What is an Ankle Sprain?
A twisting injury or going over on the ankle usually results in an inversion of the foot and ankle. This produces a spectrum of injuries to the lateral ankle. These injuries very commonly occur in running sports such as soccer, basketball and netball.
A bad ankle sprain results in tearing or rupture of the lateral ligaments (ATFL and CFL). These ligaments will heal but they heal with the ligaments in a stretched position. This causes the ankle joint to feel sloppy and increases the risk of the patient going over on the ankle in the future. Every time you go over on the ankle the ligaments may stretch a bit more and render the ankle more unstable. There is also a risk of damaging the ankle joint surface every time you go over on the ankle.
What treatment is required for Ankle Sprains?
Most ankle sprains (80%) recover completely with conservative treatment. Active rehabilitation is the mainstay of treatment for chronic ankle instability. This involves physiotherapy that concentrates on soft tissue massage, range of motion exercises, peroneal muscle strengthening and proprioceptive retraining. Bracing may be helpful. However, If you continue to have instability despite a 2-3 month trial of physiotherapy treatment then surgery is indicated.
The patient can usually localize the pain to the front (anterior), back (posterior), inner side (medial) or outer side (lateral) of the ankle. This will determine the type of surgery performed.
Surgery for Anterior Ankle Pain
If the pain is anterior then articular (joint) surface injury and anterior ankle impingement should be considered.
1. Articular Surface Injury
Articular surface injury may involve cartilage alone (chondral) or cartilage and bone (osteochondral). These patients will usually experience pain with walking, running and jumping activities. The pain is often worse with stairs or uneven ground. There may be start up pain where the patient has pain when he/she starts an activity such as running and the pain eases as the patient continues. With these lesions, the talar dome is more frequently injured than the tibia.
2. Anterior Ankle Impingement
This procedure is performed when the pain is worse with walking or running up hill, inclines or stairs. Squatting (eg with weight lifting) and landing after a jump (eg gymnastics or acrobatics) may make this pain worse. Sometimes the patient may be able to localize this pain to the inner or outer side of the ankle. There is limited range of ankle motion, particularly in dorsiflexion. Anterior ankle spurs are the most common cause of anterior impingement. The cause of the anterior spurs is unknown and they most likely are the result of repetitive minor injuries. Anterior impingement secondary to spur formation is quite common in athletes especially in soccer, rugby and basketball.
Surgery for Lateral Ankle Pain
Lateral ankle pain may be due to inflammation of the ankle joint from a recent sprain, peroneal tendon tear, peroneal tendon dislocation, or occult fractures.
1. Ankle synovitis
This can cause anterolateral (front outer side of the ankle) ankle pain located just anterior to the lateral malleolus. The pain is usually worse with activities such as stair walking and running and relieved by rest. There may be associated ankle swelling or loss of joint motion.
2. Peroneal Tendon Tear
This is commonly associated with lateral ligament instability. The peroneus brevis is more commonly torn than the peroneus longus. The tear is usually located at the level of the tip of the fibula. The person with a peroneal tendon tear does not often present acutely but will present later with persistent lateral ankle pain and swelling along the tendon. The lateral pain is located behind the lateral malleolus. The pain is worse with activity especially on uneven ground.
3. Peroneal Tendon Dislocation
Skiing is a common cause of this. It may also occur with ankle sprains. It is due to forceful contraction of the peroneal tendons as the skier edges the skis into the snow while making a turn. It may also occur with ankle sprains. The patient will often experience a popping sensation during the accident. The peroneal tendon may remain dislocated or it may reduce and cause repeated dislocation episodes with activities. There is posterolateral ankle pain and swelling behind the lateral malleolus. If there are repeated dislocation episodes then there will be a snapping or popping sensation. The symptoms are worse on uneven ground.
4. Fracture of the Anterior Process of the Calcaneus
This can occur with a lateral ankle sprain. It is an avulsion fracture of the bifurcate ligament. The patient presents with persistent lateral ankle pain following an ankle sprain. The pain and tenderness is maximal in an area that is about 2 cm anterior and 1 cm inferior to the anterior surface of the lateral malleolus.
5. Fracture of the Lateral Process of the Talus (the snow boarder’s fracture)
The patient presents with localized pain, swelling and bruising anterior to the lateral malleolus. There is tenderness around the lateral malleolus. Thus this fracture clinically appears like a lateral ankle sprain. This and the fact that the plain radiographs often do not show the fracture or have only subtle changes are the reasons why this fracture is frequently diagnosed late in patients who have had a presumptive diagnosis of an ankle sprain. The symptoms do not resolve with physiotherapy and the patient presents with chronic lateral ankle pain.
6. Fracture of the Tuberosity of the Fifth Metatarsal
This follows an inversion injury to the ankle. This can be associated with an ankle sprain. This injury represents an avulsion fracture of the base of the fifth metatarsal, which is where the peroneus brevis tendon inserts.
Surgery for Posterior Ankle Pain
Posterior ankle pain may be due to posterior ankle impingement. Posterior ankle impingement may be secondary to repetitive injury. For example it occurs more commonly in ballet dancers who do Pointe work or in mens leading foot of fast bowlers.
Posterior ankle impingement may be due to several causes. The most common cause of painful posterior ankle impingement is due to the presence of an os trigonum. This is the un-united posterolateral tubercle of the talus. Its incidence is about 10% and occurs in both ankles in up to 50% of cases.
They will complain of pain in the area of the posterior heel or deep in the back of the ankle. The pain is aggravated by Pointe work, jumping or running activities or when they stand on the tip of their toes or if they wear high heel shoes.