Jairo: Hello, this is Dr. Jairo Cruz Jr. of Advanced Podiatry, and I’m here to talk to you today about ankle arthroscopy. Frequently, we see patients with ankle pain, ankle instability and complaints of just chronic swelling and tenderness to the ankle when performing certain physical activities.
Our population is quite diverse in age, and the activity level seems to be high even throughout the elderly ages. We find that sporting events such as pickle ball have been increasingly more popular amongst the elderly population, and therefore more injuries have been either uncovered from chronic injury from the past or are acute in nature, and therefore need to be treated accordingly.
What I’d like to talk to you about is number one: what do we do to improve ankle joint symptoms and improve the symptoms of chronic ankle sprains and/or a previous injury from a time past? And also, in what conservative ways we try to treat it, and then also surgically if surgical intervention is warranted what minimally invasive techniques are utilized in order to preserve the patient’s overall foot structure and also decrease recovery time after a surgical intervention.
So, ankle pain is typically a type of symptom that occurs with activity. The ankle joint is made up of the tibia and then the talus which is right underneath the tibia which is the leg bone. If you look at the model bone here, you could see that the tibia is this large bone here, and that the talus is the one right underneath it, and that creates the ankle mortise.
There is also a fibula on the outside, and that’s the malleolus on the outside of the foot called the lateral malleolus that you can palpate through your skin. So, we have the medial malleolus and the lateral malleolus, and then the two bones makes up the ankle joint when adjacent to the talus.
But the talus is a uniquely shaped bone and has a lot of cartilage on the top which can become damaged during chronic injury or previous injury that happened to the patient in the past.
So, what do we do? We typically see a patient come in and say, “Hey Doc, I have complaints of pain in the ankle when I’m running, when I’m playing tennis, when I’m changing direction.” And what we do initially is a physical exam. We try to determine where the exact pain is in order to see what anatomy is involved with the symptoms.
Typically, what we’ll see is ankle sprains or chronic ankle sprains where we push on the lateral side of the ankle which is on the side of the smaller bone, the fibula right around here. And what’s there is called the anterior talofibular ligament. Again, the name of the ligament is descriptive of where it connects to. So, the fibula—the little bone—and then the talus, and it connects in that way across the two bones. And what it does is it prevents anterior motion of the ankle joint, so it prevents anterior motion of the ankle joint when performing physical activity.
There’s also more ligaments that surround the lateral ankle and these are called the calcaneofibular ligament, and then also the posterior talofibular ligament. So, those ligaments are all present, and they all have a certain job to do where they prevent motion in abnormal direction. But when we have chronic injury or have had an acute injury, it compromises these ligaments and makes them weaker, attenuated. When they become weak and attenuated, the foot moves abnormally, it causes swelling within the joint and obviously symptoms and pain for the patient.
So, again, on our physical exam, we push on the areas that we think are painful, and if they are painful, we note that okay, there could be a compromise of the anterior talofibular ligament, it could be compromised at the other lateral collateral ligaments, and so on and so on.
Sometimes, if the ATFL or the anterior talofibular ligament is not comprised and it’s not painful at all, sometimes when we actually press on the ankle joint itself through the skin the patient feels pain. And that would lead me to believe that the differential diagnosis would be some kind of problem within the ankle joint itself. There are ligaments and structures that are across the front of the ankle as well and that could be involved as well. But typically, it will spur me to investigate the ankle joint further with X-ray and an MRI.
What I’d be looking for in the X-ray is any kind of loose body or bone within the ankle that’s just floating around in there and every now and again getting lodged in between two bones and causing symptoms or inflammation.
Also, what I’d be looking for is any kind of lesion or defect in the talus, that’s that bone right here. I’ll look for any kind of lesion or defect in the talus so that I can see if there’s any kind of ankle joint pathology that’s visible on the X-ray. If there’s a lesion present, I’ll inform the patient. And what we’ll do in that case is we’ll give a diagnostic block meaning I’ll inject cortical steroid directly into the ankle joint usually from the lateral side and I’ll see if their pain completely subsides.
If it completely subsides, then I know that there’s something wrong within the ankle joint and that it’s isolated to the ankle joint itself. If I give an injection outside the ankle joint, for instance if I block or diagnostically block a tendon on the outside of the ankle or any other soft tissue structure or bony structure and the result is a pain-free foot, then we know that the pathology is outside the ankle joint and not internally. This makes pretty good sense since again, whatever the pathology is, if we numb it or cause it to decrease inflammation, then the symptoms will improve. If we’re blocking the wrong area, the symptoms would persist and therefore we’d know that we’re not in the ball park of wherever the pathology is.
So, I’ll typically block the ankle and inject about one to two cc’s—more likely one cc—of cortical steroid and lidocaine and Marcaine—a numbing agent—into the ankle to see whether or not the patient does have a reduction in pain. If that is the case, then an MRI will be warranted. What we do with the MRI is we analyze the soft tissue. An X-ray will show bone very well but MRI shows soft tissue.
