Ski & Snowboard Ankle Injuries | Dr Ali Abbasian London

The Ski season is upon us. Snow has been falling on the Alps and the excitement is growing. Last minute purchases of gloves and thermals are in full flow. But every winter the same conversation happens: people heading to the Alps talk about ACL tears, broken collarbones and wrist fractures. The big, obvious ski injuries everyone knows. Ski ankle injuries rarely get a mention. It’s tightly wrapped in a solid boot, it feels safe, and most people assume it can’t get hurt.

That’s only partly true. Ski and snowboard boots protect the ankle from the typical lateral ankle sprain but can create others. The design of the boot changes how the force travels through the leg. Instead of twisting at the ankle and getting the typical ankle sprain, it moves higher or deeper leading to injuries that are easy to miss and can potentially be more serious.

Below are the main ankle and foot problems I see every ski season and what to look out for whether you are a physio assessing these patients or a skier planning your next trip.

1. High-Ankle (Syndesmosis) Injuries — The Classic Skier’s Injury

 

When a ski catches the snow and twists outward, the external-rotation force on the ankle can be several times higher than it would be if only the foot were involved. With a stiff boot locking the foot and ankle together, the ski acts as a long lever which is about three times the length of the foot. So the same body weight generates roughly three to four times the rotational moment at the ankle. That torque is transmitted directly to the syndesmosis, explaining why high-ankle (syndesmotic) sprains are much more common in skiing than in other sports. The longer the ski the greater the force. So even at low speed or a fall from standing, serious damage can be done, if the binding doesn’t release. Sometimes a small fragment of bone pulls off the back of the tibia (posterior malleolus fracture).

These are often labelled as “high ankle sprains”, but that makes them sound mild. They’re not. They take time to heal and can cause ongoing pain if missed early. Some Ski ankle injuries may need surgical stabilisation.

For patients:

  • Pain sits above the ankle joint, not on the side.

  • Turning or climbing stairs makes it worse.

  • Swelling is often mild, which can be misleading.

  • It can happen even with a minor fall.

For physios:

  • Tenderness over the anterior inferior tibiofibular ligament.

  • Positive external-rotation or squeeze test.

  • Pain out of proportion to swelling.

  • Consider MRI or weight-bearing CT if suspicion remains high.

 

 

 

2. Lateral Process of the Talus Fracture — The Snowboarder’s Fracture

 

Snowboarders live in softer boots with more movement. When the ankle is forced upwards and inwards (dorsiflexion + inversion), a small ridge of bone on the outer talus (lateral talar process) gets jammed and can crack.

Unfortunately the small fracture can be difficult to see on standard x-rays of the ankle and its therefore commonly missed. Due to the pain being on the outer side of the ankle patients are labelled as having had an ankle sprain. If it looks and feels like a sprain, but doesn’t get better then this is the “snowboarder’s fracture.” These injuries can lead to serious morbidity and need to be assessed urgently. large fracture fragments are best fixed. I have managed many missed injuries some of which have resulted in permanent arthritis in the subtalar joint.

For patients:

  • Pain and swelling on the outside of the ankle that won’t settle.

  • Pain when pushing off or landing.

  • You can often still walk, which makes it easy to ignore.

For physios:

  • Local tenderness just below and behind the fibula.

  • Pain with dorsiflexion and inversion.

  • If symptoms haven’t improved after two to three weeks, request a CT — plain X-rays often miss it.

Lateral Talus fracture

 

 

3. Peroneal Tendon Injuries & Fifth-Metatarsal Base Fractures

 

These two often come as a pair. A sudden inversion catching an edge or stepping awkwardly off a lift  can tear or dislocate the peroneal tendons and sometimes pull a fragment of bone from the base of the fifth metatarsal.

For patients:

  • A sharp “snap” or tearing feeling on the outer ankle.

  • Pain behind the fibula or along the outer foot.

  • Still sore weeks later, especially when pushing the foot outwards.

For physios:

  • Watch for tendon subluxation on resisted eversion.

  • Palpate the fifth-metatarsal base for tenderness.

