Medial Ankle Pain And Anterior Ankle Pain:

Sportspeople, particularly ballet dancers, footballers and high jumpers, may complain of ankle pain that is not related to an acute ankle injury. Clinical management is simplified if the presentations are further divided into:

• medial ankle pain
• lateral ankle pain
• anterior ankle pain.

Note that the region that might be considered posterior ankle pain is defined as the Achilles region.

Medial Ankle Pain

Clinical experience suggests that the most common cause of medial ankle pain is tibialis posterior tendinopathy. Posterior impingement syndrome of the ankle may occasionally present as medial ankle pain. Flexor hallucis longus tendinopathy is not uncommon and may occur together with posterior impingement syndrome. Tarsal tunnel syndrome, in which the posterior tibial nerve is compressed behind the medial malleolus, may present as medial ankle pain with sensory symptoms distally.

History

In patients with medial ankle pain there is usually a history of overuse, especially running or excessive walking (tibialis posterior tendinopathy), toe flexion in ballet dancers and high jumpers (flexor hallucis longus tendinopathy) or plantarflexion in dancers and footballers (posterior impingement syndrome). Pain may radiate along the line of the tibialis posterior tendon to its insertion on the navicular tubercle or into the arch of the foot with tarsal tunnel syndrome. Sensory symptoms such as pins and needles or numbness may suggest tarsal tunnel syndrome.

Examination

Careful palpation and testing of resisted movements is the key to examination of this region.

1. Observation

• standing
• walking
• supine

2. Active Movements

• ankle plantarflexion/dorsiflexion
• ankle inversion/eversion
• flexion of the first metatarsophalangeal joint

3. Passive Movements

• as for active
• subtalar joint
• midtarsal joint
• muscles stretches
• gastrocnemius
• soleus

4. Resisted Movement

• inversion
• first toe flexion

5. Functional Tests

• hop
• jump

6. Palpation

• tibialis posterior tendon
• flexor hallucis longus
• navicular tubercle
• ankle joint
• midtarsal joint

7. Special tests

• Tinel's test
• sensory examination
• biomechanical examination
• lumbar spine examination

Investigations

Plain X-ray should be performed when posterior impingement is suspected to confirm the presence of either a large posterior process of the talus or an os trigonum. A lateral view with the foot in a maximally plantarflexed position (posterior impingement view) can be useful to determine if bony impingement is occurring. A radioisotopic bone scan may show an area of mildly increased uptake at the posterior aspect of the talus in cases of chronic posterior impingement. In suspected cases of tendinopathy, ultrasonography or MRI may be indicated if pain has been longstanding or if there is doubt about the diagnosis. Nerve conduction studies should be obtained if tarsal tunnel syndrome is the likely diagnosis.

Anterior Ankle Pain

Pain over the anterior aspect of the ankle joint without a history of acute injury is usually due to either tibialis anterior tendinopathy or anterior impingement of the ankle.

Anterior impingement of the ankle

Anterior impingement of the ankle joint (anterior tibiotalar impingement) is a condition in which additional soft or bony tissue is trapped between the tibia and talus during dorsiflexion and may be the cause of chronic ankle pain or may result in pain and disability persisting after an ankle sprain. Although this syndrome has been called footballers ankle it is also seen commonly in ballet dancers.

Causes

Anterior impingement occurs secondary to the development of exostoses on the anterior rim of the tibia and on the upper anterior surface of the neck of talus. The exostoses were initially described in ballet dancers and thought to be secondary to a traction injury of the joint capsule of the ankle that occurs whenever the foot was repeatedly forced into extreme plantar flexion. Subsequently the development of the exostoses has been attributed to direct osseous impingement during extremes of dorsiflexion, as occurs with kicking in football and the plie (lunge) in ballet. As these exostoses become larger, they impinge on overlying soft tissue and cause pain.

Ligamentous injuries following inversion injuries to the ankle may also result in anterior ankle impingement, it has been shown that the distal fascicle of the anterior inferior tibiotibular ligament may impinge on the anterolateral aspect of the talus.

Clinical Features

The patient complains of:

• anterior ankle pain, which initially starts as a vague discomfort.
• pain ultimately becoming sharper and more.
• localized to the anterior aspect of the ankle and foot.
• pain that is worse with activity, particularly with running, descending plie (lunge) in classical ballet, kicking in football or other activities involving dorsiflexion.
• As the impingement develops, the patient complains of ankle stiffness and a loss of take-off speed.

Examination reveals tenderness along the anterior margin of the talocrural joint and, if the exostoses are large, they may be palpable. Dorsiflexion of the ankle is restricted and painful. The anterior impingement test, where the patient lunges forward maximally with the heel remaining on the floor,

Investigations

Lateral X-Rays in flexion and extension show both exotoses and abnormal tibiotalar contact. Ideally performed weight bearing in the lunge positions, showing bone-on-bone impingement, confirms the diagnosis.

Treatment

In milder cases, conservative treatment consists of a heel lift, rest, modification of activities to limit dorsiflexion .NSAID and physiotherapy, including accessory anteroposterior glides of the talocrural joint at the end of range of dorsiflexion. Taping or orthoses may help control the pain if they restrict ankle dorsiflexion or improve joint instability, which has been shown to contribute to the development of anterior impingement. More prominent exostoses may require surgical removal arthroscopically or as an open procedure.