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This ankle just won’t get better..

Jan 11th, 2014

Kate asked The Guru for the following Physiotherapy Advice:

Hi Guru,

I slipped and inverted my ankle 8 weeks ago – thought to be a Grade 1/2 sprain with partial tear of the ATFL and CFL. There was pain and swelling that got worse over the next 24-48 hours but I was able to weight bear (albeit with discomfort!). Since then I have been having physio, doing strengthening exercises and proprioceptive work and am back in the gym using the bike and cross trainer generally without discomfort.

However, I still have pain on bending the foot up and down especially across the front of the joint and behind my ankle (making stairs particularly painful) and there is still swelling which is worse at the end of the day. I have intermittent tingling in the outer part of my foot, up my outer leg to my calves. I have attempted easing back into running (run/walk ~20mins) but my ankle consistently has a dull ache with impact (3-4/10 severity). There is also what feels like a hard bit coming off the outer ankle crossing over the front of the joint which I think may be causing the pain on bending the foot – could this be scar tissue? Is it significant that the pain is not always reproduced with passive movement but consistently occurs with active movement?

I have a recent history of peroneal tendinosis for which I am wearing orthotics for running and daily going about which I think could be aggravating the ankle further – going without means bilateral tendon pain.

There has been little improvement since the injury and I don’t know what to do. As much as I enjoy it, should I avoid running altogether at the moment and just stick to low impact exercise? Although the pain isn’t sharp or severe enough to make me stop, it remains throughout the set time and I can’t help but think it’s doing more harm than good especially as the other day when I ran for just over 20mins, I had some discomfort walking the next day.

What do you suggest? Are there any other therapies that may be beneficial – ultrasound? acupuncture? Any advice would be much appreciated as I am keen to avoid the need for steroid injections or anything more invasive and I’m beyond fed up! Many thanks!

The Guru Responded:

Hi Kate
.
Ankles can be right so-and-so’s especially if they are sitting amongst
an already dodgy foot type. Ankles can also be right little angles if
they are diagnosed and looked after appropriately.
.
If I rewind back 8 weeks or so, you may have clonked your ankle more
than you imagined, with a more severe sprain of your ATFL. This may
have benefited from being immobilised in an Aircast Boot for a month
or so. BUT we are beyond this bit and have to crack on.
.
Sprained ankles have a problem with excessive movement and not enough
control. Your rehab is about getting the control, then strength and
then regaining normal movement. Your block and pain (backward and
forwards) could be a 2 fold issue.
.
Firstly, there is a lump of scar tissue sitting in your lateral gutter
or at the front of your joint. It appears due to the traumatic nature
of what you did and the bleeding/scaring later. The scar tissue just
gets in the way, and hurts.
.
Secondly, and perhaps more relevant to the first issue about correct
diagnosis is that if you have got a more severe sprain, you’ve less
stability from the ligaments and so the actual movement of the joint
increases. If you can’t control this excessive movement it’ll become
painful at the end of ranges and give a very unsatisfying dull
throbbing ache after activity…..
.
The weird tingling sensation is from your common peroneal nerve which
either gets irritated due to the local sprain, or the top bit of your
ankle bone (the head of the fibula just below your knee) shifts and
bangs into the nerve -it can be an indicator of just how severe your
sprain was.
.
What would I do? I wouldn’t go near ultrasound – you’d have as much
success as rubbing a left handed newt on your forehead (!) and
acupuncture may help with the pain, but it will not get rid of why
you’ve still got probs.
.
Instead, do really get your ankle and ligaments properly assessed –
ask your physio to have a good careful look and paly with your
ligamanets. If they are super wobbly doing less rather than more is on
the cards. Really go to town on stability (right from the pelvis
down), control and balance. Add strength with the control, not apart
from it. Don’t just crunch the ankle into increasing your range – make
it move better. Slowly introduce loading, so stop go back and start
running in the pool, trampet, easy plyometrics and see what the
effects are.
.
As for jabbing the ankle, it may be necessary, but I think you’ve got
to fail at good conservative treatment first of all.
.
Good Luck

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