The ankle consists of 3 joints : talocrural joint, inferior tibiofibular joint and subtalar joint.
Talocrural (Ankle) Joint
This is a hinge joint formed between the inferior surface of the tibia and superior surface of the talus. The medial and lateral malleoli provide additional articulations and stability to the joint. The movements of the joint are plantarflexion and dorsiflexion. This leads to an increased number of injuries with the foot in the position of plantarflexion.
Inferior Tibiofibular Joint
This joint is the articulation of the distal parts of the fibula and tibia. It is supported by the inferior tibiofibular ligament or syndesmosis. A small amount of rotational movement is present at this joint.
This joint lies between the talus and calcaneus bones and is divided into an anterior and posterior articulation by the sinus tarsi. The main roles of the subtalar joint are to provide shock absorption and to permit the foot to adjust to uneven ground.
The lateral ligaments consist of 3 parts : anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), posterior talofibular ligament (PTFL).
The medial or deltoid ligament is strong and composed of deep layers.
Inversion injuries are far more common than eversion injuries due to the relative instability of the lateral joint and weakness of the lateral ligaments compared with the medial ligament.
The mechanism of injury is important information for the physiotherapist by providing clues to diagnosis. An inversion injury suggestslateral ligament damage, an eversion injury suggests medial ligament damage. If the injury has involved compressive forces on the ankle mortise, the possibility of an osteochondral injury has to be considered.
Lateral Ankle Pain
Lateral Ligament Injuries
These injuries occur in activities that require rapid changes of direction, especially if these take place on uneven surfaces, such as football, rugby and basketball.
The usual mechanism of lateral ligament injury is inversion and plantarflexion, which usually damages the ATFL and CFL. Complete tear of the ATFL, CFL and PTFL results in dislocation of the ankle joint and is frequently associated with a fracture. Such an injury is rather infrequent however.
Injuries to the ATFL are most common and can occur in isolation, whereas isolated ligament ruptures of the CFL and PTFL are rare.
Ankle sprains may be accompanied by an audible snap, crack or tear, which although often of great concern to the athlete, has no diagnostic significance (unlike with knee injuries, which has profound significance !!).
Swelling may appear rapidly, although it can be delayed for some hours. Tears of ligaments are graded from 1 to 3, with 3 being the most serious.
Reduction of Pain and Swelling
Lateral ligament injuries require a RICE treatment protocol in order to limit the swelling which restricts joint range of motion and increases pain. The injured athlete must avoid factors that will promote blood flow and swelling, such as hot showers, heat rubs, alcohol or bexcessive weight-bearing.
Analgesics may be required. After 48 hours, gentle soft tissue therapy and mobilisation may reduce pain and swelling, resulting in minimising muscle inhibition and permitting the patient to begin range of motion exercises. Anti-inflammatory medication can also be used 2-3 days after injury to reduce the risk of joint synovitis.
Restoration of Full Range of Motion
Physiotherapist assisted range of motion exercises can start once the acute inflammatory rection has subsided. The patient is then provided with home exercises to regain the ankles range of motion.
Active strengthening exercises, including plantarflexion, dorsiflexion, inversion and eversion should begin as soon as pain allows. They should be progressed by using therbands for resistance, particularly by strengtheing the ankle eversion movements (peroneal muscles).
Proprioception is invariably impaired following ankle ligament injuries. The physiotherapist will begin proprioceptive re-training early in rehabilitation and these exercises will gradually progress in difficulty. An example of a common progression is balancing on one leg, then using a wobble board or disc, to ultimately performing functional activities while balancing.
Exercises such as jumping, hoping, twisting, turning when running are prescribed when the athlete is pain-free, has full range of motion and strength and adequate proprioception. It should be borne in mind that approximately 75% of those that sustain an ankle ligament injury have had a previous injury, in many cases not fully rehabilitated.
Return to Sport
Return to sport is permitted when functional exercises can be performed without pain during or after activity. Further ankle protection can be provided with either taping or bracing.
If, despite appropriate rehabilitation and protection , the patient complains of recurrent episodes of instability or persistent pain, then surgical reconstruction of the lateral ligament complex is indicated.
