Soft tissue surgery of the ankle

Surgery of ligaments, tendons, and tissue envelope

The Foot and Ankle Clinic treats soft tissue disorders of the ankle and foot. Several surgical techniques can be used depending on the injuries, including arthroscopic and endoscopic techniques, as well as percutaneous and minimally invasive techniques.

Anatomy of the ankle: ligaments, tendons, and other soft tissues

The ankle is a complex hinge joint where ligaments, tendons, and other soft tissues provide joint stability and mobility while withstanding the mechanical stresses of walking, running, and impact from sports activities.

On the lateral side of the ankle, the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament form the external ligament complex that resists inversion of the foot. The anterior talofibular ligament, stretched between the lateral malleolus and the neck of the talus, is the ligament most frequently injured in isolation.

On the medial side of the ankle, the strong deltoid ligament has 2 ligament bundles, a short deep bundle and a superficial bundle extending from the medial malleolus to the talus, calcaneus, and navicular. It blends with the upper edge of the spring ligament, preventing excessive eversion of the ankle and midfoot.

Above the tibio-talar mortise is the tibiofibular syndesmosis, made up of 4 ligaments: the anterior and posterior tibiofibular ligaments, the inferior transverse ligament, and the interosseous ligament. The syndesmosis enables elastic tightening between the tibia and fibula, stabilizing the talus in the various positions of ankle flexion. All of these ligaments act as passive struts that also contribute to joint proprioception and the distribution of mechanical stress when bearing weight.

The Achilles tendon, formed by the gastrocnemius muscles and the soleus muscle, inserts onto the calcaneus and provides the push-off force essential for plantar flexion during propulsion in walking. Behind the medial malleolus, the posterior tibial tendon supports the medial plantar arch and provides inversion while stabilizing the ankle during the stance phase. On the lateral side, the tendons of the peroneus brevis and peroneus longus muscles glide behind the lateral malleolus; they play a major role as dynamic evertors that help correct the ankle during varus equinus movements. Varus equinus injuries to the ankle often result in sprains of the lateral side.

At the front of the ankle, the tendon of the tibialis anterior muscle is the main dorsiflexor of the ankle when walking, and the tendons of the extensor digitorum longus muscle and the tendon of the extensor hallucis longus muscle allow for dorsiflexion and clearing of the foot with each stride. The efficient gliding of these tendons in their sheaths is made possible by the retinacula, which hold them against the ankle for optimal transmission of muscle contraction forces.

The fibrous articular capsule envelops the tibiofibular-talor mortise; thin at the front and back but thickened laterally and medially, it is lined with a synovial membrane that lubricates the cartilaginous articular surfaces. Two essential bursae (the deep retrocalcaneal bursa and the superficial subcutaneous calcaneal bursa) cushion the friction between the Achilles tendon, the calcaneus, and the skin during repeated movements.

The posterior tibial nerve, protected in the tarsal tunnel along with its sensory calcaneal branch, medial plantar, and lateral plantar branches, provides plantar sensation and motor function to the plantar muscles. The superficial fibular nerve runs subcutaneously and typically has 3 sensory branches that provide cutaneous sensation to the dorsum of the ankle and foot. The deep fibular nerve runs with the anterior tibial vascular bundle beneath the retinacula. It notably provides sensory innervation to the first web space.

Pathologies and indications

The ankle, subjected to significant mechanical stress, can be the site of various soft tissue injuries:

Each of these conditions presents symptoms (pain, swelling, instability) whose persistence, despite appropriate conservative treatment, may suggest a possible surgical intervention. Recurrent sprains can progress to chronic ligament laxity, resulting in abnormally high mechanical stress on the ankle cartilage. The risk of ankle osteoarthritis in the medium and long term increases with the severity of ligament laxity.

Achilles tendon ruptures, which cause a loss of calf muscle propulsion strength while walking, can be treated non-surgically, but surgical treatment is often proposed to reduce the risk of tendon lengthening callus with associated loss of strength in the triceps surae. Chronic tendinopathies of the Achilles tendon or the posterior tibial tendon, which do not respond to rest, anti-inflammatories, or physiotherapy protocols, may require surgical treatment:

When a synovial cyst originating from a tendon sheath or the capsule becomes large and painful, it may be troublesome when wearing shoes or may compress small nerve branches. Complete surgical removal of the cyst and its capsule is then recommended.

Surgical techniques

Different surgical techniques may be proposed depending on the lesions and the quality of the tissues. Arthroscopy, performed through very small incisions, allows for the analysis and treatment of certain intra-articular lesions. Percutaneous surgery enables targeted correction while minimizing soft tissue trauma. More broadly, minimally invasive procedures promote tissue healing by limiting surgical dissection of soft tissues.

Non-surgical treatments

Before considering an intervention, several solutions can be considered:

Care pathway for scheduled surgical intervention

Each patient is cared for through a personalized treatment plan. The initial consultation is important; it involves asking the patient specific questions about the suspected condition, then the clinical examination confirms the diagnosis, and the analysis of imaging tests such as X-rays, CT scans, ultrasounds or MRI provides detailed information on the lesions. The proposed treatment is systematically tailored to each patient.

The procedure is then scheduled and performed, followed by a post-operative follow-up adapted to the treated lesions, which includes a rehabilitation program and personalized advice to optimize recovery. Throughout this process, our team remains available: we provide continuous support, answer any questions, and adjust the follow-up as necessary, ensuring a comprehensive approach to care.

Non-surgical therapies

Our interventions targeting the soft tissues of the ankle combine manual therapies, joint mobilizations, myofascial techniques, and proprioceptive retraining. This multimodal approach relieves pain by reducing local inflammation and releasing muscular tension, which promotes healing. By gradually restoring the range of motion (flexion-extension, inversion-eversion), it gives the ankle the essential mobility needed for walking, running, or simply standing without discomfort; support becomes secure again, posture is balanced, and compensatory strain on the knee or hip diminishes.

At the same time, a graduated program of muscle strengthening and proprioceptive training restores the dynamic stability needed for changes in direction and repeated impacts experienced in sports activities. This regained stability allows you to resume leisure activities as well as daily movements, while reducing the risk of a sensation of instability. Finally, by correcting residual proprioceptive deficits and strengthening the periarticular muscles, the treatment significantly lowers the risk of ankle sprain recurrence; it thus contributes to overall well-being, extends benefits in the long term, and supports your quality of life.

Potential complications and prevention

Like any surgical procedure, interventions on the soft tissues of the ankle can have complications. Risks include postoperative infection, which is minimized by strict aseptic protocols and appropriate antibiotic prophylaxis. Joint stiffness may occur, but it is prevented by early mobilization and appropriate rehabilitation. Healing disorders, more common in diabetic or smoking patients, require increased monitoring and sometimes an adaptation of the care protocol.

Algodystrophy, an unpredictable but relatively rare complication, manifests as persistent pain and swelling. Early management generally allows a favorable outcome. Recurrence of the initial condition remains possible, especially if sports activities are resumed too quickly or if rehabilitation is insufficient. To minimize these risks, we implement rigorous and personalized postoperative follow-up, tailored to each patient and their activity level.

FAQ about soft tissue surgery of the ankle

The procedure is often performed on an outpatient basis and rehabilitation is personalized according to the specific lesion, with a return to activities in a few weeks to a few months.

The risk of complications is always possible, as with any surgical procedure. However, each case is individually assessed to adapt the treatment.

When pain, instability, or dysfunction persist despite conservative approaches, surgery may be proposed.