Chronic Ankle Pain
Sharese M. White, MD
LCDR MC USN
Thank you’s for some slides:
• Kevin deWeber, MD, FAAFP, FACSM
• AAOS Instructional Course Lecture
– JBJS Volume 92-A, Number 10, August 18, 2010
Anatomy
Anatomy
Anatomy
Anatomy
Anatomy
ANKLE JOINT ROM
• Dorsiflexion
• Plantarflexion
• Exam – check both
active and passive
SUBTALAR JOINT:
Inversion and Eversion
ROM: Inversion/Eversion
Anterior Drawer Test (ATFL)
Talar Tilt - ATFL/CFL
Syndesmosis
Injury
Squeeze Test
External Rotation Test
Ankle Radiographs
AP
Lateral
Mortise
Lateral Ankle Sprains
• Inversion injuries
• Graded 1-3
– 1: no ligament laxity
– 2: slight laxity
– 3: complete ligament rupture
• ATFL first  CFL second  PTFL last
• ATFL 3rd-deg: + Anterior Drawer
• ATFL & CFL 3rd-degr: + AntDrawer & Talar Tilt
Chronic Pain after Ankle Sprain/Injury
Inadequate Rehab
Instability
Talar Dome OCD
Peroneal Tendon Injury
Anterior Impingement
PTT dysfunction
FHL tendonitis
Sinus Tarsi Syndrome
Osteoarthritis
Tarsal Tunnel
Occult Fracture
CRPS
Achilles tendonitis
Where is the pain?
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Anterior
Lateral
Posterior
Medial
Anterior Ankle Pain
• Anterior ankle
impingement
– osseous or soft tissue
• Osteophyte
• Synovial tissue
• Ligamentous tissue
– “walking uphill”
– Painful limited passive
dorsiflexion
– Tx – small heel lift, NSAIDs,
ice, PT
– Surgery for refractory cases
Anterior Ankle Pain
• Osteochondral talar
lesions
– Anterior pain
– effusion
• Acute – anterolateral
– fractures
• Chronic – posteromedial
– Recurrent ankle sprains
• Treatment – depends on
stage
– STRONGLY RECOMMEND
ORTHOPEDIC
CONSULTATION
Anterior Ankle Pain
• Nerve entrapment
• Deep peroneal nerve
– Branches into medial motor
and lateral sensory branch
1cm proximal to joint line
• Compressed by extensor
retinaculum and EHB
• Tx:
– Steroid injection around
nerve
– Surgical release
Lateral Ankle Pain
• Chronic instability
– Usually painless unless
underlying lesion
• OCD, peroneal tendon,
loose bodies, etc.
• Tx – physical therapy,
proprioceptive training
• Surgery for refractive
cases
Lateral Ankle Pain
• Peroneal tendon injury
– Tears
– Subluxation
– Peroneus quartus
• 20% of population
• Increased risk of synovitis
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Retromalleolar pain
Look for hindfoot varus
Eversion testing
Tx – cast; surgery
Lateral Ankle Pain
• Sinus Tarsi Syndrome
• Diagnosis of exclusion
– Injection relieves pain
• X-rays are normal
• MRI – nonspecific
inflammation
• Tx
– Steroid injection (US
guided best)
– operative debridement
Lateral Ankle Pain
• Occult fractures
– Lateral talar process
• Eversion moment on
dorsiflexed axially loaded
foot
– Anterior calcaneal process
• Inversion of plantarflexed
ankle
• Tx – depends on size of
fragment
– Surgery for fragment >1 cm
and >2 mm displacement
Posterior Ankle Pain
• Posterior ankle impingement
– Enlarged posterolateral talar
tubercle – Steida process
– Os trigonum
• Repeated plantarflexion
• Tx – immobilization followed
by physical therapy
• Surgery for refractory cases
– excision of os trigonum
– decompression of posterior
talar process
Posterior Ankle Pain
• Achilles tendinitis
– Paratenonitis
– Noninsertional tendinosis
– Insertional tendinosis and
retrocalcaneal bursitis
• Shoe wear, activity
• Tx
– Acute paratenonitis: relative rest
– Midsubstance tendinopathy:
eccentric rehab 3-6 mos
• ? Dextrose prolotherapy
– Insertional tendinopathy: nothing
works very well
• surgery after six months of
conservative management
• NO STEROID INJECTIONS!!!
