Problems after a “Simple Sprain”
Ankle sprains are very common, and although it is often reported that up to 30% of people will run into long term trouble after an ankle sprain in my opinion this is patently nonsense. It clearly depends on the degree of sprain that we are talking about. Almost everyone has had an ankle sprain of one degree or another at sometime whether or not they are sportsmen and the vast majority will settle without any treatment. More severe injuries, however, will run into secondary problems either as a result of muscle wasting leading to loss of dynamic control of the ankle or alternatively as a result of damage either to the soft tissue or articular lining of the joint. Even after complete tears of the ligaments around the ankle it is actually quite uncommon to run into problems with looseness of the ligament leading to instability and recurrent sprains. More commonly, the feeling of instability and looseness is as a result of either a failure of rehabilitation or a hidden problem inside the joint itself. The foot is held in a mortise made by the tibia & fibula, and as it twists there will often be damage to the lining of the joint which leads to an irregularity in the surface and a feeling that something is coming out of place.
Before thinking about surgery to address either the problems inside the joint or of the ligaments, it is important to make sure that a course of physiotherapy has been followed, directed at range of movement and strengthening, but more particularly co-ordinating the muscles around the ankle with exercises on uneven surfaces, wobble-board etc. It is well recognised that the secondary problems inside the joint will often settle with this sort of conservative programme and expensive and complicated investigations & treatments can be avoided.
If it is felt that there is an intra articular problem which is causing the symptoms and not settling spontaneously, then ankle arthroscopy has become absolutely routine to deal with these in just the same way as we deal with cartilage tears in footballers’ knees.
Very occasionally we have to do surgery to reconstruct the ligament, particularly on the outer side of the ankle, and this involves a small open operation. It is almost invariably possible to find the torn and stretched out ligaments and tighten them up, but very occasionally we have to do a reconstructed procedure in a similar way to the anterior cruciate ligament reconstruction in the knee using a graft taking a tendon usually from around the knee. I think that this is a great advance over the traditional procedure of re-routing one of the tendons around the ankle. It avoids damaging any of the tendons which are vital in the ankle’s dynamic control system. The recovery from this more major type of surgery involves about 4 weeks of immobilisation in a removable splint and at least 3 months before returning to full sport.