  • These injuries often occur together — check tendons and bone.

  • Ultrasound or MRI if symptoms persist beyond expected recovery.

 

Boot Fit & Pre-Season Strength

A lot of these Ski ankle injuries injuries can be prevented.

Boot fit:

  • Snug enough to stop excess movement but not so tight that it locks the joint completely.

  • Check binding release settings. If its too stiff and you risk twisting forces.

  • Replace worn liners that let your ankle roll inside the boot.

Pre-season prep:
A few simple exercises before you go make a big difference:

  • Single-leg balance work (wobble board or cushion).

  • Calf raises and peroneal strengthening with a resistance band.

  • Core and hip stability exercises for better landing control.

Even two short sessions a week in the month before your trip help reduce fatigue-related falls which is the root of most ski injuries.

 

When to Get It Checked

If ankle or foot pain isn’t improving within a week of a fall or if it feels higher, deeper, or sharper than a normal sprain the you need to get it checked.
Persistent pain, swelling that lingers, or trouble pushing off the ground are red flags.
Most of these injuries heal fully with the right diagnosis and plan, but only if they’re recognised early.

Ali Abbasian is a Consultant Orthopaedic Surgeon specialising in Foot and Ankle Surgery – click here to find out more  or get in touch 

Top 4 causes of heel pain in runners.

As the London Marathon draws near, the excitement among runners is tangible. However, with the heightened training intensity, the risk of injuries, particularly heel pain, becomes more prevalent. In this post, I’ll delve into the top four culprits behind heel pain in runners, that I am diagnosing with increasing frequency: Plantar Fasciitis, Stress Fracture of the Calcaneus, Insertional Achilles Enthesopathy (Haglund Syndrome), and Non-Insertional Achilles Tendinopathy. Understanding these causes and their symptoms is crucial for both prevention and early intervention.

  1. Plantar Fasciitis:

Plantar fasciitis is a common ailment that results from inflammation of the plantar fascia, a thick band of tissue connecting the heel to the toes. Runners experiencing plantar fasciitis often complain of sharp pain near the bottom of the heel and the instep, particularly in the morning or after prolonged periods of inactivity.

Self-Diagnosis Tips:

  • Sharp heel pain, especially in the morning.
  • Tenderness along the bottom of the foot and the instep.
  • Increased pain after long runs or extended periods of standing.

What You Can Do:

  • Stretching exercises for the Achilles and calf muscles.
  • Icing the affected area.
  • Supportive footwear.

  1. Stress Fracture of the Calcaneus:

Stress fractures in the heel, or calcaneus, can occur due to repeated stress on the bone, commonly seen in long-distance runners. Symptoms may include localised heel pain that intensifies during activity and decreases with rest. Swelling around the heel is another giveaway. Comparing one foot to another can be helpful in demonstrating subtle swelling around the heel bone.

Self-Diagnosis Tips:

  • Pain that worsens during or after running.
  • Swelling or bruising on the heel.
  • Tenderness to touch on both sides of the heel.

What You Can Do:

  • Rest and avoiding high-impact activities.
  • Gentle stretching exercises.
  • Consultation with a healthcare professional for imaging.

  1. Insertional Achilles Enthesopathy (Haglund Syndrome):

This condition involves inflammation where the Achilles tendon inserts into the heel bone. Runners may experience pain, swelling, and a noticeable bump at the back of the heel.

Self-Diagnosis Tips:

  • Pain and swelling at the back of the heel.
  • A visible bump or prominence.
  • Discomfort while wearing shoes.

What You Can Do:

  • Heel pads or cushions in shoes.
  • Avoiding tight or rigid footwear.
  • Physiotherapy for stretching and strengthening exercises.

  1. Non-Insertional Achilles Tendinopathy:

Non-insertional Achilles tendinopathy affects the middle part of the Achilles tendon, causing pain and stiffness. Runners may notice pain during or after running, along with swelling and thickening of the tendon.

Self-Diagnosis Tips:

  • Pain along the middle of the Achilles tendon.
  • Stiffness in the morning.
  • Swelling or thickening of the tendon.

