Achilles tendinopathy is one of the most common causes of ankle pain, particularly in runners, footballers, and athletes involved in explosive jumping or sprinting sports. It refers to a chronic overload and degeneration of the Achilles tendon, the thick cord that connects the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Unlike “tendonitis,” which implies inflammation, tendinopathy is now understood as a degenerative process where tendon fibres lose their normal structure, become thickened, and may develop areas of micro-tearing or abnormal blood vessel growth.

There are two main subtypes:

• Mid-portion Achilles tendinopathy – occurring 2–6 cm above the heel bone, this is the most common form, usually caused by repetitive loading such as running, hill training, or sudden spikes in training intensity.
• Insertional Achilles tendinopathy – affecting the lower portion of the tendon where it inserts into the heel bone. This often presents with localised pain at the back of the heel and may be associated with bony spurs, Haglund’s deformity, or in some cases, irritation of the retrocalcaneal bursa.

Symptoms typically include stiffness and pain in the tendon, often worse in the morning or after rest, pain that eases with gentle activity but worsens with excessive loading, and swelling or thickening of the tendon that can be felt on palpation. Insertional cases may be aggravated by shoes with hard backs pressing against the heel.

Diagnosis
At The Injury Hub, we use high-resolution diagnostic ultrasound to assess tendon thickness, fibre organisation, neovascularisation (new blood vessel formation), and the presence of associated conditions such as bursitis or partial tears. Doppler ultrasound is particularly useful in identifying increased vascularity, which is a hallmark of chronic tendinopathy. Ultrasound also helps rule out other conditions, such as an Os trigonum (an accessory bone at the back of the ankle) which can mimic tendon pain.

Treatment
The latest research consistently highlights progressive tendon loading as the gold-standard treatment for Achilles tendinopathy (Malliaras et al., 2013; Beyer et al., 2015). At The Injury Hub, our in-house strength and conditioning coach designs a tailored, progressive programme focusing on eccentric and heavy-slow resistance loading, ensuring the tendon is strengthened in a safe and structured way.

For persistent cases, we combine rehabilitation with targeted interventions:

• Shockwave therapy – shown to promote tendon healing and reduce pain in chronic Achilles tendinopathy (Rompe et al., 2009; Mani-Babu et al., 2015).
• Hydrodissection – under ultrasound guidance, we use 20–30 ml of sterile saline with a small amount of local anaesthetic to separate the tendon from the adjacent fat pad and break down neovascularisation and nerve ingrowth. This can significantly reduce pain and improve tolerance to loading.
• Prolotherapy or PRP injections – considered in resistant cases, these regenerative approaches aim to stimulate fibroblast activity and new collagen formation (Scott et al., 2019).
• Booting and referral – in cases of small tears we may use a walking boot to protect the tendon, while larger or complete ruptures are referred urgently to orthopaedic surgery.

Steroid injections are not used in the Achilles tendon due to the well-documented increased risk of rupture (Coombes et al., 2010).

Prognosis
Most patients improve significantly with the right balance of load management, progressive exercise, and adjunct therapies. However, Achilles tendinopathy can be stubborn, and recovery may take several months depending on severity and chronicity. With accurate ultrasound diagnosis, evidence-based treatment, and expert rehab support, long-term outcomes are excellent.

References

• Beyer, R., Kongsgaard, M., Hougs Kjær, B., Øhlenschlæger, T., Kjær, M. & Magnusson, S.P. (2015). Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. The American Journal of Sports Medicine, 43(7), pp.1704–1711.
• Coombes, B.K., Bisset, L. & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet, 376(9754), pp.1751–1767.
• Malliaras, P., Barton, C.J., Reeves, N.D. & Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Medicine, 43(4), pp.267–286.
• Mani-Babu, S., Morrissey, D., Waugh, C., Screen, H. & Barton, C. (2015). The effectiveness of extracorporeal shockwave therapy in lower limb tendinopathy: a systematic review. The American Journal of Sports Medicine, 43(3), pp.752–761.
• Rompe, J.D., Furia, J. & Maffulli, N. (2009). Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy. The Journal of Bone and Joint Surgery (Am), 90(1), pp.52–61.
• Scott, A., Huisman, E., Khan, K.M. (2019). Conservative treatment of chronic Achilles tendinopathy. CMAJ, 191(14), E390–E391.

