News Category: Ankle

Sprained ankles are a very common injury and are frequently seen in doctors’ offices and emergency rooms around the country. Teens are not immune to the injury and one study, done in Norway, found that most ankle sprains occurred in people under the age of 35 years, and most commonly in teens between the ages of 15 and 19 years.

Although they may take a while to heal, sprained ankles are usually treated conservatively, meaning that the injured person must refrain from putting too much pressure on the ankle, rest it, ice it, use a compression bandage or brace, and elevate it as much as possible. However, sometimes, this doesn’t work as well as it should, resulting in chronic ankle pain in the ankle that was originally sprained. One of the main causes of this is a condition called ankle impingement, which occurs when the soft tissue in the ankle gets trapped in the joint, pinching the tissue.

In the past, there have been studies on adults on using surgery to manage ankle impingement after ankle sprains, but no such research exists on adolescents (teens). The authors of this article evaluated the surgical management of ankle impingement caused by a sprain in adolescents, and compared it with conservative, nonoperative treatments.

Researchers looked at 13 teens (11 girls) who were, between 11.9 years and 18.3 years old. They had experienced symptoms for between four to 15 months and were treated conservatively for between two and 12 months. The treatments consisted of nonsteriodal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation, activity modification, and physical therapy, for at least six weeks. Any bracing that the patients may have used occurred during the initial ankle sprain, but not later on.

None of the patients was able to return to their previous sports because of the pain. Using a rating scale called the Ankle-Hindfoot functioning rating scale, the researchers evaluated the extent of disability. With this scale, the higher the number, out of 100, the better the function. Forty points are related to pain, 50 to function, and 10 to ankle alignment. Before nonoperative management, the average scale rating was 68.4, ranging from 40 to 84. After the nonoperative management, the numbers barely moved: 68.2, ranging from 63 to 76.

All the patients had arthroscopic debridement, minimally invasive surgery using tiny incisions and long handled instruments that allow the surgeon to see inside the ankle using a camera. The debridement surgery is done to remove any dead or loose tissue that could be causing the pain. Most of the patients had more physical therapy after the procedure for a period of six week.

After the procedure and recovery time, the scale ratings rose to an average of 90.6, ranging from 52 to 100. Most patients were able to return to regular activity after 2.5 months (ranging from 0.7 to 4.7 months). Three patients did experience complications from the surgery however, and one patient had a deterioration of the ankle problem.

The complications were for two patients, a neuroma, a growth in the nerve tissue or neuropathic pain and the third patient had a painful condition called complex regional pain syndrome.

The authors concluded that doctors should be aware of the possibility of ankle impingement and once the diagnosis has been made, there does not need to be a waiting period before performing surgery to manage the problem. The procedure is noted to do well with adults and the results of this small study back this up for adolescents.

In this clinical sports medicine update, orthopedic surgeons from the Hospital for Special Surgery in New York City present current diagnostic and treatment ideas on the topic of osteochondral lesions (OCL) of the ankle. The term osteochondral tell us that the joint cartilage (chondral) and bone (oste) underneath have been damaged.

With some of the more severe osteochondral lesions (OCL), there is a piece of cartilage with the bone attached that is loose in the joint causing further problems. Sometimes these loose fragments are referred to as joint mice. That name refers to the fact that there is a squeaking sound in the ankle joint. This sound occurs as the osteochondral fragments move or rub against other anatomical structures in the joint.

With any overview and update on a topic, the condition is defined, explained, and the etiology (cause) discussed. This article adds a description of the classifiction systems used to describe the severity of the condition. Diagnosis and treatment (both operative and nonoperative) along with results of each type of management approach are included as well. With updated technology, both the diagnostic process and the treatment options for this condition have changed remarkably in the last few years.

Here’s a summary of the information provided in this extensive and detailed article. Ankle sprains are the most common cause of osteochondral lesions. Sports athletes are affected most often. But anyone who injures the ankle or develops bone chips or fragments for any reason can develop debilitating osteochondral lesions.

Besides acute trauma, osteochondral lesions (OCLs) can also occur as a result of vascular diseases, chronic microtrauma, degenerative joint disease, and endocrine or metabolic disorders. Problems with joint alignment is a risk factor for osteochondral lesions no matter what the underlying cause may be. People who develop OCLs in multiple joints and who have a family history of OCLs, may have a hereditary factor that has not been fully defined yet.

The diagnosis is made based on the patient’s history, clinical presentation, and X-ray findings. Imaging studies like CT scans and arthroscopic exam make it possible to determine the size, shape, location, and extent of the cartilage/bone displacement. These characteristics are used to classify the injury. Various classification methods have been proposed. The authors provide a table summarizing eight different schemes reported in the literature based on X-rays, arthroscopy, MRIs, and CT scans.

Most people who are diagnosed with osteochondral lesions report ankle pain, swelling, stiffness, and weakness. There is often a history of repeated jumping, prolonged running, or other high impact activities. Many of the athletes describe frequent episodes of the ankle giving out from underneath them. This is a sign of ankle instability.

Once the condition has been accurately diagnosed, what can be done about it? Well, treatment depends on the results of the classification process. Some of the milder lesions that have not been displaced (damaged pieces have not pulled away from the bone or moved into the joint) can be managed conservatively (without surgery). Children especially seem able to heal with a short period of rest, the use of antiinflammatory medications, and ankle immobilization in a cast, splint, or brace. Spontaneous healing is less likely in adults who tend to get better results with surgery.

Surgery to remove or replace the loose fragment seems to have the best success in adults. This particular area of the anatomy (cartilage) doesn’t have a very good blood supply, so healing with new tissue doesn’t happen unless the defect is so deep the bone marrow is exposed. Nondisplaced pieces can be fixed in place with pins.

For more severe damage, the surgeon can use arthroscopic surgery combined with computer-assisted techniques to fill in the defect with bone graft material or even the newer bone graft substitute products available. Other techniques such as microfracture (drilling tiny holes around the defect) are designed to stimulate the production of fibrocartilage at the site of the lesion.

Depending on the location of the osteochondral lesion, it might be possible to graft plugs of bone into the ankle defect. The bone plugs are taken from a nonweight-bearing spot in the patient’s knee joint. This is called autologous tissue transplantation or mosaicplasty.

More extensive, open-incision surgery may be needed for large or deep osteochondral lesions. The damaged area is debrided (cleaned and smoothed) before bone graft material (usually from a donor) is transplanted to the opening left after debridement. The area is packed with graft material and held in place with a screw.

An alternative treatment to bone grafting is a procedure called autologous chondrocyte implantation/transplantation (ACI/ACT). This is a two-step operation where the surgeon first harvests normal, healthy chondrocytes (cartilage cells) from the patient and transfers them to a lab. In the lab, the cells are reproduced for a period of four weeks until there are enough cells to transfer back into the defect (the second step in the procedure). The multiplied chondrocytes are sealed in place with a special fibrin glue.

Although these various techniques can work well, there are still a lot of unknowns about when to use each one, which patients are the best candidates for each procedure, and how long the graft will last. Researchers are continuing to look for easier, less expensive, and more effective ways to treat osteochondral lesions.

One of the techniques under investigation is called viscosupplementation therapy. This is the injection of a hyaluronic acid into the joint. This treatment approach has been used in arthritic knees to preserve and protect cartilage while stimulating new cartilage growth. Preliminary results suggest this might be a safe and effective way to treat osteochondral lesions (OCLs) and maybe even prevent ankle arthritis from developing later as a result of this injury. Using it along with cartilage graft techniques might help preserve the graft as well.

Other new techniques using electrical or electromagnetic stimulation, ultrasound, stem cell transplants, and platelet-rich plasma are also under consideration as potential management techniques for OCLs. Most of these approaches are being used in animal studies right now. Scientists are exploring the mechanisms by which each of these methods work to stimulate new cartilage growth. And research continues to expand now including experimentation with growth factors and gene therapy as a way to promote optimal healing. Again, these studies remain in the early stages using animals as subjects before trying these ideas on humans.

The crystal ball isn’t entirely clear but some experts predict that traditional orthopedic surgery for OCLs will give way to robot-assisted and computer-navigation surgery. These techniques make it possible to perform minimally invasive procedures that reach right into the exact spot in need of treatment. The increased accuracy of placement of graft materials may result in better outcomes for the patient.

Osteochondral lesions are becoming more common as more and more people of all ages participate in sports activities. Finding more effective ways to treat this problem will continue to be the focus of research and debate. Studies are needed to provide evidence as to which procedures work best for patients based on factors such as age, severity of injury, and activity level.

If you’ve ever held an older infant, you know when placed in an upright position, they tend to bounce on their feet. That’s a reflex. Pressure on the balls of the feet causes the ankles to plantar flex (toes point down). Eventually, the nervous system matures a bit more and this reflex is no longer so dominant. Now the child can put the foot down on the ground and walk without the plantar reflex causing bouncing.

This reflex seems to come back in adults who have had a cerebrovascular accident (CVA) (stroke). Damage to the brain from the stroke results in muscle hypertonicity (increased muscle tone). The increased tone and abnormal reflex reactions make walking normally difficult.

Physical therapists are often key members of the rehab team helping people with strokes to recover movement and function. Finding ways to reduce the excess tone and keep from triggering the plantar flexor reflex is an important part of the program. And in order to know if the treatment is working, it’s necessary to measure the muscle tone and reflex response from before to after intervention.

Physical therapist researchers in Japan have been working on this problem for quite some time now. In previous studies, they examined the muscle hypertonia of patients after a stroke. They have used various measuring tools already available to evaluate speed and excitability of the ankle plantar flexor muscles. This group of muscles includes the gastrocnemius (large calf muscle) and the soleus muscle (a smaller muscle that forms part of the calf).

