Treatments of the Ankle

The Achilles tendon is the largest tendon in your body. It connects the upper calf muscles to the back of the heel bone. When the Achilles tendon degenerates and becomes inflamed, it is called Achilles tendinosis. If you have Achilles tendinosis, your tendon can swell and become painful. This condition is common in athletes, runners, and people who have calf tightness. Achilles tendinosis may occur in the middle of the tendon (known as midsubstance Achilles tendinosis) or at the point where the tendon connects to the heel bone (known as insertional Achilles tendinosis).

For midsubstance Achilles tendinosis, surgery focuses on removing the diseased portion of the tendon. If most of the tendon is damaged, your foot and ankle orthopaedic surgeon often will use the tendon that goes to the big toe to support the Achilles tendon after repair. Other procedures may include lengthening the Achilles tendon or calf muscles if they are too tight.

The goal of Achilles tendon repair is to reconnect the calf muscles with the heel bone to restore push-off strength. Regaining Achilles tendon function after an injury is critical for walking.

Ankle arthroscopy is a minimally invasive surgical procedure that orthopaedic surgeons use to treat problems in the ankle joint. Ankle arthroscopy uses a thin fiber-optic camera (arthroscope) that can magnify and transmit images of the ankle to a video screen. Ankle arthroscopies can reduce ankle pain and improve overall function.

Arthroscopy can be used to diagnose and treat different disorders of the ankle joint. The list of problems that can sometimes be treated with this technology is constantly evolving and includes:

Ankle arthritis: Ankle fusion is a treatment option for many patients with end-stage ankle arthritis. Ankle arthroscopy offers a minimally invasive way to perform ankle fusion. Results can be equal to or better than open techniques.

Ankle fractures: Ankle arthroscopy may be used along with open techniques of fracture repair. This can help to ensure normal alignment of bone and cartilage. It also may be used during ankle fracture repair to look for cartilage injuries inside the ankle.

Ankle instability: Ligaments of the ankle can become stretched out, which can lead to a feeling that the ankle gives way. These ligaments can be tightened with surgery. Arthroscopic techniques may be an option for treating moderate instability.

An ankle cheilectomy is a surgery that removes a bone spur from the talus or tibia, which are the lower and upper bones of the ankle joint. 

The goal of an ankle cheilectomy is to relieve ankle pain caused by bone impingement or pinching at the front of the ankle. While this may be a sign of early ankle arthritis, an ankle cheilectomy is a joint preserving option that may help with pain and function and buy time before additional treatment is needed.

The ankle is made up of three bones:

• the tibia (shin bone), which forms the inside, front, and back of the ankle
• the fibula, which forms the outside of the ankle
• the talus, a small bone that sits between the tibia and fibula and the heel bone

The ends of these bones are called malleoli. The tibia has a medial (inside) malleoli and a posterior malleoli. The fibula forms the lateral (outside) malleoli. 

Distraction arthroplasty is a distraction (stretching out) of the ankle joint. The ankle is held in this distracted position for a period of time. This technique is used to unload  the ankle joint and allow healing of the damaged joint. It may be recommended for a patient who has ankle arthritis.

The major goal of this treatment is healing of damaged tissue that occurs from arthritis. Distracting and unloading the ankle joint, along with the use of range of motion activity, is believed to help restore some of the damaged tissue in the ankle. With this restoration, a patient may be able to avoid or delay a more invasive procedure such as an ankle fusion or total ankle replacement. This allows patients to maintain motion of the ankle joint, which would be lost with an ankle fusion, and potentially avoid activity restrictions that may be necessary after an ankle replacement.

The flexor hallicus longus (FHL) is the primary flexor muscle of the big toe. It originates at the back of the leg, transitions into a long tendon as it enters the foot and attaches on the bottom of the big toe.

The peroneus brevis (PB) muscle starts in the leg and continues along the outside of the ankle. It then takes a sharp turn and ends on the outside of the foot. The peroneus brevis works with the peroneus longus (PL) to turn the ankle and foot outward. 

The FHL to PB tendon transfer is a surgery to improve the function of the foot. The FHL is passed behind the ankle to the outside of the foot to either assist or replace the damaged PB tendon.

The goal of this surgery is to restore the power of the ankle and foot to turn outward, which is required for cutting and turning movement. 

Ankle sprains are one of the most common sports-related injuries. They affect 10,000 people per day. When the ligaments on the outside of the ankle are stretched or torn, patients can have pain and feelings of instability. If symptoms persist after non-surgical treatment, surgery may be required. The goal of this surgery is to restore normal stability to the ankle. This should also fix your feeling that the ankle “gives way” and any pain that is associated with an unstable ankle.