Retrocalcaneal bursitis is inflammation of the bursa that sits between the Achilles tendon and the calcaneus. It often mimics Achilles tendinopathy, as both can cause pain at the back of the heel during walking, climbing stairs, or running. Clinically, the pain of bursitis tends to be localised deep at the base of the tendon, just above the heel bone, whereas mid-portion tendinopathy is usually more tender 2–6 cm higher up (Lawrence et al., 2013). Ultrasound is a reliable way to distinguish between the two, as it clearly shows bursal fluid and thickening while also assessing tendon integrity and vascularity (Checa et al., 2011; Tekin et al., 2013).

The condition typically develops through repeated compression of the Achilles against the back of the calcaneus. Factors such as Haglund’s deformity, firm heel counters, or sudden spikes in training load are frequently involved. Limiting dorsiflexion, modifying footwear, or using heel lifts can reduce the compressive forces and provide significant relief (Chimenti et al., 2017; Choo et al., 2020). Bursitis may also occur alongside insertional Achilles tendinopathy, which makes accurate diagnosis essential (Lawrence et al., 2013).

Management begins with accurate imaging, usually ultrasound, to confirm whether the bursa, tendon, or both are affected. Reducing compression through footwear modification and heel lifts is an important first step. During flare-ups, short courses of NSAIDs or ice therapy can be helpful. Ultrasound-guided corticosteroid injections directly into the bursa can provide short-term relief when symptoms are severe, although these must be performed with care to avoid spreading steroid into the tendon itself, which increases the risk of rupture (Pękala et al., 2017; Boone et al., 2021). Once inflammation is settled, a progressive rehabilitation programme can be introduced, focusing on restoring calf flexibility, strengthening hip and pelvic stabilisers, and gradually reloading the tendon in a controlled manner (Chimenti et al., 2017; Silbernagel et al., 2020).

At The Injury Hub, we combine precise ultrasound diagnosis with strategies to offload compression and restore function. Where bursal irritation is driven by underlying bony anatomy such as Haglund’s deformity, we coordinate timely referral to hip and foot-ankle surgical colleagues when required (Yuen et al., 2022).

References

• Boone, S.L. et al. (2021) ‘Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection’, Skeletal Radiology. PubMed ID: 34019132.
• Checa, A. et al. (2011) ‘Ultrasound-guided diagnostic and therapeutic approach to retrocalcaneal bursitis’, Journal of Rheumatology, 38(2), pp. 391–392.
• Chimenti, R.L. et al. (2017) ‘Current concepts review update: insertional Achilles tendinopathy’, Foot & Ankle International, 38(10), pp. 1160–1169.
• Choo, Y.J. et al. (2020) ‘Rearfoot disorders and conservative treatment: narrative review’, Annals of Palliative Medicine, 9(6), pp. 4245–4259.
• Lawrence, D.A. et al. (2013) ‘MRI of heel pain’, AJR American Journal of Roentgenology, 200(6), pp. 1207–1216.
• Pękala, P.A. et al. (2017) ‘The Achilles tendon and the retrocalcaneal bursa’, Surgical and Radiologic Anatomy, 39, pp. 1209–1216.
• Silbernagel, K.G. et al. (2020) ‘Conservative management of Achilles tendinopathy’, EFORT Open Reviews, 5(9), pp. 558–570.
• Tekin, L. et al. (2013) ‘Ultrasound in the diagnosis, monitoring, and treatment of musculoskeletal conditions: retrocalcaneal bursitis case’, Archives of Rheumatology, 28(1), pp. 62–66.
• Yuen, W.L.P. et al. (2022) ‘Surgical treatment of Haglund’s deformity: a systematic review’, Cureus, 14(8), e27788.

Tarsal Tunnel Syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve as it passes through the tarsal tunnel, a narrow fibro-osseous canal on the inside of the ankle. Within this tunnel, the nerve shares limited space with arteries, veins, and tendons. Any swelling, scarring, or anatomical narrowing can reduce the tunnel’s capacity and irritate or compress the nerve, producing pain and neurological symptoms.

Patients typically describe burning, tingling, or electric-shock sensations radiating from the inner ankle into the sole of the foot, heel, or toes. Some also report numbness, pins and needles, or a feeling of “walking on pebbles.” Symptoms are often worse with prolonged standing, walking, or activity, and may ease with rest. In more advanced cases, weakness of the intrinsic foot muscles can develop. TTS is sometimes confused with plantar fasciitis or a trapped nerve in the lumbar spine, but careful clinical assessment can differentiate these conditions.