Now they present the results of another study using a new way to measure muscle tone of the ankle plantar flexor muscles. They developed this test themselves and call it the ankle plantar flexor tone scale. This new scale is meant to measure the quality of the plantar flexor muscle reaction when the (ankle) joint is passively moved (moved by the examiner rather than actively moved by the patient).

Any time a new testing method is developed, it must go through a rigorous examination to see if it is valid (does it really measure what it’s designed to measure?) and reliable (does it consistently come up with the same results each time it’s used?). They also checked the new test for intrarater reliability and interrater reliability. Intrarater reliability is the ability of one examiner to get the same results each time the test is administered to the same patient. Interrater reliability means the test will give the same results when given to the same patient by other examiners.

In this study, ankle flexor tone was measured using a handheld dynamometer, a device used to measure muscle force. All participating subjects were adults who had a diagnosis of cerebrovascular disease with hemiplegia. Hemiplegia means the stroke only affected one side of the body (usually both the arm and the leg).

To perform the test, patients were positioned supine (on their backs). The plantar flexor muscle force was measured during passive ankle motion using two velocities: as slow as possible and as fast as possible. The measurements were carried out using these two velocities in two separate positions: knee bent and knee straight.

After all the data was gathered and analyzed, they found that their test was, indeed, a valid and reliable way to measure ankle plantar flexor tone. And by comparing their test with other tests already available, they discovered that the Ankle Plantar Flexor Tone Scale gives more accurate and more complete information than the other tests.

Because this new test measures muscle resistance throughout the range of motion (beginning, middle, end), it can give the therapist additional information about the increased muscle tone present. Seeing the force of the stretch reflex and comparing it to the quality of muscle reaction helps the therapist. Now the therapist can identify when the problem is coming from changes in the brain (from the stroke) and when the exaggerated reflex is from local changes in the ankle muscle fibers and connective tissue.

The authors conclude that the greater detail provided by the Ankle Plantar Flexor Tone Scale will aid physical therapists when conducting research. The test will also provide an effective means of measuring changes in muscle tone for patients with neurologic conditions like stroke. Since muscle tone changes over time following a stroke and moving toward recovery, the scale might be able to offer another way of assessing progress and healing.

Athletes who sprain their ankle often report that the ankle feels like it’s going to give way, a symptom called functional ankle instability (FAI). Physical therapists and athletic trainers work with these athletes to restore normal ankle function and prevent recurrent sprains or other ankle injuries. It makes sense that anyone who feels this way is at risk for recurrent injuries. But are they really? That’s what the authors of this study tried to find out.

Physical therapists and athletic trainers from Indiana University and a nearby high school teamed up to test and compare a group of active college athletes with and without ankle instability to see just what was their functional ability. One group of 30 athletes was perfectly normal (no previous ankle injuries). They served as the control group.

The second group of 30 college athletes tested positive on the Ankle Instability Instrument (AII) for functional ankle instability (FAI). These athletes were considered the FAI group. The FAI group was divided into two separate groups based on whether or not the ankle actually gave way during the AII test. No one in the FAI group had active signs of inflammation (swelling, warmth, redness) at the time of this study.

They used four different hopping-on-one-leg tests to measure function and performance and to identify any deficits. The four tests included: 1) figure-of-8 hop, 2) side hop, 3) 6-meter crossover hop, and 4) square hop. Everyone watched a videotape of these tests with a narrator describing exactly how to do each one. Each athlete was allowed to practice the hopping test skills (three trials each) before taking the test. The figure-of-8 test involved hopping on one foot in a figure-8 pattern around two cones set five meters apart (about 15 feet). The pattern was repeated two times as fast as possible.

The side-hop test required the test subject to hop on one foot sideways 30 centimeters (eight inches) and back 10 times (also as fast as possible). The six-meter crossover hop test required the athlete to hop over a four-inch wide line from the right side to the left side and back along a path that was eight feet long.

And finally, in the square hop test, a 10-inch by 10-inch square of tape was placed on the floor. The subjects had to hop in and out of the square all the way around (clockwise for the right leg/counterclockwise for the left leg). Each of the four tests was repeated three times and each trial was timed. The athletes in both groups were asked if the ankle on the hopping side felt unstable during any of the trials.

The control group had no trouble completing any of the tests on either leg. The FAI group had the most trouble with the figure-of-8 and side hop tests. There were reports of a sensation of giving way in the FAI group for the figure-of-8, crossover hop, and square hop tests. Even when all four tests could be completed, there was a difference between the side of the ankle injury and the uninjured side (slower times needed to complete tests on the involved leg). And as might be expected, for athletes in the FAI group who experienced a sensation (or actual) giving way of the injured ankle, the results of their tests were slowest of all the participants.

In any of the trials, if the athlete fell, missed the stopping point, hopped in the wrong direction, didn’t hop all the way over the line, or put the other foot down, the trial was invalid and they had to do it over. Remember, the whole idea behind this study was to find a way to identify who really needs rehab after an ankle injury and when they are ready to return-to-play safely.

The authors also pointed out that the hopping tests they used require more than just muscle strength. Speed, coordination, and agility are important components of these tasks. And testing an athlete’s agility is critical to the return-to-sports decision, especially for activities that require cutting and changing directions quickly. Moving with speed in different directions is a prime ingredient in functional sports performance.

So, can these tests be used to predict who can get back on the field and who needs more rehab? Maybe. The differences between the FAI group and the control group weren’t so broad that the authors could categorically say Yes, these hopping tests gave all the information needed to make the return-to-sport decision. The group most likely to need further help was the group who self-reported ankle instability (giving way).

But even within this group, there was a wide range of hopping ability and variable amounts of ankle instability. The authors conclude that just asking about the presence of instability isn’t enough. The two tests that provided the most accurate indicator of trouble ahead were the ones that stressed the side of the ankle where the original injury had occurred (figure-of-8 and crossover hop). Oh yes, and in case anyone is wondering — they did analyze whether or not leg dominance affects the performance of these tests and found that it was not a critical factor in the results. This finding was based on the fact that function and performance were equally good on both legs for the control group.

More research is needed in this area. But for now, it seems reasonable that the hop tests described here can be used to identify problems in athletes with known functional ankle instability (FAI). The same tests can give therapists and athletic trainers a better idea of athletes’ progress in rehab. And these hopping tests might prove very useful when prescreening athletes for possible ankle instability. Preventing ankle sprains makes a whole lot more sense than always retraining and rehabilitating athletes who have ankles that give way under them when in the heat of sports action.

Chronic ankle instability (CAI) can be the end of an athlete’s career. If the ankle gives out when landing a jump, it can severely hamper the movements of gymnasts, volleyball players, basketball players, soccer players, and many others involved in sports that require jumping. Efforts have been made to research the best way to rehab this problem and then protect it from recurring. One of those methods is ankle taping. In this study, the effect of taping on the ankle joint and the rear foot movement on landing jumps is the focus.

Previous studies have shown that when the rear part of the foot is inverted (turned in slightly), the risk of ankle sprain increases. As the athlete lands and makes contact with the floor or ground, the inverted position of the rear foot strains the lateral (talofibular) ligament of the ankle. An unexpected landing or a landing with more force than the foot and ankle were prepared for can cause hyperinversion (increased inversion) and ankle sprain.

A second factor in ankle sprains is the position of the front part of the foot. When the toes are pointed down, the ankle is in a position of plantar flexion. Plantar flexion combined with inversion of the rear foot, has been shown to increase the risk of ankle sprain. That’s why so many studies have focused on seeing if wearing an ankle splint or other external support would help prevent first-time ankle sprains and/or prevent recurrent (second and third) sprains.

This study takes it a step further and investigates the effect of taping on ankle stability during a functional activity such as when landing jumps. The study was done by a group of physical therapists in a biomechanics laboratory at the School of Physiotherapy and Performance Society in Dublin, Ireland. The subjects in the study were young men and women with a history of chronic ankle instability but who had never had rehab or surgery for the problem.

After learning how to do a drop landing (jumping down from a platform onto a force plate), each subject was tested in three ways. First, they jumped down on to the unstable foot/ankle without any supportive tape. They each did three jumps. Then they repeated the same three jumps with tape around the ankle. The next step was to complete 10 repetitions each of hopping, ladder, and cutting drills before being tested again. These particular exercises are typical of the type used in sports training. This final drop landing test was done with the tape still supporting the ankle, but this time the test was performed after exercising for almost a half hour (25-minutes).

At the start of the study, the investigators expected that the ankle tape would restrict ankle and rear foot motion. They also expected the tape to lose its ability to restrict motion after exercising. For those who might like to reproduce this study or use tape with their patients, the authors give clear, step-by-step instructions on how they applied the tape. As for the force plate, this computerized device records the moment the foot hits the ground (called the initial contact) and the amount of force exerted. At the same time, 12 high-speed motion capture cameras were used to record ankle and foot motion from all angles.

Once the testing was done and the data was all collected, analysis showed that the taping did, indeed, hold the ankle better than without taping. And the tape was still effective after exercise. Results weren’t any different or better between jumps made before and after exercise with tape. So long as the tape was on the ankle, the position of the foot and ankle remained the same. For sure, there was more ankle plantar flexion and rear foot inversion when there was no tape used to support and hold a neutral ankle/foot position.

So! This is good news for athletes with chronic ankle instability. Not only is it worth the time to tape the ankle before each practice or game, but the effects hold over a period of at least 25 minutes. Now, that’s not the same as playing hard for an entire two-hour practice or game, but it’s a start. With a goal of preventing repeated ankle sprain injuries in sports athletes, taping is a good tool.

