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Please see foot & ankle anatomy for more information about the ankle joint.
As the name suggests this is a fracture involving the ankle joint. Fractures of the ankle are a common sports injury.
A “Fracture”, “break”, and “crack” are often used to describe an injury to a bone. Contrary to what most people think, they all mean the same thing. A fracture is a complete or incomplete break in a bone resulting from the application of excessive force.
There are many different types of ankle fracture, and as a result there are many different ways of classifying and describing ankle fractures.
We will use two systems, one based on anatomy to describe the location of the fracture, the other based on stability which helps guide management of the injury.
The anatomical descriptive classification outlines the part(s) of the ankle joint injured:
A – lateral x-ray of the ankle best demonstrates the posterior malleolus B – the AP (front to back) x-ray best demonstrates the medial and lateral malleoli
Ankle fractures can also be classified as:
We can define stability as the ability of a body structure to withstand physiological load without deformation and displacement.
Stable injuries can be managed non-operatively while unstable fractures require surgical fixation.
A – isolated stable avulsion fibular fracture B – stable fibular fracture C – medial malleolar fracture D – bimalleolar fracture
The exact mechanism of injury differs according to which anatomical area the fracture has occurred in.
The following can cause an ankle fracture:
Symptoms can vary from patient to patient and depend on the severity of the underlying fracture.
Common symptoms and signs following an ankle fracture include:
Most fractures of the ankle can be identified on an x-ray (radiographs).
Radiographs provide the following information regarding the fracture:
Radiograph (x-ray) demonstrating a fracture of the lateral and posterior malleolus
A – normal ankle x-ray B – unstable ankle fracture, note the increased gap in the inner aspect of the ankle due to rupture of the deep deltoid, resulting in the talus moving outwards, the lateral malleolus is also broken
CT is not usually required to make the diagnosis in acute setting for straight forward ankle fractures.
CT maybe used for imaging a particularly complex ankle fracture pattern and for pre-operative planning purposes.
It may also be considered in the setting of a delayed union or non-union.
CT demonstrating subluxation of the ankle joint with posterior malleolar fracture fragment
3D CT reconstruction of a complex ankle fracture A – fibular fracture B – posterior malleolar fragment C – large medial malleolar fragment
MRI is not usually required to make the diagnosis in acute setting.
MRI provide high resolution images of both bones and soft tissues, such as cartilage and ligaments. In select cases it may be necessary to request an MRI to visualise ligaments and cartilage damaged in an ankle fracture.
The majority of people with an ankle fracture have no long term complications.
Patients who have stable fractures are very unlikely to develop further problems such as arthritis.
Unstable fractures and fractures extending into the joint surface that damage the cartilage are likely to develop degenerative changes (arthritis) in the ankle joint.
An operation that restores anatomy and provides rigid fixation can minimise these risks. With severe injuries such as open fractures (break in the skin with bone exposed), fracture dislocations and high energy injury resulting in significant joint (cartilage) damage, despite surgery there is a significant risk of developing post traumatic arthritis. See Ankle arthritis for further information.
A – Normal ankle x-ray, note the even joint surface B – post traumatic ankle arthritis in a patient with previous trimalleolar ankle fracture C – Post traumatic ankle arthritis in a patient with a medial malleolar fracture
Many ankle fractures can be treated non-operatively.
If the fracture configuration is suitable and the ankle felt to be stable then this will be the treatment of choice.
A weight bearing ankle or gravity stress view is usually required to make sure that the ankle is indeed stable.
A – x-ray of the ankle demonstrating a fracture of the lateral malleolus B – on weight bearing views there is no displacement of the bones indicating this is a stable fracture and can be managed non-operatively
While the fracture heals, which may be anywhere form 6 weeks to 6 months, the ankle needs to be protected.
Non-operative treatment would typically comprise of one of the following depending on individual patient and fracture characteristics for at least 6 weeks:
An x-ray would be repeated at the 6 week clinic appointment to assess healing.
Depending on the radiological and clinical findings at the 6 week appointment, further protection may be required.
If the fracture has healed, a referral to physiotherapy will be advisable in most cases.
Surgical management is reserved for patients who have an unstable fracture configuration, patients who require early return to sports and function or have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
A variety of surgical options exist which need to be tailored to the individual and the actual fracture. Mr Malik, Consultant Orthopaedic Foot and Ankle Surgeon has over 15 years experience of fixing ankle fractures and has undertaken hundreds of ankle fracture procedures with excellent results.
Ankle fractures are best fixed once the soft tissue swelling has subsided. It may be necessary to delay surgery for a week or so until the swelling has gone down. Operating while the foot is too swollen increases the risk of wound breakdown and infection. There is usually a window of up to 2 weeks to fix an ankle fracture, before the body starts to heal the fracture, which then makes it more difficult.
This operation has excellent outcomes in terms of pain relief and return to activities of daily living.
It involves reducing the fracture (restoring the anatomy), and then fixing the fibular bone with screws and a plate.
The operation is usually carried out through one incisions on the outer aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
A – an x-ray of lateral malleoli fracture, B – an x-ray showing a fixed with plate and screws with anatomical reduction
It involves reducing the fracture (restoring the anatomy), and then fixing the medial malleolus typically with one or two screws and rarely a plate.
The operation is usually carried out through one incisions on the inner aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
A – an x-ray demonstrating isolated medial malleolus fracture (white circle), B – an x-ray showing a successful fracture fixation with two screws
Surgery involves reducing the fracture (restoring the anatomy), and then fixing the posterior malleolus typically with screws and a plate.
The operation is usually carried out through an incision at the back of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
It involves fixing the fibular bone with screws and a plate and the medial side of the ankle with screws (rarely a plate).
The operation is usually carried out through two incisions on the outer and inner aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
This operation has good outcomes in terms of pain relief and return to activities of daily living. Due to the nature of the injury there is however increased risk of developing post traumatic ankle arthritis even despite surgery.
It involves fixing the fibular bone with screws and a plate and the medial side of the ankle with screws (rarely a plate), and the posterior malleolus with screws and a plate.
The operation is usually carried out through two incisions on the posterior and inner aspect of the ankle. The operation is undertaken under a general anaesthetic and patients usually require at least one night stay in hospital.
