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Achilles Tendon Pain

What is the Achilles tendon?

The Achilles tendon connects the calf muscle to the heel bone. It lets you rise up on your toes and push off when you walk or run.

What are common Achilles tendon problems?

The two main problems found in the Achilles tendon are:

  • Achilles tendinopathy. Achilles tendinopathy includes one of two conditions:
    • Tendinitis. This actually means “inflammation of the tendon,” but inflammation is rarely the cause of tendon pain.
    • Tendinosis. This refers to tiny tears (microtears) in the tissue in and around the tendon caused by overuse. In most cases Achilles tendon pain is the result of tendinosis, not tendinitis. Some experts now use the term tendinopathy to include both inflammation and microtears. But many doctors may still use the term tendinitis to describe a tendon injury.
  • Achilles tendon tear or rupture. An Achilles tendon also can partially tear orcompletely tear (rupture) camera. A partial tear may cause mild or no symptoms. But a complete rupture causes pain and sudden loss of strength and movement.

Problems with the Achilles tendon may seem to happen suddenly. But usually they are the result of many tiny tears to the tendon that have happened over time.

What causes Achilles tendon problems?

Achilles tendon problems are most often caused by overuse or repeated movements. These movements can happen during sports, work, or other activities. For example, if you do a lot of pushing off or stop-and-go motions when you play sports, you can get microtears in the tendon. Microtears can also happen with a change in how long, hard, or often you exercise. Microtears in the tendon may not be able to heal quickly or completely.

Being out of shape or not warming up before exercising may also cause Achilles tendon problems. So can shoes with poor arch supports or rigid heels.

An Achilles rupture is most often caused by a sudden, forceful motion that stresses the calf muscle. This can happen during an intense athletic activity or even during simple running or jumping. Middle-aged adults are especially likely to get this kind of injury.

A rupture most often occurs in sports such as basketball, racquet sports (including tennis), soccer, and softball. A tendon already weakened by overstretching, inflammation, or small tears is more likely to rupture.

What are the symptoms?

Symptoms of Achilles tendon problems include swelling in the ankle area and mild or severe pain. The pain may come on gradually or may only occur when you walk or run. You may have less strength and range of movement in the ankle.

A rupture of the Achilles tendon may cause a sudden, sharp pain. Most people feel or hear a pop at the same time. Swelling and bruising may occur, and you may not be able to point your foot down or stand on your toes.

How are Achilles tendon problems diagnosed?

Your doctor can tell if you have an Achilles tendon problem by asking questions about your past health and checking the back of your leg for pain and swelling. The doctor may ask: How much pain do you have? How did your injury happen? Have you had other injuries in the ankle area?

If your symptoms are severe or do not improve with treatment, your doctor may want you to get an X-ray, ultrasound scan, or MRI.

How are they treated?

Treatment for mild Achilles tendon problems includes rest, over-the-counter pain medicine, and stretching exercises. You may need to wear well-cushioned shoes and change the way you play sports so that you reduce stress on the tendon. Early treatment works best and can prevent more injury.

Even in mild cases, it can take weeks to months of rest for the tendon to repair itself. It’s important to be patient and not return too soon to sports and activities that stress the tendon.

Treatment for severe problems, such as a torn or ruptured tendon, may include surgery or a cast, splint, brace, walking boot, or other device that keeps the lower leg from moving. Exercise, either in physical therapy or in a rehab program, can help the lower leg get strong and flexible again. The tendon will take weeks to months to heal.

Although treatment for Achilles tendon problems takes time, it usually works. Most people can return to sports and other activities.

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Know More About GOUT

Gout causes attacks of pain and swelling in one or more joints. An anti-inflammatory painkiller usually eases an attack quickly. Lifestyle factors may reduce the risk of having gout attacks. These include losing weight (if overweight), eating a healthy diet, and not drinking much alcohol or sugar-sweetened soft drinks. If gout attacks recur, then taking vitamin C supplements and/or allopurinol each day can prevent them.

Gout causes attacks of painful inflammation in one or more joints. It is a type of arthritis (although it is very different to the more common rheumatoid arthritis and osteoarthritis). The pain of a gout attack can be severe.

