Ankle & heel Pain

Presented by
Dr.Abdulaziz Alharbi family medicine resident
Supervised by
Dr.Ahmad Aldoseri Family medicine consultant
 Pain
• Ankle and Heel pain is a common presenting symptom to family physicians and has an
extensive differential diagnosis.
• Most diagnoses stem from a mechanical etiology.
• The specific anatomic location of the pain can help guide diagnosis.
• A thorough patient history, physical examination of the foot and ankle and appropriate
imaging studies are essential in making a correct diagnosis and initiating proper
management.
• The history should provide information about the onset and characteristics of the pain,
alleviating or exacerbating factors, changes in activity, and other related conditions.
• Examination should include inspection of the foot at rest and when weight bearing, as
well as palpation of bony prominences, tendon insertions, and the foot and ankle joints.
Any tenderness, defects, or differences between the sides should be noted. Active range
of motion of the foot and ankle should be assessed; if full range of motion is not present,
passive range of motion should also be evaluated.
Sprained Ankle
Also known as twist ankle, rolled ankle or ankle ligament
injury.

• An ankle sprain occurs when the strong ligaments that

support the ankle stretch beyond their limits and tear.
• Ankle sprains are common injuries that occur among
people of all ages.
• They range from mild to severe, depending upon how
much damage there is to the ligaments.
• the sprained ankle is the most common type of athletic
injury with research suggesting that ankle sprains
account for 15-30% of all sports injuries. 
 Sprained Ankle
Risk factors
• Poor athletic conditioning.
• Muscle and ligament fatigue.
• Not warming up before activity.
• Carrying excess weight.
• Inappropriate footwear.
• Prior history of sprains or strains.
• Walking Uneven surfaces
 Symptoms of Sprained Ankle

• Swelling
• Pain
• Discoloration
• Redness
• Warmth
• Inability to walk
• Ankle Instability
 classification
Ankle sprain classified in to:
• Low ankle sprain:
I. Lateral ankle sprain “classic sprain”- 80% to 85%
II. Medial ankle sprain- 5% to 10%
• High ankle sprain (Syndesmotic sprain) - 5% to 10%
Low ankle sprain
Lateral ankle sprain (Inversion sprain)
• The most common mechanism of ankle
injury is inversion of the plantar-flexed
foot.
• The anterior talofibular ligament is the
first or only ligament to be injured in the
majority of ankle sprains.
• Stronger forces lead to combined
ruptures of the anterior talofibular
ligament and the calcaneofibular
ligament.
 Low ankle sprain
medial ankle sprain (eversion sprain)
• The medial deltoid ligament complex is the
strongest of the ankle ligaments and is
infrequently injured.

• Forced eversion of the ankle can cause damage

to this structure but more commonly results in
an avulsion fracture of the medial malleolus
because of the strength of the deltoid ligament.
 High ankle sprain
High ankle sprain (Syndesmotic sprain):
• A high ankle sprain, also known as a syndesmotic ankle
sprain (SAS), is a sprain of the syndesmotic ligaments
that connect the tibia and fibula in the lower leg
• Dorsiflexion and eversion of the ankle may cause
sprain of the syndesmotic structures.
• There generally tends to be less swelling with a
high ankle sprain, however there tends to be pain
that is more severe and longer lasting.
• Syndesmotic ligament injuries contribute to
chronic ankle instability and are more likely to
result in recurrent ankle sprain and the formation
of heterotopic ossification.
 DIAGNOSIS
• Hx Physical examination Imaging studies
The patient gives history of a •Plain radiography
twisting injury to the ankle ▪ Anterior Drawer of the Ankle •Stress-view
followed by pain and swelling anterior talofibular ligament radiography
over the injured ligament, • CT scanning
Weight bearing gives rise to ▪ Talar tilt •MRI
excruciating pain. Anterior Talofibular ligament •Bone scanning
In case of with complete tears, and the Calcaneofibular
patient gives history of feeling ligament.
of ‘something tearing’ at the ▪ Squeeze Test
time of the injury. high ankle sprain
▪ Crossed-leg test
high ankle sprain
Anterior Drawer of the Ankle
Talar Tilt Test
Squeeze Test
Crossed-leg test to detect high (syndesmotic) ankle sprain. A high ankle
sprain will cause pain in the syndesmotic area (just above the ankle) when
pressure is applied to the lateral side of the proximal lower leg
 studies
The National Athletic Trainers’ Association (NATA) noted the following regarding
imaging studies :

•The Ottawa Ankle Rules remain valid for determining the need for x-rays
•Stress radiography is unreliable for detecting acute injuries to the ankle and midfoot
•MRI is reliable for detecting acute tears of the anterior talofibular ligament and
calcaneofibular ligament; diagnostic ultrasonography is useful but less accurate and sensitive
than MRI
•MRI is highly sensitive, specific, and accurate after acute trauma for determining the level of
injury to the ankle syndesmotic ligaments
•MRI is not indicated unless unusual features are present, such as extensive swelling,
ecchymosis, or pain, that suggest an osteochondral lesion not observed on plain radiographs.
Even if MRI scans demonstrate bone bruising or actual articular cartilage damage,
conservative ankle sprain treatment is indicated initially.
Ottawa ankle and foot rules.
Ankle radiography is indicated only if a patient has pain in the

malleolar zone + bone tenderness at A or B or the inability to bear weight (four steps)
midfoot zone + bone tenderness at C or D or the inability to bear weight (four steps)

immediately after injury and in the emergency department or physician's office.

