1. Medial Ankle and Heel Pain
Excluding plantar fascia
Dr Jimmy McLaren

2. Introduction
Anatomy & DDx
Hx and Exam
Insidious Medial Ankle

3. Medial Ankle Anatomy Bones – MM, talus, calcaneus, navicular Ligaments
Deltoid ligament
Calcaneonavicular (Spring) ligament 
Plantar Fascia, Fat Pad
Tendons
Tib post
FDL
FHL
Tibial Nerve Branches
Medial Calcaneal N
Posterior Tibial N - Medial Plantar N
- Lateral Plantar N

4. Chronic Medial Ankle/Rearfoot DDx
Tendons - Tib Post Tendinopathy (common) - FHL Tendinopathy Nerves - Medial Calcaneal Nerve entrapment - Tarsal Tunnel Syndrome Bones - Stress # - Navicular - Calcaneus - Medial Malleolus Plantar Fascia, Fat pad contusion Posterior Impingement Syndrome Referred pain – Lumbar CRPS Type 1

5. History Previous injury Overuse (eg tib post)
Sport: FHL tendinopathy - ballet, high jump
Posterior impingement - dance, football
Radiation - to navicular (tib post),
- to arch (tibial tunnel syndrome)
Parasthesia - tarsal tunnel syndrome

6. Examination Biomechanical exam, KTW Functional - jump, hop
Lumbar Screen
Active - Ankle PF/DF, Inv/Eversion, 1st MTP flex
Passive - Subtalar, midtarasal,
Resisted - inversion(TP), 1st toe flexion (FHL)
Palpation - Ankle, Midtarsal joint,
- Tib Post, FHL,
- MM, Navicular, Calcaneal compression
Tinnel’s - compresses tibial nerve
Sensation - pin prick

7. TENDINOPATHIES
Tib post: Insertion- navicular, cuboid, cuneiforms, 2-4MT, spring ligament
FDL
FHL: Most posterior when deep to felxor retiinaculum, b/w lat+med tubercles of talus, b/w sesamoid, insert base distal phalynx

8. Tibialis Posterior Tendinopathy
Path - posterior to MM
Insert - navicular, cuboid,
- cuneiforms, 2-4MT, spring ligament
Fxn - dynamic stabilizer medial long arch invert STJ
Causes:
Overuse - Walk/run/jumping
Mechanics - Excessive ST pronation (ecc load)
Acute - ankle eversion sprain/#, avulsion
Inflam - rheumatoid, seronegative arthopathy

9. OE
Single heel raise pain/lack of inversion
Tender posterior+inferior to MM, towards navicular
Resisted inversion painful
Swelling unusual – extensive/seroneg arthopathy
Grades
II - pes planus,
III - rigid valgus hindfoot STJ OA,
IV - deltoid ligament compromise

10. Ice, eccentric exercises, orthotic, +/- NSAID if inflammatory
Investigations
Treatment
Ice, eccentric exercises, orthotic,
+/- NSAID if inflammatory
+/- synovectomy +/- reconstruction
XR – pes planus,
MRI - Axial view, right ankle T2 fat suppressed. Oedema around Tib post, reactive boney oedema

11. FHL Tendinopathy
Anatomy most posterior, - b/w lat+med tubercles of talus - b/w sesamoid, insert base distal phalynx Fxn - big toe flexion, ankle plantarflexion Cause - Overuse - ballet/dance - “Toe grip” shoes to big - Tenosynovitis Association with Posterior Impingement - Large/displaced posterior process talus - Os trigonum
Origin – distal 2/3 fibula and IO membrane
Association – Posterior Impingement. FHL tendon lies in firbosseous tunnel b/w medial and lateral tubrercles pof the posterior process of the talus.

12. FHL Tendinopathy Hx Pain behind MM, on toe-off or forefoot WB OE
Pain resisted flexion, passive hallux extension
‘Triggering’
Excess inversion/eversion on toe off
Posterior impingement
Shoes size
Inv
+/-XR, MRI – assess associations
Painful audible crepitation due to thickened/scarred tendon catching on fibroosseous tunnel

13. MRI - Axial view, right ankle T2 fat suppressed
MRI - Axial view, right ankle T2 fat suppressed. FHL with synovitis, behind the talus
XR – indirectly looking for posterior impingement association

14. FHL Tendinopathy Rx Ice Activity Mod – avoid en pointe, hard floors
Tape/orthoses – correct excess pronation
Well fitted shoes
Mobilise - if STJ hypomobile
FHL strength/stretching, STW proximally

15. NERVES
Deep peroneal N

16. Tibial Nerve Branches
Branches 1) Medial Calcaneal N - Pierce flexor reitinaculum Divides deep to flexor retinaculum
Terminal braches divide under flexor retinaculum 2) Medial Plantar 3)Lateral Plantar N

17. Tibial Nerve Branches 1) Medial Calcaneal N
Pierce flexor retinaculum
Supply medial heel
Terminal Branches divides deep to flexor retinaculum
2) Medial Plantar N
3)Lateral Plantar N