The most common overuse injury causing lateral ankle pain is tendinopathy at the peroneus longus and peroneus brevis tendons. The peroneal muscles serve as ankle dorsiflexors and primary evertors.
1. Excessive eversion of the foot as with running on slopes or cambered surfaces
2. Excessive pronation of the foot
4. Secondary to traumatic ankle inversion injury
1. Lateral ankle pain or heel pain and swelling which is aggravated by activity and relieved by rest
2. Local tenderness and crepitus over the peroneal tendons
3. Painful passive inversion and resisted eversion, although eccentric contraction can reproduce pain
If available, MRI and ultrasound scanning are appropriate. Treatment initially involves settling the pain with rest from exacerbating activities, analgesic medication if needed and soft tissue therapy. Stretching in conjunction with mobilisation of the sub-talar and mid-tarsal joints can be helpful. Footwear will be assessed and orthoses may be required to correct biomechanical abnormalities.
Strengthening exercises should include resisted eversion (theraband), especially in plantarflexion as this position maximally engages the peroneal muscles. In severe cases, surgery may be required, which may involve a synovectomy, tendon debridement or repair.
Repeated ankle sprains may cause this condition, whereby inversion injuries cause disruption to the anterior talofibular ligament which promotes synovial thickening. This residual tissue then becomes moulded and trapped between the articular surfaces of the talus and fibula during ankle movements. A meniscoid lesion can then develop in the anterolateral gutter as a result of repeated tears of the anterior talofibular ligament.
The classic presentation is pain and tenderness at the anterior aspect of the lateral malleolus and an intermittent catching sensation.
Investigations and Treatment
Clinical assessment has been shown to be more reliable than MRI to diagnose the lesion. An arthroscopic examination confirms the diagnosis. Corticosteroid injection may be helpful initially but, frequently arthroscopic removal of the fibrotic, meniscoid lesion is required.
Anterior Ankle Pain
Pain over the anterior aspect of the ankle joint without a history of acute injury is usually due to either tibialis anterior tendinopathy or anterior impingement of the ankle.
This is a condition in which additional soft or bony tissue is trapped between the tibia and talus during ankle dorsiflexion and may be the cause of chronic ankle pain. Although this syndrome has been termed ‘footballer’s ankle’, it is also commonly seen in ballet dancers.
Anterior impingement occurs secondary to the development of exostoses on the anterior rim of the tibia and on the upper anterior surface of the neck of the talus. Exostoses are thought to be secondary to a traction injury of the joint capsule of the ankle that occurs whenever the foot is repeatedly forced into extreme plantarflexion. As these exostoses become larger, they impinge on the overlying soft tissue and cause pain.
Ligamentous injuries following inversion injuries to the ankle may also result in anterior ankle impingement whereby the anterior inferior tibiofibular ligament may impinge on the anterolateral aspect of the talus.
1. Anterior ankle pain
2. Pain becomes sharper and more localised to the anterior aspect of the ankle and fot
3. Pain is worse on activity, particularly with running and kicking a football
4. As the impingement develops, the patient complains of ankle stiffness and a loss of take-off speed
Examination reveals tenderness along the anterior margin of the talocrural joint and if the exostoses are large, they may be palpable. Dorsiflexion of the ankle is restricted and painful. The anterior impingement test, where the patient lunges forward maximally with the heel remaining on the floor, reproduces the pain.
Lateral x-rays in flexion and extension show both exostoses and abnormal tibiotalar contact.
In milder cases, conservative treatment consists of a heel lift, rest, modification of activities to limit dorsiflexion, anti-inflammatory medication and physiotherapy techniques to mobilise the joint. More prominent exostoses may require surgical removal arthroscopically or as an open procedure.
Tibialis Anterior Tendinopathy
The tibialis anterior tendon is the primary dorsiflexor of the foot, in addition to inverting foot.
Tendinopathy of the tibialis anterior may result from overuse of the ankle dorsiflexors secondary to restriction in joint range of motion, as may occur with a stiff ankle. It may also be due to downhill running, playing racquet sports involving constant changes of direction, or with excessive tightness of strapping or shoelaces over the tibialis anterior tendon.
