In our practice we see many people with chronic ankle sprain reporting that surgery has been recommended as their only option. Why? Because chronic ankle instability is very common and unfortunately prone to re-injury or recurrent problems.
Chronic Ankle Instability
An estimated 40 percent of people who suffer from an ankle sprain will be left with long-term pain and weakness and up to 70 percent will eventually develop osteoarthritis. The reason is because the majority of ankle injuries do not heal properly after injury and respond poorly to the traditional methods of treatment.
There are three types of ankle sprain, separated into grades of severity. The first, a grade one sprain, is the least severe. This occurs when the ligaments are slightly stretched out, causing minimal tearing of the tissue fibers. This is the type of injury that doesn’t cause severe pain, and the victim can usually “walk it off” without permanent damage. A grade two sprain involves further tearing of the ligaments and can cause instability in the ankle joint. This type of sprain leads to a lot of swelling and tenderness, which makes it difficult to walk and move around. A grade three sprain is indicated by a complete tear of the ligaments, and will make itself known with extreme pain, swelling, and lack of function.
Sprinting and change of direction in chronic ankle instability
A May 2022 study (1) discussed rehabilitation programs: “Chronic ankle instability in athletic populations appears to be highly associated with declines in functional performance and to a somewhat lesser extent, ankle range of motion, strength and muscle endurance measures. This may suggest that optimal rehabilitation for athletes with Chronic ankle instability may require a greater focus on improving sprinting speed and change of direction ability in the mid to latter stages of rehabilitation, with regular assessments of these functional performance tests necessary to guide the progression and overload of this training.”
Mid-tarsal joint sprains
Mid-tarsal joint sprains are generally seen in athletes who play sport or activity where there is jumping and landing. The ligaments that are typically sparined and injured are the calcaneocuboid ligament and the Calcaneonavicular ligament. Part of these ligaments join together as a bifurcate ligament.
An April 2020 paper (2) wrote about the undiagnosed ligament injuries in the subtalar and midtarsal joints. “Ligament injuries around the subtalar, talocalcaneonavicular, and calcaneocuboid joints are often underestimated on clinical and imaging findings during investigation of patients with ankle and foot injuries. Because a delayed diagnosis of midtarsal ligament tears may lead to chronic pain and functional disability.”
While recognizing ankle sprain as a common injury in professional soccer, researchers discussed the lack of research on a concurrent injury to ankle sprain. That being a midtarsal sprain.
In this paper from February 2021 (3), 52 professional soccer players who underwent 59 MRI examinations after acute ankle trauma were assessed.
- MRI revealed isolated ankle sprain in 24 of 59 MRI examinations (40.6 %).
- Acute midtarsal ligament injury was present in 15 examinations (25.4 %).
- Four of the 15 examinations (26.7 %) had isolated midtarsal injuries and
- eleven of the 15 examinations (73.3 %) had concomitant ankle sprain.
In the isolated midtarsal injuries, return to play time was on average 39 days. Return to play time was significantly higher for athletes with combined ankle and midtarsal sprain (47 days on average when compared to athletes with isolated ankle sprain (24 days on average).
The conclusion of this study was presented as: “Our MRI study reveals that midtarsal sprain is a frequent injury in professional soccer players with ankle sprain. Midtarsal ligament findings on MRI combined with evidence of lateral ankle sprain is associated with a longer time of return to play compared to isolated lateral ligament injuries.”
This research followed an early study from 2018 (4) which wrote: “Midtarsal sprains are commonly associated with acute ankle injury and with ankle sprains. Presently, midtarsal sprains may be underrecognized by radiologists; thus, greater familiarity with the MRI spectrum of ligamentous and osseous injuries at the Chopart joint is important for accurate diagnosis and clinical management.”
1 Jamsandekar MS, Patel VD, Prabhakar AJ, Eapen C, Keogh JW. Ability of functional performance assessments to discriminate athletes with and without chronic ankle instability: a case-control study. PeerJ. 2022 May 27;10:e13390.
2 Zaottini F, Picasso R, Pistoia F, Perez MM, Möller I, Rossi F, Bruns A, Tagliafico AS, Martinoli C. Ultrasound imaging guide for assessment of the intrinsic ligaments stabilizing the subtalar and midtarsal joints. InSeminars in Musculoskeletal Radiology 2020 Apr (Vol. 24, No. 02, pp. 113-124). Thieme Medical Publishers.
3 Leiderer MT, Welsch GH, Molwitz I, Maas KJ, Adam G, Bannas P, Henes FO. Magnetic resonance imaging of midtarsal sprain: Prevalence and impact on the time of return to play in professional soccer players. European Journal of Radiology. 2021 Feb 1;135:109491.
4 Walter WR, Hirschmann A, Alaia EF, Garwood ER, Rosenberg ZS. JOURNAL CLUB: MRI Evaluation of Midtarsal (Chopart) Sprain in the Setting of Acute Ankle Injury. AJR. American Journal of Roentgenology. 2017 Nov 7;210(2):386-95.