Chronic Ankle Instability: Cause, Symptom & Treatment

Chronic ankle instability is developed after multiple sprains or a single severe sprain that was not properly healed. The ankle easily gives way to the lateral side, especially during sports activities or walking on uneven surfaces. This condition is common among athletes and people with high physical demands as they may have resumed their activities before the previous injury is fully recovered. Because of the ankle instability, people who are affected may find themselves incurring more sprains and developing other conditions such as arthritis and tendon tear over time.

Causes

When an ankle is sprained, the ligaments are stretched or torn and balance is affected. If the ankle muscles are not strengthened to regain the ability to balance, it would be prone to repeated sprains. With multiple sprains, the ligaments are weakened and more difficult to heal, leading to chronic ankle instability.

Symptoms

Patients of chronic ankle instability experience a constant ache and swelling in the ankle, with pain and tenderness when engaged in physical activities. The ankle would be unstable and often rolls over to the lateral side. Usually, patients would complain about these persistent symptoms after the ankle has been sprained several times.

Diagnosis

The doctor would first take a history of your condition to find out if you had any previous ankle injuries and how long the symptoms have persisted. A physical examination is then carried out to check for swelling, tenderness and instability. X-rays or other tests, such as bone scan or MRI, may be ordered.

Treatment

Based on the degree of instability, the recommended treatment may be surgical or non-surgical. For severe cases and if the condition does not improve or recur after non-surgical treatment, surgery would be required.

Non-Surgical Treatment:

Physical therapy incorporates different exercises to help strengthen the ankle muscles. This would retrain the tissue to regain balance and range of motion. For athletes, the rehabilitation may include exercises that specifically help them get back to their sport.

To help support the ankle, a brace is worn to keep it in position and prevent further injury. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed to reduce the pain and inflammation.

Surgical Treatment:

The goal of the surgery is to reduce the symptoms of the condition to prevent more serious injuries. As such, the surgeon would excise loose fragments and debride the ankle joint of any scar tissue or fibrous bands. The ligaments are then repaired or reconstructed. Tendons may also be transferred to align the ankle for better motion.

What Is Equinus? Diagnosis & Treatment

Equinus occurs when the Archilles tendon or calf muscles are too tight to allow upward bending motion of the ankle. The person would find it very difficult or impossible to bring the foot toward the shin.

Symptoms

People with equinus deformity often overcompensate this limitation of motion with the other foot, leg, back, hip or knee, causing problems in those areas. To ease movements, many of them flatten the arch of the foot when walking, placing their body weight on the ball of the foot or toes instead and causing pain and callusing. Others use the support of their hips or knees, resulting in an unusual walking stance.

Causes

The tightness in the Archilles tendon or calf muscles may be inherited from parents or the person is born with shorter Archilles tendon. Having a cast on for a long period of time or wearing inappropriate footwear such as heels, could also cause the stiffness. If the foot suffered a serious ankle injury before, there could be a broken bone blocking the joint, thereby restricting motion.

This deformity could also be a symptom of a more serious condition. Diabetes causes many foot problems, including tightening of the Archilles tendon. If spasms are felt in the calf, it could be a sign of a neuromuscular disease.

Diagnosis

To find out the cause of equinus, the doctor would move the ankle when the knee is bent and straightened to assess if the tightness is from a tendon, muscle or bone block. X-ray may be used for further evaluation. If a neurologic disorder is suspected, the patient is referred to a specialist.

Treatment

The cause of the condition is most important in determining the course of treatment, which could be surgical or non-surgical.

Non-Surgical Treatment:

To relieve the symptoms of equinus, the patient might have to use heel lifts and/or custom orthotic devices in their shoes for better support, weight distribution and reduce pressure in the Archilles tendon. If the stiffness is from the calf muscles, a night splint is used to hold the foot in place during sleep. Physical therapy may be recommended to exercise the muscles and reduce tightness.

Surgical Treatment:

Surgery is opted for when the patient does not show significant improvement with non-surgical treatment or when the condition is too severe. The Archilles tendon can be surgically lengthened to reduce the tightness and gastroc recession is used to correct a portion of muscle. If the problem is a bone block, the fragment of broken bone impeding the joint motion is surgically removed.

