Severe Ankle Sprain, Deltoid Ligament Repair, Think my Foot May Be Going Flat/Collapsing

Triathlon Forum
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Background:

30 yo male. Athletic. Trying to get back to running/physical work

Initial injury:

In October 2023 I had a bad inversion sprain. Significant pain, bruising and swelling all over from shin to toes.

X-ray showed small fibular avulsion fracture

MRI showed: Complete ATFL tear, partial CFL tear, Partial tears to deep and superficial deltoid. Osteochondral lesion to the talar dome. Everything else unremarkable.

Conservative Management Failure:

My first foot and ankle ortho doc put me in a boot and said I could weightbear and move out of it as tolerated. I spent a week mostly non weight bearing in the boot. Then about two more weeks in it weight bearing. Moved to an ASO brace and the worst I did for it was walking though at times it was painful I still felt it was tolerable. Told my doc I had tolerable pain but a strange feeling of pronation. He said it didnt matter boot or not as long as it was tolerable, just play it by ear. I think I should have been in the boot and no weight bearing for longer and I’m kicking myself for listening to my first doc. A few moments of bad pain but it would always settle down after like a day of rest. I noticed that the bones on my medial side ankle appears to be sticking out farther with the collapse.

Surgical Management Ongoing:

Skip to December and I can walk, can’t run without pain and feeling like my ankle is collapsing a bit and surfaces that evert me cause pain. I get a second opinion from another foot and ankle ortho who says given the feeling of medial collapse that a repair of the deltoid ligament with internal brace along with microfracture and arthorscoptic clean out would be reasonable (he said this after looking at second MRI he insisted on). Said he isnt worried about the tightness in the PTT and the MRI shows no damage or fluid to it. He also said my first doc missed a nondisplaced talus fracture on the MRI that has now healed well on its own.

Second MRI showed: CFL and ATFL had scarred in somewhat well, deep deltoid had scarred in but superficial deltoid still had small partial tear. PTT was completely normal in both MRIs

I got the repair in February about 3 months ago (5 months from initial injury) and though I have some relief My foot definitely still collapses inward unless I actively flex it. 1 month no weight bearing. 1 month progressive weight bearing. 1 Month into real PT now. I am worried this surgery did not solve the issue and I may do more damage to something. In general my functionality is improving, but the little collapse still worries me.** I always have tightness in my Posterior tibial tendon always compared to my other leg but minimal to no pain unless Im stretching calves**. Its just tightness and I can heel raise and generally that is not where I have most pain. During dynamic PT I have pain around where the ATFL is. I cant tell if my PTT is swelling between the tibia and navicular or if its just from the incision scar, but there is swelling there. Not painful to the touch.

Even when the ankle collapses inwards a bit it still has a visible arch.

Also seems like I have a really inactive abductive hallucis and a hallux valgus now. I will say the surgery improved a feeling of hindfoot valgus I had though its not completely the same as the other side.

My second surgeon said he expects I will improve immensely with the next 2 months of PT.

I’m just worried that I may be on the road to a collapsing foot and I would rather get ahead of it than not. At this point I am hoping I can run in some way at some point in the future.

Questions:

How long should I actually have been in a boot or non-weight bearing?

Is it worth investigating the PTT anymore after 2 MRI’s?

What else could be causing the collapse?

Is this an injury you would expect someone to recover from given how it was initially managed and is managed now?

What is my best plan moving forward?

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Disclaimer: Non ortho MD here.

I was reluctant to post initially, but given it has been a few days I will now.
The situation you find yourself in is not really one in which you will find good reliable advice from the likes of this forum and others.
It is a highly specialised area (in terms of what you are dealing with), as shown by the treatment you have received so far.
You need advice from high experienced people in this area (too often in internet forums you will receive well meaning but misguided advice from people who do not always know the specifics of their own injury versus your own etc).
I do wish you all the best in terms of recovery and treatment (and for finding advice online). I for one know how frustrating injuries can be. Just be careful with whom you take advice from, especially in an online environment.

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I don’t know anything about this but I can empathize w injuries absolutely sucking. If you need an awesome foot and ankle surgeon in Portland ME, pm me for a name

Keep us updated. Sorry I can’t help you more.

