Causes and Treatment of Ankle Pain

The most common causes of ankle pain are acute injury, arthritis, or normal wear and tear of the bones, muscles, cartilage, ligaments, or tendons of the ankle. Depending on the cause, you might experience sudden pain, swelling, and redness or feel pain when you place weight on the joint. There might also be stiffness or deformity of the ankle.

Oftentimes, the only way to determine why your ankle hurts is to see a healthcare provider and undergo a physical exam and imaging studies like an X-ray or CT scan. The visit might also include blood tests to check for inflammation, infection, or autoimmune conditions like rheumatoid arthritis.

This article covers the common and uncommon causes of ankle pain, including how they are diagnosed and treated.

Common causes of ankle pain

Alexandra Gordon / Verywell

Where Ankle Pain Occurs: Anatomy of the Ankle

Ankles are part of the musculoskeletal system that enables the movement of the body. The ankle is an important part of the system as it enables balance and the ability to walk, run, turn from side to side, jump, and land safely.

The ankle is made up of the following parts:

  • Bones that connect the talus (foot bone) with the tibia and fibula (lower leg bones)
  • Ligaments that hold the bones together
  • Muscles that direct the movement of the ankle, including rotation, dorsiflexion (bringing the toes toward the shin), and plantarflexion (pointing your toes away from the shin)
  • Nerves such as the tibial nerve and peroneal nerve that direct the movements of the muscle and provide sensations to the ankle
  • Tendons that connect muscles to bones
  • Joints called the talocrural joint (that enables dorsiflexion and plantarflexion), subtalar joint (that enables foot rotation), and inferior tibiofibular joint (that prevents over-rotation or over-flexion)
  • Cartilage that covers joint surfaces so they can move smoothly
  • Synovial fluid inside of joints that provide lubrication
  • Bursa that act as fluid-filled cushions inside joints

Injury to any of these parts can cause pain. Oftentimes, multiple structures are involved. Because the ankle is very complicated, people who are older, overweight, have obesity, or who engage in sports involving jumping or sharp turns, are at an increased risk of ankle injury.

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. It can happen from stepping off a curb, walking on an uneven surface, falling, or playing sports like tennis where a rapid change in direction causes the ankle to roll or twist inward.

There are several types of ankle sprain:

  • Anterior talofibular ligament sprains are the most common, affecting the ligament 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 become irritated and inflamed. Three types commonly affect the ankle:

  • Peroneal tendonitis is inflammation of the peroneal longus or peroneal brevis tendons that run along the outside of the ankle. Symptoms include a dull ache, tightening, or a popping sensation on the outside of the ankle that worsens with standing or walking but gets better with rest.
  • Posterior tibial tendonitis involves the tendon that runs along the inside of the ankle, causing pain and swelling on the inside part of the joint. While a twisting injury is a common cause, many people do not recall when the injury occurred and experience the gradual onset of pain.
  • Achilles tendonitis involving the tendon that runs from the lower calf to the heel causes a burning, tightening pain along the back of the ankle, along with swelling and morning stiffness. It often occurs with sports that require sudden starts and stops or changes in direction.

Arthritis 

Three main types of arthritis affect the ankle:

  • Osteoarthritis ("wear and tear arthritis") is the aging-related deterioration of joint cartilage. Over time, this causes the bones to rub against together and form bone spurs. Symptoms include pain and stiffness which is worse in the morning and eases with activity.
  • Rheumatoid arthritis is an autoimmune condition in which the immune system attacks joints throughout the body, including the foot and ankle. A person with rheumatoid arthritis may experience bilateral pain (involving both ankles) along with swelling and fatigue.
  • Post-traumatic arthritis may develop after any ankle-related injury. It is similar to osteoarthritis in that the cartilage within the 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, including the tibia, fibula, and talus. The twisting or rolling of the ankle is a common cause.

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.

