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ankle sprains
Ankle sprains are the
most common musculo-skeletal sports injury, although a sprain may
occur unrelated to participation in sports. According to the
American Academy of Orthopedic Surgeons, approximately 25,000 people
sprain their ankle every day.
Several ligaments help
surround the ankle to help provide support. An ankle sprain may
involve any number of these ligaments. The most common sprain
occurs when the foot is inverted (heel is turned inward) and the
lateral, or “outside” ligaments are injured. However, ligaments on
the inside of the ankle or between the two lower leg bones (called
the syndesmosis ligaments) may also be injured with a more severe
injury, but these are less common.
The anatomy of these
important ligaments can be seen in the figure below:
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Ankle sprains are usually
classified as mild, moderate, severe, or involving the syndesmosis.
Mild sprains are those that do not affect walking, have minimal
swelling, and are not significantly tender to touch. With mild
sprains, pain may only be felt when the ankle is put in the position
of injury. Moderate and severe ankle sprains involve more swelling,
walking with a limp or not being able to bear weight at all.
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A severe sprain is more
common in those patients who noticed a distinct “pop” and immediate
swelling along with an inability to walk. When the syndesmosis ligaments are involved, it is called a
“high ankle sprain”. All sprains usually produce bruising that is
present all over the ankle, not just on the outside part.
Diagnosis of ankle sprain
is usually made with a careful history and physical examination.
Tenderness in a particular part of the ankle or special exam
tests will help your
physician determine what ligaments were likely injured. X-rays
might be taken to rule
out a fracture in the area. Other tests may be ordered by your
physician to rule out other conditions that might present in a
similar way.
Treatment of
ankle sprains usually involves some kind of bracing, such as with an
ACE wrap, ankle brace, or sometimes even a cast. Rest, ice, and
elevation are used to reduce swelling. The decision of whether or not to
weight bear immediately on the ankle will be made by your physician
and depends on the severity of the sprain. Many ankle sprains are
not simple injuries, and up to 40% of patients may experience some
degree of residual symptoms. It is important to note that recovery
time varies with each patient’s injury.
Physical therapy,
taping/ bracing for sports participation, and/ or wearing supportive
shoes may be recommended even after you have been treated. Not
treating the ankle sprain or a history of multiple ankle sprains can
lead to lax ligaments and chronic ankle instability, pain, and the
development of arthritis later.
achilles tendon injuries
The Achilles tendon,
commonly referred to as the “heel cord” is a tendon that attaches
the calf muscles (gastroc-soleus) to the calcaneous (heel bone) in
the foot. The function of the Achilles tendon is to help facilitate
the foot to point down in activities such as sprinting, jumping,
climbing, or raising up on toes. A diagram of the achilles tendon
and adjacent structures is shown below:
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Several problematic
conditions can occur that involve the Achilles tendon.
Briefly, they are: |
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Bursitis:
This is when the bursa (fluid-filled sac) behind the heel bone becomes
irritated and inflamed and no longer helps limit friction as the
Achilles tendon glides up and down behind the heel. This causes
pain and irritation right at the back of the heel, with possible
redness and swelling of the area, and tenderness when the area is
touched.
Tendonitis:
This is usually an overuse or overstrain (but no rupture) of the calf muscles or
Achilles tendon structures. Chronic
tendonitis may contribute to degeneration and thickening of the
Achilles tendon, making it weaker and predisposing it to rupture.
Patients usually complain of similar symptoms as with bursitis (see
above), but often the pain is further up the leg, just above the
heel bone, and with pushing off the toes.
Paratendonitis:
This refers to when the paratendon, the outer covering of the
Achilles tendon, becomes irritated or inflamed. This often results
from overuse or rubbing, ill-fitting shoes. Paratendonitis may be
present alone or concomitantly with tendonitis/ bursitis
conditions.
Tendonosis:
This refers to the thickening of the tendon as a result of advancing
age and wear-and-tear related degeneration of the collagen fibers in
the tendon. Subsequent formation of weaker, but thicker scar tissue
or a scar nodule occurs and predisposes to rupture.
Rupture:
A rupture is an acute event that can occur at the junction of the
calf muscles and the Achilles tendon or within the Achilles tendon
itself. The typical presentation is a middle-aged male who is
involved in quick, stop-and-go sports sporadically, such as the
weekend recreationalist. Rupture can occur when too much stress is
placed on the tendon and is usually felt as sudden, severe calf pain.
This pain usually resolves but can be followed by problems with walking if
left untreated. With this type of injury, there usually is no
prior heel or calf pain prior to the rupture event,
but this might be present if a predisposing tendonitis condition (as above) is
present prior to rupture. Ruptures can also be caused by direct trauma to the tendon
itself. Swelling in the leg, painful weight-bearing or walking,
inability to raise up on the toes, and a palpable defect are often
signs and symptoms of this injury.
Diagnosis of any of the
above conditions usually is made by a careful history of the problem
and by physical examination. If there is uncertainty from exam
about a rupture, a MRI scan might be recommended.
Further diagnostic tests may be considered by the physician to
exclude other problems that may present in a similar way.
Treatment of Achilles
tendon conditions depends on the nature of the condition and
consideration of the patient. Bursitis and tendonitis type
conditions are usually treated with rest, ice, over the counter
anti-inflammatory medications and physical therapy. For severe
cases, surgery to split the tendon and remove degenerative portion
may be merited. The preferred treatment for acute ruptures is
surgical repair of the ends of the tendon because this has the
lowest re-rupture rate and allows for a more functional recovery.
However, patients who are elderly, inactive, or whose medical state
would predispose them to a poor surgical result or complication are
usually not recommended for surgery. Both surgical and non-surgical
management involves a graduated program of splinting or casting to
regain the “neutral” or flexed position of the ankle.
Physical therapy is a mainstay for all kinds of Achilles
problems.
ANKLE INSTABILITY
Ankle sprains can
sometimes cause more problems long term than fractures. This is
the case with ankle instability. Following one or more occurrence
of an ankle sprain, the ligaments that
hold the ankle together tightly sometimes do not heal properly or
become stretched. Patients with this problem often report chronic
pain in the unstable area (usually outside of the ankle) as well as an unstable or weak
feeling in the ankle. Additionally, a patient may report that the
ankle turns in frequently because ankle instability
limits a person's ability to sense the ankle’s position correctly. These problems
may keep an individual from sports participation or even normal
daily activities.
Treatment for ankle
instability begins conservatively with a course of
physical
therapy to regain perception of where the ankle is, as well
as motion and strength. Aircast or other ankle braces can be worn
during strenuous activity to help keep the ankle stabilized. If
conservative measures fail to achieve a stable feeling, ligament
reconstruction can be performed to tighten the ankle by using other
tendons from the foot. After surgery, patients will be in a splint
followed by a short leg cast while the foot and ankle heal.
Physical therapy most likely will be recommended to help
regain motion and strength once the cast is removed.
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