Gout is caused by a chemical in the blood called uric acid (urate). Uric acid is usually harmless and is made in the body. Most is passed out with the urine and some from the gut with the stools (faeces). In people with gout the amount of uric acid in the blood builds up. From time to time the level may become too high and tiny grit-like crystals of uric acid may form. The crystals typically collect in a joint. The crystals irritate the tissues in the joint to cause inflammation, swelling and pain – a gout attack.

Note: some people have a high level of uric acid but do not form crystals or have gout. Also, rarely, some people with a normal level of uric acid have gout attacks. However, as a rule, the higher the level of uric acid, the greater the chance of developing gout.

Why does uric acid build up?

Normally, there is a fine balance between the amount of uric acid (urate) that you make and the amount that you pass out in the urine and faeces. This keeps the level of uric acid in the blood in check. However, in most people with gout, their kidneys do not pass out enough uric acid and the blood level may rise. They are said to be under-excreters of uric acid. Their kidneys usually work otherwise normally.

In some people, the build-up of uric acid may due to other factors. For example:

  • Drinking too much alcohol can cause uric acid to build up.
  • If you do not have enough vitamin C in your diet.
  • If you drink sugar-sweetened soft drinks high in fructose it can cause uric acid to build up. A recent research study found that having two drinks a day of a sugar-sweetened soft drink increased the risk of developing gout by 85%. (Drinks labelled as ‘diet’ or drinks containing artificial sweeteners were not found to increase the risk.) Fructose-rich fruits and fruit juices may also increase the risk.
  • Certain foods may ‘tip the balance’ to raise your uric acid higher than normal. In particular, eating a lot of heart, herring, sardines, yeast extracts, or mussels may increase the level of uric acid. However, eating a normal balanced diet should not have much effect on the uric acid level.
  • Some medicines may raise the level of uric acid. For example, ‘water’ tablets (diuretics) such as bendroflumethiazide, aspirin (at full painkiller dose – not low-dose aspirin used to prevent blood clots), and some chemotherapy medicines.
  • More uric acid is made than usual in illnesses where the cells of the body have a rapid turnover. For example, severe psoriasis and some blood disorders.
  • People with certain other conditions have an increased risk of developing gout. These include:
  • Obesity.
  • High blood pressure.
  • Kidney damage.
  • Diabetes mellitus.
  • Bone marrow disorders.
  • Lipid disorders (especially hypertriglyceridaemia).
  • Vascular disease.
  • Enzyme defects such as hypoxanthine guanine phosphoribosyltransferase (HGPRT) deficiency and glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Gout affects about 1 in 200 adults. Men are more commonly affected than women. A first attack of gout typically develops in middle age but it sometimes occurs in younger people. It tends to run in some families, as there is a family history of gout in about 1 in 5 cases. It may be that the genetic make-up that you inherit from your family may be a factor in becoming an under-excreter of uric acid (urate).

Gout usually occurs in attacks. An attack typically develops quickly over a few hours. It usually causes severe pain in one joint. The base of the big toe is the most commonly affected joint. Walking can be very painful and even the weight of bedclothes can hurt.

However, any joint can be affected. Sometimes two or more joints are affected. Affected joints usually swell and the nearby skin may look red and inflamed. If left untreated, a gout attack may last several days but usually goes completely within 7-10 days. Less severe attacks can occur which may be mistaken at first for other forms of arthritis. Weeks, months or even years may go by between attacks. Some people only ever have one attack.

A gout attack can be very painful. However, other effects from gout are uncommon. Joint damage may occur if you have recurring attacks. In a few people, uric acid crystals form kidney stones or may cause some kidney damage. Sometimes the crystals form bumps (tophi) under the skin. These are usually harmless and painless but sometimes form in awkward places such as at the end of fingers. Tophi occasionally become infected.

Gout is usually diagnosed if you have the typical gout symptoms and a raised blood level of uric acid. If there is doubt as to the cause of the pain and swelling, your doctor may take some fluid out of a swollen joint. This is done with a needle and syringe. The fluid is looked at under the microscope. Crystals of uric acid (urate) can be seen in the fluid to confirm the diagnosis of gout.

