Dr. Robert A. Kornfeld: Chronic Ankle Instability
How many of you can relate to this? You are out walking (or playing a casual game of basketball) when all of a sudden -- pow!! Your ankle gives out and it collapses under your body weight. You hit
the ground hard. People gather around you telling you to get up and walk it off. Others are telling you to put ice on it. Others examine it with their unprofessional gaze and then tell you not to
worry. If you can walk on it, it's not broken. So you manage to limp home and get off your foot. A couple of days later, the ankle has become very swollen and painful. It's all "black and blue." So
you go to the emergency room or to one of the "quick care" centers to have it checked. An X-ray is taken. You are told it's not fractured and not to worry, it is only a sprain. They put an Ace
bandage on it. No other care is rendered. And you spend the next couple of months dealing with swelling, pain, stiffness, muscle spasms and secondary pains from compensating for the ankle sprain. You
tape it, you tie it, you wrap it, you soak it. And finally, it "heals." Or has it?
Somewhere down the road, it happens again, and maybe again and perhaps again after that. You catch my drift here. This is an ankle that has never properly healed and is left with weakened ligamentous
support, making you vulnerable to chronic ankle sprains and a life of chronic pain.
So why would something like a simple ankle sprain wind up creating chronic ankle instability? To understand this, let's look at the actual dynamics here. An ankle sprain can lead to an over-stretched
ligament that can cause bleeding in the "pulled-open" spaces of the tissue, it can cause a partial tear of the ligament, it can cause an avulsion (where the ligament is pulled off of its bony
attachment) and of course, a complete tear of the ligament. Since there are numerous ligaments supporting the ankle on both sides, depending on the type of forces that have occurred, there can be
multiple ligaments involved in the injury. The mistaken notion that if it's not broken, it does not require treatment could not be further from the truth.
Ligaments are extremely condensed tissues. They have no direct arterial blood flow. They receive oxygen and nutrients from microscopic circulation. So in the best of circumstances, blood flow to
ligaments is somewhat restricted. Since the healing of all injuries depends on good perfusion of the involved tissues, ligaments are at a distinct disadvantage due to their inherently poor blood
supply. If you put this together with some other factors that I will enumerate, inadequate treatment may result in painful, chronic ankle instability.
So what are the other factors affecting healing in a case such as this? Most important would be compression and immobilization. Using an Ace bandage may limit some swelling, but it does not
immobilize the ankle. Movement and the stress of weight-bearing on these tissues makes it that much more difficult for the ligament to heal. In most cases, I will use a removable walking brace which
functions as a cast but can be removed for sleeping, bathing and therapeutic treatments. As I explained, since ligaments are poorly perfused with blood, therapy designed to increase blood flow into
the microscopic circulation is very important. In my office, I use MicroVas(R) therapy, which is a bilateral high voltage stimulation treatment which dramatically increases blood flow to these
injured tissues. It decreases healing time which also helps reduce the length of time the patient is forced to compensate and overuse the other limb, often leading to secondary pain syndromes. Learn
more about it at www.neurovasix.com. (I have no financial relationship with this company).
Additionally, there are ways to assist the body in re-organizing and healing the injured tissues. I have been using a treatment known as prolotherapy for many years, which involves the injection of
low level irritants into the area of the injured ligaments. The irritation leads to a more profound push by the immune system to heal these ligaments by fostering the migration of fibroblasts (which
are the cells responsible for healing connective tissue) thereby increasing the collagen matrix. Prolotherapy also increases the rate of growth of new blood vessels to the injured tissues (known as
angiogenesis) which further facilitates healing. When prolotherapy is not successful, we can improve outcome by using platelet-rich plasma injections. This is the injection of the patient's very own
platelets into the area of injury. Platelets are very high in growth factors which can be helpful with many difficult and stubborn cases.
Lastly, making sure that the patient is properly hydrated improves peripheral blood flow and assists in the delivery of nutrients and oxygen and the removal of inflammatory infiltrates from the area.
This means drinking plenty of water and limiting dehydrating compounds such as caffeine, alcohol and salt. I have also found an improvement in healing my patients with the use of proteolytic enzymes
(which also help break down inflammatory infiltrates and catalyze repair processes) as well as dietary sulfur, known as MSM, which is the bond/framework of connective tissue.
Treating the majority of ankle sprains in this fashion will dramatically improve outcome and prevent an enormous number of chronic ankle instability. However, once the condition is set as a
chronically unstable ankle, many of these patients go on to ankle stabilization surgeries. My experience shows that a conservative attempt at healing this condition in this way is always worth the
effort, as many of my patients avoided the necessity of surgical intervention.
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