Mar 8, 2019
Multiple ankle sprains can lead to chronic ankle pain for some patients. Dr. Ali Rahnama explains how minimally invasive surgery can help these patients avoid much larger procedures in the future.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama.
Dr. Rahnama: Thank you for having me.
Host: Today we’re discussing chronic ankle pain after a sprain and what could be going on inside the foot and ankle. Dr. Rahnama, many of us have experienced an ankle sprain. How many would you say you treat in a year?
Dr. Rahnama: I would say it really depends on the time of year, especially as we get closer to the winter months. Sometimes I may see as many as 4 to 5 of these a week, sometimes even more.
Host: Student athletes and leisure athletes are at risk of sprains. Are there other groups of people who are susceptible?
Dr. Rahnama: While it’s true that typically we do see a lot of athletes with sprains because of the increased level of activity that they engage in on a day to day, we do see them in various patient populations and even non-athletes, particularly as we get closer in to the winter months. Slip and falls, especially in cities like Washington where people use a lot of mass transit and are walking outside on the sidewalk. We, a lot of times, see people slip on little patches of ice and things like that, and injure themselves and get sprains and even sometimes fractures.
Host: How do you determine whether an ankle sprain is mild, moderate, or severe?
Dr. Rahnama: I typically look at three things. I want to see how much tenderness there is, swelling, bruising, that kind of thing, the patient’s ability to bear weight or not be able to bear weight. Those are typically how I determine how bad the injury is.
Host: How long should a patient expect to fully recover from a mild or moderate ankle sprain?
Dr. Rahnama: Typically, a mild to moderate ankle sprain, I would expect to clear up in the ballpark of about 2 to 4 weeks, depending on how bad the injury is and exactly what part of the ankle they’ve injured. Typically, the lateral ankle ligaments are the ones that are affected more commonly. Those would be the ankle ligaments on the outside, as opposed to the inside ligaments.
Host: How long should a patient expect to recover from a severe ankle sprain?
Dr. Rahnama: Severe ankle sprains can take anywhere from up to 6 weeks to even up to 12 weeks to heal, depending on the injury.
Host: Is there anything special that an individual would have to do when they’re taking care of a severe ankle sprain?
Dr. Rahnama: Typically, with a severe ankle sprain, I would say it’s important for them to initially have a period of immobilization, rest, where they can ice it and elevate it and stay off it. And then, it’s really important for them to get with a physical therapy colleague of ours that I’ll very often send my patients to, who will work with them on proprioceptive exercises and strengthening exercises, to help get them to strengthen the tendons and muscles in and around the foot and ankle to help the patient avoid having a similar injury again in the future.
Host: Of course, spraining an ankle is painful, but how long does the pain typically last before it’s considered “chronic?”
Dr. Rahnama: The chronicity of the sprain isn’t just based on how long it takes for them to heal. It really has to do with how many spraining incidents they’ve had total. So, if I have a patient who comes to me for an acute sprain, meaning that they recently had one and so they’ve decided to present for care, or somebody sent them to me for evaluation, the first thing I want to make sure and ask them is that have they had similar incidences in the past that maybe they didn’t see somebody for and that maybe healed on their own and that now they’re noticing a pattern, where they had an initial sprain, sometimes even up to years ago, and as time has gone on, they, every so often depending on what they’re doing, particularly if they’re active, if they continue to have more and more of these incidences - and, so then, that’s when I start to think that it’s something chronic because there’s multiple episodes of it.
Host: So, it’s just being more and more susceptible to sprains?
Dr. Rahnama: Exactly right.
Host: What’s the standard first-line treatment for a sprain?
Dr. Rahnama: So, I would divide it into three things. One, I would say resting and protecting the ankle with a brace or boot, sometimes even a splint. And then second, I would follow that with resting range of motion, strength and stability exercises. And finally, maintenance exercises that would slowly get them back to more intense physical activity and for them to be able to engage in sports that would need sharp cutting, like tennis or basketball, for example.
Host: At what point do you typically recommend surgery for an individual with chronic sprains?
