Ankle injuries are very common. Most people, have had an ankle injury or two in their lifetime. Most ankle injuries do not require surgery and will resolve within 2-6 weeks with good quality rehabilitation. But not all ankle injuries are the same, and some patients will require surgery to achieve the best outcome.
Your ankle joint is made up from 3 different bones. You can think of the ankle joint, in simple terms, as being a connection between your leg and your foot.
Your leg has 2 bones inside it. The largest leg bone is called the tibia, and sometimes it is referred to as the shin bone. The tibia is located on the inside of your leg. The end of the tibia is responsible for forming the knuckle, or bump, on the inner side of your ankle. The smaller bone on the outside of the leg is called the fibula. This is what causes the little knuckle on the outer side of your ankle.
Ankle Injury Types
To help patients understand their injury, and treatment options, I tend to divide ankle sprains into 3 main categories; simple ankle sprains, complex ankle sprains and syndesmosis injuries, and chronic ankle sprains.
Simple Ankle Sprains
Simple ankle sprains usually involve a lower grade injury to only the ATFL, CFL or Deltoid ligaments. But the syndesmotic ligaments are not injured, and there is no associated cartilage injury or fracture.
Usually the injury mechanism is minor, such as tweaking your ankle during sports practice or your ankle giving way when walking on uneven ground. Patients don’t usually hear or feel a ‘pop’ within their ankle as the injury occurs. In general, you are not in horrible pain and you can continue to walk on your ankle. There can be swelling and bruising, but this is not usually major.
Within hours to days after your injury you should be walking more comfortably, with minimal pain. Yes, you might still be a bit sore and swollen, but overall things start to improve quite rapidly.
Complex Ankle Sprains and Syndesmosis Injuries
Complex ankle sprains involve higher grade injuries to the ATFL, CFL or Deltoid ligament. Commonly, they also involve damage to the syndesmosis ligaments and there is associated bone and cartilage injury. Complex ankle sprains are less likely to recover without surgery, or they may require longer periods of non-operative management compared to simple ankle sprains.
The injury mechanism for a complex ankle sprain and syndesmosis injury is often more severe, such as a significant sporting injury, falling from a bike at high speed or even slipping over in high heels. However, it is also true that a complex ankle sprain can also occur with a relatively minor injury. Sometimes you can just be unlucky. Pain and swelling are significant, and in the days that follow there can be major bruising around the ankle and foot.
In this situation I would recommend an appointment with a podiatrist, general practitioner or sports doctor, and it is likely they will arrange an x-ray.
In general, unstable syndesmotic injuries, where the two legs bones have separated, have very poor long-term results if managed without surgery. The leg bones heal slightly separated, and this creates uneven stress through your ankle joint, and there is a high risk of on-going pain and arthritis.
If you have a severe syndesmosis injury, we then need to hold these bones together securely, so that the ligaments can heal back in the normal position. We do this with a technology called a ‘tight rope’.
A tight rope is a very strong piece of suture material with a small, metal button at each end. We drill a small tunnel between the two leg bones, then thread the tight rope between them. The tight rope is then tightened in place over the metal buttons. It is extremely strong and holds the leg bones in their normal position.
The ruptured syndesmotic ligaments will then heal during the next 6-8 weeks. Once the ligaments have healed, the tight-rope has finished its job – it’s a temporary holding device until those ligaments heal.
Syndesmotic injuries should ideally be discussed with an orthopaedic surgeon, so they can examine your ankle, view your scans and explain the pros and cons of surgery.
Chronic Ankle Sprains
Even though many patients recover fully from a simple ankle sprain without surgery, there are a number of patients who will not. In these patients, the ankle continues to give way, or they repeatedly sprain their ankle, even months or years after the original injury.
If you are continually spraining your ankle, then it is likely that you have sustained a major injury to the ATFL and the CFL. These ligaments are the main restraint to your ankle giving way and turning in without warning. In chronic ankle instability, the ATFL and CFL are like over-stretched elastic bands. They can no longer provide normal support to your ankle.
The muscles and tendons around the ankle joint are also very important to preventing your ankle from giving way. This is why rehabilitation to strengthen these is crucial after an ankle sprain. But sometimes, even the best rehabilitation isn’t enough to compensate for badly torn and stretched out ankle ligaments.
Fortunately, surgery for on-going ankle instability is a reasonably small operation, with minimal risks and a high success rate. Surgery should only be considered if non-operative management has failed.
An ankle arthroscopy, or key-hole-surgery, is performed through two, small incisions in the front of your ankle joint, about 3-5mm in size. You will also have an incision about 3-4cm in length on the outer side of your ankle.
The ankle joint is inspected with a camera, to ensure there is no cartilage damage that needs to be treated. Even the best MRI scans will not diagnose a significant number of ankle cartilage injuries, so arthroscopy is the gold standard to assess and treat this.
Ankle surgery usually takes place under general anaesthesia, so you will be asleep. It is usually day surgery or a one-night stay in hospital.
If there is a small piece of cartilage loose within the joint, then this would require simple removal. If there was a larger piece of damaged bone and cartilage, then this may require fixing back into place with a small screw.
Sometimes are large piece of cartilage has broken loose, but it is too severely damaged to be fixed back into place. This may require a key-hole procedure called a microfracture. There is specific information about what a microfracture is, and how it helps your joint, on my website.
We also remove inflamed scar tissue inside the ankle joint, called arthrofibrosis. Removing this, along with any blood that has set in the joint, will help your ankle move more freely after surgery and reduce the risk of stiffness.
Ankle Arthroscopy Recovery Time
You may require crutches, but I allow my patients to put as much weight through their ankle as they wish, from day one of surgery. I don’t advise patients to wear a full moon boot after surgery, and you certainly will not be in a cast or a splint. In both professional athletes, and weekend warriors, the best results are seen when we move your ankle early after surgery.
You will be able to return to office-based work or study. But you will still require regular Panadol and anti-inflammatory medication.
You should make an appointment with your own physiotherapist within 2-3 weeks of surgery. It makes sense to see a physiotherapist who is close to where you live or work. Otherwise, you will be less inclined to see them.
If you have a manual job then it may be 2-4 weeks before you can return to work, and in that situation, I would recommend wearing a brace for 6-8 weeks.
Usually, from 8 weeks after surgery a patient can begin to gently jog in a straight line.
A return to full activities and sports can be 3-4 months.
Your ankle will continue to improve for 6-12 months after surgery.
Ankle Arthroscopy Risks
All surgery has risks, but in general I would consider this a low-risk procedure with excellent results.
The risk of deep infection is far less than 1%, but if this occurred you may need further surgery and antibiotics for a number of weeks. A mild skin infection occurs 2-3% of the time, but all that is needed is some tablet antibiotics, and it is unlikely there would be any long-term problems.
It is not uncommon for patients to have some numbness on the top of their foot due to swelling, and also damage to sensory nerves beneath the skin from the key-hole surgery. This usually improves over weeks to months, but in some patients it may be permanent. It will not affect the stability or function of your ankle.
Ankle ligament repair has a high success rate, and in general your ankle should remain stable. However, if you were unlucky enough to have another injury, you could rupture the ligaments again. In this situation another period of rehabilitation, and sometimes revision surgery, is required.
Longer term outcomes are also greatly influenced by the severity of the original injury. Patients with associated cartilage injuries and/or fractures are at higher risk of ongoing pain, stiffness and arthritis. These patients will also take longer to maximally improve after their surgery.