News Category: Ankle

What’s the risk of first-time ankle injury for athletes? Are women more likely to sprain their ankles compared to men? Are there more injuries in high school athletes compared to college athletes? Which sport has the most ankle sprains? These are the questions researchers at the University of Vermont tried to answer in this study.

Over 900 high school and college athletes were included. Athletes in basketball, soccer, lacrosse, and field hockey were studied over a period of four years.

The authors report a rate of less than one ankle sprain per 1000 days of exposure to sport. This was less than expected. The risk of an ankle sprain was slightly higher in women compared to men. There was no difference between high school and college athletes. Basketball was the sport with the greatest number of injuries, especially for women.

This study showed that the risk of ankle injury depends on the sport for women. The same is not true for men. Just as many injuries occurred during practice as during the games. The authors suggest any steps taken to reduce ankle injuries should be used at all athletic events.

In this report two physical therapists review the exam and results of treatment for seven athletes with cuboid syndrome from a sprained ankle. Cuboid syndrome occurs when the cuboid bone inside the ankle partially or fully dislocates. A partial dislocation is called a subluxation.

In the cuboid syndrome a strained or sprained ligament allows the cuboid to angle downward. The person with this problem has increased pain when trying to stand on the toes or when rolling the arches toward the outer edge of the foot.

All patients were treated with a specific manipulation called the cuboid whip. Pain was decreased or gone completely after manipulation. Some patients returned to sports activity the same day. No one had a relapse or return of symptoms.

More studies are needed to find out what works best to treat cuboid syndrome. Based on this study, joint manipulation has good results. Other treatment may include taping, orthotics, and stretching.

Knee replacements are becoming standard treatment for osteoarthritis. More and more people are having both knees replaced. In this study researchers compare the way patients walked before and after having both knees replaced.

All patients were women who had both knees replaced. The second knee was done within three weeks of the first. Their walking patterns were analyzed before and after the operations. Results were compared with 12 women who had normal knees and a normal gait pattern.

A computerized gait analysis system was used to measure cadence (steps per minute), step length, and stride length. Special sensors in the walkway signaled the amount of force between the foot and the floor. This is called ground reaction force.

The authors report improved cadence and step length from before to after surgery. Results didn’t equal the control group who had a faster cadence and longer step length. Total range of motion in the knee stayed the same from before to after joint replacement.

The authors conclude that gait analysis isn’t possible for the average patient. Even so studies like this can offer helpful information about changes in patients before and after having both knees replaced.

Physical therapists need more information to help them with patients who have ankle joint stiffness after casting for bone fractures. Knowing how to stretch the muscles to regain motion is important. Is five minutes of stretching enough? Would 10 minutes be better? If 10 minutes is good, what about 30 minutes?

In this study there were three groups of patients with plantar flexor contractures. Plantar flexion contracture means the foot is stuck in a slightly pointed position. The patient can’t pull the toes up toward the face as far as normal. Group one was treated with exercise only. Group two had exercise plus short duration stretching. Patients in group three did exercise plus long duration stretching.

All patients were seen by a physical therapist and did a home program, too. Everyone did 30 repetitions daily of ankle, stepping, and balancing exercises. Patients in the short stretch group did ankle stretching exercises for six minutes every day. The stretches were held for 30 seconds. The patient did them 12 times daily.

The long-stretch group used a wedge under the foot for 30 minutes at a time. They could be standing or sitting while stretching. Everyone in all three groups got advice and gait training. Measures of success included pain, walking speed, stepping rate while going up or down stairs, and satisfaction with treatment.

The results of this study show that stretching to increase ankle motion after casting for an ankle fracture is no better than exercise alone.

Treatment for ankle sprain is often directed at reducing painful swelling. The idea is to restore function by limiting inflammation. However this treatment approach has been called into question by a new study.

Thirty-six men and women with a recent ankle sprain were in this study. All were seen within five days of the injury. Ankle swelling was measured and questions were asked about pain and function. The results showed no link between swelling and function.

