Lateral/Medial Ankle Sprain (8 months and counting)

[LucyLexi]

Eight months ago , I missed the last step going down the stairs and badly sprained my left ankle. I could barely walk on it for several days and it was severely bruised and swollen. I followed up on day 3 with my Orthopedic office by seeing the foot and ankle physician's assistant. Had x-rays which showed no break. Put in a walking boot. 3 weeks later followed with foot and ankle Orthopedic Surgeon, had x-rays, still no break, so moved onto lace-up brace despite still having swelling and pain.


Started physical therapy in beginning of month 3, but was referred back to Orthopedic surgeon after 4 visits due to excessive pain. Back in the walking boot until sent for an MRI at 3 month post-injury. Results showed torn lateral ligaments (all 3), torn medial ligaments, tendinitis, and talus bone bruise. The doctor said I had to have twisted my ankle 360 degrees to have these injuries and that you'd usually break a bone before this would all occur.


Continued with walking boot with little improvement. Put in a non-weight bearing (NWB) cast at 4 month mark for 3 weeks with little improvement. Cast removed. Sent for a bone scan which showed healing in 2 locations and ruled out regional pain syndrome. Back in the walking boot, and NWB for a total of about 7 weeks between the cast and boot. Worked back to weight bearing in walking boot.


Follow up MRI at 6 month mark showed ligaments and bone bruise were still healing but looked better then 3-month mark MRI. Cortisone shot in ankle joint at the 6 month mark- got 50% improvement. Cortisone shot in subtalar joint at 7 month mark. Felt great for a week, then some pain returning. Now at month 8, it seems both cortisone shots have completely worn off so I'm back to pain- made worse if I walk or stand for any length of time. Also irritated while driving. Still swollen. More swollen on lateral side, but more pain on medial side. Also, some pain at bone bruise location.


In addition to what's noted above, did RICE, alternating hot/cold soaks, anti-inflammatory (oral and gel), oral prednisone, and massage. I've had multiple more minor sprains before and broken my other foot 4 times, but I've always healed in 6-8 weeks. Any idea how to proceed from here? What else to consider in terms of diagnosis and/or treatment?

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[priyankshah]

I think you still need to rest more. More of nwb exercise along with that RICE whatever you are doing to be continued.
You can try pushing your lateral maluolus posteriorly and upwards if it eases your pain while standing.
As ligaments are the structures with poor blood supply you have to wait and watch. it can tape upto a year to improve.

[LucyLexi]

Would more physical therapy help?

[priyankshah]

Yes it would definitely help.
In India we would give you tens wax probably ultrasound and nwb exercises.

[LucyLexi]

Thanks....I am set-up for Physical Therapy starting next week.
I did finally get my MRI reports which at 3 months stated deltoid fibers poorly-visualized with decreased signal, most consistent with partial to full-thickness tear or secondary fibrosis. The 6 month MRI said the deltoid ligament fibers are poorly visualized suggesting chronic talar fibrosis rather than sprain.....what does that mean?

[iphysio]

Hi LucyLexi. "talar fibrosis" means scarring near the talus bone. Scarring can limit your ankle range of motion. I hope you are doing lots of ankle movements. How's your physical therapy going? Is it getting better? What kind of treatments are you receiving? Hope you get better soon!

[LucyLexi]

I had my PT assessment this morning. I had the same PT as in January so she was able to compare with where we left off. Said its at least 50% better, less swollen, and less areas of pain (since everything was painful before). ROM was not limited except in one direction. A little too much range of motion (both feet) when pointing my toes down. Way too much ROM due to the lateral torn ligaments being over stretched. Started me on a few exercises with low reps and low resistance. Also did estim. Not too much pain during the session but the stabbing, random pain in my deltoid ligament was definitely increased for 3-4 hours after. She said I may have nerve impingemebt that's causing the pain in that area?

[marj]

I had my PT assessment this morning. I had the same PT as in January so she was able to compare with where we left off. Said its at least 50% better, less swollen, and less areas of pain (since everything was painful before). ROM was not limited except in one direction. A little too much range of motion (both feet) when pointing my toes down. Way too much ROM due to the lateral torn ligaments being over stretched. Started me on a few exercises with low reps and low resistance. Also did estim. Not too much pain during the session but the stabbing, random pain in my deltoid ligament was definitely increased for 3-4 hours after. She said I may have nerve impingemebt that's causing the pain in that area?

Sounds like you had a very severe injury. If surgery has not been recommended then try to be patient and stick it out with physio. TENS is sometimes effective for nerve pain and an be used at home. I suggest you ask your physio about it. Good luck.

[katebirks]

Hi Lucy

What stage are you at with the exercises? Have you considered acupuncture? If not it maybe worth asking your physio as i have used it on many patients with Medial and Lateral ankle sprains and after 3 sessions they have felt the benefit in pain reduction and increase range of movement.

Good Luck

[LucyLexi]

So far I've had 4 PT sessions that involved NWB exercises (band, wobble board, alphabet, towel scrunges) followed by an ion patch and ice. Ankle flared up after a minimal amount of walking/stairs last Saturday so the last session was mostly massage, ion, and stretches. Tried PT in the water today so we could try some strengthening and ROM exercises. That PT mentioned TENs so I guess we'll see. Both said we need to strengthen the muscles but its challenging to do with pain when WB. I've got another water PT, one regular PT, and then a follow up with the Dr next week. No discussion of acupuncture so far. At this point the Dr says surgery not an option as you don't do surgery for pain...and that soft tissue damage and bone bruises can take awhile to heal

[katebirks]

Sounds like you are still in the early stages of rehab so just keep perservering with the ex's and stretches. Are you taking any medication to help modulate pain? Considering you have had this injury for 8 plus months, it will take a few months of physiotherapy and home exercises to enable the soft tissue to heal in its own time. Keep going

[toddchaney]

According to many orthopedic doctors, even with an ankle sprain, you can usually still exercise other muscles to minimize deconditioning. For example, you can use an exercise bicycle with arm exercise handles, working both your arms and the uninjured leg while resting the injured ankle on another part of the bike.
And follow RICE as suggested by many.
Most important of all, and often the most neglected, is balance training, which starts with standing on one foot (the injured one) on a firm, even surface, then on a foam surface or trampoline, first with eyes open, then eyes closed.

[toddchaney]

According to my orthopedic doctors at OrthoTexas, even with an ankle sprain, you can usually still exercise other muscles to minimize deconditioning. For example, you can use an exercise bicycle with arm exercise handles, working both your arms and the uninjured leg while resting the injured ankle on another part of the bike.
And follow RICE as suggested by many.
Most important of all, and often the most neglected, is balance training, which starts with standing on one foot (the injured one) on a firm, even surface, then on a foam surface or trampoline, first with eyes open, then eyes closed.

[LucyLexi]

After trying all conservative measures, each multiple times, I'm scheduled for surgery at the end of the month....arthroscopy as well as looking at the tendon on the medial side of my ankle. Hopefully this'll improve things

[LucyLexi]

Turns out I had a 1" tear in the posterior tibial tendon, a cartilage tear in the same region, and lots of inflammation/scar tissue. Hopefully it's all resolved now that the tendon is repaired and the ankle debrided.