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Dr. Miller: You sprained your ankle, could you have a fracture and what to do about it? I'm Dr. Tom Miller in here with Scope Radio.

Difference Between an Ankle Fracture and a Sprained Ankle

Dr. Miller: I'm here today with Dr. Alexej Barg and he is an orthopedic surgeon here at the University of Utah. He specializes in foot and ankle problems. Alexej, ankle sprains are very common and occur frequently among adolescents and kids who are playing sports. Under what circumstances should one go receive additional attention after spraining an ankle to make sure that they haven't fractured the ankle?

I think this is a typical concern that I see in my practice. People come in, they sprain their ankles and they want to know, "Well, could I have fractured the ankle?"

Most Common Sports Injuries

Dr. Barg: The ankle sprain is for sure the most common injury in the United States. This is actually also the most common sports injury. More than every 10th patient who is showing up in the emergency room is coming to the clinic because of the ankle sprain. Of course, you cannot just do in every patient without seeing this patient, just the routine radiograph assessment.

In the last case, there are some clinical studies addressing the efficacy or whether the radiograph need to be done or not. I don't think those guidelines are good. However, it's still in the hands of the treating surgeon or orthopedic surgeon whether the patient does need the radiographs or not. In my experience, if it's just a mild sprain, especially in the younger kids or teenager, there's definitely no need to do immediately radiographs.

Dr. Miller: What does a mild sprain look like to you?

What Is a Mild Ankle Sprain?

Dr. Barg: A mild sprain looks like for me, for example, it's always only on the lateral side. That means on the outside, not the inside. Usually, it's just mildly small and the patient still can go for weight bearing. [inaudible 00:01:53] sort of pain or maybe just a sore, not necessarily the pain. They don't have the swelling on the medial side, on the inner side. This is for me the mild sore.

If the patient does present with a swelling with some hematoma, that means some color change, on the medial and/or lateral side, there's definitely need to perform or to do the radiographs, the X-rays to exclude a bone fracture.

Dr. Miller: What about if right after the ankle is sprained that they cannot weight bear? Does that make a difference? I've heard that sometimes, if the person who sprains their ankle is not able to put weight on that foot for a period of time right after the injury, they should receive an X-ray.

Dr. Barg: Usually, right after the injury, almost everybody who has ankle sprains cannot bear weight. I would definitely wait a couple hours. Usually, those patients have some substantial pain relief within four to six hours after the injury, especially if they do elevate the foot, if you do the cooling of the injured ankle.

If they still experience a very severe pain after six hours so they cannot walk on it at all, there is definitely an indication or the need to do the radiographs. Another question is if the patient continues having pain two or three weeks after the injury, it doesn't matter whether it was a mild injury, they need an x-ray. They should go to the clinic and, first of all, the orthopedic surgeon should take a look at it.

It can be a foot and ankle surgeon, it can be also the guy or the colleague who is experienced in sports injuries and then, finally, we will decide whether this particular person needs radiographs or not.

Dr. Miller: Question for you, is the injury of an ankle sprain usually to the inside or the outside? Medial or lateral on the foot?

Dr. Barg: Most likely, it is on the lateral side. On the lateral side, we have actually three ligaments and especially the anterior ligament. That means that the ligament in the front. It's a very thin ligament and almost everybody of us has already injured this. Fortunately, they do heal very well and I would say only maybe five percent of those patients with the lateral ankle sprain, that means the sprain on the outside, they develop the chronic instability that needs to be treated.

That is different on the medial side. Fortunately, on the medial side, the injuries are definitely rare. They are not as often than on the lateral side. However, most likely, the patient with the severe sprain of the medial ligaments, that means on the inner side, they do develop later the chronic instability that needs to be treated surgically.

Dr. Miller: After an ankle sprain, we determine it's not a fracture. What are the sorts of things that a patient can do, a person can do to eliminate the discomfort, the swelling and then get back in the game, so to speak?

Dr. Barg: Usually, I divide the severity of ankle sprains in four grades. Like first grade is a very mild sprain, the fourth grade is definitely the severe sprain. The mild sprain, the patient with the mild sprain doesn't need a specific therapy. They can [below] the ankle if it's comfortable for them.

