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3 September 2017

Graham set out to turn his life around – but all he got was a twisted ankle

The ankle is far and away the commonest sprain site we see. 

By Phil Whitaker

Fifty-year-old Graham was an infrequent attender, and his only recent consultation was a couple of months previously, when he’d come for his NHS Health Check. I saw from the notes that my nursing colleague had found a borderline risk of heart disease – a bit overweight, blood pressure a little up – so I prepared myself for a discussion about the issues.

But it wasn’t that at all. I noticed Graham limping as he walked to my consulting room.

“I thought it was just a sprain,” he told me, slipping his shoe and sock off. “But it won’t settle down.”

I quizzed him about the history. Yes, he’d turned the ankle. Yes, it went on to swell over the outer side. He’d done all the right things – ice, rest, compression bandaging – but while the swelling had improved, he was getting pain a couple of months later, and his foot felt distinctly unstable.

The ankle is far and away the commonest sprain site we see. All joints are kept within their usual range of motion by a combination of bone anatomy and fibrous ligaments. Put enough force in the wrong direction, though, and the joint can be made to move in ways nature never intended. The ligaments stretch and tear, causing the familiar pain and swelling. Usually things repair themselves with time and rest.

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Examining Graham’s foot, I noticed something very odd. We’re all familiar with the bony lumps at either side of our ankles – the medial and lateral malleoli, to give them their proper names. Sliding about in front of Graham’s lateral malleolus were a couple of rope-like structures that ought not to have been there. Though I’ve seen countless ankle injuries over the years, it was the first time I’d encountered this particular variety.

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“You’ve subluxed your peroneal tendons,” I told him, much to his bemusement.

The movements of our feet and ankles are controlled by the muscles in our lower legs. The peroneal muscles lie at the outside of the calf, and form two tendons that hook round the back of the lateral malleolus before running forward to attach to the bones of the foot. They’re held in place by an extremely tough ligament called the retinaculum. Tear that, and there’s nothing to stop them popping out of place, rendering the peroneal muscles effectively useless.

The most famous sufferer of this injury was Gareth Bale, the Welsh star striker, who tore his right retinaculum during his club, Real Madrid’s, successful 2016 Champions League campaign. Bale had his fixed by top surgeons at a private hospital in London.

While surgery is usually necessary once the injury is established, if diagnosed early enough it is possible to effect a reasonable result (though not good enough for a top-class athlete) by immobilising the ankle in a plaster cast and allowing the retinaculum to heal without interference from the wayward tendons.

I asked Graham when he did the injury, wondering if he might still be suitable for casting.

He looked a bit sheepish. “The day I came for my health check,” he said. He’d been shocked to hear about his heart-disease risk. As soon as he’d got home, he’d looked out his old tracksuit and dusted off an ancient pair of trainers, then set off at a canter round the field behind his house. He’d intended to turn his life around. All he’d ended up turning was his ankle.

NHS Health Checks, offered at five-yearly intervals between the ages of 40-74, have been widely criticised as a waste of money. The idea seems sound: an opportunity to identify people at risk and help them avoid future health problems. But the theory doesn’t match reality: no study has yet found any concrete improvements in actual disease outcomes for the £450 million spent annually on the programme. And while it’s assumed that the advice dished out can only have a positive impact, in Graham’s case, his overly enthusiastic response has left him distinctly worse off, and will end up costing the NHS a few thousand for an operative repair.

This article appears in the 30 Aug 2017 issue of the New Statesman, The decline of the American empire