ANKLE PAIN

What is Ankle Pain?

Ankle pain is any pain or discomfort in the ankle joint that restricts normal joint functioning. It significantly affects daily activities and quality of life. 

The ankle is a complex joint with many ligaments and muscles supporting and producing movements. It plays a crucial role in bearing the whole body’s weight while allowing for a good range of motion. 

Because of its complex nature and critical role in body mechanics, the ankle joint is highly susceptible to various injuries and conditions that result in ankle pain. 

This blog explores the potential causes, the comprehensive assessment, and the management of ankle pain.

What is the main cause of ankle pain?

Ankle Pain is Caused by

The above image is nothing just a main causes of ankle pain

Ankle pain can be caused by various reasons such as an injury to the ankle, abnormal loading, or structural damage to the tendons, ligaments, and muscles around the ankle. 

Here are some main causes of Ankle pain:

  • Ankle Ligament sprain 
  • Fractures 
  • Tendon rupture 
  • Tendinopathy- Achilles, peroneal, posterior tibial tendinopathy 
  • Plantar fasciitis,
  • Nerve-related pathology- Morton’s neuroma, nerve entrapment- tarsal tunnel syndrome 

Ankle sprain:

It is characterized by the stretching or tearing of a ligament in the ankle. As reported in the study done by Halabchi, F., et al., it is the most common musculoskeletal injury in athletes accounting for 16%-40% of all sports-related injuries.

The lateral ankle sprain is the most common and occurs due to a sudden inward roll of the ankle, such as an awkward landing on an uneven surface or during a rapid direction change. 

The medial ligament sprain is less common due to the strength of the deltoid ligament but can be injured by excessive outward roll of the ankle, which often occurs in high-impact injuries like collisions or falls.

Symptoms of ankle sprain include pain, swelling, tenderness, redness, difficulty walking, and instability. 

Fractures:

Ankle fracture is the break in one or more bones that make up the ankle joint (tibia, fibula, talus). 

A study on ankle fractures by Hermena, S., & Slane, V. H.  states that about 187 per 10,0000 adults sustain ankle fractures every year. 

One can sustain an ankle fracture due to twisting injuries, crush injuries, a fall from height, direct impact as in sports, road traffic accidents, and even due to repetitive overuse and it ranges from a simple, stable fracture to a severe, unstable fracture.

Tendon rupture:

Tendon rupture is the partial or complete tear of a tendon, often caused by trauma, overuse, or injury due to high impact. The Achilles tendon is usually involved in tendon rupture in the ankle due to its extensive use in daily activities. Other tendons, like the peroneal and posterior tibial tendons, are also involved.

Tendinopathy:

Tendinopathy is the pathology of tendons that results in pain, swelling, and impaired function due to degeneration or overuse. 

The commonly affected tendons include the Achilles, peroneal, and tibialis posterior tendons. 

Achilles tendinopathy:

It is characterized by pain, swelling, stiffness, and crepitus at the tendon (often 3 to 5 cm above insertion to the calcaneus). 

This commonly occurs in athletes, however, it occurs in the non-athletic population as well. It usually occurs due to an imbalance between muscle power and tendon elasticity. 

Peroneal tendinopathy:

It presents as swelling posterior to the lateral malleolus and pain with active eversion and dorsiflexion against resistance.

Posterior tibial tendinopathy:

The common presentation is pain and swelling posterior to the medial malleolus, which worsens with weight bearing, inversion, and plantar flexion against resistance.

What causes ankle pain without injury?

Causes Of Ankle Pain Without Injury

The above image is just a infographic of Causes of pain in Ankle without injury

Ankle pain can sometimes occur even without any injury as in arthritis, other inflammatory conditions, and nerve-related pathologies. 

Atraumatic causes of ankle pain include: 

  1. Osteoarthritis 
  2. Rheumatoid arthritis 
  3. GOUT 
  4. Plantar fasciitis
  5. Morton’s neuroma 
  6. Tarsal tunnel syndrome 
  7. Bursitis 
  • Osteoarthritis: an inflammatory degeneration of the ankle joint caused by repetitive use, leading to pain, stiffness, and reduced mobility. It is less common. 
  • Rheumatoid Arthritis: a chronic autoimmune disorder that causes inflammation of the ankle joint resulting in pain, stiffness, redness, progressive damage, and deformed joints.
  • GOUT:  an inflammatory arthritis caused by the deposition of uric acid crystals in the joints, resulting in severe pain, swelling, and redness. It commonly affects the big toe (first metatarsophalangeal joint), and also involves the ankle.
  • Plantar fasciitis: The inflammation and irritation of the plantar fascia, due to repetitive stress or overuse, leading to heel pain which worsens with walking and standing for a long time.
  • Morton’s neuroma: The inflammation and thickening of the interdigital nerves causing pain commonly in the region between the 3rd and 4th metatarsal heads.
  • Tarsal tunnel syndrome: The compression of the tibial nerve in the tarsal tunnel, due to trauma, repetitive stress, inflammation, foot deformities, and diabetes.
  • Bursitis: The inflammation of the bursae around the ankle joint, due to repetitive stress, trauma, infection, or poor footwear, leading to pain and difficulty in ankle movements. 

