Ankle Conditions

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Ankle Arthritis
Ankle Sprains
Ankle Instability
Osteochondral defect
Anterior bony and soft tissue impingement
Posterior ankle impingement
Peroneal tendon injury
Achilles tendinitis
Achilles tendon rupture

ANKLE ARTHRITIS

Ankle arthritis is less common than hip or knee arthritis. The ankle is a very tight mortise joint so any fracture that has united with a step can lead to abnormal wear of the cartilage. The majorities of cases are posttraumatic and may be related to previous ankle fractures, repeated sprains or significant ankle injuries. The principle problems are pain, swelling and the effect it has on walking.
Weight bearing plain x-rays will show the hallmarks of osteoarthritis - loss of joint space, subchondral hardening of the bone with cyst formation and marginal bone spurs, which can block motion. The adjacent joints should be evaluated on the X-ray as they may also have developed degenerative change.

Initial treatment options include non-steroidal antinflammatory medicines such as Ibuprofen or Voltarol. Immobilisation with an ankle brace can help.

Steroid (cortisone) or a viscosupplement injection may produce temporary relief.
If the main radiological findings are prominent bone spurs (osteophytes) at the front of the ankle then these can be removed through a keyhole procedure or through an open incision.
More advanced cases require ankle fusion. In this procedure the bone surfaces are softened and prepared with power instruments so that all debris, cartilage remnants and hard bone are removed. The joint surfaces are excised.

This recreates a fracture environment. The bones are fixed in the correct position with large screws and the ankle put in plaster. As the bones mend, the two bones join together. As there is no joint there will be no pain. The gait afterwards is slightly stiffer- similar to if you were wearing a boot.  If there is a limp it is fairly subtle.

In carefully selected patients there may be a role for ankle replacement though the long-term results of this procedure are not as successful as hip or knee replacement.

ANKLE SPRAINS

An inward or inversion force applied with the ankle in a slight tiptoe position usually causes ankle sprains. The commonest ligament to be ruptured is the anterior talo-fibular ligament (ATFL), which is part of the lateral ligament complex.

The ankle will be tender over the anterior part of the lateral ligament. It is essential to palpate three other areas when evaluating an ankle sprain to exclude any associated fractures - the base of the 5th metatarsal, the proximal fibula neck and the medial malleolus.
Plain X-rays are indicated if there is tenderness on the bone of the tibia or fibula, or an inability to weight bear to exclude a fracture.
Symptoms that are still present at six weeks may justify an MRI scan. An MRI in the early stages is not that helpful as there will be distortion from the soft tissue swelling and has little input in the management plan.

The immediate management of a sprain is rest, ice, compression and elevation (RICE). Compression can be with a’ tubigrip’ bandage or even in severe cases by immobilisation with a plaster backslab. Rest and elevation are important- the leg must be lifted on pillows so that it is at the same level as the heart.

Most ankle sprains settle with the above regimen.
If the pain and swelling has not settled by 10 days then an x-ray and referral to physiotherapy should be considered.

Continued symptoms at six weeks warrant specialist evaluation and possibly an MRI or CT scan to exclude any other associated injuries. Even many normal patients with no ongoing ankle problems show evidence of previous damage to their ankle ligaments on the MRI scan, so a finding of ankle ligament damage on an MRI is only relevant in the appropriate clinical context.

ANKLE INSTABILITY

If a patient has repeated sprains because of the ligaments being permanently lax they are at risk of permanently damaging the ankle joint. Once the diagnosis of the extent and severity of the ankle instability (the ankle giving way) is made then a treatment plan can be initiated. A strengthening program is helpful. This is true even with patients who have had recurring sprains and chronic recurrent instability. About 50 percent of patients will respond to a regime of intensive peroneal strengthening and balance exercises. If the ankle is still unstable then surgical repair of the chronically loose ankle ligaments can be performed. There are many different techniques used to stabilize the ankle. The one I most commonly use is the Brostrom-Gould lateral ligament reconstruction. In this operation the lax ligaments are first taken them off the bone. They are then secured with a special stitch and advanced and reattached by drill holes into a bony channel made on the fibula bone. At the same time I use another local structure called the extensor retinaculum to reinforce the repair. Occasionally a tendon behind the ankle (the peroneal tendon) or a tendon graft may need to be used. These operations usually work very well allowing individuals to return to all forms of athletic activity without risk of recurrent injury to the ankle.

