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Wednesday, August 1, 2012

Chronic Swelling Post Ankle Sprain: Email Advice

Hi, Dr. Blake,
I’ve written you in the past about my sesamoiditis, which hasn’t been giving me any trouble since working to help it heal based on your suggestions, and wearing the right footwear since then.  THANK YOU!
Now, I am having an issue with a spot on my right ankle.  I sprained it badly last September, when I was out of town for a conference, and couldn’t take care of it very well.  It healed OK, as far as I could tell but since the sprain it's always had a larger profile.  Now, without any precipitating event that I can tell, I have had swelling in the same spot for about three weeks—at first, hard to tell the difference between left and right silhouettes, but now pronounced.  It subsides during sleep, but then by the end of the work day (I am wearing compression socks, the kind nurses wear, all day, on both legs) it is getting swollen.  It’s right over the ankle bone, above and along the edge of my shoe on the outside of my foot towards the back and the area of swelling is about 4” long by 1” wide. 
There has been no pain, except a few twinges, and no range of motion has been affected … which is why I waited so long to write.  I kept thinking it was something minor, but now that it is not resolving I am wondering if I reinjured myself?  I just read your post to Roberta from 2/5/2012 with alarm—I am WAY past 14 days with this.  Most of what I read is about immediately post sprain-- what to do much later?
Do you have any suggestions for me?  I have made an MD appointment, but as great as my MD is, she is not the expert that you are.  Thank you, again, for your help!
Ann from Seattle

Hey Ann,

     Thank you so very much for your email and I am glad that the sesamoiditis has resolved. When I did a study in the 1980s on ankle sprains, I found nearly 20% of all ankle sprain victims still had some symptoms after one year. Only 1-2% of those patients had a significant injury like a missed fracture. The other 98% of these patients had problems, but did not know if they had any significance, and thus were just living with them. The reasons were varied, like still feeling weak or unstable, and approximately 20% of them complained swelling like you. If I do my math correctly, that means 4% of all ankle sprains patients are still having swelling issues after one year post injury. 

     So, why is this a big deal? The ankle joint is the tightest major weight bearing joint in the body. The tibia (leg bone) and the talus (foot bone) normally fit like a hand and glove. Swelling causes instability by separating the joint surfaces. Add some amount of ligament damage with your typical sprain and more potential instability or wobble can occur. Add the typical sub par re-strengthening program of most ankle sprains, and the potential of significant re-injury occurs. Add the heels that most women want to wear, or the cobble stones streets in Europe, or the months of deconditioning/weakness produced by a new job, move, illness, etc, and more potential for injury occurs. 

     Question #1: Does the swelling without pain mean something really bad is lurking? Probably not.
     Question #2: Should you work aggressively on the swelling with more PT, contrast bathing, elevation, acupuncture, etc? Probably not, although some daily icing with a pack 20 minutes to the front and outside of the ankle is helpful. At least, you can slip inside your sock and walk around the house with an ice pack. Do for the next 2 months, near the end of each day, Also, if your soaks or support hose when you take off produce a visible depression in the skin, this alone may be preventing the fluid from getting back to your heart. 
     Question #3: What should be your primary focus over the next 2 months? Place yourself on a great ankle restrengthening program with the balance and theraband exercises listed in this blog. Do these for 5 minutes every night within 2 hours of going to sleep to gradually strengthen the ankle and then go to 3 days per week. Over the next year, make sure the time or difficulty increases each month, so you become super strong. Then let me know how you feel. If you do the various exercises, and you can isolate one that hurts you, now we have probably labeled some form of tendinitis and the treatment can be more exacting. 

Sure hope this helps you Ann, Rich. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.