Trail running ankle impingement: causes, relief and recovery

You're listening to the Restoring Human Movement Podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, it's your co-host Sebastian with the Restoring Human Movement Podcast. Thanks for joining the show with me today. You are on the right show if you're an active individual, such as a runner or people who like to challenge your body through sport, and you have not been able to actually do so because of an injury. So we've covered various things from hips, groins, low backs, sciaticas, knees, plantar fasciitis, and so on.

And today I'm going to cover a case today that I think it would be nice to share, which was with ankle impingement. Ankle impingement, for those of you who are not aware of it, is there's a pinching pain in the backside of the ankle right around the Achilles. Today I want to cover a little bit about the presentation so you can help identify it with your, by yourself today, but also give the right type of information to your healthcare provider since they will be the ones who would guide you the most efficiently to solving the problem. And also I'm going to share some exercises and other thinking points that you should be aware of and that your healthcare provider should be aware of as well to get you back into activity as soon as possible.

So this was a trail runner. The trail runners are known for having lots of lower leg injuries, plantar fasciitis, ankle injuries, and even knee ones top the list. There's obviously things like groin conditions they tend to have, but overall, I'd say far and beyond, they tend to have more conditions below the knee than anything else. And obviously it's going to stop them from being able to run. So this individual is not able to run anymore. In fact, things, simple things like hopping, even lunging, bother him. Walking up a hill is completely fine. So hiking is perfectly fine, but walking down a hill is not fine unless he changed his foot position.

So it's a little bit more of like you're scuffling down the sideways down the hill versus straight down like toes towards the downside of the hill, which is pretty common with ankle impingement. The troubling thing I think a lot of people get misled about this type of condition is they feel like it's Achilles tendinopathy or Achilles tendinitis. Achilles tendinitis or even tendinopathy usually has some type of swelling around the actual Achilles. And if you reach down to your ankle, you can feel where the Achilles is. It's the biggest tendon in the area. It's on the backside. And it actually can be compared to the other side to see if there's actually swelling.

Most of the time, the Achilles is actually fairly thin. It's probably only about the diameter of it, like a little bit bigger than your pinky finger. Maybe it's as big as your ring finger if you were to feel it down at the very lower part of it. But it's not very big, but it's a very strong structure. And then for those people who have had longstanding injuries or longstanding irritation to the tendon, a lot of times there's swelling that happens, not really around it, but within it. When you look at a ultrasound of Achilles injury, you'll actually see that it's actually, it's full of fluid. It's more black than a standard Achilles tendon would be.

And this would be more indicative of a possible Achilles tendinopathy or Achilles tendonitis. So that was not the case in this individual, but he actually felt around that he said because it was around the inner part and outer part of the ankle, it kind of feels like it's Achilles, Achilles issue is where he was going to rupture it. So he had kind of pulled the plug on running overall just because of the fear of making things worse. But he's hiking and doing things that he can, which is a perfect thing to do. Obviously, you do whatever you think is safe for you. But generally speaking, we like to encourage people here at Performance Place to do the things that they are able to do.

And if they focus too much on things they can't do, they'll drive themselves a little bit mad and they'll just stop doing everything. Ideally, we want a green light and okay all the things that are not symptomatic. And then we start to build in a process to make it so the symptomatic things are more acceptable. That's our job. We've actually done this on telehealth with people. I've done it with, I remember a dancer with an ankle injury or an ankle impingement that it fared really, really well. I showed her how to actually do her own self-mobilizations and we did exercises following and it cleared that baby right up.

Like it took only maybe like two weeks in that case. This person's been having it since I believe it was about four months ago. So it's been a long time. The danger of waiting too long is that, again, you decondition the rest of your body. And as most people do, they wait things out a little bit to see if it gets better, natural and acceptable. But when they have an event coming up like another marathon, then all of a sudden the training time is going to start. So they also need to consider, okay, I better think about what I'm going to do with this thing because it hasn't gotten any better. And I need to get my mileage and my body in better shape to actually perform the task of the marathon.

So we're at that point with him. And I like that he has a baseline of activity, which is the hiking. And we'll find more creative ways for him to actually get the running back in. But it sounds like running uphills is going to be okay for a little bit in time. Downhills is probably not going to work out super well for him, at least at this moment. So where areas tend to become symptomatic around ankle impingement is kind of in the area, that little sinkhole between like the ankle bones and the Achilles. It's going to be just above like your calcaneus or your heel bone. And it's a little sinkhole in there.