Dr. Rahnama: Well, first I’d like to emphasize that, even as a foot and ankle surgeon, the vast majority of sprains are treated nonoperatively. Only in the setting where a patient has not healed for more than 6 or 8 to 12 weeks and they’ve oftentimes had multiple incidences of sprains, will I start to think of surgery for correction of it. The surgical procedure is actually quite simple for a straight-forward, isolated, chronic lateral ankle tear, or laxity. We make a small incision, and oftentimes we’ll try minimally invasive techniques where we can make small, few-millimeter stab incisions and enter the joint and evaluate for any type of synovitic or pre-arthritic tissue, debride that. Debridement is when we use a shaver and the guidance of the camera, once we’ve gotten into the joint, to essentially just clean up and take out any of that arthritic or inflammatory tissue that doesn’t belong into the joint. And then we can even do our lateral ankle repair through those same incisions so that we don’t have to make any large incisions and open the patient up. It’s fairly straight-forward surgery. So, they actually did studies where they split two groups of surgeons up who had never done minimally invasive surgery before. And, in the first group, they had the surgeons do video games. And then, they had the other group not do anything at all. And, then they trained all...both groups at the same time in minimally invasive surgery and arthroscopic or laparoscopic surgery. And the group that had had the video game training before the surgical training actually got it a lot faster and did much better. So, if you’ve got a kid at home who’s good with video games, he may be good with minimally invasive techniques someday.
Host: When it comes to foot and ankle surgery, why is minimally invasive surgery a good approach?
Dr. Rahnama: Minimally invasive surgery is good for patients for a number of reasons. But, probably the most important things are many times patients undergoing minimally invasive surgery get back to doing what they want to do a lot sooner. There are much smaller incisions that need the body to heal them. And so, overall, they tend to have better outcomes, is what we found.
Host: Have you ever had a patient come in thinking they had sprained their ankle, but it was actually something else?
Dr. Rahnama: So, that’s a great question. We actually see this quite often where somebody will come in with the complaint of a sprain, or what they think to be a sprain, that’s not getting any better and it doesn’t really fit the description of what we would like to see for classifying it as chronic ankle sprainers. And, that’s really when we start to think about, ‘what else could this be, masking itself as an ankle sprain?’ Things like osteochondral defects of the talus, meaning an injury to the cartilaginous surface of one of the bones in the ankle, can cause pain, especially if there’s loose pieces of cartilage from that injury that are now in the joint. Those oftentimes can mask themselves with the same symptoms or similar symptoms as an ankle sprain. Also, tendon injuries can also mask themselves as sprains, where it may really be a tendon tear or even a rupture and the patient comes to us with an ankle sprain that’s just not healing. And so, those would definitely be a couple of things that we see fairly often that patients think are ankle sprains but they’re not. And, obviously, the last thing would be fractures, particularly if the patient was seen in an environment...because a lot of times, primary care offices don’t have X-ray available and so the patient is sent to us with a sprain. And, one of the first things that I’ll do, if the patient doesn’t already have one, is obtain an X-ray to make sure they don’t have any fractures anywhere.
Host: What can people do to reduce the risk of ankle sprains?
Dr. Rahnama: I would say it’s really important for people to keep in to consideration the type of shoes that they wear and particularly be mindful of the type of activity they’re trying to engage in. Runners, a lot of times here in the city particularly, it’s best for them to try to avoid, especially in the colder months, the wet months, avoid trying to go out for a run right after a snow or the rain. And, in the summer months, when we’re out on trails and things like that, really make sure you know the terrain that you are about to go out for a run in, for example, or embark on any type of physical activity, so that you don’t find yourself with any surprises.
So, what I would say is that, particularly in the winter months, if you’re a runner, make sure you have the appropriate shoe gear. Make sure your laces are tied nice and snug. And, maybe avoid the day right after a snow storm. Make sure you know the environment that you’re going to be running in so that you can avoid little slicks of ice and the really wet, deep puddles. Those are really where we see the biggest problems or people will say, “I slipped on a patch of ice,” or “I went off the curb and it was just too wet, and I slipped and I sprained my ankle,” or sometimes even worse. And in the spring and the summer months trail runners - I know that’s very popular these days - familiarize yourself with the terrain that you are about to go on a nice run for. Make sure you understand where there might be a ditch or a hole that you might want to avoid. So, before we go full speed ahead it’s nice to pause and try to really familiarize yourself with our environment.