Usually, we can start with physical therapy pretty quickly and the physical therapy, the main of the physical therapy is the first main, is to decrease the local swelling. The second main is the so-called proper [inaudible 00:05:20] exercises. Proper [Inaudible 00:05:22] exercises would work meaning that the physical therapist can teach the patient how to better control the ankle.

Again, if the sprain is more severe, for example, when I have a feeling that all ligaments on the lateral side are torn or even those medial ligaments can be damaged, in those patients, I recommend immobilization in a boot, for example, six weeks with only partial weight bearing. During that time, we're just trying to give the ligaments the chance to heal, time to heal. Exactly.

Dr. Miller: What I'm hearing is if a person has an ankle sprain, number one, look to see if there's discoloration. So anything that looks like blood beneath the skin. By discoloration, you mean black and blue?

Dr. Barg: Yes, and I do mean exactly this.

When Do I Get an X-Ray?

Dr. Miller: You probably need an X-ray or should get an X-ray and seek attention for that. If you can't weight bear immediately after, that doesn't necessarily mean that you have a fracture, but if that persists beyond a day or 12 hours to a day, then you probably need an X-ray. Even if it's a mild sprain and you're still struggling with pain after a couple of weeks, then you need to seek attention for that and get radiographs to make sure you haven't had a fracture.

Dr. Barg: Yes, absolutely. Another specific situation in this patient group is, for example, again, 95 percent of this group do heal without any restriction in the long term. However, those five percent, they still have, for example, four, six months after the initial injury, they still have some pain in the ankle or especially the instability feeling. Specifically, when the patient tries to walk on an uneven surface. Those patients need to see the doctor to see whether they need to be treated or not for ankle instability.

updated: October 28, 2020
originally published: September 9, 2015

Dr. Miller: Painful feet, especially in the morning, could that be plantar fasciitis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm here with Alexej Barg. He's an orthopedic surgeon here at the University of Utah and we're going to talk about foot pain as it relates to plantar fasciitis. Alexej?

Dr. Barg: Yeah, the plantar fasciitis, I'm originally from Switzerland and in Switzerland we call it the folks disease. Almost everybody in the country did experience this type of disease at least once in his life. Dr. Miller: What is it?

Dr. Barg: Actually, many people do not really know what it is. And I really do believe that plantar fasciitis is not a diagnosis. It's like a headache. A headache is not a diagnosis, it is just a symptom. And I do strongly believe that plantar fasciitis is also just a symptom.

Dr. Miller: Then it has multiple causes?

Dr. Barg: Yeah. Dr. Miller: Is it just pain?

Dr. Barg: It is the pain, but then you should figure out what is causing this pain and this is the most important part to plan the treatment. And maybe let me tell you what are the typical causes for plantar fasciitis.

Dr. Miller: Could we, before we talk about the causes, let's talk about what the symptoms might be. So if someone comes to you, how will they present with their problem before you look for the causes?

Dr. Barg: So, first of all, everybody can come with a plantar fasciitis regarding age. There is no big difference between genders. It can be female patient. It can be male patient. Typically, the patient presents with heel pain localized across the heel but with some radiating pain along, for example, the arch of the foot. These are the typical symptoms of plantar fasciitis.

Dr. Miller: Is it more common in people with high arches or what we call flat feet?

Dr. Barg: Yeah, the patient's with the flat feet do usually present with those pains, but there are also some different, some other causes. For example, for plantar fasciitis another cause can be the tightness of the lower leg muscles, especially on the back of the lower leg.

Dr. Miller: The calf muscles?

Dr. Barg: The calf muscles, exactly. And the second kind of common reason for plantar fasciitis can be the problem with the Achilles tendon. That means the Achilles pain can actually radiate to the plantar fascia so the people do think that the plantar fasciitis . . .

Dr. Miller: So it's a referred pain almost?

Dr. Barg: Exactly. Dr. Miller: So the typical person with what we would call the typical symptoms of plantar fasciitis, they experience that when they are putting weight on their feet? When they first get up in the morning and walk across the room or do they have that pain even at rest when they're not weight-bearing?

Dr. Barg: So usually the patient presents with two types of pain during the day. First of all, early in the morning so they have some problems getting into their shoes. For example, to get out of the house to walk to the car and during the day they're getting better. However, if they are all day on their feet at the end of the day they usually experience the same pain after they are weight-bearing on their feet.

