Injuries Around the Ankle Joint…

Ankle sprain is an extremely common complaint with many causes. An ankle sprain occurs when the ligaments surrounding the ankle joint are stretched or torn as the ankle joint and foot is turned, twisted or forced beyond it’s normal range of motion. The most common cause of an ankle pain in athletes is a missed step or a missed landing from a jump or fall. Ankle sprains vary in severity and are classified by the degree of severity.

History

The usual mechanism of injury to the ankle joint is a rotational violence in which the body swings around a trapped foot. Depending on the quantum of force, there may be ligamentous injury or bony injury around the ankle. The exact position of the foot at the time of injury is elicited. Ankle injuries are usually classified by the direction of the force and the position of the foot at the time of injury. Following a tibial plateau fracture or talar fracture, the ankle and subtalar joint may go in for secondary degenerative arthritis, which can present as chronic pain and recurrent effusions of the ankle joint. Presence of knee pain and hip pain should be asked for as the foot and ankle disorders can alter the biomechanics of the limb predisposing the knee and hip to degenerative osteoarthritis.

Examination

Inspection

The foot, ankle and the leg are completely exposed. The position of the foot in relation to the leg is determined. The foot may be displaced anteriorly, posteriorly or sideways depending on the type of injury. The foot is usually displaced laterally in external rotation injuries. It may be displaced medially in adduction injuries and displaced upwards and laterally in vertical compression injuries. In vertical compression injuries with diastasis of inferior tibiofibular joint, the ankle may appear broadened. In fracture dislocation of the talus, the displaced fragment may stretch the skin of the dorsum of the ankle and may impend rupture of the skin.

Palpation

The bony points palpated are:

Lower end of tibia and fibula including the malleoli:

As these bones are subcutaneous, it is easy to find out any fractures, irregularity abnormal mobility. In ligamentous injuries around the ankle, the insertion sites of these ligaments such as anterior talofibular ligament, deltoid ligament may be tender to palpation. To demonstrate the ligamentous injury further, the ankle joint is stressed by giving valgus and varus forces to it. Any abnormal opening out can be demonstrated both clinically and radiologically.

Tarsal bones:

The calcaneum is palpated bidigitally on either side to demonstrate tenderness or thickening or irregularity. In chronic degenerative arthritis of subtalar joint, tenderness and restriction of movements of subtalar joint will be present.

Metatarsal bones:

In Jones fractures the base of the Vth metatarsal is avulsed due to the pull of the peroneus brevis muscle. Fractures of the shaft of the metatarsals are demonstrated by eliciting tenderness on axial pressure over the metatarsal head. Diffuse swelling over the tarsometatarsal joints may be seen in Lanfranc’s fracture dislocation. In ‘march fracture’, there will be diffuse swelling over the neck of lInd metatarsal with pain.

Muscular compartment:

Tendo-Achilles which gets inserted in the calcaneum is frequently injured resulting in loss of active plantar flexion.

Thompson’s test:

Squeezing the calf muscle will cause plantar flexion of the ankle joint. When there is a discontinuity in the tendon, this manoeuvre will not cause plantar flexion.

Movements:

In acute injuries, active movements may not be possible.

Measurement

The leg segment is measured from the medial joint line to the malleolus.The vertical height of the heel is measured from the tip of the medial malleolus to the floor in a standing patient. In fractures of the talus and calcaneum, this height may be decreased. The longitudinal measurement of the foot from the tip of the heel to the tip of great toe and then to the tip of the little toe are measured. Circumferential measurement of the foot at the level of the ankle joint, at the level of maximum arch and at the level of the metatarsal heads are measured and compared with the normal side.

Neurovascular examination

Ankle injuries may rarely be associated with posterior tibial artery and nerve injuries. In Lanfranc’s fracture dislocation, the digital arteries and nerves may get damaged and careful animation is needed to diagnose this. The chronically disabled group usually suffers from the sequelae of old trauma or inflammatory infective or degenerative or neoplastic causes. These patients need to be examined by proper history, detailed examination of the individual bone and joints. After eliciting a detailed history, the examiner should arrive at a provisional differential diagnosis based from the history and then proceed to physical examination. This will help in finding the subtle signs of the disease.

Clinical Features

The Patient typically present with a twisting injury of the foot following which they complain of inability to bear weight, pain around the ankle and very often swelling around the ankle. Clinically the stability of the ankle joint must be tested by valgus and varus stress under anaesthesia, Associated injury to the tendons and the neurovascular bundles, which run in close vicinity to the joint, has to be ruled out. The state of skin must be checked. The skin over the deformed ankle may get unduly stretched, resulting into necrosis, if not reduced immediately.

Physical therapy modalities (such as ultrasound) and manual therapy modalities (such as friction massage) are often used when the acute phase is over.A Physical Therapistis a specialist trained to work with you to restore your activity, strength and motion following an injury or surgery. Physical therapists can teach specific exercises, stretches and techniques and use specialized equipment to address problems that cannot be managed without this specialized physical therapy training.