Ankle Fractures
Definition: The ankle consists of three bones: the tibia, fibula and talus. (picture) An ankle fracture is a partial or complete break in one or more of these bones. Ankle fractures usually occur during a twisting injury with either inversion or eversion of the ankle. A fracture is usually classified according to the location of the fracture. A fracture at the end of the fibula is called a lateral malleolus fracture, a fracture at the end of the tibia is called a medial or posterior malleolus fracture, and a fracture to the fibula and the tibia is called a bimalleolar fracture.
Symptoms: Patients commonly experience bruising, swelling and pain over the fracture site. Blistering of the skin may occur. It may be difficult to walk or bear weight at all.
Diagnosis: Ankle fractures can be diagnosed with x-ray. Additional, specific x-ray views may be obtained to determine if you have also injured the syndesmosis, the ligaments and fibrous tissue between the tibia and fibula. In cases where the fracture is in many pieces or the talus is involved a CT scan may also be ordered. An MRI can be helpful in determining injury to the ankle ligaments but is not always needed.
Treatment: Treatment of your ankle fracture will depend on the location of the break, the number of bones involved and the alignment of your bones and ankle joint. If your fracture involves one bone and remains in appropriate anatomical alignment it can be treated non-surgically. You will be put in cast or walking boot and will be allowed to weight bear as your pain tolerates with crutches or a knee scooter as needed in the beginning. The cast or walking boot will be worn for ~6 weeks. Your fracture healing will be followed sequentially on x-ray.
If the fracture involves both the tibia and fibula (a bimalleolar fracture) it is considered unstable and surgery is almost always recommended. Surgery involves reducing your fracture into correct alignment and fixating the bone with plates and screws or a nail (FibuLock) that goes inside of the bone.
Recovery: Recovery time and weight-bearing after surgery will depend on the type of fracture and hardware used. In the cases where a FibuLock fibular nail is used patients are able to start walking a few days after surgery. To view an informational video on the FibuLock system please click here
Peroneal Tendinosis
Definition: The peroneal longus and peroneal brevis tendons travel along the lateral ankle, underneath the fibula bone. They function to plantarflex the ankle (point the foot toward the ground), and evert the ankle (point the foot outwards). Tendinosis is a clinical syndrome that results in enlargement and thickening of the tendon after an initial period of tendon inflammation and is often related to over-use. Activities that place stress on the peroneal tendons include sports with quick lateral movements and frequent pivots including soccer, basketball and football. Trail running and loose fitting shoes are also common causes. Feet with high arches are at an increased risk for peroneal tendon problems.
Symptoms: Patients notice gradual, increasing pain in the lateral ankle without a specific injury. Swelling on the outside of the ankle may be present. Some patients report a “popping” sensation on the outside of the ankle. Having the patient dorsiflex (point foot upwards) and evert (point foot outward) the ankle against resistance often reproduces the pain they are experiencing.
Diagnosis: Peroneal tendinopathy can often be diagnosed with history and physical examination alone without imaging. X-rays are helpful to rule out fracture if there was an acute injury. An MRI is obtained if the patient fails to improve after initial conservative management and provides detailed information on the health of the tendon, presence of splits within the tendon fibers or the presence of a small accessory bone (os peroneum) within the tendon.
Non-surgical Treatment: Initial treatment of peroneal tendinosis includes rest, ice and oral anti-inflammatory medication. A walking boot for one month is often indicated to help rest the tendons. Physical therapy with eccentric exercises are essential to help strengthen the tendons.
Surgical Treatment: If a patient has a tear in the tendon, an os peroneum, or the pain does not improve with rest and physical therapy, surgery may be indicated. Surgery involves cleaning out the damaged tendon and repairing any split tears in the tendon fibers. Sometimes the groove that the peroneal tendon runs through needs to be enlarged to prevent excessive rubbing, friction and impingement. In cases where one of the tendons is very damaged it can be sewn together with the adjacent tendon to provide additional strength and stability.
Surgical Recovery: You will be put in a plaster splint after surgery and will be non-weightbearing on the operative foot for two weeks after surgery. At your 2 week follow up appointment your stiches will likely be removed and you will be given a walking boot and will typically weight bearing at that time. After a month of walking in the boot physical therapy will be started.