Dr. Miller: So it sounds like there are different causes. There must be different treatments.

Dr. Barg: Yes, there are. So, first of all if the patient has a flat foot deformity then you should try to correct the flat foot deformity. In most cases, there is no need for surgery. For example, you can prescribe custom-made shoe insoles with some medial arch support. Most commonly, I also recommend the physical therapy. The physical therapy helps to reduce the local pain. And when we speak, for example, with the patient with the tight calf muscles there are some very specific exercises you can prescribe to the patients to elongate or to strengthen the calf muscles which may help to get the pain relief.

Dr. Miller: Now, I've seen some of my patients with plantar fasciitis who've seen physicians or podiatrists who treat that using a ball they roll up and down their feet. I don't quite know what that's for.

Dr. Barg: It helps actually. It helps even better if you put this ball in the freezer or in the fridge because then it's cool. What is even more important is to try and strengthen the plantar fasciitis. And the doctors can show them in the clinic how to do that or the patient can go to the physical therapist and the physical therapist can teach the people how to do that. Very important those stretching exercises should be done at least 10 times a day.

Dr. Miller: So for the calf or the bottom of the foot?

Dr. Barg: It's for the bottom of the foot. It's hard to describe how to do that. So what you usually do is bend your knee and you put your foot on the contralateral. That means the other ankle and pull on your toes so you try to flex the foot. You try to bring the plantar fascia in tension. And then you go with your thumb over this fascia, which is actually quite painful. So therefore I do recommend to do it just one minute or two minutes, but it's better to do it 10 times a day. Dr. Miller: So it's self-massage?

Dr. Barg: Exactly.

Dr. Miller: So it's basically massage of the sole of the foot while the foot is flexed. And how effective are the treatments if done correctly?

Dr. Barg: It's very, very effective. I would say in 90 to 95% of all those patients with these very simple measures can get pain relief. And usually I'd like to see the patient maybe six or eight weeks after the initial treatment. Fortunately, the patient normally doesn't show up in my clinic then because that means they ignore the follow-up appointment because they are absolutely pain-free.

However, the patient that has remaining pain, if they are coming back, then I do recommend shockwave therapy, which is extremely effective in treating plantar fasciitis. However, I do not like to start with this therapy despite the fact that it's an effective therapy because this therapy is very painful. So you're using kind of ultrasound machine and it hammers on the insertion of the plantar fascia, which is painful, which induces inflammation and the inflammation induces in itself the self-repairing process for the plantar fasciitis.

Dr. Miller: So if it doesn't hurt it's not going to do you any good?

Dr. Barg: Exactly. Exactly.

Dr. Miller: Now, one final question. I've heard some people mention that they've had a bone spur and someone told them that was the cause of their plantar fasciitis. Could you comment on that?

Dr. Barg: In the meantime, we know exactly that the bone spur is not the cause of plantar fasciitis. Many patients coming to me say, "My family doctor told me to remove the bone spur." I would definitely not recommend to do it because if you do just remove the bone spur, first of all, you will not eliminate the pain, but you may weaken the plantar fascia and even rupture the plantar fascia while you do remove the spur, which can be a big problem for the patient.

Dr. Miller: So, basically, lots of people have bone spurs. That doesn't mean it's the cause of the problem.

Dr. Barg: Yeah. So when we take just 100 normal people off the street without any pain and do any radiographs of the feet, I'm pretty sure we would detect maybe 10 or even 20 people of these 100 asymptomatic people, meaning people without pain, and we will see in up to 20% some spurs of the heel bone.

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Dr. Miller: Who gets ankle arthritis and what to do about it. We're going to talk about that next on scope radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Alexej Barg. Alexej is a professor of orthopedic surgery here at the University of Utah. Alexej, who gets ankle arthritis?

Dr. Barg: This is a very particular problem. We don't know actually why that people do develop, for example, knee osteoarthritis or hip osteoarthritis, however, we know exactly who does develop the osteoarthritis of the ankle joint or the subtibiotalar joint.

Dr. Miller: That's really interesting. I mean, we are more commonly used to hearing about knee and hip arthritis, not so much about ankle arthritis.