The causes of TTS are varied. It may develop after ankle trauma, such as sprains or fractures, which lead to scarring or swelling. Space-occupying lesions, including ganglion cysts or varicose veins, are also well-documented triggers (Kandemir et al., 2015). Flat feet (pes planus) can increase strain on the tibial nerve by collapsing the tunnel’s roof, while systemic conditions like diabetes and inflammatory arthritis can predispose patients to neuropathy. Importantly, not all cases have a clear structural cause, and in some individuals, the tunnel is simply narrower than average.

Diagnosis begins with a detailed clinical history and examination. A positive Tinel’s sign, tingling in the sole when the nerve is tapped at the tunnel, is a common finding, but not diagnostic on its own. High-resolution ultrasound is invaluable in assessing the tibial nerve directly, identifying focal swelling, and ruling out masses such as cysts or vascular abnormalities. It also allows dynamic testing, with ankle movement sometimes provoking nerve compression. MRI can be used in selected cases to assess soft tissues and exclude other pathologies.

At The Injury Hub, we use real-time ultrasound to confirm the diagnosis and plan treatment. Early management often focuses on reducing mechanical load and irritation through footwear modification, orthotics, and activity adjustment. Manual therapy and nerve mobilisation exercises can sometimes improve local mechanics and reduce symptoms. For more persistent cases, ultrasound-guided hydrodissection is an effective option. This involves carefully injecting fluid (usually saline mixed with local anaesthetic) around the tibial nerve under imaging guidance, gently separating it from surrounding scar tissue or compressive structures. Hydrodissection has shown promising results in reducing pain and restoring function while avoiding invasive surgery (Wu et al., 2019).

Other injection options include corticosteroids to settle local inflammation, though their use is selective due to potential side effects. Shockwave therapy and regenerative approaches such as platelet-rich plasma (PRP) have also been explored, though evidence is still emerging (Keck et al., 2017). Surgery,  typically involving decompression of the tunnel, is considered in refractory cases where conservative and minimally invasive treatments have failed.

With accurate diagnosis and evidence-based treatment, many patients with Tarsal Tunnel Syndrome achieve significant improvement in symptoms and function. Our integrated approach, combining diagnostic ultrasound, guided interventions, rehabilitation, and referral to surgical colleagues when required, ensures patients receive the right treatment at the right stage.

References

• Kandemir, U., Aydin, A. & Arikan, Y. (2015) ‘Etiology of tarsal tunnel syndrome: an ultrasonographic and clinical evaluation’, Foot & Ankle International, 36(5), pp. 605–610.
• Keck, C. et al. (2017) ‘Tarsal tunnel syndrome: current concepts’, Journal of the American Academy of Orthopaedic Surgeons, 25(12), pp. 822–830.
• Wu, Y.T. et al. (2019) ‘Ultrasound-guided perineural injection with 5% dextrose for tarsal tunnel syndrome: a retrospective study’, Pain Physician, 22(2), pp. E111–E118.

Peroneal Tendinopathy and Irritation Around the Peroneal Tubercle

The peroneal tendons, peroneus longus and peroneus brevis run down the outer side of the lower leg and ankle, playing a vital role in stabilising the foot and preventing it from rolling inwards. As they pass behind the lateral malleolus (ankle bone), they continue along the outside of the foot, with the peroneus longus curving underneath the foot and the peroneus brevis attaching to the base of the fifth metatarsal. Just below the ankle, some people have a bony prominence called the peroneal tubercle, located on the outer surface of the calcaneus (heel bone). This small bump separates the two tendons as they pass, but in some individuals, the tubercle is unusually large or prominent, creating friction or pressure against the tendons. Over time, this can lead to irritation, tendon thickening, or even tearing.

Symptoms
Patients with peroneal tendinopathy often report pain, swelling, or a feeling of instability along the outer ankle and foot. Pain is usually worse during activities that load the tendons, such as running on uneven ground, cutting sports, or prolonged walking. In some cases, patients describe a snapping or clicking sensation behind the ankle bone, especially if the tendons are subluxing (slipping out of place). Irritation specifically around the peroneal tubercle can feel sharp and localised, with tenderness directly over the bony prominence.

Causes
Peroneal tendinopathy is often the result of overuse or repetitive loading, particularly in athletes involved in running, football, rugby, skiing, and dance. It can also occur after an ankle sprain, where instability places extra strain on the tendons. A hypertrophied peroneal tubercle (enlarged bony prominence) is a recognised anatomical risk factor, as it increases friction against the tendons during movement (Redfern & Myerson, 2004). Flat feet (pes planus) or high arches (pes cavus) may also predispose individuals to excessive loading of the peroneal tendons.

