Overview
Ankle & Rearfoot pain
Posterior ankle
Lateral ankle
Medial ankle
Anterior ankle
Acute ankle
Posterior ankle pain
Possible causes of pain
Achilles tendinopathy
Retrocalcaneal bursitis
Posterior impingement syndrome
Achilles rupture
Sever’s disease
Referred pain
Achilles tendinopathy due to inflammatory
arthropathy
Achilles Tendinopathy
Pathophysiology
Aetiological theories
Assessment
Management:
Conservative
Alfredson (1998)
Nieson-Vertommen (1992)
Other related conditions:
Partial
tear
Acute onset of pain with local
tenderness and swelling
May be indistinguishable from tendinopathy
by ultrasound and MRI
Requires lengthy rehabilitation
~1 month relative rest
Treated as for tendinopathy but with very
gradual eccentric strengthening program
Retrocalcaneal bursitis
Causes
Assessment
Management
ICE, NSAIDs, relative rest (2-3 wks)
Stretching, biomechanical correction, padding,
shoe modifications, 0.5ml corticosteroid with LA
Posterior impingement syndrome
Impingement of posterior talus against tibia (during plantarflexion)
Causes
Enlarged posterior tubercle of talus or os trigonum
Inversion sprains
Assessment
Management
Rest, mobilisation, ICE/NSAIDs, corticosteroid, surgery
Achilles rupture
Assessment
Management
surgery
Medial ankle pain
References
Brukner & Khan. Clinical sports medicine; chapter 30: 575-583
Possible causes of pain
Tibialis posterior tendinopathy
Calcaneal, talar, medial malleolus stress fracture
Flexor hallucis longus tendinopathy
Medial calcaneal nerve entrapment
Tarsal tunnel syndrome
Posterior impingement syndrome
Referred pain
Navicular stress fracture
Acute ankle complications
Tibialis posterior tendinopathy
Causes (Excessive loading)
Training errors
Excessive pronation (shoes)
Assessment
Management
As for Achilles tendinopathy
Orthoses (rearfoot control)
Stress fractures: calcaneus, talus, medial malleolus
Cause
Too much too soon/new activity
Assessment
Management
Calcaneus: symptomatic – 6 weeks
relative rest, stretching, heel cups/orthoses
Talus: 6 weeks non-WBing cast, orthoses
Medial malleolus: 6 weeks pneumatic
leg-brace (non-displaced), surgery (displaced), orthoses
Lateral ankle pain
References
Brukner & Khan. Clinical sports medicine; chapter 30:
575-583
Klausner
VB & ME McKeigue (2000). The sinus tarsi syndrome. The Physician
and Sports Medicine; 28: May
McLennan JG (1980). Treatment of acute and chronic luxations of
the peroneal tendons. Am J Sports Med; 8: 432-436.
Arrowsmith SR et al (1983). Traumatic dislocations of the peroneal
tendons. Am J Sports Med; 11: 142-146.
Possible causes of pain
Peroneal tendinopathy
Sinus tarsi syndrome
Impingement syndromes
Recurrent peroneal dislocation
Talar, distal fibula, calcaneus stress
fracture
Referred pain
Osteochondral lesion(s)
Cuboid syndrome
RSDS
Peroneal tendinopathy
Causes (Excessive loading)
Assessment
Management
As for Achilles tendinopathy
Sinus tarsi syndrome
Trauma to soft tissue within sinus
tarsi
Tearing or compression (Klausner & McKeigue
2000)
Causes
Trauma: Inversion ankle sprain
Overuse: Excessive pronation
Assessment
Management
Conservative
Physical therapy and rehabilitation – mobilisation
STJ…as for acute ankle sprains
Orthoses - if excessively supinated/pronated
LA and corticosteroid injections (Weekly 3-6 wks)
Surgical…
Sinus tarsectomy (with anterior talofibular ligamentoplasty)
very effective
Anterolateral Impingement syndrome
Scar tissue (ATFL or CFL) or bone spurs within antero-lateral
ankle
Causes
repeated minor or major inversion ankle sprain(s)
Assessment
Management
Corticosteroid, arthroscopy
Peroneal dislocation
Partial or complete anterior dislocation of
peroneus longus/brevis
Causes:
Forceful dorsiflexion with peroneal contraction
Inversion stress
skiing, others…soccer & basketball
Assessment
Management
?conservative…
non-WBing 3-6 weeks & taping with crescent pad
Elastic bracing
Cast..with progressive return to WBing
Surgery
“No place for conservative therapy in chronic lesions”
(Arrowsmith et al., 1983)
Stress fracture: distal fibula, talus, calcaneus
Cause
Too much too soon/new activity
Assessment
Management
Fibula: symptomatic – 6 weeks relative rest,
stretching, orthoses
Calcaneus: symptomatic – 6 weeks relative rest,
stretching, heel cups/orthoses
Talus: 6 weeks non-WBing cast, orthoses
Anterior ankle pain
References
Brukner & Khan. Clinical sports medicine; chapter 30:
575-583
Possible causes of pain
Anterior impingement
Tendinopathy
Tibialis anterior
Extensor hallucis longus, digitorum longus, peroneus
tertius
Inferior tibiofibular joint injury
Refer to ‘Acute ankle’
Anterior impingement
Exostosis(es) neck of talus and anterior tibia
Cause
Sports causing forced d/flexion:football, ballet
Joint instability
Assessment
Management
Mild exostoses:
Rest, cryotherapy, NSAIDs, mobilisation of ankle joint
Moderate-severe exostoses:
Surgical excision
Tibialis anterior tendinopathy (extensor hallucis longus,
digitorum longus, peroneus tertius)
Causes (Excessive loading)
Surfaces
Training errors
Biomechanics
Assessment
Management
As for Achilles tendinopathy
Acute ankle
References
Brukner & Khan. Clinical sports medicine; chapter 29: 553-573.