The researchers were surprised by the findings. They offered several possible reasons for the results:

There’s a fibrous band of tissue between the two lower leg bones called the syndesmosis. It holds the bones together giving the ankle stability while still allowing motion. It’s a real challenge to repair the syndesmosis when it’s torn during an ankle injury. This is a report about a new way to suture the two bones together.

Until now most surgeons have used a long screw through the two bones to hold them together during healing. There are many problems with this treatment method. Since the two bones are meant to move slightly, the screw often loosens or gets broken. When healing does take place, a second surgery is needed to remove the screw.

The new flexible fixation uses a suture-button to hold the bones together. This means a braided piece of plastic goes through both bones. It’s held in place by a button on the outside of each bone. The plastic is nonabsorbable but doesn’t have to be removed after healing takes place.

With this new suture-button method of repair, patients can put weight on the leg sooner. They get back to work sooner, too. Ankle motion and function is better in patients who have this operation compared to patients who have a metal screw to hold the bones together.

After comparing patients with suture-buttons to patients with a metal screw, the authors conclude the suture-button is safe and cost-effective. With faster rehab, the suture-button may become the treatment of choice for patients with a torn syndesmosis.

Jumping and landing are important skills in sports like basketball, soccer, and volleyball. Ankle sprains make landing difficult. Pain, swelling, and giving way of the ankle lead to functional ankle instability (FAI). FAI occurs when the ankle is unstable but the ligaments aren’t damaged.

Sports researchers are looking for a way to explain what causes FAI. In this study scientists try to find a way to measure hidden joint deficits that lead to instability. They compare two groups using two tests. One group included healthy adults with normal ankles. The second group had FAI. The first test was stepping down from a five-inch height. The second test was a forward standing jump.

There were no differences in the groups in terms of ankle stiffness or laxity. Group differences were seen with the jump test. The jump test was harder because strength, coordination, and ankle stability are needed. Any ankle swelling may decrease the joint’s ability to sense motion and position.

The authors conclude that the jump test is a better way to find hidden ankle problems than the step-down test. They recommend its use for anyone with FAI. Finding and correcting such problems with stability may help prevent future re-injuries.

Ankle injuries are common in ice hockey because of the nature of the sport. It’s a high-speed contact sport played with the feet in rigid boots. The game is played on a hard surface with boards all around. This study reports the number of ankle injuries in two National Hockey League (NHL) franchises. It’s the first study of its kind.

Two kinds of ankle sprains were seen: lateral ligament and syndesmosis sprains. Most of the sprains occurred during play time rather than during practice. This study focused on the syndesmosis sprains. A syndesmosis sprain, sometimes called a high ankle sprain injures at least one of the key ligaments that joins the two bones of the lower leg together.

Most of the syndesmosis ankle injuries identified in this study occurred in players who played the forward position. Usually the injury was caused by a fall with the foot turned out (externally rotated). Speeds of 30 mph are common during this sport. Sliding speeds on the ice after a fall have been measured at 15 mph. Players often lose control and are at risk of hitting the goal, another player, or the boards.

Compared to lateral ankle sprains, syndesmosis sprains take much longer to heal. The average number of days missed on the ice was 1.4 for lateral ankle sprains and 45 for syndesmosis sprains. Players with syndesmosis sprains were sore and stiff for several weeks after rehab. Most said they didn’t really feel normal until the next season.

According to this study, the hockey skate doesn’t protect players from syndesmosis ankle injuries. As the sport gains popularity more and more athletes will be at risk for this injury. Time lost from a sydesmosis injury is much more than for a typical lateral ankle sprain.

Experts in foot and ankle injuries report that a rare ankle fracture is on the rise. Snowboarders land on the foot and ankle when they are twisted in and pulled up. The force can be enough to break off a piece of bone from the talus bone. The talus is the ankle bone between the heel and the lower leg.

Two cases are reported here as a result of injuries while wearing soft-shell boots. Both men fell with the ankle in a dorsiflexed position. This means the foot was pulled up toward the knee. The force of the impact displaced a fragment of bone and tore the nearby ligament.

Both patients had surgery to repair the fracture with screws to hold the bones in place. A year later both snowboarders were back on the slopes at their preinjury level of snowboarding.