Os Trigonum Syndrome
Definition: An os trigonum is an extra bone on the posterior talus bone caused by the persistence of an ossification center after skeletal maturity. It occurs in 15% of the population. Among those with an os trigonum it occurs in both ankles 50% of the time. The os triogonum does not always cause symptoms and can be an incidental finding on x-rays. When the ankle in plantar flexed (toes pointed to the ground) the os can become trapped between the calcaneus and the back of the tibia. This can cause impingement, inflammation and pain of the surrounding tendons and soft tissues in that region.
Symptoms: Pain is usually present in the posterior, lateral ankle. Pain can be worsened by walking downhill or by pointing the toes (ballet dancing). You may experience pain with movement of the big toe as the tendon that flexes the toe (FHL) runs right next to the os trigonum.
Diagnosis: An os trigonum can be identified with x-rays. Sometimes an MRI is also useful to visualize the amount of inflammation in the surrounding tissues, FHL tendon or stress reaction in the os trigonum.
Conservative treatment: Initial treatment of this condition consists of rest, ice, oral NSAIDs and possible walking boot immobilization. A steroid can be injected into the hindfoot to provide localized pain relief.
Surgical treatment: If the symptoms do not improve after conservative treatment a surgery can be performed to remove the os trigonum and release any entrapment of the FHL tendon. This is usually done with an arthroscopic technique but may require an open incision.
Recovery: After surgery you will have a soft dressing covering your incisions. You may begin walking as soon as the nerve block from surgery has worn off (usually 12-24 hours). You will have generalized soreness in the hindfoot for 1-3 months after surgery but may resume all your activities as your pain tolerates.
Ankle Sprains
Definition: Ankle sprains occur when the ligaments around the ankle joint are stretched too far and tear. Ligaments are strong, fibrous tissues that connect one bone to another. They are important to provide stability to a joint and keep the joint in a correct alignment. The most common type of ankle sprain is an inversion injury in which the foot rolls inward underneath the leg. During this injury the ligament that is most commonly torn is the anterior talofibular ligament (ATFL), which connects the talus bone to the fibula bone on the outside of the ankle. The second most commonly injured ligament is the calcaneal fibular ligament (CFL) which connects the calcaneus (heel bone) to the fibula, also on the outside of the ankle.
Symptoms: Swelling, bruising and pain after rolling an ankle are the most common symptoms of an ankle sprain. You may or may not be able to walk on the ankle depending on the severity of the sprain.
Diagnosis: Diagnosis of an ankle sprain can be made by physical examination alone. The examiner will manipulate your ankle in several ways to determine how much laxity is in the joint and press on certain areas to determine where your pain is localized. An x-ray is also helpful to rule out any fractures that may have occurred during your injury. If you exhibit slow or delayed healing after 6 weeks of conservative treatment an MRI may be obtained to look for damaged cartilage within the ankle joint and to visualize the quality of your ligaments.
Non-operative treatment: Ligaments can heal on their own without surgery in the majority of cases. The length of treatment and expected recovery time will vary depending on the severity of your sprain. Treatment is broken into three phases. During the first phase we focus on rest, reducing swelling and protecting the ankle. This can involve wearing a walking boot, icing the ankle for 20 mintues 4 times daily, using ACE compression wrapping and taking oral NSAIDs. In phase two we work on strengthening your ankle and achieving pain free range of motion through physical therapy. In the third phase you begin gradually returning to your sport or activity.
Operative treatment: Patients with continued pain, ankle instability or recurrent injuries after months of physical rehabilitation are candidates for surgery. Chronic, untreated ankle instability can lead to painful ankle arthritis and should not be ignored. During surgery an ankle arthroscopy is preformed, which uses a tiny camera to look inside the ankle joint to visualize any damage to the cartilage and remove debris within the joint. The damaged lateral ligaments are then reconstructed and reinforced with strong suture.
Surgical FAQs
How long does the surgery take? Will I need general anesthesia?
Before surgery your anesthesiologist will give you a regional block to make your ankle completely numb for 12-24 hours. You will be lightly sedated during surgery but will not be under general anesthesia. An ankle scope with lateral ligament repair is an outpatient procedure and takes about 45 minutes. You will be kept for observation after your surgery for at least 30 minutes. You will need someone to drive you to and from the surgery center.
Can I walk after my surgery?