What You Can Do:

  • Eccentric exercises to strengthen the tendon.
  • Rest and ice after running.
  • Consultation with a healthcare professional for personalised advice.

 

As you gear up for the London Marathon, being aware of these common causes of heel pain is essential for your overall well-being. If you experience persistent symptoms or have concerns about your heel pain, seek professional advice promptly. Early intervention can make a significant difference in your running journey, ensuring you cross the marathon finish line with strength and resilience. Happy running!

 

Ali Abbasian is a Consultant Orthopaedic Surgeon specialising in Foot and Ankle Surgery – get in touch  to find out more or request a consultation and our team will get back to you. 

 

Total Ankle Replacement – FAQ

Total ankle replacement (TAR) is a surgical procedure that involves replacing a damaged ankle joint with an artificial joint. It is typically performed on patients with severe ankle arthritis or other conditions that have caused damage to the ankle joint. If you are considering TAR, you may have questions about the procedure, the recovery process, and the potential benefits and risks. In this article, we will answer some of the most frequently asked questions about total ankle replacement.

 

 

  1. How successful is total ankle replacement surgery?

Total ankle replacement surgery has a high success rate, with most patients experiencing significant improvement in their pain and mobility after the procedure. There has been a significant improvement in outcomes over the last decade and the technology and experience with the procedure has progressed rapidly in the recent times.

 

  1. What is the recovery time after the surgery?

The recovery time after surgery can vary depending on the individual patient and the extent of the surgery. In general, patients can expect to be restricted in their weightbearing and in a cast for up to two weeks after the surgery, and then to gradually transition to physical therapy and rehabilitation exercises whilst using a walker boot. It can take several months to fully recover from the procedure and return to normal activities.

 

  1. Who is a good candidate for total ankle replacement?

A good candidate for total ankle replacement is typically someone who has severe ankle arthritis or other damage to the ankle joint that is causing significant pain and mobility issues. Candidates for the procedure should have healthy bones and good circulation, and should not be significantly overweight. It is also important to have realistic expectations about the procedure and to be committed to the recovery process. Those with uncontrolled diabetes who may have nerve damage and those you have an active infection are also excluded.

 

  1. What are the risks and complications of this type of surgery?

As with any surgical procedure, there are risks and potential complications associated with total ankle replacement. These can include infection, blood clots, nerve damage, and problems with the artificial joint such as loosening or wear over time. Your surgeon will discuss these risks with you before the procedure and help you understand what you can do to minimize your risk of complications. You can also read more about the surgery and any potential complications on this site.

 

  1. How long does a total ankle replacement last?

Ankle replacements can last for many years, but they are not necessarily considered a permanent solution. The lifespan of an artificial joint can vary depending on factors such as the patient’s age, weight, activity level, and the extent of their arthritis. Some patients may need to have their ankle replacement revised or replaced after several years, while others may enjoy many years of pain-free mobility. Recent analysis of the data suggests an average of 1-1.5% of implants may fail each year post implantation. As such 85-90% of implants are likely to be in place after 10 years.

 

  1. How much does total ankle replacement surgery cost?

The cost of surgery can vary depending on factors such as the geographic location, the surgeon’s fees, and the extent of the surgery. In the United States, the cost can range from $20,000 to $40,000 or more, depending on the specific circumstances. In the UK, the cost of total ankle replacement surgery is generally covered by the National Health Service (NHS), however to fund this outside of the health services the costs could range from £12,000 to £18,000 depending on the surgeon and the facility performing the surgery.

 

  1. How is total ankle replacement surgery performed?

This surgery is typically performed under general anaesthesia, and involves making an incision at the front of the ankle to access the joint. The damaged joint is then removed and replaced with an artificial joint made of metal and plastic. The surgeon may use screws or other hardware to secure the new joint in place. The incision is then closed and the patient is monitored for any potential complications. I use the Infinity total ankle replacement and the Prophecy pre-operative navigation system which produces patient specific guides. This ensures that the implant is best positioned and sized to fit the particular anatomy exactly on the basis of pre-operative CT scans. You can watch the animation of the surgical process here.

