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Foot & Ankle

Achilles tendinopathy
Achilles tendinopathy is a condition that causes pain, swelling and stiffness of the Achilles tendon that joins your heel bone to your calf muscles. It is thought to be caused by repeated tiny injuries to the Achilles tendon. These may occur for a number of reasons, including overuse of the tendon - for example, in runners. Treatment includes rest, ice packs, painkillers and special exercises to help to stretch and strengthen the Achilles tendon. For most people, the symptoms of Achilles tendinopathy usually clear within 3-6 months of starting treatment.

Your Achilles tendon is an important part of your leg. It is found just behind and above your heel. It joins your heel bone (calcaneum) to your calf muscles. The function of your Achilles tendon is to help in bending your foot downwards at the ankle. (This movement is called plantar flexion)

What is Achilles tendinopathy and what causes it?
Achilles tendinopathy is a condition that causes pain, swelling and stiffness of the Achilles tendon. It is thought to be caused by repeated tiny injuries (known as microtrauma) to the Achilles tendon. After each injury, the tendon does not heal completely, as should normally happen. This means that over time, damage to the Achilles tendon builds up and Achilles tendinopathy can develop.

There are a number of things that may lead to these repeated tiny injuries to the Achilles tendon. For example:

  • Overuse of the Achilles tendon. This can be a problem for people who run regularly. (Achilles tendinopathy can also be a problem for dancers and for people who play a lot of tennis or other sports that involve jumping.)
  • Training or exercising wearing inappropriate footwear.
  • Having poor training or exercising techniques - for example, a poor running technique.
  • Making a change to your training programme - for example, rapidly increasing the intensity of your training and how often you train.
  • Training or exercising on hard or sloped surfaces.
Achilles tendinopathy is also more common in people who have certain types of arthritis, such as ankylosing spondylitis or psoriatic arthritis. It is also thought that your genetic 'makeup' (the material inherited from your parents which controls various aspects of your body) may play a part for some people who develop Achilles tendinopathy. It is also more common in people who have high blood pressure, high cholesterol or diabetes .

People who are taking medicines from a group called fluoroquinolones (for example, the antibiotics ciprofloxacin and ofloxacin) also have an increased risk of developing Achilles tendinopathy.

Achilles tendinopathy used to be known as Achilles tendonitis. In general, 'itis' usually refers to inflammation, so tendonitis would mean inflammation of a tendon. However, Achilles tendinopathy is now thought to be a better term to use because it is thought that there is little or no inflammation that causes the problem.

If the Achilles tendon is torn, this is called an Achilles tendon rupture.

How common is Achilles tendinopathy?
About 6 in 100 inactive people develop Achilles tendinopathy at some point in their lifetime. However, the chance of it developing is higher in athletes or those who train regularly or do a lot of exercise. It can be a particular problem for some runners. It used to be thought that it is more common in men than in women but this may not be true.

What are the symptoms of Achilles tendinopathy?
The main symptoms include pain and stiffness around the affected Achilles tendon. Pain and stiffness tend to develop gradually and are usually worse when you first wake up in the morning. (Severe pain that comes on suddenly and difficulty walking can be symptoms of Achilles tendon tear (rupture). See a doctor urgently if you develop these symptoms.)

Some people have pain during exercise but, in general, pain is worse after exercise. Runners may notice pain at the beginning of their run, which then tends to ease and become more bearable, followed by an increase in pain when they have stopped running. Pain due to Achilles tendinopathy may actually prevent you from being able to carry out your usual everyday activities such as walking to the shops, etc. You may notice that you have pain when you touch the area around your Achilles tendon. There may also be some swelling around this area.

Do I need any investigations?
Your doctor will usually diagnose Achilles tendinopathy because of your typical symptoms and from examining your Achilles tendon. They may feel for swelling or tenderness of the tendon. They may also ask you to do some exercises to put some stress on your Achilles tendon. For example, they may ask you to stand on the affected leg and raise your heel off the ground. For most people with Achilles tendinopathy this movement brings on (reproduces) their pain. If this does not bring on your pain, your doctor may ask you to hop on that foot, either on the spot or in a forwards direction. Your doctor may also do some other tests to make sure that there are no signs that you have torn (ruptured) your Achilles tendon. For example, squeezing your calf muscles and looking at how your foot moves.

