On the lateral side of the ankle
there are three ligaments
that make up the lateral ligament complex.
the anterior talofibular ligament
the calcaneofibular ligament
and the posterior talofibular ligament
The very common inversion injury
to the ankle
usually injures the anterior talofibular ligament and the calcaneofibular ligament.
The ATF ligament keeps the ankle
from sliding forward and the CF ligament keeps the ankle
from rolling over on its side.
An ankle injury
, sprain and swelling is the single most common acute ligament injury
in the United States.
Of all joints in the human body, the ankle
by far experiences the most use and sustains the most abuse.
injuries such as sprains can occur under many different circumstances, they are most likely to occur during active participation in athletics.
From basketball games to tennis matches to track and field events, athletes depend on the ability of the ankle
to control balance, vertical propulsion, and forward and lateral movement.
Not surprisingly, ankle
injuries are the most frequent sport-related injuries, accounting for an estimated 30% of all such injuries.
They represent as high as 45% of all injuries in men's basketball, and 38% of injuries for women.
Tendinitis, Paratendinitis and Tendinosis
Of all the overuse problems associated with ankle injury
tendinitis is among the most common. In the past, all conditions have been termed tendinitis and treated accordingly-cramps, spasm and foot aches.
There now are several different pathological entities.
partial and complete rupture.
Tendinitis is a catch term for inflammation of the tendon itself from a ankle injury
, and can often co-exist with paratendinitis causing all the symptoms of ankle
pain, cramps, spasm and aches.
The cause of tendinitis usually results from microscopic tears within the tendon and triggering an inflammatory response within the tendon.
Common areas susceptible to tendinitis are;
tibialis posterior and flexor hallucis longus tendons
sprains may be the most common acute orthopedic injury
. Although this frequently happens during athletics
or exercises, ankle
s are often injured just stepping off a curb, in a hole or on uneven ground. It's not unusual to hear from a patient that this has happened before, sometimes on multiple occasions.
The injured person usually presents with a history of their ankle
"turning." Sometimes a "pop" or "snap" is felt or heard. Difficulty walking follows the incident and in a short time, the ankle
swells, sometimes so excessively that people are quite sure it's broken.
The typical ankle
sprain results in a stretching or tearing of the small ligaments that attach bone to bone on the outside or lateral aspect of the ankle
The physical examination almost always shows swelling and discoloration (black and blue) over the outside part of the joint. Frequently, there is instability noted on the drawer test (as above), when we gently move the heel structures forward and back as the leg is stabilized. A less reliable sign, called the tilt test
, is sometimes used by turning the heel from side to side. Range of motion in the ankle
can be limited secondary to pain and swelling but strength is not usually affected.
This is certainly one area of Sports Medicine and Orthopedic Surgery when xrays are essential, even though sprains are usually negative. However, fractures must be ruled out, as the treatment would likely be different-- with some unstable fractures even requiring surgical internal fixation.
Although the treatment varies from place to place, I believe for any acute ankle
sprain, the best initial ideas are ice
, physical therapy
and elevation. If the sprain is minor (Grade 1), these measures will suffice, although additional bracing or taping
of the ankle
gives much more support and allows the patient more confidence while ambulating or exercising.
The more severe sprains, that have greater instability and tearing of the ligaments, should be placed in a walking cast for three weeks to allow the injured structures to heal. These casts can be the typical, non-removable fiberglass or the removable variety. Following this three week period, I recommend exercises and two to three weeks of physical therapy
to strengthen the ankle
and reduce swelling. During this period, the ankle
is often taped or braced by the doctor
, therapist, or trainer
Although many urgent care and emergency room facilities treat ankle
sprains with an ace bandage and crutches. I find this protocol to be terribly inadequate and, I feel, increases the likelihood of recurrent sprains and possible arthritis in the future.
In the long run, the very best treatment of ankle
sprains is prevention. This means when you're doing activities that have a high incidence of ankle
injuries, wear a brace or get your ankle taped
so you won't sprain it. Braces are relatively inexpensive and easy to use. Taping works well, but requires someone available who is well trained to apply it, appropriately.
