The ankle is one of the most versatile joint complexes in the body. It is specifically built for weight bearing, mobility, adaptability, and stability. The foot and ankle allow us the ability to walk, stand, and serve as our connection to the ground. The ankle must be able to withstand the stress of body weight and also be able to adapt to and react quickly to changes in the environment and walking surface.
Generally, your ankle ligaments have many important tasks, which are to:
- Stabilize your ankle joint.
- Stop your ankle from moving in any unsafe or unnatural directions.
- Keep the bones in the proper position.
- Connect the bones of your foot with your lower leg.
- Absorb shock when your foot strikes a surface.
There are three sets of ligaments within your ankle…
- Medial ligaments – Also known as deltoid ligaments, these ligaments begin at the medial malleolus (the end of the tibia, which forms the bump on the inside of your ankle). Then the four ligaments fan out to connect to the talus, calcaneus, and navicular bones.
- Lateral ligaments – The lateral ligaments begin at the lateral malleolus (the end of the fibula, which forms the bump on the outside of the ankle). Additionally, the three ligaments connect to the talus and calcaneus.
- Syndesmotic ligaments – This set of four ligaments connects the tibia and fibula.
Pain at the front of the ankle is known as anterior ankle pain. It can either be sudden onset (acute) or develop gradually through overuse. The tibialis anterior muscle is the large muscle that runs down the outside of the shin. It is a powerful dorsiflexor of the ankle (lifts the foot up). Inflammation of the tendon sheath can cause pain at the front of the ankle, particularly when bending the foot and toes up. Also, if you push your fingers into the tendon, you can sometimes feel a creaking when you move the foot up and down.
Ankle impingement (also known as footballer’s ankle) is another condition when a bony growth at either the front or back of the ankle bone restricts normal ankle range of motion. A bony spur at the front causes anterior ankle pain. Generally, impingement means tissues have become trapped between bones. It occurs where the ankle bone meets the shin bone, and often follows a sprain that hasn’t fully healed.
Causes & Symptoms of Anterior Ankle Pain
There are several ways your anterior ankle can be caused. Some causes include sprains, trauma, or inflammation (arthritis). In cases of ankle impingement, it causes a painful limitation of ankle range of motion due to soft tissue or bony abnormality.
Soft-tissue impingement results from irritation to the fibers that go around a joint, or the joint’s ligaments or cartilage, which may thicken over time. In most cases, the impingement symptoms follow acute traumatic events, usually ankle sprains or small injuries, that accumulate over time from repetitive activities such as running and jumping. Impingement of the ankle is typically divided into two main types, such as described below.
Anterior ankle impingement
This occurs in the anterior part of the ankle and is very common in all athletes who sustain repetitive ankle dorsiflexions, such as soccer players, football players, and runners. These patients report pain over the front-outside aspect of the ankle that is reproduced with cutting and pivoting movements.
Posterior ankle impingement
This occurs in the posterior part of the ankle and is very common in athletes who sustain forced plantarflexion. It is recognized most commonly in ballet dancers who stand in the demi point or in point positions but can also be seen in runners and soccer players. It is also seen more frequently in athletes who have an accessory or extra bone in the back of the ankle as this can lead to pinching of the ankle capsule.
In cases of tibialis anterior muscle pain, the pain generally comes from the muscle, which lies at the front of the lower leg, and attaches to the top of the foot. Pain in this area can be confused with shin splints, which is pain on the inside of the lower leg / shin. Instead, this pain would be at the front of the lower leg to the outside of the tibia bone, or at the tendon on the top of the foot. It is very rare to tear or injure the anterior tibialis muscle from a sudden injury.
However, if this does occur, you may experience pain or tightness at the front of the lower leg. This can be while walking or while applying pressure to the affected area. While walking, the pain would be more severe while lowering your foot to the ground, immediately after a heel strike.
Symptoms regarding anterior ankle pain due to the conditions mentioned above include:
- Ankle swelling
- Ankle pain with specific motions
- Limited ankle range of motion
Who gets Anterior Ankle Pain?
Anterior ankle pain typically occurs in athletes who have played years in sports that involve a kicking motion and therefore repeated ankle extremes or motion either up or down.
This is common in soccer players but has since been described to occur in American football, volleyball, ballet, and runners. All of these sports involve forceful ankle joint motions that place tremendous pressure on the joint itself. As this is an overuse injury that slowly progresses over time, symptomatic athletes tend to have participated in their sport for a long period of time and are often at least 25 years of age.
How Does Anterior Ankle Pain Affect You? How Serious is it?