There were a few caveats (beware statements) in this study. First of all, only one method of taping was tested. There may be other taping techniques that are more (or less) effective with jumping. Second, there were only 11 people in the study. That’s a very small number, making this a preliminary study. Future studies are advised in order to repeat the results with more subjects. And finally, drop landing onto a force plate in a controlled laboratory study doesn’t really mimic the playing conditions on the field with other players making body contact with the athlete at the time of the jump landing. To off set this problem, the authors suggest future studies also include using different drop and jump landing protocols.

Just how long does it take to recover from an ankle sprain? Can you get back to normal in six weeks? Eight weeks? At all? When is ankle rehab needed? These are the questions this group of athletic trainers addressed in their biodynamics research lab at the University of North Carolina (Charlotte).

By testing ankle movement three days after an ankle sprain and a second time eight weeks after the injury, the researchers were able to compare the results with a group of normal, healthy adults who had not injured their ankles. They found significant differences in ankle laxity (looseness) between the groups.

A special tool called an instrumented arthrometer was used to measure ankle stability. No one has ever used this device right after injury and compared it to later measurements. This is the first study to do so and to report the results. As with any first (pilot) study, a small number of individuals were included. There were 16 young adults with recent ankle sprains and 16 healthy controls.

The ankle sprain group all had a mild to moderate lateral ankle sprain (lateral means along the outside of the ankle). The sprains were graded as I or II, which means there was at least a partial tear of the ligaments along the lateral side of the ankle. Swelling, bruising from hemorrhage into the area, pain, and loss of motion were commonly reported signs and symptoms.

The ankle sprain group was told to use ice and to elevate the ankle in order to help with the swelling. They were allowed to use an Ace bandage wrapped around the ankle to provide some compression and reduce the swelling. But no one was enrolled in a formal rehab program. That way, they could really assess the natural recovery of this type of injury.

This information is important because ankle sprains are common, especially among athletes. But also because many people end up spraining the same ankle over and over. Persistent pain and giving way of the ankle results in a condition called chronic ankle instability (CAI).

Why does this happen to some people, but not others? The answer to that question remains unknown. One theory is that the damaged ligaments never really heal. Without strong, intact ligaments, the bones can shift more and the joint becomes lax or loose. Joint laxity leads to mechanical instability, which results in CAI. But CAI can persist in patients who have had appropriate rehab following the injury. Even with a year’s time to recover, they still have excess motion in the joint.

The arthrometer results showed more anterior (forward) motion of the ankle and more inversion rotation (foot turns inward) in the ankle sprain group compared to the control group. The amount of extra inversion motion available after injury gradually declined during the eight weeks following the injury. No change was observed in the amount of forward displacement between day three and week eight.

The groups also filled out several surveys answering questions about daily function. Analysis of their answers showed a significant loss of function on day three that gradually got better by week eight. But the level of function in the ankle sprain group did not equal the level of function in the control group (or even the level of function of their other, uninvolved ankle).

The authors say they think using the arthrometer gave much better results than just manually testing ankle motion. Using the arthrometer may actually give a better indication of when an ankle sprain is mild, moderate, or severe — a grading scale that helps guide treatment choices. At the same time, not having the ankle sprain patients in a rehab program may have affected the outcomes. It’s possible they would have gotten better faster with an appropriate program.

Future studies need to compare patients with an ankle sprain who do have rehab and those with an ankle sprain who do not. Since many people sprain their ankles without ever seeking help, knowing if rehab might help could place a higher premium on follow-up. Athletes interested in the fastest recovery time possible may be especially helped by this information.

The curious fact that even with rehab, one-third of ankle sprain patients still report instability may be because they were immobilized for a period of time right after the ankle sprain. The authors speculate that preventing joint motion early on may inhibit ligament healing. If this is true, then the current standard of care for the initial injury must be re-evaluated. And, it’s possible that a longer period of rehab (beyond eight weeks) is really needed for optimal results.

Once you’ve sprained an ankle, there’s a good chance you’ll sprain it again. And each time the ankle is injured, the more likely it is that you’ll develop chronic ankle sprains. The orthopedic term for this condition is functional ankle instability (FAI). People with FAI report episodes where the foot and ankle just collapse, give way, or roll under them.

Lateral ankle sprains are the most common. Lateral refers to the outside ankle or the side away from the other leg. Physical therapists and athletic trainers help patients regain normal muscle activation and joint proprioception after ankle sprains. This type of rehab program is a strategy for preventing future (repeat) ankle sprains. Joint proprioception refers to the joint’s sense of its own position.

But sometimes even after rehab, people end up spraining the ankle again. This is a puzzle. If rehab isn’t effective, is it because it’s the wrong rehab program? Or is there something else going on in the nervous system that can’t be changed with rehab? Or maybe there’s a need for a different approach altogether.

To test out this idea, experts in the area of kinesiology (movement) set up an experiment to test and measure ankle stability and function. They specifically focused on muscle activation of the peroneal muscles. The peroneal muscles evert the foot and ankle. Evert means to move it away from the other foot. The idea was to check for a deficit of muscle activation called arthrogenic muscle inhibition (AMI).

AMI refers to the fact that the peroneal muscles are not being activated with sufficient force for a strong muscle contraction. Without this dynamic activation, the ankle is more likely to be unstable, giving way without warning. If the muscle isn’t getting the nerve messages needed to contract, why not? Is there a problem with local control of the nerve to muscle communication pathway? Or is the breakdown occurring more centrally in the spinal cord of the nervous system?

Here’s what they did. First, they built a walkway with special trapdoors that could be triggered simulating ankle eversion or the giving way experience of chronic ankle sprain sufferers. Then they measured the electromyographic (EMG) output of the peroneal muscles while walking on the flat walkway and when the trapdoors were activated.

They compared one ankle to the other for two groups of people. The first group was made up of patients with functional ankle instability (FAI). They were accepted for the FAI group based on results of two testing tools: the Functional Ankle Instability Questionnaire and the <i Ankle Instability Instrument. The second (control) group had no ankle sprain (past or present). EMG measurements were compared from one leg to the other in both groups.

EMG can be used to calculate H-reflexes (H) and M-waves (M) for the peroneal muscles as an indication of muscle inhibition. The control group (no ankle sprains) had equal measurements from side to side. Their H:M ratios were the same on both sides. The ankle sprain group had larger peroneal H:M ratios on the uninjured side. The ankle sprain group also had lower EMG readings than normal when the foot/ankle was dropped unexpectedly. This suggests that the peroneal muscles weren’t firing as they should be to stabilize the foot and hold the ankle stiff when the person is suddenly off balance.

After conducting the experiment, it became clear that the problem was still in the peroneal muscles. It wasn’t a matter of neuromuscular inhibition or processing at the central nervous system interfering with ankle stability. That means we are back to the drawing board reviewing rehab protocols. Obviously current approaches are not restoring peroneal muscle function as needed to prevent reinjury.

This study helps point researchers in the right direction when evaluating what’s best for functional ankle rehab. Future studies are needed now to identify specific exercises, activities, or interventions that target and return peroneal muscle activation to normal.

In this review article on ankle sprains, three doctors of osteopathy (musculoskeletal medicine) look at the normal and abnormal ankle anatomy that might contribute to chronic lateral ankle pain. Lateral refers to the outside of the ankle (away from the other leg). The main focus of this review is the peroneal tendon.

The peroneal tendon is located along the lateral side of the leg coming down from near the knee to the base of the big toe under the foot and the base of the little toe. The peroneal muscle is actually made up of two separate bundles: peroneus longus and peroneus brevis. That’s why it can attach to two different bones on opposite sides of the foot.

These two muscles with their tendons work together to stabilize the ankle, especially the lateral side of the ankle. Their main functions are to evert (turn out), pronate (flatten), and plantarflex (point) the foot and ankle.

Other soft tissue structures around these two tendons that are affected when the ankle is sprained include the fascia (connective tissue) and protective sheath (covering) that covers and blends these muscle/tendon units together.

The authors discuss unusual variations in ankle anatomy that might contribute to chronic ankle sprains. For example, sometimes there are extra bony bumps, extra bones, or a slightly displaced muscle belly. Some people have an additional muscle such as the peroneus quartus, peroneus digiti quinti, or peronealcalcaneus. In others, the tendon is angled more than is considered within normal limits. Any of these added anatomical features change the dynamics of how the foot works and can contribute to problems.

With MRIs now, it’s possible to see soft tissue anatomy that bone X-rays just don’t show. Cadaver studies have also revealed new information. We realize now that a fair number of people (up to 20 per cent or one in five) have at least one of these anatomical variations. Even small changes such as a more prominent bone, flat groove for the tendon, or oddly shaped bone can result in peroneal injuries.

The authors suggest that peroneal tendon disorders occur much more often than is realized. That’s why anyone with chronic lateral ankle sprain should be examined carefully for peroneal tendon involvement. The way to do this is to take a thorough patient history, order imaging studies (when deemed appropriate), and exam the foot and ankle by comparing it to the other (uninjured) side.

The history will reveal signs and symptoms that might point to ankle instability. For example, an ankle that rolls easily when walking on slightly uneven ground (or for no apparent reason) might be a sign of lateral instability. Ankle popping, excess ankle and/or foot range-of-motion, ankle swelling, and pain with certain resisted movements are indicators of possible tendon and ligament instability.

CT scans, ultrasonography, and MRIs help show swelling, fractures, tendon injuries, and tendon subluxation or dislocation. Scars or thickening on the tendon can indicate a poorly healed injury that puts the person at risk for re-injury. MRIs can give useful information about the integrity of the peroneal muscle complex.

The type of damage observed with advanced imaging techniques helps in the diagnosis. Fluid all the way around a tendon indicates the presence of an inflammatory condition called tenosynovitis. Recognizable changes in the MRI signal and intensity alert the radiologist to the possibility of a tendon tear.

Putting the patient history together with signs and symptoms and results of imaging studies helps the physician finalize the diagnosis. Repetitive or prolonged activity, recent injury or trauma, recent participation in competitive sports events are common histories given in tendon tears.

