Ankle + Achilles Injuries
Ankle Sprains
What is an ankle sprain?
Ligaments are strong, fibrous tissues that connect bones to other bones throughout the body. Numerous ligaments in the ankle help to keep the bones in proper position and stabilize the joint. Joint stability is important for all types of activities, including standing, walking, and running.
- Around 90% of ankle sprains involve an inversion injury (the foot turns inward) to the anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments — the lateral ligaments on the outside of the ankle.
- The less common medial ankle sprain is caused by an eversion injury (the foot turns out) to the deltoid ligament on the inside of the ankle.
Sprains can range from tiny tears in the fibers that make up the ligament to complete tears.
If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. Over time, this instability can result in damage to the bones and cartilage, the smooth lining of the joint.
What are the symptoms of an ankle sprain?
The types and severity of symptoms for a sprained ankle vary widely depending on the degree of the injury. Symptoms may include:
- Pain, both at rest and with weightbearing or activity
- Swelling
- Bruising
- Tenderness to touch
- Instability of the ankle, or feeling that your ankle is giving out
Symptoms of a severe sprain are similar to those of an ankle fracture (broken bone) and warrant X-Ray evaluation.
Do I need imaging?
An ankle sprain is largely a clinical diagnosis based on how the injury happened, symptoms, and examination by a medical professional. Occasionally, imaging studies, such as X-rays and magnetic resonance imaging (MRI) scans, are obtained to rule out a fracture or other injury to the nearby tendons and cartilage.
X-rays. X-rays provide images of dense structures, such as bone. Depending on your symptoms and examination, your doctor may order X-rays to evaluate the bones in your ankle and foot. Severe ankle sprains can have a similar degree of pain, bruising, and swelling as a fracture, making it difficult to distinguish between the two.
Stress X-rays. In addition to plain X-rays, your doctor may also order stress X-rays. These images are taken while the ankle is being pushed in different directions in a controlled manner. Stress X-rays help to show whether the ankle is unstable because of injured ligaments.
Magnetic resonance imaging (MRI) scan. An MRI scan is not required to diagnose ankle sprains. Your doctor may obtain an MRI:
- To evaluate other structures, such as cartilage and tendons, around the ankle
- If you exhibit signs of a high ankle sprain — an injury to the ligaments and structures connecting the bones of the lower leg (tibia and fibula)
- If your symptoms persist beyond 6 to 8 weeks after the injury despite conservative treatment
How do I treat an ankle sprain?
Nonsurgical Treatment
Nearly all isolated low ankle sprains can be treated without surgery. Even a complete ligament tear (Grade 3) will heal without surgical repair if it is immobilized and rehabilitated appropriately.
A three-phase program guides treatment for all ankle sprains — from mild to severe:
Phase 1
- Includes a short period of immobilization, rest, and ice to reduce the swelling.
- Early weight bearing as tolerated is typically recommended during this phase.
- For a Grade 2 sprain, a removable plastic device, such as a walking boot or aircast brace, can provide support.
- Grade 3 sprains may require a short leg cast or cast-brace for 10 to 14 days.
- In most cases, swelling and pain will last 2 to 3 days. Walking may be difficult during this time, and your doctor may recommend that you use crutches as needed.
Phase 2
- Is typically initiated early and includes functional rehabilitation that focuses on:
- Range of motion exercises
- Isometric strengthening
- Proprioception (balance) retraining exercises
- It is important to discontinue ankle immobilization during this phase to avoid stiffness.
Phase 3
- Includes advancement of strengthening and proprioception exercises and the gradual return to pre-injury activities. This begins with activities that do not require turning or twisting the ankle, followed later by activities that require sharp, sudden turns (cutting activities), such as tennis, basketball, or football.
- Early return to sporting and work activities may require ankle taping or bracing.
This three-phase treatment program may take just 2 weeks to complete for minor sprains, or up to 6 to 12 weeks for more severe injuries.
The RICE protocol. Follow the RICE protocol as soon as possible after your injury:
- Rest your ankle by not walking on it or returning to sport.
- Ice should be immediately applied to keep the swelling down. It can be used for 20 to 30 minutes, 3 or 4 times daily. Do not apply ice directly to your skin.
- Compression dressings, bandages, or ace-wraps will immobilize and support your injured ankle. The compression may also help with swelling.
- Elevate your ankle above the level of your heart as often as possible during the first 48 hours. Elevation also helps control the swelling.
Physical therapy. Rehabilitation exercises during phase 2 and 3 of recovery are used to improve flexibility, strength, and proprioception (balance).
- Early motion. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
- Strengthening exercises. Once the swelling and pain have improved, exercises to strengthen the dynamic stabilizers (muscles and tendons) in the front and back of your leg and ankle will be added to your treatment plan. Water exercises may be used if weightbearing strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
- Proprioception (balance) training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
- Endurance and agility exercises. Once you are pain-free, other exercises, such as agility drills, may be added gradually. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.
