Ankle lateral ligament sprain

Tibialis Anterior Ganglion Cyst

Here's a photo of one of the recreational badminton athlete who found that he had a small swelling at the ankle. Upon examination, I found a 2cm X 2cm cystic swelling just before the insertion of the Tibialis Anterior tendon. An ultrasound scan should be done to confirm the findings.

Usually, the cyst is treated conservatively with a corticosteroid injection. Care should be taken to ensure that the tendon is not damaged in the process. Surgical excision may also be carried out. However, such lesions are known to recur.

Lateral Ligament Complex Sprain: Anterior Drawer's Test

Achilles Tendon Paratenonitis

Mr Lim is a businessman who does regular brisk walking. He came 2 weeks ago with complaints of painful swelling in his back of his left ankle (Achillles Tendon). He started using a pair of leather shoes with a high heel tab which comes in contact with the Achilles tendon every time he walks.



He was examined and I found that had pain standing on his toes (ankle plantarflexion) but little pain stretching his calf (ankle dorsiflexion). He had severe tenderness, oedema and mild redness over the middle of his Achilles tendon.


I advised him to use a low-cut shoe, apply RICE treatment and Anti-Inflammatory gel (e.g. Reparil, Volteran Emulgel). His gait was otherwise normal and he did not have any calf muscle spasm. He would do well with a course Ultrasound treatment.

Extensor Retinaculum Injury and Extensor Digitorum Longus tenosynovitis

A male artistic gymnast was seen a few days ago with complaints of pain in the dorsum of the left foot after intensive training involving runs and jumps since 2 weeks earlier. He had difficulty standing on-toes, taking-off from jumps and landing.

After examining his ankle, I found that he had slightly reduced range of plantarflexion in the left ankle due to pain. There was tenderness and mild oedema of the extensor retinaculum and mild tenosynovitis of the Extensor Digitorum Longus tendons. However, resisted extension was pain free.






I did a simple taping to prevent extreme plantarflexion while enabling him to point his toes during his routine(Two figure of 6, and a double medial and lateral ankle locks and closed up the 'holes'). That seemed to do the trick and he should be back doing some training. However, he was told to refrain from sprinting or jumping to his maximal height as it may aggravate the injury. He was advised to undergo physiotherapy to reduce the symptoms and strengthen his lower limb.

Bilateral Peroneal Subluxation

The videos of a fencing athlete showing both feet plantarflexed and going into eversion to initiate subluxation of the peroneal tendons.

The left peroneal subluxation (suffered after a game of futsal) causes pain with sprinting and quick lunges hence limiting his performance in his sport. His rehabilitation may take up to 8 weeks before return to sport.


The right preoneal tendon partially subluxes but doesn't seem to give the athlete any problems as he is still able to plantarflex comfortably without pain.

Also see a previous post on peroneal subluxation here.

Morton's Neuroma (Interdigital Neuroma) and Ankle Instability

My ex-colleague referred a housewife in her forties with complaints of left forefoot pain since 4 months duration. The excruciating pain is worse while taking the first few steps after sitting or lying down. She got herself a pair of soft Japanese slippers at home to help her walk at home. Hence, she places her weight on her right lower limb and just drags the left lower limb (painful gait). Her back started to hurt when she needed to walk a while longer. She told me she had seen multiple surgeons (received 2 Corticosteroid injections with pain-relief lasting for 2 months), traditional medicine practitioners, massage therapists and general practitioners but the pain relief was inadequate and short-lived.

After probing a little more, she told me that it first started when she twisted her left ankle 4 months ago. She then visited a traditional chinese medicine practitioner who massaged her foot and ankle. Apparently her foot started hurting after the treatment.

Upon examination of her posture and gait, I found that she had overpronation and unstable ankle. Her anterotalofibular ligament was torn and she had poor muscle tone in her left lower limb due to disuse atrophy. She had tenderness between the 4th and 5th metatarsal heads (uncommon for Morton's Neuroma) and a positive squeeze test. She would probably need an Ultrasound scan (more economical than MRI) for definitive diagnoses.

Taping her medial longitudinal arch seem to reduce her pain. A further double ankle lock and lateral stirrups seemed to complete eliminate the pain. I was concerned that she had lost muscle power and tone since she was placing her weight on the opposite side. I left her with some NSAIDS and athletic tape after teaching her the technique but she would need at least 4 - 8 weeks rehabilitation to return her normal function.
We will look into getting her a suitable orthoses for her feet. She may not require Corticosteroid or Alcohol injections if symptoms subside with the use of corrective insoles. If conservative treatment fails after 3-6 months, surgical excision could be done.


Articles of interest:
Morton's Neuroma
Alcohol Injections under Ultrasound guidance
Investigations for Morton's Neuroma
Interventions for the treatment of Morton's neuroma (Cochrane Review)

Ankle Posterior Impingement

Ms Ann (not her real name) is an elite level badminton athlete who came with complaints of pain in the back of both ankles with net-play and jumping smashes since 3 months duration. To her dismay, she still had the pain despite taking a month off from training. These symptoms are also common in gymnasts and dancers who do repeated jumps and en-pointe. Soccer players have been reported to have similar symptoms in literature.

I examined her ankles and found that she had tenderness and bogginess (oedema) of the posterior aspect (back) of her ankle joint (between the Achilles tendon insertion and the calcaneal and talus bones). She had pain when I compressed her hindfoot with her foot plantarflexed (Impingement test). If he jumped repeatedly on the spot, it would give her the same pain. She also had tenderness of her Achilles tendon insertion (Insertional tendinopathy) and associated hindfoot varus.

I have advised her to do some calf stretching with the knees bent slightly and knees straightened. She was also taught to tape her ankle to prevent full plantarflexion. She was planned for an X-ray to rule out Os Trigonum or fracture of the lateral tubercle of Talus. An MRI of the ankle would identify bone bruising, tendon and joint capsule inflammation.

