Got a Sprained Ankle That Won’t Heal? What It Might Mean, and What To Do

Do you have a sprained ankle that won’t heal? It’s not that rare. Studies have shown that 10 to 30 percent of sprains will have symptoms later. So what is a sprained ankle anyway? It’s the most common injury in all of sports and dancing.

Dancing pushes your body to its limit. If you roll over on your ankle when landing from a jump, you can sprain or injure the ligaments on the outer (lateral) side that hold the joint together. This is different from a “strain,” which affects your tendons and muscles. An easy way to remember this distinction is this: You sprain your ankle, but you strain your Achilles tendon.

The degree of injury varies, depending on the damage to the ligaments. We determine this by a physical exam and X-rays that help us classify the ankle sprain as Grade I (mild), II (moderate), or III (severe). The most serious sprain involves a complete tear of the ligaments with marked instability that often requires surgery. Fortunately, most sprains are Grade I or II and heal in three to six weeks. The exceptions are those that continue to cause trouble. This is the “sprained ankle that won’t heal.”

In medical circles, residual problems from sprained ankles that won’t heal cause considerable angst, because they can be hard to diagnose and difficult to treat—especially when telltale signs are ignored. Problems with old sprains tend to fall into three categories: swelling, pain, and instability (“giving way”).

Swelling

It’s normal for a sprained ankle to swell, sometimes for four to six weeks, or longer. But swelling that persists for more than three months may be a sign of trouble. The lining of the capsule surrounding a joint is called the synovium, and anything inside the joint that irritates the synovium will cause it to secrete fluid. Swelling inside of a joint is often a sign that something is causing irritation. (The swelling that is seen from the outside is a combination of soft tissue swelling around the joint and fluid within the joint itself. ) In the ankle there are several reasons for this condition. While these may seem alarming, treatment is possible. But first, let’s take a look at the culprits.

Chronic synovitis
Sometimes there is damage to the surface of the joint that does not show up on any tests, such as an X-ray or MRI, even though it continues to cause irritation and excess fluid.

A bone chip
At the time of injury, a bone chip may have been knocked loose, leaving a “loose body” floating around inside to cause trouble.

An OCD lesion
“OCD” in sports medicine stands for osteochondritis dissecans (not obsessive compulsive disorder). The easiest way to think of this is like a cavity in a tooth. It is something that leaves a small hole in the surface on the ankle bone (the talus) with a dead piece of bone in it. An MRI study will usually pick this up.

A bone bruise
This is not black and blue. Instead, it feels like an achy pain that is difficult to explain and lasts for months. There is edema, or fluid, within the bones themselves that we can only see on an MRI study. Fortunately, it is rarely serious and gradually fades away.

What can you do? Treatment for chronic swelling, no matter what the cause, usually requires sleeping with the leg elevated on a pillow at night and putting on an elastic ankle support in the morning when you get out of bed. If the swelling is minimal and is slowly going away with no other symptoms, it is OK to dance, but go easy on the jumps and grand plies till all the swelling is gone. However, if it doesn’t feel so good then don’t do it! An ankle support (no need for metal hinges, etc.) usually feels good at this stage.

It also helps to avoid the saltshaker, which leads to water retention. With diligence, the swelling should go away. However, if the leg is swollen up the shin, something else may be happening, and it needs to be checked out by your doctor. Swelling that does not go away is a sign that something more is wrong. Normal joints do not swell.

Pain

There are several common causes of ankle pain that does not go away:

The sinus tarsi syndrome
Lingering inflammation, scar tissue, or a partly torn ligament can occur in the hollow place in the side of the anklebone called the sinus tarsi (sinus in Latin means hollow or sunken and the tarsus is the ankle). This is the most common cause of the sprained ankle that won’t heal. While it can be difficult to discern this problem on an X-ray or MRI, a physical exam by a dance medicine specialist can pinpoint the diagnosis by locating the exact area that hurts.

A tarsal coalition
Residual pain in the sinus tarsi after the original sprain heals can also be due to an unrecognized tarsal coalition. The ankle has two components: the regular ankle joint that moves up and down, and the subtalar (ST) joint beneath it that moves in and out. Together, they make up the ankle joint complex. Some people are born with limited motion in their ST joint because the bones in this area are joined together where they ought to be separate—a coalition. It can usually be seen on an X-ray or MRI. This condition is present in about five percent of ankles. It usually occurs in one ankle only, rather than both. As with a sprain, it can be mild, moderate, or severe. In dancers, it is usually mild or it would have caused trouble before the sprain. Dancers with mild symptoms can often work around it.