Each foot has five metatarsals. These are the long bones of the foot. They connect the toes to the rest of the foot. They also make the ball of the foot. The lesser metatarsals are the bones that connect to the second through fifth toes (not the first, or big toe). 

An osteotomy is a cut made in the bone. It is similar to breaking the bone but in a very controlled manner. A lesser metatarsal shortening osteotomy changes the pressure distribution under the ball of the foot, relieving pain. It also can be used to put a chronically dislocated toe back in position.

Percutaneous Achilles tendon lengthening in a procedure used to stretch a tight Achilles tendon and increase motion at the ankle joint.

The tibia (shin bone) and the fibula are the bones of the lower leg. Pilon fractures are injuries that occur at the lower end of the tibia and involve the weightbearing surface of the ankle joint. The fibula also may be broken. These injuries were first described more than 100 years ago and remain one of the most challenging problems for orthopaedic surgeons to treat. Common causes of pilon fractures are falls from a height and car accidents. 

The goals of pilon fracture surgery are to restore alignment and stability and allow healing of the tibia and fibula at the ankle joint. Once the fractures are healed, your foot and ankle orthopaedic surgeon's goals are to restore movement and strength at the patient’s ankle. 

Posterior ankle endoscopy/arthroscopy is a technique used to look at and treat problems in the back of the ankle. 

First, it’s important to understand ankle anatomy. The ankle joint is the joint between the lower leg bones (tibia and fibula) and the ankle bone (talus). The joint below the ankle joint is called the subtalar joint; it lies between the ankle bone and the heel bone (calcaneus). The talus has a bony prominence in the back next to the flexor hallucis longus (FHL) tendon. This is the tendon that moves the big toe downward toward the floor.

The bony posterior prominence might be the cause of ankle pain in some people if it is large (called a trigonal process) or it is not completely fused with the talar bone (called an os trigonum).

The subtalar joint is located just below the ankle joint between the talus and the calcaneus (heel bone). The main job of the subtalar joint is to allow for side-to-side movement of the foot and ankle. This movement aids in walking, especially on uneven surfaces.

Parts of the ankleWhen there is a problem in the subtalar joint, the location of pain is described as being deep. The exact location may be hard to describe. Pain may be felt in the soft spot on the outside of the ankle or in a horseshoe distribution behind and below the ankle.

The subtalar joint is located just below the ankle joint between the talus and the calcaneus (heel bone). The main job of the subtalar joint is to allow for side-to-side movement of the foot and ankle. This movement aids in walking, especially on uneven surfaces.

When there is a problem in the subtalar joint, the location of pain is described as being deep. The exact location may be hard to describe. Pain may be felt in the soft spot on the outside of the ankle or in a horseshoe distribution behind and below the ankle.

The two bones in the lower leg are the tibia and the fibula. The point just above the ankle where these two bones meet is called the syndesmosis. While technically a joint, it does not function like most joints as there is very little motion between the two bones. Its main functions are to provide stability to the ankle joint and allow for motion of the joint.

The most common way the syndesmosis is hurt is from a twisting or rotational injury to the ankle. The ligaments that support the syndesmosis are needed to stabilize it, and it is these ligaments that are stretched or torn when this type of injury occurs. Ankle sprains can injure the syndesmosis. The ligaments also can be injured when the ankle is broken. High ankle sprains that are commonly seen in football players are injuries to the syndesmosis.

Surgery of the syndesmosis most often is needed after a traumatic disruption. The goal of surgery is to properly align and stabilize the joint so the ligaments can heal in the correct position.

A Syme amputation is an amputation done through the ankle joint. The foot is removed but the heel pad is saved so the patient can put weight on the leg without a prosthesis (artificial limb). The goals of a Syme amputation are to remove diseased tissue or a non-usable foot and create a functional, painless limb.

The talus bone makes up part of the ankle joint and the subtalar joint. The ankle joint allows for up-and-down motion and the subtalar joint supports side-to-side motion. A talar fracture is a break in the talus bone that often involves both of these important joints. 

The ankle and foot must be well-aligned for proper function. The goal of surgery is to realign the bone pieces and restore the normal bone shape. The surgery also will restore the function of the ankle and subtalar joints. This surgery should reduce the chances of developing arthritis or losing blood supply to the bone.

Total ankle replacement, also known as total ankle arthroplasty, is a surgical procedure that foot and ankle orthopaedic surgeons use to treat ankle arthritis. Arthritic changes may be a result of normal wear and tear due to aging or from an injury such as a broken ankle or dislocation. Arthritis eventually leads to loss of cartilage, pain, and/or deformity.

The goal of ankle replacement is to provide pain relief while preserving ankle motion so the patient has less pain and better function during activity.