 

  1. What kind of rehabilitation is required after total ankle replacement surgery?

Physiotherapy and rehabilitation exercises are an important part of the recovery process after total ankle replacement surgery. Patients may work with a therapist to learn exercises to improve their range of motion, strength, and balance. They may also use special equipment such as crutches or a walking boot to help support the ankle as it heals. The specific type and duration of physical therapy will vary depending on the patient’s individual needs and the extent of their surgery. The aim is to improve the range of motion and strengthen the muscles around the lower leg.

 

  1. When can I return to normal activities after total ankle replacement surgery?

The timeline for returning to normal activities after total ankle replacement surgery can vary depending on the individual patient and the extent of the surgery. In general, patients should avoid putting weight on the ankle for the first two weeks after the surgery, and should gradually increase their activity level as directed by their surgeon and physical therapist. It may take several months to a year to fully return to higher impact activities. Low impact exercise such as cycling, walking, golf and swimming can commence by 6 months post surgery. High impact sports are not recommended if you have a total ankle prosthesis although a social game of tennis or a brisk hike is often tolerated.

 

  1. How does total ankle replacement compare to ankle fusion surgery?

Ankle fusion surgery is an alternative to replacement for patients with severe ankle arthritis or other damage to the ankle joint. Ankle fusion involves fusing the bones of the ankle joint together, which can eliminate the pain but also limit mobility. A replacement preserves more of the natural movement of the ankle joint, but may not be suitable for all patients depending on their individual circumstances. Your surgeon can help you decide which option is best for you based on your specific needs and goals.

 

 

Ali Abbasian is a Consultant Orthopaedic Surgeon specialising in Foot and Ankle Surgery – click here to find out more  or get in touch 

The Marathon – Final week preparations

The final week before a marathon can be both exciting and nerve-wracking. As someone who has recently run the Paris marathon and with the London marathon coming up in just one week, I understand the importance of proper preparation. Here are some final week preparations that worked for me:

Nutrition – It’s important to fuel your body with the right nutrients before a marathon. This means sticking to a balanced diet and avoiding foods that may upset your stomach. One week before the marathon, I focused on eating complex carbohydrates, lean protein, and healthy fats. I also made sure to hydrate throughout the day.

Alcohol – While it’s tempting to celebrate the upcoming race with a few drinks, it’s best to avoid alcohol in the week leading up to the marathon. Alcohol can dehydrate you and affect your sleep, which can negatively impact your performance on race day.

Foot hygiene – Taking care of your feet is crucial during the final week before a marathon. Make sure to keep your feet clean and dry, and wear clean socks every day. You may want to use a foot cream to keep your feet moisturised and prevent blisters.

Toenails – It is important to trim your toenails before the marathon to prevent them from rubbing against your shoes and causing discomfort. However, be careful not to trim them too short as this can also cause pain.

Shoes – It’s best to stick with the shoes you’ve been training in during the final week before the marathon. Wearing new shoes can cause blisters and other foot issues that can affect your performance on race day. Many runners choose to wear a different pair of shoes on race day, known as their “race day shoes.” These shoes are often lighter and more cushioned than the shoes worn during training. However, it’s important to break in your race day shoes and have had some time in them previously to ensure they feel comfortable on race day.

Last minute necessary purchases – In the final week before the marathon, make a checklist of any last-minute items you may need such as energy gels, electrolyte tablets, or running belts. Make sure to purchase these items in advance so you’re not scrambling on race day.

Making a playlist – If you’re someone who likes to run with music, take some time to create a playlist that will keep you motivated during the marathon. Choose songs that are upbeat and make you feel energized. Also make it 30 minutes longer than your expected finish time!

Rest and sleep – During the final week before the marathon, it’s important to prioritize rest and sleep. This means allowing your body to recover from your training and conserving your energy for race day. Make sure to get at least 7-8 hours of sleep per night, and take naps if you feel tired during the day. It’s also important to listen to your body and take rest days if needed. Overtraining can lead to injury or burnout, so make sure to give your body the time it needs to recover. You would now be in your final week of taper.