The high ankle sprain
This is marked by tenderness in the front of the ankle on the outside. Unlike routine ankle sprains where the main damaged ligaments lie right in the sinus tarsi, this one affects a ligament that is higher up, at the level of the ankle joint itself. This is the so-called “high” ankle sprain, which can be a real bugaboo because it takes two to three times longer to heal than a routine sprain. It may not show up on medical tests, so the diagnosis is usually made on the basis of the physical exam.

Secondary problems
Lastly, there are several conditions, such as FHL tendonitis (“dancer’s tendonitis”) and the os trigonum syndrome that seem to pop up out of nowhere. Dancers often think that the residual pain is part of the healing process when it is actually a separate problem. Later the sprain may heal, but these conditions can continue to be painful and may even require surgery if left unaddressed.

Instability

“My ankle gives way” is probably the second most common leftover problem with ankle sprains after the sinus tarsi syndrome. We doctors see it all the time. Many things can cause this problem. Fortunately most respond to appropriate treatment.

Peroneal weakness
There are two peroneal tendons that run parallel down the outside of the ankle; one is short and the other is long. Their major function is to keep the ankle from rolling over and prevent sprains. After an injury they can remain weak, so the ankle is poorly protected from further roll-overs. It’s easy at this point to fall into the vicious cycle of “Because it’s weak it rolls over and because it rolls over it’s weak,” which can go on for months. If this is the problem, it is easy to fix. Simply restore the normal peroneal strength with physical therapy. A few months of daily use of a theraband, under the guidance of a physical therapist, will usually strengthen the peroneals. (They gain strength faster if the exercises are done in the full “tendu” position.)

Laxity of the ankle ligaments
Grade I sprains do not usually damage the ankle ligaments to any extent, but repeated Grade II or Grade Ill injuries can lead to permanent looseness of the ligaments that hold the anklebones together. This is a difficult situation, because they can be tightened only by surgery. The surgery is quite effective, but the recovery is usually three months or more. So it is nice to avoid it if you can.

Many loose ankles often give way because of a combination of looseness and weakness. These can often be brought up to full strength with physical therapy and then they don’t give way anymore. The number one indication for ankle ligament surgery is the failure of rehab to correct the problem.

Pain, Swelling and Instability

The problems associated with a recurring sprained ankle can co-exist and produce all three symptoms. In this ease the diagnosis is particularly difficult. There is one last problem that might be going on:

Peroneal tendon damage
With repeated sprains, the peroneal tendons can develop small longitudinal rents or tears. When this happens, the tendons swell up in the sheathes that surround them and cause achy pains, chronic swelling and weakness that cannot be corrected by exercise. This problem is easy to miss and hard to correct because it usually gets worse in spite of all treatment. Fortunately, this condition also responds well to surgery.

The best way to diagnose these various problems is to see a sports or dance medicine specialist for a history, physical exam, and appropriate studies. Your doctor may request X-rays followed by an MRI, CT and/or bone scan. Physical therapy is usually the first step in the recovery. Do not try to treat yourself! There is an old expression in medicine that says, “Someone who treats themselves has a fool for a physician.”

William G. Hamilton, M.D. is the orthopedic consultant for New York City Ballet, American Ballet Theatre, The School of American Ballet and the Jacqueline Kennedy Onassis Ballet School.

Ankle pain Information | Mount Sinai

Pain – ankle

Ankle pain involves any discomfort in one or both ankles.

Mild to severe swelling and bruising can accompany a sprain to the ankle. Bruising usually indicates tearing of ligament tissue and a more severe sprain.

An ankle sprain is a common injury to the ankle. The most common way the ankle is injured is when the ankle is twisted inward (inversion injury). With this injury, ligaments that support the ankle can be torn which lead to swelling, inflammation, and bruising around the ankle. An ankle sprain injury may take a few weeks to many months to fully heal.

A sprain is caused by the twisting or bending of a joint into a position it was not designed to move. The ankle is the most commonly sprained joint. Some common symptoms of a sprain are pain around the joint, swelling, and bruising.

Causes

Ankle pain is often due to an ankle sprain.

• An ankle sprain is an injury to the ligaments, which connect bones to one another.
• In most cases, the ankle is twisted inward, causing small tears in the ligaments. The tearing leads to swelling and bruising, making it difficult to bear weight on the joint.