The main features are pain, swelling and stiffness in the anterior ankle, which are aggravated by activity, especially running, and walking up hills or stairs. On examination, there is localised tenderness, swelling and occasionally crepitus along the tibialis anterior tendon. There is pain on resisted dorsiflexion and eccentric inversion.
Ultrasound or MRI may be used to confirm the diagnosis and exclude tears of the tendon.
Eccentric strengthening, soft tissue therapy and mobilisation of the ankle joint are common treatments. Correction of biomechanics with orthoses may be helpful.
Inferior Tibiofibular Joint Injury
The tibiofibular syndesmosis, consisting of the anterior and posterior inferior tibiofibular ligaments and interosseous membrane, maintains the joint between the distal tibia and fibula. It plays a dynamic role in ankle function.
Separation occurs with partial or complete rupture of the syndesmosis ligament. Ruptures of the syndesmosis are rarely isolated injuries but generally occur in association with deltoid ligament injuries, or more frequently, with fractures of either the fibula or medial malleolus.
1. Anterior ankle pain following a moderate to severe injury
2. Tenderness on examination located at the anterior aspect of the syndesmosis and interosseous membrane
3. Painful active external rotation of the foot. If there is severe disruption of the syndesmosis, the squeeze test is positive.
Plain x-rays are recommended to exclude fractures and osseous avulsions. Mortise views may reveal widening of the syndesmosis. Stress x-rays in external rotation may demonstrate the separation. CT or MRI scanning are required to exclude osteochondral lesions. Isotope bone scan may reveal a focal increased uptake in the region of the anterior tibiofibular ligament and interosseous membrane.
Provided there is no widening of the distal tibiofibular joint, conservative management with rest, anti-inflammatory medication and physiotherapy is required. As the pain settles, strengthening, range of motion and proprioceptive exercises are introduced.
In more severe cases, when there is widening of the distal tibiofibular joint, surgery and insertion of a temporary syndesmosis screw is required.
Medial Ankle Pain
Medial (Deltoid) Ligament Injuries
Because the deltoid ligament is stronger than the lateral ligaments, it is a less common form of injury. This injury should be treated in the same manner as lateral ligament sprains.
Tibialis Posterior Tendinopathy
This tendon functions to invert the subtalar joint and is the main dynamic stabiliser of the hind foot against valgus (eversion) forces, as well as providing stability to the plantar arch. It passes behind the medial malleolus, then divides and sends attachments to the navicular tuberosity, the cuboid, cuneiforms, and bases of the 2nd and 4th metatarsals.
Medial ankle pain behind the medial malleolus, extending towards the insertion of the tendon. Tenderness along the tendon, but with minimal swelling. Resisted inversion of the ankle usually elicits pain and weakness compared to the contralateral side. A single heel raise test viewed from behind will reveal lack of inversion of the hind foot, and if severe, the patient has difficulty performing a heel raise.
Conservative management consists of controlling pain with ice and prescribing concentric and eccentric tendon loading exercises. Soft tissue therapy and orthotic prescription to control excessive pronation can also be indicated.
Flexor Hallucis Longus Tendinopathy
This tendon flexes the big toe and assists in plantarflexion of the ankle. It passes posterior to the medial malleolus, and runs between the two sesamoid bones to insert into the base of the distal phalanx of the big toe.
This condition may occur secondary to overuse or a tendon tear. Wearing shoes that are too big and require the athlete to ‘toe-grip’ and excessive plantarflexion, as seen with ballet dancers, can also be common causes.
Pain on toe-off or forefoot weight-bearing, which can be aggravated by resisted flexion of the first toe or stretch into full dorsiflexion of the hallux. Triggering or popping can also occur at the metatarsophalangeal joints of the toe.
In the acute phase, treatment may include :-
ice, avoidance of aggravating activities, stretching and strengthening exercises, soft tissue therapy and joint mobilisation.
Surgical treatment should be considered when persistent synovitis or triggering prevents normal activities, particularly with ballet dancers.
Tarsal Tunnel Syndrome
This condition occurs as a result of entrapment of the posterior tibial nerve in the tarsal tunnel where the nerve winds around the medial malleolus.
