Anatomy: Under the heel bone (calcaneus) there is a shock absorbing fatty pad (corpus adiposum) which protects the heel bone and the hollow foot tendon (aponeurosis plantaris) which fastens on the heel bone under the heel.

Symptoms: Pain when walking as well as when applying pressure on the edges of the heel pad. In some cases, it will be possible to see haemorrhaging in the heel pad (article).

Acute treatment: Click here.

Examination: Medical examination is not always necessary in light cases with minimal tenderness and no pain when walking. If satisfactory progress is not made, or if there is a sense of a “snap”, or sudden shooting pains, medical attention should be sought as soon as possible to make the diagnosis. A normal medical examination is usually sufficient in order to make the diagnosis, however, if there is any doubt concerning the diagnosis an ultrasound scan can be performed.

Treatment: Rest from the painful activity (running). The injury can in some cases heal within a few weeks if treatment is commenced at an early stage. It is imperative that footwear is in order, with a suitably tight heel cap to hold the heel pad in place under the heel, and with shock absorbing soles. 

Rehabilitation of children and adolescents: Treatment is primarily rest. The principles under of children and adolescents in general can be followed until the pain has gone, after which running and jumping can be cautiously resumed.

Bandage: Taping to relieve problems with inflammation of the heel pad is of questionable significance, but can be attempted as the tape will not invoke further injury if applied in the correct manner (tape-description).

Complications: If there is not a steady improvement in the condition, x-ray or an ultrasound scan should be performed to exclude :

• bone fracture in the foot
• stress fracture
• muscular bleeding
• metatarsus ligament rupture
• inflammation of the bursa
• inflammation of the hollow foot tendon under the heel bone (fasciitis plantaris)
• inflammation of the growth plate of the heel bone (apophysitis calcanei)
• inflammation of the Achilles
• bone membrane tear (periosteal avulsion)
• inflammation of the tendon sheath

Shock absorbing shoes or insoles will reduce the risk of inflammation of the heel pad.

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 MR-scan (article), and possibly an arthroscopic examination of the ankle joint.

Treatment: If a piece of bone is loosened in the knee (osteochondritis dissecans) it is important that the diagnosis is made as early as possible, as the earlier the treatment starts, the better the result (article). Treatment can comprise relief or surgery, dependant upon the extent of the condition and whether a piece of bone has become loose. If the condition is a result of twisting, 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 of children and adolescents: The load and type of rehabilitation which can be permitted is completely dependant upon the severity of the condition, the location, and the form of treatment. Rehabilitation should therefore be performed in close cooperation with the doctors controlling the treatment.

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 result 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 foot bones comprise the 7 tarsal bones (ossa tarsi), the 5 metatarsal bones (ossa metatarsi) and the 14 bones in the toes (phalanx). Furthermore, the lower part of the shin bone (tibia) and calf bone (fibula) form a part of the ankle joint.

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

Acute treatment: Click here.

Examination: X-ray examination will usually reveal the fracture (article-1)(article-2). The fracture can in some cases first be seen after 14 days, thus the x-ray examination should be repeated if there is a continued suspicion of a fracture.

Treatment: Treatment is completely dependent upon which bones are broken, and whether there is a dislocation of the fracture. In some cases relief and rest without bandaging can be opted for, whereas other types of fracture require bandaging and possibly surgical intervention (article) (X-ray picture).

Rehabilitation of children and adolescents: The load and type of rehabilitation which can be permitted is completely dependent upon the severity, and the treatment of the fracture. It is therefore important that the rehabilitation is performed in close cooperation with the doctors controlling the treatment.

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 (renewed) surgical treatment (X-ray picture). There can be a risk of growth disturbance if the fracture includes the shin bone’s growth zones at the ankle (article).