After your ankle scope and lateral ligament reconstruction you will be put in a plaster splint. You will wear the splint for 2 weeks during which time you will put no weight on the operative foot. Crutches or a knee scooter will be used during the first two weeks. At your two week follow up visit your splint and skin sutures will be removed and you will be given a walking boot and can begin weight bearing as tolerated. The walking boot will be worn for one month.
OCD
Definition: An osteochondral lesion, also known as an osteochondral dessicans(OCD) or fracture, is a region of softening in the cartilage overlying the talar dome with underlying bone cyst formation or fracture. The lesions can occur both from chronic ankle instability or an acute injury. Common acute injuries include impact to the talar dome after falling from a height or a forceful inversion ankle sprain. Inversion sprains are associated with damage to cartilage 6% of the time. In cases of chronic ankle instability there is damage to the articular cartilage ~20% of the time. The talus is more prone to these injuries because it is a bone with poor blood supply which makes healing more difficult.
Symptoms: Patients with an osteochondral lesion experience lingering ankle pain, ankle stiffness, swelling, and mechanical ankle joint symptoms (catching, locking, grinding).
Diagnosis: The history you give the clinician as well as the physical exam will be helpful in determining the diagnosis. In some cases the lesion can be seen on x-rays but in most cases an MRI is needed to make the diagnosis. Even with MRI the lesion may not be visualized but is later confirmed with an ankle scope.
Treatment: Studies reviewing non-operative treatment outcomes have been disappointing and surgical intervention is generally recommended. Surgery includes an ankle scope in which a small camera is inserted into the joint to visualize the cartilage surface of the talus bone, identify any defects and remove any loose debris in the joint. If the lesion can be accessed appropriately it will be treated using arthroscopically, otherwise the skin will be opened. Treatment will include removal of the injured cartilage and bone, drilling of the lesion to stimulate new fibrocartilage formation. Bone grafting will also be considered.
Recovery: After surgery you will have a plaster splint placed on the lower leg. Depending on the size of your lesion you will be non-weightbearing for 2-3 weeks and then will begin walking in a boot. 6 weeks after surgery you will transition out of the boot into regular shoes with the use of an ankle brace and begin physical therapy. It will take 10 weeks after surgery to return to high impact activities like jumping and running.
Ankle & Foot Arthritis
Definition: Arthritis of the ankle can result from a chronic, non-traumatic cause, from previous trauma to the joint, or from a medical condition. Chronic, non-traumatic ankle arthritis is related to the genetic, anatomic malalignment of the ankle joint in which forces are placed inappropriately on the joint overtime, leading to chronic degeneration. The cartilage between the bone wears away which can cause rubbing of bone on bone and the formation of painful osteophytes (bone spurs). Traumatic causes of ankle arthritis include ankle fractures, torn ligaments or untreated chronic ankle instability. Medical conditions that cause ankle arthritis include rheumatoid arthritis, lupus, gout, and psoriatic arthritis.
Symptoms: Symptoms of ankle and foot arthritis include stiffness and pain in the joint that is often worse in the morning or after periods of rest. You may have swelling, redness or warmth around the affected joint. You may experience increased joint pain after being physically active.
Diagnosis: Arthritis can often be diagnosed by history and physical exam alone but x-ray is used to confirm signs of arthritis including joint space narrowing, formation of osteophytes (bone spurs), subchondral cysts and possible angular deformity. MRI and CT scans are also used in some cases.
Non-surgical treatment: Conservative management begins with proper shoe wear with a cushioned, rocker-bottom sole as well as bracing. Scheduled oral or topical anti-inflammatories are prescribed. Injections into the joint with a localized corticosteroid is another option for relief that can be repeated every 3 months.
Surgical treatment: Surgery is indicated if your arthritis pain fails to improve with conservative management and negatively affects your quality of life. Surgery options include fusion of the affected joint or a joint replacement (in the case of ankle arthritis). Both are very effective in eliminating pain and the pros and cons of each option will be discussed at length during your appointment.
To view animation of the Infinity ankle replacement system please click here:
Recovery after surgery: After fusion of a midfoot joint, ankle joint or an ankle replacement you will remain non-weightbearing on the operative side for 6 weeks after your surgery. Crutches, a knee scooter or walker will be used to help you mobilize. After 6 weeks, x-rays will be taken to view the progress of your bone healing and you will most likely be able to start walking in a tall boot at that time. After one month of walking in the boot (2.5 months post-op) another x-ray is taken and you will likely begin transitioning out of the boot into regular shoes with a soft brace.
