I saw a patient today in Grand Cayman who had ankle instability missed after a big tib-fib fracture. I have seen more cases like this than I can easily count. Why does this happen? The bright shiny object syndrome! Let me explain.
What Is Ankle Instability?
The ankle joints are held together by strong ligaments that protect these structures. There are ligaments on the inside and outside of the ankle that can be damaged by trauma, and, regrettably, this is also common with the wear and tear that happens when you "turn" your ankle. When these ligaments get stretched out, the ankle joints can move too much, which is called instability. When this happens, the joints can get worn out faster and arthritis can set in.
How Could This Problem Be Missed?
Orthopedic surgeons often have a binary view of ligament injury. Meaning, if the ligament is torn in half, it needs to be surgically fixed, but if it's stretched and not working properly, it's often invisible as a problem and considered normal. Why? MRIs often miss stretched ligaments as this is a static imaging technology. Meaning, a ligament that's not working can only be tested by stretching it and seeing if it gives too much. That can be done on X-ray or ultrasound, but it's difficult to do with MRI.
How Is It Diagnosed?
The only accurate way to diagnose ankle instability is either with stress X-rays or ultrasound imaging. The ankle ligaments are stressed with movement, and if there's too much motion in the joint or ligament, the structure isn't doing its job. Please see my video below for more on this topic:
What Are the Consequences of Missing It?
If you miss this problem, the patient is much more likely to get ankle arthritis. In fact, in experimental animal models, this is one of the more common ways to create arthritis (damaging ligaments). Despite this, we see orthopedic surgeons miss this problem all the time. Why? What I call the "bright shiny object" syndrome. Meaning in multitrauma cases, like a fracture of both leg bones (the tibia and the fibula or "tib-fib"), they focus on the fracture and ignore possible ligament injuries. However, it's pretty hard to fracture bones without ligaments that hold those bones together also getting damaged.
What Happened to My Patient?
My patient was backcountry skiing and hit a big rock, which fractured her tib-fib bones. She ended up getting surgery to install hardware to hold the pieces together, which healed. Eventually, the hardware was removed at a famous sports-medicine clinic, and there she also had an injection of bone marrow concentrate into the main ankle joint. The problem? That fact that her ankle was unstable went over their heads. They missed that diagnosis, which likely ended up frying the joint as she became more active.
How Do You Fix This?
First, you need to know this problem exists. Second, you need to diagnose it. Third, the treatment is simple. For my patient, who was seen in Grand Cayman because of the severity of her arthritis, I performed prolotherapy injections into the lax ligaments using ultrasound guidance. She'll likely get one additional round of injections of platelet-rich plasma at our Colorado office due to the significant laxity. Finally, when she returns in March, we will hit them once again with her own culture-expanded stem cells.
The upshot? For my orthopedic colleagues, please check for ankle instability! We see it missed several times a week in patients who have seen orthopedic surgeons who should know better. That means our clinic has seen hundreds of patients with preventable ankle arthritis! So let's all get the memo!