Ankle injuries can affect many people, especially those who do sports. The ankle is a complex structure which is vulnerable to many injuries that can be acute or chronic. Ankle injuries can be separated into outer, inner and back of ankle pain, with sprains being the most common of them.
Acute ankle injuries
Sprains are the most common cause of acute ankle pain and are one of the most common overall sports injuries. Acute ankle injuries can happen from a sudden movement of the ankle or occasionally from a severe impact.
Most people know immediately if they have sprained their ankle. The ankle normally rolls outwards (so the foot turns inwards) which damages the ligaments on the outside of the ankle. This will normally cause instant outside ankle pain and swelling and bruising may appear. There are different grades of ankle sprains depending on their severity. With grade 1 sprains you may still be able to carry on with training (although with difficulty) but with a grade 3 sprain, the pain will be severe and the ankle will feel very unstable.
This is normally more severe and complicated to treat than a normal ankle sprain. Swelling and bruising will often be seen at the front and outside of the ankle, with pain being particularly felt at the top of the ankle/bottom of the leg. It will be difficult to walk, with pain being reproduced when the ankle is rotated and when the foot and toes are pulled upwards.
This type of ankle sprain is less common and occurs when the ankle rolls inwards (instead of outwards). This damages the ligaments on the inside of the ankle, which are much harder to injure than the outer ligaments. The fibula bone in the calf usually prevents the ankle turning too far inwards, so this ankle injury is often accompanied by a fracture of the end of the bone. Inside ankle pain, especially when bearing weight, is the main symptom, along with swelling and bruising.
Dislocated ankles are relatively rare but are a severe injury that usually occurs with a fracture or complete rupture of ligaments. This would normally happen on the outside of the ankle. Sudden and intense ankle pain is the main symptom of this injury, sometimes with a visible deformity.
This injury is a lesion, or fracture, of the cartilage which occurs on top of the ankle bone (talus) and often occurs with an ankle sprain. Ankle pain, stiffness, and swelling are the main symptoms and the ankle may 'catch' or 'lock'. This injury may not be detected initially, but if the ankle fails to heal after a sprain and continues to cause pain and swell up, it may indicate a lesion.
Most ankle fractures are caused by an acute, traumatic injury or impact. Fractures can occur with a sprain when the ankle rolls over particularly forcefully or quickly. A lateral fracture, or Pott's fracture, is the most common ankle fracture.
Fractures can occur in any of the 3 bones in the ankle joint. The bottom of the tibia and fibula (the shin bones) are the bones most commonly fractured in the ankle. Sudden and severe ankle pain, rapid swelling and inability to put weight on the ankle can indicate a fracture. Bruising may also appear. An x-ray can identify if the ankle is broken.
This specifically refers to a fracture of one of the bony parts of the ankle, called malleoli. It can occur to the lateral (outer) bone or the medial (inner) bone, with lateral being most common. It can be caused by an ankle sprain and show similar symptoms to it, including instant pain, swelling, tenderness, and inability to put weight on the leg. Feeling around the area carefully may identify whether you have a fracture. Maximal tenderness on the bone (rather than around the bone) can indicate a break.
When a tendon or ligament tears and pulls of a piece of bone, this is called an avulsion fracture. Symptoms are similar to an ankle sprain, and often only an x-ray can show any difference. Immediate ankle pain, rapid swelling, and difficulty in moving and putting weight on the ankle can indicate this injury.
Pain at the back of the ankle can indicate an issue with the Achilles. Achilles injuries can be acute, such as a tendon rupture, or chronic, like tendonitis. Read more on Achilles pain.
Medial ankle pain
This focuses on inside ankle pain that normally comes on gradually. An acute injury that hasn't fully healed may also cause pain on the inside of the ankle.
PTTD is one of the more common gradual onset injuries and occurs when the posterior tibialis muscle in the calf doesn't function correctly. This causes 'flat feet' or a fallen arch as the muscle is not inverting the foot. This can cause further injury problems which makes the ankle and foot painful.
Pain will originate from the inside of the heel and may radiate to the centre of the heel and under the sole of the foot. There will normally be a burning pain and tenderness below the bony bit on the inside of the ankle (medial malleolus) and running activities will often aggravate the pain.
Stress fracture of the medial malleolus (bony bit on the inside of the ankle) is a rare injury. Inside ankle pain and tenderness, particularly when running or jumping can indicate a stress fracture.
Lateral ankle pain
This focuses on outside ankle pain which develops over time or pain that is caused by an acute injury which hasn't fully healed.
