Ankle problems are common in sport. These may be either due to a specific traumatic event or due to repetitive strain. Symptoms produced are either instability or pain or sometimes a combination of the two.
Essentially ankle pathology can be divided into 3 main groups - the instabilities, the impingements and chondral or osteochondral lesions.
Ankle ligament injury, generally with an inversion sprain, is very common. The angle of the foot at the time of application of the sprain determines which structures are at risk. Early functional activity provides the best results and there is no place for early surgical intervention. Persistent pain that is not steadily improving over the first few weeks is an indication for further investigation.Residual laxity is common but the vast majority of patients do not have symptomatic instability. For those who do have symptomatic instability not responding to conservative measures, surgical reconstruction is highly successful at restoring sporting activity. The difficulty is in picking those who are not functionally unstable but who will go on to accelerated degenerative change.
Inversion sprain in neutral, quite common in footballers, can damage the posterior talofibular/tiibo-fibular ligaments. This can lead to a posterior impingement with pain on sprinting and striking a ball. Ultrasound guided injection can often settle this down without the need for surgery.
Deltoid ligament injury is very rare. I have only seen one case in the last 12 years and that was in a player who had a rigid flat foot secondary to a tarsal coalition.
Syndesmotic sprains can produce lumps of torn ligament which hang down into the joint and can be very troublesome. Arthroscopic debridement of the torn ligament can produce symptomatic relief.
Impingement around the ankle is an occupational hazard for a professional footballer. Anterolateral soft tissue impingement and bony anteromedial impingement are most frequently seen and often require a surgical solution. Bony posterior impingement (common in dancers) in the form of a symptomatic os trigonum or lateral process of the talus, may require intervention in the form of hindfoot endoscopy for its removal.
The ankle is a very congruent joint and tolerates areas of damage to the joint surface much better than similar damage in the knee. Chondral injuries can be difficult to delineate other than by arthroscopy. Osteochondral lesions are readily diagnosed by conventional imaging techniques and can be treated by arthroscopic debridement and microfracture with a high degree of success. Symptomatic loose bodies can usually be removed via the arthroscope but can be difficult to locate!