Ankle Pain Management
Learning Objectives
- Perform a systematic assessment of ankle pain using a structured approach
- Identify key anatomical structures involved in ankle injuries
- Apply the Ottawa Ankle Rules appropriately to determine need for imaging
- Develop evidence-based management plans for ankle injuries
- Recognize red flag presentations requiring urgent referral
1. Introduction and Epidemiology
Ankle injuries are among the most common musculoskeletal presentations in primary care and emergency settings in Australia. Ankle sprains account for up to 40% of all sports injuries, with the highest incidence occurring in younger athletes engaged in court and field sports.
Australian Epidemiology
- Approximately 300,000 Australians experience ankle sprains annually
- Lateral ankle sprains represent 85% of all ankle injuries
- 20-40% of patients develop chronic ankle instability following initial injury
- Only 50% of patients with ankle sprains seek medical attention
2. Ankle Anatomy and Biomechanics
Understanding the anatomy of the ankle joint is essential for accurate diagnosis and management of ankle injuries.
2.1 Joint Structure
The ankle complex comprises three joints:
- Talocrural joint: Formed by the tibia, fibula, and talus
- Subtalar joint: Between the talus and calcaneus
- Distal tibiofibular syndesmosis: Connection between the tibia and fibula
2.2 Ligament Complexes
Lateral Ligament Complex
- Anterior talofibular ligament (ATFL): Most commonly injured ligament; connects the lateral malleolus to the neck of the talus
- Calcaneofibular ligament (CFL): Connects the lateral malleolus to the calcaneus
- Posterior talofibular ligament (PTFL): Connects the lateral malleolus to the posterior process of the talus
Medial Ligament Complex (Deltoid Ligament)
- Anterior tibiotalar ligament
- Tibionavicular ligament
- Tibiocalcaneal ligament
- Posterior tibiotalar ligament
Syndesmotic LigamentsLigaments</h
- Anterior inferior tibiofibular ligament (AITFL)
- Posterior inferior tibiofibular ligament (PITFL)
- Interosseous membrane
2.3 Tendons Around the Ankle
- Achilles tendon: Posterior aspect, inserts on the calcaneum
- Peroneal tendons (longus and brevis): Lateral aspect
- Tibialis posterior tendon: Medial-posterior aspect
- Tibialis anterior tendon: Anterior-medial aspect
3. Clinical Assessment
3.1 History Taking
A thorough history helps narrow differential diagnoses and guide physical examination.
Essential History Components (SOCRATES+)
| Component |
Key Questions |
Clinical Significance |
| Site |
Where is the pain? (Medial, lateral, anterior, posterior) |
Lateral pain suggests lateral ligament injury; medial pain suggests deltoid ligament injury |
| Onset |
When and how did it start? |
Acute vs chronic presentation |
| Character |
How would you describe the pain? |
Sharp pain suggests fracture; dull ache suggests soft tissue injury |
| Radiation |
Does the pain spread anywhere? |
Radiation may indicate nerve involvement |
| Associated symptoms |
Any clicking, popping, instability, swelling? |
Popping/snapping suggests ligament tear; immediate swelling suggests hemarthrosis |
| Timing |
Is it constant or intermittent? |
Pattern of symptoms |
| Exacerbating factors |
What makes it worse? |
Weight-bearing difficulty suggests fracture |
| Relieving factors |
What helps the pain? |
Response to RICE (rest, ice, compression, elevation) |
| Severity |
Rate pain from 0-10 |
Helps track improvement |
| Mechanism of injury |
Exactly how did the injury occur? |
Inversion (lateral sprain); eversion (medial sprain); dorsiflexion (syndesmotic injury) |
Additional History Components
- Past medical history: Previous ankle injuries, arthritis, connective tissue disorders, diabetes
- Medications: Steroids, anticoagulants
- Psychosocial history: Occupation, sporting activities, living situation (stairs)
Red Flags in History
- Inability to bear weight immediately after injury (possible fracture)
- Gross deformity (possible displaced fracture)
- Numbness, tingling, burning pain, coolness (neurovascular compromise)
- Pain out of proportion to injury with tense swelling (compartment syndrome)
- Pain on passive stretch (compartment syndrome)
3.2 Physical Examination
A systematic approach to physical examination helps identify the structures involved.