X-rays or other tests are not usually needed to diagnose Achilles tendinopathy. However, an ultrasound scan or an MRI scan may sometimes be suggested if the diagnosis is not clear.

What is the initial treatment for Achilles tendinopathy?
There are a number of treatments that may help. The treatments below are usually suggested first. They are all considered as conservative treatments. This means treatments that do not involve surgery.

Rest
Rest and time off from sporting activities are important if you have Achilles tendinopathy. At first, you should stop any high-impact activities or sports (such as running). As pain improves, you can restart exercise as your pain allows. It is thought that complete rest, if it is prolonged, can actually be worse for the injury. Talk to your doctor or physiotherapist about when you should start exercising again.

Painkillers
Painkillers such as paracetamol or ibuprofen may help to relieve pain. Ibuprofen is from a group of medicines called non-steroidal anti-inflammatory drugs (NSAIDs). However, you should not use ibuprofen or other NSAIDs for more than 7-14 days if you have Achilles tendinopathy. This is because they may possibly reduce the ability of the tendon to heal in the long term. They may also cause symptoms of Achilles tendinopathy to be masked, or covered up, which again may delay healing.

Note: side-effects sometimes occur with anti-inflammatory painkillers. Stomach pain, and bleeding from the stomach, are the most serious. Some people with asthma, high blood pressure, kidney failure and heart failure may not be able to take anti-inflammatory painkillers. So, check with your doctor or pharmacist before taking them if you are unsure if they are suitable for you.

Ice packs
Ice treatment may be useful for pain control and may help to reduce swelling in the early stages of Achilles tendinopathy. An ice pack should be applied for 10-30 minutes. Less than 10 minutes has little effect. More than 30 minutes may damage the skin. Make an ice pack by wrapping ice cubes in a plastic bag or towel. (Do not put ice directly next to skin, as it may cause ice burn.) A bag of frozen peas is an alternative. Gently press the ice pack on to the injured part. The cold from the ice is thought to reduce blood flow to the damaged tendon. This may reduce pain. Do not leave ice on while asleep.

Achilles tendon exercises
Some special exercises to help to stretch and strengthen your Achilles tendon have been proven to be helpful. You should aim to do these every day. Such exercises may help with pain control and stiffness. A physiotherapist may be able to help you with these exercises as needed. They may also use other treatments such as ultrasound and massage to help relieve symptoms and promote healing of your Achilles tendon.

The following exercises can be used to help treat Achilles tendinopathy:

  • Stand about 40 cm away from a wall and put both hands on the wall at shoulder height, feet slightly apart, with one foot in front of the other. Bend your front knee but keep your back knee straight and lean in towards the wall to stretch. You should feel your calf muscle tighten. Keep this position for several seconds, then relax. Do this about 10 times and then switch to the other leg. Now repeat the same exercise for both legs but, this time, bring your back foot forward slightly so that your back knee is also slightly bent. Lean against the wall as before, keep the position, relax and then repeat 10 times before switching to the other leg. Repeat this routine twice a day.
  • Stand on both feet. Use your unaffected leg to raise up on to tiptoes. Transfer your weight across to your affected leg and lower yourself down. Repeat and aim for three sets of 15 repetitions twice each day. The standing on tiptoe exercise should be performed with your knees straight and with your knees bent.
  • Stand on the bottom step of some stairs (facing upstairs) with your legs slightly apart and with your heels just off the end of the step. Hold the stair rail for support. Raise up on tiptoes, then, standing on the affected leg, lower your heel, keeping your knee straight. Put your good leg down before lifting your heel. Repeat and aim for three sets of 15 repetitions twice each day. Repeat but this time keeping the knee of the affected leg slightly bent. Try to do these exercises twice a day. These exercises are sometimes called Alfredson's exercises after the person who first showed that they work.
  • Keep a towel (or a long piece of elastic) by the side of your bed. First thing in the morning, before you get out of bed, loop the towel around the ball of one of your feet. Then pull the towel towards you, keeping your knee straight. Hold the pull for about 30 seconds. This exercise will pull your toes and the upper part of your foot towards you. Repeat this exercise three times for each foot.
  • Sit on a chair with your knees bent at right angles and your feet and heels flat on the floor. Lift your foot upwards, keeping your heel on the floor. Hold the position for a few seconds and then relax. Repeat about 10 times. Try to do this exercise five to six times a day.
Orthotics
An orthotics specialist may suggest changing your footwear or putting special inserts in your shoes, such as inserts to lift your heel. This may help to reduce pain and symptoms.