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Brostrum Recovery

ANTERIOR BONY AND SOFT TISSUE IMPINGEMENT

In football players and other sportsmen repetitive trauma when kicking a dead ball is thought to cause micro tearing of the anterior capsule, a structure that covers the front of the ankle. This leads to additional bone formation in the capsule leading to pain due to the bone and soft tissue getting pinched in the ankle hinge. It often presents with aching after the game and tightness at the front of the ankle when squatting. The bone and soft tissue overgrowth can be removed with keyhole surgery using powered bone abrading instruments.

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OSTEOCHONDRAL DEFECT

The cartilage lining of the ankle joint can be bruised when a sprain of the ankle occurs. As the talus twists in its mortise it can jam against the tibia. This causes a bruise and leads to localised softening of the cartilage. It may lead to a small crack in the cartilage and a cyst forming in the talus bone. This we refer to as an osteochondral injury of the talus ('osteo' is bone and 'chondral' is cartilage).
Osteochondral injuries often present in a non-specific way. The main presenting symptom is pain, which may be quite diffuse or localised to the region of the lesion. The ankle may also swell up. There is usually a history of injury to the ankle, which may have been a sprain that failed to resolve. Sometimes the presentation is quite acute, with severe pain and swelling in the ankle after injury and difficulty weight bearing.

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Some patients complain of locking or catching - which may be due to a loose body acting as a 'pebble in the shoe,' inflamed tissue at the front of the ankle getting pinched in the hinge or of giving way (instability).

There are many grades of severity of this osteochondral injury to the talus. Minor events lead to bruising of the talus. If the injury is more severe, large pieces of bone and cartilage can break off and lie loose in the ankle joint.

The treatment depends on the severity of the osteochondral injury. The more severe types require surgery. If bruising of the bone is present, resting the ankle may be all that is required to alleviate the process. If a cyst has formed then these cysts or osteochondral defects are invariably symptomatic and require treatment.

The treatment for an osteochondral defect of the talus is extremely varied and depends on the size of the defect and the extent of bone and cartilage loss. The simplest surgical treatment is arthroscopy. This is a keyhole procedure. Through one small hole a fine camera is inserted and another hole is used to pass instruments. 

Any loose flaps of cartilage are removed and associated inflamed tissue excised (synovectomy). The lesion is then inspected and the hard bone is penetrated with a curette or with a hard pick (microfracture). Both cause local bleeding and trauma to this previously hard, bald bone. The body lays down fibrocartillage, a rough cartilage that pads the previously bare area. Other, more extensive surgeries occasionally need to be performed. These range from replacing portions of the talus using a graft from the knee to harvesting and growing the patients' own cells in the lab and then attaching them to the defect (the latter technique is still experimental). If the defect in the talus is very large the ankle may need to be fused to eliminate the pain.

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POSTERIOR ANKLE IMPINGEMENT

Impingement is the pinching of soft tissue, bone fragments, or scar tissue causing painful and limited ankle motion. Posterior ankle impingement is caused by traumatic injury or overuse in dancers, football players, runners, and other athletes. Sometimes dancing or running on a hard surface contributes to the problem. In other cases, there is a slight difference in the normal foot and ankle anatomy that eventually leads to posterior ankle impingement. The joint capsule may be thickened causing pain when it gets pinched between two bones in the ankle. There may be bone fragments inside the joint that have broken off the bone and become free-floating pieces that get stuck between two bones. Whatever the cause, the end result is the same: chronic ankle pain along the back of the ankle (at rest and with palpation), pain with movement, and loss of ankle plantar flexion. One common cause of posterior impingement syndrome is called the os trigonum. There is an extra piece of bone present in affected individuals. For the person who has an os trigonum, pointing the toes downward catches the os trigonum between the ankle and heel. The repetitive force downward on the os trigonum every time the foot is pointed causes the bone fragment to pull loose. As the os trigonum pulls away, the tissue connecting it to the talus is stretched or torn. The area becomes inflamed causing pain and loss of ankle motion. Conservative care with physiotherapy and injections is the first line of treatment. When this is unsuccessful, surgery can done to remove the offending tissue (e.g., bone fragments, scar tissue, thickened joint capsule). In recent years this surgery is now done through a keyhole approach with a much quicker recovery.

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PERONEAL TENDON INJURY

The two peroneal tendons lie immediately behind the fibula, the bone on the outside of the ankle. They move the foot outwards. They are important in balance, as they counteract the inward motion that usually causes sprains or instability. They are slightly weaker than the muscles and tendons on the inside of the ankle and are prone to injury as the ankle turns, rolls or becomes sprained.

