What is the most common injury in a recreational tennis player and how can I avoid it?

According to a report by Dines et al, there are several studies which have concluded that the most common injury to the tennis player is an ankle sprain. One of the easiest prevention measures to take, and if you notice at the US Open this summer most professionals have them, is to utilize a supportive ankle brace while playing. This helps to support the ankle and can minimize inversion ankle sprains, which occur easily with abrupt stopping and change of direction movements. Other preventative measures can be taken including improving ankle and hip strength, as well as working on your balance. You can speak to a tennis professional or even a physical therapist in your area to get more specific recommendations.

What is the best treatment for reducing swelling in an ankle injury?

Using a multilayer compression wrap, like an Ace wrap, can be very effective at reducing swelling whether you sprain your ankle or break it. Using a combination of cold pack applications, elevating your swollen foot and using the compression wrap can be even more helpful for reducing pain, improving ankle range of motion and mitigating edema.

Do those pneumatic compression socks work at reducing ankle swelling after I break my ankle?

Manuela Rohner-Spengler, a clinical Physical Therapist and a team of MD/PhDs from the Departments of Rheumatology and Physiotherapy and Trauma Surgery at the Lucerne Cantonal Hospital in Switzerland took interest the optimal pre-operative swelling management techniques to yield the best post-operative outcomes. They found when impulse compression devices or pneumatic compression socks are used as a ‘stand-alone treatment’, they are not effective. This study did not assess their effectiveness when used in combination with other treatments.

I am a ballet dancer who has been diagnosed with Os trigonum syndrome can I keep dancing?

The best option for you is to remove the aggravating factor from your daily routine.  Symptoms can often diminish with rest, thus it is best to stop performing the specific triggering activity.  If you continue to dance on pointe or demi-pointe not only is an increase in pain possible, this can lead to compensations in form which can predispose you to additional injuries.

I have posterior heel pain do I need surgery?

First off it’s important to determine the cause of your pain.  Os trigonum syndrome is diagnosed primarily from clinical history and plain radiography. Typically conservative non-operative management will be the first treatment option. If this option fails to change symptoms or progress then surgical options may be discussed with your specialist.  

My mother is considering a total ankle replacement. She has also been told that she has a coronal-plane deformity. What is this and what does this mean for her surgery?

A coronal-plane deformity is a bony deformity of the calcaneus (heel bone) that changes the angle of the ankle from the normal position. This angle can be valgus or varus meaning the heel is angled out or in respectively. This can be corrected at the time of the ankle replacement with a procedure called an osteotomy. In this particular study there were thirteen (twelve percent) patients who underwent corrective changes for such a diagnosis. The results of this study and another similar one found no difference in complication rates or patient reported outcomes as long as adequate correction was achieved at the time of the replacement.

I am in my 50’s and my ankle pain has gotten to the point where I can barely walk without pain, especially in the mornings.  I’m normally fairly active and my ankle has been bothersome since I fractured it in my 20’s.  What are my treatment options as far as pain reduction?  Can they replace your ankle like they do knees now?

Advances in technology now show good results with ankle replacements. Currently, there are two options that allow for improved function and decreased pain: a mobile implant, that allows for motion in multiple planes, and a fixed-bearing, that allows for pointing and flexing the ankle, but little side to side motion.  Both are considered equal and implant choice is determined by the surgeon and the patient.

I have end stage ankle arthritis and my surgeon wants to perform a total ankle replacement, specifically a fixed implant.  I’m concerned about this because normally don’t ankles move in more than one direction.  I can make a circle with my other ankle.  I know they make a mobile implant.  Why does he not use this one instead?  What are the disadvantages to a fixed implant?

There is a mobile implant available but recent evidence suggests that there is little difference between the two implant types.  A fixed implant actually allows for better gait mechanics.  People with mobile implants report better pain reduction, but this could be a study flaw.  This is ultimately a discussion you should have with your surgeon as he is basing his decision on your needs, specific function, and pain.  Do know, however, that both implants are considered equal and effective.

I have been diagnosed with osteonecrosis in my ankle, what are my treatment options?

The treatment options are classified into two main categories, joint preserving techniques and non-joint preserving procedures. Non-joint preserving techniques are typically chosen in advanced stage osteonecrosis. These techniques include arthrodesis or joint fusion, talectomy or removal of all or a portion of the talus, and arthroplasty or a joint resurfacing. Joint preserving techniques include core decompression, vascular bone grafting and non-vascular bone grafting. These techniques are typically preferred for younger populations and early stage osteonecrosis. One variation of core decompression, described as percutaneous drilling, has been the subject of recent attention as it has been successful in treating osteonecrosis in the femoral head, knee, shoulder, and ankle. This technique differs slightly from other core decompression techniques in that it uses smaller drill bits and is thus less invasive and removes less bone.

