Ankle Pain

Overview

With peroneal tendinopathy, you may experience pain around the lateral malleolus (outer ankle bone) and/or along the outside border of the foot. This pain usually increases with activity and reduces with rest, and can occur when turning the foot in or out. Ankle instability and swelling may also be present.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programmes that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

The main principle of treating tendinopathies is to reduce the load on the tendon and increase the ability of the tendon to tolerate load. Shockwave therapy, dry needling and western medical acupuncture can all help, as can strapping – which can help temporarily reduce the load on the tendon and may be enough to help pain settle.
Other treatment options include:

• Relative rest and activity modification
• Footwear advice
• Rehabilitation exercises to progressively load the tendon
• Foot orthotics if there are biomechanical factors that need addressing moving forward.

Overview

Ankle sprains are very common injuries that often occur during vigorous sporting and physical activities, as well from trips, falls and uneven ground. In most cases, an ‘inversion’ sprain occurs, where the foot rolls forcibly inwards. In this scenario, damage occurs to the ligaments on the outside of the ankle. You may hear or feel a ‘pop’, followed soon after by pain, bruising and swelling.

The mechanism of injury can determine the different signs and symptoms that may be displayed after an ankle sprain. The mechanism of injury is the way in which the injury was sustained.

• Lateral ankle sprain: This happens when turning the toes in while pointing them down (usually from inversion with plantarflexion) leading to injury of the ligaments on the outside of the ankle. With this sort of injury the signs and symptoms are:
  • Potential significant swelling within 2 hours because of the rich blood supply.
  • Tender to the touch over the outside ankle ligaments, bruising that drains into the foot.
  • Different levels of instability (depending on grade of the sprain).
  • Positive tests for ligament laxity of your outside ankle ligaments.
  • X-ray shows no signs of fracture.
• Medial ankle sprain: This happens when turning the toes out while pointing them up (usually from eversion with dorsiflexion)  leading to injury of the ligaments on the medial side of the ankle.  Because the ligament here (deltoid ligament) is very strong, this injury is rarer and can take up to twice as long to heal than lateral sprains.  It is also often associated with fractures of the fibula or other bones in the ankle (medial malleolus, talar dome, articular surfaces). With this sort of injury the signs and symptoms are:
  • Tender to the touch over the inside ankle ligament.
  • Bruising and swelling along the medial side of the ankle
  • Positive test for ligament laxity of the inside ankle ligament.
  • X-ray needed to rule out avulsion fracture (bone fragment pulled away from the bone) or fracture of the inside ankle bone, or top of the ankle.
• Syndesmotic sprain: Injury to the front and/or back lower ligaments of the ankle. This often occurs from hyperdorsiflexion (pointing the toes up too far) and eversion (pointing the toes out). With this sort of injury the signs and symptoms are:
  • Positive tests for front/back ligament laxity and severe swelling (possibly fracture) in the lower leg
  • Pain and swelling over the front/back ligaments and the lower leg space.
  • Specific X-ray may show abnormal joint space in the lower leg.
  • Recovery time is longer compared to other sprains.
  • Need to rule out fracture and avulsion.

Ankle sprains are graded from Grade 1 (mild) through Grade 2 (partial ligament tear) to Grade 3 (complete tear and joint instability). To diagnose and gauge the severity of an ankle sprain, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programmes that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

This will vary according to severity/grade of sprain. With milder Grade 1 sprains, you may be able to return to activity within a few days, with the help of a brace or strapping. Grade 2 sprains may take closer to 2-3 months before strength and stability is regained. Grade 3 sprains may require some form of immobilization lasting several weeks, with recovery taking as long as 4 months.

Once your injury has been graded, we will discuss with you the best plan of treatment. This may involve a combination of a walker boot (moonboot), ice, rest, strapping and padding, western medical acupuncture/dry needling, shockwave therapy, supportive footwear and orthotics. An exercise program to restore strength and balance is particularly important with ankle sprains, and will also reduce the likelihood of chronic ankle instability and recurrent sprains.