Activities such as basketball, volleyball, soccer, tennis, and other sports requiring a lot of stopping, starting and twisting motions have a high incidence of ankle
injuries. Beware of the uneven and pot-holed playing fields often used by soccer and baseball teams
A ligament is made up of multiple strands of tissue - similar to a nylon rope. A sprain results in tearing of the ligaments. The tear can be a complete tear of all the strands of the ligament or a partial tear, where a portion of the strands of the ligament are torn. The ligament is weakened by the injury - how much depends on the degree of the tear. The lateral ligaments are by far the most commonly injured ligaments in a typical inversion injury of the ankle. An inversion injury simply means that the ankle tilts over to the inside (towards the other foot), and the pressure of all your body weight is forced onto the outside edge of the foot. This causes the ligaments on the outside of the ankle to stretch - and possibly tear.
Initially the ankle is swollen, painful, and may turn eccyhmotic (bruised). The bruising, and the initial swelling, is due to ruptured blood vessels from the tearing of the soft tissues. Most of the initial swelling is actually bleeding into the surrounding tissues. This initial swelling due to bleeding then increases due to edema fluid leaking into the tissues as well over the next 24 hours.
The diagnosis of an ankle sprain is usually made by examination of the ankle and X-rays to make sure that there is no fracture of the ankle. If there is a complete rupture of the ligaments suspected, your doctor may order stress X-rays as well. These X-rays are taken while someone twists or stresses the ligaments.
Ankle sprains can be placed into two categories, acute and chronic.
sprains occur by a sudden unexpected twist.
They are graded:
grade I sprains
or a severe stretching of the ligaments are considered a mild injury
with minimal pain, swelling and little or no loss in function of the ankle
grade II sprains
or partial tears of the ligaments involve an increase in pain with loss of function and difficulty in placing pressure on the ankle
grade III sprain
is due to a complete tear of the ankle
ligaments along with a loss of stability and even partial dislocation.
Chronic sprains are developed by repetitive injury
to the ankle
These may be caused by a functional problem with the foot and ankle
which may predispose an individual to twist their ankle
Additional tests such as MRI may be needed to determine the extent of the injury
to resume classification
sprains are graded by health care providers in terms of degree of severity.
The more severe the sprain, the higher the degree and the longer the time to recover.
First degree ankle
sprains are the most common. In this injury
the ligaments including the anterior talofibular ligament(ATFL) are stretched but not completely torn.
There is modest swelling but no gross instability.
Second degree sprains involve partial tearing of the anterior talofibular ligament.
There is more swelling, more pain and generally longer time to recovery.
Third degree ankle
sprains involve complete rupture of the lateral ankle
ligaments beginning with the anterior talofibular ligament and extending posteriorly to the talocalcaneal ligament
Treatment begins initially by:
controlling weight bearing
Elevation will help control the swelling
Gentle compression and ice will control swelling
Mild pain relievers will help with the pain
Crutches will prevent weight bearing.
Casts have fallen out of favor, and as treatment progresses, early weight bearing
has been shown to be beneficial. Braces that can be worn to support the ankle
- but still allow weight bearing are the most popular treatment method today. Healing of the ligaments usually takes about 6 weeks. The swelling may be present for several months. A physical therapist may be suggested to help you regain full function of your injured ankle
. (See rehabilitation below)
In a small number of cases, the ligaments will not heal back as strong as normal.
This results in an ankle
that is unstable and has a tendency to give away, or twist again very easily. Ankle instability
can lead to an ankle
that is sore and painful, sometimes swollen, and untrustworthy on rough terrain.
If your ankle
ligaments do not heal back adequately following an ankle
sprain there are several things that may be suggested by your doctor.
