Anatomy: Behind the inner ankle knuckle (mediale malleol), one of the lower leg’s large nerves (Nervus tibialis) runs down to the foot.

Symptoms: A burning, prickling sensation is felt in the sole of the foot and the toes, often localised to the inward side of the foot. There can be symptoms from the calf. The pain is aggravated when walking and running. The heel is not affected.

Examination: Medical examination is usually sufficient to make the diagnosis, as the symptoms can be provoked by applying pressure to the nerve behind the inner ankle knuckle (mediale malleol) (article). The pain will diminish with use of a local anaesthetic above the nerve (diagnostic blockade). If the physician has doubts about the diagnosis, it can be confirmed by use of an EMG examination (ElectroMyoGraphy)

Treatment: Treatment primarily comprises relief from the pain inducing activities (running). Use of shoes with a high heel often alleviates the pain. If smooth progress is not achieved by relief and rehabilitation, the treatment can be supplemented by medicinal treatment in the form of rheumatic medicine (NSAID) or injection of corticosteroid in the tarsal tunnel. If the desired effect is not forthcoming, surgery can be attempted to release the nerve, however, the results are often disappointing (article).

Complications: If there is not a steady improvement in the condition, medical assistance should be sought to determine whether the diagnosis is correct or whether complications have arisen, with consideration being given to:

• Inner ligament injury in the ankle joint
• Bone membrane tear (periosteal avulsion)
• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Slipped disc (discusprolaps)

Anatomy: The surfaces of the joints are lined with a cartilage covering of a few millimetre’s thickness which serves to reduce the load or strain on the joint surfaces.

Symptoms: Pain in the joint with movement under load. Occasionally swelling in the joint.

Examination: Normal clinical examination is often sufficient. However, it is also often necessary to perform an x-ray (or ultrasound scan or MRI examination) to make the diagnosis. Ultrasound scanning will often reveal inflammation surrounding new bone development at the joint surfaces.

Treatment: Treatment comprises relief from the painful activities until the swelling has gone down, after which training can commence with the primary aim to strengthen the muscles surrounding the joint and retain joint mobility. There is no treatment which can restore the damaged cartilage (and bone). Cartilage transplants are, as yet, not suitable for general degenerative arthritis. In cases of swelling in the joint, and with inflamed new bone development at the joint surfaces, inflammation of the synovial membrane can be attempted subdued by using rheumatic medicine (NSAID), or by draining the fluid and injecting corticosteroid. The injections can be performed to advantage by utilising an ultrasound guided method. Pain without swelling of the joints is best treated with paracetamol. In severe cases of degenerative arthritis where there is pain when resting (at night), it may be necessary to fix the joint by operation.

Rehabilitation: Rehabilitation is completely dependent upon the degree of the degenerative arthritis and in which joints it is located.
Also read rehabilitation, general.

Bandage: A supportive tape (Hollywood bandage) can be attempted to aid degenerative arthritis in small joints (toes) (tape-instruction). Tape provides no help to attacks in the ankle joint.

Complications: Degenerative arthritis which sits on the weight bearing parts of the joint is one of the most serious sports injuries, and often results in a termination of active sport. It is usually possible to continue sport activities with light strain on the joints (cycling, swimming), whereas it is advisable to participate in activities with great strains on the joint (running, ball games) with restraint. The diagnostic considerations in connection with degenerative arthritis include:

• Bone fracture
• Stress fracture
• Bone membrane tear (periosteal avulsion)
• Tendon luxation of the outer ankle knuckle (luxation of the peroneus tendon)
• Inflammation of the tendon sheath
• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Cartilage damage in the joint
• Metatarsus ligament rupture
• Inflammation of the bursa

Special: Shoes with shock absorbing inlays will reduce the discomfort of degenerative arthritis.

Anatomy: The surfaces of the joints are lined with a cartilage covering of a few millimetre’s thickness which serves to reduce the load or strain on the joint surfaces.