What Is Progressive Flatfoot? Signs, Causes & Treatment

Another name for progressive flatfoot is Posterior Tibial Tendon Dysfunction. The posterior tibial tendon is found in the calf down to the inside of the ankle to the middle section of the foot. It is responsible for holding up the arch of the foot and gives us support when walking. Progressive flatfoot happens when the tendon becomes inflamed, stretched or torn, causing the arch to collapse.

Not to be confused with plantar fasciitis, which is the inflammation of the plantar fascia, causing the bottom of the foot to hurt and swell. While progressive flatfoot is an injury to the tendon, plantar fasciitis is a strain to the ligament.

Signs

Patients with progressive flatfoot will experience pain on the inner side of the ankle. The arch of the foot is now flat and pain gradually develops on the outer side of the ankle as well. Patients may be unable to or experience difficulty in supporting their weight on their toes.

Causes

Progressive flatfoot is often caused by trauma to the ankle from sports or outdoor activities such as soccer, running and hiking. The posterior tibial tendon is overstretched, resulting in inflammation. This condition can also happen to patients with an abnormality of the tendon, usually women over the age of 50. Obese and diabetic patients are also at higher risk for this injury.

Treatment

Treatment is important to prevent chronic pain or even disability. If left unattended, the tendon would stiffen up and it might be difficult to walk or wear shoes. Arthritis would develop in the hind foot and the pain would spread to other parts of the ankle.

Non-Surgical Treatment:

If the condition is mild, patient would be wearing a cast or brace for 6-8 weeks to prevent the foot from weight bearing. At this point, anti-inflammatory drugs and plenty of rest are needed to recover. Patient would need to wear a shoe insert to support the arch after the cast is removed.

Surgical Treatment:

For more severe cases or if the condition does not get better with non-surgical treatment, the doctor would recommend surgery. The surgical procedure may include cleaning away inflamed tissue, changing the alignment of the heel bone, repairing the damaged tendon, recreating the arch of the foot or joining two bones together to stabilize the hind foot.

Osteochondral Lesion: Cause, Symptom & Treatment

Osteochondral lesions are injuries to the end of the talus – the bone that connects with the tibia and fibula bones to form the ankle joint – and the layers of cartilage that covers it. Some of the injuries include fracture of the talus, tearing of cartilage, blisters on the cartilage and formation of lesions on the underlying bone which affect the cartilage as well.

Such lesions may be result of osteochondral fractures which can happen on both the ankle and knee. When this fracture occurs in the knee, it means there is articular cartilage damage and the bone and cartilage may be fragmented. If it occurs in the ankle, usually only a piece is torn from the surface of the cartilage when the outer side of the talus bone is fractured. But if the inner side is fractured, osteochondral lesions may form that affect both the bone and the cartilage.

Causes

Most often, osteochondral lesions occur from direct trauma to the ankle joint down to the talus. However, recurring injuries like ankle sprains can also fracture the inner side of the bone, resulting in osteochondral lesions. The surface of the talus is sheared off when it crushes with the other bones that form the ankle joint in a sprain or a car accident.

Symptoms

Patients would feel prolonged pain and swelling that does not get better with the basic treatment for an ankle sprain. The ankle joint feels unstable and sometimes unable to bend due to the osteochondral lesion or the fragmented bones and cartilage that broke off in the fracture.

Treatment

Non-surgical treatment may be used if the injury is not severe and if the patient’s health condition is not ideal for surgery. The injured foot is immobilized in a cast to prevent weight bearing in order to allow the bone and cartilage to heal. Following the removal of cast, patient has to go through physical therapy to regain strength and mobility in the joint.

Surgical treatment is done to piece back the fragmented bones and fix the surface of the talus to restore the movement of the joint. Some of the surgical treatment options include arthroscopy, debridement and internal fixation. The decision for the procedure used depends on the size and location of the lesions and the health condition of the patient.

Talus Fracture: Cause, Symptom & Treatment

The talus is the anklebone that connects the lower leg bones, the tibia and fibula, to form the ankle joint. A talus fracture happens when the anklebone is chipped, broken or fragmented.

Causes

Talus fracture occurs in high impact falls, automobile accidents or overexertion in sports that involve sharp changes in direction. The ankle is rolled up in an awkward angle and breaks when it could not withstand the traumatic stress.

