The ankle joint is frequently injured in active, or even non-active populations. Whether participating in athletics, having a fall, or simply rolling your ankle while walking, most people will experience some injury of the foot or ankle in their lifetime.
Due to the fact that there are many ligamentous structures around the ankle joint and the fact that it a highly mobile joint, injuries to this structure are common.
Some of the injuries to the ankle include:
- High ankle sprains
- Lateral (side) ankle sprains
- Medial (inside) ankle sprains
- Fractures of the ankle complex
Many ankle injuries do not require surgery and can be rehabilitated with physical therapy and rest. However, there are some traumatic injuries or repetitive motions that can cause a breakdown of the musculoskeletal structures that will require surgical repair.
These surgeries may include:
- Bone fixation
- Ligamentous repair
- Tendon repair
- Screw implantation
Bone fixation involves an implant of metal plates, screws, and pins to approximate the two ends of the broken bone to help with healing.
Ligamentous repair involves stitching the torn ligament and implanting a screw into the bone.
Tendon repair is usually stitching and suturing a torn ligament. All of the procedures above will be performed by an orthopedic surgeon.
After surgery, most people will demonstrate increased swelling, fatigue of the joint, and soreness. Sometimes this swelling can persist for many months. Additionally, you can have some pain in the joint even after the surgery has been performed.
How long does it take bones, ligaments, muscles and tendons to heal after surgery?
Some tissues in the body will heal faster than others. Muscles and bones typically heal fast than tendons and ligaments. Typicall, the body heals the injured tissue or area by sending the building components of the body to that area.
After a muscle is injured, the body will send certain metabolic cells to repair the injured area by laying down collagen, fibrocartilage, and elastin that serve as the lattice on which your muscles operate.
Muscles typically heal the fastest due to the fact that they have good vascularization and innervation, which, is to say that they have a good blood supply and a good nervous system supply, respectively.
This allows the metabolites to get to the injured area faster and in the most efficient manner. Muscles will mostly be healed after 4-6 weeks from the injury.
Bones also have a good vascular supply; however, it is not as thorough as muscles. Additionally, bones will have osteoclasts and osteoblasts which, along with the collagen, fibrocartilage and elastin will help to heal the bone. Typically, it can take 6-8 weeks for a bone to heal.
Tendons and ligaments
Tendons and ligaments are the slowest structures in the body to heal, if at all. Due to the fact that they have a poor blood supply, these parts of the body are slow to receive the metabolites and healing components of the body that help to repair tendons and ligaments.
Again, if the injuries are severe enough and the tears are significant, surgery will have to be performed. Tendons will typically heal in 16-20 weeks after surgery, and most ligaments heal 6-8 months after surgery.
If the injury is severe enough, tendons and ligaments almost always need some type of surgical repair in order to approximate the two torn pieces and allow healing.
Depending on the structures involved, the biological process of recovery may be slow and you can experience pain and swelling months after surgery.
How does the CAM boot affect your healing after surgery?
A CAM boot is a device that will stabilize your ankle for a time after foot and ankle surgery. It will usually look like a normal boot and will stop at mid-calf or right below the knee.
The purpose of this is to stabilize the ankle so that there is no lateral/medial movement and to allow for the healing of ligaments and tendons. It also helps to disperse load on the foot to reduce concentrated pressure on the injured area.
Often times, a surgeon will advise you to wear a CAM boot for 6-8 weeks after most surgeries for ligaments, tendons or bone repairs.
The idea is that, since you walk every day, you need to limit the amount of pressure and tension that you place on a repaired ligament, tendon or bone.
The CAM boot allows for stability. Unfortunately, it also leads to stiffness, atrophy of the surrounding muscles, swelling, and soreness. While it is important to let the injured area heal, it is also vitally important to start to strengthen and engage small intrinsic muscles in the foot as soon as possible.
A good way to increase mobility and strength is to start an exercise program under the supervision of a physical therapist. Gentle range of motion will help you to reduce atrophy and reduce tightness/scar tissue formation.
Exercises can be done while out of the boot if you maintain a non-weight bearing status and follow the guidelines of your surgeon and physical therapist.
It is important that you discuss with your surgeon when you can start to work on gentle range of motion outside the cam boot due to the fact that these structures are slow to heal and can be delicate for the first few weeks.
Should I stop going to rehab after insurance decides I no longer need to go? What are the benefits of continuing rehabilitation?
Due to the high mobility, constant use, and long healing time of the ankle joint, it is important to continue physical therapy for 6 -18 months after the surgery. Of course, this depends on the type of surgery that is performed and what activity you are trying to get back to.
Some injuries such as dislocations, fractures and lateral ankle sprains will require extensive rehabilitation. Most athletic endeavors involve heavy impact on the ankle joint such as cutting, changing directions, accelerating and deceleration on the ankle joint.
If you are engaging in this type of activity, your therapist will need to implement and engage in return to sport activities.
Plyometrics (jumping), balance activities and running sprints are the most typical return to sport activities. Some examples of plyometrics are box jumping for basketball or lateral cone jumping for football or soccer.
Re-learning how to land on the ball of your foot and utilizing the lower calf muscles is important for performance and injury reduction of the ankle.
For other injuries, such as a high ankle sprain or a lateral (side) ankle sprain, it may take a long time to rehabilitate due to the poor healing nature of the ankle structures and due to the constant use of this joint in many activities.
Your therapist might recommend bracing, balance training, or continued manual therapy to alleviate any pain or sensitivity in the joint.
Bracing could include a high ankle brace that prevents inversion/eversion (in and out) motion of the ankle that would help to reduce lateral and high ankle sprains.
Balance training such as walking on even and uneven surfaces or single leg balance exercises will train intrinsic musculature of the foot to reduce the risk of injuring the ankle again.
Finally, manual therapy can help to mobilize scar tissue after surgery and reduce knots inside the muscles that may lead to pain and decreased flexibility.
Why does physical therapy end before I am ready to go back to my sport? What are the benefits of continuing physical therapy after my insurance coverage ends?
In today’s healthcare environment, your insurance company or provider will only want to see a few objective measurement improvements in therapy, then they will usually try to end therapy stating that it is no longer necessary.
These measurements are reflected in range of motion, strength, and flexibility. What these insurance companies and providers fail to include in their assessment is return to play/sport.
While your objective measurements may, on paper, look very good, it may not give a full assessment of explosive strength or pain with high intensity activity.
A person who is not active may not need a lot of explosive strength or engage in sprinting, however, many athletes or active individuals will require these abilities.
Very frequently, insurance companies will stop paying for therapy and cause a cessation in your rehab before you are reasonably expected to perform plyometrics, running training, or return to sport.
Depending on the sport, walking is simply not enough to participate in most sports due to their explosive nature. Physical therapy will end well before you are ready to start return to sport protocols or return to activity.
In order to prevent further injury and to get back to what you were doing before your injury, it is important that you continue with therapy until you and your therapist determine your readiness and fitness for return to play.
Rehab of 1 year or longer after surgery will help reduce the risk of re-injury, improve athletic performance, and improve overall health and well-being by getting you back to your activities with full abilities.