Anatomy: The ankle joint is stabilised by a joint-capsule as well as a wide fan shaped ligament on the inside (ligamentum deltoideum/mediale), and a set of outer ligaments (ligamentum talofibulare anterius fore, ligamentum calcaneofibulare centre, and ligamentum talofibulare posterius at the rear). There is also a strengthening of the ligaments in front and behind (ligamentum tibiofibulare anterius & posterius). The surrounding tendons are often enclosed by tendon sheaths and joined to the bones with connective tissue strings. The ligaments stabilise the ankle joint, especially when twisting and running with sudden directional changes. (Photo).

Symptoms: Pain on and under the outer ankle bone (malleolus lateralis), swelling due to bleeding, pain when walking.

Acute treatment: Click here.

Examination: A medical examination is not necessarily required for very minor cases (slight sprain) with only minimal swelling and no discomfort when walking. The extent of the swelling is, however, not always a mark of the degree of the injury. Medical examination is recommended with more extensive swelling or pain, in order to eliminate bone fracture in the ankle and a rupture of the ligament between the shin and calf bones (syndesmosis rupture). A normal medical examination is usually sufficient in order to make the diagnosis (article).X-ray examination should be performed in all cases where there is a suspicion of a fracture or syndesmosis rupture (article). Vigorous twisting of the ankle in the acute stage to appraise the degree of looseness is not indicative, as this has no influence on the choice of treatment (article). Ultrasound examination can give valuable information when the ligament is ruptured (Ultrasonic image)

Treatment: Treatment of ligament injuries is today conservative (rehabilitation). Many patients have earlier undergone operations and setting of plaster cast, however, this course of treatment has practically been abandoned in relation to uncomplicated ligament ruptures, although there is not definitive agreement on this subject (article-1), (article-2).

Bandage: t is recommended to use tape in the course of rehabilitation when starting to run on an uneven surface, or with sudden directional change. Nerve cells (proprioreceptors) in the ligaments transmit information to the brain on the position of the ankle joint. The brain sends information to the muscles, which are activated, ensuring that the ankle is held correctly. The nerve paths do not function in an optimal manner when the ligament is injured, and the risk of a new twist of the foot is increased thereby. Use of tape is primarily designed to stimulate the small nerve cells in the skin, thus enabling these to act as a substitute for the nerve cells temporarily damaged in the ligament. The function of the tape is thus not a pure mechanical stabilising of the ankle joint (tape-instruction). In some cases, certain forms of bandaging around the ankle can be used to advantage (article-1), (article-2).

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
• Bone membrane tear (periosteal avulsion)
• Luxation of the peroneus tendon
• Inflammation of the tendon sheath
• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Cartilage damage in the joint

It is extremely rare that the injury results in a chronically loose ankle joint if rehabilitation is handled sensibly. If the injury does result in a chronically loose ankle joint, intensive co-ordination training must be recommended. Bandages can be tried if this is not sufficient, and if this still does not give the desired effects, surgical intervention to tighten the ligaments can be attempted. The results are usually quite acceptable (article). Reduced mobility in the ankle joint is a common condition following ankle injuries in children (article).

Special: Seesaw exercise is important in the rehabilitation phase, as well as in a preventive capacity. As a preventive measure, seesaw exercises should be performed frequently throughout the rest of the active sporting career if ligament injuries in the ankle joint have previously been experienced. Begin by standing with both feet on the seesaw and use hands for support on the wall. Gradually let go of the support to finally train by standing on only one leg (article).

Anatomy: The ankle joint is stabilised by a wide fan shaped ligament on the inside (ligamentum deltoideum), and a set of outer ligaments (fore, centre, and at the rear). The ligaments stabilise the ankle joint, especially when twisting and running with sudden directional changes (Photo).

Symptoms: Pain on and under the inner ankle bone (malleolus medialis), swelling due to bleeding, pain when walking.

Acute treatment: Click here.

Examination: A medical examination is not necessarily required for very minor cases (slight sprain) with only minimal swelling and no discomfort when walking. The extent of the swelling is, however, not always a mark of the degree of the injury. Medical examination is recommended with more extensive swelling or pain, in order to eliminate bone fracture in the ankle and a rupture of the ligament between the shin and calf bones (syndesmosis rupture). A normal medical examination is usually sufficient in order to make the diagnosis (article). X-ray examination should be performed in all cases where there is a suspicion of a bone fracture, or syndesmosis rupture (article). Vigorous twisting of the ankle in the acute stage to appraise the degree of looseness is not indicative, as this has no influence on the choice of treatment (article). Ultrasound examination can give valuable information when the ligament is ruptured (Ultrasonic image).

