Ankle Pain: Causes and Diagnosis

Ankle pain is a symptom that occurs with ligament and tendon damage, inflammatory and degenerative diseases of articular cartilage, compression syndromes, as well as systemic metabolic and infectious processes. In the acute phase, it most often involves a sprain or rupture of the lateral ligament complex after a twisted ankle. In the chronic phase, the consequences of incomplete restoration of stability, impaired biomechanics, and overload of the tendons and cartilage often predominate. Understanding the source of the pain determines the treatment strategy: from early functional rehabilitation to targeted treatment of the specific cause. [1]

Even with the same provoking movement, the mechanics of injury vary: the lateral ligaments are affected by inversion injuries, the tibiofibular syndesmosis by external rotation and dorsiflexion, and the posterior segment by repeated forceful push-offs with the foot. These details are important for selecting examinations and predicting recovery time. [2]

Some patients complain of a "twisting" sensation when walking, a feeling of instability, and joint locking after several weeks. These are signs of residual instability or impingement syndromes, which persist pain and reduce quality of life. Early diagnosis and accurate risk stratification reduce the likelihood of chronicity. [3]

Finally, ankle pain can be a manifestation not only of local trauma, but also of gout, septic arthritis, nerve compression in the tarsal canal, or osteochondral damage to the talus. Therefore, clinical judgment must combine algorithms for excluding fracture with an assessment of soft tissue and systemic causes. [4]

ICD-10 and ICD-11 codes

For the symptom of "ankle pain," the International Classification of Diseases, Tenth Revision, uses the category M25.57 "Pain in the ankle and foot joints," with specification by side, which is important for statistics and routing. For injuries, codes from block S93 "Dislocation, sprain, and rupture of ligaments at the ankle and foot" are used. [5]

The International Classification of Diseases, Eleventh Revision, provides the ME82 "Joint Pain" group for joint pain syndromes, with the option to specify "ankle or foot." For chronic pain conditions, additional coding is permitted under the chronic pain section MG30, and for complex regional pain syndrome, 8D8A.00, which facilitates multimodal treatment planning and reflects severity. [6]

Table 1. Frequently used codes

Situation	ICD-10	ICD-11	Comment
Pain in the ankle and foot joints	M25.57 with side clarification	ME82 with the area "ankle or foot" indicated	Symptom rubric
Collateral ligament sprain	S93.4	ND14.70-ND14.73	Traumatic injury
Subacute and chronic pain without structural diagnosis	M25.57	MG30.0 in primary chronic pain	Accounting for chronic pain
Suspected complex regional pain syndrome	-	8D8A.00	Additional severity coding

Epidemiology

Acute ankle sprains are one of the most common sports injuries. According to large reviews, the population-wide incidence is approximately 2 to 7 cases per 1,000 person-years, with higher rates in adolescents and young adults. A significant proportion of injuries are recurrent. [7]

In emergency departments in the United States, the incidence of visits for strains has been estimated at 2-3 per 1,000 people per year. In professional and collegiate sports, the incidence is higher, but the numbers vary greatly depending on the type of activity and the recording methodology. [8]

The financial burden on the healthcare system is significant: according to some estimates, the total cost of treating sprains in schoolchildren and in national cohorts amounts to hundreds of millions of euros per year. The economic impact increases with recurrence and the development of chronic instability. [9]

In 20-40% of patients, long-term symptoms with decreased function and recurrent ankle twists develop after the initial injury, which is classified as chronic lateral instability. This condition increases the risk of early ankle osteoarthritis. [10]

Reasons

Most often, pain is caused by damage to the lateral ligament complex during an inversion injury, including the anterior talofibular and calcaneofibular ligaments. External rotation and dorsiflexion damage the tibiofibular syndesmosis, a so-called high strain. Repeated microtears and poorly restored stability alter load distribution, maintaining pain. [11]

Tendon-related causes account for a significant proportion: Achilles tendonitis and Achilles tendonitis, peroneal tendons, and posterior tibial muscle, leading to progressive collapsing foot deformity. Clinical presentation and localization tests vary in each case, and imaging is tailored to the suspected cause. [12]

Osteochondral causes include osteochondral lesions of the talus, anterior and posterior impingement syndromes, and posttraumatic osteoarthritis. These conditions are more often diagnosed in chronic complaints and require targeted imaging and often intervention. [13]

