankle disease. At this point, the surgical options go from ligament reconstruction to the possibility of ankle fusion.

As a side note, one curious symptom and one that should clearly point to chronic ankle instability and should be explored in patients with chronic knee instability and hip instability are Dynamic balance problems related to the ankle.

In two studies from University College Dublin, 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 (19) and one-year follow (20) after a single ankle sprain event, patients showed a reduced balance that created stress on the entire limb side, hip, knee, and ankle included.

Injections for ankle instability and degenerative ankle problems

In February 2021, leading Italian and Swiss researchers publishing in the journal International Orthopaedics (21) attempted to offer evidence supporting the safety and effectiveness of intra-articular injective treatments for ankle lesions ranging from osteochondral lesions of the talus to osteoarthritis. They explored previously published research on:

In all the injection research there were no severe adverse events were reported.

However, the conclusion of this research could not offer a definitive recommendation because there is not enough evidence in the research to support the use of one injection treatment over another.

Ankle Instability and Prolotherapy

This section will deal with the question, How do WE treat chronic ankle sprains and instability?

In this video, Danielle R. Steilen-Matias, MMS, PA-C demonstrates treatment to the lateral ankle

The treatment begins immediately in the video

This is comprehensive Prolotherapy, meaning there are a lot of injections. The patient getting the injections in this video is comfortable and tolerates the treatment well. The patient in this video is having the lateral or outer ankle treated.

Caring Medical’s first line of treatment for chronic ankle pain and ankle instability is Prolotherapy. In treating with Regenerative Injection Techniques (RIT), i.e., 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 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, (22) we reported on 19 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.

Of these 19 patients:

Prolotherapy effects

In regard to the quality of life issues prior to receiving Prolotherapy:

What are we seeing in this image? A good candidate for Prolotherapy.

In this x-ray, we see a very good candidate for Prolotherapy treatments to the ankle. The patient has some mild loss of cartilage in her ankle and a mildly limited range of motion. For this reason, she was rated as a good candidate for Prolotherapy. She is not an excellent candidate due to the loss of cartilage and range of motion.

In this x-ray we see a very good candidate for Prolotherapy treatments to the ankle. The patient has some mild loss of cartilage in her ankle and mildly limited range of motion. For this reason she was rated as a good candidate for Prolotherapy. She is not an excellent candidate due to the loss of cartilage and range of motion.

For significant deterioration, we may recommend to patients a more aggressive approach incorporating Platelet Rich Plasma and bone marrow aspirate stem cell treatments.

In the medical journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, Caring Medical published our findings on seven patients receiving combined bone marrow aspirate stem cell treatments. Patient case 1 represented an ankle case.

A 59-year-old female patient came into our office with right ankle pain following a lateral sprain. The patient reported she could barely walk without severe ankle pain.

The patient had unsuccessful treatment with cortisone injections and was being recommended for an ankle fusion based on X-ray and MRI findings that suggested osteoarthritis, avascular necrosis of the talus, and synovitis. Please see our published research on bone marrow aspirate injections into the talus and the case history of regenerative repair.

The patient received four bone marrow/dextrose treatments over a period of eight months.

PRP Ankle Injection Research on ankle sprain

Throughout this article, we reinforce the message that damage to the ankle may require more than rest or ice or immobilization. It may take more than a single treatment of anything and it may be unrealistic for patients to think that one treatment or injection of anything with getting them back on their feet quicker or better. This is the case with Platelet Rich Plasma therapy as well. When exploring this treatment that utilizes your blood platelets injected into the site of injury, patients should be aware that in many cases, a single one-time “shot,” will not be a successful treatment. We offer PRP with Prolotherapy in many patients.

A September 2019 study in the journal Foot and Ankle Surgery (23) evaluated the effect of Platelet-Rich Plasma (PRP) therapy in patients with acute lateral ankle sprain treated with rigid immobilization.

In this study, (Twenty-one) Patients with first-time grade II lateral ankle sprain clinically diagnosed were evaluated. A rigid immobilization was placed in all patients for ten days. In the PRP treatment experiment group application of PRP over the anterior talofibular ligament was performed. Standard pain and disability scoring evaluations were given at 3, 5, 8, and 24 weeks of the follow-up period.

The results of this study show: “The (PRP treated) experimental group presented the highest reduction in pain and better functional scores than the control group at 8 weeks. At the end of the follow-up period, the results of both groups were similar. A similar evolution was observed in patients treated with rigid immobilization with or without PRP after 24 weeks.

