PERSONAL INJURY LAW JOURNAL, May 2007

Ankle ligament injuries are probably the commonest injury seen by orthopaedic surgeons with one in ten thousand of us injuring our ankle lateral ligaments a day.  What is not realised by many members of the public and indeed PI lawyers is that some 10% to 50% of such patients are left with chronic pain or problems.  These problems include the following:-

(1) An undiagnosed fracture or break of the dome of the central bone in ankle joint called the talus (this is officially call an osteo-chondral defect) which occurs in some 5% of patients and is usually missed by plain x-rays, requiring CT or MRI Scanning to confirm the diagnosis, a service which is rarely available in the NHS.  This will cause pain, swelling, clicking, and a sensation of instability, and the patient requires arthroscopic treatment for this condition which normally produces 80% good or excellent results.

(2) Chronic lateral ligament laxity/insufficiency which is when having damaged the lateral ligaments of the ankle joint patients have chronic weakness and instability of that ankle.  This is usually treated initially with a physiotherapy programme and is normally successful, however, in a significant percentage of patients, approximately some 10% when this physiotherapy programme has failed then a surgical repair of the stretched and torn ligaments is required.  The most common procedure now performed for this is a Brostrum or modified Brostrum repair which is an anatomic reconstruction of the ankle ligaments followed by three weeks immobilisation in an aircast (Wayne Rooney esque) boot for three weeks followed by a physiotherapy programme and success rates for this surgery are in the order of 95% good or excellent results.

(3) Post traumatic impingement syndrome/meniscoid band formation, this is a condition when a sheet or shelf of tissue forms inside the ankle joint following the lateral ligament tear and acts like a torn or loose piece of cartilage in the ankle joint hence the name, meniscoid band.  This condition can only be diagnosed clinically or arthroscopically and is missed certainly by plain x-rays and frequently by MRI Scans.  Patients partially recover from their ankle ligament injuries, but continue to report episodes of sharp pain on the outer aspect of the ankle which prevent them from returning to full activity.  The condition is treated successfully with ankle arthroscopy resecting with keyhole surgery these sheets or shelves of tissue that have formed.  The surgery is carried out as a day case, patients are normally fully recovered within three to six weeks and success rates are in the order of 80% good or excellent results.

(4) Arthrofibrosis, this is a condition when cobwebs of scar tissue form after an ankle ligament injury to criss-cross the front and back parts of the ankle joint causing persisting pain, swelling and most obviously stiffness after a standard ankle sprain.  Typically patients will present to orthopaedic surgeons with a painful stiff, swollen ankle some months down the line having been seen initially in casualty and a bony injury excluded by casualty officers with plain x-rays.  Again this is a condition which is poorly visualised by imaging techniques such as MRI Scanning however, it is one which is suspected clinically and the diagnosis confirmed with an ankle arthroscopy which then goes on to treat the condition removing the bands of arthrofibrotic tissue which criss-cross the ankle joint.  Success rates for the arthroscopic surgery are in the order of 85% good or excellent results.

(5) The next most common problem seen in the ankle joint after an ankle ligament injury would be the development of a localised area of swelling and inflammation within part of the ankle joint, typically immediately beneath the injured lateral ligaments or if not in the joints between the tibia and fibular.  (This is officially called a post traumatic synovitic lesion/impingement lesion.) This normally causes fairly well localised pain in the region of the ankle in which it is present and normally presents to orthopaedic surgeons three to six months after the ankle ligament injury when range of movement and stability have been recovered but the patient continues to report chronic ankle pain.  This condition which is common is only picked up by MRI Scans in approximately 50% of patients.  This type of lesion is described in research papers as being present in approximately 3% of ankle ligament injuries, but in my own practice I would estimate the incidents as being higher.

(6) The next most commonly recognised injury to the ankle joint associated with soft tissue injuries is the posterior impingement lesion or labral tearing.  This occurs in association with a hyper flexion injury to the ankle joint, an injury in fact commonly associated with ballet dancers.  The hyper flexion injury to the ankle joint tears off a lip of fibrocartilaginous tissue on the posterior or back end of the ankle joint.  Patients again will present to orthopaedic surgeons typically three to six months after an ankle ligament injury when the ankle is stable with a full range of movement but they report pain and clicking in the rear of the ankle joint.  Again this diagnosis may be confirmed on MRI Scan but is usually confirmed and treated with an arthroscopy.

7) In conclusion, therefore, despite ankle ligament injuries being the commonest soft tissue injury seen by orthopaedic surgeons and accident & emergency consultants alike, a large majority of injuries, as you can see, do not settle.  Patients with ongoing symptoms lasting more than three to six months should be referred to a consultant orthopaedic surgeon with a special interest in ankle injuries and with expertise in ankle arthroscopy.  Personal Injury lawyers should also be asking why their clients have not been investigated with an MRI Scan after ankle ligament injuries, if they have got persisting symptoms why they have not been offered an ankle arthroscopy.