An Overview of the Problem and Treatment Procedures
Sprained ankles are very common and happen to approximately 25,000 people each day. These injuries occur with athletes and non-athletes, children and adults, when one takes part in sports and physical fitness activities or simply steps on an uneven surface or down at an angle.
Ligaments hold the ankle bones and joint in position while protecting the ankle joint from abnormal movements such as twisting, turning, and rolling of the foot.
Ligaments are elastic structures which usually stretch within their limits and then return to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain can actually tear the elastic fibers.
How it happens
Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions because a great force is transmitted upon landing. You can sprain your ankle if your foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range into an abnormal position.
Mechanism of injury
If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear.
You may lose your balance when your foot is placed unevenly on the ground or fall and be unable to stand on that foot. When excessive force is applied to the ankle’s soft tissue structures, you may even hear a popping sound and experience pain and swelling.
The amount of force determines the grade of the sprain. A mild sprain is Grade 1, a moderate sprain is Grade 2, and a severe sprain is Grade 3. (See Table 1.)
- Grade 1 sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament.
- Grade 2 sprain: Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.
- Grade 3 sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.
Toe and Forefoot Fractures
Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken bone (fracture) in your forefoot (metatarsals) or in one of your toes (phalanges) is often painful but rarely disabling. Most of the time, these injuries heal without operative treatment.
Types of fractures
- Frequently occur in the bones of the forefoot (your toes to the middle of your foot).
- Tiny cracks in the bone surface can occur with sudden increases in training (such as running or walking for longer distances or times), improper training techniques or changes in training surfaces.
Fractures which extend through the bone
- Stable (no shift in bone alignment), usually result from trauma
- Displaced (bone ends no longer line up), usually result from trauma
- Trauma may occur due to a twisting injury or a heavy object dropped on the foot
- Closed fracture is when the fractured bone does not break through the skin
Forefront bone fractures (fifth metatarsal, on the side of the little toe)
- Ballet dancing missteps or falls from a pointe position.
- Ankle-twisting injury may tear the attached tendon and pull a small piece of the bone away.
- Jones fracture (more serious) occurs near the base of the bone and disrupts its blood supply – these take longer to heal and may require surgery.
Signs and symptoms
Pain, swelling, and bruising are the most common signs of a fracture. You may be able to walk with a broken toe but this usually aggravates the pain. If pain, swelling and discoloration continue for more than two or three days and interfere with walking, something could be seriously wrong. Delays in getting treatment can permit development of persistent foot pain and arthritis. Changes in gait (the way you walk) can lead to the formation of painful calluses on the bottom of your foot or other injuries.
The most common long-bone injury is a broken or fractured shinbone (tibia). Several types of fractures can occur ranging from the hairline stress fractures common in runners to severe open fractures (broken skin) resulting from motor vehicle crashes. These include toddler’s, growth plate, stress, closed and open fractures,.
During the past 30 years, doctors have noted an increase in the number and severity of broken ankles, due in part to an active, older population of “baby boomers.” In 2003, nearly 1.2 million people visited emergency rooms because of ankle problems. The ankle actually involves two joints, one on top of the other. A broken ankle can involve one or more bones, as well as injuring the surrounding connecting tissues (ligaments).
Anatomy of the Ankle
The top ankle joint is composed of three bones:
- the shinbone (tibia)
- the other bone of the lower leg (fibula)
- the anklebone (talus)
The leg bones form a scooped pocket around the top of the anklebone. This lets the foot bend up and down.
Right below the top ankle joint is another joint (subtalar), where the anklebone connects to the heel bone (calcaneus). This joint enables the foot to rock from side to side. Three sets of fibrous tissues connect the bones and provide stability to both joints. The knobby bumps you can feel on either side of your ankle are the very ends of the lower leg bones. The bump on the outside of the ankle (lateral malleolus) is part of the fibula; the smaller bump on the inside of the ankle (medial malleolus) is part of the shinbone.
Lisfranc (Midfoot) Fracture
Has a heavy item been dropped on the top of your foot? Have you accidentally stepped in a small hole and fallen, thereby twisting your foot? These two common accidents can result in a Lisfranc fracture – dislocation of the midfoot. Lisfranc was the French doctor who first described the injury.
Lisfranc injuries occur at the midfoot, where a cluster of small bones forms an arch on top of the foot between the ankle and the toes. From this cluster, five long bones (metatarsals) extend to the toes. The second metatarsal also extends down into the row of small bones and acts as a stabilizing force. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. No connective tissue holds the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.
Signs and symptoms
Lisfranc fracture-dislocations are often mistaken for sprains because the top of the foot is swollen and painful and there may be some bruising. If the injury is severe, you may not be able to put any weight on the foot. These may be difficult to see on X-rays. Unrecognized Lisfranc injuries can have serious complications such as joint degeneration and compartment syndrome, a build-up of pressure within muscles that can damage nerve cells and blood vessels. If the standard treatment for a sprain (R.I.C.E.) doesn’t reduce the pain and swelling within a day or two, ask your physician for a referral to an orthopaedic specialist.
Fracture of the Talus
The talus (TAY-lus) is a small bone that sits between the heel bone (calcaneus) and the two bones of the lower leg (tibia and fibula). It has an odd humped shape, somewhat like a turtle. The bones of the lower leg “ride” on top and around the sides to form the ankle joint. Where the talus meets the bones of the foot, it forms the subtalar joint, which is important for walking on uneven ground. The talus is an important connector between the foot and the leg and body, helping to transfer weight and pressure forces across the ankle joint.
Most injuries to the talus result from motor vehicle accidents or falls from heights. These are often associated with injuries to the lower back. An increasing number of talar fractures result from snowboarding, which uses a soft boot that is not rigid enough to prevent ankle injuries.
Signs and symptoms
Most talar fractures are marked by:
- acute pain
- an inability to bear weight
- considerable swelling and tenderness
A fracture that breaks through the skin has an increased risk of infection. Talar fractures that result from snowboarding injuries may be mistaken for ankle sprains because of the tenderness on the outer side of the ankle and severe bruising.
It’s not easy to break your heel bone (calcaneus). Because it takes a lot of force, such as that sustained in a motor vehicle accident or a fall from a height, you may also incur other injuries as well, particularly to the back.
Signs and symptoms
- An inability to bear weight
The pain may be centered on the outer side of the ankle, just below the lower leg bone (fibula). Or, it may be focused in the heel pad, particularly when you try to put weight on the foot. Your foot may become swollen and stiff. See your doctor right away, because if the bone heals improperly, severe problems may result later.