A – an x-ray showing a normal lateral ankle, B – an x-ray showing Trimalleolar ankle fracture, C – an x-ray after surgical fixation the ankle joint has been anatomically restored and the fractures fixed with plates and screws
This operation has good outcomes in terms of pain relief and return to activities of daily living in the short term. Due to the nature of the injury there is however increased risk of developing post traumatic ankle arthritis even despite surgery in the mid to long term.
The details of the operation depend on the specifics of the fracture configuration.
A – x-ray of a normal ankle, B – an x-ray of an open fracture dislocation of the ankle with contaminated wound, this patient is at high risk of developing osteomyelitis and post traumatic ankle arthritis, note this patient had a severe syndesmotic injury – see below
These are high energy injuries that rupture some or all of the syndesmotic ligaments. Read about the anatomy of the syndesmotic ligaments here.
The syndesmosis binds the fibula and tibia together. Injury to this ligament complex can be either a sprain or complete rupture resulting in gross instability of the ankle.
A syndesmotic injury can be purely ligamentous or associated with an ankle fracture.
The operations to repair the syndesmosis with or without ankle fracture fixation has excellent outcomes in terms of pain relief and return to activities of daily living.
It involves reducing the fracture (restoring the anatomy )when present, and then fixing the syndesmosis.
The operation is usually carried out through more than one incision. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
X-rays of the ankle demonstrating A and B – bimalleolar ankle fracture with syndesmotic injury resulting in ankle dislocation and gross instability, C and D post operative x-rays demonstrating anatomical fracture reduction, rigid fixation and restoration of the normal joint
It should be borne in mind that complications can result from a condition with or without surgery.
X-ray of a fracture dislocation of an ankle, note how the skin is being stretched over the sharp edge of bone (blue arrow), left untreated the skin will breakdown and the patient will be at serious risk of developing osteomyelitis and ankle arthritis
Complications can occur as with any type of surgery. Please see Foot and Ankle Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
You will have a backslab applied post operatively for two weeks. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.
A picture of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for approximately 6 to 8 weeks based on the ankle fracture configuration. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.
A picture demonstrating high elevation after a foot operation
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your toes and knee at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling.
You will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.
Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.
If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
Am ankle fracture fixation can take up to 90 minutes.
Depends on the side operated on and whether you drive an automatic car. If the car is manual then regardless of the side operated on it will be roughly 3 months post surgery. If you drive an automatic and the left foot has been operated on then it will be roughly 4 weeks before you can drive short distances.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and return to full activities of daily living in the majority of patients.
Following a fall from my horse I visited A&E where I was diagnosed with a left ankle fracture. Because I had had a spiral fracture of my left leg twenty years prior, I had a number of metal pins and a rod in place. Consequently the hospital consultant recommended I underwent an operation to repair my ankle. I decided to get a second opinion and scoured the internet for names of consultants specialising in ankle injuries. Having read Mr Malik’s website, along with his testimonials, I felt he was the obvious choice.
I spoke to his secretary and was given an appointment for his clinic that same day. After an initial examination he immediately arranged for me to have further X rays and a CT scan which revealed my injury was far more extensive than originally diagnosed. My condition was medial malleolar fracture but in addition Mr Malik diagnosed a posterior malleolar fracture, a syndesmotic injury and lateral ankle ligament injury. My consultation was meant to be a twenty minute duration but Mr Malik spent nearly two hours with me making sure he had all the information he needed for a complete diagnosis. He arranged for me to have an operation within two days. I felt extremely reassured by Mr Malik’s thoroughness, his passion for his profession and his obvious levels of expertise in his field.
I didn’t have any concerns about the operation. Mr Malik chatted to me before I went to theatre and explained the exact procedure I was going to have. He also explained how my pain would be managed.
The operation went to plan. It was a two hour procedure and I felt very groggy for the next twenty-four hours after. I decided not to go home the next day as my operation hadn’t finished until very late the night before. Looking back this was the right decision as being in hospital one more day made me feel more confident my pain could continue to be managed whilst giving me the time to regain some strength.
My recovery was long, very long! It was a seven week period before I was fully weight bearing. I had to spend 55 minutes of every hour with my leg elevated. I managed well with the crutches for the small amount of time I was allowed to be on them. I made good use of a rucksack to take light items from “A to B” and I overcame the challenge of carrying hot drinks by making up a flask. A friend lent me a shower chair which was a god send! I was in plaster for two weeks following the operation and a boot for the next five. The boot was more comfortable but sleeping in both was challenging.
The seven week non weight bearing period was definitely the most difficult. I have a daughter, three horses, two dogs and a husband that works very long hours, so I needed to organise a lot of help to care for my family. It was very frustrating not to be able to do things for them. I really missed the physical exercise and the mental wellbeing it provides.
Be prepared. Make all the arrangements for help and support for you and if appropriate your family, before the operation. Once home have all the things you need each day close to hand. Make sure you have a suitable chair or sofa which allows you to lie or sit with your ankle in an appropriate position, located in the main hub of your home. It will help to give you a sense of normality. Accept you will not be able to resume life as before during your recovery period and welcome all offers of help from friends and family. Remind yourself that your immobility is for just a short period of time in your life and as long as you follow Mr Malik’s instructions you will be one step closer to a full recovery with each passing day.
Lisa King November 2016
Please see foot & ankle anatomy for more information about the Achilles tendon.
Many different names and terms have been used historically to describe problems with the Achilles tendon such as Achilles tendinitis, Achilles tendinosis, Achilles paratendinitis and Achilles paratendinosis. All of these are now out of date, especially as the suffix “itis” suggests inflammation and numerous studies have shown that on the whole the problem is a lack of inflammation and the presence of degeneration instead.
Achilles tendon disorders can be broadly classified into 2 main groups:
1 – Non insertional Achilles tendinopathy 2 – Insertional Achilles tendinopathy
The exact underlying cause (mechanism) is still not clearly understood. What we do know is that multiple factors (multifactorial) are involved. The Achilles tendon is the largest tendon in the body. It is subjected to tremendous loads on a daily basis. The tension across the tendon can be up to eight times the body weight during running and jumping and four times during walking. It is felt that repetitive stresses (microtrauma) results in damage to the tendon. The Achilles tendon does not have a good blood supply, so injuries in this region take longer to heal.
