Foot & Ankle Pain & Pathology + Physio

a. Lateral Ligament Injuries or Sprains

Ankle Sprain (Lateral ligament sprains of ATFL, CFL, PTFL)

It presents like this to us:

  • Ankle sprains are arguably the most common acute sport trauma especially in sports requiring jumping, twisting, turning and rapid change of direction movements such as football, netball, volleyball and basketball. Ankle sprains are typically characterised by pain, swelling and bruising over the antero-lateral aspect of the ankle following a typical pattern of ankle inversion with plantarflexion such as occurs when rolling an ankle on the playing surface or landing on a competitor’s foot.
  • This mechanism of injury is a very important clue to diagnosis and can help differentiate lateral ligament damage with other structures in the ankle such as medial ligament damage, osteochondral lesions, tendon rupture, syndesmotic sprains and fractures (including avulsions)
  • The degree of disability both immediately following the injury and subsequently can vary and indicates the severity of injury. Mild grade 1 sprains often are characterised by mild pain with weight bearing activities, minimal pain and little to no joint instability whereas more severe grade 2 and 3 injuries will be accompanied by moderate to severe pain, swelling and joint instability.

What it feels like to you at rest and with sport:

  • Ankle sprains are typically characterised by pain, swelling and bruising over the antero-lateral aspect of the ankle following a typical pattern of ankle rolling in.

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b. Deltoid ligament

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c. High Ankle Sprains

High Ankle Sprain- Syndesmosis Injuries

The syndesmosis refers to the “high ankle” – the unification of the tibia and fibula (two long bones of the shin. These bones are stabilised strongly by a number of important structures including:

  • Interosseous membrane
  • AITFL
  • PITFL
  • Deltoid ligament

It presents like this to us:

  • Injuries to the syndesmosis are often mistaken for “garden variety” lateral ankle sprains. The most common mechanism of injury involves external rotation of the foot relative to the shin.
  • Pain is often quite diffuse and due to movement of swelling will often spread further down the foot and ankle in the hours after injury.

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d. Pott’s fracture

Pott’s Fracture

It presents like this to us:

  • A Pott’s fracture involves one or more of the malleoli.
  • Often symptoms may present similarly to an acute moderate to severe ligament sprain, due to the mechanism, pain and inability to weight bear.

What it feels like to you at rest and with sport:

  • Pain in the ankle or lower leg
  • Swelling, pain and bruising around the area, with touching of the area quite painful
  • Difficult to weightbear through ankle.

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e. Maisoneeuve fracture

Maisoneeuve Fracture

It presents like this to us:

  • A Maisonneuve fracture is the complete rupture of the medial ligament, the anteroinferior tibiofibular ligament, interossessous membrane, and proximal fibular fracture.

What it feels like to you at rest and with sport:

  • Pain in the ankle or lower leg
  • Swelling, pain and bruising around the area, with touching of the area quite painful
  • Difficulty weightbearing through ankle.

We look for this in the assessment:

  • A weight bearing X-ray is required to identify the fracture. The fracture may present in a high impact sport injury. Orthopaedic referral is required in this presentation.

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f. Osteochondral lesions of the talar dome

Osteochondral Lesions of the Talar Dome

It presents like this to us:

  • An osteochondral lesion of the talar dome is commonly seen in association with an ankle sprain where a compressive motion has occurred during an inversion injury. Commonly individuals landing from a jump present.
  • The osteochondral surface is affected from the compression of the talar dome from the tibial plafond.

We look for this in the assessment:

  • Initial x-ray of the fracture may not present depending on the size.
  • Commonly following non-detection on initial x-ray, an individual will present later in the rehabilitation process with contact ankle pain and locking.

What it feels like to you at rest and with sport:

  • Occasionally an individual may report progress following an ankle sprain, however develop symptoms later on reporting pain, catching, stiffness and swelling with increased activity and exercise.

