What are the treatment options for gradually increasing ankle pain?

Treatment of Gradually Increasing Ankle Pain

For gradually increasing ankle pain persisting beyond 6 weeks, initiate conservative treatment with NSAIDs, functional ankle support (semirigid or lace-up brace), and graded proprioceptive exercises, while obtaining plain radiographs as the first imaging study to identify underlying structural pathology. 1

Initial Diagnostic Approach

Imaging Strategy

• Obtain plain radiographs first with anteroposterior, lateral, and mortise views (mortise obtained by internally rotating the foot 15-20 degrees) to evaluate for osteoarthritis, osteochondral lesions, stress fractures, ossified bodies, or prior trauma 1
• If radiographs are negative but pain persists >1 week, advance to MRI without contrast as it globally evaluates all anatomic structures including ligaments, tendons, cartilage, and bone marrow edema patterns 1
• MRI demonstrates high accuracy for ligament tears, tendon abnormalities, osteochondral lesions, synovitis, and impingement syndromes 1, 2

Key Clinical Distinctions

• Lateral heel pain with history of inversion trauma suggests calcaneofibular ligament sprain or lateral process talus fracture 3
• Posterior heel pain indicates Achilles tendinopathy or retrocalcaneal bursitis, particularly with prominent posterior superior calcaneus (Haglund's deformity) 3, 4
• Calcaneal squeeze test (medial-to-lateral compression causing pain) suggests stress fracture, which may not be radiographically visible initially 3
• Reexamine at 3-5 days post-injury as excessive swelling within 48 hours limits accurate assessment of ligament rupture 1, 3

Conservative Treatment Algorithm

First-Line Interventions

• NSAIDs reduce swelling and pain while decreasing time to return to activities (Level B evidence) 1
• Semirigid or lace-up ankle supports provide functional treatment and are superior to prolonged immobilization 1, 5
• Cryotherapy for 3-7 days reduces pain and improves recovery time 5
• Early mobilization speeds healing more effectively than prolonged rest 5

Rehabilitation Protocol

• Graded exercise regimens with proprioceptive elements (ankle disk training) reduce risk of recurrent sprains (Level B evidence) 1
• For patients with previous ankle sprains—the greatest risk factor for reinjury—implement neuromuscular training programs and sport-specific warm-up exercises 5
• Eccentric strengthening exercises are primary treatment for midportion Achilles tendinopathy (pain 2-6 cm proximal to heel insertion) 4

Diagnosis-Specific Modifications

• Plantar fasciitis: Add plantar fascia stretching and foot orthotics; consider extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma if first-line fails 4
• Insertional Achilles tendinopathy: Use open-backed shoes, heel lifts, decreased activity, and stretching; avoid corticosteroid injections near the Achilles tendon due to rupture risk 3
• Haglund's deformity with bursitis: Open-backed shoes, accommodative padding, NSAIDs, and corticosteroid injections (avoiding the tendon) 3

When Conservative Treatment Fails

Referral Indications

• No improvement after 6-8 weeks of appropriate conservative treatment 3
• Persistent pain >6 weeks after sprain may indicate inadequate rehabilitation, impingement syndrome, occult osteochondral lesions, peroneal tendon injury, syndesmosis injury, or lateral instability 6
• Approximately 30% of Morton neuroma patients and 44% of plantar fasciitis patients at 15 years do not respond to conservative treatment and may require surgical intervention 4

Advanced Imaging for Persistent Symptoms

• MRI without contrast identifies soft tissue impingement, synovial hyperplasia, abnormal tissue interposition, ligament tears, and bone marrow edema not visible on radiographs 2
• CT without contrast is equivalent alternative to MRI for occult fractures, particularly talar fractures and posterior malleolar fractures that are radiographically occult 1
• Technetium bone scanning for suspected stress fractures with negative radiographs, as symptoms precede radiographic findings 3

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon due to rupture risk 3
• Do not rely solely on initial examination within 48 hours of injury—swelling and pain limit accuracy; always reexamine at 3-5 days 1, 3
• Stress fractures are frequently missed because radiographs are initially negative; maintain high suspicion with history of increased walking activity and positive calcaneal squeeze test 3
• Inadequate rehabilitation is a common cause of persistent pain after ankle sprains; supervised rehabilitation and home exercises are essential 6
• High ankle (syndesmotic) sprains caused by dorsiflexion-eversion with internal tibial rotation are increasingly recognized and require different management than lateral sprains 5