Medial Ankle Pain
• Tarsal Tunnel Syndrome
• Symptomatic entrapment of
tibial nerve within the tunnel
– Rule out space occupying
lesion
• Paresthesias on percussion
(Tinel’s)
• Dorsiflexion and eversion
(Phalen’s)
• Tx
– Conservative: orthotics, steroid
injection (US-guided)
– Surgery for refractory cases
Medial Ankle Pain
• Posterior Tibial Tendon
Dysfunction
• Begins with inflammation,
ends with dysfunction
– “too many toes” sign
– Single leg heel rise - fails
• Tx – conservative (3
months)– boot/Arizona
brace/cast
• Surgery for refractory cases
• NO STEROID INJECTIONS
Posteromedial Ankle Pain
• Flexor Hallucis Longus
Tendonitis
• Pain w/ passive toe motion
• Cause: Repetitive push-off
activities
• Tx – rest/activity
modification
• Surgery for refractive cases
• NO STEROID INJECTIONS!!!
Review Time!
• Question Text:
A 36 year old female recreational soccer player presents with
insidious onset of left posterior heel pain and a limp. She is wearing
flip flops because shoes make the pain worse. Examination reveals
swelling and erythema of the posterior heel. There is no palpable
defect in the Achilles tendon and a Thompson test is negative. The
most likely diagnosis is:
Possible Answers:
A. Stress fracture of the calcaneus
B. Plantar fasciitis
C. Achilles tendon avulsion
D. Sural neuritis
E. Retrocalcaneal bursitis
Review Time!
•
Correct Answer: E
Critique:
Retrocalcaneal bursitis (also called Haglund’s syndrome) is associated with overuse and
presents with pain behind the calcaneus. Examination reveals swelling and erythema of the
posterior heel. A prominence, called a “pump bump” may be noticeable. Retrocalcaneal
bursitis is associated with pain and tenderness anterior to the Achilles tendon, along the
medial and lateral aspects of the posterior calcaneus. Plantar flexion of the foot and/or
squeezing the bursa from side to side reproduces the patient’s complaint.A stress fracture of
the calcaneus produces mid-calcaneal bony tenderness and occurs with acute overuse. The
symptoms of plantar fasciitis include tenderness and pain underneath (plantar surface),
rather than behind the heel. A pop is generally heard and felt along with a palpable defect in
the tendon and a positive Thompson test with an Achilles tendon avulsion injury. Sural
neuritis is rare and the result of direct trauma. A positive percussion sign over the nerve
lateral to the Achilles tendon is diagnostic of sural neuritis.
References:
1. Snider, R. K. (1997). Essentials of musculoskeletal care. USA: American Academy of
Orthopaedic Surgeons.
More Review Time!
• Question Text:
• A 22 year old dancer presents to clinic with pain over the posterior
aspect of her ankle. On exam she is tender to palpation over the
posteromedial ankle.
• Provocative testing with compression over the posteromedial ankle
with dorsiflexion of the great toe reproduces the pain. What is the
most likely diagnosis?
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• Possible Answers:
• A. Flexor hallucis longus synovitis
• B. Os trigonum syndrome
• C. Hallux rigidus
• D. Posterior tibial tendonitis
• E. Peroneal tendonitis
Even MORE Review Time!
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Correct Answer: A
Critique:
Tenosynovitis of the flexor hallucis longus (FHL) is most commonly descried in classical ballet
dancers. It is the hyperflexed position of the ankle that causes
compression of the tendon as it passes posterior to the subtalar joint complex. This most
commonly presents as pain in the posterior medial ankle. On physical
exam there is tenderness to palpation over the musculotendonous junction of the FHL. Pain can
also by elicited by forced dorsiflexion of the ankle and first MTP
joint simultaneously. Conservative treatment includes rest, anti-inflammatories, and physical
therapy modalities. This should include specific FHL stretching
exercises. In cases of recalcitrant pain, surgical decompression is warranted.
References: 1. Michelson J, Dunn L. Tenosynovitis of the flexor hallucis longus: a clinical study of the
spectrum of presentation and treatement. Foot Ankle Int,
2005;26(4):291-303.
2. Gould N. Stenosing tenosynovitisof teh flexor hallucis longus tendon at the great toe. Foot Ankle,
1981;2:46-48.
3. Hedrick, W; Mcryde, A. Posterior ankle impingement. Foot Ankle Int,1994;15:2-8