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Part of the body

ANKLE (ankle joint)

The ankle joint can be described simply as a fork of the outer and inner ankle, between which the ankle bone (talus) is symmetrically positioned.

Ankle stability is ensured by three ligamentous tissue systems:

  • Tibiofibular sindemosis – is a connection of tibia and fibula;
  • Delta ligament – a stabilizer in the inner ankle region;
  • Stabilizers in the outer ankle region formed by three ligaments;
    • Anterior tibiofibular ligament (Ligamentum tibiofibulare anterius);
    • Posterior tibiofibular ligament (Ligamentum tibiofibulare posterius);
    • Calcaneofibular ligament (Ligamentum fibulocalcaneare).

In case of ankle sprain, the anterior tibiofibular ligament (FTA) is most often damaged.  This structure is a direct part of the articular capsule, so its severe damage is almost always associated with the occurrence of a blood lesion in the area of the outer ankle.

Causes of ankle pain

  • Sprain of ankle joint (distorsion)
  • Fracture in the area of the ankle joint
  • Chronic ankle instability
  • Luxation of the peroneal tendons
  • Ankle joint arthrosis

Sprain of ankle joint (distorsion)

What is it?

The ankle sprain or distorsion is a very common injury both in sports and in everyday life. It most commonly results from a bad step or jump on one leg turned inward (inverse injury mechanism). This is followed by stretching or partial rupture of the ligament structures from the inside or outside of the ankle joint. Distorsion, as opposed to dislocation (luxation), does not lead to a violation of the stability of the ankle joint.

Degrees of severity of damage to the ankle ligaments:

  • 1st degree: ligaments are stretched, the ankle function is slightly impaired;
  • 2nd degree: ligaments are partially torn, the ankle function is impaired;
  • 3rd degree: ligaments are completely torn, the ankle function is severely impaired.

Diagnostics

  • In the event of the first degree of ankle distorsion, it is usually possible to continue walking and running; swelling and pain occurs later, blood discharge does not occur at all or is of minimum extent.
  • In the second and the third degree of injury, a rapid haematoma originates in the area of the outer ankle, which swells rapidly and the patient normally cannot continue walking or running.
  • Distinguishing the second and the third degree is difficult and a thorough orthopaedic examination is necessary, including complementary diagnostic examinations such as X-ray or MRI, which is currently the most accurate examination method.

Treatment options

The treatment of the sprained ankle is dependent on the degree of injury of the ligament apparatus. Treatment of all distorsions begins with conservative approach: rest, protection, ice cooling, application of compression bandage; the limb must be relieved and maintained at a higher position. The purpose of these measures is to prevent swelling. It is also advisable to employ supplement medication according to the physician’s recommendation to speed up the absorption of swelling and hematoma and thereby speed up convalescence.

 

  • 1st degree – so-called functional therapy, without firm fixation, ice cooling, about 14 days rest, relief with crutches, local application of anti-inflammatory substances. After 2 weeks, rehabilitation and physical exercise procedures are initiated.
  • 2nd degree – therapy with a suitable stronger orthosis or a cohesive bandage that prevents the foot from standing in the trauma-inducing position, relieving with crutches for about 3-4 weeks and subsequent rehabilitation.
  • 3rd degree – Immobilization by gypsum or plastic fixation for 5 – 6 weeks; professional athletes are advised to subject to surgical solution – suture of torn ligaments + subsequent 6 weeks of immobilization followed by rehabilitation and physical therapy.

A new trend in the treatment of ankle joint distorsion is the application of hyaluronic acid, which helps to create the spatial mesh and accelerates the healing process. The first injection is applied to the region of the affected ligaments within 48 hours of the injury, the second one after another 48 hours. The healing time is reduced to one third, the number of relapses decreasing to a half. This treatment is not covered by public health insurance, and the patients have to pay that on their own.

Fractures in the area of the ankle joint

What is it?

Fractures in this area are one of the most common leg injuries. They result from severe sprains of the ankle joint and are the so-called luxation fractures.

During this kind of injury, the following may occur:

  • internal ankle fracture (fractura malleoli medialis);
  • outer ankle fracture (fractura malleoli lateralis);
  • both ankle fracture (fractura bimalleolaris);
  • fractura trimalleolaris (fracture of both ankles with breaking of the rear edge of the lower end of the tibia).

Diagnostics

Fractures in the ankle area are characteristic by dislocation, rapidly increasing swelling and haematoma. A thorough orthopaedic examination and complementary diagnostic methods like X-ray or CT are essentially important for the diagnosis.

Treatment options

In the first treatment of the luxation fractures of the ankle, it is necessary to partially reposition and fix the fracture in the least dislocated position.

  • Conservative solution – Only fractures that are not dislocated or with minimal dislocation only can be treated in this manner, by employing a gypsum fixation for 6 weeks.
  • Surgical solution – the aim is to restore the length and shape of the fibula and to reconstruct the joint surfaces.
    • The fracture of the outer ankle is mostly fixed by a splint and screws.
    • Osteosynthesis of the inner ankle is usually performed with only one screw and one wire.
    • The split rear edge is fixed to suit individual needs.
    • Fractures of the pylon are most often fixed by an LCP splint.

If there is an open fracture or ankle swelling is significant or there are traumatic blisters, the reposition is performed in general anesthesia and fixation by an external fixation element. The osteosynthesis with a splint and screws is performed in the second time after the soft tissue swelling has receded and stabilized.

Chronic ankle instability

What is it?