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g. Avulsion fracture of 5th metatarsal

Avulsion Fracture of 5th Metatarsal

It presents like this to us:

  • An avulsion fracture of 5th metatarsal may occur in isolation or with a lateral ligament sprain. Avulsion of the peroneus brevis tendon from the base of the fifth metatarsal results in the fracture.

We look for this in the assessment:

  • X-ray is recommended for suspected 5th metatarsal fractures.  A Jones’ fracture involving the proximal diaphysis of the fifth metatarsal should also be cleared, in an ankle present as an acute injury, however with a mechanism of overuse resulting in a stress fracture.

What it feels like to you at rest and with sport:

  • Pain in the ankle, lower leg and foot
  • Swelling, pain and bruising around the area, with touching of the area quite painful
  • Difficulty weightbearing through ankle.

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h. Impingement syndromes

Impingement Syndromes

It presents like this to us:

Impingement syndromes of the ankle often present due to overuse, with individuals reporting persistent pain following a recent ankle injury.

What it feels like to you at rest and with sport:

  • Pain with end range ankle movements
  • Pain can be in the front, side or back of ankle depending area of impingement
  • Swelling may also be present around the area of pain
  • Movement can feel restricted

We look for this in the assessment:

  • Restricted end range movement in the area where the impingement is suspected
  • Joint feel is important to determine what kind of restriction is causing lack of mobility

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i. Tendon dislocation/ rupture

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j. Anteroinferior tibiofibular ligament injury (AITFL)

Anteroinferior tibiofibular ligament injury (AITFL)

 

It presents like this to us:

  • An anteroinferior tibiofibular ligament injury often presents in association with a high ankle sprain or ankle fracture.

What it feels like to you at rest and with sport:

  • In individuals presenting with marked swelling on the medial ankle, in addition to more proximal swelling and pain than standard ATFL sprains, an AITFL may be suspected. An initial x-ray is recommended to exclude fractures and avulsions.  MRI is the best investigation for suspected AITFL injuries.

We look for this in the assessment:

  • Pain on active external rotation of the lower leg
  • Pain on the anterior aspect of the ankle, with potential bleeding and swelling medially
  • Anterior and medial ankle pain with moderate to severe ankle sprains
  • An initial x-ray is recommended to exclude fractures and avulsions. MRI is the best investigation for suspected AITFL injuries.

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k. Medial Ankle Pains

i. Shin Splints:

It presents like this to us:

  • Shin splints (Medial Tibial Stress Syndrome) is a condition characterised by pain along the lower third of the tibial border, commonly resulting from repetitive loading and stress in activities such as running or jumping.
  • Dysfunction of the tibialis anterior and posterior are common, in addition involvement of tightness and muscular imbalance of the triceps surae (plantaris, soleus and gastrocnemius).
  • Altered running mechanics from tricep sure weakness can lead to early fatigue during running and increase the strain and load on the tibia.
  • Often an change in training or competition volume is associated to the development of symptoms, with changes in duration, intensity or distance common.

What it feels like to you at rest and with sport:

  • You can expect to feel a dull pain in the lower tibia, of at least 5cm, with symptoms commonly experienced on both legs.
  • The area is often sensitive and painful to press.   Symptoms may initial be felt during the beginning of training, reduce once warm, and then return was cooling down.
  • If symptoms remain during the entirety of training, the condition is typically worse. A history of worn footwear or biomechanical abnormalities may also be presented.

We initially manage pain by:

  • We initially manage the condition with hands on manual therapy, dry needling, modification of training load and exercise, taping, and use of ice/heat.

Longer term management strategies to aid performance and prevention include:

  • Later on we look to review running technique, footwear, biomechanics and single leg strength and control to address any underlying issues contributing to the condition.

