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. Here we explain the most common causes of pain on the inside of the ankle, some less common medial ankle injuries and important conditions that should not be missed. Tibialis posterior syndrome is probably one of the more common gradual onset injuries along with stress fractures and nerve impingements.
On this page:
- Sprains, strains & fractures
- Tibialis posterior tendinopathy
- Flexor hallucis longus tendinopathy
- Medial calcaneal nerve entrapment
- Tarsal tunnel syndrome
- Stress fractures
- Ankle impingement
- Referred pain
Sprains, strains & fractures (acute ankle injuries)
Acute ankle injuries such as ankle sprains and fractures occur suddenly and have symptoms of immediate pain and often swelling. An eversion ankle sprain will cause injury to the ligaments and bone on the inside of the ankle. A more common inversion ankle sprain will likely cause most pain on the outside of the ankle but brusing of the bones on the inside of the ankle can also occur.
Read more on acute ankle injuries.
Most common causes of medial ankle pain are Tibialis posterior tendinopathy and Flexor hallucis longus tendinopathy
Tibialis posterior tendinopathy
The tibialis posterior tendinopathy is a degeneration of the tibialis posterior tendon causing pain on the inside of the ankle, just behind and below the medial malleolus (bony bit). Pain may radiate under the foot arch along the path of the tendon. It is more likely to affect older female athletes who walk or run a lot, however, sports and activities such as ballet dancing, ice skating, and track sprinting around bends are at a higher risk.
Treatment involves decreasing initial pain and inflammation with the PRICE principles of protection, rest, ice and compression followed by a rehabilitation program consisting of stretching, strengthening, and functional exercises.
Read more on Tibialis posterior tendinopathy
Flexor hallucis longus tendinopathy
Flexor hallucis longus tendinopathy or flexor tendonitis is inflammation or degeneration of the flexor tendons in the foot causing pain on the inside of the ankle and along the length of the tendon as it passes round the back of the medial malleolus to the arch of the foot, inserting at the big toe (Hallucis means big toe in Latin).
Treatment for most cases involves applying the PRICE principles of protection, rest, ice, compression, and elevation followed by a full rehabilitation program consisting of stretching and strengthening exercises. Surgery is sometimes necessary to treat this injury if conservative measures fail.
Medial calaneal nerve entrapment
Medial calcaneal nerve entrapment has similar symptoms to that of tarsal tunnel syndrome. Pain will radiate from the inside of the heel out towards the centre of the heel. Resting and icing the ankle are effective ways to help ease the pain and recover from this injury.
Read more on medial calaneal nerve entrapment.
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is caused by pressure on the posterior tibial nerve as it passes on the inside of the ankle. It can cause a burning pain in the heel that can radiate into the arch of the foot. The sole of the foot may feel numb or have pins and needles. Treatment involves rest and identifying the underlying cause of the condition. Most are treated with cold therapy, physical therapy, and biomechanical assessment, however, injections and surgery are required in some cases.
Read more on Tarsal Tunnel Syndrome
Talar stress fracture
The talus bone is the bone at the top of the ankle which the tibia or shin bone sits on. A stress fracture of the talus is a hairline crack in the bone caused by overuse. Symptoms are more likely to include pain on the outside of the ankle which will have come on gradually but may also be felt on the inside of the ankle. Exercise will make symptoms worse, particularly running, and symptoms will ease with rest. There is likely to be tenderness and possibly swelling over the sinus tarsi which is a small canal where nerves pass into the ankle. Bone scans and CT scans can confirm the diagnosis as a stress fracture is unlikely to show up on an X-ray until healing has begun.
Treatment usually involves six weeks immobilization in a plaster cast. Surgery to remove the lateral process of the talus bone is sometimes done which can speed up the healing and rehabilitation process. Biomechanical correction of any over pronation with orthotic inserts is done if required. Identifying the causes of the stress fracture in the first place is important.
Read more on Talar stress fracture.
Medial malleolar stress fracture
The medial malleolus is the bony bit on the inside of the ankle. A stress fracture of the medial malleolus can occur but is very rare. It cause pain on the inside of the ankle which is exacerbated by activity.
Symptoms of a medial malleolus stress fracture will include pain on the inside of the ankle which is made worse by running and jumping activities. There will be specific point tenderness over the medial malleolus or bony part on the inside of the ankle. There may also be swelling seen but not in all cases. If the stress fracture is in the early stages it may not show up on X-ray but a bone scan, CT scan, or MRI can confirm the diagnosis.
Treatment is basically rest from weight-bearing activities for around 6 weeks. An ankle brace or support may help protect and support the joint. If the injury has progressed to a complete fracture then surgery will most likely be required.
Posterior ankle impingement
Ankle impingement is when a bony growth at either the front or back of the ankle bone restricts normal ankle range of motion. Impingement means tissues have become trapped between bones. This injury occurs where the ankle bone meets the shin bone and often follows an ankle sprain that hasn't fully healed.
Pain is usually felt at the back of the ankle but can radiate or manifest on the inside of the ankle. There will be tenderness behind the bottom tip of the fibulabone. Pain will most likely be worse at the end of the movement when the foot is pointed down into plantarflexion with the foot pointing downwards. Going up onto tip toes may be painful. An X-ray can show up any bony spurs on the talus (heel bone) and end of the tibia (shin bone).
Pain on the inside of the ankle may be referred from injuries or conditions elsewhere in the body. For example, sciatic pain from the lower back can radiate down into the leg. Trapped nerves in the foot may also cause medial ankle pain.
Important do not miss:
The following injuries do not commonly cause pain on the inside of the ankle, however, if missed, more serious long term damage may occur.
Navicular stress fracture
Symptoms of a navicular stress fracture include a poorly localized ache in the midfoot which gets worse with exercise. Pain may radiate along the inside arch of the foot and goes away quickly with rest, only to return again as training resumes. Tenderness may be felt when the thumb is pressed into the top of the foot over the navicular bone, called the N spot.
Read more on Navicular stress fracture.
Complications of ankle sprains and Complex regional pain syndrome should also not be overlooked.