Finally, gout, septic arthritis, posterior tibial nerve compression in the tarsal tunnel, stress fractures, and neurological causes should not be overlooked. While these diagnoses are less common, missing them increases the risk of complications. Management algorithms should include laboratory verification and joint aspiration in cases of fever, significant effusion, and systemic signs. [14]

Risk factors

Risk factors include previous ankle injury, poor proprioception, weakness of the peroneal muscles, high demands on directional changes in sports, inappropriate footwear, and uneven surfaces. These factors increase the likelihood of primary injury and recurrence. [15]

Excess body weight, female gender in older age groups, and sport-specific factors are associated with higher rates of illness. In military and professional cohorts, rates are significantly higher than in the general population, highlighting the role of stress. [16]

Age over 40, prolonged standing, diabetes, hypertension, systemic inflammatory diseases, and previous foot injuries are all factors that contribute to the posterior tibialis muscle's development. [17]

Pathogenesis

Acute ligament injury causes microtears, hemorrhage, and an inflammatory response, followed by proliferation and remodeling. Premature return to load-bearing activity leads to elongation and decreased mechanoreception, which impairs joint position control and contributes to relapse. [18]

Chronic instability alters the kinematics of the talofibular and subtalar joints, increases shear loads, and provokes soft tissue impingement and cartilaginous microdamage. These cumulative changes become the basis for post-traumatic osteoarthritis. [19]

In posterior tibial dysfunction, the primary mechanism is tendon degeneration and weakness of the medial stabilizers, leading to valgus deformity of the posterior segment and collapse of the longitudinal arch. The staging process explains the progression from pain without deformity to fixed changes. [20]

Symptoms

Lateral ligament injuries are characterized by sharp external pain, swelling, and bruising within the first 24 hours, worsening with inversion, and pain along the anterior talofibular ligament. With syndesmotic injury, pain is most noticeable above the ankles, and worsens with external rotation and walking up stairs. [21]

Tendinous causes give local pain along the tendon and pain with specific tests: pain behind the ankle with peroneal pathology, medially and when pushing off - with dysfunction of the posterior tibialis muscle, behind with extreme plantar flexion - with posterior impingement. [22]

Osteochondral lesions manifest as deep pain, a feeling of locking and jamming, worsening with exertion and after rest. Increasing morning stiffness and starting pain are characteristic of osteoarthritis. Systemic causes include fever, redness, and severe effusion. [23]

Classification, forms and stages

In practice, sprains are classified by severity: mild with microdamage to the ligaments and preserved stability, moderate with a partial rupture and moderate instability, and severe with a rupture and significant instability. The duration of immobilization and the amount of early loading depend on the severity. [24]

For posterior tibial muscle dysfunction, the Johnson and Strom system, modified by Myerson, is used: from pain without deformity in the early stages to fixed valgus and arthrosis in the late stages. This classification guides the choice between orthotics, rehabilitation, and reconstructive surgery. [25]

Table 2. Classification of sprains

Degree	Clinic	Stability	Basic tactics
Easy	Pain, slight swelling	Saved	Functional rehabilitation and tape or orthosis
Average	Severe swelling, hematoma	Moderately reduced	Short immobilization, then active rehabilitation
Heavy	Severe pain and instability	Significantly reduced	Immobilization, assessment for rupture and indications for surgery

Table 3. Stages of posterior tibialis muscle dysfunction

Stage	Signs	Approach
I	Pain and swelling without deformity	Orthosis, exercises, load reduction
II	Flexible heel valgus, arch collapse	Orthotics, guided rehabilitation, discussion of reconstruction
III	Fixed deformation	Surgical correction of deformity
IV	Ankle joint involvement	Combined reconstructive interventions

Complications and consequences

Without adequate rehabilitation, chronic instability with repeated twists and falls can develop. This condition is associated with premature cartilage wear and impingement, requiring complex treatment. [26]

Post-traumatic osteoarthritis leads to persistent pain, decreased walking distance, and activity limitation. In later stages, surgical correction may be considered. [27]

In some cases, complex regional pain syndrome develops with disproportionately severe pain, changes in skin temperature and color, and allodynia. Timely diagnosis and multimodal management reduce the risk of chronicity. [28]

