ALGORITHM

ANKLE PAIN

Group # 5

Group Participants
1. Rabeea Saeed
2. Mahnoor
3. Ruhmah Tariq
4. Ulveena Riaz
5. Sonia
6. Ushma Nasir
Ankle Joint
Sprained ankle
The most common ankle injury is a sprained ankle. It’s a
common musculoskeletal injury that involves the stretch or
tear of the ligaments of the ankle. They occur when the
ankle moves outside of its normal range of motion.

Sports participation. Ankle sprains are a common sports

injury, particularly in sports that require jumping, cutting
action, or rolling or twisting of the foot such as basketball,
tennis, football, soccer and trail running.
Sign and symptoms:
• Pain, especially when you bear weight on the affected
foot.
• Tenderness when you touch the ankle.
• Swelling.
• Bruising.
• Restricted range of motion.
• Instability in the ankle.
• Popping sensation or sound at the time of injury.
What causes a sprained ankle?

Poor proprioception
Proprioception is body’s awareness and ability to judge the position of body
parts. If damaged, muscles are less able to detect if your joint is at risk of injury.
As a result, poor proprioception is a leading cause of sprains, especially
recurrent injuries.

Inappropriate footwear
Using the wrong type of shoes for sports or activity can also increase the risk of
a sprained ankle. Make sure the shoes fit and are suitable.
Risk factors: Investigations

• X-rays provide images of

• Uneven surfaces. dense structures, such as
• Prior ankle injury. bone.
• Poor physical condition. • Stress x-rays.
• Improper shoes. • Magnetic resonance
imaging (MRI) scan.
• Ultrasound.
 Treatment for sprained ankles
• Cold therapy & compression
Applying ice or cold therapy reduces pain, inflammation, and swelling. Apply cold
for 10 mins every hour initially, reducing the frequency as symptoms improve.
Elevate the ankle as this reduces swelling by allowing tissue fluids to drain away.

PRICE Therapy
• Wear an ankle brace
Wear an ankle brace or support to protect the injured ligaments and provide
compression.
• Electrotherapy
Use of therapeutic ultrasound will help relieve pain and reduce swelling.
Anterior Ankel Pain
 Anterior Ankle Pain
• Anterior Impingement Syndrome
(Footballer's Ankle)
It is pain and pinching of bone, soft tissue or
scar tissue at the front of the ankle. This can
happen after a new or old injury like multiple
sprains. The swollen tissue or scar tissue gets
caught between the bones, tibia and talus.
As a natural response, our body starts to build
up bone spurs called osteophytes in the
injured area.
 Causes:
• Anterior ankle impingement can be due to scar tissue and
inflammation or bone spurs that form in the anterior (front)
of the ankle joint.
• This process is felt to develop as a result of repeated
strain on the anterior capsule (front of the joint) with
repeated plantar flexion that leads to calcific deposits, or
from repetitive dorsiflexion that leads to subchondral
injury (damage to the bone) to the talus (ankle bone)
which leads to bone spur formation. This can also be
found in the chronically unstable ankles. The end result is
a decrease in motion (primarily dorsiflexion) due to these
Sign and Symptoms:
• Pain on the anterior aspect of ankle.
• Pain with active repitative dorsiflexion.
• Continued pain even after the ankle has healed.
• Weakness or feeling unstable in ankle.
• Pain when using stairs, walking or running uphill,
or squatting low.
• Tenderness on ankle.
Investigation:
• The diagnosis is made from a careful physical
examination and x-rays of the ankle.

• Occasionally an MRI is also utilized to evaluate other

structures of the ankle.
 Treatment
• Over-the-counter anti-inflammatories like ibuprofen to reduce
pain,swelling and help speed up the healing process
• Icing the ankle to reduce swelling and inflammation, PRICE
Therapy
• A cast or brace, or an alternative everyday shoe that better
supports the ankle and controls movement
• Physical therapy to help improve your range of motion, break
down bone spurs, scar tissue and restore overall ankle function.
 Anterior Ankle Pain