In addition to ankle sprains, ankle pain can be caused by:

• Damage or swelling of tendons (which join muscles to bone) or cartilage (which cushions joints)
• Infection in the ankle joint
• Osteoarthritis, gout, rheumatoid arthritis, Reiter syndrome, and other types of arthritis

Problems in areas near the ankle that can cause you to feel pain in the ankle include:

• Blockage of blood vessels in the leg
• Heel pain or injuries
• Tendinitis around the ankle joint
• Nerve injuries (such as tarsal tunnel syndrome or sciatica)

Home Care

Home care for ankle pain depends on the cause and what other treatment or surgery has taken place. You may be asked to:

• Rest your ankle for several days. Try to NOT put much weight on your ankle.
• Put on an ACE bandage. You also can buy a brace that supports your ankle.
• Use crutches or a cane to help take the weight off a sore or unsteady ankle.
• Keep your foot raised above the level of your heart. When you are sitting or sleeping, place two pillows under your ankle.
• Ice the area right away. Apply ice for 10 to 15 minutes every hour for the first day. Then, apply ice every 3 to 4 hours for 2 more days.
• Try acetaminophen, ibuprofen, or other pain relievers made by the store.
• You may need a brace to support the ankle or a boot to rest your ankle.

As the swelling and pain improve, you may still need to keep extra weight and stress off your ankle for a period of time.

The injury may take a few weeks to many months to fully heal. Once the pain and swelling are mostly gone, the injured ankle will still be a little weaker and less stable than the uninjured ankle.

• You will need to start exercises to strengthen your ankle and avoid injury in the future.
• DO NOT begin these exercises until a health care professional tells you it is safe to start.
• You will also need to work on your balance and agility to avoid another injury or sprain.

Other advice your health care provider may give you include:

• Avoid putting on extra weight since this could increase strain on your ankles.
• Warm up before exercising. Stretch the muscles and tendons that support the ankle.
• Avoid sports and activities for which you are not properly conditioned.
• Make sure that shoes fit you properly. Avoid high-heeled shoes.
• If you are prone to ankle pain or twisting your ankle during certain activities, use ankle support braces. These include air casts, ACE bandages, or lace-up ankle supports.
• Work on your balance and do agility exercises.

When to Contact a Medical Professional

Go to the hospital if:

• You have severe pain even when you are NOT bearing weight.
• You suspect a broken bone (the joint looks deformed and you cannot put any weight on the leg).
• You can hear a popping sound and have immediate pain of the joint.
• You can’t move your ankle back and forth.

Contact your provider if:

• Swelling does not go down within 2 to 3 days.
• You have symptoms of infection. The area becomes red, more painful, or warm, or you have a fever over 100°F (37.7°C).
• The pain does not go away after several weeks.
• Other joints are also involved.
• You have a history of arthritis and are having new symptoms.

Chiodo CP, Price MD, Sangeorzan AP. Foot and ankle pain. In: Firestein GS, Budd RC, Gabriel SE, Koretzsky GA, McInnes IB, O’Dell JR, eds. Firestein and Kelly’s Textbook of Rheumatology. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 52.

Irwin TA. Tendon injuries of the foot and ankle. In: Miller MD, Thompson SR, eds. DeLee, Drez, & Miller’s Orthopaedic Sports Medicine. 5th ed. Philadelphia, PA: Elsevier; 2020:chap 118.

Osborne MD, Esser SM. Chronic ankle instability. In: Frontera WR, Silver JK, Rizzo TD, eds. Essentials of Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier; 2019:chap 85.

Rose NGW, Green TJ. Ankle and foot. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 51.

Rothenburg P, Swanton E, Molloy A, Aiyer AA, Kaplan AR. Ligamentous injuries of the foot and ankle. In: Miller MD, Thompson SR, eds. DeLee, Drez, & Miller’s Orthopaedic Sports Medicine. 5th ed. Philadelphia, PA: Elsevier; 2020:chap 117.

Last reviewed on: 6/13/2021

Reviewed by: C. Benjamin Ma, MD, Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery, San Francisco, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Swelling does not go down after ankle sprain

Author of the article: Eduard Svitich – orthopedist-traumatologist

Sprain, or, more correctly, tear of the ligaments is one of the most common injuries of the ankle joint. Pain after a slight tear can go away after a few days. Lameness and local swelling linger longer, which we will discuss later.

