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Patient Guide to Ankle Pain and Tendinitis (Tendonitis)

Ankle pain and tendinitis facts

  • The ankle is a “hinged” joint.
  • Ankle pain can be caused by injury or disease of the ankle joint.
  • The severity of ankle sprains ranges from mild (which can resolve within 24 hours) to severe (which can require surgical repair).
  • Tendinitis of the ankle can be caused by trauma or inflammatory arthritis.

The Anatomy of Ankle:

The ankle is a “hinged” joint capable of moving the foot in two primary directions: away from the body (plantar flexion) and toward the body (dorsiflexion). It is formed by the meeting of three bones. The end of the shinbone of the leg (tibia) and a small bone in the leg (fibula) meet a large bone in the foot, called the talus, to form the ankle. The end of the shinbone (tibia) forms the inner portion of the ankle, while the end of the fibula forms the outer portion of the ankle. The hard, bony knobs on each side of the ankle are called the malleoli. These provide stability to the ankle joints, which function as weight-bearing joints for the body during standing and walking.

Ligaments on each side of the ankle also provide stability by tightly strapping the outside of the ankle (lateral malleolus) with the lateral collateral ligaments and the inner portion of the ankle (medial malleolus) with the medial collateral ligaments. The ankle joint is surrounded by a fibrous joint capsule. Tendons that attach the large muscles of the leg to the foot wrap around the ankle both from the front and behind. The large tendon (Achilles tendon) of the calf muscle passes behind the ankle and attaches at the back of the heel. A large tendon of the leg muscle (posterior tibial tendon) passes behind the medial malleolus. The peroneal tendon passes behind the lateral malleolus to attach into the foot.

The normal ankle has the ability to move the foot, from the neutral right-angle position to approximately 45 degrees of plantar flexion and to approximately 20 degrees of dorsiflexion. The powerful muscles that move the ankle are located in the front and back portions of the leg. These muscles contract and relax during walking.

Ankle sprains are one of the most common musculoskeletal injuries. Sprains are injuries to the ligaments of the ankle, causing them to partially or completely tear as a result of sudden stretching. They can occur on either or both of the inner and outer portions of the ankle joint. Ankle sprains more commonly happen when there is a preexisting muscle weakness in the ankle area or a history of previous ankle injuries. The typical injury occurs when the ankle is suddenly “twisted” in a sports activity or by stepping off an uneven surface. The pain is initially severe and can be associated with a “popping” sensation. Immediate swelling over the area of injury often occurs as the injured blood vessels leak fluid into the local tissue. Examination of the area may cause severe pain when the ankle is moved. The degree of pain may not necessarily indicate the degree of damage to the ligament(s). Ligament injuries are often graded from I to III, ranging from partial to complete tears. Partial tears retain some ankle stability, whereas complete tears lose stability because the strapping ligaments no longer brace the ankle joint. After an examination, significant ankle sprains are commonly evaluated with an X-ray. X-rays can determine whether there is an accompanying break (fracture) of the bone.

Acute ankle sprains are initially treated with ice, rest, and limiting the amount of walking and weight-bearing on the injured ankle. The leg can be elevated to reduce swelling, and crutches are often recommended to avoid further trauma to the injured ligaments. Anti-inflammatory medications can be given to reduce local inflammation. Ice packs help decrease further swelling of the area and can reduce pain. Patients with severe injuries are placed in immobilization casts. Surgical repair of grade III injuries is considered, especially for those patients contemplating future athletic participation. Physical therapy programs are part of the rehabilitation process, incorporating strengthening exercises of the lower leg muscles. Broken ankles (fractures) can accompany ankle sprains or occur without sprains. Fractures are repaired with casting to immobilize the bone for healing. Depending on the severity, fractures can require orthopedic casting, surgical procedures including pinning, and open repair of the fractured bone.

Tendinitis

Tendinitis (also referred to as tendonitis) is an inflammation of the tendon. Tendinitis of the ankle can involve the Achilles tendon, the posterior tibial tendon, or the peroneal tendon. This condition usually results from trauma, such as from sudden injury in sports or overuse injury as from running but can result from underlying inflammatory diseases or illnesses such as reactive arthritis (formerly called Reiter’s syndrome), rheumatoid arthritis, and ankylosing spondylitis. All forms of tendinitis cause pain, swelling, and tenderness in the tendon area involved. The onset may be rapid, such as with an athletic injury. Immediate treatment of tendinitis involves immobilizing the area, elevation, and limiting weight-bearing, applying ice, and using nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease inflammation. NSAIDs are commonly used for this purpose. More severe inflammation can require orthopedic casting. Athletic participation should be limited when the tendon is still inflamed, as there is a significant risk of rupturing or tearing the tendon, especially in the Achilles area, with continued athletic activity. Achilles tendon more frequently occurs in patients who have had previous Achilles tendon inflammation. When the Achilles tendon ruptures, it usually requires orthopedic surgical repair.

