Traumatic Ankle Capsulitis
After a severe auto accident with traumatic injury to the ankle, not everyone recovers normally. Some people can form a “capsule” around the ankle that inhibits the mobility of the ankle. Ankle capsulitis, for example, can happen after osteochondral fractures, which are fractures that occur within the joint itself, resulting in loose bone fragments in the joints and ultimately to severe degeneration of the joint. In response to the joint damage, the joint freezes and mobility is lacking.
Traumatic ankle capsulitis is a type of adhesive capsulitis, which is a disease of the joints that can also affect the joints of the hip, wrist and shoulder. Once the ankle freezes by the formation of connective tissue around the joint, it is extremely difficult to treat and it leads to disability and walking difficulties.
Traumatic ankle capsulitis causes increased pain in the ankle along with limitations of the range of motion of the ankle, both active and passive motion. The patient can no longer evert the ankle (meaning it cannot bend laterally) and eventually it is unable to invert (bend inward) or rotate. In the late stages, there is global lack of motion of the ankle, chronic pain and an inability to walk normally.
Risk Factors to having Ankle Capsulitis
Certain populations of individuals have an increased risk of developing ankle capsulitis. These include people who have the following conditions:
• Inflammatory arthropathy
• Heart disease
• Joint infection
• Connective tissue disease
• Autoimmune diseases
• Degenerative joint disease
Traumatic ankle capsulitis doesn’t happen right away. As the joint attempts to heal itself, inflammatory cells infiltrate the joint, causing an increase in connective tissue formation in the joint. After three to four weeks, the capsular or “fibrous” layer of the joint thickens, damaging the integrity of the joint and creating bands of collagen that stiffen the joint, preventing full range of motion. Eventually, the presence of inflammatory cytokines within the joint capsule cause contractures of the joint and permanent thickening of the joint capsule itself.
Symptoms of Traumatic Ankle Capsulitis
Those who suffer from ankle capsulitis will report having had an ankle injury that involved severe sprain or fracture of the ankle, often due to a fall or automobile accident. Pain is chronic and often associated with crackling of the joint and the sense that the joint is “popping” with any motion whatsoever. The joint can appear normal or can be contracted with thickening around the ankle joint itself.
Other signs and symptoms of ankle capsulitis include the following:
• Ankle swelling
• Freezing of the ankle
• Increased pain with any active or passive movement of the ankle
• Limping and difficulty bearing weight on the ankle
• Atrophy of the muscles surrounding the ankle
What causes ankle capsulitis?
Ankle capsulitis is most commonly associated with some sort of severe trauma to the ankle although there are cases of idiopathic ankle capsulitis and capsulitis that occurs as a result of suffering from many ankle sprains.
How is ankle capsulitis diagnosed?
Patients with ankle capsulitis will describe having multiple ankle sprains or a significant trauma to the ankle as a result of a fall, inversion injury to the ankle or an ankle injury as a result of a motor vehicle accident. The capsulitis often follows the injury by several weeks. Some patients experience temporary relief of their ankle pain, only to go on to increased pain and stiffening of the ankle with an inability to move the joint.
On physical examination, passive dorsiflexion and plantar flexion of the ankle is limited with increased pain on attempting to move the ankle. If the diagnosis is in question after a thorough history and physical examination, an arthrography can be performed to clarify the diagnosis. This is an x-ray dye study of the ankle which will reveal the following:
• Decreased volume of the joint space from 10-25 cc to less than 5 cc
• Resistance noted when attempting to inject the contrast dye (due to excessive fibrous layer around the joint)
• Absence of ankle reflexes
• Backflow of contrast dye which flows backward due to inability to put in more than a few milliliters of contrast dye into the joint during the procedure
Arthroscopy can also confirm the presence of ankle capsulitis, although it is more invasive than arthrography and is a painful procedure. Ordinary x-rays of the ankle may or may not show the increased fibrous capsule around the ankle unless the capsule becomes infiltrated with calcium deposits (this can occur after several years of suffering from the condition). Some doctors are resorting to MRI analysis of the ankle joint, which often shows the lack of joint fluid and the increase in thickness of the joint capsule itself—both classic findings in ankle capsulitis.
What is the treatment for ankle capsulitis?
Physical therapy can help patients with traumatic ankle capsulitis. During therapy, the focus is initially on increasing the passive range of motion of the joint, followed by strengthening and increasing the active range of motion about the joint. It is not unusual to require up to ten weeks of physical therapy in order to regain adequate strength and range of motion about the ankle.
Physical therapy helps only some patients with ankle capsulitis. Others will need to have arthroscopy, which includes removal and scraping away of the fibrous capsule around the joint so that an immediate increase in range of motion is possible. Increases of range of motion can approach an average of 18 degrees of increased dorsiflexion and 23 degrees of ankle plantar flexion with surgery alone. In some cases, injectable corticosteroids are introduced into the joint space to relieve inflammation and maximize the positive results gained during arthroscopic surgery.
In one situation, a 36 year old male patient suffered from pain in the ankle and recurrent bouts of ankle swelling following an oblique fracture of the fibula along with a fracture of the medial malleolus in an automobile accident. The fractures were immediately casted until the fractures healed. Following removal of the cast, the patient experienced a decreased range of motion of the ankle and increasing pain. An arthrogram was ordered which showed a bony loose body within the joint itself, osteoporosis of the ankle and a persistent deformity of the distal fibula. The patient was unable to tolerate more than 1.5 cc of contrast dye without feeling a sense of tightness in the joint and backflow of the contrast joint was noted. The arthrogram was abnormal with a lack of contrast dye infiltrating the entire joint space, instead leaching back through the injection site. Based on these findings, a diagnosis of traumatic ankle capsulitis was made.
Traumatic ankle capsulitis can be a complication of severe ankle trauma, such as is seen in severe falls or motor vehicle accidents. Rather than recovering normally, the ankle forms a thick capsule around it so that it has limited range of motion, muscle atrophy around the joint and increased pain when attempting to walk on the affected leg.
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