The ankle is the most commonly injured joint in sport. The most common ankle injury is a sprain of the lateral ligaments but there are other less common injuries that are easily missed that can cause more disability and time away from sport. Foot pain and injury is also common but the differential diagnosis is broad. The role of the midfoot is to allow the foot to adapt to uneven surfaces while standing and walking. The anatomy of the foot allows both mobility and stability but pain can arise if one of these features is compromised.
The ankle joint complex is made up of 3 interrelated joints. The joint between the two shin bones (tibiofibular joint), the joint between these two bones and the main ankle bone (talocrural joint) and the joint below this, between two of the tarsal bones (subtalar joint).
There are two main groups of ligaments on either side of the ankle joint. The lateral ligament on the outside of the ankle is actually 3 separate ligaments (ATFL, CFL, PTFL) and the medial ligament on the inside of the ankle is one big fan shaped ligament with separate parts (the deltoid ligament). There are also the syndesmosis ligaments, which run between the tibia and the fibula (the two shin bones) that can get injured in a “high ankle sprain”. Additional to these ligaments, there are many tendons and nerves running near the ankle joint that can get injured and cause pain.
The foot has 28 bones including 14 phalanges (toe bones), 5 metatarsals (forefoot bones), 7 tarsals (midfoot bones connecting the foot to the ankle) and 2 sesamoid bones (in the tendons under the big toe). Any of these bones can get fractured leading to pain and disability. There are also numerous ligaments between these bones that can get injured and many tendons and nerves of the foot that can be a source of pain and dysfunction.
The most common injury to the ankle is a “rolled ankle” which causes an ankle ligament sprain. If the ankle is rolled with the foot pointing in (most commonly) then a lateral ligament injury will occur. If the sole of the foot points outwards (usually when stepping off the side of a gutter or uneven surface accidently), then a medial ligament sprain will occur. The injury usually results in pain, swelling and tenderness in the area. It can be diagnosed clinically and x-ray is only indicated in some circumstances if there is tenderness along specific parts of the bones in the area or if the person can’t walk 4 steps after the injury or during the examination (Ottawa ankle rules).
Simple ankle sprains are usually managed well with physiotherapy and a comprehensive rehabilitation program. They should resolve in 4 to 6 weeks and any significant pain lasting longer than that despite adequate treatment could signal another injury that has been missed initially or indicate that a common complication of ankle joint injury such as synovitis or ankle impingement has occurred. For more information on ankle sprain see the ankle sprain topic in the football (soccer) injuries section.
Syndesmosis injury (high ankle sprain)
The syndesmosis is a fibrous joint formed between the two shin bones (the tibia and fibula). The syndesmosis ligaments are four ligaments at the bottom of the shin, just above the ankle joint. Their purpose is to provided stability to the ankle joint to stop the tibia and fibula from being wedged apart by the talus and the ligaments are under most tension in ankle dorsiflexion (flexed foot). The biggest risk of rupture is when the foot is externally rotated in this position. This commonly occurs during contact in sport when the foot is planted and the person is forced into a flexed and rotated position or when the player is on the ground and an opponent steps on their heel and forces it into rotation.
Syndesmosis injuries are much less common than lateral ankle sprains, only accounting for 5-10% of all ankle sprains. Males are three times more likely to have this injury and syndesmosis injuries are more likely to occur in high-level sport, particularly on artificial turf. They result is longer time away from sport than a lateral ankle sprain and need to be treated differently.
The pain of a syndesmosis injury is usually felt just above the ankle and ironically there is usually less swelling and bruising than a lateral ligament sprain. The athlete may be able to play through a mild injury but a severe injury may mean the player can’t walk off the field. Other injuries may occur at the same time and an x-ray may be needed to rule out an associated fracture.
Diagnosis of a syndesmosis injury is made using a combination of clinical examination and imaging. The management depends on the grade of the injury and if the ankle is stable or unstable. Grade 1 stable injures can be managed non-operatively with initial immobilisation in a boot followed by a comprehensive rehabilitation program. Grade 3 unstable injuries may need surgical management to regain stability and reduce the risk of chronic painful ankle disability. Return to sport can take anywhere from 2 to 10 weeks depending on the grade of injury and any other associated factors.
