Lower-Leg and Ankle Injuries

William D. Hamilton, MD; Andrew A. Brief, MD

    Ankle injuries are extraordinarily common in sports, particularly in pivoting and contact sports such as basketball, soccer, and American football. The unique anatomy and relatively meager support of soft tissue make the ankle joint especially prone to sports injury.
    The ankle consists of an ankle bone (talus) held firmly in an upside-down box-like structure called the mortise, as in mortise and tendon joints, formed by the two bones of the lower leg: the shinbone (tibia) and the small bone that runs down the outside of the leg (fibula). The talus moves only up and down, so a second joint under the ankle, the subtalar joint, moves in and out and provides the motion the ankle itself lacks. This motion is powered by the Achilles tendon in back of the ankle; by the posterior tibial tendon on the inside of the ankle; by the peroneal tendons on the outside of the ankle; and by the extensor tendons in the front, which move the ankle in various directions.
    The ankle is turned outward by about 10 to 15 degrees in relation to the knee and is built to allow up-and-down motion but very little inward-outward rotation. If inward­outward rotation is forced on the ankle, an injury often results because the joint is not made to move that way. The subtalar joint allows us to walk on uneven ground, such as cobblestones or the side of a hill. This motion of the subtalar joint is surprisingly important and when lost, through arthritis or injury, extremely disabling.
    The primary purpose of the ankle (along with the foot) is to absorb energy when landing and then to propel us forward again off the toe. This occurs by means of the subtalar joint beneath the ankle, which transmits the power of the Achilles tendon efficiently through the foot into the ground. Anything that limits or interferes with this motion in the subtalar joint significantly alters the function of the entire lower extremity.
    Sports that involve jumping require ankles that absorb energy well, whereas in repetitive sports such as running (there are 1,000 foot strikes in every mile, and each one is almost exactly the same), small differences such as a slight inequality in the length of the legs or stiffness in the subtalar joint can lead to repetitive stress injuries. In this chapter we look at the most common lower-leg and ankle injuries and discuss how to treat them.

SHIN SPLINTS

Common Causes
    Shin splints and medial tibial stress syndrome (a more severe form of shin splints) are caused by an inflammation of the periosteal sleeve of tissue surrounding the tibia. This type of injury frequently occurs in running or other repetitive cardiovascular activities in which the athlete suddenly increases the distance, duration, or frequency of a training regimen. The muscular insertion of the tibialis anterior, tibialis posterior, and soleus are frequently affected.
 

Identification
    Symptoms typically include a burning or aching pain on the medial (nearer the middle of the body) aspect of the leg or shin after completion of the activity. This pain is a common complaint among runners who are training for a marathon or young athletes who are conditioning at the outset of a new sporting season. The area of pain and tenderness usually spreads out over an area of three-fingers width along the front or back edge of the shinbone. X-rays are usually normal but bone scan reveals localized uptake along the edge of the bone.
 

Treatment
    Treatment for shin splints involves a change in the athlete's training regimen (e.g., decreased mileage, frequency, or intensity of exercise). Icing of the involved area after activity helps in the short term. If pain persists, or gets worse, despite curtailing the level of activity, the athlete should seek professional attention to rule out a more serious injury such as a stress fracture or exertional compartment syndrome. Examine the athlete's footwear and feet for additional problems. Look for excessive and uneven wear on the soles of running shoes, which may represent biomechanical flaws. Also, if the athlete's feet pronate excessively (the arch flattens as the foot strikes the ground under load), an orthotic may be indicated.
 

Return to Action
    Typically, a one- to two-week layoff from impact exercise allows for a rapid return. A return is recommended when the athlete can practice comfortably and is pain free after vigorous exercise. Taping is seldom useful in achieving a quicker recovery from shin splints.

LOWER-LEG COMPARTMENT SYNDROME

Common Causes
    All muscles in the body are grouped into anatomi­cal compartments, each of which is encased with a soft tissue covering called fascia. In these tight compartments, the muscles may swell and expand with vigorous exercise, choking off their own blood supply and endangering the viability of the muscle tissue. This injury usually occurs in distance run­ners or athletes who engage in continuous running activity.
 

Identification
    The symptoms of compartment syndrome are more generalized than in other lower-leg conditions. Typically, there is pain, swelling, and sensitivity of the involved muscular compartment that occurs during the peak of exercise. Symptoms typically get worse during the course of a workout and subside afterward. The condition is most accurately diagnosed by measuring the compartment pressures during exercise under local anesthesia.
 

