Foot and Ankle

Ankle Pain

CLINICAL DEPARTMENT

Causes of Ankle Pain

Arthritis
Pain, stiffness and swelling in the ankles can arise from various forms of arthritis and related conditions that affect the bones, joints, and muscles. These include:

•    Osteoarthritis (including post traumatic)
•    Rheumatoid arthritis (including Juvenile arthritis)
•    Gout
•    Pseudo gout
•    Reactive arthritis
•    Lupus
•    Psoriatic arthritis
•    Septic arthritis 
•    Scleroderma

Ankle injury
The most common cause of ankle pain is an injury such as a sprain or a fracture.  A sprain occurs when the ligaments that support the ankle become stretched or torn.  This happens when the foot twists, turns or rolls as a result of fall or misstep.  A fracture (broken bone) can occur following the same mechanism of injury.  A broken ankle can cause the same symptoms as a sprained ankle – severe pain, swelling, bruising, tenderness to the touch, or deformed appearance – so it can be hard to distinguish between the two.

If you have an ankle injury, it's important to see a doctor who can assess your ankle fully and decide if an x-ray or other investigation is necessary to make an accurate diagnosis.

Achilles tendonitis
Achilles tendonitis is inflammation of the Achilles tendon which runs from the calf to the heel.  It can result from repetitive stress to the tendon or from overstressing the tendon during exercise.  Symptoms may include pain and stiffness of the tendon together with thickening or swelling of the tendon or bone spurs.

Achilles tendon rupture
An Achilles tendon rupture is a break in the Achilles tendon.  Most ruptures occur during strenuous activity.  The break itself may cause a loud pop and feel like the ligament has been kicked or shot.  Symptoms of a ruptured tendon may include severe pain and swelling, difficulty walking and the inability to stand on the toes of the injured foot.  A possible Achilles tendon rupture needs to be seen by a doctor with an interest in Foot and Ankle surgery at the first available opportunity.

Diagnosing Ankle Problems

Diagnosing the cause of your ankle pain will begin with an assessment of your clinical history and a physical examination.  Your doctor will be looking for areas that have tenderness, pain or swelling, as well as indications that the joint may be damaged.  Depending on the findings of the history and exam, your doctor may order investigations such as imaging tests and blood tests to help make or confirm a diagnosis.

Ankle imaging 
These are non-invasive tests that help your doctor see inside your ankles. 

•    X-ray:  A standard X-ray is a simple test in which an X-ray beam is passed through the ankle to create a two-dimensional picture of the bones that form the joint. 
•    Computerized axial Tomography (CT) scan:  This test combines X-ray equipment with sophisticated computers to produce multiple images, which are combined to depict cross-sectional slices of internal structures. CT scans are particularly useful for demonstrating occult fractures and showing bony deformity in 3 dimensions to allow the planning of corrective surgery. 
•    Magnetic resonance imaging (MRI):  This procedure uses a strong magnet linked to a computer to create a picture of the internal structures in black and white and shades of grey. Because an MRI shows the soft tissues, as well as the bones, it is particularly useful for diagnosing injuries to the cartilage, tendons and ligaments, as well as areas of swelling.

Blood tests 
Blood tests can be helpful in confirming the diagnosis of a number of painful ankle conditions including: rheumatoid arthritis, gout, pseudo gout, lupus and infection.

Management of the Painful Ankle

Physiotherapy to improve range of movement, muscle strength and proprioception can be helpful in reducing ankle pain and swelling and improving function.  This is particularly so after injury.

Orthotics including insoles, braces and splints as well as adjustments to footwear are frequently of benefit by controlling or reducing painful ankle movement.

Surgery has a role in the management of ankle pain that fails to settle with non-surgical treatment.  Displaced fractures that cannot be controlled in a cast may need to be fixed with metal plates and screws.  Ankle arthroscopy is a minimally invasive surgical procedure which allows direct visualisation and treatment of damaged structures within the joint.  Damaged soft tissues such as tendons and ligaments can be directly repaired and strengthened using a variety of surgical approaches.  In Ankle fusion (arthrodesis) the surfaces of the joint are removed and the bones are joined with plates and screws until they fuse.  The procedure leaves the ankle stiff but it can be an effective and permanent pain relief option for ankles affected by arthritis. 
Ankle replacement may be an option when arthritis interferes with joint function and causes pain that is not relieved by medication.  During this surgery the damaged bone and joint cartilage is removed.  The damaged bones are reshaped and the artificial joint is attached. In patients who are suitable this can be an effective long term solution to eliminating ankle pain and preserving important ankle motion.

Consultants

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    Mr Simon Henderson Consultant Orthopaedic Surgeon (Foot and Ankle)

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