Can cervical stenosis at C4, C5, C6, and C7 cause pain in the ankle?

Cervical Stenosis at C4-C7 Does Not Typically Cause Isolated Ankle Pain

Cervical stenosis at C4-C7 is extremely unlikely to cause isolated ankle pain, as these cervical levels do not directly innervate the ankle region. However, severe cervical myelopathy from multilevel stenosis can produce lower extremity symptoms including leg weakness, gait disturbances, and neurogenic claudication—but isolated ankle pain without upper extremity findings would be highly atypical and should prompt evaluation for alternative diagnoses 1, 2.

Neuroanatomical Considerations

The cervical nerve roots at C4-C7 primarily innervate the upper extremities, not the ankle:

• C4-C7 nerve roots supply the shoulders, arms, and hands, with typical radiculopathy presenting as radiating pain, numbness, or tingling in the arms 1
• The ankle is innervated by nerve roots from L4-S1, which originate from the lumbar and sacral spine—anatomically distant from the cervical levels in question 3
• Isolated ankle pain without any upper extremity symptoms would be inconsistent with C4-C7 pathology 3

When Cervical Stenosis Affects the Lower Extremities

Severe cervical spinal cord compression (cervical myelopathy) can produce lower extremity symptoms, but the clinical presentation differs markedly from isolated ankle pain:

• Cervical myelopathy manifests as gait disturbances, balance problems, bilateral leg weakness, and neurogenic claudication—not focal ankle pain 1, 2
• Lower extremity involvement from cervical stenosis typically presents with progressive bilateral leg weakness, spasticity, hyperreflexia, and bowel/bladder dysfunction in advanced cases 1, 2, 4
• A 2023 case report described a 38-year-old with severe C6-C7 stenosis presenting with lower extremity symptoms, but this included progressive numbness, weakness, severe spasms in both legs, and eventual bowel/bladder incontinence—not isolated ankle pain 2

Critical Diagnostic Pitfall

The most important clinical pitfall is failing to recognize that lower extremity symptoms without upper extremity findings should raise suspicion for lumbar pathology, not cervical stenosis:

• In the case series from 2023, when a patient presented with lower extremity symptoms, lumbar MRI was performed first and showed degenerative changes at L3-L4/L5-S1 2
• Only after cervical imaging revealed severe C6-C7 stenosis and the lumbar findings were deemed insufficient to explain the symptoms was cervical myelopathy diagnosed 2
• If you encounter ankle pain in a patient with known cervical stenosis, you must evaluate for lumbar spine pathology, peripheral arterial disease, or other local causes before attributing it to the cervical spine 3, 2

Expected Clinical Pattern of Cervical Myelopathy

When cervical stenosis at C4-C7 does affect the lower extremities through myelopathy, the presentation follows a predictable pattern:

• Upper extremity symptoms typically precede or accompany lower extremity findings, including hand clumsiness and fine motor skill deterioration 1, 2
• Lower extremity manifestations include wide-based gait, bilateral leg weakness, hyperreflexia, positive Hoffman sign, ankle clonus, and positive Romberg sign 1, 4
• Cord signal changes on T2-weighted MRI images indicate myelopathy and correlate with neurological deficits 1, 3
• The absence of upper extremity findings with isolated ankle pain makes cervical stenosis an extremely unlikely cause 2

Alternative Diagnoses to Consider

Ankle pain requires evaluation for conditions that actually affect the ankle region:

• Lumbar spinal stenosis or radiculopathy (L4-S1 levels) can cause leg and ankle pain, often with neurogenic claudication that improves with rest 3
• Peripheral arterial disease produces claudication with exertional leg/ankle pain that resolves with rest, distinguished by diminished pedal pulses 3
• Local ankle pathology including osteoarthritis, tendinopathy, or inflammatory conditions should be considered 3