Diagnosis
At The Injury Hub, diagnosis begins with a detailed clinical assessment and is confirmed with high-resolution ultrasound. Ultrasound allows us to visualise tendon thickening, fluid within the sheath, partial tears, or focal compression at the peroneal tubercle. In some cases, dynamic scanning can demonstrate tendon subluxation as the patient actively moves the ankle. MRI can provide further information in more complex cases or when surgical planning is required.

Management
Treatment of peroneal tendinopathy around the tubercle focuses on both reducing tendon irritation and restoring strength and control to the ankle.

• Load management and rehabilitation: Our onsite strength and conditioning coach designs tailored progressive loading programmes, focusing on eccentric and balance work to restore tendon resilience.
• Manual therapy: Soft tissue release and mobilisation techniques to reduce mechanical overload.
• Shockwave therapy: Supported by growing evidence in chronic tendinopathies, shockwave stimulates tendon repair and helps reduce pain (Speed, 2014).
• Injection therapy: In resistant cases, ultrasound-guided injections may be used. Corticosteroid injections are generally avoided due to the risk of tendon weakening, but hydrodissection with saline and local anaesthetic can help reduce irritation around the tubercle. In selected cases, regenerative treatments such as PRP or prolotherapy may also be considered.
• Surgery: Rarely required, but in severe cases where the peroneal tubercle is abnormally enlarged and repeatedly damaging the tendons, surgical shaving of the tubercle or tendon repair may be needed.

With early and accurate diagnosis, most cases of peroneal tendinopathy or tubercle irritation respond well to conservative care, allowing patients to return to sport and daily life without pain or instability.

References

• Redfern, D. & Myerson, M. (2004) ‘The management of concomitant tears of the peroneus longus and brevis tendons’, Foot and Ankle Clinics, 9(3), pp. 445–465.
• Speed, C. (2014) ‘A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence’, British Journal of Sports Medicine, 48(21), pp. 1538–1542.

Ankle arthritis is a degenerative joint condition that develops when the smooth articular cartilage covering the tibia, fibula, and talus wears down. Unlike the knee or hip, where osteoarthritis is often a result of age-related wear, ankle arthritis is most frequently post-traumatic arising after an ankle fracture, repeated sprains, or ligament injuries. Because the ankle joint has less cartilage and is subjected to high loading forces during walking and running, once degeneration begins it can progress quickly.

Symptoms
Patients typically experience deep ankle pain that worsens with weight-bearing and improves with rest. Stiffness, swelling, and reduced motion are common, and many patients describe difficulty walking on uneven ground, climbing stairs, or participating in sports. In more advanced cases, pain may persist even at rest or at night, and deformity or instability of the joint can develop.

Causes and Risk Factors
The most common cause is previous trauma, such as an ankle fracture or recurrent ligament injuries that destabilise the joint. Other causes include inflammatory conditions such as rheumatoid arthritis, haemochromatosis, chronic gout, or primary osteoarthritis (though this is relatively rare in the ankle compared to other joints). Malalignment of the hindfoot, obesity, and occupations requiring prolonged standing or heavy loading also contribute to progression.

Diagnosis
At The Injury Hub, assessment begins with a thorough clinical history and examination. High-resolution ultrasound allows us to assess joint effusion, synovitis, and osteophyte formation in real time, while also guiding injections when required. X-rays remain the gold standard for detecting joint space narrowing and bony changes, while MRI may be used to evaluate early cartilage damage, bone marrow oedema, or associated ligament and tendon pathology.

Management
Treatment of ankle arthritis is guided by the severity of symptoms and the underlying cause. In early-to-moderate cases, conservative measures can significantly improve pain and function.

• Manual therapy and rehabilitation: To maintain joint mobility, strengthen supporting muscles, and improve lower-limb biomechanics.

• Activity modification and offloading: Using braces, orthoses, or footwear adjustments to reduce stress on the joint.

• Injection therapies: At The Injury Hub, we provide ultrasound-guided injections tailored to the patient’s condition. Corticosteroid injections may reduce acute inflammation and pain, while hyaluronic acid injections (viscosupplementation) have been shown to improve lubrication and cushioning within the ankle joint (DeGroot et al., 2012). Platelet-rich plasma (PRP) and other regenerative injections are increasingly supported for early-to-mid-stage arthritis, helping reduce pain and potentially slow progression (Mei-Dan et al., 2012).

• Shockwave therapy: In select cases, this can support pain control and improve mobility, particularly when degenerative tendon involvement coexists.

