Ankle pain

There are two joints that allow the ankle to move. These joints are as follows: 

• Tibiotalar joint: This is the true ankle joint. It allows articulation (joints are also called articular surfaces) between the lower end of the tibia (shin bone) and the body of the talus (main ankle bone, just above the heel). It helps in the dorsiflexion (upward movement of the foot) and plantar flexion of the ankle (pointing the foot away from the body or the downward movement).
• Subtalar joint: It is the articulation (joint) between the two bones, i.e., talus and calcaneus (heel bone). It helps in inversion and eversion of the ankle (inside and outside movement of the foot).

A sprain, torn ligament and pain of gout may all present in slightly different ways.

Ankle sprain or ligament damage

• Damage to the ankle ligaments may result in swelling, inflammation and bruising in the area of the affected joint. 
• Joint movement is painful
• The severity of the ankle sprain can be graded based on the level of damage to the ankle ligament. The grading is as follows: 
  • Grade I: Mild stretching of the ligament without joint instability.
  • Grade II: Partial tear (rupture) of the ligament but without joint instability (or with mild instability).
  • Grade III: A severe sprain or complete rupture of the ligament with instability of the joint.
• The most common ankle ligaments to be injured in an ankle sprain are on the lateral side. These two ligaments are the anterior talofibular ligament and the calcaneofibular ligament.
• High ankle sprains are less common compared with lateral ankle injuries. In this kind of injury, the ligaments above the ankle joint are torn. These ligaments link the bones of the lower leg i.e. the tibia and fibula. High ankle sprains are typically seen in sports like football and hockey. They may occur when the foot is forcefully twisted away from the lower leg. This kind of injury takes much longer to resolve as compared to a lateral ankle injury. 

Ankle fractures

• Ankle fractures result in severe sudden onset pain.
• Someone with an ankle fracture would need to stop whatever they are doing at the time they break the ankle bone, as it becomes impossible to stand, walk, run, jump with an ankle fracture.
• Ankle fractures also result in a lot of swelling due to bleeding. The swelling appears rapidly, usually within the first thirty minutes of the injury. 
• Ankle fractures result in an inability to bear weight. Patients are unable to bear body weight in case of an ankle fracture, except stress fractures where sometimes patients may be able to tolerate bearing weight. 
•  Ankle fractures are usually associated with bone tenderness. 
•  Ankle fractures may result in deformities. In case the ankle looks off, it is highly likely that a displaced fracture has occurred. It is an emergency as the bones may be displaced and trap nerves and blood vessels. Hence, it is important to assess the fracture immediately.

Gout in ankles

• Pain, swelling, redness and heat (the ankles becomes hot to the touch) could occur because of gout
• Gout occurs because of high uric acid levels in the blood. Some with gout is also likely to have pain and swelling in other joints, like the big toe.

Ankle stress fractures

We usually think of dancers and athletes when we think of stress fractures. The truth is, our ankles take a lot of load throughout the day. Anyone who has a job that requires standing and walking for many hours, anyone who jogs or runs in ill-fitting or worn-out shoes, anyone who has recently changed the duration or intensity of their work out, anyone who is overweight or has poor ankle stability and balance is prone to stress fractures—tiny cracks or severe bruises that appear in the bone over a long time. The signs and symptoms of an ankle stress fracture can often be easy to ignore. They include:

• Ankle pain that gets better after resting
• Swelling in the affected area
• Rarely, bruising in the affected area

Ankle bursitis

• Pain, especially while standing on tip toes or while shifting the weight back on the heels
• Pain while flexing the foot (pointing the toes up)
• Swelling
• Limping

Gout, arthritis, rheumatoid arthritis

• Recurring and severe pain, tenderness and swelling in the ankle joint
• Limited range of movement in the ankle joint

From bone insufficiency in conditions such as osteoporosis to a twisted or sprained ankle, there can be many causes of ankle pain. These include:

• Sprained ankle
• Ankle fracture, including avulsion fracture of the ankle. An avulsion fracture is one in which a part of the bone connected to a ligament or tendon breaks off from the main bone
• Stress fractures
• Tarsal tunnel syndrome: Compression of the posterior tibial nerve that runs down the leg, on the inside of the ankle, and down to the foot.
• Gout: Build-up of high uric acid in the blood (read more: What to eat and what not to eat when you have gout)
• Osteoarthritis: A degenerative disease that affects the joints
• Ankle bursitis: Bursitis is swelling of the cushiony fluid-filled sacs called bursa that prevent friction between the bones of a joint. There are at least three bursae near the ankle: the subcutaneous bursa of the medial malleolus, the retrocalcaneal bursa and the subcutaneous calcaneal bursa (in the heel). 
• Osteochondritis dissecans: In osteochondritis dissecans, low blood flow causes the death of some parts of the bone present underneath the cartilage. Though the condition typically affects the knees, it can affect other joints like the hips, elbows and sometimes ankles.
• Psoriatic arthritis: A complication of psoriasis (an autoimmune condition in which the skin cells grow 10 times faster than normal), psoriatic arthritis can affect multiple joints of the body.
• Rheumatoid arthritis: Rheumatoid arthritis is an autoimmune disease that causes inflammation in the joints
• Joint infection, also known as septic arthritis
• Achilles heel problems: The Achilles tendon that connects the back of the leg to the heel runs behind the ankle. A problem with this tendon (fibrous tissue that connects muscle to bone), like Achilles tendonitis or Achilles tendon rupture, may cause ankle pain.
• Plantar fasciitis: Plantar fasciitis typically affects the heel and the soles of the feet, but the patients may also experience ankle pain in this condition.

When a patient presents to the emergency room with severe ankle pain, the doctor takes a detailed history and performs a thorough physical examination to determine the possibility of an ankle fracture. 

Patients may be asked the following questions:

• When did you get hurt?
• How did the injury occur? Usually, injuries that affect the ankle occur when walking on uneven ground or due to sudden change in direction while working out or playing sports. (Read more: Workout injuries)
• If there was a ‘snap’ sound or not.
• Where does it hurt?
• Are you able to bear your weight on your feet, to stand? 
• Did you need help to walk after the injury? 
• In case of sports injuries, were you able to continue playing afterwards? 
• Did you get the swelling immediately (this could suggest bleeding and significant tissue injury)?
• Do you have any previous ankle injuries (this could suggest an underlying weakness)?
• Do you have any relevant medical history; for example, osteoporosis? 
• Do you have a history of any drug intake, like long-term corticosteroids? 

After taking a proper history, a thorough physical examination has to be performed. This includes the following:

• Seeing whether the patient walked into the room and if he or she was in any discomfort. The doctor will also look for any obvious ankle deformity, swelling, bruising or any open wounds.
• Next step is to palpate (feel and gently press) the affected area. The doctor will look for any crepitus (popping or creaking while moving the joint) and tenderness, especially over the area of the affected joint. He/she will also check if applying pressure on the calcaneus (heel) bone elicits any pain. 
• The doctor will also assess the neurovascular status (status of nerves and blood vessels) near the affected area by checking for sensation in the foot and by palpating the pulse over the affected area. In case of any issue with the vascular status over the affected area, the doctor would consider dislocation or fracture of the joint as possibilities. Nerve injuries may also occur in ankle injuries. Sural nerve (running through the calf) is the nerve that can be involved. 
• The doctor would test the range of movement and joint power; however, this may not be possible in case of dislocations and fractures. 
• Thompson’s test: It is an important test to rule out Achilles tendon injuries. The patient should lie prone with the knee flexed at an angle of 90 degrees. The doctor will gently squeeze the calf muscles. If the ankle moves down automatically, it suggests that the Achilles tendon is normal.
• Anterior drawer test: In case the anterior talofibular ligament is injured, the talus (ankle) bone will move in front compared to the normal ankle. To do this test, the ankle is placed in a neutral position, the leg is stabilised and the foot is pulled forward. A positive test is when there is a greater forward movement on the injured side as compared to the normal side. 
• The doctor would also examine the patient’s other (normal) ankle which would help in getting an idea about the normal range of motion and power of the ankle joint.

The doctor may also order some tests, depending on what he/she suspects to be the cause of your pain. The tests may include:

• Blood test and culture to check for joint infection
• MRI to check for ligament or tendon damage
• X-ray to look for broken bones

1. X-ray for ankle pain

The treatment would depend on the cause:

1. How are ankle sprains treated?
2. How are ankle fractures treated?
3. Treatment for other causes of pain in ankle

You should see a doctor if you have any of the following concerns: 

• You feel that a bone may be broken 
• You suspect that a ligament may be ruptured 
• You have bone tenderness 
• The affected area looks deformed and swollen 
• Your foot is numb and cold, with bluish skin 
• You have severe pain
• You can’t put any weight on the affected ankle 
• You have severe bruising in the affected ankle 
• Your symptoms do not settle over time
• Your ankle joint does not perform its functions properly 
• Your joint feels unstable even after the pain settles down