 Management of Sprained Ankle
Conservative therapy
The family physician can successfully manage uncomplicated ankle sprains. Because increased
swelling is directly associated with loss of range of motion in the ankle joint, the initial goals are to
prevent swelling and maintain range of motion

• RICE/PRICES
Rest, ice, compression, and elevation (ie, RICE) are the mainstays of acute treatment; more
comprehensively, the combination of protection, relative rest, ice, compression, elevation,
and support (PRICES) is used.

Ankle braces
Immobilization can aid healing but can hinder it as well. Acutely protecting the weakened,
painful area is appropriate, but prolonged immobilization leads to muscle atrophy and loss of
motin

ANTI-INFLAMMATORY MEDICATION
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in treating sprains is somewhat
controversial. However, a recent meta-analysis of 46 papers found that there was strong evidence
that use of non-steroidal anti-inflammatory drugs resulted in better control of pain, reduction of
swelling and improved function after an acute sprain

Physical Therapy
The treatment plan during the recovery phase is aimed at the patient regaining full ROM,
 Management of Sprained Ankle
Surgical Management
• Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that
fail to respond to nonsurgical treatment, and for patients who experience
persistent ankle instability after months of rehabilitation and nonsurgical
treatment.

• Distal tibiofibular ligament sprain with widened ankle

One of the few absolute indications for surgery in patients with a high ankle sprain
involving the distal tibiofibular ligament is a third-degree sprain that causes widening or a
diastasis of the syndesmosis between the distal fibula and tibia.

• Entrapped deltoid ligament

The main indication for deltoid ligament surgery is the infrequent case in which the
deltoid or posterior tibial tendon becomes entrapped between the talus and the medial
malleolus, preventing anatomic reduction of the talus within the mortise.
 When to Return to Normal Activity
• Return-to-play criteria during the
recovery phase (3 d to 2 wk post
injury) include the following:
• Full, pain-free active and passive
ROM
• No pain or tenderness
• Strength of ankle muscles 70-80%
of that on the uninvolved side
• Ability to balance on 1 leg for 30
seconds with eyes closed
• Return-to-play criteria during the functional
phase (2-6 weeks postinjury) include the
following:
• Normal ROM of the ankle joint
• No pain or tenderness
• Satisfactory clinical examination
• Strength of ankle muscles 90% of the
uninvolved side
• Ability to complete functional examination
Plantar Heel Pain
• Its the most common cause of plantar heel pain.
• Men and women affected equally.
• lifetime prevalence of 10% in the general population.
• Plantar fasciitis causes throbbing medial plantar heel pain that
is worse with the first few steps in the morning or after long
periods of rest.
• The pain usually decreases after further ambulation, but can
return throughout the day with continued weight bearing.
• Tenderness is noted on the medial calcaneal tuberosity and
along the plantar fascia .
• Pain often increases with stretching of the plantar fascia, which
is achieved by passive dorsiflexion of the foot and toes.
RISK FACTORS
• Foot arch “flatfeet”
• Obesity or sudden weight gain
• Long-distance running
• Tight Achilles tendon
• Shoes with poor arch support or soft soles
• Radiography is usually not necessary, although
weight-bearing radiography can help rule out other
causes of heel pain.
• Approximately 50 percent of patients with plantar
fasciitis have heel spurs but they are most often an
incidental finding and do not correlate well with
the patient's symptoms.
• Ultrasonography can demonstrate a thicker heel
aponeurosis of greater than 5 mm.
• Treatment of plantar fasciitis is typically
conservative, although resolution can take months
to years.
 Management of PLANTAR
FASCIITIS
• Initial treatment is typically conservative
with rest, activity modification, stretching, strengthening exercises, ice massage, and use of
anti-inflammatory or analgesic medications
• Custom or prefabricated orthotics, arch taping, night splinting, and physical therapy are effectiv
and can be combined with more conservative approaches.
• Corticosteroid and platelet-rich plasma injections -ultrasound guidance - can provide short-term
pain relief and are often used when conservative measures are ineffective or more immediate
pain control is desired.
• Corticosteroid injections increase the risk of plantar fascia rupture or fat pad atrophy.
SURGERY
In cases that do not respond to any conservative treatment, surgical release of the plantar fascia
may be considered.
 STRETCHING
Calf muscle stretch
Calf muscle stretching can be either 3 times or 2 times day, sustained(3mini) or
intermittent(20sec).
Plantar fascia specific stretch
Performed in sitting, with the patient placing the fingers of one hand across the
toes of the involved foot. Then pulling the toes back.
 TAPING