So other conditions that mimic this is impingement of the fat pad. You can also have bony impingement. I know a lot of people believe that it could be the tendons of the muscles from the calf crossing down, like the tibialis posterior is a really hot topic. But again, that would usually be swollen in that case. And also it can mimic something like tarsal tunnel as well. But usually that's associated with foot numbness or tingling. So for him, at least in testing, really the only things that bothered him was hopping. And actually I had him do a lunge position with keeping the heel up just to see if being in that foot cocked back position was painful for him.

And it was hopping. No more than one hop actually bothered him. He can continue hopping, but it really didn't feel super good. So those are the things we use as an audit process to figure out actually what to do with this individual. Now, in my experience, whatever movement is actually the provoking one, we need to find a different movement, which we can use as a way to pump the joint, to loosen up the impingement aspect of it. In this case, I chose ankle supination. Ankle supination, if you're not familiar with what it is, it's almost like you've turned your ankle. That is the most common direction where people turn their ankle.

And we used that. It was not painful for him to do whatsoever. And so I actually pumped it into terminal supination. I helped him with it and showed him that it was not painful to do. And we actually went ballistic and a little bit harder with it too. So to force that joint to swirl up some of its insides and decrease the amount of impingement. Within about 30, 40 reps, we stopped and I had him hop again. And he said it was significantly better. We did more of it. Most of it cleaned up. It was about 80% better by the time we had done about 100 reps of this. And we sent him home with that activity.

Now, the important thing to figure out though, is not just what the condition is like impingement, but also what are other things that actually drive this condition to become symptomatic in the first place. Since it wasn't a bony impingement, because there's nothing that I would have done that day to actually help him out with bony impingement. And actually, we've had people with bony impingement before. We had to have them surgically removed and the person feared really well after the fact. The thing that drives this condition to continue is abnormal single leg mechanics, which ends up creating more pressure on the certain parts of the ankle as we go through certain movements.

Now, we had him squat actually. His squat was, he was way drifted over onto the side where his ankle hurt. So he's putting more weight onto the symptomatic side. And I've said this in many podcasts before. In what world does someone put more weight on a painful limb? Usually they don't. So when that happens, and we can see it very clear as day, it leads us to believe that his symptoms are actually a result of some other thing, which is making him take weight off of the other limb. So in this scenario, his right ankle hurt. He drifted weight off of his left limb. Which joint was it? I'm not quite sure.

And we actually didn't identify it that day. But he's putting more weight onto the symptomatic limb. Normally, I ask people at that point, what is an old injury that's been on that other side? Usually it's the first injury they've ever had and one that's reoccurred. A lot of times people mention things like, oh, I have an old knee injury over there that happened when I was in college. Oh, I had an old sciatica or back pain that went down that leg, which happened when I was 15 years old. And it's been way better, but I've had a couple of instances over time. Sometimes they say, I had an old Achilles tendinopathy on that side.

And you look and it's still swollen because a lot of times they stay swollen. But they're taking weight off it because that's the older injury. This now, this current ankle impingement is more of a result of long-term compensation and load. So we know he's squatting, putting weight onto it. And then so part of the rehab protocol is to identify, number one, what is the symptomatic tissue? And we did that for him. And we also figured out then what is driving the condition to continue. Well, he's putting more weight on it. He's putting more weight on that limb. So we have to find some exercises that auto-default that away from that painful pattern.

Now, some of you may be thinking, well, I'll just change my squatting mechanics. That's not going to work. You should not be having to think about it when you're actually trying to solve it. A better way to do it is actually to change your underlying body conditions or what we say, changing the individual, changing stiffnesses, changing range of motion. And then the movement auto-corrects back most of the time to a better pattern. So the example I usually give is if I kicked you in the ankle and, or let's say I kicked you in the quad and your quad became stiff over the next couple of days and you started running, would you run differently?

