Ligament Problems in the Ankle

Ankle sprain is the most frequently encountered injury in the musculoskeletal system. Only a small portion of these injuries become chronic.

a) Acute lateral instability:

Injury is classified into three degrees:

Grade 1: Elastic deformation, no or minimal tear in the ligament

Grade 2: Plastic deformation, elongation and/or larger tear than grade 1

Grade 3: Complete tear of the ligament

Depending on the severity of the ligament injury, there is regional pain, tenderness, swelling, and pain when bearing weight. This injury may also be accompanied by damage to the peroneal tendons and joint cartilage. Treatment is done through conservative methods.

Initially, rest, bandaging, and elevation of the ankle are applied. Physical therapy, combined with the use of a protective device or rigid taping to allow early weight-bearing, accelerates recovery. Rigid taping prevents the foot from returning to the injured position, thus protecting the ankle from repeated trauma.

After physical therapy, the use of appropriate footwear is important. Strengthening exercises for the peroneal muscles reduce the clinical effects of ligament damage. With this method, 90% of acute injuries benefit from treatment. If conservative treatment is unsuccessful in acute ligament tears, surgical treatment is applied.

b) Chronic lateral instability:

There is a sensation of giving way and instability in the ankle. Pain between sprains is a significant sign of newly developed problems and should be investigated. To prevent chronicity after the first sprain, proprioceptive and balance exercises must be included in the physical therapy program.

This helps support the ankle’s self-protective mechanism against new injuries.

Chronic lateral instability should be evaluated for other associated problems (cartilage lesions, fractures, arthrosis, heel deformities). For surgical treatment, the patient must report functional instability and/or have demonstrable mechanical instability.

Various methods for anatomical repair and reconstruction have been described. Any accompanying problems should be treated simultaneously.

c) Syndesmotic instability:

Occurs with upward and outward force on the foot. In severe syndesmotic injuries, deltoid ligament injury and fibula fracture may also occur. If the damage is unstable, weight-bearing is not possible.

There is tenderness over the tibiofibular syndesmosis and deltoid ligament, swelling, and ecchymosis in the ankle. In stable injuries, ice application, rest, bandaging, and elevation are applied in the early stage. Rigid taping is beneficial.

After the acute phase, the anterior and posterior gliding motion of the talus should be regained. Weight-bearing is avoided until the painful period passes. Healing takes twice as long as a simple sprain. Surgical treatment is required in unstable injuries.

d) Deltoid ligament instability:

Occurs due to outward sprain of the ankle. Injury to the deep layer of the deltoid ligament leads to medial instability. Deep layer injury of the deltoid ligament usually occurs along with lateral injury.

If there is concurrent lateral and syndesmotic injury, the deltoid ligament generally heals without intervention after fixation of the fractures and repair of the syndesmotic ligament.

In chronic deltoid ligament weakness, lower extremity alignment disorders (most commonly flatfoot) should be investigated. Treatment should address not only repair or strengthening of the deltoid ligament but also the underlying cause.

e) Subtalar instability: Can occur with ankle instability. Since the calcaneofibular ligament contributes to both ankle and subtalar joint stability, it may be overlooked in patients with ankle instability. It is diagnosed via stress radiographs. Treatment is surgical.

Cartilage Problems in the Ankle Joint

a) Osteochondral lesions of the talus: These occur due to acute trauma or repeated microtrauma. Those that develop over a long period are usually on the medial side, deeper and wider. Acute lesions are usually lateral, smaller, and shallower. Treatment options are evaluated according to the size and depth of the cartilage damage. In non-surgical treatment, for acute injuries, rest should be followed by cartilage regeneration exercises. In chronic cartilage injuries, treatment can begin directly with cartilage regeneration exercises. In addition, the rehabilitation program should include balance and proprioception exercises. In surgical treatment, depending on the characteristics of the lesion, osteochondral fragment fixation or mosaicplasty may be performed using open or arthroscopic techniques.

b) Arthrosis:

Most commonly occurs after trauma. Its incidence is lower compared to knee and hip arthrosis. Patients complain of pain during walking. In addition, pain may also occur when moving the ankle at rest. There is limited range of motion and swelling in the ankle.

In non-surgical treatment, the regenerative potential of joint cartilage should be taken into account. All exercises within the treatment plan should be performed within the pain threshold. Exercises that nourish cartilage should be performed at all degrees of joint motion. Pain-relieving medications, activity modification, intra-articular corticosteroid injection, use of appropriate footwear, and supportive devices can be beneficial.

In surgical treatment, joint debridement (may be useful in early stages of disease), supramalleolar osteotomy (if there is malalignment in the lower extremity in joints with mild to moderate cartilage damage), arthrodesis (considered the gold standard for advanced arthrosis), and total ankle arthroplasty (an option for advanced arthrosis) may be performed.

Muscle & Tendon Problems

a)Achilles tendon:

It is the largest tendon in the body. Its primary function is to perform plantar flexion of the ankle. The retrocalcaneal and superficial bursae contribute to lubricating the tendon. Surrounding the tendon is a tissue called the paratenon. The paratenon is not a true tendon sheath. Therefore, there is a poorly vascularized area 2–6 cm above the tendon’s insertion at the heel. This is a risk area in injuries.