The following factors are associated with the development of Achilles tendinopathy:
It is very important to be sure about the cause of the underlying pain as a number of conditions can cause heel pain, and more than one condition may be attributable.
The following conditions can cause pain around the heel:
An x-ray highlighting the common conditions that cause heel pain
Patients with non insertional Achilles tendinopathy typically complain of the following symptoms:
Patients with insertional Achilles tendinopathy typically complain of the following symptoms:
Clinical picture demonstrating features of insertional Achilles tendinopathy in the left foot with swelling of the distal Achilles tendon and bony enlargement at its insertion into the calcaneum
Investigations are not usually required to make the diagnosis of Achilles tendinopathy. Occasionally investigations will be requested (for example in the presence of atypical symptoms) to confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Ultrasound is a quick, painless and non invasive method of visualising the Achilles tendon. It offers excellent real time high definition images of the Achilles tendon. The radiologist will be looking for the presence of the following to confirm the diagnosis of Achilles tendinopathy:
MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
The radiologist and your surgeon Mr Malik, will be looking for the presence of the following to confirm the diagnosis of Achilles tendinopathy:
A – MRI of the Achilles tendon demonstrates this to be a well defined hypointense (dark) structure (arrow) inserting onto the calcaneus, thereafter becoming continuous with the plantar fascia (arrow). B – Abnormal MRI demonstrating thickened Achilles tendon and calcification at the insertion (arrows)
MRI of Achilles tendon demonstrating normal Achilles tendon body with abnormal insertion and island of calcified bone in the tendon (arrow)
MRI of non-insertional Achilles tendinopathy with bone marrow oedema in the calcaneum (blue arrow) and partial tear at the Achilles tendon insertion (yellow arrow)
X-rays are usually not required to confirm the diagnosis of Achilles tendinopathy. However it is a quick and effective way of confirming calcific insertional Achilles tendinopathy in patients with a painful bump at the back of their heel. It is also a useful pre operative test.
Plain radiograph demonstrating calcification in the Achilles tendon at its insertion
CT is rarely used in the diagnosis of Achilles tendinopathy. Very occasionally it may be used for pre operative planning for example in the case of a very large bony calcified Achilles tendon.
A – CT 3D reconstruction demonstrating a large calcified Achilles tendon insertion; B – CT image revealing normal posterior border of heel bone (broken yellow line) and abnormal calcified Achilles tendon insertion behind it
The majority of people with Achilles tendinopathy improve with conservative management. However one third of patients will fail to improve with non operative management and 1 in 20 professional athletes will have to end their career due to symptoms.
Some people with Achilles tendinopathy may go on to develop Achilles tendon rupture. Patients with insertional Achilles tendinopathy often develop progressive calcification (new bone formation) at the tendon insertion into the heel bone (calcaneum). Patients with calcific insertional Achilles tendinopathy may find the bump gets bigger and more symptomatic over time.
An- x-ray of a normal foot, B – Moderate calcification at the Achilles tendon insertion; C – severe calcification at the Achilles tendon insertion
Non-operative management for Achilles tendinopathy aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. New training regime and exercise program.
Avoid footwear and running shoes that aggravate symptoms. Patients with large posterior bumps should wear soft heeled shoes. Patients with tight calf muscles will find that shoes with a slight heel will be more comfortable.
Heel sleeves or pads to cushion the bony prominence from a calcified insertional Achilles tendon.
Custom insoles and orthotics will help correct any underlying lower limb malalignment. Heel raises can ease symptoms in patients with tight calf muscles. Night splints are also available and aim to reduce morning stiffness and pain. Results from studies are inconclusive. Many people find them quite uncomfortable to sleep in.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with early Achilles tendinopathy. Very early in the disease process there is an element of inflammation, but this is short lived and soon the pathology is degeneration with NO inflammation. That is why most people find that NSAID’s do not work, or have stopped working after an initial period of symptomatic relief.
Calf stretches (particularly eccentric) as part of a comprehensive physiotherapy program of at least 3 months, has been shown by studies to alleviate symptoms in approximately 90% of patients.
A tight calf muscle will increase the force going through the Achilles tendon and predispose the tendon to micro-tearing and frank rupture. Reducing tension across a tendon by stretching a tight muscle can help reduce painful symptoms.
The following exercises are recommended as part of any physiotherapy program:
Please read here for more details about the exercises.
Extracorporeal shockwave therapy is a technique that employs the use of a machine that produces shockwaves. It is not entirely understood how it works but it is felt that the shockwaves produce microtears which starts an inflammatory (healing) response. It is also believed that ESWT inhibits pain mechanisms.
Treatment involves 3 sessions spaced 1-2 weeks apart. One session lasts for 15 minutes. It should be noted that this is a painful process. Results are comparable with physiotherapy. Effects will not become apparent for approximately 12 weeks. It is a useful treatment for patients who have failed all other conservative options.
The evidence is not robust, but side effects and complications are minimal. Possible mechanism of action may be that the acupuncture needles cause local microtrauma which results in an inflammatory (healing) response.
There is no one treatment that has a reliably successful, quick and easy cure for Achilles tendinopathy. Therefore researchers and doctors are constantly looking for new and better ways of treating Achilles tendinopathy.
Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.
Current treatment options that have little or conflicting evidence in their favour include:
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for Achilles tendinopathy. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.
There are a number of treatments that involve an injection or series of injections for the treatment of Achilles tendinopathy.
Many patients claim to have had excellent temporary pain relief from steroid injections. However steroids weaken tendon tissue and have adverse effects on tendon healing. Any benefit is short lived and at a considerable risk of tendon rupture, weakened tendon tissue and other complications.
Very few foot and ankle orthopaedic surgeons now inject steroids for Achilles tendinopathy due to these risks and lack of long term benefit. We do not carry out this procedure at The London Foot & Ankle Clinic.
This injection is carried out under ultrasound guidance by a consultant radiologist. High concentration glucose and local anaesthetic is injected alongside (not into the tendon itself) the painful area of the tendon.