Treatment: Treatment of ligament injuries is today conservative (rehabilitation). Many patients have earlier undergone operations and setting of plaster cast, however, this course of treatment has practically been abandoned in relation to uncomplicated ligament ruptures (article).

Bandage: It is recommended to use tape in the course of rehabilitation when starting to run on an uneven surface, or with sudden directional change. Nerve cells (proprioreceptors) in the ligaments transmit information to the brain on the position of the ankle joint. The brain sends information to the muscles, which are activated, ensuring that the ankle is held correctly. The nerve paths do not function in an optimal manner when the ligament is injured, and the risk of a new twist of the foot is increased thereby. Use of tape is primarily designed to stimulate the small nerve cells in the skin, thus enabling these to act as a substitute for the nerve cells temporarily damaged in the ligament. The function of the tape is thus not a pure mechanical stabilising of the ankle joint (tape-instruction). In some cases, certain forms of bandaging around the ankle can be used to advantage.

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 membrane tear (periosteal avulsion)
• Inflammation of the tendon sheath
• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Cartilage damage in the joint

It is extremely rare that the injury results in a chronically loose ankle joint if rehabilitation is handled sensibly. If the injury does result in a chronically loose ankle joint, intensive co-ordination training must be recommended. Bandages can be tried if this is not sufficient, and if this still does not give the desired effects, surgical intervention to tighten the ligaments can be attempted. Reduced mobility in the ankle joint is a common condition following ankle injuries in children (article).

Special: Seesaw exercise is important in the rehabilitation phase, as well as in a preventive capacity. As a preventive measure, seesaw exercises should be performed frequently throughout the rest of the active sporting career if ligament injuries in the ankle joint have previously been experienced. Begin by standing with both feet on the seesaw and use hands for support on the wall. Gradually let go of the support to finally train by standing on only one leg (article). Special bandages have in some studies been shown to reduce the risk of ligament injuries. (article-1), (article-2).

Anatomy: The calf muscle (M Gastrocnemicus) is comprised of two muscle heads which gather in a wide tendinous ligament and continue in to the Achilles tendon. Another of the larger calf muscles (M Soleus) is attached to the front side of the Achilles tendon and thus forms a part of the Achilles tendon. The calf muscles are attached to the rear of the heel bone (calcaneus) via the Achilles tendon. The hollow foot tendon (aponeurosis plantaris) runs from the heel bone under the sole, and is attached to all five toes. The hollow foot tendon is a functional extension of the Achilles tendon, and is instrumental in maintaining the arch running the length of the foot (Photo).

Cause: Occurs after repeated overload in the form of running or jumping. Since the hollow foot tendon is a functional extension of the Achilles tendon, the provoking factors which are instrumental in injuries due to overload of the hollow foot tendon and the Achilles tendon are often the same.

Symptoms: Pain when running and jumping, as well as when applying pressure at the attachment point of the hollow foot tendon directly under the heel bone. The pain is often most pronounced slightly on the inner side of the attachment.

Examination: Medical examination is not necessarily required in slight, early cases where the tenderness is slowly increasing without sudden worsening. A normal medical examination is usually sufficient in order to make the diagnosis, and in all cases when there is a sense of a “crack”, or sudden shooting pains in the tendon, medical attention should be sought as soon as possible to exclude a (partial) rupture of the hollow foot tendon and bone fracture. This situation is best determined by use of ultrasound scanning (or MRI examination). In cases where satisfactory progress is not in evidence, an ultrasound examination should be performed. Ultrasound scanning enables an evaluation of the extent of the change in the tendon; inflammation of the tendon (tendinitis), development of cicatricial tissue (tendinosis), calcification, Inflammation of the tissue surrounding the tendon (peritendinitis), as well as (partial) rupture (article) (Ultrasonic image).

