ANKLE PAIN
What you should know about ankle pain
The ankle joint plays an essential role in balance, force transfer and alignment
movement related to moving the body weight in multiple planes during running and
walking. The ankle joint is classed as a ‘hinge’ joint meaning that most of its movement
occurs through one plane, as seen when the foot is raised and lowered. But when the
foot is taken into account the cumulative movement includes inwards and outwards
movements and some rotation. The ankle and foot is reinforced by a number of
ligaments that connect the bones of this joint. Ligaments are fibrous tissues that usually
connect bone to bone. The way the ankle functions is closely connected with the knee,
hip and trunk. If you lack full range of motion at the ankle and foot you will often
experience discomfort and dysfunction further up the chain.
If we compare the ankle to a ball and socket joint, the hip, we will see that the both are
large, stable joints however they gain their stability in different ways. The shape or
geometry of the hip provides much of its stability, whereas strong ligaments
surrounding the ankle provide much of its stability including your medial (deltoid)
ligament, inferior tibio-fibular ligament and anterior talo-fibular ligament. The bones of
the shins (Tibia and fibula) join onto the top of one of the bones of the foot (Talus) to
form the ankle joint. The top of the talus is essentially a domed surface which has
cartilage (meniscus) that allows smooth guiding of movement while bending the ankle.
The ankle has large groups of muscles also that provide stability to the hinge joint. The
calf’s (triceps surae) provide support at the back of the ankle including the soleus and
the gastrocnemius; they extend from above the knee to the attachment at Achilles
tendon at the rear of your heel. You also have ‘Peroneal’ muscles that support the lateral
side of the ankle, ‘Tibialis’ muscles that support the inside of the ankle in addition to
other musculature that we will not discuss here.
Now that you understand some of the functional anatomy basics of the ankle, the two
following conditions of the ankle may be easier to understand.
Firstly, lateral ligaments of the ankle (ATFL or Anterior Talo-Fibular Ligament) can be
damaged when sudden or repetitive forces are placed on to the joint, particularly if the
joint is in an unstable or vulnerable position. Stepping or landing awkwardly causing
end range uncontrolled end range movement can achieve this. This can present as a
mild strain, a partial tar or a full tear and is usually accompanied by significant swelling
around the outside of the ankle. If you cannot weight bear on the foot, see your physio
immediately to rule out a fracture and see if further investigation is warranted.
Another common problem is Achilles Tendonitis. Achilles tendonitis can be further di
vided into either an ‘insertional tendinopathy’ and or ‘classic Achilles tendinopathy’
involving the mid portion of the tendon. It is important to have an accurate assessment
as the management of these two conditions can vary significantly depending on your
presentation. There can be further confusion if you pain is felt more than 6cm above the
Achilles insertion point where it may be from an additional muscle called ‘plantaris’. The
good news is that physiotherapy is effective in the prevention, assessment and
treatment of these conditions.
References
Movement – Grey Cook
ANKLE PAIN
The one-two-three of ankle rehabilitation
1.
Reset – Make a change in movement or pain
Your physiotherapist will look to provide a change in pain your ankle movement to allow a
window of opportunity to lock in correct movement patterns. This reset may be focused on the
spine and trunk, pelvis, hips, foot itself or the surrounding muscles depending on the driver of
your symptoms. An example may best illustrate this point, if you have reduced ability to dorsiflex
(move your knee forward with your heel down) during walking, this will need to be increased by
mobilizing the indicated joints at the ankle. This will help restore your stride length offloading
the pressure at the knee, hip and lumbar spine. This reset may come in many forms including but
not limited to stretching, mobilization, dry needling and/or soft tissue release.
2.
Reinforce – Support the change in movement or pain
In order to reinforce your new movement or reduced pain it is important to address any negative
lifestyle factors that may limit your recovery. For example, 10 hours of walking in poorly fitted
steel cap boots can’t be reversed by 5 minutes of physio exercises per day, so changing your body
position during work and sleep may be important to prevent you aggravating your pain. There
will be some changes that are essential. Reinforcing these changes may come in the form of
strapping or orthotics.
3.
Reload – Lock in the change in movement or pain
Reloading the tissues involves your physio giving you specific exercises to train the ‘brain-body
connection’ to ‘lock in’ this new pain free movement and function at your ankle. This will be
progressive, initially starting gentle and moving toward more dynamic and functional exercises.
It may involve you performing exercise in vulnerable positions to stimulate the reflex stability of
your ankle. This will ultimately end with you returning to full pain free work duties and/or other
activities.
Functional Movement Screening
At your last session of physiotherapy you should complete a ‘functional movement screen’. This
will establish the baselines for your body mobility and stability and function identifying potential
injury risk factors. You will also be given strategies to correct or reduce this injury risk
throughout the body to improve your body’s longevity.
References
Movement – Grey Cook