Performed by – David Hinsley, Ngwe Phyo, Nick Ward

There are many sports injuries that can occur in the foot or ankle region, but the conditions below are probably the most common. All of our foot and ankle surgeons are experienced in managing these conditions.

Ankle sprains
The ankle sprain is one of the commonest sporting injuries incurred. Most sprains are relatively minor and settle after a short period of rest, elevation and ice therapy. Some patients warrant an X-ray to exclude a fracture, but if there is no bone injury, a period of rest followed by rehabilitation is usually sufficient.

Ankle sprains that continue to be painful may be an indication to seek professional medical advice. Ligaments that are invariably damaged during the sprain injury may not heal fully and be a cause of ongoing pain and inflammation. Some patients find that the ankle continues to feel weak or unstable. Occasionally, an ankle sprain can lead to damage to the cartilage joint surface, which can cause ongoing pain and swelling. Such conditions are normally investigated with x-rays and further scans depending on symptoms and signs. Persistently unstable ligaments can be reconstructed.

Cartilage damage is a more serious injury but can be helped in most instances by an injection or arthroscopy and microfracture. If pain persists, there are more invasive procedures available to try and regenerate the injured cartilage by placing an artificial scaffold matrix in the injured lesion.

Sometimes persistent pain after a sprain is due to a missed bony injury. Plain x-rays are not 100% sensitive in picking up bone injury and sometimes different views to those commonly taken in the emergency department, or further scans are required to detect these.

Stress fractures
A stress fracture is an injury to a bone that occurs at as a result of repetitive, low energy stresses, that normally by themselves would not cause injury. Although they are commonest in people who carry out repetitive activities such as running, dancing or marching, they can occur when people step up their exercise regimes from a relatively low level. Stress fractures can occur in most bones but are most common in the metatarsals in the foot. They can come on relatively suddenly and cause pain, swelling and mild erythema. They are often more painful during or after subsequent exercise. They may not be immediately apparent on plain x-rays but invariably show on MRI scans. They are normally managed nonoperatively through relative rest and a reduction in the repetitive action that caused them. Dietary deficiencies should also be addressed, and sufficient vitamin D taken.

An insufficiency fracture is similar to a stress fracture in that it occurs due to a low energy insult to bone, but normally comes about because of abnormal bone structure, such as osteoporosis. Such fractures tend to be in the elderly and are most commonly seen in the heel bone or the distal tibia. They may be visible on plain x-ray or sometimes require MRI scans to diagnose them. These are also managed nonoperatively.

Achilles tendon rupture
An Achilles tendon rupture is a serious injury but is unfortunately sometimes missed or misdiagnosed as another ankle problem. It tends to present with sudden pain either in the Achilles tendon or sometimes felt higher up in the calf. Sometimes there is an audible crack as the tendon tears, and it can feel like a blow to the back of the ankle. Although this leads to a lack of power in flexing the ankle, it is still possible to bend the foot down due to other tendons travelling into the foot. The tendon can sometimes partially tear, causing weakness, but without the ends completely separating. Anyone who suspects they may have sustained an Achilles tendon injury should seek immediate medical advice. Scans are sometimes required to confirm the diagnosis or the level of injury. Most Achilles tendon injuries are managed in a functional brace however there are some indications for surgery such as significant gaps in the tendon ends, or delayed presentations. Prolonged physiotherapy rehabilitation is normally required after the period in a brace has finished.

Achilles tendinopathy/tendinitis
Achilles tendinopathy normally presents with an insidious onset of pain, tendon swelling and stiffness, particularly on starting activities or when resting afterwards. The exact cause of tendinopathy is not known. It can occur in the middle of the tendon or at its insertion onto the back of the heel bone. Achilles tendinopathy is difficult to settle down quickly, and it can often drag on for many months. There are a number of treatment options available including stretching through physiotherapy, shockwave therapy, high-volume injections, indirect muscle releases and sometimes direct surgical procedures.

Peroneal tendinopathy/tendinitis
The peroneal tendons sit behind the fibula on the outside of the ankle, and travel down the side of the foot and underneath the foot. Like Achilles tendinopathy, peroneal tendinopathy can come on without any apparent cause. The peroneal tendons may also be injured by an inversion sprain injury, or sometimes due to the abnormal posture of the foot. The tendons themselves can develop splits, become thickened, swollen and painful. The sheath within which they sit may become inflamed. Occasionally a peroneal tendon may rupture. Scans may be useful in diagnosing tendinopathy and picking up splits or tears. Tendinopathy is usually managed with a combination of physiotherapy exercises, anti-inflammatory sheath injections and occasionally surgery to debride tissue or repair splits. If there is an abnormal heel posture which is driving the problem, this could be addressed through a custom-made orthotic (insole), or surgery to realign the heel.

Shin pain
There are a number of possible causes of shin pain. “Shin-splints” is relatively common, particularly in those who are building up their training. Other causes include inflammation of the covering of the bone where muscles attach, stress fractures to the tibia and chronic exertional compartment syndrome (CECS). CECS comes on during exercise as the muscles expand due to increased blood flow, causing the pressure to rise within the compartments. If the pressure rises to an abnormal level this can impede further blood flow to the muscles causing pain, loss of power and sometimes neurological signs in the feet. It usually resolves once the exercise ceases. Treadmill pressure testing is usually diagnostic. Abnormal biomechanics should be addressed. Other, rarer conditions, may be considered if the investigations above are negative.