Many people suffer from ankle pain, achilles pain and calf pain. Our osteopaths work in our specialist rehabilitation clinic for Cambridge pained patients with pain management treatment and dynamic exercise rehabilitation therapy, for ankle pain and ankle control, and other lower limb pain conditions, including achilles tendon and calf conditions. Working with a vast range of physical capabilities, allowing us to have very positive contact with such pain symptom sufferers. This is why we provide some of the most effective Cambridge Sports Injury Treatments.
In fact, ankle pain (including calve muscle pain, tendinopathy, lower leg pain, ligament sprain, or similar pain syndromes and muscle strain) are currently common musculoskeletal disorders, and the burden is most likely underestimated, and poorly understood. The ‘physical and personal impact’ of musculoskeletal illnesses are believed to generate some of the highest costs to society. Ankle pain and ankle mobility seems to have large effects on daily activities, disability levels and quality of life.
Chronic ankle instability (CAI) serves as a conduit to a significant global healthcare burden.
This risk of ankle pain and achilles pain including lower extremity tendinopathy is a common sports injury, however it ‘can also affect non-athletes’. Having an effect on people’s ability to work and their quality of life.
For most ankle and calf pain suffers, the most cost effective therapy options include exercise therapy and manual therapies, to improve physical function and performance. Additionally, preventative interventions are important and a suggested focus.
Some of the most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of ankle pain, with or without ‘swelling’ (filling of the ankle joint and capsule or fluid around the joint area) are:-
Functional ankle instability, ‘functional chronic ankle instability’, structural ankle instability, ‘medial calcaneal nerve entrapment’, calcaneal stress fracture, ‘tarsal tunnel syndrome’, tarsal stress fracture, medial malleolar stress fracture, ‘posterior impingement syndrome’, ‘referred pain from the lumbar spine’, ‘complications of acute ankle injuries’, ‘complex regional pain syndrome type 1’, ‘ankle injury’, flexor halluces longus tendinopathy, medial ankle pain, lateral ankle pain, ‘sinus tarsi syndrome’, peroneal tendinopathy, ‘anterolateral impingement syndrome’, ‘posterior impingement syndrome’, recurrent subluxation / dislocation of peroneal tendons, stress fracture of the talus, referred pain, stress fracture of distal fibula, ‘cuboid syndrome’, anterior ankle pain, anterior impingement of the ankle, anterior inferior tibiofibular ligament (AITFL) injury, tibialis anterior tendinopathy, tibialis posterior tendinopathy, ankle subluxation, collateral ligament sprain, deltoid ligament sprain, strain, motor control imbalances, tendonitis, ligament sprain, muscle strains, muscle spasms, ankle tendinopathy, Achilles tendinopathy, over use syndromes, degeneration, arthritis, cartilage injury, ‘inflammation’, ‘wear-and-tear Injuries’, tendon ruptures, ‘wear and tear’, Achilles strain, peroneal longitudinal tear, mechanical ankle pain, ankle stiffness, ankle swelling, ‘talocrural joint restriction’, bursitis, capsular laxity, ‘chondral damage’, ‘calf injury’, ‘tendinitis’ (tendonitis), leg strain, trigger points, trapped nerves, ‘nerve entrapment’, ‘sprains and strains’, osteoarthritis, ‘arthritis of the ankle‘.….The list goes on!
The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!
How This May Affect People
So, what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, stretch the ankle?, or no stretching of the ankle?, use medication management?, topical or oral?, use massage?, use mobilisation?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, surgery?, should we focus on structure or function?, or is it just age?!!!
I visited Michael following a recommendation from a friend. My previous osteopath had ‘maintained’ the problems with my lower back. Michael’s approach is not only to relieve discomfort, but to work on weak areas and improve muscle tone and flexibility. We have made steady progress and I am now able to undertake fairly strenuous walks e.g. in the Lake District and still be mobile and pain-free at the end of them. He is patient and always explains why we are doing particular exercises and ensures that I am doing them correctly. Michael’s approach is holistic. We have discussed other areas of my health and he has suggested complementary supplements to improve these.
