Read about common sports injuries of the ankle. If your problem is not covered or if you have any questions then contact me for some answers.
There are ligaments on the outside of the ankle (us doctors call these ‘the lateral ligament complex’), and on the inside of the ankle (referred to as ‘the medial ligament complex’). It’s quite common to roll your ankle and tear one of these lateral ligaments. The important thing to know about this is that it usually settles down with the right treatment, without the need for surgery or anything special.
Sprained lateral ligaments do benefit from wearing a brace for a period of about six weeks and definitely benefit from physiotherapy to rebuild your strength and balance. Rarely people don’t make a full recovery and end up needing an operation.
Injuries to the medial ligaments on the inside of the ankle (the Deltoid ligament) are less common and again usually settle using a brace. It’s actually a bit more common to break the ankle than to badly tear the ligament on the medial side of the ankle.
In either case, it is better to get it looked at early on. I will listen carefully to your story, then carry out a gentle examination to work out what is wrong. Sometimes we need an X-ray to make sure there is no fracture, and sometimes an MRI scan to assess the damage to the ligaments.
There is a less common type of ankle sprain called a high ankle sprain (or syndesmosis injury). It involves damage to the ligaments between the tibia and fibula. This gives pain a bit above the ankle and it is quite commonly missed by less experienced doctors or by Accident and Emergency. Unfortunately, it can have really bad consequences if it is not treated properly (with surgery). This is why it is well worth getting any ankle sprain looked at by a good sports specialist.
Cartilage surface injuries in the ankle
The insides of all of our joints are lined with slippery shiny smooth articular cartilage. With a bad ankle sprain, you can scuff off a piece of this cartilage leaving a bare hole and a loose fragment. The ankle joint is particularly prone to this. It can leave you with a lot of pain and swelling, sometimes some clicking or catching, or maybe even the sensation of something loose in the ankle. A bit like going for a walk with a stone in your shoe it can be a bad idea having a loose piece floating around in the ankle and often you would need keyhole surgery to remove it and to try to grow new cartilage to cover over the hole.
Tendon problems / Achilles tendinitis
There are many tendons around the ankle that can cause problems, the most common is the Achilles tendon at the back, but also the ones on the outside (the peroneal tendons), and those that run on the inside of the ankle (called tibialis posterior). These typically get inflamed with a condition that us doctors called tendinopathy.
All inflamed tendons can initially be treated with ‘activity modification’ (changing what you do), physiotherapy and strengthening, but there is also a really good, modern, non-invasive treatment called shockwave therapy. This works brilliantly if it is used early on and can also be very useful on stubborn cases which won’t get better with physiotherapy alone.
Steroid injections around tendons are not such a good idea unless everything else has been tried and it is really rare to need surgery. If injections are needed, then there are better things to use than steroids such as hyaluronic acid and platelet-rich plasma.
For the Achilles tendon, in particular, there are some common patterns to the problems people experience. Typically the pain is at its worst for the first few steps of each day as the Achilles tendon is stretched out and you’re actually making tiny little tears in it. The same is true if you’ve been sat down in a chair for a while or after a long car journey. Often once you are warmed up the tendon is not so bad but every time you rest and then start up again you have problems. I have had all of this myself! It is no fun…
For the Achilles tendon, there are some really good exercises that can help called the Swedish eccentric loading exercises. If these aren’t helping after a few weeks then you should certainly try and get shockwave therapy.
This is a less common condition which can mimic Achilles tendonitis. There is pain right at the back of the heel bone often where it rubs in the shoe. It can be so severe as to stop you doing sport and stop you running. When it’s really bad it will make you limp. People often confuse it with ordinary Achilles tendonitis but actually this is a little inflamed bag of fluid where the Achilles tendon rubs over the heel bone. I see this problem in sportspeople but also in more sedentary people who have just done a bit more walking than normal.
It’s usually quite easy to establish the diagnosis by carefully listening to the problems which you are experiencing and then gently examining the foot. We sometimes confirm the diagnosis with a scan to make sure we are treating the right thing.
If it really is retrocalcaneal bursitis then an injection can be a real help, but sometimes there is a certain type of heel bone shape that makes this more common and we call this Haglund’s deformity. In this condition, there is a prominent corner of bone digging into the Achilles tendon and causing the inflammation and the inflamed bursa. If nothing else works then with Haglund’s deformity surgery can be brilliant.
The ankle joint is quite prone to pinching pieces of soft tissue which causes pain at the extremes of movement. This can either be at the front of the ankle (we call this anterior ankle impingement), or at the back of the ankle (which is called posterior ankle impingement). These problems give sharp pains at the extremes of movement and can be apparent going up or downstairs, with kicking or with jumping and landing. You will often have a background dull ache too. It can be quite hard to find the sore sport yourself, but it is usually quite easy to find when I examine you and listen to your story.
Impingent type problems are one of the things that do respond well to steroid injections and often this, coupled with physiotherapy, can be enough to break a sort of vicious cycle and solve the problem for good. Sometimes keyhole surgery is needed.
Frequently asked questions
Sorry, but in the NHS I run the knee service, but not other things. I can refer you to the foot and ankle team in the NHS and this can save a lot of waiting.
Until I have seen you it's hard to know if you will need a scan and certainly a lot of people don't. Also sometimes an X-ray or an ultrasound is better. Sometimes the problem is so obvious to me that no tests are needed. For this reason, I usually suggest I see you first to work out what the best sort of tests will be (if any).