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Ankle Instability and Ankle Sprains

The ankle works in a systematic way. Movement is only supposed to be in one plane, in other words, up and down. We call this dorsiflexion and plantarflexion. The ankle joint is held in place securely by a group of bones that house the main anklebone (called the talus) inside a box-like effect. On the inside is the medial malleolus and on the outside the fibula.

Front of the ankle.
M= medial malleolus, L=lateral malleolus (fibula). The outside of the heel is pushed inwards to stress the joint. In the normal ankle, no tilting of the ankle should occur at all. Note the tilting of the talus in the ankle.

The inward and outward movements of the back of the foot do not actually occur in the ankle joint but occur in the joint underneath it called the subtalar joint. The muscle that pulls the foot inward (inversion) is slightly stronger than the muscles that pull the foot outward (eversion). When the foot lands in an awkward manner there is a tendency for the heel to roll inwards and create stress on the outside ligaments. If this stress is severe then a sprain of the ankle occurs. A sprain is actually a tear that occurs in the outer supportive ligaments of the ankle. As these ligaments are stretched, a critical point is reached beyond which ligaments do not return to their normal elastic function and a tear of the ligament occurs. Sprains can range from the relatively minor to those where the ligaments are completely torn and the ankle can be quite loose.

The acute sprain of the ankle is commonly associated with marked swelling and bruising on the outer side of the ankle. Rest of the ankle with immobilization of some sort is critical. The classic treatment for a sprain of the ankle is what we refer to as the Rice Program. It involves rest, ice, compression and elevation. This treatment is designed to decrease the inflammation and swelling of the ankle associated with the sprain. The Rice Program by itself will not heal the ligaments. In order for the ligaments to heal the ankle needs to be immobilized with either a cast or a boot. For minor sprains a brace can be applied to the ankle. Walking is permitted during this recovery process, allowing the ankle ligaments to heal.

Following this period of initial immobilization, strengthening exercises are essential to regain the balance of the ankle. It is critical that the tendons and muscles on the outside of the ankle (the peroneal tendons) are strengthened. This should be done initially in a supervised exercise program. If the ligaments have been severely torn, the ability to fine tune the ankle and prevent further sprains from occurring depends on the strength of the peroneal muscles. As the ankle turns repeatedly, the peroneal muscles weaken further. This weakens the ability to prevent recurring sprains. Patients with a high arch or a heel that is naturally turned in slightly are predisposed to sprains.

As a result of continued rolling, turning or instability of the ankle, the ability to fine tune the foot on uneven surfaces becomes limited. The ability to make rapid changes in the position of the foot on the ground surface is called proprioception. If this ability is diminished, the likelihood of a more severe ankle sprain occurring is increased. In recurring ankle sprains we call this chronic recurrent instability of the ankle. The ankle is at risk of developing other problems. These include bruising of the cartilage of the talus and bone spurs that develop around the front and sides of the ankle. These are all precursors of ultimate arthritis of the ankle.

These pictures illustrate a patient with chronic ankle instability. Note how loose the ankle is when it is turned slightly inwards. The ligaments are completely torn in this ankle and the likelihood of recurring sprains is very high.

The diagnosis of chronic recurrent instability is made through a careful examination of the ankle and X-rays that are taken while stress is applied to the ankle.

Here are two X-ray’s of a patient with chronic recurrent instability of the ankle. In both the right and the left ankle, an assistant is pushing on the outside of the foot (in the direction of the white arrow) while the XR is taken. The XR on the left is normal, while the one on the right demonstrates a loose (unstable) ankle.

Once the diagnosis of the extent and severity of the ankle instability is made then a treatment plan can be initiated. A strengthening program is helpful before proceeding with surgery. This is true even with patients who have had recurring sprains and chronic recurrent instability.

Fortunately, surgical repair of the chronically loose ankle ligaments can be performed. There are many different techniques used to stabilize the ankle. Some rely upon repairing the ligaments themselves by tightening them up. Others depend more on using a tendon behind the ankle (the peroneal tendon) or a tendon graft to tighten up the ankle completely. These operations are usually very successful. Individuals are able to return to all forms of athletic activity without risk of recurrent injury to the ankle.

Read more about Ankle Sprain

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Achilles Tendon Pain

Achilles tendon pain occurs when there is an irritation or an inflammation of the Achilles tendon. The Achilles tendon joins the heel of the foot to the calve muscles. It is the largest tendon in the body, and is thick enough to support the entire body weight. Any rupture (small or big), inflammation, or injury to it causes pain while walking or running, as the tendon has to bear nearly eight times an individual’s body weight during a sprint or a run.

Causes of Achilles Tendon Pain
There are numerous reasons why Achilles tendon can inflame. A common cause is the advancing age, where it becomes less flexible, and more susceptible to injury. It can also be caused due to excessive shearing and stretching forces placed on the Achilles tendon, resulting in inflammation and tightening of the calf muscles.

Footwear contributes heavily to tendon irritation. Ill fitting shoes or high heels force the feet to be confined in less space, shortening the Achilles tendon, leading to an increased tension to the Achilles tendon. Shoes that have excessive heel cushioning for greater shock absorption, stretch the tendon, as absorption of shock sinks the shoe more frequently when the heel makes contact with the ground. Mechanical abnormalities and misalignment such as misshapen foot or heel bones, unequal leg length, short or tight Achilles tendons or calf muscles, weak calf muscles, all lead to placing excessive stress on the tendon, making it prone to injuries and pain. Athletes who increase their training duration with more powerful movements during exercises also experience Achilles tendonitis.

Symptoms of Achilles Tendon Pain
The most common symptoms associated with Achilles tendon is the searing heel pain experienced over the back of the heel. This occurs because the tendon gets pushed on the heel bone. It causes tenderness around the tendon and in some extreme cases there is an occurrence of a localized nodule filled with a small sack of fluid on the tendon. For most people suffering with Achilles tendon pain, walking during early mornings, or a long period of inactivity is the most painful time. A sudden sprint, or a jumping activity also results in a lot of pain. A slight swelling around the heels and sometimes around the calf muscles are also an exhibited symptom of Achilles tendon pain.

Prevention and Treatment of Achilles Tendon Pain
Preventing the condition of the Achilles tendon pain is simple. Avoiding any activity that places stress on the tendon is the simplest preventive measure. Treatment includes therapy as well as medications. A therapeutic approach includes rest and immobilization. Together, it will help reduce the swelling and inflammation on the tendon. To reduce swelling and increase the flow of blood around the tendon, one can apply an ice pack several times a day. Avoid giving heat treatment, and wearing thick warm socks (unless medically recommended). Heel relaxing products such as arch supports, heel cups, etc. inserted into the shoes, are used to minimize the stress on the Achilles tendon. Many physical therapists recommend stretching and rehabilitation program to increase the flexibility of the Achilles tendon. Medications mostly include non-steroidal anti-inflammatory medications along with painkillers, or in severe cases cortisone injections are administered.

Achilles tendon pain is a very painful condition, which can hamper the course of a normal life. A constant painful tendon leads to rupture, and in extreme cases an individual is rendered immobile for days. Prevention can help many avert the condition of painful Achilles tendon.

Stop the Pain and get your Ankle checked today!  Call +65 6471 2744 for Appointment or Email to: info@boneclinic.com.sg