18. Tibial Tarsal Syndrome
Tibial Nerve Compression
Identify Underlying Cause: Idiopathic 50%
Intrinsic
Extrinsic
Tendonopathy/tenosynovitis
Varicose Veins
Ganglion
Osteophytes
lipoma/tumor
Anatomic - tarsal coalition
- valgus hindfoot
Shoes
Trauma:inversion/#/post-op
Systemic inflammation
Oedema

19. Poorly defined burning/tingling/numbness plantar foot Hx
Poorly defined burning/tingling/numbness plantar foot
Agg by activity, relieved by rest
But some worse in bed, relieved by moving foot OE
Valgus hindfoot, pes planus, excess pronation
Thickenings/VV/ganglion/swelling
Tinnel’s sign – reproduce pain, +/- fasciculation
Compression test (PF, invert, and press)
Pain on passive eversion
+/-parasthesia +/- intrinsic muscle wasting

20. Investigations Clinical Diagnosis NCS false negative 50%
inability to predict which respond to surgical decompression
XR - tarsal coalition
MRI/USS – mass /accessory muscle

21. Treatment Nonoperative Correct pronation: orthosis/taping/foot wear
Neural glide
NSAID/Iontophoresis / CSI
Surgical Decompression
failed conservative treatment & +ve NCS
best results when compressing structure identified (cf traction neuritis poor response)

22. Medial Calcaneal Nerve Entrapment
Aka Baxter’s Nerve
Branch of tibial nerve at MM (or lateral platar N)
pierce flexor retinaculum
medial heel sensation
Presentation
Burning inferomedial calcaneous
Tinnel’s +ve
Valgus hindfoot, excessive pronation

23. Medial Calcaneal Nerve Entrapment
Investigations
Diagnostic LA
NCS – often false negative
Treatment
Change footwear, pad
LA/CSI
Decompression of nerve

24. STRESS FRACTURES General Features Agg with activity
Absent / persists at a lower level at rest
If training continues, brought on with less intensity
History
Previous injury
Training load
Female triad/REDS: Eating disorder, menstruation
PMH – thyroid,
Meds – glucocoticoids

25. OE
Tenderness, +/-redness +/- swelling +/- palpable periosteal thickening
Percussion of long bones -> pain at distant points
Biomechanics: LLD, excessive pronation, weakness, stiffness
Investigations
XR +/- linear sclerosis
MRI T2 hyperintensity
Bone Scan – 100% sensitivity, but not specific
CT – cortical bone defects

26. Medial Malleolus Stress Facture
vertical from jxn of tibial plafond and MM
(may arch obliquely from distal tibial metaphysis) 
Coronal view, T2 imaging, Increased signal, Peri-osteal reaction,

27. MM Stress Fracture Treatment
No fracture line
NWB until tenderness resolves, RTS 6/52
+/- air brace
Fracture / cortical defect
Screw (Shelbourne et al)
(Lempainen)
Biomechanics, orthosis, footwear

28. Navicular Stress # #1 tarsal stress fracture
Navicular impingement reduced ankle DF
Middle 1/3 navicular (relatively avascular)
Clinical
Usually midfoot pain
“N spot” tenderness – dorsal prox navicular
Stress # until proven otherwise

29. Navicular Stress # Treatment Stable # - NWB cast, 6-8 weeks
T1 weighted axial MRI and CT (axial image and coronal)
CT – poor positioning can miss them. Get thin 2mm slices from distal talus to distal navicular
Treatment
Stable # NWB cast, 6-8 weeks
Unstable/distracted # - Screw

30. Calcaneal Stress # 2nd most common tarsal stressy Hx
Military, runners, jumpers, dancers
Technique – overstriding, heavy landing
Poor cushioning OE
Localised tenderness med or lateral posterior calcaneous
Pain on calcaneal compression

31. Upper posterior margin / medial tuberosity Treatment
activity / short period NWB
Soft heel pad, orthotic, shoes
Technique – overstriding, heavy landing
XR - sclerosis

32. SUMMARY Plantar Fascia, Fat Pad Ligaments Tendons Bones Nerves
Referred

33. Medial Ankle Ligaments
Focus on Deltoid ligament
Superficial Ligament – 4 parts as above(start from bottom up), cross both ankle and subtalar joint
Deep Ligament – cross only ankle joint, MM to talus

34. Deltoid Ligament Superficial Layer
Crosses both ankle and subtalar joints
Fans - Anterior tibiotalar (neck of talus)
- Tibionavicular
- Tibiocalcaneal (sustenaculum tali)
- Posterior tibiotalar
Deep layer
Crosses only ankle joint
Inferior & posterior MM - medial+posteromedial talus
prevents lateral displacement & ER of talus 
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35. Deltoid Ligament
O/E
Eversion test - with ankle neutral, evaluates superficial layer
ER stress - evaluates syndesmosis and deep layer
XR – stress view with medial clear space widening
Associated clinical conditions
Medial malleolus fracture
Maisonneuve fracture
Variant of syndesmosis sprain
Ruptured medial ligament, AITFL + IO membrane, proximal fibula fracture

36. Calcaneonavicular (Spring) Ligament
sustentaculum tali to  navicular 
stabilize medial longitudinal arch & talar head
OE - flattened medial longitudinal arch
Clinical conditions
Assoc with tibialis posterior tendon dysfunction
Acute spring ligament tear
forceful landing on flat foot