The authors of these two case reports conclude that cases of snowboarder’s fracture are on the rise. Early diagnosis and treatment bring about a good result. X-rays don’t always show the break, and MRIs don’t always show how much the bone fragment is pulled away from the main bone. Therefore, CT scans are advised when an ankle injury with forced dorsiflexion is reported.

Doctors may expect to see more of these injuries as snowboarding gains in popularity.

Which is better: ankle fusion, or a replacement joint for ankle arthritis? Doctors at the University of California looked at cost, durability, and function to help answer this question.

Results of studies on ankle fusion and total ankle replacement (TAR) were reviewed. A special computer program was used to make a model for the treatment of end-stage ankle arthritis. All patients in the model were 55 years old or older. The data collected from the reviews was projected out for 25 more years of life.

This model allowed researchers to add up the cost of both operations. Then they compared the cost of ankle replacement versus ankle fusion. Doctors’ fees and hospital charges were summed up. Postoperative care was also included in the analysis of costs. Complications after either operation raised the overall total costs.

New ankle implants are on the market now, making this an option for end-stage ankle arthritis. The implant gives the ankle better motion and movement. However, the TAR cost $10,000 more than an ankle fusion. In the studies reviewed, the TAR didn’t last more than seven to nine years.

The authors conclude that it looks like the TAR may be the best choice in the future, but not for now. It costs much more, and doesn’t usually last as long as a fusion.

Volleyball players are at increased risk for ankle sprain. And once an ankle is injured, the chances of spraining it again go up. This large study of 116 volleyball teams presents some ideas for preventing ankle sprains.

Two groups of male and female volleyball players were formed. One group trained on a balance board. This training strengthens muscles and ligaments around the ankle. It also restores proprioception, which is the sense of joint position. A second control group did their regular training program.

The balance training group spent five minutes doing one of 14 different exercises on and off the balance board. Training for both groups was carried out during the 36-week volleyball season.

The number of ankle injuries was reported for every 1000 hours of play. Playing time included practices and games during the season. Players with a previous ankle injury had fewer reinjuries in the balance training group compared to the control group. However, the researchers noticed that players with a history of knee injuries had more knee reinjuries in the balance training group.

The authors conclude that balance board training is a good way to prevent ankle sprains. It doesn’t have the negative side effects of ankle tape or bracing. They also note that it may not be a good choice for players with previous knee injuries.

The Achilles tendon is located on the back of the lower calf and foot. Its location and function make it vulnerable to lots of force. This puts it at risk for tendonitis and rupture. In this study, hylan G-F 20 was used on the Achilles tendons of 18 rats. The scientists wanted to see what effects the hylan would have on Achilles tendonitis.

Hylan G-F 20 is an elastic fluid made from a substance called hyaluronan. Hyaluronan is found in normal joint fluid. Hyaluronan helps joints absorb shock. It’s needed for the joint to work normally. When injected into the joint of a patient with osteoarthritis, hylan G-F 20 helps to restore the shock-absorbing effect of the fluid within the knee.

The authors tried hylan for Achilles tendonitis. They describe the experiment:

Ankle fusion is often the best way to treat severe ankle arthritis. But major problems can occur. The patient can end up with a painful and very stiff joint that doesn’t allow for walking on uneven ground or climbing stairs. This study looks at the results of a new treatment option after ankle fusion: total ankle replacement (TAR).

The first 18 patients to have TAR after ankle fusion were followed for an average of three years. Results were measured for pain, function, and motion. Condition of the joint and alignment were also viewed on X-ray as part of the results.

All but three patients had a good outcome. Most had relief from pain and improved function even without increased motion. The joint implant prevented amputation for 15 patients. The three who had the implant removed would not have tried to convert the ankle fusion if they could do it over again. Three others had to have a second operation to revise the TAR.

When faced with amputation after a failed ankle fusion, TAR is a possible option. The patients most likely to do well converting from fusion to implant have a clear source of pain. They also have intact ankle bones on both sides and a strong deltoid ligament.

