Sports Rehabilitation | Medial Ankle Pain

Monday 8th November 2021

Hours: 4

Patient presentations:

Reflection Focus

Reflection Model

What Happened?

Patient’s 2nd visit to clinic – Medial ankle pain, pinpointed inferior and posterior to the medial malleolus.
Reassessed PoP reduced from 1o to a 7/10. No longer any pain on passive DF but 2/10 on passive EV. No longer experiencing pain at rest or at night.
Patient is a runner and although running load had reduced it is causing pain VAS 5/10. Calf raises also cause pain 6/10 – pain lasts for an hour and eases with ice.
No pain when wearing trainers, but pain when walking in boots or barefoot.

What were you thinking and feeling?

I was really unsure on what was causing the patients pain. When I asked for support from the clinic supervisor they were also unsure.
The patient was experiencing pain several weeks before this session; however, she ran a marathon which resulted in a significant exacerbation in her symptoms. So, my thoughts were leaning towards an overuse/overload injury.
The patient didn’t feel as though their condition was improving initally; however, they were also quite down at not being able to run so this may have clouded the small improvements she had made. When we discussed other exercises such as swimming she admitted that this was something that she could do and does actually enjoy. Furthermore, when we reflected on the improvements to date she acknowledged that things were better.

What was good and bad about the experience?

As the patient’s symptoms were improving we agreed to keep the same exercise prescription. I wanted to removed calf raises due to the pain but the patient felt it was, ‘targeting the right area.’ So, we kept the calf raises but eliminated running entirely to see how this would impact her symptoms. It was good to have a discussion with the patient in this way and it also resulted in her guiding her own rehabilitation as she stated if it kept causing her pain or the pain increased she would cease and just keep up with the non-painful exercises.
It wasn’t great that I didn’t really know what the issue was. However, rather than get caught up in not knowing a possible diagnosis I treated the symptoms. There was a suspicion of tarsal tunnel syndrome as the patient did have numbness in her toes two weeks prior.

Analysis

On reflection, the patient was likely presenting with tarsal tunnel syndrome. Night pain, pain on EV and DF are all common presentations as well as numbness, tingling and pain on walking (Kiel and Kaiser, 2021). It is also possible for pain to localise to the posterior of the medial malleolus; therefore, there is a strong indication that this patient has TTS. Calf raises were a good prescription to give; however, stretching may prove more beneficial so there should be a focus on the eccentric phase if tolerable (Kiel and Kaiser, 2021) Furthermore, tibial posterior strengthening should be incorporated on her next visit to aid ankle stability and potentially offload irritated structures.

Conclusion

To benefit this patient further I will read literature on the rehabilitation of tarsal tunnel syndrome to see if there are any protocols in existence.
Eccentric calf raises, and tibialis posterior strengthening should be incorporated into exercise prescription

Revisiting Reflection

References

Kiel J, Kaiser K. Tarsal Tunnel Syndrome. [Updated 2021 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513273/

Medial Ankle Pain – Runner