What are the treatment for ankle pain?

Treatment for ankle pain depends on the underlying cause, mechanism of injury, severity, duration of pain, and patient’s needs and goals. 

A thorough assessment is required to identify the actual cause and provide appropriate treatment. 

Here are some suggestions for treating ankle pain, 

Treatment for acute ankle injury: 

Treatment for acute ankle injury can be Non-surgical or surgical depending on the severity of the injury and the potential development of complications. 

Conservative (Non- surgical) treatment: 

The conservative measures are to be administered first unless there is an immediate need for surgical intervention.

PEACE and LOVE protocol : 

It is divided into 2 phases

  • PEACE- Immediate post-injury phase(1-3 days after injury) 
  • LOVE- Recovery and rehabilitation phase

PEACE

P- Protect from further injury
E- Elevation
A – Avoid anti-inflammatories 

C- Compression
E- Education 

LOVE
L- optimal Loading
O- Optimism
V- Vascularization
E- Exercise for strengthening the ankle joint

Surgical intervention: 

If the injury is very severe and immediate repair of the injured tissue is needed, surgical interventions are considered.

Ankle Fracture Surgery (Open Reduction and Internal Fixation – ORIF)

This surgery is done to fix and stabilize fractured bones in the ankle with screws, plates, or rods. It is required in severe ankle fractures (e.g., bimalleolar or trimalleolar fractures)

The main aim of this surgery is to restore joint alignment, and function and prevent long-term complications.

Ligament Reconstruction or Repair 

This involves repairing or reconstructing torn ligaments (commonly the anterior talofibular ligament) using grafts. It stabilizes the joint in chronic ankle instability and severe ankle sprains.  

Tendon Surgery

This is done to repair the damaged tendons and regain strength and normal function. This includes Achilles tendon repair, tibialis posterior tendon reconstruction, and peroneal tendon repair.

Tarsal Tunnel Release

It is done to relieve compression of the tibial nerve in the tarsal tunnel by releasing the ligament that is compressing it.

Ankle Fusion (Arthrodesis)

It involves the permanent fusion of bones in the ankle joint to relieve pain associated with severe arthritis or deformities and also to improve weight-bearing stability. 

Ankle Replacement (Total Ankle Arthroplasty)

It involves replacing the ankle joint with an artificial metal implant. It is done in end-stage arthritis and severe deformity to preserve joint mobility and reduce pain. 

All surgical interventions should be followed by proper rehabilitation to attain efficient outcomes and ensure a better quality of life for the patient.

How to prevent ankle injury?

To prevent ankle injuries, strengthen the ankle muscles through regular strengthening exercises. Overloading injury can be prevented by a gradual increase in the intensity of the exercises and by using appropriate footwear. Balance and proprioception exercises can also enhance stability and reduce the risk of sprains.

Ankle injury is very common in sports-related injuries. Athletes who are involved in high-impact sports should improve the stability and mobility of their ankle joints with guided training. 

How to strengthen ankle?

To strengthen the ankle, integrate exercises that improve stability, mobility, and proprioception. Targeting all the muscles around the ankle joint to train dorsiflexion, plantar flexion, inversion, and eversion. Exercises should be gradually progressed, by including resistance bands, sandbags, etc. Activities to improve balance, such as standing on one leg or a wobbleboard, will enhance joint stability and neuromuscular control.

What are the exercises for ankle pain?

Calf raises: It is a strengthening exercise that involves lifting your heels off the ground to rise onto your toes and then lowering back down. It targets the calf muscles, improving strength and stability.

Shin raise:  It strengthens the muscles in the front of your lower leg. To perform this, lift your toes upward while keeping your heels on the ground, then lower toes back down. 

Banded inversion: It involves pulling your foot inward against the resistance of a band. It strengthens invertors especially, tibialis posterior. 

Banded eversion:  It involves pushing your foot outward against the resistance of a band. It targets the evertors of the ankle and foot.

We have included 12 exercises for ankle pain. 

How we approach for ankle injury and pain?

Our treatment approach starts with a thorough patient assessment, which involves analyzing the person as a whole rather than just their condition. This helps us design a tailor-made treatment program that suits their needs and goals. 

OUR APPROACH: 

  • Complete history collection about the injury, comorbidities, and fitness level of the patient 
  • Analysing the psychosocial component 
  • Understanding the patient’s perspective, needs and goals 
  • Identifying the accurate diagnosis with the history and clinical assessment 
  • Educating the patient about their condition. Being positive and explaining in simple, understandable terms. 
  • Designing a treatment program specific to that person 
  • Treating the person as a whole, addressing biomechanical and psychological aspects.
  • Addressing other areas of body which might potentially be a cause for
  • Special focus on reducing the risk of recurrence 
  • Performance enhancement, return to sport training, and preventing reinjury in athletes. 

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