Dr. Barg: The most common reason to develop ankle osteoarthritis is previous trauma. It can be the bony fracture, but it can be also the repetitive ligament sprain of the ankle joint.

Dr. Miller: Due to sports injuries typically? Or is this some line of work that would be a problem?

Dr. Barg: Both injuries can lead or can end up final in end-stage ankle osteoarthritis. And many people do speak about hip or knee osteoarthritis however the ankle osteoarthritis is a growing problem. Upcoming in Europe and in Europe right now every tenth patient who is coming to an outpatient clinic for an orthopedic problem is coming with a problem of ankle or the foot, including ankle osteoarthritis. So this is a growing problem. It should not be underestimated. There are some studies showing that the patient having end-stage ankle osteoarthritis have the same pain, the same disability in daily activities comparable to those patients having, for example, hip osteoarthritis.

Dr. Miller: So it's obviously painful. So again, what is it that causes this arthritis? What sorts of people are prone to develop ankle arthritis?

Dr. Barg: In the past decades, several studies have been published to figure out which are the risk factors to develop ankle osteoarthritis, especially posttraumatic ankle osteoarthritis. And I would say in my opinion there are two very important factors: the first is definitely the severity of the initial injury. For example, if you have a fracture of the lower leg including the tibiatalor joint surface, that means that those patients have also the cartilage lesion at the time of the initial injury. And the second significant risk factor is for sure the deformity because some people or the most people, more than the half of all patients with ankle osteoarthritis, have a concomitant lower leg deformity. That means they have uneven load distribution within the joint, which finally leads to end-stage disease.

Dr. Miller: So it sounds like fracture of the foot, fracture of the ankle can lead to ankle arthritis. Is that correct?

Dr. Barg: This is correct. This is absolutely correct. And . . .

Dr. Miller: So automotive accidents, industrial accidents can lead to arthritis.

Dr. Barg: Yes, absolutely correct. However, the bony fractures of course they are severe injuries and everybody is aware of it. However, I mentioned this before, also there are repetitive ankle sprains and ankle sprains are definitely the most common sports injury in this country but also worldwide. I would say if you have at least two or three ankle sprain a year that means you are at high risk to develop, sooner or later, ankle osteoarthritis.

Dr. Miller: And so does ankle arthritis develop at a younger age typically than we see hip and knee arthritis in the United States? I think in general we will see knee and hip arthritis at the age of 55 and above.

Dr. Barg: This is another challenging problem specifically in this patient group. You mention this correctly. The patient with knee or hip osteoarthritis, they are usually in their fifth or sixth life decade. Patients with end-stage ankle arthritis, they are much younger. So sometimes I even see patients that are 30, 35 years old and their ankle joint is really gone. That makes the treatment is this patient group specifically very challenging because whatever you plan to do in those patients they should usually last for many years. That means for another 50 or maybe even 60 years in the future.

Dr. Miller: Typically patients with ankle arthritis will present with pain and, I suppose, immobility, some type of immobility in the ankle. So what then are the next steps? Obviously they make their way to you, they know about your practice. What do you advise them?

Dr. Barg: First of all, I take a very exact medical history. So I want to know exactly how long the patient had the pain. What type of injury, if they had an injury, what type of injury exactly they had? Usually, I collect all possible medical records from the past. And the second step is definitely the clinical assessment, the clinical investigation. I do see how good the movement of the ankle is. I want to also check the alignment. That means they ask whether the ankle joint is straight or not. I also check the stability. And then finally I go further with the imaging, which is an extremely important part.

Dr. Miller: X-rays, typically?

Dr. Barg: Yeah, I always stay with a weight-bearing radiograph. Weight-bearing if very important. Many patients come from the family doctors, for example, with some imaging, but this imaging is not useful. I call is accidental imaging. Because you see just a very small part of the ankle, not weight bearing. That means you still see some ankle osteoarthritis, however, because they are not weight-bearing radiographs, you cannot really assess for example the alignment of the ankle joint.

Dr. Miller: So you're going to do a more thorough radiographic examination based on weight-bearing than typically you would see in a standard practice. Okay.

Dr. Barg: Yes.

Dr. Miller: Then, moving on to treatment, there are obviously different types. You can fuse the ankle, but there are other aspects of that care as well, I gather.

