Causes of Ankle Pain and Treatment Options

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ankle pain
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There are many potential causes of ankle pain, ranging from acute injuries, such as an ankle sprain or fracture, to chronic conditions like ankle arthritis. In turn, how this kind of pain is experienced can vary: It may be burning, aching, or throbbing, and it may come on suddenly or gradually. Your doctor will be interested in this information, as it provides initial clues as to what may be the cause of your ankle pain.

After a physical exam and possibly imaging, you will move forward with a treatment plan that may entail simple measures like resting and icing your ankle or more time-intensive measures, like physical therapy, or rarely, surgery.

Causes

Your ankle joint consists of bones, muscles, cartilage, and tissues called ligaments and tendons. Injury or disease that affects any of these ankle structures may cause pain.

In the end, becoming familiar with these unique diagnoses can help you prepare for the visit with your doctor, whether that is your primary care physician, podiatrist, orthopedic surgeon, or an emergency care provider.

Common

If you or a loved one is experiencing ankle pain, there is a good chance it may be due to one of these common causes:

Sprains 

An ankle sprain refers to an injury of one or more ligaments (tough, fibrous tissues that connect bone to bone). Ankle sprains are common injuries that may occur from stepping off a curb, walking on an uneven surface, a fall, or while engaging in a sport, like tennis or basketball, where a rapid change in direction causes the ankle to roll or twist inward.

The lateral ligament, located on the outside of the ankle, is the most common ankle ligament sprained. With a lateral ligament sprain, a person develops throbbing pain on the outside of the ankle. Swelling, bruising, and/or a feeling that the joint may give out, especially if there is a complete tear through the ligament, may also occur.

Medial and high ankle sprains occur much less frequently than lateral ankle sprains. Medial ankle sprains cause throbbing pain on the inside of the ankle and result from the ankle rolling outward.

High ankle sprains cause pain above the ankle, where ligaments connect the two lower leg bones. They result from the foot rotating out with respect to the leg and are most common in people who play impact sports like football.

Tendonitis

Ankle tendonitis occurs when the tendons, the attachments of muscle to bone, become irritated and inflamed.

A common type of ankle tendonitis is peroneal tendonitis, which refers to injury of the peroneal longus or the peroneal brevus tendons. These two tendons run along the outside of the ankle joint. People with peroneal longus or brevis tendonitis often report a history of running on an uneven or slippery surface, or playing in sports that involve rapidly changing directions.

The pain of peroneal longus or brevis tendonitis, often described as a dull ache or a tightening sensation, is located on the outside of ankle, develops over a period of several weeks, and worsens with standing or walking. Swelling may occur with more severe cases of tendonitis. In addition, sometimes people describe a popping sensation felt along the outside of the ankle.

Another type of tendonitis—posterior tibial tendonitis—typically causes gradual ankle pain on the inside part of the joint, along with swelling. If left untreated, posterior tibial tendonitis may lead to significant walking problems. While a twisting injury may cause posterior tendonitis, most people do not actually recall a specific trauma.

The Achilles tendon is the largest tendon in the body, joining your calf and lower leg muscles to your heel bone. Achilles tendonitis causes a burning, tightening pain along the back of the ankle. Mild swelling may also occur, along with morning stiffness in both the heel and calf.

Any activity that places stress on the Achilles tendon can trigger tendonitis, such as playing sports that require sudden starting and stopping or a change in direction. Wearing poor-fitting shoes, inadequate training, or having bone spurs on the heel may also lead to Achilles tendonitis.

Arthritis 

There are three main types of arthritis that affect the ankle:

  • Osteoarthritis is the "wear and tear" type of arthritis in which the cartilage in the ankle joint gradually deteriorates. Over time, cartilage loss causes the bones to rub against each other. Bony growths (osteophytes) may also develop. The pain of osteoarthritis varies but often starts out as an achy, intermittent sensation that progresses with time into a sharper, more constant pain.
  • Rheumatoid arthritis is an autoimmune condition in which a person's immune system attacks multiple joints throughout the body, including, in the majority of cases, the foot and the ankle. Besides other joint involvement, a person with rheumatoid arthritis may experience whole-body systems like fatigue or unintentional weight loss.
  • Posttraumatic arthritis may develop after any ankle-related injury and is similar to osteoarthritis in that the cartilage within the ankle joint begins to wear away.