Once the initial pain and swelling begins to resolve, physical therapy
will probably be initiated to regain as much of the normal range of motion as possible. One of the problems that tearing the ligaments around the ankle
causes, is that small proprioceptive
nerve endings in the ligaments are torn as well. These nerves function to give the brain information about where the body is in 3D space. For instance, these nerves are what makes it possible for you to touch your nose with your eyes closed.
The joints rely on these nerves to fine tune the muscles' actions that allow the joint to properly function
A good physical therapy program will help retrain these nerves as they repair themselves, and will strengthen certain muscles that will take over some of the functions of stabilizing the ankle
joint from the loss of the ligaments.
brace may also help control some of the instability and prevent the ankle
from giving way.
If all these simple measures fail, surgery may be suggested to reconstruct the ligaments that have been torn.
Surgery involves making an incision
on the side of the ankle
. A portion of the tendon
called the peroneus brevis
is used to reconstruct the lateral ligaments.
A drill hole is made in the fibula, near the attachment the original ligament.
A second drill hole is made in the area where the ligaments attached to the talus.
The tendon graft
is then woven these holes to recreate the ligament complex.
After surgery, you will usually be placed in a cast or brace for about 6 weeks to allow the tendon reconstruction to heal.
Following removal of the cast, physical therapy will be required to regain full use of the ankle
Whether you have had an ankle sprain that did not require surgery or whether you are recovering from surgical reconstruction of the ankle ligaments you will probably benefit from physical therapy.
In the beginning....
Treatment may vary depending on how bad of an ankle sprain you’ve had. In each case, the first line of treatment is to calm the inflammation and halt the swelling. The RICE (Rest, Ice, Compression, Elevation) principle can help address each of these needs.
A brace or splint will keep the ankle
in a safe position, helping you avoid more strain to the sore area. In severe cases, you may require a pair of crutches to limit weight through the foot.
Cold therapy, in the form of an ice pack, can aid in slowing the inflammatory process and in limiting pain.
An elastic wrap can compress the sore area, keeping the swelling to a minimum.
Keeping the ankle
elevated above the level of your heart will help drain the extra fluid (edema) back into the blood system and reduce swelling.
As you progress....
Range of Motion Exercises:
As healing gets underway, it is important to begin a series of movement exercises for range of motion
(ROM). At first, you’ll work on simply bending and straightening the ankle
. These exercises will keep the ankle
from becoming stiff.
Next, you’ll begin strengthening the muscles around the ankle
may be chosen in the early stages of rehabilitation. These are strengthening exercises in which the muscles are working but the joint stays still. Isometrics allow you to exercise with the ankle
at different angles, helping you stay away from painful positions of the ankle
. These exercises provide the benefit of reducing overall pain and swelling. They also help the muscles remember
what they’re supposed to be doing.
Balance exercises are especially important following an ankle
. Remember, healthy ligaments send information to the brain about the position
of a joint. Once a ligament has been injured, these nerves are unable to receive and send the needed information to the brain. Balance exercises help retrain the new nerves and help you regain your proprioceptive
sense around the joint.
he next part of your rehabilitation following injury
will focus on strengthening the ankle
even more. A set of exercises called closed kinetic chain exercises
have become popular among therapists. These are exercises done with the foot fixed to the ground. They generally do not require any fancy equipment and can be done at home. These exercises are designed to allow the muscles around the ankle
to be exercised while easing stress on the ligaments. These exercises are functional
- because they represent activities we do throughout the day.
PATELLAR TENDINITIS, TENDONITIS, TENDENITIS (JUMPER'S KNEE)
One of the big differences between the effects of patellar tendinitis (that is, tendinitis of the patella--the kneecap), and chondromalacia is that tendinitis sufferers are much better able to locate the pain. Whereas people with chondromalacia may rub their fingers up, down, and around the knee to indicate where it hurts, when you have tendinitis you can put a fingertip right on the spot. It's so tiny and specific that you can put the tip of a ballpoint pen right on the spot and just about levitate yourself into the air with pain. And that spot is right at the bottom of the kneecap, where the tendon that goes on to connect to the shinbone begins--hence the name, patellar tendinitis
LIGAMENTS OF THE ANKLE JOINT
Stability of the ankle joint depends on ankle position and applied loads. Ankle position determines the orientation of the ligaments. Applied load across the joint may affect stability; the fully axially loaded ankle tends to be stable, but instability may occur during loading and unloading.