 

ii. Tib Poserior tendinopathy

 

iii. FHL tendinopathy

FHL Tendinopathy

Your diagnosis (pathology) is: Flexor hallucis tendinopathy

It presents like this:

  • Secondary to overuse or repetitive flat foot stances, a tendon tear, wearing shoes too large for foot
  • Pain felt on toe-off movement/ weightbearing through forefoot
  • Aggravated with resisted first toe flexion/ stretch into dorsiflexion

It feels like this at rest:

  • Pain underload or movement typically, in more severe cases, a dull ache at rest worse in the morning or after loading may be present

We look for this in assessment:

  • History of overuse, poor footwear, changes to activity/ load, tenderness with end of range movements of first toe and resisted flexion

We initially manage pain by:

  • Activity modification, ice, strengthening/ stretching, manual therapy, taping

Longer term management strategies to aid performance and prevention include:

  • Orthotic assessment, running assessment, strength and condition for return to sport

iv. Tarsal tunnel syndrome

Tarsal Tunnel Syndrome

Your diagnosis (pathology) is: Tarsal Tunnel Syndrome

  • Consequence of posterior tibial nerve entrapment, resulting in pain and neural symptoms in the medial heel
  • Resultant from trauma, overuse, or secondary to other musculoskeletal conditions

It presents like this:

  • Non-specific sensory changes on the plantar surface of foot, extending to toes
  • Symptoms aggravated by activity, decrease with rest
  • Tenderness around the tarsal tunnel
  • Altered sensation arch of foot

It feels like this at rest:

  • Rest usually eases pain
  • Symptoms vary; some individuals are worse at night, with movement and massage easing symptoms

We look for this in assessment:

  • Confirmation with subjective assessment, negative signs/ tests of other neural structures (S1 nerve root), imaging may be required to confirm

We initially manage pain by:

  • Neural glides, manual therapy, activity modification
  • Surgical option if mechanical pressure on nerve

Longer term management strategies to aid performance and prevention include:

  • Strength and conditioning of lower limb, return to sport protocol

v. Stress fracture medial malleolus

Stress Fracture Medial Malleolus

Your diagnosis (pathology) is: Stress Fracture medial malleolus

It presents like this:

  • Seen typically in a runner or soccer player with constant medial ankle pain worsened with activity
  • Presentation of pain with ankle pain that increases with jumping or running
  • Commonly an acute aggravation, resulting in individual presenting for treatment
  • Tenderness of the medial malleolus
  • Mild ankle effusion
  • May increase over weeks to months

It feels like this at rest:

  • Rest usually eases pain

We look for this in assessment:

  • X-ray may be negative in early stages
  • MRI or CT scan best option
  • Tenderness over medial malleolus, mild joint effusion
  • Symptoms aggravated with activity/ functional movements

We initially manage pain by:

  • Activity modification
  • Non-weight bearing rest with air cast brace/ Cam Boot until tenderness ceases, typically six weeks
  • Displaced facture requires internal fixation from surgery

Longer term management strategies to aid performance and prevention include:

  • Graduated return to activity (12 weeks)

vi. Medial calcaneal nerve entrapement

Medial Calcaneal Nerve Entrapment

Your diagnosis (pathology) is: Medial calcaneal nerve entrapment

It presents like this:

  • Buring pain over calcaneus
  • Radiates to arch of foot
  • Aggravated by running
  • Positive Tinel’s sign
  • Associated over-pronation of hindfoot

It feels like this at rest:

  • Rest usually eases pain

We look for this in assessment:

  • Tenderness over medial calcaneus, aggravation with functional movements/ tests
  • Positive nerve conduction test if required

We initially manage pain by:

  • Activity modification, change of footwear, orthotics, taping, manual therapy
  • Cortisone steroid injection for severe cases

Longer term management strategies to aid performance and prevention include:

  • Strength and conditioning of lower limb, return to sport protocol

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l. Lateral Ankle Pains

i. Peroneal tendinopathy

Peroneal Tendinopathy

Peroneal tendinopathy is characterised by aggravation of one or both or the peroneal tendons, resulting in degeneration and inflammation.   Acute or chronic presentations may present dependent on the nature and severity of the symptoms.    Both the peroneal longus (long) and brevis (short) are located in the lateral side of the lower leg.  The peroneal tendon joins from the muscle before the ankle joint, with the brevis attaching into the base of the fifth metatarsal and the longus attaching into the first metatarsal and medial cuneiform.

