The ankle joint is extremely important to walking and running. It acts as a hinge, which allows the leg (and body) to pass over the planted foot. A functional ankle therefore allows the body to move smoothly in a forward direction. Any disorder effecting its function will therefore necessitate the body to compensate in other ways to allow forward motion. This might mean walking on the ball of the foot, rotating the hips outwards, hyper-extending the knee or over working the subjacent joint (the sub-talar joint). In any case, the method of compensation can be very destructive to other parts of the body and can rapidly lead to pain elsewhere.
Anterior Ankle Pain (Pain on the Front):
Pain at the front of the ankle is commonly due to impingement of the joint’s capsule or the bones themselves. This might develop secondary to trauma (e.g. as a sequelae to an ankle fracture) or slowly over time as a consequence to wear and tear. Both instances can lead to osteo-arthritis of the ankle joint.
Posterior ankle pain (Pain on the Back):
Pain behind the ankle can be caused by impingement of the joint’s capsule or bones themselves. This is usually seen in sports where the foot and toes are required to be pointed (e.g. ballet dances and the front
foot of cricket bowlers). However, the most common cause of posterior ankle pain would be attributed to disorders of the Achilles tendon.
Medial Ankle Pain (Pain on the Inside): pain on the inside of the ankle usually involves pathology of the supporting structures that prevent the foot and ankle from rolling too far inwards. Structures such as the deltoid ligament and tendons passing by the ankle are frequently affected. These soft tissues can be acutely damaged (e.g. due to an ankle sprain) or worn out if they are over-worked (e.g. tendinopathy).
Lateral Ankle Pain (Pain on the Outside): pain on the outside of the ankle can occur when the foot and ankle are rolled too far outwards or too far inwards. In acute cases, the lateral ligaments are commonly sprained when the ankle rolls outwards. This happens a lot during sports and the ensuring pain can sometimes linger for many weeks. Painful tendons are also a result of a high arched foot, which tends to roll outwards and chronically strains the tendons that act to resist this movement. Conversely, pain can result from a foot that tends to roll inwards (over pronates). In this instance, soft tissues on the outside of the ankle joint become impinged.
With so many possible sources of ankle pain, there are just as many treatments. However, regardless of the nature of the pain the guiding principles are the same.
Irritated tissues need to be offloaded to allow them to recover. Once a podiatrist has determined what forces are acting on the affected tissue then an appropriate intervention can be employed. In the case of anterior ankle pain, techniques and exercises to increase the ability for the ankle to dorsiflex (movement of the foot toward the shin) are important. This might include mobilization by the therapist or through prescribed exercises and calf stretches. Posterior ankle pain due to impingement is best managed with a period of rest and modifying the sports person’s technique to stop recurrence, however in certain cases surgery may be required. Posterior ankle pain involving the Achilles tendon involves stretching, strengthening and modifying load on the tendon by way of a heel raise in the shoe, occasionally an orthosis (shoe insert) and better management of training loads (in sports people). Finally, medial and lateral ankle pain are most readily treated by better positioning of the rearfoot. This usually involves the prescription and supply of orthoses. The exception being acute ankle sprains, which after a short period of rest, ice, compression and elevation, respond best to gentle movement exercises, strengthening and balance exercises to reduce the likelihood of future sprains.