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Ankle Fusion Surgery or Prolotherapy for Ankle Ligament Injury

Jun
18
2013

Ligaments can take a lot of abuse yet remain resilient. Eventually however, wear and tear causes ankle ligaments to fray and tear leading to chronic ankle sprains.

Ankle sprains: causes and treatments

Sprains happen most frequently when the ankle is turned inward, tearing or stretching the ligaments on the lateral side of the ankle. An ankle sprain can also happen when the ankle is turned outward, pulling or tearing the deltoid ligament on the inside of the ankle. Once an ankle is sprained, it may take weeks to months for the ligaments to heal. Even after the pain stops, the sprained ankle will remain weaker than the other one. Left untreated, these sprains often become chronic.

Most athletic trainers and doctors typically follow the R.I.C.E. (Rest, Ice, Compression, and Elevation) protocol for these types of injuries. The athlete is told to stop all activity. This usually is not a problem at first, as the ankle is swollen and painful. They then prescribe an ice regimen and anti-inflammatory drugs (NSAIDs) along with the rest while keeping the injury elevated. This decreases the pain, which is why most athletes feel that they are ready to return to their sport. However, the ice, rest, and anti-inflammatory drugs actually impede the healing process while temporarily getting rid of the pain. One study noted:

“Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.”1

Some doctors will let the athlete return to their sport while wearing an ankle brace or ace bandage to “support” the injury. But this just gives the athlete a false sense of security, leading to a repeat of the injury. The athlete often bends to pressure from coaches, teammates, and friends to play on the ankle before the ligaments are fully healed. This stops the healing progress of the ligaments, leading to what is known as “chronic ankle instability”. This is characterized by a “giving way” of the ankle. This is, in fact, the first stop toward degenerative arthritis and long-term pain. If the looseness of the ligaments is not corrected, the ankle will develop arthritis, leading to chronic pain and discomfort.

More serious options for continued ankle pain:

When the athlete returns to the doctor with complaints of continued pain, the next step will probably be either stronger NSAIDs or cortisone shots to the ankle. Cortisone has been shown to further degenerate the injured ligaments in joints, leading the athlete on the fast track to osteoarthritis. When the cortisone shots don’t work and leave the patient with pain, the words “ankle fusion,” “arthroscopy,” and “joint replacement” are often mentioned.

Ankle surgeries often do not cure the injury
An ankle fusion is a type of surgery commonly suggested for a degenerative ankle joint. An ankle fusion makes the shinbone grow together with the bone directly under it, called the talus. The boney bumps on either side of the ankle are removed so the surgeon can get into the joint. The joint surfaces are commonly removed, and sometimes reshaped. The joint is then corrected and secured with two or three screws. It is usually necessary to add extra bone to the ankle fusion. After an ankle fusion, patients are told that they can usually walk normally, but that they will be experiencing a lot of pain after surgery.

Arthroscopy cuts and shaves away tissue. This should only be used if the patient is experiencing pain with pinching sensations and blocking. If it is used on someone whose ankle is already degenerative it makes the problem worse and more painful. Joint replacement is exactly what it sounds like: the surgeon removes the degenerative joint and replaces it with a prosthetic.

It may seem surprising, but athletes often have ankle pain after surgery! Unfortunately conservative treatments like Prolotherapy are overlooked when, in fact, “conservative treatment of patients with CAI must be the first-line therapy. Surgical treatment must be indicated only when conservative treatment fails.”2

But in other research, it seems that the best way to treat chronic ankle spains of the ligament is to replace the ligament with a tendon from the deep thigh area!3 We have to ask why replace a ligament that can be repaired and weaken another area and call this the best way?

Prolotherapy for ankle sprains

Patients often come to Prolotherapy offices frustrated and in pain, unable to do the physical activities they love, willing to try anything. As Prolotherapy is explained, they often wonder why they hadn’t heard of this treatment before they had the expensive procedures done in the first place. The best time to get Prolotherapy is after the initial injury: the ankle sprain. The reason the ankle inflames is because it needs increased blood flow to the area in order to heal the injury. Many people do not realize that the body heals from inflammation. This is where Prolotherapy makes so much sense. When the dextrose-based solution is injected, it creates a mild inflammatory reaction, causing increased blood flow again, thereby signaling the body to heal itself. This healing cascade produces new collagen, which is what ligaments and tendons are made of. New collagen shrinks as it matures. While it shrinks, it tightens the loosened ligaments and makes them stronger. Prolotherapy has the potential to relieve the patient from all of their pain permanently.4

1. van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, Van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012;47(4):435-43.

2. Rodriguez-Merchan EC. Chronic ankle instability: diagnosis and treatment. Arch Orthop Trauma Surg. 2012 Feb;132(2):211-9. Epub 2011 Nov 5.

3. Zhang L, Li ZY, Liu JS, Sun J, Ma J, Zhang S, Liu XH. [Clinical results of anatomical reconstruction of the lateral ligaments for chronic ankle instability]. Zhongguo Gu Shang. 2012 Nov;25(11):886-90.

4. Fullerton BD. High-resolution ultrasound and magnetic resonance imaging to document tissue repair after prolotherapy: a report of 3 cases. Arch Phys Med Rehabil. 2008 Feb;89(2):377-85. doi: 10.1016/j.apmr.2007.09.017.

 

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