Anatomy: The shin bone (tibia) and the calf bone (fibula) are held together by a connective tissue membrane (membrana interossea cruris) which is particularly strong at the ankle joint and forms a false joint. This, together with the membrane, is termed syndesmosis tibiofibularis which is strengthened in front and behind with two strong ligaments (ligamentum tibiofibulare anterius & posterius).

Symptoms: Pain in front of the ankle joint between the shin and calf bones. The pain is aggravated when the foot is turned in relation to the shin.

Acute treatment: Click here.

Examination: As the injury is almost always combined with a fracture of the bones in the ankle, an x-ray examination will always be indicative. The x-ray will show the fracture and a possible increase in the distance between the shin and calf bones.

Treatment: Dressing with a bandage and possible surgical intervention dependant upon the presence of a bone fracture.

Rehabilitation: Rehabilitation is dependent upon the course of treatment (conservative/surgical operation), and of possible fractures and their treatment.
Also read rehabilitation, general.

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:

• Bone fracture
• Outer ligament injury in the ankle jointt
• Inner ligament injury in the ankle joint
• Bone membrane tear (periosteal avulsion)
• Inflammation of the tendon sheath
• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Cartilage damage in the joint

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). Large or small ligaments (metarsus ligaments) run between all the bones, which stabilise the joints if twisted and running with directional change.

Symptoms: Pain in the ligament also occuring with load (twist) on the joint which the ligament stabilises.

Acute treatment: Click here.

Examination: Clinical examination is normally not required in light cases (strain/sprain) with only minimal tenderness, and no discomfort when walking. More pronounced pain will demand examination to exclude bone fracture, bone membrane tear (periosteal avulsion), inflammation of the tendon sheath, concentration of fluid in the joint (traumatic arthritis/synovitis). A normal medical (evt. clinical) examination is usually sufficient in order to make the diagnosis. X-ray will confirm or exclude any suspicion of fracture. Small bone membrane tears are best seen under ultrasound scanning.

Treatment: Treatment of uncomplicated metatarsus ligament rupture will normally be conservative (rehabilitation).

Bandage: In the rehabilitation phase, tape can be used when running on uneven surfaces or running with rapid directional change begins. The tape has, however, not the same important purpose as for ligament injuries on the large outer or inner ligaments in the ankle, (tape-instruction).

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:

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

Anatomy: The muscles often comprise a muscle belly and a muscular tendon, which are attached to a bone. The muscle belly is found on the back of the foot, between forefoot bones and under the sole.

Symptoms: Pain when pressure is applied, activating and stretching the damaged muscle. There is often a sense of the muscle being firm or filling out.

Examination: A medical examination is not required in slight cases. If satisfactory progress is not achieved a medical examination may be required in order 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: Bleeding on the muscles is treated with relief and rehabilitation. In instances where the bleeding is particularly excessive it may be necessary to perform draining.

Rehabilitation: Rehabilitation is totally dependent upon which muscle is injured. Running can normally be resumed as soon as the pain subsides. Until this is possible, the guidelines under rehabilitation, general should be followed.

Complications: If satisfactory progress is not achieved, an x-ray examination should be performed to exclude the possibility of:

• Bone fracture
• Stress (fatigue) fracture

Similarly, an ultrasound scan should be performed to exclude:

• Concentration of fluid in the joint (traumatic arthritis/synovitis)
• Metatarsus ligament rupture
• Bone membrane tear (periosteal avulsion) in the forefoot
• Degenerative arthritis
• Inflammation of the bursa
• Inflammation of the tendon sheath
• Infection
• Rupture of tendons

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).