What are the treatment options for severe ankle pain that wakes a patient up at night?

Severe Ankle Pain Waking Patient at Night

Night pain in the ankle is a red flag that demands urgent evaluation for serious pathology including infection, inflammatory arthritis, or neurologic causes—this is not typical of simple ankle sprains and should not be treated as such. 1

Critical Diagnostic Considerations

Night pain is highly atypical for mechanical ankle injuries and should immediately raise suspicion for:

• Septic arthritis: Can present with isolated joint swelling and tenderness even without fever or erythema, and requires urgent evaluation 1
• Inflammatory arthropathies: Gout, pseudogout, or rheumatoid arthritis commonly present with atraumatic joint pain and characteristically worsen at night 1
• Neurologic heel/ankle pain: Nerve irritation or entrapment can cause severe nocturnal pain and requires subspecialist referral for electromyography, nerve conduction studies, and MRI 2
• Tumors or infections: Rare but serious causes that can present with night pain and require proper diagnostic testing and consultation 2

Immediate Management Approach

First-Line Actions

• Obtain detailed history: Specifically assess for trauma mechanism, systemic symptoms, fever, rapid progression, or inability to bear weight 1
• Rule out fracture if any trauma history: Apply Ottawa Ankle Rules to determine need for radiography 2
• Urgent medical evaluation indicated if: Inability to bear weight develops, systemic symptoms emerge, rapid progression of swelling occurs, or erythema suggesting infection appears 1

Symptomatic Relief Pending Diagnosis

• NSAIDs may be used cautiously for pain and swelling control while awaiting evaluation, though they may suppress natural healing and should not delay definitive diagnosis 2, 1
• Elevation can help reduce swelling 1
• Avoid standard RICE protocols without establishing traumatic mechanism, as this may delay diagnosis of serious conditions like infection, inflammatory arthritis, or venous thrombosis 1

Specific Conditions to Consider

If Heel Pain Component Present

• Plantar fasciitis: Typically presents with morning pain but can cause night pain; 44% of patients continue to have pain 15 years after diagnosis 3
• Insertional Achilles tendinitis: Chronic posterior heel pain with swelling, though usually relieved when walking barefoot 2
• Neurologic causes: Require subspecialist referral for diagnostic testing including EMG and nerve conduction studies 2

If Anterior Ankle Pain

• Anterior impingement syndrome: Characterized by pain on dorsiflexion, though plain radiographs often negative; may require arthroscopic treatment 4

Treatment Algorithm Based on Findings

If infection suspected → Immediate referral for joint aspiration and culture 1

If inflammatory arthritis suspected → Urgent rheumatology referral and laboratory evaluation 1

If neurologic pain confirmed → Subspecialist referral for EMG, nerve conduction velocity studies, and MRI; podiatric foot and ankle surgeon may manage local conditions while lumbar pathology requires appropriate referral 2

If chronic ankle instability after previous sprain → Supervised exercise-based rehabilitation program focusing on proprioception, strength, and coordination; surgery reserved only for cases not responding to comprehensive exercise treatment 2

Critical Pitfall to Avoid

Do not assume this is a simple ankle sprain and apply standard sprain protocols. Night pain that wakes the patient is not characteristic of typical ligamentous injury and demands investigation for serious underlying pathology before initiating symptomatic treatment 1. Delayed diagnosis of septic arthritis, inflammatory arthritis, or neurologic pathology can lead to permanent disability and poor outcomes.