Chronic Ankle Injury: Email Advice

Dear Dr. Blake,

I came across your blog while searching for an answer to my ankle problem; I am wondering if you can give me some idea?

I am a 22 year old female, BMI is in the normal category; I injured my right ankle when I was 12 (jumping down the stairs). From what I can remember, it was really painful but I didn't do anything (compress with ice etc) and I only went to the doctors some times after. I think the doctor said one of the ligaments is torn. I have been wearing ankle braces and minimize sports activity  (though still keep on running occasionally). There is not any problem, although sometimes in the morning when I get up, I feel the joint is a bit "tight" or sore but not up to a level that is painful and the symptom is gone soon after.

Dr Blake's comment: This is fairly common for joint injuries. The symptoms may plateau below perfect, but definitely manageable. There is probably some scar tissue in the wrong place, but the disability of removing it is far worse than the disability of leaving it alone. 

However, 2 months ago when I woke up (was woke up by the pain actually) the pain is unbearable, even if I did not touch the ankle. Standing was not possible and I had to use crutches. I went to the doctors and was diagonosed arithritis, happened for no reason (the blood test was normal). I took Naproxen sodium and Ranitidine tablet for 2-3 days before I can walk independently without crutches.

Dr Blake's comment: This may or may not be separate from the old injury. Sleeping in the wrong position for an extended period of time can cause the joint lining to be pinched. The joint lining is full of nerve endings and when  and when irritated are very unhappy. This pain normally goes down over 4-5 days, unless some extra scar tissue is stuck. The treatment for this acute type of pain is icing for 96 hours 3 to 4 times per day to reduce the inflammation. Arthritis always sounds bad and permanent and dark, but actually means joint inflammation. Yes, you had joint inflammation. The rest of the seriousness has to be followed and possibly explored with imaging. 

What I am not sure now is that my ankle is swollen, without pain. I do not notice if it is always like this (I know it is not completely right but never compare the size between left and right ankles). Since the incident 2 months ago, I stopped every sports and only walk and swim. I also have ankle braces on all the time no matter what. The swelling is positioned at the anterior part between Tibia and Talus bones and also a small part above the ankle. It appears to be twice bigger than my left ankle (normal one).

Dr Blake's comment: Pain in and around the ankle causing swelling. Long after the pain is gone, and the disability, the swelling can remain and remain. Up to 4-6 months longer than the pain. Ankle braces can hold in the swelling. Inactivity can also hold in the swelling. It is best to judge what you should and shouldn't do, and what you should and shouldn't wear based on pain. Remember the wise old adage of "Listen To Your Body". It was not look at the swelling of your body for good reasons. 

What do you think might be the cause to the swelling? And would you suggest to go for an operation or any alternatives? Is it possible to avoid surgery at all in this circumstances?

Dr Blake's comments: You irritated your ankle from sleeping funny, and this caused the initial pain. The pain was intense enough that your body tried to heal something by bringing in swelling. Now the swelling is trapped. Twice daily ice pack the ankle for 20 minutes, and once day do contrast bathes. See the blog for info on these techniques. Avoid tight fitting socks that leave a skin indentation. Your chance of surgery is less than 1% at this time, unless further info comes forward. You have surgery for unrelenting pain, never for swelling. Hope this helps. Rich

I am grateful for any comments that you have! Thank you for your time in advance.

Sincerely,

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.