Common foot and ankle injuries: sprains, fractures and tendons

You're listening to the Restoring Human Movement podcast, and now, your host. Hello, everyone, and welcome to the Restoring Human Movement podcast. Thank you for joining the Movement Movement. This is your co-host, Dawne Costantino, and in today's podcast, we are going to be going over common musculoskeletal injuries of the ankle and the foot. This is not going to be an exhaustive list. We're just going to go over what we see most commonly in our office. We'll talk about how they occur, what they feel like, and if they respond to conservative care or not. If this is your first time joining us, welcome. We do have tons of other podcasts that you can check out on our page where we've gone over injuries encumbering almost the entire body.

So if you have other things that are going on or you just want to learn a bit more, feel free to check those out. A lot of those are also covered on our YouTube page. Our YouTube page usually consists of things that you can try to see if you can help alleviate some discomfort or start to build back when you're looking to resolve some of these injuries. So check out those exercises and videos on our YouTube as well. If you have been listening for a while, welcome back. We're glad that you're here again. Thank you for supporting us. So let's hop right into this. Again, we're going to be covering the ankle and foot.

Common musculoskeletal injuries of the ankle include, we're going to start at the ankle. Sorry, let me just back up a little bit. We're going to cover ankle and foot. At first, I was going to make those two separate podcasts and realize that a lot of ankle injuries do also affect the foot. So combining these two together, I thought was better in this podcast. So we're going to start at injuries of the ankle and then we'll kind of work our way down to the foot and you'll see how they, it kind of converged there. So common musculoskeletal injuries of the ankle include sprains like ligaments or sprains are typically ligament stretching or tearing, fractures such as broken bones, not completely broken, but fractures are just like partially fractured areas of the bones, tendon injuries such as Achilles tendinopathy or peroneal tendon issues.

These injuries often result from things like missteps, falls, trauma during physical activity, which usually lead to pain, swelling and limited mobility. So ankle sprains, let's hop into that first. A sprain occurs when the ligaments connecting bone to bone are stretched too far or are torn. They happen mostly with a misstep like off a curb or in sports or falls. My ankle sprains typically occurred in soccer, usually when another player would slide across, try to get the ball, step on your foot, hit the inside of your ankle, cause an ankle sprain. A lot of times you'll see it too when the cleat gets stuck in turf or in the grass, but yet the body and the leg keep going.

So that was, it can really occur that way a lot in sports as well. I've had patients who talk about missteps off the curb or falls in hockey onto their own foot. These are just, you know, some of a few ways that ankle sprains can occur. So the different types of sprains, they usually happen in different areas of the ankle. Normally it's, you know, just isolated ankle sprains in the one area of the ankle, but depending on how bad this sprain is, they can coincide with different types of sprains as well as, again, if it's really bad, they can be accompanied by fractures as well. So we'll be discussing all these different parts.

The most common ankle sprain is laterally, so on the outside of the ankle, called an inversion sprain. So this is picture, this is just picturing kind of where the bone on the outside of your ankle there, that big bone that you can kind of palpate and touch, rolls outward on the other side of your foot. During these types of injuries, typically tearing to the ATFL, the CFL, and the PTFL can occur. Those, the ATFL, just, they're just shortened versions of what the ligaments are called. So I'm not going to go into depth about what these ligaments are, what they do, anything like that. Those are just, just know that those are the common ones that can be torn in a inversion ankle sprain.

Medial sprains, so just think about the opposite side, the inner part of the ankle, the other pointy bone that you can palpate on the inside of your ankle, that's medial ankle. They're much less common and occur when the foot moves just the opposite way. So inward, or the ankle moves inward. The deltoid ligaments located there are known to be much harder to sprain because they're thicker. These injuries are typically found during contact, sports, and trauma. So I actually have a patient who I've seen who has one of these. It's actually got both of what we just covered, the inversion. Or he's got the sprain of the lateral part, but also sprains of the medial deltoid ligament too, because it was a hockey fall onto his ankle and foot.

