Ankle Pain Workshop by Michael Dermansky of MD Health Pilates

1. Ankle Pain Workshop
MD Health Physiotherapy

2. Ankle
• Talocrural, inferior tibiofibular and
subtalar joints
• The talocrural joint is a synovial hinge
joint with a joint capsule and
associated ligaments
• Predominately allows dorsiflexion/
plantarfelxion
• Subtalar joint allows for complex
movement of supination and pronation
• MCL (Fan-shaped deltoid ligament)
– Controls valgus stresses
• LCL
– 3 bands (anterior and posterior talofibular and
calcaneofibular ligaments)
– Controls varus stresses
– Are weaker and more susceptible to injury than
the MCL
http://www.bartleby.com/107/95.html

3. Ankle
• Collateral ligament injuries
– LCL
• Is usually injured in inversion and plantarflexion from “rolling” the
ankle, or landing on uneven surfaces
• ATFL is usually injured before CFL, as the ATFL is taut in plantar flexion
and is relatively weaker
• Isolated ruptures of the CFL and PTFL are rare
• Divided into 3 grades based on severity
• Swelling usually appears rapidly
– MCL
• Much stronger than the LCL
• Mechanism of injury is eversion
• Sometimes associated with fractures
(eg. medial malleolus or talar dome)
http://content.revolutionhealth.com/contentimages/h9
991457_002.jpg

4. Ankle
• Anterior shin splints (medial tibial stress syndrome)
– Inflammatory traction phenomena on the medial aspect of the
tibia – can also be called medial tibial traction periostitis
– Chronic traction (usually of the medial soleus) occurs from
excessive pronation or overuse and repetitive impact loading
– Contributing factors include:
• Excessive foot pronation
• Training errors, incl. recent increase in activity
• Incorrect/poor shoe design
• Running on hard/unforgiving surfaces
• Decreased bone mineral density
• Poor hip and knee biomechanics
• Inflexibility
– Inflammation can lead to anterior compartment
http://www.sportsinjuryclinic.net/cybert
herapist/front/lowerleg/shinsplints.htm
syndrome, causing further pain and loss of function

5. Ankle
• Tenoperiostitis – tibialis posterior
– The tibialis posterior functions to invert the
subtalar joint, is the main dynamic
stabiliser of the hind foot against
valgus, and provides stability to the
longitudinal arch
– The cause of injury is usually overuse, and
is due to:
Tibialis
posterior
• Excessive walking, running or jumping
• Poor foot biomechanics (ie. excessive subtalar
pronation – this increases eccentric tendon
loading during supination for toe-off)
– It may also present as a tenosynovitis
secondary to rheumatoid arthritis, or
seronegative arthropathies
http://www.eorthopod.com/public/patient_
education/6489/posterior_tibial_tendon_pr
oblems.html

6. Ankle
• Tibial stress fracture
– Continual stresses from running on hard surfaces or from
heavy strain in the tibialis muscles can weaken and
eventually fracture the tibia
– Commonly caused by activities that involve highimpact running and jumping
– Patients with shin pain who try to work
through it sometimes end up developing
a stress fracture in the tibia
– 90% of tibial stress fractures affect the
posteromedial tibia, usually in the middle third
– Anterior tibial stress fractures are quite
resistant to treatment and have a propensity
to develop a non-union
http://www.eorthopod.com/images/ContentImages/
ankle/shinsplints/leg_shinsplints_cause02.jpg

7. Ankle
• Achilles tendinopathy
– May be mid-portion or insertional (less common)
– Associated with collagen fibre disarray – focal losses
of normal fibre structure
– The paratendinous structures can be
oedematous or scarred
– There are areas of hypervascularity, but lack
of tissue repair
– Predisposing factors include:
• Overuse factors (increased training loads,
decreased recovery times)
• Change in surface, footwear
• Abnormal biomechanics (excessive
subtalar pronation, hip and knee dysfunction)
• Poor muscle flexibility ad weakness
http://www.eorthopod.com/public/patient_edu
cation/6478/achilles_tendon_problems.html

8. Ankle
• Plantar fascia pain
– Includes both plantar fascia strains and plantar fasciitis
– The plantar aponeurosis provides static support for the
longitudinal arch and dynamic shock absorption
– Risk factors for development of plantar fasciitis:
• Repetitive activities that involve maximal plantarflexion of the ankle and simultaneous dorsiflexion
of the MTP joints (eg. running)
• Pes planus or pes cavus
• Non-supportive footwear
• Reduced ankle dorsiflexion
• Obesity
• Tight proximal myofascial structures,
especially the calf, hamstring and gluteals
http://www.uptodate.com/patients/content/images/r
heumpix/Plantar_anatomy_for_patient.jpg