The aim is to stimulate inflammation and thereby a healing response. Results are mixed and for that reason this should only be undertaken after conservative measures have failed.
In some patients with Achilles tendinopathy there is evidence on utrasound of new blood vessel formation (neovascularisation) around the damaged tendon. These new blood vessels carry with them pain fibres. The high volume injection aims to damage these new vessels and thereby the accompanying nerve supply which in turn should theoretically reduce pain.
Results are mixed and for that reason this should only be undertaken after conservative measures have failed and in suitable patients.
Platelets are cells in the body that help the blood to clot. They are also felt to have important healing properties. In recent years there has been a lot of interest in injecting concentrated platelets into damage tissue to help promote healing. There is little conclusive evidence to show that PRP injections work. We would only consider this option if a patient accepted that a PRP injection:
The procedure involves drawing some blood, spinning it in a centrifuge and then re-injecting it into the tendon under local anaesthetic. Typically 3 courses of injections spaced 1-2 weeks is necessary. Effects will not become apparent for 8-12 weeks.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
This operation involves making a small 2cm incision at the back of the knee and releasing the medial head of the gastrocnemius muscle. It lengthens the calf muscle and relieves the tension across the Achilles tendon. It is very effective in reducing pain and improving in function and has a 85-90% success rate.
The operation is carried out under local anaesthetic and a short sedation. It is a day case procedure so you can expect to go home the same day. As the wound itself is small and the operation involves cutting fascia and not muscle most patients are able to walk out of hospital without crutches and are able to drive within 4 to 5 days. Calf stretching exercises are recommended for 2 weeks post surgery to help maintain the increased length obtained by surgery.
Expect to feel the benefit of the operation 6 to 8 weeks post surgery.
A typical wound following a proximal medal gastrocnemius release
A small incision is made along side the Achilles tendon which is opened in the midline. Damaged and degenerate tendon tissue is removed (debridement). If more than 50% of the cross section of the tendon has had to be removed then the Achilles tendon is augmented with a tendon transfer (from FHL) because of the risk of Achilles tendon rupture.
The Flexor Hallucis Longus (FHL) is a powerful muscle that bends the big toe down, and secondarily helps bend the foot so that it points down. When the Achilles is very damaged (worn and torn from disease) it is advantageous to removed the diseased and damaged portions of the Achilles tendon (which is also a source of pain) and to transfer the FHL tendon to the calcaneum (heel bone). The FHL muscle is normally much smaller than the calf muscles from which the Achilles tendon forms. However as more demand and load is placed across it, so it hypertrophies and gets bigger and stronger, taking over much of the function and load of the calf muscles and by extension the Achilles tendon.
After a year of intensive physiotherapy patients typically report an excellent outcome: pain free heel, normal gait and good strength and power in the leg.
This operation is carried out under general anaesthetic. Almost all cases are done as a daycase. After the operation expect to be in a backslab plaster for at least 2 weeks with high elevation (level of the heart) followed by mobilisation in a boot for roughly 4 weeks. Physiotherapy typically starts around week 3-4 post op and will continue for at least 3 months.
A small midline incision is made and the Achilles tendon exposed. The distal end of the insertion of the Achilles tendon is elevated and the damaged tendon removed (debrided) and excess bone growth (calcified tissue) also excised.
The Achilles tendon is then reinserted into the heel bone (calcaneum). This operation is carried out under general anaesthetic. Almost all cases are done as a daycase. After the operation expect to be in a backslab plaster for at least 2 weeks.
This operation is very successful in removing the bump at the back of the heel and relieving painful symptoms. Advances in technology have enabled this operation to be done safely and effectively.
If more than 50% of the cross section of the tendon has had to be removed then the Achilles tendon is augmented with a tendon transfer (from FHL) because of the risk of Achilles tendon rupture.
This operation tackles the problem of insertional Achilles tendinopathy indirectly. Prior to the introduction of the Speedbridge technique, open surgery was associated with complications such as Achilles tendon reattachment and wound healing problems for example. The Zadek calcaneal osteotomy removes a wedge of bone from the calcaneum (heel bone). The heel bone is then secured with 1 or 2 screws. By removing the wedge of bone, the bump is brought forward and no longer and the Achilles tendon is effectively lengthened and the tension reduced.
This operation is carried out under general anaesthetic. This procedure may be undertaken in suitable patients using a minimally invasive surgical technique. Almost all cases are done as a daycase. After the operation expect to be in a backslab plaster for at least 2 weeks.
A – Zadeks calcaneal osteotomy involves removing a wedge of bone, the yellow dotted line represents the anterior border of the Achilles tendon B – Post Zadeks calcaneal osteotomy the superior calcaneal border is shortened (double blue arrow) and the Achilles tendon (yellow dotted line) is no longer under tension
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Almost all surgical procedures for Achilles tendinopathy will be undertaken as a day case.
Following a proximal medial gastrocnemius release –
You will have a small waterproof dressing applied to the back of the knee. It is advised not to remove this until seen at clinic by Mr Malik at the 2 week follow up.
For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.
Most patients are able to walk comfortably without any aids after the operation. If both legs have been operated on then crutches maybe necessary. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence calf stretching exercises as soon as possible after the operation. Activities can be gradually increased as pain allows.
In addition following an Achilles tendon debridement, Speedbridge or Zadeks calcaneal osteotomy –
You will have a backslab applied post operatively for two weeks.
A photograph of a backslab
You will be non weight bearing for 2 weeks post operatively. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high foot elevation following surgery
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. You will require to wear a special walking boot for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.
You may be referred at this stage for physiotherapy for early rehabilitation and Achilles tendon strengthening exercises.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
X-rays will be requested if a Zadeks calcaneal osteotomy was performed to check that the bone has healed.
Final clinical examination. Discharge if satisfactory.
The time given below is only a guide to the actual surgical time.
For a proximal medial gastrocnemius release
15 minutes
For an Achilles tendon debridement, Speedbridge or Zadeks calcaneal osteotomy
30 to 60 minutes
Most patients are able to drive within a week or two. Please see guidance below.
Following an Achilles tendon debridement, Speedbridge or Zadeks calcaneal osteotomy –
Most patients are able to return to work within 3 to 5 days.
