Ankle Trauma

What is Ankle Trauma?

Ankle trauma encompasses a range of injuries that affect the ankle joint, which is made up of three bones: the tibia (shinbone), fibula (smaller lower leg bone), and talus (a bone in the foot). Ligaments, tendons, and muscles also play crucial roles in the stability and mobility of the ankle joint. When any of these structures are damaged, it constitutes ankle trauma.

Causes of Ankle Trauma

Ankle trauma can occur due to various reasons, including:

• Sprains: A sprained ankle is one of the most common forms of ankle trauma. It happens when the ligaments are stretched or torn, often due to a sudden twisting motion.
• Fractures: Ankle fractures can result from falls, direct blows, or accidents. The type and severity of the fracture depend on the force and angle of impact.
• Overuse: Repetitive movements or activities that strain the ankle joint can lead to overuse injuries, such as tendinitis or stress fractures.
• Accidents: Motor vehicle accidents, workplace accidents, and recreational accidents can all result in ankle trauma.
• Medical Conditions: Certain medical conditions, such as osteoporosis or rheumatoid arthritis, can weaken the bones and increase the risk of ankle fractures.

Types of Ankle Trauma

Ankle Fracture

Ankle fractures are a common fracture that can occur due to an inversion or eversion injury to the ankle. An ankle fracture is a break of one or more bones that make up the ankle joint. Sometimes, ligaments may also be damaged.

Common symptoms of an ankle fracture include pain & swelling, bruising, the inability to bear weight and deformity if the injury is severe or the ankle is dislocated.

An ankle fracture can usually be diagnosed with a simple X-ray; however, sometimes, a CT scan or an MRI may be required to evaluate the fracture pattern or any associated ligament or cartilage injury sustained at the time.

Treatment varies depending on the type and severity of the injury. If the fracture is nondisplaced and has minimal ligamentous damage, the most common treatment method would be a Moonboot and followup xrays with Physio.

If a significant displacement or the ankle fracture is deemed unstable, you may require surgery to realign the bones. During surgery, your doctor may place plates, screws or pins to hold the broken bone until healing happens.

After your surgery, you may be placed into a plaster cast or a moon boot. Once the fracture has healed, your surgeon will usually recommend Physiotherapy to increase the range of motion and rehabilitate your ankle.

Achilles Tendon Rupture

The Achilles is one of the strongest and largest tendons in the lower limb. It is important for walking, running, and jumping. A rupture can occur by direct trauma or laceration to the Achilles, though the most common cause is usually participation in sporting activities.

Usually, patients report a loud pop or snap that causes them to be unable to bear weight, which is associated with severe pain and swelling. Upon presentation to their GP or surgeon, they may notice a gap or depression in the tendon just above the heel bone.

The rupture can usually be diagnosed clinically or with an ultrasound, though your surgeon may occasionally order an MRI to further delineate the severity of the tear.

The Achilles rupture can be treated either conservatively or with surgery. Conservative management usually involves placing you into a plaster cast and transitioning into a moon boot. You may be allowed progressive weight bearing and physiotherapy to encourage rupture healing.

Surgical repair of the Achilles can either be done through an incision to expose the rupture and suture the ends of the tendon together. Surgery has the added benefit of increasing the push-off power of the Achilles and increasing return to sport.

Ankle Sprain

An ankle sprain is an injury caused by a twist of the ankle, either inwards (inversion) or outwards (eversion). The most common method of injury is usually in plantarflexion (toes pointed down) and inversion. This is a very common injury, and it is important to note that 90% of patients recover very well without surgery.

Initial symptoms of bruising and swelling can be severe; therefore, it is important to present to your GP for an initial investigation, which usually includes an X-ray and an ultrasound. You may require crutches initially, and your GP may either use a compression stocking to control your pain and swelling or a moon boot.

To aid the swelling and bruising, the mnemonic RICE—Rest, Ice, Compression, and elevation—must be adhered to. It can take up to two weeks or more for the symptoms to settle.

The X-ray is usually normal or may reveal small avulsion flakes of bone off the tip of the fibula, representing ligaments of the ankle that have pulled off these small dots of bone. The ultrasound report can also sound daunting, reporting ruptures of ligaments such as the ATFL and the CFL. Despite this, many ankles recover well, as these ligaments are anatomically weak and are commonly ruptured with a simple ankle sprain.

Upon presentation to your surgeon, they will examine you to ensure you do not have any other serious injuries that may have occurred during the sprain. However, it is tempting to perform an MRI; an ankle sprain is usually diagnosed clinically or with an initial x-ray and ultrasound. The only reason to perform an MRI would be to exclude other injuries within the ankle that do not appear to be settling after 4-6 weeks.