Here we have research again that shows one treatment is usually not a good treatment. While early indications show PRP was effective, at 24 weeks the single PRP treatment and immobilization results were about the same. This helps reinforce the idea that PRP is usually not as effective as a single, “magic bullet,” injection. The treatment needs to be repeated as part of a comprehensive program. You can ask about our program below.

PRP and 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 difficult to heal.

In recent research, (24) doctors examined the success of platelet-rich plasma (PRP) into the injured anteroinferior tibiofibular 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:

CONCLUSIONS:
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.

The caption reads: Direct bone marrow injections into the ankle.

Direct Bone Marrow Injection

A demonstration of Stem Cell Therapy and Prolotherapy

In our clinics, stem cell therapy, which are cells taken from the patient, NOT donated “stem cells,” are used in only the most advanced cases. This is not our “go-to,” treatment. In the same way, the joint degeneration does not occur overnight, one cannot expect the repair to be achieved overnight. In more advanced cases it can take more than 1 treatment to achieve treatment goals.

The treatment begins at 1:06 of the video

Summary and contact us. Can we help you?

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 has 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 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 stubborn 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:

Clearly, this type of chronic ankle problem cannot be treated with a single injection of PRP, Prolotherapy, or Stem Cell Therapy, this is a complicated problem needing a comprehensive plan.

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.

We hope you found this article informative and it helped answer many of the questions you may have surrounding your ankle problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

 

