Ankle pain

Introduction

Ankle pain refers to discomfort or aching in or around the ankle joint.

• May affect bones, ligaments, tendons, or surrounding soft tissues.

• Can be localized (due to trauma or inflammation) or referred (from knee, hip, or systemic disease).

• Accurate diagnosis is essential to distinguish benign causes from serious conditions requiring urgent treatment.

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Anatomy of the Ankle (Brief Overview)

• Bones: tibia, fibula, talus form the ankle joint.

• Ligaments: medial (deltoid ligament) and lateral (anterior/posterior talofibular, calcaneofibular).

• Tendons: Achilles tendon, peroneal tendons, tibialis posterior/anterior.

• Cartilage: smooth lining within the joint.

Pain can arise from injury or disease of any of these structures.

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Causes of Ankle Pain

1. Traumatic / Mechanical

• Ankle sprain: overstretching/tearing of ligaments (most common).

• Fractures: tibia, fibula, talus.

• Dislocation.

• Tendon injuries: Achilles tendon rupture, tendonitis.

2. Inflammatory / Arthritic

• Osteoarthritis: wear-and-tear degeneration.

• Rheumatoid arthritis.

• Gout: deposition of uric acid crystals.

• Pseudogout (CPPD).

• Reactive arthritis.

3. Overuse / Sports Injuries

• Achilles tendonitis.

• Peroneal tendonitis.

• Plantar fasciitis (heel pain radiating to ankle).

• Stress fractures (tibia, fibula).

4. Infections

• Septic arthritis.

• Osteomyelitis (bone infection).

• Cellulitis.

5. Vascular / Neurological

• Peripheral arterial disease (reduced blood flow).

• Deep vein thrombosis (DVT) → usually swollen, painful ankle/leg.

• Peripheral neuropathy (diabetes, trauma).

• Tarsal tunnel syndrome (nerve entrapment).

6. Systemic Causes

• Lupus.

• Psoriatic arthritis.

• Sarcoidosis.

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Clinical Features

• Pain location: anterior, lateral, medial, or posterior ankle.

• Onset: sudden (trauma) vs gradual (arthritis, tendonitis).

• Associated symptoms:

  • Swelling, bruising (sprain, fracture).

  • Redness, warmth (gout, infection).

  • Stiffness (arthritis).

  • Instability, “giving way” (ligament injury).

  • Numbness, tingling (nerve entrapment).

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Diagnostic Approach

1. History

• Recent trauma or sports injury?

• Onset, duration, severity.

• Past medical history (arthritis, gout, diabetes).

• Occupational/physical activity.

2. Examination

• Inspect swelling, redness, deformity.

• Palpate for tenderness, warmth, crepitus.

• Range of motion testing.

• Neurovascular assessment (pulses, sensation, capillary refill).

3. Investigations

• X-ray: fractures, arthritis.

• MRI: soft tissue injuries (ligaments, tendons, cartilage).

• Ultrasound: tendonitis, effusions.

• Blood tests:

  • Uric acid (gout).

  • ESR/CRP, rheumatoid factor, ANA (autoimmune arthritis).

• Joint aspiration: if effusion — check for crystals (gout), bacteria (septic arthritis).

• Doppler ultrasound: rule out DVT if swelling and pain.

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Management and Treatment

Treatment depends on cause.

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A. General Measures (for mild/moderate pain)

• RICE protocol: Rest, Ice, Compression, Elevation.

• Analgesics:

  • Paracetamol (Acetaminophen) 500–1000 mg orally every 6–8 h (max 4 g/day).

  • NSAIDs: Ibuprofen 400 mg orally every 8 h, or Naproxen 250–500 mg twice daily.

• Supportive braces or walking aids if unstable.

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B. Specific Treatments

1. Ankle Sprain

• RICE, physiotherapy, ankle brace.

• Severe ligament tears → surgical repair.

2. Fractures / Dislocations

• Immobilization with cast or boot.

• Surgery (open reduction internal fixation) if displaced.

3. Arthritis

• Osteoarthritis:

  • NSAIDs, weight reduction, physiotherapy.

  • Intra-articular steroid injection: Triamcinolone 20–40 mg intra-articular.

  • Surgery (arthrodesis, joint replacement) in advanced cases.

• Rheumatoid arthritis:

  • DMARDs: Methotrexate 7.5–25 mg orally weekly.

  • Biologics: Etanercept, Adalimumab.

• Gout:

  • Acute attack: Colchicine 0.5 mg orally every 8 h OR Naproxen 500 mg orally twice daily.

  • Long-term: Allopurinol 100–300 mg orally daily (for uric acid control).

4. Tendon Injuries

• Achilles tendonitis: rest, physiotherapy, heel lifts.

• Rupture: surgical repair.

5. Infection

• Septic arthritis: emergency — IV antibiotics (Ceftriaxone 2 g daily) + surgical drainage.

• Cellulitis: Amoxicillin-clavulanate 875/125 mg orally twice daily × 7–10 days.

6. DVT

• Anticoagulation:

  • Enoxaparin 1 mg/kg SC every 12 h.

  • Then Warfarin (INR 2–3) or DOAC (Apixaban, Rivaroxaban).

7. Tarsal Tunnel Syndrome

• Rest, orthotic insoles.

• NSAIDs.

• Corticosteroid injections.

• Surgery if severe.

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Complications

• Chronic pain, stiffness.

• Repeated sprains → instability, arthritis.

• Missed fractures → deformity.

• Untreated infection → sepsis.

• Untreated DVT → pulmonary embolism.

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Prognosis

• Sprains and mild injuries: usually excellent recovery in 2–6 weeks.

• Fractures: good with treatment, but risk of arthritis long-term.

• Arthritis: chronic, but manageable with therapy.

• Infection/DVT: serious, but good prognosis if treated early.

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Patient Education

• Most ankle pain is from minor injuries, but persistent or severe pain needs medical evaluation.

• Early RICE therapy reduces swelling and speeds recovery.

• Wear supportive footwear; avoid high heels for long periods.

• Maintain healthy weight to reduce joint stress.

• Seek urgent care if:

• Sudden severe pain after trauma.

• Red, hot, swollen ankle with fever.

• Pain with chest pain/shortness of breath (possible DVT/PE).