Once the area of pathology has been located and the underlying cause identified, then the physician turns his or her attention to planning the best treatment. Acute injuries with pain, swelling, and bruising are still treated conservatively with R.I.C.E. (Rest, Ice, Compression, Elevation). Recent evidence has shown that a short-leg cast may actually result in faster healing for moderate to severe ankle sprains than using a splint or elastic wrap to support the lower leg and ankle.

Surgery is considered when the injury is chronic — either the person sprains the ankle over and over or symptoms of pain, weakness, and swelling just never go away. Anyone who has completed a three- to six-month course of physical therapy but the ankle is still unstable is also a potential candidate for surgery.

The type of surgery done depends on what’s going on inside the ankle. Is the tendon partially torn or fully ruptured? Are both tendons involved? Are there any other injuries in the foot, ankle, or leg? The surgeon also takes into consideration the age and activity level of the patient. Young athletes may need a different approach from an older, more sedentary adult.

Torn tendons can be repaired or reconstructed with a tendon transfer. Excess or protruding bone can be shaved down, frayed tissue can be shaved or smoothed away, and tight or swollen tendon sheaths can be released or removed. The authors describe their surgical techniques for tendon repairs (e.g., debridement, tendon repair, excision, tubularization, tenodesis).

The surgeon evaluates the patient’s ankle/foot movement, movement, and biomechanics. Surgery may need to address variations in anatomy leading to ankle subluxation (partial dislocation) and dislocation. Muscle/tendon imbalances can be corrected surgically. Young, active athletes who want to get back into sports activities are more likely to consider surgery without trying rehab first.

Individuals who suffer peroneal tendon tears without apparent cause (no trauma, no sports injuries) may have other predisposing conditions. Diabetes, hyperparathyroidism, rheumatoid arthritis, and psoriasis can put patients at an increased risk of tendon injury and ankle instability. Steroid injections for chronic inflammation can also thin and weaken the very soft tissue structures they are trying to treat. The result can be a tendon tear or rupture.

Sometimes the groove in the bone that holds the tendon in place is too shallow. The peroneal tendon may pop out of the groove. The surgeon may have to make the groove deeper, put the tendon back in place, and repair the connective tissue that was holding the tendon in place back together. This piece of reinforcing fibrous band is called the superior peroneal retinaculum (SPR). Again, the authors provide drawings and descriptions of the tendon rerouting techniques they prefer.

After surgery comes the inevitable rehabilitation. Splinting or casting, limited weight bearing, and physical therapy are part of the post-operative plan. Physical therapy focuses on helping the patient regain motion, strength, and mobility.

Eventually sports specific activities may be added to prepare the patient for a return to full form. Full sports activities are allowed at different times depending on the type of injury, type of surgery, and level of activity.

High-demand patients with significant loss of function and who want to be involved in athletic activities may be out of the game for three months or more. All of this depends on an accurate diagnosis, which brings us back to the start of this article. The authors contend right from the start that knowing the ankle/foot anatomy, mechanism of injuries, and choosing the right treatment is the most important part of recovery from peroneal tendon disorders.

It’s the job of every physician to assess patients for risk factors that predict future outcomes. Doing so helps doctors guide patients in the direction of reducing those risks and preventing future problems. In the case of the orthopedic surgeon, patients undergoing surgery have the additional risk of potential complications during or following the procedure. Once again, awareness of risk factors is important in assuring a successful operation and positive long-term results.

In this study, surgeons from the Department of Orthopedic Surgery at the University of California (Los Angeles) turn their attention to ankle fractures. Specifically, they examined the risks of complication after surgery for severe ankle fractures.

And not just severe ankle fractures but those requiring open reduction and internal fixation (ORIF). Open reduction means the surgeon makes an open incision to treat the fracture. Internal fixation tells us that some type of metal plate, screws, rods, and/or wires were used to hold the bones together.

Knowing the possible risk factors, complications, and risks from those complications is important for every procedure. It’s the first step toward prevention and goes a long way to ensure success. With any surgical procedure, there’s always a risk of infection, delayed wound healing, or blood clots. With severe ankle fractures, there’s the added risk of malunion (fracture heals in poor alignment), nonunion (fracture doesn’t heal at all), or the need for revision surgery.

Revision surgery refers to a second procedure. This could be to revise the original work done. It could be to fuse the ankle, a procedure called arthrodesis. If the first attempt to repair the damage done (using an ORIF) fails and fusion fails or isn’t possible, then an ankle replacement may be needed. If worse comes to worse, it may be necessary to amputate.

The seriousness of possible complications and risks of complications shows us the reason why surgeons pay such close attention to patient risk factors. And statistics have shown that ankle fractures are becoming more common in older adults (third in frequency after hip and wrist fractures).

Since the authors are from California, they could use the California discharge database to collect their data. The discharge database is an electronic bank of information about patients who are hospitalized and released for any reason. By entering in codes that represent ankle fractures and even more specifically, patients who had an ORIF, they were able to find over 50,000 people in a 10-year period of time treated in California for ankle fractures.

The advantage of a study of this type is that the patient population is diverse in age, general health, race/ethnicity, and insurance type. Since only nonfederal hospitals were included, it also allowed for analysis of hospital location, type, and volume as possible risk factors.

They found that patients ranged in age from 18 to 103. The majority of patients were white, female, and younger than 50 years old. The severity of the ankle fracture was defined as a single lateral malleolar fracture, bimalleolar, and trimalleolar fracture. In this study, 16 per cent of the fractures were lateral malleolar, 45 per cent were bimalleolar, and 39 per cent were trimalleolar.

The lateral malleolus is the anklebone along the outside of the ankle (away from the other leg), Bimalleolar means both the medial (inside closest to the other ankle) and lateral bones were broken. A trimalleolar fracture involves the lateral malleolus, medial malleolus and the bottom posterior (backside) tibia. This portion of the tibia is sometimes referred to as the posterior malleolus.

The overall complication rate was extremely low (less than one per cent) — both in the short- and intermediate-term. When broken down into categories, infection was the biggest problem. Other problems included pulmonary embolism (blood clot to the lungs), revision, amputation, and death.

In the short term (90 days to one-year after surgery) there were not more complications with bimalleolar or trimalleolar fractures than with lateral fractures. But within five years, the more severe fractures (trimalleolar) had the highest rate of revision. Patients with diabetes, open fractures, and/or trimalleolar fractures were also more likely to develop arthritis requiring additional surgical procedures.

Rates of complications were higher in cases of open (versus closed) fractures and for older patients. Older adults with complicated diabetes and peripheral vascular disease (PVD; poor circulation) had the most problems. These were the patients who were most likely to end up with infection or amputation. The risk of death as a potential complication was greatest for the patients who were over age 75.

The rates of complications were similar for high-volume versus low-volume hospitals. Location (rural versus urban teaching hospital) did not have a major impact on the results. These kinds of hospital-related factors have been shown in other studies to affect outcomes of hip and knee replacement surgeries. This may be the first study to show that provider volume isn’t always a factor in the success or failure of orthopedic procedures.

The results of this study give surgeons a way to recognize high-risk patients about to undergo an ORIF. Armed with this information, the surgical and postoperative teams can monitor the patient more carefully. Additional preventive measures can be taken to avoid complications. For example, older patients and anyone with medical problems should be considered for blood thinners prior to surgery to prevent blood clots. It may even be necessary to change the surgery plans until the patient’s health status has stabilized. After surgery, patients with diabetes and/or peripheral vascular disease should be assessed carefully for any signs of infection, malunion or nonunion, or other complications.

Years ago, surgeons asked the question: joint replacement has worked for the hip, knee, shoulder, and hand — why not for the ankle? It could spare ankle motion and would certainly be better than a fusion with no motion. But early attempts failed. The ankle is just so much more complex in its biomechanical design than even the shoulder.

So it was back to the drawing board. And now there’s a second-generation of implants that seem to have better results. Second-generation refers to the new and improved designs that have replaced those first implants. The studies available are somewhat limited, but it looks like there are fewer problems and a lower rate of failures with the newer ankle prosthetics.

In this report, surgeons from the Orthopedic Foot and Ankle Division of the New Jersey Medical School bring us up to date on the subject of modern total ankle arthroplasty (replacement). They review current implant design, patient selection, and survival rates. They suggest that based on more recent results, there is a new interest in the use of ankle replacements.

The modern implant design tries to reproduce sliding, gliding, and rotational movements present in the natural ankle. By experimenting with different coatings sprayed on the implant, researchers have found materials that preserve bone and foster improved bone growth around the implant. With better ingrowth, cement is no longer needed to hold the implant in place. That helps eliminate problems caused by the use of cement.

Improved polyethylene (plastic) parts have also improved movement between the parts and reduced overall wear on the implant. That means they are less likely to break or shift causing a partial or complete joint dislocation.

The second-generation prosthetic design can have fixed component parts or they can be mobile-bearing. Fixed means motion is somewhat limited. Translation and rotation are not allowed in all directions. This makes for a more stable joint but with less motion. There is less stress where the implant meets the bone and therefore less chance of implant failure from loosening.

Mobile-bearing means it can move in more than one direction. That allows for greater torque (twisting motions) and rotation. Multiplane motion also means the joint is less stable. Strong ligamentous support around the ankle is needed for this type of implant. Mobile-bearing implants have not been approved for use in the United States yet. Results reported are from studies in Europe and Canada.

The authors describe fixed implant designs currently available in the United States. Food and Drug Administration (FDA)-approved implants include the total ankle systems from DePuy, Wright Medical, Tornier, and Integra. Compared to other parts of the world, the selection of implants in the U.S. is fairly limited right now. With more studies confirming successful results, this trend is expected to change in the near future.

