Ankle avulsion fracture is the tearing away of a fragment of ankle bone away from the main bone. Distal fibula avulsion fracture would describe the tearing away of a tiny fragment of bone with a lateral ligament injury. Avulsion fracture tibia malleolus happens when a bone fragment is broken away from the distal tibia with a deltoid ligament injury. Ankle avulsion fracture treatment requires a team approach from you, your coach, your doctor and your physiotherapist.

Avulsion fractures are more common in children. Although it is not deemed a medical emergency, if not treated ankle avulsion fractures can fail to heal, take longer than necessary to heal or cause long term symptoms to a young athlete.

Your ankle joint functions like a corporate entity, with different departments responsible for different movements, but all working together to walk, hike, run, change direction, balance or land from a jump.

Your ankle is formed by your tibia, fibula and talus bones.

1. The tibia, or the shin bone, makes up the inside part of your ankle.
2. The fibula is the smaller bone that runs parallel to the tibia in your lower leg. The fibula makes up the outside part of your ankle.
3. The talus is a small cube-like bone in your foot and carries all the weight of your body when standing on 1 leg.

What do my bones, ligaments and tendons do?

Bones

The talus bone is wedged between the dome of the tibia and the fibula of your lower leg above, and calcaneus or heel bone from below. Two important joints are formed here, the tibiotalar & subtalar joints, that work synergetically to point and flex your ankle joint.

Ligaments

Ligaments attach bone to bone. The ligaments of your lateral ankle include the anterior tibiofibular, anterior talofibular, calcaneofibular and lateral talocalcaneal ligaments. These can be injured when you roll over your ankle and cause a lack of static stability. The deltoid ligament on the inside of your ankle is much stronger and injured less frequently. These ligaments provide static stability to your ankle joint, like when you balance on one leg in tree pose.

Tendons

Tendons attach muscle to bone. The muscles and their tendons provide dynamic stability during movements. This enables your ankle to move in all directions when lifted off the ground and stay stable when planted on the ground and your body moves, like when you do single-leg deadlifts.

Warehouse of storage

Your skeleton is a living organ capable of healing. Bones with marrow produce blood cells, like your pelvis, vertebrae and ribs. All other bones of your skeleton store minerals, like calcium and phosphorus, which can be utilised as and when needed by your body.

The bones of your skeleton are continuously remodelled through an internal maintenance team. Osteoclast cells break down damaged bone like little Pacman, while osteoblast cells rebuild like Bob the Builder.

Bone is elastic, which means that the tissue allows for some shape change, but much less than a ligament or muscle. A growing child’s bones would be more elastic than an adult’s. When the load applied exceeds the elastic capacity, tissue failure occurs. The angle, movement, force and strength of the tissue determine if you end up with a muscle tear, ligament rupture or avulsion fracture.

Ankle avulsion fractures can happen under two different scenarios:

• High force injury

A single incident that surpasses the stress/strain curve of the bone’s elasticity can cause an avulsion fracture of the ankle. A small bone fragment is pulled away from the bone. This can happen with a single forceful muscle contraction, as an internal cause. The tendon attachment will tear away a bone fragment, like with a base of the 5th metatarsal avulsion fracture. External trauma, like a forceful tackle and rolling over the ankle, can cause a distal fibula avulsion fracture or tibia malleolus avulsion fracture. Now the ligament tore a bone fragment away from either the tibia, fibula or talus.

• Repetitive overload

High training load and inadequate rest can cause bone fatigue. This is a chemical change where the bone cannot repair in between bouts of mechanical load. This increases the risk of any bone injury, including a stress fracture or ankle avulsion fracture.

Pathophysiology

An avulsion fracture initiates a cascade of events to heal. Inflammation will cause the area to swell, feel warm and look red. Within 72 hours a haematoma, a blood clot, forms. You may see a visible bruise the next day. This stops bleeding, bones have a rich blood supply. Within a week the clot will spread out “tentacles” to enclose the avulsion fracture and form a callus. Osteoclast cells will resorb any dead tissue and debris, and osteoblast cells will start to build new bone cells. This process of remodelling can take between 6 – 12 weeks.