Symptoms

Since the talus is responsible for weight transfer from the lower leg to the foot, patient with a displaced fracture would not be able to bear weight on the injured foot. A sharp pain will be felt mainly at the front of the ankle and perhaps the sides and back as well. Patient will also see swelling and bruising, with occasional numbness in the ankle, foot or toes.

Diagnosis

An X-ray is often required to diagnose and assess the severity of the injury. If the injury is suspected to be more severe, an MRI, CT scan or bone scan may also be required. The doctor may also examine other areas to check for injuries that usually come with the fracture.

Treatment

Depending on whether the bones are displaced or not, different treatment methods are used.

Non-Surgical Treatment:

If the bones are not displaced and the joints are still aligned, surgery is not required. Patient is put in a cast with crutches or a brace to prevent weight bearing and to keep the injury in the correct position to allow the bones to heal up by itself. Patients with health conditions like diabetes and poor blood circulation are not able to go through surgery and would be recommended non-surgical treatment as well.

Surgical Treatment:

While non-surgical treatment is an option, most of the time, the anklebone is broken into small pieces and patients are required to go through surgery. The fragmented bones are pieced back together and held together by metal plates and screws. Open reduction and internal fixation (ORIF) is used to align the large pieces back in place by cutting open the side of the foot to insert metal plates and screws. This procedure allows for a better recovery.

Recovery

The patient has to wear a cast for about 8-12 weeks with those having gone through surgery taking longer to heal. During this time, patient should not walk or bear any weight on the injury. If not well taken care of, recovery time might be prolonged.

After the cast is removed, physiotherapy is started to regain strength and reduce stiffness in the ankle. There might still be pain and swelling after the treatment but most patients are well enough to return to work while avoiding vigorous movements.

What Is High Ankle Sprain? Symptoms & Treatments

Less common than regular low ankle sprains, a high ankle sprain bears damage on the ligaments that connect the tibia and fibula just above the ankle. Injury to the ligaments at this level causes walking to be extremely difficult as a lot of force is placed on this area to make the movements possible.

Causes

High ankle sprain is a twisting or rotational injury. It occurs when the ankle is rolled outwards from the leg or the foot is overly bent towards the shin, tearing the ligament. Usually occurring in athletes, American football players and soccer players get this injury when they fall with their ankles twisted outwards or get tangled with other players in a fall.

In an ankle fracture, the fibula might be broken above the ankle level, causing a rupture of the ligaments and the interosseous membrane that supports the tibia and fibula. The fracture usually involves a high ankle sprain and a surgery is most likely need to repair the torn ligament and broken bones.

Symptoms

Patients with high ankle sprains experience minimal swelling but more severe and lasting pain than regular ankle sprains. The injury takes longer to recover as well. The pain occurs just above the ankle and it gets more acute with external rotation.

Treatments

A mild case of high ankle sprain can be treated with RICE (rest, ice, compression, elevation) as like regular sprains. However, recovery will take much longer. X-rays are done to check for broken bones and if there are none, patient can use a brace after applying RICE to reduce weight bearing on the injury.

A more serious case would require cast immobilization for up to 6 weeks and go through physiotherapy after the cast is removed. This is needed to restore balance and strength as the joints get stiff after weeks of being in a cast.

If the X-ray shows broken bones or a widening between the tibia and fibula, surgery is required. The bones are held back together with screws and a cast followed by a brace has to be worn for 12 weeks. The screws are then taken out in a small surgery and follow-upped with physiotherapy before patient can resume physical activities.

Complications

Patient may still experience stiffness after full recovery and certain movements of the ankle might not be as fluid as before. With surgery, infection may occur or the superficial peroneal nerve might get damaged, causing a loss of sensation in the foot. If the injury involves damage of the ankle cartilage, there is a possibility that arthritis would develop.

Peroneal Tendinosis: Symptoms & Treatment

The peroneal tendons are located just behind the fibula, the calf bone. Peroneal tendinosis is the swelling of the tendon usually caused by prolonged strain from a repetitive physical activity over a period of time.

Symptoms

Peroneal tendinosis causes pain and swelling on the back of the ankle. Patient experiences sharp pain when the foot is inverted or turned inwards and the calf muscle feels tight.

Causes

Because this injury is caused by the overuse of the tendon, those that engage in activities that involve an excessive eversion of the foot are more likely to suffer from this condition. Examples of such patients are athletes, marathoners and ballet dancers.