Strength training and  cross-training – Incorporating strength training and cross-training into your final week preparations can help you improve your performance and reduce the risk of injury. Strength training can help improve your running economy, speed, and endurance by targeting the muscles used in running. Cross-training, such as cycling or swimming, can provide a low-impact workout that helps you maintain your cardiovascular fitness without putting extra stress on your joints.  During the final week before the marathon, it’s best to focus on low-intensity workouts that won’t leave you feeling sore or fatigued on race day. This may include light weightlifting, bodyweight exercises, or gentle yoga. Cross-training activities such as swimming, cycling or walking can help improve your cardiovascular fitness without adding extra stress to your body.

Weather forecast – The weather can play a significant role in your marathon experience. It’s important to keep an eye on the forecast in the days leading up to the race and dress appropriately. This close to race day, the forecast is likely to be quite accurate, so pay attention to any potential rain or wind. If the forecast calls for rain, make sure you have the appropriate clothing, such as a waterproof jacket or hat. If you need to purchase any additional clothing or gear, make sure you do so with plenty of time to spare.

With these final week preparations, you’ll be ready to tackle the London marathon with confidence and ease. Good luck!

 

 

Ali Abbasian is a Consultant Orthopaedic Surgeon specialising in Foot and Ankle Surgery – click here to find out more  or get in touch 

 

Why ‘taper’ when training for a Marathon?

 

Training for a marathon is a rigorous and demanding process that requires a significant amount of physical and mental preparation. Having just completed the Paris Marathon myself I can say with first hand experience that a key aspect of marathon training that is often overlooked is tapering. Tapering refers to the gradual reduction of training volume and intensity in the weeks leading up to a race. In this blog, I will discuss why tapering is important for marathon training and how it can benefit your overall performance on race day.

  • Reduce Fatigue and Injury Risk

One of the main reasons why tapering is essential for marathon training is to reduce the risk of injury and fatigue. During the training process, your body undergoes significant stress and fatigue as you gradually increase the intensity and duration of your workouts. This can lead to muscle damage, inflammation, and other physiological changes that can increase the risk of injury.

By tapering, you give your body time to recover and repair from the stresses of training, allowing you to enter the race with fresh legs and a reduced risk of injury. Additionally, tapering can help you to reduce mental and emotional fatigue, allowing you to approach the race with a clear mind and positive attitude.

  • Maintain Fitness and Improve Performance

While tapering involves a reduction in training volume and intensity, it does not mean that you should stop training altogether. Rather, tapering involves a strategic reduction in training that allows you to maintain fitness while also promoting recovery.

Research has shown that tapering can improve athletic performance by allowing for optimal recovery and peak physiological adaptation. By tapering, you allow your body to adapt to the stresses of training and to maximize its potential for energy production, oxygen uptake, and muscle strength.

  • Mental Preparation

Marathon training can be physically and mentally taxing, and it is important to approach the race with a positive mindset. Tapering can help to reduce stress and anxiety, and to build confidence and mental toughness. By reducing the intensity and duration of your workouts, you can focus on maintaining a positive attitude, visualizing success, and mentally preparing for the challenges of the race.

Example of a Tapering schedule:

It’s important to remember that tapering is not a one-size-fits-all approach, and the ideal tapering schedule may vary depending on your fitness level, experience, and training goals. Consult with a coach or trainer to develop a tapering plan that works best for your needs and abilities. I tried to taper over a three week period and followed something similar to the following:

 

  • Week 1: Reduce Volume

During the first week of tapering, reduce your training volume by about 20-30% compared to your peak training week. This can include reducing your weekly mileage, the number of days you train, or the intensity of your workouts.

For example, if you were running 50 miles per week during your peak training, reduce your mileage to around 35-40 miles per week. This will help you to maintain your fitness level while also promoting recovery and reducing the risk of injury.

  • Week 2: Reduce Volume and Intensity

During the second week of tapering, further reduce your training volume by another 20-30% compared to week 1. Additionally, reduce the intensity of your workouts by focusing on shorter, easier runs and incorporating more rest and recovery days.

