Ankle Problems (Dr has mentioned possible CRPS)

HI,
Although my post is similar to some others I have read, I haven't managed to find any answers. Approximately 10 weeks ago I went over on my ankle whilst playing rugby (both my body weight and the weight of 1 other person). Within 5 minutes the ankle was severely swollen, very painful and I couldn't put any weight on it.
Next morning I decided to go to A&E as it was no better if not worse than the day before. The ankle was x-rayed, following which, I was told that there was no break and that the ankle was sprained. I was given follow up appointment 10 days later.
Following the 2nd appointment (ankle hadn't improved at all since the initial injury) the Dr decided to re x-ray, which still found no break. The ankle was then put in plaster. Another appointment scheduled for 2 weeks.
Same story for the 3rd appointment, no improvement, plaster for another 2 weeks.
4th appointment i was referred to a consultant, who decided to take the plaster off, but book me in for MRI scan as I was still in a lot of pain and couldnt walk on it.
Gradually over the next 2 weeks, I could start to put some weight on the ankle but walking/hobbling for any distance over a couple hundred yards was not possible.
I had MRI scan, results came 2 weeks later (by which time the ankle was pretty much the same as it was 2 weeks earlier). The MRI came back clear, even though there is still swelling on the outer part of my ankle and on both sides of my achillies tendon. Movement is very restricted still (even after a few physio sessions), the Dr noticed that the foot was a different colour to my other one and suggested CRPS. However my physio doesn't seem convinced.
Has anybody any ideas on
A). What the problem could be?
B). What's the best action plan to get back into training as soon as possible?

Thanks

I would treat it just as a regular ankle sprain. The casting has added to your recovery time by sensitizing the tissue, maintaining the oedema, weakening your soft tissues and reducing your mobility. Circulatory problems and discolouration are common post sprain and post casting but generally improve with massage, modalities (ultrasound etc) and mobility exercises. You should ideally seek a physio with manual therapy training and experience working with athletes. Good luck. Marj

Hi,

I would agree with Marj. I think it is unlikely to be CRPS at this stage. The only other thing I personally would try is acupuncture which I find more useful for a quicker recovery than other modalities. It should help almost immediately with the hypesensitivity, pain and swelling. This, in conjunction with regular good manual therapy skills, should do the trick.

Good Luck!
Zoe

Hi,

While not disagreeing with what has been said, you should not rule out the possibility of CRPS. Regardless, given the deconditioning post injury, any rehab must be respectful of pain limits, as pushing too hard will exacerbate the problem particularly if CRPS is the predominant pathology. Certainly, your presentation is a little different to what would be expected from a simple strain, and any soft tissue damage should have shown up on MR. CT is a little more sensitive for identifying occult bony injuries however.

Regardless, your prognosis is good assuming no unidentified bony injury as long as you rehab appropriately.

Good luck, Matt

Hi Callum

Amkle sprains unfortuantely can result in many different permutations, some last longer than others. One thing you need to be aware of is the secondary accommodative changes that can take place and that I find commonly with ankle sprains. These include sympathetic nerve dysfunction, either due to a prior dysfunction(common if you are involved in sport), or due to the reaction to the injury, and biomechanical dysfunction often in the hip of the injured leg, ie weakness developing in the muscles of the hip due to altered accommodative mechanics to support the injured ankle.

Both are essential to correct before the ankle can recover correctly. It is possible that your discolouration and swelling continue because the sympathetic nerve control of the blood flow to that area is sluggish, thus resulting in a poorer blood flow rate, thus sluggish return of blood flow and fluids to the heart. Swelling can often remain for months if untreated. Swelling also occupies a space not normally occupied thus resulting in tender irritable local tissues.

Hip weakness means the muscles may be starved of a good blood flow, and/or they are being trapped in their own (fascial) sheath often due to overuse in adapting to the injury. Walking with a limp or carrying an ankle with POP on it can put unnecessary strain on the leg and hip and weakness resulting from this means the support for the ankle is missing, causing the calf muscles to work too hard, thus a viscious cycle is set up. I would think if I did a study on all the ankle sprains I have treated in the past 16 years, I would probably find >90% of them had hip weakness, which if not treated, results in the ankle not being supported by the higher mechanical centres. So the ankle injury cannot repair fully.

Excuse the long-winded view, but it is not as simple as exercise and mobility, there is often a bigger picture involved. You would benefit from a manual muscle test from the hips down, find the weaknesses and restore these through some form of work on the T10 to L2 sympathetic area of the spine, and soft tissue release (myofascial) over the weak muscles and tight areas of the calf. It would not be unusual to find resisted weakness in the ankle dorsi and plantar (with inversion) flexion, as well as hip weakness. The fascia of the calf reacts to the injury by tightening up in the posterior tibial areas (behind the shin bone), and the anterior tibial muscles become weak from the sudden overstretch and reciprocol inhibition to the tightness of the posterior tibial group.

All these need work to restore flexibility, circulation and thus strength. Only when these have been restored should you think about exercise. Exercise when there is still weakness of this type and stiffness and the problem expands.

Hope this helps

Thank you all for your replies, I shall certainly mention to my physio (next appointment this Wednesday) about the muscle test. I have been performing the exercises given to me by her, no improvement yet but it is early days. I shall post any devolpments.

Thanks again
Callum