Tears of these tendons do occur. One or both of the tendons can be torn. This leads to swelling, pain and a sense of instability behind the outside of the ankle.

Occasionally the tendons can be injured in either a fall or an athletic injury. They pop out of the supporting ligaments that hold them in place and dislocate. Once this occurs, recurrent dislocation and tearing of the tendons is inevitable. If the tendons dislocate acutely in an injury, they need to be repaired to prevent future tearing of the tendons. Once dislocated, the tendons can only be stabilised through surgery.       

The diagnosis of peroneal tendon injury is made through careful examination and palpation by the orthopedic surgeon. An MRI or ultrasound may be required to document the extent of the tear.
The diseased tissue needs to be excised after which the tendons can be repaired. Sometimes both tendons need to be attached together.

Sam performs live surgery for dislocating peroneal tendons - View the video here

ACHILLES TENDINITIS

The Achilles tendon is the strongest, thickest tendon in the body. It is the tendon for the gastrocnemius and soleus muscles whose primary motor function is plantar flexion of the ankle.
Achilles tendonitis, which is seen in athletes, runners and hikers, is caused by local irritation of the paratenon or degeneration within the tendon.

The pain may be felt at site where the tendon inserts into the calcaneus (Insertional Achilles Tendinosis) or in the watershed area about 3cm from the insertion (Non-insertional Achilles Tendinosis). The latter is often associated with a fusiform or spindle like swelling at this point. The pain is typically exacerbated by activity and sometimes precipitated by a change in training pattern or shoe wear.

The exact cause is not known but there are several factors that contribute. One simpler explanation is that part of the strength of the achilles tendon comes from the fact that the tendon fibers are twisted. As we push off with our heel the tendon untwists and this elastic recoil improves the “bounce” generated by the tendon. The epicentre of the twist is about 3cm from where the tendon attaches to the bone so here we are wringing the tendon of its blood supply- just like when we dry a wet sock! Small tears in the tendon at this sit don’t heal as well and as they heal with scar, the tendon gets fatter.

Most cases settle with medical treatment with NSAIDS, eccentric loading exercises  following the Alfredson regime, hell lifts and a reduction in activity. It can take some months to settle.
Injection of a high volume of fluid around the tendon by the x-ray doctor under ultrasound guidance may help. The fluid and steroid can free the sheath off the underlying tendon. The small nerve endings that cause pain can be chemically destroyed with concentrated glucose.

Only when symptoms fail to settle with the above simpler measures do I consider
Surgeries to tidy up the tendon. If the pain is where the tendon inserts into the heel then often a bony prominence (Haglund bump) will need to be removed. If the tendon is very damaged with lots of extra calcium in the tendon itself then part of the tendon will have to be lifted off the bone and the muck scooped out. The tendon is then reattached with very strong sutures.

When the pain or disease in the tendon is away from where the tendon inserts into the bone then the bad tissue is scooped out of the tendon, any splits in the tendon are repaired. If the sheath around the tendon is tight it is released.

Post-operative rehabilitation varies with each case and is something I will go over with you.

ACHILLES TENDON RUPTURE
The Achilles tendon is the strongest, thickest tendon in the body. It is the tendon for the gastrocnemius and soleus muscles whose primary motor function is plantar flexion of the ankle.

This is a potentially very serious condition that, surprisingly, is often missed.
Its incidence appears to have increased in recent years, a change possibly related to pursuing sports until a later age or more accurate diagnosis.

Patients may or may not have a pre-existing history of pain in their Achilles tendon. They may report hearing a loud noise such as a ‘pop’ or ‘bang’, or feel that they had been kicked or shot in the leg.

If the rupture presents within 48 hours of the injury then both conservative and surgical treatment is possible. The duration of immobilisation is the same with both options, typically 8 weeks in a combination of a cast and in the latter period a waking boot.

Surgical repair is associated with extra risks, in particular wound healing problems but does offer a reduced risk of re-rupture. After 48hours, surgical repair is favoured as the blood clot that fills the void starts to mature and harden, preventing tendon ends from coming together even if the foot is put in a cast with the toes pointing downwards.

The mainstay of physiotherapy starts when the boot is off at 8 weeks. We want to regain the range of motion in the ankle and the strength in the calf. There will be a mild limp for some months. Return to full contact sports can take 6 months.

View acute achilles tendon rupture:
diagnosis and assessment video