Choosing the right patient is as important as selecting the best implant design. Not everyone is a good candidate for a total ankle replacement. The patients most likely to benefit from this procedure are those with severe osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis. They have tried and failed with conservative management. They are candidates for ankle fusion called arthrodesis but would like to save joint motion.

Most of the patients selected for ankle replacement are older and less active. They have severe pain from their ankle arthritis. Those with rheumatoid arthritis seem to have the best results so far. Using these implants for younger, more active adults remains a topic that is debated.

For sure, anyone with a large amount of bone loss, infection, or severe deformity won’t qualify as a candidate for ankle replacement. Surgeons may carefully screen patients who are obese, have severe ankle instability, engage in heavy-labor, or have poor skin or bone quality. These people may be more likely candidates in the future but right now, they aren’t considered good candidates for this procedure.

Implants are expected to last at least five years. Some studies show fair-to-good survival rates at 10 years. Slow healing and fracture of the ankle bone are the two main problems that develop. There’s evidence to suggest that these problems are less common as the surgeon’s level of experience increases.

Sometimes the implant migrates (moves) or sinks down into the bone (called subsidence). That doesn’t always mean the implant is a failure. Many patients still report great improvement over their pre-operative state of severe pain and loss of function. They can move their ankle through a greater arc of motion. And they can walk with a normal or near-normal gait pattern. Some even participate in sports.

The authors advise surgeons to be aware that ankle replacements have improved but still carry a high degree of risk and potential problems even when carried out by an experienced surgeon. Choosing patients carefully, being familiar with the various implants, and knowing how to do the surgery are essential for a successful outcome. The surgeon must plan carefully for individual patient variations in anatomy, alignment, and joint biomechanics.

Fragments of bone loose in a joint is a problem called osteochondritis. Improved technology in the area of imaging such as CT scans, MRIs, and arthroscopic exam has brought it to our attention that these osteochondral lesions occur in the ankle more often than we thought. That’s why the authors of this article thought it might be time to bring us current information about osteochondral lesions of the talus.

The talus is a bone in the ankle between the calcaneus (heel) and the two bones of the lower leg (tibia and fibula). Sometimes the talus is referred to as the anklebone but really there are many bones that work together to form ankle motion.

Trauma is the main reason why a corner of the talus breaks off and enters the joint space. Other causes may include heredity, hormones, and loss of blood supply to the area. A small number of people seem to develop this problem for no apparent reason. Scientists are still scratching their heads over that and trying to figure out what’s really going on.

Chronic ankle pain and loss of ankle motion are the two main symptoms of this problem. Severe ankle pain after trauma (such as an ankle sprain) could be caused by problems other than osteochondritis. There could be a disruption of the blood supply, a fracture, infection, nerve damage, or even an unstable (dislocated) ankle.

The doctor will examine the foot and ankle carefully for any signs that can help point to the correct diagnosis. X-rays, MRIs, and arthroscopic examination of the bone help pinpoint the exact location and amount of damage. MRIs also show the condition of the cartilage and layer of bone just under the cartilage (subchondral bone). Early signs of bone edema and subchondral damage will show up on MRIs when X-rays still look normal.

Once an osteochondral lesion of the talus has been identified as the problem, the physician uses the same diagnostic X-rays to now classify or stage the condition. Staging places the lesion in a category (I through IV) based on the size of the lesion, whether or not it has detached from the talus and/or has been displaced (moved).

All of this information will help guide the surgeon in establishing the best plan of care. Sometimes conservative (nonoperative care) is possible. Small, stable lesions (stages I and II) can be treated with immobilization such as casting or bracing. Even with protected weight-bearing, healing can take a very long time (up to a year).

More severe damage (stages III and IV) or lesions that just don’t heal with nonoperative care may require surgery. If surgery is needed, CT scans will help outline the bone shape and structure as well as accurately display the bone lesion.

The surgeon has several techniques at his or her disposal for the treatment of osteochondral lesions of the talus. It may be possible to use glue, wires, pins, or screws to reattach and hold the piece of bone back on the talus. This procedure is called internal fixation.

Sometimes, the surgeon just removes the bone fragment and smoothes down the edges of the talus where it broke off. This type of surgery is called excision and curettage. Drilling into the bone or creating tiny fractures in the bone are two more ways to stimulate healing. The repair cells that show up build a scaffold or matrix upon which bone cells can attach and fill in. This technique is called marrow stimulation. The joint can’t restore damaged surface cartilage this way but enough healing occurs to allow for functional weight bearing activities.

Newer surgical techniques such as osteochondral grafting or chondrocyte implantation now allow for restoration of the cartilage. Graft (donor) material can come from a donor bank or can be taken from a place in another one of the patient’s joints that is non weight-bearing. Grafting is reserved for large defects in the bone that probably won’t heal on their own even with drilling or marrow stimulation.

Implantation of chondrocytes is done by taking some of the patient’s own healthy cartilage cells and growing more in a laboratory setting. Then the multiplied cells are placed in the hole created by the defect.

If nothing is done, the lesion will progress to form severe ankle arthritis that will require an ankle fusion or even an ankle replacement. Early identification and treatment is ideal for preventing chronic pain from a chronic problem developing. Restoring motion, full weight-bearing, and a smooth gait (walking) pattern is the focus of treatment.

Almost everyone has either sprained an ankle or knows someone who has. It’s one of the most common musculoskeletal injuries. Most people recover well from sprained ankles, but about 10 percent to 40 percent end up with some problems, such as chronic instability, which can make it easier to sprain your ankle again.

Researchers don’t understand why a certain percentage of people end up with this instability, but a research team led by van Deun found that in a group of patients with unstable ankles, the patients had a different walk than those with stable ankles. The unstable ankle patients used their leg muscles in a different manner. In another study by Strauss and colleagues, it was found that patients with unstable ankles had higher rates of tendon problems, as well as other injuries or malformations in the foot.

The risk factors are a bit of a vicious circle. Having an unstable ankle increases your risk of having an ankle sprain – but having an ankle sprain increases the risk of having an unstable ankle. Other risk factors include the way you walk, any problems with your feet that may throw your walk out of alignment, as well as malformations of the bones. Lifestyle choices also increase risk. People who run and jump in the same sport (such as basketball and volleyball) have a higher risk of spraining their ankles.

Interestingly, if you’ve had repeated sprains, the risk increases not only because of the injury, but because of the way repeated sprains are often treated. Studies show that people who have sprained their ankle more than once tend to not take care of it as well as they should and they return to their pre-sprain activities earlier than recommended.

Sprained ankles may be prevented in some cases. If you know your ankle is unstable, you may want to learn how to tape it up before your activities, to provide support to the ankle. Bracing may also be an option for some people.

Diagnosing a sprain is partly ruling out a fracture (through x-rays), although some people with unstable ankles may find that stress x-rays (x-rays that show you standing on your foot or flexing it) show something in the soft tissue that helps the doctors identify the problem. Magnetic resonance imaging (MRI) is also a test that could show if the ankle is sprained.

During the physical exam, your doctor may move your foot up and down, especially if you knee is at a 90 degree angle. This tells the doctor a lot about your ankle’s ability to move.

Standard treatment for a sprained ankle involves light or no weight-bearing, avoiding activities that could injure the ankle, along with ice, compression, and elevation. As soon as the acute pain fades and the swelling goes down, usually it’s time to begin rehabilitation with either physiotherapy or exercises. Most people find good relief within two weeks or so, but it can take up to six to eight weeks for a full recovery.

In order to protect the ankle during recovery and prevent a recurrence, some people choose to use braces when doing activities such as running. Whether this works really seems to depend on the patient.

Surgery is not a common treatment for sprained ankles but sometimes it is the last resort if the ankle becomes dangerously unstable. The surgeries can replace the injured structures into their original locations or a tendon is taken from elsewhere and used to replace the damaged one. In some cases, arthroscopic surgery, surgery done through tiny incisions using long handled instruments and a camera to visualize the area are done to clean out problems left behind after the surgery.

The authors of this article concluded that standard treatment for ankle instability is functional rehabilitation but that surgery may be needed if the standard treatments don’t work.

This article is the first part of a series on disorders of the foot and ankle. Surgeons from the University of North Carolina Department of Orthopedic Surgery provide an update in this sports medicine topic. The specific focus is on peroneal tendon problems causing ankle pain and dysfunction.

The peroneal tendon is divided into two parts: the peroneus longus and the peroneus brevis. It is located on the lateral (outside) of the lower leg and ankle. The two sections start together at the upper portion of the lower leg and travel down the length of the lower leg. Both parts of the tendon wrap around under the ankle bone and then separate again and attache to two separate places on the foot.

Peroneal tendon injuries can occur as a result of misalignment of the ankle, frequent (repeated) ankle sprains, or overuse in athletic activities. It’s not a common problem. So, treatment isn’t based on evidence from large scientific studies. Instead, surgeons rely on what’s referred to as a consensus approach. This means they listen to what the experts have to say and see how others treat it as reported in published case studies.

Several specific conditions affecting the peroneal tendon are presented. The authors describe and discuss peroneal tendinopathy, os peroneum syndrome, peroneal tendon dislocation, and peroneal tendon tears. A special section is included for each one called the Author’s Preferred Treatment to help guide other surgeons treating any of these problems.

Tendinopathy refers to any inflammation of the tendon or the sheath (the covering) around the tendon. Dancers, runners, and athletes with chronic ankle instability from repeated ankle sprains are the people most likely to develop this problem. Os peroneum syndrome is a very painful condition caused by fracture of the os peroneum, ruptured tendons around the os peroneum, or entrapment of the os peroneum or peroneus tendon. The os peroneum is an extra little piece of cartilage or bone that is located within the peroneus longus tendon.

