Breaking an ankle can be a very painful injury at the onset. Unfortunately, there are cases when pain persists much longer than it should.
A broken ankle can range from a simple crack in the bone up to a complete break of one of the ankle bones that may even puncture the skin.
Treatment for a broken ankle can be as simple as keeping weight off of it while it is in a cast during healing or, for more severe cases, be corrected with a surgical procedure that uses plates and screws to align and stabilize the bones.
Unfortunately a broken, or fractured ankle, sometimes takes a considerable amount of time to return to the prior pain-free ankle that it was before the fracture, if possible.
Research has shown that individuals who have broken their ankle can have pain with walking, stiffness, swelling, or some type of physical disability 14 months to 6 years after their initial injury.
Another study of ankle injuries reported that one in five individuals did not report a good or excellent outcome when surveyed 4 to 14 years after their ankle fracture.
One reason given as a possibility for the poor outcome is insufficient or sub-optimal rehabilitation, or physical therapy, following the broken ankle.
Complications that may lead to prolonged pain
Although they are not common, there are issues that can occur after a broken ankle that may delay complete healing and increase the likelihood of prolonged pain.
1. Arthritis: If the area of the break goes into one of the ankle joints there is a chance of developing arthritis in that joint. The inflammation and pain in that joint are classified as post-traumatic arthritis. The mechanics in the joint are altered because of the break and therefore the wear and tear on the joint surfaces are accelerated, leading to an earlier onset of arthritis in that joint versus what would have been expected otherwise. At times, the joint can get irritated from overexertion or altered mechanics of the joint resulting in inflammatory arthritis. If the inflammation persists then adaptive changes may occur in the cells by the damaged area causing chronic inflammation.
2. Bone infection: If the fracture causes the skin to be punctured from the bone it opens up a space for bacteria to enter the body and lead to infection. Also, with any surgery, there is always a chance of infection. Measures to keep the area clean will assist in preventing this negative side effect.
3. Nerve damage: If a break is severe enough it may cause stretching of nerves which can lead to pain. There is a chance of nerve damage during an ankle surgery which can also cause pain to persist longer into the recovery period. The ankle is more susceptible to nerve damage because the nerves run closer to the surface of the skin from the lower leg to the foot. Nerves can be damaged through overstretching during the break itself, compression from the swelling due to the break or post-surgical swelling, injury from the hardware used during the surgical procedure or from a bone fragment.
Stages of pain following a fracture
Many people with ankle fractures will only experience the typical stages of pain. This would include the initial pain from the injury, or acute pain. This is typically the most severe the pain will be and it is expected to gradually decrease over time. The acute period lasts up to a few weeks.
The second stage is called sub-acute pain and it is that pain that continues as the healing is taking place. It will not be as severe as acute pain and may not be constant in nature. The cause of this pain is due to the weakening of the surrounding muscles, shortening of the soft tissue around the break due to lack of movement during the healing process, a buildup of scar tissue, and lingering inflammation in the area.
This sub-acute pain should also decrease over time as the muscles surrounding the break regain their flexibility and strength. Healing time for a broken bone lasts typically 6-8 weeks. The sub-acute pain period will typically last during this time period.
It is the third stage or chronic pain, that can be most discouraging. Luckily not everyone will experience chronic pain. Many individuals with an ankle fracture will progress from the more severe acute pain into a gradual decrease in pain symptoms while in sub-acute pain and then fully recover to a pain-free state. However, for those that do not reach a pain-free level, an explanation of this pain can be the first step in becoming pain-free.
Chronic pain is that pain that persists after the bone and the surrounding soft tissue has healed. This raises the question of what is causing the pain if the bone is now healed.
Persistent, or chronic pain after a broken ankle, can often be due to an over-excited nervous system. In some cases, changes occur in the central nervous system, or spinal cord, which allows pain to be felt when it typically would not be.
For instance, normal motion of the ankle that would not hurt after the break is healed or even something as little as light touch to the area of the break can cause pain sensations when the nervous system is in the over excited state.
This simply stated, means that the pain is not coming from the broken ankle itself, but rather is the body not being able to properly process the movement or touch. Injury level does not always equal the pain level that is felt.