Treatment
    When rest and modifying activity to avoid stressing the lower extremity fail to alleviate symptoms, a minor surgery is required to release the tight fascia surrounding the affected compartment (fasciotomy).
 

Return to Action
    Following surgery, athletes typically return to sport gradually, reaching maximum recovery by four to six months postoperation. Athletes can typically begin lower­extremity workouts two weeks postoperatively. Following conservative treatment, athletes should refrain from running or full sport participation until pain is minimal upon repetitious striding, such as on a treadmill.

LOWER-LEG STRESS FRACTURE

Common Causes
    A stress fracture is a process that occurs in response to abnormal stress placed on a normal bone. Such a fracture can occur when a bone is repetitively overloaded for a prolonged period of time. This is particularly apt to occur when a bone is weak to begin with. Patients vulnerable to stress fractures include those with osteoporosis, improper diet, sudden increases in a training regimen, or eating disorders.
 

Identification
    Pain associated with a stress fracture is typically activity related. There is a period of time prior to the actual presence of a fracture in which the bone structure is damaged, but it has not actually cracked yet; this is called a stress reaction. A good analogy is bending a paper clip repeatedly to weaken it (stress reaction) until it breaks (stress fracture). Once the fracture occurs, the pain increases considerably and can be local­ized (one finger width) on examination to a very specific area. If the bone has been symptomatic for a long time, a small and tender bump might develop on the bone (callus) where it is trying to heal. The most accurate way to diagnose a stress reaction or stress fracture in the early stages is with a bone scan; an X-ray might reveal nothing until the fracture has been there a month or more. There have been several cases of a bone breaking all the way through during running or jumping on a chronic stress fracture.
 

Treatment
    The treatment for both a stress fracture and a stress reaction is usually a marked reduction in activities to allow the fracture to heal. If symptoms are severe, partial weight bearing on crutches and use of a bone stimulator (which may assist in the laying down of new bone and expedite the healing process) might be necessary.
    Female athletes with chronic stress fractures should always be checked for symptoms of the female athlete triad: disordered eating, amenorrhea, and osteopenia or osteoporosis. If these related problems are present, the athlete should be treated for them while recovering from the injury.
 

Return to Action
    Once treatment has started, stress fractures tend to take as long to heal as the athlete has been exercising with pain. For some athletes that means three to six months before a return to regular training and competing. However, athletes can often engage in nonimpact types of cross-training (such as deep-water running and some forms of weightlifting) to maintain fitness while the fracture heals.

CALF STRAIN OR TEAR

Common Causes
    A calf strain or tear, often called a calf pull, is usually caused by improper stretching before engaging in exercise or sports or by the inability of the calf muscles to accom­modate the concentric (muscle-shortening) and eccentric (muscle-lengthening) forces generated by sudden changes in direction of the lower limbs that can occur in many sports. Calf strains are noted in tennis (the strains are sometimes called tennis leg), racquetball, paddle ball, and in most cutting and pivoting sports. Calf strains seem to be more prevalent in weekend warriors and others who do not regularly engage in sport.
 

Identification
    The athlete experiences a popping sensation in the calf, followed by well-localized tenderness over the inside calf muscle in the middle portion of the leg. Because of the immediate pain, athletes often have difficulty putting weight on the affected leg. The severity of this injury ranges from mild (grade I), to moderate (grade II), to severe (grade III) depending on the extent of damage to the muscle belly.
 

Treatment
    The immediate treatment is PRICE (protection, rest, ice, compression, and elevation) followed by an evaluation by a physician. Severe pulls might need cast immobilization or a removable boot. Often, a simple leg sleeve will suffice. After healing is complete, physical therapy is important to restore strength and flexibility and to prevent recur­rence. Given time to heal and proper rehab, calf strain is usually a benign injury with a good prognosis. Many people with this condition are more comfortable wearing clogs or shoes with an elevated heel, which takes tension off the Achilles tendon during the healing phase.
 

Return to Action
    The athlete should avoid all cardiovascular exercise for at least a month from the time of injury. Activity should be increased as tolerated thereafter. Taping or strapping of the calf can be applied as needed. The key is not to return too soon. Often athletes are tempted to get back out there after only three weeks, but if the return to sports occurs prematurely, a retear could turn a four- to six-week recovery into a three-month recovery.

