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.
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.
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.
thanks again for any thoughts.