Calcaneal taping or low-dye taping used for short- term pain relief. Taping does cause
improvement in function.
 ORTHOTIC DEVICES

• Heel cuffs
• Viscous elastic heel pad
• Accommodative inlays
• Prefabricated and custom made orthosis: All these orthosis used for exceesive
foot pronation and improvement of the condition.
 NIGHT SPLINTS

• It is used for patient with symptoms greater than 6 months in duration.

• The desire length of time for wearing the splint is 1 to 3months.
• This splint maintain ankle in neural position and toes in slight extension.
 SUMMARY
• Plantar Fasciitis is a painful condition caused by overuse of
the plantar fascia or arch tendon of the foot.
• The most common cause of plantar fasciitis is very tight calf
muscles
• Treatment can last from several months to 2 years
• Some people may need surgery.
 HEEL PAD SYNDROME
• Pain from heel pad syndrome is often falsely attributed to
plantar fasciitis.
• Patients with heel pad syndrome present with deep,
bruise-like pain, usually in the middle of the heel, that can
be reproduced with firm palpation.
• Walking barefoot or on hard surfaces exacerbates the pain.
• The syndrome is usually caused by inflammation, but
damage to or atrophy of the heel pad can also elicit pain.
• Decreased heel pad elasticity with aging and increasing body
weight can also contribute to the condition.
• Treatment is aimed at decreasing pain with rest, ice, and
anti-inflammatory or analgesic medications. Heel cups,
proper footwear, and taping can also be used.
 CALCANEAL STRESS FRACTURE
• Calcaneal stress fractures are caused by repetitive
overload to the heel and most commonly occur
immediately inferior and posterior to the posterior facet
of the subtalar joint.
• Pain usually begins after an increase in weight-bearing
activities or after changing to a harder walking surface.
• The pain initially occurs only with activity, but it can later
occur at rest.
• Swelling or ecchymosis may be noted on examination,
with point tenderness at the fracture site.
• A positive calcaneal squeeze test (i.e., pain on squeezing
the sides of the calcaneus) suggests the diagnosis.
 CALCANEAL STRESS FRACTURE
• Radiography often does not reveal
a fracture, so bone scans,
computed tomography, or MRI
may be required.
• Activity modification, with little to
no weight bearing for up to six
weeks if pain is severe, is usually
successful.
• Heel pads or walking boots can
also be used.
• Calcaneal stress fractures tend to
heal well in otherwise healthy
patients
 NEUROPATHIC ETIOLOGIES
• Heel pain accompanied by burning, tingling, or numbness may suggest a neuropathic
etiology, either with nerve entrapment or the development of a neuroma.
• Nerve entrapment can be caused by overuse, trauma, or injury from a previous surgery.
• Neuropathic plantar heel pain typically involves branches of the posterior tibial nerve, the
lateral plantar nerve, or the nerve to the abductor digiti minimi
• Lumbar radiculopathy at the L4-S2 levels should also be considered regardless of the
presence of associated low back pain.
• Neuropathic heel pain is usually unilateral, and underlying systemic disease should be ruled
out in patients with bilateral pain.
• MRI and ultrasonography may be helpful in visualizing the nerve entrapment.
• Treatment initially involves rest, ice, use of anti-inflammatory or analgesic medications,
relief of pressure at the pain site, and stretching.
• Surgical decompression should be considered if conservative treatment is ineffective.
 PLANTAR WARTS
• Plantar warts, which are raised skin lesions resulting
from infection with the human papillomavirus, can
cause heel pain.
• Lesions can be noted on inspection of the heel and
may be tender to palpation.
• They are usually self-limited; however, patients often
desire quicker resolution.
• Over-the-counter medications, cryotherapy, topical
medications, laser therapy, and shaving the wart are
effective treatments but may worsen pain in the
short term.
• Occlusion with duct tape has not been proven
effective for plantar warts
Posterior Heel Pain
 ACHILLES TENDINOPATHY
• achilles tendinopathy is usually caused by running,
wearing high heels, and other activities associated with
overuse of the calf muscles.
• The achilles tendon is formed by the union of the
gastrocnemius and soleus muscle tendons.
• The condition can be insertional or within the mid of
the tendon, leading to posterior heel pain that is achy,
is occasionally sharp, and worsens with increased
activity or pressure to the area, such as from contact
with shoe backing.
• Fluoroquinolone use has also been shown to
precipitate Achilles tendinopathy, particularly in older
persons.
• Palpation reveals tenderness along the Achilles tendon
and sometimes a palpable prominence from tendon
thickening.
