The sprained ankle that won't heal: pain? Swelling? Weakness? Here's what's going on.

Do you have a sprained ankle that won't heal? It's not that rare. Studies have shown that 10 to 30 percent of sprains will have symptoms later. So what is a sprained ankle anyway? It's the most common injury in all of sports and dancing.

Dancing pushes your body to its limit. If you roll over on your ankle when landing from a jump, you can sprain or injure the ligaments on the outer (lateral) side that hold the joint together. This is different from a "strain," which affects your tendons and muscles. An easy way to remember this distinction is this: You sprain your ankle, but you strain your Achilles tendon. The degree of injury varies, depending on the damage to the ligaments. We determine this by a physical exam and X-rays that help us classify the ankle sprain as Grade I (mild), II (moderate), or III (severe). The most serious sprain involves a complete tear of the ligaments with marked instability that often requires surgery. Fortunately, most sprains are Grade I or II and heal in three to six weeks. The exceptions are those that continue to cause trouble. This is the "sprained ankle that won't heal."

In medical circles, residual problems from sprained ankles cause considerable angst, because they can be hard to diagnose and difficult to treat-especially when telltale signs are ignored by stoic dancers. Problems with old sprains tend to fall into three categories: swelling, pain, and instability ("giving way").

SWELLING

It's normal for a sprained ankle to swell, sometimes for four to six weeks, or longer. But swelling that persists for more than three months may be a sign of trouble. The lining of the capsule surrounding a joint is called the synovium, and anything inside the joint that irritates the synovium will cause it to secrete fluid. Swelling inside of a joint is often a sign that something is causing irritation. (The swelling that is seen from the outside is a combination of soft tissue swelling around the joint and fluid within the joint itself.) In the ankle there are several reasons for this condition. While these may seem alarming, treatment is possible. But first, let's take a look at the culprits.

Chronic synovitis Sometimes there is damage to the surface of the joint that does not show up on any tests, such as an X-ray or MRI, even though it continues to cause irritation and excess fluid.

A bone chip At the time of injury, a bone chip may have been knocked loose, leaving a "loose body" floating around inside to cause trouble.

An OCD lesion "OCD" in sports medicine stands for osteochondritis dissecans (not obsessive compulsive disorder). The easiest way to think of this is like a cavity in a tooth. It is something that leaves a small hole in the surface on the ankle bone (the talus) with a dead piece of bone in it. An MRI study will usually pick this up.

A bone bruise This is not black and blue. Instead, it feels like an achy pain that is difficult to explain and lasts for months. There is edema, or fluid, within the bones themselves that we can only see on an MRI study. Fortunately, it is rarely serious and gradually fades away.

What can you do? Treatment for chronic swelling, no matter what the cause, usually requires sleeping with the leg elevated on a pillow at night and putting on an elastic ankle support in the morning when you get out of bed. If the swelling is minimal and is slowly going away with no other symptoms, it is OK to dance, but go easy on the jumps and grand plies till all the swelling is gone. However, if it doesn't feel so good then don't do it! An ankle support (no need for metal hinges, etc.) usually feels good at this stage.

It also helps to avoid the saltshaker, which leads to water retention. With diligence, the swelling should go away. However, if the leg is swollen up the shin, something else may be happening, and it needs to be checked out by your doctor. Swelling that does not go away is a sign that something more is wrong. Normal joints do not swell.

PAIN

There are several common causes of ankle pain that does not go away:

The sinus tarsi syndrome Lingering inflammation, scar tissue, or a partly torn ligament can occur in the hollow place in the side of the anklebone called the sinus tarsi (sinus in Latin means hollow or sunken and the tarsus is the ankle). This is the most common cause of the sprained ankle that won't heal. While it can be difficult to discern this problem on an X-ray or MRI, a physical exam by a dance medicine specialist can pinpoint the diagnosis by locating the exact area that hurts.

A tarsal coalition Residual pain in the sinus tarsi after the original sprain heals can also be due to an unrecognized tarsal coalition. The ankle has two components: the regular ankle joint that moves up and down, and the subtalar (ST) joint beneath it that moves in and out. Together, they make up the ankle joint complex. Some people are born with limited motion in their ST joint because the bones in this area are joined together where they ought to be separate--a coalition. It can usually be seen on an X-ray or MRI. This condition is present in about five percent of ankles. It usually occurs in one ankle only, rather than both. As with a sprain, it can be mild, moderate, or severe. In dancers, it is usually mild or it would have caused trouble before the sprain. Dancers with mild symptoms can often work around it.

The high ankle sprain This is marked by tenderness in the front of the ankle on the outside. Unlike routine ankle sprains where the main damaged ligaments lie right in the sinus tarsi, this one affects a ligament that is higher up, at the level of the ankle joint itself. This is the so-called "high" ankle sprain, which can be a real bugaboo because it takes two to three times longer to heal than a routine sprain. It may not show up on medical tests, so the diagnosis is usually made on the basis of the physical exam.

