Background & Etiology (Cause)
The ankle is made of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body. It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to, and react quickly to changes in environment and walking surface.
Bones and Joints
There are three bones that come together to form the ankle joint. The tibia and fibula (lower leg bones) end in prominences called the malleoli. The malleoli create the bony prominence seen on either side of the ankle, these are called the lateral malleus and medial malleolus. The ankle is made up of two joints, the inferior talocrural joint and the subtalar joint.
The inferior tibiofibular joint is located between the large bone of the lower leg (tibia) and the smaller fibula, which then attach to the talus bone of the foot to form the talocrural joint. The talocrural joint is sometimes called the true ankle joint and is responsible for dorsiflexion and plantar flexion (up and down) movement of the foot. The joint between the tibia and talus bears the most of our body weight.
Beneath the talocrural joint is the subtalar joint. The subtalar joint is located between the talus bone and calcaneus or heel bone. This joint is responsible for ankle inversion (turning in) and eversion (turning out).
Running between the tibia and fibula is a fibrous membrane called the interosseous membrane. This membrane joins the tibia and fibula all the way up the lower leg, extending toward the knee. At the upper end, near the outside of the knee, is the superior tibiofibular joint.
Any restriction or dysfunction of these joints can produce symptoms in the ankle. The bony joint surfaces all have articular cartilage that covers the ends of the bones. The articular cartilage has a smooth and shiny surface, which allows the ends of the bones to slide freely over each other.
A fracture is defined as a partial or complete crack in a bone. Fractures can be minor with little or no displacement of the bone, or more severe with complete displacement of the two ends of the bone, which requires surgery to realign. There are closed fractures that do not break the skin, and open fractures that do break the skin (also called compound fractures.) An ankle fracture can be an injury to the tibia, fibula, lateral or medial malleoli, talus, or calcaneus bones.
The most common cause of a fracture is trauma. Trauma can result from falls or incidents like traffic accidents. Participation in sports or other high impact activities can also cause an ankle fracture.
Signs and Symptoms
Fractures are acute injuries (occur suddenly) therefore symptoms can often be noticed immediately following injury.
- Sudden, sharp pain in the ankle
- Swelling and tenderness at the site of injury
- Visible deformity of the bones in the ankle
- Inability to move the ankle or foot without pain
- Inability to weight bear on the involved leg
In the event that an individual suspects they may have sustained an ankle fracture, a radiographic evaluation (X-Ray) will be essential to a proper diagnosis. A bone can fracture in different ways, causing complications or secondary conditions that your physician will look for. Conditions that can be related to an ankle fracture include:
- Comminuted fracture: a bone that is broken in several pieces
- Dislocation: a bone that is not properly aligned in the correct joint
- Greenstick fracture: a fracture on only one side of a bone (commonly seen in children)
- Malunion: when the bone heals in the improper position
- Nonunion: when the ends of the broken bone do not fuse together properly
- Growth plate injury: in children, areas at the ends of bones (near the joint) are responsible for growing the bone as the child develops. If the growth plate is injured it may effect the growth of the bone. It is essential to future development that the growth plate is realigned and heals properly.
The most common course of treatment for an ankle fracture is realignment (referred to as reducing the fracture) and casting or placing the foot and ankle in a boot to immobilize the joint, and give the bones time to heal. For more severe fractures, surgery may be needed to realign the bones properly. Pins, screws, plates or wires may be used to hold the bones properly in place. How much movement should be restricted following the fracture will depend on the severity of the break.
Once cleared by the physician, a physical therapy program should be initiated to reverse the effects of immobilization and restore ankle motion. In more involved fractures recovery can take more time. Formal therapy and compliance with an extensive home program is essential to restoring function of the ankle.
Physical therapy interventions
- Post ankle fracture immobilization can have detrimental effects that can be improved through physical therapy. These effects include:
- Joint articular cartilage softening
- Shortening and atrophy of musculotendinous units
- Decreased circulation
- Loss of active and passive motion
Goals for physical therapy post-fracture immobilization of the ankle are optimal loading and restoration of normal tissue relationships to improve motion, strength and the ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the ankle bones and surrounding muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the lower extremity, improve proximal joint stability and improve movement technique and mechanics (for example: jumping, running etc) in use of the involved lower extremity in daily activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the ankle and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Most fractures can be diagnosed with X-Ray studies and when necessary a CAT Scan. The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe fractures or when the injury affects the integrity of the joint.
Rate of recovery and the prognosis from an ankle fracture will depend on a number of factors:
- Severity – Minor fractures do well with immobilization and physical therapy, while fractures that are more severe and require surgery or effect joint integrity take longer to heal. Patients may have residual motion and strength deficits.
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually have better pre-injury tissue integrity.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.