Ankle Injuries

They may and often do occur in conjunction with each other. New research is showing that the main cause of ankle sprains is a generalized lack of proprioception by the athlete (patient).

If their proprioception is compromised, then when the surface height is changed, ie: stepping into a hole, landing on another players foot after jumping, stepping off of a curb etc. then the athlete / patient does not have full control of the ankle when it impacts the surface and thus a sprain occurs.
85% of all ankle sprains involve some plantar flexion of the ankle and inversion of the foot. The remaining 15% consist of eversion mechanisms which are often the result of an outside force such as being fallen on from the outside. The syndesmosis ligament is often also injured with an eversion force. If the tibia and fibula spread on the talus, the ankle mortise is disrupted and the ankle can become very unstable. It is also not unusual to see an associated fibula fracture with an eversion mechanism. (see x-rays below) Assessment of a syndesmosis sprain will be difficult for the initial 24 to 48 hours. If the ankle is quite swollen and edematous assessment of a syndesmosis sprain may be difficult until the pain and swelling have isolated to individual areas or x-rays show some spreading of the ankle mortise.

This injury represents a "high" sprain. This athlete got his foot caught on a base while sliding. The x-ray shows a widening at the mortise. This occurs when the syndesmosis ligament (tib-fib) has been torn.

The distal tibial and fibula must be re approximated so the ligament will heal. Otherwise, this athlete will be left with a very unstable ankle. However, the practitioner must note that if this type of spreading is seen distally on the leg, the forces may have caused other trauma.
See below.

Notice the high fibula fracture on the same patient.

Maison - Neuve type fracture.

Distal Fibula fracture with associated medial deltoid ligament
disruption. This injury is frequently the result of the foot being planted with a valgus load applied to the leg.

Notice the disruption of the medial deltoid ligament and the widening between the medial malleolus and the talus. This is indicative of a ruptured deltoid ligament. This fracture requires surgical fixation of the fibula using a screw and plate system. The plate should be removed prior to return to competitive athletic activity as it will cause stress areas in the bone at each end of the plate. Recovery time (return to athletic activity) for a generally healthy patient with this type of fracture will be in the 6 month range.

These X-Rays show a fracture of the proximal end of the 5th Metatarsal. This fracture is commonly called a "Jones Fracture".
Treatment of Jones Fractures includes several options. Option 1 - immobilization of foot and ankle with non weight bearing for a period of 1 month to 6 plus weeks and more time may be required if the bone healing is delayed. The peroneus brevis tendon attaches at the proximal end of the 5th Metatarsal and treatment without ankle immobilization is not effective. Every time the muscle contracts and pulls on the tendon, the fracture site is disrupted. This type of fracture is known to form a non union. Option 2 - insertion of a intramedullary screw into the fracture to compress the fragment and the bones back together. May or may not be used with a bone graft. Many physicians will also opt to use a bone growth stimulator on this fracture to insure that healing occurs. Option 2 is certainly preferred in the authors opinion since the fracture site is stabilized and the ends of the fracture are approximated. The screw fixation allows for earlier return to weight bearing and decreased immobilization time. (Dr. Joe Milne, Dr. Steve Brotherton)
	Surgical Fixation using and intramedullary screw.
Forefoot fracture
	Surgical Fixation
This is a picture of a ruptured Achilles tendon. Notice the lump under the skin where the Achilles tendon has retracted. This patient presented after a pick up basketball game. Positive "Thompson test" for Achilles tendon rupture.

The patient is put into a short leg cast in plantar flexion for 6-8 weeks, non weight bearing.


Open tear of the Achilles, notice the Plantaris muscle tendon is still intact.	The ends are prepared for repair.