Foot and Ankle
The foot and ankle in the human body work together to provide balance, stability, movement, and Propulsion.
This complex anatomy consists of:
- 26 bones
- 33 joints
- Blood vessels, nerves, and soft tissue
The ankle joint is composed of three bones: the tibia, fibula, and talus which are articulated together. The ends of the fibula and tibia (lower leg bones) form the inner and outer malleolus, which are the bony protrusions of the ankle joint that you can feel and see on either side of the ankle. The joint is protected by a fibrous membrane called a joint capsule, and filled with synovial fluid to enable smooth movement.
Ankle injuries are very common in athletes and in people performing physical work, often resulting in severe pain and impaired mobility. Pain after ankle injuries can either be from a torn ligament and is called ankle sprain or from a broken bone which is called ankle fracture. Ankle fracture is a painful condition where there is a break in one or more bones forming the ankle joint. The ankle joint is stabilized by different ligaments and other soft tissues, which may also be injured during an ankle fracture.
Ankle fractures occur from excessive rolling and twisting of the ankle, usually occurring from an accident or activities such as jumping or falling causing sudden stress to the joint.
With an ankle fracture, there is immediate swelling and pain around the ankle as well as impaired mobility. In some cases blood may accumulate around the joint, a condition called hemarthrosis. In cases of severe fracture, deformity around the ankle joint is clearly visible where bone may protrude through the skin.
Types of fractures
Ankle fractures are classified according to the location and type of ankle bone involved. The different types of ankle fractures are:
- Lateral Malleolus fracture in which the lateral malleolus, the outer part of the ankle is fractured.
- Medial Malleolus fracture in which the medial malleolus, the inner part of the ankle, is fractured.
- Posterior Malleolus fracture in which the posterior malleolus, the bony hump of the tibia, is fractured.
- Bimalleolar fractures in which both lateral and medial malleolus bones are fractured
- Trimalleolar fractures in which all three lateral, medial, and posterior bones are fractured.
- Syndesmotic injury, also called a high ankle sprain, is usually not a fracture, but can be treated as a fracture.
The diagnosis of the ankle injury starts with a physical examination, followed by X-rays and CT scan of the injured area for a detailed view. Usually it is very difficult to differentiate a broken ankle from other conditions such as a sprain, dislocation, or tendon injury without having an X-ray of the injured ankle. In some cases, pressure is applied on the ankle and then special X-rays are taken. This procedure is called a stress test. This test is employed to check the stability of the fracture to decide if surgery is necessary or not. In complex cases, where detail evaluation of the ligaments is required an MRI scan is recommended.
Immediately following an ankle injury and prior to seeing a doctor, you should apply ice packs and keep the foot elevated to minimize pain and swelling.
The treatment of ankle fracture depends upon the type and the stability of the fractured bone. Treatment starts with non-surgical methods, and in cases where the fracture is unstable and cannot be realigned, surgical methods are employed.
In non-surgical treatment, the ankle bone is realigned and special splints or a plaster cast is placed around the joint, for at least 2-3 weeks.
With surgical treatment, the fractured bone is accessed by making an incision over the ankle area and then specially designed plates are screwed onto the bone, to realign and stabilize the fractured parts. The incision is then sutured closed and the operated ankle is immobilized with a splint or cast.
After ankle surgery, you will be instructed to avoid putting weight on the ankle by using crutches while walking for at least six weeks.
Physical therapy of the ankle joint will be recommended by the doctor. After 2-3 months of therapy, the patient may be able to perform their normal daily activities.
Risks and complications
Risks and complications that can occur with ankle fractures include improper casting or improper alignment of the bones which can cause deformities and eventually arthritis. In some cases, pressure exerted on the nerves can cause nerve damage, resulting in severe pain.
Rarely, surgery may result in incomplete healing of the fracture, which requires another surgery to repair.
The calcaneus or heel bone is a large bone found on the rear part of the foot. The calcaneus connects with the talus and cuboid bones to form the subtalar joint of the foot. A fracture is a break in a bone from trauma or various disease conditions. The types of fracture to the calcaneus depend on the severity and include stable fractures, displaced fractures, open fractures, closed fractures and comminuted fractures.
A fracture of the calcaneus is most commonly due to a traumatic event such as falling from a height, twisting injury, motor accidents, sports injuries and ankle sprain.
Fracture of the calcaneus is considered serious and can cause longstanding problems if not treated correctly. Stiffness and pain in the joint and arthritis are commonly reported risks of a calcaneal fracture.
The commonly seen signs and symptoms of calcaneal fractures are
- Pain in the heel
- Swelling in the heel
- Bruises in the heel
- Inability to walk or bear weight on the foot
The evaluation of the calcaneal fracture is done by imaging i.e., X-ray and CT scan. Based on the severity of the fracture, the doctor recommends the plan of treatment.
