Anatomy of the Ankle
The ankle joint is made up of three bones: the tibia, the fibula, and the talus. The tibia is the major bone of the lower leg which bears the majority of the body's weight. At the ankle, the inside bump of the tibia forms the medial malleolus. The fibula is the smaller of the two bones in the lower leg. The lower end of the fibula forms the lateral malleolus. In the ankle joint, the talus articulates with the tibia. The talus is involved in multiple movements of the foot. Ligaments in the ankle provide connection between these three bones.
Anterolateral Ankle Pain
A high ankle sprain is a sprain of the syndesmotic ligament that connects the tibia and the fibula at the ankle. The diagnosis of a syndesmotic injury is usually done by the use of external rotation stress view examination or CT scan. This patient may require surgery. An anterolateral impingement is the painful limitation of full range of ankle motion due to soft tissue or osseous (bony) pathology.
The soft tissue thickening and adhesion is commonly seen in athletes with prior trauma that extends into the ankle joint. In this case, arthroscopy and debridement may be helpful. In many athletes, a tibial bone spur impinging on the talus can become a source of chronic ankle pain and limit ankle motion.
Osseous (bony) is a spur on the anterior lip of the tibia contacting the talus during dorsiflexion and limiting the movement of the ankle. In this case the patient may need debridement of the spur.
In an ankle sprain, pain is usually anterior and around the fibula. It can usually be attributed to a ligament sprain. When the ankle is forced into an unnatural position, the ligaments are torn and the tear can be partial or complete. Treatment for an ankle sprain includes immobilization, ice, physical therapy and rarely surgery. With an ankle sprain, the patient will be able to walk, but it will be painful. If the patient has an ankle fracture, the patient will be unable to walk.
Lateral Ankle Pain
Pain that is posterior to the fibula can usually be attributed to an injury of the peroneal tendons. The superior peroneal retinaculum is usually holding the two tendons in position behind the fibula. Patients with peroneal tendon problems usually describe pain in the outer part of the ankle or just behind the lateral malleolus. The problem mainly occurs in the area where the tendons of the two muscles glide with a fibrous tunnel. Peroneal inflammation/tendonitis is inflammation due to excessive repetitive forces casing pain and swelling. Peroneal Tendon Subluxation is almost like an ankle sprain with the superior peroneal retinaculum injury. It occurs with dorsiflexion and usually eversion of the ankle.
Posterior Ankle Pain And Injury
Achilles Tendonitis refers to irritation and inflammation due to overuse. Achilles Tendonitis is associated with pain, swelling and sometimes tears. The Achilles tendon can also rupture with age, lack of use or by aggressive exercises.
The Thompson test is performed to determine the presence of an Achilles tendon rupture. A rupture is indicated by a lack of movement of the ankle when you squeeze on the calf muscles. Posterior ankle impingement can occur due to the os trigonum or large posterior process of the talus (stieda syndrome). This usually occurs in athletes such as ballet dancers and may be seen in association with flexor hallucis longus tenosynovitis.
Medial Ankle Pain
Tarsal Tunnel Syndrome is the compression or squeezing on the posterior tibial nerve that produces symptoms of pain and numbness on the medial (inside) area of the ankle. When conservative methods fail, surgical treatment or tarsal tunnel release surgery may be needed. Posterior Tibial Tendon Tears are one of the leading causes of failing arches (flatfoot) in adults.
When the tendon is torn, the "Too Many Toes" exam may be performed. This exam requires the physician to look at the patient's foot from behind the heel. Normally only the 5th toe and part of the 4th toe are seen, but when a tendon is torn (flatfoot deformity) more are in the field of vision. Also, a torn tendon will result in loss of the medial arch height and pain on the medial ankle when weight bearing.
Global Ankle Pain
Global ankle pain can occur due to arthritis of the ankle joint. This commonly occurs as the result of a prior injury or inflammation to the ankle joint. It can usually be easily diagnosed with an examination and x-ray. Global ankle pain can also occur due to an osteochondral lesion of the talus. Arthroscopic debridement may be necessary in some situations.
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