Ankle

The ankle is the joint that connects our foot to our leg. The ankle joint moves to allow us to push off and propel ourselves forward using our calf muscles in conjunction with muscles such as our tibialis posterior, flexor hallucis longus and many more.

Sports that involve repeated jumping and landing as well as pivoting and change of direction, such as football, soccer, basketball, netball, lacrosse, hockey, volleyball, tennis etc are common sports that put our ankles at risk of injury. In day to day life, ankle sprains or fracture are most commonly caused when we get into an awkward position due to uneven ground or a pot hole.

The most common ankle injury is a lateral ankle sprain (or inversion ankle sprain) and is explained in great depth via the ankle sprain button below. Other common injuries involving the ankle are ankle fracture, achilles tendinopathy, syndesmosis injury and posterior ankle impingement.

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ACHILLES TENDINOPATHY

Achilles tendinopathy describes pain and dysfunction in the Achilles tendon, usually as a result of excessive loading. The Achilles tendon connects the muscles of the calf (gastrocnemius and soleus) to the back of the heel bone (calcaneum). It acts like a spring and allows us to run and jump with ease. If the tendon’s capacity is exceeded, tendinopathy may develop. 

In the early stages, Achilles tendinopathy is caused by increased numbers of cells in the tendon that try and account for the excessive load. This cellular reaction causes pain when the tendon is loaded (but not at rest). In chronic cases, the cellular reaction may lead to structural disorganisation of fibres of a small part of the tendon.

Though commonly thought to be due to inflammation (and previously widely known as ‘tendinitis’), research evidence does not support inflammatory cells as a cause of tendinopathy.

Achilles tendinopathy is seen either at the insertion (right where it attaches on to the heel), or at the mid-portion (in-between the muscles and the heel bone). It is important to distinguish between the two as they have slightly different treatment methods.

What causes Achilles tendinopathy?

Achilles tendinopathy is caused by an acute change in load or activity. This change may be due to a sudden increase in training loads in athletes or beginning an exercise program for sedentary individuals. Compression of the tendon is also an important factor in the development of pain. The Achilles insertion is compressed in positions where the foot is bent up (dorsiflexion). These positions combined with high energy storage tendon loads (running and jumping) may lead to the development of symptoms. A variety of other factors are proposed to contribute to this condition:

  • obesity (causes systemic changes in circulating cytokines that increase the risk of tendinopathy)
  • type 2 diabetes
  • fluoroquinolone antibiotics and statin medications
  • genetic factors
  • poor function of the lower limb muscles.

The following, however, are not linked with the development of Achilles tendinopathy:

  • poor flexibility
  • foot pronation (flat foot)
  • age (though tendinopathy is more common in older adults, it is a result of lifetime exposure to load).

How do I know if I have Achilles tendinopathy?

Achilles tendinopathy causes very localised pain where the Achilles attaches to the heel in insertional cases, or between the heel bone and muscle in mid-portion cases.

Importantly, this pain is specific, and does not cover a large area. If pain covers an area larger than a coin, or is vague in nature, alternate diagnoses should be considered. Achilles tendinopathy causes pain with loading activities—running, jumping or sport. Classically, it affects both young and older distance runners. It is characterised by stiffness and pain first thing in the morning. It does not usually cause pain at rest but can be sore when walking after sitting for a period. Often the tendon may appear thicker; however, this is a sign of your body trying to adapt and overcome the problem by creating more tendon tissue.

Your physiotherapist will be able to diagnose Achilles tendinopathy. They will need to carefully ask about your history and any changes to your activity and loading. They will perform tests, such as a single leg calf raise or hop, to assess your tendon’s response to load. It is also important to look at the strength of your leg as a whole. Importantly, a number of other conditions cause pain in a similar area to this condition, and careful assessment will be necessary to differentiate these based on the behaviour of your symptoms.

It is not necessary to have scans ordered for this condition, and there is a poor link between findings on ultrasound imaging and pain. Scanning should only be contemplated when considering alternate diagnoses.

How can physiotherapy help with Achilles tendinopathy?

