S & MT, SUMMER 1998
Ankle injuries have long been the dread of all athletes and sports professionals. One tumble could mean being out of action for more than 3 months, and sometimes even the end of a career. An estimated 1 in 10,000 people sustain an ankle injury each day, and some 5% do not fully recover. The typical sorts of ankle injuries that are commonly experienced fall into two categories: acute sprains or overuse injuries.
Acute injuries
Actions such as pivoting on the ankle can create extreme pressure on the ligaments, leading to tearing or disruption of the ankle’s outer ligament complex. The effects are immediate bleeding and swelling around the outer border of the ankle and difficulty in bearing weight. It is important to take quick action. In these cases conservative treatment is best. This includes:
Immediate rest
Ice compression
Elevation
Physiotherapy
Some specialists prefer a two to three week period immobilising the injured ankle in a walking plaster cast to reduce chronic instability and further problems. In either event, after six to twelve weeks, around 95% of these injuries go on to make a full recovery.
Overuse injuries
During any game of sport, the ankle is subjected to enormous pressure. Over time, a variety of injuries can occur. When repetitive minor injuries occur to the achilles tendon, swelling, inflammation and partial tears to the collagen fibres are produced. This condition, known as chronic achilles tendonitis is very difficult to cure. Such injuries are fairly common in the professional sporting arena. Treatment often involves long periods of rest, physiotherapy, the use of ultrasound and the modification of footwear.
In mildly arthritic or worn ankle joints, small pieces of bone may break off. This can present with pain, swelling, locking and a sensation of instability and occasionally the joint can give way.
Other overuse injuries to the ankle include the generation of bony spurs on the front of the ankle. This causes pinching within the ankle during running, particularly during the ‘heel-off phase of the running cycle.
For those who have injured themselves whilst playing sport, it is best to stop playing immediately as continuing can further aggravate the injury. As a rule, it is generally unwise to run through pain in the ankle or achilles. Pain is, after all, the body’s way of telling us that something is wrong. Similarly, if joints are regularly locking, clicking or giving way, this is an indication that something may be amiss. What must be taken into account is that during exercise the body secretes its own morphine-like substances which can mask the pain arising from a damaged joint, muscle or tendon. Such parts of the body normally issue signals of pain because there is an underlying problem. Athletes ignoring such symptoms are more likely to develop further problems later in their careers. Resting, applying ice and some compression to the injured ankle whilst elevating it will ensure that no further immediate damage is done.
If, after a course of physiotherapy, symptoms fail to settle down after the usual six to twelve week healing period, sports professionals who continue to get pain, swelling, clicking or locking in their ankle after this period should seek referral to a specialist for treatment. X-rays and magnetic scans of the ankle are taken to access the joint and detect conditions such as residual ligament instability, the presence of bony spurs forming at the front of the ankle joint, loose bodies or scar tissue.
Until five to ten years ago surgery was a lengthy and painful ordeal. Surgery required the patient to stay in hospital, certainly overnight and more usually for two or three days. In order to access the joint, the surgeon had to make a fairly large incision, which, combined with the effects of the general anaesthetic added to the recuperation period. Furthermore, the patient left hospital on crutches, often in plaster, with a sizeable scar. In practice, very few ankle injuries could be treated and the results of
surgery were often unsatisfactory. The joint was just too small for the instruments available and for surgeons to see inside the joint.
The future of ankle surgery
Technological developments have led to ankle arthroscopy or keyhole surgery, which has transformed the treatment of ankle injuries. Two or three tiny holes are made around the ankle, into which 2mm wide fibre-optic scopes are fed. Surgeons are able to carry out the intricate range of repairs and procedures whilst watching the operation onscreen. This type of surgery can usually be undertaken as a daycase procedure. Patients typically experience very little post-operative pain and are able to walk out of hospital with no difficulty.
Results are better, there is less discomfort involved, shorter hospital stays, lower complication rates and shorter recovery times. The cosmetic results are better
too n very often just a couple of tiny scars that are barely visible or quickly fade. Rest and elevation of the limb is prescribed for the first 48 hours, followed by a supervised physiotherapy programme.
