Ankle Sprains: Insights on Ligament Tears and Treatment Options - Orthopedics

Ankle sprain - anterior talofibular ligament rupture and tear?

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Hello, Doctor.
I fell down a flight of stairs (about 10 steps) in April 2017, and my right ankle rolled over.
It initially rolled inward and then outward.
I couldn't get up at first and sat on the ground for over ten minutes before I managed to stand up.
After that, I went for traditional Chinese medicine treatment with ice and topical medication.
The next day, I went to an orthopedic clinic for an X-ray, which showed no fractures.
I continued to visit the traditional Chinese medicine clinic daily for dressing changes.
Once the swelling subsided, I received acupuncture and manual therapy, along with physical therapy and ultrasound examinations at the rehabilitation department, which revealed a 2/3 tear of the anterior talofibular ligament.
Consequently, I underwent physical therapy three times a week and acupuncture with heat therapy twice a week, sometimes including manual therapy.
This process continued without interruption for a year.
Although the swelling in my right ankle improved, I still experienced numbness, soreness, and pain, with frequent bruising that sometimes took a month to resolve.

The numbness radiated from the outer side of my right ankle to my calf, while the soreness was localized to the outer side of my right ankle.
Sometimes, after walking for just ten minutes, I would experience soreness accompanied by sharp pain, which could also include numbness.
Particularly, if I squatted for less than a minute, I would feel soreness and numbness to the point where I could barely get up, and I would also feel dizzy.
Bruising occurred whenever I walked; if I walked for less than ten minutes, I would have bruising on the outer side of my right ankle the next day.
Even if I walked without pain for over an hour, I would still have bruising the next day, with the bruising extending from the outer side of my right ankle to about ten centimeters towards my toes.

A year after the injury, an ultrasound clearly showed a torn ligament with a distinct appearance.
I still experienced pain while walking, and even during physical therapy (ultrasound and electrical stimulation), I would feel soreness and numbness, sometimes accompanied by sharp pain.
The rehabilitation physician suggested shockwave therapy to alleviate the pain, but after one session, the pain worsened, and swelling increased, so I was hesitant to continue.

In the second year post-injury, due to persistent symptoms, I underwent prolotherapy, which caused swelling for a few days, but once the swelling subsided, there was still no improvement.
Additionally, other rehabilitation physicians advised against prolotherapy due to concerns that the proliferated tissue might grow inappropriately.
After numerous treatments yielded no improvement and with ongoing numbness, I was referred to a major hospital for a neurological examination.
The results indicated that the values in the injured area on the right side were half of those on the left, but functionally, it was still intact.
The physician recommended supplementing with B vitamins, as my rehabilitation over the previous two years had only involved physical therapy.
The physician stated that I needed strength training to compensate for the ligament function.

Thus, for the past six months, I have been undergoing strength training at the major hospital, but the aforementioned symptoms have not improved, and the frequency of numbness and soreness has increased.
I am now considering surgery.
Recently, I underwent ultrasound and MRI scans, and the physician indicated that neither test showed any significant findings regarding the anterior talofibular ligament.
They also asked if I had experienced any swelling recently.
In the 2-3 weeks prior to these tests, I had no bruising or significant swelling, but I continued to experience soreness, numbness, and pain.

I am considering surgery for the following reasons: 1.
To regain normal activity without experiencing soreness, numbness, and bruising while walking.
2.
I enjoy exercising, but I have not been able to do so for two and a half years.
Regardless of the activity, I experience bruising, even after swimming, which causes pain for several days.
I hope that surgery will alleviate the symptoms of soreness, numbness, and bruising, allowing me to exercise at least once a week.

I have consulted two orthopedic surgeons from different hospitals.
The first surgeon suggested using either my own ligament or a donor ligament to repair the anterior talofibular ligament.
After surgery, I would need to use an inflatable ankle brace and crutches for two months.
After observing my standing posture, they noted internal rotation and recommended changing to a full-length insole to see if it could alleviate the pain; if not, we would consider surgery.
The second surgeon indicated that I have ligament laxity in both ankles and that there is no need to harvest a ligament for repair unless I were an athlete.
They suggested simply reconnecting the ligaments and tightening them.
Post-surgery, I would need to use a removable cast and crutches for two months.

Here are my questions for the physician:
1.
A rehabilitation physician mentioned that surgery may not necessarily improve my condition.
What recommendations do you have regarding my ankle situation?
2.
Recent ultrasound and MRI did not show any ligaments, but a year ago, there were clear images of a torn ligament.
Could the results of the ultrasound and MRI be affected by swelling or other factors, or has my ligament atrophied?
3.
Regarding ligament repair surgery:
(1) What are the differences between using other ligaments to repair the ankle ligaments in terms of range of motion and strength, or are there other differences?
(2) If the ligaments are indeed absent or atrophied as indicated by the MRI results, would it be necessary to harvest other ligaments for repair?
(3) If ligaments need to be harvested, what are the differences between using autografts versus allografts? If using allografts, is there a risk of rejection, and would that require a second surgery? Are there artificial ligaments available, and if so, how do they differ?
(4) The physician mentioned ligament laxity in both ankles.
If ligaments are simply sutured together without harvesting, could this lead to an imbalance (for example, the right ankle ligaments being too tight and the left ankle ligaments being too loose)?
(5) The physician mentioned internal rotation and recommended changing to a full-length insole.
If I do not undergo surgery, will changing insoles truly help?
(6) What are the differences between using a removable cast and an inflatable ankle brace post-surgery?
Thank you for your attention, Doctor.
If you need the MRI and neurological examination reports, I can provide them.
I kindly ask for your answers.

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Coco, 20~29 year old female. Ask Date: 2019/06/29