Treatment: Rest from the painful activity (running). The injury can in some cases heal within a few weeks if treatment is commenced at an early stage (article). If the pain has been present for several months, and especially if ultrasound scanning reveals thickening and change in the tendon, a rehabilitation period of several months must be anticipated. It is imperative that the footwear is in order, with good running shoes including shock absorbing heels. Pressure on the hollow foot tendon can be relieved by walking in shoes with an arch support. Treatment with ice can be repeated every time the hollow foot tendon becomes tender during the rehabilitation phase. Injection of corticosteroid is not appropriate in the course of treatment (article).

Heel spur: Inflammation of the hollow foot tendon is occasionally connected to a heel spur. A heel spur is a new bone development which is seen in connection with a prolonged Inflammation at the point of attachment of the hollow foot tendon on the heel bone due to overload. A heel spur is thus a consequence of an injury due to overload, and not the cause. If a heel spur has developed, it will never disappear. Heel spurs have no practical significance, and require no treatment. Many symptom free athletes have heel spurs without having had symptoms from the point of attachment of the hollow foot tendon. Surgical removal of heel spurs as performed in earlier days is now virtually no longer used

Bandage: Taping to relieve problems with the hollow foot tendon is of questionable significance, but can be attempted as the tape will not invoke further injury if applied in the correct manner (tape-instruction).

Complications: If there is not a steady improvement in the condition a medical examination should be performed to exclude:

• bone fracture in the foot
• stress fracture
• inflammation of the bursa
• bone membrane tear (periosteal avulsion)
• inflammation of the tendon sheath

Special: As prolonged overload or strain on the hollow foot tendon has a large risk of developing in to chronic Inflammation, which is extremely difficult to treat, it is important to prevent the injury from arising or recurring. The principles in “Rehabilitation, general” should be followed to ensure that quickly increasing training loads at the season start, or after an injury period, are avoided. It is important that running shoes fit well (tight heel cap, shock absorbing soles ). It is vital that the first signs of tenderness or pain are reacted upon, to enable the training to be adapted before the injury reaches the stage where continuing the sports activity may be at risk.

Anatomy: The calf muscle (M Gastrocnemicus) is comprised of two muscle heads which gather in a wide tendinous ligament and continue in to the Achilles tendon. Another of the larger calf muscles (M Soleus) is attached to the front side of the Achilles tendon and thus forms a part of the Achilles tendon. The Achilles is attached to the heel bone (calcaneus) where a growth zone is found in children represents the weakest area of the Achilles tendon and calf muscle in non-adult persons.

Symptoms: Pain when activating the Achilles tendon (running and jumping) and with stretching of the tendon. Tenderness is experienced when applying pressure at the rear of the heel bone.

Examination: Medical examination is not necessarily required in slight, early cases where the tenderness is slowly increasing without sudden worsening. In all cases when there is a sense of a “crack”, or sudden shooting pains in the Achilles tendon, medical attention should be sought as soon as possible to exclude a (partial) rupture of the Achilles tendon. This situation is best determined by use of ultrasound scanning. A medical examination is usually sufficient in order to make the diagnosis, however, in all cases where satisfactory progress is not in evidence, an ultrasound examination should be performed. Ultrasound scanning enables an evaluation of the extent of the change in the tendon; inflammation of the tendon (tendinitis), development of cicatricial tissue (tendinosis), calcification, inflammation of the tissue surrounding the tendon (peritendinitis), inflammation of the bursa (bursitis), as well as (partial) rupture and fraying of the bone membrane, as is often the case in children with inflammation at the point of attachment of the Achilles tendon at the growth zone on the heel bone (Photo) (article).