It presents like this:

  • Peroneal tendinopathy commonly affects runners, usually endurance runners, in addition to sports requiring frequent change of direction.
  • A history of chronic lateral ankle instability, poor foot biomechanics, calf tightness, inappropriate training, muscular weakness and incorrect footwear may all contribute to the condition.
  • Often a return to sport or rapid increase in training volume without appropriate recovery is noted.

It feels like this to you at rest and with sport:

  • You can expect to feel pain along the tendon, and may present with swelling. Movements onto the ball of the foot often exacerbate and aggravate symptoms.  Symptoms are typically gradual and worsen over time if left unmanaged.

We initially manage pain by:

  • We initially manage peroneal tendinopathy with hands on manual therapy. The use of non-steroid anti-inflammatories (NSAID) and ice may be use to manage symptoms.
  • Activity modification is important; reducing activities or load aggravating the tendon may be required.

Longer term management strategies to aid performance and prevention include:

  • Longer term we look to strengthen peroneals, re-introduce or increase previous activity and address any mechanical dysfunctions that may have led to the development of the condition.

ii. Sinus tarsi syndrome

Sinus Tarsi Syndrome

Your diagnosis (pathology) is: Sinus tarsi syndrome

  • Result of chronic overuse secondary to poor biomechanics
  • The majority of sinus tarsi presenting individuals have a history of at least one or more inversion ankle injuries
  • The area contains a vast amount of synovial tissue that can be prone to inflammation and synovitis during injury
  • May also be caused by gout, osteoarthritis or other chronic inflammatory conditions

It presents like this:

  • Anterior to lateral malleolus, poorly localised
  • Worse in morning, decreases with exercise and movement
  • Aggravated with running on angle, uneven ground walking
  • Full range of motion ankle, stiff subtalar joint
  • Tenderness of the lateral ankle, ATFL and mild swelling

It feels like this at rest:

  • Rest usually eases pain
  • Mild localised swelling may be present

We look for this in assessment:

  • Aggravation with functional tests, stiff subtalar joint

We initially manage pain by:

  • Activity modification, ice, manual therapy
  • Subtalar joint mobilisation important
  • Strength and proprioception exercises

Longer term management strategies to aid performance and prevention include:

  • Graduated return to sport protocol
  • Orthotics

iii. Anterolateral impingement

Anterolateral Impingement

Your diagnosis (pathology) is: Anterolateral impingement

  • Result of repetitive ankle sprains
  • Inversion sprains may lead to thickening and scarring of the ATFL, resulting in impingement. A meniscoid lesion may develop from ligament tears; alternatively, chondromalacia of the talus wall from synovitis may cause an impingement.

It presents like this:

  • Anterolateral ankle pain, intermittent catching in ankle
  • Pain on cutting, change of dirction, functional movements requiring jumping/ hopping

It feels like this at rest:

  • Rest commonly eases symptoms

We look for this in assessment:

  • Tenderness in region, symptoms ease with release of peroneal tendons, engaging the tibialis posterior tendon
  • Poor proprioception

We initially manage pain by:

  • Activity modification, ice, manual therapy, exercise (strength and proprioception)
  • Corticosteroid injection or arthroscopic removal of scar tissue may be required

Longer term management strategies to aid performance and prevention include:

  • Return to sport/ activity protocol

iv. Posterior impingement syndrome

Posterior Impingement Syndrome

Your diagnosis (pathology) is: Posterior impingement syndrome

  • Impingement of the posterior talus by the posterior tibia during plantarflexion
  • Commonly presents in individuals who perform repetitive plantarflexion
  • Also present following repetitive ankle platnarflexion and inversion injuries

It presents like this:

