Understanding ankle sprains

In his latest online article, Mr Paul Halliwell gives us insights into complications of ankle sprains. He talks about why your ankle sprain may not be healing, the underlying issues and the signs that your ankle sprain may be more serious.

Why is my ankle sprain not recovering and what could be the underlying issues?

Ankle sprains are a common injury. They're frequently encountered by physiotherapists and orthopaedic surgeons in clinics, happening quite regularly. The positive aspect is that in about 8 or 9 cases out of 10, a sprained ankle will recover, but can take five to six weeks or even longer.

Some people manage the injury themselves rather than seek professional help, while others opt to consult a physiotherapist. Seeking the expertise of a seasoned sports physiotherapist is advisable for a few reasons. Firstly, an experienced sports physio can discern between a severe sprain and a more typical one. Some sprains can be less straightforward, and a seasoned physiotherapist can have an intuitive sense that this is the case. Even if the exact issue isn't immediately apparent, an experienced physio can make a referral based on their expertise.

Another crucial reason to consult a physiotherapist is related to the effect of the sprain on the leg as a whole, especially the muscles. While the torn ligaments are healing, the muscles that operate the ankle quickly lose conditioning after an injury. This loss of muscle condition can lead to instability, even if the ligaments have healed. Physiotherapy involves early active rehabilitation, encouraging patients to start exercises as soon as possible to minimise this loss of conditioning and sense of balance (proprioception) for better outcomes.

Despite these efforts, some sprained ankles may not show improvement. Physiotherapists often grapple with the dilemma of when the right time is to refer a patient for an orthopaedic opinion, wishing to avoid unnecessary visits or delayed intervention. Typically, if a sprained ankle fails to progress at three months, a referral to an orthopaedic surgeon is recommended. Problems persisting beyond six months certainly signal a need for further investigation.

Issues that may persist include ongoing pain, recurrent pain during activity, a sensation that the ankle might give way or that the ankle actually gives way repeatedly. Identifying the specific problem within the ankle, the diagnosis, is crucial for determining the appropriate treatment. This process may involve various scans, such as ultrasound, MRI, or CT scans, depending on the suspected issue. The goal is to confirm the diagnosis, assess the severity, and recommend the most suitable treatment, which may or may not involve surgery.

What are the signs that my ankle sprain might be more serious than I initially thought?

In cases of a significant tear of the ligaments, there is often considerable swelling and intense pain initially, resembling a broken ankle. Not every sprained ankle requires an xray to rule out a break but an x-ray is often arranged if there is any doubt. Unfortunately, it has proven very difficult to identify features present at the beginning predicting that a particular sprain is likely to be one of the “problem” ones. Even very badly bruised & swollen ankles usually go on to fully heal while some apparently more minor twists fail to settle despite a good rehab programme. Even early scans are of limited value. They can reveal areas of damage but the initial treatment is usually the same: active physio rehab. Features that will  make a physiotherapist consider referral for an orthopaedic opinion include:

• Pain and swelling on the medial side of the ankle (the side facing the other foot). Sprains on the medial side are more unusual, more commonly fail to heal and should generally have early orthopaedic assessment.
• Pain higher up just above the ankle where it blends with the shin; called a “high sprain”. Again, these often require early orthopaedic assessment.
• Inability to begin fully weight bearing after a few days.
• Pain or ankle instability persisting or failing to progress by 3 months as discussed above. Most sprains are doing well by 6-8 weeks.

When patients describe their experience, it helps to gather specific details. For instance, understanding if the pain occurs unexpectedly while walking on flat ground or if it's triggered by uneven surfaces is valuable. Additionally, knowing whether the pain is continuous or only occurs during episodes of the ankle giving way aids in diagnosis.

Treatment is aimed at relieving pain and restoring stability, in that order. This is because anything causing pain can prevent the rehab programme from restoring stability. Causes of pain include scar tissue in the joint and damage to the cartilage (osteochondral lesion; OCL). This will not be visible on X-rays unless a piece of the underlying bone is attached but can be detected through MRI scans. Cartilage has limited healing capabilities, making treatment more challenging. Since OCLs can be caused by the first sprain or by subsequent ones when ankles keep going over for any reason, repeated sprains are bad news. In instances where the ankle gives way because the ligaments haven't healed, surgical intervention, most commonly through a Broström procedure, proves highly successful in stabilising the ankle, with a recovery period of about five to six weeks. However, any causes of pain between instances of the ankle giving way, such as OCLs, must be treated at the same time or beforehand for maximum chances of success. Preventing frequent ankle sprains is crucial since cartilage damage can accumulate, even becoming arthritis in the longer term. Assessment of an ankle failing to recover can reveal fewer common injuries which usually require surgical repair, such as damage to tendons or the “straps” (retinaculum) that holds them in place.

In summary, early assessment and management by an experienced physiotherapist is usually wise and rarely a waste of time. Most sprains settle with an active, physio-supervised rehab programme but unusual features that worry the physio should prompt early referral to an orthopaedic surgeon and persistence of pain and / or instability beyond 3 months also warrants orthopaedic assessment.

Mr Paul Halliwell is a respected orthopaedic surgeon with over 35 years of experience. You can schedule an appointment with Mr Halliwell on his Top Doctors profile.