Let’s twist again…

Injuries of the ankle can happen to us on many occasions: while we are doing sports (landing on the foot of another player after jumping !), walking on uneven ground, hurrying down stairs or are on high heels.

Most of us already do have a clear picture of how it feels when the ankle is twisted and begins to swell and hurt and parts of the skin become bruised in the next hours. First, we rest, cool, compress and elevate.

Worker with sprained ankle on floor in warehouse

In the majority of cases pain- killers and limping for a couple of days will do.  But what if the pain is too strong, the whole ankle is swollen and bruised and we cannot move the ankle joint at all or even think about putting weight on the foot ?

The ankle joint is formed by three bones. From the top end, tibia (inner = medial side) and fibula (outer= lateral side) are building a frame in which the head of the talus can be moved (mainly lifting up and lowering your foot). A joint capsula and several ligmanents on the lateral, medial, anterior and posterior side are stabilising the joint. Furthermore there are tendons on each side of the joint.

By twisting the ankle one can suffer from a range of injuries. These start with sprains of the soft tissue (capsula of the joint and ligaments), continue over partial to complete ruptures of one to a number of ligaments and end with fractures. The most serious fracture is a fracture with a dislocation of the joint, even worse when the skin is injured and it is an open fracture. Fracture dislocations of the joint have to be suspected when the axis of the foot is abnormally deviated and there is enormous pain. These dislocations need to be reduced and immobilised under sufficient analgesia as soon as possible (from professional help) to avoid secondary damage and worse outcome. Luckily, these injuries are rare and most often are caused by a very high energy trauma.

Sprained ankle blue x-ray

Basically, the ankle might twist into two directions- inversion (sole of foot turns shows in the direction of the other foot) and eversion (sole of foot shows to the outer side). More often, we do invert our foot. By inverting, one or more of the three ligaments on the lateral side of the ankle can be torn or ruptured. Ruptures of the ligaments lead to different degrees of swelling and bruising on the outer aspect of the ankle. Moving the ankle and weightbearing is painful. However, also the medial aspect of the ankle might hurt after eversion injuries as the can talus hit the inner knuckle from within.  A fracture should be suspected, if there is direct pain over one or both of the bony knuckles of the ankle when pressing on them.

However, differentiating between sprain, rupture and fracture might is challenging.

Sprains normally only swell minimally and without bruising. They should be fine with cooling and maybe a stabilising bandage and some painkillers for 2 days. Also, a return to fully weightbearing should be possible soon, if even unpossible after the injury.

If this is not the case, you should go and see a doctor. He will do a proper clinical examination, maybe an ultrasound of the ankle and a x- ray if he cannot exclude a fracture by the examination.

Young woman suffering from an ankle injury while exercising and

Ruptured ligaments are treated without surgery but with an immobilisation of the ankle for 6 weeks (day and night !) in an ankle – stabilising- brace (a whole bunch of them is on the market). You will addtionally need crutches for some days to only put as much weight on the foot as pain allows.

A fracture of the ankle initially is treated in a plaster (plaster of Paris, splitted !) until the swelling is gone. Fractures of the ankle need surgery in the majority of cases. Exeptions are minor and undisplaced fractures as well as other co- morbidities that interfere with surgery. As most ankle fractures are interarticular fractures they should heal in anatomical alignment as otherwise they might lead to posttraumatic osteoathritis.

In severe fracture- dislocations where initial reduction is not to stable and to hold in a plaster, your doctor might advise a stepwise surgical approach. First, an external fixation device is put on (to hold the reduction) until the soft tissues are fine for final surgery.
Sprained ankle black x-ray

In most cases, ankle fracture need open reduction and internal fixation. Plates and screws are commonly used for fixation. Generally, these can stay in but often (on the outer bone) do interfere with shoewear. So often, after bony healing, these are taken out again. Also, in young and sporty persons one should think about taking out the material as in case of another injury plates and screws might aggravate the situation. After surgery of an ankle fracture most doctors will additionally treat you in an immobilising device (plaster / brace) for another 4- 6 weeks and partial weight bearing on crutches. After that, physiotherapy can be necessary to stabilise your ankle.

Finally, there is one more injury you should have heard of as it is sometimes missed. Especially in inversion injuries a ligament connecting the fibula and tibia anteriorly can be ruptured leading to an enlargement of the frame for the talus. Clinically, there is pain slightly above and medial to the lateral knuckle. There are certain clinical tests , x- ray and ultrasound to help diagnosing this injury. However, only MRI will reliably rule in or out this injury. If the ligament is torn and there is enlargement of the bony frame (lager gap inbetween the bones = instability) you might be advised to have surgery to temporarily stabilise the frame with one or two screws (for 6 weeks) and reattach the ligamentous structure.

Doctor and patient