Fractured Ankle Physio

Hi,

I hope someone can help? I broke my Tibia and Fibula (and another I dont know which) on 23rd Aug falling down a step and dislocating my ankle. I was in hospital for 6 days before they would perform ORIF surgery due to the severe swelling in my ankle. I was given a plate and 10 pins on my fibula and 1 screw to hold my tibia and put in a knee length cast. I returned to hospital for x-rays and a new cast after 2 weeks and was told that the screw has slipped on my tibia....4 weeks later my cast is removed (6 weeks NWB) and I am told the screw slipping moved the bone out of alignment slightly but the bone was regrowing into the gap that had appeared. They have now put me into a walking boot which I am to wear for 6 weeks and for any weight bearing as a precaution.
I started physio on Thursday and have very little movement in my ankle and was given various exercises to help strengthen my ankle which was very painful. I am wondering if everything should be this painful???? When I am stretching my toes moving my ankle forwards and backwards the pain is horrendous and bordering on intolerable. This feels the same with most the exercises and I am feeling pain when my foot is rested. Also after doing the physio below my toes swells up more than usual...
I was under the impression the exercises were meant to bring the swelling down.
I am worried that the pain i am feeling is a warning there may be something wrong or am I pushing it too much I was told little and often is the key but this is what I am doing!

Any help would be appreciated, Thanks!:)

Hi Hopalong80

I can't say for certain but having severe pain like that and when it is accompanied with swelling - this is suggestive of complex regional pain syndrome (CRPS). CRPS is a pain reaction that probably involves the autonomic nervous system that supplies the leg. It is not fully understood but this is not an uncommon reaction to an injury in a limb. It is a real B&*%#@RD of a thing to get. However it generally is self limiting and there are positive things you can do about it. I would seek some help. There is no cure for it but there are lots of things that can help while it runs its course. Here is a reliable information sheet on what it is and treatment available:


Complex Regional Pain Syndrome Information Page: National Institute of Neurological Disorders and Stroke (NINDS)



In addition to the medical treatments describe here physio can often help. Physio can help reduce the symptoms and improve function. So talk it over with your physio.

If this is what you have (and I am not saying you definitely do have CRPS) then don't go it alone. Get someone to diagnose it and get support. You need help with pain management along with other symptoms.

Dear hopalong 80,
If you have 24hour pain, no matter if it worsens with exercise and calms down a bit but not disappearing at rest, it implies an inflammation in progress. This could be due to fixation units. You didn't mention pain before initiation of physio treatment, redness or a mild swelling during the day and night, as well as night pain. These could lead one to hypothesize inflammation in progress.
In any case, if symptoms remain the same or get worse in the next 2-3 days, I would suggest ceasing of physiotherapy and a visit to your MD to exclude any side effects of the surgery.
ilias

Thanks both for your replies!!

iliastolos - You are correct This pain has started since the start of physio (I was out of cast a week before the physio started and had no real problems) and it seems to be worse whilst and after doing the exercises it feels as though daggers are being pushed in my ankle!! The rest of the time it is throbbing or feels like little electric shocks through my foot.
The swelling looks worse after the exercises and is mainly on the top of my foot and looks as bad as when the cast was removed (3 weeks ago)
My foot either is hot and red in places or a blochy purple which feels cold to the touch, I also have a slight rash appearing around one of the scars.
The pain at night is bearable and has only woken me up once so far and this was the night I didnt take any Tramadol before bed.

I see the physio again tomorrow and will see what they think based on what you have said? I dont hold out much hope after my first visit as I was told to keep pushing through the pain and it hurts more now so we will see.

Many Thanks Again

Liz

beware of post op infection, its unlikely as the skin is cold but always something to beware of. For the physio to tell you to push through the pain they need to be certain that the area is now well healed - have they seen the xray report that should have been taken after you were taken out of the walking boot.
The bone may not be healed and doing excessive exercises can cause damage.
Let us know what your physio says but don't be afraid to go to the doctor for pain relief and second opinion

Thanks Pudding Bowl,

As far as I am aware my physio hasn't seen any info or x-rays regarding my injury all the info they have I have given them.
I have another appointment tomorrow with physio so will see how I'm going. Still cant believe after nearly 10 weeks post op I have such limited range of ankle movements and still can't put weight on it without awful pain. The physio has said it will be a slow process.

Just dont think I was aware how bad it would be as when I saw the consultant 2 weeks post op he said another 4 weeks then cast off and you walk.. sounded so simple and easy. I knew it wouldn't be THAT easy but I didn't expect this.... I'm going to see doc this week regarding pain killers and work trying to get me back now!! Just feel bit lost with it all!!!