Uncommon Causes of Ankle Pain

While your healthcare provider will consider the following potential causes for ankle pain, they are not as common:

  • Gout, a type of inflammatory arthritis, develops as a result of the formation of uric acid crystals in joints. The condition is linked to diet, genetics, and other causes. It is characterized by recurrent attacks of a red, tender, hot, and swollen joint.
  • Bursitis is inflammation of bursae typically caused by overuse of a joint. This can cause pain, swelling, and difficulty moving the ankle. There are three in the ankle which can become inflamed with an ankle injury, foot infection, or wearing poor-fitting shoes.
  • Osteomyelitis is an infection of the bone, which sometimes involves the ankle. Besides a tender joint, other signs of an infected bone include warmth and swelling. It is usually caused by a bacterial infection and rarely a fungal infection.
  • Tarsal tunnel syndrome is the compression of nerves within a channel called the tarsal tunnel of the ankle (similar to carpal tunnel syndrome of the wrist). This causes aching or burning pain, numbness, and tingling in the sole and toes as well as the heel, ankle, and calf.
  • Peroneal neuropathy is the compression of the common peroneal nerve that runs down the lower leg. Deep nerve compression (often caused by wearing tight-fitting shoe straps) can cause pain on the sides of the ankle along with burning or tingling sensations between the toes.
  • Tumors in the ankle, both benign (noncancerous) and malignant (cancerous), can cause ankle pain and discomfort. These include benign synovial cysts and rare malignant cancers called chondrosarcoma.

Diagnosing Ankle Problems

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. Think through these details before your appointment:

  • Where your pain is located (for instance, the inside or outside of the ankle)
  • What your pain feels like (aching vs. sharp) and how intense it is (mild vs. severe)
  • How long your pain has been going on
  • Whether the onset of pain has been sudden or gradual
  • Whether you are experiencing other symptoms 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, including:

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 and 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 (called 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:

  • Deep vein thrombosis is a potentially serious blood clot in the leg which can cause pain, swelling, and warmth in the ankle, foot, or lower leg.
  • Cellulitis is the spread of a local skin infection to deeper tissues. When it involves the ankle or foot, it can cause pain along with fever, redness, swelling, and warmth.
  • Lumbar radiculopathy is the pinching of a nerve in the lower since that causes nerve pain to radiate to other parts of the body. It often affects the leg, foot, and ankle causing shooting pains and burning or tingling sensations.
  • Acute compartment syndrome is a serious condition that occurs as a result of the severe pressure build-up in the muscles, often as a result of a bone fracture or severe crush injury. In the ankle, it can cause pain, numbness, burning, or tingling sensations.

Treatment for Ankle Pain

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:

  • Rest: The first goal is to simply rest the joint and allow the inflammation to subside. Sometimes this is the only step needed to relieve mild ankle pain.
  • 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.
  • Compression: Compression bandages, like an ACE wrap, can help support and immobilize the ankle joint. It also reduces swelling and helps ease pain.
  • 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.

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.

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).

Medications

There are over-the-counter and prescription drugs that can help ease ankle pain and inflammation:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen) or Aleve (naproxen) are useful for inflammatory conditions like arthritis, sprains, and tendonitis.
  • Opioids are prescription painkillers like Percocet (hydrocodone and acetaminophen) that may be prescribed for a short period for severe pain such as caused by a complex ankle fracture.
  • Cortisone shots delivered into the joint space provide longer-lasting pain relief. It may be used for chronic conditions such as bursitis or tendonitis when conservative treatments fail.

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 the following:

  • Ankle debridement involves the removal of loose cartilage, diseased tissues, or bone spurs from around the joint. It may be performed arthroscopically using small incisions, a tiny camera, and specialized surgical tools.
  • Arthrodesis is another option for ankle arthritis in which the ankle bones are fused to prevent the joint from moving, thereby easing pain.
  • Total ankle replacement, or ankle arthroplasty, involves the replacement of the damaged ankle bone with an artificial ankle implant.

When to See a Healthcare Provider

Seek medical attention promptly if you are unsure of the cause of your ankle pain or you have symptoms like:

  • An inability to walk on the affected ankle
  • A deformity around the ankle joint
  • Ankle pain that occurs at night or while resting
  • Ankle pain that persists beyond several days
  • An inability to bend the ankle
  • Progressive swelling of the joint into the foot or the calf area
  • Signs of an infection, including fever, redness, and/or warm skin
  • Any other unusual symptoms

If needed, your healthcare provider will refer you to a podiatrist, orthopedic surgeon, or emergency care provider for treatment.

How to Prevent Ankle Pain

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.
  • Maintaining a healthy weight puts less stress on the ankle and may decrease your risk of developing ankle tendonitis. Obesity can be a contributing factor to ankle pain.
  • 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.

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By Jonathan Cluett, MD
Jonathan Cluett, MD, is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams.