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4.24: Ankle Pain

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    There are a number of different things to take into consideration when assessing a patient with ankle pain.

    • One cause of ankle pain can be peroneal tendinopathy, which is described as persistent peroneal tendon pain and loss of function related to mechanical loading (Scott et al., 2020).
    • Another causes of ankle pain is a sprained ankle, there are three different types of ankle sprain all with varying severity:
      • Inversion (lateral) ankle sprain – The most common type of ankle sprain involving tearing of the ligaments on the outside of the ankle (anterior talofibular ligament).
      • Eversion (medial) ankle sprain – Involving a tear of the deltoid ligaments, on the inside of the ankle.
      • High (syndesmotic) ankle sprain – Injury to the tibiofibular ligament above the ankle.

    Pathophysiology

    The structure of the foot consists of 26 bones, 33 joints (20 of which are actively articulated), 4 layers of arch muscles, and 100+ muscles, tendons, and ligaments. Following an initial ankle injury there is a risk of re-injury dependent on a combination of factors including, but not limited to: sensorimotor deficits and changes in ankle biomechanics.

    Examination

    A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

    Outcomes Measurements

    Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

    • Self-Rated Recovery Question
    • Patient Specific Functional Scale
    • Brief Pain Inventory (BPI)
    • Visual Analog Scale (VAS)
    • Lower Extremity Functional Scale (LEFS)
    • Foot and Ankle Ability Measure
    • Foot and Ankle Disability Index

    Physical Examination

    Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

    • Talar Tilt Test
    • Anterior Drawer of the Ankle
    • Calcaneocuboid Stress Test
    • Calcaneofibular Stress Test
    • Talofibular Ligament Stress Test (Anterior & Posterior)
    • Deltoid Ligament Stress Test
    • Dorsiflexion External Rotation Stress Test (Kleiger’s Test)
    • THE SYNDESMOSIS SQUEEZE TEST
    • Tinel’s Sign

    Treatment

    Education

    Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

    Manual Therapy

    Massage therapists are uniquely suited to incorporate a number sensory-targeted rehabilitation strategies for patients with chronic ankle instability (Mckeon et al., 2016). This may include superficial peroneal nerve mobilization – the superficial peroneal nerve passes between peroneal muscles and the extensor digitorum longus. It then pierces the deep fascia and is divided in cutaneous nerves that enter the foot to innervate the dorsal surface (Plaza-Manzano et al., 2016). The specific movement to mobilize the superficial peroneal nerve involves plantar flexion with inversion combined with straight leg raise. Branches of the saphenous nerve also innervate the talocrural capsule.

    Structures to be Aware of When Treating Ankle Sprains

    A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from ankle pain may include neurovascular structures and investing fascia of:

    • Plantar Fascia
    • Lumbricals
    • Adductor Hallucis
    • Flexor Hallucis Brevis
    • Metatarsals & Interossei
    • Peroneals (peroneus longus, peroneus brevis)
    • Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius)
    • Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)
    • Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior, popliteus)
    • Ankle Joint (talocrural joint, subtalar joint and the inferior tibiofibular joint)

    Self-Management Strategies

    Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as stretching, strengthening and proprioceptive exercises may be useful for people with ankle pain.

    Prognosis

    Prognosis is favorable, a multi-modal rehabilitation approach utilizing exercise (proprioceptive and strengthening) and manual therapy (plantar massage, joint mobilizations and nerve mobilization) can be used to enhance motor control in patients (Doherty et al., 2017; Plaza-Manzano et al., 2016).

    Key Takeaways

    Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for ankle pain based on patient-specific assessment findings including, but not limited to:

    • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
    • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
    • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
    • Hydrotherapy (hot & cold)
    • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

    References and Sources

    Albin, S. R., Koppenhaver, S. L., Van Boerum, D. H., McPoil, T. G., Morgan, J., & Fritz, J. M. (2018). Timing of initiating manual therapy and therapeutic exercises in the management of patients after hindfoot fractures: a randomized controlled trial. The Journal of manual & manipulative therapy, 26(3), 147–156. doi:10.1080/10669817.2018.1432542

    Albin, S. R., Koppenhaver, S. L., Marcus, R., Dibble, L., Cornwall, M., & Fritz, J. M. (2019). Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. The Journal of orthopaedic and sports physical therapy, 49(5), 310–319. doi:10.2519/jospt.2019.8864

    Cleland, J. A., Mintken, P. E., McDevitt, A., Bieniek, M. L., Carpenter, K. J., Kulp, K., & Whitman, J. M. (2013). Manual physical therapy and exercise versus supervised home exercise in the management of patients with inversion ankle sprain: a multicenter randomized clinical trial. The Journal of orthopaedic and sports physical therapy, 43(7), 443–455. doi:10.2519/jospt.2013.4792

    Cox, T., Sneed, T., & Hamann, H. (2018). Neurodynamic mobilization in a collegiate long jumper with exercise-induced lateral leg and ankle pain: A case report. Physiotherapy theory and practice, 34(3), 241–249. https://doi.org/10.1080/09593985.2017.1377793

    Delahunt, E., Bleakley, C. M., Bossard, D. S., Caulfield, B. M., Docherty, C. L., Doherty, C., … Gribble, P. A. (2018). Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. British journal of sports medicine, 52(20), 1304–1310. doi:10.1136/bjsports-2017-098885

    Doherty, C., Bleakley, C., Delahunt, E., & Holden, S. (2017). Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. British journal of sports medicine, 51(2), 113–125. doi:10.1136/bjsports-2016-096178

