Background & Etiology (Cause)
The ankle is made of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body. It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to, and react quickly to changes in environment and walking surface.
Bones and Joints
There are three bones that come together to form the ankle joint. The tibia and fibula (lower leg bones) end in prominences called the malleoli. The malleoli create the bony prominence seen on either side of the ankle, these are called the lateral malleus and medial malleolus. The ankle is made up of two joints, the inferior talocrural joint and the subtalar joint.
The inferior tibiofibular joint is located between the large bone of the lower leg (tibia) and the smaller fibula, which then attach to the talus bone of the foot to form the talocrural joint. The talocrural joint is sometimes called the true ankle joint and is responsible for dorsiflexion and plantar flexion (up and down) movement of the foot. The joint between the tibia and talus bears the most of our body weight.
Beneath the talocrural joint is the subtalar joint. The subtalar joint is located between the talus bone and calcaneus or heel bone. This joint is responsible for ankle inversion (turning in) and eversion (turning out).
Running between the tibia and fibula is a fibrous membrane called the interosseous membrane. This membrane joins the tibia and fibula all the way up the lower leg, extending toward the knee. At the upper end, near the outside of the knee, is the superior tibiofibular joint.
Any restriction or dysfunction of these joints can produce symptoms in the ankle. The bony joint surfaces all have articular cartilage that covers the ends of the bones. The articular cartilage has a smooth and shiny surface, which allows the ends of the bones to slide freely over each other.
A bursa is a fluid filled sack that serves to reduce friction between tendons, and between tendons and bone. Bursa are important structures in both the ankle joint and the subtalar joint, because they ensure that the structures of the joint move smoothly. Bursa can become inflamed due to overuse or stress, causing pain and trouble moving the joint comfortably. The major bursa located in the ankle region are the Achilles bursa, retrocalcaneal bursa and the bursa of the medial malleolus.
- Achilles bursa: Also called the subcutaneous calcaneal bursa, the Achilles bursa is located between the skin and the posterior aspect of the distal Achilles tendon. Like the retrocalcaneal bursa the Achilles bursa is located superior to the insertion of the Achilles tendon. Pain from an injury to this bursa will occur along the back of the ankle near the heel.
- Retrocalcaneal bursa: Sometimes called the sub-tendious bursa, the retrocalcaneal bursa is located between the anterior aspect of the Achilles tendon and the calcaneous bone (heel). Like the Achilles bursa, the retrocalcaneal bursa is located superior to the insertion of the Achilles tendon. Pain from an injury to this bursa is concentrated at the back of the ankle by the heel.
- Medial Malleolar Bursitis: Also called the subcutaneous bursa of the medial malleolus, this bursa is located between the skin and the medial malleolus (the flattened end of the tibia that forms the prominence of the ankle, sometimes referred to as the ankle bone). Injury to this bursa can cause pain along the outside of the ankle at the medial malleolus bone.
- A direct blow to the bursa can produce inflammation and irritation.
- A fall where one lands improperly on the ankle or bursa.
- Constant pressure on the bursa from use of the ankle.
- Repeated stress injury to the bursa and tendons (particularly the Achilles) from a high level of activity, which can also cause tendonitis in addition to bursitis.
- Complications from rheumatoid arthritis, osteoarthritis or gout.
- Infection of the bursa or ankle.
- Bursa can become swollen as a response to other ankle conditions.
- Pain and tenderness over the location of the bursa
- Loss of motion of the ankle
- Pain with activities that stress the bursa like walking, jumping, running or activities that cause stress on the tendons that are lubricated by the bursa.
Avoiding the activities that produce the pain or stress the involved bursa is the first line of treatment.
- Avoiding activities that produce pain or stress of the bursa and associated tendons (jumping, running, etc.)
- RICE: (Rest, Ice, Compression, Elevation) should be used to reduce the stress on bursa
- The use of ice to reduce inflammation and pain.
- NSAIDS (nonsteroidal anti-inflammatory drugs)
- Physical Therapy
- Drainage of the fluid in the bursa for severe cases. Fluid can be checked for possible infection.
- Antibiotic in the case of infections of the bursa
- Steroidal injections in non responsive cases
- Surgery to remove the bursa may be indicated in extreme cases if the problem becomes chronic.
Physical Therapy Interventions
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals. Physical therapy for an ankle bursitis must remain conservative at the onset in order to not aggravate the condition. Emphasis will be in rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has reduced a program of stretching and light strengthening will be initiated to restore full motion and improve strength to reduce stress on the tendons and ankle joints.
Physical Therapy Interventions
Common Physical Therapy interventions in the treatment of Ankle Bursitis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the ankle. Use of mobilization techniques also help to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the ankle to support, stabilize, and decrease the stresses place on the bursa and tendons of the ankle joint.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, or jumping) of the involved lower extremity to reduce stress on bursa and tendons in daily activities.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation of the involved bursa.
- Home program including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
In general, patients respond well to conservative treatment of ankle bursitis. It is important that once the pain and inflammation is reduced and motion and strength are restored that the patient gradually returns back to full activities. Instruction in daily activities or sport performance is helpful to reduce the chance of a reoccurrence of the bursitis. In most cases full return to activity will take from 2-6 weeks depending on the severity of the condition. As a preventive measure individuals should:
- Make modifications in work or daily activities such and avoiding positions that stress the bursa or wearing protective equipment to avoid prolonged pressure or unexpected blows on the bursa.
- Maintain strength and flexibility to reduce stress on the bursa and tendons of the ankle.
- Avoid highly repetitive activities whenever possible.