Acute tendinitis: The most common cause is overuse leading to inflammation within the paratenon and the retrocalcaneal bursa. It usually occurs after unfamiliar long-distance walking, increased training intensity, or even changing shoes. Pain, swelling, and increased warmth are observed at the injury site. Considering the healing stage of the tendinitis, non-surgical treatments such as pain medications, rest, ultrasound, high-intensity laser therapy, taping, and splinting achieve 90% success. Surgical treatment is considered in patients who do not benefit from these methods.

Chronic tendinitis:

Thought to result from prolonged acute tendinitis. Interrupted or insufficient healing during the acute phase may lead to chronicity. Reasons for incomplete healing should be investigated from biomechanical, metabolic, psychological, and postural perspectives.

The general approach is to induce micro-injury at the site to restart healing. Follow-up with long intervals considering wound healing is necessary.

Chronic degenerative changes occur in the tendon. The average age of patients is higher than those with acute tendinitis. Obesity, corticosteroid or estrogen use are risk factors.

The primary complaint is pain. A palpable mass that moves with ankle motion may be felt on the Achilles tendon. Tenderness may be noted over swollen areas. Non-surgical treatment is the same as for acute tendinitis. In surgical treatment, the degenerated portion of the tendon is removed and tendon transfer is performed if necessary.

Acute ruptures:

Typically seen in men aged 30–40 who are non-athletes or exercise irregularly. Most ruptures occur in the poorly vascularized area 4–6 cm from the insertion site.

After injury, the patient complains of weakness in the ankle and difficulty walking. Conservative treatment is applied in elderly, sedentary individuals or those with additional medical conditions that preclude surgery.

Immobilization followed by physical therapy is the non-surgical method. In surgical treatment, the tendon is repaired and followed by physical therapy.

Chronic ruptures:

Ruptures older than three months that were not diagnosed. Diagnosis is similar to acute ruptures but findings are less dramatic. Muscle atrophy is observed in the leg.

Non-surgical treatment includes physical therapy and orthoses that prevent ankle dorsiflexion. Primary repair can be attempted within three months post-injury. For older ruptures (depending on size), tendon advancement and tendon transfer are performed.

b)Posterior tibial tendon: In addition to inversion and supination, it is the secondary flexor of the ankle. Injuries usually occur in the poorly vascularized area between the medial malleolus and navicular. Staging of injury is based on pain, deformity, flexibility, single-leg heel raise, subtalar arthrosis, and ankle valgus. Dysfunction of the posterior tibial tendon is the most common cause of acquired flatfoot. Patients cannot stand on their toes on one foot. Conservative treatment is possible in all stages. Stages one and two respond well to conservative treatment. In stages three and four, conservative treatment is appropriate for sedentary individuals. If conservative results are unsatisfactory, surgical treatment is performed, with different methods depending on disease stage.

c)Peroneal tendons:

Their main function is eversion. They also assist in ankle flexion. The long peroneal tendon also flexes the first ray.

Acute tendinitis:

Occurs due to hindfoot varus alignment, prolonged or strenuous activities, or stenosis in the tendon tunnel. Pain and swelling occur on the lateral side of the ankle. Pain medications and rest are useful. An insole correcting varus deformity may be applied. If these are ineffective, surgical treatment is considered.

Tendon rupture:

Usually occurs due to inversion injury and dislocation from the groove. Ruptures are generally longitudinal. Symptoms are similar to tendinitis. It should be investigated whether the tendon has dislocated from its groove.

Non-surgical treatment usually yields poor results. Surgical treatment should also address the underlying cause.

Tendon dislocation:

A shallow groove predisposes to dislocation. Typically occurs due to inversion while the ankle is in dorsiflexion. Longitudinal tear of the tendon occurs. Pain and swelling occur at the dislocation site, and tendon displacement from the groove may be observed. In the acute phase, casting may be attempted but generally yields unsatisfactory results. Surgical treatment involves tendon repair and groove deepening.

d)Anterior tibial tendon:

Its primary function is dorsiflexion of the ankle. It also performs inversion. The most common injuries are superficial trauma and closed ruptures. In young people, rupture may occur due to forceful eccentric contraction; in older patients, it may be due to diabetes, rheumatic disease, or local steroid injections. Patients report pain, swelling at the injured site, and difficulty lifting the foot while walking. In sedentary patients, orthoses may be used. Partial tears or superficial injuries can be treated with casting. Other injuries require surgical intervention.

e) Flexor hallucis longus tendon:

Its main function is flexion of the first toe. It also assists in ankle flexion.

Acute injuries:

These are the most common. The patient has difficulty flexing the big toe. The necessity of surgical treatment in isolated long flexor tendon injuries is debated. However, if both long and short flexor tendons are injured, surgery is recommended.

Tenosynovitis:

Caused by compression along the tendon path at the ankle. A nodule causing snapping may form on the tendon surface. Common in dancers and gymnasts. Pain and snapping sensation occur at the site of impingement. Pain and snapping are triggered by toe movement. Non-surgical methods should be tried first. If ineffective, surgical treatment is applied.

f) Extensor hallucis and digitorum longus tendons:

These injuries are usually due to strong eccentric contraction or wear and tear (repetitive microtrauma or post-steroid injection). Partial tear of the extensor hallucis longus can be treated with splinting. Complete ruptures require surgery. Degenerative tears of the extensor hallucis longus also warrant surgery. Surgical treatment for extensor digitorum longus injuries is debated. Advocates cite the future risk of hammer toe as justification.