Ankle Pain From Swimming

author : AMSSM

comments : 1

*The past few weeks I have had this dull, sometimes sharp pain around my ankle. It's on the front of my ankle (which is weird). I get the most pain when swimming.

Member Question

The past few weeks I have had this dull, sometimes sharp pain around my ankle. It's on the front of my ankle (which is weird), so extension hurts right at the curve. When the pain gets worse, it spreads to the inside of my ankle and up along the flexor digitorum longus (or so it seems). I get the most pain when swimming, as my extended ankle hits the water. Do you know what it is, or have suggestions of what to do?

Answer from Michael Cassat, M.D.
Member AMSSM 

The foot and ankle consist of 26 bones, 33 joints, and over one hundred muscles, tendons, and ligaments.  It is heavily used in all three disciplines of the sport of triathlon and is a common source of pain for many triathletes.

Freestyle swimming requires repeated flexion and extension of the foot and ankle throughout the kick cycle, with a typical workout requiring thousands of kicks per mile.  Adding the use of fins to a workout increases the strain placed on the muscles and tendons to perform, increasing the risk of an overuse injury. 

Two common areas of pain generation for swimmers are the flexor and extensor muscle groups and their associated tendons. These groups provide for movement of the foot and ankle in up and down planes - the motion required for kicking in the freestyle swim stroke.  In the foot and ankle, raising the foot off the floor is called dorsiflexion, and is predominantly accomplished by contraction of the tibialis anterior muscle.  Pressing the foot and ankle down into the floor is called plantar flexion, and is predominantly accomplished through the contraction of the gastrocnemius soleus complex of muscles.  Accomplishing dorsiflexion of the toes is through contraction of the extensor hallucis longus and extensor digitorum longus. Plantar flexion of the toes is through contraction of the flexor hallucis longus and flexor digitorum longus. 

Overuse of a muscle is known as a muscle strain, and is caused by damage to the muscle.  The amount of damage is on a continuum. Small amounts of micro trauma cause a mild healing response, promoting muscle growth.  This is the process capitalized on by athletes through progressive adaptive exercise to become stronger.  Overuse injury at a further level can be associated with macro trauma, or muscle tearing on a larger level, resulting in a permanently damaged muscle that can become scarred and less functional.   Injury to a muscle beyond typical delayed onset muscle soreness requires a period of relative rest until the injury improves.  During this period, alternate activities that do not cause pain are promoted to maintain overall fitness.

Overuse injury to the tendon, the structure that attaches a muscle to bone, is called tendinopathy.  After the initial injury there is a period that the damage is associated with inflammation and typically responds well to rest and anti-inflammatory medications. After this initial period of inflammation, if not treated, the damage is more of a failed healing response whith the tendon developing scarring and abnormal strength/consistency.  Addressing the injury to the tendon early is the best chance of avoiding development of a chronic tendinopathy, which can be much more difficult to heal. We often advise patients to rest, ice, and use anti-inflammatories initially for this type of early injury.

In your specific question, given the location you described of pain, you likely have sustained an overuse injury of the tibialis anterior tendon, as well as the flexor digitorum longus tendon.  Given the duration of your symptoms being relatively short, I would recommend a period of relative rest, icing over tender areas, and the use of anti-inflammatory medications.  You can continue to swim with the use of a pull buoy to remove the need to kick with your stroke.  Once pain free, you can gradually increase your use of kicking, remembering to stay in a pain free amount of work. I would avoid the use of fins at all until you have returned to a normal volume of swimming for you, and then gradually introduce their use.

Should your symptoms fail to improve with a short course of conservative measures, seek care from your sports medicine physician.  Often times they will additionally prescribe a period of physical therapy to address any range of motion or strength issues that may have predisposed you to this type of injury.  Occasionally, if symptoms fail to improve, you may require more invasive treatment options such as injections with either corticosteroids or platelet rich plasma.

Best wishes for a speedy recovery!

Michael Cassat, M.D.

http://www.drcassat.com

Dr. Michael Cassat, M.D. is a primary care sports medicine physician for The Steadman Clinic.  Located in Vail, Colorado, he provides expertise in the non-surgical treatment of athletic injuries. Dr. Cassat focuses on fitness, prevention, and a rapid return to activity.

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date: August 30, 2013