Why They Hurt, What You Can Do

Most ankle pain can be managed with rest, modifying activities, supportive footwear, over-the-counter pain medication, and other conservative measures. However, some causes may require further treatment.

What Can Cause General Ankle Pain When Walking?

Injuries

Injuries that can cause ankle pain include:

• Fractures
• Tendon sprains/tears
• Ligament sprains/tears
• Dislocations

Sprained Ankle

A sprained ankle occurs when the ligaments that support the ankle stretch too far and can tear.

A sprained ankle can cause symptoms such as pain (particularly with walking), swelling, and bruising.

There are three grades of ankle sprains:

• Grade 1: Mild injury with stretched ligaments and possible slight or microscopic ligament tissue tearing
• Grade 2: Partially torn ligaments
• Grade 3: Severe injury with fully torn ligaments that may require more extensive treatment (possibly surgery)

Broken Ankle

A broken ankle is a fracture of one or more bones that make up the ankle joint.

The injury can cause symptoms such as:

• Sudden, sharp pain
• Swelling
• Popping or snapping sound at the time of injury
• Difficulty walking or bearing weight
• Odd angle or deformity of the ankle
• Bruising
• Tenderness
• Numbness and coolness in the foot (in some cases)

Ankle fractures can be classified as:

• Nondisplaced: Bones are not out of place
• Displaced: Broken bone fragments are separated, with possible breaks in multiple areas and possible ankle joint dislocation
• Open/compound: Emergency situation in which broken bones break through the skin

Syndesmosis Injury

The group of ligaments that stabilizes the joint between the lower end of the tibia and the lower end of the fibula is called the syndesmosis.

A high ankle sprain is a syndesmosis injury that involves just the ligaments.

A syndesmosis injury may also involve a ligament sprain and one or more fractures. This usually requires surgery.

Overuse

Overuse injuries typically cause an aching pain that comes on gradually, and is often first noticed as discomfort during certain activities, such as walking or running.

If not addressed, the pain becomes more persistent and can lead to conditions such as:

Conditions

Ankle pain can occur with certain conditions.

Arthritis

The major types of arthritis that can affect the ankle include:

• Osteoarthritis: Degenerative wear and tear. Cartilage wears away and becomes frayed and rough, resulting in bone rubbing on bone, leading to pain and stiffness.
• Rheumatoid arthritis: Chronic, autoimmune disease. Immune cells attack the synovium (connective soft tissue membrane) covering the joint, causing it to swell and eventually invade and damage bone, cartilage, ligaments, and tendons. Can cause serious joint deformity.
• Posttraumatic arthritis: Develops after an injury, sometimes years later. Causes cartilage between the joints to wear away.

Osteoarthritis is the most common form of arthritis.

Unlike osteoarthritis in other joints, osteoarthritis of the ankle usually (in about 90% of cases) develops after an injury, typically a severe strain or fracture that happened years or decades ago.

The most common symptoms of osteoarthritis are:

• Pain with movement
• Stiffness, especially when moving after rest
• Swollen joints
• Less movement in the joint
• Loose or unstable feeling in the joint
• Joint warmth and redness
• Difficulty walking

Posterior Tibial Tendon Dysfunction (PTTD)

PTTD, also called progressive collapsing foot deformity (PCFD) or adult acquired flatfoot (AAF), is an inflammation of the tendon that runs from the tibialis posterior (a muscle in the lower leg) behind the inside bone on the ankle and attaches to the sole of the foot. This tendon helps hold the arch of the foot up and can become inflamed with overuse or injury.

This can result in flattening of the arch of the foot and other deformities.

Symptoms of PTTD may include:

• Pain/swelling in the arch, along the inside of the foot and ankle, or on the outside of the ankle
• Pain and weakness with activities such as standing (especially on toes), walking (especially on uneven surfaces), and going up and down stairs
• An ankle that rolls inward

Gout

Gout is a type of inflammatory arthritis caused by a buildup of uric acid (a waste product of breaking down purines in the body’s tissues and many foods) in the body. Gout usually occurs as flares causing pain, swelling, and redness in the joint. These typically last a week or two and then improve.

It usually affects the big toe but can occur in any joint, including the ankle. After years of having gout, tophi (lumps of uric acid) can form beneath the skin around the ankles.