When to see a doctor

Immediate evaluation is necessary in cases of inability to bear weight on the leg, severe deformity, severe swelling and hematoma, fever, and suspected open injury or infection. In these cases, urgent imaging and aspiration are considered. [29]

In the first hours after a home injury, it's important to follow the Ottawa Ankle Rules: X-rays are indicated for ankle pain combined with posterior ankle tenderness or the inability to walk four steps. This tool reduces unnecessary imaging while ensuring clinically significant fractures are not missed. [30]

If pain persists for more than 6 weeks, a routine examination is required to clarify the diagnosis, evaluate the soft tissues and cartilage, and adjust the rehabilitation plan. [31]

Diagnostics

The first step is a detailed examination and survey: mechanism of injury, pain location, feeling of instability, functional limitations, and associated conditions. Palpation focuses on ligaments and tendons, and stability and compression tests for the syndesmosis are performed. [32]

The second step is the decision on radiography according to the Ottawa Rules. If the criteria are negative, images are not required; if the criteria are positive, standard projections are performed to rule out fractures and significant bone pathology. The sensitivity of these methods, according to meta-analyses, is close to 97-100%. [33]

Third, if chronic pain persists for more than 6 weeks, radiography remains the initial diagnostic method. If osteochondral lesions, instability, or impingement are suspected, magnetic resonance imaging (MRI) without contrast is advisable. If tendinopathy is suspected, ultrasound and MRI are informative. Targeted injections under imaging guidance are used to pinpoint the source of pain in osteoarthritis. [34]

Step four: If signs of infection or inflammation are detected, blood tests and a joint puncture with microscopic examination of crystals and culture are indicated. This is necessary to rule out septic arthritis and gout, which require a different approach. [35]

Table 4. When and what to prescribe

Clinical task	Preferred method	Alternatives
Exclude a fracture within the first 24 hours	Ottawa Rules Radiography	-
Pain persisting for more than 6 weeks without a clear cause	X-ray	Magnetic resonance imaging if soft tissue causes are suspected
Suspected tendinopathy	Ultrasound or magnetic resonance imaging	-
Suspected osteochondral lesion	Magnetic resonance imaging or computed tomography	-
Severe effusion, fever	Joint puncture, tests	-

Table 5. Ottawa Rules: A Quick Reminder

X-ray conditions for ankle pain	Performed if at least one sign is present
Pain along the posterior edge of the lateral malleolus or at the tip	Yes
Pain along the posterior edge of the medial malleolus or at the apex	Yes
Inability to take 4 steps immediately after injury and upon examination	Yes

Differential diagnosis

Table 6. What distinguishes one from the other

State	Key Features	Confirmation
Lateral stretching	Pain and swelling laterally, positive inversion tests	Clinic, magnetic resonance imaging if necessary
Syndesmotic injury	Pain above the ankles, pain with rotational tests	X-ray, magnetic resonance imaging
Tibialis posterior dysfunction	Medial pain, arch collapse	Ultrasound or magnetic resonance imaging
Impingement	Pain with extreme movements, feeling of being stuck	Magnetic resonance imaging or computed tomography
Osteochondral lesion	Deep pain, blockages	Magnetic resonance imaging, arthroscopy as indicated
Gout, infection	Inflammatory signs, fever	Joint puncture, tests

Treatment

The first principle for an acute sprain is protection and early, targeted loading with training in a pain-free range of motion. Brief immobilization for moderate cases, a supportive brace, cold therapy for the first two days, and return to activity based on symptoms accelerate recovery and reduce the risk of recurrence. [36]

Pain relief relies on simple analgesics. Systematic reviews show that nonsteroidal anti-inflammatory drugs (NSAIDs) do not provide a clinically significant pain benefit compared to paracetamol in early pregnancy, and the risk of gastrointestinal adverse events is higher. It is reasonable to use the minimum effective dose for a short course or to prefer topical forms. [37]

Bracing and taping reduce pain in the first few weeks and reduce the risk of recurrence upon returning to sports. During the return to activity phase, a semi-rigid brace is preferred, and then functional taping can be used for training. [38]

Rehabilitation is essential: range-of-motion exercises, peroneal strength, balance and proprioception, and jumping-speed training for return to sport. Manual techniques and joint mobilization, as indicated, improve pain and function, especially in the subacute phase. [39]