Improper training, overtraining and poor footwear are some reasons that peroneal tendinosis is developed. In these cases, the tendon has to work harder to compensate for the incorrect posture of the foot or the overexertion. The tendon is stretched and rubbed repetitively against the bone and over time, it swells and becomes painful.

Treatment

The best way to recover from peroneal tendinosis is to rest the injury and let it heal by itself. Usually, surgery is not required unless the tendon is ruptured or the pain persists after conservative treatments. Depending on the severity of the injury, these are the treatment options used.

  • RICE:

The injury is managed with several sets of rest, ice, compression and elevation.

  • Anti-Inflammation Drugs:

Non-steroidal anti-inflammation drugs (NSAID) are prescribed to reduce pain and inflammation.

  • Deep Tissue Sports Massage:

Massaging to relax the tight peroneal muscles helps to reduce tension and thus the friction between the tendon and the bones.

  • Cast Immobilization:

The foot is immobilized in a cast for 2-6 weeks to stabilize the injury and prevent weight bearing so that it can heal.

  • Surgery:

If the tendon is torn, surgery is considered to repair the tendon. The groove in the back of the fibula may be made deeper to allow more space for the tendons. Only in very severe cases, the injured tendon has to be resected to connect with the other tendon behind the fibula.

 

Complications

Ignoring the condition over a long period of time may result in the tendon tearing. The weakened tendon also makes the ankle susceptible to sprains and leading to damage of the cartilage. If surgery is required, there is a risk for infection. And in the worse case scenario, patient may suffer from nerve damage if the sural nerve that brings sensation to the foot is cut or stretched.

Recovery

It is advisable not to bear weight on the injured ankle for 6 weeks. Full recovery is possible but may take a long time. Physical activity may be resumed if the injury is well taken care of, with enough time to fully recover. Otherwise, a change of physical activities might have to be considered.

Pilon Fracture: Causes, Symptoms & Treatments

Pilon fractures occur at the lower end of the tibia, or the shinbone, where the part of the bone near the ankle bears the most weight. The smaller calf bone on the lateral side of the tibia, the fibula, most often is broken as well following the fracture.

Usually occurring in adults aged 30-40s, this injury is rare, consisting of only 7% of tibia fractures. It may be difficult to treat and complications after treatment are common.

Causes

Pilon fractures are usually resulted from high-impact falls or car accidents. Airbags in cars can save a person’s life but not protect the legs. Thus in a collision, survivors may sustain pilon fractures and usually other forms of injuries.

Symptoms

Patients would feel severe pain with swelling and bruising. Walking is impossible or extremely difficult. Bearing weight on the injured foot at this point would cause the bones and soft tissue to be further damaged. The ankle would also have a deformed appearance because of the displaced bones.

Diagnosis

It is important to inform your doctor the way that you got yourself hurt to gauge the severity of the injury. Your doctor may do an X-ray, radiograph, CT scan or 3D CAT scan to fully evaluate the fracture. Whether surgery is opted for also depends on the patient’s health condition. Let your doctor know about your medical history to avoid the risk of aggravating your health issues.

Treatments

The decision to go for surgery depends on the extent of the displacement. Most pilon fractures require surgery. If the bones are minimally displaced, nonsurgical treatment might be possible.

Nonsurgical:

Cast immobilization is used for fractures with bone pieces still aligned and stable. Patients with health problems or do not need to do a lot of walking may also be recommended nonsurgical treatment. Cast has to be worn for 6 weeks and replaced with a brace after. It is recommended to not bear weight on the injured foot for 12 weeks.

There might be a chance that patient is left with a deformed-looking ankle after the fracture heals. Improper care during the recovery process or complications cause incomplete alignment. If the shape of the joints is not fully restored, patient is at a high risk of developing arthritis.

Surgical:

Metal implants such as plates and screws are used in open reduction and internal fixation to hold the bones back in place. However, if the swelling and blisters are too severe, an external fixator may be applied first to stabilize the bones and allow soft tissue to heal before the surgery can take place to reduce the risk of infection.

Full recovery typically takes 3-6 months with regular follow-ups. Physical activity should be kept to the minimal during this period to prevent jeopardizing the healing process. It is not uncommon that patients may take up to 12 months to fully recover and regularly experience stiffness, swelling and aches even after recovery. Physiotherapy might be needed for patients that take longer to heal.