It will be important for your physiotherapist to construct a treatment plan tailored to your individual findings. In the early stages, treatment will focus on reducing your pain. It will be important to modify and temporarily reduce any high load activities (such as running or jumping). Positions where the tendon is compressed (foot bent up) should be avoided, such as stretching. Holding without movement (isometric) exercises are effective at reducing pain in this condition, and should be considered.

Once your pain is more settled, it’s important to begin heavy and slow strengthening of the entire leg, depending on identified deficits. Gym equipment or weights may be required for best outcomes, and exercises need to be challenging.

As you become stronger and your pain remains settled, higher load activities will be slowly introduced. Finally, after your physiotherapist is happy that your tendon capacity is sufficient, you will be gradually eased back into whatever sport or activity you were performing.

It is very important that exercise loading forms the basis for all treatment of Achilles tendinopathy, as complete rest will often only make things worse. Massage of the calf, ice and other treatments are adjunct treatments, and alone will not be effective. There are no ‘quick-fixes’ for Achilles tendinopathy and the following treatments are not supported:

  • injections (no evidence exists for cortisone, platelet rich plasma (PRP), blood injections or stem cells)
  • ultrasound, laser or electrotherapy
  • stretching (these put the tendon into compressive positions).

How effective is physiotherapy for Achilles tendinopathy?

Exercise should form the main element of all treatment for Achilles tendinopathy, and is recommended as a first line treatment in published research. Previously, eccentric exercises (contracting muscles while lengthening them) were thought to be better; however, new research has shown that as long as exercises are heavy enough, both eccentric and concentric (contracting muscles while shortening them) exercises are effective treatments for Achilles tendinopathy. Doing eccentric only exercises may be painful for some people too. Isometric exercises (holding exercises) have also been shown to be effective at reducing pain as well as improving altered control of muscles from the brain that results from pain.

What can I do at home?

As mentioned above, exercise loading forms the cornerstone of rehabilitation of Achilles tendinopathy. You will need to complete a number of exercises at home and in the gym to improve your strength and capacity. Your physiotherapist will advise you on what exercises to complete based on your individual findings, and how often to do so.

A way to monitor your progress is to follow how your symptoms are first thing in the morning. If they are the same or better than the previous day, then what you did the day before was appropriate. If your stiffness and pain is worse the next day, then the activity you have done the day before overloaded the tendon.

How long until I feel better?

Achilles tendinopathy requires lengthy rehabilitation, and depends on the level of your pain and dysfunction and what activity you want to return to. Exercise loading needs to be heavy and challenging for you, and be done for an extended period. At minimum, 3–6 months of strengthening will be required to get back to your activity, and in more complex cases it is often longer than this.

 
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ANKLE FRACTURE

An ankle fracture is a break to one of the bones around the ankle joint. This happens when force beyond the capacity of the bone is placed on the ankle. They can occur as a result of a nasty ankle sprain or direct blow to the ankle, and can vary in severity—from a minor incomplete fracture to a complex comminuted (fragmented) and open fracture. Ankle fractures result in pain, swelling and limited function around the ankle. The break usually occurs at one of the lower leg bones (tibia and fibula), but can also occur to the talus (bone inside the hinge of the ankle).

What causes ankle fractures?

Ankle fractures commonly occur after a severe ankle sprain such as rolling over the ankle. They can also occur after a fall (down some stairs, for example) or from a direct blow such as a kick or vehicle accident. Typically (though not always), after a fracture, you may find it difficult to walk or put any weight on the area. For more severe fractures, a deformity may be seen in the bones. Those people with poor bone health (low bone density, poor nutrition or hormonal deficiencies) are at greater risk of sustaining a fracture. Importantly, fractures will heal, as long as the bones are realigned and given sufficient healing conditions.

How do I know if I have an ankle fracture?

Ankle fractures are the result of serious incidents or major trauma. They are often very painful, even at rest when you are not on your feet. In some cases, you may not be able to walk or put weight on the foot; however, being able to weight-bear does not guarantee that you haven’t sustained a break. The ankle will swell usually immediately after injury.

Your physiotherapist will be able to assess the injury and, if they are concerned about a break, they will refer you for imaging—usually an X-ray. For more serious injuries, with other associated injuries such as ligament strains, an MRI scan may be ordered.  

