Whether you are a competitive athlete preparing for your next challenge or a relaxed retiree enjoying a daily morning stroll, we can all agree on one thing: injuries are frustrating! They are unannounced, unforgiving setbacks that leave us grimacing and wondering about the future. What does this injury mean for my daily routine? How will this affect my training schedule? When will I be able to return to full strength? These are common questions we ask ourselves, and while the answers might initially seem vague or unachievable, knowing exactly what the injury entails can allow us clarity.
Injuries of the lower extremity are among the most common sports injuries. The ankle is highly susceptible to injury due to its anatomical constraints and mechanical demands. Walking produces stress through the ankle joint up to 1.5 times your body weight, while stress produced running can be as high as 8 times your body weight. And with the average adult accounting for approximately 5,000 steps per day, accidents happen.
Ankle sprains are one type of said accidents. These injuries commonly occur as the foot rolls outward and the ankle comes over the top, but may result from the opposite mechanism as well. In either situation, the most important thing to do following an ankle sprain is to be a “R.I.C.E. Pro!”
- R: Rest the extremity and cease activity; immobilize the ankle as best you can.
- I: Ice the affected ankle routinely for 20 minutes on, 20 minutes off.
- C: Compress the ankle with ACE bandage or other device. Leave on shoe gear if possible.
- E: Elevate the ankle above the level of the heart.
- Pro: Seek a professional opinion. Ankle sprains can appear similar to ankle fractures, and something seemingly innocuous might require extra attention. It is imperative that a specialist makes this distinction in order to expedite your treatment plan and recovery.
Your doctor will be able to classify your ankle sprain into one of three grades of severity:
- Grade 1: (Mild) Slight stretching of ligament, mild tenderness and swelling
- Grade 2: (Moderate) Partial tearing of ligament, moderate tenderness, increased looseness
- Grade 3: (Severe) Complete tear of ligament, significant tenderness/swelling, substantial instability
This grading system serves to appropriately guide therapy and can maximize your outcome while minimizing downtime.
Acute ankle sprains generally do not require surgery. However once the integrity of your ankle is compromised, it is unlikely to be the same again. One ankle sprain serves as a precursor for a second ankle sprain, and chronic instability can ensue. Early physical therapy has been shown to slow and prevent this from occurring, and it is important to initiate a protocol as soon as the patient is able to tolerate manipulation.
Surgical Repair for Ankle Instability
Persistent ankle instability and a history of repetitive ankle sprains not responding to physical therapy are two reasons to consider surgery. Left untreated, extra motion through the ankle joint predisposes the ankle to cartilage damage and early arthritis—at which point the situation becomes more serious.
In these examples of chronic instability, surgery is desired to tighten the ligaments along the outside of the ankle, reestablish anatomy, and prevent future abnormal motion. This surgical procedure is termed lateral ankle reconstruction. The goal of this procedure is to recreate the previously torn or damaged lateral collateral ankle ligaments through means of direct repair (your tissue), autograft (your tendon), allograft (someone else’s tendon), or synthetic (created) means. Each method carries its individual pros and cons.
Direct repair of the lateral collateral ligament complex is the most desired, simplest, and least demanding recreation. However it is also usually the most unachievable. This repair requires robust ligaments to bring together on both ends; following injury, this ideal is rarely the case. The ligaments are often shredded and ill-suited for this reapproximation alone.
Autograft transfers with use of the peroneal tendons have been used historically to recreate the lateral ankle ligament complex. These tendons are detached from their insertions and rerouted through keyholes in the ankle and rearfoot to mimic the orientation of the original ligament complex. The downside is the considerable compromise from sacrificing these tendons.
The solution to this has been use of an allograft. A cadaveric tendon is harvested from a heathy donor and appropriately screened and processed to be free of communicable diseases. This tendon is prepared and frozen for use as a donor specimen. In much the same way as the autograft, the tendon is attached and routed through the ankle and rear foot. It incorporates into the bone and becomes your own.
Finally, the use of synthetics has been increasing in this field. In the absence of healthy tissue or to supplement an otherwise acceptable repair, synthetics can add strength and security.
If you or someone you know struggles with ankle laxity, come see us at Sierra Foot and Ankle. We will develop a plan to get your feet back on even ground. The treatment starts with you.
Are you experiencing pain or sensations within your ankle that you may not be able to define? Do you feel popping, locking, stiffness, or instability when you walk?
If the symptoms of your ankle are not responding to conservative measures, you might be a candidate for ankle arthroscopy. Ankle arthroscopy is a minimally invasive surgical technique which can be used for both diagnosis and therapy. The arthroscope uses fiber-optics to illuminate, magnify, and transmit the clinical image to easily identified and visualized levels.
There is a lot of information that can be obtained through this approach. Ankle arthroscopy is a powerful diagnostic tool which extends beyond the human eye to determine what may be causing your ankle malady.
It is useful in identifying inflammation within the joint and joint capsule, and assessing the quality of cartilage and bone within the joint. Soft spots in the cartilage and bone from chronic instability (known as osteochondral lesions- OCL) can be properly attended to and addressed from within. Patients with poor wound healing characteristics may still be able to undergo arthrodesis procedures with minimal concern.
Goals of ankle arthroscopy include reduction of ankle pain and improvement in overall function. Surgeries performed with the use of arthroscopy have been shown to result in faster operating times, quicker rehabilitation, and better cosmetic results versus the traditional open surgical approaches.
The thought of having ankle surgery can be daunting. Anxiety over a potential procedure may prevent patients from attaining the care that they both need and deserve. With the advanced techniques afforded by today’s technology, we are able to gain maximal results from a minimal approach.
Is the arthritis in your ankle preventing you from participating in the activities that you love to do? Have you wanted to seek a medical opinion, but feel nervous about the potential results? Have you tried braces and tall boots, and are either not seeing any improvement or are just fed up with donning them every time you leave the house?
You might be a candidate for an ankle replacement.
“An ankle replacement? That sounds new and experimental.”
It was new and experimental… when it was developed in the 70s. The devices of today have been refined and tested to withstand many of life’s demands.
Ankle replacement surgery—called total ankle replacement (TAR) or total ankle arthroplasty (TAA)— is not a new concept, just a newly IMPROVED concept. It involves removing a small portion of bone from both the tibia and the talus, and inserting a prosthetic device meant to mimic the function of a normal ankle joint.
There are a handful of devices available today for implant. Some of the more common implants are pictured in the accompanying graphic for this section. (Clockwise from upper left: Styker STAR, Wright In-Bone, Integra Salto-Talaris, and DePuy Agility.)
This surgery is a great alternative to ankle arthrodesis in patients with end-stage arthritis, who want to remain active and not worry about ambulating on a fused ankle joint. While the primary benefit of this procedure is pain relief, ankle replacement surgery does re-establish a component of motion to a motion-starved joint. Motion at the ankle joint relieves stress from the neighboring joints, which have been compensating to assume ankle joint range of motion duties ever since the ankle became arthritic. Post-operatively, this procedure allows for earlier range-of-motion exercises, earlier weight-bearing, and less-demanding gait training versus an ankle arthrodesis.
Like any surgical procedure of the foot and ankle, complications can arise. The procedure itself is technical and requires strong knowledge of anatomy, awareness of common pitfalls, and a degree of technical skill in order to be properly performed. Complications include and are not limited to wound healing, infection, component loosening, subsidence, and fracture. A thorough discussion with your surgeon is recommended to address these potential issues prior to surgery.
At Sierra Foot and Ankle, we take pride in being on the forefront of design and innovation. We will take every step necessary to ensure a road to successful outcome.