Anatomic observations suggest that the anterior talofibular ligament (ATFL) is the primary restraint against anterior drawer loading in the neutral ankle position. However, results of a recent cadaver study suggest that the ATFL, calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) all contribute to alleviate anterior drawer stress in the nonaxially loaded ankle.
The deltoid ligament stabilizes the ankle medially, functioning as the primary restraint against valgus tilting of the talus. Superficial and deep layers of the deltoid ligament may independently prevent valgus talar tilting.
The lateral ligaments stabilize the ankle laterally. The ATFL and CFL together provide stability against anterior drawer and adduction stresses in the plantarflexed, neutral, and dorsiflexed ankle/subtalar complex. In the unloaded ankle, plantarflexion and dorsiflexion have opposite effects on ATFL and CFL strain patterns- strain in the ATFL is increased as the ankle is brought from dorsiflexion to plantarflexion; strain in the CFL does not change throughout the arc of flexion in neutral pronation-supination or rotation, but is increased by supination, supination-internal rotation, and external rotation, and further increased by dorsiflexion in positions of supination and supination- internal rotation.
Rotatory stability of the ankle joint is determined by the collateral and syndesmosis ligaments, fit of the talus in the mortise, and shape of the articular surfaces in the loaded condition . Section of the ATFL followed by the CFL and PTFL in the loaded ankle causes progressive rotatory subluxation of the talus. Division of the deltoid and syndesmosis ligaments also increase the range of rotation of the ankle joint.
The function of the extrinsic muscles on active movement of the free ankle and subtalar joint is determined by the anatomic location of the tendons in relation to the axes of joint rotation. For example, in the neutral foot and ankle, the peroneus longus and tibialis posterior evert and invert, respectively, the subtalar joint, but both act as plantarflexors of the ankle joint. Furthermore, the importance of a muscle in influencing active movement may depend on joint position. For example, the tibialis anterior is not a
major invertor of the subtalar joint in the neutral foot-ankle complex; if however, ankle dorsiflexion is present, the tibialis anterior may act as a strong invertor. The tibialis posterior is a strong invertor, primarily when the ankle is plantarflexed. Thus, tibialis posterior inversion strength should be evaluated with the free foot and ankle in the plantarflexed and everted position.
SOFT TISSUE INJURY
ACHILLES TENDON: PARATENONITIS, TENDINOSIS, PARTIAL RUPTURE.
Achilles tendon problems are common in runners, with a reported incidence of 6.5% to 18%. Probable causes include aging, poor training techniques (running on hills and wearing athletic shoes with rigid soles), and abnormal hindfoot biomechanics. Excessive varus or valgus hindfoot positionings are thought to increase stress on the Achilles tendon. Patients describe burning pain about the tendon which occurs when activity begins, decreases during activity only to become more severe after completion. Acute cases of paratenonitis can have crepitation. Partial rupture may become superimposed on chronic paratenonitis and/or tendinosis and may present with an acute episode of pain and swelling. MRI of the Achilles tendon can help differentiate among inflammation, intramural degeneration, and partial or complete rupture . Most cases of paratenonitis, with or without tendinosis or partial rupture, can be managed successfully nonsurgically with rest, phonophoresis, stretching exercises, anti-inflammatory medications, use of 1-2-cm heel lifts and will molded and cushioned Achilles pad and a gradual return to activity with training modifications. If symptoms persist despite 6 months of nonsurgical therapy, release or removal of the paratenon has good to excellent results in 70% to 90% of the cases. In cases with associated tendinosis or partial rupture, surgical treatment includes debridement of intratendinous debris through longitudinal incisions.
