Baffling 10 month ankle sprain

[sammo440]

In April 2011 I injured my ankle playing football (soccer) in what I thought at the time was a fairly routine, minor grade 2 sprain. I received a challenge on the inside of my foot, causing it to roll outwards. I was able to complete the game, playing with a degree of pain, but the next day it was too painful to walk on.

It improved steadily for the first month, until it was very nearly better but then seemed to stall. I slowly returned to playing football and it got to a point where I could feel it aching slightly when I played, but it would not restrict me in any way and would be no worse as a result of having played. Then, in July, 3 months after the initial injury, I played 3 times in a week, with the final occasion being a tournament which took place over several hours. I did not specifically re-injure my ankle again, but it felt much more painful immediately afterwards, and I had trouble walking on it for the next few days.

From then on, the injury seemed to take on a different nature. There was no longer any progress on a day to day basis, on some days it seemed to be worse or better for no apparent reason, and on the whole, it would ache progressively more throughout the days then return to its previous level in the morning. At this point I began seeing a physio, who mobilised the joint and massaged the calf muscles around it and made corrections to my posture as she felt my biomechanics may have been making a low level contribution to the lack of progress, (in that I needed to rely more on my glutes and core muscles rather than my hip flexors and lower back and I had been over-using my toe flexor in that foot, which I had been feeling as a tightness through the bottom of my foot).

These sessions with a physio seemed to get me over a hump and I was able to make progress again, culminating in a return to playing football around the end of October. At this point I still had some low-level aching in my ankle, but believed that exercise may help it to return to normal. I played 10 minutes in my first week back with no pain and while there was some aching later that night, it felt ok again the next day. The following week I intended to up my activity slightly, but due to 2 other players getting injured during the game I had to play the full 40 minutes (this is 5 a side football). Again, there was a bit of aching that night and for the next day or 2, but it basically then felt fine again. The following week however, even though I only played about 15 minutes, I sensed that something wasn’t quite right, and although I didn’t have any pain at the time in my ankle, I started to feel tightness through the bottom of my foot while I played.

Sure enough, the next day, my ankle felt similar to how it had done when I first started seeing the physio, aching persistently, (although not with great intensity), whenever I walked on it for more than a couple of minutes or sat down for longer periods without having it up. This activity/inactivity also seemed to result in it getting slightly more swollen, although not greatly, and it would normally return to a level of swelling where there is a noticeable, but not significant difference in size in relation to the other ankle, the following day.

I immediately began seeing my physio again, but this time I have not felt any signifificant improvement in the subsequent 3 months. The aching I generally experience now is low level and appears to be related to a tightness in the front and back of my calf. I feel that this tightness/aching emanates from the slightly swollen region on the upper, outer side of my ankle, but possibly continues up slightly into the front of my calf. Stretching or massage of the front or back of my calf provides some relief, but only for a matter of minutes (although this is longer when carried out by the physio), and the only other thing that stops the aching is icing it or lying down fully (like when asleep), although I do also get some relief by keeping it up on a chair or something.

In the 3 months since my failed attempt at a return to football, there have been some occasions where I felt like I was making progress for a couple of days (usually after seeing the physio), and I would get less aching during the days but these would never last. In thinking about the reasons why this might have been, as I have not been doing much on it, even keeping walking to a minimum, the only thing I can think of is cycling, as I had been doing this for up to 10 miles a day. I drastically reduced my cycling 3 weeks ago however, and in that time have also taken a week of work, (which was spent at home resting it and occasionally exercising it by standing on my leg to work on my balance) and I am still no better off.

My physio says that she does not really understand what the problem is so I am also completely baffled and would welcome any input from anyone! My physio says that it does not make any sense that it would ache when I am sat down normally as this should not be putting any stress on it, but she does not think that there is something major wrong with it, as there does not appear to be any apparent weakness and it is not massively swollen. I also have good mobility in the ankle, as demonstrated by how far I can get down when bending my legs from a standing position with my heels on the ground, although it further confirms my belief that my calf muscles have something to do with this as I feel tightness in the front and back of them when asked to do this without prior massage or stretching.

I have previously gained great help and comfort from this forum when I injured my MCL in the knee on my other leg a couple of years ago (see baffling 8 month grade 2 MCL sprain if you’re interested or remember me) so I am really hopeful people will be kind enough to share their thoughts with me again. I would really appreciate it as it is having a significant effect on my whole life, and I worry all the time about what I should or shouldn't be doing to make it better. Should I use crutches even though on a scale of 1-10 the pain is never more than a 2-3? Should I do more activity on it? Should I push for getting an MRI scan, or ultra-sound or some other form of treatment?

Thank you for reading this far anyway. Sam

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[Podiatry]

I know this may be a long shot, but have you been checked for gout at all? Do you drink much alcohol? Hope that isn't too personal.

[karen.hankey]

Hi Sam,

Have you considered Tibialis Posterior dysfunction. I had a football player who suffered a kick onto the inside of his ankle. He was treated for medial ligament sprain but did not improve over a number of weeks. As a student at the time I researched to discover any other possibilities and discovered tibialis posterior dysfunction. I strapped his foot and he was able to play with no symptoms and gradually he was weaned off the tape and returned to normal play.