Treatment for both peroneal tendinopathies and painful os peroneum syndrome (POPS) begins with conservative (nonoperative) care. Antiinflammatories, shoe (heel) wedges, and physical therapy are the first approaches in care. In some cases of severe pain associated with acute injury, the patient may be put in a short-leg cast (below the knee, including the foot and ankle) or controlled ankle motion (CAM) boot.

Surgery is an alternate treatment option but only after the patient has tried three to six months of conservative care. For patients with tendinopathy, the surgeon uses an open incision to inspect the tendon and tendon sheath. The sheath is cut open and the tendon repaired. The surgeon leaves the tendon sheath unrepaired to prevent further pressure on the tendon.

In the case of a painful os peroneum syndrome, the bone or cartilage fragment is surgically removed. The surgeon must be careful to remove the os peroneum without damaging the peroneal tendon. If the tendon has already been frayed, torn, or ruptured from rubbing against the os peroneum, then the surgeon removes the os peroneum and then repairs the tendon. With large tears of the peroneus longus, the surgeon may stitch it to the peroneus brevis to help hold it together.

Tendon dislocation occurs most often during a forceful injury or in patients who have a very shallow groove for the tendon to travel around the ankle bone. The diagnosis of an acute peroneal tendon dislocation can be confirmed by the presence of the fleck sign on X-rays. This is a gap or space seen on the film indicating at least a partial disruption of the tendon. MRIs and ultrasound studies are used to look for fractures and to assess the shape and depth of the groove holding the tendon in place.

Conservative care can be tried but surgery is usually needed for tendon dislocations. This is especially true for athletes who want to get back into action as soon as possible. The authors describe several operative procedures they use to treat peroneal tendon dislocations (or subluxation, which is a partial dislocation). They provide color photos taken during surgery to help demonstrate their operative techniques.

And, finally, the treatment of peroneal tendon tears is presented. Mechanical trauma and high shear stress contribute to this type of injury. If the injury is forceful enough to rupture the tendon, there is often damage to other soft tissue structures in the same area. Treatment depends on all the structures involved and the severity of the injuries.

For example,patients with less than 50 per cent of the tendon torn can try the same nonoperative care described for tendinopathies. Surgical repair is advised if conservative care fails to reduce pain, improve function, and/or restore ankle stability. Surgery is also recommended when more than 50 per cent of the tendon is torn (or it is fully ruptured). If the tendon can be repaired, the surgeon will clear away any frayed edges and complete the repair. A tendon graft or tendon transfer may be needed to reconstruct more severe tears or ruptures.

Without enough evidence to create clinical treatment guidelines, reviews such as these authors provide are very helpful. Surgeon experience and published case reports support the need to identify the underlying cause of the injury. It’s important to correct any anatomical abnormality present to ensure a successful result.

Tendon ruptures of the tibialis anterior are uncommon. That makes it tough to study and come up with treatment guidelines. Should surgery be done to repair or reconstruct the tendon? Will it heal with nonoperative care? How do the results between these two treatment approaches compare?

The tibialis anterior is the muscle along the front of the lower leg that dorsiflexes the foot. Dorsiflexion means the tendon pulls the ankle up toward the face. The tibialis anterior can tear partially or rupture fully as a result of trauma or degeneration. Or it can rupture without any external trauma or for some unknown reason. In some cases, the patient steps wrong, twists the ankle, and overstretches the tendon to the breaking point.

Trauma includes lacerations (cuts) or blunt trauma of some sort. Degenerative causes usually affect men over the age of 45. Other risk factors for tendon rupture include taking steroids or having gout, diabetes, or inflammatory joint disease such as arthritis.

At the time of the degenerative-related injury, the ankle is in a plantar flexed (toes pointed down) position. The large calf muscle (gastrocnemius) is contracted and overpowers the much smaller and weaker tibialis anterior tendon that was trying to pull the foot and ankle back toward a neutral position.

This is the first report of a large series of patients who had surgery to repair this injury. Results for early and delayed surgical treatment are reported and compared to the results reported in other published studies.

Surgery is suggested in order to restore a normal gait (walking) pattern. Surgery may also be done to avoid a foot deformity. Conservative (nonoperative) care is more likely for older, inactive adults or when treatment has been delayed for three months or more.

Delays can occur because the problem isn’t obvious. Other muscles and tendons take over for the damaged tibialis anterior. Motion appears normal but symptoms eventually develop. Patients report ankle weakness. There may be a visible mass that can be felt along the front of the ankle. This is where the ruptured tendon has pulled back and bunched up. The weakness can result in changes in the way the person walks.

In this study, 19 adults between the ages of 21 and 78 had surgery to repair or reconstruct a fully ruptured tibialis anterior tendon. Most of the group (16 patients) had no known trauma (atraumatic). Some of the patients had been treated at the time of the injury but ended up with an infection, failed wound healing, and in two cases, failure to repair the lacerated tendon before closing the wound.

Before the operation, an exam was performed. Strength and range-of-motion were measured and recorded. And the American Orthopaedic Foot and Ankle Society (AOFAS) score was calculated. The AOFAS rating system looks at pain, function, and alignment.

Gait pattern was also evaluated. Most of the patients were unsteady and walked with a limp. Many of them had a foot slap gait pattern. Without the strength of the tibialis anterior to pull the ankle up, the foot slaps with a noticeable sound when the foot hits the floor. Some patients end up compensating by picking the foot up higher to avoid tripping. This gait pattern is referred to as a steppage gait.

The surgical procedure performed was determined at the time of the operation. While the patient was anesthetized, the surgeon evaluated foot and ankle motion. In some cases, it was necessary to perform a partial release of the gastrocnemius muscle. This step was needed to restore proper tension and balance between the tibialis anterior (front of the leg) and gastrocnemius (back of the leg).

If the torn tibialis anterior was visible and could be pulled back down, it was repaired by reattaching it to the bone. If it could be brought back down but not far enough to restore normal function, then a tendon graft was used to make up the length. A tendon graft is taken from some other tendon in the foot or ankle and used to reconstruct the tibialis anterior. The tendon graft is called interpositional as it help bridge the gap between the end of the ruptured tendon and the bone.

Everyone was put in a short-leg cast to immobilize the ankle in a neutral (zero degrees of dorsiflexion) position. The cast was kept on for a month to six weeks. Weight-bearing was allowed after the first three weeks. Patients were progressed from a cast to a hinged-ankle boot. Motion was restricted somewhat until the boot was no longer needed.

Using before and after AOFAS scores, the authors found great improvement in 18 of the 19 patients. Strength, motion and function were much better. They could all walk without a limp. Results were not dependent on age, sex, or general health.

There were a few complications such as failure of the wound to close and heal, infection, and scar tissue holding the tendon down. Most of these problems occurred in patients who had delayed surgical treatment. Early operative care seemed to have fewer postoperative problems. One patient had an infected wound and severe pain that made walking difficult. The surgeons suggested an ankle fusion as the next step, but the patient said, No, thanks.

The authors say that most of the time, a careful clinical exam can make an early diagnosis of tibialis anterior tendon rupture. If there is any question at all, an MRI can help show the area and amount of damage.

MRI results help the surgeon plan the surgical reconstruction. Tendons available for grafting will also be seen on the MRI. Whether or not a tendon graft is needed won’t be determined by MRIs. The surgeon makes that decision at the time of the actual procedure.

Early surgical repair is advised. Nonsurgical treatment doesn’t work well — especially for younger or more active patients. If a delay does occur, surgical repair or reconstruction is still an option. Patients may be warned about the increased risk of problems or complications when treatment has been delayed.

Results of this study show positive outcomes. The results are tolerated well by patients. The surgery holds up well if the muscles are balanced properly and ankle rehab is done to strengthen the muscles. Even with rehab, there may be some permanent loss of strength with easy muscle fatigue. These changes aren’t easily seen with manual muscle testing. Patients who try walking on their heels may notice some difficulty. But since this is not a typical motion needed for daily activity, it’s not a major problem.

Scientists have found ways to get a healing response in joint cartilage, but nothing really restores the cartilage back to normal. It’s now possible to take cartilage cells from one area of the joint and transfer them to the damaged section. This has been done successfully in the knee. In this article, results from the first attempt to do the same thing in the ankle are reported.

The procedure is called an osteochondral autograft transplantation or autologous chondrocyte implantation (ACI). Patients selected for the treatment have defects in the joint cartilage that go clear down to the bone.

The body tries to heal itself but only ends up with a cyst at the hole. The cartilage just doesn’t have a self-healing mechanism. There isn’t enough blood flow to the area. And chondrocytes (cartilage cells) don’t move or reproduce themselves. Surgery is almost always needed to help the process along.

In this study, 11 patients with osteochondral lesions of the talus from trauma were treated with autologous chondrocyte implantation (ACI). The talus is a bone in the ankle that connects the calcaneus (heel bone) to the tibia (lower leg bone). In layman’s terms, the talus is the anklebone that connects the foot to the leg.

Everyone in the study gave the nonoperative approach a good, solid try. But after months of bracing, casting, and antiinflammatory medications, they were still left with stiffness, and painful clicking or popping of the ankle. Surgery to manage the problem was also tried and failed.

In some cases, debridement was done (cleaning out the area of any loose tissue, frayed edges, or fragments of cartilage). In other patients, the surgeon tried pinning the pieces together or shaving down the cartilage to the bone to stimulate a healing response at the bone level. But none of these efforts worked either.

MRIs were done to show the location, size, and depth of the lesions. Most were on the medial (inside edge) of the talus. Two patients had lateral defects (along the outside of the talus). Patients with large enough defects were included in the study. The procedure involved removing the cyst and filling in the defect with graft material taken from the knee. In half the group, a sandwich procedure was used for the implantation.