So, therefore what I want to do is I want to rule out any kind of underlying soft tissue damage that has occurred within the ankle joint, so that I can better treat the patient. Let’s say it’s a sprain of one of the ligaments in the ankle, well then I know which structure to look at and which structure that I need to stop motion at in order for the body to heal itself.
Typically, if I want the body to heal on its own, I will place the patient in a walking boot or a cast if the pain is great enough. Usually, if it’s a pain greater than 7/10 or the patient’s unable to walk, then obviously I will consider non-weight bearing as a treatment. But typically, I’ll place them in a boot, this will prevent motion of the ankle when walking and therefore the patient will have relief in the symptoms and pain.
Also, what I’ll do is I’ll prescribe some kind of an anti-inflammatory medication orally, so that the patient can have relief from the swelling as well. These two solutions of anti-inflammatory albeit injection or oral anti-inflammatory is a temporary fix, it’s not a fix for the problem, but it’s just a temporary fix to help the patient feel better, so that we can get on the road to healing.
What also needs to be utilized at the same time for conservative care is physical therapy. Once the pain subsides and the symptoms are decreased, then the physical therapy of the joint after immobilizing it, after utilizing the below-knee walker for a certain period of time, say four to six weeks, we need to make sure that the muscles and the ligaments are back up to speed and not weak when the patient starts walking on it again in a regular type fashion with a regular shoe.
So, physical therapy is often utilized for the patient after conservative treatment has been rendered with a BK walking boot or a cast.
If the MRI comes back with acute tear, or some kind of a break, or any kind of acute fracture, or acute situation or trauma, then the doctor has to consider whether or not the trauma needs to be fixed with internal fixation, or surgical intervention, or can it be conservatively treated with immobilization?
Typically, we tend to move towards immobilization as a treatment of choice because we know that in surgery there is always a chance of complications and therefore we try to limit complications and limit the healing time of the patient so that they can get on the road to recovery a lot quicker. Assuming that the injury is not a severe one, then conservative care such as non-weight bearing or offloading with a BK walker is rendered. But if the injury is acute enough and the patient is a highly active individual, they’re of a young age and their activities of life dictate that they need a faster repair, then surgical intervention may be warranted.
Again, we try to avoid surgical intervention at all times but sometimes we need to do it.
That being said, the MRI again will tell us what structures are compromised in the ankle joint and therefore lead us to a better treatment.
Let’s say the OCD lesion or the osteochondral defect of the talus, the cartilage on top of the talus here, in between the two bones there’s a layer of cartilage, a very thick cartilage and sometimes that area can be damaged, and that damaged cartilage can cause a lot of swelling in the ankle joint. And that’s why again, with the initial block we block the ankle joint to see whether or not the pain improves. If the pain improves, then we know to pursue the ankle joint as a problem and look for these OCD type lesions, or osteochondral defect lesions.
Again, if they’re found on the MRI then arthroscopy as a surgical intervention is minimal, or a minimalistic way to help these problems. So, arthroscopy is essentially the utilization of a small instrumentation to be entered into the ankle joint and utilized to fix whatever defect we see inside the ankle joint.
So, we have a small camera that we enter into the ankle joint using certain instrumentation, and then we also have a device or instrumentation that we can feed through a different portal in the ankle to fix these problems.
So, the typical fix of an osteochondral defect assuming it’s not too large is to break through the cartilage and clean it up where the area defect is, and then cause a bleeding to the underlying bone where that cartilage is defective to help the body rejuvenate itself. So, when we damage the bone underneath that cartilaginous defect, the body will release nutrients and growth potential cells to repair that area, and so what it will do is it will try to fill that hole or that defect with what’s called fibrocartilage. This cartilage is not the same exact thing as the cartilage that you were born with originally with the ankle, but nonetheless it’s sufficient to prevent any kind of prolonging nature of this defect within the ankle joint.
So, typically, with a scope you can do this very minimally because the incisions for the scope and the entrance of this instrumentation is very tiny. In fact, the incisions are basically six MM in length approximately, so that’s about the diameter of a pencil eraser if you want to look at it that way. There’s essentially two portals that we make in the ankle and that’s where we place the instrumentation into the ankle joint to be able to visualize the defect and also correct the defect with proper instrumentation.
Again, surgical intervention is avoided at all costs but sometimes the simple, minimalistic, minimally invasive procedure can help the patient greatly improve their symptoms of pain and their quality of life.
Other things that we look for inside the ankle joint: we essentially do a 21-point inspection where we look at the ankle joint and see whether or not any other ligaments or compromise within the ankle joint with a camera, and if we see inflammation of the tissues or any kind of defect within the ankle joint itself, we can repair it using the instrumentation for the scope set for the arthroscopy set.
Again, we try to avoid surgical intervention at all times, but nonetheless, sometimes it’s warranted and this method is very effective in treating ankle pain in a minimalistic way.
If you or a loved one are suffering from ankle joint pain or chronic ankle joint pain, please do not hesitate to make an appointment by dialing (813) 875-0555. The doctors at Advanced Podiatry are very well versed in ankle joint pathology and are willing to help.
We look forward to seeing you and getting you back on the road to a healthy lifestyle.