Ankle Pain

Anatomy

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.

Subtalar 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.

Ankle Ligaments

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.

Clinical Perspective

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.

Initial Management

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.

Muscle Conditioning

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

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.

Functional Exercises

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.

Surgical Intervention

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.

Peroneal Tendinopathy

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.

Causes

1.   Excessive eversion of the foot as with running on slopes or cambered surfaces

2.   Excessive pronation of the foot

3.   Overuse

4.   Secondary to traumatic ankle inversion injury

Clinical Features

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

Treatment

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.

Anterolateral Impingement

Causes

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.

Clinical Features

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.

Anterior Impingement

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.

Causes

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.

Clinical Features

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.

Investigations

Lateral x-rays in flexion and extension show both exostoses and abnormal tibiotalar contact.

Treatment

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.

Causes

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.

Clinical Features

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.

Investigations

Ultrasound or MRI may be used to confirm the diagnosis and exclude tears of the tendon.

Treatment

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.

Causes

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.

Clinical Features

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.

Investigations

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.

Treatment

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.

Clinical Features

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.

Treatment

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.

Causes

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.

Clinical Features

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.

Treatment

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.

Clinical Features

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.

Treatment

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.

Pott’s Fracture

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.

Clinical Aproach

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.

Post-Traumatic Synovitis

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.