It just created a lot of trauma there. So they can coincide, just know that. The last type of ankle sprain we'll be covering is a syndesmotic high ankle sprain. So we're thinking more up into like the shin area, closer to the ankle. If you didn't know, your shin is consistent of two bones. There's your big one, the shin that most people know is their shin. You can touch it on the front there, and then you have a small bone called the fibula on the outside. And so there's a ligament that runs between the two. That's the ligament we're talking about here. So it's located above the ankle joint between the two bones of the shin.

This occurs often due to external rotation. So rotating outward of the ankle or forced hyper dorsiflexion. So the best way I can describe dorsiflexion, if you're not familiar, is pulling your toes and your foot towards your head. That's active dorsiflexion. So forcing too much of that movement can also cause this type of sprain. These can typically be found with cutting movements in sport. All of these injuries are usually accompanied with things like pain, swelling, sometimes the feeling of throbbing in the acute stages, as well as bruising. It can be difficult to weight bear on the foot. A feeling of instability will occur as well.

When tested, you'll typically notice, so if you have a doctor testing these ligaments and how the integrity of these ligaments, you'll actually notice an increase of range of motion of a joint because the ligaments have been stretched or torn or fully torn. So the joint itself or the integrity of that ligament to prevent excessive motion is not quite there. So you can feel excessive movement in those areas. But with these injuries, the swelling can also prevent too much movement, too. It's just a normal physiological response that will occur. The swelling can cause decreased range of motion. Most of the time, these injuries can be treated conservatively with swelling treatment, balance exercises, modified activity, and rehab.

Like I mentioned before, it is just important to rule out common fractures that can occur with more severe sprains, which we're going to get into here. So ankle fractures, they typically accompany a more severe sprain. Inversion ankle sprains can also cause not only tearing of the ligaments, but fracture of the lateral malleolus, which is that prominent bone on the outside of the ankle. The avulsion fracture of the ligaments, where the ligaments get so torn that they just pull off the bone that it attaches to. They can cause a talar dome fracture, a fifth metocarpal, or just right before the bone turns to your pinky toe.

That's what we're talking about here. And in rare cases, it can actually cause a fibula fracture, so the smaller shin bone or break with all of these as well. So really just depending on how bad this ankle sprain is, where your body falls with this sprain, how it occurred, these fractures are really, really important to rule out when we have just one of those rolling of the ankles. Symptoms are usually similar to a sprain, so it can cause severe pain, significant swelling, bruising, and inability to weight bear. Fractures will usually be suspected if there's tenderness to palpation of the bones that I mentioned.

So typically, we follow what we call the Ottawa ankle rules to see if an x-ray is needed and necessary to rule out fractures. In some cases, you might be sent for an MRI or a CT if it's warranted as well. So we're going to hop next into tendon injuries. Hope I'm going through this not too quickly. As you can see, I'm not really telling stories. I'm just kind of covering the basics of these injuries. So we're just going to keep moving and chugging along here. Tendon injuries. Ligaments attach bone to bone, whereas tendons connect muscles to bone. So common types for the ankles. We'll start first with Achilles tendinopathy.

Tendinopathy is generally a term to just describe pain, inflammation, and tendon stiffness. Tendinitis and tendinosis dive further into the timeline of the injury. The Achilles tendon attaches the calf muscle to the heel and is located in the back of the ankle. Injuries can occur closer to the muscle, in the middle of the tendon, or closer to the attachment of the heel. Tendon rupture can also occur too, which is often seen in running sport or in basketball. I've heard injuries of someone simply stepping off a curb in this occurring. It's really, this tendon is not that fragile. But we know that if that occurs, it usually has to be a lot of repetitive stress or other factors that contribute to it tearing that easily, which usually include things like training load, adequate rest, footwear, and some medications that could lead to tendon vulnerability.