Excellent pain relief and return to sports by 3 to 6 months in approximately 90% of patients.
Excellent pain relief and removal of the obvious “bump” in approximately 80 to 90% of patients. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain and joint deformity.
Ankle arthritis is when arthritis involves the ankle joint.
The ankle joint bone
A – Normal ankle x-ray, white arrows indicate the even joint space (filled with cartilage) B – Abnormal ankle x-ray in a patient with severe arthritis
Any condition that damages the cartilage (joint surface) will cause ankle arthritis to develop.
The common conditions that cause ankle arthritis are:
Clinical radiograph (x-ray) demonstrating post traumatic ankle arthritis in an ankle that was previously fractured (see screws used to fix the break), the other ankle is normal
Typical symptoms of ankle arthritis include:
Clinical picture of patient with bilateral ankle arthritis worse in the right ankle, with obvious deformity at the ankle joint (blue lines)
Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Weight bearing plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they maybe normal. Most people however present when there is some structural damage.
The following are features of arthritis on a plain radiograph:
A – Normal ankle x-ray, yellow line displays normal perpendicular relationship between ankle joint line and tibia, white arrows indicate normal joint space, dotted blue line indicates normal ankle joint line B – Abnormal ankle x-ray, yellow lines show obvious angular deformity, red arrow indicates fracture of fibula due to abnormal stresses, green arrow indicates fibular impingement against side of calcaneum, dotted blue line indicates the now obliterated joint space
MRI is particularly useful in assessing:
A – MRI of ankle arthritis, Reactive bone changes (blue arrow), synovitis (yellow arrow), subchondral cyst (yellow arrow) B – MRI of ankle arthritis, anterior bone growth (shaded blue area) which results in anterior impingement and restricted movement, reactive bone changes (orange arrow), normal subtalar joint (white arrow)
CT images give excellent information on bone structure and is superior to plain radiography in that respect.
CT is particularly useful in the following cases:
Ultrasound is a quick, painless and non invasive method of assessing soft tissue structures.
Ultrasound is particularly good at ascertaining:
Bone scan is a non specific test. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present.
This test is done in special circumstances.
Picture of a bone scan showing increased uptake in the foot
The natural history of ankle arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.
The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe increasing pain and discomfort.
You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:
As the ankle arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.
Grading a disease in medicine is used for the following reasons:
There are a number of grading systems used for arthritis. We use the following grading system based on radiographic (x-ray) features at The London Foot & Ankle Clinic:
As the arthritis gets worse, the grade goes higher.
X-ray and MRI of the ankle in the same patient demonstrating localised arthritis in the joint – with time the disease spreads to involve more of the joint
Non-operative management for ankle arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.
Wearing above ankle boots that give more support to the joint. The use of a shoe with a rocker bottom sole can also help.
Ankle braces give more support and stability to the ankle joint and could ease pain particularly when doing sports and exercise. Custom orthotics in the form of an AFO (ankle foot orthosis) coupled with insoles can be successful in easing symptoms.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with ankle arthritis by reducing inflammation in the joint.
The use of paracetamol and other painkillers to help reduce pain levels.
Physiotherapy works by strengthening muscles around not only the joint but the whole kinetic chain. Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.
The use of a walking stick or cane to reduce the forces going across the damaged joint.
Can relieve the pressure on painful damaged joints.
These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.
Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.
Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.
There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.
There are a number of treatments that involve an injection or series of injections for the treatment of ankle arthritis.
This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.
The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.
Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.
We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of steroid and long acting local anaesthetic is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.
The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.
Injections are not repeated less than 6 monthly intervals.
Please read here for more information regarding injections and possible complications.
A – Placement of fine needle in ankle joint B – Radio-opaque dye confirms needle is in the ankle joint
Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.
It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.
Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. In general, mild deformities can be treated by ankle arthroscopy and debridement while severe deformities may require an ankle fusion.
This is suitable for patients with mild to moderate arthritis. It allows for not only direct visualisation of the joint surfaces (diagnostic) but also treatment as well, such as:
The operation is carried out via keyhole surgery. It is performed under a short general anaesthetic as a daycase.
In a very select group of patients this procedure maybe suitable.
In patients who are not suitable for an ankle arthroscopy and debridement, or have persistent symptoms despite this procedure, BUT are not at a stage where they are ready or suitable for an ankle fusion/replacement, this operation may be recommended. It involves the cutting (osteotomy) the bone (tibia) above the level of the ankle and realigning the ankle joint. The aim of the surgery is to move the weight bearing axis away from the damaged to the healthy cartilage. In some cases the heel bone (calcaneum) may be cut (osteotomy) and the bone shifted to achieve the same result.
For a realignment osteotomy patients ideally should have:
Patients are not suitable for a corrective osteotomy for the following reasons (contraindications):
This operation has excellent outcomes in terms of pain relief and return to activities of daily living including sports. Please read this blog about return to sports after an ankle fusion.
It involves removing all remnants of the diseased joint (cartilage) and fusing the two main bones (tibia and talus) that form the ankle joint together. With no more joint there will be no more movement and therefore no more pain.
The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. Please read this blog for more details.
However, fortunately in the foot and ankle there are several joints that have the same joint movement as the ankle joint, that point the foot up and down (dorsiflexion and plantarflexion). The other joints have enough movement in them to compensate for the loss of movement in the ankle joint for most day-to-day activites.
Gait studies have actually shown an improvement in the gait pattern following an ankle fusion. So contrary to what most people think, after a fusion you will be less likely to limp and have an almost normal if not normal walking pattern.
The operation is usually carried out as a minimally invasive procedure. In case of a severe deformity an open technique maybe used. The operation is undertaken under a general anaesthetic and patients require an overnight stay in hospital.
The main longterm complication following an ankle fusion is the development of adjacent arthritic joint disease, particularly the joint under the ankle called the subtalar joint. Studies report incidence of subtalar joint arthritis from 10 to 50%. In the majority of cases this is not clinically relevant. The main short term complication is non union (the bones not fusing together). This is reported in numerous studies to be around 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.
Currently ankle fusion remains the treatment of choice for end stage ankle arthritis.
