Managing Ankle Fracture Complications: Pain, Instability, and Rehabilitation

What are the issues following an ankle fracture injury?

Dear Dr.
Chen,
I would like to ask about my condition following a car accident on June 20, 2015.
At that time, an X-ray revealed a fracture of the left ankle's lateral malleolus, and I was placed in a cast and used crutches for mobility.
On August 2, 2015, after the cast was removed, I began rehabilitation therapy at a physical medicine and rehabilitation department.
However, on October 12, 2015, the physical therapist noticed something was wrong; my ankle was becoming increasingly painful with walking, which was not typical.
Afterward, on November 24, 2015, I went to another hospital for further examination, where an MRI revealed that the fracture site had not healed properly.
On December 3, 2015, I underwent surgery, during which an arthroscopy was performed.
A steel plate and six screws were inserted at the fracture site to enhance stability and support.
Additionally, the lateral ligaments, the medial deltoid ligament, and the posterior tibial tendon were sutured.
The physician mentioned that one of the lateral ligaments, one of the medial deltoid ligaments, and the posterior tibial tendon were ruptured.
Although they were addressed, there might still be issues with ankle instability.
To this day, I have been undergoing rehabilitation therapy, but I still experience significant pain on the medial side of the ankle when walking with weight.
I feel instability and a catching sensation in the ankle, and I am unable to squat, run, or jump.
Currently, my physical therapy consists of electrical stimulation, hydrotherapy, ultrasound, stretching, and massage.
I would like to ask Dr.
Chen the following questions:
1.
How should I address the issues of ankle instability, fluid accumulation, and inflammation? What is the management for abnormal proliferation of the medial periosteum and inflammation of the posterior tibial tendon?
2.
What rehabilitation activities can be performed after a rupture of the posterior tibial tendon? If I have previously ruptured it, will it be prone to re-rupture?
3.
I still experience pain while walking and cannot walk or stand for long periods.
Sometimes, my entire ankle and the dorsum of my foot are extremely painful.
What additional examinations can I undergo? This issue has been a significant source of distress and severely impacts my daily life.

Thank you for your assistance.

Xiao Feng, 30~39 year old female. Ask Date: 2016/04/13

Dr. Chen Yongxue reply Orthopedics

Hello,
1.
For instability issues originating from the ligaments, surgical intervention should be considered.
Pain and swelling are likely caused by inflammation, which can be managed with medication and rehabilitation.

2.
Regarding rehabilitation for tendon rupture, based on your description, it seems to have healed quite well.
However, there is still a risk of re-rupture, so please use caution.

3.
If it has been more than six months, the progress may plateau.
It is advisable to consult with your attending physician.
Thank you.

Reply Date: 2016/04/13

More Info

Managing complications after an ankle fracture can be challenging, especially when pain, instability, and rehabilitation issues persist. Your situation, following a traumatic injury and subsequent surgical interventions, highlights the complexities involved in recovery. Let’s address your concerns systematically.

1. Ankle Instability and Inflammation: The instability you are experiencing may stem from the damage to the ligaments and tendons surrounding the ankle, particularly the lateral and medial ligaments that were affected during your injury. The presence of fluid accumulation (effusion) in the ankle joint can also contribute to instability and discomfort. To manage these issues, it is essential to follow a comprehensive rehabilitation program that includes:
- Physical Therapy: A tailored program focusing on strengthening the muscles around the ankle, improving proprioception (awareness of joint position), and enhancing overall stability is crucial. Exercises may include resistance training, balance exercises, and functional movements.

- Manual Therapy: Techniques such as joint mobilization and soft tissue manipulation can help alleviate pain and improve range of motion.

- Modalities: Continued use of modalities like electrical stimulation, ultrasound, and ice therapy can help manage inflammation and pain.

- Activity Modification: Avoiding high-impact activities until you have regained sufficient strength and stability is vital. Gradually reintroducing activities can help prevent further injury.

2. Rehabilitation for the Posterior Tibial Tendon: After a rupture of the posterior tibial tendon, rehabilitation should focus on restoring function while protecting the tendon during the healing process. The rehabilitation program may include:
- Gentle Range of Motion Exercises: Initially, focus on non-weight-bearing exercises to maintain mobility without stressing the tendon.

- Strengthening Exercises: As healing progresses, incorporate strengthening exercises for the foot and ankle, particularly targeting the posterior tibial tendon and surrounding musculature.

- Functional Training: Once you have regained strength, functional exercises that mimic daily activities can help prepare you for a return to normal function.

- Monitoring for Recurrence: Given your history of tendon injury, it’s essential to be vigilant about any signs of re-injury. Gradually increase the intensity of your activities while paying attention to any pain or discomfort.

3. Persistent Pain and Further Evaluation: Chronic pain and difficulty with weight-bearing activities can significantly impact your quality of life. If you continue to experience pain, consider discussing the following options with your healthcare provider:
- Advanced Imaging: If not already done, an MRI or CT scan can provide detailed information about the healing process and any potential complications, such as non-union of the fracture or issues with the hardware.

- Pain Management Consultation: A referral to a pain management specialist may be beneficial if pain persists despite conservative measures. They can offer options such as injections or alternative therapies.

- Surgical Evaluation: If instability and pain do not improve with conservative management, a surgical consultation may be warranted to assess the need for further intervention, such as ligament reconstruction or hardware removal.

In summary, managing complications after an ankle fracture requires a multifaceted approach that includes physical therapy, pain management, and possibly further surgical evaluation. It’s essential to communicate openly with your healthcare team about your symptoms and progress to ensure a tailored rehabilitation plan that addresses your specific needs. Remember, recovery can take time, and patience is key. Best wishes for your continued healing and return to normal activities.

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