For example, if you were running 35-40 miles during week 1, reduce your mileage to around 25-30 miles per week in week 2. You can also reduce the intensity of your workouts by running at a slower pace or incorporating more easy runs into your training.

  • Week 3: Maintain Fitness and Rest

During the final week of tapering, focus on maintaining your fitness level while allowing your body to rest and recover in preparation for race day. This can include shorter, easy runs or even rest days leading up to the race.

For example, if you were running 25-30 miles during week 2, maintain your mileage at around 20-25 miles per week in week 3. Incorporate a couple of rest days in the week leading up to the race, and avoid any strenuous activities that can cause muscle soreness or fatigue.

 

And finally to my many friends and patients who are running the London Marathon – good luck!

Ali Abbasian is a Consultant Orthopaedic Surgeon specialising in Foot and Ankle Surgery – click here to find out more  or get in touch 

 

What is Brachymetatarsia?

Brachymetatarsia refers to a failure of the growth of the metatarsal bone in the foot resulting in a shortened appearance of the corresponding toe. The fourth toe is often affected. The condition is commonly bilateral meaning it is present in both feet and has been reported more commonly in females.

How common is it?

It is difficult to be certain what the true prevalence of Brachymetatarsia is. This is because most people with the condition do not come to medical attention. And most studies therefore only refer to those who have attended for treatment. The quoted incidence of 1 in 2000 is therefore likely to be an underestimate. Despite this, even at this rate we would expect over 30,000 people with the condition in the U.K

What are the symptoms?

The physical symptoms, when present, are due to abnormal load bearing.  The neighboring metatarsals (third or fifth) will end up taking more weight and can start to hurt. If the toe is sitting on top of the foot, it can also rub against shoes and be a source of discomfort.

Most cases are not symptomatic, and do not affect the function of the foot much. The degree of physical disability caused is therefore minimal. Having said that there is a significant psychosocial element to patients’ symptoms which can in some instances and cultures be very disabling. The appearance of the forefoot can result in significant restrictions on the type of shoes that patients can wear. This may mean that any open toe shoes, sandals, or flip-flops are avoided, and the patients will try and hide their foot from view. Participation in summer activities, swimming or other outdoor pursuits may therefore be impacted. This especially in the female adolescence period can have a profound effect on their wellbeing.

What causes the condition?

It is caused when the growth plate of the metatarsal closes earlier than it is supposed to. It results in a stunted growth of the bone. This occurs most commonly due to a genetic predisposition but can be because of damage to the growth plate from trauma, infection, or tumors.

Can Brachymetatarsia be treated?  

There is no medical management such as tablets or injections that can kick start the growth of the bone. The options are between managing any physical symptoms with appropriate footwear or to undergo surgery to lengthen the bone. Surgery can be very effective in relieving the physical symptoms but also to improve the appearance of the foot and thus help with the cosmesis and the psychosocial component of the condition.

What does surgery for Brachymetatarsia involve?

There are two common procedures used to surgically lengthen the short metatarsal. One option is a single stage lengthening when the bone is stretched out on the day of the operation and the gap filled with some form of bone graft; and the second option is to lengthen the bone gradually using an external fixator device that is attached onto the top of the foot. The patient will then turn a screw on the fixator several times a day and gradually lengthens the bone. Both procedures can be very effective, but each have their own problems. You can read more about the surgery for Brachymetatarsia on this site.

How much does the surgery cost?

Unfortunately, most publicly funded health systems such as the NHS and most health insurance companies do not recognise the psychosocial element of this condition as a disability and will only fund the procedure if there is evidence of significant pain or disability from the physical symptoms. Health insurance companies may also refuse to pay as this is considered a pre-existing condition in most instances.

This will mean that patients are often required to fund the treatment themselves. The costs vary according to the type of procedure planned and the clinic fees.

 

Ali Abbasian is a Consultant Orthopaedic Surgeon specialising in Foot and Ankle Surgery – click here to find out more  or get in touch 

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