I’d like to discuss ankle injuries next. The most common ankle fracture I see is an isolated malleolar fracture, making up 2/3 of ankle fractures (bimalleolar making up 25%, and trimalleolar making up 7%). Most common cause is trauma with a supination, external rotation injury (SER). Again, several factors go in to determining the care of the fracture. If significantly displaced or the ankle is unstable, surgery is often needed. More often than not these isolated malleolar fractures do not require surgery, but an x-ray and full examination is absolutely essential in determining if surgical vs conservative treatment is needed.

I’d like to spend extra time on this last section discussing ankle sprains. The most common ankle injury I see (by far) is the lateral (inversion) ankle sprain. The lateral ankle sprain is the most ubiquitous injury in all of sport. Greater than 80% of all ankle injuries involve the lateral ankle with resulting stretching or rupture of the lateral ligamentous complex. At least 65% of chronic lateral ankle pain and instability is secondary to a previous ankle sprain, especially those that failed to undergo complete rehabilitation. Consequently, the number one risk factor for a lateral ankle sprain is a history of a previous sprain. Following the acute phase of an inversion ankle injury, aggressive rehabilitation featuring peroneal muscular strengthening and proprioceptive exercise is essential. It is easy for a person with an ankle injury to neglect physical therapy particularly when there is no pain, and this is often a mistake. I am a perfect example of this as I injured my ankle in high school in a basketball game but didn’t do physical therapy as I had no pain and I never saw a doctor for the injury. What a mistake it was as I kept re-twisting my ankle and never understood why (and I was wearing ankle braces!). Finally, I saw a podiatrist (before I was a podiatrist obviously) and I did physical therapy and I’m yet to re-sprain it (knock on wood!).

When conservative treatment fails, delayed primary surgical repair of the lateral ligaments is indicated. Although ligamentous sprain and/or rupture is most common with the inversion mechanism of injury, several other associated injuries are frequently encountered. These include avulsion fracture of the fifth metatarsal base, Jones fracture, syndesmosis injury, calcaneal anterior process facture, talar lateral process fracture, talar dome fracture, peroneal or flexor tendon injury and sural nerve damage. Other mechanisms of ankle sprains are uncommon and include the medial (eversion) ankle sprain and anterior or posterior ankle impingement injury

The acute ankle injury should be managed initially following the PRICE principle: Protection, Rest, ice, compression and elevation. Non-steroidal anti-inflammatory medication may also be used to reduce edema and pain. If the patient is unable to bear weight, a compression dressing should be applied for up to seven days. The period of non-weight bearing should be limited as much as possible. A CAM walker should be applied and weight bearing encouraged as soon as possible. This is important for two main reasons: The CAM walker or “boot” allows for early weight – bearing and provides protection. Also, it maintains the ankle in a dorsiflexed position and therefore keeps the anterior talo-fibular ligament well approximated. If the ankle is in a plantarflexed position, the patient will have more pain and potentially heal at a slower rate. If injury to the syndesmosis is suspected, cast immobilization for 4 – 6 weeks is recommended. Associated injuries, such as talar dome or fifth metatarsal styloid fractures should be addressed at this time. Due to the ligamentous damage, chronic lateral ankle pain and instability is perhaps the greatest potential complication of inversion ankle sprains. An inversion ankle sprain results in some degree of functional and anatomic instability. This underscores the need for aggressive rehabilitation and physical therapy which follows distinct phases. Phase I of rehabilitation is aimed at reducing pain and edema and employs elements such as contrast bathing, interferential stimulation, range of motion exercise and pneumatic compression . Phase II consists of strengthening and stretching exercises, massage and basic proprioceptive exercise. Phase III involves more advanced strengthening and proprioceptive exercise, trampoline, jumping rope and BAPS (biomechanical ankle platform system) board. Peroneal muscular strengthening and proprioceptive exercise are the most essential elements of ankle sprain rehabilitation and prevention. Phase IV involves sport-specific exercise and preventative strategies such as braces, taping, high-top shoes and functional foot orthoses. In most cases, the ankle should be “protected” for up to six months following an injury. Braces are clearly more effective than tape, orthosis and high-top shoes in preventing lateral ankle injury. Although they provide some direct support, braces and tape primarily increase peroneal reactivity. Patients generally require somewhere between 4 –8 weeks of rehabilitation (3 times/week). In some cases (grade III) additional therapy may be necessary.