A note about steroid injections
Injection of a steroid medicine is a common treatment for some tendon injuries. However, the use of steroid injections for the treatment of Achilles tendinopathy is controversial and it is not approved in the UK. If steroids are injected directly into the Achilles tendon, there is a risk of damaging the tendon further. There have been cases where they have caused the tendon to tear (rupture). Another option is to inject the steroid around the Achilles tendon. But again, this is not approved in the UK. However, it is thought that this may have less effect on the tendon itself and be less likely to cause damage. Some specialists do suggest this treatment, using an ultrasound scan to guide the needle to the right position, to help to control pain.
What happens if initial treatment fails?

For most people, the symptoms of Achilles tendinopathy usually clear within 3-6 months of starting conservative treatment, as described above. In general, the earlier the problem is recognised and treatment started, the better the outcome. If your symptoms have not improved after 3-6 months, your doctor may suggest that they refer you to a specialist orthopaedic surgeon or sports medicine doctor. However, this timescale may change depending on your symptoms, your sporting activities, etc.
Specialist treatments that are not surgery .

There are some treatments that some specialists may suggest to help treat Achilles tendinopathy. You should discuss these treatments fully with your specialist, including their pros and cons, before any treatment is started. These treatments may not be widely available on the National Health Service (NHS). Some may also be carried out as part of a trial to look at the best ways of treating Achilles tendinopathy. Such treatments may include:

  • Extracorporeal shock-wave therapy - during this treatment, special sound waves are passed through your skin to your Achilles tendon. Side-effects can include reddening of your skin and an ache in your calf after treatment. This procedure is generally safe but there is a small risk of tearing (rupturing) the Achilles tendon with this treatment, particularly in older people. At the moment, it is uncertain how effective this treatment is and how well it works. The National Institute for Health and Care Excellence (NICE) therefore recommends that specialists discuss this treatment fully with anyone before it is started. This is so that the person understands the possible small risks and that the effectiveness of this treatment is uncertain. This does not mean that the procedure should not be done; it just means that we need to discuss it fully beforehand.
  • Platelet Rich Plasma Injections(PRP): Some Achilles tendon injuries require more aggressive treatment to help supplement traditional therapies. For these patients, I will sometimes consider adding platelet rich plasma (PRP) injections. PRP therapy is a non-surgical procedure that involves taking a patient’s blood and using a centrifuge to isolate and concentrate a platelet rich solution. This concentrated PRP is rich in a patient’s own natural healing and grown factors. It is then injected back into the injured tissue in the Achilles to help accelerate healing, reduce pain and increase functionality
Surgery for Achilles tendinopathy
Around 1 in 4 people who have persisting pain due to Achilles tendinopathy has surgery to treat the condition. Most people have a good result from surgery and their pain is relieved. Surgery involves either of the following:

  • Removing nodules or adhesions (parts of the fibres of the tendon that have stuck together) that have developed within the damaged tendon.
  • aking a lengthways cut in the tendon to help to stimulate and encourage tendon healing.
Complications from surgery are not common but, if they do occur, can include problems with wound healing.

Are there any complications of Achilles tendinopathy?
There is a risk of tearing (rupturing) your Achilles tendon if you have Achilles tendinopathy. This is because the tendon is damaged and weaker than usual. However, this risk is usually quite low. Severe pain around the Achilles tendon that develops suddenly may be a sign of tendon rupture. See a doctor urgently if you think that you may have ruptured your Achilles tendon.

