Managing Ankle Fracture Complications: Pain, Instability, and Rehabilitation

What are the issues following an ankle fracture injury?

Dr.
Chen, I would like to ask you 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.
After the cast was removed on August 2, 2015, I began rehabilitation therapy until October 12, 2015, when the physical therapist noticed something was wrong.
My ankle was becoming increasingly painful with walking, which was not typical.
After consulting another hospital on November 24, 2015, an MRI was performed, revealing 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 placed 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 doctor indicated that one lateral ligament, one medial deltoid ligament, and the posterior tibial tendon were torn.
Although these were addressed, there may still be instability in the ankle.

Since then, I have continued rehabilitation therapy, but I still experience significant pain on the medial side of the ankle when walking with force, and I feel instability and a locking sensation in the ankle.
I am currently unable to squat, run, or jump.
My physical therapy consists only of electrical stimulation, hydrotherapy, ultrasound, stretching, and massage.

I would like to ask Dr.
Chen:
1.
How should I address the issues of ankle instability, fluid accumulation, and inflammation? What is the treatment for abnormal proliferation of the medial periosteum and inflammation of the posterior tibial tendon?
2.
What rehabilitation activities can be performed after a tear of the posterior tibial tendon? Is there a risk of re-injury after a previous tear?
3.
I still experience pain when walking and cannot walk or stand for extended periods.
Sometimes the entire ankle and dorsum of the foot are 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 that stem from ligaments, surgical intervention may be necessary.
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 be quite complete.
However, there is still a risk of re-rupture, so please use caution.

3.
If it has been more than six months, the rate of improvement may plateau.
It would be advisable to consult with your attending physician.
Thank you.

Reply Date: 2016/04/13

More Info

Managing complications following an ankle fracture can be quite challenging, especially when pain, instability, and rehabilitation issues persist. Your situation, involving a complex ankle injury with multiple ligament and tendon repairs, requires a comprehensive approach to address the ongoing symptoms and improve your functional outcomes.

1. Addressing Ankle Instability and Inflammation: The instability you're experiencing in your ankle, along with the pain and swelling, could be attributed to several factors, including incomplete healing of the ligaments, inflammation, and possibly scar tissue formation. To manage these issues, it is crucial to follow a structured rehabilitation program that includes:
- Physical Therapy: A tailored physical therapy program focusing on strengthening the muscles around the ankle, improving proprioception (the body's ability to sense movement and position), and enhancing overall stability is essential. Your therapist may incorporate balance exercises, resistance training, and functional activities to help regain strength and stability.

- Manual Therapy: Techniques such as joint mobilization and soft tissue massage can help reduce pain and improve range of motion. These methods can also assist in breaking down any scar tissue that may have formed post-surgery.

- Modalities: Continue using modalities like ultrasound, electrical stimulation, and hydrotherapy as they can help reduce inflammation and promote healing.

- Activity Modification: Avoid activities that exacerbate your pain or instability. Gradually reintroducing weight-bearing activities under the guidance of your therapist can help you gauge your limits and prevent further injury.

2. Managing Tendon and Ligament Issues: The posterior tibial tendon (PTT) plays a crucial role in maintaining the arch of the foot and stabilizing the ankle. After a rupture, rehabilitation should focus on:
- Strengthening Exercises: Once cleared by your physician, exercises targeting the PTT and surrounding musculature can help restore function. This may include resistance band exercises, heel raises, and toe curls.

- Progressive Loading: Gradually increasing the load on the tendon through controlled exercises can help promote healing and strength without overloading the tissue.

- Monitoring for Re-injury: After a tendon injury, there is a risk of re-injury, especially if the rehabilitation process is rushed. It’s crucial to listen to your body and avoid pushing through pain.

3. Further Investigations: Given your ongoing pain and functional limitations, it may be beneficial to consider additional imaging studies, such as:
- MRI: If not already done, an MRI can provide detailed images of soft tissues, including ligaments and tendons, to assess for any additional injuries or complications that may not have been addressed.

- Ultrasound: This can be useful for evaluating tendon integrity and assessing for any fluid accumulation or inflammation around the ankle.

- X-rays: Regular follow-up X-rays can help monitor the healing process of the bone and ensure there are no complications such as malunion or nonunion.

4. Pain Management: Managing pain effectively is crucial for rehabilitation. Consider discussing with your healthcare provider about:
- Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation. If pain persists, your doctor may consider other pain management strategies.

- Alternative Therapies: Techniques such as acupuncture, chiropractic care, or even cognitive behavioral therapy may provide additional relief.

In conclusion, managing complications from an ankle fracture requires a multifaceted approach involving physical therapy, pain management, and possibly further diagnostic evaluations. It’s essential to maintain open communication with your healthcare team to adjust your rehabilitation plan as needed and ensure you are on the path to recovery. Remember, patience and consistency are key in the rehabilitation process, and with time, you should see improvements in your ankle function and overall quality of life.

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