In 50% of cases, the cause is idiopathic. It may also occur as a result of trauma or overuse associated with excessive pronation.
Burning, tingling or numb sensation on the plantar aspect of the foot, often radiating to the toes. Pain is usually aggravated by activity and relieved by rest. In some patients, the symptoms are worse in bed at night and relieved by getting up and moving or massaging the foot. Swellings or thickenings may be found on examination around the medial ankle or heel.
Conservative treatment is initially attempted in those with either an idiopathic or biomechanical cause. Treatment with anti-inflammatory medication or an injection of a corticosteroid into the tarsal tunnel may be helpful. If excessive pronation is present, an orthosis should be utilised. In rare cases, surgical treatment may be indicated if there is mechanical pressure on the nerve.
A fracture affecting one or more of the malleoli (lateral, medial, posterior) is known as a Pott’s fracture. If there is a significant degree of displacement, on most occasions, surgical internal fixation is required. Undisplaced, hairline fractures may be treated conservatively with 6 weeks of immobilisation using a below-knee cast.
A comprehensive rehabilitation programme should be undertaken following surgical fixation or removal of the cast. The aims of the rehabilitation programme are to restore full range of motion, strengthen the surrounding muscles and improve proprioception.
The Problem Ankle
Some patients still complain of pain, recurrent instability and swelling, 3-6 weeks after injury. This is a very common presentation in a sports medicine practice and the key to successful management is accurate diagnosis. The ankle may continue to cause problems because of an undiagnosed fracture or ligament, tendon, synovial or neurological dysfunction.
Examination of the inadequately rehabilitated ankle usually reveals decreased range of motion in the ankle joint (especially dorsiflexion), weak peroneal muscles and impaired proprioception. These findings can be reversed with adequate rehabilitation. If rehabilitation has been appropriate and symptoms persist, it is necessary to consider the presence of other abnormalities.
Appropriate investigation is a key part of management of patients with the problem ankle. Both bone scanning and MRI are able to distinguish soft tissue damage from bony injury.
Osteochondral Lesions of the Talar Dome
It is not uncommon for osteochondral fractures of the talar dome to occur in association with ankle sprains, particularly when there is a compressive component to the inversion injury, such as when landing from a jump.
The patient often gives a history of progressing well following a sprain but then developing symptoms of increasing pain and swelling, stiffness and perhaps catching or locking.
If the symptoms do not settle with conservative management and continue to be functionally restricting then referral for ankle arthroscopy is indicated and if required, relevant surgical procedure. After such treatment, a comprehensive rehabilitation programme is required.
Dislocation of Peroneal Tendons
The peroneal tendons are situated behind the lateral malleolus and fixed by the peroneal retinaculum. They are occasionally dislocated as a result of forceful passive dorsiflexion. The peroneal retinaculum is ripped off the malleolus and one or both of the tendons slip out of their groove. The dislocated tendons may remain a dislocated position or spontaneously relocate and subsequently become prone to recurrent subluxation. Examination reveals tender peroneal tendons that can be dislocated by the examiner, especially with ankle plantarflexion.
Treatment of dislocation of peroneal tendons is surgical replacement of the tendons in the peroneal groove and repair of the retinaculum, using bone anchors. If the peroneal groove is shallow, repair can be accompanied by deepening of the groove to better secure the tendons. Good results are achieved in most cases.
Some degree of synovitis will occur with any injury due to the presence of blood within the joint. This usually resolves within a few days but may persist if not adequately managed in the early stages and if the athlete returns to training too soon after injury, particularly due to insufficient rehabilitation.
These athletes will often develop persistent ankle pain aggravated by activity and associated with recurrent swelling. Treatment of synovitis includes anti-inflammatory medication, rest from aggravating activity and local electrotherapy. A corticosteroid injection into the ankle joint may also be required in persistent cases.
Sinus Tarsi Syndrome
This condition may occur as an overuse injury secondary to excessive sub-talar pronation or as a sequel to an ankle sprain. Pain occurs at the lateral opening of the sinus tarsi, which is often more severe in the morning and improves as the patient warms up.
Forced passive inversion and eversion may both be painful. The most appropriate aid to diagnosis is to monitor the effect of injection of a local anaesthetic agent into the sinus tarsi.
