Chronic ankle sprain and instability treatment

Ross Hauser, MD

In this article Ross Hauser, MD discusses chronic ankle sprain treatment, the problems of diagnosing ankle sprains and long-term problems of ankle instability. Non-surgical options including the use of Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Prolotherapy are also discussed.

  • Highlights of this article:
  • Ankle instability caused by injured ligaments
  • Ankle taping and bracing are not long-term options
  • Prolotherapy injection treatments shown to be effective for non-surgical repair.

The most common type of ankle sprain is the “rolled” or “twisted” ankle, inversion injury, turning the ankle inward, injuring or tearing the ligaments on the lateral (outer) side of the ankle, usually the anterior talofibular and the tibiofibular ligaments. Many times a patient will report that they simply “twisted” their ankle without realizing the structural damage that could have been done.

The inside of the ankle is held together by a group of ligaments called the deltoid ligament. This ligament is injured from turning the foot outward, as can happen when falling down stairs or mis-stepping. Once an ankle is sprained, the injury may take a few weeks to many months to fully heal. The injured ankle often remains a little weaker and less stable than the uninjured one.

Left untreated, ankle instability leads to cartilage deterioration with resultant degenerative arthritis. If a ligament does not heal, joint instability occurs and the end-result is ankle arthritis with good prospects for fusion or ankle replacement surgery. Treated with  stronger NSAIDs or cortisone shots can also lead the patient to surgery.

Cortisone has been shown to further degenerate the injured ligaments in joints, leading the patient towards more joint instability, degeneration and eventually osteoarthritis. Once diagnosed with osteoarthritis that is seemingly irreversible, the words “ankle fusion,” “ankle arthroscopy,” and “ankle joint replacement” are introduced into the consultation.

We get a good idea who has instability or is at risk for chronic ankle sprain when we see a patient who feels that their ankle is:

  • “giving way”,
  • has constant swelling,
  • obvious pain,
  • decreased range of motion or excessive motion from ankle instability.

They often ask what is causing their “weak ankles,”  the continued “popping,”and “clicking” sound they hear. The patients know the ankle is not right.

Chronic ankle sprains, instability and developing arthritis

Ankle Ligament Instability

Chronic ankle sprains can be tricky to diagnose and treat. Ankle instability may not show up after the first acute ankle sprain and there is no consensus on how to tell if a patient will have instability in the future. This was addressed by an Irish research team writing in the American Journal of Sports Medicine who among other findings found that patients who could not properly jump or land 2 weeks after their first lateral ankle sprain were high risk candidates for chronic ankle instability.(1)

Unfortunately, literature examining chronic ankle instability is often conflicting and confusing to patients. The Irish researchers were able to identify jumping and landing ability and non-reported ankle pain up to 6 months as being high risk factors for ankle instability, but they were not the only factors.

University researchers in Australia also tackled this problem of identifying the risk factors for ankle instability. In June of 2016 the Australian team published their intent to examine the problems of ankle instability in the medical journal Systematic reviews and correlate available research into a clearer understanding of key factors.. This was what they said:

“Ankle sprains are a significant clinical problem. Researchers have identified a multitude of factors contributing to the presence of recurrent ankle sprains including deficits in balance, postural control, kinematics, muscle activity, strength, range of motion, ligament laxity and bone/joint characteristics.

Unfortunately, the literature examining the presence of these factors in chronic ankle instability is conflicting. As a result, researchers have attempted to integrate this evidence using systematic reviews to reach conclusions; however, readers are now faced with an increasing number of systematic review findings that are also conflicting. The overall aim of this review is to critically appraise the methodological quality of previous systematic reviews and pool this evidence to identify contributing factors to chronic ankle instability.”(2)

In 2017, at the completion of their review, the researchers published their findings in the journal Sports medicine.

“Evidence from previous systematic reviews does not accurately reflect the chronic ankle instability population. For treatment of non-specific ankle instability, clinicians should focus on dynamic balance, reaction time and strength deficits; however, these findings may not be translated to the chronic ankle instability population. Research should be updated with an adequately controlled chronic ankle instability population.”(3)

Doctors are not sure if ankle sprains ever really heal

  • In Germany, doctors writing in the German language journal Der Orthopäde  say because of their frequency, the simple ankle sprain with uneventful healing (an ankle sprain that has seemingly healed) should be monitored to prevent it from becoming a potentially complicated sprain which is at risk of transition to chronic ankle instability.(4)
  • Further, conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. As you will see below chronic ankle instability is a whole joint problem and not one isolated to a single ligament element.For a full discussion please see my article on various ankle surgery options.