It occurs after repeated and inadequately treated dorsal ankle joint distorsions. With chronic instability, the lateral stabilizers are either completely absent or the ligaments are healed in elongation compared to the original length of the ligament. Repeated ankle sprains also occur as a result of inappropriate violence, often even on a totally level mat.

The patient complains of feelings of instability, mostly being able to describe the ankle sprain. The athletes who experience frequent sprains are typically subject to anterior ankle pains where osteophytes have occurred.

Diagnostics

Clinical examination evaluates the anterio-posterior shift in the ankle joint (drawer symptom). Standard X-ray images of the ankle are performed, but dynamic ultrasound examination of the drawer symptom is also appropriate.

Treatment options

  • Conservative solution – consists of reinforcing muscles in the ankle, practicing so-called proprioceptions of muscles on balance platforms. A greater physical strain is recommended with orthoses, cohesive bandage, and taping.
  • Surgical solution – indicated in patients with severe instability limiting in sports and sometimes in normal walking. There are dozens of surgical procedures addressing chronic instability.
    • The first group consists of surgeries in which the reconstruction of the original ligament is performed;
    • The second group consists of surgeries in which the damaged ligament is replaced by a tendon from the surrounding muscles, most often the musculusperoneus brevis, tendon or only a part of it. The tendon is drawn through the channel in the outer ankle and fixed to the front or the outer part of the ankle. After the surgery, the limb is fixed for a period of 6 weeks and rehabilitation starts after removal.

Luxation of the peroneal tendons

What is it?

The main cause of the dislocation of the peroneal tendons is the most common ankle sprain, especially in the dorsiflexion and the inversion of the leg (while skiing). Less frequently, the tendon is dislocated by an inherently shallow groove behind the outer ankle. It manifests by a skip behind the outer ankle, a buckling (giveaway) in the ankle joint, pain, swelling and haematoma.

Diagnostics

Based on the patient history and clinical examination (confirmation of peroneal tendon luxation by ultrasound examination or MRI).

Treatment options

  • Conservative solution – at first subluxation or luxation of peroneal tendons, fixation for 6 weeks, with removal followed by rehabilitation and physical exercise therapy.
  • Surgical solution – with relapsed subluxations or luxations of peroneal tendons. A variety of surgical techniques is available. After surgery, fixation is required for 6 weeks, followed by rehabilitation and physical exercise therapy. The total rehabilitation period is about 2 months, so recovery after the luxation of the peroneal tendons can take up to half a year.

Ankle joint arthrosis

What is it?

The ankle arthrosis is caused by degenerative joint changes, cartilage wear, development of arthrotic growth in the proximity of the joint, origination of deformities. In most cases, cartilage damage is a result of an injury (fractures, repeated distorsions). Frequent occurrence of arthrosis of the ankle joint is present in patients with rheumatoid disease. In rare cases, the cause is the so called primary arthrosis; degenerative changes are therefore not caused by an injury, but are rather a predisposition of the patient to arthrotic involvement of the supporting joints. It manifests itself with pain initially under load, then even at rest. The range of motion is gradually limited, and at the same time, a joint exudate may occur.

Diagnostics

We determine it based on the patient’s history (fracture, instability, rheumatoid disease), clinical examination. The X-ray imaging is still the key method and golden standard, as well as the ultrasound examination to determine the degree of arthrosis. CT examination is rarely indicated.

  • 1st stage: narrowing of the joint space in medial direction, beginning of osteophyte formation;
  • 2nd stage: certain reduction of the joint space, marked osteophytes;
  • 3rd stage: the joint space markedly narrowed, osteophytes, sclerotic changes, cyst formation, shape deformation
  •  4th stage: disappearance of the joint space, necrotic talus, advanced deformation of joint surfaces.

Treatment options

  • Conservative solution – in the early stages of arthrosis of the ankle joint, we initiate primarily pharmacological therapy. Nonsteroidal analgesics and antiphlogistics, chondroprotectives are employed; swelling and exudates are suppressed with corticosteroids. Intraarticular nutrition is also suitable. Reduced physical exercise activities as per recommendation, bandaging. Rehabilitation, physical procedures, spa therapy are suitable. Obese patients are motivated to reduce weight.
  • Surgical solution – in patients with insufficient response to conservative therapy.
    • Arthroscopy
    • Endoprosthesis
    • Ankle joint arthrodesis

Ankle joint arthrodesis

What is it?

This is a partial or complete immobilization of the ankle joint by means of screws and splints:

  • in patients with severe arthrosis and progressing ankle deformity
  • in patients with rest and night pain
  • in patients who are unable to fully step on foot or stand on the affected limb

Treatment options

  • Arthroscopically assisted arthrodesis – this is a mini-invasive modern method, but it cannot be used in all patients with arthrotic affection of the ankle joint. Standard arthroscopic equipment is used during surgery. After adjusting the articular cartilage and upon reaching the right position in the ankle joint, we stabilize the joint by means of 3 cannulated tension sponge-tissue screws. After surgery, the limb is fixed for a period of 6-8 weeks, after which rehabilitation and physical therapy are initiated.
  • Open ankle joint arthrodesis is most commonly performed by section in the middle of the ankle. Using the splints and screws, tibia and ankle bone are screwed together in the correct position. After surgery, fixation is necessary for 6-8 weeks, followed by rehabilitation and physical therapy. The total recovery time is 4 months.

Recovered patients are without pains, they are capable of full painless walking. The patients can exercise day-to-day walking activities, but they will no longer be able to do sports without limitation. The motility of the ankle joint is limited, but the other joints are able to partially compensate for the loss of movement in the main joint of the lower extremity.