Our knowledge and understanding of the body, and mechanical anatomy of the ankle, its associated structures and the muscles used for stability and injury prevention, are still being updated and evolving. Allowing for constantly changing assessments, treatment and rehabilitation techniques.
Sometimes additional investigations are needed. However, for ‘non-specific ankle pain’, they are rarely needed as a primary input into your assessment and treatment.
Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms. New imaging approaches have developed, and our dependency on them has increased!
However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed.
In cases of traumatic ankle injury, or in cases of tearing of tissues around the ankle, it is important to seek swift assessment to ensure correct diagnosis and management. There are clearly developed criteria of what form of ankle assessment is required following injury.
Magnetic resonance imaging is advantageous for assessing soft tissue structures around the ankle and foot, such as tendons, ligaments, nerves, masses and occult osseus lesions.
‘Mild to moderate ankle sprains typically have a full recovery in 7 to 15 days. Symptoms persisting beyond this period should prompt re-evaluation. All symptoms should be resolved before return to sports’.
Females and individuals who participate in court and team sports are more prone to ankle sprains. Ankle sprains may also increase the risk of subsequent ankle injuries.
In cases of ankle trauma (post traumatic ankle pain) Magnetic Resonance Imaging (MRI) can assist with triaging and specific tissue trauma findings. Helping differentiate between what tissues are injured.
Ultrasound imaging can assist and is a valid measure of osteophyte length findings in patients with insertional Achilles tendinopathy. However, it does not help correlation with the severity of symptoms. Meaning there is no clear relationship between tendon pain and tendon pathology.
Ultrasound is ‘an excellent tool for imaging soft tissue abnormalities’. ‘US and MRI are two complementary tools of investigation with the former being used as primary effective tool of investigation and the latter is done to confirm the diagnosis.’
Runners often have achilles tendinopathy without pain and the amount of running years is linked. ‘When clinicians interpret ultrasound findings in male distance runners they should therefore consider running history’.
All the structures around the ankle work together, and can also affect each other. Therefore how they all work together is more important than the individual anatomical structure.
Retrocalcaneal bursitis has been shown to have increased pressure in the retrocalcaneal bursa, with Higher retrocalcaneal bursa pressure values in patients suffering from chronic retrocalcaneal bursitis.
Achilles tendinopathy is not characterised by increased pressure in the retorcalcaneal bursa. This testing has to be performed invasively, with the risk of further injury during and after this. Ultimately this information supports the hypothesis that retrocalcaneal bursa hypertension can perhaps lead to an ‘impingement lesion of the corresponding anterior Achilles tendon’.
Plantaris even in the absence of tendinopathic changes (tendinopathy) plays a role on mid portion achilles tendipathy. It’s ‘involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic’
Findings indicate that Achilles tendinopathy (AT) is a multifactorial musculoskeletal disorder, involving a complex interaction between structure, function, and pain. The relative contribution of each factor may vary between individuals. Results of the included studies appears to suggest that future research should investigate the pathoaetiology, prediction and designing of interventions in AT from a multifactorial perspective.
MRI can be useful for certain conditions. However, at times the use could be misleading, It also can produce some findings that are not useful, and perhaps may be red herrings in the investigation. Image investigations show asymptomatic atheltes showed bone marrow edema lesions in more than half of the lesions, they fluctuated during the season. Suggesting that ‘the incidental finding of a bone marrow edema lesion on MRI of professional runners should not immediately be related to clinical complaints or lead to an altered training program.’
Additionally, MRI seems not able to help predict the change in symptoms, and therefore have no added value in providing a prognosis in daily clinical practice.
Leading to some suggesting, ‘let’s focus on the doughnut, instead of the hole’.
Physical assessment by a clinician is vital in all cases of ankle pain.
‘Strength measurement alone is insufficient to evaluate preoperative functional deficits, and other functional tests are required to measure postural stability’
Moderate foot pronation is not associated with increased injury risk among novice runners wearing a neutral running shoe. However, in experienced runners, who had some ‘pronation’ of the feet, there was some protection against injury.
