Ankle Sprain

An ankle sprain is the most common joint injury in the body, accounting for about 20% of all sports injuries. By rolling over or inverting the ankle, various structures around or inside the ankle joint can be injured to varying degrees. Generally speaking, the more energy involved in the injury the more potential for damage. People who have previously injured the ankle, have poor balance or coordination, or have high-arched feet are thought to be at higher risk for ankle sprain.

The most common form of ankle sprain involves an injury to the anterior talofibular ligament (ATFL), which may stretch or rupture. As the violence of the injury increases, further ligaments may be damaged and a fracture or dislocation of the ankle may even occur. Other potential consequences of severe ankle sprain are osteochondral lesions (cartilage damage), peroneal tendon problems, ankle impingement and chronic instability.

Fortunately, almost all ankle sprains recover fully within six weeks, the majority within two to three weeks. Simple supportive treatment is important to speed recovery and involves the RICE method; Rest, Ice, Compression (Tubig rip or similar) and Elevation for 48-72 hours. This is followed by a graded return to activities. Physiotherapy or Sports Therapy is often helpful in regaining strength and balance in particular. If you have not made a full or near

Osteochondral lesion

Osteochondral lesion

An osteochondral lesion of the talus (OCL, OCD or OLT) is the name given to an area of damaged cartilage inside the ankle, usually arising following a severe ankle sprain or a fracture. OCLs can occur in other joints, most notably the knee. The lesions are rarely diagnosed immediately but are one possible reason for a failure to recover from an ankle injury. Typically at the time of injury, there is a large amount of swelling and it may not be possible to weight bear on the foot for days or even weeks. Patients with an OCL may complain of persistent swelling and pain inside the ankle beyond six weeks after the injury. OCLs come in different sizes, degrees of severity and locations within the ankle. A CT or MRI scan is usually required both to diagnose a lesion and determine its characteristics. If a lesion is associated with significant symptoms, surgery is usually required. The nature of the surgery will vary depending on the individual lesion, but usually involves an ankle arthroscopy. More complex or recurrent lesions may require more complex surgery and sometimes other procedures are necessary at the same time, such as a lateral ligament reconstruction. Post-operative rehabilitation is very important after surgery for OCL and return to sport is slower than other ankle injuries. The success rate for surgery is 70-80%.

Peroneal tendon

The peroneal tendons run along the outside of the ankle, just behind the ‘ankle bone’ (fibula) and into the foot, through a specialised tunnel (retinaculum). They act as dynamic stabilisers of the ankle and malfunction of these tendons can cause functional ankle instability. During a severe ankle sprain, the retinaculum can be torn, allowing the tendons to dislocate around the fibula. This can lead to chronic peroneal tendon instability, with snapping / clicking, pain and swelling during certain activities. The peroneal tendons can also tear or rupture during a severe ankle sprain, or after prolonged and repeated episodes of tendon dislocation. Peroneal tendon problems can co-exist with other ankle pathology, such as chronic ligament instability. Acute flare-ups of peroneal tendon symptoms often respond very well to a period of rest and then rehabilitation, supervised by a physiotherapist or sports therapist. If initial treatment fails, recurrent tendon dislocation is usually cured with a peroneal tendon reconstruction operation. If a tendon tear or rupture is diagnosed prior to or during the operation, then a repair or tenodesis is performed at the same time.

Ankle impingement

Impingement

Impingement occurs when structures in or around a joint catch on or collide with each other causing pain. Many joints may develop impingement ‘syndromes’, and in the ankle the condition is a possible long-term consequence of previous injury. Ankle impingement may be caused by catching of bone spurs, pinched soft tissue, or both. It may also occur at the front or back of the ankle, and so symptoms will vary depending on the type of impingement. In anterior ankle impingement, pain is felt at the front of the ankle when running, during sport or walking, along with stiffness in the joint. Posterior impingement causes pain whilst pushing the foot downwards, particularly during dancing or jumping. Other symptoms, such as giving way or swelling may be present also. If measures such as physiotherapy fail, a steroid injection will occasionally be helpful or surgery may be considered. After investigations to determine the type of impingement, most ankle impingement lesions can be removed with keyhole surgery via an ankle arthroscopy or posterior ankle endoscopy. The success rate in terms of pain relief, and return to sport, for this kind of treatment is 70-80%, unless significant arthritis is discovered in the ankle, when there is a lower chance of success.

Brostrom procedureChronic Ankle instability

Chronic Instability

Chronic instability of the ankle manifests as multiple and frequent episodes of the ankle ‘giving way’ or ‘rolling over’, and develops after up to 20% of sprains. The symptoms may only occur during sport, running or walking on uneven ground, but in severe cases can occur even on level surfaces. There is often pain felt at the front or outside of the ankle and, sometimes, swelling associated with these episodes. In most cases, the cause is ‘functional instability’, where the muscles stabilising the ankle have lost their coordination and control (proprioception). The symptoms can usually be treated very effectively with physiotherapy. However, some patients have mechanical instability, meaning the lateral ankle ligaments have healed inadequately in a lax position. All patients are encouraged to go through a full rehabilitation programme, whichever the type of instability, but a small proportion will suffer persisting symptoms and require surgery. There are several methods for reconstruction of the lateral ankle ligaments, but currently the most effective is the Brostrom-Gould procedure, or anatomical reconstruction. Often an ankle arthroscopy is performed at the same time, particularly if further problems are known or suspected inside the ankle joint, such as osteochondral lesions or impingement.

Stress Fractures

Stress fractures are relatively common in the lower limbs, and may affect almost any bone in the foot or leg. There is always an underlying cause, either intrinsic (brittle bones, poor biomechanics) or extrinsic (inappropriate footwear, training regime, running surface etc). Treatment is tailored to the individual fracture and therefore involves careful assessment of the cause. Usually relative rest or immobilisation is prescribed, but occasionally operative fixation of the fracture is required.

Shin Splints

Shin splints are pains in the shin area on exertion. There are a number of possible causes, including chronic exertional compartment syndrome, tibial stress fracture and medial tibial stress syndrome. Once again, determination of the exact cause is critical and sometimes a dynamic measurement of muscle pressures is necessary with a Compartment Pressure Study. Treatment options range from rest and biomechanical work-up through to surgery.

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