Ankle Sprain Surgery

As mentioned before, the overwhelming majority of ankle sprains will get better with conservative care in 2-3 months.  Once x-rays have confirmed there isn’t any fracture, most sprains get better with R.I.C.E., as well as bracing and protection.  However, there are some people who will continue to have pain and discomfort despite our best efforts.  The decision to go ahead with surgery is one that is complicated. Both the patient and doctor will have to discuss and agree upon a plan as a team.  Let’s discuss some options.

One attractive option is to do ankle arthroscopy.  Similar to what is done in the knee, a small fiber-optic camera is inserted into the ankle joint along with a tool to remove any loose particles inside the ankle joint.  With multiple ankle sprains, pieces of bone, cartilage, or inflamed ligaments can impinge on the ankle joint.  Once loose particles are removed, pain is lessened and improvement is seen.  The main advantage to ankle arthroscopy is that there are only 2 small incisions made where the instruments are inserted.   The incisions heal quickly and downtime is usually 10 days to 2 weeks.

Another procedure that can be done is called a Brostrom procedure.  As we discussed, ankle sprains can cause ligaments to tear.  The Brostrom procedure attempts to sew back together a ligament that is often torn in ankle sprains.  It is sewn together with a very strong suture material, so that stability is gained and pain is minimized.  This procedure requires a longer healing period as the ligament fiber ends need to reconnect.'

In some cases, torn ligaments are so bad that it is impossible to sow them back together.  In these cases, grafts can be used.  There are many variations to what can be done to recreate the ligaments.  The doctor can use a graft made from bovine or porcine sources, or harvest tendon from another source in the body.  Depending on which ligaments are torn, the doctor can adjust what he uses to restore stability.

There are additional procedures that exist to help a persistent ankle sprain.  Work with your doctor to decide which procedure best fits your situation.

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.

Advanced Imaging: MRI

Prior to now, we have discussed ways a doctor can get an image of your foot in the office.  However, as we discussed, there are times when a more advanced and detailed image is needed.  Magnetic Resonance Imaging (MRI) is a great tool to use in these situations.

In order to obtain an MRI, a patient is placed in a room with machine containing a giant magnet.  This magnet causes the hydrogen ions in your bones, muscle, and other soft tissue to give off a signal that can be detected by a computer.  Depending on the tissue, different signals will be given off.  The computer analyzes the signals and develops a picture.  Once the 1^st picture is taken, the machine moves a couple millimeters and takes the next picture. If you can imagine slicing up a tomato or onion, an MRI is like slicing the foot into many individual sections.  These individual slices are then grouped together so the doctor can get a good picture of the inside of the foot.

The major benefit to an MRI is that it can show bone, tendon, and cartilage in a very detailed image.  This can be used by the doctor as a surgical planning tool before he takes a patient to the operating room.  MRI can be helpful to diagnose a condition, but most problems can be diagnosed during a routine office visit without the help of an MRI.  Although there are exceptions to that rule, an MRI is not usually ordered until the doctor and patient have agreed that surgical treatment is needed.

Another benefit to MRI is that no radiation is received by the patient, and it does not require a dye or contrast to be injected into the patient.  MRI is a completely noninvasive imaging technique.  For these reasons, MRIs are very safe for the patient.

On the other hand, an MRI requires you to lie motionless for an extended period of time.  If you are moving when the slices are being taken, the image becomes distorted and impossible to interpret.  This can be somewhat uncomfortable.  In addition, if you have metal plates or screws in your body from previous surgery, the metal will distort the image, making it hard to see anything.  For that reason, some patients may not be able to get a useful MRI.  Lastly, MRIs are very expensive.  Most insurance providers will not pay for an MRI until multiple conservative measures have been exhausted with no improvement in treating the patient.

MRI is a valuable tool that has helped doctors see subtle problems that x-ray and ultrasound miss.  It is primarily a surgical planning tool to help surgeons be more prepared before surgery.  However, it must be used appropriately so not as to waste resources.

Podiatric Ultrasound

I’m sure many of you hear the word “ultrasound” and correlate it with pregnancy and gynecology, but ultrasound is a very safe and useful tool podiatrists have to visualize and diagnose the source of a patient’s pain.  Let’s discuss some of the pros and cons of ultrasound.

First and foremost, ultrasound is very safe to the patient.  Ultrasound is simply a machine that sends out sound waves at a certain frequency, which then forms an image from how the waves bounce back.  Most importantly, no radiation or tissue damage occurs from these sound waves.  This is supported by multiple studies and its long and continued use in visualizing babies in utero.  This long history of safety has led to the development of ultrasound machines specifically made to see bone, tendon, and ligament.

Secondly, ultrasound gives a real-time image.  X-rays, MRI, and CT scans are frozen images.  Ultrasound gives a “living image” so that as the patient moves the foot, the image reflects that movement.  This gives the doctor more information on how the foot is functioning as it moves.  Without this insight, the doctor might miss the true source of the pain.  Ultrasound can be used to visualize bone as well as soft tissue.  In addition, when giving an injection, the doctor can give it under the guidance of ultrasound.  This can help the doctor insure that the medicine is being placed in the area of inflammation.

Lastly, ultrasound is inexpensive and convenient.  Ultrasound machines for foot and ankle imaging are very small and can be moved from exam room to exam room very easily.  When compared to CT scans and MRI, ultrasound is much cheaper and therefore, insurances are more likely to cover the cost.  Ultrasound does not require a dye to be injected into your veins (often needed for CT scans), neither does it require you to lie motionless (as is needed with MRI).  All in all, is a very cost effective way to diagnose foot and ankle conditions.

The main disadvantage to ultrasound is that it requires a trained eye to both know the mechanics of the machine and to read the ultrasound image.  Only after much experience can a technician consistently read an ultrasound accurately.  Your podiatrist will be able to correctly interpret your ultrasound.

Now that we have covered the ways to image the foot and ankle in the office, we will discuss the more advanced imaging techniques of CT scans and MRIs in our next posts.