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Ankle Pain, Sprain, Achilles Tendon Rupture, Medial Gastrocnemius Rupture, and Ankle Arthritis

There are local factors and there are systemic factors that can contribute to the common ankle problems that we see ankle pain, sprain, Achilles tendon rupture, medial gastrocnemius rupture, and ankle arthritis. There can be acute trauma, later chronic effects of remote trauma, local inflammation or overuse syndromes in and about the ankle, infection, congenital abnormalities and this

Here is someone who had constant, repetitive ankle sprains to the point that they essentially donít have any collateral ligaments here and you can see how easily they subluxate their talus relative to their tibia. There also can be systemic factors, global inflammation or rheumatologic disease, diabetes, neuromuscular, neurologic problems causing muscle weakness, muscle atrophy and deformity, and vascular insufficiency. Here is a case of someone that basically ankylosed all the joints in their feet, and all the stresses go to their ankle joint and they presented with ankle arthritis because of the rheumatologic disease that ankylosed their

So in review of the basic anatomy here, again going through the bony anatomy, the ankle is essentially comprised of three bones, the talus, the tibia and the fibula. There are three articulations, the main convex, concave articulation between the distal tibia and the talus, we also have the articulation between the lateral aspect of the talus and there is a small articular facet on the fibula as well as the articulation more proximal between the tibia and fibula here. This is part of the ankle joint. There is articular cartilage that extends up into here, itís a joint space that extends about 1 cm or so up from the tibiotalar articulation. So, ligaments that are

On the medial side of the ankle, we have the superficial and the deep deltoid ligament. Superficial ligament essentially has three or four main bands depending on who you talk to. There is a band from the medial malleolus down onto the neck of the talus, a band that extends down to the navicular, one here to the sustentaculum tali which is the bony prominence or ledge of the

The deep deltoid is a small, short but very stout ligament that is intra-articular on the inside aspect of the medial malleolus going down to the attach directly to the talus, and thatís the one that is most important for ankle stability. People can commonly injure this when it doesnít lead to instability of the ankle. If you have disrupted your deltoid and perhaps other bony or ligamentous

Anatomically, the tendons that work across the ankle, primary forces are dorsiflexion of the ankle and plantar flexion of the ankle, this slide here showing you the anterior tibial tendon, this is the most medial tendon in the anterior aspect of the ankle. Then you have the extensor halluces longus tendon, the common extensor tendon, and there is the tendon called the peroneus which runs down to the lateral border of the foot. The plantar flexors primarily the gastroc and soleus plantar flex the ankle. So the blue is the anterior tibial tendon, most medial tendon attaches down toward the base in the first metatarsal, the most medial tendon

So here we are in the medial aspect of the foot, there is the posterior tibial tendon, the tendon that is very important in stabilizing the arch thatís coming down running behind, here is the medial malleolus, right behind the medial malleolus attaching to the navicular, then you have the flexor digitorum longus running down to control flexion of the toes to the IP joint and then the flexor hallucis longus tendon down to control the big toe. Here we are in the lateral border of the foot, there is a lateral malleolus, base of the fifth metatarsal, so orange is the peroneus brevis tendon, its muscle belly extending down, attaching on to the base of the fifth, so when this fires, it everts the foot, so itís essentially pulling the foot out of the plane of this image here on the slide, pulling out toward us, and then there is the peroneus

So whatís the treatment? Most in the vast, vast majority of ankle sprains can be treated nonoperatively and certainly they should be treated nonoperatively in the initial course of management. There really isnít a rule for repair of acute ankle sprains. Whatís the treatment protocol? Rest, ice, immobilization, compression and elevation trying to reduce the soft tissue swelling associated with a musculoskeletal injury. They need to be on protective weight bearing, because if the ligament is disrupted, itís going to be sure and itís going to hurt, so you want to try and keep them off it and by restricting their weight bearing, they are going to limit their inflammation that is going to occur. If you are suspecting that someone really has a high grade II or a grade III injury, I just want to add here, grade III injuries sometimes, in very rare instances, they can actually be associated with an ankle dislocation and they have spontaneously reduced, so you may have someone with a completely unstable ankle with no fracture on the x-ray. Well for someone with a high grade injury, you may want to put them in a cast with the ankle in neutral position.

As those ligaments go to heal down, and scar down, try to reform, you want to try to get them back as close as you can to their anatomical alignment and anatomic position with the least amount of elongation. So if you have someone with a severe ankle sprain, you think they really disrupted their anterior talofibular, you want to put them in a splint where their ankle is extremely plantar flexed, you are just increasing the gap between the anterior talofibular as you plantar flex the ankle. You donít want to extremely dorsiflex the ankle so you are stretching the calcaneal fibular ligament that you are trying to get to heal down, so make sure that if you are

A couple of words about medial ankle sprains, isolated injury to the deep deltoid is rare. You can have injury to the superficial deltoid, the consequence of missing something like that would be less so than someone who had a deep deltoid disruption and the ankle was unstable. But rare is the case that you can have an isolated deep deltoid injury, I mean you can think of the ankle as a closed ring. In order to have enough displacement between the talus and the medial malleolus to disrupt the deltoid, something else in the chain has had to have given way, such as perhaps a fibular fracture or a syndesmotic disruption to put that deltoid on so much stress that it ruptured. So make sure you look elsewhere for the injury. Check out the fibula, make sure there is no bony tenderness to palpation from the proximal tibia fibula

Achilles tendon rupture is sort of the weekend warrior injury, the recreational athlete that perhaps at the start of his or her recreational season, they are out to perform their activities, they havenít sufficiently warmed up and itís been a long winter and they havenít really been doing much activity, they tear their Achilles tendon, and the mechanism here is an eccentric contracture, meaning, as they are trying to contract their Achilles tendon or put the foot into the ankle into plantar flexion, the

Here is how to make the diagnosis, there is pain and swelling over the point of disruption, there is a positive gap sign, meaning you run your finger up here, you feel the muscle belly, you feel the Achilles tendon and then you feel mush. There is a space there, there is an indentation where the tendon is not in continuity. The Thompsonís test can be done here if the patient is kneeling over a chair, they can be done on an examination table, they are squeezing the calf muscles, youíre

Medial gastrocnemius rupture, tennis leg or medial head of the gastrocnemius strain can occur in the same population of patients, it occurs by the same mechanism, eccentric contraction, so the muscle is trying to shorten, while itís actually lengthening because of the external force applied through the joint, and some

Ankle arthritis is probably rarer than knee or hip arthritis, but the patient still is going to be presenting to you with pain, limitation of motion, swelling about the ankle, with or without deformity. X-rays are going to show joint space narrowing with the loss of cartilage, there may be subchondral cyst formation on both the distal tibia and on the talus, and para-articular osteophyte formation. Then your options to treat them are, beginning with activity modification, use of anti-inflammatory