Calcaneal fractures are treated based on the type of fracture and extent of soft tissue damage.
- Nonsurgical treatment
- Rest, ice, compression, and elevation (R.I.C.E.) – is the most commonly used treatment option. Staying off (resting) the injured foot can heal the fracture to a great extent. Covering the affected area with ice packs over a towel reduces swelling and pain. Compression stockings and elastic bandages can also aid in healing the pain. Positioning the feet above the level of heart reduces swelling.
- Immobilization – Casting the injured foot prevents the fractured bone from moving. Walking with the help of crutches is advisable to avoid bearing body weight until healing has occurred.
- Surgical treatment
- Open reduction and internal fixation – This surgery involves putting the bone fragments back together with metal plates and screws to reposition them and set them to normal alignment.
- Percutaneous screw fixation – This is the best preferred treatment in cases where the bone pieces are large. The bone can either be pushed or pulled to set into place without making a large incision. Metal screws are then inserted and fixed through small incisions to hold the bone pieces together.
Irrespective of the treatment procedure, the patient is recommended to undergo physiotherapy and practice simple exercises regularly to help restore function. This would help the muscles to gain flexibility and after complete recovery, the patient can resume their daily living with normal activities.
Lisfranc (Midfoot) Fracture
Tarsometatarsal joint refers to the region found in the middle of the foot. It is also called as Lisfranc joints. It is a junction between the tarsal bones (group of seven articulating bones in the foot) and metatarsal bones (a group of five long bones in the foot). A deformity in the tarsometatarsal region can be due to arthritis and traumatic motor accidents.
Tarsometatarsal arthritis is characterized by pain, functional impairment and midfoot instability. The appearance of bruises and swelling on the dorsal side of the midfoot are the commonly observed symptoms. The doctor will first examine the physical condition of the foot by inspection and palpation (feeling with hands). You may be advised to get an X-ray taken. You might also be sent to get a CT or MRI scan done to provide more information about your condition.
The early stages of injury can be treated by analgesics, steroid injections and by wearing special footwear or casts. Tarsometatarsal joint fusion is recommended if all the non-surgical procedures fail to show efficacy in treating the injury.
Stress Fractures of the Foot and Ankle
A stress fracture is described as a small crack in the bone which occurs from an overuse injury of a bone. It commonly develops in the weight bearing bones of the lower leg and foot. When the muscles of the foot are overworked or stressed, they are unable to absorb the stress and when this happens the muscles transfer the stress to the bone which results in stress fracture.
Stress fractures are caused by a rapid increase in the intensity of exercise. They can also be caused by impact on a hard surface, improper footwear, and increased physical activity. Athletes participating in certain sports such as basketball, tennis or gymnastics are at a greater risk of developing stress fractures. During these sports the repetitive stress of the foot strike on a hard surface causing trauma and muscle fatigue. An athlete with inadequate rest between workouts can also develop stress fracture.
Females are at a greater risk of developing stress fracture than males, and may be related to a condition referred to as “female athlete triad”. It is a combination of eating disorders, amenorrhea (irregular menstrual cycle), and osteoporosis (thinning of the bones). The risk of developing stress fracture increases in females if the bone weight decreases.
The most common symptom is pain in the foot which usually gets worse during exercises and decreases upon resting. Swelling, bruising, and tenderness may also occur at a specific point.
Your doctor will diagnosis the condition after discussing symptoms and risk factors and examines the foot and ankle. Some of the diagnostic tests such as X-ray, MRI scan or bone scan may be required to confirm the fracture.
Stress fractures can be treated by non-surgical approach which includes rest and limiting the physical activities that involves foot and ankle. If children return too quickly to the activity that has caused stress fracture, it may lead to chronic problems such as harder-to-heal stress fractures. Re-injury can also occur without allowing the stress fracture to completely heal.
Protective footwear may be recommended which helps to reduce stress on the foot. Your doctor may apply cast to the foot to immobilize the leg which also helps to remove the stress. Crutches may be used to prevent the weight of the foot until the stress fracture is healed completely.
Surgery may be required if the fracture is not healed completely by non-surgical treatment. Your doctor makes an incision on the foot and uses internal fixators such as wires, pins, or plates to attach the broken bones of the foot together until healing happens after which these fixators can be removed or may be permanently left inside the body.
Some of the following measures may help to prevent stress fractures:
- Ensure to start any new sport activity slowly and progress gradually
- Cross-training: You may use more than one exercise with the same intention to prevent injury. For example you may run on even days and ride a bike on odd days, instead of running every day to reduce the risk of injury from overuse. This limits the stress occurring on specific muscles as different activities use muscles in different ways.
