Ankle Fractures

A fall, an accident, or a hard blow may cause one or more bones in the ankle to fracture or break. Depending on the type of injury, an ankle may fracture in several ways. Spiral fractures may result from twisting injuries. If bone pulls away from bone, the break is often straight. After a bad fall, or a heavy blow, bone may be crushed. Although ankle fractures tend to cause pain, you may be able to walk on the ankle. However, this is not a good idea. Your physician should check any injured ankle.

Treatment

Your treatment depends on where and how badly your ankle has been broken. Your physician will feel your ankle and foot for swelling and any displaced bones. He or she may also check to see if the ankle joint still moves. Depending on how the injury occurred, your physician may examine your leg from the knee down. X-rays will be taken to show the type of break, its exact location, and the extent of the damage.

After a fracture, a cast may be used to hold the bone in its proper position for healing. Sometimes the sections of broken bone must first be realigned. This is called reduction. The type of reduction is based on how far the bone has moved from its normal position.

Closed Reduction

If you have a clean break with little soft tissue damage, closed reduction may be used. Before the procedure, you may be given a light anesthetic to relax your muscles. Then your doctor manually readjusts the position of the broken bone.

Open Reduction

If you have an open fracture (bone sticking out through the skin), badly misaligned sections of bone, or severe tissue injury, an open reduction will be used. A general anesthetic may be used during the procedure to let you sleep and relax your muscles. Your doctor then makes one or more incisions to realign the bone and repair soft tissues. Screws or plates may be used to hold the bone in place during healing.

Casting a Fracture

To make sure the bone is aligned properly, an x-ray is taken. The ankle is then put in a cast to hold the bone in place during healing. You will probably have to wear the cast for 4 to 8 weeks. For less severe fractures, a walking boot, brace, or splint may be all that is needed to hold the bone in place during healing.

Once your fracture has been treated, your physician will tell you how to help it heal. You may be told to limit your use, take medications, and elevate the foot. If you have a cast, remember to keep it dry. To reduce swelling and control pain, elevate the ankle above the level of your heart. This simple action can help control symptoms throughout your recovery.

Protect your ankle by giving it enough time to heal. When you do become active again, expect some swelling and stiffness. To build strength and help avoid re-injury, your physician may prescribe physical therapy or home exercise. Ankle support may also help. Exercise increases the flexibility of your ankle. If your physician agrees, try the following exercise. Use your foot to write out the alphabet in the air. Be sure to work from the ankle and foot, not from the knee.

Ankle Sprains in the Runner

Ankle sprains are one of the most common joint injuries runners experience. The injury can occur when one rolls over a rock, lands off a curb, or steps in a small hole or crack in the road. Usually the sprain is only mild, but on occasion it may seriously injure the ligaments or tendons surrounding the ankle joint. Management of this injury relies on early and accurate diagnosis, as well as an aggressive rehabilitation program directed toward reducing acute symptoms, maintaining ankle stability, and returning the runner to pre-injury functional level.

General Anatomy of the Ankle

The ankle is comprised of three main bones: the talus (from the foot), the fibula and tibia (from the lower leg). The three bones together form a mortise (on the top of the talus), as well as two joint areas (on the inside and outside of the ankle), sometimes called the "gutters". The ankle is surrounded by a capsule, as well as tissue (the synovium) that feed it blood and oxygen.

Some of the more important structures that hold the ankle together are the ankle ligaments.

Most ankle sprains involving the ligaments are weight bearing injuries. When a runner's foot rolls outward (supinates) and the front of the foot points downwards as he or she lands on the ground, lateral ankle sprain can be a result. It is usually this situation that causes injury to the anterior talo-fibular ligament. However, when the foot rolls inwards (pronates) and the forefoot turns outward (abducts), the ankle is subject to an injury involving the deltoid ligament that supports the inside of the ankle. This can occur when another runner steps on the back of the ankle, as at the beginning of a race, or when a runner trips and falls on the runner in front of him.

Diagnosis

When assessing an ankle sprain, your podiatrist will want to know the mechanism of injury and history of previous ankle sprains. Where the foot was located at the time of injury, "popping" sensations, whether the runner can put weight on the ankle are all important questions needing an answer. If past ankle sprains are part of the history, for example, a new acute ankle sprain can have a significant impact.

