In ankle impingement there is a limitation in the joint mobility of the ankle due to pain from a soft tissue or bony pathology. A common finding to precipitate this pain syndrome is an irritation of the synovial membrane or the joint capsule, typically after an ankle sprain or a repetitive series of such injuries. Chronic pain in the ankle and impingement can result from the ankle being sprained and this can give a persistent pain problem with limitations on involvement in sports. Numbers are unclear but some level of impingement could occur in about ten percent of people who undergo ankle sprains.

An acute ankle sprain which precedes impingement is commonly precipitated by a person stepping into a hole or on to something uneven, forcing the foot inwards and downwards with the body weight on it. Impingent can present as anterior (front of ankle), posterior (back) or as a problem with the tibial and fibular interconnection just above the ankle. Patients with anterior impingement report that the front of the ankle joint feels blocked as they try and pull the foot up. If the ankle is dorsiflexed, especially with some force as in lunging forward whilst standing on the foot, this may point to this diagnosis if painful.

If the intervening joint between the tibia and fibula is involved then there will be tenderness and pain on palpating that area firmly and on pressing the two sides of the ankle together. Posterior impingement may be harder to diagnose, the symptoms being less clear although a forceful downward movement of the foot may cause pain. Anterior impingement can be brought on by kicking a ball in soccer and doing repetitive lunging manoeuvres such as in fencing or ballet. Repeated micro damage to the area leads to chronic injury and the formation of bony spurs at the front edge of the joint.

Ankle impingement is difficult to investigate with the usual imaging methods as little may be apparent. Normal x-rays, bone scanning and computed tomography (CT) scanning often show little abnormal, although people with a diagnosis of anterior impingement may show spurs of bone on the front surfaces of the ankle bone (talus) and the tibia. MRI scanning (magnetic resonance imaging) is more helpful to show bony or soft tissue problems.

Ankle impingement is treated initially with conservative methods with typical advice to patients to modify their aggravating activities initially so relieving the stresses on the injured areas to allow pain reduction. To limit the pain and any inflammatory local changes a patient may take nonsteroidal anti-inflammatory medications. Physiotherapy referral can involve the use of local ultrasound, friction massages, mobilisations of the local foot and ankle joints, strengthening muscles and increasing ranges of motion. Ankle braces can be useful for joint stability and to limit joint excursion, with assessment and provision of in-shoe insoles by physiotherapists.

Conservative treatment methods may not settle impingement pain and then consideration turns towards surgical intervention. Modern operation is usually performed arthroscopically, any loose tissue cut away, and bony spurs or soft tissue abnormalities removed. Patients can rapidly mobilise after surgery and almost normal walking can start a few hours after operation provided minor work has been performed. Patients may need to wait 4 to 6 weeks before fully resuming their normal routines, in some cases guided by physiotherapists. Results from trials of surgery for this condition have shown that eighty percent have good to excellent outcomes.

In more serious cases patients may wear an ankle brace and use crutches to reduce the weight borne on the ankle, working up to full weight bearing over a week or two. Physiotherapy may then commence once the brace has been removed, starting with range of motion exercises to the ankle and foot joints. Physiotherapists also use ice and other treatments such as ultrasound to reduce pain and inflammation. Once the ankle has begun to settle the physio will progress the patient onto gym exercises without significant weight such as using a static bike, and then to weight bearing exercises involving power, coordination, joint position sense and balance.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in Manchester, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

The warm weather has come round again and the garden is out there, wordlessly calling you to action. If not much has happened out there yet it soon will as the warmth and light take effect. There’s so much to be done as we try and prepare the plot for growing that perfect lawn, vegetables and flowers.

An epidemic of digging is followed every year at this time by an epidemic of low back pain, neck pain and other injuries. Most of these are preventable with just a bit of planning and preparation.

Winter is typically a time of much reduced physical activity and exercise for most people, turning us into less fit physical beings. The warm weather then calls us to action outside at the very time we are worst prepared to face significant physical demands on our bodies.

Warming up is one of the advice tips given and this has some validity but I don’t think it goes anywhere far enough. No matter how well you warm up, if you do too many hours digging without building up fitness for it you will suffer. If the forces you put on your bodily structures exceed their tolerances, something will give however warmed up you are.

It’s vital to do some preparatory work in terms of warming up but we would be unwise not to pay attention to another aspect of performing an activity, the amount of time we choose to spend doing it. Many of us are less fit after the relatively inactive winter period and our body’s tissues are not hardened to tough work especially if it is extended in time. Initial training after an athlete has had a lay-off is easy and graded carefully with no full throttle performance of their event until they have trained their tissues comprehensively.

Most people fall into the mistake of overdoing things significantly when they start out a new activity, usually because the body does not tell us that we have overdone things until its too late. This makes the decision about the level of activity we should do very difficult to judge. If we get out there in the garden, grab a spade and start digging we are highly at risk of doing too much.

