Alternatives to ankle surgery

In our practice we see many people with chronic ankle sprain reporting that surgery has been recommended as their only option. Why? Because chronic ankle pain is very common and unfortunately prone to re-injury or recurrent problems.

An estimated 40 percent of people who suffer from an ankle sprain will be left with long-term pain and weakness and up to 70& will eventually develop osteoarthritis. The reason is because the majority of ankle injuries do not heal properly after injury and respond poorly to the traditional methods of treatment.

There are three types of ankle sprain, separated into grades of severity. The first, a grade one sprain, is the least severe. This occurs when the ligaments are slightly stretched out, causing minimal tearing of the tissue fibers. This is the type of injury that doesn’t cause severe pain, and the victim can usually “walk it off” without permanent damage. A grade two sprain involves further tearing of the ligaments and can cause instability in the ankle joint. This type of sprain leads to a lot of swelling and tenderness, which makes it difficult to walk and move around. A grade three sprain is indicated by a complete tear of the ligaments, and will make itself known with extreme pain, swelling, and lack of function.

Prolotherapy ankle treatments have shown great success when treating these types of injuries. Normal treatment of ankle sprains usually involves rest, ice, compression, and elevation. This form of rehabilitation therapy has recently been called into question, however, because of the high rate of recurrent ankle sprains. This suggests the area is not healing during this method of recovery. The ice impedes the inflammation process necessary to stimulate new tissue regeneration.

Surgical methods have not fared as well as hoped either. High rates of failures and revision surgeries have made the “gold” standard choice in treating osteoarthritis clear. For instance from the American Academy of Orthopedic Surgeons: “Significant uncertainty exists about the proper role of ankle arthroplasty in the treatment of ankle arthritis,” said Nelson Fong SooHoo, MD, of the UCLA Center for Surgical Outcomes and Quality, who presented the results of a study comparing the reoperation rates of ankle arthrodesis and ankle replacement during the American Orthopaedic Foot and Ankle Society’s (AOFAS) 2008 Specialty Day program…Ankle fusion has been the traditional treatment,” said Dr. SooHoo, “and we’ve seen good functional outcomes. But concerns about adjacent joint arthritis have triggered an ongoing interest in ankle arthroplasty…A total of 4,705 ankle fusions and 480 ankle replacements were performed during the 10-year study period. Dr. SooHoo and his colleagues found that ankle replacement patients had an increased risk of device-related infection and major revision procedures. Major revision surgery rates for ankle replacement patients were 9 percent at 1 year and 23 percent at 5 years, compared to 5 percent at 1 year and 11 percent at 5 years for ankle arthrodesis patients.” (1)

Another study confirmed one on 5 ankle replacement failures (2). Surgical uncertaintey was commented upon in other literature which warned: “Conservative treatment of patients with CAI must be the first-line therapy. Surgical treatment must be indicated only when conservative treatment fails,” (3) and to use caution when basing the decision to have surgery based on MRI because of many “false positives.” (4)

This is where prolotherapy and Platelet Rich Plasma therapy can offer conservative, non-surgical alternatives. Prolotherapy and PRP ankle injections are designed to create inflammation and stimulate the body’s own natural healing processes. When the body experiences inflammation it recognizes it as injury, sending extra blood and nutrients to repair the area. The treatments build new soft tissues to strengthen the ankle joint and allow for unobstructed and pain free movement.

1. What’s better: ankle arthrodesis or ankle replacement? Jennie McKee. AAOS Now. May 2008 Issue
2. Henricson A, Nilsson JÅ, Carlsson A. 10-year survival of total ankle arthroplasties: a report on 780 cases from the Swedish Ankle Register. Acta Orthop. 2011 Dec;82(6):655-9. Epub 2011 Nov 9.
3. Rodriguez-Merchan EC. Chronic ankle instability: diagnosis and treatment. Arch Orthop Trauma Surg. 2011 Nov 5.
4 . Saxena A, Luhadiya A, Ewen B, Goumas C. J Foot Ankle Surg. 2011 Jul-Aug;50(4):413-5. Epub 2011 May 12. Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg. 2011 Jul-Aug;50(4):413-5. Epub 2011 May 12.

Problems with your ankle after a sprain? It may have never healed properly.

It is estimated that 40% of all people who suffer an ankle sprain will suffer chronic pain and weakness in that ankle long-term. The reason? Your ankle never healed properly. Here is why: Our ankles are held together by ligaments and tendons, strong bands of connective tissue. Ligaments hold the ankle bones together while tendons attach the muscles to the bones.

When ankle sprains occur, the ligaments of the ankle are stretched and torn. Most commonly, ankle sprains occur when the athlete lands unevenly from a leap or jump, or has someone fall on their ankle during contact sports. Sprains can also occur when stepping into a hole or divot on a playing field or golf course. The severest of ankle sprains are the extreme or violent twist or “roll-over” of the ankle causing a hyper-extended turning in or turning out of the foot. The turning out injury causes a sprain of the anterior talofibular ligament, and this is the most commonly injured part of the ankle.

When ankle sprain is suspected, the severity of the injury is then graded by a medical professional and a treatment suggested.

Grading the sprain

Grade 1 sprain:

A grade 1 sprain is the least severe of ankle sprains. The ligaments are slightly stretched with a minimum of tearing to the ligament fibers. More of a discomfort than pain is felt as the athlete can usually “walk it off.”

Grade 2 sprain:

There is stretching of the ligaments and partial tearing causing an unstable or loose joint. The condition is also referred to as ligament laxity as the ligament, now stretched beyond its normal range has become weakened or lax, as an overstretched rubber band. There is noticeable swelling and tenderness and depending on extent of injury, instability when walking.

Grade 3 sprain:

A complete tear of the ligament causing extreme instability, swelling, and pain

Grading the treatment:

Grade 3 sprains are not the most common forms of ankle sprains and surgery may be prescribed, but this is rare since the ligament usually scars over during healing.

Is it the treatment at fault?

The “gold” standard of treatment in Grade 1 and Grade 2 sprains is RICE. Rest, ice, compression, and elevation. Recently however this therapy has been debated by some physicians because of the high incidence of chronic or recurrent ankle sprains.

Among the theories put forth questioning the RICE treatment is that it does not fully allow the ligaments to heal because it reduces and impedes inflammation that is needed to stimulate new tissue regeneration.

Creating inflammation to heal the ankle sprain

Basic medicine tells us that the body’s natural healing response is inflammation. Inflammation is the trigger for the immune system to begin the cascade of events in injury repair. When ligaments do not heal completely, they weaken and put the athlete at risk for chronic ankle sprain.

Preventing with Prolotherapy

When there is not enough inflammation to heal a ligament injury, some physicians have turned back to a new “old-fashioned,” treatment to jump start the healing processes. Prolotherapy was first introduced in the 1950′s as a means to cure chronic pain by strengthening the ligaments of weakened, loose joints by creating inflammation – not suppressing it.

Prolotherapy works by introducing a mild irritant through injection to the exact spot of the ligament damage. This irritant is usually something as benign as simple dextrose. What the dextrose does is create a small, controlled inflammation at the spot of injury accelerating healing and returning strength and resiliency to the ligament and stability to the ankle. In remittent cases, PRP (Platelet Rich Plasma) is used as a stronger proliferant.

Prolotherapy is gaining adherents among athletes because it is minimally invasive, does not require long periods of inactivity and in fact, a Prolotherapy doctor will usually recommend supervised activity or a recommend training plan to get the athlete back on the field as fast as possible.

One to six treatments is typical for the competitive athlete, spaced at weekly intervals.