Not everyone will experience this increased excitability of the nervous system. Although it is not clearly proven what causes this to happen there are risk factors that seem to lead to its occurrence. Those factors include anxiety, fear of movement after an injury, depression, poor sleep, as well as genetic factors for having low pain thresholds.
How to avoid or decrease chronic pain after breaking an ankle
Following proper rehabilitation of the ankle is an important key to avoiding chronic pain. Physical therapy will work on reducing swelling, improving range of motion throughout the ankle, increasing strength and stability through graded exercises and working on normalizing walking patterns that have been altered during periods of less weight bearing.
While all of these will work on improving the ankle directly they also work indirectly to encourage the nervous system to function properly which in turn, decreases the risk of developing chronic pain.
If chronic pain has already developed, physical therapy can still work toward reducing the pain. Repetition of exercise can help to decrease the overly sensitive nervous system through gradual exposure of ankle movements.
This assists in breaking down the pain memories that are related to certain movements of the ankle and actually reverse the changes in the central nervous system that have developed.
The exercise will be gradually increased in intensity. Initially exercises will focus on gaining range of motion through active movement of the foot and ankle and stretching exercises. As healing continues the physical therapist will progress the ankle through strength training or resistance exercises.
Strength training will be provided through the use of resistance bands, use of one’s own body weight against gravity by performing exercises in standing, and with the use of weight machines. Resistance exercises have been shown to improve the pain threshold of individuals. This is key in improving chronic pain that has reduced the pain threshold.
Through strength training that is guided in intensity by a physical therapist, one can begin to tolerate normal movements and activities without experiencing the pain sensations.
Breaking the cycle of pain and inflammation
Chronic pain can be a discouraging factor leading to the avoidance of movement and physical activity. This, in turn, leads to more muscle loss, stiffness, and reduced function. All of which contribute to the continued pain.
Physical therapy can assist in breaking this pain cycle. Through proper training with a physical therapist, motion, strength, and pain reduction can be restored. Even in cases where pain has progressed to the chronic stage, there is evidence that shows changes can still be made that will allow pain to be reduced and even eliminated.
Progressive exposure to previously painful movements among other techniques such as mirror therapy can desensitize the nervous system ultimately reducing or eliminating chronic pain over time. It is important to know that physical therapists are trained to work with patients in such a way to not only retrain muscles but also to encourage beneficial changes in the nervous system.
For chronic inflammation, exercise will help to reduce the unwanted consequences of an overactive inflammatory response. Regular exercise will induce positive adaptations both locally at the injured site and systemically throughout the body ideally calming localized and systemic inflammation. If the exercises are specifically developed for fractured ankle recovery then there should be less strain and inflammation to your affected leg.
For both chronic pain and inflammation, recovery would not be complete without proper nutrition. People often hit barriers in their rehab when stumbling blocks get in the way. These stumbling blocks may be related to a lifestyle pitfall such as unknown food addiction to sugar and other high-carbohydrate and processed foods. Or there could be an autoimmune problem such as rheumatoid arthritis, inflammatory bowel syndrome, obesity, diabetes, or other chronic diseases adding to the complexity of your rehab.
Theoretically, you could have the perfect exercise program but still struggle with chronic pain and inflammation due to nutrient deficiencies, genetic, or metabolic dysfunctions. In order to break through these obstacles, it will be important to educate yourself about these topics.
Begin with baby steps such as starting an exercise program, reading articles, or watching videos on these topics, joining support groups, and getting inflammation under control to prepare your body for long-term success.
We can provide you with many of those options from the comfort of your own home. For example, you can access the learning center of other company, Active Atoms, to learn how curcumin, the active ingredient in turmeric, can help to support a healthy inflammatory and immune response throughout the body here:
You can also join our free broken ankle Facebook support group to connect with other people who are recovering from a similar injury as you. I help to facilitate this group and share recovery information with everyone. Free free to join our broken ankle support group or any of our other support groups at the end of this article.
Read how Grace reduced her ankle pain and inflammation after three years of suffering
Our Free broken ankle/foot quick start recovery guide book is coming soon!
This free quick start guide will include five exercises and stretches to promote continued ankle recovery after surgery. It's ideal for someone who still has pain in their ankle or foot once they finish insurance-based physical therapy.
The guide will include instructions and photos of different exercises that have helped many of my clients. The guide is currently under development, but I can email it to you when it's ready for you to download.
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