In this blog, I’m going to tell you why your ankle hurts and what you should do about it!
Be sure to also check out our Ankle Resilience Program!
Ligament Injuries (Sprains)
Not only am I going to discuss the location of these injuries, but I’m going to try to categorize them by the type of tissue involved, beginning with ligaments.
A ligament, which attaches from bone to bone, provides passive stability to joints and an injury to this structure is known as a sprain. Let’s start by reviewing the most common ankle injury.
Lateral Ankle Sprain
A lateral ankle sprain occurs when you twist or roll your ankle inward at a high speed. The ligament usually involved is the anterior talofibular ligament, or ATFL, and sometimes the calcaneofibular ligament, or CFL. Both ligaments attach to the fibula, the bone located on the outer part of your ankle.
Lateral ankle sprains are typically graded on a scale from 1 to 3. Grade 1 is a mild injury with a relatively quick return to activity. Grade 2 is a moderate injury with a slightly longer recovery. Grade 3 is a severe injury that takes the longest to rehabilitate. Generally speaking, a grade 3 injury will also present with the most swelling and bruising.
Regardless of the degree of injury, proper rehab is crucial because up to 40% of individuals develop chronic ankle instability after a first time ankle sprain.
Want to learn more?
Check out our full blog about Lateral Ankle Sprain Rehab!
Chronic Ankle Instability
Chronic Ankle Instability (CAI) is defined as a “condition characterized by repetitive episodes or perceptions of the ankle giving way; ongoing symptoms such as pain, weakness, or reduced ankle range of motion (ROM); diminished self-reported function; and recurrent ankle sprains that persist for more than 1 year after the initial injury.”
Essentially, it’s an ankle sprain that never fully healed and continues to give you problems.
Want to learn more?
Check out our full blog about Chronic Ankle Instability Rehab!
Fractures (Ottawa Ankle Rules)
Before moving on, it’s important for me to point out that after any traumatic injury to the ankle or foot, the Ottawa Ankle Rules will be used by a healthcare professional to rule out the possibility of a fracture. These criteria suggest that if you don’t have the ability to bear weight and walk four steps immediately after the injury or if you have tenderness at specific bones (the lateral malleolus, base of the 5th metatarsal, medial malleolus, or navicular), x-rays are indicated.
High Ankle Sprain (Syndesmosis Injury)
A high ankle sprain, also known as a syndesmosis injury, refers to an injury to the distal tibiofibular joint, which is the connection between the tibia, or shin bone, and fibula.
The primary ligaments that support this joint are the anterior inferior tibiofibular ligament (AITFL) in front, the posterior inferior tibiofibular ligament (PITFL) in back, and the interosseous ligament in between.
Unlike a lateral ankle sprain in which you twist or roll your ankle, a syndesmosis injury occurs when your foot is planted, your ankle is dorsiflexed, and your foot is rotating outward relative to your tibia. The majority of injuries involve contact, such as being tackled in football. Click here for a video.
This injury may be suspected based on certain characteristics, such as the mechanism of injury, location of pain, difficulty walking, or the inability to hop on one leg.
Due to the high-force mechanism of injury, it’s also possible for disruption of the deltoid ligament and fractures to occur.
Want to learn more?
Check out our full blog about High Ankle Sprain Rehab!
Medial Ankle Sprain
An isolated medial ankle sprain, which is an injury to the deltoid ligament on the inner portion of the ankle, is rare for 2 reasons:
- The bony anatomy of the ankle mostly prevents the extreme range of motion that would injure this ligament.
- The deltoid ligament, which actually consists of 4 ligaments, is very strong.
Instead, injuries often coincide with fractures or high ankle sprains as previously mentioned.
Osteochondral Lesion
Sometimes trauma, or repetitive trauma, can lead to damage or a breakdown of the cartilage and underlying bone of the ankle. This is known as an osteochondral lesion, specifically of the talus bone. Symptoms may include deep, diffuse pain toward the front of the ankle, as well as swelling and the sensation of the joint being blocked.
Anterior Impingement (Footballer’s Ankle)
Anterior impingement, also referred to as footballer’s ankle, is another reason why someone may report discomfort in the front of their ankle and the feeling of it being “blocked” when moving into dorsiflexion. This may result from irritated soft tissue structures or the development of a bone spur.