My doctor has recommended an outpatient procedure called percutaneous drilling for a Stage II osteonecrotic lesion on my talus. What can I expect after surgery for rehabilitation and long term function?

Percutaneous drilling is a type of bone decompression surgery that is relatively new. This technique differs slightly from other core decompression techniques in that it uses smaller drill bits and is thus less invasive and removes less bone. It has been the subject of recent attention as it has been successful in treating osteonecrosis in the femoral head, knee, shoulder, and ankle. Post-operatively, you will expect to be partial weight bearing for four weeks using crutches, progressing to full weight bearing thereafter. You will be restricted with no high impact activities for ten months. There is limited research looking at long term results of percutaneous drilling, however one recent research study looking at 101 patients found that at long term follow up there were significant improvements in the patient reported outcome measures and pain scores. Of the 101 patients, 83 per cent of the ankles demonstrated no further progression of osteonecrotic lesions. Seventeen of the ankles in this study had progressed to a more advanced stage, four of which were at joint collapse, however the presence of sickle cell disease and HIV was associated with this progression.

I am considering an ankle replacement, what are some of the common complications?

The most common complication reported from this study of 106 patients was a medial malleolar fracture. Other less common problems were persistent medial ankle pain, infection and a distal tibial fracture. Two patients with the persistent medial ankle pain were later diagnosed with medial impingement, and had a successful surgery to repair this problem. This study showed a slightly higher rate of complication in the osteoarthritis and rheumatoid arthritis groups. These findings at times went with other study reports and at times against other study reports. This probably indicates slight variability between patient groups. Further studies may indicate that different pre surgical diagnosis put a patient at risk for different complications, but at this time it doesn’t appear that this is the case.

I have recently had surgery for a fractured talus and my doctor discovered in my follow up x-ray that I have osteonecrosis. What is that and what does that mean for my recovery?

Osteonecrosis is defined on ankle and foot radiographs as increased radiographic density, relative to the adjacent osseous structures, essentially meaning that there has been interruption of the vascular supply to the bone causing bone death. Although this sounds bad, in this study it appears that the radiographic density will normalize in about half of the cases. In terms of your recovery it will be important to see if the osteonecrosis determined in your follow up x-ray revascularizes or if there is a resultant collapse of the talar dome. If the talar dome collapses there will be a higher likely hood that you will experience some form of post traumatic arthritis due to permanent changes in the bone and subsequent joint surfaces.

My mother had a type III fracture of her talus and the surgeon decided to wait a few days before performing her surgery. Why would they make that choice and will this increase her rick of getting arthritis in the future?

In this study the timing of fracture fixation was at the discretion of the treating surgeon and usually this decision is associated with the severity of soft-tissue swelling. The decision to delay fixation is related to a lower rate of soft-tissue complications due to several factors including being able to undertake the ORIF procedure during the day when meticulous focus can be place on the accuracy of the reduction. It appears from this study that a delayed ORIF will not increase the likely hood of osteonecrosis, and that posttramautic arthritis may be more consistently associated with a talar body, tibial plafond, or calcaneal fracture than with the timing of the fixation.

I have sprained my ankle several times but recently suffered a high ankle sprain for the first time. This sprain is taking so much longer to heal. Is this normal? Why would it take so long?

A review on ankle syndesmotic sprains identified a recent systematic review of six research studies comparing high ankle sprains to lateral ankle sprains. Athletes in these studies who suffered high anklesprains missed significantly more games, reported more residual symptoms long-term, and reported longer average recovery time compared to lateral ankle sprains.

Understanding why it takes longer for a syndesomotic sprain to heal involves understanding a bit of the anatomy of the ankle. The ankle is formed from above by the distal fibula and tibia and below by the talus and the malleolus (heel bone) below the talus. The fibula and tibia together form a syndesmotic articulation and require specific congruency and mobility to accommodate the underlying talus.

The fibula must be able to rotate, translate and migrate to allow for normal ankle movement. The syndesmotic articulation must also be stable, and thus comprises four distinct ligaments. The anterior inferior tibiofobular ligament and the deep posterior inferior tibiofibular ligament contribute the most to ankle stability, combining to provide 68 per cent of the stability to the joint.

