An ankle sprain is a common injury where one or more ligaments of the ankle become overstretched or torn, typically due to the ankle suddenly turning out. Once an ankle ligament is overstretched, the susceptibility to chronic ankle sprains becomes higher. Ligaments are taut tissues holding the ankle joint together and providing for smooth steps and strong jumps. When the ankle ligaments, such as the anterior talofibular ligament, become damaged the joint becomes unstable.
There are three types of ankle sprain, separated into grades of severity.
- The first, a grade one sprain, is the least severe. This occurs when the ligaments are slightly stretched out, causing minimal tearing of the tissue fibers. This is the type of injury that doesn’t cause severe pain, and the victim can usually “walk it off” without permanent damage.
- A grade two sprain involves further tearing of the ligaments and can cause instability in the ankle joint. This type of sprain leads to a lot of swelling and tenderness, which makes it difficult to walk and move around.
- A grade three sprain is indicated by a complete tear of the ligaments, and will make itself known with extreme pain, swelling, and lack of function.
The medical literature makes it clear, you must heal from the first ankle sprain or you are at higher risk of developing long-term ankle instability, chronic ankle sprains and eventually ankle osteoarthritis.
Doctors conducting joint research from the University of Virginia and University College Dublin confirmed this. They suggest that observing patients with the following conditions can predict who will have long-term problems
Impairments in motor control (defined as loss of function ie, limping) can predicate the onset of chronic ankle instability that can develop in the year after an acute lateral ankle sprain.
At the 2-week time point after acute ankle sprain – an inability to complete a single-leg drop landing (jumping from a small platform and landing on one leg) and a drop vertical jump (jumping from a small platform, landing on both feet and then vertical jumping). Two out of three people who cannot perform this test at two weeks are at risk of chronic ankle problems.
At the 6-month time point, 85% of these patients exhibited further problems with ankle instability and the problems radiated into the knees and hips.1
If you are reading this article looking for answers to your chronic ankle problems then the above article research is likely a mirror reflection of what happened to you.
In this article we will present three non-surgical treatment options for chronic ankle pain. Prolotherapy, Platelet Rich Rich Plasma Therapy, and Stem Cell Therapy.
Prolotherapy for Chronic Ankle Sprains
Prolotherapy is a non-surgical regenerative injection therapy that stimulates the natural healing of ankle instability and lessening the recurrence of ankle sprains.
Typically within three to six treatments, the ankle is feeling stronger and is in less pain. This is explained further in the video below.
Please also see Prolotherapy Patient Information.
Writing in the medical journal Practical Pain Management, doctors reported that patients treated for ankle problems with Prolotherapy had less pain, stiffness, crepitating, depressed and anxious thoughts, medication usage, as well as improved range of motion, walking ability, sleep and exercise ability. In addition Prolotherapy helped all patients on pain medications reduce the amount of medications taken.2
Platelet Rich Plasma Therapy for Chronic Ankle Sprains
Platelet Rich Plasma Therapy or commonly referred to as PRP is also a non-surgical injection technique that uses blood platelets as a “healing medicine to stimulate and repair soft-tissue healing. It is explained in the video below. Please see PRP Treatments for joint pain
Researchers from Duke University, University of Colorado, and from combined Israeli medical teaching institutions found that Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter return-to-play, rand less long-term residual pain.3
Stem Cell Therapy for Chronic Ankle Sprains
When chronic ankle sprains lead to continue deteriorating in the joint, many doctors may recommend utilizing stem cell therapy. Stem cells are typically taken from the patient’s fat or bone marrow and reintroduced into the ankle.
Doctor at the Royan Institute for Stem Cell Biology and Technology in Iran found that ankle osteoarthritis patients treated with stem cell therapy showed long-term benefit in pain and function. 4
Reported in Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders – A 59-year-old female patient presented with a history of three years of right ankle pain following a lateral ankle sprain.
The patient was unable to walk more than 30 feet without severe ankle pain and had ceased all weight-bearing recreational activities.
Cortisone therapy had been unsuccessful and ankle fusion had been recommended. Based on X-ray and MRI findings, the patient was diagnosed with osteoarthritis, avascular necrosis of the talus, and synovitis.
The patient received four stem cell bone marrow and prolotherapy 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. These gains were maintained throughout the treatment period.5
A doctor’s guide to Prolotherapy treatment of the ankle
Injuries to the ankle are the most common orthopedic injuries in sports, especially volleyball, basketball, football, and jogging. So we see many patients with ankle pain/sprain. In this article, we will look at the treatment of ankle and foot injury with Prolotherapy.
