Chronic Ankle Pain: Symptoms, Causes and Treatments

What is chronic ankle pain?

Chronic ankle pain is pain or discomfort in the ankle that has been present for a long time (typically, more than six weeks, and in many cases, months to even years). Many patients with chronic ankle pain cannot point to one specific injury or event that started it, and they say that the pain started gradually and progressed over time. Others may have had an injury or change in activity or shoe wear that seemed to precipitate or instigate their symptoms (for example, a new exercise routine, or a change to their regular running sneakers). Your doctor may ask you about possible inciting factors for your pain.

What are symptoms that occur with chronic ankle pain?

Although some people report a severe, stabbing pain, others say that their chronic pain is more of a dull ache. You may have swelling in the ankle or foot. You may also experience difficulty walking, especially on uneven surfaces (beaches, golf courses, poorly maintained sidewalks), stairs, and hills. Many patients also experience challenges with certain shoes, especially higher-heeled shoes.

Some patients may feel a sense of ankle instability, or the ankle being prone to twisting or spraining, while others may feel that their ankle feels stiff. Typically, the ankle may not be too painful or bothersome while sitting or at rest but becomes so after prolonged standing or increased activity. It is also normal to be able to do some or all of your regular activities on your ankle, but to then feel pain later in the day or the next day (“paying for it later”).

What are common causes of chronic ankle pain?

Various injuries and conditions can lead to chronic ankle pain. One common cause is incomplete healing after a sprained ankle. Others include tendonitis, arthritis, alignment problems, cartilage damage, ankle impingement or stress fractures. Learn more about each below.

Incomplete recovery or healing after an ankle sprain

This is one of the most common causes of chronic ankle pain, especially lateral (on the outside of your ankle) ankle pain. When you sprain your ankle, you stretch or tear the ligaments – soft tissues that connect bones in your ankle. At the same time, you can disrupt the sense of kinesthetic awareness that tells your brain and body where your ankle is in space (this is called loss of proprioception). As a result, even after time and rehabilitation, you may still have pain, a sense of instability, weakness, or a sense of not being able to trust your ankle.

Tendonitis

There are several tendons in the ankle, including the Achilles tendon (in the back of the ankle that attaches to the heel), the peroneal tendons (on the outside, or lateral side, of the ankle), the anterior tibial tendon (in the front of the ankle), and the posterior tibial tendon (on the inside, or medial side, of the ankle). Any of these tendons can become irritated or inflamed with time, activity, or changes in function. In addition, these tendons are all made of collagen, which is the protein that makes up our tendons, ligaments, hair, and skin. As a result, anything that affects collagen – including chronic wear-and-tear that comes with aging, smoking, certain genetic diseases – can affect the health of tendons.

Arthritis

Arthritis is a condition which affects joints, or the places in the ankle where two bones meet and articulate (move). Typically, arthritis causes swelling, pain, and the wearing away of the cartilage in the joint (you may hear people talk about “bone-on-bone” arthritis – when the cartilage has completely worn away). There are multiple causes of ankle arthritis, including degenerative (osteoarthritis), rheumatoid arthritis, post-traumatic arthritis (after an injury like a break or sprain), or gout. There are 33 different joints in your foot, and arthritis can affect any of them! These include:

• the ankle joint – where your shin bone (tibia) meets your foot bone (talus)
• the subtalar joint – where your talus meets your heel bone (calcaneus)
• other joints in the midfoot and forefoot

Malalignment/deformity

Pain in the ankle may also be caused by a mechanical alignment problem. The two most common types of this are a flatfoot (also called “posterior tibial tendon insufficiency,” “adult-acquired flatfoot deformity,” “pes planovalgus,” or “progressive collapsing foot deformity”) and a high-arched foot (called a “cavovarus foot”). In these conditions, the foot and ankle are malaligned (crooked) and your body weight is not evenly distributed through your foot when you stand or walk. This can cause pain, swelling, and progressive deformity of the ankle.

Cartilage lesion

We all have cartilage in our joints.This is the smooth lining that allows us to move our joints effortlessly. However, over time or after injury, some people develop defects in the cartilage (imagine a pothole in an otherwise smooth road) known as lesions. These cartilage lesions can cause pain and swelling in the ankle, and may be associated with painful clicking, catching, or the sensation that the ankle gets “stuck.”

Ankle impingement

Impingement occurs when there is scar tissue, inflammation, and/or bone spurs that form in the ankle, typically the anterior (front) of the ankle. When the ankle moves, these tissues can become pinched or painful. There may be associated swelling and less motion in the ankle.

Stress fracture

Although most fractures (breaks) of the ankle occur from acute injuries or trauma, some patients will develop a fracture in the bone from loading or injury over time. Symptoms may include pain and swelling along the bone that gets worse with activity. Many patients with stress fractures will have a history of a recent increase in activity (like training for a marathon), or an underlying, and possibly previously undiagnosed bone condition like osteoporosis or osteopenia (weakening of the bone).

Are there any other causes of chronic ankle pain?

Absolutely. Chronic ankle pain can also come from problems with the back/spine, nerves, immunologic system, or somewhere else in the leg. After evaluating your ankle, your doctor may recommend that you see a neurologist, physiatrist, pain management specialist, rheumatologist, or an orthopedist who specializes in these issues.

What do I do if I have chronic ankle pain?

The first step is understanding the cause of your ankle pain. This is typically determined in consultation with your doctor, who may be an orthopedic surgeon, a physiatrist (a non-operative physician who specializes in musculoskeletal health), or a primary care doctor with special expertise in sports medicine and the foot and ankle. They will ask you about your symptoms, examine your foot and ankle, and obtain X-rays of your ankle.

They may or may not recommend additional imaging (CT scan, MRI scan, or ultrasound) of your ankle. Although these special images can be helpful for certain patients, it is important to remember that they are not a substitute for X-rays and their examination of your ankle in person!

What are common treatments for chronic ankle pain?

The treatment will depend on the cause of the ankle pain. However, many of the common causes of chronic ankle pain can be treated conservatively at first, without surgery. Your doctor may recommend trying anti-inflammatory medications (NSAIDs), physical therapy, use of an orthotic (insert) in your shoe and/or an ankle brace, changes to your shoe wear, or even use of a specialized orthopedic walking boot for a period of time. For some conditions, they may offer an injection (shot) of a corticosteroid or other anti-inflammatory medicine, or shockwave, which is a high-energy acoustic wave, to target areas of inflammation.

If your chronic ankle pain has persisted despite trying nonsurgical options, your doctor may recommend a surgical procedure. The specific procedure, pros and cons, and recovery time, will be dictated by you, your condition, and your surgeon. Your surgeon will take into account your condition, your health, your pain and mobility, and your goals and expectations for the future when formulating your treatment plan.

Am I making my chronic ankle pain worse by walking around or moving it?

In most cases, no. Low-impact activities – things like walking, swimming, biking, and yoga – are good for your musculoskeletal health and your cardiovascular health. Your doctor will tell you if there are any specific activities they recommend avoiding – which may include high-impact activities like running, jumping, or pounding on your ankle. However, we often say that “motion is lotion,” and will not make your ankle problem worse.

I have chronic ankle pain and I have not seen a doctor for it. What should I do?

If you have experienced long-term ankle pain with no clear cause, or if you injured your ankle and it is not improving after several weeks, find a doctor at HSS who diagnoses and treats chronic ankle pain.

Posted: 11/15/2023

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