Ankle Sprains
Ankle sprains occur by twisting your ankle to one side, and as a result, the corresponding ligament or ligaments become stretched or torn. The most common ankle sprains occur to the anterior talo-fibular ligament and the calcaneo-fibular ligament on the outer side of your ankle. This is referred to as an inversion ankle injury. Sprains affecting the inner side of your ankle are much less common. These effect the deltoid ligament and are referred to as an eversion ankle injury. If you have an ankle sprain your ankle will generally be painful, you will see swelling, and often time the swelling might be quite severe. Often times your ankle may appear to show black and blue discoloration.
Treatment for this acute condition should involve:
- Elevation of the ankle: making sure it is lifted off of the ground
- Ice massage the sore ankle with ice packs
- Immobilization: making sure not to put weight on your ankle
- Compression: bandage wrap or brace to help reduce swelling and provide support
Chronic Lateral Ankle Instability
If you have had recurrent and frequent ankle sprains you may perceive some instability in your ankle when standing or walking. If your ankle feels as if it is going to twist or sprain while walking over the slightest uneven terrain, this condition is referred to as lateral ankle instability. If this condition occurs over a long period of time, it is considered chronic lateral ankle instability.
If you feel that the treatment of your suspected ankle sprain is not effective, and that your pain and/or swelling is not decreasing, these may be signs of a more advanced injury. In this situation, we recommend that you immediately seek in person professional medical attention. The picture to the right demonstrates a contemporary method of surgical correction for chronic lateral ankle instability.It involves reconstruction of the ligament using a strong suture material that is called a fiberwire bridge.The procedureis called a Brostrum-Gould Repair.
Ankle Fractures
Ankle fractures can occur as a result of direct and powerful trauma or as a result of a severe twisting of your ankle. In certain situations you may actually hear your bone cracking. Severe swelling and black and blue discoloration quickly develop. Your pain might be quite excruciating, and/or the position of your foot might be altered. If you suspect that you have a fracture, it is necessary for you to seek in person professional attention. Sometimes with severe ankle injuries subtle fractures of the articular surface of the talus occur. These are very difficult fractures to visualize on plain radiographs / x-rays and sometimes are only seen with either CAT scans or MRIs. This type of fracture which involves either a shearing of the cartilage of the joint or possibly even a subtle fracture through the cartilage of the joint and the bone underneath it, are called osteochondral fractures. The possibility of these fractures should be considered after severe ankle injuries and must be evaluated by a professional. Neglecting ankle fractures may result in the development of arthritic conditions and severe long term consequences. Once your ankle fracture is treated professionally and healed, you may find that there is some residual discomfort or swelling.
Arthritic Ankle Problems
In addition to neglected ankle injuries being a cause of arthritis, you may suffer from arthritis in the ankle as a result of generalized osteoarthritis, rheumatoid arthritis, and even psoriatic arthritis. If you have had advanced inflammation or possibly even a tear of your inner ankle tendon (posterior tibial tendon) you may have developed arthritic changes in your ankle joint. Arthritis involves the inflammation of the ankle joint structure as well as boney overgrowth and narrowing of the joint itself. Please note in the example above that this is a case of post traumatic arthritis. This condition usually causes pain with progressive walking and activities that utilize motion of the joint. Many people experience a lack of adequate range of motion of the joint as well as swelling around the joint. Often times this leads to an inability to bear normal weight on the affected extremity. This may lead to many forms of compensation which can in turn result in increased pain in other areas throughout your body..
Initial conservative treatment may involve physical therapy, oral anti inflammatories, or possible cortisone injections. If conservative therapy for treatment of ankle arthritis fails to resolve the condition, then often times surgical intervention may be required. The gold standard for treatment of severe ankle problems would involve fusion of the joint. This involves a procedure that stabilizes the joint, prevents further range of motion, usually with the use of internal fixation such as plates or screws. The picture below, on the right, shows an Integra locking plate which provides for excellent stabilization of these joints. This particular procedure often times results in significant reduction of your pain, however, it limits obvious mobility of the joint. Over the last few years a great amount of research and development has led to the creation of new implant devices for arthritic ankles. One such example is the Wright in-bone ankle implant that is demonstrated with radiograph below, on the left.
