High Ankle Sprain

The “high ankle sprain” is named in distinction to the “low ankle sprain.” You may have heard the term while watching American football or other sports broadcasts. The high ankle ligaments (also called the syndesmosis) are located above the ankle, as opposed to the more commonly injured ligaments on the outside of the ankle. These high ankle ligaments connect the tibia to the fibula. It is important to have stability between the tibia and fibula at this level because walking and running place a tremendous amount of force at this junction.

A high ankle sprain, also called a syndesmotic injury, occurs when there is tearing and damage to the high ankle ligaments. These injuries are much less common than a traditional ankle sprain.

Symptoms

If there is an associated fracture around the ankle, patients typically won’t be able to bear weight on the foot/ankle and often will need surgery. If there is not an associated ankle fracture, patients may notice increased pain with activities that cause the ankle to be flexed up placing more stretch on the injured ligaments. Activities like climbing stairs are the most common as the ankle joint is loaded and the talus bone is driven upwards placing stress on the high ankle ligaments.

Causes

A high ankle sprain occurs from a twisting or rotational injury. They are common in sports, especially impact sports. An external rotation mechanism most commonly causes these tears, when the foot is turned towards the outside with respect to the leg. A high ankle sprain also can occur if the ankle is broken.

In some cases, the ligament on the inside of the ankle (the deltoid) will be torn. In this event, the energy of the injury (indicated on the diagram with blue arrows) passes from the deltoid, through the high ankle ligaments (syndesmosis), and up the leg through the fibula. This causes the fibula to be broken at a very high level. This type of fracture is called a Maisonneuve fracture. Patients with a high ankle sprain without fracture may be able to bear weight, but will have pain over the junction between the tibia and fibula just above the level of the ankle (green circle). This is higher than the more traditional sprains (purple circle).

Anatomy

As noted above, the syndesmosis or high ankle ligaments connect the tibia and fibula and allow some rotation. There are three major components of this ligament complex. Ligaments connect bone to bone which prevents bones from moving away from each other and maintains normal movement between the bones, whereas tendons connect muscle to bone, allowing them to move parts of the body.

1. The first ligament is called the anterior inferior tibiofibular ligament, or AITFL, which runs in front of the two bones.
2. The second is called the posterior inferior tibiofibular ligament, or PITFL, which runs in the back.
3. The interosseous (IO) membrane runs down the middle of these and provides a major support between the two bones.

Diagnosis

Patients who have a high ankle ligament tear usually will have pain just above the level of the ankle, thus a “high” ankle sprain. They may also have tenderness over the deltoid ligament if they have a Maisonneuve injury, as noted above. It is important to touch the area to assess whether pain is just around the lateral ankle ligaments or higher.

Your foot and ankle orthopedic surgeon may also perform two tests called the squeeze test and the external rotation test. The squeeze test is performed by squeezing the leg just below the knee to see if pain radiates to the ankle area, which would suggest a high ankle sprain. With the external rotation test, your surgeon will bend your knee and place your ankle in neutral or 90 degrees with the foot in relation to the leg, and the foot is turned to the outside. If there is pain at the ankle area, this suggests a high ankle sprain.

X-rays are very important. A broken bone must be looked for. Three views of the ankle including the whole leg are needed. A fracture on the back portion of the tibia may indicate an injury to the high ankle ligaments given that this is where the PITFL attaches. It also is important to look for increased space between the tibia and the fibula as the high ankle ligaments keep these bones in place. Special imaging may be used, such as an MRI or CT scan, to assess the relationship of the tibia with the fibula.

Treatments

The goals of treatment are to move the tibia and fibula to the correct positions with respect to each other and to heal in those positions. This allows the ankle joint to function as intended. It is very important to note that these injuries can take a lot longer to heal than “low” ankle sprains. If you have a sprain but do not have a broken bone, the treatment immediately following the injury is to rest the leg, ice for 20 minutes every two to three hours, gently compress the leg with an ACE wrap, and elevate the leg with the toes higher than the nose. You may have enough tenderness to require a removable walking boot. Physical therapy may include strengthening the tendons on the outside of the ankle called the peroneals, as well as getting back the movement in the ankle and returning to activities.