What is the cause of this contrast is not clear. At this time and these prescription paradigms, we can assume this indicates and supports the current position that there is a lack of evidence of traditional shoe prescription preventing running related injuries.
Perhaps what is accepted is that a rapid change of shoes, and especially heel height, has been linked to tendon injuries.
A large proportion (one third) of new / novice runners, stop running in 6 months, often related to an running related injury, this stopping of running was more common in women with low perceived physical functioning and limited running experience.
Many people with ankle sprain continue to experience symptoms long after the initial injury.
Physical assessment tests alone, or along with correlation of BMI, can predict a risk of Lateral Ankle Sprain, and also reduced balance reach tests of distance, and increased BMI are at greater risk of any form of ankle sprain injury, in male athletes (No variables were associated with ankle sprain injury within female athletes).
Single-legged drop-jump landing, and the resultant horizontal ground-reaction force over 3 to 5 seconds has predictive value with regard to the occurrence of an ankle sprain.
Perhaps showing that there are more things at play than just singular local passive ankle range of motion alterations, being the course and effect of such conditions.
There are high rates of ankle sprain, lateral ankle sprains, and chronic ankle instability development, means a great need for adoption and implementation of effective prevention protocols and proven solutions for lateral ankle sprain prevention.
When ankle sprains do occur, managing ankle ligament sprains and tears, functional chronic ankle instability assessment can be outlined.
There is some evidence that ‘lower extremity tendinopathy was more prevalent among older patients’. Although, ‘no differences between tendinopathy patients and the general practice population were found regarding gender, use of medication, or comorbidity.’
Interestingly, the burden is a lot greater than previously understood for tendinopathy, and tendinopathy is even more common than osteoarthritis.
In children, lower extremity complaints are more common than upper extremity complaints. In the youngest children these are more ankle and foot complaints, and then in the older children knee complaints become more common.
There are twice as many non-traumatic lower extremity complaints than traumatic ones. Which can lead to there being ‘a large amount of non-traumatic low intensity complaints’ in the younger population, ‘that do not reach threshold for consultation’, meaning many do not get help to restore full normal function and performance.
For diagnosis purposes ankle range of motion can play an important role in determining ankle strength in young adults. Ankle dorsiflexion ROM can influence dynamic balance, specifically the anterior reach portion of the SEBT.
The results supported that balance performance worsens among the elders who do not engage in physical training.
Ultramarathon runners and endurance sports have very sport specific and sport common injury types.
Repetitive physical stresses, cause musculoskeletal injuries, such as stress fractures, which should be investigated in all ultra-endurance athletes who experience such pain. Peritendinitis of the extensor tendons at the extensor retinaculum of their anterior ankle (‘ultramarathoner’s ankle’) is a unique injury to the highly athletic sport. Along with medial tibial stress syndrome (MTSS), and chronic exercise induced compartment syndrome (CECS).
There maybe a genetic correlation to tendenopathy.
With all forms of investigation and assessment of a problem, it is worth taking on board that a clinician really should also take into account all the other areas which could be effected.
Those with post Achilles tendon rupture, Achilles tendon rupture several years earlier, ‘exhibit asymmetrical knee and ankle kinetics and loading rates’, which ‘may be a compensation pattern for reduced plantar flexor function. This movement pattern may place individuals who have had an Achilles tendon rupture at greater risk for knee injuries.’
Chronic Ankle Instability
Deficits in postural control are associated with Chronic ankle instability (CAI). In cases of Chronic ankle instability, ‘spatiotemporal postural control deficts were found in individuals with CAI on both limbs’.
Indicating that there may be more to a chronic ankle instability than local tissue changes.
Bone stress fractures are more common in women.
Does This Apply To You?
All Athletes and all relatively inactive people, could be affected by ankle trauma and non-traumatic ankle pain.