Treatment: Treatment is primarily comprised of relief from the painful activity (running, jumping). If the treatment is commenced early, the injury can in some cases heal within a few weeks. When the pain has subsided, the sports activity can be resumed preceded by stretching of the calf muscle (article). It is naturally crucial that footwear is in good condition (good running shoes with shock absorbing heel and close fitting heel cap). Pressure on the Achilles tendon can be relieved by using shoes with an elevated heel, whilst a heel cushion in the shoe is of less significance since the heightening achieved by this method is greatly limited. If experiencing tenderness at the point of attachment of the Achilles tendon during the rehabilitation period, treatment with ice for a period of at least 20 minutes is recommended. To relieve pronounced pain whilst walking, medicinal treatment in the form of rheumatic medicine (NSAID) (gel or crème) can be considered but is seldom indicated. Medicine must not be (mis)used in order to continue the sports activity. Injection of corticosteroid is not appropriate in the course of treatment (article). When a person reaches a state of being fully grown, the growth zone at the heel bone is closed and the problems disappear.

Complications: If there is not a steady improvement in the condition a medical examination should be performed to exclude:

• inflammation of the Achilles tendon
• (partial) rupture of the Achilles tendon
• inflammation of the bursa
• rupture of the Soleus muscle
• heel pad syndrome

Anatomy: The calf muscle (M Gastrocnemicus) is comprised of two muscle heads which gather in a wide tendinous ligament and continue in to the Achilles tendon. Another of the larger calf muscles (M Soleus) is attached to the front side of the Achilles tendon and thus forms a part of the Achilles tendon. The Achilles is attached to the heel bone (calcaneus). The weakest area of the Achilles tendon in adults is found approx. 3 cm. above the point of attachment on the heel bone, whereas in children and adolescents the weakest area is often at the actual point of attachment on the heel bone. Inflammation of the Achilles tendon is therefore relatively rarely seen in children and adolescents.

Symptoms: Pain when activating the Achilles tendon (running and jumping), when applying pressure and with stretching of the tendon. The tendon often feels thickened.

Examination: Medical examination is not necessarily required in slight, early cases where the tenderness is slowly increasing without sudden worsening. In cases when there is a sense of a “crack”, or sudden shooting pains in the Achilles tendon, medical attention should be sought as soon as possible to exclude a (partial) rupture of the Achilles tendon or rupture of the soleus muscle. This situation is best determined by use of ultrasound scanning, as a number of injuries requiring treatment can easily be overlooked during a normal clinical examination. In all cases where satisfactory progress is not in evidence, an ultrasound examination should be performed as early as possible. Ultrasound scanning enables an evaluation of the extent of the change in the tendon; inflammation of the tendon (tendinitis), development of cicatricial tissue (tendinosis), clacification, inflammation of the tissue surrounding the tendon (peritendinitis), inflammation of the bursa (bursitis), as well as (partial) rupture (article) (Ultrasonic image).

Treatment: Treatment is primarily comprised of relief from the painful activity (running). If the treatment is commenced early, the injury can in some cases heal within a few weeks. If the pain has been experienced for several months, and if ultrasound scanning has revealed thickening of, and changes in the tendon, a rehabilitation period of several months must be anticipated. Relief and cautious stretching will be sufficient to calm the symptoms in the majority of young athletes. In more severe, lengthy or repeated cases in teenagers, emphasis is put on fitness training where the tendon is activated simultaneously with stretching (eccentric training) (article). It is naturally crucial that footwear is in good condition (good running shoes with shock absorbing heel and close fitting heel cap). Pressure on the Achilles tendon can be relieved by using shoes with an elevated heel, whilst a heel cushion in the shoe is of less significance since the heightening achieved by this method is greatly limited. If experiencing tenderness in the Achilles tendon during the rehabilitation period, treatment with ice for a period of at least 20 minutes is recommended.

Bandage: Taping to relieve problems with the Achilles tendon is of questionable significance, but can be attempted as the tape will not invoke further injury if applied in the correct manner (tape-description).

Complications: If there is not a steady improvement in the condition an ultrasound scan should be performed to exclude:

• Rupture of the Achilles tendon
• Inflammation of the bursa
• Inflammation of the growth plate of the heel bone (apophysitis calcanei)
• Rupture of the soleus muscle