by Last updated on March 9th, 2024 at 02:42 pm
If you are reading this, you are either a clinician or somebody with an interest in the cause of ankle pain. There is something here for everyone to take away. The ankle pain differential diagnosis in this article will be divided into four sections. Anterior, medial, lateral and posterior.
Remember that the structures that make up the ankle are close together. For this reason, it’s challenging to differentiate and identify the cause of ankle pain. Nevertheless, accurate diagnosis is essential for appropriate treatment. Read on to find out more!
Anterior ankle pain causes
To aid your ankle pain differential diagnosis, consider the pathologies listed below, which affect the anterior ankle.
Anterolateral impingment
Anterolateral impingement is a common cause of anterior ankle pain. It occurs when there is a painful limitation in the range of motion at the ankle; due to soft tissue thickening or pressure, or bony spurs on the tibia. It’s often due to excessive use or overuse. It can lead to inflammation and swelling in the surrounding tissue, causing pain and discomfort. Lateral impingement is often seen in athletes or individuals who engage in high-impact activities. It can also occur in people with pronated feet or abnormal ankle joint alignment. Dorsiflexion is typically limited.
Arthritis
Arthritis is another cause of anterior ankle pain. This condition occurs when the cartilage cushioning the joint wears down, leading to bone-on-bone contact and inflammation. This can cause pain, stiff ankles in the morning, and swelling in the joint, making it difficult to walk or perform everyday activities. Arthritis is more common in older individuals but can also affect younger people with ankle injuries or genetic predispositions. Gout should not be ruled out, especially if you have sudden ankle pain. Rheumatoid arthritis should be considered if the pain is bilateral (in both ankles).
Osteochondritis dissecans
Osteochondritis dissecans of the talus is a condition that occurs when there is reduced blood flow to the bone talus, leading to the death of bone tissue and cartilage. A small fragment of bone and/or cartilage can separate and reside in the joint. This can cause pain, swelling, stiffness and instability in the ankle and may require surgery to repair.
Tibialis anterior tendonitis
Tibialis anterior tendonitis is another cause of anterior ankle pain. This condition occurs when the anterior tibialis tendon, which runs along the front of the ankle, becomes inflamed or damaged. Tibialis anterior tendonitis is often seen in athletes or individuals who engage in high-impact activities. Still, it can occur in anyone due to overuse. It generally causes pain and discomfort when walking or running and may require rest, physiotherapy, or surgery to treat if it ruptures.
Medial ankle pain causes
The pathologies discussed below should also be considered in ankle pain differential diagnosis.
Tarsal tunnel syndrome
It occurs when the posterior tibial nerve, which runs through the tarsal tunnel, becomes compressed or inflamed. This can cause pain, numbness, and tingling in the medial ankle. Common causes of tarsal tunnel syndrome include trauma to the ankle or injury to adjacent structures leading to inflammation in the tarsal tunnel. Treatment options may consist of rest and medication to manage pain and inflammation. In severe cases, surgery may be necessary to release the pressure on the nerve.
Tibialis posterior tendonitis
Tibialis posterior tendonitis occurs when the posterior tibialis tendon becomes inflamed or damaged from degeneration or trauma. The tendon helps to plantarflex, invert the foot and stabilize the medial arch. Tendonitis of the tendon causes pain and swelling in the medial ankle leading to difficulty walking or standing for long periods. Common causes of tibialis posterior tendonitis include overuse, improper footwear, and flat feet.
Treatment options include rest, posterior tibialis tendonitis exercise (eccentric), and medications to manage pain and inflammation. A rupture sometimes occurs in the hypovascular (poor blood supply) region of the tendon, which can sometimes be missed. The patient will be unable to do a single heel raise; too many toes sign and a flat foot will be present. As such surgery may be necessary to repair or reconstruct the tendon.
Flexor hallucis longus tendonitis
Tendonitis of flexor hallucis longus tendon, which helps to flex the big toe, occurs when the tendon becomes inflamed or damaged. This can cause pain, swelling and weakness in the medial ankle and may lead to difficulty walking or standing for extended periods. Common causes of flexor hallucis longus tendonitis include overuse, improper footwear, and flat feet. It is common among ballet dancers due to excessive plantar flexion. Treatment for this condition may include rest, physiotherapy, and anti-inflammatory medications to manage pain and inflammation. Again, surgery may be necessary to repair or reconstruct the tendon if it is severe.
