07. Approach to Ankle Pain

Resident Editor: Juliana Macri, MD

Faculty Editor: Paul Nadler, MD


✔ Ottawa Ankle Rule is nearly 100% sensitive for detecting fracture as the cause of ankle pain

✔ Achilles tendon ruptures should be immediately referred torthopedics



  • Traumatic and acute pain:
    • Pain location and characterization (PPQRST).
    • Mechanism of injury: “rolling” over ankle or “giving way” (suggests ankle sprain), audible “snap” or “pop” followed by calf pain (suggests Achilles tendon rupture).
    • Prior injuries, immediate ability tbear weight.
  • Non-traumatic subacute or chronic pain:
    • Pain location and characterization (PPQRST).
    • Fever, morning stiffness, pain after exercise, recent change in activity level, chronic overuse, prior injury, improperly fitting shoes




  • Anterior, medial and lateral inspection: examine for asymmetry, ankle swelling.


  • Always examine unaffected side first, compare with affected side.
  • Palpate area inferior and posterior tmedial malleolus (paresthesias will be reported with tarsal tunnel syndrome; tenderness and swelling with posterior tibial tendonitis).
  • Palpate area posterior tlateral malleolus (tenderness and swelling with peroneal tendonitis).
  • With patient lying prone, palpate insertion of the Achilles tendon (tenderness and swelling suggests tendinitis or calcific tendinosis); perform the Thompson Test (squeeze mid calf tensure there is plantar flexion and intact Achilles of both sides) if suspicion exists for a ruptured Achilles tendon. A palpable nodule or defect along the tendon may indicate a partial tear of the Achilles tendon (if in doubt, compare tunaffected side).

Range of Motion

  • Start with patient in the ZerStarting Position (foot perpendicular ttibia when patient supine, knee extended).
  • Normal active ankle dorsiflexion is 10° t20°; normal plantarflexion 35° t50°.

Special Tests

  • Eversion stress test (integrity of deltoid ligament, avulsion fracture of medial malleolus), inversion/Talar stress test (integrity of calcanofibular ligament).
  • Anterior drawer test (integrity of anterior talofibular ligament).
  • Test for “high” (syndesmotic) ankle sprain (see below)



  • Ottawa Ankle Rule* – Clinical prediction tool that is nearly 100% sensitive for detecting fracture as the cause of ankle pain, but only 30-50% specific. Validated only for patients > 17 years old.


Obtain an ankle x-ray series only if there is pain near the malleoli AND either of the following:

  • Inability tbear weight both immediately after injury and in ED/clinic (for 4 steps)
  • Bony tenderness at the posterior edge or tip of the lateral or medial malleolus


Obtain a foot x-ray series only if there is pain in the midfoot AND either of the following:

  • Inability tbear weight both immediately after injury and in ED/clinic
  • Bony tenderness at the navicular or the base of the fifth metatarsal

*Note: Rule may not be reliable in cases where patient assessment is difficult, as in intoxication, head injury, multiple painful injuries or diminished sensation due tneurological deficits. A liberal use of x-rays may be warranted tassess severity of extremity injuries in elderly patients, as they are more likely tfracture with relatively minor trauma.


Common Ankle Problems


Ankle sprain

  • Most common injury
  • Mechanism is typically inversion injury often with plantar flexion (while playing sports, walking, or stepping off curb) which causes injury tthe lateral ligamentous complex (calcaneofibular, anterior talofibular and posterior talofibular ligaments)
  • Symptoms of lateral ankle pain. In more severe sprains that cause ligamentous laxity, patients will alsreport a persistent sensation of the ankle "giving way."
  • Exam: With lateral ankle sprains, there is increased pain with forced ankle inversion, while medial ligament injuries cause pain with ankle eversion. Palpate for bony tenderness and follow the Ottawa Ankle Rule for ordering x-rays (above). Use the following maneuvers tdetermine ankle stability (laxity or tear of ligament):





Anterior drawer test: assess anterior talofibular ligament via excessive anterior displacement of calcaneus versus tibia.

Foot in neutral position. Examiner grasps the tibia with one hand and the heel is cupped with her other hand. An anterior force is applied tthe foot while a posterior force is applied tthe tibia.

Ligamentous laxity is defined as > 3mm anterior displacement.

Inversion/Talar tilt test: assess calcaneofibular ligament via excessive ankle inversion

Place ankle in ZerStarting Position and gently apply inversion force taffected ankle.

Note degree of inversion and compare with other side tdetermine severity of laxity.


Grades of Ankle Sprain

Grade 1

Mild stretching of ligament with fibers still intact. Exam shows localized tenderness, minimal swelling and normal range of motion (ROM).

Grade 2

More severe; partial disruption of ligamentous fibers, with moderate tsevere pain, swelling or ecchymosis and restricted ROM. Weight bearing is painful.

Grade 3

Complete disruption of ligament. Patient has severe pain, edema, loss of motion, and inability tbear weight.


