Injury to the ankle joint is the most common sports injury, comprising about 12 per cent of the total number of injuries. Eighty-five per cent of the ankle injuries are sprains, that is ligamentous, and four out of every five of these involve the lateral ligament. The problem with these injuries is that they are so common, familiarity breeds contempt, and the result is frequently unsatisfactory treatment. In the general public, one-third of patients with ankle sprains still have symptoms after 12 months.
The true ankle joint is of the hinge type with movements limited to dorsiflexion and plantar flexion; many of the movements we associate with the ankle joint actually occur at the subtalar and other joints of the mid-foot.
The ankle joint is formed superiorly by the concave articular surface of the tibia, a downward projection of the tibia to form the medial malleolus, and a downward projection of the fibula to form the lateral malleolus; the convex articular surface of the talus is partially held in their grip . At the ankle joint, the tibia and fibula provide a narrower mortice posteriorly and the talus itself is broader anteriorly so that in plantar flexion the joint is at its most unstable and in dorsiflexion at its most stable.
The medial and lateral ligaments of the ankle run downwards and backwards from the malleoli and prevent forward displacement of the leg in relation to the foot. The medial ligament is triangular in shape with its apex attached to the medial malleolus, its base attached to the posterior part of the talus, the calcaneus, the neck of the talus and slightly to the navicular. The lateral ligament is in three parts and is attached above to the lateral malleolus; the anterior band runs downwards and forwards to be attached to the talus and is taut in plantar flexion; the middle cord-like part is attached to the calcaneus and is taut in dorsiflexion and inversion; the posterior band is attached to the posterior tubercle of the talus and is taut on dorsiflexion. There is also a ligament between the tibia and fibula; although not in the ankle joint itself, it is often involved in injuries to the ankle .
The immediate assessment of an ankle injury on the playing area or in the dressing room is an appropriate starting point. The immediate decision to be made is whether there is likely to be a fracture and this is most easily decided immediately after injury. At this time, it is possible to examine an unswollen ankle which is ideal for inspection and palpation on all but its posterior aspect. An hour later this advantage may be lost through swelling, and examination becomes difficult. A history of an acute tearing or snapping sensation with severe pain and disability requires that the athlete should be seen by a doctor as this is likely to be a fracture or a complete tear of the ligament. In other cases, the injured joint should have all bones palpated as far as possible, at first very gently but then with increasing pressure, to be certain there is no tenderness of the bone itself which could be an undisplaced fracture. Ligamentous tenderness is usually anterior and/ or inferior to the prominence of the malleolus on either side of the joint.
The athlete should then be encouraged to move the ankle joint through a full range of movement, initially while sitting on the floor, then with partial weight-bearing and finally with full weight-bearing. The athlete should be asked to stand on tip-toe, jog, run, turn and if he manages this, he may then continue with the activity. If the athlete is unable to complete this procedure he should be removed from the activity area to a more suitable place for examination.
At this time, the areas of maximal tenderness should be reassessed and the initial area of swelling noted. Some injuries of the ankle develop considerable swelling within a very short time – this is often unrelated to the severity of injury but does itself cause considerable tenderness and disability. Swelling must be prevented as far as possible and the ice, compression and elevation routine started immediately. All the swelling has to be removed during the recovery phase and the more there is to remove, the more delayed will be the return to sport.
The most common injury is to the lateral ligament and is caused by a plantar flexion and inversion strain. There is tenderness below and usually in front of the lateral malleolus. There may also be some tenderness on the opposite side of the joint because the stretch to the lateral side of the ankle is associated with compression on the medial side of the joint and the capsule or ligament may be nipped between the bones.
A complete tear of the ligament must be excluded. This may be checked by assessing talar tilt, that is, considerably increased inversion of the heel in relation to the lower leg when the heel is manually inverted or everted. Care must be taken to compare this finding with that in the uninjured ankle because there is considerable individual variation. The test may be difficult to perform owing to pain and if there is serious doubt about the possibility of a rupture then examination under anaesthetic may be required.
A further test for stability is the anterior ‘drawer’ test which is carried out by having the foot in 20° of plantar flexion, applying the flat of one hand against the anterior surface of the tibia to push backwards and the cupped ringers of the other hand behind the talus gently pulling forwards. Significant forward movement of the talus in relation to the tibia indicates a rupture and when this is a possibility, the ankle must be assessed by an orthopaedic surgeon.
Injury to the lateral ligament is the most common but damage to the medial ligament does occur and is caused by eversion of the foot. There is also the possibility of damage to the tibio-fibular ligament due to a forced dorsiflexion strain and this injury heals extremely slowly. On examination there would be general tenderness and swelling on both sides of the joint with pain made worse by dorsiflexion of the foot.
Treatment of all these ligamentous injuries is basically the same. The first object must be the control of bleeding and swelling. The usual routine of ice, compression and elevation should be applied from the moment the injury is reported. There must be some form of strapping for 24 to 36 hours and then a re-evaluation.