Bone Break

An ankle bone break (fracture) is common and refers to a break in one or more of the following bones:

  • Tibia (a lower leg bone)
  • Fibula (a lower leg bone)
  • Talus (a foot bone)

Similar to ankle sprains, twisting or rolling the ankle, tripping on a curb, or falls may cause an ankle fracture.

Besides immediate and severely sharp pain, other typical symptoms of an ankle fracture are swelling, bruising, and an inability to put weight on the ankle. If the ankle joint becomes dislocated in addition to a bone break, the ankle may appear deformed.

Bone Bruise

An ankle bone bruise occurs from a less severe injury to the bone than a fracture. Ankle bone bruises may occur on their own or along with an ankle sprain. They are often severely painful and cause swelling, similar to that of a fracture.

Rare

While your doctor will consider the following other potential diagnoses for your ankle pain, they are not common.

Gout

Gout, a type of inflammatory arthritis, develops as a result of uric acid crystal formation within one or more joints. Since gout is an uncommon cause of ankle pain, it will be primarily considered in people who have an underlying diagnosis of gout.

Bone Infection

An infection in the bone (osteomyelitis) may rarely occur in the ankle. Besides a tender ankle joint, other signs of an infected bone include warmth and swelling.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome refers to compression of the tibial nerve within the "tarsal tunnel" of the ankle (similar to carpal tunnel syndrome, which occurs in the wrist). This syndrome may cause an aching or burning pain and numb or tingling sensations on the sole of the foot, toes, and sometimes, the heel, ankle, or calf.

Peroneal Neuropathy

The common peroneal nerve runs down the lower leg and branches into both the deep peroneal nerve and the superficial peroneal nerve. Depending on where the nerve is compressed, a person will experience unique symptoms. For instance, compression just below the knee, often from prolong lying during a hospitalization or from an excessive crossing of the legs, may cause a foot drop.

Deep peroneal nerve compression causes lateral ankle pain, along with burning or tingling sensations between the two toes of the feet. This is a rare condition, often resulting from wearing a tight-fitting strap from a shoe.

Tumor

Benign (non-cancerous) tumors of the foot and ankle, such as a synovial cyst, are not necessarily uncommon, but malignant (cancerous) bone tumors, such as a chondrosarcoma, are.

When to See a Doctor

If at any time, you are unsure of the cause of your ankle symptoms, or if you do not know the specific treatment recommendations for your condition, seek medical attention. More specifically, these signs warrant a prompt doctor's evaluation:

  • Inability to walk comfortably on the affected side
  • An injury that causes deformity around the ankle joint
  • Ankle pain that occurs at night or while resting
  • Ankle pain that persists beyond a few days
  • An inability to bend the ankle
  • Swelling of the joint or the calf area
  • Signs of an infection, including fever, redness, and/or warm skin
  • Any other unusual symptoms

Diagnosis

Many ankle conditions can be diagnosed with a medical history, physical exam, and X-ray. Other conditions require a bit more of a work-up, including additional imaging tests and/or blood tests.

Medical History

As you review your ankle pain with your doctor, try to be as detailed as possible. In fact, it is a good idea to think through these details prior to your appointment. Some thoughts to consider include:

  • Where your pain is located (e.g., lateral versus medial ankle)
  • What your pain feels like (e.g., aching versus sharp) and how intense it is (e.g., mild versus severe)
  • How long your pain has been going on for: Did it occur right after a trauma, or did it come on gradually?
  • Whether you are experiencing other symptoms besides ankle pain, such as fever, fatigue, or numbness

Physical Examination

In addition to a medical history, your doctor will perform a physical examination of your ankle. To start, he will check your ankle for swelling, bruising, or deformity. Next, he will perform special ankle-related tests, such as the following:

Ottawa Ankle Rules

The Ottawa ankle rules are used by emergency room and primary care doctors to help rule out an ankle fracture in the event of an ankle injury.

