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How can ligament injury of the ankle be treated?

Q: I am a 26 years old man suffering from pain in my right ankle for the last 2 years. The foot was injured due to an accident but there was no fracture. The MRI report stated multiple inter-tarsal ligament injuries, osteoporotic changes in tarsal bones and multiple marrow oedema involving tarsal bones. The doctor advised 20 days plaster and said it would take 4 months to cure. I am able to walk and stand easily but not for a long time. I feel pain on pressing the part. I consulted another surgeon 3 months back and he advised ultrasound and physiotherapy for 25 days. This too did not give much relief except some reduction in swelling. The pain is same as earlier. The doctor gave a local injection into the affected area, but in vain. A repeat MRI report stated that there was no obvious signal of abnormality or morphological abnormality seen in either ankles & ankle joints except slightly reduced joint fluid on the right side in tibio-talar joint and a small abnormal hyperintense signal area seen in the soft tissue of medial aspect of ankle which was not seen in the normal (left) ankle joint, S/O ligament injury, hyperintese signal intensity area seen in the antero-inferior part of talus bone of right foot S/O bone contusion. Now the doctor has advisedme to wear some good sport shoes during activity, soak my feet in warm salted water twice daily for 10 minutes and use Sayadex oil (2 times). Now I have little improvement but am not fully satisfied. How can I treat it?

A:Your symptoms have been on for two years. That is very unusual for any ligamentous injury or any infective or inflammatory condition of the bone and joint. Even fractures would have healed. However, an injury to the joint may some time persist long. As per your description two MRIs have been done and they are not conclusive. You have even had steroids locally which are also only fire-fighting without understanding the underlying cause. The MR lesion in the talus is also not very clear. Osteoporosis is expected in any case where you are not able to use your limb for long. In some cases of minor injuries there is a condition which used to be called as sudecks osteodystrophy or reflex sympathetic dystrophy. Currently this goes by a new name called complex regional pain syndrome (CRPS). The type that occurs after injury to the limb is CRPS-I, while when it occurs after an injury to a nerve it is called CRPS-II. You could possibly fit into a CRPS-I type but this diagnosis can be made only after clinical examination. This diagnosis is not often made in the treatment we have to be guided by someone who is involved in pain management. Pain killers, drugs that are called calcium channel blockers, sympathetic nerve blocks are all described. Since you already seem to be on your way to recovery, I would recommend you to continue with gentle exercises, avoid hot fomentation and gradually increase activity.

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