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Sprained Ankle

If a sprained ankle is left untreated, if you engage in activities too soon after spraining your ankle or if you sprain your ankle repeatedly, you may experience the following complications:

  • Chronic pain
  • Chronic ankle joint instability
  • Early-onset arthritis in that joint

During the physical exam, your doctor will check for points of tenderness. He or she will move the joint in a variety of ways to check your range of motion and to see if any particular position or movement causes pain.

If the injury is severe, your doctor may recommend one or more of the following imaging scans to rule out a broken bone or to more precisely evaluate the soft tissue damage:

  • X-ray. During an X-ray, a small amount of radiation passes through your body to produce images of your internal structures. This test is good for evaluating bones, but is less effective at visualizing soft tissues. Tiny cracks or stress fractures in bones may not show up, especially at first, on regular X-rays.
  • Bone scan. For a bone scan, a technician will inject a small amount of radioactive material into an intravenous line. The radioactive material is attracted to your bones, especially the parts of your bones that have been damaged. Damaged areas show up as bright spots on an image taken by a scanner. Bone scans are good at detecting stress fractures.
  • Computerized tomography (CT). CT scans are useful because they can reveal more detail about the bones of the joint. CT scans take X-rays from many different angles and combine them to make cross-sectional images of internal structures of your body.
  • Magnetic resonance imaging (MRI). MRIs use radio waves and a strong magnetic field to produce detailed images of internal structures. This technology is exceptionally good at visualizing soft tissue injuries.

Treatment for a sprained ankle depends on the severity of your injury. Many people simply treat their injury at home.

Medications
In most cases, over-the-counter pain relievers — such as ibuprofen are enough to handle the pain caused by a sprained ankle.

Therapy
A few days after your injury, after the swelling has gone down, you may want to see a physical therapist and start performing exercises to restore your ankle’s range of motion, strength, flexibility and balance.

Balance and stability training is especially important to retrain the ankle muscles to work together to support the joint. These exercises may involve various degrees of balance challenge, such as standing on one leg.

If you sprained your ankle while exercising or participating in a sport, talk to your doctor about when you can begin your activity again. You may need to wear an ankle brace or wrap your ankle to protect it from re-injury.

Surgical and other procedures
If your ankle joint is unstable, your doctor may refer you to a joint specialist for evaluation. You may need a cast or walking boot to immobilize your joint so that it can heal properly. In rare cases of severe ligament tears, or if you are an elite athlete, you may need surgery to repair the damage.

For immediate self-care of an ankle sprain, try the R.I.C.E. approach:

  • Rest. Avoid activities that cause pain, swelling or discomfort. But don’t avoid all physical activity. Instead, give yourself relative rest. With an ankle sprain, you can usually still exercise other muscles to prevent deconditioning. For example, you could use an exercise bicycle, working both your arms and the uninjured leg while resting the injured ankle on a footrest. That way you still exercise three limbs and keep up your cardiovascular conditioning.
  • Ice. Even if you’re seeking medical help, ice the area immediately. Use an ice pack or slush bath for 15 to 20 minutes and repeat every two to three hours while you’re awake, for the first 48 to 72 hours. Cold reduces pain, swelling and inflammation in injured muscles, joints and connective tissues. It also may slow bleeding if a tear has occurred. If the area turns white, stop treatment immediately. This could indicate a cold injury. If you have vascular disease, diabetes or decreased sensation, talk with your doctor before applying ice.
  • Compression. To help stop swelling, compress the ankle with an elastic bandage until the swelling stops. Don’t wrap it too tightly or you may hinder circulation. Begin wrapping at the end farthest from your heart. Loosen the wrap if the pain increases, if the area becomes numb or if swelling occurs below the wrapped area.
  • Elevation. To reduce swelling, elevate your ankle above the level of your heart, especially at night. Gravity helps reduce swelling by draining excess fluid.

Prevention

Take the following steps to help prevent a sprained ankle:

  • Warm up before you exercise or play sports.
  • Be careful when walking, running or working on an uneven surface.
  • Wear shoes that fit well and are made for your activity.
  • Don’t wear high-heeled shoes.
  • Don’t play sports or participate in activities for which you are not conditioned.
  • Maintain good muscle strength and flexibility.
  • Practice stability training, including balance exercises.

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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 Rupture

The Achilles tendon is the largest and strongest tendon in the human body.  It is crucial in transmitting forces responsible for walking, running and various other activities.  An injury or tear within the Achilles tendon can cause substantial pain and limitation due to its importance in these daily activities.

Anatomy:

The Achilles tendon is made up of the tendons of the gastrocnemius muscle and soleus muscle, which make up the largest muscles within the calf.  It inserts at the back of the calcaneus (heel bone) and many of the tendon fibers can extend further underneath the heel.  Tears of the Achilles tendon can be partial tears, which only involve a portion of the tendon or complete tears.   Most often a tear occurs in the mid-portion of the tendon, often referred to as the “water shed” area due to its limited blood supply.   It is the limited blood supply that can make Achilles tendon tears challenging and can take an extended length of time to heal.

Etiology:

Tears of the tendon are often a result of indirect trauma.  Overload forces exceed the tensile strength of the tendon which results in tearing of the tendon fibers.  Complete ruptures most often occur in individuals between 30 and 45 years of age with the majority of injuries sustained during sporting activities.  Tendon tears are can also in patients with systemic diseases such as rheumatoid arthritis, lupus, chronic hemodialysis and many others.  Other factors correlated with potential Achilles tendon tears are steroid use, fluoroquinolone antibiotics and previous injury to the tendon.

Symptoms of Torn Achilles Tendon:

  • Pain
  • Swelling
  • Bruising
  • Loss of strength
  • Palpable gap in tendon

Diagnosis:

  • The most crucial step to diagnosis of Achilles tendon tears is a thorough and detailed physical examination.   Patients may not experience complete loss of strength in many instances.  Because of this and the swelling in the area, up to 20% may be missed on initial presentation.  A delay in treatment can have long lasting effects on the overall outcome and thus emphasizes the importance of being evaluated by a foot and ankle physician in a timely manner.
  • Radiographs may be taken to rule out other associated injuries.  To fully evaluate the extent of Achilles tendon injury, an ultrasound, or more often, an MRI will be performed.   This allows the physician to visualize the extent of tendon injury and determine the best treatment plan.

Treatment:

  • Treatment will vary depending on the extent of tendon tear, duration the tear has been present, and the patient.  An acute, complete rupture of the tendon requires surgical intervention.  This is typically done by re-approximating the torn ends of the tendon to allow for appropriate healing.  For the best function results, the repair should occur within one week in order to avoid retraction of the tendon ends.  Unless the patient is relatively sedentary, cast immobilization as the primary treatment of an Achilles tendon rupture should be avoided due to the increased risk of re-rupture, decreased strength and sub-optimal functional results
  •  Achilles tendon tears that are not treated for longer than 4 weeks are considered chronic.  Because of the delay in treatment, the tendon ends are become retracted and cannot be repair like an acute rupture.   Chronic Achilles tendon ruptures are typically repaired surgically and involve more extensive tendon transfers, flaps or grafts.  After surgical intervention, patients are immobilized in a cast for 2-3 weeks, followed by a transition to a walking boot.    It is essential to try to begin strengthening of the tendon as quickly as possible to avoid weakening.  This needs to be done carefully by trained physical therapist who understand the recovery protocol of Achilles ruptures.

Read more about Achilles Tendon Pain

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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