Ultrasound guided corticosteroid has been shown to benefit most athletes with capsule or tendon inflammation. Most of these athletes are symptom free after 2 weeks and return to play within 4 weeks rehabilitation. A selected few with persistent symptoms, os trigonum or a possible nerve entrapment may require arthroscopic surgical intervention.

Find out more about the injury here:-
Posterior Ankle Impingement in Professional Soccer Players: Effectiveness of Sonographically Guided Therapy
MRI features of foot and ankle injuries in ballet dancers

Recurrent ankle pain

Ms Wong is a 25 yrs old lady who does hiking twice a month. Each short hike would usually last 4 hours. She has been regularly training in the gymnasium for a hike up Mount Kinabalu recently and found that her left ankle gives her pain in the mornings and after her 'short' hikes. She also remembered twisting her left ankle several years ago.

Clinically, she has bilateral Anterior Talofibular ligament (ATFL) laxity (left > right). Her ankles were otherwise quite normal. She would be planned for a Plain X-ray of both ankles to rule out any fractures. Meanwhile, she was advised to continue lower limb propriorceptive exercises. She was to consider using ankle bracing or ankle taping when she is to go cross-country running or hiking. We may plan for an MRI of her left ankle if her X-rays are normal and her symptoms fail to subside.

She is due to return after testing the hikes with ankle taping.

Find out more from these links:-
Climbing Mount Kinabalu
ATFL Laxity Test
CFL Laxity test

Peroneal Tendon Subluxation

Nadia (not her real name) was sub-elite gymnast when she came with sudden pain and snapping sensation in her right ankle after twisting her ankle during training 3 years ago. She was seen by another physician who diagnosed her condition and was treated conservatively with bracing for 1 month's duration followed by rehabilitation exercises for 8 weeks.

She had the snapping sensation when she stands on her toes ("On toes") and pointing her toes. I asked her to dorsiflex her ankle and evert the foot and her peroneal tendon would slip in front of the bony prominence (see photo). She only had mild pain everting her foot against resistance. As expected, there was a tendency for the opposite peroneal tendon to slip forward too due to increased laxity. Ultrasonography may be useful if we suspect a tendon tear.*

According to Ferran et al, the diagnosis and management plan are based on clinical evidence. Conservative management may be attempted in acute dislocations, and can be successful in up to 50% of patients, although there is a trend for operative management in athletes. Recurrent dislocations should be managed surgically.**

*J Ultrasound Med.2007; 26: 243-246
**Sports Med. 2006;36(10):839-46.

Ankle sprain without much swelling?

Nicole (not her real name), a part-time fitness instructor came to see me yesterday with a painful right ankle joint. She told me that she twisted the ankle 3 weeks earlier but did not do much for it as she did not have much swelling. She explained that despite a nagging pain she continued to do some classes after a week's rest. She soon realised that the pain was getting more unbearable that she decided to see a doctor.

I examined and found out that she had a tenderness of the antero-lateral aspect of the right ankle, a partially torn ligament (ATFL) and poor sense of balance on the right lower limb. He peroneal tendons and the medial malleolus seemed to be problem free. True enough both ankles seemed more flexible than usual.

She was advised to avoid doing running or jumping without taping. I taught her how to tape her ankle if she had to take classes. I ran through with her the isometric exercises, theraband resistance exercises and balancing exercises she should do. Since she had a grade II sprain, I advised her to do at least 8-12 weeks rehabilitation although she would feel much better within 2 weeks.

Flexor Hallucis Longus (FHL) Partial Rupture

Samson (not his real name) is a club soccer player who felt a sharp pain his right ankle injury during competition last Saturday. He felt pain in the inner aspect of the right ankle and could not 'push-off' to run or sprint after that. He used RICE treatment immediately after injury. The next morning he noticed a bluish discolouration of his hindfoot (see photo) due to dependent hematoma.

He saw me 2 days later and I had him dorsiflex his ankle and curl his toes downward against resistance (to strecth his FHL tendon). He grimaced in pain. He also had pain doing heel-lifts. I suspected a mild strain of his Tibialis Posterior tendon too.

He was seen by an experienced physiotherapist who told him he would be 'out-of-action' for at least a month. I told him that could be accurate but encouraged him to do some isometric exercises (without pain) and keep his fitness level by doing some aqua-jogging. He was prescribed some theraband resistance exercises and told to follow-up with his physiotherapist for electrotherapy.

For most practical purposes, he would need an ultrasound to evaluate the extent of the FHL partial rupture. Tendon partial ruptures may often require at least 12 weeks rehabilitation exercise followed by progressive return to play.

Right Ankle Lateral Ligament Complex Sprain

An athlete's swollen right ankle is shown in the photo above. He had twisted his ankle while landing awkwardly from a jump in the morning. It did not swell up much as he had applied RICE treatment and had it wrapped with crepe bandage. (Note: Do not massage a new ankle injury as it would worsen the swelling and pain).

I examined his ankle and found that he had a partially torn ATFL ligament and lots of soft tissue swelling in the outer part of his ankle. He also had pain when he plantarflexed or inverted his foot. There was difficulty balancing on his right ankle due to the loss of sense of position and balance (proprioception).

He was able to walk with a slight limp due to the pain but he was advised to rest from footwork or excessive walking for a few days. He was given an option to use an Aircast ankle brace to provide additional support. After applying RICE therapy for 3 days, there was only minimal swelling and he could walk normally. Although, the foot looked almost normal, he still had to undergo rehabilitation exercises to strengthen and provide the normal proprioception in his ankle. It often takes up to 4-8 weeks for rehabilitation of an ankle lateral sprain.