Ankle injuries
Achilles tendon
The strongest tendon in the human body is the Achilles tendon, which can support a weight of 400 kg. The proximal end of the tendon begins at the junction of the biceps and triceps muscles of the lower leg, the so-called cambal muscle. The distal end of the tendon attaches to the tubercle on the posterior surface of the heel bone.
The figure shows an image of the Achilles tendon
Tendinitis (inflammation) of the heel tendon and its rupture, are the most common pathologies that occur in people involved in sports.
The figure shows the Achilles tendon disease
Heel tendonitis (inflammation) is a traumatic injury characterized by inflammation of the tissue around the heel tendon, pain and swelling in the heel tendon area, and limited range of motion. This condition can mainly develop during running long distances at high speed. Depending on the duration of symptoms, tendonitis is divided into acute (less than 2 weeks), subacute (2-6 weeks), prolonged (6 weeks to 6 months) and chronic (more than 6 months). The main symptoms of heel tendonitis are pain and swelling in the heel tendon area, pain increase during bending and extending the lower leg muscles, local increase of sensitivity during palpation of the heel tendon.
Methods of treatment
One of the main methods of treatment is for the patient to avoid sports that can cause symptoms. Performing exercises to contract the triceps and heel tendon, and wearing an orthosis can have a positive effect during treatment. Subcutaneous injection of low molecular weight heparin for three days has an excellent effect in treatment of acute tendonitis. The patient should be warned about possible bruising of the body. Patients who have problems with blood clotting are contraindicated in heparin administration. Since heparin therapy requires the patient to have several appointments with the doctor, in addition to the increased risk of bleeding when administered, this type of therapy can only be used when the athlete needs to recover in a short time due to competition.
If symptoms are detected, anti-inflammatory drugs should always be recommended; however, these drugs should not be used in conjunction with heparin (paracetamol is used instead). If tendonitis becomes chronic, injections of glucocorticoids should be given. The passage of several weeks between the next injection is recommended. Because glucocorticoid injections increase the risk of dislocation, they should not be injected into the joint cavity. After a glucocorticoid injection, you must take a two-week break before exposing the patient to serious physical activity.
Heel tendon rupture – this type of injury is most common in men in the 30-50 age, when performing physical activities, especially during ball games. It can be said that when the heel tendon ruptures, there are always degenerative changes. Fluoroquinolone antibiotics, especially when used in conjunction with steroids, among patients over 60 years of age, increase the risk of tendon rupture.
Symptoms
Tendon ruptures cause short-term acute pain. The sensation of being hit on the back surface of the foot is very common and bothers the patient. In some cases, tears can be painless. If the tendon ruptures, the patient can’t stand on his or her toes. If the function of the flexors of the toes and peroneal muscles is preserved, partial flexion of the leg is possible. Swelling and hematoma are noted at the site of injury.
Diagnosis
The main tests for diagnosis are the Thompson and Copeland tests.
When performing the Thompson test, the patient lies on his abdomen, moves his leg to the edge of the couch, and the doctor squeezes the muscles of the lower leg. The test result is positive (indicating Achilles tendon rupture) if the foot does not flex.
In the Copeland test, the patient lies on their abdomen and bends the leg at the knee. The cuff of the tonometer is attached to the widest part of the tibia. The leg is in the flexed position (plantar flexion) and the pressure is raised to 100 mm Hg. If the tendon is healthy, extension of the leg (dorsiflexion = extensia) causes the pressure to rise to 140 mm Hg. If a tendon rupture occurs, the pressure does not change.
Magnetic resonance imaging (MRI) is a very informative method to determine the location of a tendon rupture.
Treatment
The main treatment for tendon ruptures is surgery. During surgery, the ends of the Achilles tendon are sutured end-to-end. After the surgery, the doctor puts a plaster cast on the ankle joint in a flexion position of the foot (plantar flexion). The plaster cast is removed after six weeks, and then physical therapy begins. After six months the patient returns to an active lifestyle.
The picture shows an image of the Achilles tendon and pictures taken during the operation
Damage to the ligaments of the ankle joint
The talotibial joint is composed of three bones – the tibia, fibula and talus – and is a complex joint. In this joint, the upper articular surface and the surface of the inner ankle connect to the tibia and the fibula interacts with the surface of the outer ankle. The ankle joint is strengthened by the inner ligament, the outer tibio-femoral ligament, and the heel-femoral ligament. Flexion and extension movements are possible in this joint. When a person stands upright, there is a 90-degree angle between the foot and the lower leg. When bending, the angle between the leg and shin increases, and when extending, it decreases. During flexion, the talus moves backward, the narrowest part passing into the widest part between the heel bone appendages, and so the foot can rotate inward and outward.
The ligaments of the outer surface of the foot are illustrated
The main cause of ankle ligament damage is when the foot rolls over. As a result of an abrupt and sudden action, the ligaments of the joint or the periarticular soft tissues can be damaged due to their contraction and sometimes rupture, which is called a joint turning over. There is a sharp, unbearable pain in the twisted joint. Swelling, redness, fever and limited range of motion can occur for several hours after the foot is turned over.
