Ankle Pain

Ankle pain and ankle injuries

Ankle injuries can be acute (sudden onset), such as ankle sprains, strains, and fractures, or gradual onset through overuse or degeneration of tissues. Here we explain acute ankle injuries, lateral ankle pain (outside of the ankle), medial ankle pain (inside of the ankle), anterior ankle pain (front of the ankle), and Achilles pain at the back of the ankle.

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Acute Ankle Pain (Sprains, Strains & Fractures)

Acute ankle pain sprains and fracturesAn ankle sprain is one of the most common sports injuries and can range from very mild to severe. Ankle sprains are graded one to three depending on severity, with a grade one being a mild sprain with some pain but little or no swelling, through to a grade three ankle sprain, which is a complete or almost complete rupture of the ankle ligaments. An eversion ankle sprain is rare and occurs when the ankle rolls too far inwards. This type of sprain happens when the ligaments on the inside of the ankle tear, which is often accompanied by a fracture of the fibula bone. A high ankle sprain is an injury to the anterior tibiofibular ligament which joins the tibia and fibula together just above the ankle.

A broken ankle or ankle fracture can occur in any of the bones which make up the ankle joint. If a broken ankle is suspected then seek medical attention immediately. There are a number of different types of ankle fracture. One of the most common is known as a Pott's fracture and is a fracture of the malleolus. An avulsion fracture occurs when a tendon or ligament tears pulling a small piece of bone with it, and an Osteochondral fracture is an injury to the tough cartilage protecting the ends of bones.

Read more on ankle sprains & fractures.

Pain on the inside of the ankle (medial ankle pain)

Medial ankle pain refers to pain on the inside of the ankle. This is more likely to be gradual onset ankle pain, where the athlete cannot pinpoint the exact time the injury occurred. Both Tibialis posterior tendinopathy and Flexor hallucislongus tendinopathy involve inflammation or degeneration of tendons which pass down the inside of the ankle and attach under the foot. Nerve entrapments such as Medial calcaneal nerve entrapment and Tarsal tunnel syndrome have similar symptoms and occur when nerves become trapped or impinged in the ankle or foot. A stress fracture is a hairline fracture of a bone caused by overuse and can occur in the medial malleolus and the calcaneus (heel bone) causing ankle pain.

View all causes of pain on the inside of the ankle.

Pain on the outside of the ankle (lateral ankle pain)

The most common acute or sudden onset injury causing pain on the outside of the ankle is a sprained ankle. Chronic causes of lateral ankle pain develop gradually either from overuse or from an acute injury which failed to heal properly. The most common causes of gradual onset pain on the outside of the ankle are peroneal tendinopathy (tendinitis) and sinus tarsi syndrome. Peroneal tendinopathy or peroneal tendonitis is inflammation of the peroneal tendons which run behind the lateral malleolus (bony bit on the outside of the ankle), and Sinus tarsi syndrome occurs through both overuse or following an ankle sprain.

A Peroneal tendon dislocation occurs when the tendon dislocates or slips across the malleolus on the outside of the ankle. Repeated dislocation or slipping can mean the tendon rubs against the bone, causing pain and inflammation. Stress fractures of the fibula bone, cuboid syndrome, and complex regional pain syndrome can all cause lateral ankle pain and should not be overlooked.

Read more on lateral ankle pain.

Pain at the front of the ankle (anterior ankle pain)

Front ankle painPain at the front of the ankle is more likely to develop gradually, rather than from a sudden twisting or trauma. Anterior ankle impingement occurs is when a bony growth at either the front or back of the ankle bone restricts the normal ankle range of motion. Soft tissues become trapped between bones causing pain when the ankle is at the extreme ends of the range of movement (dorsiflexed in the case of anterior impingement) and can follow an ankle sprain. Tibialis anterior tendinopathy involves the large muscle that runs down the outside of the shin which lifts the foot up and inwards. Inflammation of the tendon or tendon sheath can cause pain at the front of the ankle, particularly when bending the foot and toes up.

Read more on anterior ankle pain.

Pain at the back of the ankle

back of ankle pain

Pain at the back of the ankle is usually related to the Achilles tendon and develops gradually over time. Achilles tendonitis (tendinopathy) is inflammation or degeneration of the Achilles tendon, Tenosynovitis is inflammation of the sheath that surrounds the Achilles tendon. Sudden onset or acute Achilles tendon injury may be a partial or even complete rupture of the Achilles tendon which needs urgent medical assistance. Thompson's squeeze test can be done to rule out a complete Achilles tendon rupture. Posterior ankle impingement occurs when a bony growth at either the front or back of the ankle bone restricts the normal ankle range of motion.

Read more on Achilles tendon pain

Immediate first aid for ankle injuries

First aid for Ankle PainAll 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 cold therapy and a compression wrap. Where applicable, use 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 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.

This article has been written with reference to the bibliography.