Contributor:
Gregory Waryasz, MD, CSCS, and Jeremy T. Smith, MD, Mass General Brigham Sports Medicine foot and ankle specialists and orthopaedic surgeons

When you rely on your feet to carry you through your favorite sport, the idea of an ankle surgery (even to treat a painful injury) can be scary. Unfortunately, ankle injuries can be common in athletes, and sometimes, ankle surgery is the best treatment option. A sprained ankle, for example, is the most common injury in sports. Other common ankle injuries include a stress fracture, broken ankle and overuse ankle tendon injuries (known as tendinopathies), says Gregory Waryasz, MD, CSCS, sports medicine specialist at Mass General Brigham foot and ankle orthopaedic surgeon at Massachusetts General Hospital.

No matter what your ankle injury, you need your recovery to accomplish one thing: to get you back in the game as quickly as possible. Depending on your unique situation, that may or may not mean ankle surgery.

"You try something, patients often feel a little better, but then the pain comes back. At that point, you either try the same treatment again to see if the injury settles down, try a new treatment or you jump into surgery."

3 Factors That Determine If You Need Ankle Surgery

1. Type of Injury

The good news is that most ankle injuries don't require surgery since many ankle injuries are minor, like an ankle sprain. However, when injuries become more severe, ankle surgery becomes increasingly probable. For example, ankle tendinopathies (overuse tendon injuries that result in ankle pain, swelling and stiffness) can usually heal through rest and physical therapy. But if your ankle tendon or ligament actually tears, you may need ankle surgery in order to fully recover. Similarly, an ankle bone fracture may heal just fine with an ankle brace, boot or cast, but an ankle fracture that is displaced or involves more than one bone in the foot may require ankle surgery with the insertion of pins or screws to hold the bone , tendon and ligament in position.

2. Sport or Exercise of Choice

Sometimes, your sport or activity of choice is what determines if ankle surgery is a good idea, says Dr. Waryasz. For example, hockey players can sometimes potentially skate with a minor ankle fracture or bone bruise in their foot. However, if you play a running-heavy sport like soccer, playing with a foot or ankle fracture may be too painful and could cause further damage. A foot or ankle injury may not be safe to play on and your doctor can explain why that is. In cases like this, foot or ankle surgery might be wise, so talk through your options with your doctor.

3. Treatment History

If you've been dealing with your injured ankle for a while now and still have foot or ankle pain and or swelling, you may need ankle surgery to prevent further bone, tendon, or ligament damage. Or, if you keep experiencing the same type of ankle injury over and over again, chances are you need to switch up your treatment approach.

"That's part of the normal process of conservative care. You try something, patients often feel a little better, but then the pain comes back," Dr. Waryasz says. "At that point, you either try the same treatment again to see if the injury settles down, try a new treatment or you jump into surgery."

Ladder of Ankle Treatment Options

Regardless of how you've injured your ankle, there are different levels of treatment to consider. The first line of treatment may work for 80 percent of patients, but if it doesn't resolve your issue, you often have other options before surgery, says Jeremy T. Smith, MD , sports medicine specialist at Mass General Brigham and foot and ankle surgeon at Brigham and Women's Hospital.

Here are several types of treatment options available, listed from the least to most invasive:

Step 1: Rest

Giving your ankle a short break from sports can be just what it needs to feel better. How long you rest may vary depending on your injury and sport, so seek guidance from your doctor, physical therapist or athletic trainer. (See ankle injury prevention)

Step 2: Physical Therapy

Performing flexibility, mobility and strengthening exercises can help ease ankle stiffness and any weaknesses that may contribute to your foot pain or ankle instability. Your doctor may recommend rest in addition to physical therapy, or you may be able to do physical therapy while still participating in your sport. Check with your care team to figure out what's right for you.

Step 3: Medications and Injections

If rest and physical therapy aren't enough, there are anti-inflammatory and pain-relieving medications you can turn to. This can include over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen as well as in-office cortisone injections, according to Dr. Smith. Orthobiologic injection options can also be used for treatments.

Step 4: Extracorporeal Shockwave Therapy (ESWT)

This procedure delivers low-energy shockwave impulses to injured tendons to stimulate healing. Because it's noninvasive, doctors may try ESWT before recommending surgery.

Step 5: Surgery

When all else fails, surgery may be your best option. When considering ankle surgery, always work with a surgeon who specializes in foot and ankle injuries and has experience helping athletes such as yourself.

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