How can physiotherapy help with ankle fractures?

After a fracture, the first priority is to allow the bones to heal in good alignment. This may involve being put in a boot or cast; however, more severe cases may require surgery and fixation. Your physiotherapist (in combination with your doctor or specialist, if needed) will decide on how long you will need to offload for. In general, it takes about six weeks for bone healing to occur, but this period may be extended in some cases. You will likely not be allowed to weight-bear through the affected leg for a period, though for minor injuries, walking in an immobilising boot may be sufficient protection for the injury.

After your medical advisers are happy that bone healing has been achieved (sometimes confirmed by a repeat X-ray), you will need to begin rehabilitation and receive treatment to help return to your activity. Because of the time spent not moving your ankle, your joint often becomes stiff, and your muscles become weaker. It is crucial that you regain these deficits. You may also still have some pain around the ankle. Your physiotherapist will prescribe a program of exercises and strengthening. They may also perform some mobilisation or soft tissue work around the ankle to help decrease joint stiffness. Once you are progressing well, it is important to work on higher level function such as running, agility drills and jumping/landing to make sure you get back to the same level and better than before your injury.

How effective is physiotherapy for ankle fractures?

Though rehabilitation after ankle fracture is widely accepted, research evidence regarding its effectiveness is less clear. Recent high-quality systematic reviews (summaries of studies) showed that there was a lack of evidence available to support exercise, mobilisation and other treatments after ankle fracture. A high-quality randomised controlled trial showed that exercise rehabilitation may be more important after severe fractures, or in at-risk groups, such as older women. Early movement of the ankle may provide short-term benefits, as well as using a removable cast (such as a moon boot)—though it should only be used if the patient is adherent and sticks to the restrictions given.

What can I do at home?

It is crucial that you adhere to whatever guidelines your physiotherapist has outlined for you to allow the bone to heal. If wearing an immobilising boot, speak to your physiotherapist about whether they are happy for you to take it off at night or not. While you are offloading your affected leg, you will be able to perform strength exercises for the opposite limb. This can help limit muscle and strength loss, as around 20 per cent of the gains are carried over to the opposite side without even moving it.

Once you are allowed to begin moving and exercise, it will be very important to complete all strengthening outlined by your physiotherapist. In the early stages, it may be beneficial to do some exercises in a pool or water (hydrotherapy), and your physiotherapist will be able to recommend this as needed.

How long until I feel better?

Time frames depend on the severity of the injury. Generally, bone healing takes around 6–8 weeks, followed by a period of rehabilitation. Regaining full strength, motion and confidence without pain may take up to six months. Rehabilitation should aim to get your function back to the same level or better than before your injury.

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ANKLE SPRAIN

An ankle sprain is a well-known injury that involves the strain of the ligaments that support the ankle joint. Most commonly, it is the ligaments on the outside of the ankle that are injured (a lateral ankle sprain), as the ligaments on the inside of the ankle are much broader and stronger. On the outside of your ankle joint, three ligaments attach to the bony knob called your lateral malleolus. The ATFL (anterior talofibular ligament) spans forwards in the direction of your toes. The CFL (calcaneofibular ligament) joins to your heel bone directly under the bony knob. Finally, your PTFL (posterior talofibular ligament) spans towards the back of your heel. On the inside (medial) of your ankle, a larger ligament called the deltoid ligament fans out from the knob on the inside of your ankle to provide strong support.

What causes ankle sprain?

Lateral ankle sprains happen when the foot rolls inwards under the leg (called inversion), straining the ligaments on the outside of the ankle that prevent this movement. This can sometimes happen when walking or running over uneven ground, or when changing direction suddenly. Most people have rolled their ankle throughout their lifetime, though perhaps not seriously. It’s common to think that these injuries do not require rehabilitation; however, rehabilitation should occur after all ankle sprains, in order to reduce the likelihood of them happening again.

Medial ankle sprains are much less common due to the greater reinforcement on this side of the ankle, and occur when the ligament is stretched or strained by the foot rolling out under the leg (called eversion). They sometimes also occur after heavy, flat-footed landings.

How do I know if I have ankle sprain?