The sandwich procedure is what the surgeons call the modified ACI procedure that they invented. In order to get to the damaged area on the talus, they first had to do an osteotomy. This involves cutting away a wedge-shaped piece of the lower leg bone (tibia or fibula, depending on which side the lesion was located). A special drawing was provided to show the reader where and how to make the correct cut. Incorrect placement for the bone cut for osteotomies on both sides (medial and lateral) were also shown.

Step-by-step, detailed, colored drawings of the sandwich procedure were also provided. Once the cyst was removed and the graft was in place, then the surgeon sewed a covering over the healing site. The covering is called a periosteal flap. This is the first piece of bread in the sandwich procedure. A special fibrin glue was injected between the flap and the bone graft. This was done to seal off the bone marrow cavity from the joint.

The surgeon put the second piece of bread in the sandwich right on top of the first. This was done by placing one more layer of bone on top of the first periosteal flap. This layer consisted of another periosteal flap, this time turned so the outer bone layer was facing the first periosteal flap. The second flap was also sewn in place, but the surgeon left a tiny opening at one end.

Once the second flap was sutured in place, then fibrin glue was used to form a tight seal around the sutures. They did a water test to make sure there were no areas of leakage. At this point, the filling was placed between the two pieces of bread. In other words, the harvested chondrocytes were injected between the two layers of bone graft (i.e., between the two periosteal flaps). The surgeon injected the transplanted chondrocytes into the tiny hole left open when the second periosteal flap was sutured.

The final surgical steps involved closing the tiny hole, sealing everything one more time with the fibrin glue, and reattaching the osteotomy. After surgery, the patients participated in a rehab program. They were allowed to put partial weight on the foot and started ankle range-of-motion exercises. They gradually moved to full weight-bearing when X-rays showed healing of the osteotomy.

A physical therapy program was started six weeks after the surgery. The program was carefully designed to match each stage of healing as the patient transitioned from remodeling to maturation of the graft site. Sport-specific training was included at the very end. The surgeons requested that only one therapist (who was familiar with the protocol) treated the patient for the entire rehab program.

Measures of success were taken throughout the postoperative period. Patient symptoms, satisfaction, and the Tegner activity score (test of function) were used to assess overall improvement. The Finsen score (a modified Weber score) and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were used to look more closely at joint function.

One other very important test was done. And that was a follow-up arthroscopic exam. This took place much later (9 months up to two years later). The surgeon used the scope to examine the repair tissue color, quantity of fill, and firmness compared to normal, healthy cartilage. And last, but not least, an MRI was also done some time later (months to years) in the follow-up process.

Patients went from rating their ankles poor to fair before surgery to a good to excellent result after surgery. All test scores showed major improvement in all areas. And the surgeons reported 100% success when the graft site was viewed by arthroscopic exam. This means there was complete coverage of the defect and no sign of inflammation or cartilage fraying.

The repair tissue was overgrown in two patients. In general, the new tissue was softer than healthy cartilage next to it. It did seem like the repair tissue was getting firmer over time. Other studies using MRIs to assess changes in defect repairs of this type have shown that cartilage remodeling continues for many months. None of the sandwich surfaces were completely smooth. Mild-to-moderate irregularity was observed with one case of severe surface irregularity.

Long-term results of these 11 patients will be needed to show what happens to the integrity of the repair tissue. Will the repair tissue hold up? How durable is it? Structural and biomechanical properties will be evaluated over time. And the results of this surgical approach will have to be compared to other methods of managing osteochondral lesions of the talus.

They have already noticed that the cystic lesions came back after being removed and repaired. They aren’t sure if this affects the results or even what causes it. The authors were a little surprised that even with the sandwich procedure, the subchondral plate (bone tissue just below the cartilage) was depressed (sunk down).

When the surgery was finished, everything was smooth, even, and flat. They suggest that maybe the downward shift of the subchondral plate is somehow related to the cyst formation. More study will be needed to see if there is a link between cyst formation and structural integrity of the repair tissue. It’s possible the cysts are a totally separate problem that has nothing to do with the cartilage defects.

The authors conclude that this method of repairing joint cartilage defects can be used with good results in the ankle. There may be a slight advantage to doing the sandwich procedure and ACI (instead of just the ACI). The sandwich group got better faster, although their final results were the same as the ACI group.

Because the sandwich procedure is so new, more studies will be needed before it becomes a standard treatment technique. On the other hand, this procedure may be just a step toward better, faster treatment methods. Some surgeons in other parts of the world have already found a way to avoid the time-consuming and difficult sandwich procedure.

They used a collagen membrane over the repair. Another group has found a way to make a super chondrocyte for better transplantation results. Thus, the race is on to find the magic answer to a quick and successful repair of severely damaged joint cartilage. Someday there may be a way to completely restore (not just repair) joint cartilage.

When you sprain an ankle over and over, it may be time to do something different. Some experts suggest taping the ankle. The idea is to increase the sensory messages to the joint and surrounding muscles. The hope is that this extra input will improve how quickly and accurately the ankle detects even the slightest change in position.

Proprioception is the term we use to describe the joint’s sense of its own position. Kinesthesia refers to detection of movement of a joint or body part. No one knows exactly why taping the ankle increases proprioception and kinesthetic awareness. It’s not really even clear if taping is what improves the joint’s ability to detect movement.

In this study, subjects with recurrent ankle sprains (three or more sprains in the last two years) were tested for change in proprioception with tape on the ankle. The researchers rigged up a footplate connected to a generator. The generator could move the ankle from side-to-side up to five degrees in each direction. Ankle motion with the foot turned in is called inversion. Ankle motion with the foot turned out is eversion.

Ankle inversion and eversion were tested with and without taping at three separate speeds of motion. Sixteen (16) people with recurrent ankle sprains were tested. It was expected that putting tape on the ankle to support and stabilize it would improve how quickly the joint detected changes in these two motions.

But, in fact, the authors report just the opposite. Instead of increasing the ankle’s ability to detect motion, having tape on decreased awareness of movement and joint position. Taping is known to reduce the risk of recurrent ankle sprains. The mechanism for this evidently isn’t because of an increased ability to detect changes in inversion and eversion.

Other studies have looked at the effect of taping on sprained ankles. They were never able to answer the question of whether taping improves movement detection or not. Several studies showed no difference in movement detection thresholds (how quickly the ankle perceives a change). Part of the reason for these conflicting results may be related to the quality of the studies done.

The authors of this report suggest that poor quality in experimental design may account for some of the different opinions on this topic. The protocol used in their own study was high quality, carefully following the principles of psychophysics. They don’t know why their results showed a reduced ability to detect ankle movements with taping in place. They offer several possible theories.

First, taping might reduce signals from the skin to the muscles and joint. The mechanism by which this happens is called cutaneous receptor discharge. Second, it’s possible that when the skin receptors signal the brain as to the location of the tape, it just adds noise to the nervous system, not actual helpful information. If the tape wasn’t applied in a way that stretched the skin during movement, then the proper signals weren’t sent to the nervous system.

It’s also possible that putting the tape on too loose or too tight altered the pattern of sensory signal patterns. The ankle wasn’t able to detect true sensory change. And several of the subjects did comment that they could tell the taped ankle was moving, but not in what direction. It was much easier to detect inversion-eversion ankle movement and the specific direction of the movement without the tape.

In future studies, applying the tape in a way that mimics the natural skin stretch patterns will be tried. Finding ways to tape that avoid stretching the skin in multiple directions is an important next step. In other words, they will try and match the normal skin stretch patterns that occur with inversion/eversion during testing with the tape in place.

Different types of tape should be tested. And an effort will be made to test where the communication break down occurs. Is it tape to skin, skin to muscle, or within the muscles themselves? For now, it’s clear that taping doesn’t reduce the risk of future sprains because of its beneficial effects on proprioception during inversion and eversion ankle movements.

Most people are familiar with the typical ankle injury that occurs just below the ankle bones. But there are other types of ankle injuries. One of those is the syndesmosis ankle sprain. The syndesmosis is a specific location in the upper ankle where the tibia and fibula (bones of the lower leg) meet.

In this article, sports orthopedic surgeons review the anatomy and biomechanics of the syndesmosis injury. They also present the mechanism of injury, method of diagnosis, and principles of treatment. Let’s start with the basics of who, what, when, where, and how. Who’s affected? Athletes and soldiers have the highest incidence of syndesmosis injuries. Football players, skiers, and hockey or basketball players are at increased risk of this injury.

What happens and how does it happen? The foot is dorsiflexed (toes pulled up toward the face) and pronated (forced down into a flatfoot position). The force is enough to tear the ligaments between the tibia and fibula. There are four syndesmotic ligaments.

At first, the ligaments are stretched. But when the force is enough to rupture the soft tissues, then the talus (major bone in the ankle) shifts its position. It externally rotates and pushes against the fibula. When that happens, the deltoid ligament of the ankle is also injured. In a chain of events, soft tissues and bones are damaged, shifted, and eventually ruptured. If the injury has a force strong enough, even the bone (fibula) can get fractured.

The rupture of one syndesmotic ligament usually isn’t enough to reduce ankle stability. Once the deep deltoid ligament is damaged, then the ankle becomes unstable. If that happens, the patient is a candidate for surgery. Nonoperative management is not enough.

How does the surgeon evaluate and diagnose the problem? Of course, the history (what happened, how it happened) raises the suspicion of a syndesmosis injury. A physical exam is next. The surgeon palpates (feels) along the length of the bones for swelling and/or tenderness. Any signs of bruising are noted.

Special tests are performed that are designed just to look for a syndesmosis injury. These include the Cotton test, the Amendola stabilization test, the squeeze test, and the fibula translation (drawer) test. The examiner chooses the most appropriate test(s) for each patient. A separate test called the external rotation test has the best correlation with syndesmotic sprains. When this test is positive, the athlete can expect a longer recovery time before returning to a preinjury level of participation.