Overview

The sinus tarsi is a canal type structure on the outside of the ankle. The structures within the sinus tarsi can become damaged or compressed with acute ankle sprains. If this occurs, you may experience:

• Pain at the lateral (outside) ankle, which is aggravated by weight-bearing activity
• Swelling
• Feeling of instability
• Increased pain on uneven ground.

To identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programmes that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.) which will also rule out differential diagnoses.

Treatment

A number of treatments and solutions may be used to help overcome this condition, including:

• Activity modification if acutely irritated
• Temporary strapping and/or brace
• Supportive footwear
• Foot orthoses to stabilise the rear-foot and reduce pronation will help reduce compression forces at the sinus tarsi.

If symptoms remain, we may refer on for guided injection of local anaesthetic into the sinus tarsi or to our orthopaedic colleagues for discussions around other exploratory surgery.

Overview

Tendonitis in the foot is a common problem because we use our feet continuously. It is a common example of an overuse injury. One of the most frequently affected tendons is the posterior tibial tendon, a structure that is normally hard at work, helping to hold the arch up and prevent over-pronation or rolling in of the foot.

The symptoms of tendonitis of the posterior tibial tendon include pain in the instep area of the foot and swelling along the course of the tendon. You may also experience pain and swelling right behind the inner ankle bone. There may also be burning, shooting, tingling, stabbing pain, because the nerve is inflamed inside the tarsal tunnel.

You may experience significant pain:

• When walking, steadily worsening toward the end of the day
• When inverting the foot
• Upon passive stretching of the posterior tibial tendon
• On eversion or flattening of the foot.

In some cases, the tendon may actually rupture or tear due to weakening of the tendon by the inflammatory process. Rupture of the tendon leads to a fairly pronounced flatfoot deformity that is easily recognisable.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Once confirmed through a series of tests with your podiatrist, the following treatments may help. When the foot is acutely painful:

• Rest and ice
• Non-steroidal anti-inflammatory drugs like Advil are recommended, and
• A compressive dressing may be applied.

Once the pain has eased, you may also need:

• A custom orthoses or brace fitted to help immobilise the foot during the rehabilitation period
• Special shoes with external additions to the heel side (i.e. medial heel wedge) to support the foot and prevent arch collapse
• A custom foot orthotic based on the flexibility of the foot.

If the condition becomes severe and chronic, or the tendon has ruptured, surgery may be required.

Overview

Haglund’s Deformity

Haglund’s deformity is a bony enlargement on the back of the heel where the soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. This often leads to painful bursitis, which is an inflammation of the bursa (a fluid-filled sac between the tendon and bone). This often occurs from rigid back shoes such as heels, skates and dress shoes however it can also be inherited.

Haglund’s deformity can occur in one or both feet. The symptoms include:

• A noticeable bump on the back of the heel
• Pain in the area where the Achilles tendon attaches to the heel
• Swelling in the back of the heel
• Redness near the inflamed tissue

Retrocalcaneal Bursitis

Retrocalcaneal bursitis is the most common heel bursitis and is located between the calcaneus (heel bone) and the anterior surface of the Achilles tendon. Also known as Achilles tendon bursitis, retrocalcaneal bursitis can often be mistaken for Achilles tendonitis and can occur in conjunction with Achilles tendinopathy. These bursae’s can also occur from trauma related to a fall or sport related impact. It can also onset gradually due to repetitive traumas like jumping, running or loading excessively. In addition to this, having tight or poorly fitting shoes or having a Haglund deformity can put you at risk of developing this bursae. Retrocalcaneal bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies. In some cases, retrocalcaneal bursitis may be caused by bursal impingement between the Achilles tendon and an excessively prominent posterosuperior aspect of the calcaneus, where the impingement occurs during ankle dorsiflexion.