Ankle sprains always occur after a specific incident, such as your foot rolling inwards, or stepping on a pothole. They lead to pain and swelling over the affected ligaments, and often some difficulty walking. Ligaments provide information to the brain about how the ankle is positioned in space (called proprioception), so that movement can be coordinated. In an injury, this is disrupted and pain inhibits the function of your muscles. A physiotherapist can diagnose and help rehabilitate a sprained ankle. It is vital, particularly for those playing sport, to work to regain the strength, proprioception and function around your ankle, as these injuries often become recurrent. Your physiotherapist will need to assess the severity of the injury, and will perform tests to assess the stability of the joint. If there is significant tenderness over the bones around the ankle, or you are unable to walk on the leg, an X-ray should be ordered to rule out fracture. ​

How can physiotherapy help with ankle sprain?

In the initial phase after your injury, following the POLICE protocol (protect, off-load, ice, compression and elevate) can help settle down early symptoms. Complete non-weight bearing is likely not needed, unless the injury is very severe, in which case your physiotherapist will likely refer you for an X-ray to rule out a fracture. You will be able to begin moving your ankle and walking around on your ankle from day one, and this will help you return to activity quicker.

Strengthening and balance exercises

As soon as you are able, your physiotherapist will create a program of exercises to regain movement at the ankle, strengthen the muscles around the ankle (such as the calf), and also work on your joint position sense and confidence with challenging single leg tasks. These balance type exercises are sometimes called neuromuscular exercises, and should be similar to the activity you are returning to (eg, a basketball player should work on jumping, landing and cutting exercises).

Mobilisation and manual therapy

It is important to regain full range of motion after an ankle sprain and also to reduce pain quickly to get back to your desired activity. Your physiotherapist may mobilise around your ankle joint, and use soft tissue work to help with any swelling or muscle tightness.

Taping and bracing

It may be beneficial to have your ankle taped or braced when you return to activity, to help supplement the support of your ligaments and muscles, and to provide confidence using your ankle for full function. Your physiotherapist can show you how to tape your ankle or advise you on what brace to purchase.

How effective is physiotherapy for ankle sprain?

Only around seven per cent of lateral ankle sprains receive active treatment and it is estimated that up to 30–40 per cent of ankle sprains go on to have recurrent instability. Therefore, it is vital that you seek adequate rehabilitation and treatment for this injury.

Strengthening and proprioceptive exercises are strongly supported by research for reducing pain, returning to sport quickly and preventing further re-injury. Most studies, however, look only at short-term outcomes. A high-quality randomised controlled trial showed that accelerated rehabilitation (beginning exercises early in the first week) had superior short-term outcomes compared to resting and offloading in the first week.

Mobilisation and manual therapy is also supported by research as helping to improve range of motion and reduce pain in the short term, and is a good addition to rehabilitation (alongside exercises).

Taping and bracing is also shown to be effective in reducing future injuries and was recommended to be worn for six months or more following an injury.

Ice appears to be helpful in reducing pain in the short term and is best applied 10 minutes on and off.

Anti-inflammatory medication is also strongly supported as helping reduce pain in the short term.

The following treatments are not supported by published research:

  • acupuncture and dry needling
  • ultrasound
  • electrotherapy.

What can I do at home?

Early movement and exercise will help you get back to your activity best after an ankle sprain. In the early phase, ice for 10 minutes on/off three times for the first 2–3 days may help settle pain. A compression bandage may help reduce swelling, as will elevation of the affected leg.

As your pain allows, movement of the ankle will help to regain function quickly. An easy exercise to start movement with is to draw the alphabet with your foot every few hours throughout the day. You can also start some muscle activation and strengthening exercises by doing 5 x 10-second holds, pushing your foot down, up, in and out against a resistance such as your own foot or a wall.

Once you are over the early phase of the injury, your physiotherapist will prescribe an exercise plan involving exercises such as calf raises, single-leg balance and gentle bounding or hopping exercises. You can do balance exercises anywhere in your spare time, such as when waiting for a coffee or standing in a queue.

How long until I feel better?

Usually swelling and pain should begin to settle within the first week. Minor ankle injuries may not require much time away from sport or activity; however, they will still require 3–6 weeks of strengthening and exercise. It is important to get back your full ankle function that you had previously to reduce the risk of the injury recurring. More major ankle sprains may result in some time off from your desired activity, and your physiotherapist will be able to give you a guide to when you can return.

