The Comprehensive Resources on Foot Pain, Foot Pain Treatment and Foot Care

Ankle

Ankle

 

By Adam Bryniczka, D.P.M.

 

 

 

            The ankle is a ginglymus joint that connects the foot to the lower leg and that helps propel the body through the gait cycle.  The ankle joint is also known as the talocrural joint which aids in stability, shock absorption, and proprioception.  The ankle joint is a crucial weight-bearing joint which allows the foot to move up and down upon the lower leg.  (The side to side motion of the foot is primarily provided by the subtalar joint which is located just below the ankle joint).  

The ankle is made up of a very complex anatomic network of bones and soft tissue structures.  The ankle comprises of three bones. Two of the bones are located in the lower leg called the tibia and fibula, and one bone is located in the foot called the talus.  There are two bony prominences that are felt on the inside and outside of the ankle joint which are called the medial malleolus and lateral malleolus.  The medial malleolus is a direct extension of the tibia and is located and felt on the inside of the foot.  The bony prominence located on the outside of the ankle is called the lateral malleolus and it is a continuation of the fibula.  There are three articular facets located within the ankle joint, which are made up of cartilage that allows range of motion within the joint.

The soft tissue structural anatomy is made up of the ankle joint capsule, syndesmosis, and ligaments.  The ankle joint capsule harbors synovial fluid within the ankle joint to allow range of motion within the joint.  The syndesmosis is located just above the ankle joint line and is made up of the anterior inferior tibiofibular, posterior inferior tibiofibular, and interosseous ligaments as well as the interosseous membrane.  These soft tissue structures contribute to the stability of the ankle.

The ligamentous structures that help hold the bones of the ankle joint together are divided into two categories called the lateral collateral ligaments and the medial collateral ligaments.  The lateral collateral ligaments are comprised of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments.  The medial collateral ligaments, also called the deltoid ligaments, are divided into superficial and deep portions.  The superficial deltoid ligaments are made up of the tibionavicular, calcaneotibial, and superficial posterior talotibial ligaments.  The deep deltoid ligaments are made up of the anterior talotibial and deep posterior talotibial ligaments.  These ankle joint ligaments are very durable, but not completely resistant to injuries.

 The most common injuries seen in the ankle joint are sprains, ligament ruptures, and bone fractures.  These injuries can be treated with or without surgery.  If these injuries are not treated properly, they can lead to arthritis within the ankle joint.

    Ankle sprains are the most common injuries that are seen in emergency rooms at the hospitals.  Ankle sprains occur when there is a sudden twist or rotation of the foot upon the lower leg.  This puts strain on the ligaments of the ankle joint which can cause different types of structural problems.  An ankle sprain occurs when the ligaments of the ankle become overstretched or even partially torn during excessive motion.   If the sprain or excessive motion is great enough, the ligament or ligaments can even rupture.  An avulsion fracture can occur when the ligament does not rupture, but the bone breaks with the ligament still attached.  These problems are very different and are treated in different ways.

The most common ankle sprain that occurs is when the foot falls inward, called an inversion ankle sprain.  This direction of excessive motion usually damages the lateral collateral ligaments of the ankle and the pain is located on the outside of the ankle.  The first and most common ankle ligament that gets damaged is the anterior talofibular ligament.  When the sprain is greater, it can cause damage to the calcaneofibular ligament or even more severe, the posterior talofibular ligament.   

Another type of ankle sprain is called an eversion ankle sprain. Here, the foot falls outward.  This can lead to pain on the inside part of the ankle.  The superficial deltoid and sometimes deep deltoid ligament can become injured depending on the severity of the sprain.

Ankle sprains are commonly treated without surgery.  The conservative treatment follows the pneumonic PRICE.  The P stands for protection, the R for rest, the I for ice, the C for compression, and the E for elevation.  Protection can consist of a cast, or a walking boot.  Rest is important to allow the sprained ligaments to heal.  Ice is important to decrease the inflammation that occurs during the healing process of the sprain.  Compression is equally important to reduce the swelling.  Elevation also reduces the swelling that occurs during the healing process.  The process can take up to 3-5 weeks depending on the severity of the injury, followed by a rigorous physical therapy regiment.

  Surgery is indicated when the pain has not been resolved in a reasonable period of time, or when the ligaments are ruptured, or when there is a loss of ankle stability.  Some surgeries involve direct primary repair of the ruptured ligament or ligaments.  Tendon transfers, tendon grafts, and rerouting of ligaments can be used when a direct repair is not enough to stabilize the ankle.  An avulsion type fracture can be repaired with the use of anchors that reattach the tendon to the bone.

