Recovery Comparison: Expectations

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Different than the lateral ankle ligaments that are described above, the high ankle sprain consists of injury to one of the syndesmotic ligaments (Fig – RED; above black line): anterior inferior tibiofibular (AITFL), interosseous (IOL), posterior inferior tibiofibular (PITFL), and inferior transverse ligament (ITL). These ligaments are important in keeping the distal ends of the two long bones of the leg, the tibia and fibula, together so the ankle remains stable. Syndesmotic sprains occur anywhere between 10-32% of all ankle sprains, higher in the athletic population.1 While lateral ankle sprains are a result of inversion of the ankle, high ankle sprains typically have an additional component of rotation of the foot or leg. A specific set of physical exam tests will be performed by your physician to test the existence of a high ankle sprain injury (“squeeze test,” “external rotation test,” and “crossed-leg test”).

Most of the time, the doctor will first start his or her evaluation with an X-ray to rule out a broken bone in the ankle or foot. Certain bony relationships cue the doctor into potential ligamentous injuries. A CT or MRI may be additionally ordered depending on the X-ray findings, physical exam findings, and mechanism of injury to assess the ligaments and tibia and fibula relationship at the syndesmosis.

It is important to remember with any ankle sprain that healing is not instant.  It is key to protect the ankle in the first 2-3 weeks of healing followed by physical therapy to strengthen both the ligaments in the ankle and the muscles of the foot, leg, and thigh. Ligaments need one year to restore original mechanical strength.  Scar tissue that forms following a sprain will take 6-12 weeks to mature to sport tensile strength. It is also important to differentiate a lateral ankle versus high ankle sprain as the treatment protocol for each is different with the high ankle sprain often requiring more initial rest and immobilization (sometimes twice that of a lateral ankle sprain) before starting therapy. These injuries often have a more delayed return to sport by several weeks. In some instances, severe syndesmotic injuries require immediate surgical correction.

After a first sprain, 70% of people will have a repeat sprain at some point and 40-50% of sprainers will have some long term symptom (decrease ROM, pain, swell, weakness, lateral ankle instability), specifically with Grade 2-3 sprains. In syndesmotic injuries, symptoms can remain for up to 6 months after the incident. Furthermore, recurrent sprains (2-3/year) can lead to a condition called lateral ankle instability that often requires surgical correction to tighten the ligaments. It is important to undergo guided physical therapy to safely progress through the healing process and assess when it is appropriate to return to activity (ie. sport).

If you have been dealing with an ankle sprain, whether it is your first or a recurrence, or have continued ankle pain, schedule an appointment with a foot and ankle specialist to discuss your treatment options. Furthermore, if your ankle feels unsteady and you chronically sprain, you may have chronic lateral ankle instability with harm not just to the ligaments about the ankle, but the bones/cartilage, joint, and tendons as well. Your doctor will help you determine a personalized treatment plan for you.

Dr. Hood is a fellowship trained foot and ankle surgeon. Follow him on Twitter at @crhoodjrdpm.

Image credit from:

1. Sprained Ankle. 2015. Available at: < http://www.thevisualmd.com/panel/?c=719.37>

References:

1. Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E. Lateral and syndesmotic ankle sprain injuries: a narrative literature review. J Chiropr Med. 2011;10(3):204-219. doi:10.1016/j.jcm.2011.02.001.
2. Golanó P, Vega J, de Leeuw PAJ, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surgery, Sport Traumatol Arthrosc. 2016;24(4):944-956. doi:10.1007/s00167-016-4059-4.

Christopher R. Hood JR, DPM

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Plantar fasciitis is the most common cause of heel pain and probably the most common foot and ankle disorder we see at the office. The plantar fascia is a flat band (“ligament”) of tissue on the sole of your foot that connects your heel bone (calcaneus) to your toes. Its main purpose is to support your arch. The condition of plantar fasciitis is caused by straining of this fascia with resultant micro-tears leading to pain and swelling.

Heel pain can have a few different causes and is not always plantar fasciitis. This includes: structural abnormalities (ex. biomechanics, bone tumor), trauma (ex. calcaneal stress fracture, plantar fascia tear), neurologic (ex. nerve entrapment), or arthritic (ex: inflammatory or osteo- arthritis). One common condition that mimics plantar fasciitis is tarsal tunnel syndrome. It is important to see a foot and ankle specialist to differentiate plantar fasciitis from tarsal tunnel syndrome or another potential diagnosis, as each entity has a different treatment course. If you have been treated for plantar fasciitis by another physician with limited results, it may in fact be a tarsal tunnel syndrome or one of the other differentials listed above.

For plantar fasciitis, the most common locations of pain are the central-medial arch, plantar-medial heel just at the beginning of one’s arch, or the central-plantar heel. The pain, usually described as a non-radiating sharp/stabbing pain, occurs with weight-bearing often after a period of rest (ie. first steps in the morning after sleep). It gradually improves as you become more mobile but can also be a dull ache to your heel for the rest of the day without relief until you get off of your feet.

Most of the time, the cause is mechanical overload: high arch foot, excessive pronation; tight Achilles, lack of support (ex. flip-flops, flat sneakers, old sneakers), obesity, work-load (standing/walking for long periods on hard surfaces), poor posture, or change in activity level.

When you visit your doctor, he may ask about your shoe gear choices, recent changes in activity, work habits, history of trauma, and any attempted treatments. The visit typically starts with a weight-bearing radiograph to evaluate the biomechanical structure of the foot. Your doctor may or may not find the quoted “heel spur” which is believed to be caused by tension of the plantar fascia pulling on the bone. This is often an incidental finding and not the reason for your pain as only 50% of patients with plantar fasciitis are found to have the spur.1

Once the diagnosis is made, your physician will make recommendations for treatment. This typically includes some combination of the following: dispensing a stretching exercise protocol or formal physical therapy; night splint to keep the fascia stretched during the sleeping hours; oral anti-inflammatory medication; steroid injection to the target site of pain; arch support. Follow-up is typically 2-4 weeks later to evaluate the treatments and make changes as needed.

Treatments are targeted at eliminating the pain and then promoting a lifestyle to prevent recurrence, avoiding triggers and maintaining good habits. One studied reported upwards of 80% of patients with plantar fasciitis has resolution of pain with conservative treatment alone.2 The sooner you are evaluated, the better the prognosis. Patients with untreated pain for 6-12 month are less likely to respond to conservative measures alone and may require surgery.

If you’ve been dealing with heel pain, or any other foot and ankle pains, schedule an appointment with a foot and ankle specialist at Premier Orthopaedics to discuss your treatment options. Your Premier physician will help you determine the best course of action for your situation.

References:
1. Karr SD. Subcalcaneal heel pain. Orthop Clin North America 25: 161-175, 1994
2. Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int 1994;15:97-102.

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