This risk of ankle pain and achilles pain including lower extremity tendinopathy is a common sports injury, however, it ‘can also affect non-athletes’. Having an effect on people’s ability to work, move as they desire, physically express themselves, perform, and their general quality of life.
What Can Help
For lower extremity injury, ‘Prevention of injury remains an important goal for clinicians and researchers’.
Kinesio taping does not seem to decrease swelling in acute, lateral ankle sprain of athletes. The trial authors concluded… ‘The application of Kinesio Taping, with the aim of stimulating the lymphatic system, is ineffective in decreasing acute swelling after an ankle sprain in athletes.’
Fibular taping does not largely influence ankle range of motion, or balance, and the ‘results suggest that the benefits of fibular taping are not related to an increase in ankle dorsiflexion ROM or dynamic balance.’
This fits with similar overviews that have found… ‘kinesiology tape may offer short-term reduction in pain but does not appear to provide long-term pain relief’, and they go on highlight that ‘Pain-reducing effects of kinesiology tape may not be large enough to be significant to patients’
Perhaps even more importantly, taping of the foot and ankle ‘produces an input overload that impairs proprioception in those who originally performed well when no-taping’ was applied.
In fact, ankle braces such as soft shell and semi rigid versions, seem to negatively affect quadriceps muscle use, alter gastrocnemius lateral activity in jumping, and negatively impacts jump height.
Ankle braces maybe at times cost effective for initial care, and introduction of functional methods in the right cases, at the right time. Perhaps assessment is important to assist the best timing of each treatment method.
Stretching and Foam Roller Use
Foam roller on calf no effect post exercise. Additionally, stretching has no effect on Delayed Onset Muscle Soreness (DOMS) after exercise.
Stretching has no positive effect on the prevention or treatment of contracture.
Should we stretch tendinopathy?. There may be no positive effect on the risk of injury, and more importantly, in asymptomatic tendons, prophylactic eccentric training and stretching, increased the injury risk.
Chronic Ankle Instability
Orthotics for ankle instability seems to have some detrimental affects on motor control. The authors state that ‘Foot orthoses alter feedforward motor control strategies during walking’.
In cases of chronic ankle instability management, options of clinical care are becoming more clarified.
With chronic lateral ankle sprain, treatment conservatively, with neuromuscular training is advised. Neuro-muscular training programmes, provide short term improvement in functional stability.
Other methods such as ‘special cycle pedal assessments’ were found not to make an important difference to function.
After surgical reconstruction, early functional rehabilitation enabled patients to return to work and sports quicker than six weeks immobilisation.
Achilles tendinopathy and associated structures conservative management and rehabilitation protocols are evolving.
In cases of plantaris involved mid-portion achilles tendonopathy, which maybe load resistant. ‘Initial treatment should consist of a modified loading programme avoiding end-range loading.’
In the early stages of rehabilitation, it is now clear that eccentric exercises should not be the first method of intervention of such cases of tendinopathy.
In the later stages of rehabilitation of achilles tendonitis, ‘Eccentric loading may not be effective for all patients (athletes and non-athletes) affected by tendinopathy. It is possible that in athletes, eccentric work is an inadequate load on the muscle and tendon. A rehabilitation program aiming to increase tendon load tolerance must obviously include strength exercises, but should also add speed and energy storage and release.’
The protocol provided by a clinician should include ‘exercises designed to incorporate progressive load to the tendon: isometric work, strength, functional strength, speed and jumping exercises to adapt the tendon to the ability to store and release energy.’
In chronic midportion Achilles tendinopathy, with the right conservative treatment, tendon volume and tendon maximum cross-sectional area (CSA) were found to have decreased significantly after 24 weeks. Showing that even chronic tendinopathy, with the right focus, patience and commitment, positive changes can be made to symptoms.
Midportion Achilles tendinopathy sufferers who underwent pain-guided hopping intervention, found if they followed progression and activity advice, were generally able to implement hopping without adverse events, as a treatment for pain and improved function.
The addition of manual therapy in combination with eccentric exercise in the management of Achilles tendinopathy, has been evaluated. With the suggestion of manual therapy directed at local and remote sites, may enhance the rehabilitation of patients with achilles tendinopathy.