Peroneal tendonitis is when the tendon that runs on the outside of the ankle becomes inflamed, which can cause swelling. Overuse and tight calf muscles may cause this injury as the tendon rubs against the bone, increasing the friction. Exercise and pressing in on the tendon will normally make the pain worse. Stretching the tendons by turning the foot inwards can recreate the pain.
The sinus tarsi (a bony canal which runs into the ankle) can be damaged by overuse or a sprain. Pain and tenderness in front of the bony bit on the outside of the ankle, which is exacerbated by running on a curve, can indicate this injury. Turning the foot inwards may reproduce pain.
The peroneal tendon runs on the outside of the ankle, behind the malleolus (or bony bit), and continuous 'slipping' or dislocation can cause inflammation. As the tendon rubs against the bone, pain and tenderness may appear around the outer ankle bone, especially when the feet are rolled outwards. There may also be swelling and bruising on the outside of the ankle.
Outside ankle pain that comes on gradually and worsens with exercise can indicate this injury. The talus is the bone on top of the ankle, and biomechanical issues like overpronation can increase the risk of a stress fracture here. The injury may also make the outer ankle feel tender and swollen.
Anterior ankle pain
Pain at the front of the ankle often comes on gradually rather than from an acute injury. Sudden twisting or a direct impact may cause anterior ankle pain, but impingement or inflammation are more common causes.
This injury may cause redness and swelling on the front of the ankle. When pushing onto the tendon at the front of the ankle, a creaking sensation may be felt when moving the foot. It may be difficult to lift the foot up, and there is often pain when bending the foot and toes up.
Impingement is when a bony growth restricts the range of motion in the ankle. The ankle may feel weak and pain will likely be felt at the front or side of the ankle. Moving the foot upwards (into dorsiflexion) may reproduce pain. Impingement may be anterior and affect the front of the ankle, or posterior which affects the back.
If you have this injury it will feel painful and tender when pressing over the front of the ankle joint. Moving the foot up and down may exacerbate the pain, and there may be a bony lump at the front of the ankle. Kicking a ball can reproduce the pain.
Immediate first aid for ankle injuries
All acute and chronic ankle injuries should be treated using the P.R.I.C.E. principles (protection, rest, ice, compression & elevation). This should be applied at home for at least the first 2 - 3 days.
Protect- Prevent the ankle from suffering further damage. Stop training or playing immediately and apply a cold therapy and compression wrap. Where applicable, use an ankle support or brace.
Rest - Refrain from exercise and try to reduce the demands of your daily activity to encourage recovery. It not only refers to the time that the athlete will be out of action but also to the immediate period after the injury. An athlete must know when to stop training and allow the injured area to heal otherwise repetitive minor injuries can often result in a more severe injury that keeps the athlete out for much longer.
Ice - The application of ice or cold therapy to the area of the ankle injury/swelling can assist in reducing the symptoms of pain and inflammation.
Compression - The use of a compression support or compression bandages to the ankle can help reduce swelling and offer support.
Elevation - Keeping the foot elevated above heart level whenever possible can help reduce swelling due to the effects of gravity.
Read more on PRICE principles.
When should I see a doctor?
The majority of ankle injuries, especially the minor ones can be treated at home. However, if you have any of the following symptoms including severe ankle pain, severe swelling, a pop or crack, locking and altered sensation you should seek further medical assistance.
- Severe pain in or around the ankle joint, especially during walking.
- Severe swelling (oedema) in the ankle.
- An audible “pop” or “crack” in the ankle joint that is painful, particularly at the back of the ankle where the Achilles tendon is.
- A feeling when the ankle “locks” whilst trying to move it.
- Altered sensation in the foot or ankle – such as a feeling of “pins and needles” (paresthesia) or a “loss of feeling” (anaesthesia) in the lower leg.
- Unable to complete your normal daily activities after the initial 72 hours.
Further medical assistance can be sought through your local doctor or a private clinician such as a physiotherapist, sports therapist, osteopath or chiropractor.
If you have followed the P.R.I.C.E. principles (see above) and are still unable to walk after 72 hours, or still have severe pain that is not subsiding after the first 72 hours, you should visit your local A&E department for further assessment.
If you have applied P.R.I.C.E. principles and still have weakness or ankle pain that lasts a long time (more than 2 weeks) or have ongoing discomfort in your joint, we recommend you seek advice from a specialist expert - such as a physiotherapist, sports therapist, osteopath, or chiropractor. Experts can provide you with advice and an appropriate and effective recovery and rehabilitation program