Posterior ankles pain causes
Pain can also emanate from the back of the ankle, and ankle pain differential diagnosis should include those conditions. Some are listed below.
Os Trigonum syndrome
The Os trigonum is a small non-united bone located behind the talus in the ankle joint that can cause posterolateral ankle pain. As such, the pain from this condition is more pronounced during ankle plantar flexion (the nutcracker phenomenon). Interestingly, many individuals are born with this bone but are unaware they have it until it becomes pathological due to overuse or trauma. The bone becomes wedged between the tibia, talus, calcaneus and soft tissue, causing inflammation and pain. Although conservative treatments such as rest, ice, and anti-inflammatory medications are helpful for Os Trigonum syndrome, surgery may often be necessary to remove the bone if it is causing persistent pain or other problems.
Achilles tendonitis
This is another common cause of posterior ankle pain. This condition occurs when the large tendon that runs from the calf muscles to the heel becomes inflamed or strained, causing pain, swelling and stiffness in the tendon. It occurs mainly from overuse. Treatment for Achilles tendonitis includes rest, a heel raise device and eccentric exercises. The Alfredson Protocol has been proven to be effective in rehabilitating the tendon.
Surgery is rarely needed, if at all. Corticosteroid injection should be avoided as it can rupture the tendon. If the tendon is ruptured, early functional rehabilitation or surgery can help. However, surgery carries the risk of infection as well as skin and wound complications. Note that re-rupture is not uncommon with conservative treatment.
Retrocalcaneal bursitis
The retrocalcaneal bursa is a small fluid-filled sac located between the heel bone and the Achilles tendon which sometimes becomes inflamed causing a bursitis. This condition is often caused by repetitive strain or trauma to the area, such as running or other physical activities. Treatment for retrocalcaneal bursitis includes rest, ice, anti-inflammatory medications, appropriate footwear and, in some cases, injection. Caution must be exercised with corticosteroid injection since the injection site is close to the Achilles tendon.
Haglund’s deformity
This a bony protrusion on the back of the heel bone, which can sometimes be misdiagnosed as insertional Achilles tendonitis. The condition is often caused by wearing shoes with a rigid or hardback. Hence, the reason it is also called “pump bump“. Additionally, participating in activities that put a lot of strain on the heels, such as running or dancing, can contribute to it. Treatment for Haglund’s deformity involves wearing backless or softback shoes, rest, ice, stretching exercises, heel pad and raises and orthotic where required. Surgery is only needed where conservative treatment fails.
Lateral ankle pain causes
No ankle pain differential diagnosis can be complete without considering lateral ankle pain pathologies. The conditions listed below may help in with your diagnosis.
Ankle sprains
This is a common cause of lateral ankle pain. The most common is a low ankle sprain. This occurs when the ligaments that support the ankle are stretched or torn. For example, when the ankle is twisted or turned in an awkward direction. Such as what happens when stepping on uneven surfaces or participating in sports. A high ankle sprain involves the tibia and fibula. Often the syndesmotic ligament, which holds the two bones together, is torn, leading to pain and swelling. This is a serious injury, and treatment should be had right away to help reduce the ankle sprain healing time.
Symptoms of an ankle sprain include pain, swelling, bruising, and difficulty walking or bearing weight on the affected limb due to instability. The treatment may include rest, ice, compression, ankle elevation, and physiotherapy to strengthen the ligaments and increase proprioception around the ankle.
Fractured ankle
A fractured ankle is another cause of lateral ankle pain. This occurs when one or more of the bones in the ankle are broken. The distal portions of the fibula and medial tibia are most affected. Fractured ankles can result from a traumatic injury, such as a fall or car accident, or from overuse or repetitive stress on the ankle. Symptoms include severe pain, a swollen ankle, difficulty walking or bearing weight on the affected leg and ankle instability. Treatment for a fractured ankle may consist of immobilization with a total contact cast or splint and physiotherapy to strengthen and restore range of motion at the joint.