There are two primary joints at the ankle: the ankle joint proper, and the sub-talar joint. I almost always treat them both when either one is involved. I identify the ankle joint by feeling anteriorly while flexing and extending the foot at the ankle. Feel for the dorsalis pedis artery so the injection can be given lateral or medial to it (and the accompanying anterior tibial nerve). Cleanse the skin, extend the ankle to open up the joint, then insert a 25G, 1.5-inch needle. Inject 3-4cc of 25% dextrose directly into the joint. (See Figure 1.) After withdrawing the needle, repeatedly flex and extend the joint to distribute the proliferant throughout the ankle joint. HGH may be added to the Prolotherapy solution if the joint is severely degenerated.1
The sub-talar joint is readily identified as a palpable depression about 1 cm anterior and distal to the lateral malleolus. It is opened up by extending and internally rotating the foot at the ankle. (See Figure 2.) The skin is again cleansed, and a 25G 1.5-inch needle is inserted into the joint. Three to 4cc of 25% dextrose are injected and the needle withdrawn. The joint is flexed and extended several times to distribute the fluid throughout the sub-talar joint. As with the ankle joint, HGH may be added depending on the clinical indication.
Lateral: The lateral ligament complex is all too easily sprained. The lateral ligament complex is weaker than the medial, resulting in ankles being sprained laterally much more commonly than medially. The anterior talofibular is the most common injury at the ankle, usually at the fibular attachment. Examine carefully for injury to each of the major ligaments extending from the distal fibula (anterior and posterior talofibular, and the calcaneal-fibular ligaments). (See Figure 3.) Also, check the calcaneo-cuboid ligament 1 cm proximal and above the fifth metatarsal prominence laterally. This ligament is often injured along with the sprain to the lateral ankle.
Place a double paper towel under the foot. Cleanse the area to be treated. A 10cc luer lock syringe is filled with standard Prolotherapy solution and fitted with a 25G 1.5-inch needle. I begin at the posterior distal fibula and inject 0.5cc at each injured area around to the anterior aspect as indicated. (See Figure 4.) Next, I will inject the injured ligament attachments to the calcaneous and talus including the calcaneo-cuboid ligament, if necessary. (See Figure 5.)
Medial: The medial (deltoid) ligaments are injured much less commonly. Examination will reveal tenderness at the ligament attachments to the medial malleolus and calcaneous, navicular and talus (anterior and posterior talo-fibular ligaments, calcaneo-fibular ligament, and talo-navicular ligament. (See figure 6.) In this area, we will exercise caution at the posterior aspect of the medial malleolus due to the tibial nerve and posterior tibial artery. We will only give the injections with the needle touching the bone and will reposition the needle if the patient reports “lightning” shooting into the foot. After identifying the injured areas and prepping the skin, we utilize 6 to 10cc of standard Prolotherapy solution. Using a 10cc luer lock syringe with a 25G 1.5-inch needle we will inject 0.5cc at each point of the injured ligaments of the medial malleolus. (See Figure 7.) Next we will inject 0.5cc into each spot of injured deltoid tendon at its attachment to the calcaneous, talus and navicular.
Injury to the Achilles tendon is common. (If the tendon has a complete rupture then orthopedic surgery is required and referral will be made promptly). This injury is not difficult to identify. The offending spots are very tender to palpation and in many cases there is a tender swelling mid-tendon (not merely at the teno-osseous junction). (See Figure 8.) Treating injury to the Achilles tendon is one of the exceptions to “injecting only with the needle touching bone” guideline.
After identifying the injured areas I will draw up 3 to 6cc of standard Prolotherapy solution. Using a 25G 2-inch needle, I will “pepper” (See A.) (See Figure 9.) the attachment to the calcaneous with 3cc of Prolotherapy solution, as indicated, and further “pepper” any mid-tendon tear with an additional 3cc of solution. (See Figure 10.)
The patient will be requested to do no jumping, running, climbing, or sudden starts and stops. I routinely ask them to wear a heel (about 1.5 inches works well). For men, this is challenging, cowboy boots work for many.