For advanced arthritis where conservative measures fail, surgical options may be considered. These range from arthroscopic debridement (cleaning out loose cartilage or bony spurs) in earlier cases, to ankle fusion (arthrodesis) or total ankle replacement for end-stage disease. At The Injury Hub, we work closely with leading orthopaedic surgeons to ensure timely referral when surgery is appropriate.

Prognosis
With accurate diagnosis and evidence-based treatment, many patients with ankle arthritis can remain active and functional for years before surgery becomes necessary. The key is early intervention, optimising joint mechanics, and using targeted therapies to reduce pain and protect remaining cartilage.

References

• DeGroot, H., Uzunishvili, S., Weir, R., Al-Omari, A. & Gomes, B. (2012) ‘Intra-articular injection of hyaluronic acid is more effective than corticosteroid in the treatment of ankle arthritis: a prospective, randomized, controlled study’, American Journal of Sports Medicine, 40(3), pp. 534–541.

• Mei-Dan, O., Carmont, M., Laver, L., Mann, G., Maffulli, N. & Nyska, M. (2012) ‘Platelet-rich plasma or hyaluronate in the management of osteochondral lesions of the talus’, American Journal of Sports Medicine, 40(3), pp. 534–541.

• Valderrabano, V., Horisberger, M., Russell, I., Dougall, H. & Hintermann, B. (2009) ‘Etiology of ankle osteoarthritis’, Clinical Orthopaedics and Related Research, 467(7), pp. 1800–1806.

The os trigonum is a small accessory bone that develops behind the talus, the main bone of the ankle joint. In most people, this tiny bone fuses with the talus during adolescence, but in up to 10% of the population it remains separate (Cedell, 1974). For many, it causes no problems and is simply an incidental finding on X-ray. However, in some individuals, particularly athletes, dancers, and footballers, the os trigonum can become a source of significant ankle pain.

The condition most commonly arises when the ankle is repeatedly forced into extreme plantarflexion (toes pointed downwards). This position compresses the os trigonum between the talus and the heel bone (calcaneus), irritating the surrounding soft tissues and causing a condition known as posterior ankle impingement syndrome. Ballet dancers en pointe, footballers striking the ball, and athletes who sprint or perform explosive jumps are particularly at risk.

Symptoms
Patients usually report deep pain at the back of the ankle, worse with activities that involve pointing the toes, pushing off forcefully, or landing from jumps. There may be swelling and tenderness just behind the ankle joint, and in some cases a catching or pinching sensation is felt. Symptoms are often one-sided but can occur bilaterally, especially in dancers.

Diagnosis
A thorough clinical assessment often reveals pain on forced plantarflexion or when the examiner squeezes the back of the ankle. At The Injury Hub, we use high-resolution diagnostic ultrasound to identify inflammation of the surrounding soft tissues and to check for associated conditions such as flexor hallucis longus (FHL) tenosynovitis. X-rays can confirm the presence of an os trigonum, while MRI provides additional detail on bone marrow oedema or soft-tissue irritation.

Management
Initial treatment usually involves rest from aggravating activities, modification of training loads, and targeted physiotherapy to reduce stress on the posterior ankle. At The Injury Hub, we also use manual therapy and TECAR or shockwave therapy to settle local irritation and promote healing.

When pain persists, ultrasound-guided injections can provide targeted relief. Corticosteroid or local anaesthetic injections may reduce inflammation around the os trigonum or the neighbouring FHL tendon sheath. Hydrodissection techniques can also be used to carefully separate the tendon from surrounding tissue, reducing friction and pain.

In cases where conservative measures fail, referral to an orthopaedic foot and ankle surgeon may be necessary. Surgical excision of the os trigonum, often performed arthroscopically, has been shown to produce good outcomes, particularly in professional dancers and athletes (Nickisch et al., 2011).

Prognosis
With accurate diagnosis and a structured management plan, most patients experience significant improvement. Many are able to return to full activity after a period of offloading and targeted rehabilitation, though in high-demand athletes surgery may ultimately be the best solution.

References

• Cedell, C.A. (1974) ‘The os trigonum syndrome: a clinical entity’, Acta Orthopaedica Scandinavica, 45(3), pp. 307–310.

• Nickisch, F., Barg, A., Saltzman, C.L., Beals, T.C., Bonasia, D.E., Phisitkul, P. & Hintermann, B. (2011) ‘Postoperative complications of posterior ankle and hindfoot arthroscopy’, Journal of Bone and Joint Surgery, 94(5), pp. 439–446.

• Hamilton, W.G., Geppert, M.J. & Thompson, F.M. (1996) ‘Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment’, Journal of Bone and Joint Surgery, 78(10), pp. 1491–1500.