Ankle Pain

There are many causes of ankle pain, some are minor whilst some are severe and require urgent treatment. The ankle is split into anterior (front), posterior (back), medial (inside) and lateral (outside).

Tibialis Posterior Tendinopathy or Dysfunction
Can be a crippling injury. The Tibialis Posterior muscle sits behind the Tibia and runs behind the medial malleolus (Ankle) and attaches to multiple places within the foot, however the main place is the Navicular and one of it’s jobs is to facilitate the rate of pronation.

Tibialis Posterior Tendinopathy can present with pain along the line of the muscle and it’s tendon, however normally the pain is just behind the medial malleolus and tracks up the leg, this will also be a place where it is tender to palpate. Any activity that makes the foot pronate will aggravate the pain, wearing a flat ballet pump style shoe will increase pain, whilst wearing a supportive running shoe or higher heeled shoe will reduce the pain. If you try to do a single leg heel raise this will be tender and may be impossible to complete or control.

If you notice an immediate drop in the arch of your foot, with pain and swelling, please seek your Sports / Musculoskeletal Podiatrist or any other medical professional for advice as this requires immediate investigation and treatment.

It is important to remember that Tibialis Posterior Tendinopathy and Tibialis Posterior Tendon Dysfunction are two different pathologies. The state of the tendon helps decide which pathology is present. A dysfunction tends to be a chronic pathology which has been present for many years where the tendon has been stressed and is now unable to return to it’s normal state. There are 4 grades of Tibilais Posterior Tendon Dysfunction. Think of it like an elastic band, they are over stretched and becoming weaker and weaker until eventually it does not return to it’s original state and eventually it can stop working all together and possibly rupture, this would be stage 4. Areas A tendinopathy tends to be more acute and may have an obvious time when the pain started, for example after a race or match, or whilst wearing poor footwear during a holiday and if treated correctly can return to full strength.

Ankle Sprains
Are one of the most common reasons for attendance to an A & E department here in the UK and the recurrence rate is high, hence why there is plenty of research in the treatment of ankle sprains. Professional football teams spend a lot of time and money on the rehabilitation and prevention of ankle sprains and one of the reasons for recurrence of ankle sprains is poor rehabilitation.

Ankle sprains can occur to the medial or lateral aspect of the ankle. The lateral aspect known as an inversion injury is much more common than the medial aspect known as an eversion injury.

An inversion injury occurs by excessively supinating the foot which can lead to a sprain, tear or rupture of the three main lateral ankle ligaments, surrounding muscles and can even cause fractures.

Ankle sprains tend to ache or present with a burning sensation, there will be a history of trauma and if a chronic sprain possibly some instability within the ankle. High heeled shoes will increase the risk of ankle sprain as the foot is most unstable when on your toes or in propulsive phase of gait. Testing of the ankle ligaments, is usually tender and can also help to decide if there is a rupture present. After a sprain it is common for the ankle to swell, adopting the POLICE principles (Protect, Off Load, Ice, Compression and Elevation) can help. It is very important to note that you should never put bare ice in direct contact with the skin as this can result in a burn, so always wrap ice in a cloth and using an on and off technique works best, 10 minutes on and 10 minutes off repeated 3 times. Resting the ankle is difficult hence why sprains can take 3 months plus to heal even if rehabilitated properly. Much longer than a sprain in a non-weight bearing part of the body.

Peroneal tendinopathy
Peroneal tendinopathy – The Peroneals are a group of 3 muscles Longus, Brevis and Tertius in the lateral compartment of the leg and the Peroneal Tertius which is found in the anterior compartment of the leg.

They work in opposition to Tibialis Posterior and can cause pain along the lateral aspect of the leg, down into the lateral ankle and is often linked with ankle sprains. The pain will be an ache or burning sensation which is worse on walking or sports, especially sports involving twisting such as football, hockey or squash. There may be tenderness along one of the 3 Peroneal muscles and their tendons. Peroneal Longus tendinopathy can also cause some lateral midfoot pain, this is due to Peroneal Longus running under the foot to the medial aspect of the foot via a bone known as the Cuboid.

The pain will be a burning sensation along the path of the muscle and its tendon and will present the same as any other tendinopathy and strain.

Anterior ankle impingement
Is also known as ‘Footballer’s ankle’ and is an impingement of a structure in the anterior ankle which could be bone, nerve, tendon or ligament. Pain will be located in the anterior aspect of the ankle and the type of pain is related to the structure that is impinged. The difference between a bony impingement and all others is that a bony impingement has an abrupt end feel to the ankle joint when dorsi-flexing the foot. The impingement of the ankle can also occur in the posterior aspect.

Posterior Ankle impingement
This is linked to have an accessory (extra) bone in the back of the ankle called Os Trigonum, which can just block the range of motion within the ankle. It is often aggravated with excessive dorsi-flexion injuries. It can be treated conservatively, however can sometimes require surgery.

Terminology
Anterior – Front
Posterior – Back
Medial – Inside, same as Hallux (big toe)
Lateral – Outside
Tibia – Large shin bone, on the medial aspect
Medial Malleolus – Inside ankle bone
Navicular – Bone in front on the ankle
Pronation – A complex tri-planar motion made up of dorsi-flexion, eversion and abduction – in summary the foot rolling inwards
Supination / Supinating – A complex tri-planar motion made up of plantar-flexion, inversion and adduction – in summary the foot rolling outwards
Dorsi-flexing – Moving the foot upwards
Pathologies – Problems