Treatment consists of rest, anti-inflammatory medication, electrotherapy modalitioes, subtalar joint mobilisation and taping to correct excessive pronation if present. If conservative management is unsuccessful, injection of corticosteroid and local anaesthetic agents may help to resolve the inflammation.
The Achilles tendon, the thickest and strongest tendon in the human body, is the combined tendon of the gastrocnemius and soleus muscles. Pain in the main body of the tendon (2-3cm above the insertion) appears to respond much better to treatment than pain at the insertion itself.
The bursae are also important potential sources of pain, as is the superolateral tubercle of the calcaneum (heel bone), which, when excessively large, is called ‘Haglund’s Deformity’.
This type of injury to the Achilles tendon occurs when the load applied to the tendon, either in a single episode or over an extended period of time, exceeds the ability of the tendon to withstand the load.
Factors that may predispose to Achilles tendinopathy include :-
1. Years of running
2. Increases in activity (distance, speed, gradient)
3. Decrease in recovery time between training sessions
4. Change of training surface
5. Change of footwear
6. Excessive pronation
7. Calf weakness
8. Poor muscle flexibility
9. Poor footwear
Presentations can vary but typically include :-
Pain in morning and on activity, pain on stretching, tendon thickening, tenderness, redness, swelling.
Treatment of Mid-Portion Achilles Tendinopathy
Most evidence for treatment includes :-
1. Heel-drop exercises
2. GTN patches
3. Sclerosing injections
4. Shockwave therapy
5. Heel raises
Alfredson’s Heel-Drop Protocol (Eccentric Strengthening)
1. 3×15 repetitions, twice daily, 7 days per week, for 12 weeks
2. Do exercises with knee straight and knee bent (45 degrees)
3. Exercises are expected to be painful.
4. Progress exercises until they become pain-free.
5. Increase load / resistance until exercises are painful again.
6. Carry out a total of 180 drops/day.
It should be pointed out that certain groups of patients may not be able to tolerate the above protocol and it may have to be adapted on physiotherapist advice.
Glyceryl Trinitate (GTN) Patches
There is evidence that GTN patches, applied locally to the tendon, can reduce pain on activity by 12 weeks. The patches come in varying doses. A 0.5mg patch should be cut in quarters and applied to the site of maximum pain for 24 hours at a time and then replaced. A 0.2mg patch would best be cut in hlaf and applied similarly.
The injection of corticosteroids in Achilles tendinopathy has short-term pain relieving effects, but can be detrimental in the longer term without the appropriate period of rehabilitation.
This innovative treatment consists of using ultrasound guidance while injecting a vascular sclerosant (polidocanol) in the area of neovascularisation anterior to the tendon. Short- and long-term evaluation of this treatment has shown promising results and would require a specialist in lower limb disorders to carry out such a treatment. This can be arranged at the clinic.
Rehabilitation after sclerosing injection includes 1-3 days of rest, then gradually increased tendon loading activity, whilst being careful to avoid jumping, fast running and heavy strength training during the first 2 weeks. After this period, such activities that load the tendon maximally are permitted.
Treatments such as extracorporeal shock wave therapy and ultrasound can potentially improve the symptoms of Achilles tendinopathy in combination with an eccentric strengthening programme.
Adjunct Conservative Treatments
Biomechanical evaluation of the foot and leg is a clinically important part of Achilles tendon management and modification of foot posture in some patients can reduce pain and increase the capacity to load the tendon. Similarly, soft tissue therapy of the calf complex and tendon mobilisation, can assist in the overall management of Achilles tendinopathy.
Procedures range from simple percutaneous tenotomy to removal of tendon pathology via an open procedure. Research has shown that 75% of patients reported good to excellent results after 18 months post-surgery.
All Achilles tendon surgery requires early postoperative rehabilitation which needs to continue for 6-12 months. Wise patients will continue with a maintenance programme of physiotherapist-prescribed rehabilitation exercises even after having returned to training and competition.
