Member Case Study: Ankle Injury Turned Chronic Inflammation and Instability

author : AMSSM

comments : 1

I missed what would have been my second season of triathlons. I would love to get back to activity and training for triathlons but I don’t know how to get past the inflammation in my ankle.

Member question from Mandi:

I am a 25-year-old female with a history of hyper-mobile joints, loose ligaments and chronic soft tissue pain. However I successfully completed my first season of triathlon training and raced a couple of sprints a year ago with no pain and no injuries! I felt the best I ever have.

Unfortunately, 8 months ago I injured my right ankle during rehearsal as a professional Folklorico dancer. Over the years I have sprained and strained that particular ankle at least 10 times. So, it tends to be unstable. I wasn’t conditioned at the time of the injury and I was doing a lot of high impact stomping. I immediately had pain bearing weight. The pain and swelling was primarily in my ankle with pain that traveled up the lateral side of my tibia-like shin splints. I rested for a week or so and then continued to dance and be active. The pain and inflammation never went away completely. Nearly every two weeks I re-injured or aggravated the injury; each time was a little worse. 

Six weeks after the original injury, I took 3 weeks of rest and this helped a lot. After the period of rest, I slowly started back to activity and dancing again. I still had times of inflammation and pain. Then a month later I woke up one morning with an unusual amount of pain in my ankle and lateral aspect of the tibia. By the end of that day I couldn’t bear weight on the foot. I finally went to a doctor for the first time: an orthopedist specializing in foot and ankle reconstruction.

X-rays and the MRI of my tibia and fibula were unremarkable and showed only slight inflammation. I was diagnosed with periostitis and strain of the lateral collateral ligaments. The orthopedist put me on a prescription anti-inflammatory, gave me a lace-up brace to limit inversion-eversion, recommended rest for 4-6 weeks, and prescribed physical therapy. The PT continued for 5 months and included manual techniques, laser, ASTYM, stretching, and some stabilizing exercises to strengthen my hip and ankle.

It has been 6 months since that diagnosis. The periostitis cleared up within a month but I was left with significant pain and some swelling in my ankle. Though I was almost completely inactive, save some swimming which was primarily pulling, the pain and inflammation got worse during the PT and I was on crutches or in a walking boot several times. Now, I have custom orthotic inserts from the orthopedist which have helped. Though I have been able to walk without being immobilized for 2 months, I continue to have inflammation in my ankle and lateral collateral ligament.

My original ankle injury has turned into a chronic inflammation and instability problem. At this time I am only able to do limited stabilizing exercises and when the PT tries to give me some strengthening exercises my ankle gets inflamed. Her approach is to put me on a very slowly progressive 16 week walking to running program, and avoid all other activity. Both biking and kicking when swimming inflame the ankle as well. I’ve started out walking 1 mile, 3 days a week, but haven’t been able to progress to the next “week” because I still have some pain with that. I don’t know what to do. The orthopedist mentioned the option of reconstructive surgery for the collateral ligament. But I would also require calcaneal repositioning at the same time because my foot is very high arched, rigid and tends toward inversion. However he was quite vocal that he was not recommending the surgery at this time.

I gave up my professional dancing career, and I missed what would have been my second season of triathlons. I would love to get back to activity and training for triathlons but I don’t know how to get past the inflammation in my ankle. Are there any other options? Is it a possibility that this injury will never completely heal?
 

Answer:

The most important thing to consider when a “typical” ankle sprain does not get better is where your pain is truly coming from. Make sure you have done adequate strengthening and balance rehabilitation before giving up on rehabilitation. In addition, make sure the orthotics give you the proper foot control to best handle your injury. Some non-surgical sports medicine physicians are doing proliferative therapy (prolotherapy) with very good success to help “tighten up” loose ankle ligaments and this may help avoid surgery in your case. Also, before considering surgery, I would recommend stress x-rays of your ankle to see if there is indeed instability that surgery can correct.

Other possibilities would be to examine structures around the ankle that could continue to give pain outside of your lateral ligaments. Possibilities include ankle impingement, sinus tarsi syndrome, syndesmotic injury, and chondral injuries among others. Some of these problems would not be evident on an MRI and injections to certain areas with lidocaine (a numbing medicine) can help diagnose these. Some of these require a steroid injection to help the inflammation settle down.

Proper diagnosing of the pain generator is the key to a successful treatment.

Ken Mautner, MD
Assistant Professor Dept of PM&R and
Assistant Professor Dept of Orthopedics
Emory University in Atlanta, GA
Member, AMSSM
 

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date: February 8, 2007