ANKLE /ACHILLES INJURIES
The ankle is wrapped in an Ace bandage and the patient is advised to see a specialist if no better in a week or two. The implication is that this injury is no big deal.
This attitude always upsets me because ankle sprains are commonly potentially serious injuries. In my opinion, if not aggressively treated early on, they may not sufficiently heal and could cause ongoing and chronic trouble in the future.
A sprain is a stretch injury or tear of a ligament. A ligament is a tight, fibrous cord that holds joints together and provides stability. A force that stretches a ligament can cause merely a stretch injury ( Grade 1 ), a partial tear of the ligament ( Grade 2 ) , or a complete rear or rupture ( Grade 3 ).
There are two groups of ankle ligaments. On the inner or medial side of the ankle is the broad and thick Deltoid ligament. On the outer or lateral side are two lateral ligaments. The lateral ligaments are injured more often-probably because the foot has a greater tendency to twist inward.
A mild sprain causes some discomfort and localized swelling, but the patient can usually walk. A more severe sprain –in which the lateral ligaments are either partially or completely torn is much more serious. There is greater swelling and the patient can barely walk. It is because of these injuries, that I believe ankle sprains require urgent attention by an orthopedist. A delay of several weeks in addressing a Grade 2 or Grade 3 ligament tear could result in a permanently lax ankle–prone to re-injury.
First, an x-ray needs to be performed to rule-out the possibly of a fracture. And, sometimes a stress x-ray–performed while pressure is placed against the ankle—is required. A positive stress x-ray will indicate ankle joint tilting or instability. In extreme cases, I may order an MRI to deteremine if a ligament is torn and to what extent.
We all have out different ways of treating a sprain and, with the exception of pure neglect, there may be no right or wrong way. The practice of medicine, after all, is an art.
I prefer to treat simple sprains by wrapping the ankle with 2 inch white sports tape which I leave on for a week. This is in effect,a soft cast, and it gives support and controls swelling. My patients usually feel much better and have less pain once the tape is applied. Many can suddenly walk again. If the sprain is worse, say, Grade 2, I may supplement the tape with a brace like an aircast.
I recommend anti-inflammatory medication for a week or so and later, I may order physiotherapy.
I personally rarely use an ace bandage to treat an ankle sprain.
Most people with Grade 1 sprains recover within three weeks but some can take longer.
I also may treat people with Grade 2 sprains in a similar manner, but if there is ankle looseness and laxity, I very well may recommend a solid cast for three weeks to allow the ligament to heal. This may be somewhat inconvenient for the patient, but allowing the ligament to heal in its normal length and tension may save that patient future injuries and aggravation.
A Grade 3 complete tear –confirmed by an MRI – should either be treated in a cast or with surgical repair. The latter would be my preference in many cases, but this decision is ultimately tailored to an individual patient’s requirements.
Recently a saw a man in his late thirties who complained of recurrent ankle sprains. A stress x-ray in my office indicated severe laxity. I told him that unless he wanted to live with this, reconstructive surgery would be the only feasible treatment to stabilize the ankle. He initially injured his ankle years before while playing college football, and it was my impression– from speaking to him–that he never received adequate treatment early on after he sprained his ankle. Thus, the outcome did not surprise me. The torn ligament probably never healed.
The deltoid ligament on the inner side of the ankle is basically treated the same, but because it is a broader ligament and is an important stabilizer of the ankle, I am more inclined to treat deltoid injuries in a cast or surgically, if they are completely torn.
There are three muscles in the calf. All converge into a large broad tendon above the back of the ankle—the Achilles Tendon.
I refer to these muscles –the Gastronemius, the Soleus, and the Plantaris as the three bears.
The planteris—the baby bear – is a long thin muscle / tendon and it is of little significance. It is famous because many people tear it –frequently in a tennis or basketball game. People with an acute planteris tear develop stabbing calf pain. Some describe a feeling that they were struck in the calf by a tennis ball. They limp and may have pain for several weeks.
There is no treatment except RICE – rest, ice, compression, elevation. To this I would add anti-inflammatory medication and possibly physiotherapy. Since people complain of calf pain, an ultrasound to rule out a blood clot may be considered depending on the patient’s history.
These usually heal completely in a few weeks with no residual problems or lasting impairment. Surgery is never necessary.
A rupture of the Achilles tendon is a different story.
Frequently, this is a sports injury as the heel forcibly extends. Severe stress and tension is placed on the stretched Achilles tendon. A rip, pop, or tear is felt or even heard. The victim can walk but limps noticeably as the foot drags. The diagnosis is easily made on the field, court, or in the office. A gap can be felt in the tendon and ankle motion is compromised. X-rays and an MRI are not really necessary. But, an MRI could be ordered –if for no other reason but to satisfy the patient that surgery is necessary.
These injuries can certainly be treated in a cast with the foot fully tipped down like a ballet dancer en pointe. The tendon should come together and it should heal.
But today, most orthopedists—myself included – recommend surgery. The procedure is fairly routine and the incision does not need to be very large. No, it cannot be performed arthroscopically. With surgery, the tear is brought together and stitched under direct visualization. And the success rate for healing is high.
A post operative cast for a few weeks is still necessary, but I have lately been replacing the cast with a brace–sooner– after a few weeks, and this helps the patient regain motion earlier. The overall recovery is not quick, but the results are usually excellent.
Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.