Symptoms: Pain in the joint when under load or strain. Occasional inflammation of the synovial membrane which causes concentration of fluid in the joint.

Examination: Normal medical examination is often not sufficient. To make the diagnosis correctly it is therefore necessary to perform an arthroscopic examination or an MR-scan.

Treatment: Treatment comprises relief from the painful activities until the pain is no longer experienced, after which gradual training can be commenced. There is no treatment that can restore the damaged cartilage, which has itself poor restorative ability. Different procedures to enhance the healing can be attempted using arthroscopic examination, however, the results are generally unsatisfactory (article-1) (article-2). Results from experimental cartilage transplants are still not successful enough to warrant introduction as a routine treatment in the near future. Joint mouse which provokes the symptoms must be surgically removed.

Rehabilitation: Rehabilitation is completely dependent upon the type of cartilage damage (size and position in the joint) and treatment (conservative or surgical).
Also read rehabilitation, general.

Complications: Greater cartilage injuries which are positioned on the weight-bearing parts of the joint are some of the most serious sports injuries, and often results in an end to the sporting career.

Special: As there is a risk that the injury can be permanent, all cases should be reported to your insurance company.

Anatomy: The joints in the foot comprise the large ankle joint (between the shin and the foot, articulatio talocruralis), as well as many smaller joints between the tarsal bones (ossa tarsi) and the metatarsal bones (ossa metatarsi), and the toe joints.

Symptoms: Swelling of the joint. Pain with pressure on the joint lines, as well as with passive and active movement of the joint.

Acute treatment: Click here.

Examination: In pronounced cases the diagnosis is made from a normal medical examination, however, experience has shown that diagnosis is difficult and is often overlooked. Ultrasound scanning enables the diagnosis to be made from minor swelling, and swelling in joints that are otherwise difficult to examine.
(article), (Ultrasonic image-1), (Ultrasonic image-2).

Treatment: Treatment is primarily based on relieving the affected area (and treatment of other possible injuries that have developed at the same time). If swelling of the joint persists despite relieving the area as much as possible, a supplement of medicinal treatment in the form of rheumatic medicine (NSAID) can be administered. Alternatively, draining and evaluating the fluid can be performed, and injection of corticosteroid into the joint. Injection into the joint is best performed if ultrasound guided (article).

Rehabilitation: Rehabilitation is completely dependent upon which joint is injured, and which treatment has been administered. Until the swelling and the pain has subsided, the guidelines under rehabilitation, general should be followed.

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

• Tearing of the bone membrane (periosteal avulsion)
• Bone fracture
• Inflammation of the tendon sheath
• Cartilage damage
• Outer ligament injury in the ankle joint
• Inner ligament injury in the ankle joint
• Rupture of the joint capsule at the front of the ankle joint
• Metatarsus ligament rupture

Anatomy: Tendons from the shin bone to the foot pass both inwardly, outwardly, in front and behind the ankle joint, and continue on the back of the foot and the sole to the toes. The tendons are during part of the course deposited in synovial sheaths.

Symptoms: Inflammation of the tendon sheath causes pain along the tendon sheath itself, which is aggravated by stretching and activation of the muscle tendon.

Examination: In obvious cases the diagnosis can be established from a normal medical examination. The diagnosis is, however, easily determinable by use of ultrasound scanning, which can also be advantageously used in cases where steady improvement is not noticeable from relieving the affected area (Ultrasonic image).

Treatment: Treatment is primarily based on relieving the affected area and removal of the provoking factor, if such a factor is in evidence (i.e. tightly bound shoes). If satisfactory progress is not made, the treatment can be supplemented by medicinal treatment in the form of rheumatic medicine (NSAID) Alternatively, draining and evaluating fluid form the tendon sheath can be performed, and injection of corticosteroid into the tendon sheath. Injection into the tendon sheath is best performed if ultrasound guided.

