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Chronic Ankle Pain

Chronic Ankle Pain

Unresolved, chronic ankle pain secondary to ankle inversion sprain is a commonly seen condition. Many mechanisms have been suggested as the reason for chronic ankle pain. These include

Lack of appropriate and early immobilisation in severe cases of ankle sprain.

Lack of appropriate stretching and strengthening exercises after an ankle sprain (in the acute phase) leading to development of scar tissue.

Continuing aggravation due to unrecognised or untreated biomechanics.

Too much immobilisation. Immobilising the ankle after the acute phase can lead to degeneration of the tissues surrounding the ankle.

Chronic ankle pain anatomy

The ankle joint is made up of three bones. The bones are called the tibia, fibula, and talus. These bones form a socket in which the ankle joint moves.

The tibia, fibula and talus are connected to each other by ligaments. Think of ligaments as thick rubber bands that hold bones together so that joints are stable and function properly. When an ankle is sprained, a ligament is stretched, partially torn or completely torn. Muscle and tendon structures surround the ligaments. These structures provide motion of the ankle joint for walking and running. Blood vessels, nerves and skin overlie the ligaments and tendons. The ankle joint moves the foot upward and downward. Just below the ankle joint is a ball and socket type joint that allows inward and outward motion. This is called the subtalar joint.

Symptoms

The symptoms of chronic ankle instability are feelings of the joint giving way, swelling, pain, decreased range of motion or excessive motion, and recurring sprains. The pain is usually chronic or recurrent. The symptoms will usually feel at their worst in the few hours just after exercise.

Chronic ankle pain the healing process explained

Ligament injuries anywhere in the body can be much more serious than muscle injuries. Muscles have a tremendous blood supply and can heal quickly. Even if the muscle injury does not completely heal, the only symptom that you would notice would be weakness in the muscle. With some exercise, even that symptom would resolve. This is not the case with ligaments.

chronic ankleLigament injuries are different because most of them do not totally heal Even if the pain resolves, the ligament will not be as strong as it was prior to the injury. Since ligaments stabilise the joints, by definition ligament injury produces a loose joint. If the ligament never heals, chronic joint looseness or instability results.

Studies on injured ligaments show that at least one year is required before healing has been completed or the total amount of healing occurs.

Injured ligaments do not entirely regenerate. Rather, they repair with scar tissue. Repair and regeneration begin at 48 hours to 72 hours post-injury, and continue maximally for six weeks. From six weeks to 12 months the ligament tissue remodels, contracts, and gains tensile strength. After 12 months the ligament and scar tissue generally matures and achieves 70 to 90 percent strength of the original ligament. On average, ligaments only heal to 70 to 90 percent strength when they are injured.

Treatment

IF SYMPTOMS PERSISTS OR NUMBNESS/ DISCOLOURATION OF THE FOOT OCCURS CONSULT A MEDICAL PROFESSIONAL IMMEDIATELY.

Bracing- Chronic ankle ligaments are at risk of rupture when inflamed. Supporting the area with an ankle brace will give the ligaments time to REST. These braces are designed to be worn under clothing and with normal footwear. On the left is the brace that our clinicians recommend. This can be worn continually in the initial phase of injury (to be taken off at night). Then once symptoms have subsided it can be worn during exercise and sporting activity to provide support to the damaged ankle ligament. This support was worn by Andy Murray tennis star when he hurt his ankle at Wimbledon in 2008.

chronic ankle pain restoring normal tendon function

chronic ankle pain strengthening exercises

Prevention

Remember that virtually all chronic ankle pain problems happen at the contact phase of gait (when the foot hits the ground) due to increased biomechanical stress at this point. It is therefore vital to strengthen the ankle and control biomechanical forces

Golden rule- Don’t ignore the problem, it won’t go away!

The way we function biomechanically is predominantly controlled by genetics, its hereditary (runs in the family). The way you function is set and cannot be cured. What you can do however is control lower limb biomechanics by altering foot position during the contact phase of gait. This can be achieved by wearing a good shoe (see our shoe guide) with orthotics  (foot beds), ankle strengthening and ankle support.

asics1. Check your footwear

Are your running shoes worn and in need of replacing? If so change them. Chronic ankle pain is made worse by high impact forces so a good shock absorbing shoe is a must. For more advice on running trainers our running shoe advice page is worth reading. Read more->

Below are a selection of trainers that are ideal for athletes.

Trainers for a neutral or under pronating foot type

Trainers for over pronators

2. rectify Poor biomechanics with orthotics

The way your foot strikes the ground and the forces that are placed on it can have a direct effect on causing chronic ankle pain and can also delaying healing times. Check our biomechanics page for detailed information. Read more->

 

3. Ankle strengthening

wobble

The single best exercise to improve the strength of the muscles around the ankle is eccentric loading. This is usually done none weight bearing, however the use of a wobbleboard is an excellent way to strengthen muscles around the foot and ankle in a controlled gentle manner. Whilst our clinicians have found it a brilliant way to strengthen ankle muscles, traditionally a wobbleboard was used to help balance (proprioception). Proprioception is the nerve connection from the brain to the foot. This is usually found to be very poor in patients with chronic ankle pain. This is often damaged/ disrupted after injury and can increase the chances of injury from re occurring It can also significantly delay recovery.

Use of a wobbleboard therefore has a dual benefit in the treatment of chronic ankle pain.

4. Ankle support

Usually an athlete who has damaged their ankle only needs minimal support post injury, such as the support given by a neoprene brace. However it is our view that with chronic ankle pain, something more substantial should be worn when partaking in sporting activity. We recommend the air cast ankle support as it allows the patient to wear normal shoes/ running trainers and it can be worn when exercising.

chronic ankle pain prevention checklist summary

  • Rectify Biomechanics if necessary
  • Check Running shoes
  • Ankle strengthening
  • Ankle support
  • Bracing

Returning to Activity

The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your chronic ankle injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your ankle recovers, not by how many days or weeks it has been since your injury occurred.

You may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true:

You have full range of motion in the injured leg compared to the uninjured leg.

You have full strength of the injured leg compared to the uninjured leg.

You can jog straight ahead without pain or limping.

You can sprint straight ahead without pain or limping.

You can do 45-degree cuts, first at half-speed, then at full-speed.

You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.

You can do 90-degree cuts, first at half-speed, then at full-speed.

You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.

You can jump on both legs without pain and you can jump on the injured leg without pain.

Think you require treatment for your biomechanical problems?

Visit our Sports podiatry clinic directory pages for a clinic near you.