 

Picture of the metatarsal (foot) and calcaneus (heel) bones, the plantar fascia ligament, and the Achilles tendon of the lower leg and foot

What diseases and conditions can cause ankle pain, and how are they treated?

Inflammatory types of arthritis (inflammation of the joint) that can involve the ankle area include rheumatoid arthritis, reactive arthritis, gouty arthritis, ankylosing spondylitis, and psoriatic arthritis, among others. They generally are not induced by trauma injury and often develop gradually. A thorough evaluation by a doctor with blood testing can be necessary for ultimate diagnosis. These types of arthritis are associated with pain, swelling, stiffness, redness, and warmth in the involved area. These diseases each have unique management as described elsewhere.

Other conditions of the ankle which can cause ankle pain include tarsal tunnel syndrome. This is a result of nerve compression at the ankle as the nerve passes under the normal supportive band surrounding the ankle called the flexor retinaculum. Tarsal tunnel syndrome is described elsewhere.

Infections of the ankle joint are rare. They most commonly occur as a result of bacteria being introduced into the ankle joint through puncture wounds or trauma. They also occur with a breakdown of the skin over the ankle as a result of ulcerations or abrasions. Patients with impaired immune systems such as those with AIDS, or other immune diseases, are at an increased risk of infections in the joints, including the ankle. Also, patients with diabetes or those who take cortisone medications have an increased risk for bacterial infections of the joints. Bacterial joint infections are serious and require drainage and antibiotics, usually intravenously.

It is possible to develop viral infections of the ankle joints. In an isolated joint, such as the ankle, this most commonly occurs in children and is referred to as “toxic synovitis.” It results in temporary joint inflammation and can be first noticed as subtle limping in the child. It is benign and resolves on its own with only symptomatic treatment, such as acetaminophen(Tylenol), for relief of pain.

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Achilles Tendon Pain

Achilles tendon pain occurs when there is an irritation or an inflammation of the Achilles tendon. The Achilles tendon joins the heel of the foot to the calve muscles. It is the largest tendon in the body, and is thick enough to support the entire body weight. Any rupture (small or big), inflammation, or injury to it causes pain while walking or running, as the tendon has to bear nearly eight times an individual’s body weight during a sprint or a run.

Causes of Achilles Tendon Pain
There are numerous reasons why Achilles tendon can inflame. A common cause is the advancing age, where it becomes less flexible, and more susceptible to injury. It can also be caused due to excessive shearing and stretching forces placed on the Achilles tendon, resulting in inflammation and tightening of the calf muscles.

Footwear contributes heavily to tendon irritation. Ill fitting shoes or high heels force the feet to be confined in less space, shortening the Achilles tendon, leading to an increased tension to the Achilles tendon. Shoes that have excessive heel cushioning for greater shock absorption, stretch the tendon, as absorption of shock sinks the shoe more frequently when the heel makes contact with the ground. Mechanical abnormalities and misalignment such as misshapen foot or heel bones, unequal leg length, short or tight Achilles tendons or calf muscles, weak calf muscles, all lead to placing excessive stress on the tendon, making it prone to injuries and pain. Athletes who increase their training duration with more powerful movements during exercises also experience Achilles tendonitis.

Symptoms of Achilles Tendon Pain
The most common symptoms associated with Achilles tendon is the searing heel pain experienced over the back of the heel. This occurs because the tendon gets pushed on the heel bone. It causes tenderness around the tendon and in some extreme cases there is an occurrence of a localized nodule filled with a small sack of fluid on the tendon. For most people suffering with Achilles tendon pain, walking during early mornings, or a long period of inactivity is the most painful time. A sudden sprint, or a jumping activity also results in a lot of pain. A slight swelling around the heels and sometimes around the calf muscles are also an exhibited symptom of Achilles tendon pain.

Prevention and Treatment of Achilles Tendon Pain
Preventing the condition of the Achilles tendon pain is simple. Avoiding any activity that places stress on the tendon is the simplest preventive measure. Treatment includes therapy as well as medications. A therapeutic approach includes rest and immobilization. Together, it will help reduce the swelling and inflammation on the tendon. To reduce swelling and increase the flow of blood around the tendon, one can apply an ice pack several times a day. Avoid giving heat treatment, and wearing thick warm socks (unless medically recommended). Heel relaxing products such as arch supports, heel cups, etc. inserted into the shoes, are used to minimize the stress on the Achilles tendon. Many physical therapists recommend stretching and rehabilitation program to increase the flexibility of the Achilles tendon. Medications mostly include non-steroidal anti-inflammatory medications along with painkillers, or in severe cases cortisone injections are administered.

Achilles tendon pain is a very painful condition, which can hamper the course of a normal life. A constant painful tendon leads to rupture, and in extreme cases an individual is rendered immobile for days. Prevention can help many avert the condition of painful Achilles tendon.

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