Sprains, twists or damage to the many ligaments in the ankle can cause problems. Although the ligaments are weakened, it is actual damage to the surrounding proprioceptive nerves that make the ankle ‘give way’ and lead to the diagnosis of ankle instability.
All sprains are painful, but minor ones will repair with self-care. Severe injury is indicated if you cannot bear any weight on the ankle, if the skin is broken, if the ankle looks unusual or deformed, or if you suffered a blow or a heavy fall. Another warning sign is that swelling does not reduce after four days.
Simple sprains should be treated following the acronym RICE. This stands for Rest, Ice packs, Compression and Elevation. Recovery should be within 6 – 8 weeks. More serious injuries are usually treated first with physiotherapy. These exercises aim to retrain the nerves to respond to the ankle muscles, and improve their strength. In many cases, physiotherapy is sufficient to regain comfort and control of the foot.
If problems continue, Mr. Samarji may use arthroscopy to explore the joint. This is a minor operation. If this test shows the ligaments are still weak, and a brace has not helped, there are two operations that can help. The Brostrum procedure tightens the damaged ligaments and re-attaches them to the bone. Alternatively, tissue is borrowed from a nearby tendon and this is stitched in. This creates a strong repair but it does tend to remain stiff.
Not all patients with damage to the ligaments need surgery. Surgery is advocated for patients whose ankles give way at a frequency that is sufficiently troublesome to warrant an operation. Sometimes ligaments may be damaged, but the ankle does not give way and surgery would not be needed. There are also alternatives to surgery, which include using lace up boots, soft ankle supports and modifications to shoewear to stabilise an unstable ankle.
The decision to undergo an operation is based on assessing the impact of an unstable ankle on everyday life and sports, when weighing up the pros and cons of an operation whilst also taking into account the other options. At the consultation, this is all discussed so that you are able to come to what you feel to be the right decision. Most patients are able to decide which treatment option is the most appropriate for them following a consideration of the options and the pros and cons of surgery after the cause of the complaint has been diagnosed. To make the correct diagnosis for ankle instability clinical examination along with scans and special types of X-rays are needed.
The operation generally takes approximately one hour to perform. The incision is through a small curved incision over the outer side of the ankle allowing for identification of the damaged ligaments. These are then repaired and surrounding tissue is used to augment the repair. The repair is then protected in a plaster cast or walker boot for six weeks. The operation can be carried out as a day case. Sometimes an overnight stay is needed. The scar is generally very small and is quite cosmetically acceptable. Most patients are comfortable after surgery as a large amount of local anaesthetic is used to overcome any post-operative pain.
Following an operation for an unstable ankle to repair the lateral ligament complex and also to reconstruct the lateral ligament complex, this type of surgery can often be done as a day case. Sometimes an overnight stay is required with discharge from hospital early the following morning.
Following surgery to repair / reconstruct the lateral ligament complex of the ankle, it is possible to get back to sedentary / office type job at approximately two to three weeks following the operation. To return to full duties would take approximately six to eight weeks, given that driving may be restricted for surgery to the right ankle for approximately six weeks and return to a more manual type job could take up to three months.
For patients who a heavier or more manual commitment to their work amended duties or light duties may allow for you to return to work after approximately two weeks.
Return to full sports is at six months following an ankle ligament reconstruction / repair of the lateral ligament complex.
All patients undergoing surgery for an unstable ankle to repair the lateral ligament complex or to reconstruct the lateral ligament complex will require physiotherapy. Initially, the physiotherapy will need to be fairly gentle and restricted to strengthening and improving range of movement around the ankle. After a month of this type of treatment, the physiotherapy may become more aggressive for a further six weeks until the rehabilitation of the ankle is complete.
All surgery carries the risk of complications. Ankle ligament surgery to repair or reconstruct the ligament complex is subject to risks that affect all operations including infection, clots, nerve or vessel injury and complex pain. The risks are small, but nevertheless need to be taken into account when considering whether to undergo surgery.
Before any operation is carried out and usually at the consultation where it has been decided to go ahead with surgery a consent form for surgery is signed, which includes an explanation and the setting out of risks, as well as the potential benefits of surgery.