Secondary problems Lastly, there are several conditions, such as FHL tendonitis ("dancer's tendonitis") and the os trigonum syndrome that seem to pop up out of nowhere. Dancers often think that the residual pain is part of the healing process when it is actually a separate problem. Later the sprain may heal, but these conditions can continue to be painful and may even require surgery if left unaddressed.

INSTABILITY

"My ankle gives way" is probably the second most common leftover problem with ankle sprains after the sinus tarsi syndrome. We doctors see it all the time. Many things can cause this problem. Fortunately most respond to appropriate treatment.

Peroneal weakness There are two peroneal tendons that run parallel down the outside of the ankle; one is short and the other is long. Their major function is to keep the ankle from rolling over and prevent sprains. After an injury they can remain weak, so the ankle is poorly protected from further roll-overs. It's easy at this point to fall into the vicious cycle of "Because it's weak it rolls over and because it rolls over it's weak," which can go on for months. If this is the problem, it is easy to fix. Simply restore the normal peroneal strength with physical therapy. A few months of daily use of a theraband, under the guidance of a physical therapist, will usually strengthen the peroneals. (They gain strength faster if the exercises are done in the full "tendu" position.)

Laxity of the ankle ligaments

Grade I sprains do not usually damage the ankle ligaments to any extent, but repeated Grade II or Grade Ill injuries can lead to permanent looseness of the ligaments that hold the anklebones together. This is a difficult situation, because they can be tightened only by surgery. The surgery is quite effective, but the recovery is usually three months or more. So it is nice to avoid it if you can.

Many loose ankles often give way because of a combination of looseness and weakness. These can often be brought up to full strength with physical therapy and then they don't give way anymore. The number one indication for ankle ligament surgery is the failure of rehab to correct the problem.

PAIN, SWELLING, AND INSTABILITY

The problems associated with a recurring sprained ankle can co-exist and produce all three symptoms. In this ease the diagnosis is particularly difficult. There is one last problem that might be going on:

Peroneal tendon damage With repeated sprains, the peroneal tendons can develop small longitudinal rents or tears. When this happens, the tendons swell up in the sheathes that surround them and cause achy pains, chronic swelling and weakness that cannot be corrected by exercise. This problem is easy to miss and hard to correct because it usually gets worse in spite of all treatment. Fortunately, this condition also responds well to surgery.

The best way to diagnose these various problems is to see a sports or dance medicine specialist for a history, physical exam, and appropriate studies. Your doctor may request X-rays followed by an MRI, CT and/or bone scan. Physical therapy is usually the first step in the recovery. Do not try to treat yourself! There is an old expression in medicine that says, "Someone who treats themselves has a fool for a physician." Merde!

What Works for Me

ANDREW VEYETTE, soloist, New York City Ballet 

I had three severe sprains on my left and three not so bad on my right. The last time, I knew exactly what I had done, which grade it was, and what to expect pain-wise. Even my Grade III only ever took six to eight weeks to recover. While I was out I did cycling and basketball free-throws--any kind of physical exertion. Dr. Phillip Bauman gave me a Malleotrain, an ankle brace with supportive pads. I wore it for a week solid until I needed to wash the thing. I did normal icing wrapped around the ankle, 15 minutes on and 15 off, every two hours the first 48 hours. After that it was two, maybe three, times a day. If you come back from an injury too fast it will swell up again.

Maybe this happens when I let myself get distracted. I stop paying attention in the air, and then I'm on my butt. Now I try to focus on dancing in a sound, organic place starting at the barre. It's always when you think you don't have to think about it any more that you hurt yourself.

KEITH ROBERTS, Movin' Out

My first sprain was Grade II plus. My ankle swelled to size of my calf, and I was in a boot for two months. There was nasty bleeding inside, so I had arthroscopic surgery to clean out scar tissue. But I would always get minor sprains, rolling over when landing from a jump. Then, in performance, I injured the deltoid ligament on the inside. After two years of taking anti-inflammatories, I realized I needed to have the ligament fixed. Dr. Hamilton did reconstructive surgery, and it's worked really well. I haven't sprained my ankle since then. The best exercise is to balance on a flat foot, standing for a minute with eyes closed. There are sensors within your foot that are the first thing that go, and that's the first that you need to get back. And you can do ballet steps in a swimming pool, where you don't have your full weight. That's where I relearned how to jump.

BY WILLIAM G. HAMILTON, M.D.

William G. Hamilton, M.D. is the orthopedic consultant for New York City Ballet, American Ballet Theatre, The School of American Ballet, and the Jacqueline Kennedy Onassis Ballet School.