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263x252The 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 20degrees 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.

Causes of Ankle Pain

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. Once you have suffered a sprained ankle, you are more susceptible to repetitive sprains if the sprain hasn’t completely healed because the joint has been weakened. If you suffer multiple sprains then the ligaments may be permanently weakened making repeat injuries much more common. You may experience chronic pain from the damaged ligaments when this happens.

Tendonitis is an inflammation of the tendon. Tendonitis of the ankle can involve the Achilles tendon, the Posterior Tibial Tendon, or the Peroneal Tendon. A tendon is a tough yet flexible band of fibrous tissue. The tendon is the structure in your body that connects your muscles to the bones. The skeletal muscles in your body are responsible for moving your bones, thus enabling you to walk, jump, lift, and move in many ways. When a muscle contracts it pulls on a bone to cause movements. The structure that transmits the force of the muscle contraction to the bone is called a tendon. Tendons come in many shapes and sizes. Some are very small, like the ones that cause movements of your fingers, and some are much larger, such as your Achilles tendon, in your heel.

When functioning normally, these tendons glide easily and smoothly as the muscle contracts. Sometimes the tendons become inflamed for a variety of reasons, and the action of pulling the muscle becomes irritating. If the normal smooth gliding motion of your tendon is impaired, the tendon will become inflamed and movement will become painful. This is called tendonitis and literally means inflammation of the tendon. Tendonitis is most often an overuse injury that can occur with activities like running, but can also result from trauma, such as from a sudden injury in sports.

Often people begin a new activity or exercise that causes the tendon to become irritated. Tendon problems are most common in the 40-60 year old age range. Tendons are not as elastic and forgiving as in younger individuals, yet bodies are still exerting with the same force. Tendonitis causes pain, swelling, and tenderness in the tendon area involved.

Arthritis causing ankle pain is much less common than degenerative changes in other joints. However, ankle cartilage can wear away and is often quite painful. Ankle arthritis is most commonly the result of a prior injury to the ankle

joint. In patients who sustain an injury such as an ankle fracture, the cartilage may be damaged and lead to accelerated arthritis. When fractures occur, often permanent surgical fixation with hardware is necessary, and inflammatory changes around these metal materials can also lead to chronic pain.

Inflammation of the ankle joint cartilage can also result from “wear and tear” from repetitive motions. Joint surfaces consist of bone covered with a smooth lining of cartilage. Cartilage is a smooth material that is found throughout your body, and it allows the joint to move freely. When one smooth cartilage surface glides against another, the amount of friction between the surfaces is five times less than the friction of ice gliding on ice! Individuals who suffer from osteoarthritis, the most common type of arthritis, experience a loss of this cartilage surface. As the cartilage is worn away, the bone becomes exposed, and the unprotected joint surfaces rub against each other. Also known as Degenerative Joint Disease, or Wear-and-Tear Arthritis, Osteoarthritis occurs more frequently in older populations, but can also affect younger individuals.

When arthritis occurs, signs of inflammation of the ankle joint, including heat, warmth, swelling, pain, tenderness, and decreased range of motion. Range of motion of the ankle is decreased with arthritis of the ankle because the swollen joint impedes the range of motion.

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.

“Traditional” Treatment Options

These different conditions in the ankle can be very difficult to completely eradicate. Even when incremental improvements are made, it is very easy to exacerbate the conditions and suffer major set backs. Traditionally, Rest, Physical Therapy, Steroid Injections Non-Steriodal Anti-inflammatory Drugs (NSAID’s) and Opiates have been the mainstay of treatment. And some of these can be very helpful–specifically rest and physical therapy can help and is always worth trying.

However, often your body is overwhelmed by the degree of accompanying inflammation or degeneration in the joint, and is not able to repair itself on its own.

The problem with some of these treatments (namely NSAID’s, Steroids, and Opiates) is that they often allow a quick return to the activities that caused the injury in the first place before the affected area is fully healed. This often leads to continued additional micro-trauma to the ligaments and tendons making it very difficult to ever achieve the permanent pain relief and improved function that patients seek.

Ankle surgeries are not as commonly performed as with other major joints in the body (for chronic conditions) because results are often less satisfactory than non-surgical methods, are associated with prolonged recovery periods, and potential complications.