Other Conditions

Other conditions that can cause ankle pain include:

• Peroneal tendinosis: Posterolateral ankle pain that worsens with activity and improves with rest. Tenderness of peroneal tendons and palpable mass that moves with the tendon. Thickening, swelling, and focal tendon degeneration.
• Lupus: Chronic autoimmune disease. Ankle swelling, and/or ankles that turn blue from sensitivity to cold can be signs of lupus.
• Benign tumors and tumor-like lesions: Most tumors of the foot are benign. Malignant tumors of the foot are rare.
• Blood clot: Ankle pain can be caused by a blood clot anywhere in the leg. Usually occurs with swelling and pain in other areas of the leg, such as behind the knee.
• Pinched nerve: Tarsal tunnel syndrome (pinched nerve in the ankle) or sciatica (pinched nerve in the back) can cause foot or ankle pain with numbness and weakness in the foot.

Achilles Tendon Rupture

The Achilles tendon is the band of tissue that attaches the calf muscles to the heel.

A ruptured (full or partial tear) of the Achilles tendon can cause symptoms such as:

• Popping or snapping sound during the injury
• Sharp, sudden pain in the heel
• Swelling
• Difficulty walking

Heel Bursitis

Retrocalcaneal bursitis occurs when the bursa (a small, fluid-filled sac) between the back of the heel bone and the Achilles tendon becomes inflamed.

This can cause pain, swelling, redness, dull aching, and tenderness in the heel or the back of the foot.

This condition develops gradually, typically from pressure from the back of the shoe, or activities that repetitively overflex the foot upward, like running uphill.

Achilles Tendonitis

Types of tendon injuries include:

• Acute tears: Sudden tears
• Tendinosis: Tears that occur over time due to stress
• Tendonitis or tendinopathy: Inflammation of the tendon

Achilles tendonitis is an acute inflammation of the Achilles tendon. Over time, the damaged tendon fibers may harden (calcify).

There are two types of Achilles tendonitis that can occur separately or at the same time:

• Noninsertional: Affects the fibers in the middle portion of the tendon (above where it attaches to the heel). Fibers may begin to break down over time and develop tiny tears, which can lead to swelling and thickening of the tendon.
• Insertional: Affects the lower part of the tendon, where it attaches to the heel bone. Can lead to bone spurs on the heel.

Achilles tendonitis tends to happen from repetitive stress to the tendon rather than a specific injury.

Symptoms may include:

• Pain along the tendon or back of the heel (worsens with activity)
• Pain in the back of the heel when wearing shoes
• Pain and stiffness along the tendon in the morning
• Severe pain the day after exercising
• Swelling (present all the time, but gets worse throughout the day or with activity)
• Thickening of the tendon

Plantar Fasciitis

The plantar fascia is a band of connective tissue that runs along the sole of the foot, from the heel to the ball. Plantar fasciitis is bruising or overstretching of this tissue, causing inflammation and heel pain.

Plantar fasciitis can cause symptoms such as:

• Pain in the bottom of the heel or arch that may feel like a bruise or ache (this tends to go away when you walk a bit, but can return with continued walking)
• Pain radiating into the ankle (caused by an irritated nerve in the foot)

Heel Spur

Over time, plantar fasciitis can lead to tears and bleeds in the heel, which calcify and form a bony growth called a heel spur.

A heel spur itself does not cause pain and may not have symptoms, but the inflammation associated with it can cause pain.

When to Contact a Healthcare Provider

Call 911, or seek emergency medical treatment, if you have symptoms such as:

• Severe ankle pain
• A snap, popping, or grinding noise at the time of injury
• The pain causes you to feel faint, dizzy, or sick
• The ankle or foot is at an odd angle or has changed shape
• Your calf is hot, swollen, and tender
• You have had a significant trauma (such as a fall or a direct blow to the ankle)
• You are unable to walk
• Significant pain, even when you are not bearing weight
• Inability to move ankle back and forth
• Large open wounds, or significant bleeding
• You think you may need urgent care

See a healthcare provider if you experience symptoms such as:

• Pain that is not improving, getting worse, or keeps coming back
• Pain that stops you from doing normal activities
• Tingling or loss of sensation in the ankle or foot
• Foot or ankle pain/injury and you have diabetes
• Pain with weight-bearing
• Changes in sensation, such as burning pain or numbness
• Swollen or stiff feet
• Signs of infection, such as redness, increased pain, warmth, or fever over 100 F (37.7 C)
• History of arthritis
• Continued ankle weakness or “giving way” easily
• Increased discoloration (red, black, or blue)