Symptoms that coincide with this type of injury can present a sensitivity, swelling, and stiffness of the tendon. This can present along the entire length of the tendon, but more often it will present at a very specific area where the tear occurs. A note I want to add to this, and I think that this also should just be covered in when we're talking about just like ankle pain and injuries, is that a lot of these injuries, they present similarly. So how do you know, you know, which one is your diagnosis, which structure is causing your discomfort? And so I want to talk about how tightness or feelings of sharp discomfort behind the ankle and in the calf or heel can also come from branches of the sciatic nerve that runs down the back of the leg.

When we think nerve, we usually think numbness and tingling, which may or may not occur when we're talking about just behind the ankle discomfort with these nerve issues. There's chances that, or chances of this being what might be causing your discomfort is increased if you also know, notice low back pain, glute discomfort, hamstring tightness as well, but it's not required. Like I've had multiple people I've seen where they're not dealing with a tendon injury or maybe have healed from a tendon injury and are now just dealing with the leftovers of what happened to that nerve during this injury too.

So keep that in mind. It's more common than you think. And it's really, really important that whoever you're seeing is considering this when talking about how to properly treat your injury. Other diagnoses that I won't go over today but can mimic Achilles discomfort include posterior ankle impingement and bursitis. If you're confused or you just want to know more about this, reach out to us. We'd love to learn more about your injury and just hope that you're in the right direction, guide you down the right path. We work virtually or in person, so keep that in mind. Treatment of these injuries are usually conservative just depending on the severity of the tear.

Rupture is usually not conservative. That's a surgical consult that you need there. So, yeah, again, it's most of these tears, most of these injuries with time, with rehab, with manual therapy, with guidance and education. Modified activity can heal on their own and then just a properly progressive loading program. But if it's fully torn, this is something that needs to be surgically repaired. Next up is a peroneal tendon. Injuries such as inflammation, subluxation, or tear to these tendons on the outside of the ankle. Can occur. This includes the peroneus, longus, and brevis. An injury to these tendons also affects stability of the ankle.

It's not just felt on the outside of the ankle, but can also be felt in the outside of the foot, too. So this is where I'm talking about some of these injuries. Like, it's really hard to separate the foot and ankle because so many things pass from the lower leg through the ankle and into the foot. And they all kind of work together. So that's where discomfort on the outside of the ankle and into the foot, this is something to consider here. You may notice that pain, swelling, popping or clicking on the outside of the ankle, tenderness along the outside of the shin, or feeling of instability or weakness can occur.

And again, treatment just usually includes improving foot mechanics, talking about shoe wear, rehab, and just a proper diagnosis. Because again, this is very, very similar to like an inversion ankle sprain type of presentation. So just testing it and talking your history and what's been going on and all of that stuff is important to figure out what kind of injury you're dealing with here. Next tendon that we're going to talk about is tibialis posterior dysfunction. This is pain on the inside of the ankle now due to injury of the posterior tibial tendon. This tendon runs behind that prominent bone on the inside of your ankle called the medial malleolus.

Usually it feels like inside of the ankle and foot pain. Long-term dysfunction will usually present in the foot because it's considered an integral part of stability of the arch. With posterior tibial dysfunction, it's really a part of the conversation of like the stability of your arch of your foot and like foot collapsing or flat foot deformity. Having flat feet is not necessarily always something that should be fixed. But when the arch of the foot is changing from your normal, is causing discomfort, affects your function, then we should be considering this. The most common cause is simply repetitive loading.

Other causes are metabot. When I say repetitive loading, this doesn't mean like just being an active human. It's really, really important to, I don't think I've said it yet in this podcast, but I did in the diagnoses of the thigh. Repetitive loading too quickly for that specific tissue to, you know, repair properly from the demands of what you're putting on it is what we're talking about here. So just like deciding to go for a run is not just considered repetitive loading or that over time is not just repetitive loading. It's are we, you know, considering adequate rest? Are we allowing proper healing in between?