The authors conclude that converting to a TAR isn’t perfect and doesn’t work for everyone. But the results of this first study are encouraging. They think fusion can be improved with this operation.

The results of ankle replacement are better than ever. Researchers at the University of Minnesota have found a way to measure true ankle motion to prove this.

Until now, other studies reported measures of the ankle, midfoot, and hind foot motion. True ankle joint motion is measured where the tibia (lower leg bone) meets the talus. The talus forms the lower part of the ankle dome. The point where these bones meet is the tibiotalar joint.

The ankle has several different motions. Normal ankle motion allows the foot to point down a full 50 degrees. This motion is called plantarflexion. Pulling the toes up toward the face is called dorsiflexion. Most adults can dorsiflex about 20 degrees. Both motions are needed for walking and going up and down stairs.

In this study, all ankles were X-rayed with the patient in the standing position. A second X-ray was taken from the side with the ankle in both full dorsiflexion and full plantarflexion. X-rays were taken before and after the joint replacement. This method allowed researchers to detect motion at the true ankle joint.

Everyone got the same type of ankle implant, called the Agility Ankle. Results of this study showed that patients had five degrees more true tibiotalar motion after the operation. This was enough motion to allow the patients to walk normally. There were still some problems going up and down stairs.

The authors think patients should be told before the surgery that the benefit is mostly pain relief. The increase in ankle motion isn’t especially good. Final ankle motion is based on ankle joint motion before surgery. Most patients do seem able to make use of the motion they have when the pain is gone.

This new study from the University of Iowa reports the long-term results of ankle replacement surgery. The Agility total ankle replacement was used in 126 patients. An earlier report by these same authors gave the short-term results using this same implant.

All patients had disabling ankle arthritis. About half the arthritis occurred because of trauma. Others had osteoarthritis, rheumatoid arthritis, or joint infection resulting in arthritis. Nonsurgical treatment didn’t work, so surgery was the next step.

Patients were followed for at least seven years. Some were followed for up to 16 years. Pain, function, and patient satisfaction were measured. X-rays were used to see the joint and the placement of the implant. X-rays also showed the condition of the bone. Doctors looked for bone loss around the joint implant and signs of arthritis.

The authors report a 90 percent rate of patient satisfaction. About 11 percent of patients needed a second operation to revise or remove the implant. Some of these patients had to have the joint fused. Implants failed because of bone loosening or the implant settling too far into the bone. Infection and fracture accounted for other implant revisions.

Early attempts at ankle replacement had many problems. As better implants were developed results seemed to improve. This report shows encouraging results with the Agility implant over an average of nine years.

You step down or jump down and feel a sudden snap in the calf muscle. You’ve just ruptured your Achilles tendon. What do you do now? Doctors don’t agree on the best treatment early after Achilles tendon rupture. Treatment for Achilles tendon rupture is divided into two basic groups: with or without surgery.

This study reports on 140 patients treated without surgery. Casting is the most common nonoperative treatment. At the Musgrave Park Hospital in Belfast, Northern Ireland, doctors used a cast right away. The patients didn’t put any weight on the foot.

Four weeks later, patients were switched to a removable brace called an orthosis. The orthosis was worn for four weeks. Patients were given training in walking during this time. Physical therapy continued until the patient could perform normal activities.

After eight weeks, pain levels, range of motion, and strength were measured on both legs. This way the injured leg could be compared to the normal leg. The results of orthotic treatment were better than results reported in other studies using surgery. The patients in this study were very happy with their final outcome.

As the number of cases of ruptured Achilles tendon rises, so has the use of surgery to treat it. The results of surgical treatment are usually good, but problems are common. That’s why this group of researchers is studying ways to recover without an operation. The orthotic treatment in this study worked well in place of surgery. The authors suggest nonoperative treatment as the number one choice when experienced staff can follow the patients.

Nitric oxide (NO) is a naturally occurring gas in the body. Scientists are finding many new uses for NO. This study looks at the use of NO for torn or injured tendons called tendinopathies.

Two groups of patients with tendinopathy were studied. Both groups wore a special skin patch on the injured Achilles tendon. The patch was removed and replaced with a new patch every 24 hours for six months. The control group had a patch with nothing on it. The treatment group had a patch with NO in it.