General measures

If you are able to, raise the affected limb (usually a leg) to help reduce the swelling. The easiest way to raise your leg is to recline on a sofa with your leg up on a cushion. An ice pack (or pack of frozen peas) held against the inflamed joint may ease the pain until the gout treatment medicines (below) start to work:

  • Wrap the ice pack (or peas) in a towel to avoid direct skin contact and ice burn.
  • Apply for about 20 minutes, and then stop. (It should not be applied for long periods.)
  • Repeat as often as required BUT make sure the temperature of the affected part has returned to normal before applying again.

Anti-inflammatory painkillers

A short course of an anti-inflammatory painkiller will quickly ease most gout attacks (within 12-24 hours). There are several types and brands, such as diclofenac,indometacin and naproxen. Your doctor will prescribe one. Many people with gout like to have a supply of tablets on standby in the home just in case an attack occurs. They are usually needed only for a few days until the inflammation and pain go.

Most people can take short courses of anti-inflammatory painkillers without any problem, although side-effects occur in some people:

  • Bleeding from the stomach is the most serious possible side-effect. This is more of a risk if you are aged over 65, or have had a duodenal or stomach ulcer. Stop the tablets and see a doctor if you develop indigestion, have upper tummy (abdominal) pain, pass black stools (black faeces), or if you are sick (vomit) or pass blood. Read the leaflet that comes with the tablets for a list of other possible side-effects.
  • Some people with asthma, high blood pressure, certain kidney problems and heart failure may not be able to take anti-inflammatory painkillers.
  • Some people taking certain other medicines should not take anti-inflammatory painkillers. This is because of a possible risk of the two medicines interacting. Therefore, check with your doctor or pharmacist if you are taking other medication, before taking anti-inflammatory painkillers.

Also, don’t take more than one anti-inflammatory painkiller at a time unless specified by a doctor. For example, some people take low-dose aspirin every day (which is classed as an anti-inflammatory medicine) to prevent blood clots. Aspirin plus another anti-inflammatory medicine increases the risk of bleeding from the stomach.

Therefore, if you are already taking aspirin and develop gout, you need to discuss the options with your doctor. For example, your doctor may advise that you take another medicine to ‘protect the stomach’ if you need to take aspirin and another anti-inflammatory medicine. Remember – some painkillers that you can buy from pharmacies contain aspirin.

Other treatments

Colchicine is an alternative medicine that eases gout attacks. It is usually only used if you have problems or side-effects with anti-inflammatory painkillers. Steroid tablets or injections can also reduce the pain and inflammation. They are another alternative if there are problems or side-effects with anti-inflammatory painkillers and colchicine.

Canakinumab is another option that has recently been introduced.

Lifestyle measures and medicines can help to prevent gout attacks.

Lifestyle suggestions

  • If you are overweight, try to lose some weight. This can help to lower the uric acid (urate) level. However, do not use diets that increase uric acid levels, such as high-protein diets or starvation diets.
  • Eat sensibly. A high uric acid level may be lowered a bit by avoiding a high protein intake and foods rich in purines, such as liver, kidneys and seafood. Also avoid eating foods high in yeast extracts, such as Marmite®. See separate Gout Diet Sheet for more details.
  • If you drink a lot of alcohol then it may help if you reduced the amount that you drink. You do not need to stop drinking alcohol altogether but cutting down may help if you drink a lot. In particular, avoid binge drinking. Keep to within the recommended levels of alcohol – these are 21 units per week for men and 14 units per week for women.
  • If you drink a lot of sugar-sweetened soft drinks, especially those containing fructose, it may help to reduce the number or cut them out all together.
  • If you are taking any medicines, check whether they are a cause of gout (see above). An alternative medicine may be available. Your doctor will advise.
  • Avoid lack of fluid in the body (dehydration) by drinking plenty of water (up to two litres per day unless there is a medical reason why not to).
  • Have your blood pressure checked at least once a year. High blood pressure is more common in people with gout.

With the help of lifestyle changes, many people only have an attack of gout every now and then. All you may need is to have some anti-inflammatory painkillers on standby to treat each attack.

For some people, attacks occur more often. In this situation, you can take a medicine to prevent attacks.