4

So, when you say you feel like your foot is collapsing, you are not talking about the arch but the way the ankle rolls inward with each step? I’m just trying to picture what’s going on here.
Have you filmed yourself walking to see the difference between your two ankles.
I’ve not had the same surgery as you but I did have a repair of the ligaments (Brostrom) and a repair of my peroneal tendon. For months after surgery, my ankle felt weak and was definitely swollen. It seemed to take around 6-7 months for the swelling to go away. It took me about 3-4 months, after each ankle surgery, to return to running. When I was in the first few months postop, I definitely felt like one side of my foot/ankle was weaker than the other. The biggest issue related to this was my calf strength. I had none and it has taken forever to build it back up even close to the same level as my other calf. At first, doing a single leg calf raise was impossible, and I thought it would never come back. It has taken almost a year of fairly intense calf strengthening to have my two calves anywhere close to equal. Like I said, I know my surgery is not the same as yours but this can give you a little perspective how I felt during all of the healing and recovery

5

Little update after a meeting with my surgeon.

Yeah the ankle collapses inwards and I don’t have good push off pressure through my first ray. It seems in general that my medial longitudinal arch is present but lax. The plantar fascia is looser and the abductor hallucis doesn’t seem to work well. We are looking into nerve damage there as I have some tingling in areas indicative medial plantar nerve damage.

I basically got a Brostrum for the medial ligaments after 3 months months of the sprain getting better in some ways but not in others. It’s been 3.5 months since the surgery so a little early but I can tell my ankle is just constantly slanted towards pronation. I’ve recovered from bad lateral sprains before and this is a whole different beast. Unfortunately it seems the medial ankle is much more prone to progressive failure once it is weakened. And unfortunately I was allowed to weight bear as tolerated out of the gate and even after it was discovered I had the deltoid tear. Idk it’s just hard to wonder what if and blame myself for pushing it too hard after the injury and in PT and whatnot.

My second surgeon, who did my procedure, thinks it’s likely my first doc did not notice the slow beginning of medial collapse in my ankle after allowing me to weight bear too early. When I got the surgery the deltoid ligament was still very slightly torn and was stretched out. I had posterior tibial tendonitis throughout my injury. His and my theory is that since the ligament was stretched it caused a very small tear or stretching of the posterior tibial tendon (couldn’t do single leg heel rise at my first PT appointment but could later). This led to all the medial longitudinal arch structures to be over stressed and partially collapse. He thinks I will have good results with PT but I think it’s gonna be tough given that I feel my ankle alignment is still off.

I had symptoms that were minor but in context seem specific and now with my knowledge seem important. I stepped backwards one day and tweaked my posterior which I was told was just tendonitis. I had some arch pain while recovering that was likely my medial arch ligaments attenuating a bit. One day I woke up and had trouble spreading my big toe as well (this is when I got a second opinion) which was likely the start of abductor hallucis failure. As a patient with only knowledge of lateral sprains I just thought this was all sort of normal (except the big toe one) when recovering from a bad sprain. Where I really feel like I was let down was when I told my doc I felt like I was slightly on the wrong part of my heel which is a big sign of developing hind foot valgus.

So basically the deltoid ligament being sprained and slightly torn caused everything medially to stretch for a month or two and now that it’s fixed everything else is still lax which is why there is still collapse (think early stage iia adult acquired flatfoot).

Pretty devastating for me as I just got a really good physical job in a place I love and now it’s kinda up in the air what my future mobility will be. Especially devastating because I didn’t know as much about ankles when I was originally hurt and asked if the deltoid involvement meant I should weight bear less or stay in the boot longer. One of those wish I had a better doc, wish I had more knowledge situations.

I have a follow up with a head of foot and ankle reconstruction at a major fellowship hospital in my city in a few months. It’s probably all too little too late but I’ll let you all know the update.

I guess my advice to anyone out there is to take the deltoid ligament very seriously. It’s not like the lateral ligaments and the posterior tib and ligaments can’t be repaired like the atfl and peroneals can.