Rehabilitation: Rehabilitation is completely dependent upon which tendon is involved, and whether the inflammation of the tendon sheath is a part of another injury (ligament rupture). The guidelines above (rehabilitation, general) should be followed. Strenuous exercises can be gradually resumed when the pain has decreased.

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

• Rupture of the ligament between shin and calf bones (syndesmosis rupture)
• Bone fracture
• Tearing of the bone membrane (periosteal alvulsion)
• Outer ligament injury in the ankle joint
• Inner ligament injury in the ankle joint
• Tendon luxation on the outer ankle knuckle (peroneus luxation)
• Stress fracture
• Metatarsus ligament rupture
• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Cartilage damage in the joint
• Inflammation of the bursa

Special: Shock absorbing shoes or inner inlays will reduce the risk of various forms of inflammation of the tendon sheath. In the event of unsatisfactory progress, or relapse after successful rehabilitation, consideration must be given to performing an analysis of the patient’s running style to establish whether a correction of the running style should be recommended.

Anatomy: The tendons surrounding the ankle joint are connected to the bones in several places by connective tissue strings (retinaculum). Two peroneus muscles are positioned behind the outer ankle knuckle, which are used to stabilise and flex the ankle joint.

Symptoms: Pain at the outer ankle knuckle (malleolus lateralis), where certain movements of the ankle joint can give rise to a painful sense of “slipping”.

Acute treatment: Click here.

Examination: When the painful movement of the ankle joint is performed, normal examination can detect the tendon slip over the outer ankle knuckle. A normal medical examination is usually sufficient in order
to make the diagnosis, however, if there is any doubt concerning the
diagnosis it can be made with certainty by use of ultrasound scanning while the ankle joint is in motion (dynamic ultrasound scanning). Ultrasound scanning will reveal whether there is bleeding in the acute stage. Inflammation of the tendon sheath can develop at a later stage.

Treatment: Treatment is primarily concentrated on providing rest from the painful activities (running). If steady progress from rest and rehabilitation is not achieved, and ultrasound scanning reveals inflammation of the tendon sheath, the treatment can be supplemented by medicinal treatment in the form of rheumatic medicine (NSAID) Alternatively, draining and evaluating fluid can be performed, and injection of corticosteroid into the tendon sheath. Injection into the tendon sheath is best performed if ultrasound guided. Surgical intervention can be attempted in certain cases, if resting, rehabilitation and medicinal treatment do not provide the desired result (article).

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

• Outer ligament injury in the ankle joint
• Rupture of the joint capsule at the front of the ankle joint
• Bone membrane tear (periosteal avulsion)
• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Inflammation of the bursa
• Arthritis

Possibly supplement with further examinations (x-ray, ultrasound scanning).

Anatomy: The foot bones comprise the 7 tarsal bones (ossa tarsi), the 5 metatarsal bones (ossa metatarsi) and the 14 bones in the toes (phalanx).

Symptoms: Pain when applying pressure (direct or indirect tenderness), and when applying load or strain.

Examination: X-ray examination will usually, but not always, reveal a stress fracture. The x-ray examination can be repeated after a few weeks as a number of stress fracture are not easily discernible in the early stages. Bone scintigraphy, ultrasound scanning and MRI examination can often diagnose a stress fracture much earlier than x-ray examination (Ultrasonic image), (Scintigraphy-image).

Treatment: Treatment is primarily relief and rest, and possible bandaging. Surgical intervention is only required in very special cases. It is imperative that shoes are equipped with impact absorbing soles (article).

Rehabilitation: Rehabilitation is totally dependent upon the type of fracture, and the treatment (conservative or surgical). Until the pain has subsided, the guidelines under rehabilitation, general should be followed.

Complications: If there is not a steady improvement in the condition a medical examination should be performed once more to ensure that the fracture is healing according to plan. In some cases, a false joint can develop which will require surgical treatment.