An active process of rehabilitation is favoured but there are some cases which do better with a short period in plaster of Paris. Infilling of the two hollows at the back of the ankle joint, on either side of the Achilles tendon, usually implies an effusion within the joint and this should be treated in plaster for one week. There are also some players who cannot be guaranteed to follow advice and therefore require effective immobilisation in plaster for two or three days to prevent them causing further damage to the joint. There are considerable problems with the long-term use of plaster in an athletic situation; microscopically it has been possible to show that the ligamentous attachment to bone remains abnormal for 24 weeks after six weeks in plaster, consequently prolonged periods in plaster for an athlete require a considerable period of rehabilitation.
Thirty-six hours after the initial injury the stage of definitive treatment and rehabilitation begins. Initially, this may only consist of attempting to regain the full range of movement non-weight-bearing, gradually progressing to weight-bearing, strengthening and rotation exercises with particular emphasis on all those activities requiring coordination. This active programme must not be forced too quickly and any evidence of increased swelling or pain requires an immediate re-adjustment of the exercise. Care must be taken to correct abnormal gait as soon as possible because false patterns of movement rapidly become habit. The exercises are time consuming and laborious but appear to produce satisfactory results. Strapping is no substitute for strength and coordination around the joint; for in order to be effective in reducing the force of bodyweight and providing stability to the joint, strapping has to be so strong that normal movement is abolished.
The ankle injury which persists for several weeks also requires great care to be taken in re-establishing the strength of inversion and eversion of the foot. It must also be remembered that there will be some wasting of the involved calf and thigh musculature which has to be corrected.
There has to be a check on the extensibility of the gastrocnemius and soleus muscle group, because limited dorsiflexion appears to be an important factor in the causation of a sprained ankle. This is thought to be due to the tightness of the Achilles tendon which tends to naturally invert the foot thereby making further inversion and sprain likely.
Full functional testing must be carried out before the player or athlete resumes activity. Attention to these apparendy minor injuries is important to ensure that the individual does not develop a chronic or recurrent ankle problem.
OTHER SOFT TISSUE INJURIES
An ankle complaint which is not always directly related to injury is discomfort around the joint due to tendinitis. Tenderness may be localised along the course of the posterior tibial tendon running behind the medial malleolus or along the peroneal tendons running behind the lateral malleolus. Palpation may reveal a fusiform swelling, acute tenderness and crepitation on movement of the involved tendon. This condition is most often seen in runners and there does not appear to be any local treatment with a significant advantage. Some people favour the use of ultrasound, others apply ice directly to the area, or prescribe anti-inflammatory tablets or an injection of hydrocortisone alongside the tendon.
The most important factor is to restrict markedly the athlete’s activities until symptoms and signs subside after which there has to be a graduated return to activity. Adhesive strapping to limit the movement of the joint is of some value but it must be carefully applied because any direct pressure over the involved tendons will aggravate the condition.
There are various lesions of the Achilles tendon which may be extremely disabling. The most spectacular is a rupture of the tendon which classically occurred in the older, heavier athlete but is now more common in the younger group. There is usually a very definite history of sudden, acute pain over the tendon with remarks from the patient such as ‘I thought I had been shot’. Examination two or three hours later may be confused by the considerable swelling which occurs but there is usually a palpable gap in the Achilles tendon about Scm from its distal attachment. Function of the Achilles tendon must be checked and many doctors or coaches merely ask the patient to plantar flex the foot against slight resistance but the athlete can do this by using the accessory muscles and considerable resistance should be provided to check the functional capacity of the Achilles tendon.
The treatment of an acute rupture is open to argument in terms of the usual conservative versus radical approach. Plaster of Paris with the foot in slight plantar flexion for six weeks produces reasonable results but with a rehabilitation period lasting several months. Surgery with end-to-end suture may produce an excellent result but still involves six weeks in plaster, a long rehabilitation period and the associated risks of anaesthesia, infection and delayed healing in a relatively avascular area. It would appear to me that surgery is the treatment of choice in the younger, athletic patient.
In the runner, particularly, there are various less dramatic Achilles tendon pains which are, none the less, disabling. The common condition is a peritendinitis where the athlete develops swelling, usually along the medial border of the tendon, and associated with considerable tenderness. This typically occurs in runners with a large training mileage and is usually associated with some minor abnormality of gait or flat foot which affects the alignment of the Achilles tendon in relation to the calcaneus. The initial treatment of this condition is to stop training, elevate the heel with a pad of chiropody felt or Plastazote and use ultrasound. Peritendinitis sometimes shows a good response to an injection of hydrocortisone alongside but not into the tendon. Occasionally the condition persists and surgery is required; then there has to be a gradual return to activity in a condition which has a great tendency towards chronicity. It is essential to look for minor biomechanical abnormalities and attempt to correct these during the rehabilitation phase.
There is a superficial bursa over the attachment of the Achilles tendon and this may become an acute problem as the result either of direct blows or by friction from the so-called ‘Achilles protector’. Usually this bursitis settles with control of the footwear and judicious padding. There is also a deep bursa which is less frequently a cause of trouble. Inflammation of both these bursae may be helped by a direct injection of hydrocortisone; sometimes surgery is necessary.