Keep in mind that except in the cases of more severe or impactful injuries, rehabilitation is usually the first line of treatment for most of the diagnoses I’m discussing in this blog.
Tendon Injuries (Tendinitis/Tendinopathy)
Let’s move on to tendons, which connect muscles to bones.
Despite popular belief, tendinitis is not a recommended diagnostic label for tendon-related pain because acute inflammation does not seem to be the primary driver of symptoms.
This means that rehabilitation does not need to take an anti-inflammatory approach involving ice, medication, and complete rest for an extended period of time.
Unlike ankle sprains, tendinopathies are usually gradual in nature with no distinct mechanism of injury. Although their onset is multifactorial, it’s easiest to think about tendinopathies as load-related issues.
Load refers to any position, movement, or activity that challenges the affected tendon, such as walking, running, jumping, hopping, etc. Capacity is your ability to tolerate those loads, recover, and adapt appropriately. Therefore, tendinopathies are thought to arise when these various loads exceed your capacity to tolerate them.
Much of the time they’re described as repetitive overuse or relative overload injuries, along the lines of “doing too much, too soon.”
It’s important for me to point out that your capacity is influenced by a variety of factors, such as certain medications, lack of sleep, and your metabolic health.
Now let’s review the tendinopathies of the ankle.
Achilles Tendinopathy (Mid Portion and Insertional)
Named for the Greek mythological hero, Achilles, the Achilles tendon is the strongest and thickest tendon in the human body. During walking and running, the load experienced by the Achilles tendon reaches up to 4 and 8 times your bodyweight. The primary calf muscles, the gastrocnemius and soleus, attach to the calcaneus, or heel bone, via the Achilles tendon.
Individuals with Achilles tendinopathy will typically report localized pain of the tendon that is provoked with palpation, stretching, or loading, such as with walking and running. Stiffness, especially in the morning, and thickening of the tendon are also common.
Achilles tendinopathy is categorized based on the location of symptoms as either mid-portion or insertional. Mid-portion Achilles tendinopathy is the more common diagnosis of the two.
Want to learn more?
Check out our full blog about Achilles Tendinopathy Rehab!
Achilles Tendon Rupture
Individuals with Achilles tendinopathy are often fearful about rupturing their Achilles tendon, but it’s actually unlikely to occur in those experiencing pain.
Unfortunately, there usually aren’t warning signs or symptoms leading up to the injury.
An Achilles tendon rupture most commonly occurs from a sudden and forceful contraction of the calf muscles while the ankle is dorsiflexed, such as during sport-specific movements like forward acceleration, cutting, and jumping.
People describe the feeling as if they were “kicked in the back of the leg” or as “a popping or giving way sensation in their heel.”
It typically presents with swelling and bruising, and there may be a palpable gap, most frequently 2-6 cm above the heel bone.
In the physical therapy setting, specific clinical tests like the Thompson test help confirm the diagnosis. While the patient is lying on their stomach, the calf muscles are squeezed. Normally, this results in ankle plantar flexion, but in cases of an Achilles rupture, no ankle movement will occur.
Want to learn more?
Check out our full blog about Achilles Tendon Rupture Rehab!
Sever’s Disease
Although the location of symptoms may be similar, Sever’s disease should not be confused with insertional Achilles tendinopathy.
Sever’s is an irritation of the growth plate where the Achilles tendon attaches to the calcaneus. It usually occurs in children and adolescents involved in sports requiring repetitive jumping and running.
Posterior Impingement (Dancer’s Heel)
A diagnosis located in the back of the ankle that does occur in adults is posterior ankle impingement. Unlike individuals with anterior impingement who experience symptoms with dorsiflexion, people with posterior impingement experience symptoms with plantarflexion. This is why it’s often referred to as dancer’s heel.
Peroneal Tendon Injuries
The peroneal longus and brevis muscles are located in the outer compartment of the lower leg. The tendons of these muscles wrap around the lateral malleolus, the bony landmark on the outer portion of your ankle, and are held in place by the superior and inferior peroneal retinacula.
There are three primary types of peroneal tendon injuries: subluxations, tears, and tendinopathies.
