Ankle Sprain with possible syndesmosis fixation required. Questions.
I fell down some steps and sprained my ankle pretty badly. It was an inversion injury I think (I was looking to balance myself, not at my feet, so I'm not 100% sure) with my body going forward over the ankle. During the injury, I felt things tighten up around the outside and top of my ankle, then extreme pain, then I felt pain on the inside of my knee, then I completely fell forward head first to the bottom of the stairs (no injuries other than my ankle, thankfully).
I went to the ER who did x-rays. Swelling on the top part of my ankle but nothing too bad. They said nothing broken/fractured and put me in an aircast and crutches and referred me to a podiatrist. The pod said I likely did a lot of ligament damage and may or may not need surgery, put me in a boot and did an ankle wrap and told me to come back in a week.
When I revisited him, he took new x-rays - AP (front), lateral, and mortise (where he asked me to tilt my ankle inwards slightly). He came in the room and said I def need surgery (syndesmotic screw or a tightrope) b/c of an excessive gap between the tib fib clear space on the mortise view. I said I'd like to get an MRI and a 2nd opinion before any surgery, and he said OK.
I got the MRI and the radiologist report seems to be a bit confusing.
Findings There is marrow edema within the talus (predominantly the anterior portion, sparing of the talar dome), the anterior process of
the calcaneus and adjacent portion of the cuboid. A small focus of marrow edema is also present in the tarsal navicular.
There is edema within the posterior talofibular ligament suggesting ligamentous sprain without frank disruption. The other
tendons and ligaments about the ankle appear normal.
Impression Bone contusions of talus, calcaneus, cuboid and tarsal navicular. PTFL sprain.
What confuses me is the radiologists mentions a sprain of the PTFL, but the other ligaments appear normal. How can that be? After googling around, the PTFL is the strongest and last ligament to be injured (after the ATFL and CFL) and only injured in 5% or less of sprains and usually occurs with a dislocation of the talus. I tried calling the diagnostic center to clarify things and I'm waiting to hear back from them.
I went to a generalized orthopedic surgeon for a second opinion. He took more xrays, only frontal views up to my knee. He said he didn't see any fractures or excessive tib fib spacing and disagreed with the first doctor on the need for surgery (but he didn't do any mortise xrays?). He looked at the MRI and said lots of bone bruising and grade 2 sprains but the ligaments appear to be intact. He said 4 more weeks (which would be about 7 weeks total) in the boot and I should be fine.
It's been almost 4 weeks since the injury and I'm still in the boot unless I'm in bed. I also have a tight compression wrap that the pod put on, around my ankle up to my mid-calf, which he said will provide extra support. I haven't tested out my ankle in any way out of the boot , but I do know it still hurts b/c when i push on the tips of my toes back to my ankle, i feel the pain on the top of my ankle. I tried slightly turning my ankle inward and i felt sharp pain on the outside of my ankle, haven't tried it again since.
_______________________________ Questions that hopefully some other people have some thoughts/comments on (thank you in advance!):
Since I have 2 totally different opinions, I have an appt with a specialized foot/ankle orthopedic surgeon for yet another opinion 2 weeks from now. Is this what you would do/good idea? I definitely don't want to rush into surgery.
How could the orthopedic surgeon I saw be so sure about the tib fib clear space being ok without mortise xrays? Of course it looked ok on the AP view, but doesn't it almost always?
Considering I have a lot of bone bruising, can I form fractures by walking around while in the boot? I've read about osteochondral defects and bone chips and stress fractures, and I don't want to do any further damage.
Is the pain normal that I'm experiencing? Should I be moving my ankle around more? Should I be going to PT already or do I wait until the pain subsides? Can PT do damage to healing ligaments if you go too soon?
I've read that syndesmosis instability that requires fixation generally results from eversion (not inversion) sprains with fractures. is it possible to damage the syndesmosis with an inversion sprain with no fracture?
is it possible they missed a small fracture on the xrays? should i request a CT?
if the radiologist noted a PTFL sprain, doesn't that automatically mean my atfl and cfl are severely sprained as well? why wouldn't he have noted that? i've read that isolated ptfl sprains are extremely rare.
Re: Ankle Sprain with possible syndesmosis fixation required. Questions.
I have to say that you have gotten some very confusing information. How did the 3rd opinion with the foot/ankle OS go? I was going to suggest that you see a board certified foot/ankle OS. I'm interested to hear what s/he said and did diagnostically. You are right in that the PTFL is usually the last ligament injured in an ankle sprain. Isolated PTFL injuries are extremely rare. Usually if your PTFL is injured, then your ATFL and CFL are injured as well. Supposedly, the ATFL is injured in 100% of ankle sprains. I have had several ankle sprains and am about to have my 2nd surgery because of them and my ATFL and CFL were injured every time, but my PTFL has never been injured. Even my peroneal tendons were injured, but not my PTFL. I'm also wondering how the OS could tell that your tib/fib joint space was normal if there were no mortise view xrays. What I will say about radiologists is, in my experience, their findings never match up with the surgeon's findings. Having been on both sides of the table as a patient and in health care, I always trust my doctor's findings of the MRI before the radiologists (that is if you trust your doctor, which I understand is an issue for you right now). The reason being is that s/he is well trained in reading the MRIs and they have your clinical exam to put with it to help them figure out what is wrong. Case in point: my MRI prior to my first surgery read that my ATFL and CFL were fine, although poorly visualized on MRI and my peroneal tendon was torn. Based on my clinical exam, my surgeon doubted that. He gets into my ankle and my ATLF and CFL are completely ruptured. This time around, my MRI stated that all my ligaments and tendons were intact and I only had soft tissue swelling. When my surgeon showed me my MRI (we went through it together, it was his first time to see it too), he saw that my ATFL, CFL, tendon retinaculum, and peroneus longus tendon were torn and the peroneals were subluxing. He went through each injury step by step to show me exactly on MRI where the tears were. So for what it's worth, don't always go by the radiologist's report.
I don't blame you for not rushing into surgery. I wouldn't either, trust me. And I haven't on either one of mine. Bone bruises shouldn't turn into fractures especially if you have the boot on. That limits how you walk on your foot to avoid stress fractures and protect the foot if there's a fracture already present.
I hope all this helps. Let us know what the foot/ankle surgeon says!
Re: Ankle Sprain with possible syndesmosis fixation required. Questions.
You have a lot of good questions you are asking here and I am sure there will be someone to help you out. I just thought I would jump in to let you know that I had the Arthrex tightrope put in for what my MRI showed with a syndesmosis sprain. I believe the MRI showed grade 2. My doctor at the time, didn't even mention a syndesmosis injury before my MRI showed it. I guess that should have made me hesitant in the first place. I still can't believe I didn't go for another opinion. SOOOO STUPID!
When I had my second surgery because my pain was still there, I asked my doctor to take the tightrope out because it was really bothering me. It felt like the buttons had almost flipped 180 degrees and that the thread was going to poke right through my skin. I felt a lot more comfortable without it. On a good note... the recovery from having the tightrope put in wasn't bad at all pain wise. My DR had me NWB for about 5 weeks. I was then in a boot til about 8 weeks post-op. Goodluck and just don't jump into anything while you still have unanswered questions.