The Ankle Joint
The ankle is made up of two joints - the subtalar joint and the true ankle joint. The true ankle joint is composed of three bones: the tibia (shin bone) which forms the inside bone of the ankle; the fibula (smaller outer leg bone) which forms the outside bone of the ankle; and the talus bone underneath. The true ankle joint is responsible for the up-and-down motion of the foot. Beneath the true ankle joint is the subtalar joint, which consists of the talus bone on top and calcaneus (heel) bone on the bottom. The subtalar joint allows side-to-side motion of the foot.
The ends of the bones in these joints are covered by articular cartilage allowing the smooth motion of the ankle joint. Three ligaments make up the lateral ligament complex on the side of the ankle farthest from the other ankle. These include the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). A thick ligament, called the deltoid ligament, supports the medial ankle (the side closest to your other ankle). The various ligaments that surround the ankle together help form part of the joint capsule, a fluid-filled sac that surrounds and lubricates articulating joints.
The ankle joint is also supported by nearby tendons. The large Achilles tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the calcaneus and allows us to raise up on our toes. The tibialis posterior tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. The tibialis anterior muscle allows us to raise the foot. The peroneal tendons run behind the outer bump of the ankle (the lateral malleolus) and help to turn the foot down and out.
Common Ankle Injuries
Ankle sprains are prevalent sporting injuries but can happen to anyone whether they are playing sports or simply working in the garden. A sprained ankle occurs when the ligaments that support the ankle joint are stretched and can happen to the medial or the lateral ligaments, depending on the mechanism of injury. Most commonly a sprained ankle occurs to the lateral ligaments as a result of an eversion (outwards roll) injury.
The severity of the injury depends on the extent of the damage to the ligaments and the number of ligaments involved, and can range from a minor to a severe injury. A minor strain often only stretches the ligaments, with more severe injuries resulting in partial or complete tears to one or a number of the supporting ligaments.
Commonly ankle sprains are treated very effectively with conservative management, consisting of ice, rest, modifying your activity and a rehabilitation program.
Occasionally when the severity of damage to the ligaments is severe, the healing may not be sufficient, and the ankle may become unstable. This can also occur when a patient suffers a number of ankle sprains over time.
Common symptoms included:
- swelling and bruising to the ankle;
- inability to walk;
- pain in the ankle;
- pain with movements of the ankle;
- pain with twisting and turning;
- loose feeling ankle; and/or
- reoccurring ankle sprains.
Diagnosis is made through a combination of clinical examinations and investigations. The clinical examination involves a detailed subjective history on the mechanism of injury and clinical tests examining the range of motion, the ligaments integrity and pain on palpation.
An X-ray and, at times, an MRI will often be attained to help diagnose the grade of the injury.
Initially, ankle instability is managed conservatively where you will undergo a detailed strength and proprioception program aimed at strengthening the stabilisers of the ankle and improving balance. A brace is often also used to prevent further injuries while completing the rehabilitation program and when building back into sporting activities.
Surgical intervention may be required in the following instances:
- if you suffer from severe instability and are unable to return to activity following conservative management; or
- if you develop significant structural damage due to the increased movement in the joint.
The aim of surgery is to restore the stability of the joint and involves reconstructing the supporting structures of the ankle (ligaments and tendon). Following surgery, you will undergo a period of non-bearing and then protected weight-bearing and may be in a cast or moon boot. Once cleared by your surgeon, you will then start a functional rehabilitation program focusing on regaining the movement in your ankle, your muscle strength and control.
The Achilles tendon is formed by the calf and soleus muscles and attaches to the calcaneus bone (base of your heel). It is a strong fibrous cord-like structure and one of the largest tendons in your body. It plays an essential role in allowing us to walk, run and jump and therefore is vulnerable to injury.
The significance of the injury is determined by the extent of damage to the tendon. Mild injuries commonly occur to the Achilles due to overtraining or overuse. These injuries often cause structural changes to the makeup of the tendon but do not result in any tearing of the tendon’s fibres.
More significant injuries occur when there is a stretching force to the tendon and result in tearing the fibres of the Achilles. These injuries can be classified into two groups – partial tears and full-thickness tears:
Partial tear: occurs when less than 50 per cent of the tendon fibres have been damaged.
Full-thickness tear: occurs when there is a complete disruption of the tendon fibres.
Tears commonly occur in the mid-belly of the tendon approximately 5-6cm above the heel bone or at the insertion of the tendon on the heal
Tears most commonly occur during sporting activities when pushing off to sprint or whilst slowing down. Another mechanism commonly seen is when a patient misses the step off a curb or lands in a hole whilst running.
Common symptoms include:
- a pop in the back of your heal;
- feeling like someone kicked you;
- a sharp pain in the heal;
- swelling in the ankle;
- unable to push off toes;
- unable to lift foot up; and/or
- unable to walk.
Diagnosis of a complete rupture is made through a clinical examination and is easily identified through a subjective history and clinical squeeze tests. For partial injuries often an ultrasound or MRI is also used to determine the degree of damage to the tendon.
The management of Achilles tendon injuries is dependent on the severity of the damage and often also depends on your age and activity level.
For injuries that do not result in a tear to the tendon, such as Achilles tendinopathy, conservative management involving a phased strengthening and stretching program and activity modification is usually very effective. The timeframes for return to full activity levels will vary between patients, but it usually takes between six weeks and three months for recovery. Occasionally, patients that have completed conservative management and still suffer from functional limitation will require more invasive interventions such as shock wave treatment or surgery.
Partial tears are also commonly treated conservatively. This typically involves having to wear a moon boot for a period between two to six weeks or until cleared by your specialist. Once cleared a phased strengthening program will then start, and as you get stronger you will be allowed to increase your activity levels gently. The period needed to return to full activity will depend on the significance of injury, but will often take between two to four months.
Full-thickness tears can be treated conservatively or surgically. This decision will be discussed with you by your specialist and will take into account your age and activity level. Conservative management involves a period of non-weight bearing in a cast followed by a period of protected weight-bearing in a moon boot. This period can range between six to eight weeks, depending on how your tendon is healing and will be guided by your specialist. Once cleared, you will then start a phased strengthening program and will be allowed to increase your activity levels gently. The timeframe to return to full activity level typically takes between six and nine months.
Surgical repair involves joining the torn tendon back together with surgical sutures, and, if possible, the surgical repair may also be reinforced with another tendon to assist with the healing.
After surgery, you will still undergo a period of non-weight bearing followed by a period of protected weight-bearing in a moon boot. Timeframes for recovery can range between four and eight weeks, depending on the integrity of the surgical repair and this will be guided by your specialist. Once cleared, you will then start a phased strengthening program and will be allowed to increase your activity levels gently. The timeframe to return to full activity takes typically between six and nine months.
Other common ankle injuries we treat
- Anterior impingement of the ankle
- Talar dome fracture
- Metatarsal fractures
- Posterior impingement
- Tib post tendon injuries
- Peroneal tendon injuries