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Syndesmosis injury (high ankle sprain)

A high ankle sprain is an injury to the ligaments that connect the bones of the lower leg above the ankle (tibia and fibula). This strong connection forms the top of the hinge of the ankle joint. This is also known as the ‘syndesmosis’ and is made up of a number of ligaments at the base of your lower leg, as well as a connective tissue that joins the bones from the top of the ankle all the way up to your knee. High ankle sprains are more serious injuries than more standard lateral ankle sprains (rolled ankle), and generally require more assessment and management. Injuries to the syndesmosis are often associated with lateral ankle injury; however, they usually lead to more pain, swelling and activity limitations. In severe cases, they may also be accompanied by a fracture.

What causes high ankle sprain?

High ankle sprains occur slightly differently to normal ankle sprains (ankle rolling outwards). They often happen when the foot is trapped underneath someone—in a tackle, for example—and the foot is twisted and rotated outwards. Another common mechanism is rolling directly forward over the ankle (not just sideways). It often helps your physiotherapist to describe exactly how the injury occurred (rolled over it while walking vs caught under someone else), as this may help them diagnose what areas are injured.

How do I know if I have high ankle sprain?

High ankle sprains are usually more severe than normal ankle injuries, and are often accompanied by swelling and pain, not only on the outside of the ankle joint but also over the front at the end of your tibia and fibula (lower leg bones). Often walking may be more painful at the bottom of your leg and top of the ankle, as weight-bearing causes the syndesmosis to separate slightly because of the ligament injury.

Your physiotherapist will be able to diagnose a high ankle sprain, and will ask you about how the injury happened. Often this condition is missed as people presume the injury was just a normal ankle sprain, and if you delay seeing your physiotherapist, it will be important to discuss how the sprain has changed since injury. They will look at your ability to walk, stand on one foot and do simple exercises such as a calf raise. It will also be important to do specific tests for the high ankle ligaments. If you are unable to walk because of the injury, or if your physiotherapist suspects it is a more serious injury, you may be referred for an X-ray or MRI for further assessment.

How can physiotherapy help with high ankle sprain?

Physiotherapy will be essential for effective rehabilitation from a high ankle sprain. The first step is to identify the severity of the injury. Minor injuries can be managed conservatively; however, more severe cases, where there is significant laxity or ‘gapping’ of the syndesmosis at the top of the ankle, will require surgery to stabilise this area.

Early management of high ankle sprains may involve a period of non-weight bearing on crutches and in a CAM boot to allow the injury a chance to begin early healing. Your physiotherapist will guide you as to how long you will need to do this for, based on the severity of the injury. Once this early phase is over, you will be able to begin walking, and it will be important to begin strengthening exercises to regain the strength and function of your leg and ankle. As your function improves, you will be guided back into running and then whatever desired activity you are returning to. It will also be important to develop the confidence to use your ankle again for pushing off, jumping and stopping as required.

How effective is physiotherapy for high ankle sprain?

Currently, no high-quality trials investigating physiotherapy treatment for high ankle sprains exist. Most research into the area is limited to expert opinions and recommendations, as well as surgical case series. Clinical opinions largely agree that a period of non-weight bearing is recommended early for less severe injuries, and that the length of time immobilised depends on the severity of the injury. Surgery appears to be effective for more complex injuries; however, no studies exist comparing surgical to conservative treatment.

What can I do at home?

In the early phase, immediately after a high ankle sprain, your physiotherapist will advise you on how long to spend non-weight bearing. It will be important to adhere to these guidelines to allow proper healing of the injury. In the early stages, ice may help with pain, and using a compression bandage and elevation may help reduce swelling. During this phase, you will be able to do strengthening exercises for your unaffected leg. This may be helpful to prevent loss of strength, as around 20 per cent of the strength gains will be carried over from the uninjured side to the affected side. This may help in a quicker return to activity or sport. Once you are able to begin exercising and strengthening, it will be important to complete the program outlined by your physiotherapist.

How long until I feel better?