Are we eating properly to make sure that the nutrients are given to the body to be able to repair naturally just from, you know, the types of movements we put on our body? So this is what we're talking about here. Over time, too much, too quickly is what we need to be considering here. And that's why when you go and see a healthcare provider, they should really be diving into your history. How, you know, what has been going on leading up to this point is really important when it comes to discussing the diagnosis at hand. So other causes of dysfunction in this tendon are metabolic, so things such as diabetes and hyperlipidemia.

It's important to consider other supporting structures such as the plantar fascia, the deltoid ligament, because those are supporting, just making sure that those areas are supporting the foot properly and not just like blaming the tibialis posterior tendon. And we just want to make sure, like, how are all these supportive structures working together? Mostly, again, these can be treated conservatively. Excuse me. Most of these can be treated conservatively. You'll notice a lot of the stuff I'm talking about can be, and that's probably why I'm choosing these. It is because I think I can help you with these, or people in the career path that I'm in can help you with these.

Most MSK conditions can be treated conservatively. Again, it's just how bad is this? What are the goals and what are the things we're trying to get back to? There's a lot to consider when we're talking about is this a conservative management or not, or do we need help from somewhere else? Things like strengthening of the tendon, working mechanics of the foot are things to consider when treating this. Orthotics are often used as well. If this is metabolic or inflammatory, though, then we need to be co-managing with other doctors, maybe discussing medications. That's not something I would discuss with you.

It's not in my scope of practice, but this is why we co-manage with other people. If there's like inflammatory, systemic inflammatory stuff leading to things like this. Referral to functional medicine is something to consider in these cases too, so for dietary and supplemental and lifestyle changes. So like I mentioned, as you can tell, ankle and foot injuries typically go hand in hand, and there are some structures that are primarily located in the foot. The body works as one unit, so many foot conditions are related to function of the ankle. Many ankle issues are related to function of the foot.

Many foot and ankle issues are related to function of the knee, the hip, the low back, the core. So I'm being pretty, I guess, nonspecific when I'm talking about like the treatment of conservative care and just saying like rehab, manual therapy, all of that stuff. It's because there isn't usually no just like one specific way to treat all people who deal with this one injury. We have to consider what's going on with you, your specific life, your specific goals, your history, time and commitment, all of that stuff. And so when we're looking at foot and ankle issues, we're not just looking at the foot and ankle.

We are assessing the entire body, looking at other areas that could have contributed to why we're putting so much repetitive load through this area of the foot. You know, that's just like one common question that I might have in my brain when assessing somebody. So just keep that in mind. When you are getting injuries like this treated, if we're just looking where the pain and discomfort is at, most of the time you're probably not going to get 100% better or like the improvement that you're looking for. Most of the time, the whole body movement and systems should be considered when properly treating these injuries.

So kind of moving into the foot here, we're going to talk about plantar fasciitis. We're going to talk about stress responses or fractures. And we're going to talk about Morton's neuroma. Let's see here. So injuries can be acute, such as fractures and sprains or chronic resulting from overuse, repetitive stress or underlying conditions like arthritis. Inflammatory and overuse injuries, such as plantar fasciitis, which is inflammation of the plantar fascia. It's that band of tissue on the bottom of your foot. Like you really could just like take your thumb right into the arch of your foot. And that's typically what you're feeling.

It will cause heel and arch pain and often worse with the first steps in the morning or just after some prolonged rest. It plays a vital role in maintaining the normal biomechanics of the put, of the put, of the foot, providing essential arch support and serving as a shock absorber. Typically, it's caused from overuse and will be preceded by things such as foot position, ankle mobility issues, lower limb function and tightness, things like the calf. This is often seen in runners, obesity, or jobs with prolonged standing. Again, treatment can be conservative and usually is. Modifying activity, working the areas that need improved function through rehab, manual therapy, and education.