For posterior tibial dysfunction, the foundation is orthotics with medial arch support and a program to strengthen the inverted arches, flexor extensors, and gait correction training. As the condition progresses, reconstructive surgeries are discussed based on the stage. [40]

Achillodynia and posterior impingement require load modification, eccentric triceps surae exercises, and adjustments to running and jumping techniques. Physiotherapy methods are used based on individual indications, and in cases of persistent impingement, arthroscopic correction is considered. [41]

For osteochondral lesions of the talus, the choice of strategy depends on the size and stability of the fragment: from unloading and injections under image guidance to arthroscopic repair or transplantation. The decision is made after magnetic resonance imaging and a discussion of the patient's goals. [42]

Chronic lateral instability unresponsive to conservative management is an indication for anatomical reconstruction using the Bröström procedure, with augmentation as indicated. Current protocols demonstrate high rates of return to sport and reduced recurrence. [43]

For severe osteoarthritis that is resistant to non-surgical treatments, arthrodesis or total ankle arthroplasty are used. Both approaches improve function when appropriately selected, and modern joint replacement demonstrates comparable satisfaction rates and different risk profiles compared to arthrodesis. The choice is individualized and takes into account deformity, activity, and comorbidities. [44]

Table 7. Treatment methods and level of support

Method	Where appropriate	Comment
Early functional loading	Acute sprains	Reduces recovery time
Support orthosis	Acute and chronic conditions	Reduces pain and relapses
Strength and balance exercises	To all with instability	The Key to Relapse Prevention
Arch orthosis	Tibialis posterior dysfunction	Stabilization and unloading
Visualization-guided injections	Focal pain in osteoarthritis or impingement	Diagnostics and therapy
Arthroscopy	Impingement, osteochondral lesions	Minimally invasive treatment of the causes
Ligament reconstruction	Chronic instability	Return to sport, reduction of relapses
Arthrodesis or endoprosthetics	Final stages of arthrosis	Improving function with proper selection

Prevention

After the initial injury, a relapse prevention program includes regular balance and proprioception exercises, strengthening of the peroneal muscles, and a gradual increase in jumping load. This reduces the risk of recurrent injuries and accelerates the restoration of confidence in support. [45]

In sports, it is reasonable to use semi-rigid orthoses or functional taping during the return to training and competition, especially in contact sports and those with frequent changes of direction. Monitoring landing technique and footwork is essential. [46]

Forecast

For mild to moderate sprains, most patients return to normal activity within a few weeks, provided they follow the recommended exercise and rehabilitation guidelines. Failure to do so increases the risk of recurrence and delays recovery. [47]

Some patients develop chronic instability and post-traumatic osteoarthritis, especially with repeated injuries and premature return to sports. Early correction of risk factors improves long-term outcomes. [48]

FAQ

Can a sprain be treated with rest and ice alone?
Rest is helpful in the first few days, but early, pain-free weight-bearing and exercise speeds recovery and reduces the risk of recurrence, so rehabilitation is essential. [49]

Does everyone need anti-inflammatory tablets?
Not always. According to reviews, the benefits over paracetamol are minimal, and the risk of gastrointestinal reactions is higher. Topical forms and non-drug measures are often sufficient. [50]

When should imaging be performed?
If a fracture is suspected, follow the Ottawa Rules. In cases of chronic pain, radiography is performed first, and then the method is chosen based on the clinical need. [51]

How long should the orthosis be worn?
Typically, 1 to 3 weeks for moderate cases, followed by active rehabilitation and gradual weaning while maintaining the prophylactic sports tape. The timeframe varies from person to person. [52]

When is surgery necessary?
In cases of chronic instability, severe osteochondral damage, persistent impingement, and end-stage osteoarthritis. The decision is made after a full examination and a conservative program. [53]

Table 8. Brief algorithm of patient actions

Step	Action	For what
1	Rest and protection during the first day, cold for a short time	Reduction of pain and swelling
2	Early painless mobilization and orthosis	Improving function and preventing relapse
3	Ottawa Rules Assessment	Decision on radiography
4	Graded rehabilitation of strength, balance, and skills	Return to sports and work
5	If pain lasts longer than 6 weeks, further examination is required.	Search for soft tissue and cartilaginous causes