Ankle pain is a common clinical disorder of pain in the foot and ankle region. Pain may arise from the bony joints of the foot and ankle, periarticular structures such as tendon sheaths, tendon attachments or synovial bursae, metatarsal tendon membranes, nerve roots and peripheral nerves, or the vascular system, or it may originate from the lumbar spine and knee joints. Systemic diseases such as rheumatoid arthritis and gout can also affect the ankle joint. Foot and ankle pain disorder affects walking and reduces the patient’s physical activity which in turn affects the quality of life.
I. Ankle pain classification Foot and ankle pain is divided into the following categories according to the primary pain and major lesions and pain sites.
(A) Joint-related ankle pain
Related to the joint’s own pathology, including.
1, arthritis: rheumatoid arthritis, osteoarthritis, psoriatic arthritis, gout.
2, toe disease: bunion, stiff bunion, mallet toe.
3, arch disease: flat feet, high arch feet.
(B) Peri-articular ankle pain
Arthralgia is mainly caused by periarticular lesions, such as
1.Epidermis: corns, calluses
2, subcutaneous: rheumatoid arthritis nodules, gout stones, ingrown nail disease.
3, metatarsal tendon membrane: metatarsal plantar nodules, fibroma, sick plantar fasciitis.
4.Tendon: Achilles tendonitis, Achilles tendon tear, peroneal tendovaginitis, posterior tibial tendovaginitis.
5, mucous bursa: bunions, small toe bursitis, posterior Achilles bursitis, posterior Achilles tendon bursitis, internal and external ankle bursitis.
6.Acute calcific osteoarthritis periostitis: hydroxyapatite pseudofoot (initially metatarsophalangeal joint).
(C) Ankle pain of bone
Including fracture (traumatic and stress), seed osteitis, swelling ulcer, infection, epiphyseal inflammation (osteochondritis), second metatarsal head (Frieberg’s disease), foot navicular osteitis (Köhler’s disease) heel osteitis (ischemic necrosis of the heel bone), paronychia pain.
II. Etiology
The ankle joint or talofibular joint between the distal tibiofibular and talofibular talus is a flexor joint. The synovial cavity cannot communicate normally with other joints, adjacent tendon sheaths or synovial bursae. The tendon spanning the ankle joint area is partially encased within the tendon sheath. Secondly, the tendons of the gastrocnemius and hallux valgus muscles (Achilles or Achilles tendons) attach to the dorsal aspect of the heel, which has no synovial sheath but is surrounded by loose connective tissue, paratendinous tissue, or tendon sheaths.
The posterior synovial bursa of the Achilles is located between the point of attachment of the Achilles tendon and the dorsal aspect of the heel bone and is anteriorly encased by Kager’s fat pad, which protects the distal Achilles tendon from posterior heel bone abrasion. The posterior Achilles bursa is located between the skin and the Achilles tendon and serves to protect the tendon from external pressure. The subacromial synovial bursa is located between the skin and the base of the heel bone. There are two other bursae, the internal subcutaneous bursa and the external subcutaneous bursa, or “last” bursa, located near the tip of the inner and outer ankle, respectively.
Ankle injuries are common in clinical practice, especially traumatic ankle pain. The incidence is quite high, accounting for about 3% to 4% of orthopedic outpatient visits, and is one of the disorders that seriously affect people’s daily life and work.
Some patients with soft tissue impingement syndrome of ankle joint have no obvious changes on X-ray examination, but the swelling and pain of the anterolateral and anteromedial side of the ankle for a long time, which affects the activities, is actually due to the tearing of the surrounding ligaments (such as the tibiofibular ligament, anterior talofibular ligament, deltoid ligament, etc.) after the acute injury of the ankle joint, such as anterior rotation, posterior rotation and dorsal extension, and the scarring of the fibrous bundle at the later stage, which is embedded in the joint space and causes soft tissue injury and synovial inflammation of the joint. This causes soft tissue damage and synovial inflammation, resulting in swelling and pain in the ankle joint. This kind of long-term swelling and pain of the ankle joint without fracture and dislocation is called soft tissue impingement syndrome of the ankle joint. Depending on the location of the injury, it can be divided into anterolateral, anteromedial and anterior ankle soft tissue impingement syndromes.
Clinical manifestations
The main causes of inflammation of the ankle, subtalar joint and other joints of the foot include rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, gout, trauma and osteoarthritis. Ankle arthritis is characterized by diffuse swelling, tenderness at the joints, limited motion, and obstruction of the two small depressions normally present in the anterior aspect of the ankle by viscous synovial fluid. A large amount of ankle exudate has the potential to enter the extensor tendon, resulting in fluctuations, when pressure applied to one side of the ankle can cause waves of fluid to travel to the other side of the joint. Traumatic tearing of the talofibular ligament results in forward motion of the tibiofibula over the talus, and ankle tenosynovitis manifests as linear, superficial tenderness with swelling limited to the tendon distribution extending to the edge of the joint. Movement of the associated tendon produces pain.