All about Ankle Splinting

Ankle splints are used to stabilise injuries to the bones of the ankle until the patient can be professionally attended to by an orthopaedic surgeon. It is also used to immobilise the ankle joint following an injury before the surgery date in order to prevent further injuries. Patients who have splinted their ankles will often be referred to a specialist within 3 days.

Anatomy of ankle joint

The ankle joint is a hinged synovial joint that allows plantar flexion and dorsiflexion. When the range of motion of the joint is considered, the ankle joint becomes a complex universal joint. This complex joint will allow movement of more than 100°, making it extremely flexible. Protecting this joint is the anterior and posterior ankle capsular ligaments which are relatively thin.

Preparing for ankle splinting

Ankle splinting is fairly painless and can be tolerated without the need for anaesthesia. However if the patient is suffering from immense discomfort during the splinting process, anaesthesia may be used depending on the severity:

  • Nerve blocks will temporary provide pain relief by blocking nerve signals to the brain. This is done by injecting a substance into a nerve.
  • Procedural sedation acts by administering sedatives to induce a state where the patient is still conscious but will not have any feeling.

Tools required

The tools involved in ankle splinting are fairly simple:

  • Stockinette
  • Undercast padding
  • Fiberglass splint
  • Bandage
  • Sterile water
  • Medical scissors
  • Disposable sheets
  • Bandage tapes

After splinting

Postsplinting care is important to ensure complications are reduced to the minimal. The patient should adhere to rest, ice and elevate the injured limb. If any numbness is experienced or the limb is turning purple, the patient needs to go to the nearest emergency department as this mean that the bandage is too tight and is restricting blood flow. At all times, the splint must be kept clean and dry to prevent infection. If the area feels itchy, the patient can use a pen to scratch the inside of the splint for itch relief. However, using such tools might injure the skin and cause an unwanted infection. After 3 days, the patient will be scheduled to see a specialist who will advise further.

Complications

Despite proper techniques, complications may still arise but they are rare:

  • Thermal burns may result from the exothermic reaction when the plaster solidifies. If any intense pain is experienced, the patient should remove the plaster immediately.
  • Contact dermatitis may occur if the patient is sensitive to the chemicals that are used in the splinting process.
  • Decreased range of motion will result as the area is immobilised and simple actions will be restricted.

What Is Achilles Tendon Rupture?

The Achilles tendon is located at the back of our heel. Rupturing of it can occur due to several reasons but the most common is because of a sudden trauma acting on the ankle or foot. When the Achilles tendon is torn, the ability to tiptoe is diminished and the walking action will be that of a flat feet person. Due to the severity of this type of injury, it is important to be able to identify it immediately and perform the necessary remedial actions.

What is it?

The role of the Achilles tendon is extremely important. It is located at the back of the heel for a reason. This tendon connects the heel bone to the calf muscles to facilitate the downwards bending of the foot to the ankle. Medically, this action is termed as plantar flexion. A tear of the Achilles tendon be it a partial or complete one will result in the loss of connectivity between the bone and muscle.

What causes the rupture?

As mentioned above, there are various causes of a rupture but the most common is due to a sudden trauma. This extremely high force will cause the tendon to tear instantaneously. This is prevalent during high impact sports such as basketball or football. Constant repetitive movements may also lead to the weakening of the tendon, causing it to tear easily. Awkward landings from falls may also lead to the tearing of the tendon. This is due to the over flexing of the tendon which trying to cushion yourself from the fall.

Symptoms of a torn Achilles tendon

Rupture of the Achilles tendon can produce little to no symptoms in some people. For the others, there are a few common symptoms – there will be severe pain, tenderness and swelling present at the heel region. Some patients may also be unable to stand up on their own without the usage of crutches. During the time of injury, a pop sound may be heard and this is due to the tendon rupturing.

Types of treatment available

A suspected Achilles tendon tear should be diagnosed immediately in order to allow for proper treatment. The team at the emergency department will often refer you to an orthopaedic doctor who is equipped with the skills and knowledge of these musculoskeletal injuries. Treatment is classified into 2 groups – Surgical and non-surgical. Surgical treatment involves the repair and stitching back of the torn tendon together or the usage of a graft tendon from the hamstring. Non-surgical treatment on the other hand involves rehabilitation, physical therapy and a protective leg brace to allow the body to heal on its own.