The physical examination should confirm the suspected diagnosis, based on the history of the injury. One looks for any obvious deformities of the ankle or foot, black and blue discoloration, swelling, or disruption of the skin. When crackling, extreme swelling and tenderness are present, together with a limited range of motion, one may suspect a fracture of the ankle. A feeling of disruption on either the inside or the outside of the ankle may indicate a rupture of one of the ankle ligaments.

To check for ankle instability, the runner should be evaluated while weight bearing. Manual muscle testing is also valuable when checking for ankle instability. One of the more critical tests that a runner should be able to perform before allowing resumption of activity is a "single toe raise" test. If the runner is unable to do this, one might suspect ligamentous injury or ankle instability.

X-rays help rule out fractures, "fleck fractures" inside the ankle joint, loose bodies, and/or degenerative joint disease (arthritis). Stress X-rays are taken when ligamentous rupture or ankle instability is suspected. When a stress test is taken of your ankle, don't be surprised if the same test is performed on the other ankle. This is done to compare the two ankles, particularly in cases of ligamentous laxity (loose ligaments).

In the past, more commonly, ankle arthrography has been used. This involves injecting a dye into the ankle joint as it is X-rayed. This helps determine if a rupture of a ligament or tear of the ankle capsule has occurred. However, this procedure does involve some discomfort during the injection process, and, on rare occasions, an allergy to the dye occurs.

Other diagnostic tests include computerized tomography (CT Scan) to discover injuries of the bone, and magnetic resonance imaging (MRI) to isolate and diagnose specific soft tissue injuries (ligaments, tendons, and capsule). The MRI is very specific, and gives a clear-cut view of these important structures.

Treatment

Treatment of an acute ankle injury usually begins with an aggressive physical therapy program that controls early pain and inflammation, protects the ankle joint while in motion, re-strengthens the muscles, and re-educates the sensory receptors to achieve complete functional return to running activity.

Modalities that decrease pain and control swelling include icing, electrical nerve stimulation, ultrasound, and/or iontophoresis patches. Easy, mild motion, with the limits of pain and swelling, can actually reduce the effects of inflammation. A continued passive motion (CPM) machine can be very helpful in decreasing pain and swelling.

Resumption of running activity is usually dependent on the runner's limits of pain and motion, and is begun to tolerance. As the runner improves, diagonal running can be prescribed. It is important to protect the runner with braces such as air casts, ankle braces, etc., which help to allow motion at the ankle joint under weight bearing.

Home exercise programs are very helpful for the post-ankle sprain runner. Proprioception re-education is critical for both the acute as well as the chronic ankle sprain. It may involve using a simple tilt board or more sophisticated proprioceptive training and testing devices.

For the acute grade III lateral ankle sprain, or complete deltoid tear, complete immobilization is usually recommended for at least four weeks. Afterwards, a removable cast is used to restrict motion and allow for physical therapy. If the ankle does not respond and ankle instability is diagnosed, surgical intervention may be required.

Today, ankle arthroscopy is a much less invasive procedure than other surgery and allows the ligament to be stabilized with tissue anchors. This eliminates an extended period of immobilization, joint stiffness and muscle atrophy. Post-operatively, this primary ligament repair is protected for approximately a two-to three-week period of time in either a cast or removable cast boot, with daily-continued passive motion, cold therapy, and controlled exercise.

At three weeks, a simple air cast or ankle brace is applied for an additional three weeks while therapy and rehabilitation is progressing. At six weeks, these devices are used only during running and other athletic activity as a safeguard. As the runner resumes strength and proprioceptive capabilities, the devices are discontinued.

Conclusion

When an acute or chronic ankle sprain is not treated, as unfortunately is all too often the case, repeated ankle sprains may occur. Because chronic ankle injuries do not show acute inflammation even when the ankle is weak and unstable, this may set the runner up for another ankle sprain when least suspected. A successive sprain may be more severe than the first, and cause an even more significant injury.

The most important point to keep in mind when talking about ankle injuries, then, is to prevent the condition from becoming chronic or recurrent.

So the next time you roll over that stone, or land in that small hole, make sure that your simple ankle sprain is just that: "simple".

If you don't want to have a swollen ankle all the time while running, don't ignore early warning signs. If you have any doubts about its seriousness, have your podiatrist check your injury.

