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What We Treat

Ligament injuries & instability

Ankle Ligament Injuries

Ankle ligament injury, also known as ankle sprain, can be caused by a sudden twisting movement of the foot during any athletic event or during daily activities. It is one of the most common orthopaedic injuries and can also be caused by walking down a slope or over any uneven surface. The injury can range from mild to severe, depending on the condition of the injured ligament and the number of ligaments involved.

Ligaments are made up of elastic tissues that interconnect bones to one another. They bind the joint together providing stability and support to the joint. The ligaments protect the ankle joint from abnormal movement and stabilize the joint during movement. When stretched beyond its limit, the ligament may partially or completely tear.

Causes

Ankle ligament injury may be caused by a sudden twist, fall, and blow to the joint or any abnormal movement. Use of inappropriate shoes during physical activity, or any forceful movement over an uneven surface may also cause a ligament injury. Previous ankle or foot injury and congenitally weak ankle increase the propensity for ankle sprain.

Symptoms

Pain is the most common symptom of ankle ligament injury and can be associated with swelling and bruising. Sometimes the joint may develop stiffness and the patent may have difficulty walking. The symptoms of ankle ligament injury depend on the severity of the injury which correlates with the extent of damage to the ligaments.

Diagnosis

A complete physical examination by the physician will determine the degree and nature of the injury. The doctor may move the ankle in different directions to evaluate the extent of the injury. The examination may be painful. X-rays may be needed to confirm the severity of the injury and rule out the possibility of a fracture. In severe cases, a MRI scan may also be ordered.

Treatment

Ankle ligament injuries need immediate medical attention as if left untreated they may cause chronic ankle instability. Conservative as well as surgical treatment may be used for the management of ankle ligament injuries.

Conservative Treatment

Conservative treatment may be used for immediate relief and the treatment includes RICE therapy (rest, ice, compression and elevation) and medications. The RICE therapy reduces the pain and swelling and provides rest to the injured ligament. Non-steroidal anti-inflammatory (NASAIDs) medications may be recommended for management of pain and inflammation.

Surgical Treatment

Surgery is not commonly recommended for the management of ankle sprain. However, if the conservative treatment fails to provide any benefit, surgery may be required. Surgery is recommended for ankle joint instability persisting even after months of rehabilitation. Common surgical procedures performed for the management of ankle sprain include ankle reconstruction surgery and ankle arthroscopy.

Rehabilitation

After the non-surgical or surgical treatment, rehabilitation of the injured ankle is important. Physical therapy is effective for complete rehabilitation. It includes strengthening exercises, mobilization exercises and gait training. PT provides long term benefits to the patient and can help prevent a recurrence of the injury.

Ankle Instability

Ankle instability surgery is performed to treat an unstable ankle and involves the repair or replacement of a torn or stretched ligament.

There are two types of ankle instability surgery:

  • Anatomic repair: This surgery involves shortening and tightening the stretched ligament; and
  • Non-anatomic repair: This surgery uses a tendon as a graft to replace the damaged ligament

Ankle instability is a chronic condition characterized by a recurrent slipping of the outer side of the ankle. Instability is generally noticed during movement of the ankle joint but can also occur during standing as well.

Symptoms include the following:

  • The ankle feels unstable
  • The ankle turns repeatedly while walking on uneven surfaces or during a sporting activity
  • Pain, tenderness and swelling is present in the ankle joint

Ankle Instability usually results from repeated ankle sprains. Inadequate healing of a sprained ligament or incomplete rehabilitation of the affected ligament can result in instability. Recurrent injury to the ligaments further weakens them and aggravates the instability which predisposes to the development of additional ankle problems.

Indications

Surgery is recommended in patients with a high degree of ankle instability and in those who have failed to respond to non-surgical treatments.

  • Anatomic repair is preferred in most cases of ankle instability.
  • Non-anatomic repair is performed in obese patients requiring increased stability or when tightening of the stretched and scarred ligaments is not strong enough and needs to be reinforced with a tendon graft.

Surgical procedure

Ankle instability surgery involves the repair or reconstruction of the injured ankle ligaments. Ankle-instability surgeries can be categorized into either anatomic repair or non-anatomic repair, also called reconstructive tenodesis.

Anatomic repair involves reconstruction of the stretched or torn ligaments. The surgery is performed under epidural anesthesia. Your surgeon makes an incision on the ankle to expose the damaged joint and ligaments. The joint capsule and ligaments are examined and the edges of the torn ligament are shortened and repaired with sutures. The ends may be overlapped and then sutured to strengthen the ligament. Your surgeon then covers the repaired ligament with the extensor retinaculum, a dense band of connective tissue, in order to reinforce the ligament further. Range of motion is evaluated, the incision is closed and a sterile bandage is applied.

Reconstructive tenodesis is a tendon transfer procedure that uses your own tendon or a cadaver tendon as a graft to replace the damaged tendon. The surgery is performed under epidural anaesthesia. Your surgeon makes an incision on your ankle. Drill holes are created where the damaged ligament normally attaches to the lower end of the fibula (calf bone) on one side and the talus (anklebone) on the other end. Your surgeon then harvests the peroneus brevis muscle tendon, found on the outer edge of the small toe, and weaves it through the drill holes to form a ligament complex. Range of motion is evaluated, the incision is closed and a sterile bandage is applied.

Post-Operative Care

After surgery, your foot will be immobilized with a cast or splint. You will be provided crutches to avoid bearing weight on the operated ankle. Your doctor will remove the splint and provide a removable boot to be worn for 2 to 4 weeks. Physical therapy will be initiated to strengthen your joint and improve range of motion. Complete recovery may take 10 to 12 weeks.

Advantages & Disadvantages

The advantages of the anatomic repair include:

  • Simple surgical procedure that makes use of your own anatomy to repair the damage
  • Preserves complete joint mobility
  • Rapid recovery
  • Smaller incision
  • Fewer complications

The disadvantage of the anatomic repair includes:

  • Loosening of the ligaments, requiring additional repairs

The advantages of the nonanatomic repair include:

  • Provides increased strength
  • Can be used when host tissues are severely damaged
  • Provides additional stability in obese patients

The disadvantages of the nonanatomic repair procedures include:

  • Decreased rear foot motion
  • Does not preserve the peroneus brevis, an important structure for the ankle‚Äôs dynamic stability

Risks and complications

As with all surgical procedures, ankle instability surgery may be associated with certain complications including:

  • Injury to the superficial nerves
  • Chronic pain
  • Stiffness
  • Need for second surgery (rare)