Posterior Ankle Pain

Pain at the back of the ankle is one of the most common complaints I see in dancers. The position of full plantar flexion (plantar flexion is the technical name for the motion of pointing one’s foot i.e. en pointe, degage/tendu, en rise) is not a “normal” position for the ankle to be in and requires an extreme amount of motion in the ankle. The action of extreme plantar flexing of the ankle joint creates a compressed position of the hind foot, mostly at the talocrural joint. This results in reduced space at the back of the ankle. 

There is a “highway” of tendons, ligaments, nerves and blood supply that pass the back of the ankle and much of the pain that dancers experience in this area is due to inflammation and swelling. If the tendons that run through the back of the ankle are inflamed, they take up more room than usual, and so get even more squashed when you point your foot causing a posterior ankle impingement.

Symptoms that dancers often describe when they have pain at the back of the ankle include: 

· Pain felt in the back of the ankle usually with full plantar flexion (pointing) of the ankle 

· Pain with demi pointe and pointe work 

· Left untreated the pain can start with plie or dorsiflexion of the ankle 

· Swelling at the back of the ankle 

· Refered pain can be felt in the calf or foot 

Some of the common diagnoses of pain in the back of the ankle are: 

· Posterior Impingement 

· Tibialis Posterior Tendinopathy · FDL or FHL Tendinopathy · Achilles Tendinopathy · Trigger Toe 

· Severs Disease · The presence of an Os Trigonum 

· Talar or calcaneal fractures 

· Retrocalcaneal bursitis

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A lot of the time pain at the back of the ankle is caused by an overuse injury; meaning that it develops slowly overtime rather than because of an accident or trauma. Usually pain comes on because of poor technique. Some of the possible causes are: 

· Poor firing of the medial gastrocnemius (calf) muscle 

· Clawing toes 

· Pushing over on the big toe in tendus 

· Rolling in of the arches (pronation)

· Over correcting the arches using tibialis posterior instead of the intrinsics muscles 

· Poor control of the intrinsic muscles of the feet both in standing and with movement 

· Hypermobility and poor support of the position of the heel 

· Pes Cavus foot (“rigid high arch”) – resulting in poor shock absorption with jumps 

· Poor control of the soleus muscle in eccentric lowering

Treatment

Pain at the back of the ankle is not something that dancers have to live with, nor should they think it is a normal thing. Initially rest to settle inflammation combined with appropriate exercises can make a big difference to symptoms. Working closely with a dance physiotherapist or healthcare provider can ensure you progress your rehabilitation in a dance specific way finding a balance between returning to class work and ensuring that the injury does not return. 

· Wearing supportive shoes – no thongs, ballet flats or flip flops 

· Training of the intrinsic muscles of the feet support the arches* 

· Taping techniques to reduce the load on the affected tendons 

· Soft tissue massage to release tight calves. 

· Pelvic stability and core activation exercises. 

· Gluteal activation exercises and retraining walking and normal movements. 

· Gentle stretching of the calves 

· Modified class work whether that be a number of hours, restricting specific movements or a combination of both 

· Stopping pointe work for a time. 

· Using heel cups or soft orthotics in street shoes. 

*please see our previous article on strengthening the Intrinsic muscles of the Feet for exercises to assist

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If an Os Trigonum is the cause of pain, depending on the size and the level of the dancer, it can be surgically removed. A specific rehabilitation and training program is then undertaken in the weeks and months following the surgery to ensure a safe return to class. Return to class should be taken gradually as symptoms settle. As posterior ankle pain is usually due to an overuse injury it is important to monitor symptoms and technique to ensure pain does not return.

And remember; always be guided by your physiotherapist or health care professional.

Article written by Haydee Ferguson.

Physiotherapist with a dance history spanning more 25 years.