Dr. Barg: In the literature, mostly two treatments are described for the end-stage ankle osteoarthritis. This is to fuse the ankle or to replace the ankle. That means to use an ankle prosthesis. An ankle prosthesis, especially in the last two decades, experienced a really great progress. Regarding the design of prosthesis, they are definitely some designs are more anatomical design, which may really mimic much better the normal anatomy and normal biomechanics of the ankle joint.

However, in my opinion, both treatment options are not perfect. And so, therefore, in my clinic, we always try to use the joint preserving procedure. That means a surgery where you try to correct the underlying deformity. And you don't have to fuse the ankle. You don't have to replace the ankle. That means the patient still has their own ankle.

Dr. Miller: For our listeners, fusing the ankle, what does that mean?

Dr. Barg: To fuse the ankles means that you can do it actually laparoscopically, that means minimally invasive. Or you can do an open procedure. You just remove the remaining cartilage, you stabilize the tibiatalar joint using different implements. It can be screws, it can be plates.

Dr. Miller: These are the large joints at the back of the ankle, I guess.

Dr. Barg: Yes. And this for many decades has been the gold standard procedure for end-stage ankle osteoarthritis. The problem is for those patients the ankle joint does not move. That means that the functionality of the ankle joint should be taken over by adjacent joints. For example, by the subtalar joint, which is the joint underneath. And that means sooner or later those patients will develop diminutive changes in their adjacent joints. That's the biggest problem following ankle fusion.

Dr. Miller: Similar problem to folks who have disc fusions in their back.

Dr. Barg: This is maybe a similar problem, yes. Absolutely.

Dr. Miller: Some of them develop arthritis above and below the fusion.

Dr. Barg: I agree with you.

Dr. Miller: So because the points of stress change.

Dr. Barg: I agree with you.

Dr. Miller: Interesting. Alexej, in your experience, rebuilding the ankle joint, how durable is that? How long-lasting is that surgery? How much relief will it give and how long can one expect that to be helpful?

Dr. Barg: These questions cannot be answered clearly with a certain number, like two years, five years, 10 years. In my experience, if you do the joint preserving procedure, approximately 20% of all patients still need a bigger surgery like ankle fusion or ankle replacement within 10 years after the surgery. Which maybe the first sign is not that encouraging number, however, I can just tell you that if you do a very exact selection for this procedure, the patients are very happy because they still have their own joint. They don't have any restrictions doing, for example, recreation or sports activity. And actually this number is very dependent on how severe the ankle osteoarthritis is. I do communicate this very often and very clearly with the patient and I tell him what his expectation should be in the particular case.

Dr. Miller: It sounds like you have a great knowledge of the prognosis of each of these procedures that would help your patients make a decision on what to do.

Dr. Barg: Yeah, most likely we can say and predict exactly whether the procedure will last for two years or five years or for the 10 years. And for two years, sometimes if the patient is, for example, a hard worker and has to work on the street and has to lift heavy weight, this patient will not profit immediately, for example, for ankle fusion or ankle replacement. He'll want to wait another two or five years until he's retired and then he's ready for another surgery. Those patients are very thankful that you can offer them the joint preserving procedure.

Dr. Miller: Are there other tips for people who might have ankle arthritis? How do they find their way to a particular orthopedic surgeon? Should they see a specialist? Should they see a generalist orthopedic surgeon or should they see someone else, like a sports medicine physician?

Dr. Barg: I would suggest if the patient has ankle osteoarthritis, it doesn't mean a late stage. If it's at the early stage or the end-stage, this is a very challenging problem with many concomitant problems, which can be overseen by a person who is not that experienced in this area. By concomitant problems, I'm speaking, for example, about a concomitant deformity, a concomitant instability and so forth. So I do really think that those patients should really be seen be a person who has experience in dealing with this problem and who can also offer a different treatment option. Because the treatment options in the beginning of ankle osteoarthritis are definitely different, for example, than for patients with end-stage ankle osteoarthritis.

Dr. Miller: So bottom line is if you have ankle pain, try to have that diagnosed earlier rather than later. And if you have ankle arthritis, find your way to an orthopedic specialist who specializes in lower extremity problems.

Dr. Barg: Yes, absolutely. I agree with you.

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