To summarize, these tests entail your doctor pressing on the medial and lateral malleolus (the round bones that jut out on both the inside and outside of the foot). If tenderness is felt there, or if you cannot bear weight right after the ankle injury and for four steps in the emergency room or doctor's office, then an X-ray is needed to evaluate for a fracture.

Talar Tilt Test

During this test, your doctor will hold the heel of your painful ankle in his hand and then gently invert (turn inside) and evert (turn outside) your ankle. He will compare the laxity of your ankle joint movement to the uninjured ankle. An increased laxity or pain with ankle inversion suggests a potential lateral ankle ligament sprain, while increased laxity or pain with ankle eversion suggests a potential medial ankle ligament sprain.

Squeeze Test

During this test, your doctor will compress your lower leg bones at the mid-calf level. The test is positive and suggestive of a high ankle sprain if pain is felt above the ankle joint.

Blood Tests

Depending on your doctor's suspicion for a particular diagnosis, blood tests may be ordered. For instance, if rheumatoid arthritis is suspected, your doctor may order an anti-cyclic citrullinated peptide (anti-CCP) level. A white blood cell count or inflammatory markers, like an erythrocyte sedimentation rate, may be ordered if a bone infection is suspected.

Imaging

An X-ray is often utilized to access ankle pain, mostly to differentiate between an ankle sprain or a fracture. An X-ray can also reveal signs of gout or osteoarthritis.

Sometimes, other imaging tests, like a computed tomography (CT) scan or magnetic resonance imaging (MRI), are utilized as well. This is especially the case when it comes to more complex diagnoses like a high ankle sprain, a bone tumor or infection, or a suspected fracture not visualized on the initial X-ray.

To diagnose a nerve problem, like peroneal neuropathy, a doctor who specializes in nerve disorders (a neurologist) may perform a nerve conduction study and electromyography (EMG) test.

Differential Diagnoses

While it is sensible to believe that ankle pain is related to a problem within the actual ankle (i.e., ligament, tendon, muscle, or bone), this is not always the case.

Here are a few examples of conditions that may cause pain in the ankle but that don't actually originate from any ankle structure:

Blood Clot

A blood clot in the calf (called a deep venous thrombosis) may cause pain, swelling, and/or warmth in the ankle, foot, or lower leg. The good news is that a Doppler ultrasound is a simple, quick test a doctor can order to diagnose this serious, but treatable condition.

Skin Infection

A skin infection (cellulitis) of the foot, ankle, or lower leg may cause ankle pain, along with fever, redness, swelling, and warmth. While a medical history and physical exam are often all a doctor needs to diagnose cellulitis, sometimes certain blood tests are helpful, such as an elevated white blood cell count.

Lumbar Radiculopathy

Sometimes, nerve pain around the ankle (burning or tingling) is not from a nerve in the ankle but rather referred from an irritated nerve in the lower spine. This condition, called lumbar radiculopathy, can be diagnosed with an MRI of the lower (lumbar) spine.

Acute Compartment Syndrome

Acute compartment syndrome—a serious condition that occurs as a result of severe pressure buildup in the muscles, often as a result of a bone fracture or severe, crush injury—may develop in the lower leg.

In addition to severe pain, other symptoms of acute compartment syndrome include numbness, tingling, and/or burning sensations within the affected area. Emergent measuring of the pressure within the affected body compartment is required to make this diagnosis.

Treatment

Treatment depends entirely on your specific ankle problem, but one common treatment plan for many ankle diagnoses is the RICE protocol. This protocol is a good first step to undertake prior to your doctor's appointment.

