Stone Clinic Podcasts
The Ankle: Getting it Healthy, Keeping it Healthy
Description:
Kevin R. Stone, M.D., discusses the ankle, common ankle injuries, treatments, and rehabilitation. Followed by a patient Q&A. 9:29 minutes/8.7MB
Kevin R. Stone, M.D., discusses the ankle, common ankle injuries, treatments, and rehabilitation. Followed by a patient Q&A. 9:29 minutes/8.7MB
I’m Dr. Kevin Stone. It is June 2006 and the topic today is ankle injuries.
The most common questions is, “I twisted my ankle, it swelled, it hurts; now what do I do?” The most common injuries are tears to the anterior ligament of the ankle, the anterior talofibular ligament, which is the ligament that is on the front of the ankle, on the outside. If you put your hand down on the bump on the outside of your ankle, that’s called the lateral malleolus, and if you run your finger a little bit forward, that’s where the ankle ligament is that most commonly tears when you land from a jump and you twist your ankle inwards, or when you twist over a curb, or trip over your ankle and either hear a pop or feel ankle pain and have swelling. Those tears of that ankle are often graded, Grades I, II, and III, which is a degree of sprain, or stretch, or tearing. We, however, most commonly grade them by, “Is the ankle unstable or stable?” If it is stable after a tear of that ligament, then the usual careful treatments of ice, soft tissue massage, ankle support, and swelling reduction work very well and the ankles usually return to feeling pretty normal within a couple of weeks.
If the ankle is unstable after the ligament tear, that means that enough of the ligament is torn or that other ligaments around the ankle are torn to permit the talus bone to move out from underneath the tibia, the shinbone. Then, the ankle is unstable. That instability, if left unrepaired, or unhealed, leads to the chronic unstable ankle or “Doc, my ankle turns in on me whenever I’m playing sports or it commonly gives way type syndrome.” Tears of that ankle ligament most commonly heal on their own and they heal best, when during the healing period the ankle is supported and stabilized. The ligament is given a chance to heal in the normal position and not in the stretched out or scarred position. There are specific treatments that we do, in order to help people heal their ankle ligaments ideally. Those treatments include ice, elevation, soft tissue massage, ankle training exercises, which help stimulate the ligament to heal along the lines of stress in a normal fashion rather than just a scar, sometimes electrical stimulation, and a host of balance and proprioception exercises, which all help quite a bit.
One in 500 or so of the ankle ligaments that we see do not heal properly and leave the athlete with an unstable ankle. We go on and repair those ligaments surgically. There are more significant types of ankle injuries, where not only the anterior talofibular ligament tears but the ligaments along the side and the back of the ankle tear and sometimes the membrane going up the front, outside aspect of the leg, the membrane between the shinbone, the tibia, and the small bone on the outside, the fibula, also tears. Those ankle injuries, or high ankle sprains, involve tearing of more tissue, and usually more instability, more pain, and a longer period of time to heal. The most important first treatments for the ankle injuries are, getting off the ankle and getting rid of the swelling because swelling distracts or distends the tissues that are trying to heal, distorting them and preventing healing in a tight, stable fashion. So, swelling reduction is step one and swelling reduction is best achieved by elevation, ice, massage, careful exercises and bracing.
We will now open it up to specific questions that we may or may not have covered. Are there any questions?
Q: Dr. Stone, what is the difference between a high ankle sprain and a low one?
The degree of injury really determines a high versus low ankle sprain and the location of tearing. So, a low ankle sprain, classically, is tearing of the anterior talofibular ligament that produces some swelling in that area but not pain and swelling going up the front of the leg. The more it goes up the front of the leg, the more the tissues in the front, the tissues between the tibia and the fibula are involved, and therefore the more instability.
Q: Dr. Stone, what are your thoughts on taking ibuprofen or any other anti-inflammatory to help a sprain?
We used to use anti-inflammatory medications, such as ibuprofen, Advil, Aleve, or Naprosyn to reduce swelling and diminish pain for people who have injured their ankles and broken their bones. Unfortunately, there is good data now that shows that these non-steroidal, anti-inflammatory medications inhibit tendon healing and inhibit bone healing. So, because of that data, we now use Tylenol, which is acetaminophen, or aspirin, which is a good pain reliever and anti-inflammatory that does not appear to have the deleterious effects on the soft tissue and bone in the immediate post-injury period. So we are avoiding use of non-steroidal anti-inflammatories and hopefully speeding healing by doing so.
