The back of my ankle hurts! (For the soccer and ballet buffs out there…)
If you are a dancer or a soccer player or to a lesser extent a jumping athlete (think volleyball etc.) then you may have run into a problem characterised by point tenderness at the back and inside of the heel that exacerbates when you plantarflex the ankle (point the toes). Or if you are that dancer perhaps, when you come up into a demi-pointe position. The cause of this pain is an irritation of the flexor halicus longus muscle – the muscle that pushes your big toe into the ground as you stand/walk. The cause of this condition, Posterior Ankle Impingement (PAI), is multifactorial – ranging from congenital deformity of an ankle bone (the talus) that makes friction against the tendon more common and irritating, to simple overuse of the tendon from activity.
A common misdiagnosis for the problem is achilles tendinopathy. But achilles tendinopathy differs in that the point location of the pain is distinctly on the tendon, behind the ankle joint anywhere from its insertion on the calcaneus (heel bone) to the meaty part of the calf where the tendon meets the belly of the gastrocnemeus muscle. By comparison PAI pain sticks lower down, at the back and inside of the ankle and not on the calcaneus.
Treatment is relatively simple, and as is typical with good rehab has a few different prongs:
proprioceptive exercise – Think of proprioceptive exercise as that class of exercises that focuses on balance and posture/body positioning. These exercises can help to strengthen muscles that support the foot arch which reduces the amount of frictioning and irritation on the Flexor Halicus Longus tendon.
Single leg stance activities and bosu work are great examples of this, and you can see the video above for demonstration of this type of exercise with Vanessa. Also consider the short foot exercise shown here as a good option.
Discontinue aggravating exercise: I know this seems like an obvious suggestion but you’d be surprised how people will power through tremendous pain and aggravation of their injury and then throw up their hands in confusion when it inflames afterward.
Paying attention to the activities that bother it and modifying anything that causes an increase in pain lasting more than 24hrs is a good rule of thumb and good athletic discipline as well. Remember, when you are hurt, good athletic discipline includes is managing your injury, so activity monitoring and modification truly is athletic in the injury context.
Other modalities like dry needling the flexor halicus longus and the medial gastrocnemius (the inside, bulky part of your calf) can also be helpful in reducing baseline tone in the muscle and the associated pull on the unhappy tendon. There is even research suggesting that a more aggressive needling technique called fenestration, which uses the needle to actively create some trauma and trigger a natural healing (inflammatory) response is helpful, however this is more aggressive than I would choose to practice.
Isometrics: In cases of tendinopathy, Isometric exercise is well documented pain management modality. This type of exercise uses a static muscle contraction (just like pushing into a wall would be a static contraction of the pecs) held for 45seconds and repeated 5 times. The use of this modality is well documented for other type of tendon problems and can be used in the case of PAI as well. See the video above for a demonstation
As is shown in the video, you can contract the FHL muscle by flexing the big toe against a wall, ensure that you are not at end range of ankle planterflexion (pointing the foot) otherwise it will be painful and irritating. Hold for 45sec and repeat 5 times. You should find a relief from pain that last for up to a few hours!
In the worst case, if there is a bony congenital issue surgery may be indicated. There are a couple of congenital defects that may be relevant. In one case people can be born with an excessive bony outcropping at their talus bone called an enlarged stedia’s process. In another case, an accessory bone -a “floating” bone that sits adjacent to, but is not attached with a larger skeletal bone- exists next to the talus by the flexor halicus longus tendon. This situation, known as an “os trigonum” is atypical (most people don’t have this, it’s a congenital defect) and is sometimes found in cases of PAI.
In either of these cases the offending bony defect is modified surgically, and after rehab the athlete should have significantly improved activity tolerance.
Of course, and just to be clear, most cases of PAI resolve with conservative (not surgery) treatment including activity modification, exercise and other non surgical treatments. Talk with your physiotherapist to see if PAI is an appropriate diagnosis for you. If it is, the exercises as shown can be a good starting point as part of a management plan.
Further reading (if you really want to impress your friends)
Heier, K. A., & Hanson, T. W. (2017). Posterior Ankle Impingement Syndrome. Operative Techniques in Sports Medicine.
Kudaş, S., Dönmez, G., Işık, Ç., Çelebi, M., Çay, N., & Bozkurt, M. (2016). Posterior ankle impingement syndrome in football players: case series of 26 elite athletes. Acta orthopaedica et traumatologica Turcica, 50(6), 649-654.
Senécal, I., & Richer, N. (2016). Conservative management of posterior ankle impingement: a case report. The Journal of the Canadian Chiropractic Association, 60(2), 164.
van Ark, M., Cook, J. L., Docking, S. I., Zwerver, J., Gaida, J. E., van den Akker-Scheek, I., & Rio, E. (2015). Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. Journal of Science and Medicine in Sport.