So plantar fascia, we're not just treating the plantar fascia. A lot of times it's something else that has caused a lot of load on the plantar fascia that needs the attention, that needs help improve or help needs improvement and improvement in function to help the plantar fascia heal, relax, all that stuff. So, again, just, you know, rolling your plantar fascia on a frozen water bottle and putting an orthotic in your shoe and hoping it's going to get better is not the approach here. There's something else that's contributing to overuse of this specific tissue of the foot that needs to be considered.

Again, if you want to know what's the right approach for you, maybe you've been getting treated for a little while or you tried to treat this on your own with just rest and it just does not seem to be getting better, you've rested for six, eight weeks and then have tried to return back to your sport and there it is again, reach out to us. We can help you virtually in person. We'd love to guide you down the right path. Stress responses. So, repetitive loading of an area of the foot too quickly or without proper recovery can lead to bone marrow edema responses, which are known as stress responses, and any, really any bones of the foot there.

If they're not properly managed or if the load is not taken away from that area, they can lead to fractures. So, activities like running is the most common cause of this. It is typically tender to palpation and can usually be diagnosed with a detailed history of activity and imaging. Swallowing may also occur. This is typically managed with modifying activity for six to eight weeks and slowly progressing back to activity over time. That is super important to consider. It's not like rest it and then go right back where you were. Where you were was what got you here. Too much too quickly is what got you here.

So, a progressive program where you can properly, sorry, I just got distracted by a squirrel in the tree out the window. My bad. A progressive program over time to slowly get you back to where you were is what we're looking at here. And then you can kind of continue on in your goals and in your improvements. But we may also look at your load management strategies too. So, improving upon these things. There's always stuff that you can do. Rest doesn't mean like bed rest and not do anything. It's just that we need to take the load off the area that is involved. There's still other areas we can be working on in the meantime in a very safe way that can keep you in shape, that can improve your function, that can improve this injury and kind of prevent it from happening again in the future.

Again, we can never predict the future, but we can always, you know, try our best to set you up for success. Lastly, I'm going to cover Morton's Neuroma. It's a nerve condition causing pain, numbness, and tingling in the ball of the foot, usually between the third and fourth toes. It's often due to repetitive stress or ill-fitting shoes. I haven't managed this condition through rehab. They manage this condition through rehab. So, just wanted to mention that lastly because a lot of times, I think when I've spoken to people who have had this or have heard stories through colleagues, they've been told like this is kind of just something you have to deal with maybe or it's only a, you know, like a surgical thing.

Honestly, I'm not going to sit here and babble, but I know that it has been successfully treated conservatively. So, just find somebody around you who can confidently treat this and approach this and make sure that this is what you're dealing with. I know they exist out there. Let me know if you need some help finding somebody. So, I want to highly recommend, lastly, just to close this podcast to not try to manage these conditions on your own. I always say there's nothing wrong with just taking a little bit of time to see if your body can physiologically repair things on its own because that's what it's made for, right?

It knows it's really smart. It really just needs a good environment to do what it does well to heal most of these things. Like, I've just seen too many people where they're like, you know, unfortunately, I tried to do this on my own for this long. Like, there's nothing wrong with trying that, but it's like, give yourself a timeline here. Like, four to six weeks on your own with just like modifying your own activity. Not a bad idea, but for some reason, you're going right back to what you were doing. Doesn't seem to be getting better. Maybe you're seeing somebody and not seeing the progress that you want.

Maybe you've gone a lot of places, tried a lot of things. It's just not improving. I promise you the help you need is out there. Again, you can always reach out to us. We can guide you in the right direction, whether that be with us virtually or in person, or we can help, you know, find somebody in your area. We know a lot of people in different states. So, again, don't try to do this on your own for too long. Waiting simply a few weeks to see if it'll heal on its own is okay. Chronic conditions or sticking with the treatment protocol that isn't working, I just wouldn't recommend. So, that's it.

I think I'm repeating myself. So, now I'm just going to go ahead and end this podcast. Thanks for listening.