Causes of Ankle Pain and Treatment Options

There are many potential causes of ankle pain, ranging from acute injuries such as an ankle sprain or break to chronic conditions like arthritis. These can cause different types of pain.

Ankle pain may be burning, aching, or throbbing, and it may come on suddenly or gradually. Details about your pain can help your healthcare provider figure out the cause of your ankle pain.

This article covers the common and rare causes of ankle pain, how a diagnosis is made, and typical treatment methods.

Causes

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

Becoming familiar with these diagnoses can help you prepare for a visit with your healthcare provider, whether that is your primary care provider, podiatrist, orthopedic surgeon, or an emergency care provider.

Common Causes of Ankle Pain

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

Sprains 

An ankle sprain is an injury of one or more ligaments (tough, fibrous tissues that connect bone to bone). Ankle sprains may happen from stepping off a curb, walking on an uneven surface, falling, or playing a sport like tennis or basketball where a rapid change in direction causes the ankle to roll or twist inward.

Most commonly, ankle sprains happen in the anterior talofibular ligament (ATFL), which is on the outside of the ankle. Symptoms include throbbing pain on the outside of the ankle, along with swelling, bruising, and/or a feeling that the joint may give out.

Medial sprains, involving the ligaments on the inside of the ankle, occur much less frequently. Medial ankle sprains cause throbbing pain on the inside of the ankle and result from the ankle rolling outward.

High ankle sprains are also unusual. They cause pain above the ankle, where ligaments connect the two lower leg bones. They are most common in people who play impact sports like hockey or football.

Tendonitis

Tendonitis occurs when the tendons, which attach muscle to bone, become irritated and inflamed. There are three types of tendonitis that can happen in the ankle: peroneal tedonitis, posterior tibial tendonitis, and Achilles tendonitis.

Peroneal tendonitis is inflammation of the peroneal longus or peroneal brevis tendons. These two tendons run along the outside of the ankle joint.

With this type of tendonitis, people feel a dull ache or tightening sensation on the outside of the ankle. The pain often develops over several weeks and worsens with standing or walking but gets better with rest. In severe cases, there is swelling, and some people describe feeling a popping sensation along the outside of the ankle.

Peroneal longus or brevis tendonitis often happens in people who frequently run on uneven or slippery surfaces or play sports that involve rapidly changing directions. But the condition can also result from improper training, poor running and jumping techniques, and improper footwear.

Posterior tibial tendonitis typically causes ankle pain on the inside part of the joint, along with swelling.

If left untreated, it may lead to significant walking problems. While a twisting injury may cause posterior tibial tendonitis, many people do not recall a specific trauma, and the pain comes on gradually.

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

Any activity that places stress on the Achilles tendon, such as playing sports that require sudden starting and stopping or changes in direction, can trigger tendonitis. 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. Bone spurs 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 the immune system attacks multiple joints throughout the body, including, in the majority of cases, the foot and ankle. A person with rheumatoid arthritis may also experience whole-body symptoms like fatigue or unintentional weight loss.

Post-traumatic arthritis may develop after any ankle-related injury. It is similar to osteoarthritis in that the cartilage within the ankle joint begins to wear away.

Bone Breaks

Ankle bone breaks (fractures) are common and refer to a break in one or more of the bones that attach to the ankle joint:

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

Similar to ankle sprains, twisting or rolling the ankle or falling may cause ankle fractures.

Symptoms include immediate and severe sharp pain, 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 Bruises

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 Causes of Ankle Pain

While your healthcare provider will consider the following potential causes for 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 already been diagnosed with 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. If this nerve is compressed, it can cause symptoms that vary depending on where the compression happens.

For instance, compression on the outside of the knee and upper shin, which can occur from prolonged recumbency (lying down) during hospitalization or from an excessive crossing of the legs, may cause a foot drop.

Deep peroneal nerve compression causes pain on the sides of the ankle along with burning or tingling sensations between the toes. This is a rare condition that can result from wearing a tight-fitting strap from a shoe.

Tumors

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

Diagnosis

Seek medical attention promptly if you are unsure of the cause of your ankle pain, you do not know the specific treatment recommendations for your condition, or you have these symptoms:

• Inability to walk comfortably on the affected side
• A deformity around the ankle joint
• Ankle pain that occurs at night or while resting
• Ankle pain that persists beyond a few days
• 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

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

Medical History

As you review your ankle pain with your healthcare provider, try to be as detailed as possible. It is a good idea to think through these details prior to your appointment. If you can, be prepared to discuss:

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

Physical Examination

Your healthcare provider will perform a physical examination of your ankle. To start, they will check for swelling, bruising, or deformity. Next, they will perform special ankle-related tests, such as the following:

Ottawa Ankle Rules

Emergency room and primary healthcare providers use the Ottawa ankle rules to help rule out an ankle fracture. They press on the medial and lateral malleolus (the round bones that jut out on both the inside and outside of the foot).