Tibialis posterior is involved in maintaining the arch of your foot. With a kick to it, even though you don't tear the muscle, you effectively stop it from working properly. Due to this you then start to pronate more (loose the natural arch in your foot) which in turn stretches the tendon which stops it working properly - so in a big cycle!. The aching is a sign that the muscle is trying to work to hard to maintain the arch but isn't strong enough to do so. This becomes more noticeable with quicker, unexpected movements.

The initial thing to try with it is a taping technique called "low-dye taping" which will support the arch of your foot and therefore take pressure off the muscle and should help with the aching. There are exercises that you can complete, but as you've had this for so long, they may not be effective. So due to this, if the taping technique works, then an insole would be the best thing to go for - however, I would get one custom made if possible. Before that, ensure that your shoes are supportive - ideally a trainer with a good arch support is best, rather than a smart/dress shoe. Also try not to walk around at home with no shoes on, especially if you have hard floors

Hope this is some help to you.

[sammo440]

Thanks a lot for your thoughts. I'm certain it's not gout as the swelling has been light for many months now, to the point that it is only possible to know that it is swollen when comparing it with the other ankle iunless I've done a lot on it that day. The swelling is also over the exact part of the ankle which I sprained (which I'm now pretty certain is the anterior talofibular calcaneo fibular ligament) and I can't really see any indicators that it might be gout (I have a healthy lifestyle etc).

I'm fairly certain that this is just a chronic ankle sprain, and whilst I have been trying to be careful, I think it's just so sensitive to any stress whatsoever, that I'm doing something without realising that has caused it to get stuck, so that it aches a bit most of the time and more so whenever I walk on it for more than a few minutes. I think this because it seemed like a regulation ankle sprain at first (and not even a major grade 2 one), got better fairly quickly, got stuck a bit just before it was fully recovered, took longer when it was re-injured, and now again is taking longer still after it was re-injured 3 months ago. Maybe if I describe how I've been using it day to day it might give some clues as to what I do differently

To get to work, I cycle to the train station where I have to take my bike up a largeish set of stairs to take on the train with me. I then have to carry it down the stairs at the other end, then do the same again at the next train station. I take my bike with my because it saves me having to walk the 5 minutes between the 2 train stations and the 10 minutes from the 2nd train station to my office.

At work I keep my foot up on a chair, and for the last few weeks have been icing it regularly throughout the day. If I am in a meeting and cannot keep my leg up then up until a couple of days ago I have been extending my leg out a bit and my heel only on the floor as this seems more comfortable, but my physio just told me that this extends the ligament so I shouldn't do it. I had it in my mind that it was less comfortable to sit normally with my feet flat as it felt like there was more pressure going through my ankle, but I guess I might be wrong in this, and certainly when I sat with my foot stretched for 2 hours the other day my whole foot seemed to be aching afterwards.

I do the same journey from work to home afterwards and then I basically keep my foot up again as much as possible whilst walking around a bit to cook etc. I am also now mindful of the fact that sometimes when I sit with my leg up, the ankle is again a bit stretched, so I am now trying to rest it up but with my foot against something to keep it at a right angle to my leg.

The only other thing I do during the day is stretch my calf and hamstrings, and sometimes massage the front of my calf as this seems to give some temporary relief to my aching ankle, although the relief it gives lasts shorter amounts of time throughout the day, going from maybe 40 minutes to 5 minutes. I only feel tightness ever in the front of my calf rather than the back, but stretching either seems to give some relief.

As for the tightness I feel in the bottom of my foot and around the arch, from looking it up, tibialis posterior dysfunction seems unlikely. When I had a similarly chronic knee injury which finally ended about a year ago, my physio looked at my biomechanics and noticed that my feet rolled in a lot naturally so I made efforts to correct this, but probably relied too much on my toe flexors to support my arch rather than gain the required strength in my glutes by building them up. When I then injured my ankle I think that this put even more pressure on the toe flexors to provide stability and support in my feet and so they are very prone to tightness. I am slowly getting there with building up my glutes and using my core muscles more to improve my posture but this obviously takes time to correct the mistakes I had developed over my first 26 years and then the new "quick fix" ones I developed over the followig 2.

I do have a tendency to go on a bit on these posts don't I. Does anyone even read this far?! Thank you a lot for anyone who has done, and thanks again to Karen and Podiatry for your thoughts.

[sammo440]

Oh yeah, an extra bit of relevant information: before any of this happened, I was told that I have lax ankle ligaments. Also, with all the changes I've been trying to make to my posture I think instability in my ankle might be something to do with what's going on. I have seen a podiatrist about my feet pronating in the past, but they just gave me insoles. I feel like now I'm this far in, I want to sort everything out properly rather than just go for a quick fix like that, although my priority is first to get my ankle sorted, so again I'm not really sure what to do!!

Finally, any recommendations for physiotherapists who have a specifically strong awareness of chronic ankle sprains in London, please let me know.

