Essential Insights In Treating Medial Ankle Sprains

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Christopher Corwin, DPM, MS

   Custom orthotics to address the posterior tibial tendon and medial ankle can be of great value for these patients. These orthotics often include a low medial flange and deep heel cup to support the medial column. Send cleats with the molds to the lab to help ensure a proper athletic fit.

   Modifying shoegear is also important. This may involve switching from narrow, firm ground cleats to a wider, more supportive turf shoe. Too often, clinicians ignore the shoes athletes wear off the field or court. Wearing good shoes on the field or court, and then wearing flip-flops or Ugg-type boots (“the winter flip-flop”) off the field can be self-defeating. The fashion arguments of young athletes aside, patients will benefit from an appropriately fitted running shoe worn off the field for at least the first few weeks out of the boot.

   Physical therapy is extremely important. This must include proprioceptive and balance exercises, and progress to the complex movement patterns of the athlete’s particular sport. The athlete must then continue these exercises at home for a few months after the conclusion of physical therapy.

Pertinent Pointers On Surgical Intervention

The majority of isolated medial ankle injuries heal well without the need for surgical intervention. However, chronic instability may require reconstruction. This involves direct repair of the deltoid ligament and may involve removal of a fracture fragment or accessory bone from the medial gutter. While these fragments may clearly show on radiographs, they are often encased in scar and the thick fibers of the deltoid ligament. Accordingly, they can be somewhat difficult to find. Intraoperative imaging to localize the fragment can be of great benefit in this case.

   When you are having thoughts about deltoid ligament reconstruction, you should also give significant consideration to the posterior tibial tendon, which is often involved in the injury and may become insufficient. Direct repair of the deltoid ligament and posterior tibial tendon may not be enough. Severe valgus deformities may require medial calcaneal slide osteotomies, spring ligament repair or other procedures associated with flatfoot reconstruction to provide long-term successful outcomes.

In Conclusion

While medial ankle injuries are not nearly as common as lateral ankle injuries, they can cause prolonged pain and discomfort. Some high-level soccer players report feeling occasional symptoms while playing for up to nine months after the injury. Most of the time, protection, physical therapy, shoegear modification, orthotics and appropriate bracing can get the athlete back into play without the need for surgical intervention.

   Dr. Corwin is an Associate of the American College of Foot and Ankle Surgeons. He is in private practice in Media and Phoenixville, Pa.

   Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.

1. DiGiovanni BF, Partal G, Baumhauer J. Acute ankle injury and chronic lateral instability in the athlete. Clin Sports Med 2004; 23(1):1-19.
2. Myerson M. Foot and Ankle Disorders. W.B. Saunders Company, Philadelphia, 2000, p. 1459.
3. Mann R, Coughlin M. Surgery of the Foot and Ankle, 6th ed. Mosby, St. Louis, 1993, p. 1139.

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