Insertional Achilles Tendinopathy
This condition is closely associated with retrocalcaneal bursitis and Haglund’s deformity. It is a condition of the ‘enthesis organ’. The physiotherapy assessment will include evaluation of the tendon, bursa and calcaneum with inspection of the region for bony prominence and local swelling as well as palpation of the area of maximal tenderness. Ultrasound and MRI can help to assess the extent of pathology in the tendon and the bursa. Radiography can complement clinical assessment f the calcaneum and will reveal tendon calcification, if present.
A heel lift worn inside both shoes is a good practical way of unloading the region. Alfredson’s heel drop protocol should be implemented into the rehabilitation programme, but it should be stated that it is less successful than when used for mid-portion tendinopathy.
Sclerosant injections with polidocanol have been shown to be effective. Additionally, symptoms can appear to arise from the retrocalcaneal bursa. In these cases the symptoms may respond to non-steroidal anti-inflammatory medication or intra-bursal corticosteroid injection. Abolition of pain after local anaesthesia helps confirm the diagnosis. Following injection, the patient should rest for 48 hours and then slowly resume activity, building up to full activity over a period of 2-3 weeks.
If conservative management fails in cases of Haglund’s disease where a deformity is present, surgery is indicated.
Achilles Tendon Rupture
Complete rupture of the Achilles tendon classically occurs in athletes in their 30′s or 40′s. The typical patient is a 40 year old male, and the male : female ratio is 10 : 1. The patient describes a feeling “as if I was hit or kicked in the back of the leg” and pain is not always the strongest sensation. This is immediately followed by grossly diminished function. A snap or tear may be audible.
The patient will usually have an obvious limp but may have surprisingly good function through the use of compensatory muscles. That is, the patient may be able to walk, but not on the toes with any strength. Assessment and diagnosis are typically confirmed by the physiotherapist with the use of the Simmond’s or Thomson’s calf squeeze test. There may also be a palpable gap in the tendon.
Surgical treatment of Achilles tendon rupture is associated with 27% lower risk of re-rupture compared with non-surgical treatment. Post-operatively, patients are placed in a functional cast or brace for up to 8 weeks. Because range of movement and strength can be difficult to regain after rupture repair, earliest possible mobilisation and rehabilitation is carried out by the physiotherapist.
Non-surgical management of an Achilles tendon rupture is not indicated for athletes, but may be appropriate for older patients or patients with a low level of activity. This involves cast immobilisation for up to 8 weeks with a structured rehabilitation programme.
Posterior Impingement Syndrome
This condition of the ankle refers to the impingement of the posterior talus by the adjacent aspect of the posterior aspect of the tibia in extremes of ankle plantarflexion. An enlarged posterior tubercle of the talus, or an os trigonum, may be present.
The os trigonum represents an unfused ossific centre in the posterior process of the talus. This is a normal anatomical variant present in approximately 10% of the population. The diagnosis of posterior impingement syndrome is suggested by pain and tenderness at the posterior aspect of the ankle and confirmed by a positive posterior impingement test.
If further confirmation is required, a small amount of a local anaesthetic can be injected around the posterior talus and the impingement test performed without pain. In practice, this is not always feasible and the test relies on the clinical accuracy of the physiotherapist.
Treatment includes rest from exacerbating activities, manual mobilisation of the sub-talar, talo-crural and mid-foot joints, anti-inflammatory medication and electrotherapy modalities. If the condition persists, a corticosteroid injection around the area of maximal tenderness may reduce pain. This is performed on the lateral side of the ankle, as the medial aspect contains the neurovascular bundle. Frequently this condition does not respond to conservative management and requires surgical removal of the posterior processor the os trigonum.
This is a common insertional enthesopathy among adolescents and is discussed earlier.
Accessory Soleus Muscle
Although considered a rare cause of Achilles region pain, anatomical studies suggest that an accessory soleus is present in about 6% of people. The typical presentation is pain and swelling and if symptoms do not settle, surgical removal of the accessory soleus may be the best treatment.
Other causes of pain in the Achilles region
Achilles bursitis is generally caused by excessive friction, such as by heel tabs, or by wearing footwear that is either too tight or too loose. Pressure can often be relieved by widening the heel of the boot manually or providing ‘donut’ protection to the area of bursitis as it resolves.
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