    Fraser, J. J., Saliba, S. A., Hart, J. M., Park, J. S., & Hertel, J. (2020). Effects of midfoot joint mobilization on ankle-foot morphology and function following acute ankle sprain. A crossover clinical trial. Musculoskeletal science & practice, 46, 102130. https://doi.org/10.1016/j.msksp.2020.102130

    Helly, K. L., Bain, K. A., Gribble, P. A., & Hoch, M. C. (2020). The Effect of Plantar Massage on Static Postural Control in Patients With Chronic Ankle Instability: A Critically Appraised Topic. Journal of sport rehabilitation, 1–5. Advance online publication. https://doi.org/10.1123/jsr.2020-0092

    Hertel, J., & Corbett, R. O. (2019). An Updated Model of Chronic Ankle Instability. Journal of athletic training, 54(6), 572–588. doi:10.4085/1062-6050-344-18

    Khalaj, N., Vicenzino, B., Heales, L. J., & Smith, M. D. (2020). Is chronic ankle instability associated with impaired muscle strength? Ankle, knee and hip muscle strength in individuals with chronic ankle instability: a systematic review with meta-analysis. British journal of sports medicine, 54(14), 839–847. https://doi.org/10.1136/bjsports-2018-100070

    McKeon, P. O., & Donovan, L. (2019). A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift. Journal of athletic training, 54(6), 628–638. doi:10.4085/1062-6050-474-17

    McKeon, P. O., & Wikstrom, E. A. (2016). Sensory-Targeted Ankle Rehabilitation Strategies for Chronic Ankle Instability. Medicine and science in sports and exercise, 48(5), 776–784. doi:10.1249/MSS.0000000000000859

    Plaza-Manzano, G., Vergara-Vila, M., Val-Otero, S., Rivera-Prieto, C., Pecos-Martin, D., Gallego-Izquierdo, T., … Romero-Franco, N. (2016). Manual therapy in joint and nerve structures combined with exercises in the treatment of recurrent ankle sprains: A randomized, controlled trial. Manual therapy, 26, 141–149. doi:10.1016/j.math.2016.08.006

    Porter, D. & Schon, L. (2020). Baxter’s The Foot and Ankle in Sport (3rd ed.) Elsevier.

    Powden, C. J., Hoch, J. M., Jamali, B. E., & Hoch, M. C. (2019). A 4-Week Multimodal Intervention for Individuals With Chronic Ankle Instability: Examination of Disease-Oriented and Patient-Oriented Outcomes. Journal of athletic training, 54(4), 384–396. doi:10.4085/1062-6050-344-17

    Rosen, A. B., Needle, A. R., & Ko, J. (2019). Ability of Functional Performance Tests to Identify Individuals With Chronic Ankle Instability: A Systematic Review With Meta-Analysis. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine, 29(6), 509–522. doi:10.1097/JSM.0000000000000535

    Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British journal of sports medicine, 54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885

    Urits, I., Hasegawa, M., Orhurhu, V., Peck, J., Kelly, A. C., Kaye, R. J., … Viswanath, O. (2020). Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review. Current pain and headache reports, 24(3), 8. doi:10.1007/s11916-020-0840-7

    Vuurberg, G., Hoorntje, A., Wink, L. M., van der Doelen, B., van den Bekerom, M. P., Dekker, R., … Kerkhoffs, G. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine, 52(15), 956. doi:10.1136/bjsports-2017-098106

    Walsh, B. M., Bain, K. A., Gribble, P. A., & Hoch, M. C. (2020). Exercise-Based Rehabilitation and Manual Therapy Compared With Exercise-Based Rehabilitation Alone in the Treatment of Chronic Ankle Instability: A Critically Appraised Topic. Journal of sport rehabilitation, 1–5. Advance online publication. doi:10.1123/jsr.2019-0337

    Weerasekara, I., Osmotherly, P., Snodgrass, S., Marquez, J., de Zoete, R., & Rivett, D. A. (2018). Clinical Benefits of Joint Mobilization on Ankle Sprains: A Systematic Review and Meta-Analysis. Archives of physical medicine and rehabilitation, 99(7), 1395–1412.e5. doi:10.1016/j.apmr.2017.07.019

    Weerasekara, I., Deam, H., Bamborough, N., Brown, S., Donnelly, J., Thorp, N., & Rivett, D. A. (2020). Effect of Mobilisation with Movement (MWM) on clinical outcomes in lateral ankle sprains: A systematic review and meta-analysis. Foot (Edinburgh, Scotland), 43, 101657. https://doi.org/10.1016/j.foot.2019.101657

    Wikstrom, E. A., Song, K., Lea, A., & Brown, N. (2017). Comparative Effectiveness of Plantar-Massage Techniques on Postural Control in Those With Chronic Ankle Instability. Journal of athletic training, 10.4085/1062-6050.52.4.02. Advance online publication. doi:10.4085/1062-6050.52.4.02

    Zhao, M., Gao, W., Zhang, L., Huang, W., Zheng, S., Wang, G., … Tang, B. (2018). Acupressure Therapy for Acute Ankle Sprains: A Randomized Clinical Trial. PM & R: the journal of injury, function, and rehabilitation, 10(1), 36–44. doi:10.1016/j.pmrj.2017.06.009

    4.24: Ankle Pain is shared under a not declared license and was authored, remixed, and/or curated by LibreTexts.

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