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Dance is the hidden language of the soul.

Martha Graham, dancer and choreographer, 1894–1991

Sportspeople, particularly ballet dancers, footballers, basketballers and high jumpers, may complain of ankle pain that is not related to an acute ankle injury (Chapter 41). Clinical management of such ‘overuse’ injuries is simplified if the presentations are further divided into:

  • medial ankle pain

  • lateral ankle pain

  • anterior ankle pain

  • posterior ankle pain: defined in this book as the ‘Achilles region’ (Chapter 40).

It is important to note that clinically, patients often present with combinations of pain, such as anterolateral ankle pain in soccer players. In those circumstances, the systematic clinical approach outlined in this chapter still aids in diagnosis and management.


Although there are numerous causes of medial ankle pain, the most common is tendinopathy, in particular of the tibialis posterior tendon, and to a lesser degree the flexor hallucis longus tendon. Another important cause of medial ankle pain is tarsal tunnel syndrome, where the posterior tibial nerve is compressed behind the medial malleolus. This may present as medial ankle pain with sensory symptoms distally. Posterior impingement syndrome of the ankle can also present as medial ankle pain (Chapter 40).

The causes of medial ankle pain are listed in Table 42.1. The anatomy of the region is illustrated in Figure 42.1.

Table 42.1

Causes of medial ankle pain

Figure 42.1

Medial aspect of the ankle (a) Surface anatomy (b) Anatomy of the medial ankle


In patients with medial ankle pain there is usually a history of overuse, especially running or excessive walking (tibialis posterior tendinopathy), toe flexion in ballet dancers and high jumpers (flexor hallucis longus tendinopathy) or plantarflexion in dancers and footballers (posterior impingement syndrome). In the case of tibialis posterior tendinopathy, pain may radiate along the line of the tendon to its insertion on the navicular tubercle, or in tarsal tunnel syndrome the arch of the foot. Associated sensory symptoms such as pins and needles or numbness may suggest tarsal tunnel syndrome. Crepitus is commonly associated with flexor hallucis longus and occasionally tibialis posterior tendinopathy.

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