When the injury is more severe than an ankle sprain, the articular cartilage within the ankle joint can become damaged.  The location of the talus bone within the ankle joint predisposes itself to impaction injuries that occur during a fall from a height or excessive rotation within the ankle joint.  When this occurs, the articular cartilage of the talus can become weakened or even fractured.  When the cartilage gets weakened, it can form large cyst like lesions called Osteochondral Dessicans.  This osteochondral injury to the talus is a very difficult injury to diagnose and is often not seen on radiographs.  A Magnetic Resonance Imaging may be required to help diagnose the injury and define the treatment plan. 

When an Osteochondral Dessicans or osteochondral lesion occurs, conservative measures do not have very high success rates and surgical intervention is usually required.  The surgical treatment of osteochondral defects varies greatly.  The main purpose of surgery is to resolve pain which may involve replacing the cartilage that is damaged with healthy cartilage from a different location within the body or from a cadaver.     

When an ankle injury occurs at very high velocity, the bones of the ankle can become deformed and lead to fracture.  The bones that most commonly break within the ankle are the tibia and fibula.  The orientation that the bones break depends on the forces that are applied and the direction in which it occurred in. 

An “open” ankle fracture is a serious injury that involves a broken bone within the ankle in the presence of a break in the skin.  There is a high chance of infection with an open ankle fracture and so treatment involves multiple procedures and intravenous antibiotics.  A “closed” ankle fracture is less serious and is described by any fracture of bones within the ankle in which the skin is still totally intact.

  There are many classification systems that are used by surgeons to help guide the treatment of ankle fractures.  A common and easy system that is used to describe ankle fracture is the Danis Weber classification, which is based on the location of the fracture within the fibula bone.  A Danis Weber A is a fracture on the fibula that is below the ankle joint.  A Danis Weber B is a fracture on the fibula that occurs at the ankle joint.  Finally, a Danis Weber C is a fracture on the fibula that occurs above the ankle joint. 

The management of ankle fractures is determined by the amount of displacement of the fractured bone, any loss of stability within the ankle joint, and if an open fracture is present.  Any ankle fracture can have fracture blisters associated with this traumatic event.  Fracture blisters can contain blood or serous fluid within the blister which can be treated by draining them or by deroofing the blister and applying a sterile protective bandage.

The nonsurgical treatment is implemented when there is no loss of ankle stability, fracture displacement or breaks in the skin.  The nonsurgical management consists of ice, elevation, compression, and immobilization with a below the knee cast.

Surgery is indicated when the ankle fracture is considered “open,” or when there is a loss of stability, or when there is displacement of the fracture bones.  Surgery is usually delayed for 7-10 days to reduce the swelling that occurs with ankle fractures.  The fractured bones are fixed with screws, plates, K-wires, Steinmann pins, and external fixation devices.  The post operative period is determined by the time is takes for healing of the bone and soft tissues.

Another associated disorder that can occur with or without ankle fractures is an injury to the syndesmosis of the ankle joint.  The syndesmosis helps control the stability of the ankle joint which is located just above the tibia and fibula articulation.  An injury to the syndesmosis displays an excessive amount of space within the ankle joint making it unstable and painful.  Surgery is performed to stabilize the syndesmosis and ankle joint by using screws and suture material.    

Any injury that occurs within the ankle joint can lead to arthritis with or without the proper treatment.  The chances of arthritis forming within the ankle are decreased by the length of time treatment starts and the severity of injury.  Arthritis can be displayed within the ankle joint by forming bony exostoses and decreasing ankle joint space leading to decrease range of motion.  This can be treated with cortisone injections temporarily or by surgical fusion or total ankle replacement.

ANKLE SURGEONS

Ankle Surgeons

 

By: Craig W. Halihan D.P.M.

 

Ankle surgeons are podiatric physicians who are specially trained to perform ankle and reconstructive surgery. They are licensed to provide complete medical and surgical care of not only the foot, but the ankle joint as well. The ankle is a very important and complex joint that requires special care and training to treat. Care includes:

           

  • Ankle fracture repair
  • Achilles tendon rupture repair
  • Ankle ligament rupture stabilization and repair
  • Flat foot reconstruction
  • Post traumatic salvage and fusions
  • Trauma care to the Fibula and Tibia

 

Care is extended to patients of all ages.

