Ankle pain is an extremely common complaint with many causes. It is important to accurately diagnose the cause of your symptoms so you can get appropriate treatment.
Anatomy of the Ankle
The ankle is made up of 4 distinct bones, the tibia, fibula, talus and calcaneus. The interaction between these bones allows for movement of the joint in certain directions. In turn, the ankle is made up of 3 separate joints:
- Talocrural Joint: This is a hinge joint formed by the distal ends of the fibula and tibula that enclose the upper surface of the talus. It allows for both dorsiflexion (decreasing the angle between the foot and the shin) and plantarflexion (increasing the angle).
- Inferior Tibiofibular Joint: This is a strong joint between the lower surfaces of the tibia and fibula. This is supported by the inferior tibiofibular ligament.
- Subtalar Joint: This joint comprises the articulating surfaces of the talus and the calcaneus. It provides shock absorption and the movements of inversion and eversion (inward and outward ankle movements respectively) occur here.
The ligaments of the ankle joint are comprised mainly of the collateral ligaments, both medial (inner) and lateral (outer). These are extremely important in the stability of the ankle itself:
A. Lateral Collateral Ligament:
The lateral collateral ligament prevents excessive inversion. It is considerably weaker than the larger medial ligament and thus sprains to the lateral ligament are much more common. It is made up of 3 individual bands:
- Anterior talofibular ligament (AFTL): passes from the fibula to the front of the talus bone.
- Calcaneofibular ligament (CFL)- connects the calcaneus and the fibula
- Posterior talofibular Ligament (PTFL)- passes from the back of the fibula to the rear surface of the calcaneus.
B. Medial Collateral Ligament:
The medial ligament (also known as the deltoid ligament) is considerably thicker than the lateral ligament and spreads out in a fan shape to cover the distal (bottom) end of the tibia and the inner surfaces of the talus, navicular, and calcaneus.
The severity of ankle sprains ranges from mild (which can resolve within 24 hours) to severe (which can require surgical repair).
The symptoms associated with a sprained ankle include:
- restricted movement
- limited ability to put weight on the injured foot
Ankle sprains occur when the foot twists, rolls or turns beyonds it normal motions. If there is a severe in-turning or out-turning of the ankle, the force causes the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear.
The amount of force determines the grade of the sprain:
Mild Force – Grade 1 Sprain
Slight stretching and some damage to the fibres of the ligaments.
Moderate Force – Grade 2 Sprain
Partial tearing of the ligament. If the ankle joint is examined, laxity will be identified.
Severe Force – Grade 3 Sprain
Complete tear of the ligament. If the ankle joint is examined, gross instability will be identifed.
It’s important that you begin to treat your sprained ankle as soon as possible. This will speed up your return to activity and reduce the chance of it happening again.
In the first 48 to 72 hours after your injury, it’s important to follow the PRICE procedure. Many minor sprains and strains will respond well to this.
- Protect your injury from further harm.
- Rest your injury for the first two to three days, and then re-introduce movement so you don’t lose too much muscle strength.
- Ice the injured area using an ice pack or ice wrapped in a towel to reduce swelling and bruising. Don’t apply ice directly to your skin as it can damage your skin.
- Compress the area by bandaging it to support the injury and help reduce swelling. The bandage should fit snugly but not be too tight, and you should remove it before going to sleep.
- Elevate the injured area above the level of your heart to control swelling. Keep the area supported and try to keep it elevated as much as possible until the swelling goes down.
If your injury doesn’t improve, it’s important to seek advice from a professional.
For the first 72 hours there are certain things you should not do. These can be remembered using HARM.
- Heat. Don’t use heat packs, hot water bottles or heat rubs on the affected area, as well as saunas or hot baths. Heat encourages blood to flow to the area, the opposite effect of using ice.
- Alcohol. Don’t drink alcohol because it can increase bleeding and swelling to the area, slowing down the healing process.
- Running or any other form of strenuous exercise. Such activities may cause more damage.
- Massage. This can increase bleeding and swelling.
Achilles Tendon Injuries
The most common Achilles tendon injuries are Achilles tendinosis (formerly called Achilles tendonitis) and Achilles tendon rupture. Achilles tendon ruptures, also known as tears, can be full ruptures or partial ruptures. A specialist may be required to distinguish between acute Achilles tendinosis and a partial Achilles tendon rupture. Tennis Leg is a rupture of the connection between the calf muscle and the Achilles tendon. Achilles tendons can also be injured as a result of medication side effects, laceration or crushing.
Achilles tendinosis, which is also known as Achilles tendinopathy, is a soreness and stiffness that comes on gradually and continues to worsen until treated. It is a common injury among middle and long distance runners.
Achilles tendon rupture is a partial or complete tear of the Achilles tendon. It comes on suddenly, sometimes with a popping sound, and can be debilitating. A full rupture is more severe, but less common, than a partial rupture.
A full rupture splits the Achilles tendon so that it no longer connects the calf muscle to the heel: the calf muscle can no longer cause the foot to “push off”, so normal walking is impossible. If it is a full rupture, then lightly pinching the Achilles tendon with the forefinger and thumb will reveal a gap in the Achilles tendon.
Partial and full Achilles tendon ruptures are most likely to occur in sports requiring sudden stretching, such as sprinting and racquet sports. Partial Achilles tendon tears are also common among middle and long distance runners. Achilles tendon ruptures can happen to anyone, but are most likely to occur to middle-aged athletes who have not been training or who have been doing relatively little training.
A Calf muscle injury is common in sports. Calf injuries are sometimes known as a ‘pulled Calf’. The term ‘pulled muscle’ comes from the description of how the injury takes place. Usually the Calf muscle is forcibly stretched beyond its limits and the muscle tissue becomes torn. A tear in the Calf muscle is referred to as a Calf strain and depending on its severity it is classified as a first, second or third degree strain:
- A first degree strain is damage to a few muscle fibres.
- A second degree strain is damage to a more extensive number of muscle fibres.
- A third degree strain is a complete rupture of the muscle itself.
The Calf muscle group consists of the Gastrocnemius, Soleus and Plantaris muscles, situated at the back of the lower leg. The function of the Calf muscles is to pull up on the heel bone during the ‘push-off’ phase of walking and running.