Suppose your surgeon or GP diagnoses an ankle sprain. In that case, the initial treatment once the pain & swelling settle will be to gradually increase the range of motion in your ankle with simple flexion & extension exercises of the ankle and to slowly increase the amount of weight you can put through the ankle. Your surgeon will encourage you to wean yourself out of your moon boot and perhaps recommend an ankle brace temporarily until you regain strength & confidence in the ankle. They will also refer you to a physiotherapist, who can guide you through exercises necessary to restore range of motion, strength and proprioception in your ankle.

Depending on the severity of your injury, it can take up to 6 weeks or more to recover from an ankle sprain and sometimes up to 3 months before you can return to sport. The most common reasons your surgeon would recommend surgery would be:

• There is other pathology within the ankle as a result of the sprain that requires surgery
• Ongoing pain, likely due to chronic inflammation & scar causing impingement within the ankle joint
• Chronic instability or frequent giving way of the ankle (ankle instability)

Ankle Instability

Ankle instability is a condition causing recurrent giving way of the ankle, usually into inversion. This condition develops after repeated ankle sprains that have not been treated or rehabilitated appropriately, though occasionally, it can be linked to ligamentous laxity or particular soft tissue conditions, causing your ligaments to be stretchier than normal.

This condition can be particularly debilitating as you gradually lose trust and confidence in your ankle. You may feel particularly unstable initially on uneven ground or when playing sports, progressing to instability even when doing normal activities of daily living. Each ankle sprain will progressively weaken your ligaments, resulting in greater loss of confidence and increased instability.

This instability can be clinically proven when your surgeon examines your ankle and notices increased tilt of the talus (ball joint of the ankle) and increased laxity to pulling your ankle anteriorly (anterior drawer). 

An ultrasound that reveals chronic tears or the absence of the ligaments that stabilise the ankle can further confirm this. Occasionally, your surgeon may order an MRI to exclude any other concomitant pathology within the ankle. Repetitive sprains to the ankle can sometimes cause damage to the cartilage within the ankle joint, called talar osteochondral defects, and it is important to identify these if surgery is required, as these can be addressed simultaneously.

Treatment for chronic ankle instability is the same as an acute ankle sprain, which in the initial period of a sprain is still RICE (Rest Ice Compression Elevation), then progressing to physiotherapy to strengthen and improve proprioception and balance in the ankle. Wearing a brace can also help increase ankle stability and proprioception.

Occasionally, your surgeon will recommend surgery when non-operative measures have failed or additional damage within the ankle requires attention. Stabilising the ligaments is usually done through an open approach on the lateral (outside) aspect of your ankle, where your surgeon will identify the torn or lax ligaments and tighten and repair them up to the fibula, using sutures or anchors – which are special screw-like devices with sutures within them. You may be placed into a plaster cast or moon boot while the ligaments repair themselves, and there may be a period of non-weight bearing to allow the wound to heal. After that, you are encouraged to come out of your moon boot/plaster to allow a gentle range of motion in your ankles. Once the ligaments are healed, ongoing physiotherapy is encouraged to continue strengthening the ligaments and obtain adequate ankle range.

Diagnosis of Ankle Trauma

Diagnosing ankle trauma involves a combination of clinical evaluation and diagnostic tests:

• Physical Examination: A doctor will examine the injured ankle, checking for signs of swelling, bruising, tenderness, and instability. They may also assess your range of motion and perform specific tests to determine the type and extent of the injury.
• Imaging Studies: X-rays are commonly used to visualise fractures and dislocations. In cases of soft tissue injuries, such as ligament tears or tendon injuries, MRI (Magnetic Resonance Imaging) or ultrasound may be necessary for a more detailed assessment.
• Arthroscopy: In some cases, arthroscopy, a minimally invasive procedure, may be used to directly visualise the interior of the ankle joint and assess the extent of the injury.

Treatment of Ankle Trauma

The treatment of ankle trauma depends on the type and severity of the injury:

• Conservative Treatment: Mild ankle sprains and minor fractures may be treated conservatively. This typically involves rest, ice, compression, elevation (RICE protocol), immobilisation with a brace or cast, and physical therapy to regain strength and mobility.
• Surgical Intervention: Severe ankle fractures, dislocations, Achilles tendon ruptures, and cases where conservative treatment fails may require surgery. Surgery aims to realign fractured bones, repair torn ligaments or tendons, and stabilise the joint.
• Physical Therapy: Regardless of whether surgery is needed, physical therapy is often an essential component of ankle trauma treatment. It helps improve strength, flexibility, and overall joint function.
• Medications: Pain relievers and anti-inflammatory medications may be prescribed to manage pain and inflammation during recovery.