Ankle pain can be an indicator of an undergoing condition caused by an incident or repetitive overuse. People who participate actively in sports have a higher chance of suddenly getting their ankle hurt or overusing it but ankle pain is not strictly restricted to them. Here we are going to discuss two of the diseases that cause posterior ankle pain – their nature, causes and symptoms and how to treat them.
Posterior ankle impingement or also known as Os Trigonum syndrome, Posterior impingement syndrome, Posterior impingement of the ankle, or simply Ankle impingement
What is it?
Patients with posterior ankle impingement experience pain at the back of the ankle joint. This pain is a symptom showing there is compression of the bone or soft tissues that happens when the individual performs activities involving frequent and maximal ankle plantarflexion. The anatomy of the ankle joint is the following: there is a bone called tibia (shin bone) which forms a joint with the bone called talus (a small bone lying directly beneath the tibia). They both have articular cartilage on their surface which is there to soften the impact between them in the course of weight bearing activity. When plantarflexion occurs (the foot and ankle are directed away from the body to a maximal degree), the ankle is squeezed at the back of the joint, which might lead to pain and tissue damage and irritation if the compression is vigorous or done repetitively. This is particularly true if there is ankle swelling present or if there is an extra bone at the back of the ankle, called “os trigonum”. Os trigonum
This tiny, extra bone is found in approximately 5-10% of people. It is located behind the talus bone and there are joined by fibrous structures and usually fuse together, forming part of the lateral tubercle (a small lump on the talus), but if they fail to do so, the os trigonum remains a separate piece of bone. It is so small that it does not often cause problems but people that have this anatomical anomaly (and are physically active) are more prone to developing the Os Trigonum syndrome – another name for posterior ankle impingement.
What are its causes?
- It is purely related to activity – gender and age have nothing to do with its developing;
- Gymnasts, ballet dancers, runners and footballers commonly develop posterior ankle impingement Posterior ankle impingement;
- If there is an acute ankle injury (for example a sprained ankle) already present, it can develop due to its inadequate treatment;
- Overuse – if there is repeated plantarflexion (when the foot is pointing downwards);
- Trauma – sudden excessive plantarflexion resulting in an ankle injury
If the os trigonum has not fused with the talus, overuse or trauma can lead to the so-called “nutcracker injury” – the unfused bone and surrounding soft tissues are jammed between the ankle and the heel bones and the tissues become inflamed.
What are its symptoms?
- Sharp pain at the back of the ankle joint – it tends to get worse when performing activities that require maximum plantarflexion of the ankle; dull ache when resting or after doing activities that can provoke it (especially at night or in the morning). Pain may increase if you touch the spot firmly and may spread to the calf or foot;
- Tenderness of the affected area;
- As the soft tissues are inflamed, you may expect the development of swelling;
- At times, the os trigonum may be felt – it forms a small lump near the Achilles tendon
- In one third of the cases, both feet are affected by this condition.
How is it treated?
- The R.I.C.E. treatment – rest, ice, compression, elevation – stop the movement or activity provoking this condition; regularly apply ice to the back of the ankle to reduce swelling and inflammation; apply a compression bandage, tubigrip compression stocking or kinesiology supportive taping in order to support the tissues and reduce swelling; elevate your ankle above your heart, again to minimize swelling;
- Use of proper medication – anti-inflammatory pills such as Ibuprofen – but first check with your doctor;
- Injections: Corticosteroid injections are sometime used to reduce pain and inflammation. You can find out more about how they work and the common side effects in the injections section on out sister site.
- Rehabilitation – consult a physiotherapist for the best exercises to stretch and strengthen your ankle and foot muscles;
- Surgery – only suggestable if symptoms persist – in involves the removing of the os trigonum. The outcome is usually very good and one can return to sports in a short while (one to two months)
Flexor Hallicus Longus Tenosynovitis or also known as Flexor Hallucis Longus Tendinopathy, Flexor Hallucis Longus Tendinitis, and Flexor Hallucis Longus Tendinosis
What is it?
Tendons are the soft but flexible tissue structures that connect our muscles to our bones. Their purpose is to serve for transmitting the pull of the muscle to the bone and thus cause movement. The flexor hallucis longus muscle inserts into the base of the big toe via the flexor hallucis longus tendon. Every time this muscle contracts or is stretched, tension is placed through the tendon. Flexor hallicus longus tenosynovitis is associated with putting too much tension onto this tendon (due to an excessive force of repetition) and thus damaging it, which leads to subsequent degeneration and inflammation.
What are its causes?
- May occur traumatically due to a sudden high force through the tendon;
- More commonly it occurs due to overuse – gradual wear and tear. As with posterior ankle impingement, this condition is very common in ballet dancers.
What are its symptoms?
Pain and/or stiffness in the inner ankle or upon touching the flexor halluces longus tendon – it may spread to the big toe; it may be felt during rest after repetitive use of the muscle (running, jumping, hopping, standing on the balls of the feet) or in the course of doing these activities; it tends to be gradually increasing over time if the person continues doing these activities
How is it treated?
- Again, undergoing the R.I.C.E. treatment may promote the faster reducing of the inflammation to significantly reduce inflammation in the initial phase of this condition. Ignoring the pain may lead to it becoming chronic and thus slowing healing and recovery and increasing the probability of another occurrence of the condition;
- Physiotherapy – a gradational program to regain flexibility, balance and strength should be made by your physiotherapist to ensure the optimal healing process. However, some patients do not improve much from physiotherapy. In that case, the treatment may involve further X-rays, Ultrasounds, CT or MRI scans, as well as autologous blood injections or corticosteroid ones;
- A gradual return to activity or sports – this should be done following the advice of the treating practitioner, if there is no increase in the symptoms, and is the last stage of the rehabilitation;
- Exercises – foot and ankle up and down; foot and ankle in an out; and lunge stretches – commonly prescribed to people suffering from this condition. They should be done 3 times a day, providing they do not cause additional symptoms or increase the already existing, but you should still discuss if they are suitable for your situation with your physiotherapist.
These are only two of the most common conditions associated with posterior ankle pain. Whichever the cause, it is important to know that you should not undergo self-treatment without having consulted a medical specialist to certify the exact nature of your problem. Keep in mind that immediate and proper treatment is crucial in order to ensure fast healing and avoid complications, as well as to decrease the probability of another occurrence of the ailment.