General Observation
- Gait assessment (limping, weight-bearing capacity)
- Position of comfort
- Distress level
Inspection
- Swelling, bruising, ecchymosis
- Deformity, skin breaks
- Alignment of joints
- “Too many toes” sign (indicative of posterior tibial tendon dysfunction)
Palpation
- Temperature (warmth suggests inflammation/infection)
- Pulses (dorsalis pedis, posterior tibial)
- Capillary refill time
- Sensation (L4, L5, S1 dermatomes or peripheral nerve distribution)
- Systematic palpation following Ottawa Ankle Rules:
Ottawa Ankle Rules
X-ray is indicated if there is pain in the malleolar zone AND:
- Bone tenderness at the posterior edge or tip of the lateral malleolus, OR
- Bone tenderness at the posterior edge or tip of the medial malleolus, OR
- Inability to bear weight for four steps immediately after injury and in the emergency department
X-ray is indicated if there is pain in the midfoot zone AND:
- Bone tenderness at the base of the fifth metatarsal, OR
- Bone tenderness at the navicular bone, OR
- Inability to bear weight for four steps immediately after injury and in the emergency department
Level A Evidence: The Ottawa Ankle Rules have a sensitivity of >95% for detecting clinically significant fractures.
Range of Motion
- Active movements: Dorsiflexion, plantarflexion, inversion, eversion
- Passive movements
- Resisted movements (helps assess tendon injuries)
Special Tests
| Test |
Technique |
Positive Finding |
Significance |
| Anterior Drawer Test |
Stabilize tibia/fibula, pull calcaneus forward |
Increased anterior translation compared to uninjured side |
ATFL injury |
| Talar Tilt Test |
Stabilize distal leg, invert calcaneus with ankle in various positions |
Excessive inversion compared to uninjured side |
CFL injury (neutral position); ATFL injury (plantarflexion); PTFL injury (dorsiflexion) |
| Squeeze Test |
Compress tibia and fibula at mid-calf level |
Pain at distal tibiofibular joint |
Syndesmotic injury |
| External Rotation Test |
Stabilize leg, rotate foot externally with ankle in neutral position |
Pain at syndesmosis |
Syndesmotic injury |
| Thompson Test |
Patient prone with feet hanging off bed edge, squeeze calf muscle |
No plantarflexion response |
Achilles tendon rupture |
4. Differential Diagnosis
Based on the history and examination findings, consider the following differential diagnoses:
4.1 Ligament Injuries
- Lateral ankle sprain: Most common (85% of ankle injuries); involves ATFL, CFL, PTFL
- Medial ankle sprain: Involves deltoid ligament; less common due to ligament strength
- Syndesmotic injury (“high ankle sprain”): Involves AITFL, PITFL, interosseous membrane
4.2 Fractures
- Malleolar fractures: Lateral, medial, or bimalleolar
- Fifth metatarsal fracture: Often associated with inversion injuries
- Navicular fracture
- Talar fracture
- Calcaneal fracture: Often from falls from height
- Growth plate injuries: In pediatric and adolescent patients
4.3 Tendon Injuries
- Achilles tendon rupture or tendinopathy
- Peroneal tendon injuries: Tendinopathy, subluxation, or tear
- Posterior tibial tendon dysfunction
- Anterior tibial tendon injuries
4.4 Other Conditions
- Osteochondral lesions: Present with clicking, locking
- Nerve entrapment syndromes: Tarsal tunnel syndrome, superficial peroneal nerve entrapment
- Chronic ankle instability: Following previous injuries
- Inflammatory arthritis
- Infection: Septic arthritis or osteomyelitis
5. Classification of Ankle Sprains
| Grade |
Pathology |
Clinical Features |
Healing Time |
| Grade I (Mild) |
Stretching and microscopic tearing of ligament fibers |
Minimal swelling, tenderness, no instability, able to bear weight |
1-2 weeks |
| Grade II (Moderate) |
Partial tear of ligament |
Moderate swelling, bruising, tenderness, mild-moderate instability, difficult weight-bearing |
3-6 weeks |
| Grade III (Severe) |
Complete rupture of ligament |
Severe swelling, bruising, tenderness, significant instability, unable to bear weight |
8-12+ weeks |
6. Investigations
6.1 Imaging
Not all ankle injuries require imaging. Use the Ottawa Ankle Rules to guide decision-making.