Surgical treatment for ankle sprains is rare.
- Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability and pain after months of rehabilitation and nonsurgical treatment.
- Surgery may also be indicated for some high ankle sprains with instability of the ankle syndesmosis.
- Sometimes surgery is recommended if a severe ankle sprain is associated with additional injuries, such as an ankle cartilage injury or tendon rupture.
Achilles Tendinitis
What is Achilles Tendinitis?
Achilles tendinitis is a common condition that occurs when the large tendon that runs down the back of the lower leg becomes irritated and inflamed.
The Achilles tendon is the largest tendon in the body. It connects the calf muscles to the heel bone and is used when you walk, run, climb stairs, jump, and stand on your tip toes. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse.
Simply defined, tendinitis (also spelled "tendonitis") is acute inflammation of a tendon. Inflammation is the body's natural response to injury and often causes swelling, pain, or irritation. You may also come across the term "tendinopathy," which is used to describe a condition in which the tendon develops microscopic degeneration as a result of chronic damage over time. Tendinitis, tendinosis, and tendinopathy are all common terms which essentially refer to the same problem.
Noninsertional Achilles Tendinitis
In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon (above where it attaches to the heel) are affected. Over time, the fibers may begin to break down and develop tiny tears. This can lead to tendon swelling and thickening. Noninsertional tendinitis more commonly affects younger, active people, especially runners.
Insertional Achilles tendinitis
Insertional Achilles tendinitis involves the lower portion of the tendon, where it attaches (inserts) to the heel bone (also known as the calcaneus).
In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may calcify (harden) over time. Bone spurs often form on the heel with insertional Achilles tendinitis.
Insertional Achilles tendinitis can occur at any time or activity level, although it is still most common in runners. It is frequently caused by calf muscle tightness, which places increased stress on the Achilles tendon insertion.
Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too quickly. Other factors can also make a person more likely to develop Achilles tendinitis, including:
- A sudden increase in the amount or intensity of exercise activity. For example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance may cause irritation and inflammation.
- Tight calf muscles. Calf muscle tightness puts extra stress on the Achilles tendon, especially where it inserts into the heel bone.
- Haglund's deformity. This is a condition in which there is enlargement of the bone on the back of the heel. This can rub on the Achilles tendon and cause inflammation and pain.
Common symptoms of Achilles tendinitis include:
- Pain and stiffness along the Achilles tendon in the morning
- Pain along the tendon or back of the heel that worsens with activity
- Severe pain the day after exercising
- Thickening of the tendon
- Bone spur formation (insertional tendinitis)
- Swelling that is present all the time and gets worse throughout the day or with activity
- Pain on the back of the heal when you wear shoes
If you have experienced a sudden pop in the back of your calf or heel, you may have torn your Achilles tendon.
Do I need imaging?
X-rays provide clear images of bones. They can show bone spurs on the back of the heel, which may be present in patients with insertional Achilles tendinitis. In cases of severe noninsertional Achilles tendinitis, X-rays may show calcification in the middle portion of the tendon.
Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery if nonsurgical treatment is not effective. An MRI scan can show the severity of the damage in the tendon. If surgery is needed, an MRI is helpful to determine the extent of tendon damage.
Do I need surgery?
The mainstays of nonsurgical treatment include anti-inflammatory pain medications, activity modification, shoe wear modification, and physical therapy exercises.
Surgery for Achilles tendinitis should be considered only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon.
Achilles Rupture
The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump.
Although the Achilles tendon can withstand great stresses from running and jumping, it is vulnerable to injury. A rupture of the tendon is a tearing and separation of the tendon fibers so that the tendon can no longer perform its normal function.
Do I need surgery?
Treatment for a ruptured Achilles tendon often depends on your age, activity level and the severity of your injury. In general, younger and more active people, particularly athletes, tend to choose surgery to repair a completely ruptured Achilles tendon, while older people are more likely to opt for nonsurgical treatment.
Nonsurgical treatment
This approach typically involves:
- Resting the tendon by using a boot with a heel wedge
- Applying ice to the area
- Taking over-the-counter pain relievers
- Nonoperative treatment avoids the risks associated with surgery, such as infection.
However, a nonsurgical approach might increase your chances of re-rupture and recovery can take longer, although recent studies indicate favorable outcomes in people treated nonsurgically if they start rehabilitation with weight bearing early.
Surgery
The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together. Depending on the condition of the torn tissue, the repair might be reinforced with other tendons (grafting). A comprehensive rehab program is then prescribed to ensure optimal recovery and return to activity.
Post op sleeping splint - this splint was recommended by one of our patients and has been useful our patients moving forward!
Ankle Mobility
My favorite blog on ankle mobility by @Evolution PT - learn how ankle mobility influences your squats, lunges and overall function - as well as how to improve your ankle mobility.