It can take up to 6-8 weeks to return to normal activity, but can sometimes take even longer. A general rule of thumb is that bones take roughly six weeks to heal while soft tissues (e.g., ligaments) take around three months to heal. One good indication that you are ready to go back to sports is if you can hop on the foot 15 times. This hopping test is acceptable if there is no obvious widening between the tibia and the fibula on X-rays. If there is widening, which is called diastasis, or if there is a broken bone, surgery may be needed. There is debate as to how to properly fix these injuries, but the idea is to put the fibula and tibia back together and hold them with either screws or new devices that contain a suture, which is the same type of material used to close wounds.

Recovery

As mentioned above, the recovery for high ankle sprains can take considerably longer than typical ankle sprains. In those cases in which a separation of the tibia and fibula or fracture has occurred and surgery is necessary, patients will likely need to be non-weightbearing in a cast followed by a walking boot for about 12 weeks. It is important to do early range of motion passively, meaning with the help of a physical therapist who moves the ankle, to help avoid stiffness. The screws commonly are removed in a second, small surgery before full weightbearing is allowed so they will not break.

Outcomes generally are good if the injury is recognized and treated appropriately. It is more likely, however, to have some stiffness of the ankle after a high ankle sprain as compared to a standard ankle sprain. This is especially true if a fracture has occurred.

Risks and Complications

Stiffness can occur in the ankle. If surgery is performed, one can have an infection or damage to one of the nerves that provides sensation to the top of the foot called the superficial peroneal nerve. This is because that nerve runs very close to the outside of the leg where the incision is commonly made. Arthritis also can develop from a very severe sprain if the cartilage of the ankle is damaged at the time of the original injury.

FAQs

Should I be concerned if I have sprained my ankle and it is not better after six weeks?

Yes. It is probably worth seeing a foot and ankle orthopedic surgeon to assess if any other injuries have occurred. Sometimes high ankle sprains can take that long or longer to heal, but it is wise to make sure that another injury has not occurred.

Hammertoe

A hammertoe is a deformity of the second, third, or fourth toe. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Hammertoes typically start as a flexible deformity but if left untreated could potentially develop into a fixed/rigid deformity that may require more aggressive surgery to correct.

Symptoms

People with hammertoe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They also may feel pain in their toes or feet and have difficulty finding comfortable shoes. The most common complaints are the middle joint of the hammertoe rubbing against the top of the shoe or the tip of the toe digging into the ground.

Causes

Hammertoe results from shoes that don’t fit properly or a muscle imbalance, usually in combination with one or more other factors. Muscles work in pairs to straighten and bend the toes. If the toe is bent and held in one position long enough, the muscles tighten and cannot stretch out.

Shoes that narrow toward the toe push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. A higher heel forces the foot down and squishes the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles are unable to straighten the toe, even when there is no confining shoe.

Treatments

Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. Avoid wearing tight, narrow, high-heeled shoes. You may be able to find a shoe with a deep toe box that accommodates the hammertoe. Or, a shoe repair shop may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.

Your foot and ankle orthopedic surgeon may recommend toe exercises that you can do at home to stretch and strengthen the muscles. For example, you can gently stretch the toes manually. You can use your toes to pick things up off the floor. While you watch television or read, you can put a towel flat under your feet and use your toes to crumple it.

Finally, your surgeon may recommend that you use straps, cushions, or non-medicated corn pads to relieve symptoms. If you have diabetes, poor circulation or a lack of feeling in your feet, talk to your doctor before attempting any self-treatment.

Hammertoes can be corrected with surgery if conservative measures fail. Usually it is an outpatient procedure, meaning the patient can go home the same day as surgery, done with a local anesthetic. The procedure will depend on the type and extent of the deformity. After the surgery, there may be some stiffness, swelling, and redness and the toe may be slightly longer or shorter than before. You will be able to walk, but should not plan any long hikes while the toe heals, and you should keep your foot elevated as much as possible.