  • Treatment:
  • Rest, ice (10 min on, 10 min off), elevation, and NSAIDs help limit pain and inflammation
  • Compression dressing will help control swelling and provide joint stability. Either an air stirrup brace combined with an elastic compression wrap, or a lace-up support alone is preferable tan elastic compression wrap alone.
  • Early mobilization and focused range-of-motion exercises (“trace the alphabet with foot”) as pain allows improves outcomes. Consider prescribing a cane or crutches for comfort
    • Recovery takes 2-6 weeks for most, but residual symptoms for months is common. Rehabilitation (with balance training, plyometrics and strengthening) and bracing>taping will prevent future injuries in high risk patients (e.g. athletes, unstable joints)
    • Surgery is reserved for chronically unstable joints



High (syndesmotic) ankle sprain

· Injury tthe tibiofibular syndesmosis ligaments

· Mechanism of injury involves dorsiflexion and eversion of the ankle with internal rotation of the tibia.

· Special tests are required tdiagnose a syndesmosis sprain.

“Squeeze Test”: compress the fibula and tibia at the midcalf. Positive if pain is elicited distally over the tibia and fibular syndesmosis

“Crossed-leg test”: pain just above the ankle when affected leg crossed over proximal unaffected leg

· Treatment: similar tabove, but anticipate prolonged recovery (4-5 months)



Posterior tibial tendonopathy

  • Typically chronic overuse injury, though may have remote trauma. Without proper treatment, can progress ttendon disruption and flatfoot deformity
  • Symptoms: Pain and swelling posterior tmedial malleolus. Worse with weight bearing, inversion, and plantar flexion against resistance, painful flat foot
  • Exam: “Tomany toes” sign (“additional” toes seen on lateral aspect of involved foot when viewed from behind), excessive pronation, pain and weakness with single-leg toe raise. Complete tendon rupture has occurred if there is sag of the naviculocuneiform joint (asymmetric “flat foot”) or inability tperform single-leg toe raise.
  • Treatment: Relative rest, immobilization for 2-3 weeks, NSAIDs only for acute injury (otherwise Tylenol), and molded arch supports or UCBL hindfoot brace
    • Referral tspecialist, if complete tendon disruption or failure of conservative management.


Peroneal Tendinopathy

  • Spectrum of injury, from tendinitis and tendinosis (common) tsubluxation and complete tear (rare, requires referral)
  • Symptoms: Pain and swelling posterior tlateral malleolus, sometimes extending tbase of 5th metatarsal. Often chronic and associated with subjective instability, and can be misdiagnosed as ankle sprain. Consider Os perineum syndrome (pain along plantar lateral foot), sinus tarsi syndrome, RA, or seronegative arthropathy.
  • Exam: Peroneal tunnel compression test (pain with active dorsiflexion, eversion against resistance).
  • Treatment: lateral heel wedges, ankle taping, PT with ROM exercises, eversion strengthening
    • Referral tspecialist, if complet tendon disruption or failure of conservative management.




Achilles tendonosis/tendonitis

  • May result from disuse or overuse, inappropriate footwear. Risk increased by poor hamstring and gastrocnemius-soleus flexibility, overpronation, calcific tendinitis, seronegative spondyloarthropathies, and fluoroquinolone use.
  • Symptoms: Pain 3-5 cm superior tinsertion on calcaneus that increases with dorsiflexion. Differential includes retrocalcaneal bursitis. Haglund deformity, and Achilles tendon rupture (see below)
  • Treatment: Rest, ice, gentle calf stretching, NSAIDs, shoe correction. Early focus on eccentric strengthening exercises. Avoid interval training, impact activities, and exercise on hills. Dnot recommend steroid injections. Consider extracorporeal shock wave therapy if recalcitrant. When inflammation resolves, use heel inserts tcushion impact and prevent re-injury.


Achilles tendon rupture

  • Most commonly seen in periodic athletes (“weekend warriors”) exercising on uneven surfaces with poor footwear. Risk increased by fluoroquinolone and steroid use.
  • Symptoms: Audible “snap” or “pop,” during dorsiflexion or forced plantar flexion (e.g. jumping), followed by sudden calf or ankle pain. Often described as though one “tackled or kicked from behind.” Partial Achilles tendon rupture generally has a more gradual symptom onset.
  • Exam:
    • Thompson Test: Patient prone with both feet hanging or kneeling on a chair. Examiner squeezes the mid-calf, which should cause plantarflexion. Positive if nplantarflexion of affected side. Must compare tunaffected side. May be negative in partial rupture

Note: Asking a patient tplantarflex his foot while lying on the exam table lacks sensitivity; long toe flexors can dthe work of the Achilles if a patient is not weight bearing. Inability tstand on toes is more sensitive.

  • A painful nodule can be palpated along the Achilles tendon in many partial ruptures
  • Treatment: Acutely the ankle should be splinted with foot plantar flexed (never 90 degree splint). Provide crutches and refer immediately torthopedics.
    • Surgical repair offers a quicker return tactivity and lower re-rupture rate compared with plaster splinting for 8 weeks (2% vs. 20%).


Plantar fasciitis (See “Approach tfoot pain”)



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