Ankle tilting occurs when the joint is out of alignment due to a sudden movement. This sudden movement strains one or more of the ligaments of the joint, and can cause a partial or complete tear. Damage to the anterior fibula ligament is the most common. Damage to the metatarsophalangeal ligament occurs in 10-20% of all ligament injuries. The posterior talus-cavicular ligament is damaged only as a result of ankle dislocation. In rare cases, the inner ligament may be damaged. There are three degrees of foot tuck depending on the degree of injury: mild, moderate, and severe.
Grade I: this degree of injury results from light ligament strain and minimal damage.
Moderate severity (Grade II): this degree of injury is characterized by a partial tear of the ligaments.
Severe severity (Grade III): this degree of injury is characterized by a complete tear of the ligament. Instability of the ankle joint can be observed during examination. Significant swelling and bruising can be seen.
The following illustration shows the extent of ligament injury
The following are the causes of ankle sprains:
- Falls that cause the foot to bend
- Excessive strain on the foot after bouncing or turning
- Playing sports and walking on bumpy terrain
Risk factors
Sports
Foot sprains are injuries that are very common in sports such as basketball, tennis, soccer, and running. This type of injury accounts for 20-30% of physical activity injuries. Half of basketball injuries and one-third of soccer injuries involve ankle ligament strain.
Uneven surfaces
Walking and running on uneven terrain can increase the risk of foot sprains.
Previous injuries
After a previous foot rollover, the risk of another ankle rollover increases.
Ankle weakness
Weakness in the ankle joint during athletic activities and increased elasticity increases the risk of foot sprains.
Inappropriate footwear
Shoes that don’t fit properly and for a certain activity, as well as high-heeled shoes can contribute to the occurrence of foot tucking.
Symptoms and diagnosis
The symptoms and clinical signs of a plantar foot turnover vary depending on the severity of the injury. Symptoms of tarsal turning include pain, sensitivity in the feet, swelling, bruising, limited range of motion, weakness in the foot area, stiffness, and discoloration of the skin.
Diagnosis
During ankle tucking, the diagnosis is established on the basis of complaints and the results of the clinical examination. During the examination, a thorough examination of the shin, foot and heel is performed. The doctor checks the sensory points and the amount of movement. In order to understand in which position the patient experiences discomfort and pain, the doctor asks the patient to make leg movements.
If the injury is severe, certain examinations are recommended in order to rule out possible bone fractures or to determine more accurately the extent of ligamentous apparatus damage.
X-rays: X-rays of the ankle joint allow the presence/absence of a fracture in this area to be determined. For this purpose, the patient is exposed to low-dose radiation.
Magnetic resonance imaging (MRI): Thanks to this imaging technique, all soft tissues in the ankle area, including ligaments, can be evaluated.
Computed tomography (CT): This method of examination provides additional information about the bones that make up the joint. A CT scan allows images to be taken from different angles using X-rays. It combines them in order to obtain a three-dimensional image.
Ultrasound: This study uses ultrasound waves. This examination helps assess the condition of the ligaments and tendons in different positions.
Methods of treatment
Treatment of ankle sprains is planned depending on the severity of the injury. The goals of treatment are to reduce pain and swelling, accelerate healing of the injured ligament, and restore function to the foot. The RICE protocol is used to treat ankle sprains (especially if the injury is mild).
R…Rest – With this point of treatment, orthotics are used and it is recommended to not put stress on the leg. Activities that contribute to pain, discomfort and swelling in the foot area are stopped.
I…Ice – this treatment involves applying an ice bandage several times a day, held for 20 minutes. However, caution should be exercised when bandaging patients with vascular atherosclerosis, diabetes mellitus or decreased sensitivity in the feet.
C.. Compression – This treatment involves the use of elastic bandages or special bandages for the foot. In order to prevent an impairment of blood flow, the bandages must not be applied too tightly. In the case of serious complaints, in order to speed up the recovery, the ankle joint should be stabilized completely, by applying a plaster cast like a bandage to prevent any movement.
E.. Elevation – With this point of treatment, the foot should be elevated and kept at heart level to reduce swelling.
Pain medications such as ibuprofen, naproxen and acetaminophen may be sufficient during treatment. When the size of the swelling and the degree of pain are reduced to a level where the patient can move, exercise and physical therapy are recommended in order to restore the foot’s strength, stability, and elasticity. If the ligament damage is not cured and stability and joint stability are not restored, in some cases surgical treatment is required.
Treating ankle sprains the wrong way, repeated sprains, or returning to sports activities immediately after the injury can cause many complications. The most common complications of foot-reversals include chronic foot pain, chronic instability in the ankle joint, and osteoarthritis.
In order to reduce the risk of repeated foot tilts, you should: warm up before performing athletic movements; be very careful when walking or running on uneven terrain; use an elastic bandage for the previously injured ankle joint; wear shoes that fit the movements being performed; avoid wearing high-heeled shoes.
