What causes ankle pain?

Causes of Ankle Pain

Ankle pain results from osseous or soft-tissue abnormalities affecting the joint structures, with the most common etiologies being osteoarthritis, osteochondral injury, tendon abnormalities, ligament injuries with instability, and impingement syndromes. 1

Primary Osseous Causes

Bony pathology represents a major category of ankle pain and includes:

• Osteoarthritis with joint space narrowing and osteophyte formation, identifiable on plain radiographs 1
• Osteochondral lesions involving the talar dome or other articular surfaces, which may be occult on initial imaging 1, 2
• Stress fractures of the calcaneus, presenting with progressively worsening pain following increased activity and positive calcaneal squeeze test (medial-to-lateral compression) 3
• Acute fractures including lateral process of the talus ("snowboarder's fracture") following inversion trauma, or calcaneal fractures from falls onto the heel 3
• Anterior bony impingement from osteophytes or spurs causing pain with dorsiflexion, particularly in athletes with recurrent hyperdorsiflexion 4
• Posterior bony impingement from os trigonum or hypertrophic posterior talar process causing hindfoot pain with forced plantarflexion, common in ballet dancers and downhill runners 4

Soft-Tissue Pathology

Ligamentous injuries are extremely common, particularly:

• Lateral ankle ligament sprains (calcaneofibular ligament) causing lateral heel pain, especially with inversion trauma and pain on dorsiflexion 3
• Chronic ligamentous instability from inadequate rehabilitation of prior sprains, leading to persistent pain beyond 6 weeks 2
• Syndesmosis injuries (tibiofibular ligament) requiring specific evaluation and potentially surgical intervention depending on severity 5

Tendon abnormalities include:

• Achilles tendinopathy (insertional or non-insertional) producing pain at the tendon insertion site or mid-substance 3, 6
• Peroneal tendon injury or dislocation causing lateral ankle pain 2, 5
• Tibialis posterior tendinitis presenting with medial ankle and hindfoot pain 6
• Flexor hallucis longus tendinopathy often associated with posterior impingement 4

Bursal inflammation:

• Retrocalcaneal bursitis with or without Haglund's deformity (prominent posterior superior calcaneus) causing posterior and lateral heel pain 3, 6

Soft-tissue impingement syndromes:

• Anterior soft-tissue impingement from synovial proliferation or ligamentous scarring and hypertrophy, causing anterior ankle pain without visible osteophytes on radiographs 1, 7
• Posterior soft-tissue impingement from scar tissue formation 4

Neurologic Causes

Nerve compression or radiculopathy must be considered when pain has atypical features:

• Lumbar radiculopathy (L5-S1 nerve root compression) can cause pain radiating from the heel proximally through the posterior leg, presenting with burning, tingling, or numbness 8
• Peripheral nerve entrapment causing neurologic heel pain requires immediate subspecialist referral for electromyography, nerve conduction studies, and MRI 8, 3

Inflammatory and Systemic Causes

Arthritides should be suspected when:

• Bilateral symptoms are present 3
• Pain involves multiple joints 3
• Patient has known inflammatory arthritis conditions 3

Rare but important causes requiring appropriate referral include:

• Infections (soft tissue or osteomyelitis) 3
• Tumors (malignant or benign) 3
• Vascular compromise 3

Pediatric-Specific Causes

• Sever disease (calcaneal apophysitis) is the most common cause of heel pain in adolescents and children 3
• Distal fibular epiphyseal fractures in young athletes 5
• Tarsal coalition causing persistent foot and ankle pain 5

Post-Traumatic Chronic Pain

Inadequate healing or rehabilitation of acute injuries leads to chronic pain syndromes:

• Pain persisting beyond 6 weeks after ankle sprain may indicate inadequate rehabilitation, occult osteochondral lesions, peroneal tendon injury, or lateral instability 2
• Synovial proliferation and ligamentous scarring from prior trauma causing mechanical impingement 7

Common Pitfalls

Do not assume isolated plantar fasciitis when pain radiates proximally beyond the heel—this pattern demands neurologic evaluation 8. Never diagnose based on imaging alone—combine symptoms, clinical signs, and imaging findings 8. Consider systemic causes when symptoms are bilateral, involve other joints, or are unexplained by mechanical causes 8, 3.