Achilles tendon injury
The Achilles is the largest tendon in the body. There are many tendons that can get injured or be a source of pain around the ankle but the most common is the Achilles. A quarter of athletes will experience pain in the Achilles in their athletic careers and this may be up to 50% in runners. The two main calf muscles, the soleus and gastrocnemius converge in the posterior leg to form the Achilles tendon. The Achilles can be injured acutely, with a sudden partial or full thickness rupture or the pain can gradually build up over time if too much load is applied to the tendon, which eventually leads to tendinopathy.
Achilles tendinopathy usually occurs when there is an abrupt increase in training volumes, such as a recreational runner who decides to train for a half or full marathon or when a previously sedentary person commences a new exercise. Tendon loads can be increased too quickly with change in speed, frequency or duration of training over a short period of time (see overload injuries for more details). There are two types of tendinopathies that affect the Achilles – one at the insertion onto the heel bone and one in the middle of the tendon. The Achilles may also be injured in an acute rupture. Only around 10% of people with an Achilles rupture report previous pain or injury in their Achilles. The classic case is a 40-year-old male who suddenly accelerates during a game of tennis or other change of direction sport. Rupture is 5-10 times more common in males. They may hear a pop and have immediate pain and walk with a limp. The injury usually occurs during take off not during landing.
Achilles ruptures can be managed surgically or non-operatively but surgical management reduces the risk of re-rupture. Return to sport is 3-6 months after injury if managed well. It is important to present as soon as possible after the injury for assessment and management as the tendon will shorten quickly after rupture and this can cause long-term disability if not treated correctly in the initial stages. Achilles tendinopathy is managed non-operatively with correction of any modifiable risk factors and load management. A comprehensive rehabilitation program is needed to ensure the tendon receives the optimal load to adapt favorably.
Fractures of the foot not to be missed
Repetitive loading to the bones of the foot with sudden increases in training speeds, frequency or duration coupled with poor biomechanics and weakness in the kinetic chain can lead to stress fractures of many different bones of the foot. The metatarsals are the most commonly affected bones and there are a few stress fractures that are important not to miss because they are prone to non-union and other complications. In particular, stress injuries to the navicular (see navicular stress fracture in the football (soccer) injuries section) and a type of stress fracture to the base of the 5th metatarsal can be difficult to treat. The second metatarsal at the end closest to the ankle (proximal) can also be the site of a stress fracture common to ballet dancers as well as runners when increased forces due to repetitive activities are applied to the bone in this area.
The base of the 5th metatarsal, on the outside of the foot, just below the ankle, can be injured in a lateral ligament sprain. Some fractures here are due to avulsion of the bone with the tendon that attaches here (peroneus brevis) due to it contracting forcefully after a rolled ankle to try to correct the foot position. Other fractures at this site, including one known as a Jones fracture and also a stress fracture of the bone a bit further towards the toes, can have problems with healing and other complications. These fractures need to be treated with non-weight-bearing and sometimes even surgery. It is important to distinguish between the different fractures at this site as they are treated very differently.
There are also some specific fractures that are easy to miss after an ankle sprain that can be the cause of ongoing pain and disability despite adequate treatment for the ligament injury. These include bony injuries to the talar dome (the part of the talus inside the ankle joint), fractures to two parts of the talus that stick out from the main bone known as the lateral and posterior processes of the talus and a fracture to the front part of the heel bone known as the anterior process of the calcaneus. These fractures can be picked up using a combination of clinical examination looking for specific points of tenderness in the foot as well as imaging to look for fractures in these locations. It’s important not to miss them, as they need specific management including a period of offloading in order to allow the bone to heal.
If you have sustained a foot or ankle injury that has resulted in significant pain or a limp, or you can no longer participate in your preferred activity due to pain, a consultation at Shire Sports Medicine can be beneficial for you to get an accurate diagnosis, to help guide management of your condition and to ensure the prevention of further complications.