Properly administered first aid and subsequent treatment reduces the risk of complications to a minimum. However, the result is also affected by such indicators as the degree of rupture, the volume of the hematoma, and the initial state of the circulation of the lower extremities. If the swelling after the injury does not go away for a long time, it should be considered as a separate pathology and act correctly and intensively.

Contents

• What happens when you sprain?
• What should I do to make the puffiness go away?
• What to do if the swelling does not go away?

What happens when the ligaments are stretched?

“Sprain” is not the best name for an ankle ligament injury. Elastic tissues such as muscle, epithelial, and adipose tissue can be stretched. Ligaments are strong and low-stretch elements, their elasticity is minimal. Such a structure is necessary to perform the main function – stabilization of the joints.

In case of awkward movement or overload, the fibers of the ligament do not stretch, but tear. If some fibers are damaged, they speak of a tear, if everything is a rupture of the ligament. In this case, one or more ligaments can be torn or torn.

Small nerves and blood vessels run along and less often inside the ligaments. They also permeate the entire space around the joint. With any injury, damage to certain vessels occurs. The edema that appeared in the first hours after the injury is nothing more than blood that has poured out of a “torn” artery or vein.

What should I do to make the swelling go away?

In order for less blood to flow from the injured vessels, and the already released liquid to dissolve faster, it is enough to follow simple rules. They can be told by the doctor at the reception, but it is better to know and remember them yourself. Here are the actions that will be relevant for any “sprain” of the ankle ligaments:

• Give your leg a rest. Do not walk or jump on it, every extra movement prevents the formation of a strong blood clot and the cessation of bleeding.
• Elevate the limb. Sit less. In the first 2-3 days after the injury, it is better to lie more and put your foot on a pillow. It is desirable that the ankle is slightly higher than the level of the body (in the supine position).
• Apply cold objects to the site of swelling every 2-3 hours (through a cloth). This will reduce the intensity of blood flow and stop bleeding sooner.
• If you are sitting or still walking, use compression bandages. They will reduce pain and mechanically “press down” the hematoma, preventing its growth. In addition, the anatomical knitting of the correct fixator improves proprioception – the regulation of the balance of the muscles that stabilize the joint.

What to do if the tumor does not come down?

Insufficient decrease in swelling or its increase is a reason to consult a doctor. Usually a simple palpation (palpation) is enough to understand the source of the problem. For a more reliable diagnosis, ultrasound is useful. The prolonged presence of edema is most often associated with the following reasons:

• Violation of the venous outflow. Both chronic varicose veins and post-traumatic changes can play a role. Good compression underwear or a special bandage will help to overcome swelling (if the swelling area is very small). Reducing the stagnation of blood and lymph speeds up local metabolism and in most cases solves the problem.
• So-called organized hematoma. Sometimes blood after an injury does not resolve, but becomes overgrown with a membrane. This shell (capsule) prevents not only the reduction of the hematoma, but also the penetration of drugs into it. In this case, the result is puncture (suction) of the hematoma with a syringe and subsequent compression with an ankle bandage. Less often, a full-fledged operation is required for the final removal of a hematoma with a capsule.

Salons “ORTO SMART – Medtekhnika, orthosalon” in Odessa, Kiev, Kharkov, Lvov, Dnipro and other cities of Ukraine – the best place to choose compression stockings and bandages. The presence of positions of the most respected manufacturers, a good choice of types and sizes of products allow you to individually select the most suitable solution. And the experience and organization of consultants will help to do it even faster and more accurately.

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Accumulation of fluid in the joint | ECHR Handbook

What is fluid accumulation in a joint?

The accumulation of fluid in the joint is considered one of the symptoms of hydrarthrosis or dropsy – a kind of syndrome in which the volume of the joint increases due to the formation of synovial fluid in its cavity. Most often, this syndrome is observed in the knee joint, less often in the ankle, elbow and others.

There may be limited flexion of the joint, the intensity of pain depends on the amount of fluid and the degree of stretching of the joint capsule. An increase in local temperature is not observed, unless the inflammatory process has begun.

Causes

The accumulation of fluid in the joint may be the result of a disease, but the most common cause is damage. These include:

1. Trauma – sprain, rupture of ligaments. This can lead to a buildup of fluid that gets infected after a viral illness.
2. Various diseases of the joints, including gout or arthritis.
3. Lupus erythematosus.
4. Bursitis which is characteristic of dancers or sportsmen.
5. Blood incoagulability and others.

