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Saturday, February 27, 2016

Frozen Ankle post Sprain: Email Advice

Dr. Blake,

Good afternoon.  I just came across your blog and I just want to say thank you for taking your time to respond to so many people!  I would love any information you could provide me after I tell you about my injury. 

Ok, so here we go. March 16, 2015, I went to one of those
wonderful trampoline places for a birthday party and badly sprained my left ankle.  I had to be carried off and my ankle swelled up instantly.  It took me about a month to get an appointment to see a podiatrist.  In the meantime, I kept it iced, elevated, wrapped with an ankle brace and I was using crutches/cane/knee walker to get around.  My first appointment with the doc,  after x-rays, I did not break anything.  He said it seemed like a 3rd degree sprain with a high ankle sprain and it was frozen, which does not happen very often after a sprain.  He said this happens maybe 1 in every 1,000 sprains. Just my luck, huh?
Dr Blake's Comment: High ankle sprains involve the ligaments between the two ankle bones (tibia and fibula). When those ligaments get sprained, you lose forward bend of the ankle, thus "a frozen ankle". The more common lower ankle inversion sprains have full mobility to bend, it is the side to side ligaments that were injured and have to be protected. So, everything makes sense so far. Rich

I was put in a knee-high air boot, weight bearing and sent to physical therapy and  to check back in 6 weeks later.  After about 2 weeks, we realized my ankle was not moving or going to start moving, so we moved my check up to be seen earlier.  I had an MRI, and my doc said it was a basically a frozen joint and still the high ankle sprain and 3rd degree sprain. 
Dr Blake's comment: This is good medicine to get an MRI early in the game to rule out cartilage or bone injury. So far, you have been in the Immobilization Phase, and you are not going to gain alot of motion at this point until you are out of the boot. So, everything still seems normal. 

 We tried numbing it in the office about 3 times and tried to manipulate it, but that did not work.  So, he wanted to try a manipulation under anesthesia, where I could not fight him, but my insurance didn't cover that.  We are also in June 2015 by this time.
Dr Blake's comment: So, since a high ankle sprain can take 12 months or so to gradually loosen up as you balance pain free protection with gradually more and more stress, why was there so much concern about your ankle. Was it totally locked? How much did it hurt? What was the range of motion with the knee straight bending the ankle and with the knee bent? Do you have an excessive scar formation problem? Are we 100% sure that there were no bone/cartilage injuries?

  I was supposed to have surgery right after 4th of July weekend and found out that my surgery was not approved less than 24 hours before my procedure.  They would only cover the scoping.  My doc didn't want to just cut into me, so we tried to appeal the surgery and 30 days in, we found out the appeal was never started, so 60 days total, it was denied again.  This is now September, and by this time I would have rather him do both, the manipulation and scope, to be safe because the joint has been frozen going on 6 months now.  So, we scheduled my surgery and after it being cancelled one more time, the big day was October 22nd.  I had my one week follow-up and he released me to start back up physical therapy.  My 2 week follow-up, he removed the stitches.  We wanted to be aggressive with the therapy so the joint did not freeze up again, but not too much so the body went into shock and froze up by being to forceful too soon.
My physical therapy doc wanted to start dry needling me, but we had to wait until I could do a good stretch.  By the beginning of November I was being dry needled twice a week and she started grastoning me as well.  She thought because I had such short movement from the knee down for so long, that my muscles were so tight and that is why my ankle could still not move up very well.  I went from PT 3x per week, to 2x about a month ago.  In January I had a follow-up with my foot doc and he released me to full physical activity like I used to before my injury.  I was pretty active, working out pretty much everyday, so not working out for about the last 10 months or so has been killing me.
Ok, so I've been going to pt since my first post op and doing all my home stretching and my ankle is still not moving very well.  The front is better, but I am super tight in the inside,  like I can feel it pulling when I try to move my foot upwards.  After many breakdowns at pt, my pt doc told me a frozen ankle can take 1-3 years to fully heal, called it "a thawing out period".  After accepting that a few weeks ago, I am still not convinced.  I am tired of everyone telling me this does not happen very often and not really sure what to do.  We get it to stretch pretty good while Im at pt, but then it freezes back up.  I want to know what to do to fix this.
Dr Blake's comment: You definitely want a new MRI, because a one year comparison can tell you what is wrong and if there is anything to do to fix it. But, what did the surgery find? Too much scarring? Scuffed cartilage? More info on this tight ankle is needed. Make a comment to this post and I will reply directly to the comment. Yes, these can take this long, but I agree something does not make sense. Something is missing. 
Last week, I went and got a second opinion from another podiatrist.  He took more x-rays and looked at my MRI from before the surgery and I had pics from my scoping.  He told me it looks like he only scoped the front of my joint and not the back.  He showed me my MRI and the notes, and  there was no evidence that it was a high ankle sprain.  He said I did a number on it, but in the lower bones, I banged both together in 2 spots and he showed the bruising.  From the x-rays, he said it looked cloudy in the back part and when he showed me that my heel doesn't move side to side, because he believes the scar tissue it still there.  That was a pretty hard pill to swallow.  He recommended getting a steroid shot and ordered a JAS splint for my ROM issues.  The doc said he had a similar patient and he did the scope of the ankle and then put a cushion in the back to help with movement and she is at 80% mobility.  Here I am 4 months post surgery and unless I am very warm and all my weight is stretching the joint, I am not where near that.  I didn't get the shot that day, but I have it scheduled for Monday, Feb. 22, and I am very nervous.
Dr Blake's comment: Okay, now we are getting somewhere. So, I am sorry I am answering this after that appt. Definitely opt for a new MRI. If the initial MRI was misread as no bone injury, no wonder you are not better. If you injury bones, they need to heal before you can begin to get mobility back. I did have a PT who could not work for 3 years waiting for her bone edema (swelling) to completely resolve. Exogen bone stimulators can definitely help, along with flushing with contrast bathing nightly. There is still hope. Can you send a snapshot of the MRI image or two that shows the one edema?

I have a follow-up with my main doc on March 1st and I am going to ask if he scoped my whole ankle or just the front.  I am also going to ask about my MRI. 
Dr Blake's comment: Most docs just scope the front in these cases, the back being too hard to see. To access the back potentially can cause more tissue damage or scarring, so he probably erred on caution which makes sense. 
I guess my question to you is whether you think the shot is a good idea? 
Dr Blake's comment: If you had a shot on your visit fine, but keep them to a minimum until you know the bone/cartilage has completely healed. So get another MRI, get an Exogen bone stim if the bones still light up, get me some pictures. Hope this helps you somehow. Rich

 That is how I came upon your blog, looking up info about the steroid shots.  When they told me they would have to inject the shot into the ports where I was scoped, I freaked out because I am still in pain when my therapist tries to work on the scars.  I am only 31 and I just want to be able to be active again.  I thought after my surgery, I would be fine and now to find out that it is still frozen in the back, I am not sure what to do.  I asked the doc I had the second opinion with, was all this dry needling to get my foot to move basically a waste if the scar tissue is still there?  He said it isn't hurting anything, but I said it isn't really helping anything either and he said no.  I just spent the last 4 months going through some rough stuff and to find out my ankle it still messed up, I don't even know where to begin.  I have been reading reviews about these shots and I am reading more negative ones than positive.  I just want to make sure I am doing the right thing.  I really hope this and the JAS splint helps, because I really do not want to go through another surgery if possible. 
Any help would be greatly appreciated.  Thank you for taking the time to read this.
Very Respectfully,


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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.