Ankle Sprain Conservative Treatments

We talked last week about ankle sprains, how they happen, and what conditions predispose someone to getting one. Let’s now discuss some of the initial treatment available. Fortunately, most ankle sprains will eventually resolve without long term issues. When compared to bone or muscle, a ligament’s blood supply is significantly less. Since blood carries oxygen and healing factors within it, blood supply partially determines how fast an injury heals. For this reason, ankle sprains heal slower than bone or muscles, resulting in about a 6-8 week heal time. A person can usually engage in full activity 3 months after the initial injury. Conservative treatment for ankle sprains is what you might expect with any foot injury. After making sure there are no fractures with x-rays, ankle bracing, ankle taping, short leg casting, protection, RICE (rest, ice, compression, and elevation), anti-inflammatory shots, and anti-inflammatory oral medication have all been used to treat these types of injuries. A common regiment for treating ankle sprains is RICE for 2-4 days, followed by ankle bracing and strengthening exercises for a couple weeks. Once you can weight bear without discomfort, a short regiment of physical therapy will help you to regain confidence in the ankle. You’ll notice that with the exception of physical therapy and anti-inflammatory shots, most of the treatments mentioned can be obtained over the counter. So you might wonder why you need to see your podiatrist. The reason is simple. What may feel like a simple ankle sprain might actually be an ankle fracture. In some cases, an ankle sprain might actually have damaged cartilage in the ankle, or broken one of the leg bones (the fibula) up close to the knee. If these injuries go undiagnosed and undertreated, there may be some irreversible damage done. Although a simple ankle sprain is more common, these other injuries happen often enough to warrant evaluation by a doctor. If pain persists despite conservative measures, or you are someone who has chronic ankle sprains, surgical options may need to be discussed. At this point, the doctor will probably request an MRI to assist in planning what operation needs to be done. We’ll discuss these options next post.

What Do Podiatrists Do?

Podiatrists have long been known to be the people to see for ingrown nails, hammertoes, and heel pain.  But today’s podiatrist does much more than that.  Let’s first talk about their education, and then what that allows them to do.

To become a podiatrist, after high school, a person must attend an undergraduate university and receive a 4 year bachelor degree.  Most choose to major in a science related major, such as biology, chemistry, exercise science, physiology etc…  By completing these degrees, they have taken the necessary courses to prepare to take the Medical College Admission Test (MCAT).  An applicant then submits their college transcript along with their MCAT score to a podiatric medical college.  Although separate from MD medical schools, podiatric medical school’s curriculum is held to the same standard of other doctorate level medical programs.  After 4 years of medical school and passing of board exams, a person must then complete a 3 year residency program at a hospital somewhere across the country.  During these 3 years, a podiatrist receives their surgical training.  And at last, once licensed, a person can then practice as a podiatrist.  All in all, a licensed podiatrist receives at least 11 years of additional education after high school.

As academic standards and competitiveness have increased, the level of training has also increased.  Today’s podiatrist can still trim calluses and nails of high risk patients like diabetic like we always have.  But they are also trained to fix ankle fractures, repair Achilles tendons, and even put a camera into the ankle joint and clean it out like an orthopedic surgeon commonly does to a knee.  Just like in many medical specialties, some podiatrists like to focus their efforts in pediatrics, athletes, or geriatric patients.  Even if the podiatrist you are seeing doesn’t routinely treat your current condition, he/she surely knows of another podiatrist in the community that does.  

Ask your podiatrist what he can treat.  You’ll be pleasantly surprised what they can help you with.

Bone Scans

The last imaging technique we’ll discuss will be different types of full body scans available, specifically used by podiatrists to determine if bone infection is present.

A scan, either for bone or WBCs (white blood cells), is done by injecting a very small amount of a specific type of radioactive dye into a vein.  This dye will then spread through the body as the blood is pumped through all the bone, muscle and internal organs.  The dye contains a certain substance that will bind to somewhere in the body.  The dye for bone scans binds to bone that is currently being remodeled.  The dye for WBCs will search out WBCs and bind to them.  The person is then scanned at different time intervals with a gamma camera, which is able to detect where the most activity is concentrated.   This can be very useful in diagnosing foot conditions.

When it comes to podiatry, these scans are primarily useful with diabetic patients.  Diabetic patients struggle with two conditions, osteomyelitis (bone infection) due to ulceration, and Charcot Foot (a non-infected bone destructive process).  These two conditions are sometimes difficult to tell apart clinically.  With infected bone, both a bone and WBC scan will be positive, whereas only a bone scan will be positive with Charcot.  Bone scans can give the podiatrist clues to which process if going on.  Scans are generally cheap tests and readily available.

A downside to bone scans is that they are not very specific.  There are many conditions that will have a positive bone scan.  A fracture, infected bone, growth plates, arthritis etc. will all give positive bone scans.  So even if I suspect bone infection, and the bone scan comes back as positive, I still have to perform other tests to confirm my suspicions.  There could be another underlying condition giving the positive bone scan test.  This obviously limits their usefulness. Some types of scans are technically difficult to perform, and others are difficult to read.  Scans also expose the patient to some radiation, thus making it necessary to make sure these scans are not ordered unless absolutely necessary.

Imaging techniques used by podiatrists are essential in determining the source of patient’s complaints.  These techniques are very safe when used in the appropriate situations. 

Podiatric CT Scans

We’ve discussed some of the more well-known imaging techniques used by foot doctors to help understand and diagnose foot pain.  There are additional tests that podiatrists use less routinely, but nonetheless give important information in the right circumstances.  Let’s discuss CT scans and their use in podiatry.

If you remember when we discussed MRI, we talked about how a magnet is used to take sequential slices through the foot, which are then grouped together to give a three dimensional image of foot.  CT scans are similar in that they take slices of the foot like an MRI.  However, instead of using a magnet, CT scans use a computer that generates x-rays.  Whereas regular x-rays only give a two dimensional image, when grouped together, CT scan can give a 3D image. 

CT offers some very useful advantages over other imaging techniques.  CT scans allow incredible visualization of bone.  In cases of high impact injury like falling from tall heights, or dropping a heavy object on the foot, bone can fracture into many small fragments.  In many of these cases, surgery is required to fix the fractures.  CT scans can help the surgeon to know before surgery how many fragments there are and where they are located.  This allows the surgeon to plan in advance how to best go about repairing the fractures, and to make the most appropriate decisions for the patient.

CT scans do have some limitations.  The main disadvantage to these scans is the amount of radiation the patient is exposed to.  When compared to a single x-ray, a CT scan exposes you to several times over the amount of radiation.  For this reason, in podiatry, they tend to be ordered with very badly fractured heel or ankle bones.  Although CT scans can differentiate between bone, tendon, and muscle, MRI gives a much clearer picture of these structures without exposure to radiation.

In our next post, we’ll discuss bone scans, another type of imaging that can be useful in diabetic conditions and infections.