Ankle pathologies

We are going to discuss a number of different injuries that can happen at the ankle joint.  I did a lecture a few weeks ago on this for a course in Vancouver.  I think the lecture was well received as there was some participation from the group of new-ish physiotherapists, I was helping to co-instruct the course on.  

In this post, I will discuss; lateral ankle sprains, osteochondritis dessicans, achilles tendinopathy, shin splints and high ankle sprains.  


Lateral Ankle Sprains

This injury is one of the most common injuries out there.  Why is that?  Did you know that the number one predictor of having an ankle sprain is having a previous ankle sprain!!  One reason is because we do not take the time to rehabilitate ourselves after an ankle sprain.  Have you ever, stepped off a curb, thinking it was 3 inch drop only to find it was a 6 inch drop and you turn your ankle?  You mutter a few curse words and ‘walk it off’.  That is an ankle sprain that will not get rehabilitated.  If you end up doing that a few more times, you can really turn your ankle badly, sometimes surgery is needed if a fracture occur.  


The most commonly injured part of the foot is the anterior talofibular ligament (ATFL).  It is a long band about 24-25 mm in length and about 7 mm wide.  It attaches from the fibula to the talus.  It resists the typical ankle sprain.  The second  most common injury is to the calcaneofibular ligament.  This ligament is stronger than the ATFL.  

What do ligaments do for us, other than protect our joints.  Ligaments have some pretty cool nerves in them.  They are called proprioceptors.  Google defines a proprioceptor as ‘a sensory receptor that receives stimuli from within the body, especially one that responds to position and movement’.  Basically, they tell our body where our body parts are in space.  Have you ever climbed up stairs in the dark?  How do you think our bodies know how high to lift our feet?  It is the nerves in the ligaments, and muscles, that let our brains know how we are moving… Fascinating!

When we turn our ankles numerous times, our proprioceptive input from those nerve is not as crisp as it was previously.  Those nerve tell our brain that our ankles/feet are in a certain position but they might not actually be in that position.  Which is why it is much easier to sprain your ankle a second time.

How do we treat it?  Treatment should include some sort of balance exercise.  Starting on two feet, then progressing onto the one leg, the injured ankle.  Taping, either tradition white tape or K-tape, can be used to help protect the ankle.  Wearing an ankle brace can to help prevent the ankle turning again.  I really like the ASO brace, it was designed really well.  How does a brace work?  We now think that it works through increased proprioception.  Basically, the brace pushes on the skin, which can cause the nerves to fire, telling your brain there is a brace around the ankle joint.  This increase in subconscious awareness we think helps to keep you from turning your ankle again.  The same effect can occur with tape.  Very interesting…


Osteochondritis dissecans

The top left hand corner of the talar dome is flaking off. It has the potential of coming off and causing the talocrural joint to get stuck.

The top part of the talus is flaking off with the cartliage due to an injury.

What the heck is this?  It sounds like something scary.  Osteochondritis = inflammation of the cartilage.  Dissecans = desiccate or to dry out.  Putting those two words together = flaking dried out cartilage.  How does this happen?  There is some traumatic injury to a small part of the bone.  The bone chips stay underneath the cartilage.  There is no blood supply to a bone chip, so the bone dies aka avascular necrosis.  With the piece of bone dead under the cartilage, the cartilage can start to flake away.  This will let the bone chips float around in the joint.  The bone chips can sometimes get stuck in the joint, almost like a door stopper.

What do you do if you get a bone chip stopping the movement of your joints?  You can try a loose body manipulation from your physiotherapist.  Another very viable option is to go to the emergency room at your local hospital.  While it is not a true emergency, you may see an orthopaedic surgeon.  They can decide to go into the joint and remove the bone fragment.  


Achilles tendinopathy

A black and white picture, looking at the posterior lateral aspect of the foot. The Achilles tendon, where it attaches to the heel, is the only thing coloured red.

Achilles tendinopathy frequently occurs in this area.

What is it?  Localized pain and stiffness in the Achilles tendon area that is usually worse after a period of inactivity or after activity.  An interesting point is that activity can make the symptoms get less while doing activity, i.e. walking or running.

How do you get it?  There is really no one way to get it but there are multiple ways to get you there.  For example, decreased  range of motion at the talocrual and subtalar joints, increased pronation, decreased plantar flexor (calf) strength.  Abnormal tendon structure is a funny one.  Do they get the Achilles tendinopathy because they have a different tendon structure or does the tendon structure change once they have the tendinopathy?  Hypertension, obesity, hyperlipidemia, diabetes these might be because people get these from being inactive and they try to get up and do too much and get Achilles tendinopathy? Training errors = too much, too soon, too fast = won’t last.  Environmental factors were that more recruits got Achilles tendinopathy in the winter vs. summer.

What kind of symptoms do people get?  There can be local tenderness to palpation with possibly some palpable thickening, nodule or gap in tendon continuity.  Swelling and redness might be present.  Pain on resisted plantarflexion or repeated plantarflexion in the Achilles tendon area.  Pain can occur with stretching and some people notice a decrease in their range of motion.