Imaging studies with X-rays, CT scans, and/or MRIs may be ordered. If a syndesmotic injury is suspected, the surgeon will order full-length films of the lower leg along with the standard ankle series. X-rays will show fractures and any change in the normal alignment of the tibia and fibula. Sometimes stress radiographs are taken. For the most sensitive and specific tests, MRIs are needed.

Once the injury has been identified and evaluated, the surgeon uses the information to classify it as a grade one, two, or three injury. The difference between the grades is based on amount of edema, tenderness, and ability to put weight on the foot. Distance between the two bones (as seen on imaging studies) is also factored into the classification.

The final step is to plan a course of treatment. There are two basic choices: conservative (nonoperative) care and surgery. There haven’t been enough studies done to show what’s the best way to approach conservative care. Right now, nonoperative treatment is broken down into three parts or phases.

Phase one is the acute phase. When there is swelling, the ankle joint must be protected until the inflammation is controlled. Moderately painful injuries are aided by an ankle brace or taping to provide compression and stability along with ice, rest, and elevation. Severe pain may require immobilization in a cast or splint. Physical therapy to restore normal joint motion and neuromuscular control may be needed.

Therapy continues during phase two, the subacute phase with strength and functional tasks. The program is progressed until the patient is no longer using assistive devices (splints, braces, crutches). When the athlete is ready for more advanced training, then phase three begins. The focus will be on returning the athlete to active sports participation at the preinjury level whenever possible.

There’s no set amount of time before players return to sports. This varies according to the severity of the injury. Studies report anywhere from three and a half weeks up to two months before rehab is complete. In some cases, conservative care isn’t even possible. Surgery to repair the damage and restore ankle stability is required. With surgery, recovery is delayed by three to four months.

Various types of surgery can be used to fix fractures, tighten the syndesmosis, and realign the ankle. Screws, sutures, suture buttons, and EndoButton suture techniques are surgical techniques used to stabilize the ankle syndesmosis. Research efforts are ongoing to find a way to return athletes to competitive play as early as six weeks after surgery.

The senior author of this article developed a minimally invasive way to treat posterior ankle impingement. Impingement is the pinching of soft tissue, bone fragments, or scar tissue causing painful and limited ankle motion. Plantar flexion (pointing the toe) is affected most often.

Posterior ankle impingement is caused by traumatic injury or overuse in dancers, soccer players, runners, and other athletes. Sometimes dancing or running on a hard surface contributes to the problem.

In other cases, there is a slight difference in the normal foot and ankle anatomy that eventually leads to posterior ankle impingement. The joint capsule may be thickened causing pain when it gets pinched between two bones in the ankle.

There may be bone fragments inside the joint that have broken off the bone and become free-floating pieces that get stuck between two bones. Whatever the cause, the end result is the same: chronic ankle pain along the back of the ankle (at rest and with palpation), pain with movement, and loss of ankle plantar flexion.

The new procedure is called a two portal posterior endoscopic approach. A special tool called an endoscope was used to access the ankle joint through points called portals. A small incision was made and the scope was slid into the joint from the back of the ankle. A tiny TV camera on the end of the scope gave the surgeon a view inside the joint. A detailed description of the surgical procedure was provided in the article.

In this study, the endoscopic approach was used to treat 55 patients with posterior ankle impingement. All had posterior impingement syndrome from overuse (35 per cent) or trauma (65 per cent). Conservative (nonoperative) care was the first line of treatment. When that was unsuccessful, surgery was done to remove the offending tissue (e.g., bone fragments, scar tissue, thickened joint capsule).

One common cause of posterior impingement syndrome is called the os trigonum. There is an extra piece of bone present (usually at birth) in affected individuals. It is located behind the talus bone (part of the ankle complex). It is connected to the talus by a band of fibrous tissue. When this bony bump gets separated from the main body of the talus, it is referred to as an os trigonum.

For the person who has an os trigonum, pointing the toes downward catches the os trigonum between the ankle and heel. The repetitive force downward on the os trigonum every time the foot is pointed causes the bone fragment to pull loose. As the os trigonum pulls away, the tissue connecting it to the talus is stretched or torn. The area becomes inflamed causing pain and loss of ankle motion.

Results were compared with outcomes reported in other studies when the same surgery was done with an open technique. Measures used to compare the results included score on the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score (measures of pain, function, and alignment) and the Tegner score (measure of activity level). Time to return to work and to sports activities were also recorded and compared between the endoscopic and the open procedure.

The posttraumatic group was able to return to work in about one week. The overuse group needed more time with an average return-to-work return rate as two and a half weeks. However, it took longer for the posttraumatic group to get back on the field or involved in sports once again (11 weeks) compared with the overuse group (eight weeks).

These figures also corresponded with function (better function in the overuse group that returned to sports faster). And the overuse group was much happier with their results compared with the posttraumatic group.

There were two main differences between patients who had minimally invasive endoscopic surgery and those who had open surgery for posterior ankle impingement. These were reported as far fewer complications and faster recovery in the endoscopic group.

Patients whose impingement was caused by overuse had better results in both the endoscopic and open surgery procedures. The authors speculated that this may be related to more pathology (damage) in the ankles of patients with posttraumatic impingement. Not only is there an os trigonum after trauma, but also tendinitis of the flexor hallucis longus develops in the majority of patients. The tendon of this muscle in the foot lies in a groove that goes behind the talus, under the calcaneus (heel bone), and inserts into the base of the big toe. The tendinitis occurs as a result of displacement of the os trigonum.

The authors conclude that a skilled surgeon can operate endoscopically to treat posterior ankle impingement. The two-portal method from the back of the leg gives easy access to the ankle joint, flexor hallucis longus tendon, and os trigonum. Important nerves and blood vessels are avoided with this method. Fewer complications means a faster recovery, which is important in the typical patient population (ballet dancers, athletes).

Managing arthritis in the foot can be difficult. With pantalar arthritis, arthritis in the back of the foot towards the ankle, it can be particularly difficult if it gets to the point that surgery is needed. Right now, it’s common to do a total ankle arthroplasty to help manage the pain. This can involved either resurfacing, rebuilding, or completely replacing the ankle. But, researchers have found that it may be better for the patients if they had a combination surgery that included the arthroplasty with fusion (joining together) of the hind foot, or back of the foot.

In a study done by Kelly L. Apostle and colleagues, 73 patients who had a total ankle arthroplasty and one of two types of fusions were compared with 72 patients who had only the arthroplasty. After following the patients for two years, the researchers found that both groups improved at the same rate. The researchers used the Ankle Osteoarthritis Scale (AOS) and Foot Function Index when they examined the patients at six, 12, and 24 months after their surgery.

However, there were differences in the complication rate. There was a 32 percent complication rate, 16 patients experienced major complications, in the arthroplasty plus fusion group. These included mostly loosening of hardware. It turned out that 30 percent of the patients needed to have repeat surgery, one of whom underwent an amputation below the knee. In the arthroplasty-only group, 42 percent of the patients had complications, half of which were major and mostly related to the hardware. And, 26 percent of the patients needed surgery again.

In conclusion, the researchers found that although the pain relief obtained from both procedures, as well as returning function to the ankle, were similar, the complication rate of the arthroplasty alone was quite a bit higher than the arthroplasty plus fusion group.

Injection of hyaluronic acid into the knee to treat osteoarthritis is an approved treatment now. The Food and Drug Administration (FDA) has given the use of this type of viscosupplementation in the knee a green light. The FDA has NOT approved the use of this viscosupplement for the ankle yet. Why not?

The underlying cause of osteoarthritis in the knee versus the ankle is often different. Experts think this may make a difference in how effective viscosupplementation may be for the ankle. The main difference in cause is trauma: arthritis in the ankle joint is more likely to be caused by trauma. Knee osteoarthritis is usually just that — arthritis that started in the knee without a history of trauma.

Studies show that viscosupplementation isn’t really effective for knee post-traumatic osteoarthritis. So there’s no reason to believe (and minimal proof yet) that this type of treatment will work in patients with posttraumatic ankle osteoarthritis. Why not?

No one is exactly sure yet why viscosupplementation works well for primary arthritis affecting the knee but not posttraumatic joint arthritis. Research on hyaluronic acid shows that this substance is the main ingredient in joint synovial fluid. It seems to have many roles. Besides remaining elastic under high shear forces, it also keeps the synovial fluid slippery or viscous.

Lubricating fluid inside the joint makes it possible for the joint to withstand the heat that develops within the joint even with low shear stress. Hyaluronic acid can store mechanical energy for release later when needed. It bathes the cartilage cells with fluid and keeps them nourished. It even has antiinflammatory properties to reduce joint inflammation and an ability to reduce pain — or at least the perception of pain.

Would injection of hyaluronic acid into the arthritic ankle have these same effects and benefits? Some studies have been done with this treatment for ankle osteoarthritis. But the number of patients involved was small and the results have only been measured for up to six months. The results did show a positive effect of viscosupplement injections when compared with placebo (fake) injections. Some viscosupplements have been given approval in Europe for use with ankle patients.

Research is now underway to test hyaluronic acid in the treatment of ankle osteoarthritis. The hope is to find equal (if not better) results as have been reported with knee viscosupplementation. Minimizing adverse side effects is a secondary goal of current studies. Reports of temporary effects such as pain, warmth, swelling at the injection site have been noted. Up to one third of the patients treated with viscosupplementation experience some type of negative side effect.

When larger studies with more long-term results are available, the FDA may approve the use of viscosupplementation as a treatment tool for ankle osteoarthritis. The complex nature of the joint with its many bones (compared to the single hinge-type knee joint) make it necessary to research this treatment option carefully before approving it for use in the U.S.A.