Instability or the feeling of giving way is indicative of tissue damage. Your ankle can feel weak with movement in a specific direction because the tendon cannot exert force because it no longer has an attachment to the bone that it is supposed to move. You will feel apprehensive about bearing weight and walking.

Distal Fibula Avulsion Fracture

This is the most common ankle avulsion fracture due to the relative “weakness” of the ligaments on the outside of the ankle compared to the ligaments on the inside. It can happen when rolling over your ankle, tripping over an obstacle or landing poorly from a jump. One or all three of the lateral ligaments can tear away a fragment of the fibula.

Avulsion Fracture Tibia Malleolus

These injuries are less common due to the strength of the deltoid ligament. They can occur due to high-force collision or a tackle, forcing the foot to aim outward and you to fall back. The ligament tears away a bone fragment from the tibia. This is the same mechanism of injury for an ankle syndesmosis injury and immediate evaluation is advised.

Base of the 5th Metatarsal Avulsion Fracture

This injury shares the same mechanism as a fibula avulsion fracture, by rolling over the ankle. Here the peroneal muscle pulls away a bone fragment of the base of the 5th metatarsal.

• Repeated ankle sprains that lead to ankle instability

A “weak ankle” is just an ankle that you haven’t gone through the trouble of rehab. Instability due to lack of movement and stability can increase your risk of sustaining an ankle avulsion fracture.

• Contact sports

Tackles made in soccer, rugby and hockey can cause ankle avulsion fractures.

• Repetitive or high training load

Athletics, dance, endurance or long-distance running and cross-fit training volumes can increase your risk of sustaining an ankle avulsion fracture.

• Footwear with inadequate support for the terrain

There is a reason companies have different lines of shoes for hiking, trail and road running.

Avulsion fracture severity is classified in terms of the degree of separation and displacement.

The diagnosis of an avulsion fracture necessitates treatment because of the bone injury. If the avulsion fracture is stable non-surgical care is advised with immobilisation and graded rehabilitation. Displaced avulsion fractures may require surgical repair, immobilisation and then graded rehabilitation. Separation of 1.5 – 2 cm requires surgical repair.

Lawrence and Botte’s Classification is used to describe the severity of a base of the 5th metatarsal avulsion fracture by indicating the area where the bone fragment was displaced from the metatarsal.

Our physiotherapists are experts in anatomy, we have experience in movement disorders and understand how something as far away as your hip may have contributed to your ankle avulsion fracture because of overuse. At the practice, we pride ourselves in taking the time to understand the impact of your ankle avulsion fracture on your life. We have the skills to test muscle length and strength, nerve function and joint control and stability. Our physiotherapists will guide you to make responsible choices during your recovery in training in the future.

X-rays will show the integrity and alignment of the joints of your ankle to identify avulsion fractures.

Your physiotherapist can refer you to get x-rays taken if necessary.

Diagnostic ultrasound can be used to visualise the superficial ligaments of the ankle. This can confirm avulsion fractures of the ankle and other soft tissue injuries ligaments and tendons.

An MRI scan can show all of the structures of your ankle joint, including the bone, ligaments and tendons. This is a costly image that needs to be ordered by a specialist.  If your physiotherapist suspects trauma within the joint, you will be referred to the right specialist.

Your skeleton is a living organ, capable of healing. If you get stuck in a cycle of pain, rest and avoiding activities, only to return and be in pain again, you will feel frustrated. You can be unsure, not knowing if it is safe to move or not. That is why getting the right diagnosis from the start is important to treat your ankle avulsion fracture correctly. Ankle avulsion physiotherapy treatment aims to empower you to know the dos and don’ts. That way you can fast track your recovery and not unnecessarily lose out on training, events or everyday life.

When you rest completely you risk losing out on the benefits of muscle contraction and weight bearing on bone resorption. Active recovery can mean walking partially weight-bearing with a moon boot, enabling you to get the good effects without delaying your healing. We see patients who were wrongly diagnosed participating too soon and ultimately prolonging their recovery.

