Ankle Pain

Ankle pain is divided into the following categories:

Acute ankle injuries

The most common cause of ankle pain is a sprained ankle. But there are a number of other less common ankle injuries as well as important conditions and ankle injuries which should not be missed! Immediate first aid (RICE) rest, ice, compression and elevation is important for all ankle injuries, especially sprains. If the injury is severe or a fracture is suspected always seek medical advice as soon as possible.

Ankle sprain

An ankle spain probably affects most people at some point in their lives. A sprained ankle is simply injury or damage to the ligaments of the ankle, most likely to be the lateral ligaments on the outside of the ankle caused by the ankle inverting or violently turning inwards. This results in a stretching or tearing of the ankle ligaments and is known as an inversion sprain. An eversion ankle sprain is possible where the ankle turns violently outwards injuring the ligaments on the inside of the ankle, however this is often accompanied by a fracture to the fibula bone which normally prevents and inversion sprain occurring.

Less common acute ankle injuries

Osteochondral lesions of the talus are fractures of the cartilage which sit on top of the Talus (ankle bone). They most commonly occur in combination with an ankle sprain.

Broken ankle or fractured ankle is a common injury which is often associated with a sprained ankle, although the two injuries can occur in isolation. The term broken ankle is a general term that can refer to a fracture of any of the ankle bones, although the most common is a Potts fracture of the maleolus or bumpy bits on the inside and outside of the ankle.

Dislocated ankle is a severe injury which usually happens in conjunction with a fracture or complete rupture of the lateral ligaments. The patient will be in considerable pain with instant swelling and will require emergency medical care.

Tendon ruptures can occur in the ankle and will usually by associated with an ankle sprain. Avulsion ruptures where the tendon is pulled away from the bone should also be considered a cause of acute ankle pain.

Important not to miss

Greenstick fracture is an incomplete fracture mostly affecting children. Also known as a Metaphyseal fracture, the most common of which is a buckling of one side of the bone. It is termed a greenstick fracture because the bone will partially break in the same way as a young or live stick would break when bent.

Tarsal coalition is a  fusion or sticking together of the tarsal bones in the foot. Symptoms include pain in the midfoot area, mostly seen in adolescents and is usually felt after hard training or activity.

High ankle sprain or sprained syndesmosis is an injury to the ligaments above the ankle joint which connect the bottom ends of the tibia and fibula bones of the lower leg.

Lateral ankle pain

Lateral ankle pain is pain which occurs on the outside of the ankle. It can come on gradually over time as a niggle which gets worse, or it can occur after an acute ankle injury which does not heal.

Most common causes of lateral ankle pain

Peroneal tendinitis or peroneal tendinopathy refersPeroneal tendinitis to inflammation of the peroneal tendons which run behind the lateral malleolus or the bony bit on the outside of the ankle. Symptoms include pain and swelling on the outside of the ankle, just below the bony bit or malleolus.

Sinus tarsi syndrome - The sinus tarsi is a small bony canal which runs into the ankle under the talus ankle bone. Symptoms of Sinus taris syndrome include pain which may difficult to pin point just in front of the  lateral malleolus.

Less common

Impingement syndrome is when a bony growth either at the front of the back of the ankle impedes normal ankle movement. Symptoms include pain at the side of the ankle which does not go, possibly after an ankle sprain heals.

Peroneal tendon dislocation is when the peroneal tendon which runs round the back of the bony bit on the outside of the ankle repeatedly dislocates across it causing friction, inflammation and pain.

Stress fracture of the talus - The Talus bone is the bone at the top of the ankle which the tibia or shin bone sits on. Symptoms include a gradual onset of pain on the outside of the ankle.

Referred ankle pain - Pain on the outside of the ankle can also be referred from spine or the peroneal nerve in the lower leg or superior tibiofibula joint which is the joint at the top of the shin where the tibia and fibula bones of the lower leg meet.

