Updated: Mar 2
The ankle joint is formed by the tibia and fibula bones of the leg and the talus bone of the foot. It is a hinge joint. The movements that occur at the true ankle joint are dorsiflexion (the toes move up towards the shin bone), and plantarflexion (the toes move away from the leg towards the floor). The sideways movement tends to occur between the talus and the calcaneum underneath. Inversion, an inwards turning of the foot and eversion, an outward turning of the foot are the sideways movements. These movements occur due to muscles acting at the ankle and other joints in the foot.
The main extensor muscles, or dorsiflexors, of the ankle and foot are tibialis anterior, extensor halluces longus and extensor digitorum longus. The main flexor muscles, or plantarflexors, are tibialis posterior, gastrocnemius, soleus and plantaris. Ankle inversion and eversion are produced by a combination of flexor and extensor muscles working on the ankle and foot.
The 2 main ligaments are the medial or deltoid ligament, on the inside of the ankle and the lateral ligament, on the outside of the ankle. They are made up of various smaller ligament parts which function to stabilise the ankle and resist too much turning out or in of the foot. The tibio-fibular ligament is a band of fibres that binds the tibia and fibula together.
The ankle joint has many proprioceptive receptor organs located in the surrounding capsule, tendons and ligaments. These are essential for the automatic protective reactions that provide good balance and normal function.
There are 26 bones in each foot (7 tarsal bones, 5 metatarsal bones and 14 phalanges). There are 6 joints between the tarsal bones and further joints between the tarsal and metatarsals; metatarsals and phalanges and in each phalanges, 1 further joint in the big toe or hallux and 2 joints in each of the other toes. There are 20 foot muscles which mainly contribute to inversion or eversion but also to plantarflexion and dorsiflexion. The muscles give the foot its shape, support and ability to move.
The main ligaments of the foot are the plantar fascia, plantar calcaneo-navicular ligament and calcaneo-cuboid ligament. The Achilles tendon connects the heel to the calf muscle and is essential for running, jumping and standing on tiptoes.
Common ankle and foot complaints and injuries
Fractures at the ankle occur as the result of a trauma, impact or twist and can involve one or more bones.
Stress fractures in the foot can occur where excessive and repetitive impact is placed on the foot. This can cause bone damage and tiny cracks can appear in the bone over a period of time. They are more commonly seen in the 2nd or 3rd metatarsal, base of the 5th metatarsal or navicular bone of the tarsus.
Ligaments are bands of tissue that provide stability to joints and prevent excess movement. Sprains occur when they are over stretched. They are graded 1-3. If ankle ligament sprains are left untreated, they can result in recurrent sprains which over time, may damage the joint and causedegenerative changes.
The most frequently occurring ligament injury at the ankle occurs when the foot is inverted or stretched inwards. This mechanism overstretches the lateral ligament and soft tissue on the outside of the ankle. The most commonly involved portion of the lateral ligament damaged is the anterior talo fibular ligament.
When the foot is stretched outwards (everted) damage can occur on the inside of the ankle, and involve the deltoid ligament- This ligament is very strong so rather than tearing with trauma, it may pull a small piece of bone away from the tibia- known as an avulsion fracture.
A high ankle sprain (syndesmosis) occurs when the interosseous ligament which runs between the tibia and fibula is damaged. The mechanism of injury in this instance is usually excessive dorsiflexion. These types of sprains are also classified 1-3 depending on the severity of the damage.
Lisfranc joint injury
This is damage to the ligament of the tarso metatarsal joint complex or fracture dislocation at this joint. It occurs where there is high energy trauma to the top of the foot.
Muscles can become strained or tore, this frequently occurs as a result of participation in sports, where the muscle becomes overloaded and consequently more likely to be injured usually through a sudden forced over stretch but can be the result of muscle fatigue. Strains are graded from grade 1 where a few fibres are torn, to a grade 3 with a complete rupture.
Symptoms vary between a cramp, tightness, pain on stretch or muscle contraction through to immediate stabbing/burning pain, bruising and swelling, difficulty weight bearing. The calf muscles are the most commonly affected muscle group.
The peroneal tendons run along the outside of the foot, one attaching to the 5th toe and the other passing under the foot and attaching to the inside arch. The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. These tendons along with the Achilles tend to be the most common sites of injury in the foot.
The Achilles is a thick, powerful tendon that attaches the two calf muscles to the bone in the heel. Overuse, trauma or excessive loading can cause damage. A tear or complete rupture can occur as a result of sudden trauma or following repeated, ongoing damage to the tendon.
Sever’s disease is an injury to the bone where the Achilles attaches; usually this occurs during activity and in children between the ages of 8 and 14 years.
This is pain in the front or ball of the foot. The area feels painful and can be inflamed. It may come on after activities such as jumping and running, or may be due to a foot deformity or poor fitting shoes or poor foot posture or muscle weakness. It may feel like there is a small stone stuck under the foot. It generally feels better when the foot has no weight on it and is rested and worse if walking barefoot or on a hard surface.
Osteoarthrosis, degenerative joint disease or wear and tear is a common cause of ankle problems. When a joint develops this, some of the cartilage covering the ends of the bones roughens and thins so the joint doesn’t move as smoothly as it should. All the tissues within the joint become more active than normal; your body is trying to heal itself. The bone underneath the cartilage can react by growing. Bony outgrowths are called osteophytes.
The symptoms of osteoarthritis can include: pain, stiffness, a grating or grinding sensation when the joint moves (crepitus), swelling (either hard or soft) and heat. You are at more risk of having OA if you are female, over 40, over weight, have had a previous injury or repetitive trauma and because of certain genetic factors.
Plantar fasciitis is one of the more common foot conditions that affect the population. It is an irritation of the fascial band that runs along the arch of the foot and causes pain in the heel. It is often associated with pain first thing in the morning and following periods of resting or inactivity.
Bursitis is an inflammation of a bursa. Bursae are small fluid filled sacs that help to reduce friction between tendons and bones. They can become inflamed, painful, swollen and warm due to a sudden injury eg fall or direct blow; from recurrent minor trauma; due to infection eg skin break or as part of Rheumatoid arthritis or Gout.
The most commonly affected bursa in the foot is the retro calcaneal bursa, with symptoms of swelling and tenderness at the back of the heel. It tends to be more painful when wearing shoes and during activity.
Gout is an inflammatory condition in which small crystals are deposited in the joints. It is most common in the big toe and the joint is often very painful with local redness, heat and swelling.
The main surgical procedures for the ankle or foot tend to be performed post fracture eg open reduction and internal fixation of the bones or surgical repair after an Achilles tendon rupture.
Other surgical procedures tend to be performed to alleviate the pain associated with OA and include ankle joint replacement where the joint is replaced in an attempt to reduce pain but maintain mobility or an arthrodesis (joint fusion) This is performed to reduce pain but mobility will be reduced.
Other common procedures include osteotomies where the bone is broken and then re-aligned. This is generally used to correct a deformity eg Bunion.
Your physiotherapist will access you and determine what the likely cause of your ankle or foot pain is. They may feel that additional investigations are necessary such as X-rays or scans and can contact your doctor to request these as appropriate. In some instances, your physiotherapist may suggest orthotics or insoles are appropriate. They may advise you directly on these or may feel a referral to a podiatrist would be more appropriate.
Your treatment programme will be tailored to you but is likely to include some of the following strategies.
Advice, strengthening, stretching and proprioception exercises, management strategies, orthotics, mobilisations- soft tissue and joint mobilisations, Acupuncture, shockwave therapy, PNF, taping.
If you would like to book an appointment or request further information, please contact your nearest clinic or click here.
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