 ACHILLES TENDINOPATHY
• Passive dorsiflexion of the foot increases the pain.
• Radiography may demonstrate spurring at the Achilles
tendon insertion site or intratendinous calcifications.
• Ultrasonography may show thickening of the tendon .
• The most beneficial treatment of Achilles tendinopathy
is eccentric exercises, which involve lengthening a
muscle in response to external resistance.
• Initial treatment should also include reduction of
pressure to the area, heel lifts or other orthotic
devices, and anti-inflammatory or analgesic
medications.
• Nitroglycerin patches and platelet-rich plasma
injections have shown benefit in some studies.
• Surgical debridement may be needed for severe cases.
 HAGLUND DEFORMITY
• A Haglund deformity is a prominence of the superior
aspect of the posterior calcaneus .
• The condition can occur in anyone, but is most
common in women who are in their twenties.
• Repeated pressure, from this deformity or from
ill-fitting footwear, can cause inflammation and
swelling between the calcaneus and Achilles tendon,
leading to retrocalcaneal bursitis.
• Patients with bursitis have erythema and swelling over
the bursa and tenderness to direct palpation.
 HAGLUND DEFORMITY
• Treatment of Haglund deformity, with or without
bursitis, targets decreasing the pressure and
inflammation with open-heeled shoes,
anti-inflammatory or analgesic medications.
• Corticosteroid injections (ultrasound-guided injections
are preferable to avoid disruption of the Achilles
tendon).
• Physical therapy may also help reduce pain.
• In some cases, surgery to remove the Haglund
deformity may be necessary.
 SEVER DISEASE
• The most common etiology of heel pain in children and adolescents is Sever
disease (calcaneal apophysitis).
• Patients usually present between eight and 12 years of age with
activity-associated heel pain, particularly with running or jumping.
• often worse at the beginning of a new sports season or during a growth spurt.
• Pain may be elicited by palpation around the Achilles insertion site, with
mediolateral calcaneal compression, and with passive dorsiflexion.
• Radiographic findings are typically normal but may show fragmented or sclerotic
calcaneal apophysis.
• Treatment is conservative and includes limiting of pain-inducing activities, use of
anti-inflammatory or analgesic medications, ice, stretching and strengthening the
gastrocnemius-soleus complex, and shoe modifications with orthotics, heel cups,
or lifts.
Midfoot Heel Pain
 TARSAL TUNNEL SYNDROME
• The tarsal tunnel is a space formed by the flexor
retinaculum, medial calcaneus, posterior talus, and medial
malleolus.
• Compression of the posterior tibial nerve most commonly
occurs as it courses through this tunnel, causing neuropathic
pain and numbness in the posteromedial ankle and heel
which may extend into the distal sole and toes.
• Patients often report worsening of pain with standing,
walking, or running, and alleviation of pain with rest or
loose-fitting footwear.
• Physical examination may reveal a pes planus deformity,
which increases tension of the nerve with weight bearing, or
muscle atrophy in more severe cases.
 TARSAL TUNNEL SYNDROME
• Pain can be reproduced by tapping along the course of the
nerve (Tinel sign) and with provocative maneuvers to stretch
or compress the nerve (dorsiflexion-eversion test, plantar
flexion-inversion test).
• Electromyography and nerve conduction studies may be
useful to confirm the diagnosis.
• Treatment is mostly conservative, with activity modification,
orthotic devices, neuromodulator medications (tricyclics or
antiepileptics), or anti-inflammatory medications.
Corticosteroid injections into the tarsal tunnel may also be
beneficial.
• Surgery is available if conservative measures are ineffective
Tinel sign
 SINUS TARSI SYNDROME
• The sinus tarsi, or talocalcaneal sulcus, is an anatomic space
bound by the calcaneus, talus, talocalcaneonavicular joint,
and posterior facet of the subtalar joint.
• Sinus tarsi syndrome can be caused by a single traumatic
event, repeated lateral ankle sprains, or repeated
hyperpronation of the foot, leading to instability of the
subtalar joint.
• Patients with sinus tarsi syndrome typically present with
pain in the lateral calcaneus and ankle accompanied by a
feeling of foot and ankle instability that is provoked by
running, cutting and jumping, walking on uneven surfaces,
or even stepping off a curb.
 SINUS TARSI SYNDROME
• Imaging may include MRI or radiography with stress views.
• Treatment includes ice, massage, taping, balance and
proprioceptive training, muscle strengthening,
corticosteroid injections ,and use of anti-inflammatory
medications, ankle braces, and orthotics.
• Surgery is usually required in patients for whom
rehabilitation has been ineffective.