Ruptures typically occur in sedentary middle-aged men engaged in episodic activity. Risk factors include tendinosis , paratenonitis, impeded tendon nutrition, steroid injections, direct trauma, dramatic increases in training programs with mechanical overload from sudden elongation of the tendon; and simultaneous eccentric contraction of the muscle. Acute ruptures are often associated with a sharp tearing sensation and the immediate onset of pain and swelling. Patients typically have a palpable defect in the Achilles tendon and are unable to do a single heel rise. A positive Thompson test is present; that is, the foot does not plantarflex upon squeezing the superficial calf muscles. Optimal treatment of acute Achilles tendon ruptures is still controversial. The literature reports satisfactory results following nonsurgical and surgical treatment. Rerupture rates and power deficits up to 40% have been published for nonsurgical treatment. The reported complication rates from surgery range up to 20%. These include fistulas, necrosis of skin and tendon, deep and superficial infections, skin adhesions, and nerve injuries. In deciding between surgical and nonsurgical treatment of an acute Achilles tendon rupture, the risks and benefits must be weighed for each patient. The professional athlete desiring early return to function may be willing to accept the surgical risk for the potential advantage of a lower rerupture rate. The standard surgical treatment consists of a medial approach and simple end-to-end Bunell type approximation of tendon stumps. Recent reports have favored early passive and active range of motion exercises after surgical repair. The OKU Foot and Ankle reported on 13 patients treated surgically with passive range of motion initiated at 10 days and active range of motion at 3 weeks. All resumed running by an average of 3 months.
FLEXOR HALLUCIS LONGUS: STENOSING TENOSYNOVITIS AND POSTERIOR IMPINGEMENT
The FHL runs in a groove in the posterior talar process between the medial and lateral tubercles. The lateral process is larger and often has a separate ossification center. This ossification center normally fuses to the lateral tubercle, however, in 7% of the population, it remains separate and is called the os trigonum. Posterior ankle impingement is manifested by pain in the posterolateral aspect of the ankle and may be due to a large posterior process or os trigonum, a thickened posterior capsule, calcific debris, a large posterior process of the calcaneus, or instability. It can be confirmed on physical examination by tenderness behind the peroneal tendons in back of the lateral malleolus (it is often mistaken for peroneal tendinitis) and by pain with forced passive plantar flexion of the ankle- the plantar flexion sign. Treatment for posterior impingement should follow an orderly sequence. The first approach as with tendinitis is modification of activities, and administration of NSAID's. If this approach fails, then, an injection of lidocaine to confirm the diagnosis followed by a mixture of short and long acting corticosteroids can often give dramatic and permanent relief of symptoms. Occasionally, it does cause enough disability to warrant surgical excision, but this is only indicated after the failure of conservative therapy . If the problem is an isolated os trigonum with no medial symptoms, then it can be approached posterolaterally between the FHL tendon and the peroneals. In patients with concomitant FHL tendinitis, the posteromedial approach is used so that the neurovascular bundle can be isolated and protected. A tenolysis of the FHL tendon and removal of the adjacent os trigonum is then performed.
Patients with FHL tenosynovitis at the ankle typically present with pain, swelling, and crepitation posterior to the medial malleolus. Physical examination will demonstrate tenderness and, sometimes, even triggering 'hallux saltans' in the tendon sheath with active and passive motion of the hallux interphalangeal joint. Most cases of FHL tenosynovitis respond to nonsurgical treatment, consisting of NSAID's, rest, stretching exercises, training modifications, and, in very selective cases, the judicious use of a tendon sheath steroid injection. If symptoms persist, surgical tenolysis from a medial approach followed by early motion is recommended.
POSTERIOR TIBIAL TENDON: DYSFUNCTION / RUPTURE
Anatomic factors and systemic conditions may predispose the tendon to inflammation and degeneration. Compressive forces behind the medial malleolus, and its tenuous blood supply have been implicated in the pathogenesis of posterior tibial tendon dysfunction. In one study, 60% of patients with posterior tibial tendon rupture had one or more of the following associated medical conditions: hypertension, obesity, diabetes, and steroid exposure.