A – Clinical picture demonstrating deformity of right ankle as a result of ankle arthritis B – x-ray demonstrating severe arthritis and abnormal biomechanical axis C – clinical picture of ankle 10 weeks post operation D – x-ray post fusion with correction of biomechanical axis
Plain radiographs demonstrating A- severe post ankle fracture arthritis B – successful fusion and deformity correction of the ankle joint (note screws used for fusion have been removed in this case at patients request)
Mr Charnley popularised the total hip replacement in the 1960s for the treatment of hip arthritis. It allowed for pain free joint movement and significant improvement in quality of life. Over the last 50 years there has been incredible advances in technology and biomaterial science. Many changes have been and continue to be made to the total hip replacement. Total hip replacements now have a success rate of around 99% at 10 years and around 90% at 15 years. It is undeniably an orthopaedic success.
Orthopaedic surgeons wish to replicate the success of the total hip replacement by creating similar joint replacements for other arthritic and damaged joints around the body.
In the 1970’s the total knee replacement was introduced and while not as effective as the total hip replacement has a success rate of around 95% at 10 years.
Since the 1990’s orthopaedic foot and ankle surgeons have been testing and developing total ankle replacements. Several different types of ankle replacement have been developed in the last 20 years. In the last 5 years there has been a significant advance and the next generation total ankle replacement promises to offer excellent results in terms of pain free movement and return to function with minimal complications and failure rates.
Total ankle replacement is intended to improve function in patients with limited mobility by restoring alignment, reducing pain and preserving the flexion/extension movement within the ankle joint.
Mr Malik at the London Foot and Ankle Clinic uses the Zimmer Trabecular Metal Total Ankle, the first surgeon in the UK to do so. This latest total ankle replacement removes very little bone and utilises innovative technology. More information about this ankle replacement can be found here.
So why consider a total ankle replacement?
Who would be suitable for an ankle replacement?
Patients are not suitable for a total ankle replacement for the following reasons (contraindications):
A + B Radiographs demonstrating post traumatic ankle arthritis C + D treated successfully with a total ankle replacement
All surgical procedures for ankle arthritis will be carried out under a general anaesthetic.
Following ankle arthroscopy and debridement
You will have a small waterproof dressing applied to the front of the ankle to cover the arthroscopy portal sites and a bandage applied. It is advised not to remove this bandage for 48 hours and certainly not to remove the underlying dressings covering the wounds until reviewed by Mr Malik at the 2 week post operative check up. For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.
Weight bearing status will really depend on how much has been done in side the ankle. Most patients are touch weight bearing for 48 hours and then weight bear as tolerate after that with or without the use of crutches. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence ankle range of motion exercises as soon as possible after the operation to prevent stiffness. Activities can be gradually increased as pain allows.
In addition following an ankle supramalleolar osteotomy, ankle fusion and total ankle replacement –
You will be non weight bearing for approximately 6 to 8 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
A photograph demonstrating high foot elevation after surgery
You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection. Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months. If completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
A referral to physiotherapy will be made at this stage. This is the earliest you may return to work.
In addition following an ankle supramalleolar osteotomy and ankle fusion –
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your ankle will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.
In addition following a total ankle replacement –
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your ankle will be placed in a fixed walker boot and you will be allowed to touch weight bear. Early range of motion exercises will commence at this stage.
Significant improvement in swelling and pain. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
Full weight bearing through a fixed walker boot will be expected at this stage and weaning off the boot gradually over the next 4 weeks. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
Following an ankle supramalleolar osteotomy and ankle fusion
Check radiographs should show signs of bone healing.
Following a total ankle replacement
Check radiographs should show excellent secure positioning of the prosthesis. Patients after an ankle replacement are followed up at yearly interviews due to the lack of robust longterm data.
For an ankle arthroscopy and debridement
Up to 60 minutes.
For an ankle supramalleolar osteotomy and ankle fusion
60 to 90 minutes.
For an ankle replacement
Around 120 minutes.
For an ankle arthroscopy and debridement –
Most patients are able to drive after two weeks. Please see guidance below.
For an ankle supramalleolar osteotomy, ankle fusion and total ankle replacement –
Not for at least 3 months post surgery.
Following ankle arthroscopy and debridement –
Most patients are able to return to work within 10 to 14 days.
Following an ankle arthroscopy and debridement –
Excellent pain relief and return to sports by 3 to 6 months. Failure of this outcome warrants further investigation and possible treatment.
For an ankle supramalleolar osteotomy –
Excellent pain relief and return to full activities of daily living. In some cases return to sport. Delay the progression of further arthritis. Possible need for further surgery. Aim is for this operation to delay the need for an ankle fusion by at least 5 years.
For an ankle fusion –
Excellent pain relief and return to full activities of daily living.
For a total ankle replacement –
Excellent pain relief and return to full activities of daily living. A yearly review will be necessary to monitor the ankle prosthesis.
After suffering with my ankle arthritis for quite sometime it became such a constant pain that it was becoming unbearable, and really was only getting worse and not better. After speaking to Mr Malik and going through some possible options I thought a Total Ankle Replacement would benefit me more as I wanted to keep the range of movement and have as normal an ankle as possible.
Would it even work? I understand every operation can come with risks but as the total ankle replacement is one of the less common joint replacements the success rate didn’t seem very high. I was also concerned with the length of time I would not be able to use the operated foot as it would be completely non weight bearing for 6 weeks.
The surgery went very well with no problems at all, everything had gone smoothly. I had a regional block so when I woke I was in no pain and that lasted for me until the next day. Once the block wore off the pain was then controlled by pain relief, pain is better treated before it arrives so a regular regime of pain killers were taken throughout my 3 night stay with some continued at home if needed. My operated foot was in a cast and elevated from the moment I woke and that was mandatory to keep it like that for the first two weeks to reduce as much swelling as possible.
I went to see Mr Malik for my 2 week check up, the operated ankle was healing great so stitches were removed and plaster cast was off and my ankle was placed into an Aircast walker boot which was a nice change. I was still advised to keep the foot elevated to help with the swelling which wasn’t a problem as I would still be non weight bearing for 4 more weeks. I went back for my 6 week review and had a few x-rays done which also showed everything is how it should and was healing well. I am now currently on week 8, fully weight bearing in no boot and best of all no pain.