 

            Training for podiatric ankle surgeons is extensive. Four years of undergraduate pre-medical studying leading to a bachelor’s degree is required. This is followed by four years of medical training that is in line with and along side MDs and Dos. This training leads to the DPM degree and qualifies the candidate as a physician. After extensive testing the candidate is licensed and then goes through residency training that includes all of the required rotations of MD residency training as well as extensive surgical training in the Foot and Ankle. After completion of residency and more testing the candidate can now be licensed to practice as an attending physician and surgeon. Once in practice the physician begins compiling cases and experience that will eventually qualify him/her to sit for board certification. At this stage the candidate is considered board qualified.

 

            Once the required experiences of ankle surgeons are acquired the candidate will undergo rigorous written and oral testing. When completed, the candidate will classified as board certified.

Board certified physicians have gone through extensive testing, training and real world experience by the time the patients see them in their private practices. This gives the patient confidence that their foot and ankle surgeon is up to the task of getting them on their feet and back to their lives.

Ankle

The ankle is a ginglymus joint that connects the foot to the lower leg and that helps propel the body through the gait cycle. The ankle joint is also known as the talocrural joint which aids in stability, shock absorption, and proprioception. The ankle joint is a crucial weight-bearing joint which allows the foot to move up and down upon the lower leg. (The side to side motion of the foot is primarily provided by the subtalar joint which is located just below the ankle joint).

The ankle is made up of a very complex anatomic network of bones and soft tissue structures. The ankle comprises of three bones. Two of the bones are located in the lower leg called the tibia and fibula, and one bone is located in the foot called the talus. There are two bony prominences that are felt on the inside and outside of the ankle joint which are called the medial malleolus and lateral malleolus. The medial malleolus is a direct extension of the tibia and is located and felt on the inside of the foot. The bony prominence located on the outside of the ankle is called the lateral malleolus and it is a continuation of the fibula. There are three articular facets located within the ankle joint, which are made up of cartilage that allows range of motion within the joint.

The soft tissue structural anatomy is made up of the ankle joint capsule, syndesmosis, and ligaments. The ankle joint capsule harbors synovial fluid within the ankle joint to allow range of motion within the joint. The syndesmosis is located just above the ankle joint line and is made up of the anterior inferior tibiofibular, posterior inferior tibiofibular, and interosseous ligaments as well as the interosseous membrane. These soft tissue structures contribute to the stability of the ankle.

The ligamentous structures that help hold the bones of the ankle joint together are divided into two categories called the lateral collateral ligaments and the medial collateral ligaments. The lateral collateral ligaments are comprised of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments. The medial collateral ligaments, also called the deltoid ligaments, are divided into superficial and deep portions. The superficial deltoid ligaments are made up of the tibionavicular, calcaneotibial, and superficial posterior talotibial ligaments. The deep deltoid ligaments are made up of the anterior talotibial and deep posterior talotibial ligaments. These ankle joint ligaments are very durable, but not completely resistant to injuries.

The most common injuries seen in the ankle joint are sprains, ligament ruptures, and bone fractures. These injuries can be treated with or without surgery. If these injuries are not treated properly, they can lead to arthritis within the ankle joint.

Ankle sprains are the most common injuries that are seen in emergency rooms at the hospitals. Ankle sprains occur when there is a sudden twist or rotation of the foot upon the lower leg. This puts strain on the ligaments of the ankle joint which can cause different types of structural problems. An ankle sprain occurs when the ligaments of the ankle become overstretched or even partially torn during excessive motion. If the sprain or excessive motion is great enough, the ligament or ligaments can even rupture. An avulsion fracture can occur when the ligament does not rupture, but the bone breaks with the ligament still attached. These problems are very different and are treated in different ways.

The most common ankle sprain that occurs is when the foot falls inward, called an inversion ankle sprain. This direction of excessive motion usually damages the lateral collateral ligaments of the ankle and the pain is located on the outside of the ankle. The first and most common ankle ligament that gets damaged is the anterior talofibular ligament. When the sprain is greater, it can cause damage to the calcaneofibular ligament or even more severe, the posterior talofibular ligament.

Another type of ankle sprain is called an eversion ankle sprain. Here, the foot falls outward. This can lead to pain on the inside part of the ankle. The superficial deltoid and sometimes deep deltoid ligament can become injured depending on the severity of the sprain.

