Sporting Ankle Injuries

Plymouth Orthopaedic and Sports Injury Clinic

The ankle joint is very prone to injury. In fact a sprained ankle is the commonest musculoskeletal injury in the UK. In the vast majority of cases the symptoms this injury causes are relatively minor and short lived; pain and swelling can be treated with simple painkillers, anti inflammatory drugs, compression and application of ice. In a minority of cases ankle sprains can lead to persistent problems, with pain and /or instability.

In the common ankle sprain, ligaments on the outer (lateral) side of the ankle are injured. They may simply be stretched, or in more severe injury, ruptured. In severe sprains, the bones that make up the joint can impact causing damage to the lining surface (articular cartilage), and on occasions cause a small fracture of the articular cartilage and underlying bone (osteochondral fracture).

In most cases, even if ligaments are ruptured, they heal satisfactorily. If they fail to do so however, patients can experience repeat episodes of ankle instability with sprain injuries occurring frequently. Pain can be caused by the development of scar tissue in the ankle joint, osteochondral injuries or persistent instability.

Investigation

Careful clinical examination and plain Xrays will allow an accurate diagnosis in many cases. MRI scanning will sometimes be required.

Treatment

In the absence of identified damage within the joint a course of physiotherapy will often resolve symptoms of pain and instability. However, if symptoms fail to resolve, ankle arthroscopy (key hole surgery) permits direct inspection of the joint with appropriate treatment of any injuries.

Ankle Arthroscopy is performed by inserting a small telescope in to the joint through two small stab incisions at the front of the ankle. This is usually done as a day case procedure under a light general anaesthetic. If indicated, an unstable ankle joint can be treated at the same time, by directly tightening the damaged ligaments. This is often called a Brostrom Repair.

All operations involve some risk, but this surgery is generally safe (see section on complications).

Post-operative recovery

This depends on what is found inside your ankle and what procedures are carried out. In a simple arthroscopy, early weight-bearing is possible, with swelling and discomfort resolving within two weeks. However it will take a minimum of six weeks  to return to normal. In more complex cases, you may have to limit weight bearing for up to six weeks with crutches. Following Brostrom repair, most patients need to wear an orthopaedic boot for six weeks and then require a splint for a further six weeks. Supervised rehabilitation with a physiotherapist is required and total recovery in terms of return to sports can take up to six months.

Why look into the ankle with a telescope

The ankle is a small joint where the bones are covered with a smooth shiny cartilage. The ankle is supported by ankle ligament and tendons. After an ankle fracture or a sprain, there can be scar tissue formed in the ankle joint. The joint surfaces may have become scuffed during the original injury. These problems may cause symptoms such as pain and swelling in the ankle.

The inside of the ankle can be assessed by performing and ankle arthroscopy. This means looking inside the ankle with a telescope. This is usually performed under a general anaesthetic. The telescope is inserted by making small cuts in the skin rather than making a large incision. These small cuts heal very quickly and will allow you to get back to normal sooner than using a large cut.

What does an ankle arthroscopy involve.

An ankle arthroscopy can be performed under general anaesthetic. It is usually performed as a day case meaning you can go home on the same day of surgery.

During the arthroscopy the joint surfaces are inspected. Any soft tissue scarring can be removed by using special machines. This can often make the ankle more comfortable.

If the articular cartilage is scuffed, then this roughened surface can rub when the ankle is moved and this can cause pain. This damaged cartilage can be smoothed with special machine. Sometimes the cartilage damage extends to the surface of the bone. In this situation holes are drilled into the bone. This stimulates the growth of a new type of cartilage. This technique of drilling holes in bone is called microfracture.

After the operation you will have some stitches. The ankle is wrapped in a big wooley bandage.

Ankle arthroscopy : post operative course

After the operation you will be issued with crutches for comfort. You will be able to put as much weight on the foot as you can tolerate. Most patients build up their weight bearing over a two week period.

Stitches are removed after 2 weeks. From two weeks is likely that you will be fully weight bearing comfortably. Your ankle will be swollen and stiff for up to three months following the ankle arthroscopy.

If you have a microfracture technique than you will be partial weight bearing meaning you must not put all your weight on the ankle.

Risks of the arthroscopy of the ankle joint

Infection

This is an uncommon complication. Most infections are superficial and may be treated with a short course of antibiotics. If the infection is deep then an admission to hospital and further surgery may be required. This is an uncommon occurrence.

Nerve Injury

A small nerve about 1mm in diameter lies just beneath the skin. This may be damaged during the approach to ankle. This may lead to permanent damage to the nerve with permanent numbness on the top of the foot.

Pain and Swelling

It is not surprising that it may take several weeks or months for your foot and ankle to settle down after this extensive surgery. Many patients experience pain and swelling especially in the first few weeks. Rest and high elevation are required to keep these at a minimum.

Deep vein thrombosis and pulmonary embolus

After any lower limb surgery there is a risk of a clot on the leg ( deep vein thrombosis) and clot on the lung (pulmonary embolus) . After this procedure you will be mobile and so the risk of these complication is small and prophylaxis is not required. If you have had a previous DVT or PE you may be at increased risk.

A risk assessment will be performed preoperatively. The majority of people undergoing this surgery are at a low risk and do not require any prophylactic medication to reduce the risk of these clots. If your risk is moderate or high prophylactic treatment may be necessary.

Worsening of symptoms

There is a small chance that the symptoms after ankle arthroscopy may worsen. If this happens then an injection of local anaesthetic and steroid may reduce any inflammation and improve the comfort in the ankle. If the symptoms continue then a further assessment and treatment may be necessary.