Ankle pain: causes and treatment

Where it hurts is the first clue

Sprains are the most familiar cause of ankle pain, but an unstable ankle, arthritis, gout, an irritated tendon, a broken bone, a pinched nerve, infection or poor alignment of the leg or foot can also be to blame.^[7] At our offices in Lyndhurst, Paramus and Millburn, NJ, the first thing we ask is exactly where it hurts.

Pain on the inside of the ankle

• Posterior tibial tendon. This tendon runs behind the inner ankle bone and holds up the arch. When it is inflamed or torn, pain and swelling build along the inside of the ankle and the arch can flatten. It is more common in women and after 40.^[1] See flat feet.
• Tarsal tunnel syndrome. The tibial nerve passes through a narrow tunnel behind and below the inner ankle bone.^[9] Pressure on it causes tingling, burning, numbness or electric-shock feelings in the inner ankle or the sole, often brought on by long periods of standing or walking.^[2]
• An inner ankle sprain, from the foot turning outward, is less common than a sprain on the outside.^[3]

Pain on the outside of the ankle

• A sprain. Around 90% of ankle sprains happen when the foot turns inward and stretches or tears the ligaments on the outside of the ankle.^[3] See ankle sprains.
• The peroneal tendons. These two tendons run behind the outer ankle bone and help steady the ankle.^[4] Problems with them are an under-appreciated cause of outer ankle pain and can be hard to tell apart from a ligament injury.^[10] See peroneal tendon problems.
• An ankle that keeps giving way. Chronic ankle instability usually follows a sprain that didn’t heal well or wasn’t fully rehabilitated.^[11]

Swipe sideways to see the whole drawing.

Pain at the front of or deep in the ankle

In athletes, repeated small injuries can thicken the soft tissue in the joint until it gets pinched at the front (anterior ankle impingement), and bone spurs at the front of the joint can rub in the same way.^[12,13] Arthritis causes pain and stiffness in the joint itself that usually builds gradually and flares with vigorous activity.^[13] A cartilage injury on top of the talus usually follows an injury such as a sprain, and it can take months to cause a deep ache in the ankle when you are on your feet, with clicking, catching or bouts of swelling.^[14] See cartilage injuries.

Pain at the back of the ankle

Achilles tendinitis causes pain and stiffness along the tendon at the back of the ankle, often worst in the morning and with activity.^[5] See Achilles tendon problems and Haglund’s deformity.

A sudden pain that feels like a kick, often with a pop, can be a torn Achilles tendon.^[15] These tears are reportedly mistaken for ankle sprains in 20 to 25% of patients.^[16]

Ankle pain after an injury

A bad sprain can hurt, swell and bruise as much as a fracture.^[3] The Ottawa ankle rules, which check for tenderness over specific spots on the bones and whether you can take four steps, pick up almost every fracture and avoid many unnecessary X-rays.^[6] When they point to a possible fracture, we take X-rays at the practice. See sprain or fracture? and fractures and trauma.

For most sprains, anti-inflammatory medicine and an early return to walking ease pain and swelling, and exercise therapy and bracing help prevent the next one.^[17] If you can’t take four steps, or you felt a pop at the back of the ankle, get it checked before walking on it.^[6,15] Pain that lingers after a “simple sprain” can signal another problem, such as a peroneal tendon injury.^[4]

Ankle pain without a recent injury

• Arthritis. An old injury may be catching up with you: ankle arthritis is mostly related to an earlier injury,^[18] and repeated sprains can lead to long-term pain, arthritis and instability.^[3] Rheumatoid arthritis often starts in the feet and ankles, usually on both sides.^[13] See arthritis.
• Gout. Uric acid crystals can inflame any joint, though the big toe is the most common. A flare brings sudden, intense pain, often at night or on getting up, with redness, swelling and warmth.^[19] Infection can also make an ankle painful, red, warm and swollen, so get it seen the same day.^[7,8] See gout.
• Tendinitis. Achilles tendinitis usually comes from repeated stress, such as a sudden increase in exercise, rather than one injury.^[5] The posterior tibial tendon can wear down from overuse too, even in people who aren’t athletes.^[1]
• A pinched nerve in the tarsal tunnel, from flat feet, a ganglion cyst, a swollen tendon or a bone spur.^[2]

Swollen ankles

Painless swelling of the feet and ankles is a common problem, especially in older people, and is often caused by fluid buildup (edema). Long periods of standing, long trips, extra weight, pregnancy, weak leg veins, some medicines (including certain blood pressure pills, hormones, anti-inflammatory drugs and steroids) and heart, kidney or liver failure can all cause it. Don’t stop a medicine without talking to the doctor who prescribed it.^[8]

Get seen the same day for new swelling in only one leg, which can be a blood clot, a swollen leg that is red or warm, or swelling with a fever.^[8] If you are pregnant, call your doctor or midwife right away for more than mild swelling or a sudden increase in swelling, which can be a sign of preeclampsia. If you have heart, kidney or liver disease, call your doctor right away if swelling is new or getting worse.^[8] Swelling with shortness of breath or chest pain is an emergency: call 911.^[8] If you have diabetes and neuropathy, a warm, red, swollen foot or ankle can be Charcot foot and needs to be seen right away.^[20] See Charcot foot.

How we evaluate and treat ankle pain

We examine each tendon, ligament and joint and watch you walk, with X-rays and ultrasound at the practice. An MRI helps when the soft tissues need a closer look, or when a sprain hasn’t settled after six to eight weeks.^[3] Treatment is matched to the cause:

• Support and rehabilitation: a brace or a short time in a walking boot, then exercises for motion, strength and balance.^[3,17]
• Shoes, orthotics and braces: orthotics and braces treat most early posterior tibial tendon problems without surgery, and stiff, rocker-soled shoes and a custom brace ease arthritis pain.^[1,13] See custom orthotics.
• Medicine and injections: anti-inflammatory medicine (check with your doctor first if you have heart, kidney or stomach problems), and a cortisone injection for an arthritic joint, which relieves pain but often only for a while.^[1,13]
• Shockwave therapy: for insertional Achilles tendinopathy, the evidence favors shockwave, alone or with exercise.^[21] See shockwave therapy.
• Gout flares are treated with medication or an injection; repeated attacks need longer-term treatment with your primary care doctor.^[19]

If pain persists despite good non-surgical care, an operation may help: repairing ligaments or a torn tendon, clearing out pinched tissue or bone spurs through small incisions, or fusing or replacing a worn-out joint.^[3,4,12,13]

Common questions

Why does my ankle hurt when I walk?

Ankle pain is often a dull ache that comes on with weight and movement.^[7] Arthritis hurts with motion, and a cartilage injury is worse on your feet and better at rest.^[13,14] If the pain changes how you walk or lasts more than a few weeks, have it examined.^[3]

Why does my ankle hurt for no reason?

There is usually a reason, even without a recent injury: arthritis (often from an old injury), gout, overuse tendinitis and a pinched nerve can all cause ankle pain.^[7,18]

What kind of doctor treats ankle pain?

Dr. Ozturk is a Foot and Ankle Surgeon and podiatrist who treats ankle pain with and without surgery. He is double board certified, by the American Board of Podiatric Medicine and as a Fellow of the Academy of Physicians in Wound Healing. A podiatrist, or doctor of podiatric medicine (DPM), is a physician and surgeon for the foot, the ankle and the related parts of the leg.^[22] Our article on podiatrists and orthopedic surgeons compares the training.

When to seek care