Plain Radiography
When indicated by Ottawa Ankle Rules, standard ankle series includes:Ottawa Ankle Rules, standard ankle serie
- Anteroposterior (AP) view
- Lateral view
- Mortise view (AP with 15-20° internal rotation)
Advanced Imaging
- Ultrasound: Useful for tendon injuries; can be used to assess ligament integrity
- MRI: Gold standard for soft tissue assessment; indicated for:
- Persistent symptoms despite appropriate management
- Suspected osteochondral lesions
- Elite athletes requiring precise diagnosis
- Complex injuries
- CT scan: Better for complex fractures or when subtle fractures are suspected
When to Order Advanced Imaging
Advanced imaging is generally not required for most ankle sprains but should be considered when:
- Patient fails to improve with appropriate conservative management after 4-6 weeks
- There is diagnostic uncertainty
- Patient is an elite athlete where precise diagnosis affects management
- Suspected occult fracture with negative X-rays but persistent symptoms
Level B Evidence: MRI should not be routinely ordered for acute ankle sprains unless there are specific indications.MRI sh
7. Management
7.1 Acute Phase Management (0-72 hours)
The POLICE protocol has replaced the traditional RICE protocol:
- Protection: Avoid activities that exacerbate pain
- Optimal Loading: Early controlled movement and weight-bearing as tolerated
- Ice: 15-20 minutes every 2-4 hours to reduce swelling and pain
- Compression: Elastic bandage to limit swelling (ensure not too tight)
- Elevation: Keep foot elevated above heart level when possible
Analgesia
- Paracetamol: First-line, regular dosing
- NSAIDs: Consider for more severe pain, but use caution in first 48 hours (may increase bleeding) and with contraindications (gastritis, renal impairment, anticoagulant use)
Level B Evidence: Early controlled loading and mobilization leads to better outcomes than strict immobilization.
7.2 Rehabilitation Phase (after 72 hours)
Progressive rehabilitation should begin after the acute inflammatory phase:Pro
Movement and Strengthening Exercises
- “Ankle alphabet” – tracing letters with the big toe
- Gentle ankle circles
- Progressive weight-bearing as tolerated
- Strengthening exercises for peroneal muscles and calf
- Proprioception and balance training (essential for preventing recurrence)
Functional Progression
- Walking without pain
- Straight-line jogging
- Figure-8 running
- Sport-specific drills
- Return to full activity
Additional Support
- Taping or bracing: May be used during rehabilitation and return to sport
- Walking boots: Sometimes used for grade II-III sprains and syndesmotic injuriessprains and syndesmotic injuries</li
Level A Evidence: Supervised exercise rehabilitation reduces the risk of recurrent ankle sprains.
7.3 Special Considerations
Syndesmotic Injuries
- Often require longer immobilization (4-6 weeks in walking boot)
- More cautious rehabilitation progression
- Consider orthopedic referral for unstable injuries
Grade III Lateral Ankle Sprains
Controversy exists regarding optimal management:
- Conservative management with functional rehabilitation is generally first-line
- Consider orthopedic referral for:
- Elite athletes
- Significant functional instability
- Failed conservative management
Level B Evidence: For grade III sprains, most patients can be managed conservatively, but surgical intervention may be considered for select patients.