[physiofi]

Hi Sam,

Sorry to hear you're suffering with ankle pain. Thought I would add my 2 cents although I don't have extensive experience with ankles - and they can be fiddly at the best of times! While reading your post, I'll admit, as Karen did, it did crop up in my mind that perhaps it was tibialis posterior dysfunction, as that is notoriously difficult to rehab and can respond poorly. Where specifically are you getting the pain? Is it on the inside or outside of your ankle? When you say front and back of calf, do you mean back of leg and shin?

Are you doing any rehab or specific exercises at home now? A suggestion would be to work hard on balance and your ankle proprioception (your joint's sense of awareness of what position it's in). If you are very hypermobile (lax ligaments), your proprioception will be poorer even without any prior injury, so it is important to work on improving this. Examples could be: single leg standing, single leg standing with heel raise / semi squat, single leg standing with eyes closed, throwing and catching a ball (or passing it around body) while standing on one leg, work on wobbleboards etc.

P.S. with regards to insoles - do you still have them / wear them? do you wear them the majority of the time you're on your feet? they do take a while to get used to and you won't see the improvements immediately...give it a few months' if you haven't already (obviously irrelevant if you have).

[sammo440]

Thanks a lot for that. I think it's a chronic sprain of the anterior talofibular calcaneo fibular ligament rather than tibialis posterior dysfunction as the aching I get is nearly entirely over that ligament, on the outer side of the ankle. The tightness I sometimes feel under my foot comes when I walk on it for more than a few minutes and in my calf (yes, the back of my leg and my shin), it comes after I've been sitting down it seems. My aching does seem to be a little better since I started strapping it a few days ago (which keeps my foot at a right angle to my leg) so I'm of the opinion now that it's the instability in my ankle which means the ligament is unable to repair itself, now that it's got to a position where it's so sensitive. I have read that this may lead to having to get an operation to stabilise it, but how do I know if it's still saveable with physio and what can I do to maximise my chances of recovery? Should I maybe get crutches, and only weight bear on it when I do my one-leg balancing exercises (which my physio has already recommended to work on my proprioception, so thanks for giving me more confirmation in that one)?

Oh, and I no longer wear the insoles I was given be a podiatrist, as he gave me them years ago on the basis that I was flat footed, even though that's not the case. I have good arches, but my feet would roll inwards, which was to do with my posture, which I've been trying to sort properly by increasing the power and use of my glutes and core muscles for walking and stability rather than back and hip flexors. I started trying to do this over a year ago, but it's only been over the last few months that I've really felt able to begin really using those muscles at all, particularly my glutes and I've still got a long way to go, so it is very possible that this is having an effect, but I don't know what or why.

[sammo440]

And also, as an extra question, I've been strapping my ankle for the last week or so as it doesn't ache when it's strapped but I don't know how long I should be leaving it on for. I've been changing the strapping every day or 2, but should I go without strapping for a few hours or a day inbetween to avoid anything weakening or does it need it constantly to begin healing when it is at such a sensitive stage having been re-injured so many times?

[physiofi]

I wouldn't get too hung up on if your ankle's "saveable" or reading too far in to different possible conditions which can make you catastrophise and which will no doubt enhance your pain levels (due to the powerful psychological and complex nature of pain). First off, although everyone wants a definitive diagnosis and a clear cut label, sometimes that's not just do-able. Based on what you've said here, I'll assume you were a patient I'd seen and explain what I'd do - I'd probably call your "condition" chronic ankle pain ?obviously due to old injury which possibly hasn't fully healed. I'd work on movement of the ankle in all directions (if you didn't already have full movement) and strengthening if you had any weakness. Proprioception exercises (working on balance and the "fine tuning" of that ankle/foot and leg) is essential.

I'd suggest doing a course of balance exercises as I outlined before...you need to start off slow and gradual but do them regularly. Do you take any painkillers? It's likely the exercises will cause pain but remember, this does not mean that your condition is "serious" and that you should not take weight on the ankle. I'd strongly advise against using crutches as you need to take weight on the ankle to build strength and proprioception and taking weight off it (other than to rest after activity/when in a lot of pain) is counterproductive. I'd advise as pain allows, progressing exercises as you're able. You will obviously have some discomfort and pain initially, but this is more likely due to the longstanding nature of your problem rather than any acute inflammation (assuming your ankle is not swelling regularly/warm to the touch/red?).

You need to work on your proprioception until your balance on the affected side with your eyes closed is exactly the same as your good leg. I can't remember what your activity levels are/were like but after this, if you were into sports or wanted to return to running etc...I would advise practising jumping with both feet slow and controlled as able (and pain allowing) and then progress to hopping...also in different directions.

People who have ankle sprains or nasty ankle injuries with/without fractures will generally have some instability and laxity in the ligaments post-injury and this is quite common. With regards to strapping, I take it you mean taping? As opposed to using an orthotic or fitted support? If you're taping your ankle you should definitely have rest days to allow your skin to recover, as taping constantly can lead to skin breakdown. I wouldn't leave tape on longer than 2 days max and would have at least 24 hours free of tape before re-applying. You might find that if it's less painful with the tape on, then tape so you are able to do the exercise regime and gradually reduce as pain decreases / your proprioception increases (hopefully this will be proportionate)!

Hope this helps.