Allopurinol is used to prevent gout attacks

Allopurinol is a commonly used medicine to prevent gout attacks. Allopurinol does not have any effect during a gout attack and it is not a painkiller. It works by lowering the level of uric acid in the blood. It takes 2-3 months to become fully effective. You need to take it every day to keep the uric acid level normal to prevent gout attacks.

As a general rule, regular allopurinol may be advised by your doctor if you:

  • Have had two or more attacks of gout within a year.
  • Have one or more tophi (described above).
  • Have any joint or kidney damage due to gout.
  • Have one or more kidney stones made from uric acid.
  • Have had a gout attack and are taking long-term medication that can cause gout.

When you first take allopurinol, it can sometimes cause a gout attack. This is because it may cause the level of uric acid to rise slightly before it falls. For this reason it is not normally started during a gout attack. It is best to start it about 3-4 weeks after an attack has settled. Also, an anti-inflammatory painkiller is often prescribed for the first 2-3 months after you start allopurinol, just in case the allopurinol causes a gout attack. Once the level of uric acid has been brought down, taking allopurinol each day usually works well to prevent gout attacks.

The dose of allopurinol needed varies from person to person. Treatment is usually started with a low dose. A blood test is often done after a month or so to check that the level of uric acid has come down. If not, the dose may need to be increased. Most people end up taking about 100-300 mg each day to stop gout attacks.

If a gout attack occurs while you are taking allopurinol, you can still take an anti-inflammatory painkiller to relieve the pain. However, this may indicate that you need an increased dose of allopurinol. Side-effects are uncommon with allopurinol. Read the information that comes with the packet of tablets for details about possible side-effects. If side-effects do occur, other medicines with a similar action are sometimes prescribed. For example, a medicine called febuxostat may be an option if you cannot take allopurinol for medical reasons or due to side-effects.

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Achilles Tendonitis

Achilles tendinitis

Achilles tendinitis is when the tendon that connects the back of your leg to your heel becomes swollen and painful near the bottom of the foot. This tendon is called the Achilles tendon. It is used for walking, running, and jumping.

Causes

There are two large muscles in the calf. These muscles are important for walking. They create the power needed to push off with the foot or go up on the toes. The large Achilles tendon connects these muscles to the heel.

Heel pain is most often due to overuse of the foot. Rarely it is caused by an injury.

Tendinitis due to overuse is most common in younger people. It can occur in walkers, runners, or other athletes.

Achilles tendinitis may be more likely to occur if:

  • Suddenly increase the amount or intensity of an activity
  • Your calf muscles are very tight (not stretched out)
  • You run on hard surfaces such as concrete
  • You run too often
  • You jump a lot (such as when playing basketball)
  • You do not have shoes with proper support
  • Your foot suddenly turns in or out

Tendinitis from arthritis is more common in middle-aged and elderly people. A bone spur or growth may form in the back of the heel bone. This may irritate the Achilles tendon and cause pain and swelling.

Symptoms

Symptoms include pain in the heel and along the tendon when walking or running. The area may feel painful and stiff in the morning.

The tendon may be painful to touch or move. The area may be swollen and warm. You may have trouble standing up on one toe.

Exams and Tests

The doctor will perform a physical exam. The doctor will look for tenderness along the tendon and pain in the area of the tendon when you stand on your toes.

X-rays can help diagnose bone problems.

An MRI scan may be done if your doctor is thinking about surgery or is worried about the tear in the Achilles tendon.

Treatment

The main treatments for Achilles tendinitis do not involve surgery. It is important to remember that it may take at least 2 to 3 months for the pain to go away.

Try putting ice over the Achilles tendon for 15 to 20 minutes, two to three times per day. Remove the ice if the area gets numb.

Changes in activity may help manage the symptoms:

  • Decrease or stop any activity that causes you pain.
  • Run or walk on smoother and softer surfaces.
  • Switch to biking, swimming, or other activities that put less stress on the Achilles tendon.

Your health care provider or physical therapist can show you stretching exercises for the Achilles tendon.

They may also suggest the following changes in your footwear:

  • A brace or boot or cast to keep the heel and tendon still and allow the swelling to go down
  • Heel lifts placed in the shoe under the heel
  • Shoes that are softer in the areas over and under the heel cushion

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen can help with pain or swelling. Talk with your health care provider.