Let’s do a medical equation and combine the research of two studies.

Above the German doctors said the simple ankle sprain that looks like it healed should be monitored to prevent it from becoming a potentially complicated sprain which is at risk of transition to chronic ankle instability.

In the British Journal of Sports Medicine researchers say that a new ankle injury is not always a new or  acute one, but one that can be identified as an old chronic injury with an increase in symptoms.(5)

  • A “new” ankle sprain may be an old ankle injury that went undetected and never healed.
  • Doctors should be aware that chronic ankle instability can be a problem of an injury that never healed.

If you do not heal an ankle sprain or chronic ankle instability you will get osteoarthritis

A study from Dutch doctors publishing in the International journal of sports medicine looked at 98 patients with chronic, persistent ankle sprains. MRI revealed signs of osteoarthritis (cartilage loss, osteophytes (bone spurs) and bone marrow edema) were seen in the talocrural joint where the tibia, fibula and talus meet (TCJ) in 40% and the talonavicular joint (TNJ) in 49%. In other words, the ankle joint is making the inevitable voyage from from instability to degenerative joint disease to osteoarthritis.(6)

Chronic ankle instability – treating the whole ankle joint

In the Journal of physical therapy science, Doctors at South Korea’s Sport Science Institute, Incheon National University looked at male soccer players and found the complexity of the problem needed to be solved by addressing the entire ankle joint and not simply a ligament tear or chronic ligament weakness.

Here are their findings:

  • Over 70% of patients who experience ankle sprains report additional symptoms resembling chronic ankle instability, such as re-injury or ankle function abnormalities.
  • Chronic ankle instability has been connected to  reduced muscle strength and proprioception (ankle joint function as a whole) which interferes with postural control.
  • It is presumed that chronic ankle instability is caused by complex functional deterioration. It is not a simple solution.
  • Correcting ankle structure and muscle strengthening exercises are important for the rehabilitation of ankle instability. (In other words the ankle needs to be repaired and strengthened – the obvious goal of anyone suffering with chronic ankle instability).(7)

Knee, Hip, Ankle and Balance problems

One curious symptom and one that should clearly point to chronic ankle instability and should be explored in patients with chronic knee instability and hip instability is Dynamic balance deficits.

In two studies from University College Dublin, patients who suffered from an acute ankle sprain were followed and tested for problems of balance. Not only were their injured ankles tested but also the same side knees and hips. At 6 months follow up (8) and one-year follow (9)  up after a single ankle sprain event, patients showed reduced balance that created stress on the entire limb side, hip, knee, and ankle included.

Elastic bandages, tape, do they provide stability and balance or worse?

A team of physical therapists in Spain have published a soon to be released study (April 2018) in the journal Disability and rehabilitation. They wanted to report on their findings surrounding the immediate and prolonged (one week) effects of elastic bandage on balance control in subjects with chronic ankle instability.

  • Twenty-eight individuals: 14 were randomly assigned to the elastic bandage group (7 men, 7 women) and 14 were assigned to the non-standardized tape (typical white adhesive tape) group (9 men, 5 women).
  • This study did not observe differences between elastic bandage group and non-standardized tape group during the follow-up in the majority of measurements.
    • Elastic bandage of the ankle joint has no advantage as compared to the non-standardised tape.
    • The effects of the bandages could be due to a greater subjective sense of security. It is important to be prudent with the use of bandage, since a greater sense of safety could also bring with it a greater risk of injury.
    • The application of the bandage on subjects with chronic ankle instability should be prolonged and used alongside other physiotherapy treatments.(10)

My comment here: Short-term, ankle bandages and tape are to be used with caution, long-term, keep the tape and bandage on because there is little else that can be offered. UNLESS, you are familiar with Prolotherapy.

Ankle Instability and Prolotherapy

This section will deal with the question, How do you treat a sprained ankle?