  • Pain and tenderness at the posterior ankle

It feels like this at rest:

  • Rest usually eases pain
  • Mild localised swelling may be present

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Pain and reproduction of symptoms with posterior impingement test, passive plantar flexion

We initially manage pain by:

  • Activity modification, manual therapy, ice, NSAIDs

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions
  • Orthotics

v. Stress fracture talus

Stress Fracture Talus

Your diagnosis (pathology) is: Stress fracture of the talus

  • May result from excessive subtalar pronation/ plantarflexion, impinging the calcaneus on the talus

It presents like this:

  • Gradual onset of lateral ankle pain
  • Aggravated by weight-bearing or running
  • Localised tenderness/ swelling in region

It feels like this at rest:

  • Rest usually eases pain
  • Mild localised swelling may be present

We look for this in assessment:

  • Aggravation and pain on functional tests

We initially manage pain by:

  • Immobilisation in cast for 6 to 8 weeks, followed by graduated rehabilitation

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions
  • Orthotics

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m. Anterior Ankle Pains

i. Anterior impingement

Anterior Impingement

Your diagnosis (pathology) is: Anterior Ankle Impingement

  • Soft/ bony tissue caught between tibia and talus in dorsiflexion of ankle

It presents like this:

  • Presents secondary to bone spurs (seen in ballet dancers, footballers) following repetitive forced plantarflexion
  • Generalised discomfort anterior ankle
  • Pain increases with dorsiflexion
  • Reduced ankle range of motion
  • Decreased take-off speed
  • Tenderness on the joint line
  • Reduced or painful dorsiflexion

It feels like this at rest:

  • Rest usually eases pain
  • Mild localised swelling may be present

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Impingement when forward lunge performed and reproduces symptoms

We initially manage pain by:

  • Activity modification, heel lift, NSAIDs, manual therapy, exercise prescription
  • X-ray may be required

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions
  • Orthotics

ii. Tibialis anterior tendinopathy

Tibialis Anterior Tendinopathy

Your diagnosis (pathology) is: Tibialis anterior tendinopathy

  • Main dorsiflexor of the foot

It presents like this:

  • Overuse secondary to a reduced joint range of motion of ankle, descending hills running, walking up stairs
  • Activities requiring repetitive change of direction
  • Shoe laces too tight across tendon

It feels like this at rest:

  • Pain with initial activity, decrease once warmed up, symptoms return during cooling down period post exercise

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Reduced muscle length/ joint stiffness
  • Tenderness on palpation of tendon
  • Swelling, stiffens anterior ankle

We initially manage pain by:

  • Activity modification, manual therapy, ice, taping, exercise prescription

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions
  • Orthotics

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n. Rear Foot, Midfoot & Forefoot Pains

i. Rear foot

Plantar Fasciitis

Your diagnosis (pathology) is: Plantar Fasciitis

  • Overuse condition of the plantar fascia
  • Repetitive maximal plantarflexion and simultaneous dorsiflexion of MTP is a common cause (running)
  • Common in older individuals due to poor footwear/ excessive walking

It presents like this:

  • Gradual onset of medial heel
  • Symptoms worse in the morning, aggravate following activity
  • Symptoms ease with movement and activity
  • In severe cases, weight-bearing/ aggravates with activity

It feels like this at rest:

  • Rest usually eases pain
  • Mild localised swelling may be present

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Acute tenderness on the medial heel and plantar fascia
  • Poor footwear/ foot mechanices
  • Reduced muscle length/ joint range of motion
  • Single leg balance – toe clawing is a sign of weak intrinsic foot muscle strength/ instability

We initially manage pain by:

  • Activity modification, taping, manual therapy, ice, exercise prescription

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions
  • Orthotics

 

Calcaneal Stress Fractures

 Your diagnosis (pathology) is: Calcanel stress fracture

  • Second most common stress fracture of tarsal
  • Associated with heavy-landing, poor heel cushioning, over-striding

It presents like this:

  • Heel pain, insidious onset
  • Worse with weight-bearing, in mornings

It feels like this at rest:

  • Pain around the heel, worse with activity and in mornings
  • Mild localised swelling may be present

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Tenderness on posterior calcaneal
  • Pain on squeeze of calcaneal on both sides

We initially manage pain by:

  • Activity modification, small period non-weight bearing
  • Pain free – commence increased weight-bearing
  • Stretching/ joint mobilisation
  • Heel pads

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions
  • Orthotics

 

Lateral Plantar Nerve Entrapment

 Your diagnosis (pathology) is: Lateral plantar nerve entrapment

  • Entrapment of lateral plantar nerve

It presents like this:

  • Heel pain, insidious onset
  • Worse with weight-bearing

It feels like this at rest:

  • Pain referring down the medial portion of the heel and
  • Not common to experience numbness in heel/ foot

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Tenderness on palpation of nerve and localised area
  • Nerve conduction test may be required

We initially manage pain by:

  • Activity modification, small period non-weight bearing
  • Pain free – commence increased weight-bearing
  • Stretching/ joint mobilisation
  • Heel pads

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions
  • Orthotics

ii.  Midfoot

Stress Fracture Navicular

Your diagnosis (pathology) is: Stress fracture navicular

  • Common in athletes (sprinting, hurdling, jumping)
  • Delayed union common due to poor blood supply to area
  • Overuse and poor technique associated with risk of pathology
  • Decreased ankle dorsiflexion may contribute to impingement of the navicular and risk of stress fracture

It presents like this:

  • Insidious onset, difficulty localising during activity
  • Pain refers along arch of foot
  • Symptoms decrease with rest

It feels like this at rest:

  • Tenderness mid foot at navicular, aggravation during activity

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Tenderness on navicular, pain radiating along arch

We initially manage pain by:

  • Activity modification, period of weight bearing rest
  • Pain free – commence increased weight-bearing
  • Stretching/ joint mobilisation

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions

 

Extensor Tendinopathy

Your diagnosis (pathology) is: Extensor tendinopathy

  • Tibilias anterior tendinopathy most common of extensor muscles

It presents like this:

  • Gradual onset from increased activity or changes to biomechanics
  • Commonly pain in morning or following exercise,
  • Symptoms decrease during warm up/ movement

It feels like this at rest:

  • Tenderness on extensor muscles and tendons with activity

We look for this in assessment:

  • Aggravation and pain on functional tests
  • Tenderness on extensor muscles and tendon

We initially manage pain by:

  • Activity modification, strengthening
  • Stretching/ joint mobilisation

Longer term management strategies to aid performance and prevention include:

  • Correction of underlying biomechanical dysfunctions

 

Midtarsal Sprains

It presents like this:

  • Seen in footballers, gymnasts and jumpers
  • Midfoot pain following inversion injury

It feels like this at rest:

  • Tenderness and swelling
  • Inversion stress increases pain

We look for this in assessment:

  • Tenderness along the lateral midfoot, swelling
  • Aggravation with functional movements

We initially manage pain by:

  • Immobilisation in boot for non-displaced injuries
  • Displaced injuries may require sugery

Longer term management strategies to aid performance and prevention include:

  • Exercise prescription (strength and propriocpetio), return to sport protocol

 

Lisfranc Joint Injuries

It presents like this:

  • Mid foot pain between the 1st and 2nd metatarsal bases
  • History of sprain, non-direct and direct injury, not common

It feels like this at rest:

  • Mid foot pain and aggravation with weight-bearing post-acute injury
  • Swelling, pain with running

We look for this in assessment:

  • Aggravation with function tests
  • Pain on loading of ligaments
  • Localised swelling sometimes
  • Tenderness on the dorsal midfoot

We initially manage pain by:

  • Imaging, immobilisation, surgery for displaced cases

Longer term management strategies to aid performance and prevention include:

  • Return to sport protocol, strength and proprioception

 


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