Ankle Conditions

Ankle instability refers to the subjective feeling of the ankle giving way. Generally, it pertains to a lateral ligament injury which involves the Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL). These injuries can occur in isolation or in conjunction with other orthopaedic injuries such as osteochondral lesions. The diagnosis is made in conjunction with clinical history and examination as well as diagnostic scans such as ultrasound +/- MRI. These injuries can occur at any stage in life; however, adolescents and younger adults are more susceptible. Some patients may have genetic conditions such as ligament laxity or alignment issues which may predispose them to such injuries.

Treatment 

Treatment for first-time, isolated ankle instability is usually non-operative. This may involve physiotherapy, proprioceptive exercises, and developing ankle strength. There may also be a particular focus placed on return to sport or hobbies (for example, AFL, netball, or basketball). The use of an ankle support orthosis is often recommended for high-risk activities.

In patients that have recurrent instability, surgery may be considered. Surgical intervention is usually in the form of a ligament reconstruction which, in certain cases, is augmented with an internal brace. Theepan typically performs a modified Brostrum reconstruction. In certain circumstances, (such as ligamentous laxity, or failed previous reconstructions) an allograft (donor) tendon can be used. Recovery can take up to three months on average, before the patient is able to to return to playing sport or high-risk activities.

Risks of surgery, while low, include damage to surrounding neurovascular structures, infection, Deep Vein Thrombosis (DVT) and recurrence or injury or failure of the repair. People who have recurrent episodes of instability are at a higher risk of developing arthritis in the future.

Ankle arthritis refers to degenerative changes within the ankle joint whereby the cartilage that lines the joint surfaces has worn away. The cause of arthritis in the ankle is usually post-traumatic, but can be related to inflammatory arthropathies, such as rheumatoid arthritis. Ankle arthritis usually develops in middle age or later in life. However, following significant injuries, it can also occur in younger people. Unfortunately, at this stage, there are no medical therapies to reverse the effects of ankle arthritis. Arthritis can typically be seen on plain x-rays but, in certain cases, further imaging may be required.

Treatment

In the early stages of ankle arthritis, non-operative interventions are preferred. This usually takes the form of physical therapy to keep the joint mobile, as well as various modalities to reduce pain. These treatments include the judicious use of anti-inflammatories, corticosteroid injections, and supportive bracing. When non-surgical interventions fail, various operative interventions can be utilised. In cases of early arthritis, where the ankle is mal-aligned, the use of an osteotomy (breaking and realigning the bone) to offload the affected area of the joint can be performed. When the arthritis has progressed more significantly, two options exist: ankle fusion and ankle replacement. Ankle fusion involves preparing the joint surfaces of the ankle and bringing the talus and tibia together with screws +/- plates in order to minimise the pain caused by movement within the joint. Ankle replacement involves resurfacing both surfaces of the ankle joint with metallic implants, with a polyethylene liner in between. This procedure will allow for movement to remain within the joint. While both ankle fusion and ankle replacement procedures have good results, Theepan will discuss with you which option may be more suited for your needs, as both procedures involve certain risks and benefits.

An ankle fractures refer to a break in the fibula, tibia, or talus bones, or a combination of these. The injuries typically result from a twisting injury and can result from low or high velocity force. Some ankle fractures are related to dislocation of the ankle joint, and these will typically require reduction in the emergency department. The correct treatment for ankle fractures is crucial to ensure the highest chance of return to function, reduce pain, and prevent long-term arthritis. X-rays will diagnose the majority of injuries; however, a CT and/or MRI scan may be required for further assessment as well as assistance with surgical planning.

Treatment

Simple, undisplaced ankle fractures can typically be treated non-operatively in either plaster or a moon boot. The length of immobilisation will often be dictated by the severity of the injury and any associated injuries. Fractures with significant displacement or deemed to be unstable will usually require surgical fixation. This will usually involve a combination of plates and screws with or without fixation of associated ligamentous injuries (Syndesmosis). The recovery for these fractures will be dictated by the significance of the fracture/s and associated ligament injuries, typically taking at least three months to regain most function in the ankle. Risks of ankle fracture surgery include deep vein thrombosis, infection, damage to neurovascular structures, and post-traumatic ankle arthritis.