Important! These reasons must be mentioned when visiting a doctor, this will help to correctly establish the diagnosis and prescribe competent treatment.

Classification

Fluid accumulating in the joint cavity can be classified according to its nature into exudate and transudate. Accordingly, the exudate is associated with the course of inflammatory processes and can be of several types:

1. Serous.
2. Purulent.
3. Hemorrhagic.
4. Chile.

Transudate is formed for other reasons, not related to inflammation, but associated with circulatory disorders and other abnormalities.

Pathologies

The accumulation of fluid in the joints is a health hazard and can lead to the development of the following pathologies:

1. Hemarthrosis, formed due to damage and blood flow to the joint.
2. Arthrosis is the most common pathology and occurs as a result of mechanical damage or age-related changes.
3. Arthritis can occur for a variety of reasons, including infections or allergic reactions.
4. Synovitis is an inflammatory disease.
5. Bursitis, may develop due to trauma or after an infectious disease.

Diagnosis of the causes of accumulation of fluid in the joint

Diagnosis of this pathology consists in the initial examination of the patient by a specialist, for example, an orthopedist or traumatologist. After an external examination, palpation and questioning of the patient, the doctor makes a preliminary diagnosis and sends the patient for clarification for an additional examination: A complete or extended blood count, ECG, and blood type identification may be needed to detect latent infections.

After a thorough study of the examination data, the specialist will prescribe a complex treatment depending on the cause of the disease.

Which doctor treats fluid accumulation in the joint

Fluid accumulation in the joint is considered a fairly common problem, which, even in the absence of pronounced symptoms, requires immediate medical attention. As with the treatment of the spine, the removal of fluid from the joint cavity should be done immediately after a problem is detected. You need to contact an orthopedic traumatologist who specializes in diseases of the musculoskeletal system and rehabilitation after surgical interventions.

In our Kuntsevsky Medical and Rehabilitation Center, you will not only receive qualified assistance from experienced orthopedic traumatologists in case of fluid in the joints, but you will also be able to undergo a full examination using the latest diagnostic equipment and, if necessary, recover in our rehabilitation center after injuries according to a specially developed comprehensive program.

The accumulation of fluid in the joint significantly reduces the patient’s quality of life. As a rule, a person cannot fully perform movements, complains of pain and discomfort in the articulation area.

Important! This symptom cannot be ignored, because the progression of the pathology can lead to the development of chronic inflammatory diseases of the joints.

At the first sign of a pathology, make an appointment with a qualified orthopedic traumatologist of the Kuntsevsky Medical and Rehabilitation Center, who will be able to fully examine the joint, find the source of the pathology and prescribe the correct treatment, in particular, at the rehabilitation stage.

Make an appointment

Types of treatment for fluid accumulation in the joint

Fluid accumulation in the joint can be treated in different ways, depending on the degree of neglect of the disease. Among the various methods of joint treatment offered by the Kuntsevo Center, the following can be listed:

1. Drug treatment, which consists in prescribing and taking medications and vitamins.
2. One of the ways to treat diseases of the joints and relieve pain is blockade – special injections into the joint or periarticular tissues. This method of therapy is also used in the rehabilitation period after the end of treatment.
3. ACP SVF Therapy is the newest unique treatment for degenerative joint diseases. To implement this type of treatment, it is necessary to extract the stromal-vascular fraction from the patient, then prepare a special composition on its basis and introduce it into the affected joint area by injection.

Rehabilitation

For the rehabilitation of the patient’s condition after joint treatment, our center offers the following procedures:

1. Therapeutic and preventive physical education in a specially equipped room.
2. Massage treatments.
3. Manual therapy.
4. Physiotherapy procedures – electrotherapy, magnetotherapy, ultrasound therapy and others.

Lifestyle advice

In order to reduce the risk of recurrence or exacerbation of the disease, the patient is advised to:

• follow a special diet;
• perform physical therapy exercises;
• undergo preventive treatment in specialized institutions.

Compliance with these conditions will help avoid joint problems.

You may find it useful:

• Rehabilitation program for joint diseases.

References:

1. Chronic synovitis in rheumatology. Evaluation of activity and treatment tactics. breast cancer. 2005
2. Lyalina, V.V. Post-traumatic synovitis of the knee joint – an interdisciplinary problem [Text] / V.V. Lyalina, F.L. Lazko // Traumatology and Orthopedics of Russia. – 2005.