The subtalar (talar heel) joint is located between the talus and the heel bone and allows for 30 degrees of inversion (inward rotation of the plantar aspect of the foot) and 10 to 20 degrees of valgus (outward rotation of the plantar aspect of the foot). In subtalar arthritis, inversion or valgus can produce pain with diffuse swelling and tenderness under the talus, but it is difficult to palpate the joint directly.
The intertarsal (transverse tarsal) joint includes the talar navicular and heel dice joints. The dice and navicular bones are usually connected by fibrous tissue, but a synovial cavity may exist between them. The intertarsal joint facilitates inversion (posterior rotation) and valgus (anterior rotation) motion of the talonavicular joint at the level of the subtalar articular surface and also allows for 20 degrees of adduction (tip of the foot toward the midline) and 10 degrees of abduction (tip of the foot away from the midline). Transverse tarsal arthritis causes painful internal and external rotation, diffuse tenderness, and swelling of the intertarsal joint.
The intertarsal joints are planar gliding joints that lie between and intercommunicate with the navicular, cuneiform, and dice bones of the foot, and also communicate with the intermetatarsal and tarsometatarsal joints.
The metatarsophalangeal joint is an elliptical joint with a linear distribution along each synovial cavity, which is distributed approximately 2 cm ventral to the toes. transverse metatarsal ligaments hold the metatarsal heads together to prevent excessive separation of the forefoot. The intermetatarsophalangeal joint capsule is often found between the metatarsal heads. Chronic inflammation of the metatarsophalangeal joint is characterized by localized pain, swelling, synovial thickening, and a positive metatarsal compression test (pain is caused by gently squeezing the five metatarsal heads with one hand). Lateral metatarsal ligament weakness often results in anterior foot spread and toe deformity. Mucocutaneous bursae (bunions) are usually located on the medial aspect of the first metatarsophalangeal joint and, less commonly, a small mucocutaneous bursa located on the lateral aspect of the fifth metatarsal head (microphalangeal bursitis or “tailor’s bursitis”). The proximal and distal interphalangeal joints are articulating joints. The interphalangeal flexor tendon sheath extends around the short and long flexor tendons to the base of the third toe on the sole of the foot. Proximal and distal interphalangeal arthritis is associated with swelling and pain, synovial thickening, limitation of motion, and often toe deformity.
Rest pain is due to wearing ill-fitting shoes, foot deformity, and/or most patients with foot pain are due to weak intrinsic musculature.
IV. Diagnosis
Proper diagnosis relies on knowledge of anatomy, detailed history, assessment of joint function, periarticular soft tissue structures, nerve and blood supply, and the lumbar spine. Diagnosis includes routine laboratory tests, synovial fluid analysis (when possible), plain radiographs, nerve conduction analysis, vascular observation (Doppler analysis), bone scintigraphy, ultrasound, CT and MRI. special radiographic arthrography, arteriography, gait analysis and footprint studies are sometimes required.
V. Treatment
(i) Etiological treatment
Treatment of inflammation of the ankle, subtalar, intertarsal, metatarsophalangeal, proximal and distal interphalangeal joints relies on removing the underlying cause. If necessary, arthroscopic surgery or orthopedic surgery can be given. Under the supervision of ankle arthroscopy, intra-articular debridement and revision of uneven articular cartilage surfaces are performed by means of vaporization and arthroscopic planer.
(II) Symptomatic treatment
1.General treatment
Including moderate rest, local physiotherapy, non-steroidal anti-inflammatory and analgesic drug treatment.
2.Ankle joint injection treatment
For the more stubborn inflammatory synovitis, corticosteroid injection is very effective. When injecting the ankle joint, the joint is slightly plantar flexed forward medially, and the medial tibialis anterior tendon and the distal end of the inferior tibial edge are used as the entry points. The needle is inserted 1-2 cm deep posteriorly medially and a small amount of glucocorticoid and ozone is injected. For talofibular joint injection, the patient is placed supine with the calf and ankle at 90 degrees and the needle is inserted horizontally from the talofibular joint to slightly inferior to the top of the outer ankle near the tarsal sinus. Injection of the intertarsal and tarsometatarsal joints is also easy without fluoroscopy and CT guidance. Injection of the metatarsophalangeal joint, proximal and distal intertrochanteric joints is possible via either the dorsomedial or dorsolateral route. The joint cavity is first located and a 28 gauge needle is inserted into the extensor tendon to a depth of 2-4 mm on either side. slight traction on the correct toe facilitates injection.