Someone suffering from Retrocalcaneal Bursitis will complain of the following:

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Haglund’s Deformity

Nonsurgical treatment of Haglund’s deformity is aimed at reducing the inflammation of the bursa. While these approaches can resolve the pain and inflammation, they will not shrink the bony protrusion. Nonsurgical treatment can include one or more of the following:

• Medication. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce the pain and inflammation. Ice. To reduce swelling, apply an ice pack to the inflamed area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
• Exercises. Stretching exercises help relieve tension from the Achilles tendon. These exercises are especially important for the patient who has a tight heel cord.
• Heel lifts. Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel.
• Heel pads. Pads placed inside the shoe cushion the heel and may help reduce irritation when walking.
• Shoe modification. Backless or soft backed shoes help avoid or minimize irritation.
• Physical therapy. Physical therapy modalities, such as ultrasound, can help to reduce inflammation.
• Orthotic devices. Custom arch supports control the motion in the foot.
• Immobilization. In some cases, casting may be necessary.

If nonsurgical treatment fails to provide adequate pain relief, surgery may be needed.

Retrocalcaneal Bursitis

Providing ice to the posterior heel and ankle in the acute period of the bursitis will assist with inflammation and pain management as well as gradual progressive stretching of the Achilles tendon may help relieve impingement on the bursa. In addition to this physical therapy such as shockwave therapy can be considered to release the tendon or corticosteroid injections in to the bursae to assist with inflammation and pain management.

Whilst rare, in un-resolving cases of retrocalcaneal bursitis may result in a bursectomy where the bursae is removed from the back of the ankle.

Overview

To read about Osteoarthritis click here

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

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Overview

Sural Nerve Impingement is a compression neuropathy of the Sural Nerve  and depending on the area of entrapment, different areas of the foot can be affected. If the entrapment is high, the entire foot can be affected as varying branches of the Sural nerve are involved.

What can cause sural nerve impingement.

• Previous Trauma to the Nerve
• Scar tissue
• Cyst formation compressing on the nerve

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

The aim of treatment is to reduce the irritation of the sural nerve , this is achieved by reducing pressure on the nerve. This can be achieve with:

• Orthotics with a lateral rearfoot post
• Shockwave therapy
• Surgery
• Aspiration of the ankle cyst

Overview

Click Here 

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

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Overview

The anterior ankle is the front part of the ankle and anterior ankle impingement is when the ankle gets strangled due to soft tissue (joint capsule or scar tissue) or hard tissue (Bone tissue) compression. This often occurs after a major traumatic injury to the ankle or repeated ankle sprains and is primary seen in footballers and runners.

The presenting complaint will usually be a presentation of long-standing chronic pain in the front of ones ankle/s which worsens with playing sports. There is often a long history of ankle sprains, especially inversion sprains (see above under ankle sprains). The pain will be worse when bending the ankle back and forth, especially in kicking sports. There may also be a history of recurrent swelling in the front of the ankle after sports.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Treatments vary depending on the nature of the ankle impingement however the first advise a health care provider would give is to reduce and stop any activities which increase the pain, allowing the body to start healing without causing further damage to the area. Alternative exercises such as swimming, cycling or water sports may be recommended for the lessened forces on the ankle they provide. Alternatively, you may be recommended to wear footwear with a slightly raised heel or utilise crutches for locomotion.

When reducing pain, cold therapy has been seen to be effective at analgesia along with anti-inflammatory medications or corticosteroid injections, especially if there is some underlying osteoarthritis present. In some instances, surgical intervention may be helpful or necessary if the cause of the pain is from bony spurring however this is a case to case basis as other instances of surgery may worsen the condition.

Other management options include using heat therapy to stimulate blood circulation or taping and bracing the ankle. In addition to this orthotic therapy may be indicated in conjunction with physical therapy either managed by your podiatrist, physiotherapist or exercise physiologist.