Posterior Tibial Tendinitis
This is a condition that affects the posterior tibial tendon. The particular structure begins as a muscle deep in the leg and continues as a tendon into the ankle and foot where it attaches itself to the inner side of the arch of the foot. This tendon's main function is to maintain the stability of the inner part of the foot as well as the arch of the foot. It stabilizes your arch. Various problems can develop with the posterior tibial tendon. This can range from mild inflammation, a more extensive inflammation, a partial tear, or even a complete rupture. In cases where the posterior tibial tendon is ruptured or severely damaged, the affected foot would be extremely flat compared to the opposite limb. In cases of moderate tendon change some degree of loss of arch height may be visible to the patient or to the patient’s family and an awkward gait can ensue. Pain along the inner side of the ankle as well as the inner side of the arch may develop. The patient oftentimes needs to limp in order to be able to function. The posterior tibial tendon problems have been labeled posterior tibial tendon dysfunction. This is a progressive problem that does require definitive treatment.
How is Posterior Tibial Tendon Dysfunction Treated?
Conservative treatment is based on the degree of problem present. It may involve anything from physical therapy, oral antinflammatory medications, orthotics to bracing. Injections may be of value in more advanced cases when arthritis occurs in the joint below the ankle- the subtalar joint.
Surgical Treatment
If the condition still remains problematic after this initial first step treatment, then one should seek medical consultation. More definitive treatment for this problem would involve obtaining both foot x-rays and sometimes MRIs or CAT scans. Clinical examination is mandatory. Appropriate testing on a clinical basis can prove to be extremely beneficial. Further conservative therapy may be necessary. This could include the use of custom made orthotics, custom ankle/foot orthotic device for control of the ankle and joints below the ankle (subtalar joint). Oral anti-inflammatory agents and further physical therapy may be necessary. If conservative therapy proves not to be beneficial then more definitive surgical intervention may be necessary. This may include the use of a combination procedures, depending upon the level of posterior tibial tendon dysfunction. This may involve exploration of the tendon with debridement of the tendon in its earliest forms. In the more common grade 2 level, posterior tibial tendon dysfunction is treated via osteotomy procedures. These procedures are extremely beneficial utilizing the most contemporary technology to realign the foot and rebalance the tendons on the inner side of the foot and ankle. Possible procedures that can be used may be performed in combination and include medial calcaneal displacement osteotomy with internal bone screw fixation, Evans calcaneal osteotomy with internal fixation, possible cotton osteotomy procedure of first metatarsal with internal fixation, flexor digitorum longus tendon transfer utilizing a tendinous screw and anchor, Achilles tendon lengthening and casting. In severe grade 3 abnormalities of the posterior tibial tendon where arthritic manifestations also exist then the patient may require a triple arthrodesis which involves resecting the articular surfaces and fusing them to one another in the joint below the ankle as well as realignment of the foot structure. These bones are held in place utilizing modern fixation techniques.
Peroneal Tendonitis
The peroneal muscles are two specific muscles, the peroneus longus and the peroneus brevis. They originate from the outer side of the leg. The tendons run from behind the outer ankle bone and they go towards the outer side of the foot. One tendon attaches to a bone on the outer edge of the foot and the other goes just beneath that region and actually crosses the sole of the foot and inserts close to the bone that attaches to the ball of the foot. These tendons can develop inflammation, when this occurs it is called peroneal tendinitis. Though these tendons are not as commonly inflamed as the Achilles tendon or the posterior tibial tendon, they are more commonly affected than the anterior tibial tendon and many times they become inflamed as a result of compensatory problems existing elsewhere in the foot and causes the foot to stress its outer or more lateral margin. For example, a patient may suffer from inflammatory pain on the inner side of the heel secondary to plantar fascitis and after a long period of time when trying to reduce pain on the inner side of the heel, the patient may compensate and walk more on the outer side of the edge of the lateral side of the foot. When doing so it is not uncommon for the patient to complain of pain along the outer margin of the foot or ankle. This condition is called peroneal tendinitis.
How is Peroneal Tendonitis Treated?
General recommendation is the use of an appropriate device to stabilize the ankle and prevent the foot from tilting along the lateral side. Various supports and braces may prove beneficial. Further conservative treatment may involve oarl medications or even a short course of an injectable medication inorder to reduce inflammation.
If this condition remains symptomatic, even after first step treatment, then professional consultation may be necessary. This may involve radiographs, obtaining MRIs in order to discern the degree of tendon injury. Various oral anti-inflammatory agents or injectable medications may be necessary for the resolution of the condition. Sometimes custom made orthotics or braces may be necessary to resolve the condition. In the more chronic cases surgical intervention may be necessary. This would involve appropriate procedures based on both the MRI findings as well as the clinical evaluation at the time of the surgical intervention. Various procedure that are carried out for this problem consist of debridement with tendon repair, possible tenodesis between both the peroneal tendons as well as sometimes lengthening procedures.