Dislocation of the Ankle

From carefully observing the video of Bale’s foot and ankle injury, the player has not dislocated his ankle.

What is Ankle Dislocation?

Full ankle dislocation happens when the talus bone comes out of its normal position with the ends of the tibia and fibula. During this type of traumatic foot and ankle injury, person can often experience concomitant malleolar fractures, tibial and peroneal, depending on the dislocation mechanism.

During traumatic injuries near to the tibia bone, a person can also suffer small fractures on their cartilage surface (osteochondral lesions).

There are very isolated cases of dislocation without a fracture. In these cases, at the expense of only a patient’s ligaments.

When there is a dislocation, the foot, more precisely astragalus, does not spontaneously return to its natural position. In fact for this to happen, there needs to be a reduction operation performed, to help reposition the talus bone within the mortar ankle.

In the case of a dislocation, this manoeuvring method must be carried out promptly. In fact, without prompt and rapid action, it may compromise a patient’s neurovascular bundle. Imagine the main vessels and nerves in a common duct, each wrapped by independent sheaths. A dislocation alters the course of this “conduit” and if, not reduced, can lead to a neuro-vascular compromise.

That’s why a dislocation injury must be immediately seen to. In comparison to a fracture, this type of injury needs even more urgent care.

The positive news for Gareth Bale and for Real Madrid regarding his sports injury, is that the player did not experience a traumatic dislocation of the ankle!


Ankle sprain

This month in our scientific studies, we talked about our studies of osteochondral lesions (cartilage) of the ankle and on the outcomes of the injury sprain.

A trauma distortion can occur in inversion or eversion or also have a more complex, traumatic multi-axial mechanism. Obviously, what differs from the distortion of an ankle dislocation is the absence of a complete exit of the talus from its seat. At the end, the trauma, astragalus returns to its original position. This means that reduction manoeuvring procedures are no longer necessary!

Nevertheless, even during a severe sprain, there can occur malleolar fractures, metatarsal injury, damaged cartilage and ligament injuries, to name but a few.

These types of injuries can happen but that does not mean they must become an excessive fear on the part of the patient.

In fact, distortion ankle trauma, or any type of frequent trauma injuries for that matter, can heal without negative outcomes. Even 15 days after a trauma, Bale’s ankle may still be swollen and bruised (that famous blue perimalleolar bruise may be normal). It is important, however, to understand that the magnitude of these traumas should never be underestimated. A cartilage lesion diagnosed late can be a big challenge for the surgeon and the patient!

A more rare case is, instead, a dislocation of the peroneal tendons following a distortion trauma.

Dislocation of the peroneal

Lussazione Peronieri

The dislocation of the peroneal is not as bad as a dislocated ankle. However, it can be a problem for non-sportsmen and sportswomen, and a major obstacle to the professional athlete and the sport in general.

Peroneal tendons

Generally, tendons are extreme fibrous muscle that fits on the bone and help us mobilise our limbs.

It is also important to clearly distinguish them from ligaments. The latter, however, are of fibrous expansions between bone and other bone acting as mechanical and proprioceptive stabilisers.

The short peroneal tendon and peroneus longus tendon are two tendons, which flow laterally together in the ankle, behind the fibula, surrounded by the peroneal malleolus and the fibrous sheath.

The peroneus brevis tendon is inserted on the base of the fifth metatarsal. This explains why in a sprain in reverse, similar to how a rubber band gets stretched, this tendon can cause a fracture of the fifth metatarsal. A patient who, following a distortion trauma, experiences discomfort on the outer surface of the foot should undergo a foot radiograph. However, a single ankle radiograph may not be sufficient to identify other similar problems!

The peroneus longus and the peroneus brevis tendons, run parallel to one another, linking the outer parameters of the foot to the peroneus longus and brevis muscles in the lower part of the leg.

These two tendons help ever roll your foot outwards and also aid our calf muscles in plantarflexing our feet. The two tendons also help support steadying our ankle through physical activities like running where we exert a lot of weight on our foot and ankle areas.

Crucially, these two tendons are vital during thrusting motions. For example, a change of direction, like when we sprint during running etc. 

Peroneal Tendon Injuries

The peroneiri tendons can tear after a distortion trauma or form from a foot deformity, more so than by simply over-training or taking part in a heavy work.

An inversion trauma can, in fact, determine a deep lesion inside a tendon, but again, this is not always the only cause of the lesion.

For example, patients suffering with a claw foot can put additional force on both the tendons.

Generally, patients with claw feet and who suffer from various types of severe foot deformities in general, can develop intra-tendon injuries.

In similar cases, this type of trauma can be compared to the straw that breaks the camel’s back. It does not help the condition as it gradually effects the tendons, but it is not the sole cause. Pathological tendons already rendered by the deformity (foot cable), simply triggers the lesion.

The dislocation of the peroneal tendons

Regarding the case of Gareth Bale, the retro malleolar peroneal sheath that holds the tendons in place needs to be relatively thick and not exert any compression. In short, this protective sheath should help the tendons to work properly and slide in their tracks without becoming crushed.

A lesion of this sheath may cause a dislocation of a person’s tendons. In a nutshell, the sheath is no longer sufficient to keep these tendons in place. When Bale goes to shoot or turns his ankles, he may feel and hear a “tac” sound behind the lateral malleolus, similar to the sound a rubber band makes when you stretch it and launch it through the air.

This pathological movement of the two tendons must be solved to reduce the risk of injury!

The diagnosis: Consultation, MRI and dynamic ultrasound.

The diagnosis of a dislocation of the peroneal and their instability is mainly clinical. Obviously by examining results of the scan it can help to confirm this diagnosis and to evaluate the presence of any other injuries.

An MRI of the ankle, in fact, is able to help medical professionals study the tendons in their course and to identify a possible lesion.

In contrast, a dynamic ultrasound allows the operator (the radiologist) to estimate the importance of dislocation and instability peroneals.

Surgical treatment: The tendoscopy or tendoscopia

Faced with a diagnosis of dislocation of the peroneal tendons, then surgery may be the solution.

In the past, this type of surgery always required surgical incisions to help expose the tendons.

An incision in such cases is not as drastic as it sounds: the procedure simply allows the surgeon a direct view of the tendons and a clear view of what needs repairing.

On the other hand, an incision also requires the body to heal and this can leave a patient with scar tissue.

That’s why we have recently introduced the practice of tendinoscopia (tendoscopy).

What is Tendoscopy?

Through a small hole, a tiny camera is inserted so the surgeon can observe the operation and visually assess any injury.

The tendoscopy is primarily a diagnostic procedure and a lot of the time this method is unable to replace an open more orthodox intervention.

However, in many cases this procedure can often help repair tendon injuries.

If, in fact, mild tendon injury is possible to envisage a tibularizzazione tendon. Simply put, this type of tendon injury instead of being similar to a pipe flowing, it becomes closer to a wide, flat piece of ribbon. The tibularizzazione procedure restores the shape of the cylinder relating to the tendon.

Other times, the tendon is severely compromised or even broken. In these cases, it is recommended we perform a transposition procedure. For example, the healthy tendon is moved to increase its function.

Obviously, in addition to this lesion repair procedure, in the case of instability, we proceed to repair the sheath, which surrounds both these two tendons and allows them to slide more easily.

This sometimes requires a simple reconstruction of soft tissue.

Other times, in more complex cases of instability, it becomes necessary to deepen area, by acting on the fibula, which is said to be the area where the two tendons slide.

Any procedure that is scheduled for Bale, may be difficult to make unless a tendoscopy is carried out.

Final Message

Good luck to the Welsh player! Get well soon Gareth!