There is a risk of irreversible damage if you don’t take your symptoms seriously.

Ignoring an ankle avulsion fracture won’t make the pain go away

• Waiting too long

The longer you wait, hoping that your symptoms will disappear, the bigger your chances of causing permanent damage. The bridge between the bone fragment and the bone won’t magically be gapped. Immobilisation ensures contact and encourages bone union.

• Not getting a diagnosis

You only waste time by waiting it out, get the right diagnosis from the start. This ensures the right treatment during the specific phase of healing needed.

• Trying out, but not completing, different forms of treatment

Wearing a brace or moon boot for half of the recommended time is like drinking only half of your coffee. Why go through the trouble and expense of getting the brace or boot if you won’t see it through until the end?

• Continuous use of over the counter medication

Anti-inflammatories and analgesics only mask your symptoms and do not address the root of the problem. Many tablets have some nasty gastrointestinal side effects.

• Misconceptions about treatment

Symptom management is the foundation of ankle avulsion fracture treatment. Once your pain is under control we can spend time on the good. stuff and ensure you regain full movement, strength and endurance so that you don’t ever have to say “I have a weak ankle”. Your treatment is complete when you can’t remember which side was injured.

Our physiotherapists have years of experience in recognising symptom patterns and making the correct diagnosis. We know anatomy and understand how biomechanics influence local structures but also the repercussions certain movements can have on other structures further away. Our aim is to help you understand your problem and empower you to make responsible decisions during your recovery.

We pride ourselves in our work and aim to provide guidance and answers and implement an effective and structured plan of action. Movement is medicine, we want you to feel confident in the dosage you take. We will also look at muscle strength, joint range of motion, flexibility, ligament stability and nerve control. By treating the whole of you we manage the entire problem. This can prevent future injuries by decreasing risk factors and enhance your performance.

An avulsion fracture of the tibia malleolus can heal between three to twelve weeks. Healing time is influenced by the degree of separation of the bone fragment from the main bone, your general health, diet and adherence to the treatment plan. Once diagnosed your physiotherapist will explain the period of immobilisation to you. You can continue your home exercise program daily while we see each other once every second week until you can fully weight bear. Now we can schedule your sessions to once weekly for the next month to manage your symptoms as you increase your movement, strength, flexibility and endurance.

How fast you recover will greatly be up to you.

• Your doctor (GP) will probably prescribe oral medication to manage your pain.
• A dietician/nutritionist can advise you on dietary supplements and nutrients that will encourage bone healing. Recovery demands energy, this is not the time to skip meals.
• A biokineticist will be able to help you in the final stages of your rehabilitation, once you have regained full range of movement.
• Wearing a moon boot or brace alone isn’t the solution to your problem.
• Hyperbaric Oxygen (HBO) treatment can hasten recovery.

Surgery is considered if there is a separation of 1.5 – 2 cm between the bone fragment and the bone. This is a large space, unlikely to be gapped with immobilisation. Your surgeon may do an open reduction with internal fixation to connect the bone fragment to the main bone. This will require casting for three weeks and then wearing a moon boot for another three weeks. Once out of the moon boot the real work starts to regain your ankle’s mobility and strength.

• Stress fracture

Repetitive force or overuse can cause tiny cracks in the bones that worsen with activity and improve with rest.

• Ankle sprain

An acute incident of rolling over your ankle that causes pain with weight bearing can cause a ligament sprain.

• Ankle fracture

High-force transmission can result in a fracture of any of the bones in your ankle. You will be unable to walk more than four consecutive steps.

• Sinus tarsi syndrome

Repeated ankle sprains can result in instability of the subtalar joint, pain with use, like hiking or jogging, and improvement with rest.

• Peroneal tendonitis

Inflammation of the peroneal tendons, because of poor biomechanics or new shoes, can cause pain on the outside of the ankle after stopping the aggravating activity.

• Distal fibula avulsion fracture
• Talus avulsion fracture
• Avulsion fracture tibia malleolus
• Base of 5th metatarsal fracture