Ankle Pain Causes and Treatments

The most common ankle pain causes include sprain and inflammation of the tendons (tissue that connects muscles to bone). Chronic conditions, infection, and wear and tear of the bones, muscles, and cartilage can also result in ankle pain.

Treatment for ankle pain will depend on the cause and may include the RICE protocol (Rest, Ice, Compression, Elevation), physical therapy, medications, and in some cases, surgery.

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 when stepping off a curb, walking on an uneven surface, falling, or playing sports like tennis or soccer where a sudden change in direction causes the ankle to roll or twist.

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 of tendonitis can 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 each other 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 being unable 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 less 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 bursa 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.
• Lupus is an autoimmune disease in which the body’s immune system mistakenly attacks its own healthy cells and tissues, leading to inflammation, pain, and swelling in joints and muscles.
• Osteochondritis dissecans is a condition in which a piece at the end of a bone dies and partially or fully separates from the rest of the bone that forms a joint. It is most common in the knee but can occur in the ankle too.
• Pseudogout occurs when calcium crystal deposits build up in a joint. Symptoms are similar to gout but it has a different cause. It occurs most often in the knee, wrist, or ankle and causes the joint to suddenly become red, hot, swollen, and painful.
• Sinus tarsi syndrome is a condition that causes ongoing pain on the outside of the foot, between the ankle and the heel. It is usually due to instability of the joint connecting the foot to the heel. It can cause pain, swelling, tenderness to the touch, and difficulty walking on uneven surfaces.
• Pinched nerve in the foot may occur due to trauma or certain conditions, such as tarsal tunnel syndrome. Symptoms may include pain, numbness, tingling, or weakness.

Diagnosis

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 examine 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 the inside and outside of the foot).

If these areas are tender or you can’t bear weight for four steps, you will need an X-ray.

Talar Tilt Test

Your healthcare provider will hold the heel of your painful ankle in their hand and then gently turn your ankle inside and outside. They will compare your ankle joint movement’s looseness (laxity) to the uninjured ankle.

Increased laxity or pain when turning the ankle inward suggests a potential lateral ankle ligament sprain. Increased laxity or pain when turning the ankle outward 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, your 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 (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, also known as sciatica, is a condition that occurs when a nerve root in the lower back is compressed, irritated, or damaged. It causes nerve pain to radiate to other parts of the body, such as 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

Treatment depends on the cause of your ankle pain, but one common treatment is the RICE protocol. This protocol is a step you can take before seeing your healthcare provider.

RICE Protocol

The RICE protocol is used to treat musculoskeletal injuries including ankle sprains and ankle tendonitis. The acronym stands for:

• Rest: Taking weight off and resting the joint allows 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. Do not 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 ankle strains and tendonitis, as well as post-surgery. Physical therapists will give you exercises to increase ankle muscle strength, regain mobility, minimize stiffness, and prevent chronic ankle problems.

Depending on the type of injury, your healthcare provider may recommend other devices, such as:

• Crutches
• A cane
• Ankle brace or splint
• Orthotics
• A cast

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 may include:

• 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 to help ease 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.

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.
• 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 are 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 provider will usually do a physical exam of your ankle and order imaging or other tests to make a diagnosis.

Treatment for minor ankle pain will include RICE, while more severe causes of ankle pain may require prescription medication or surgery.