Several anatomical and biomechanical factors play a role in the tendency toward ankle inversion injury. The ankle joint consists of the talar dome articulating with the tibial plafond. The ankle joint axis is angled almost 90 degrees from the sagittal plane, resulting in primarily dorsiflexion and plantarflexion. Minimal frontal plane (inversion, eversion) motion is available at the ankle joint. Inversion and eversion occur at the subtalar joint, which provides a varus or valgus force upon the ankle. Normally, the amount of subtalar inversion exceeds that of eversion by a ratio of 2:1. This increases the likelihood of an inversion-type injury to the ankle and subtalar joints. Forefoot valgus, rearfoot varus and ankle equinus may also contribute to lateral ankle instability due to the supinatory force placed on the subtalar joint. The talar dome is wide anteriorly and narrow posteriorly when viewed from above. When the ankle joint is dorsiflexed, the wider anterior aspect of the talus fits firmly in the ankle mortise. When the ankle is plantarflexed, the talar dome is less stable in the ankle mortise and consequently an inversion ankle injury most commonly occurs when the ankle is in plantarflexion (inversion-plantarflexion). Anatomically, the lateral ankle consists of three ligaments, the anterior talofibular, calcaneofibular and posterior talofibular ligaments. These structures provide stability to the lateral ankle and subtalar joint. The peroneal muscles provide additional stability to the lateral ankle and appropriate peroneal muscular reactivity is essential in preventing inversion ankle injury. Injury to the anterior – inferior tibiofibular syndesmosis is referred to as a “high” ankle sprain and is not uncommon when the ankle is subjected to a severe inversion force. The medial ankle is fortified by the deltoid ligament which consist of five separate ligaments. Medial (eversion) ankle injuries rarely result in significant ligamentous compromise nor require any long-term treatment. The tibialis posterior tendon is much more likely to be injured and should be thoroughly evaluated following
any eversion sprain. Anterior ankle impingement may occur with forced ankle dorsiflexion but is more commonly a chronic, overuse type of injury. Posterior impingement may likewise occur with repeated ankle joint plantarflexion, such as seen in releve. Injury to the flexor hallucis longus tendon and the presence of a retrocalcaneal bursitis or os trigonum must be excluded in the diagnosis when posterior ankle pain is present.

When can the patient return to activity? This is the “million-dollar question” because it has not been clearly defined. This is especially important question with athletes as the amount of stress and strain at the area requires a fully rehabbed ankle with specific tests that need to be performed before they can start back their sport. I base my decision on a few factors. One of these factors is patient must be able to walk quickly without pain or a limp. Second, the patient must be able to perform a single – leg toe raise and with athletes to be able to balance on his/her forefoot while jumping up and down. There are several other factors, clinical findings, and tests I have and a patient’s lifestyle (athlete vs sedentary patient) will weigh heavily into my decision.

When conservative care fails resulting in chronic lateral ankle pain and/or instability delayed surgical repair of the lateral ligaments is indicated. Rarely (never say never, but almost never!) is immediate repair of the lateral ankle ligaments appropriate, as rehabilitation yields excellent/acceptable results in the vast majority of cases. Studies have shown that repairing the anterior talofibular ligament is most essential, whereas repairing the calcaneofibular ligament does not provide any additional benefits. Several surgical techniques, including the modified Brostrom procedure, involve repair of the anterior talofibular ligament and reinforcement of the lateral ankle with a portion of the extensor retinaculum. Alternative surgical methods, referred to as stabilization techniques, involve reinforcing the lateral ankle with a portion or the peroneus longus or brevis tendon. However, these techniques are more technically difficult, compromise the integrity of the normal anatomy and increase the risk of over-tightening the ankle. The current literature clearly favors the Brostrom-type procedures which produce excellent outcomes without the associated technical difficulty or potential postoperative complications.