ACHILLES TENDON RUPTURE

Common Causes
    Achilles rupture is a serious injury that often occurs because of preexisting Achilles tendinitis or inadequate stretching before sports. This injury typically occurs during pivoting or twisting in sports such as soccer, American football, and basketball.
 

Identification
    The athlete experiences a pop in the back of the ankle. A gap develops in the tendon that can be felt to the touch, and the tendon no longer functions. When asked to flex the ankle in a downward position
 

Treatment
    Again, the immediate treatment is PRICE (protection, rest, ice, compression, and elevation) followed by an evaluation by a physician who will match treatment to the problem. Many Achilles ruptures are missed at the time of the injury if there is only a partial tear or if the examination is performed by an inexperienced clinician.
    Two basic treatment approaches are available for a ruptured Achilles tendon: non­surgical and surgical. Each has its advantages and disadvantages and, interestingly, the two approaches have the same complication rate (19 percent). The nonsurgical approach is cast immobilization in the foot-down position until the tendon heals, which takes six to eight weeks. The advantage here is the avoidance of surgery and all the associated complications, but the disadvantage is loss of strength and a higher likelihood of rupturing the tendon again during the healing period. The surgical approach can restore the normal length and strength of the tendon, but complica­tions can arise in the form of phlebitis and wound infections. The decision as to which approach is best should be made by the athlete and a physician. Either way, rehabilitation plays a major role in the recovery process.
 

Return to Action
    The recovery process following Achilles tendon rupture emphasizes rebuilding of muscle strength and restoration of range of motion. Return to the gym following either treatment approach begins between two and three months from the time of injury. Running can begin at about four months, and pivoting sports at six months. Advise the athlete that full recovery might take up to a year.

ACHILLES TENDINITIS

Common Causes
    Achilles injuries are especially common in athletes who allow their Achilles ten­dons to become tight by not regularly stretching and conditioning the tendon.
 

Identification
    Athletes experience chronic pain in the back and lower part of the calf and ankle that will not subside. A strained Achilles tendon usually occurs in either of two locations: within the tendon itself (usually in the isthmus or narrowest part just behind the ankle), or in the insertion of the tendon in the heel (called Haglund's disease). In the acute phase when the tendon is hot, swollen, tender, and painful, this injury is called tendinitis. In the chronic phase when the inflammatory process has quieted but not gone away, the injury is called tendonosis. The tendon usually develops a painful lump.
 

Treatment
    The healing process for Achilles tendinitis tends to be long and slow. During the healing phase, athletes might prefer to wear clogs or shoes with an elevated heel to prevent further straining of the Achilles. Athletes should avoid stretching until most of the pain is gone. This injury can take months to heal and usually occurs in people who are already very active. You can usually measure the healing by the diminution of the symptoms and the decreased tenderness in the lump. When the condition finally heals, a small, firm lump remains, but it is typically asymptomatic.
 

Return to Action
    Athletes should delay a return to sport until they are completely pain free. At this time, physical therapy and stretching exercises should be emphasized.

ANKLE SPRAIN

Common Causes
    In the United States, ankle sprains account for 1 of every 10 visits to the emergency room. Most of these sprains are sustained during contact and pivoting sports.
 

Identification
    Ankle sprains cause a painful, swollen, bruised area on the outside (lateral) aspect of the athlete's ankle. The athlete might not be able to bear weight on the ankle. Ankle sprains are usually classified as mild (grade I), moderate (grade II), or severe (grade III) depending on the extent of the damage. There are two main ligaments on the outside of the ankle that hold it together: the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). In most sprains, the ATFL tears first, and then the CFL tears. A grade I sprain is a partial tear of the ATFL, a grade II sprain is a complete tear of the ATFL with the CFL still intact, and a grade III sprain is a complete tear of both the ATFL and CFL. Fortunately, grade III sprains are very rare. An X-ray can help diagnose whether an ankle is fractured or sprained.
 