Wolfe M et al
(2001). Management of ankle sprains. American Family Physician;
63:93-104
Judd & Kim
(2002). Foot fractures misdiagnosed as ankle sprains. American Family
Physician; 66: 785-794
Sandor
R & Brone S (2002). Rehabilitating ankle sprains. The Physician
and Sports Medicine; 30(8): August
Hockenbury
R & Sammarco G (2001). Evaluation and treatment of ankle sprains.
Physician and Sports Medicine; 29(2): February
Anderson
(2002). Acute ankle sprains. The Physician and Sports Medicine;
30(12): December
Bassewitz
et al (1997). Persistent pain after ankle sprain: targeting the
causes. Physician and Sports Medicine; 25(12): December
Outline
Epidemiology
Mechanism of injury
Classification
Assessment/diagnosis
Symptoms
Physical exam
Radiology
Differential diagnosis
Management
Rehabilitation
Prevention
Epidemiology
Inversion sprains very common
20-40% of all sports-related injuries (Sandor & Brone, 2003)
85% ankle injuries are sprains (Zoch et al., 2003)
Sports
Basketball (21-53%), netball, soccer (17-29%), football, volleyball
involving jumping and landing on one foot
Sharp cutting manoeuvres
High rate of recurrence
Eversion sprains rare (3-5% of ankle injuries) (Zoch et al., 2003)
Mechanism of injury:
Plantarflexion and inversion
Assessment
History
Physical exam
Provocative tests (Hockenbury & Sammarco, 2001; Wolfe et al.,
2001)
Syndesmotic ligament
Lateral ankle instability
Radiology
X-rays: Ottawa ankle rules
CT or MRI for prolonged pain (>6 weeks) or intra-articular
pathology
Differential diagnosis
Fractures
Osteochondral lesion of talus (up to 22% of sprains)
Syndesmosis sprain (high ankle sprain – 10% of sprains)
Peroneal rupture/subluxation/avulsion/rupture
Neurovascular compromise
Management
Grades I & II (III surgery)
Range-of-motion
Muscle strengthening
Proprioception
Activity specific training
Initial
Range of motion
Muscle strengthening (esp. peroneals)
Proprioception
Wobble board
Walking on different surfaces
Gauffin et al. (1988)
Activity specific training
Prevention (Thacker et al., 1999)
Particularly in those with Hx of sprains
External ankle supports
Semi-rigid orthoses (cloth or plastic)
Air-cast brace
High top shoes – controversial
Ankle disk training - taping - effective
Muscle conditioning
Muscle stretching – no effect (Pope 1998; 2000)
Foot orthoses – reduce supination moment?
No evidence
Persistent pain (>6 weeks) (Bassewitz et al.,
1997)
Inadequate rehabilitation
Impingement syndromes
Osteochondral lesions
Peroneal tendon injury
Syndesmosis injury
Lateral ankle instability
Others…
RSDS, fractures, sinus tarsi syndrome
Consider referral for CT, MRI…
Summary
Cause(s), assessment and management…
Ankle pain
Posterior
Achilles tendinopathy, retrocalcaneal bursitis, impingement…
Medial
Tibialis posterior tendinopathy, Stress #s (calcaneus, talus
and medial malleolus)
Lateral
Peroneal tendinopathy, sinus tarsi syndrome, impingement,
stress #s (fibula, talus, calcaneus)
Anterior
Impingement, tibialis anterior tendinopathy
Acute ankle
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