Plantar fasciitis and heel pain are vexing problems that are frustrating and debilitating to patients. Fortunately they have come to us for treatment with Prolotherapy! There are three primary areas for the injury to the plantar fasciitis: the calcaneous, mid-arch, and attachments to the metatarsal heads. The patient can accurately point to the offending spot, and palpation confirms the diagnosis.
Position the patient on the table face down with the knee bent and the foot up in the air. To inject the calcaneal attachment we will avoid the thick plantar heel callus. The entry point is just medial plantar just distal to the heel pad. It is a good idea to warn patients that injecting the heel and ball of the foot is usually very painful. The 25G 2-inch needle is angled back to the attachment on the calcaneous (See Figure 11.) About 3cc of Prolotherapy solution is “peppered” into the calcaneal attachment.
Mid arch pain: there are numerous tendons and ligaments running on the under surface of the arch (long plantar ligament, plantar calcaneo-cuboid ligaments). (See Figure 12.) Prolotherapy to this area is extremely effective. And interestingly, it is not very painful to inject here. The insertion point is just plantar to the navicular tubercle. The needle is inserted straight across the arch to contact the bone on the lateral side of the under-surface of the arch. (See Figure 13.) The metatarsal and tarsal bones are “peppered” in a fan-like figure. Approximately 3 to 5cc of Prolotherapy solution are injected here using a 25G 2-inch needle. For an hour or two after the injections the patient will feel like he or she is walking on a golf ball.
For plantar fasciitis, there are a couple of concurrent treatments that are helpful. The most important is Functional Orthotics. If the patient has hyper-pronation at the ankle, and they almost all do, then orthotics are a must. Otherwise, the plantar fasciitis is likely to recur (if we can get it to heal in the first place). The second helpful treatment is again, elevating the heel about 1.5 inches. This decreases tension on the plantar fascia and is effective in relieving pain (this will not, however, heal the plantar fasciitis by itself).
Injuries at and around the MTP joints are quite painful. Careful palpation will reveal if the injury is at the plantar fascia attachment to the distal metatarsal, or to the joint itself or between the MTP joints. Each joint is palpated individually and sometimes while moving the joint. After identifying the injuries, we will treat the distal metatarsal head by cleansing the skin and if the injury is plantar, will enter through the skin just proximal to the callus of the ball of the foot and pepper the fibro-osseous junction (See Figure 14.) For injury at the proximal end of the MTP phalanx, approach is made from the skin just distal to the callus of the ball of the foot directly over the phalanx. (See Figure 15.) When the injury is on the dorsal side of the MTP, the approach is from the top. (See Figure 16.) 0.5 to 1cc is injected at each affected site.
This is a fairly common condition. Often it hurts, however, some people merely don’t like the way it looks. Here we have some good news and some bad news. The good news is that we can heal the injured ligaments and tendons so the pain is relieved. The bad news is that we can’t improve its cosmetic appearance.
The treatment is straight forward. Begin by cleansing the skin over the first MTP medially. Using a 25G 1.5-inch needle we will inject about 2cc of Prolotherapy solution around and into the joint on its medial aspect. (See Figure 17.)
The foot and ankle are very complex structures with many more ligaments and tendons and joints than we have covered in this article. I have tackled the most common conditions. Now we can Prolo our patients’ foot and ankle pains away!
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 Apr;44(4):995-1003.
2 Hauser RA, Hauser MS, Cukla J, Dextrose Prolotherapy Injections for Chronic Ankle Pain Practical Pain Management Jan 2010
3 Laver L, Carmont MR, McConkey MO, Palmanovich E, Yaacobi E, Mann G, Nyska M, Kots E, Mei-Dan O. Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial. Knee Surg Sports Traumatol Arthrosc. 2015 Nov;23(11):3383-92.
4. Emadedin M, Ghorbani Liastani M, Fazeli R, et al. Long-Term Follow-up of Intra-articular Injection of Autologous Mesenchymal Stem Cells in Patients with Knee, Ankle, or Hip Osteoarthritis. Arch Iran Med. 2015 Jun;18(6):336-44. doi: 015186/AIM.003.
5 Hauser RA, Orlofsky A. Regenerative Injection Therapy with Whole Bone Marrow Aspirate for Degenerative Joint Disease: A Case Series. Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. 2013;6:65-72.
6 Hauser RA, Feister WA, Dextrose Prolotherapy with Human Growth Hormone to Treat Chronic First Metatarsophalangeal Joint Pain. Foot and Ankle online Journal Sept 2012.