Ankle Pain Evaluation and Management
Initial evaluation and treatment of ankle pain should include plain radiographs as the first imaging study, followed by the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) and topical NSAIDs as first-line treatment. 1
Initial Evaluation
History and Physical Examination
- Determine mechanism of injury (traumatic vs. non-traumatic)
- Assess pain location (anterior, posterior, lateral, or medial ankle)
- Evaluate for swelling, tenderness, and ability to bear weight
- Check for specific tenderness points:
- Lateral ligament complex (most commonly injured)
- Achilles tendon insertion
- Plantar fascia
- Calcaneus (for possible stress fracture)
Imaging
- Plain radiographs are recommended as initial imaging for unilateral ankle pain 1
- Standard views include:
- Anteroposterior
- Lateral
- Mortise (15-20° internal rotation)
- These can identify fractures, osteoarthritis, osteochondral abnormalities, and ankle effusions
Initial Treatment
PRICE Protocol 1
- Protection: Avoid aggravating activities
- Rest: Relative rest, not complete immobilization
- Ice: Apply for 20 minutes at a time
- Compression: Use elastic bandage
- Elevation: Keep ankle above heart level
Pharmacologic Management
- Topical NSAIDs with or without menthol gel as first-line treatment, applied 3-4 times daily 1
- Oral NSAIDs (like ibuprofen) at lowest effective dose (400mg every 4-6 hours as needed) 2
- Use caution with NSAIDs in patients with:
- Hypertension
- Heart failure
- Renal impairment
- History of GI bleeding 2
Early Mobilization
- Begin gentle range of motion exercises early to prevent stiffness 1
- Avoid prolonged immobilization which can lead to deconditioning
- Consider specialized cushions or orthoses if weight-bearing is painful
Condition-Specific Management
Insertional Achilles Tendonitis
- Open-backed shoes to reduce pressure
- Heel lifts or orthoses
- NSAIDs and activity modification
- Stretching exercises
- Avoid corticosteroid injections 3
- Consider immobilization for acute or refractory cases
Bursitis with Haglund's Deformity
- Open-backed shoes and accommodative padding
- NSAID therapy
- Corticosteroid injections (avoiding the Achilles tendon)
- Physical therapy
- Weight loss if indicated 3
Neurologic Ankle Pain
- If suspected, consider referral for diagnostic testing:
- Electromyography
- Nerve conduction studies
- MRI 3
Traumatic Ankle Pain
- For acute trauma, radiographic studies are essential
- Immobilization for small, non-articular, or minimally displaced fractures
- For stress fractures, protect and immobilize the foot 3
Follow-up and Referral
When to Refer to Specialist
- Pain persisting >3 months despite conservative treatment
- Evidence of significant structural abnormality requiring surgical intervention
- Diagnostic uncertainty requiring advanced imaging or procedures 1
Advanced Imaging Indications
- MRI or CT as second-line imaging based on radiograph findings
- MRI without contrast for suspected osteochondral lesions (missed on 41% of radiographs) 1
Common Pitfalls and Caveats
- Inadequate initial assessment: Always rule out fractures before initiating treatment
- Premature return to activity: Complete a 6-week guided rehabilitation program for moderate to severe sprains
- Overlooking chronic instability: Consider orthosis for at least 6 months following moderate to severe lateral ankle ligament sprains
- Inappropriate corticosteroid use: Avoid injections near the Achilles tendon due to risk of rupture
- Neglecting early mobilization: Prolonged immobilization can lead to stiffness and delayed recovery
Remember that ankle injuries are common but can lead to chronic pain and disability if not properly managed from the outset. Early appropriate intervention can significantly improve outcomes and prevent long-term complications.