9. Assessing the Ankle

10. Ankle Dorsiflexion (DF) ROM:
• Goniometer
• Landmarks
• Lateral malleolus
• Shaft of tibia
• Line of 5th metatarsals
• Client instructed to actively DF
ankle
• Note pain patterns
• Compare both sides
Ankle Plantarflexion (PF) ROM:
• Goniometer
• Landmarks
• Lateral malleolus
• Shaft of tibia
• Line of 5th metatarsals
• Client instructed to actively PF
ankle
• Note pain patterns
• Compare both sides

11. Inferior tib/fib stability:
• Stabilise tib/fib
• Passively invert ankle with PF
• Note quality of
movement, ROM, end-feel and
pain patterns
• Compare both sides
Ankle anterior drawer (ATFL):
• Stabilise tib/fib
• Knee should be slightly flexed
• Anterior drawer calcaneus
through joint line
• Note quality of
movement, ROM, end-feel and
pain patterns
• Compare both sides

12. Ankle Eversion ROM:
• Eye-balling (10)
• Client in supine
position and instructed
to actively evert ankles
• Note ROM and pain
patterns
Ankle Inversion ROM:
• Eye-balling (10)
• Client in supine
position and instructed
to actively invert ankles
• Note ROM and pain
patterns

13. Ankle PF strength
• MMT
• Stabilise tibia
• Client instructed to actively PF
ankle
• Note pain patterns
• Compare both sides
Ankle DF strength:
• MMT
• Stabilise tibia
• Client instructed to actively PF
ankle
• Note pain patterns
• Compare both sides

14. Ankle eversion and
inversion strength:
• MMT
• Stabilise tibia
• Client instructed to
actively evert or invert
ankle
• Note pain patterns
• Compare both sides

15. Significant Findings from the Ankle

16. Grades of ankle instability:
• Grade 1
• Ligament Stretch – No tear
• Minimal swelling tenderness
• No function loss
• No mechanical instability
• Grade 2
• Torn ATFL, Intact CFL
• Moderate pain, swelling
• Mild joint instability
• Grade 3
• Torn ATFL, CFL (PTFL)
• Significant pain, swelling, lost ROM
• Functional and mechanical
instability

17. Shin splint – general:
• Noted from subjective assessment
• Pain produced with palpation of:
• Tib ant and tib post for muscular shin
splints
• Tibia for bony shin splints
• Some pain may be reproduced with weightbearing DF and PF
• Bony shin splints may indicate micro fractures
occurring within the tibia itself
• Resulting inflammatory process causes pain
and localised swelling along the bone

18. Achilles tendinopathy:
• Pain with jumping/hopping
• Decreased PF strength compared with nonpathological side
• Biomechanical predisposing factors
• Excessive foot pronation
• Calf weakness
• Poor muscle flexibility, eg tight gastrocnemius
• Poor ROM – restricted DF

19. Lateral ligament tear:
• Positive ligament testing
• Anterior drawer assess ATFL integrity
• Talar tilt test assess integrity of the
calcaneofibular ligament (laterally) and the
deltoid ligament (medially)
• Grades of instability
• I: there is no abnormal ligament laxity
• II: reveal some degree of laxity but have a
firm end feel
• III: gross laxity without a discernible end
point
• Subjective Hx:
• noted trauma
• instability

20. Plantar fascia pain:
• Subjective
• Pain worse in morning and improves during
the day
• Pain with walking
• Pain reproduced with resisted PF
• Pain reproduced with DF stretch
• Biomechanical factors
• Activities that require maximal PF of the
ankle and simultaneous DF of
metatarsophalangeal joints –
running, dancing
• Excessive pronation

21. Treating the Ankle

22. Ankle ROM:
• Aim of Rx is to improve ankle ROM without
compromising pathology
• Can be used for any pathology but note stage of
healing
• STW (gastrocs, peroneals): can ease muscle
spasm and decrease pain inhibition
• Ankle mobs: AP, PA, physiological fl/ext/eve/inv
• Once ankle ROM is improved and ankle joint more
stable, progress to plyometric exercises
• skipping, jumping, running, hopping, side-toside running/hopping

23. Ankle strengthening:
• Aim of Rx is to improve ankle strength without
compromising pathology
• Can be used for any pathology but note stage of healing
• STW (gastrocs, peroneals): can ease muscle spasm and
decrease pain inhibition
• Strengthening: heel raises, lunges
• AMC: decrease resistance on reformer to maximise
eccentric control when adding HR to exercise
• Plyo: skipping, jumping, running, hopping, side-to-side
running/hopping
• Monitor pain behaviour. If Lx, hip, knee or ankle is
irritated, exercises should be eased off and focussed on
easing pain (RICER) or focus on another joint, eg. knee