How do we treat it?  Eccentric loading there is strong evidence for this.  There is actually some evidence for  Low Level Laser therapy and Iontophoresis, not as good evidence as for the eccentric loading.  Stretching, foot orthoses/ orthotics have weak evidence supporting their usage.  I, personally, get my client to do a lot more strengthening then stretching.  It helps to control their pain much faster.  The use of orthotics, it does not seem to matter if you get over the counter or custom orthotics.  The main difference between the two are  price, $50 vs $450, respectively.  You should only wear the orthotic for a few weeks as well.  There are experts in the field of physiotherapy that agree on the use of manual therapy and taping to help with the pain.  There is conflicting evidence about heel lifts, some studies say they help others say that they do not help.  Finally, the use of a night splint is not recommended.  They tested the use of a night splint vs. eccentric exercises for pain relief.  The eccentric exercises won hands down…


Shin Splints

The two different locations for shin splints. The right leg has a red spot on the front part of the shin for anterior shin splints. The left leg has a red spot just above the inner ankle bone for posterior shin splints.

The two different locations for shin splints.

There are actually two types of shin splints.  Anterior (front of the shin) and posterior or medial (inside of the shin).  

Anterior Shin Splints

How do you get it?  Anterior shin splints are from tibialis anterior tendon irritation.  This can be caused by increased foot pronation.  It can possibly be caused by overuse, i.e. sudden increase in kicking a ball for example.  The tibialis anterior muscle lifts the foot up (top of foot comes toward the shin) as well as help to support the arch of the foot.  If the calf muscles are tight, this muscle has to work harder.  I typically treat many runners, think of running 30 minutes with a tight calf.  180 steps/minute x 30 minutes = 5400 steps.  About 2700 steps with each leg.  If the calf is tight and makes that tibialis anterior work harder and strained.     

How do we treat it?  One thing to do, especially if the calves are tight is to stretch out and loosen up the calf muscles.  The stretching can be done with  a couple of classic calf stretches or downward dog (if you know yoga).  In addition, get a massage or use a foam roller on your calves.  They will both hurt with tight calves but it will pay off in the long run.

Posterior Shin Splints

How do you get it?  Posterior or medial shin splints might be caused by tibialis posterior tendinitis. This can be caused by overuse.  I used to see a lot of Highland dancers when I worked in Halifax.  Every year when the  Royal Nova Scotia International Tattoo, a military show, which featured a number of Highland dancers, I would see many tibialis posterior tendinitis’.  The dancers would step up their game and practice more = more jumping.  

What kind of symptoms do people get?  The signs and symptoms of posterior shin splints are pain along the path of the tibialis posterior tendon from 3-4 cm above the medial malleolus to slightly distal.  There can be pain with walking in mid-stance and the heel lift stages.  Along with over pronation in hindfoot or midfoot.  Pain with plantarflexion and inversion movement of the ankle and when testing the strength of these movements.

How do we treat it?  Working directly on the muscles and tendon.  In addition, adding some strengthening exercises. As with any type of tendon issue, I really like to use eccentric exercises (you can see above in Achilles tendinopathy).  

High Ankle Sprains

This xray shows the separation of the inferior tibiofibular joint. There is normally no space between and tibia and fibula.

This xray shows the separation of the inferior tibiofibular joint. There is normally no space between and bones.

How do you get it?  This type of ankle sprain occurs in the inferior tibiofibular joint.   This occurs when the talus is forced upwards and backwards very abruptly.  Another way the injury can occur is with the foot planted, on the ground, and a forceful twisting motion occurs at the ankle.  This can happen when a hockey player goes skate first into the boards.  That type of impact may force the foot into more dorsiflexion, top of foot forced toward the front of the shin, and injure the ligaments.  

How does these types of forces injure the ligaments?  The talus is wider in the front, by about 6mm, than the back.  This causes the inferior tib-fib joint to be splayed really quickly or get wedged apart, injuring the ligaments that hold it together.  The ligaments that can be injured are the anterior tibiofibular ligament, interosseous membrane and the posterior tibiofibular ligament.  

What kind of symptoms do people get?  People with a high ankle sprain will complain of anterior ankle pain usually a pinching sensation.  The client might complain of a giving out sensation on the front of the ankle.  In addition, pain with squatting, getting the talus moving backwards into the ankle mortise.  Which causes splaying of the mortise while stretching the inferior tibiofibular joint ligaments, mentioned above.  Also, the front of the inferior tibiofibular joint can be tender to touch.

There is a minimal space in the inferior tibiofibular joint. Above the joint, you see a screw that is holding the joint together.

This is a high ankle sprain that has had surgery. Notice the inferior tibiofibular joint is very close together, minimal space.

How do we treat it?  These can be difficult to treat as there are no muscles that help to keep this joint together.  In an ideal world, the patient would be non-weight bearing for 4-6 weeks with a compression cuff/tape on the ankle to help the ligaments tighten back up.  I remember treating a hockey player with taping up his leg every 2-3 days to try and keep the tibia and fibula pushed together.  In addition, educating your client on what happened and why you are putting the restrictions on them can be very useful.  Educating my clients is an essential part of the my practice as I know it is for many other  physiotherapists.  In addition, doing some proprioceptive exercises for the client and their ankle can be useful to make sure that when they are back in their sport, they have minimized the risk of this happening again.  If there is a large spreading of the inferior tibiofibular joint, they might actually do surgery!  They put a screw through the inferior tibiofibular joint to help the ligaments tighten up.  




That is a lot of information about different ways that we can injure our ankles.  If you have any question about this post, please leave a comment!

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