If these treatments do not improve symptoms, you may need surgery to remove inflamed tissue and abnormal areas of the tendon. Surgery also can be used to remove the bone spur that is irritating the tendon.

Extracorporeal shock wave therapy (ESWT) may be an alternative to surgery for people who have not responded to other treatments. This treatment uses low-dose sound waves.

Outlook (Prognosis)

Lifestyle changes usually help improve symptoms. However, symptoms may return if you do not limit activities that cause pain, or if you do not maintain the strength and flexibility of the tendon.

Possible Complications

Achilles tendinitis may make you more likely to have an Achilles rupture. This condition usually causes a sharp pain, like someone hit you in the back of the heel with a stick. Surgical repair is necessary, but difficult because the tendon is not normal.

When to Contact a Medical Professional

If you have pain in the heel around the Achilles tendon that is worse with activity, contact your health care provider for evaluation and possible treatment for tendinitis.

Prevention

Maintaining strength and flexibility in the muscles of the calf will help reduce the risk of tendinitis. Overusing a weak or tight Achilles tendon makes you more likely to develop tendinitis.

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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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About Ankle Injury

1: Is it possible for the ankle to wear out?

Yes. However, it is not easy for this to happen as the ankle cartilage is extremely resistant. There is usually a cause, like a previous severe fracture, recurrent sprains or an infection of the ankle joint.

2: Can I ignore a sprained ankle and allow it to heal on its own?

No. A typical ankle sprain is usually one where there is an isolated tear of the anterior talofibular ligament (ATFL).

The consequences are loss of strength in turning the ankle outwards and proprioception, or the sense of body position awareness.

Patients will find that their ankles are ‘clumsy’ and weak, even for weeks after the swelling has gone down. They tend to have recurrent sprains.

Strengthening and balance exercises are needed to regain ankle stability and prevent future sprains.

A sprained ankle can also comprise injuries apart from the ATFL tear – some of these can be serious and you will need to see a doctor to exclude these injuries.

3: Is Tui Na, a form of Chinese massage, an effective way of treating sprained ankles?

When we do deep massage over the torn ligament or manipulate the joint – like in Tui Na – we may increase the bleeding in the area and separate the torn edges further, reducing the chances of the ligament regaining its integrity.

In ankle sprains, we need to address the instability by doing active balance and strengthening exercises, since position awareness and strength are not derived from Tui Na.

4: If I have injured my ankle, what activities should I avoid and for how long?

First, it is best to have your ankle injury examined and treated. All sporting activities should be avoided until the injury heals.

Sprains: It depends if the injury is acute or chronic. If acute, it is best to rest, ice, compress and elevate the ankle before undergoing physiotherapy. For chronic sprains, physiotherapy is recommended.

If patients improve with physiotherapy, then they can gradually go back to doing sports.

If there is no improvement, surgical repair of the ligaments is recommended.

Fractures: Surgical treatment is usually recommended, followed by physiotherapy. It may take about six months to a year before you can resume sporting activities.

Ankle arthritis: Activity levels are dictated by the pain experienced by patients. If the pain is mild, they are advised to limit activities to low impact sports, like swimming or cycling.

However, if the pain is severe or bothersome, it is recommended that patients undergo surgery.

5: What if my ankle still hurts a month after I injured it?

Then it is unlikely to be a simple isolated ATFL tear and you need to see your doctor. Most isolated ATFL tears feel much better within two weeks.

6: I have injured my ankle more than once. What are the consequences?

Repeat injuries to the ankle typically leave it in poorer condition and predisposes it to arthritis.

It is therefore recommended that the ankle injury be diagnosed and given the appropriate treatment.

7: I have ankle arthritis. Can I go for ankle replacement surgery?

Ankle replacement is generally suited for ankle arthritis patients who are above 50, do not do heavy manual work and are not overweight. It is not for the active, the young and manual workers who lift heavy loads. The ankle prosthesis is an artificial joint and can wear out with heavy usage.

8: Do I need to take supplements for ankle health?

No. Glucosamines have been recommended for joint health. However, there is no evidence that it helps in the ankle joint.