Ankle Osteoarthritis
Osteoarthritis of the ankle happens when
the cartilage between the bones starts to
wear away. This can cause stiffness,
swelling, and pain in the joint, which
makes walking difficult.
Causes:
• Aging.
• Being overweight or obese.
• History of injury or surgery to a joint.
• Overuse from repetitive movements of the joint.
• Joints that do not form correctly.
• Family history of osteoarthritis.
Sign and Symtoms of Ankle OA
• Pain and stiffness that is worse in the morning and after
sitting still for a long time.
• Tenderness when someone touches or squeezes the joint.
• Swelling may happen all around or on one side of your ankle.
• Decreased range of motion means your ankle won’t bend
and flex completely.
• Difficulty walking due to pain, stiffness and loss of motion.
Risk factors:
• Older age: The risk of osteoarthritis increases with age.
• Gender: Women are more likely to develop osteoarthritis,
though it isn't clear why.
• Obesity.
• Joint injuries.
• Repeated stress on the joint.
• Genetics.
• Bone deformities.
• Certain metabolic diseases.
Treatment
• Medications, including over-the-
counter options, such as NSAIDs, or
other pain medications.
• Bracing can also be very helpful. One
commonly recommended ankle brace
is called the Arizona brace, which
locks the ankle in position.
• Occasional steroid injections into the
ankle joint, which may help if you also
have ankle arthritis
Physical Therapy Treatment
Physiotherapy aims to improve function and slow the progression of
osteoarthritis using a combination of treatments including:
• Strengthening, endurance and balance exercises
• Joint mobilizations
• Bracing, taping, or orthotics
Pain reducing treatments such as:
• Therapeutic ultrasound
• TENS etc...
Posterior Ankle Pain
 Posterior Ankle Pain
Achilles Tendonitis
• Achilles tendinitis is an overuse injury of the Achilles
tendon, the band of tissue that connects calf muscles
at the back of the lower leg to heel bone.
• Achilles tendinitis most commonly occurs in runners
who have suddenly increased the intensity or
duration of their runs and in middle aged people who
play sports only on weekends.
• Common in Men and as you age
• Obesity, flat foot and tight calf muscles put strain on
the tendon leading to Achilles tendonitis
• Running in worn out shoes can cause AT
• Complications:
• Achilles tendonitis weakens the tendon due to
repetitive stress. It becomes vulnerable to tear.
Symptoms

• The pain associated with Achilles tendinitis typically

begins as a mild ache in the back of the leg or above the
heel after running or other sports activity. Episodes of
more-severe pain may occur after prolonged running,
stair climbing or sprinting.
• Patients might also experience tenderness or stiffness,
especially in the morning, which usually improves with
mild activity
 Treatment
• Icing the ankle to reduce swelling and inflammation,
PRICE Therapy
• Occasional steroid injections
• Physical therapy interventions
• Calf stretches
• Strengthening (eccentric)
• Single heel drop and bilateral heel drop
• Bracing may also help
• Shoe inserts to relieve stress
• If conservative treatment do not work than surgery to
repair Achilles tendon
Posterior ankle impingement syndrome