Treatment
    The treatment of acute ankle sprains is similar to the treatment of most acute injuries. PRICE (protection, rest, ice, compression, and elevation). Many sprains are minor injuries that improve after a few days, and these will usually take care of themselves. However, if pain is considerable and it is difficult to bear weight on the ankle, a physician should have a look at it. These injuries often require the use of crutches and some sort of a brace or support to protect the ankle while it is healing. Recovery usually starts with the healing phase, which involves elevation at night on one pillow to reduce swelling, protected motion, and weight bearing as tolerated. During this phase, ultrasound, massage, acupuncture, and nonsteroidal anti-inflammatory drugs can be useful. As healing progresses, the rehab phase begins with physical therapy to restore motion, strength, proprioception, and function to the ankle.
    Sprained ankles often heal with residual weakness. If this weakness is not corrected, a cycle might develop: the weakness of the ankle makes it liable to roll over, and after it rolls over, the ankle is weaker. A common cause of recurrent problems with ankle sprains is incomplete rehabilitation and residual, unrecognized weakness. A sprained ankle that won't heal usually involves one of the following:
     •  Weak peroneal tendons. These two tendons span the outside (lateral) aspect of the ankle, preventing the ankle from rolling.
     •  Sinus tarsi syndrome. There is a hollow area on the side of the ankle that can be painful because of scar tissue from a healed sprain.
     •  Injured peroneal tendons. Chronic unstable ankles can develop partial tears in the peroneal tendons that cause pain and improper function. Tears often don't show up well on MRI. A sonogram might reveal the damage better.
 

Return to Action
    Return to sport for grade I sprains typically takes one to two weeks; grade II sprains take two to four weeks; and grade III injuries take four to six weeks. Taping or ankle braces can provide stability in the acute phases of healing.

ANKLE FRACTURE

Common Causes
    Ankle fractures are often the result of high-energy injuries, such as falls from height, motor vehicle accidents, or contact sports.
 

Identification
    Much like ankle sprains only more severe, ankle fractures usually involve a painful, swollen, and bruised ankle. Most athletes cannot bear weight on a fractured ankle.
 

Treatment
    If an ankle is broken, but the bone is not displaced, the injury may be treated without surgery. If the bones are displaced, the fracture will almost always require surgical management to restore stability to the ankle and ensure adequate healing of the fracture.
 

Return to Action
    Much like the recovery following Achilles tendon rupture, recovery from an ankle fracture requires many months of rehabilitation. Typically, an athlete whose broken ankle requires surgery will wear a cast and be unable to bear weight on the ankle for two months. Afterward, physical therapy begins, and return to the gym occurs between two and three months from the time of injury. Running can begin at about three to four months, and pivoting sports at four to six months. The patient should be advised that maximum recovery might not be achieved until one year from the injury.

POSTERIOR TIBIAL TENDINITIS

Common Causes
    The posterior tibial tendon (PTT) is the large, strong tendon on the inside of the ankle that holds up the arch of the foot. The tibial strain is commonly seen in pronated (flat-footed) runners or those whose lower legs are rotated outward (duck-footed).
 

Identification
    The athlete often experiences increasing or chronic pain on the inside (medial) aspect of the ankle. He or she might report a progressive worsening flat-footed deformity or collapse of the arch of the foot over time. Another problem related to PTT strain is a painful accessory navicular bone.
 

Treatment
    Treatment usually involves immobilization in a boot, if the pain is bad, and supportive measures such as orthotics and strapping to support the arch of the foot. Cortisone shots are risky because they can damage the posterior tibial tendon within which the accessory navicular bone often lies. In athletes under 40, the injury tends to heal with time and therapy, whereas in athletes over 50, especially in overweight females, it tends not to heal. For these individuals, the tendon inflammation can get progressively worse and lead to slow rupture of the tendon and collapse of the foot (like an old rope that stretches out and eventually comes apart). Surgery may be performed to reconstruct the deficient tendon.
 

Return to Action
    Athletes may return to sport as soon as symptoms subside. They might consider using an orthotic during future sporting activities.

BONE SPURS ON THE ANKLE

Common Causes
    Athletes engaged in jumping activities tend to develop bone spurs in the front of the ankle where the bones bang into each other. These form slowly over time.
 

Identification
    Athletes experience persistent pain and swelling at the front of the ankle. The hallmark symptom of this condition is limitation in the upward motion (dorsiflexion) of the ankle caused by impaction of the bone spurs into each other.
 

Treatment
    If symptoms are severe enough, the spurs can be removed with an arthroscope or a small open incision. Less severe cases are treated symptomatically with local icing and medications for pain.

Return to Action
    These "cleanout" surgical procedures are usually quite effective, but the ankle is a touchy joint that tends to recover slowly after surgery. It may be several months before athletes are able to return to their usual levels of activity.

FROM: SPORTS INJURIES GUIDEBOOK By Robert S. Gotliv, DO Editor--Chapter 14