Chronic Ankle Instability
- Comprehensive rehabilitation program focusing on proprioception
- Bracing during high-risk activities
- Consider surgical stabilization for recurrent instability despite appropriate rehabilitation
7.4 Return to Sport/Activity
Criteria for return to sport/activity include:
- Full, pain-free range of motion
- At least 90% strength compared to uninjured side
- Ability to complete sport-specific functional tests
- Adequate proprioception and balance
Timeline varies based on injury severity:
- Grade I: 1-2 weeks
- Grade II: 3-6 weeks
- Grade III: 8-12+ weeks
- Syndesmotic injuries: 12+ weeks
7.5 Patient Education
Patients should be informed about:
- Expected recovery timeline
- Warning signs requiring reassessment
- Importance of completing rehabilitation
- Risk of recurrence and chronic instability
- Prevention strategies
Indications for Urgent Reassessment
Advise patients to seek immediate medical attention if:
- Pain significantly worsens despite following advice
- Unable to bear weight after 72 hours
- Increasing redness and warmth, especially with fever (possible infection)
- Development of numbness, tingling, or weakness
- Symptoms not improving after 1-2 weeks
7.6 Follow-up and Referral
- Most Grade I sprains do not require routine follow-up
- Grade II-III injuries: review at 1-2 weeks to assess progress
- Consider physiotherapy referral for:
- Grade II-III injuries
- Athletes
- Patients with recurrent injuries
- Poor progress with home exercises
- Consider orthopedic referral for:
- Fractures
- Unstable syndesmotic injuries
- Failed conservative management
- Chronic instability
8. Prevention Strategies
Prevention of ankle injuries and recurrence includes:
- Proper warm-up before physical activity
- Appropriate footwear for the activity
- Bracing or taping for high-risk activities, especially with history of previous injury
- Proprioceptive and balance training programs – shown to reduce risk by 30-50%
- Structured rehabilitation after injury
- Avoiding uneven surfaces when possible
Level A Evidence: Neuromuscular training programs significantly reduce ankle sprain incidence, particularly in individuals with previous sprains.
9. Prognosis
The prognosis for ankle sprains varies:
- Grade I sprains: Excellent prognosis, complete recovery in 1-2 weeks
- Grade II sprains: Good prognosis, recovery in 3-6 weeks with proper rehabilitationsprains: Good
- Grade III sprains: Variable prognosis, may have residual symptoms for months
Long-term sequelae may include:
- Chronic ankle instability (occurs in 20-40% of lateral ankle sprains)
- Recurrent sprains
- Post-traumatic arthritis (especially with inadequately treated syndesmotic injuries)
- Persistent pain or stiffness
Level B Evidence: Completion of a structured rehabilitation program significantly reduces the risk of chronic ankle instability.
Clinical Case: Lateral Ankle Sprain
Presentation: 25-year-old male basketball player presents with right lateral ankle pain after landing awkwardly during a game 2 hours ago. Reports feeling a “pop” and immediate pain. Unable to continue playing but can bear weight with a limp.
Examination: Moderate swelling and tenderness anterior to the lateral malleolus. Positive anterior drawer test. Ottawa Ankle Rules negative. Pain with inversion but no gross instability.
Diagnosis: Grade II lateral ankle sprain (primarily ATFL)
Management:
- Acute phase: POLICE protocol, paracetamol for pain, NSAIDs if no contraindications
- Rehabilitation phase: Early controlled mobilization, progressive weight-bearing, ankle alphabet exercises, gradual strengthening
- Return to activity: Structured progression from walking to straight-line jogging to cutting movements. Consider ankle brace for initial return to basketball
- Prevention: Balance and proprioception exercises, consider prophylactic taping/bracing for future games
Timeline: Expected return to full sport participation in 4-5 weeks with proper adherence to rehabilitation
Key Points
- Lateral ankle sprains are the most common ankle injury, with the ATFL most frequently involved
- Use the Ottawa Ankle Rules to determine the need for X-rays
- The POLICE protocol (Protection, Optimal Loading, Ice, Compression, Elevation) forms the foundation of early management
- Early controlled mobilization leads to better outcomes than strict immobilization
- Proprioceptive training is essential to prevent recurrence
- Despite being considered “minor” injuries, ankle sprains can lead to chronic problems if not managed appropriately
- Red flags requiring urgent assessment include: inability to bear weight after 72 hours, signs of neurovascular compromise, compartment syndrome, or infection
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