An acute peroneal tendon subluxation, in which the tendon has slipped out of its groove behind the lateral malleolus, may occur when the superior peroneal retinaculum is torn. The mechanism of injury often involves a contraction of the peroneals when the ankle is in a dorsiflexed and nonneutral position during stopping, landing, or cutting in sports, such as skiing, gymnastics, soccer, basketball, and football.
A complete rupture of a peroneal tendon may also occur during a high-force mechanism of injury.
Non-traumatic injuries are not acute in nature and don’t require prompt medical attention. For example, it’s possible to have chronic peroneal tendon subluxations (indicated by a history of snapping or popping) or a partial tear, while having little to no symptoms or loss of function.
Peroneal tendinopathy may be related to activities like running or playing sports, or associated with recurring lateral ankle sprains. It’s not uncommon for chronic ankle instability and peroneal tendon issues to go hand-in-hand. Symptoms may be reproduced with palpation of the tendons, stretching of the tendons into dorsiflexion and inversion, or contraction of the tendons into eversion.
Want to learn more?
Check out our full blog about Peroneal Tendinopathy Rehab!
Tibialis Posterior Tendinopathy
On the opposite side of the ankle, the tibialis posterior tendon passes behind the medial malleolus.
The tibialis posterior’s main functions are highlighted in standing, walking, and running as it helps to support and control the medial longitudinal arch of the foot.
For simplicity, it can be helpful to think about tibialis posterior tendinopathy occurring along a continuum.
On one end, it might happen in an otherwise healthy runner who recently had a spike in mileage that resulted in an acute overload of the tendon. Toward the other side of the continuum, this might be a chronic issue in a relatively sedentary individual with a higher body mass, resulting in a significant decrease in function.
In addition to pain along the inner aspect of their foot and/or ankle, individuals diagnosed with tibialis posterior tendinopathy may present with a more pronated foot posture. This too can occur along a continuum and progress as the condition worsens.
For instance, someone may present with a flexible flatfoot deformity, which is “characterized by forefoot abduction, a lowered medial longitudinal arch and/or hindfoot eversion.” A rigid flatfoot deformity would represent a more fixed posture of the foot in weight bearing and non-weight bearing, and would likely coincide with a significant progression of the condition along with other comorbidities.
Please understand that having “flat” or “flatter” feet is often normal and does not necessarily mean you’re going to develop tibialis posterior tendinopathy.
Lastly, people with tibialis posterior tendinopathy may experience pain and difficulty with performing single leg heel raises, or the complete inability to perform them.
Want to learn more?
Check out our full blog about Tibialis Posterior Tendinopathy Rehab!
Flexor Hallucis Longus Tendinopathy (Dancer’s Tendinopathy)
The flexor hallucis longus tendon is located in close proximity to the tibialis posterior tendon. Flexor hallucis longus tendinopathy, or dancer’s tendinopathy, is generally seen in dancers, gymnasts, and other sporting populations.
Symptoms can include pain along the path of the tendon, pain and weakness with resisted flexion of the big toe, limited and painful extension of the big toe, and difficulty with heel raises and pushing off of the foot, such as with walking and running.
Clicking, popping, and swelling may also be present.
As they’re frequently referred to as dancer’s heel and dancer’s tendinopathy, posterior ankle impingement and flexor hallucis tendinopathy can occur simultaneously.
Tibialis Anterior Tendinopathy
The tibialis anterior tendon is located toward the front of the ankle and top part of the foot. The tendon can be seen and felt when performing dorsiflexion.
Although tibialis anterior tendinopathy is rare compared to the other tendinopathies I’ve discussed, it may be suspected if localized symptoms started after a recent change or increase in activity involving repetitive dorsiflexion.
Bone Stress Injuries & Stress Fractures
Since I mentioned that fractures may result from a traumatic injury, it’s important for me to briefly touch on bone stress injuries and stress fractures as well.
As defined by Warden and colleagues, “Stress fractures are a type of ‘bone stress injury’ (BSI). A BSI represents the inability of a generally normal bone to withstand repetitive loading leading to localized bone weakness and pain.”
These types of injuries are said to be the result of training errors or errors in workload, which is why they’re most common in runners and military recruits. Diet and nutrition, among other factors, also play an essential role.
Many bones of the foot and ankle can be affected. Localized bony tenderness and a decreasing tolerance to weight bearing activities, such as walking and running, should raise suspicion.