If you do have problems with one Achilles tendon, there is also an increased chance that you will develop problems with the other over time.

Ankle Impingement

Anterior Ankle Impingement is a condition where an individual experiences pain at the front of the ankle, due to compression of the bony or soft tissue structures during activities that involve maximal ankle dorsiflexion motion.

It can be also known as:
 Ankle Impingement
 Anterior Impingement Syndrome
 Anterior Impingement of the Ankle
 Footballer’s Ankle

What is the Relevant Anatomy of Ankle Impingement?
The ankle joint is comprised of two bones - the tibia and talus, which glide on one another and have articular cartilage that cushions the impact of the tibia on the talus during weight-bearing activity.
During the movement of ankle dorsiflexion, the foot and shin move towards one another, meaning the tibia approaches the front of the talus. This places compressive forces on the structures at the front of the ankle joint. If these forces are in excess or beyond what the ankle can withstand, damage and inflammation of these structures can occur.

What Occurs in Anterior Ankle Impingement?
Repeated compression at the front or anterior aspect of the ankle joint results in pinching of the joint capsule and synovium that is responsible for generating pain in patients with anterior ankle impingement.
In some cases, this repeated compression of the anterior ankle joint can lead to bone spurs, otherwise known as osteophytes to form on the front edge of the tibia or talus. It is believed that these spurs can develop to help protect the surface from the repeated pulling of the joint capsule on the front lip of the tibia or just the cumulative repetition of bony contact. This process does not have to be associated with arthritis of the ankle joint, however, it can be accelerated with repeated ankle sprains. 

What Causes Anterior Ankle Impingement?
Anterior ankle impingement most commonly occurs as a result of:
 Ankle Sprain
 Recurrent Ankle Sprains
 Activities that require repeated Dorsiflexion of the Ankle - such as landing and deep squatting.

There are several factors that can predispose you to develop anterior ankle impingement including:
 inadequate rehabilitation following a previous ankle injury
 joint stiffness or swelling
 muscle tightness
 bony anomalies
 poor foot biomechanics (e.g. "flat feet" or high arches)
 poor lower limb biomechanics
 inappropriate training (including technique, footwear or training surfaces)
 excessive training
 inadequate recovery periods from training and games
 inadequate warm-up
 poor core stability
 poor proprioception or balance

Symptoms of Anterior Ankle Impingement
Individuals that suffer from anterior ankle impingement typically present with:
 Dull ache at the front of the ankle with rest, which then becomes sharp pain at the front of the ankle with excessive dorsiflexion or weight bearing
 Increased symptoms following certain activities, including:
 Walking or running excessively (especially up hills or on uneven surfaces)
 Deep squatting or lunging (especially with the knee moving forwards over the toes)
 Landing from a jump (particularly on an incline or an uneven surface)
 Performing a calf stretch (particularly with the knee bent)
 Heavy lifting or twisting activities
 Tenderness on palpation of the front of the ankle joint.
 In some cases, a clicking sensation may be experienced during certain ankle movements.
 Puffiness or swelling of the ankle joint

Diagnosis
Standard ankle radiographs (or X- Rays) can be utilised when imaging anterior ankle impingement. The x-ray view of the ankle from the side (lateral radiograph) shows the ankle in profile and the bone spurs can be seen. Sometimes when the spurs are located on the inside of the ankle (anteromedial), they can be difficult to see on the standard lateral radiograph. Therefore an x-ray taken at a slight angle (oblique radiograph) can be helpful in seeing anteromedial bone spurs.
 
Magnetic Resonance Imaging or (MRI) is a useful test for a couple of different reasons. First, it can be useful in being sure there is no other cause of foot or ankle pain present that can mimic anterior ankle impingement. Also, an MRI may show signs of swelling in the region of irritation in the front of the ankle. This can help confirm the findings in the patient’s history and physical exam as well as help with surgical planning in the future.

Anterior Ankle Impingement Treatment

PHASE I - Pain Relief, Minimise Swelling & Injury Protection
Managing your pain. Pain is the main reason that you seek treatment for anterior ankle impingement. In truth, it was actually the final symptom that you developed and should be the first symptom to improve.