Q: Dr. Stone, how effective are braces in treating ankle sprains and what is the importance of rehabilitation?
Ankle braces are often very helpful in the acute period and sometimes in the chronic period. The brace helps diminish the repeated instability episodes and permits the ligament to heal. Also, by providing compression, it helps diminish swelling and makes the ankle feel more stable. So, we always use an ankle splint after an acute ankle injury until the swelling is gone and until the pain has resolved and the ankle feels stable. For people who have chronic ankle instability, sometimes they find relief from ankle wraps or ankle braces but not always. When they don’t find adequate relief, then we primarily repair the tissue, which has been very effective in our hands at restoring ankle stability. The most important feature of restoring ankle stability is the rehabilitation program and that is because the first thing to go, after an ankle injury, is the balance or proprioceptive ability, your ability to maintain a stable ankle, and it is the last thing to come back and the thing that most people fail to rehabilitate or think about, after their ankle feels good again. And thus, there is a higher incidence of repeat ankle injuries in people who have had their first significant ankle injury. So the most important thing about ankle rehabilitation, after the swelling and pain are gone, is, of course, to ensure that there is a full range of motion, ensure that there is good strength within the small muscles of the foot, the intrinsic muscles, and to ensure that your balance and proprioception are returned. We ask people to do exercises on single stance and also on unstable surfaces. So, for instance, if somebody likes to do a biceps curl, we would ask them to do an upper extremity biceps curl while standing on one leg. Therefore, while they’re doing their curl, they will be doing lower extremity balance and proprioceptive exercises. We will also use Bosu balls, unstable tilt balls, and trampolines to help people rehabilitate their ankle.
This concludes our short presentation on ankle injuries and we hope that this has been helpful to you.
One thing to note is that, if you are having continued ankle pain after what seemed like a minor ankle injury, then we worry about damage to the articular cartilage surfaces inside the joint, or damage to the bone itself. Often x-rays, a careful examination, and an MRI of the ankle can determine whether or not there has been cartilage injury, bone injury, or more extensive ligament injury after an ankle injury itself.
The most common questions is, “I twisted my ankle, it swelled, it hurts; now what do I do?” The most common injuries are tears to the anterior ligament of the ankle, the anterior talofibular ligament, which is the ligament that is on the front of the ankle, on the outside. If you put your hand down on the bump on the outside of your ankle, that’s called the lateral malleolus, and if you run your finger a little bit forward, that’s where the ankle ligament is that most commonly tears when you land from a jump and you twist your ankle inwards, or when you twist over a curb, or trip over your ankle and either hear a pop or feel ankle pain and have swelling. Those tears of that ankle are often graded, Grades I, II, and III, which is a degree of sprain, or stretch, or tearing. We, however, most commonly grade them by, “Is the ankle unstable or stable?” If it is stable after a tear of that ligament, then the usual careful treatments of ice, soft tissue massage, ankle support, and swelling reduction work very well and the ankles usually return to feeling pretty normal within a couple of weeks.
If the ankle is unstable after the ligament tear, that means that enough of the ligament is torn or that other ligaments around the ankle are torn to permit the talus bone to move out from underneath the tibia, the shinbone. Then, the ankle is unstable. That instability, if left unrepaired, or unhealed, leads to the chronic unstable ankle or “Doc, my ankle turns in on me whenever I’m playing sports or it commonly gives way type syndrome.” Tears of that ankle ligament most commonly heal on their own and they heal best, when during the healing period the ankle is supported and stabilized. The ligament is given a chance to heal in the normal position and not in the stretched out or scarred position. There are specific treatments that we do, in order to help people heal their ankle ligaments ideally. Those treatments include ice, elevation, soft tissue massage, ankle training exercises, which help stimulate the ligament to heal along the lines of stress in a normal fashion rather than just a scar, sometimes electrical stimulation, and a host of balance and proprioception exercises, which all help quite a bit.