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References

1 Aicale R, Maffulli N. Chronic Lateral Ankle Instability: Topical Review. Foot & Ankle International. 2020 Dec;41(12):1571-81. [Google Scholar]
2 Mailuhu AK, Oei EH, van Ochten JM, Bindels PJ, Bierma-Zeinstra SM, van Middelkoop M. Subgroup characteristics of patients with chronic ankle instability in primary care. Journal of science and medicine in sport. 2019 Mar 6. [Google Scholar]
3 Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. British journal of sports medicine. 2005 Mar 1;39(3):e14-. [Google Scholar]
4 Green T, Willson G, Martin D, Fallon K. What is the quality of clinical practice guidelines for the treatment of acute lateral ankle ligament sprains in adults? A systematic review. BMC musculoskeletal disorders. 2019 Dec 1;20(1):394. [Google Scholar]
5 Mulcahey MK, Bernhardson AS, Murphy CP, Chang A, Zajac T, Sanchez G, Sanchez A, Whalen JM, Price MD, Clanton TO, Provencher MT. The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015. Orthopaedic journal of sports medicine. 2018 Jul 17;6(7):2325967118786227. [Google Scholar]
6 Houston MN, Hoch JM, Hoch MC. 40 Collegiate athletes with ankle sprain history exhibit increased fear-avoidance beliefs. [Google Scholar]
7 Alguacil-Diego IM, de-la-Torre-Domingo C, López-Román A, Miangolarra-Page JC, Molina-Rueda F. Effect of elastic bandage on postural control in subjects with chronic ankle instability: a randomised clinical trial. Disability and rehabilitation. 2017 Jan 16:1-0. [Google Scholar]
8 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. [Google Scholar]
9 Guillo S, Bauer T, Lee JW, Takao M, Kong SW, Stone JW, Mangone PG, Molloy A, Perera A, Pearce CJ, Michels F. Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy. Orthopaedics & traumatology: surgery & research. 2013 Dec 1;99(8):S411-9.  [Google Scholar]
10  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. [Google Scholar]
11 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 Jun 7;5(1):94. [Google Scholar]
12 Thompson C, Schabrun S, Romero R, Bialocerkowski A, van Dieen J, Marshall P. Factors Contributing to Chronic Ankle Instability: A Systematic Review and Meta-Analysis of Systematic Reviews. Sports Medicine. 2017 Sep 8:1-7. [Google Scholar]
13  Cao Y, Hong Y, Xu Y, Zhu Y, Xu X. Surgical management of chronic lateral ankle instability: a meta-analysis. Journal of orthopaedic surgery and research. 2018 Dec;13(1):159. [Google Scholar]
14 Hanada M, Hotta K, Matsuyama Y. Comparison Between the Simultaneous Reconstructions of the Anterior Talofibular Ligament and Calcaneofibular Ligament and the Single Reconstruction of the Anterior Talofibular Ligament for the Treatment of Chronic Lateral Ankle Instability. The Journal of Foot and Ankle Surgery. 2021 Oct 22. [Google Scholar]
15 Wang DY, Jiao C, Ao YF, Yu JK, Guo QW, Xie X, Chen LX, Zhao F, Pi YB, Li N, Hu YL. Risk Factors for Osteochondral Lesions and Osteophytes in Chronic Lateral Ankle Instability: A Case Series of 1169 Patients. Orthopaedic Journal of Sports Medicine. 2020 May 26;8(5):2325967120922821. [Google Scholar]
16 Clair BL, Winder ML, Neubauer EF. Open Evaluation of the Peroneal Tendons should be considered in Patients with Chronic Lateral Ankle Instability Undergoing Ankle Arthroscopy with Lateral Ankle Stabilization. The Journal of Foot and Ankle Surgery. 2021 Nov 2. [Google Scholar]
17 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. [Google Scholar]
18 van Ochten JM, de Vries AD, van Putte N, Oei EH, Bindels PJ, Bierma-Zeinstra SM, van Middelkoop M. Association between Patient History and Physical Examination and Osteoarthritis after Ankle Sprain. International journal of sports medicine. 2017 Jul 24. [Google Scholar]
19 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. [Google Scholar]
20 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. [Google Scholar]
21 Boffa A, Previtali D, Frattura GD, Vannini F, Candrian C, Filardo G. Evidence on ankle injections for osteochondral lesions and osteoarthritis: a systematic review and meta-analysis. International Orthopaedics. 2020 Jul 9:1-5. [Google Scholar]
22 Hauser RA, Hauser, MA, Cukla J. Dextrose Prolotherapy Injections for Chronic Ankle Pain Practical PAIN MANAGEMENT, January/February 2010 p 70-76. [Google Scholar]
23 Blanco-Rivera J, Elizondo-Rodríguez J, Simental-Mendía M, Vilchez-Cavazos F, Peña-Martínez VM, Acosta-Olivo C. Treatment of lateral ankle sprain with platelet-rich plasma: A randomized clinical study. Foot and Ankle Surgery. 2019 Sep 28.
24 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. [Google Scholar]
25 May NR, Driscoll M, Nguyen S, Ferkel RD. Analysis of Return to Play After Modified Broström Lateral Ankle Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2022 Feb 2;10(2):23259671211068541. [Google Scholar]
26 Tee E, Melbourne J, Sattler L, Hing W. Evidence for Rehabilitation Interventions After Acute Lateral Ankle Sprains in Athletes: A Scoping Review. Journal of Sport Rehabilitation. 2022 Dec 30;1(aop):1-8. [Google Scholar]
27 Eiff, M. Early mobilization versus immobilization in the treatment of lateral ankle sprains. American Journal of Sports Medicine. 1994; February: 83-88. [Google Scholar]
28 Konradsen L, Holmer P, Sondergaard L. Early mobilizing treatment for grade III ankle ligament injuries. Foot Ankle. 1991;12(2):69-73. [Google Scholar]
29 Tee E, Melbourne J, Sattler L, Hing W. Evidence for Rehabilitation Interventions After Acute Lateral Ankle Sprains in Athletes: A Scoping Review. Journal of Sport Rehabilitation. 2022 Dec 30;1(aop):1-8. [Google Scholar]
30 Jamsandekar MS, Patel VD, Prabhakar AJ, Eapen C, Keogh JW. Ability of functional performance assessments to discriminate athletes with and without chronic ankle instability: a case-control study. PeerJ. 2022 May 27;10:e13390. [Google Scholar]
31 Malakoutikhah H, Madenci E, Latt LD. The impact of ligament tears on joint contact mechanics in progressive collapsing foot deformity: A finite element study. Clinical Biomechanics. 2022 Apr 1;94:105630.- [Google Scholar]
32 Michels F, Clockaerts S, Van Der Bauwhede J, Stockmans F, Matricali G. Does subtalar instability really exist? A systematic review. Foot and Ankle Surgery. 2020 Feb 1;26(2):119-27. [Google Scholar]
33 Pereira BS, Andrade R, Espregueira-Mendes J, Marano RP, Oliva XM, Karlsson J. Current Concepts on Subtalar Instability. Orthopaedic Journal of Sports Medicine. 2021 Aug 13;9(8):23259671211021352. [Google Scholar]

This article was updated June 16, 2022

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