Ankle arthroscopy has revolutionised the work of the orthopaedic surgeon, both in diagnostic techniques and in surgery. Both standard x-rays and magnetic scans miss problems in the ankle, particularly where the damage is to the soft tissue. Arthroscopy as a diagnostic tool is virtually 100% accurate, enabling exactly the right treatment to be administered. The success rate of the treatment is also high. For example, the pain of soft tissue lesions can be alleviated in 84% of case whilst arthroscopic ankle fusions carry a 95% fusion rate. Sprains, fractures, torn ligaments, rheumatoid arthritis, degenerative disease, loose bodies and bone spurs can all be treated by this method.
ArthroWand
Developments in technology have meant that surgical instruments used in arthroscopy are becoming smaller and smaller. One of the latest weapons in the surgeon’s armoury is the ArthroWand used for the process of `coblation’. Coblation, derived from cool ablation, is a new technique for removing damaged soft tissue, rapidly and precisely with minimal damage to surrounding tissue. The process uses radiofrequency energy to remove the tissue through a significantly cooler process than is possible with traditional electrosurgery. The method disintegrates tissue layer by layer, giving the surgeon excellent control to remove tissue whilst leaving the healthy tissue intact.
Before the coblation wand, options available to surgeons included traditional electrosurgi-cal tools and lasers. These work by a heat-driven process that can produce thermal damage in tissue surrounding the area of surgery. The coblation wand applies radiofrequency energy to convert the fluid found in the gap between the wand and the tissue into an ionised vapour layer called plasma. Charged particles accelerate through the plasma and gain sufficient energy to break the molecular bonds within cells. This literally causes the cells to disintegrate molecule by molecule, so that tissue is removed. As this effect is confined to the surface layer of target tissue, and at lower temperatures, thermal damage to the surrounding tissue is minimised. As a result, the coblation wand improves operative precision and efficiency for the surgeon. The patient enjoys reduced postoperative pain, less bleeding, reduced surgical time and a speedier recovery.
Case study
S. is a keen runner who in his younger days played a lot of rugby and football. About five years ago, he noticed that his ankle had started to give way, particularly when he was bending his knee over his left foot. He visited a sports physiotherapist who prescribed a short course of physiotherapy. The pain continued to worsen and S. was referred for further specialist investigation.
An X-ray revealed “Footballers ankle” also known as a tibial spur. The operation took place on Friday to remove the spur and on Saturday, Steven went home with just two small stitches on either side of his ankle. By Monday, he was back at work. Just one week later, the stitches were removed and he had some physiotherapy to work the joint and muscles. Not long afterwards, he started running again.
W., a professional dancer, also depends on his ankle for his profession. He was appearing in a musical show and was coming off stage when he fell down some stairs. iI heard what I can only describe as a`pop’ and my ankle literally gave way underneath me,i he recalled. He immediately went to hospital and was put in plaster for three days. Rest and physiotherapy were prescribed and he was told all would be well within six weeks.
Nine weeks later, with the ankle still swollen and painful, S. returned to work. iIt was agony and really I was only operating at about 40 per cent. I honestly thought I might be finished as a dancer,i he said. After an initial consultation, S. underwent an ankle arthroscopy to remove a spur and meniscoid band. He had the operation, stayed in overnight, and then left hospital wearing a crepe bandage. He was allowed to return to work two weeks later.
Take preventative measures
However good today’s technology has become, it should not be used as a substitute for careful history taking, examination and investigation. Prevention is always better than cure and for those who lead an active life or are involved in regular sport, joint flexibility and regular stretching programmes are key. Stretching calf muscles, hamstrings and quads is the main route to preventing foot and ankle problems. The muscles act as shock absorbers for the skeletal system. Short, tight muscles have less shock absorbing capacity. This means that athletes with these types of muscles pass more of the force of their activities on to the joints. This increases the forces going through the joints or tendons, making them more liable to injury.
Good footwear is another means of avoiding injury. Well fitting shoes with a shock absorbing system built in will
help. Beware, however, such shoes lose their shock absorbing capacity after about three months of use. Sorbathane rubber insoles may extend the life a little.
Ankle arthroscopy is gradually becoming a very important tool in the sporting world, and is helping to extend the professional careers of some athletes and sports professionals.
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