I would say just being laid up for sometime, it could become very frustrating as you really won’t be able to do an awful lot yourself and will need to depend on those around you, but you do get set into a new routine and the days start passing by quickly.
Definitely opt for it. To be a few weeks down the line and have no pain is just amazing I cannot believe the difference. Just be patient and follow any advice/instructions given as it really does get better day by day. Make sure your prepared for the recovery time, plan home activities, find a new hobby, anything that will help with the weeks you wont be able to participate in normal activities. The key is to just rest and above all keep weight off the operated ankle and let it heal.
This is when the Achilles tendon at the back of your heel tears. The injury can be complete or partial.
An Achilles tendon tear can be acute or chronic depending on when the diagnosis is made. An injury presenting after 4 weeks would be considered chronic.
It typically occurs when the Achilles tendon is suddenly and forcibly stretched while weight bearing.
It more commonly occurs in males aged 30 to 40 who are participating in sports. However it can affect anyone of any age and from seemingly innocuous events such as stepping off a kerb.
Risk factors for Achilles tendon rupture include:
Symptoms vary considerably. Some patients describe feeling as if they had been “kicked from behind” while others feel they had “sprained” their ankle. Often their is a loud audible “bang” or “pop” at the time of injury.
Most patients will describe considerable swelling and bruising shortly after their injury. Some people struggle to walk while others may have only a mild limp. Due to the varied presentation and symptoms, not surprisingly up to a quarter of Achilles tendon ruptures are missed.
Clinicians looking for a fracture (broken bone) on an x-ray will be falsely reassured when they see a normal x-ray. Tendons do not show up on an x-ray and Achilles tendon ruptures are not diagnosed in this way.
The diagnosis of acute Achilles tendon rupture is a clinical one based on history and examination findings.
On examination the following is noted:
Clinical picture of an acute achilles tendon rupture
Clinical picture of a patient with chronic right Achilles tendon rupture, note the thickened Achilles tendon and loss of normal resting tone and position of the foot (blue arrow)
Ultrasound is a quick, painless and non invasive method of visualising the Achilles tendon. It offers excellent real time high definition images of the Achilles tendon. The radiologist will be making note of the following during the examination:
MRI provides excellent high definition static images. It is useful in pre operative planning particularly with Chronic Achilles tendon ruptures, and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
If one has sustained a partial tear of the Achilles tendon, left alone and untreated it can lead to a full rupture.
Patients with a complete Achilles tendon rupture left untreated will find that their gait pattern (the way you walk) will be affected, with difficulty in push-off (plantarflexion power) and subsequent limp. This will have a knock-on effect with some patients then complaining of knee, hip and back pain. There may also be reduced ankle stability.
Achilles tendon chronic rupture MRI
The aim of surgery or non operative treatment is allow the two ends of the tendon to come together. This can be achieved non operatively by placing the foot in an equinus position. This is where the toes are pointing down maximally. This brings the two ends of the tendon together and is a very effective way of treating this condition as long as it has been picked up acutely.
An ultrasound scan can help in confirming that the two ends of the tendon have indeed come together. Where there is a persistent gap or the injury has been missed and is chronic, surgery is advised to help bring the two ends of the tendon together and decrease the complications.
Patients treated non-operatively will typically have a plaster applied for two weeks in full equinus and be non weight bearing. At the two week stage they can then go into a boot with four wedges and start full weight bearing. At weekly intervals thereafter one wedge is removed at a time. This will gradually bring the foot into a plantigrade position at the six week post injury mark.
At two weeks, patients will be able to start active plantarflexion exercises with restricted dorsiflexion for a further 3 to 4 weeks. Physiotherapy typically recommences at weeks 3-4 post injury, and will continue for up to six months. It can take up to nine months for Achilles tendon ruptures to heal. It is important to follow the physiotherapy rehab regime and not to return to sports too soon as there is a re-rupture risk typically four months post-injury.
To summarise non operative management maybe suitable in the following cases:
Surgery involves bringing together the two ends of the torn Achilles tendon. The advantage of surgery is that potentially there is a:
Surgery may also be advised in the presence of a large gap, proven on ultrasound.
The actual operation would be undertaken under general anaesthetic and in almost all cases would be done as a day case procedure.
In the first instance the surgical repair would be undertaken using a minimally invasive surgical (MIS) technique.
MIS Achilles tendon repair A – A small incision is made at the site of the Achilles tendon rupture B – The tendon ends are brought together and repaired C – The wound is closed with minimal soft tissue damage images courtesy of Arthrex
Most surgeons would agree that patients with symptomatic chronic Achilles tendon ruptures require surgery.
The exact details of the operation depend on the individual case:
For small defects, and under 3 months presentation an end to end repair with FHL tendon transfer may be possible.
For large and chronic defects an FHL tendon transfer with or without interposition graft, V-Y tendon alignment and turn down flap may be necessary.
Almost all surgical procedures for Achilles tendon rupture will be undertaken as a day case.
A picture of a backslab plaster
A picture demonstrating high elevation
At this stage you can will go into a boot with four wedges and start full weight bearing. At weekly intervals thereafter one wedge is removed at a time. This will gradually bring the foot into a plantigrade position at the six week post injury mark. Short trips can be made outside, within limits of pain and swelling.
Excellent pain relief and return to full function. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
My right ankle had been mildly aching (especially when walking uphill) since Feb, but on 28th Aug while walking the dog I tripped on my left foot and put my right foot down heavily to save myself. It was immediately very painful, but I thought I had just sprained my ankle and that it would get better with rest, ice packs etc When it did not improve I went to my GP who thought it was an Achilles problem and referred my to Mr Malik. He saw me on 19th Sept and thought I had severed the tendon, which was confirmed by an ultrasound scan which showed the ends of the tendon were 2cm apart. He operated to repair the tendon on 23rd Sept.
Very few really. I obviously had to have the operation and Mr Malik’s confident approach gave me confidence as well.
The 2 weeks in the plaster when I had to keep all weight off my right foot. All daily tasks were a challenge, especially as my left ankle is not that strong.