Posterior tibial tendon dysfunction (PTTD) has been divided into three clinical stages, depending on the presence and severity of secondary deformity.
Stage I- involves pain, swelling, and mild weakness of the PTT without secondary deformity.
Stage II- refers to disruption with a flexible, secondary flatfoot deformity.
Stage III- is a rigid flatfoot deformity.
Symptoms may be present for months or years before presentation and they often do not correlate with the degree of deformity. The patient may notice pain, swelling, or tenderness of the medial side of the ankle or may have lateral pain due to impingement of the calcaneus on the lateral talar process or fibula. On physical examination, the patient may have swelling, tenderness, inversion weakness, deformity with standing , or pain with attempted heel rise. On standing examination, the acquired flatfoot assumes a posture of hindfoot valgus, talar plantarflexion, and forefoot abduction. Seen from behind - 'too many toes sign'. MRI is currently the method of choice for imaging the posterior tibial tendon. It is extremely sensitive to intratendinous changes and appears to be more predictive of clinical outcome than any other form of assessment. Treatment depends on the clinical stage at presentation.
Stage I- nonsurgical treatment consisting of rest, NSAID's, and immobilization. If symptoms persist, tenosynovectomy with selective tendon debridement is recommended.
Stage II- nonsurgical treatments for flexible deformities include use of a medial heel wedge, longitudinal arch support, medial outflare, short articulated AFO, and rigid AFO. The most commonly described surgical treatment is reconstruction of the PTT with that of the FDL.
Stage III- generally requires some form of arthrodesis.
PERONEALS: TEARS / SUBLUXATION OR DISLOCATION
Longitudinal tears have been postulated to result from peroneus longus (PL) wedging peroneus brevis (PB) into the lateral border of the peroneal groove. Tears may be associated with a low-lying peroneal muscle belly and are centered over the distal tip of the fibula. The symptoms of peroneal tear are pain and swelling in the retromalleolar area. On examination, the pain can be reproduced by passive inversion of the ankle or resisted eversion. In addition, several authors have noted an association between chronic tears of the PB and lateral instability of the ankle. Nonsurgical treatment consists of NSAID's, stretching, a lateral heel wedge, a lateral outflare, and case immobilization. If symptoms persist, surgical exploration of the tendon with tenolysis or debridement may be indicated.
The mechanism of injury of subluxation or dislocatoion involves forced dorsiflexion/eversion with forceful contraction of the peroneals. Some patients may have anatomic predisposition with a shallow, flat, or convex retromalleolar groove.
The initial injury is frequently mistaken for a simple ankle sprain, especially because spontaneous reduction following acute subluxation/dislocation is common. Pain and swelling are more posterior in peroneal subulxation than in lateral ligament injury. Patients presenting with recurrent subluxation/dislocation characteristically complain of painful snapping over the lateral malleolus. During PE, the symptoms can be reproduced by resisting dorsiflexion with the foot held in a plantarflexed, everted position. On radiographs, the presence of a rim avulsion from the lateral aspect of the lateral malleolus is considered pathognomonic for peroneal tendon dislocations.
The treatment for acute injury is being debated. Although strapping and taping has not been effective, good results with casting in mild plantarflexion for 6 weeks have been reported. Likewise, surgical repair of the superficial peroneal retinaculum generally has yielded good results in the acute setting. Thus, stable injuries may be treated in plantarflexion for 6 weeks in a non-weightbearing short leg cast; all others are surgically repaired followed by cast immobilization.
Surgical treatment is generally recommended for recurrent dislocation. Studies have reported good to excellent results in 95%. Several procedures havae been described and may be divided into five categories:
Direct repair or reattachment of the superficial peroneal retinaculum.
Reconstruction of the peroneal retinaculum with other local soft tissues.
Bone block procedures.
Groove deepening procedures.