Persistent Ankle Pain After Injury: Causes and Solutions

Avulsion fracture

Hello doctor, I injured my ankle while playing basketball after colliding with someone and falling down.
Although it was very painful, I managed to walk home with a limp.
I went to a small clinic where they diagnosed me with a ligament tear and put me in a cast for a month, but there was no improvement.
I then consulted a doctor at a larger hospital who said a small piece of bone was pulled off along with the ligament, but it was too small for surgery.
I was advised to rest for three months and to use a pneumatic brace.

Now, three months have passed, and while I can put weight on my ankle, it still hurts significantly when I apply force outward.
The doctor mentioned that the X-ray shows the bone has healed and that the ligament should not be torn.
Logically, I shouldn't still be in pain after three months.
I also have some immune issues; could this be related? If not, why is there still pain? The outer part of my ankle had bruising before, but it has since subsided.
Is that related?

Shuo Er, 10~19 year old female. Ask Date: 2015/12/04

Dr. Shi Guozheng reply Orthopedics

An avulsion fracture typically occurs at the junction between a ligament and a bone, meaning that the ligament is not torn; rather, a piece of bone has been pulled away.
Treatment at the site where the ligament and bone connect usually involves conservative management, as the fragment is too small for surgical fixation.
Therefore, immobilization with a cast or splint is sufficient.
After three months, rehabilitation is necessary, and if pain persists, medication may be required for relief.
Recovery will gradually occur and is not related to the immune system.

Reply Date: 2015/12/04

More Info

Persistent ankle pain after an injury can be a complex issue, especially when the initial diagnosis and treatment do not lead to the expected recovery. In your case, it seems that you have experienced a significant injury to your ankle, which was diagnosed as a ligament tear and possibly an avulsion fracture (where a small piece of bone is pulled off by a tendon or ligament). Despite the initial treatment with a cast and subsequent rest, you are still experiencing pain, particularly when applying pressure to the outer side of the ankle.

There are several potential reasons for the ongoing pain:
1. Incomplete Healing: Even though X-rays show that the bone has healed, the ligaments may not have fully recovered. Ligament injuries can take longer to heal than bone injuries, and sometimes they can heal in a way that leads to chronic instability or pain. The fact that you feel pain when applying force to the outer side of the ankle suggests that there might still be some underlying instability or weakness in the ligaments.

2. Chronic Inflammation: After an injury, the body can sometimes continue to produce inflammatory responses even after the initial healing phase. This can lead to chronic pain and swelling, which may not be visible on imaging studies. Conditions such as Complex Regional Pain Syndrome (CRPS) can develop after an injury and lead to prolonged pain and sensitivity.

3. Scar Tissue Formation: After an injury, scar tissue can form around the ligaments and tendons. This scar tissue can sometimes restrict movement or cause pain when the ankle is used. Scar tissue can also lead to a condition known as adhesive capsulitis, which can limit the range of motion and cause pain.

4. Biomechanical Issues: If the ankle is not functioning properly due to the injury, it can lead to compensatory movements that place additional stress on other structures in the foot and ankle. This can result in pain in areas that were not directly injured.

5. Immune System Factors: Given that you mentioned having immune issues, it is possible that your body’s healing process is affected. Conditions such as autoimmune disorders can lead to prolonged inflammation and pain, which may complicate recovery from an injury.

6. Previous Bruising: The bruising you experienced on the outer side of the ankle could indicate that there was significant trauma to the area. Even after the bruising resolves, the underlying tissues may still be sensitive or inflamed, contributing to your pain.

Recommendations for Management:
1. Follow-Up with a Specialist: It may be beneficial to consult with a sports medicine physician or an orthopedic specialist who focuses on ankle injuries. They may recommend further imaging studies, such as an MRI, to assess the ligaments and soft tissues around the ankle.

2. Physical Therapy: Engaging in a structured physical therapy program can help strengthen the muscles around the ankle, improve stability, and enhance range of motion. A physical therapist can also provide modalities to reduce pain and inflammation.

3. Pain Management: Discuss with your doctor about pain management options. This could include medications, physical therapy modalities (like ultrasound or electrical stimulation), or even injections if appropriate.

4. Activity Modification: Avoid activities that exacerbate the pain, particularly those that involve lateral movements or excessive weight-bearing on the affected ankle. Gradually reintroducing activities under the guidance of a healthcare professional can help prevent further injury.

5. Consideration of Underlying Conditions: If you have an autoimmune condition, it may be worth discussing with your healthcare provider how this could be impacting your recovery and pain levels.

In conclusion, persistent ankle pain after an injury can arise from various factors, including incomplete healing, chronic inflammation, scar tissue formation, biomechanical issues, and underlying health conditions. A comprehensive approach involving further evaluation, physical therapy, and possibly pain management strategies will be essential in addressing your ongoing symptoms and facilitating recovery.

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