It is possible that after surgery your hammertoe may come back. If this happens and you have discomfort in the toe, an additional surgery may be needed to address the pain.

Haglund’s Deformity

A Haglund’s deformity is a bump in the back of the heel bone. The Achilles tendon runs over this bump. Patients with a Haglund’s deformity may or may not have pain.

Sometimes, people will have pain due to shoes rubbing against the bump. At other times the pain is related to degeneration in the Achilles tendon. It is not always clear how much of this Achilles tendon problem is due to the Haglund’s deformity.

If prominence is the main issue, then the goal of Haglund’s deformity surgery simply is to make the heel bone less prominent. If the Achilles tendon has degenerated as well, then the procedure may involve removing or repairing a portion of the Achilles tendon.

Diagnosis

Patients should consider Haglund’s deformity surgery if they don’t get relief from non-surgical treatments such as medication, exercises, or changing shoes. Patients at high risk for wound issues should avoid this surgery. If the Achilles tendon is degenerative, there is a low risk of rupturing the tendon. You should discuss your options with your foot and ankle orthopedic surgeon before proceeding with surgery.

Treatment

This surgery is usually an outpatient procedure, meaning you can go home the same day as your surgery. General anesthesia or a nerve block at the knee to make the leg numb will be given. If the prominent bone is being removed, the surgeon does this by making an incision at the heel next to the Achilles tendon and then removing the prominent bone. If the Achilles tendon is degenerative, then the incision often is made in the midline, and the degenerative portion of the Achilles tendon is removed along with the prominent bone. Sometimes, a tendon is transferred to replace a portion of the Achilles tendon that cannot be repaired.

Recovery

If the surgery consists of removing the prominent bone only, you will be in a splint for approximately two weeks. After that your sutures will be removed and you will be allowed to begin bearing some weight.

If the surgery involves repair of the tendon to any degree, then weight bearing may be delayed. A boot with a heel lift is used and physical therapy may be started at two weeks from surgery. Over the following weeks, you will take the lift out of the boot and then come out of the boot altogether.

Risks and Complications

The most significant complication with surgery in this area of the body is that sometimes the wound can be slow to heal. If the wound is slow to heal or does not heal, there may be infection requiring further surgery.

FAQs

How did I get this bony prominence in my heel?

It is unclear what causes the bone growth in this area. The severity of the symptoms depends on the types of shoes people wear and the activities they perform. Some people may experience swelling related to the Achilles tendon or structures around the bone.

The gastrocnemius (gastroc) and the soleus are two muscles that make up the calf. The gastroc is the larger and more superficial of the two muscles. The soleus is a deeper muscle within the lower leg. The gastroc tendon combines with the soleus tendon to form the Achilles tendon.

Tightness in the calf can limit how far the ankle can flex up. This may make it difficult to walk with the heel on the floor. Over time, calf tightness may contribute to many foot problems, including heel pain, Achilles tendon pain, flatfoot deformity, toe pain, and bunions.

Gastrocnemius Release

A gastrocnemius release lengthens the gastrocnemius tendon. This is done to increase the flexibility of the calf muscle, which can decrease pressure at the front of the foot, improve function, and decrease deformity.

Diagnosis

Your foot and ankle orthopedic surgeon may recommend this surgery if you have tightness of the gastroc that has not improved with stretching exercises. This procedure can be combined with other reconstructive procedures or be performed by itself.

Surgery may not be recommended if you can obtain an appropriate range of motion and flexibility with conservative treatment (stretching). It should also be avoided if there are contractures of multiple tendons in the leg, and not just the gastroc.

Treatment

Your surgeon may perform this surgery through several different incisions. Most commonly, a small incision is made on the inner side of the lower leg. Sometimes an incision directly in the back of the calf is used, or even an endoscopic incision, which is about ½ inch. Once the gastroc tendon is identified, it is separated from the underlying muscle belly of the soleus, then cut straight across. Once the tendon is released, the ankle is flexed up and an increased range of motion is noted intraoperatively.