Dislocating peroneal tendons are an uncommon injury to a group of two tendons whose muscles originate on the outside of the calves. These two muscles are named the Peroneus Brevis and Peroneus Longus. These two muscles are responsible for eversion of the foot. This movement of the foot is demonstrated by standing and then rolling to the outside of the foot. These tendons are also called "stirrup" tendons because as they pass into the foot they act as a stirrup to help hold up the arch of the foot. As these tendons pass behind the outside ankle bone, called the fibula, they are held in place by a band of tissue called the peroneal retinaculum. Injury to the retinaculum can cause it to stretch or even tear. When this occurs the peroneal tendons can dislocate from their groove on the back of the fibula. The tendons can be seen to roll over the outside of the fibula. This will cause the tendons to function abnormally and can cause damage to the tendons. Dislocating peroneal tendons most commonly occur as a result of injury during participation in athletic activities. The most common sport causing injury is snow skiing. It can also occur while playing football, basketball, and soccer. This injury can occur in non-athletes, as a result of a severe ankle sprain. The injury typically results in a popping or sharp pain on the outside of the ankle. The outside of the ankle is called the lateral malleolus. Commonly however, there may be little to no discomfort at the time of injury, which later becomes symptomatic.

Diagnosis

Physical examination will reveal swelling behind the outside of the ankle if it is an acute injury. If the injury is chronic there may be little to no swelling. There is usually tenderness particularly when pressure is applied behind the outside of the ankle. Having the patient forcefully turn the foot outward against the physician's hand can demonstrate dislocation of the peroneal tendons. This will cause the peroneal tendons to dislocate over the outer edge of the lateral malleolus.

X-rays and occasionally an MRI exam may be necessary to confirm the diagnosis. X-rays are commonly taken to ensure that there are not any other injuries to the bones of the foot and ankle. An MRI will provide your physician with information about abnormal positioning and/or possible tears of the peroneal tendons.

Treatment

Non Surgical Treatment

If there is an acute injury the initial treatment is usually crutches with no weight being applied to the foot. Usually a splint or compressive wrap is applied to decrease swelling. Anti-inflammatory medications and ice are often utilized to help decrease swelling. Once the swelling has subsided your physician will be better able to tell the true extent of injury. Mild injury can be treated with conservative, non-surgical means. Mild injury results in stretching of the peroneal retinaculum without dislocation of the peroneal tendons. The patient is placed in a cast or removable cast boot and must use crutches for six weeks. During this time no weight can be applied to the foot. After six weeks the patient is re-examined. If the injury has not healed further treatment may be necessary.

Surgical Treatment

Surgical correction is necessary in cases of failed conservative therapy and moderate to severe injuries. With moderate to severe injuries the peroneal retinaculum is either torn or severely stretched to a point that the peroneal tendons will easily dislocate. Surgery will involve tightening the stretched or torn peroneal retinaculum. Both absorbable and non-absorbable suture or stitches will be necessary to hold the tissue in place until it heals. This may require drill holes or metallic anchors to be placed in the fibula to aid in suturing the peroneal retinaculum back onto itself.

Twenty-five percent of the population does not have a groove on the back of the fibula for the peroneal tendons to move in. This groove is called the peroneal groove. This can be a causative factor for peroneal tendon dislocation and can only be identified at the time of surgery. If this is encountered during surgery a peroneal groove will be created by performing bone cuts in the back of the fibula. These may require bone screws or pins to hold the bone in place while it heals. During the surgery the peroneal tendons will be examined for possible tears or damage. If this is found it will be repaired by suture.

Post-operatively the patient is placed on crutches and in a splint or cast for 4 to 6 weeks with no weight being applied to the foot. This is followed by 2 to 4 weeks of protected weight bearing in a cast or removable cast boot. This is usually followed by 3 to 6 weeks of physical therapy to regain strength and motion.

Potential Complications

Once an injury occurs it is always possible for a person to re-injure or re-dislocate their peroneal tendons. Surgical complications are rare but can include: infection, reoccurrence, stiffness and weakness of the peroneal tendons, and delay or failure of bone cuts in the fibula to heal. The risk for complications is greatly reduced by taking your prescriptions as instructed and strictly following post-operative instructions.