High ankle sprains take significantly longer to get better than normal ankle sprains. When managed conservatively, it will take at least six weeks, and more complex cases may take closer to three months to return to full activity without symptoms. High ankle sprains result in higher rates of long-term complications than normal ankle sprains, and it will be important to address all areas before returning to sport and activity.

 
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POSTERIOR ANKLE IMPINGEMENT

Posterior ankle impingement is the result of structures at the back of the ankle getting caught between the heel bone (calcaneum) and the lower leg bone (tibia). It causes pain at the back of the ankle, just above the heel bone, in activities where the foot is pointed down. It is commonly seen in dancers who spend extended time with toes pointed maximally (‘en pointe’), as well as in gymnasts, kicking sports and fast bowlers in cricket.

What causes posterior ankle impingement?

The cause of the impingement in this condition differs from person to person. Often the causes are soft tissue structures at the back of the ankle, such as the joint capsule and covering of the ankle (synovium), and ligaments at the back of the ankle. In some people, the impingement may be due to a small extra bone in the back of the ankle called an ‘os trigonum’ that is present in about 10 per cent of adults (having an os trigonum doesn’t guarantee that you will get this condition). Other people have a slightly more prominent bony point at the back of their bone in the ankle joint (talus), which can cause the impingement. Remember though, you may have the same features on your other ankle that are not painful, so be sure to discuss how relevant any imaging may be (or not) with your physiotherapist or GP. 

How do I know if I have posterior ankle impingement?

Posterior ankle impingement causes pain at the back of the ankle when the foot is pointed (plantarflexed) and when the structures mentioned above become caught or impinged. This condition may sometimes also begin after a previous ankle sprain. Importantly, the pain should only be present when in loaded plantarflexion, and won’t affect day-to-day activity. Your physiotherapist will be able to diagnose this condition, and may ask you about what activities you do and any previous foot or ankle injuries. They will try and reproduce your symptoms by getting you to do the activity that provokes your pain, and may perform some special tests that force the ankle into plantarflexion. Scans and imaging are not required unless you are not responsive to treatment.

How can physiotherapy help with posterior ankle impingement?

Your physiotherapist will be able to help design a treatment plan to settle your pain. This will usually consist of a period of offloading from the aggravating activity, such as avoiding time en pointe or reducing kicking loads for a period. Medications may be advised to help settle any pain or associated inflammation if needed.

Your physiotherapist may perform mobilisation and distraction (gentle pulling on the joint to gap the irritated parts) techniques to the ankle joint that may also help to settle symptoms and improve joint mobility. Strengthening exercises will be prescribed for the calf, as well as for any deficits identified further up the leg. It will be important to initially avoid having the foot fully pointed during strengthening exercises.

Finally, it will be important to assess your technique, particularly in performance sports such as dancing or gymnastics. In ballet dancers, turning out of the foot while on toes may lead to the condition, and any issues should be identified and changed as part of rehabilitation. In some cases, the condition may persist and sometimes requires a corticosteroid injection to settle the pain. Your physiotherapist will be able to organise a referral for you, if this is required; however, this should not be the first line of treatment and should always be followed by a thorough rehabilitation of at least six weeks.

How effective is physiotherapy for posterior ankle impingement?

Currently, no clinical trials have examined the effect of physiotherapy on posterior ankle impingement. Most research on this topic relates to surgical case reports and anatomical studies, investigating the cause of impingement. Expert opinions would suggest always trialling a lengthy period of conservative management before moving towards injection or surgery only in severe and stubborn cases.

What can I do at home?

In the early stages of this condition, it will be important to avoid having your ankle in forced plantarflexion (toes pointed). This will help to settle down any irritation before beginning a slow progression back to normal activities. You will likely be given tailored strengthening exercises for the calf as well as other lower leg muscles if deficits are identified. You will also be able to do other forms of exercises for cross training, as long as the aggravating position is avoided to begin with.

How long until I feel better?

How quick you return depends on what activity you are completing. For ballet dancers, because of the extended time ‘en pointe,’ rehabilitation may take 2–6 months. For kicking sports such as football or soccer, activity may not need to be limited as much; however, the condition may also require ongoing treatment for the following months.

 
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