Ankle sprains are commonly treated without surgery. The conservative treatment follows the pneumonic PRICE. The P stands for protection, the R for rest, the I for ice, the C for compression, and the E for elevation. Protection can consist of a cast, or a walking boot. Rest is important to allow the sprained ligaments to heal. Ice is important to decrease the inflammation that occurs during the healing process of the sprain. Compression is equally important to reduce the swelling. Elevation also reduces the swelling that occurs during the healing process. The process can take up to 3-5 weeks depending on the severity of the injury, followed by a rigorous physical therapy regiment.

Surgery is indicated when the pain has not been resolved in a reasonable period of time, or when the ligaments are ruptured, or when there is a loss of ankle stability. Some surgeries involve direct primary repair of the ruptured ligament or ligaments. Tendon transfers, tendon grafts, and rerouting of ligaments can be used when a direct repair is not enough to stabilize the ankle. An avulsion type fracture can be repaired with the use of anchors that reattach the tendon to the bone.

When the injury is more severe than an ankle sprain, the articular cartilage within the ankle joint can become damaged. The location of the talus bone within the ankle joint predisposes itself to impaction injuries that occur during a fall from a height or excessive rotation within the ankle joint. When this occurs, the articular cartilage of the talus can become weakened or even fractured. When the cartilage gets weakened, it can form large cyst like lesions called Osteochondral Dessicans. This osteochondral injury to the talus is a very difficult injury to diagnose and is often not seen on radiographs. A Magnetic Resonance Imaging may be required to help diagnose the injury and define the treatment plan.

When an Osteochondral Dessicans or osteochondral lesion occurs, conservative measures do not have very high success rates and surgical intervention is usually required. The surgical treatment of osteochondral defects varies greatly. The main purpose of surgery is to resolve pain which may involve replacing the cartilage that is damaged with healthy cartilage from a different location within the body or from a cadaver.

When an ankle injury occurs at very high velocity, the bones of the ankle can become deformed and lead to fracture. The bones that most commonly break within the ankle are the tibia and fibula. The orientation that the bones break depends on the forces that are applied and the direction in which it occurred in.

An “open” ankle fracture is a serious injury that involves a broken bone within the ankle in the presence of a break in the skin. There is a high chance of infection with an open ankle fracture and so treatment involves multiple procedures and intravenous antibiotics. A “closed” ankle fracture is less serious and is described by any fracture of bones within the ankle in which the skin is still totally intact.

There are many classification systems that are used by surgeons to help guide the treatment of ankle fractures. A common and easy system that is used to describe ankle fracture is the Danis Weber classification, which is based on the location of the fracture within the fibula bone. A Danis Weber A is a fracture on the fibula that is below the ankle joint. A Danis Weber B is a fracture on the fibula that occurs at the ankle joint. Finally, a Danis Weber C is a fracture on the fibula that occurs above the ankle joint.

The management of ankle fractures is determined by the amount of displacement of the fractured bone, any loss of stability within the ankle joint, and if an open fracture is present. Any ankle fracture can have fracture blisters associated with this traumatic event. Fracture blisters can contain blood or serous fluid within the blister which can be treated by draining them or by deroofing the blister and applying a sterile protective bandage.

The nonsurgical treatment is implemented when there is no loss of ankle stability, fracture displacement or breaks in the skin. The nonsurgical management consists of ice, elevation, compression, and immobilization with a below the knee cast.

Surgery is indicated when the ankle fracture is considered “open,” or when there is a loss of stability, or when there is displacement of the fracture bones. Surgery is usually delayed for 7-10 days to reduce the swelling that occurs with ankle fractures. The fractured bones are fixed with screws, plates, K-wires, Steinmann pins, and external fixation devices. The post operative period is determined by the time is takes for healing of the bone and soft tissues.

Another associated disorder that can occur with or without ankle fractures is an injury to the syndesmosis of the ankle joint. The syndesmosis helps control the stability of the ankle joint which is located just above the tibia and fibula articulation. An injury to the syndesmosis displays an excessive amount of space within the ankle joint making it unstable and painful. Surgery is performed to stabilize the syndesmosis and ankle joint by using screws and suture material.

Any injury that occurs within the ankle joint can lead to arthritis with or without the proper treatment. The chances of arthritis forming within the ankle are decreased by the length of time treatment starts and the severity of injury. Arthritis can be displayed within the ankle joint by forming bony exostoses and decreasing ankle joint space leading to decrease range of motion. This can be treated with cortisone injections temporarily or by surgical fusion or total ankle replacement.