I needed an Achilles tendon reconstructed (a tendon transfer) because I ruptured it during a fall at the beginning of August 2015. The tear measured 26mm but was not diagnosed when I first attended High Wycombe Minor Injuries Clinic.
I was concerned about undergoing a major operation at the age of 82 years and was frightened and worried whether the operation would be successful. I felt it might be better to leave things as they were because my damaged leg was not painful. The problem was that it was causing my other side, already damaged by a previous dislocation of the shoulder, to become extremely painful and made walking very difficult.
Surprisingly I found the experience much more straightforward than I anticipated. The treatment could not have been better. The cleanliness of High Wycombe Hospital was immaculate and the food was excellent. Mr. Malik and all the nursing staff could not have been more helpful or attentive. They changed my whole expectations of the NHS. I cannot speak too highly of my treatment. Since the operation I have been undergoing Physiotherapy with Mr. Zahoor at Amersham Hospital. He is extremely patient and clear in his explanation of my treatment and exercise programme.
The most challenging part of the procedure was not being able to bear weight on my foot. As I was in plaster for two weeks it was impossible for me to hop, even to the toilet.
I would advise any future patient to consider carefully the advice given by their consultant. I really did not want the operation but Mr. Malik was confident, despite my age, that I should go ahead because the Achilles injury would cause further problems to my other side. He was right because it worsened prior to the operation. If you are offered treatment by Mr. Malik, grab the opportunity with both hands. I send my thanks and gratitude to everyone.
I had been in some discomfort since June and a long hilly walk in unwise footwear. In August I had a fall which hurt a lot, but was not thought to be more than a sprain at first. After a couple of months when rest had not improved things I went to my local doctor and persuaded him to take a bit more interest because I was finding it difficult to do all the normal things I do, including cycling with a club, quite long walks and standing at work. A scan immediately showed what was needed.
Had I left it too late to expect a perfect repair? Would I be able to cope with a long period of inactivity? Could I persuade anyone to look after me for however long it took?
The operation was so easy from my point of view, quick , virtually painless, no after effects from the anaesthetic . The instructions in using crutches (including up and down steps) were adequate if rather brief, but adequate, the first plaster was less uncomfortable than I had expected, but having to hop for two weeks was not good for my back. The boot was not uncomfortable except in bed (but it did not keep me awake). We borrowed a wheelchair for a brief trip to the seaside and it was very useful.
It was an effort to fit in my normal busy life style, but fortunately I had a caring and competent partner and I was able to drive my automatic. Minor annoyances were mainly, being only temporarily incapacitated, I was unable to use locked public toilets or specific parking spaces. ( Fortunately I also have a friend with a blue card, so we went out together quite a lot). It was also virtually impossible to shower for the first two weeks, but no one complained!
You will need a really good friend for the first two weeks. Rest as instructed, but once mobile take sensible exercise, if it does not hurt keep moving just a bit. Try to do normal things, but take your time.
An accessory navicular is an extra bone found next (proximal) to the navicular bone. It occurs in up to 1 in 10 of the normal population. It is the most common accessory bone in the foot. It is in continuity with the tibialis posterior tendon which inserts into the navicular tuberosity.
Please see foot & ankle anatomy for more information about the navicular and the tibialis posterior tendon.
The underlying cause is unknown but there may be a genetic predisposition.
Most people with an accessory navicular are asymptomatic and not even aware that they have an “extra” bone. However it can cause symptoms particularly around adolescence. It can be associated with a flat foot deformity, and certainly if this is a unilateral finding, needs to be investigated.
The joint between the navicular and the accessory bone is know as a synchondrosis. Trauma or repetitive sprains to the foot can result in injury to the synchondrosis or the tibialis posterior tendon, resulting in abnormal motion and pain.
Typical symptoms include:
Radiographs will be arranged at your initial clinic consultation. These will help confirm the diagnosis, the severity of the deformity and aid in pre operative planning.
Accessory navicular is classified according to the radiographic features:
Clinical radiograph demonstrating Type 1 Accessory Navicular in the right foot
Clinical radiograph demonstrating Type 2 Accessory Navicular in the left foot and a Type 3 Accessory Navicular in the right foot
Occasionally an MRI scan may be requested to assess the state of the tibialis posterior tendon, rule out a navicular stress fracture and determine whether there has been any irritation or damage to the synchondrosis.
The vast majority of people with an accessory navicular are asymptomatic. It is a condition that can get worse with trauma or repetitive stress injury.
If there is a history of increasing pain, inability to do sports and development of deformity you may wish to consult with your orthopaedic foot & ankle surgeon, Mr Malik.
Non-operative management aims at relieving pain and limiting deformity progression. It is likely to be most effective in the early stages of the condition.
A period of rest from sports and strenuous exercise.
Made of gel or foam, can be worn over the prominent bump to protect from direct pressure and rubbing against footwear.
Provide more support to the ankle and prevent it from turning in.
Custom insoles with an arch support will minimise forces going through the tibialis posterior tendon. It will also prevent the foot from rolling inwards.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from a painful and inflamed synchondrosis.
Wearing a wider shoe to accommodate the bump. A shoe with a stiff sole may also help.
Calf stretches will minimise the deforming force a tight calf muscle has on the foot. Tibialis posterior strengthening exercises.
A short period of cast immobilisation may help alleviate symptoms.
Injection under image guidance and a short general anaesthetic can help confirm the diagnosis as well as treat an acutely inflamed synchondrosis.
An injection may offer short to mid term relief and occasionally may cure any symptoms. An injection will not correct any underlying bony or foot deformity.
Injection under x-ray control with correct placement of needle confirmed with dye
This procedure involves excising the accessory navicular and re-insertion of the tibialis posterior tendon. This is done with the use of bone anchors.
This procedure will not on its own correct a fallen (acquired) arch. Please read flat feet for further information regarding surgical correction of a flat foot deformity.
Almost all surgical procedures for an accessory navicular excision will be undertaken as a day case.
A picture of a backslab cast
A picture demonstrating high elevation of a foot with a backslab cast
You may be referred at this stage for physiotherapy for early rehabilitation and tibialis posterior strengthening exercises.
Excellent pain relief and removal of the obvious “bump”. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