RICE Protocol

The RICE protocol is a standard home-based method of treating a variety of musculoskeletal injuries including ankle sprains and ankle tendonitis. The acronym stands for four essential steps:

  1. Rest: The first type of treatment for most ankle diagnoses is to simply rest the joint and allow the acute inflammation to subside. Sometimes this is the only step needed to relieve mild ankle pain. If the pain is severe, crutches may be helpful.
  2. Ice: Ice bags or cold gel packs are among the most common treatments for ankle pain and should be applied for 15 to 20 minutes, three or more times per day to keep the swelling down and soothe your pain. Be sure not to apply the ice directly to your skin.
  3. Compression: Compression bandages, like an ACE wrap, can help support and immobilize your ankle joint. That said, be sure to not compress too much. Signs of excessive compression include a sensation of numbness, tingling, increased pain, cooling, or swelling in the foot or area of your ankle just below the bottom of the bandage or wrap.
  4. Elevation: Raising your ankle above the level of your heart (by propping your foot on pillows) can help reduce swelling for the first couple of days after an ankle injury.

    Support and Stability Items

    Depending on the type of injury, crutches or a cane, ankle braces or splints, orthotics, and/or a cast may be necessary. The specific injury and its cause will determine which of these will be recommended by your doctor.

    Physical Therapy

    Physical therapy is commonly utilized for many ankle diagnoses, including strains, tendonitis, and after an ankle surgery. Physical therapists use various rehabilitation exercises to increase your ankle muscle strength, regain mobility, minimize stiffness, and prevent chronic ankle problems.

    Medications

    Nonsteroidal anti-inflammatory medications, commonly referred to as NSAIDs, are some of the most commonly prescribed medications, especially for patients who have ankle pain caused by problems such as arthritis, sprains, and tendonitis. For more significant pain, like that caused by a severe fracture, stronger pain medications such as opioids may be prescribed for a short period of time.

    For severe cases of arthritis, cortisone—a steroid that reduces inflammation—may be injected into the ankle joint, though the benefit of a steroid shot is temporary.

    Surgery

    Surgery may be required to treat certain ankle conditions. For instance, for a severe ankle fracture, an orthopedic surgeon will need to fix and position the ankle bones back in place, using screws, pins, rods, and/or plate.

    Arthroscopic Ankle Depridement

    For the early stages of ankle arthritis, your surgeon may perform debridement in which loose cartilage, inflamed tissue, and bony growths are removed from around the joint. This surgery may be performed arthroscopically, which involves the surgeon inserting a small camera inside the ankle joint. Instruments can then be inserted through other small incisions to perform the debridement or "clean out."

    Ankle Arthrodesis

    Other surgeries for ankle arthritis include arthrodesis, which entails fusing the ankle bones together to prevent the arthritic joint from moving, thus minimizing pain.

    Ankle Arthroplasty

    Total ankle replacement is another type of ankle surgery. Ankle arthroplasty involves a surgeon removing the damaged cartilage and bone and replacing it with an ankle implant.

    Prevention

    Maintaining good muscle strength and flexibility in the ankle is key to preventing many types of ankle-related injuries. Some easy strategies you can adopt to help prevent an ankle injury include:

    • Warming up before engaging in physical activity
    • Wearing appropriate footwear (basketball shoes for playing basketball and running shoes for running, for example)
    • Using pain as your main guide: If your foot or ankle hurts, slow down or stop your activity.
    • Maintaining a healthy weight, as obesity can predispose you to ankle tendonitis and place stress on arthritic ankle joints
    • Switching from a high-impact aerobic sport to a low-impact one like swimming to prevent your ankle problem from worsening

    A Word From Verywell

    Getting to the bottom of your ankle pain and back on your feet may be straightforward, or it may require a more intensive evaluation. Regardless, once you have your diagnosis, you can move forward with a treatment plan—a stepwise journey to obtaining the pain relief you deserve.

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    Article Sources
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