Achilles rupture refers to a tear in the Achilles tendon, one of the major tendons contributing to push-off strength within the ankle. Such ruptures usually occur during sporting activities but can also happen in everyday activities, particularly in individuals with an already weakened tendon. The majority of injuries can be confirmed on ultrasound, but occasionally an MRI scan is required.

Treatment

Treatment for Achilles tendon rupture is typically non-surgical, especially for injuries that are identified and treated within 24 to 48 hours of the injury. Current literature suggests that patients managed through an accelerated physiotherapy programme tend to have good functional outcomes. The typical treatment involves the patient being placed into a cam boot with some wedges to help bring the tendon ends together. This is followed by physical therapy to aid the repair and then gradual strengthening of the tendon.

In some circumstances, surgical intervention is warranted, in the form of a surgical repair of the torn tendon. This is typically reserved for patients with delayed presentations of injuries or delay in treatment. Certain athletes may also prefer to have a surgical repair of their Achilles tendon. Regardless of whether the management is surgical or non-surgical, recovery typically takes up to six months, depending on the circumstances.

Risks associated with surgical intervention include infection, deep vein thrombosis, nerve damage, and re-rupture of the tendon.

Achilles tendinopathy is broadly divided into insertional and non-insertional tendinopathy. Insertional Achilles tendinopathy, as the name suggests, involves the part of the Achilles tendon which attaches to the bone. The mechanism of Achilles tendinopathy is usually a repetitive microtrauma which causes tendon inflammation and overgrowth of the tendon, with or without bone spurs. Pain is usually experienced in the heel area, and there can be inflammation of the tissue (bursa) surrounding the Achilles tendon.

Non-insertional Achilles tendinopathy affects the tendon higher up than its insertion into the bone. This is also thought to be related to microscopic tearing of the tendon. Pain is usually present in activities such as running and is often associated with increased swelling in the area. Achilles tendinopathy can be diagnosed both clinically and with the use of ultrasound or MRI.

Treatment

Treatment for both insertional and non-insertional Achilles tendinopathy starts with non-operative therapy. This includes activity modification and shoe wear modification, as well as targeted physiotherapy. We typically recommend against the use of steroid injections into the Achilles tendon as it has an increased rate of Achilles tendon rupture.

Surgery for Achilles tendinopathy can include debridement of the tendon as well as removal of diseased tendon and any bony prominences, including a Haglund's deformity. In some instances where a significant portion of the Achilles tendon is diseased, a tendon graft from an adjoining tendon may need to be utilised. Recovery from Achilles tendon surgery can take up to six months for full recovery. Risks of Achilles tendon surgery include skin breakdown, infection, damage to the nerves in the surrounding area, as well as re-rupture or re-disease of the tendon.

Syndesmotic injuries involve damage to the ligament complex that sits between the tibia and fibula bones at the level of the ankle. The syndesmosis complex has a crucial role in stabilising the ankle joint and any damage to this ligament can potentially affect function and increase the chance of developing arthritis later on in life.

Typically, the injury occurs from a twisting motion and is commonly associated with contact sports, but can also result from low velocity injuries. Syndesmotic injuries can occur in conjunction with ankle fractures. The diagnosis is typically confirmed on x-rays, CT scans or MRIs.

Treatment

Treatment for syndesmotic injuries is often surgical, aimed at stabilising the ankle complex. In the acute setting, the syndesmosis is usually stabilised by a flexible suture device, which helps to maintain the fibula in its correct location within the tibia whilst the ligament heals. At the time of the surgery, a camera is inserted into the ankle joint to assess the cartilage and treat any associated injuries.

Partial or incomplete injuries to the syndesmosis, without any movement of the bones, can be treated non-operatively in a moon boot for six weeks, followed by physiotherapy. Risks of syndesmotic surgery includes damage to nerves, failure of fixation, and the potential development of arthritis later on in life.