Recovery

For the first two weeks after surgery, the patient typically is immobilized in a splint or boot. It is important to keep the ankle in a proper position while the tendon is healing. A cramping feeling in the back of the calf is normal. Gentle range of motion and stretching exercises begin once the ankle is removed from the splint/boot. Timing can vary depending upon the other procedures that are performed.

Risks and Complications

After a gastroc release, some patients experience nerve injury that results in irritation or numbness over the outside of the heel. This usually is temporary. In addition, some patients may notice a difference in the appearance of one calf compared to the other and temporary calf weakness.

FAQs

Why are my calf muscles tight?

Most frequently a tight calf muscle is an inherited problem that only causes problems later in life. Other reasons for calf tightness are nerve injuries, muscle problems, and other medical problems like stroke and diabetes. People can also get tight calf muscles after trauma to the leg, ankle, or foot.

Will a gastrocnemius lengthening affect my strength or ability to walk?

This procedure will cause some weakness but most patients will not notice it. Some patients may have a subtle limp, but this typically resolves within six months of surgery.

Ganglion Cyst

A ganglion is a cyst that forms on top of a joint, ligament, or tendon. The cyst is filled with fluid. Because the ganglion is not cancerous and may disappear in time, if you do not have symptoms such as pain, your doctor may recommend observation only to make sure that no unusual changes occur.

The procedure to remove a ganglion is called ganglion resection. The initial treatment of a ganglion is not surgical, but if pain becomes a problem, your foot and ankle orthopedic surgeon may recommend aspiration, a procedure to remove the cyst’s fluid through a needle. If the cyst returns, surgery to remove the ganglion might be an option.

Diagnosis

A ganglion may cause pain. The enlargement of the ganglion may cause skin irritation or make it difficult to wear shoes. The ganglion may cause pressure on nerves and produce burning, tingling, or numbness. For some patients, the appearance of a ganglion may not be acceptable.

If the ganglion is not causing any problems, non-surgical treatment may be preferable. Your doctor may recommend surgery if your symptoms are not relieved by non-surgical methods, or if the ganglion returns after aspiration.

Treatment

Ganglion resection typically is an outpatient procedure and patients are able to go home the same day. You can be given a local or a general anesthetic. The choice depends partly on which you prefer, and partly on what your surgeon thinks is best. Often, local anesthesia is used in conjunction with IV sedation.

Usually open surgery is done, though in certain circumstances your surgeon may recommend arthroscopic surgery. The entire ganglion wall is removed and some surrounding tissue that may be the root of the ganglion is removed to prevent recurrence of the ganglion cyst. The cut made in the skin to resect the ganglion is at least as wide as the lump. The wound will be closed with sutures and covered with a dressing.

Recovery

Your doctor will decide whether the foot and ankle requires immobilization in a cast or boot following surgery and also whether or not you can walk with full weight on the foot right away. If not, you may require crutches for a period of time.

There is some tenderness, discomfort, bruising, and swelling after surgery. Pain medications, elevation and rest help during wound healing. The wound should be kept clean and dry. It usually will heal within two weeks.

You will have a scar instead of a ganglion. The skin around the scar may be permanently numb. You should avoid footwear rubbing against the scar.

Normal activities may be resumed 2-6 weeks after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications from a ganglion resection are rare and seldom serious. Ganglion resection surgery can occasionally result in pain or scarring. Recurrence of the ganglion will happen in 1 out of 5 patients.

FAQs

Would you recommend removal rather than aspiration?

Aspiration (removal of fluid through a needle) of the ganglion cyst and injection of steroid is less invasive than ganglion resection but there is a relatively high rate of recurrence. It is reasonable to simply observe the ganglion cyst if it is causing no problems or to have it aspirated and injected to see whether this is effective before considering surgery.

May I continue to exercise after surgery?

Depending on several factors, including the size and location of the wound, your doctor will advise you when it is safe to return to exercise. It is usually between 2 and 6 weeks after surgery.

Can this surgery make me worse?

This is possible but unlikely. Ganglion resection will result in a scar and there is a 1 in 5 chance of the ganglion coming back after the operation.

Will my foot be pain-free after surgery?

If you have foot pain that is not related to the ganglion then this may not be relieved by ganglion resection.