MRIs, not X-rays, are the gold standard for the diagnosis of bone stress injuries.
Nerves
The final group of tissues I want to discuss is nerves. Nerves can get irritated as the result of an acute event, like an ankle sprain, if they’re quickly overstretched, but problems can also happen more gradually. Typical signs and symptoms include tingling, numbness, burning, and weakness in the ankle or foot.
Keep in mind that nerve issues can originate higher up in the leg or low back, so it can be helpful to work with a healthcare provider to determine the source of symptoms.
What About Other Diagnoses?
What about other diagnoses that I didn’t mention? Well, there are 2 things to consider:
- I can’t cover every possible diagnosis, but I did my best to review the ones that are most prevalent.
- As you’re about to learn, most of the strategies and goals for rehab are similar between diagnoses.
How To Rehab Your Ankle
Assuming you don’t have a fracture, you’ve received clearance from your medical doctor, and you have no other contraindications to exercise, you should be ready to jump into full training, right?
Not necessarily.
Consider these two ankle sprain examples:
- A person experiences a grade 1 lateral ankle sprain, takes it easy for a day or two, and then gradually gets their ankle moving and resumes normal activity within a couple of weeks with no major problems.
- A different individual suffers a more severe ankle sprain with significant swelling and bruising. Based on their symptoms and function, this person decides to use crutches for a few days, an ankle brace for a month, and it takes them longer to fully recover.
You rarely need to completely rest and avoid all symptoms after an injury, but you also shouldn’t approach rehab with a “no pain, no gain” mentality. Unfortunately, it’s not a perfect science. Rehab is about finding that fine line between doing too much and doing too little. Whether you need more or less movement depends on different factors, such as the recency of your injury and the severity of your symptoms.
In the case of an ankle sprain, you want to allow the injured tissues to heal while minimizing swelling, managing pain, and slowly restoring function. Sometimes the temporary use of tape, a brace, or assistive devices are beneficial for helping to accomplish those goals.
With regards to exercises, your selection will be dependent on your needs. Sticking with the ankle sprain example, exercises might focus on:
- Swelling
- Range of Motion
- Single Leg Balance
- Ankle and Foot Strength (with an emphasis on heel raise variations)
- General Lower Body Strength
- Jumping and Hopping Progressions
These would likely be performed during different phases of your rehab over the course of weeks or months.
As you resume your normal activities and sports, you’d want to do so using a graded approach. Small, structured progressions in your rehab help ensure that you’re adequately prepared for whatever it is you want to get back to.
Although I’ve been referencing ankle sprains, this information would apply to tendinopathies and other overuse-type injuries as well. However, there might be slight differences in priorities. For example, a runner with Achilles tendinopathy may not need to address swelling or work on improving their range of motion. Instead, their emphasis should be on improving the capacity and tolerance of their calf and Achilles complex through heel raises and, eventually, jumping and hopping. There should also be a focus on appropriate load management, meaning the runner adjusts the speed, distance, and frequency of their runs to a tolerable level, while implementing reasonable progressions over time.
For any injury, your overall health should not be overlooked. For instance, at the very least, a person with a bone stress injury should evaluate their diet and nutrition. An individual with tibialis posterior tendinopathy and Type 2 Diabetes may simultaneously address their ankle and foot while also trying to adopt a healthier lifestyle.
For those of you wondering about shoes and orthotics, they can be used as part of a comprehensive treatment plan. However, it’s usually best to think about shoes and orthotics as shifting forces to, or away from, certain tissues of the foot and ankle as opposed to changing the structure of your feet. For example, someone with a highly symptomatic Achilles tendinopathy may opt for shoes with a greater heel-to-toe drop to temporarily reduce the load on their Achilles tendon. Similarly, an individual with tibialis posterior tendinopathy may choose to use supportive, athletic footwear or trial inverted foot orthoses to reduce the demand on the tibialis posterior tendon during walking.
With all that being said, just be aware that rehab can require significant time and effort.
And as a reminder, we have full-length blogs dedicated to most of these diagnoses, so check those out if you’re looking for more in-depth information.
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Ankle Resilience Program!
Thanks for reading. Check out the video and please leave any questions or comments below.
