Ankle Pain & Achilles 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.

On this page:

  • Acute ankle injuries (sprains and fractures)
  • Pain on the inside of the ankle
  • Pain on the outside of the ankle (lateral ankle pain)
  • Pain at the front of the ankle (anterior ankle pain)
  • Pain at the back of the ankle (Achilles pain)
  • Immediate first aid for ankle injuries
  • When should I see a doctor?

Acute Ankle Injuries/Ankle Joint Injuries

Ankle Sprain

An ankle sprain is one of the most common sports injuries and is also the most frequently re-injured. You will know if you have sprained your ankle immediately. The ankle rolls outwards as the sole of the foot turns inwards. Depending on severity ankle sprains are graded one to three with the more severe grade three injuries being a complete tear of the ligaments on the outside of the ankle.

With minor injuries, there is likely to be little or no swelling but grade two or three sprains will have rapid swelling and bruising is likely to develop. Although sprained ankles are common injuries it is essential they are treated immediately with the PRICE principles of cold therapy and compression, then a full rehabilitation program of strengthening and sports specific exercises.

There are also a number of complications that can arise from a sprained ankle including fractures, avulsion fractures or damage to other structures within the joint. Read more on:

Eversion Ankle Sprain

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. It is hard for these inside ligaments to be sprained, it is much more common to damage the outer ligaments. Read more on the causes, symptoms, and treatment of this ankle injury.

Ankle fractures

A broken, ankle or ankle fracture can occur in any of the bones which make up the ankle joint. They can occur from a bad sprain or from a severe impact or trauma. If a broken ankle is suspected then seek medical attention immediately. There are a number of different types of ankle fracture.

Pott's Fracture

A Pott's fracture is a fracture to one of the bony parts of the ankle called the malleoli. Fractures can occur to the lateral malleoli on the outside or the medial malleoli on the inside. It can be difficult to separate this ankle injury from a sprain, though feeling the ankle with the hands can sometimes indicate if it is a fracture or not. An x-ray can show for sure if it is a fracture.

High Ankle Sprain

A high ankle sprain is an injury to the anterior tibiofibular ligament which joins the tibia and fibula together just above the ankle. This ankle injury is generally more severe and more complicated to treat than a normal sprain, Read more on the causes, symptoms, and treatment of a high ankle sprain.

Osteochondral Lesions of the Talus

Osteochondral lesions (or fractures) of the cartilage, which sits on top of the Talus (ankle bone), most commonly occur in combination with an ankle sprain. An osteochondral lesion may not be diagnosed immediately. It may only be identified if a sprain doesn't fully heal and the ankle continues to cause problems when further investigations would be made.

Ankle Avulsion Fracture

An ankle avulsion fracture occurs when a tendon or ligament comes away from the bone often pulling a small piece of bone with it. The symptoms are similar to an ankle sprain, but unlike a sprain, an avulsion fracture pulls a piece of bone off when the ligament tears. An x-ray can determine which ankle injury you have and so how best to treat it.

Read more on ankle joint injuries

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 of gradual onset than an acute, sudden onset injury.

Tibialis posterior tendinopathy

The tibialis posterior tendon passes along the inside of the ankle joint and is a main stabilizer of the joint when walking and running. Symptoms include pain on the inside of the ankle which occurs gradually. Swelling is unusual except in the more severe cases and it is more common in women over the age of 40.

Flexor hallucis longus tendinopathy

The flexor hallucis longus tendon bends the big toe and passes down the back of the medial malleolus (prominent bony bit on the inside of the ankle). Symptoms include gradual onset pain on the inside and towards the back of the ankle where the tendon passes, particularly when going up on the toes or pushing off the toes for example when jumping.

Medial calcaneal nerve entrapment

Medial calcaneal nerve entrapment has similar symptoms to that of tarsal tunnel syndrome. Symptoms include a burning pain below the medial malleolus or bony bit on the inside of the ankle, which may also radiate under the sole of the foot. Activities such as running will usually aggravate the condition. There may be tenderness around the medial malleolus. A positive sign for tinels test will be seen on examination.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is caused by pressure on the tibial nerve as it passes down the inside of the ankle. A burning pain, numbness or pins, and needles are felt in the heel which can radiate into the arch of the foot.

Medial malleolar stress fracture

The medial malleolus is the prominent bony bit on the inside of the ankle. A stress fracture is rare but can occur through overuse. Gradual onset pain is felt on the inside of the ankle, which gets worse with exercise. Specific point tenderness over the medial malleolus is a common symptom and there may or may not be swelling over the point of injury. An X-ray may not show up until healing has started to take place, but a bone scan, CT scan or MRI can confirm the diagnosis.

Calcaneal stress fracture

This is a hairline fracture in the big heel bone or calcaneus as it is called. Pain will come on gradually over time and will get worse with weight-bearing activities like running or jumping. It is an overuse injury commonly seen in soldiers, roadrunners, and dancers. Often a stress fracture cannot be seen on an X-ray until it has started to heel which occurs following a significant period of rest.

Other injuries which may cause pain on the inside of the ankle include talar stress fracture, posterior impingement syndrome and referred pain from the spine. Rare conditions, but often overlooked include Navicular stress fracture, complications following acute ankle injuries and complex regional pain syndrome.

Read more on medial ankle pain.

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

Peroneal tendinopathy or peroneal tendonitis is inflammation of the peroneal tendons which run behind the bony bit on the outside of the ankle (the lateral malleolus). Symptoms include gradual onset pain and swelling on the outside of the ankle. Pain is often worse during exercise. Treatment involves reducing pain and inflammation through rest, ice and bracing then stretching tight muscles in the lower leg.

Sinus tarsi syndrome

The sinus tarsi is a small bony canal which runs into the ankle under the talus bone. Damage to the sinus tarsi can be caused by overuse or following an ankle sprain. Symptoms of pain and tenderness near the bone on the outside of the ankle, which is often worse when running on a bend or curve.

Peroneal tendon dislocation

The peroneal tendon runs behind the lateral malleolus or the bony bit on the outer ankle. Repeated dislocation or slipping can mean the tendon rubs against the bone, causing pain and inflammation.

Stress fracture of the fibula, 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)

Pain at the front of the ankle which has come on gradually rather than from a sudden twisting or trauma.

Anterior impingement

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

The tibialis anterior muscle is the large muscle that runs down the outside of the shin. It controls the movement of the foot as it lifts the foot up and inwards. Inflammation of the 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.

Achilles Pain

Pain at the back of the ankle is usually related to the Achilles tendon and comes on gradually over time. A 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. More commonly Achilles tendonitis or similar injuries tend to occur over time.

Read more on Achilles pain and Achilles injuries.

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