The answer is yes. Would you have to think about it? No. So in that scenario, I kicked you, which is an unfortunate thing, but I sure made your quad stiff. So if we improve stiffness into the other limb somehow, some way, like into the quad, into the glute, or even into some of the core musculature, we can auto-correct that pattern right then and there. And a lot of times it'll last for a couple of days, but it'll surely go back to what it was because old habits die hard. And remember, this is a long-term compensation probably in this scenario. So what we want to ideally do is, number one, give the person a means to control their pain, which is what we did with those ankle inversion exercises, the mobilizations.

If they do them throughout the next couple of days, a lot of times they will feel better and it'll decrease their symptoms quite a bit. And they can also be used as a first aid kit, where if your symptoms return over the next month or so, when they're starting to add back in running, then they can use that as a means to control their symptoms and also keep some mileage up. Identify that they have the squatting pattern, which is altered, which is a reflection of overall other types of patterns too. So he's going to have more knee cave on the right side, which we all know is for runners, that's a no-no.

He also will probably have hip drop, which is going to be a no-no. So ways that we would probably correct this in a long-term fashion is, number one, we can get the core more active, which is usually a really good thing to do with runners because they like to default into an extension or anterior tilt type of position, which doesn't really lend well for a lot of cohesive core activity. So we like an exercise called a hard plank, which works out super well. It does need to be coached oftentimes to coach a neutral or a posterior pelvic tilt because a lot of people will, again, default into old habits die hard.

They will extend their back through this exercise and it will not help them. So that's number one. Number two is we need to load the other limb and encourage the other limb to do some good work. Usually a single leg patterning exercise, which then ends up turning into a single leg deadlift of some type or a single leg deadlift with a cable or a weight. Those are the easiest things to do. But we can also load the squatting pattern, add some strength training to this individual, get the hips stronger because we all know corrective exercises like glute bridges and clam chills aren't going to make you stronger.

They just make the tissue more active for a little bit, but it does not change the strength of the individual. So if we want to change the stiffnesses, the corrective exercises are great. If we want to do a long-term change and build strength as an attribute the person can use in their movement patterns, we need to make sure that we're actually building some strength by using heavier weights with the appropriate amount of reps and sets and so on. And now let's wrap this all up into a ball here. If we're dealing with ankle impingement, yes, we need to make sure that we identify the right diagnosis, the tolerances of the tissue.

In this case, plantar flexion was a big no-no, and then figure out ways to get the joint healthy again without provoking it, which we did, supination. Number two is we need to identify corrupted patterns which aren't making it easy for the joint to settle itself down. In this case, we did. Squatting pattern. We drifted more body weight onto the side involvement, which doesn't necessarily happen on everybody. It happened on a lot of people. And then we can make that, reduce that amount of time in that pattern by increasing stiffnesses with corrective exercises and so on. I've mentioned a few. Number three, build a better strength and conditioning program for this person to not only get better race times, but also decrease chances of injury.

Stronger people usually get injured less. So although we see, I saw this individual in person, this could easily have been done in a telehealth session. We have tons of people we see on telehealth. We're licensed in different states. And if you guys are looking for help, let us walk you through this process. It's very simple to do for most people. I would venture to say a lot of times with ankle impingement, we don't need to do any soft tissue work. It can be helpful for older cases, but for someone who's been experiencing it for a couple months, we don't necessarily need to do so. So coaching them how to find pain management on their own, showing them their movement patterns are a little bit corrupted and showing them ways to solve this problem.

We don't need to create dependency for you guys on us, but we certainly need to show you how to do the step-by-step approach on your own, but also to be able to be your, not be able to be your own self-advocate. Like you need to be able to solve your own problems over time, especially if, you know, there's no need to need to pay us all the time to do this for you. And you're not going to want to pay us all the time to do it either. So, but there's surely ways to be your own self-advocate and to be able to, to coach yourself on a lot of these things too, and be able to identify when it comes back, what to do about it.

So I hope this was helpful to everybody. And if you are looking for some free resources, we do have YouTube. YouTube has a lot of the, we have over a thousand videos on YouTube. We also have a great book that Dr. Mandy wrote on plantar fasciitis. It's not specific to this ankle impingement case, but actually a lot of the mechanics associated to ankle and foot injuries is actually in there. And a lot of them are very common. So there's a lot of crossover and a lot of the strength conditioning, which is shown in there as well too, is very appropriate as well. But again, if you want some one-on-one help, reach out to us, 714-502-4243, or all of our contact is in the description for the podcast. We'll see you next time.