Achilles Tendon Tears and Ruptures
‘Delayed diagnosis is a primary cause of delayed treatment’, in cases where Achilles rupture was present and missed, or neglected in management for a period of time (At 4– 6 weeks), the positive news is that often after surgical repair, it can then be assisted with rehabilitation approaches to the point that ‘Patients can expect a functional return to preinjury levels’.
The protocol of weight bearing with bracing, manual therapy, progressive therapeutic exercises, dynamic exercise and cryotherapy, are advised.
Walking improved the balance and ankle reposition sense among the elderly. It can be used as an alternative form of training to promote balance and ankle proprioception. The results supported that balance performance worsens among the elders who do not engage in physical training.
In athletes even at late stage rehabilitation, were found to have persisting deficits in plantar-flexion and dorsiflexion, and inversion, following ankle sprain. Who despite meeting functional sports-specific goals, found weight-bearing plantar flexion range of motion (ROM) remained diminished, in comparison to the healthy leg. Making it clear that more needs to be understood by sports rehabilitation experts about ankle sprain physical rehabilitation.
Ultimately, for even just an acute lateral ankle ligament sprain, there are no clear prognosis factors for recovery at this time. Indicating a real need to look at all available options of conservative management, and as well as locally, as globally as required for a positive outcome.
Mobilization and manual therapy on sub-acute and chronic ankle injuries. helped Joint motion and pain and functional capacity with improved ankle dorsiflexion range of motion.
Whole Body Integration
Then we can start to look at more global motor patterns, and treatment plan.
Screening methods and clinical assessment can be used to effectively assess limitations in ranges of motion of the ankle. Assessment of ankle range of motion in dorsiflexion movements, can be assessed with an overhead squat, and forward arm squat.
‘Strength measurement alone is insufficient to evaluate preoperative functional deficits, and other functional tests are required to measure postural stability. The results of this study provide further evidence for a rehabilitation programme consisting of proprioceptive training as well as strengthening. The proprioceptive training must be an integral part of the rehabilitation programme in addition to strengthening exercise.’
Leg exercises are critical to brain and nervous system health. People who are unable to do load-bearing exercises — such as patients who are bed-ridden, or even astronauts on extended travel — not only lose muscle mass, but their body chemistry is altered at the cellular level and even their nervous system is adversely impacted,”
However, due to variability in some tests, it is not possible to ‘distinguish between pathological and non-pathological groups’ , which means there is still a real need for clinical competence, and interpretation of any tests and findings.
Poor postural control is most likely associated with an increased risk of sustaining an acute ankle sprain. Postural control is clearly impaired after acute lateral ankle sprains, with deficits identified in both the injured and uninjured limbs compared with controls.
Specific conditions may have different processes of sensory experience (different ways of interpreting pain) In tendinopathy of achilles, the modern concept of widespread pain states, does not apply, and tendons pain seems to be local , and related to loading of a tendon without significant features of central sensitisation.
The ankle works more than the knee for running or walking. Great demand on ‘ankle extensors may be a key biomechanical factor limiting our locomotor ability and influencing the way we locomote and adapt to accommodate compromised neuromuscular system function’.
Perhaps ankle issues left without improved function, could lead to knee issues developing.
The pain felt in the foot, maybe due to other areas, such as the ankle or Achilles tendon, creating ankle pain, that is then expressed / felt in the foot, through biomechanical strain, or neural interpretation.
Intrinsic foot muscle modifications are seen in patients with Achilles tendinopathy. The thickness of the foot muscles were increased and cross-sectional area was increased in individuals with mid-portion achilles tendinopathy.
In chronic non-insertional achilles tendinopathy, extrinsic foot muscles, such as tibialis anterior (TA) and peroneus muscles (PER) are reduced in size. The thickness of the tibialis anterior muscle is increased proportionally to the peroneus muscles.
Foot pain is associated with knee osteoarthritis. Foot and ankle issues may boost risk of clinical and radiographic knee Osteoarthritis.
