In medicine, we’re sometimes guilty of over-treating mconditions. We may feel pressured to dole out prescriptions for self-limiting conditions, and we may be accused of pronouncing too readily that a patient has a popular or fashionable diagnosis, (Gilmore’s groin and Piriformis syndrome spring to mind). I feel strongly, however, that we undertreat ankle injuries, and wonder if we should rightly be chastised for our lack-lustre management of ankle ‘sprains’ in particular.
It’s all too common to dismiss an ankle sprain as being merely ‘inconvenient’, but staggeringly, over 30% of patients who sustained such a ‘sprain’ are still experiencing significant problems seven years later.
Why are we occasionally naff at looking after ankles, and how could we improve?
Let’s take for example, a patient limping into clinic on a Monday morning after a weekend footy tackle. Understanding the mechanism of the ‘twist’, can give us clues as to which structures are potentially injured. This is sometimes where we get it wrong. The commonest mechanism is an ‘inversion’ injury, which occurs when we roll the ankle under the foot, so that the sole of the foot is facing inwards. Easy to understand, and easy to visualise what could be busted:
We’re taught that the ankle joint consists of the tibia and fibula, which form a ‘mortise’ or arch in their arrangement, and the talus bone, which sits like a ‘key’ within the mortise ‘lock’.
On the medial side of the ankle, there’s a strong fan shaped structure, the deltoid ligament, and it links the tibia to the foot, whilst three smaller ligaments form the lateral restraints – the ATFL, CFL and PTFL. All of these structures can be partially or completely torn during an inversion injury, but it’s the AFTL that is most commonly affected, followed by the CFL. Sometimes, the inversion can twist the talus in the mortise, scuffing up the articular cartilage, or creating a small fracture in its surface. This kind of damage can lead to long-term swelling and pain, and may sometimes even need arthroscopic surgery to correct it.
Ankle osteoarthritis, unlike that of the hip or knee, is traumatic in origin, so it’s important that we treat these injuries with respect.
If the ankle remains mechanically unstable because of the ligament damage, a person may find that it’s too irritable to allow them back to sport. Most inversions will settle with first aid, physio and exercises to improve range of motion, reactivate the calf complex and small intrinsic muscles of the feet, and make their proprioception and control shiny and new.
But what about those patients for whom their irritated ankle remains, well, irritated? Some patients have persistent lateral pain, and an ankle that reacts with discomfort and swelling after exercise. This kind of behaviour lasting for more than 3 months (and arguably even beyond six weeks), should not be tolerated. It means something ‘dodgy’ is probably going on inside that ankle, and it isn’t good enough to just ‘keep going with the wobble board’. Interesting, it’s uncommon that patients truly describe lateral instability – some may sometimes report ‘going over’ repeatedly on the ankle, but it’s rare that they describe it as feeling truly ‘unstable’. Yet lateral ligamentous instability causes significant morbidity. Why is this? Too much ‘play’ in the lateral restraints can lead to overload of the peroneal tendons, a soft tissue ‘gutter’ syndrome or irritated capsule, and in the long term, can lead degeneration of the talocural joint. An ankle that’s not improving needs an MRI to ascertain the extent of the damage. Such ankles may need a little ‘taming’ of inflamed structures (e.g. with an ultrasound guided corticosteroid injection), but repeat offenders may need some form of a Brostrom’s reconstruction to regain harmony within the ankle.
As a physician, it’s rare for me to ‘promote’ surgery, but I’ll stick my neck on line and say that I think we should be performing more, and not less, ankle stabilisation procedures.
We’re all used to the idea of the inversion injury, but what if our footy player describes something more atypical in the way they fell? What if they deny inversion, and instead report ‘going over the top of their foot’, with their ankle being pushed into hyper dorsi-flexion and eversion? What if, the patient described being barely able to weight bear, and really couldn’t play on.
Chances are, they are probably reporting a symptoms aligned to a syndesmosis injury. This is SUCH an important injury but is frequently missed by clinicians – yep, even orthopaedic surgeons, and it’s a major cause of long-term ankle morbidity.
So how do you spot a syndesmosis injury?
Firstly, embrace your inner detective whenever a patient presents with a ‘well, I don’t really remember how I twisted it – all I know is that it hurt like hell and I knew I’d really done something bad’ story. Patients with a poorly syndesmosis find it difficult to walk, they particularly find it difficult to tip toe, and they absolutely hate the idea of trying to hop.
In addition to this, they lose their ability to plantar and dorsiflex fully, they’re likely to have a doughnut shaped (and sometimes unimpressive) swelling around the anterior ankle, and they’ll hate you for pushing their ankle into dorsiflexion and eversion.
As soon as you’re even a little bit suspicious that your patient might have stuffed their syndesmosis, you should dust off that pair of elbow crutches you have hanging around in the clinic, and promptly put your patient on them. Forget everything you’ve read about weight bearing x-rays revealing gaps between the tibia and the fibula, these folk need a high resolution MRI scan, read by someone who knows what they’re looking at. There are anterior and posterior components to the syndesmosis -ping both, and you’re very likely headed for surgery. Ping one, and you might get away with conservative treatment.
So what’s the management?
You probably won’t go wrong if you pop the poorly ankle into an aircast boot (yep, the patient will hate you for that too), non-weight bearing on crutches, for two weeks. This will give you a period of healing and protection, and time to reassess from there. A syndesmosis injury is bad enough, but patients are really in deep trouble when they combine a syndesmosis injury with a significant lateral ligament disruption. Again, boot them, off load them, scan them, and call for expert assessment. They may need an early surgical stabilisation of the lateral ligaments, and a syndesmosis ‘tightrope’.
So next time a patient with a wounded trotter limps into clinic, take pity on their piggies, and refer on quickly if their progress is getting stuck in the mud.
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