Peroneal tendon subluxation
It occurs when the peroneal tendons, which run along the outside and under the lateral malleolus of the ankle, become partially dislocated. This can occur due to an ankle sprain, overuse, poor foot alignment or other injuries that cause the superior retinaculum to rupture. Symptoms of peroneal tendon subluxation include ankle instability, pain, swelling, and difficulty walking or standing on the affected leg. Helpful treatment consists of rest, ice, and physiotherapy to help increase the range of motion and joint proprioception. Orthotics may be prescribed to address any foot abnormalities.
Peroneus longus tendon rupture
This is a tear in the peroneus longus tendon, which runs along the outside of the ankle inferior to the medial malleolus. The tendon helps with foot eversion. This injury can be caused by sudden force, such as a fall, overuse or repetitive stress on the tendon. Symptoms of a peroneus longus tendon rupture include ankle instability, swelling, difficulty walking or standing and yes peroneus longus pain. Conservative treatment is not uniform or successful in many cases, so surgery may be the “port of call” to address the problem.
Peroneal tendonitis
Peroneal tendonitis is an inflammation of the peroneal tendons, which causes lateral ankle pain. This condition is often the result of overuse or repetitive stress on the tendons from sports or activities that involve a lot of running or jumping. Symptoms of peroneal tendonitis include pain, swelling, and tenderness along the inferior outer part of the ankle. Treatment will consist of rest, ice and eccentric exercises to rehabilitate and strengthen the tendon.
Anterior process of the calcaneus fracture
An anterior process of the calcaneus fracture is a break in the front part of the calcaneus or heel bone. This injury is caused by excessive inversion of the ankle and subtalar joints from a traumatic impact, such as a fall or car accident. Symptoms of an anterior process of the calcaneus fracture include pain, swelling, and difficulty walking. Often it is accompanied by an ankle sprain due to the mechanism of injury.
Depending on the injury’s severity, it may be treated conservatively by placing the foot in an immobilizing boot for about 4-6 weeks, after which physiotherapy can then begin to address range of motion and strengthening. Surgical fixation may be necessary for those who did not get resolution from conservative treatment and where large fragments or nonunion are present.
Lateral process of the talus fracture
This is a break in the lateral, or outer, part of the talus, a small bone in the ankle. The mechanism of injury involves a dorsiflexion and eversion force against the distal fibula. This injury can be caused by a traumatic impact, a fall or playing sports. Symptoms of a lateral process of the talus fracture can mimic a lateral ankle sprain, including pain, swelling, and difficulty bearing weight on the affected foot.
Conservative treatment includes rest, icing and medications to relieve pain. Depending on the severity, the foot may be placed in an immobilizing boot. If the displacement is large, your surgeon may do a surgical fixation. Physiotherapy will be necessary to increase the range of motion, strength, and proprioception going forward.
Conclusion
These are just some of the conditions that can be used to help with ankle pain differential diagnosis. That said, they should be a guide or a starting point as each individual is unique, and diagnosis should be approached with this in mind. You should consult your healthcare provider for an accurate diagnosis if you suffer from ankle pain. Remember, your health is your wealth, so always seek help for your ankle pain!
FAQs and Answers
1. How is ankle pain diagnosed?
Ankle pain is usually diagnosed through a physical examination, imaging tests (such as X-rays or MRI), and a review of the patient’s medical history.
2. How is ankle pain treated?
That depends on the condition. But in general, treatment for ankle pain may include rest, ice, compression, elevation, physiotherapy, medications, and/or surgery, depending on the severity and cause of the pain.
3. Can ankle pain be prevented?
In many instances, yes. Ankle pain can often be prevented by wearing proper footwear, warming up properly before physical activities, and avoiding or being cautious when doing activities that stress the ankles.
4. What are some warning signs that ankle pain may be more serious?
Severe pain, swelling, difficulty walking or bearing weight, numbness or tingling, deformity and pain, especially at night. If these symptoms are present, it is vital to seek medical attention immediately.
5. Can ankle pain be caused by other health conditions?
Yes, ankle pain can sometimes be caused by underlying health conditions such as nerve damage and seronegative rheumatoid arthritis.
6. Is it always necessary to see a doctor for ankle pain?
Yes! If the ankle pain is severe, persistent, or accompanied by other symptoms. If the pain is mild and goes away quickly, it may not be necessary to see a doctor.