One in 500 or so of the ankle ligaments that we see do not heal properly and leave the athlete with an unstable ankle. We go on and repair those ligaments surgically. There are more significant types of ankle injuries, where not only the anterior talofibular ligament tears but the ligaments along the side and the back of the ankle tear and sometimes the membrane going up the front, outside aspect of the leg, the membrane between the shinbone, the tibia, and the small bone on the outside, the fibula, also tears. Those ankle injuries, or high ankle sprains, involve tearing of more tissue, and usually more instability, more pain, and a longer period of time to heal. The most important first treatments for the ankle injuries are, getting off the ankle and getting rid of the swelling because swelling distracts or distends the tissues that are trying to heal, distorting them and preventing healing in a tight, stable fashion. So, swelling reduction is step one and swelling reduction is best achieved by elevation, ice, massage, careful exercises and bracing.
We will now open it up to specific questions that we may or may not have covered. Are there any questions?
Q: Dr. Stone, what is the difference between a high ankle sprain and a low one?
The degree of injury really determines a high versus low ankle sprain and the location of tearing. So, a low ankle sprain, classically, is tearing of the anterior talofibular ligament that produces some swelling in that area but not pain and swelling going up the front of the leg. The more it goes up the front of the leg, the more the tissues in the front, the tissues between the tibia and the fibula are involved, and therefore the more instability.
Q: Dr. Stone, what are your thoughts on taking ibuprofen or any other anti-inflammatory to help a sprain?
We used to use anti-inflammatory medications, such as ibuprofen, Advil, Aleve, or Naprosyn to reduce swelling and diminish pain for people who have injured their ankles and broken their bones. Unfortunately, there is good data now that shows that these non-steroidal, anti-inflammatory medications inhibit tendon healing and inhibit bone healing. So, because of that data, we now use Tylenol, which is acetaminophen, or aspirin, which is a good pain reliever and anti-inflammatory that does not appear to have the deleterious effects on the soft tissue and bone in the immediate post-injury period. So we are avoiding use of non-steroidal anti-inflammatories and hopefully speeding healing by doing so.
Q: Dr. Stone, how effective are braces in treating ankle sprains and what is the importance of rehabilitation?
Ankle braces are often very helpful in the acute period and sometimes in the chronic period. The brace helps diminish the repeated instability episodes and permits the ligament to heal. Also, by providing compression, it helps diminish swelling and makes the ankle feel more stable. So, we always use an ankle splint after an acute ankle injury until the swelling is gone and until the pain has resolved and the ankle feels stable. For people who have chronic ankle instability, sometimes they find relief from ankle wraps or ankle braces but not always. When they don’t find adequate relief, then we primarily repair the tissue, which has been very effective in our hands at restoring ankle stability. The most important feature of restoring ankle stability is the rehabilitation program and that is because the first thing to go, after an ankle injury, is the balance or proprioceptive ability, your ability to maintain a stable ankle, and it is the last thing to come back and the thing that most people fail to rehabilitate or think about, after their ankle feels good again. And thus, there is a higher incidence of repeat ankle injuries in people who have had their first significant ankle injury. So the most important thing about ankle rehabilitation, after the swelling and pain are gone, is, of course, to ensure that there is a full range of motion, ensure that there is good strength within the small muscles of the foot, the intrinsic muscles, and to ensure that your balance and proprioception are returned. We ask people to do exercises on single stance and also on unstable surfaces. So, for instance, if somebody likes to do a biceps curl, we would ask them to do an upper extremity biceps curl while standing on one leg. Therefore, while they’re doing their curl, they will be doing lower extremity balance and proprioceptive exercises. We will also use Bosu balls, unstable tilt balls, and trampolines to help people rehabilitate their ankle.
This concludes our short presentation on ankle injuries and we hope that this has been helpful to you.
One thing to note is that, if you are having continued ankle pain after what seemed like a minor ankle injury, then we worry about damage to the articular cartilage surfaces inside the joint, or damage to the bone itself. Often x-rays, a careful examination, and an MRI of the ankle can determine whether or not there has been cartilage injury, bone injury, or more extensive ligament injury after an ankle injury itself.
***
The Stone Clinic in San Francisco concentrates on returning injured people to their active lives, fitter, faster, and stronger than they were before. The Stone Clinic includes Dr. Kevin Stone, physician and surgeon, a staff of physical therapists, and an x-ray and MRI facility. Our specialties include the treatment of joint injuries and arthritis with leading edge surgical and rehabilitation techniques. Elite athletes and everyday people alike come to The Stone Clinic from around the world for the best in orthopaedic care. The Stone Clinic is located at 3727 Buchanan St., San Francisco, CA 94123. For more information, please call us at (415) 563-3110