Important injuries not to be missed

Stress fracture of the fibula is a small fracture or hairline crack in the bone. It is not as common as a stress fracture of the tibia because the fibula is not used in load bearing in the same way although the constant stress of muscles pulling on the bone through overuse can cause this injury. Symptoms include pain and local tenderness at a point on the fibula as well as pain on weight bearing.

Cuboid syndrome occurs when the peroneus longus muscle in the lower leg applies too much force to the cuboid bone causing it to partially dislocate. Symptoms are similar to that of a sprained ankle and include pain when weight bearing on the outside of the foot

Complex regional pain syndrome

Medial ankle pain

Medial ankle pain refers to pain on the inside of the ankle which is not a sudden acute ankle injury. Pain may come on gradually or from an acute injury that has not healed properly. We explain the most common causes, some less common medial ankle injuries and important conditions that should not be missed.

Most common

Tibialis posterior tendinitis (or tendinopathy) - The Posterior Tibialis tendon passes down the back of the leg and under the foot. Injury or degeneration of the tendon may cause pain on the inside of the foot that may radiate along the line of the tendon.

Flexor tendonitis is inflammation of the flexor tendons in the foot which bend the big toes. Symptoms include tenderness along the length of the tendon and pain may be felt in the arch of the foot, on the inside back of the ankle and when the big toe is bent against resistance. The most commonly affected is the flexor hallucis longus tendon.

Less common

Medial calcaneal nerve entrapment has similar symptoms to that of tarsal tunnel syndrome where pain will radiate from the inside of the heel out towards the centre of the heel.

Calcaneal stress fracture is a hairline fracture of the calcaneus bone. Symptoms include a gradual onset of pain in the heel. The pain is made worse by weight bearing activities and can be reproduced by a therapist may help diagnose the injury by squeezing the back of the heel from both side which should reproduce the pain.

Tarsal tunnel syndrome is a painful condition of the foot caused by pressure on the Posterior Tibial Nerve. Symptoms include pain which is often described as a burning pain which radiates into the arch of the foot, heel and sometimes the toes.

Talar stress fracture is a stress fracture or hairline crack in the talus bone in the ankle. Symptoms are more commonly a gradual onset of pain on the outside of the ankle rather than the inside which is made worse during running.

Medial maleolar stress fracture is a hairline fracture to the medial malleolus or prominent bony bit on the inside of the ankle. Symptoms include pain and tenderness on the inside of the ankle which becomes worse the more it is used, particularly when running.

Posterior impingement syndrome is when a bony growth at the back of the ankle impinges the normal movement of the ankle causing pain, particularly during movements when the foot is pointed downwards.

Referred pain from the lower back is where pain is felt in the ankle but it is coming from a problem in the lower back via the sciatic nerve. A back specialist, chiropractor or osteopath should be consulted if this is suspected.

Important not to be missed

Navicular stress fracture is one of the more common stress fractures seen in the feet of athletes, especially those involved in sprinting, jumping or hurdling. Symptoms can include a poorly localized mid foot ache that is worse with exercise. It may not show up on an X ray so a bone scan or MRI is usually required.

Complications from acute ankle injuries are injuries or conditions which result from incomplete or poor healing of an acute injury such as an ankle sprain or fracture. It may be something that was missed on the initial diagnosis of an acute injury.

Complex regional pain syndrome

Anterior ankle pain

Anterior ankle pain refers to pain at the front of the ankle. The main causes of pain at the front of the ankle are:

Anterior impingement syndrome is where a bony growth at the front of the ankle impedes the normal movement of the ankle, particularly the talus and tibia bone. Pain is felt during movements where the foot is pointed upwards.

Tibialis anterior tendinitis occurs when the tendon of the large muscle on the outside of the shin becomes inflamed (or the sheath surrounding the tendon). Symptoms include pain when bending the foot and toes up, particularly against resistance. Stretching the tendon may also reproduce pain at the front of the ankle.

Inferior tibiofibula joint injury involves damage to the ligaments that connect the the tibia and fibula at the bottom of the bones.