Ankle injuries
Ankle Anatomy
The ankle is actually made up of two joints: The ankle joint itself, and the subtalar joint. The ankle joint is comprised of two bones of the lower leg; the tibia and the fibula come together and form a very stable joint, that allows the foot to bend up and down. Two bones of the foot connect to form the subtalar joint, the talus and the calcaneus. This joint allows the foot to rock from side to side. The tarsal bones, work together as a group and allow the foot to conform to whatever surface the foot is contacting. They connect to the 5 long bones of the foot called the metatarsals.
Ligaments and Tendons
The large Achilles tendon is the most important tendon for walking, running and jumping. It attaches the calf muscles to the heel bone to allow us to rise up on the toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. The tendons of the phalanges assist with up and down motion of the toes. The anterior tibial tendon allows us to raise the foot. Altogether there are thirteen tendons that cross the ankle. They are responsible for movements of the ankle, foot, and toes; some of these tendons also help support the arches of the foot.
Muscles
The muscles of the foot are classified as either intrinsic or extrinsic. The intrinsic muscles are located within the foot and cause movement of the toes. These muscles are flexors (plantar flexors), extensors (dorsiflexors), abductors, and adductors of the toes. Several intrinsic muscles also help support the arches of the foot. The extrinsic muscles are located outside the foot, in the lower leg. The powerful gastrocnemius muscle (calf) is among them. They have long tendons that cross the ankle, to attach on the bones of the foot and assist in movement. The talus, however, has no tendon attachments.
Ankle Sprains
Ankle sprains are basically injuries to the ligaments and soft tissues around the ankle. They result from movement of the ankle joint in a variety of directions:
- Inversion - This is when the foot turns inwards, and this usually results in injury first to the lateral(outer)aspect of the ankle.
- Eversion - This is when the foot turns outwards, and the initial source of problem is in the medial (inner) of the foot.
It should be remembered there can also be a rotational element to this injury, hence if the force is great enough resulting in both aspects of the ankle joint becoming involved.
Clinical Features
- Pain. Pain is usually over either of the two bony aspects of the ankle. The pain is worse on movement and attempting to weight-bear. This pain can vary from burning to a sharp sensation.
- Swelling.There can be a great amount of swelling around the ankle joint. This can be associated with considerable amount of bruising
- There can be a great amount of swelling around the ankle joint. This can be associated with considerable amount of bruising.
- Tenderness. Touching of the area will will result in a variable amount of discomfort.
It should be stressed that it can be difficult to differentiate at times between a fracture of the ankle and a severe bruising. The ankle may seem mildly painful, with a hint of swelling but an X-ray shows the presence of an underlying fracture.
Management
- Elevate. The limb should be elevated at rest as to allow gravity to reduce the swelling. This also helps in reducing the amount of discomfort.
- Rest. Rest reduces the amount of stress on the injured ligaments and allows a more painless recovery.
- Strapping. Strapping of the ankle with crepe bandage or Tubi-grib, helps support the ankle, reduces the amount of swelling and discomfort.
- Gradual mobilize. It is important that once the initial stages of pain
have reduced to start mobilizing the ankle as to prevent stiffness
developing within the joint.
In some situations depending on the severity of the injury, the ankle is immobilized for a couple of weeks in a cast. In these situations, the integrity of the ligaments should be assessed, as there may be an underlying complete rupture of the collateral ligaments.
Ankle Fractures
Mechanism
Mechanism of injury in ankle fractures usually is when the foot is anchored to the ground and the momentum of the body continues forward. There is also the fall from a height where the foot is driven upwards into the Tibia.
There are a variety of classifications of the fracture of the ankle, depending on the anatomy, stability.
Clinical Features
- Pain. This can be on either/both sides of the ankle
- Swelling. There is a variation in the amount of swelling, and there may be an associated deformity.
Management
- Ankle fractures usually are intra-articular, and hence the articular surface has to be re-aligned to prevent any future problems such as Osteoarthritis.
- As the swelling is rapidly in onset, the treatment should be initiated rapidly, as final treatment may be delayed for several days to allow this swelling to reduce.
- Reduce. The fractures may be aligned by manipulation under anesthesia, or in more complex ones require an open procedure to bring the ends approximated as best as possible. If this is embarked, it usually involves plates and screws inserted to hold the fragments.
- Hold. Following either method the ankle is immobilized in cast for 6-8 weeks. This time period is variable, as the important feature is to allow the fracture to heal.
- Movement. Following either management, it is important following removal of the cast that the ankle is exercised as much as possible. The ankle is then placed in a temporary crepe bandage following removal of the plaster.
- If the fracture is non-displaced, below the ankle joint or in the elderly these can be treated with fiberglass casting.
Osteochondral lesion of the ankle
A localized condition affecting the articular surface of the ankle joint that involves separation of a segment of cartilage & subchondral bone. Although a traumatic etiology is believed to play a major role in production of these lesions, these lesions are seen in very sedentary individuals. Symptoms include swelling and aching pain, worsening with activity.
Diagnosis is confirmed with plain x-ray and MRI which reveals the severity of the lesion and whether or not it is displaced.
Treatment includes Conservative application of Non-weight-bearing cast for 6 to 8 weeks. If symptoms are not improved arthroscopic surgery is indicated.