The most common mechanism of injury resulting in a syndesmotic sprain is externally rotates and hyperdorsiflexes, often with sports such as soccer and football or with trauma such as a slip and fall on the ice or stairs. The injury can lead to just an isolated sprain or a sprain with fracture, often of the fibula. It is important to get a proper diagnosis from a healthcare professional before proceeding with treatment.

If your injury is an isolated sprain without fracture, conservative treatment is warranted. Typically, treatment takes place in three phases: Phase I includes rest, ice, compression, and elevation to manage
edema and protect the ankle. Simple range of motion exercises can begin in this phase as well. Phase II begins when you can walk without a limp and your pain and swelling are under control. In Phase II you will continue with range of motion and add strength and proprioception exercises such as balance.

If your goal is to return to sports, Phase III begins when you can jump and hop without pain. Phase III includes return to sport activities with more rigorous strengthening, running and sport-specific drills. This process typically takes over a month.

I fell down the stairs and sprained and broke my ankle at the end of the fibula. I have to have surgery to repair the fracture. I am not sure if I want all those screws in my ankle forever, especially since I want to continue running and biking. What are my options?

Traditionally all syndesmotic fractures are treated operatively with screw fixation being the gold-standard. There are a lot of choices for the type of screw used in this procedure, including single or double, metal or bioabsorbable. Double screws provide the greatest amount of stabilization. You are correct to be concerned about having screws in your ankle, as screws also limit the normal biomechanics of the tibia and fibula at the ankle joint. The fibula must be able to rotate, translate and migrate to allow for normal ankle movement. This movement is altered with screw fixation and can potentially contribute to a problem known as malreduction.

Syndesmotic reduction becomes an important factor with all fixation procedures as malreduction is common and results in significantly worse functional outcomes. Malreduction typically takes place when the fibula is fixed in the wrong position. There are some operative solutions to minimize malreduction.

Malreduction rates decrease from 50 per cent to 15 per cent with direct visualization of the tibiofibular joint. If direct visualization is not possible with the surgical technique, intraoperative 3D imaging show promise in reducing malreduction rates as well.

Aside from screw fixation there is another option that shows promise. Suture button fixation is a new technique that may eliminate the concern of losing normal mobility as it is not a rigid fixation like the screws. A recent systematic review showed that suture button fixation resulted in similar healing time to screw fixation, but the patients reported an earlier return to work and less frequent need for implant removal. Restoring normal biomechanics to the ankle joint whether by use of suture button fixation or removal of screw fixation after healing can lead to improved syndesmotic reduction and improved functional outcomes.

Next week I am having arthroscopic surgery to remove a tiny bone caught between the lower leg bone and the heel bone. I expect to have a full and easy recovery. But I would like to know more about other patients’ experiences. Does anyone “fail” with this kind of operation? What happens then?

It sounds like you may have an os trigonum. This bone is located on the talus, which is part of the ankle. When the foot and ankle are plantarflexed (toes pointed downward), the os trigonum (and soft tissues attached to it) get pinched between the tibia (lower leg bone) and the calcaneus (heel bone).

Ankle pain can develop that is so severe, the athlete must stop all activities and motions that aggravate the problem. Running and jumping are out of the question until the inflammation has subsided. Physical therapy may be needed to address postural and alignment issues that could be contributing.

If conservative (nonoperative) care is not successful in treating the problem, then surgery to remove the bone may be needed. Minimally invasive procedures are available now to take care of this problem. The surgeon uses a small, thin scope (either an arthroscope or an endoscope) with a tiny TV camera on the end to enter the joint and see what’s going on.

The surgeon then excises (takes out or removes) the os trigonum. Most patients improve significantly and are pleased with the results. The technique is considered “safe and effective.”

The choice between surgical instruments and techniques used (arthroscope versus endoscope) may depend on the level of surgeon experience and expertise. Large os trigonums are more difficult to remove using the arthroscopic approach. There is very little room inside the subtalar joint where the scope enters. It’s also difficult to see inside this area. Using the endoscopic approach from the back side of the ankle requires cutting the flexor hallucis longus tendon but gives the surgeon more room to work in and greater visibility.

Open surgery may be needed if arthroscopic and/or endoscopic techniques are not successful in eliminating the problem. But this happens very infrequently when it is a simple os trigonum exicision. Studies show that more serious complications occur when complex surgery is required (e.g., os trigonum excision AND ankle fusion).