• Posterior ankle impingement syndrome is

a clinical disorder characterized by
posterior ankle pain that occurs in forced
plantar flexion. The pain may be acute as
a result of trauma or chronic from
repetitive stress
• It is of two types on the basis of structure
that is compressed at the end range of
plantar flexion i-e bony impingement and
soft tissue impingement
• Bony impingement is commonly caused by Os trigonum-talar process
syndrome or fracture
• Os trigonum is an accessory bone that form around the age of 8-13
years of age and it fuses with trigonal process ( potero-lateral tubercle of
talus) by the age of 17. This process becomes wedged between tibia,
talus and calcaneus at the end range of plantar flexion.
• With forced hyper-plantar flexion fracture of trigonal process can occur or
micro trauma to the bone can irritate surrounding tissues and can cause
posterior ankle impingement syndrome.
• Soft tissue impingement is caused by FHL tenosynovitis, FHL
tendinopathy, ankle osteochondritis or subtalar capsulitis
• Due to repetitive loading inflammation or irritation of these soft tissue can
cause impingement
• Thickening and reduced elasticity of FHL tendon due to stress can lead
to posterior impingement syndrome.
 Symptoms
• Deep ankle pain with plantar flexion
• Swelling or tenderness as the back of ankle.
• Instability.
• Aching at rest, or after activities such as: Kicking a ball. Pointe work (ballet)
Walking or running (especially downhills) Jumping or hopping.
Examination:
• Depending on nature and choronicity of impingement, swelling may be observed
• Arch height should be assessed, high rigid arch causes bony impingement and in
flat foot muscles and Ligaments are tired in maintaining arch and causes soft
tissue impingement
• On palpation there will be pain and tenderness deep to Achilles tendon on
slightly medial or lateral side
• Active and passive plantar flexion will cause pain
Treatment
• The regular application of an ice pack,
• plenty of rest, avoid end range plantar flexion
• PRICE therapy
• NSAIDS
• Mobilization and gentle distraction of talocural and
subtalar joints
• Soft tissue release of tight calf muscles
• Strengthening of calf and foot intrinsic muscles
• Gradual return to activity and loading through plantar
flexion once symptoms have settled
Medial ankle pain
 Tarsal Tunnel Syndrome
• Tarsal tunnel syndrome (TTS) is a rare compressive
neuropathy of tibial nerve or its branches as they passes
under flexor retinaculum. Tibial nerve runs through tarsal
tunnel, a passage of bones and ligaments in ankle. TTS
symptoms may include pain, burning or tingling in the
bottom of your feet and toes.
• People who have TTS may have pain, tingling, numbness
or weakness in their feet.
• Causes:
• Incidence is usually unknown
• High prevalence in woman
• Majority cases are idiopathic
• Common in athletes and individuals with prolonged weight
bearing period, prolonged standing, walking and intense
physical activity
• Flat foot decreases space in tarsal tunnel and tension on nerve increases
• Compression from footwear
• Fracture, stress injuries
• Hell varus and valgus
• Fibrosis of soft tissues structures passing through tarsal tunnel or of flexor
retinaculum itself
• Space occupying lesion such as tumor, edema, osteophytes
• Systemic diseases that causes nerve compression i-e DM, arthritis
• Symptoms:
• Paresthesia (burning, numbness, tingling) in course of tibial nerve usually medial
ankle and plantar aspect of foot
• Local tenderness behind medial malleolus
• In severe cases muscle atrophy with night pain that awakes from sleep
Examination
• Arch stability
• Muscle atrophy
• Position of talus and calcaneus
• Gait analysis
• Sensory testing
• ROM of ankle and toes
• Palpation (tenderness b/w medial malleolus and Achilles tendon)
• Assess MMT at later stages
• Tinel test
• Foot dorsiflexion with eversion will aggravate symptoms
Treatment
• Acute stage: Reduce inflammation, tissue stress, pain
with ice, ultrasound, iontophoresis, plantar arch taping,
calf stretching, nerve mobility, soft tissue massage, neural
mobilization
• Subacute stage: Repeat above with tibialis posterior
strengthening in weight bearing, educate on proper
footwear
• Settled stage: Improve functional mobility strength and
flexibility bilaterally
• Heel pads and heel cups
 FHL Tendonitis
The flexor hallucis longus tendon originates from fibula and covers posterior
2/3rd of fibula and courses along the tarsal tunnel and inserted at plantar surface of
big toe, assisting with flexion of the big toe. Irritation of this tendon can occur with
repeatedly pushing off the foot and toes, which is commonly seen in ballet
dancers. Runners can be affected as well. This injury can be further worsened
with everting or rolling out the foot, often in young dancers who have improper
form when performing the ”turnout” maneuver
Symptoms

• Swelling of ankle
• posteromedial ankle pain
• great toe locking with active range of motion
• crepitus along the posterior medial ankle
• Examination:
• Pain with resisted flexion of IP joint of bog toe
• Great toe triggering with active and passive motion
• FHL tendonitis causes more severe pain with landing from jumps
than posterior impingement syndrome
• These differentiate it from impingement syndrome
Treatment

• Treatment is conservative and involves ice, rest,

and NSAIDs (e.g., ibuprofen or naproxen)
• Physical therapy is helpful to work on ankle
stability.
• Arch support
• Big toe extension stretch
• Towel curls
• Plantar fascia stretch at wall
• In rare cases, immobilization for several weeks in
a weight-bearing cast or walking boot may be
required.
• Surgery may be indicated in persistent cases
where chronic inflammation can lead to the
formation of tendon nodules.