Dynamic Exercise Therapy is very useful for ankle pain. This includes plantar flexion eccentric exercises, which can be good for achilles health. Eccentric exercise might affect Achilles tendinopathy and offers a novel mechanism by which the plantarflexor muscles may shield the Achilles tendon. As tendon adaption does not occur within timeframes associated with clinical improvements’, we may need to be aware that clinically we treat pain, and restoration of function. Even in chronic achilles tendinosis, and heavy load training.
The combination of eccentric and concentric movements may be as beneficial as eccentric movements alone. Helping muscle strength and endurance adaptations. And static isometric training load , may help to lay the ground work for these progressions. Progressively loading muscle tendon units, to promote recovery of full capacity tendon effective stimulus.
There are studies that link ankle control and ankle injuries, with altered gluteal muscular control.
Alternatively, there are also studies that show the other way around, they find that hip strength is a predictor of ankle sprains.
In chronic exertional compartment syndrome (CECS) , when walking or marching fast, increased demand on the anterior compartment musculature is seen. The ‘suppression of the walk-to-run stimulus during group marches may play a significant role in the development of chronic exertional compartment syndrome’
Indicating a possibility that adhering to normal biomechanically efficient global motor patterns, and there stimulus, maybe a method of preventing increased demand on singular areas of the body.
It seems the believed abnormal biomechanics of the ankle, during running movements (kinematics), may actually be incorrect. The kinematic differences were seen chiefly at the trunk and pelvis compared to asymptomatic cases. Additionally, these symptomatic cases are a little heavier in body weight than asymptomatic cases. Interestingly, no differences in tibialis anterior or gastrocnemius medialis muscle activity were seen.
Current running treatment packages for CECS do not focus on the actual pathological gait, as ‘no consistent differences were found at the ankle joint suggesting that current running re-education interventions which focus on adjusting ankle kinematics are not modifying pathological aspects of gait.’
Perhaps indicating that a focus on global pattern control of the trunk and pelvic posture and motion could be a useful application.
A session of respiratory muscle training reduced the activities of some ankle joint muscles. including tibialis anterior and peroneus longus, with resultant changes to the angle to reach peak activity in tibialis anterior and peroneus longus, in different phases of movement. The study concluded that ‘respiratory muscle training prevented excessive ankle joint muscle activity through stimulating local muscles’, ‘indicated an improved postural control and multisectional proprioception to maintain postural stability and stimulated the local muscles of the core area’.
This may show why whole body assessment and treatment, is reported anecdotally to be so effective in clinic.
These positive effects from manual therapy and exercise, may be due to the increasing body of evidence, that pain is a brain interpretation of data, and the local structure itself, cannot be consistently linked with pain or general function.
Additionally, manual therapy by an osteopath including the use mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs). Additionally, these are statistically safer than surgical intervention.
The point here is that there are many opinions and many solutions, to treating ankle pain (joint pain / achilles pain / ankle sprain pain / ligament pain / muscle pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.With all treatments, it’s important to get the diagnosis, advice, and treatment programme from people who are trained, skilled and prepared to aid your musculoskeletal needs, such as at our Cambridge Osteopathic and Physical Rehabilitation Clinic.
The guidelines for ‘ankle pain’, includes the guidance to when suitable remain as active as possible, seek support and advice at a specialist clinic, for, assessment, diagnosis, education, management advice, prevention of reoccurrences advice, early phase stabilisation and next stage manual therapy including mobilisation treatment, hydrotherapy application, increase in balance and muscle control (motor control training) and specialist exercise therapy for rehabilitation.
At Elementary Health, our Cambridge Osteopath Clinic, we provide a seamlessly layered combination approach, of diagnosis, education and therapeutic application. This includes education of anatomy and pain theories, manual therapy, osteopathy for ankle pain, posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!
If there are any other questions, or, you wish to book a consultation with Michael Parr the consulting osteopath in Cambridge, based at Elementary Health. Please don’t hesitate to call or email.