Diagnosing the Cause of Your Ankle Pain

To diagnose the cause of ankle pain, a healthcare provider may use tools such as:

• A physical examination, including asking about symptoms, history, and the circumstances of the injury, as well as feeling the area, checking range of motion, and doing stability testing
• X-rays, including stress X-rays (images taken when the angle is manipulated in different directions)
• Computerized tomography (CT) scan, which may include weight-bearing (i.e., the person is standing) CT scans
• Magnetic resonance imaging (MRI)
• Ultrasound
• Gait analysis (observing how you walk), and checking your shoes for abnormal or uneven wear
• Laboratory tests (such as to check for rheumatoid arthritis)
• Biopsy (if infection or a growth needs to be identified)

How Ankle Pain Is Treated 

At-Home and Conservative Treatment

Minor ankle pain, such as minor sprains, can often be managed at home with measures such as:

• RICE: Rest the ankle, apply Ice for 20 to 30 minutes, three or four times daily (do not use ice if you have problems with sensation or circulation), use Compression dressings to immobilize and support the ankle, Elevate the ankle above your heart as often as possible during the first 48 hours.
• Move: Move the ankle, starting slowly and gently for 10 to 20 seconds every hour during the first 48 hours. Gradually increase movement and exercise after 48 hours. When swelling and pain improve, do stretching and strengthening exercises.
• Take caution on stairs: Lead with the good leg going up the stairs and the problem leg going down the stairs. Use a handrail if possible.
• Apply heat: A warm compress or heating pad only after the swelling goes down.
• Pain medication: Over-the-counter pain medication, such as Tylenol (acetaminophen) or Advil/Motrin (ibuprofen), can help with discomfort. Check with your healthcare provider before taking any medication.

Lifestyle changes may help with some ankle pain, including measures such as:

• Using braces, orthotics (shoe inserts), and other tools
• Therapies, such as physical therapy or massage therapy
• Supportive, comfortable footwear (wide shoes with low heels) that fits properly
• Changing activities that irritate the condition (such as switching from high-impact to low-impact activities)

Noninvasive or Minimally Invasive Medical Treatment

Fractures, more severe sprains, and certain conditions may require medical treatment such as:

• Fluid aspiration (removal with a needle)
• Steroid injections
• Removable device, such as a walking boot or aircast brace
• Short leg cast or cast brace
• Night splinting (removable braces used during sleep)
• Extracorporeal shock wave therapy (ESWT), which uses either low- or high-energy shock waves to promote the healing of the damaged tendon tissue

Surgery

Depending on the cause, some surgeries that may be recommended include:

• Arthroscopy: A small camera looks inside the ankle joint, and miniature instruments remove loose bone fragments, cartilage, or parts of the ligament that may have gotten caught in the joint.
• Repair/reconstruction: Torn ligaments may be repaired with stitches or sutures, or a damaged ligament may be reconstructed using a tissue graft from another area.
• Tenosynovectomy: Cleaning the posterior tibial tendon and removing the inflamed tissue around the tendon. Small tears may also be repaired.
• Gastrocnemius recession or Achilles tendon lengthening: Lengthening of the calf muscles or Achilles tendon. Performed through a small incision on the back of the calf.
• Tendon transfer: A tendon from the foot is used to replace (or attach to) a diseased tendon.
• Osteotomy: Cutting and shifting bones to change the shape of a flexible flatfoot.
• Arthrodesis: Joint fusion.
• Debridement: Removal or “cleaning up” of damaged tissue, such as bone spurs, or damaged tendon tissue.
• Arthroplasty: Total ankle replacement. Damaged cartilage and bone are removed, then new metal or plastic joint surfaces are positioned to restore joint function.
• Plates and screws: May be used to repair fractures.

Can You Prevent Ankle Pain?

Ankle pain can’t always be prevented, but some things that may reduce the risk include:

• Wearing proper footwear
• Staying aware of your surroundings
• Warming up before exercising
• Doing range-of-motion and strengthening exercises
• Stretching ankles regularly
• Not “overdoing it”
• Using ankle support devices if prone to ankle pain or injury
• Maintaining a weight that is healthy for you

Summary

Ankle pain is usually the result of an injury (such as a sprain or break), overuse, or conditions such as tendonitis.

Ankle pain is usually diagnosed with a physical examination and sometimes with imaging tools or laboratory testing.

Depending on the cause, ankle pain may be treated with conservative measures such as ice, rest, and exercise, with medical treatment such as casts, or with surgery.