Ankle pain can occur for many reasons. It can range from a sprain, arthritis, instability, impingement, a ligament tear, or an osteochondral lesion. Many treatment options exist including conservative options like bracing, physical therapy, and injections to surgical options which may be required in the worst-case scenarios. The best form of treatment requires a good history, physical examination, and imaging that will allow your doctor to diagnose the reason why ankle pain has occurred. In this article, we will review the reasons why ankle pain can occur.
There are many reasons why ankle pain can occur, some of which are quite surprising.
The anatomy of the ankle joint is extremely complex having multiple ligaments, tendons, muscles, irregularly shaped bones, and accessory bones. To demonstrate how complex this joint is, when a surgeon does an ankle joint arthroscopy procedure (inserting a camera into the joint), 21 specific viewpoints need to be assessed to check every region of the ankle for any problems.
Ankle arthritis is a reason for pain
A reason ankle pain can occur is due to arthritis. Arthritis of the ankle joint impacts many people as they age resulting in limited mobility, increased risk for falls and fractures, deformity, and chronic musculoskeletal pain. The arthritic changes are the result of degenerative changes seen in cartilage that lines the joint. Cartilage normally has a beautiful white, shimmering, shiny, glistening appearance to is and is lubricated to allow for a smooth gliding motion in the joint.
There are different types of arthritis but the most common would be post-traumatic, which means damage to the cartilage because of an injury (like repeated sprains or an ankle fracture). The treatment of ankle arthritis depends on the activity goals of the patient, the amount of damage to the cartilage, and whether there is deformity present in the joint. Some examples of treatment for ankle arthritis would be an ankle brace (which supports the ankle and prevents motion). Arthritic joints only hurt the more they are used or if they are moving, this is why braces typically work well because they decrease motion at the joint.
Cortisone injections can also be helpful but work only by decreasing any inflammation associated with the arthritic changes but will not improve cartilage damage present. If someone’s goal is to maintain their current level of activity, then a brace and injections may be the only treatments needed. However, if someone wants to improve their mobility or decrease pain with activities, then surgery may be necessary. Other advanced treatments for ankle arthritis include platelet-rich plasma injections (PRP), ankle joint distraction with an external fixation device, ankle joint arthroscopy, or a total ankle replacement.
Repeated ankle sprains can cause significant ankle pain and chronic instability
An outer/lateral ankle sprain is the most common ankle injury seen. The outer ligament of the ankle gets overstretched or torn resulting in pain that can be severe. This injury has been documented to have occurred anywhere between 15% and 86% of the time in athletes participating in a variety of sports. This injury typically occurs when someone is playing basketball, volleyball, or football but can also happen while simply walking across an uneven surface like on a sidewalk that contains cracks.
Symptoms include swelling, bruising over the back outside part of the ankle (which can last for weeks), limited motion range, and pain. The treatment for this injury is RICE (rest, ice, compression, elevation) in the acute stage followed by physical therapy to improve motion range and strength of muscles surrounding the ankle. Orthotics can be helpful following a lateral ankle sprain as well but must fit appropriately into the shoe since it will change based on activity levels.
There are very important nerve endings in the ankle ligaments that help work with your nervous system to improve balance. These nerve endings can get damaged with a single or repeated ankle sprain and lead to a cyclical process that worsens itself. Every ankle sprain can make you even more susceptible to more ankle sprains and this is called chronic lateral ankle instability.
This instability can lead to pain, swelling, and even further damage. If someone experiences chronic ankle instability, physical therapy is the best form of treatment to help improve balance and decrease the risk for future ankle sprains but sometimes with higher-grade injuries, repeated sprains, and pain, surgery is usually needed to reconstruct the outer ankle ligaments. Chronic lateral ankle instability is important to treat aggressively because if the supporting ligaments are not secure, the ankle will not be aligned correctly. This can change the way the pressure distribution occurs on the cartilage present in the joint leading to wear-and-tear type arthritis.
Pain that doesn’t go away after an injury or sprain can mean there is an osteochondral lesion defect
An osteochondral lesion of the talus is a focal area of arthritis instead of widespread changes. These lesions typically result from damage to the cartilage that works as a smooth surface for bones to move against each other during motion and load-bearing. An osteochondral lesion is a common reason for diffuse pain in the ankle that doesn’t completely get better after an injury or sprain. In a worst-case scenario, the defect of cartilage can separate from the bone and float around in the joint. With ankle joint movement, the loose piece of bone can cause further deterioration of the joint until the fragment is removed. Treatment is dictated by the size and location of the injury but typically involves a procedure to clean the damaged cartilage up and to repair it either with the body’s capabilities or replacing the cartilage with a graft.
A tarsal coalition is a reason for ankle pain but the issue isn’t even in the ankle
A rare reason for ankle pain is due to a condition known as a tarsal coalition or bar. Usually, the bones in the back of the foot and ankle have pretty consistent anatomy and are separate and connected through joints or ligaments. A tarsal colation exists when there is an abnormal connection that exists between two bones that should not be connected. A common coalition is between the heel bone and the bone above inside the ankle joint called the talus. This is a talo-calcaneal coalition. Given the proximity to the ankle joint, it can feel like ankle pain even though the issue isn’t in the ankle at all. Treatment for this condition is typically surgery to separate the bones and correct the abnormal connection.
There are many other reasons to cause ankle pain and this is why seeing a specialist is so important.
Given the complexity of the ankle joint and surrounding structures and the plethora of reasons to have. ankle pain, it is really important to see a specialist if your condition does not improve for an accurate diagnosis and to come up with a good course of action.
If you are experiencing chronic ankle pain that hasn’t gotten better with typical treatment, it may be time to see a specialist. The uniqueness of the anatomy in this area means that there is no one-size-fits-all approach for treating your injury or condition. A qualified foot and ankle specialist can provide an accurate diagnosis and create a tailored treatment plan for your individual needs. Don’t wait until the pain has spread into other joints because by then it will become much more difficult to treat! Call our office today at (703) 832-9013 so we can help get you back on track without delay.