Caring Medical’s first line of treatment for chronic ankle pain – ankle instability is Prolotherapy. In treating with Regenerative Injection Techniques (RIT), i.e., Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy, a comprehensive approach must be taken. This means treating the whole ankle, not just a single injection at a single site in the joint, as some physicians attempt to do. The comprehensive problem of ankle instability requires a comprehensive treatment. Here’s what current research reveals about ankle instability and injury and how a doctor should consider treatment:

Writing in the medical journal Practical Pain Management, we reported on 19 patients surveyed following Prolotherapy ankle treatments. These patients said they had less pain, stiffness, crepitating, depressed and anxious thoughts, medication usage, as well as improved range of motion, walking ability, sleep and exercise ability.

Of these 19 patients:

  • Patients reported an average of 3.3 years (40 months) of pain and on average saw more than three doctors before receiving Prolotherapy.
  • The average patient was taking at least one pain medication.
    • Sixty-three percent (12) stated that the consensus of their medical doctor(s) was that there were no other treatment options for their chronic pain.
  • Eleven percent (2) stated that the only other treatment option for their chronic ankle pain was surgery.

Prolotherapy effects

  • Patients received an average of 4.4 Prolotherapy treatments per ankle.
  • The average time of follow-up after their last Prolotherapy session was 21 months.
  • Patients were asked to rate their pain and stiffness levels on a scale of 1 to 10 on a visual analog scale (VAS) with 1 being no pain/stiffness and 10 being severe crippling pain/stiffness.
    • The 19 ankles had an average starting pain level of 7.9 and stiffness of 5.4.
    • Ending pain and stiffness levels were 1.6 and 1.5 respectively
    • Ninety-five percent reported a starting pain level of 6 or greater, while none had a starting pain level of four or less.
    • After Prolotherapy none had a pain level of 6 or greater, and 90% of patients reported at least a 50% reduction in pain.
    • One-hundred percent of patients stated their pain and stiffness was better after Prolotherapy.
    • Over 78% reported that pain and stiffness since their last session had not returned.

In regard to quality of life issues prior to receiving Prolotherapy:

  • 74% noted problems with walking, but only 37% experienced compromised walking after.
  • In regard to exercise ability before Prolotherapy, only 47% could exercise longer than 30 minutes, but after Prolotherapy this increased to 90%.
  • To a simple yes or no question, “Has Prolotherapy changed your life for the better,” all of the patients treated answered “yes.” This question was included in many of our studies, because when it comes down to the point of any medical treatment, we feel this is the point. It’s not “Is my x-ray better?” but rather, how has your life changed for the better.(11)

For significant deterioration, we may recommend to patients a more aggressive approach incorporating Platelet Rich Plasma and Stem Cell Therapy injections.

In the medical journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, Caring Medical published our findings in seven patients. Patient case 1 represented an ankle case.

A 59-year-old female patient come into our office with right ankle pain following a lateral sprain. The patient reported she could barely walk without severe ankle pain.

Good Ankle Prolotherapy CandidateThe patient had unsuccessful treatment with cortisone injections and was being recommended to ankle fusion based on X-ray and MRI finding that suggested osteoarthritis, avascular necrosis of the talus, and synovitis. Please see Caring Medical and Rehabilitation published research on bone marrow aspirate injections into the talus and case history of regenerative repair.

The patient received four bone marrow/dextrose treatments over a period of eight months.

  • At second treatment, the patient reported the ability to stand for long periods and walk for half a mile without pain.
  • At third treatment, she reported improved range of motion, less frequent pain, and ability to take two mile walks on hilly, uneven ground, although steep climbs still induced pain.

 

Side note: PRP Ankle Injection Research on high ankle sprain

A less common but well known ankle injury is the “high ankle sprain.” This is damage to the ligaments  that connect the shin bones tibia to the fibula. Because of the high impact stress at the tibia and fibula junction, the syndesmosis joint, the high ankle sprain is difficulty to heal.

In recent research doctors examined the success of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP). They further studied the issues of ankle instability and stability before and after the PRP ankle injections.

Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain.

Here are the results:

  • Early diagnosis and treatment lead to shorter Return to Play
  • Significantly less residual pain upon return to activity was found in the PRP group;

CONCLUSIONS:
Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain.(12)


Contact the author Ross Hauser, MD


References
1. Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery From a First-Time Lateral Ankle Sprain and the Predictors of Chronic Ankle Instability: A Prospective Cohort Analysis. Am J Sports Med. 2016 Feb 24. [Google Scholar]
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