Physiotherapy practices and chiropractors and osteopaths all report a significant increase in painful conditions and injuries from outdoor pursuits such as tending the garden in the springtime. Back pain is overwhelmingly the most common presentation although other joint injuries and ligament sprains are also represented. Typically people aggravate an injury they already had before.

11 Ways to Prevent Injury and Get Fit for Gardening

1. Keep up activity and exercise during the winter so you are not totally unprepared.

2. Follow a stretching routine each time before you start.

3. Kneel down if you can, especially for planting, weeding and collecting debris.

4. Decide before starting what breaks you are going to have and when.

5. Start with very short defined times of activity initially and keep the task down to two hours or less in the first few days if you are fit. If you have problems this will need to be lower.

6. Plan a graded increase in activity, using pacing technique, sticking to times you have decided.

7. Make sure you stick to the times you have decided, especially if you feel really good and want to do much more. This is a trap.

8. Use good lifting technique and ask someone to assist if loads are heavy.

9. Avoid mowing by swinging the mower from side to side; walk up and down with it instead.

10. Avoid doing two activities which are posturally similar one after each other. Give your tissues a break by choosing tasks at different heights and angles.

11. If you feel you may have overdone it, leave the activity for a day or so just to see if it is muscle soreness. When you restart, go back with a lower time than when you brought the problem on.

Decide how much to work at before the start and then stick to this with paced increases in level.

Non-bony Structures in the Foot

Bones are not the only important structures in the feet, there are also the muscle, ligaments and tendons to consider. The ligaments, tough collagen bands or straps, connect the bony structures and stabilise the foot, allowing all normal movements to occur within their tight restrictions. Capsular structures are present between all the foot joints, giving structural stability to the foot joints and allowing the lining of the capsule to secrete the nutritional and lubricating fluid the joints require. Straddling the foot arch longitudinally underneath is the plantar ligament, the largest ligamentous structure in the foot.

The arch is partly maintained by the plantar ligament which can store energy in certain phases of gait and use it later to contribute towards giving us the spring in our step. Any injuries to the plantar ligament can have affects on the support function of the whole foot as well as being very painful and sharp. The Achilles tendon, a large and powerful band of tendon, attaches at the posterior of the heel bone, being the extension of the major muscles of the calf, the gastrocnemius and soleus. The calf musculature is the provider of propulsive power in walking and running.

Walking is a complex movement and often referred to as controlled falling. The gait cycle is the cycle we go through repeatedly with the same series of anatomical actions. The foot bears weight evenly on the front and rear on standing. In gait the foot hits the ground typically at the rear and outer border of the heel, the weight then passing forwards and towards the ball of the foot and the great toe. The plantar ligament stretches to some degree and absorbs some of the load. As the foot rolls inwards and the arch flattens to some amount, the foot moves into what is called pronation.

Hitting the ground and bearing weight on the midfoot brings the foot posture towards the outside into supination as the foot rises to push off on the ball and the big toe and the foot leaves the ground. Exaggeration of these postural positions during gait is an example of pathological changes which can occur. The big toes take around 60 percent of the weight being transferred through the foot in walking, and this can be abnormally increased if the foot overpronates and throws weight medially. The opposite tendency is underpronation as the person throws their weight laterally onto the outer foot border.

Difficulties with Gait

Changes which occur in one bodily area can have distant effects on other bodily regions due to the connected nature of body systems. A typical gait pathology is the antalgic gait, a gait where the body attempts to avoid a painful position or weight bearing posture. One of my neighbours attempts to minimise the forces which are being transmitted through his low back by gliding around smoothly, limiting spinal movement and using his legs almost exclusively to perform his gait. Pathologies can develop in other areas of the body as it attempts to limit forces by adopting an altered gait.

Babies’ feet are cute and chubby and very mobile, being made up significantly of cartilage rather than bone initially, and it takes almost twenty years for the feet to become fully bony and growth completed. The foot arch is not obvious in the very young due to the thick pad of fat which fills up this area. As the child learns to walk the fatty cushion reduces and the arch reveals itself. Typically young children are often knock kneed to some degree up to the age of six with this process changing slowly with time until they have the normal knock knee of about seven degrees.

It’s not until we are around twenty years of age until our feet are fully mature and fully ossified. Looking at the feet of young babies it is clear they are fat and bendy, with much of the internal skeleton being made up at this age of cartilage. We can’t see any foot arch due to the fat deposits occupying this area and have to wait until walking commences before the fat reduces in size and we can observe the typical foot arch. Young children commonly also have knock knees but this tends to settle gradually by the time they are 6 years of age. The level of knock knee reduces gradually towards the adult level of seven degrees.