Sunday, December 6, 2009

I sprained my ankle months ago and it still hurts?


A sprained ankle is the most common sports injury. However, it usually is easy to diagnose and will eventually always heal. Sprained ankles are expected to be back to 90% recovery within 6 weeks (This may vary depending on the degree of sprain and other associated factors). However, what if it doesn't get better? What if your symptoms have not resided by that time? Believe it or not, a simple sprained ankle can often lead to long term problems.


1) Osteochondral Lesions/Osteocondritis Dissecans of the Talus

Often when an ankle is sprained there can be a sudden loss of stability. This can cause bones within the ankle to impact or collapse into one another causing an osteochondral lesion to form. An osteocondral lesion is when the cartilage surrounding a bone is torn, crushed and in more rare causes forms a cyst. Cartilage is the cushioning our bones and joints are surrounded by to help with impact forces. With the cartilage now torn or disrupted it may break off with a small piece of bone and be wedged or displaced inside a joint.


Symptoms often include persistent pain with activity. The pain may be deep within the joint and can occur long after the pain felt from a sprained ankle has resided. The ankle may also experience catching, snapping or locking which it hasn't experienced before. There have been reports of asymptomatic cases and individuals healing spontaneously, but this is often amongst a younger population. Furthermore, these lesions can at times progress to create osteoarthritis within the ankle joint.

Do not assume you do not have this injury because you had radiographs taken. The lesions are small (2-5mm) and flake like. Furthermore, special views are commonly used to spot the injury which will often not be included in a normal series of ankle radiographs. Observe below (A & B no lesions is shown but can be seen on view C). Needless to say this injury is difficult to spot. If easily accessible an MRI should be taken as it has shown optimal diagnostic value.




Osteocondral lesion can be treated conservatively and surgically. However, there has been a lack of research to determine what factors play into the decision making process. Most children or adolescents will resolve the lesion because of their healing properties but adults often carry out the option of surgery.

2)Complex Regional Pain Syndrome/ Reflex Sympathetic Dystrophy

There is no standard definition for CRPS, as nobody has determined what causes the condition. Essentially the syndrome can be defined by its simplistic name "Complex Regional Pain". The syndrome involves a complex array of symptoms in a particular region which leads to pain. However, CRPS has a neurological component explaining the symptoms.

The cause is often attributed to the neurological system becoming confused. When someone experiences an injury the bodies nervous system reacts by producing pain, increasing swelling, changing color due to inflammation ect. However, with CRPS the nerves now are hyper-vigilant, meaning the littlest touch or activity can set of a chain reaction replicating a more serious injury. Reports have shown incidents as small as a paper-cut to cause CRPS. Simple events such as walking or putting on your socks can be interpreted by the ankles nervous system as getting hit by a hammer.


Symptoms will include pain disproportional to the event causing the symptoms originally. Light touch or the application of any form of heat or coldness may be taken as intolerable. Nerves which innervate blood vessels and sweat glands are also affected. Symptoms of this nature may will appear as excessive swelling by the ankle, changes in color, changes to the appearance of the toe nails, hair loss and even sweating when not indicated. In Addition, muscles around the ankle with time may become weakened and get smaller in appearance.

Diagnosing CRPS isn't an easy task. Radiographs, MRI and common physical examination procedures can give a good implication of a diagnosis but not always confirm. Often special imaging is carried out to assess the bodies thermo graphic patterns.

3) Ankle Impingement Syndrome

The body works on a simple concept that when a structure gets damaged it will try to repair itself. Furthermore, whenever a repetitive force or even a constant pressure is applied to a structure it will react by growing, shaping or forming a new position to compensate for this pressure. This concept is how braces work for shaping ones teeth properly.

In the ankle there are a lot of ligaments, muscles and joints. Often when repetitive trauma or strain is applied to one of these structures it will compensate similar to what was described above. Eventually the small bit of cartilage surrounding the bones or ligaments will be pulled on or experience "traction". This constant repetitive action will lead to the formation of little bone and cartilage spurs. These spurs will also occur after repetitive ankle sprains. This process is called osteophytosis.



The spurs formed can often not present any problem at all. However, occasionally bone spurs (also called "osteophytes") will "impinge" structures such as ligaments, tendons and scar tissue from past injuries.

Signs and symptoms may include an ankle which feels unstable or weak. Tenderness or a "pinching sensation" may occur when the foot is brought through flexion and extension. A painful clicking may also be observed during certain movements of the ankle. Impingement can occur in the front and back of the ankle. Usually squatting or bringing your toes towards your head will be painful in anterior impingement. Bringing your toes downward or rising on your toes will produce pain in posterior impingement.




5) Cuboid Syndrome

The cuboid is a small bone that lies on the outside of the foot. Cuboid syndrome is when this bone experiences excessive movement or a collapsing effect. The excessive movement can cause irritation of the surrounding joint capsule and ligaments or put strain on a particular muscle which attaches to the cuboid called the fibularis longus.

Up to 4% of athletes can experience cuboid syndrome with a particular high rate in ballet dancers. However, up to 6.7% of those experiencing ankle sprains can develop cuboid syndrome. When the foot is forced into this position the fibularis longus muscle experiences tension thus jamming the cuboid bone and forcing it to shift out of place.

Patients with cuboid syndrome may present with pain directly over the cuboid and radiating down the outside of the foot. Pain is often associated with a weight bearing position but can occur otherwise. Pain can be experienced with squatting or on toe off during a running gait. Weakness can often be a secondary complaint.

The good news is cuboid syndrome has been shown to be successfully treated with conservative treatment including rehab, manipulation, taping and the placement of a small felt pad under the cuboid preventing it from collapsing.


In summary, if your experiencing new symptoms after an ankle sprain get it assessed by a trained professional. The complaint may be something completely new but sprained ankles often lead to problems down the road. Assess the problem early, listen to your clinician and take precautions on your first ankle sprain to reassure these problems don't persist.

Other injuries that may occur after a sprained ankle or be confused with previous mentioned conditions are:

-Os trigonum
-Fibularis Longus Subluxation
-Sinus Tarsi Syndrome
-Osteoarthritis
-Nerve Palsy

References





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Choi WJ, Park KK, Kim BS, & Lee JW (2009). Osteochondral lesion of the talus: is there a critical defect size for poor outcome? The American journal of sports medicine, 37 (10), 1974-80 PMID: 19654429

PONTELL, D. (2008). A Clinical Approach to Complex Regional Pain Syndrome Clinics in Podiatric Medicine and Surgery, 25 (3), 361-380 DOI: 10.1016/j.cpm.2008.02.011

Jennings, J. (2005). Treatment of Cuboid Syndrome Secondary to Lateral Ankle Sprains: A Case Series Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2005.1596

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