If treatments for anterior ankle pain are not successful or if left untreated, surgery may be required. In a surgical procedure called arthroscopic debridement, in which a surgeon makes small incisions and uses a mirror to see inside your ankle to remove the bone spurs causing the pain. Of course, all surgical procedures include a low percentage of complications, such as:
- Persistent ankle pain – Some patients may experience ongoing persistent ankle pain after surgery. When this occurs, your doctor will work with you to create a treatment plan, which may include additional physiotherapy or medicines to help you recover regularly.
- Nerve or blood vessel damage – During surgery, there is a minimal chance that the nerves, veins, or tissue around your ankle can be damaged. Damaged nerves or blood vessels can cause numbness, pain, or lower blood flow around the knee.
- Blood clots – Because an arthroscopy affects the way blood flows around your ankle, it can increase your risk of developing blood clots.
Recommended Treatment & Rehabilitation for Anterior Ankle Pain
Your doctor or physiotherapist will perform a complete assessment to help diagnose the cause of your anterior ankle pain. To do this, they will take a full medical history to understand how your injury occurred. This will give an initial idea of what your injury might be. Next, they will see how your ankle moves and whether any specific movements trigger pain.
Active and passive movements give an idea of the range of motion and whether it is restricted in any sort of way. Pain on active or passive movements may indicate impingement or ligament injury. Furthermore, to provide a more definitive diagnosis, your doctor / physiotherapist may collaborate with an orthopedist or other healthcare provider. The most accurate method to diagnose anterior ankle pain injuries is by X-ray or magnetic resonance imaging (MRI), which can both be ordered by the orthopedist.
Once you have been diagnosed with a condition associated with your anterior ankle pain, your physiotherapist will work with you to achieve your recovery and help you return to activities you previously performed without pain. Your treatment programs may include:
- Pain management – Your physiotherapist may use ice massage or electrical stimulation if you have inflammation causing pain. He or she may ask you to reduce your activity level for a while, so the inflammation in your ankle can decrease.
- Range of motion exercises – Your therapist may gently move your ankle through its available range of motion or teach you the proper motions to move through in order to increase its mobility and decrease stiffness.
- Supporting equipment – Your physiotherapist will recommend proper footwear for the activities you enjoy to ensure your ankles and feet get the best support needed. It may also be necessary to get fitted for a custom-made foot orthotic to reduce stress on your tendons. In severe cases, a foot brace may be ordered to help immobilize your injured ankle for several days until your pain has subsided.
- Muscle-strengthening – It is very important to strengthen the muscles acting on the foot, ankle, and lower leg to promote proper joint mechanics. When the muscles are strong and working properly, the joint space in the ankle is maintained, which decreases the risk of compression of soft or bony tissues.
- Balance exercises – Your physiotherapist may give you balance exercises to challenge the way your body reacts to outside forces. These exercises make you more aware of where your body is in space. Improving your balance will lead to a more stable ankle because your body can easily respond to certain obstacles.
- Functional training – Once your physiotherapist has helped heal your anterior ankle pain and inflammation, you will progress to further activity-specific tasks. He / she will ensure that your ankle can withstand challenges during occupational, sport, or other activities involving repetitive lower leg movement.
Below are several helpful leg exercises in order to boost your ankle recovery:
Calf wall stretch (back knee straight)
Begin by standing and facing a wall with your hands on the wall at about eye level. Next, put your affected leg about a step behind your other leg. Keeping your back leg straight and your back heel on the floor, bend your front knee and gently bring your hip and chest toward the wall until you feel a stretch in the calf of your back leg. Hold the stretch for at least 15-30 seconds, then repeat 2-4 times a day.
Calf wall stretch (knees bent)
Stand facing a wall with your hands on the wall at about eye level, then put your affected leg about a step behind your other leg. Keeping both heels on the floor, bend both knees. Next, gently bring your hip and chest toward the wall until you feel a stretch in the calf of your back leg. Hold the stretch for at least 15-30 seconds, then repeat 2-4 times a day.
Shin muscle stretch
Sit in a chair, with both feet flat on the floor. Bend your affected leg behind you so that the top of your foot near your toes is flat on the floor and your toes are pointed away from your body. Hold the stretch for at least 15-30 seconds, then repeat 2-4 times a day.
Alternative & Homeopathic Treatment
Certain treatments depend on the type of anterior ankle pain. So, here are a few options you can try to boost your recovery of the condition:
- Immobilization – A cast or splint may be used to help keep the foot and ankle from moving and allow the injury to heal.
- Medications – Oral non-steroidal anti-inflammatory medications (NSAIDs) or pain-relieving creams may help reduce pain and inflammation.
- Ice / heat application – Applying an ice pack for 20-30 minutes can help reduce swelling and inflammation. Additionally, heat packs are useful to increase blood circulation.
- Foot shower – Placing your affected foot in a bucket filled with warm water can help relieve your foot pain and increase blood flow. Adding Epsom salt will increase recovery speed.