- Ensure to maintain a healthy diet and include calcium and vitamin D-rich foods in your diet
- Ensure that your child uses proper footwear or shoes for any sports activity and avoid using old or worn out shoes
- If your child complains of pain and swelling then immediately stop the activities and make sure that your child rests for few days
The talus is a small bone at the ankle joint that connects the heel bone and the two bones of the lower leg, enabling the up and down movement of the foot. Fractures in the talus bone may occur due to a fall from great heights, motor vehicle accidents or twisting of the ankle. The symptoms include severe ankle pain, inability to walk, swelling and tenderness.
When you present to the clinic with these symptoms, your doctor will perform a thorough physical examination and order an X-ray or CT-scan to diagnose the location and severity of the fracture. Talus fractures are treated by either non-surgical or surgical methods.
Non-surgical treatment: If the bone has not moved out of alignment, your doctor will place your ankle in a cast for 6 to 8 weeks. You will be advised to perform exercises to help strengthen your foot and ankle and restore range of motion once the cast is removed.
Surgical treatment: Your surgeon realigns the fractured bone and stabilizes it with metal plates and/or screws. Small bone fragments may be removed and replaced with bone graft. After surgery, you may have to wear a cast for 6 to 8 weeks until complete healing. Physical therapy exercises will be initiated to restore movement.
Toe and Forefoot Fractures
The forefoot is the front of the foot that includes the toes. Fractures occurring in this part of the foot are painful but very often not disabling. There are 2 types of fractures namely, traumatic fracture and stress fracture. Traumatic fractures occur when there is a direct impact of your foot on a hard surface. Stress fractures are tiny hair line cracks in the bone, most commonly caused due to repeated stress. The symptoms of toe and forefoot fractures include pain, bruising, swelling and inability to walk.
To detect toe and forefoot fractures, your doctor conducts a physical examination of the foot, and may order X-ray’s to identify the location and severity of the fracture. Toe and forefoot fractures can be treated by the following ways:
- Rest: Adequate amount of rest can sometimes help heal a traumatic fracture.
- Splinting: Splints may be applied to keep the toe in a fixed position.
- Rigid shoe: A stiff-soled shoe may be recommended to protect the toe and position it correctly.
- Buddy taping: The fractured toe is taped to the adjacent toe with a gauze pad between the toes.
- Surgery: Your doctor realigns the fractured bones using pins or screws to hold the bones together in place until they heal completely.
The foot has 26 bones, and can be divided into 3 parts:
- The hind foot is comprised of two bones, the talus bone which connects to the bones of the lower leg, and the calcaneus bone which forms the heel.
- The midfoot is comprised of the navicular, cuboid, and three cuneiform bones.
- The forefoot is made up of five metatarsal bones and 14 toe bones called phalanges.
The hind foot is separated from the midfoot by the mediotarsal joint and the midfoot is separated from the forefoot by the lisfranc joint. Muscles, tendons and ligaments support the bones and joints of the feet enabling them to withstand the entire body’s weight while walking, running and jumping. Despite this, trauma and stress can cause fractures in the foot. Extreme force is required to fracture the bones in the hind foot. The most common type of foot fracture is a stress fracture, which occurs when repeated activities produce small cracks in the bones.
Types of foot fractures
Foot fractures can involve different bones and joints and are classified into several types:
- Calcaneal fractures: This type affects the heel bone and occurs mostly as a result of high-energy collisions. It can cause disabling injuries and if the subtalar joint is involved it is considered a severe fracture.
- Talar fractures: The talus bone helps to transfer weight and forces across the joint. Talus fractures usually occur at the neck or mid portion of the talus.
- Navicular fractures: Navicular fractures are rare and include mostly stress fractures that occur with sports activities, such as running and gymnastics, as a result of repeated loading on the foot.
- Lisfranc fractures: This type of fracture occurs due to excessive loading on the foot, which leads to stretching or tearing of the midfoot ligaments.
Foot fractures commonly occur as a result of a fall, motor vehicle accident, dropping a heavy object on your foot, or from overuse such as with sports.
The common symptoms of a foot fracture include pain, bruising, tenderness, swelling, deformity and inability to bear weight.
Your doctor diagnoses a foot fracture by reviewing your medical history and performing a thorough physical examination of your foot. Imaging tests such as X-rays, MRI or CT scan may be ordered to confirm the diagnosis. Navicular fractures can be especially difficult to diagnose without imaging tests.
Treatment depends on the type of fracture sustained. For mild fractures, nonsurgical treatment is advised and includes rest, ice, compression, and elevation of the foot. Your doctor may suggest a splint or cast to immobilize the foot. For more severe fractures, surgery will be required to align, reconstruct or fuse the joints. Bone fragments may be held together with plates and screws.
Physical therapy may be recommended to improve range of motion and strengthen the foot muscles. Weight bearing however should be a gradual process with the help of a cane or walking boot.