Pain in the ankle is a common complaint which can affect persons at any stage of life. Ankle pain and impaired knee function result in limited mobility, difficulty in performing activities of daily living and reduces the ability to participate in sports.
The ankle connects the leg to the foot and is a complex region which is essential for normal mobility. The ankle consists of three different joints which have different contributions to ankle function:
· The tibiotalar (true ankle) joint – formed between the tibia (shinbone) and the talus. Dorsiflexion (bending the foot upwards) and plantarflexion (bending the foot downwards) occur at this joint.
· The inferior tibiofibular joint – formed by the lower parts of the tibia and fibula (calf bone). This joint is important for normal ankle function, despite the minimal movement there.
· The subtalar joint – formed between the talus and calcaneus (heel bone). It provides shock absorption, allows the foot to adjust to uneven ground and allows inversion and eversion (turning the foot inward and outward).
Ankle stability is achieved by the anatomical configuration of the bones as well as multiple ligaments which help to provide extra stability. Multiple tendons pass through the ankle region and attach to bones in the foot.
Common causes of ankle pain include:
· Ankle sprains
· Tendinopathy (tendon disease)
· Retrocalcaneal bursitis
· Sever’s disease in adolescents
An ankle sprain involves damage to the ligaments which provide stability to the ankle joint. The ligaments are found on the medial (inside) or lateral (outside) sides of the ankle. The lateral ligaments are more often involved in sprains as they are weaker than those on the medial side. The injury is most often caused by the foot suddenly turning inwards. The severity of the sprain can range from damage of one ligament, causing limited impairment, to damage to multiple ligaments, leading to ankle dislocation and requiring surgery. Symptoms of an ankle sprain include ankle pain, swelling, tenderness, possible skin discolouration and difficulty standing or walking.
There are multiple tendons passing through the ankle region to attach to bones in the foot. On the lateral side, there are the peroneal tendons, the tibialis posterior tendon is the major one on the medial side and the Achilles tendon on the posterior (back) aspect of the ankle. There are multiple tendons on the front of the ankle but these are much less commonly involved. Tendinopathy can range from simple inflammation of the tendon to complete rupture of the tendon. Biomechanical abnormalities and overuse are the most common causes of tendinopathy. Symptoms include pain, swelling of the affected area, tenderness and weakness of ankle/foot movement.
The retrocalcaneal bursa is a cushion of fluid found between the Achilles tendon and the calcaneus. Repetitive trauma or overuse can lead to inflammation of the bursa which is aggravated by pressure, such as from tight shoes. In some cases, the inflammation is caused by the bursa being squeezed between the Achilles tendon and an abnormally prominent calcaneus (pump bump). Symptoms include pain, swelling, tenderness and difficulty walking.
In growing children, the calcaneus is not fully fused together and the Achilles tendon can pull on the area where it attaches and lead to significant pain. This condition is called Sever’s disease (calcaneal apophysitis) and is the result of overuse in very active growing children. Symptoms include pain with activity, localized swelling and tenderness.
The rehabilitation/sports medicine physician plays a vital role in the management of ankle pain. This begins with a comprehensive evaluation (including history-taking and physical examination) to diagnose the cause of the pain. In some cases, imaging such as x-rays, ultrasound or MRI may be needed to confirm the diagnosis. Once the condition is diagnosed, patient education can begin and the individualized treatment plan can be created. This will usually include an exercise program which may be led by a physical therapist or by the patient. Pain control is essential and this is achieved by avoiding aggravating activities and use of oral or injected medications as necessary. The use of heel lifts or change of footwear may be required. In cases where indicated, a referral for surgery is made.
Ankle pain which is not improving after a short period of relative rest and pain medications or which is worsening should be evaluated. This will help accelerate the process of returning to optimal physical function.
Dr Shane Drakes is Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at firstname.lastname@example.org.