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Chronic Ankle Injuries (Inside)
Name My Pain
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Post – traumatic synovitis
After any ankle injury there is bleeding in to the joint, which can cause the joint to become inflamed, this generally resolves within a day or so, however it becomes a problem and becomes synovitis when the athlete returns to weight bearing activities too quickly following an injury, or returns to sport too early before the injury has heeled and the joint continues to fill with blood and become inflamed and painful.
It presents as a constant persistent pain and swelling a number of weeks after an ankle injury.
It can also be common when an athlete has chronic ankle instability.

Tibialis posterior tendinopathy
Generally can occur as a result of one of two major causes, either overuse through over pronantion ( where the foot rolls in too much and becomes flattened) due to excessive running and jumping,or due to rolling an ankle outwards,damaging the inside of the ankle.
It presents as ankle pain on the inside and just below the ankle bone. There may be crepitus (cracking orgrinding sound) with movement, and it may be difficult to do a single leg heel raise. Swelling is unusual.

Tendinopathy’s result from overuse of the muscle and the tendon that attaches that muscle to the bone. When the tendon is overused it sustains small microscopic tears. In order for the body to repair these tears it creates inflammation, and that inflammation can cause pain, stiffness and swelling.
These types of injuries typically are ignored at first. As the pain initially decreases with warming up, and then is not present during activity. But the discomfort returns when the athlete cools down. If not addressed this process continues and worsens the condition, so that pain becomes more present during activity, and worsening more after finishing, until ultimately there is constant pain, and limitations to all activity.

Resisted inversion, resisting turning the foot inwards is the best test to determine whether this is your particular injury.

Ankle Ankle
Foot in neutral as starting position. Foot inverted, turn foot inwards.
Ankle
With foot inverted (turninwards), resist the movement with your hand, and this will reproduce pain.


Flexor hallucis longus tendinopathy
This commonly occurs in ballet dancers, when they have to rise up on to the toes from a flat foot.
It is also common in the athlete that has been wearing shoes that are too big, and as a result they have been gripping the shoe by flexing the toe.
Pain in toe off in walking or running (‘toe off’ is generally the last part of the step and the toe is the last thing to leave the ground before you swing the leg through the air).

Tendinopathy’s result from overuse of the muscle and the tendon that attaches that muscle to the bone. When the tendon is overused it sustains small microscopic tears. In order for the body to repair these tears it creates inflammation, and that inflammation can cause pain, stiffness and swelling.
These types of injuries typically are ignored at first. As the pain initially decreases with warming up, and then is not present during activity. But the discomfort returns when the athlete cools down. If not addressed this process continues and worsens the condition, so that pain becomes more present during activity, and worsening more after finishing, until ultimately there is constant pain, and limitations to all activity.

The test below of resisted flexion of the first toe (big toe), with the toe on stretch helps to diagnose this injury.

Ankle Ankle
Starting Position. Resisted Toe flexion,with toe in extension. Use finger to resist flexing the big toe back under the foot. With this resistance there will be pain reproduced in the big toe. Continuing tobnd the toe back under the foot with the resistance of your finger will reproduce pain under the big toe.
Ankle
Further bending of the toe under the resistance will continue to reproduce pain under the foot.

 

Stress fracture of the medial maleolus
Presents with pain on the inside of the foot on the ankle bone. The pain classically worsens with activity, and can limit the athletes ability to continue exercising.
Tenderness to direct palpation on the inside ankle bone with possible associated warmth over the fracture site.

Stress fractures are overuse injuries and occur when the body, and that particular bone are placed under an excessive constant load. The body’s defenses to deal with this are to take away old bone (osteoclasts) and lay down new bone (osteoblasts). However under the constant load the body is unable to keep up with the demands and an imbalance forms and ultimately a bone weakness, and hence a stress fracture.
Traditionally stress fractures are only sore after exercise and activity, and noticed generally for the first time after the athlete has cooled down, however if not addressed the fracture can worsen and the pain become more constant during exercise and ultimately limiting activity and performance.

X-ray, and a MRI are the best way to diagnose this condition.

Sinus tarsi syndrome
This injury can occur either as a chronic overuse type injury where there is a biomechanical deficiency, but more commonly results from an acute rolled ankle, or a repetitively/recurrent rolled ankle due to loose ankle ligaments.
Pain is poorly localised, but most commonly described on the outside of the front of the foot. Where pain is more severe in the morning and decreases as the person warms the leg up, with activity or exercise.
Patient can also report pain on running a curve with affected leg on the inside, and a difficulty walking on uneven surfaces.
Often goes unnoticed and gets misdiagnosed as a straight forward ankle strain but continues to swell and be painful for a number of weeks afterwards.
The tests below of forced passive eversion, or forced passive inversion are the best diagnostic tests and if they reproduce pain, then they indicate this injury. Fig 29a,29b

Ankle
Forced passive eversion,hand pulls foot outwards, while foot is relaxed this will reproduce pain on the outside f the ankle. Forced passive inversion,hand pulls foot inwards, while foot is relaxed, this will also reproduce pain at the front of the ankle on the outside.
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