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Ankle Instability and Ankle Sprains

The ankle works in a systematic way. Movement is only supposed to be in one plane, in other words, up and down. We call this dorsiflexion and plantarflexion. The ankle joint is held in place securely by a group of bones that house the main anklebone (called the talus) inside a box-like effect. On the inside is the medial malleolus and on the outside the fibula.

Front of the ankle.
M= medial malleolus, L=lateral malleolus (fibula). The outside of the heel is pushed inwards to stress the joint. In the normal ankle, no tilting of the ankle should occur at all. Note the tilting of the talus in the ankle.

The inward and outward movements of the back of the foot do not actually occur in the ankle joint but occur in the joint underneath it called the subtalar joint. The muscle that pulls the foot inward (inversion) is slightly stronger than the muscles that pull the foot outward (eversion). When the foot lands in an awkward manner there is a tendency for the heel to roll inwards and create stress on the outside ligaments. If this stress is severe then a sprain of the ankle occurs. A sprain is actually a tear that occurs in the outer supportive ligaments of the ankle. As these ligaments are stretched, a critical point is reached beyond which ligaments do not return to their normal elastic function and a tear of the ligament occurs. Sprains can range from the relatively minor to those where the ligaments are completely torn and the ankle can be quite loose.

The acute sprain of the ankle is commonly associated with marked swelling and bruising on the outer side of the ankle. Rest of the ankle with immobilization of some sort is critical. The classic treatment for a sprain of the ankle is what we refer to as the Rice Program. It involves rest, ice, compression and elevation. This treatment is designed to decrease the inflammation and swelling of the ankle associated with the sprain. The Rice Program by itself will not heal the ligaments. In order for the ligaments to heal the ankle needs to be immobilized with either a cast or a boot. For minor sprains a brace can be applied to the ankle. Walking is permitted during this recovery process, allowing the ankle ligaments to heal.

Following this period of initial immobilization, strengthening exercises are essential to regain the balance of the ankle. It is critical that the tendons and muscles on the outside of the ankle (the peroneal tendons) are strengthened. This should be done initially in a supervised exercise program. If the ligaments have been severely torn, the ability to fine tune the ankle and prevent further sprains from occurring depends on the strength of the peroneal muscles. As the ankle turns repeatedly, the peroneal muscles weaken further. This weakens the ability to prevent recurring sprains. Patients with a high arch or a heel that is naturally turned in slightly are predisposed to sprains.

As a result of continued rolling, turning or instability of the ankle, the ability to fine tune the foot on uneven surfaces becomes limited. The ability to make rapid changes in the position of the foot on the ground surface is called proprioception. If this ability is diminished, the likelihood of a more severe ankle sprain occurring is increased. In recurring ankle sprains we call this chronic recurrent instability of the ankle. The ankle is at risk of developing other problems. These include bruising of the cartilage of the talus and bone spurs that develop around the front and sides of the ankle. These are all precursors of ultimate arthritis of the ankle.

These pictures illustrate a patient with chronic ankle instability. Note how loose the ankle is when it is turned slightly inwards. The ligaments are completely torn in this ankle and the likelihood of recurring sprains is very high.

The diagnosis of chronic recurrent instability is made through a careful examination of the ankle and X-rays that are taken while stress is applied to the ankle.

Here are two X-ray’s of a patient with chronic recurrent instability of the ankle. In both the right and the left ankle, an assistant is pushing on the outside of the foot (in the direction of the white arrow) while the XR is taken. The XR on the left is normal, while the one on the right demonstrates a loose (unstable) ankle.

Once the diagnosis of the extent and severity of the ankle instability is made then a treatment plan can be initiated. A strengthening program is helpful before proceeding with surgery. This is true even with patients who have had recurring sprains and chronic recurrent instability.

Fortunately, surgical repair of the chronically loose ankle ligaments can be performed. There are many different techniques used to stabilize the ankle. Some rely upon repairing the ligaments themselves by tightening them up. Others depend more on using a tendon behind the ankle (the peroneal tendon) or a tendon graft to tighten up the ankle completely. These operations are usually very successful. Individuals are able to return to all forms of athletic activity without risk of recurrent injury to the ankle.

Read more about Ankle Sprain

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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.

Stop the Pain and get your Ankle checked today!  Call +65 6471 2744 for Appointment or Email to: info@boneclinic.com.sg