(Active) Rest: Our first aim is to provide you with some active rest from pain-provoking postures and movements. This means that you should stop doing the movement or activity that provokes the ankle pain.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Compression: A compression bandage, Tubigrip compression stocking or kinesiology supportive taping will help to both support the injured soft tissue and reduce excessive swelling.

Elevation: Elevating your injured ankle above your heart will assist gravity to reduce excessive swelling around your ankle.
Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These may include ice, electrotherapy, acupuncture, unloading taping techniques, soft tissue massage and temporary use of a mobility aid (eg brace) to off-load the injured structures.

In severe cases, you may require a period of rest from your aggravating activity. Your physiotherapist will be able to provide you with information in regards to alternative exercise.
Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling.

Phase 2: Restore Full Range of Motion
As soon as it is comfortable, your physiotherapist will start your rehabilitation aiming at regaining full active range of motion of the ankle.

Phase 3: Restore Muscle Strength
Your calf, ankle and foot muscles will require strengthening to recover from the injury and prevent future episodes. It is important to regain normal muscle strength to provide normal dynamic ankle control and function. Your strength and power should be gradually progressed from non-weight bear to partial and then full weight bear and resistance loaded exercises. You may also require strengthening for your other leg, gluteal and lower core muscles depending on your assessment findings. Your physiotherapist will guide you.

Phase 4: Restore High Speed, Power, Proprioception and Agility 
Most cases of anterior ankle impingement occur during high-speed activities, which place enormous forces on your ankle and adjacent structures. Balance and proprioception (the sense of the relative position of neighbouring parts of the body) are required to ensure a full recovery and also to prevent re-injury.

Phase 5: Return to Normal Daily Function and Sport
Once you are able to return to normal daily function eg walking, stairs and squatting, your physiotherapist will address your specific needs. If you play sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport. Your physiotherapist will discuss your goals, time frames and training schedules with you.

The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.

Ankle Impingement Surgery
Surgery is not common for those suffering from anterior ankle impingement. However, in persistent cases of anterior ankle impingement operative treatment may be beneficial, particularly for the high-level athlete.

If a patient’s symptoms can be directly attributed to the impingement, rather than ankle arthritis, removing the prominent impinging bone spurs or soft tissue structures can help symptoms.

Surgical treatment involves removing the offending bone or soft tissue either arthroscopically or by opening up the ankle joint with an incision.

If the bone spurs are large it is often more efficient and effective to make a larger incision and open up the ankle joint and remove the bone spurs. It is important to note that surgery to remove impinging bone spurs from the front of the ankle will not typically help symptoms if the pain is due to significant ankle arthritis. In some instances, surgery to remove the bone spurs can contribute to an increase in a patient’s symptoms if it allows the ankle joint to move more and the ankle joint has significant arthritis.

Other Treatment Options

Specific Interventions eg Injection

Corticosteroid injections may be useful in the initial phase of treatment if the patient is having difficulty calming the inflammation and pain in the ankle joint.

Anterior Ankle Impingement Treatment Options
• Early Injury Treatment
• Avoid the HARM Factors
• What to do after a Muscle Strain or Ligament Sprain?
• Acupuncture and Dry Needling
• Sub-Acute Soft Tissue Injury Treatment
• Closed Kinetic Chain Exercises
• Active Foot Posture Correction Exercises
• Gait Analysis
• Biomechanical Analysis
• Balance Enhancement Exercises
• Proprioception & Balance Exercises
• Agility & Sport-Specific Exercises
• Medications?
• Heel Cups
• Orthotics
• Soft Tissue Massage
• Walking Boot
• Ankle Strapping
• Brace or Support
• Dry Needling
• Electrotherapy & Local Modalities
• Heat Packs
• Joint Mobilisation Techniques
• Kinesiology Tape
• Neurodynamics
• Physiotherapy Instrument Mobilisation (PIM)
• Prehabilitation
• Running Analysis
• Strength Exercises
• Stretching Exercises
• Supportive Taping & Strapping
• TENS Machine
• Video Analysis