Boyd W. Haynes III, MD
In the last article, we discussed common issues with the toes and feet that can cause limping. In this part of the series, we’re going to look at the ankle, and talk about the injuries and conditions that contribute to limping and how I go about treating those so that you can walk normally again.
The ankle is comprised of three joints that connect the foot to the two bones of the lower leg. These three joints function together as a universal joint to give the ankle complex, multi-directional movement. With all this mobility, there are many ligaments and tendons in the ankle that help to give this joint stability, any of which can be torn. That’s why ankle strains and sprains are so common, as is the broken ankle. Arthritis is common in the ankle, gout can also occur, but is less common, bone spurs can grow as the body’s attempt to help compensate for arthritis, and tendonitis, tendinosis and tendinopathy can be a problem as well, especially Achilles.
Treatment starts conservatively, unless we have a severe trauma that requires immediate surgical intervention to stabilize broken bones, a shattered joint or an unstable joint due to torn ligaments. In that instance, I’ll probably see you in the OR at the hospital after you fall off a ladder or a trip off your new flip-flops. Even then, surgery would most likely be outpatient and you would be sent home to recover with either a cast or a removable air-cast. Lots of elevation, icing, rest and non-weight bearing would be in your future for a few weeks as you healed. Then we would start slow and gentle physical therapy to assist with inflammation and post-surgical swelling. The intensity would increase as your recovery progressed to include range of motion work and strengthening.
Let’s start with strains and sprains that can cause pronounced limps. In the past, the treatment standard was total rest, elevation, intermittent ice, anti-inflammatories, ace bandage for compression, bracing or splinting and crutches for several weeks to allow the swelling to recede and the ligaments or tendons to heal. Nowadays, that thinking has changed somewhat, in that we are encouraging some ambulation as soon as possible, even though it is uncomfortable. We find patients tend to recover more quickly if they go ahead and start walking sooner rather than later.
Tendinitis is the inflammation of a tendon that often happens when it is injured, overused, or gets irritated by some inflammatory process going on in the body, like with an autoimmune disease. The Achilles tendon is the largest tendon in your body and connects your calf to your heel behind your ankle. It is prone to injury and can become a chronic problem, called tendinosis or tendinopathy. Injury to this tendon can cause a problem with your gait.
Achilles Tendon issues are typically treated with Physical Therapy, NSAIDs, and oral steroids, but we rarely inject with steroids as they can weaken this specific tendon and lead to rupture. PRP (Platelet Rich Plasma) has been used to treat recalcitrant tendinitis, especially in athletes. In cases of severe degradation or rupture that resists therapy and continues to cause pain and limping, I may have to surgically repair the tendon.
Recovery for Achilles Tendon repair is a long process of rest, splinting or bracing for immobilization, non-weight bearing for weeks on crutches or a knee scooter, and six to nine months of Physical Therapy. Yes, sports fans, it is a long and drawn-out process. For athletes, it certainly is worth it, but for seventy-year-olds, I would recommend a much more conservative approach with no surgery, casting and physical therapy.
Finally, as the ankle is three joints combined into one big joint, there is a lot of cartilage-covered real estate to become arthritic, simply from weight bearing and wear and tear as we age. Arthritis can set into the ankles and cause pain and dysfunction – leading to limping. We treat this with NSAIDS, heat, Physical Therapy, and oral steroids. Keeping your weight down is a big help as extra pounds put even more pressure on those ankles.
Until recently, severely arthritic ankles only had the option of being fused (arthrodesis) as ankle replacements were problematic and not recommended. The arthrodesis surgery would remove the painful arthritic joints and connect all the bones together with plates, rods and screws. The ankle would not have motion after the fusion but would be without pain.
Now, we have several prosthetic ankle replacement options that allow for movement which have shown significantly more success than previous iterations. Recovery after both ankle fusion and replacement is slow, non-weight-bearing for the first four to six weeks and then partial weight bearing for another few weeks. Full recovery takes anywhere from six months to a year. Physical therapy is a must for strengthening and range of motion. However, both procedures are not full proof, have an 80-90% success rate, and do not guarantee that the patient will be limp and pain free afterwards.