If these areas are tender, or if you cannot bear weight for four steps in the emergency room or healthcare provider's office, then you will need an X-ray.

Talar Tilt Test

During this test, your healthcare provider will hold the heel of your painful ankle in their hand and then gently invert (turn inside) and evert (turn outside) your ankle. They will compare the laxity (looseness) of your ankle joint movement to the uninjured ankle.

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 healthcare provider will compress your lower leg bones at the mid-calf level. If you feel pain above the ankle joint, this could indicate a high ankle sprain.

Blood Tests

If your healthcare provider suspects a particular diagnosis, they may order blood tests. For instance, if they are concerned about rheumatoid arthritis, they may order an anti-cyclic citrullinated peptide (anti-CCP) test.

Or, a healthcare provider may order a C-reactive protein test (which looks for inflammatory markers) to rule out an infection.

Imaging

An X-ray can differentiate between an ankle sprain or a fracture. An X-ray can also reveal signs of gout or osteoarthritis.

Healthcare providers sometimes use other imaging tests, like a computed tomography (CT) scan or magnetic resonance imaging (MRI). This is especially the case for more complex diagnoses like a high ankle sprain, a bone tumor or infection, or a suspected fracture not seen on the initial X-ray.

To diagnose a nerve problem, like peroneal neuropathy, a healthcare provider 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. Some conditions may cause pain in the ankle but don't originate from an ankle structure.

Blood Clots

A blood clot in the calf (called a deep vein thrombosis) may cause pain, swelling, and/or warmth in the ankle, foot, or lower leg. A simple, quick test called a Doppler ultrasound can help a healthcare provider 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 healthcare provider 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 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 build-up 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. It is diagnosed by physical examination and must be treated with surgery to relieve the pressure.

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 prior to your healthcare provider'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 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: Apply Ice bags or cold gel packs for 15 to 20 minutes, three or more times per day to keep the swelling down and soothe 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. Your healthcare provider will tell you which of these is right for you (if any).

Physical Therapy

Physical therapy is a common treatment for many ankle diagnoses including strains and tendonitis, as well as after an ankle surgery. Physical therapists use rehabilitation exercises to increase ankle muscle strength, regain mobility, minimize stiffness, and prevent chronic ankle problems.

Medications

Nonsteroidal anti-inflammatory medications (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, your healthcare provider may prescribe stronger pain medications such as opioids for a short period of time.

For severe cases of arthritis, your healthcare provider may suggest injecting cortisone—a steroid that reduces inflammation—into the ankle joint. 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 plates. Surgical treatments include debridement, fusion, and replacement.

Arthroscopic Ankle Debridement

For the early stages of ankle arthritis, a surgeon may perform debridement. This means removing loose cartilage, inflamed tissue, and bony growths from around the joint. You may hear your doctor refer to this as "cleaning out" the ankle.

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.

Ankle Arthrodesis

Arthrodesis is another option for ankle arthritis. It entails fusing the ankle bones together to prevent the arthritic joint from moving, thus minimizing pain.

Ankle Arthroplasty

Total ankle replacement or 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 ankle-related injuries. You can reduce the risk of ankle injuries with these practices.

• Before engaging in physical activity, make sure that you properly warm up.
• Wear appropriate footwear for the activity you plan on doing. For example, wear basketball shoes for playing basketball and running shoes for running.
• Use pain as your guide: If your foot or ankle hurts, slow down or stop your activity.
• Obesity can be a contributing factor to ankle pain. Maintaining a healthy weight puts less stress on the ankle and may decrease your risk of developing ankle tendonitis.
• High-impact aerobic activities such as plyometric exercises may make your ankle problem worse. Switching to low-impact activities like swimming can prevent worsening symptoms.

Summary

There can be many causes of ankle pain. Some pain results from acute injuries, such as sprains, while other times pain comes from chronic conditions like arthritis. A healthcare professional will usually conduct a physical exam of your ankle and order imaging or other tests to form a diagnosis.

Treatment typically involves simple measures such as resting, icing, and compressing the ankle, while more severe causes of ankle pain, like a bone fracture, may require prescription medication or surgery.

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 pain relief and a return to everyday activities and exercise.