Patients in both groups followed the same rehab program. Pain, tenderness, and activity level were used to measure the results. Pain was assessed at rest, with activity, and at night (during sleep). Measures were taken for up to six months.

The results showed a big decrease in Achilles tendon pain with activity and at night in the NO group. There was also less tendon tenderness in this group. In the control group, only 49 percent of the tendons were pain free at six months. This compares to 78 percent improved and without symptoms in the NO group.

The authors conclude that tendon rehab can be improved by using topical NO therapy. NO can’t replace a rehab program; the two treatments should be used together. It’s not clear yet why NO works to heal tendinopathy in some people but not in others. More research is planned on this subject.

One-third of all orthopedic doctors use steroid injections to treat Achilles tendonitis. The dangers of steroid injections are still questioned by many other doctors. Researchers at the University of Virginia Health System did a safety study of low-volume steroid injections. They used a special imaging method called fluoroscopy to guide the injection to the right spot.

All of the 43 patients had Achilles tendonitis that didn’t get better with regular treatment. After injection everyone was followed for at least two years. The patients were asked to report any problems after the injection. Problems included minor complaints, such as changes in skin color, infection, or skin thinning.

Major problems such as tendon rupture and deep infection were also reported. Other signs of success or failure were measured by patient response. Everyone was asked how much pain relief they got and how long it lasted. They were asked if a second injection was needed. The authors report that 40 percent of the patients got better. More than half thought there was no change. A smaller number (seven percent) reported getting worse.

The authors conclude that the method of delivering the steroid is a key factor in success. Using fluoroscopy reduced the chance of adhesions between the tendon and its lining. There was no proof in this study that properly applied steroid injections cause tendon rupture.

In 1982 a student at the University of Athens wrote a paper on a new finding in the ankle. The student’s name was Constantinos Nikolopoulos. He reported a new ligament never seen before in the ankle. The paper wasn’t published.

In 1990 another group of researchers reported on the same thing. They called the new structure a fascicle. A fascicle is a bundle. In this case, it was a fascicle of the anterior tibiofibular ligament. In this article Nikolopoulos, now a medical doctor, reports on a special study of this structure.

Looking at 24 cadavers, he found a separate ligament in 22 of the ankles. In each case the ligament was just below and parallel to the anterior inferior tibiofibular ligament (AITFL). The AITF ligament and the newly discovered ligament were two separate structures.

The new ligament was named the accessory anteroinferior tibiofibular ligament. In this report Dr. Nikolopoulos proposes that this structure is a separate ligament in the ankle. It’s not a fascicle at all. This ligament may be the cause of ankle pain after some injuries if it gets pinched between two ankle bones.

Dr. Nikolopoulos says the accessory AITL isn’t abnormal or a disease. It’s a change in the normal anatomy found in maybe more than 90 percent of all people. It can become a problem when the ankle gets sprained.

Telling someone to “break a leg” is for good luck in the theater world. This is not such a good expression for snow boarders. They actually do break bones in their legs far too often. In fact, a rare type of ankle fracture is becoming more common among snowboarders.

This break occurs in the outside edge of the talus. The talus is the bone between the heel of the foot and the lower leg bone. Doctors need to know about this injury because it often looks just like an ankle sprain. Yet without proper treatment, a talus fracture can have a bad result. The fracture may fail to heal, eventually causing arthritis. Arthritis can cause pain and disability.

The authors of this study used cadavers (human bodies saved for study) to force a talus fracture. They applied the motion snowboarders go through when falling forward. The leading leg turns toward the front of the board, putting the weight of the body over the inside of the ankle. In the lab using human cadavers, the scientists could create this injury. The amount of motion and force was measured for each test. After each test the ankle was examined for injury.

Understanding the forces that cause this injury will help doctors recognize it more quickly. In the past it was thought that falling forward on the ankle while twisting it inward (inversion) caused a talus fracture. But the results of this study show that falling forward and twisting the ankle outward (eversion) is the real cause of injury.