Thanks for your reply:)

Liz

Definately a good idea to get it checked that it healed properly... the reality may be that yes it's absolutely fine and you should be walking on it. It happens sometimes that the pain is horrendous but the therapy needs to be hard to get it better - in that situation pain killers are very helpful. But best to get an xray to confirm if there hasn't been one done.

Good luck

13 weeks on.....
A liittle update, I had my hospital appointment yesterday, another x-ray etc.. should have been quite straight forward considering my last visit was ok.
I am a smoker I have been told it doesnt help with bone healing rather aggressively by the consultant before. This same consultant I had the pleasure of seeing yesterday and here goes:
He couldn't believe he was loooking at the xray of a 29 year old and thought it was someone older as it looks as though I have osteoporosis (this wasn't the case when I saw him 10 weeks ago?) I have also been told that my ankle could crumble underneath me and end up with a useless ankle. I told him that i have CRPS to which he might aswell had laughed in my face to reply with WHO told you that, so I said my physio and he went on well with that aside you have very little change in the xray from 6 weeks ago. He is blaming all this on the fact that I smoke and I am not saying that I know it doesn't help but you would think that alarm bells would be ringing to the fact that my bones have changed that much on 10 weeks.
I have been told to wear the boot and try and have some time out of it walking (even though I have been told it could crumble) when asked how I know if I'm doing damage "You'll know" and that was that!
I really thought I was making progress with the CRPS the pain is slightly better and I have more ROM thanks to a great physio and now I am scared to walk on it.
Has anyone any idea why my foot is showing signs of osteoporosis in such a short space of time? I'm so worried I'm going to lose the use of my ankle or re-fracture it.

Many Thanks again Liz

Hi Liz
This sounds a very alarming interview. If I was in your situation I would find this all quite distressing and confusing. I think you need some reassurance about your condition – whether you have osteoporosis and how severe it is.

My comments are:

Plain xrays are not accurate for measuring osteoporosis. The gold standard for diagnosing osteoporosis is a bone densitometry test or DEXA scan. Not only does the scan diagnose osteoporosis but also quantifies the severity. DEXA scans sample vulnerable bones in the body so you probably should also include the lower legs in the scan as these aren’t usually sampled.

CRPS does result in local (not generalised) bone thinning, whether that is what you have or don’t have. From what you described earlier I would maintain that you are quite likely to have CRPS and that your physio is right. Bone thinning on xray may well be evidence for that. It could also be a combination of background abnormally thin bones for your age group and the reaction to the injury.

Disuse increases the bone thinning effect whereas more use stimulates the bone-building. I don’t know what the bones are really like so I would be loathe to contradict the your surgeons advice about the risk of bone collapse from walking but I would imagine that walking on it at this stage is a good thing and avoiding walking only makes matters worse. However if there is such a risk, the bone can be stimulated to build by applying an appropriate amount of force that will stimulate the bone but not put you at risk of bone collapse. Partial weight bearing may be an option (ie using a stick or crutches) However this needs to be properly assessed and you need to be advised about getting the maximum bone building benefit with the least amount of risk.

If you have osteoporosis at your age then I think you should have it looked at in more detail. You probably don’t know the state of your other bones and this is important in case you have a systemic cause of osteoporosis. This is very important for your future health as osteoporosis is a progressive problem that continues to increase as you get older. Osteoporosis is primarily a metabolic disease so you could get an opinion from an endocrinologist – preferably with an interest in osteoporosis. If the bone thinning is limited to the injured leg then that is again suggestive of CRPS.

Smoking is a risk factor for osteoporosis but is only one factor. My understanding is that the effects of smoking reduces oestrogen production and over a lifetime this results in lower bone density. Smoking can also bring on earlier menopause that can really increase osteoporosis. So my understanding is that the effect of smoking on osteoporosis would show much later in your life rather than now. Obviously that is not a reason for giving up smoking now – and given your situation you would be well advised to, but I think it is unlikely to be a single cause of osteoporosis at your age.

Liz I think it would be worthwhile getting this checked as you are quite young and your bones need to last you a long time. There are useful treatments available and lifestyle changes you can make to get more healthy bones, if that is the problem.

Thanks for your reply Gcoe!!

I have decided to go private and pay to see an Orthopaedic Surgeon in a weeks time. I'm hoping they will give me a bit more time and look into things more thoroughly.

I am extremely worried about the prospect of osteoporosis at 29 yrs old and hope they will check all the possible reasons, including checking if it is just in my injured ankle.

I see my physio tuesday and hope she will be able to help with safe exercises for the time being.

Thanks again for putting my mind at rest a little!

Liz