A proportion of patients will fail to return to full function after a severe ankle sprain and this may be simply that they have failed to rehabilitate the ankle adequately and the first line of treatment will invariably be to see an expert physiotherapist. Occasionally, however, there is a structural problem which will need addressing.
The Other Side of the Story
The first bone of the foot, called the talus, is a dome shaped bone which is held on three sides, inner, top and outer, by the tibia and fibula. The tibia forms two sides of this arch and the fibula the third. When the ankle sprains, the talus tilts in this ankle “mortise”, the ligaments on the outer side usually tear, but sometimes instead of this happening one of the bones breaks. This very commonly needs an operation as the ankle is so perfectly designed that it needs to be put back into exactly the position nature intended position usually with screws and plates. This is obviously an emergency and is usually done by the trauma team straight away.
A problem which is often initially missed however is an injury to the surface of the talus which, as it tilts in the three sided mortise, knocks a chunk off the corner. This either leaves a divot in the articular surface but will also sometimes leave a chunk of gristle or bone floating around in the joint which can cause trouble later. This can invariably be dealt with through the keyhole (arthroscopy) and the chunk removed. The treatment of the defect left behind is along the same lines as any articular surface defect, which I have described on the section on the knee.
Apart from acute sprains or fractures such as this the commonest problem we see, particularly in professional footballers, is of a “footballer’s ankle”. This is a spur formed on the front of the shin bone which often pinches on the front of the foot when the toes are brought up towards the knee creating what id known as a “kissing lesion”. This gives a vague ache around the front of the ankle. We think this is caused by repetitive blows from the football on the front of the ankle, but we do not really know since it does occur in athletes who do not play football at all. It is certainly not associated with degenerative changes in the surface of the joint as spurs elsewhere in the body are, and we normally see the bearing surface of the joint looks absolutely perfect when we look inside the joint with an arthroscope. This condition is one which we really like to see as it is a relatively minor problem which can be dealt with in the closed season very reliably with a key hole operation.
The same thing can occur at the back of the ankle - this is especially common in ballet dancers, but is also seen in football and rugby. This is often associated with a congenital variant of the bones at the back of the ankle known as an “os trigonum”. If this condition fails to settle with rest and physiotherapy, then surgery (usually now keyhole) may be required to remove the extra piece of bone.
Just occasionally the torn ligaments will fail to heal properly and a small proportion of individuals will need surgery to tighten up the ligaments. This is a routine procedure and is now usually best done without rerouting the tendons around the ankle as used to be done. It is almost invariably possible simply to tighten up the ligaments. If this is not the case then in my opinion the ligament is best replaced with a tendon from elsewhere, rather than weakening the ankle further, and usually one of the tendons we use to reconstruct the anterior cruciate ligament from around the knee.
The other problems commonly seen around the ankle are tendon problems, either in the peroneal tendons around the back on the outer side or the tendons on the inner side or most commonly of all the Achilles tendon itself.