Host: How do you recommend that patients prepare for foot or ankle surgery?
Dr. Rahnama: I strongly believe an informed patient can help the surgeon help them by developing protocols that are specific for them and their needs. If they feel they don’t have the upper body strength, for example, to stay on crutches and remain non-weight-bearing, they should share that with their doctor - and so that we can work with our physical therapy colleagues to help them gain the upper body strength, for example, to then get them ready for lower extremity surgery so that they can stay off of it. It’s not just about doing our portion of the procedure and then having patients go out and be on their own. We want to avoid that as much as possible. So, certainly in my exam, I try to assess the patient’s whole body to make sure that they have that ability, if they’re overweight, or have other things that impede them to remain non-weight-bearing, I definitely try to address that. But, we definitely want to encourage our patients to be forthcoming with any reservations or any concerns that they might have so that they can help us help them.
Host: What does recovery after surgery entail?
Dr. Rahnama: Typically, a period of non-weight-bearing for 2 to 3 weeks. And I will say that these protocols vary sometimes between surgeons. But there is research now that shows that the quality of new collagen that your body puts down when repairing ligaments depends on the stress being put on them. This is very similar to what we’ve known for a very long time about bone healing and bone turnover in your body. The stress of gravity and the stress of weight bearing actually helps your body heal it the way that it should be healed. And so, after a short period of non-weight-bearing, and making sure that our incisions are healed, I get my patients to therapy as soon as I can right after that to make sure that they engage them with a week to two of fairly aggressive, non-weight-bearing exercises. And then, in under a month typically, I will try to get my patients weight bearing again, again with the help of our physical therapy colleagues, to get them back on their feet and to make sure they have the best outcomes possible.
Host: What are some of those exercises that your patients are participating in during that initial couple of weeks and then the following month?
Dr. Rahnama: So, a lot of them might be resistance exercises, proprioceptive exercises, exercises that really strengthen the muscles, the tissues around the foot and the ankle and to really be able to support the repair that we’ve done. So, collagen are the little building blocks of ligaments and connective tissues in our body. And so, anytime you have an injury to the soft tissues and ligaments included in that, collagen is what your body uses to help repair things.
Host: Could you tell us about a patient who had foot or ankle surgery after a bad sprain and was able to return to an active lifestyle?
Dr. Rahnama: I had a college athlete in her twenties last year who had been spraining since she could remember and now it was getting to the point that, even with the best wrapping by her trainers, she couldn’t do what she wanted to do. So, she came and saw us. Obviously, being an athlete, she had some great trainers and therapists trying to rehab her with no good results. So, we proceeded to surgically fix the ankle ligaments, utilizing a minimally invasive technique and arthroscopy, where we make small incisions, just millimeters wide, and place a small camera into the joint and use that to help guide our repair. Surgery went as planned and we proceeded to use her training team again to help us get her back. And, she was back training in under two months, without restrictions. Now, she’s an extreme case of very aggressive rehab, but the point is that it can be done and there’s no reason to think that even the most physically demanding athletes can’t get back on their feet and get back to doing what they love.
Host: I know a lot of folks can be kind of stubborn when it comes to thinking about surgery. What are some of the reasons that you would give patients if they’re hesitant to come have surgery because they don’t want to take time off their activities?
Dr. Rahnama: That’s a great question. The one thing that I would emphasize is that a small problem, if not addressed by the right specialist, can a lot of times turn in to a much larger problem down the road that the patient then can’t avoid having taken care of. If a patient doesn’t see somebody for a chronic ankle sprain and thinks that this is something that they don’t want to have addressed, the reality is if they DO have it addressed and they have a small procedure now, that may help them avoid a much larger procedure, such as the need for a total joint replacement or joint fusion even, later on in the future as they get older.
Host: Why should someone with chronic ankle pain or a bad sprain speak to a surgeon at MedStar Washington Hospital Center?
Dr. Rahnama: We’re here to help and make sure our patients and individuals suffering from foot and ankle conditions can get back to life and do the things they love and be active. And so, that’s what we do every day, and we just want to make sure the local public knows we’re here, and if they need us, we’re happy to help.
Host: Thanks for joining us today, Dr. Rahnama.
Dr. Rahnama: Thank you so much for having me.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.