What is the best course of action for a young adult female experiencing ankle pain with no history of injury but a history of heavy weight lifting?

Ankle Pain in Young Adult Female Weightlifter Without Trauma

In a young adult female with atraumatic ankle pain and heavy weightlifting history, initiate conservative management with NSAIDs, activity modification, and functional ankle support while conducting a focused examination for overuse injuries, stress fractures, and tendinopathy—reserving imaging for pain persisting beyond 6 weeks. 1, 2

Initial Clinical Assessment

Key History Elements

• Duration and pattern of pain: Chronic ankle pain is defined as symptoms persisting >6 weeks 1, 2
• Specific weightlifting movements that provoke symptoms: Repetitive loading can cause stress fractures, most commonly posterior and inferior to the posterior facet of the subtalar joint 1
• Pain location and character: Focal tenderness suggests specific structural pathology, while diffuse pain may indicate stress injury 1
• Timing relative to activity: Pain during dorsiflexion suggests anterior impingement, while lateral pain may indicate peroneal tendinopathy 3, 4

Focused Physical Examination

• Palpate the lateral calcaneal wall for stress fracture tenderness, which often occurs before radiographic changes are visible 1
• Assess for warmth and swelling at the lateral calcaneus, highly suspicious for stress fracture 1
• Examine peroneal tendons along the lateral ankle for tendinopathy or subluxation, common in chronic lateral ankle pain 3
• Test ankle dorsiflexion range: Pain with hyperdorsiflexion suggests anterior impingement syndrome 4
• Compression test of the calcaneus: Pain on compression is highly suspicious for calcaneal stress fracture 1

Conservative Management (First-Line)

Immediate Interventions

• NSAIDs reduce swelling and pain and may decrease time to return to activities (Grade B recommendation) 1
• Semirigid or lace-up ankle supports are recommended as functional treatment for ankle injuries (Grade B recommendation) 1
• Activity modification: Reduce or temporarily cease heavy weightlifting, particularly exercises involving repetitive ankle loading 1

Rehabilitation Protocol

• Graded exercise regimens with proprioceptive elements (such as ankle disk training) are recommended to reduce risk of ankle sprain (Grade B recommendation) 1
• Supervised rehabilitation and home exercise for inadequate initial recovery 5
• Progressive return to weightlifting only after pain-free range of motion is achieved 3

Imaging Algorithm

When to Image

• Do NOT order imaging if pain is minor, inconsistent, and does not interfere with activities 2
• Obtain standard ankle radiographs (AP, lateral, and mortise views) if pain persists >6 weeks, interferes with activities, or if there are signs of joint effusion or deformity 1, 2, 6

Initial Imaging

• Plain radiographs are the most appropriate initial study for all ankle pain 1, 6
• Oblique views are recommended if anteromedial impingement is suspected, as plain radiographs are often negative 4

Advanced Imaging Indications

• MRI ankle without IV contrast should be ordered when radiographs are normal and pain of uncertain etiology persists 1, 2
• MRI is effective in detecting osseous stress injuries that may not be visible on initial radiographs 1
• Technetium bone scanning can be helpful when stress fracture is suspected but radiographs are negative 1
• Ultrasound has higher resolution than MRI for evaluating peroneal tendon pathology and peripheral nerve symptoms 1, 6

Red Flags Requiring Urgent Evaluation

• Acute inability to bear weight 2, 6
• Significant swelling or deformity 2
• Point tenderness over specific osseous structures 2
• Neurovascular compromise (coldness, numbness in the foot) 1, 2
• High level of pain with rapid onset of swelling 1

Common Pitfalls to Avoid

• Do not rely on initial examination alone if significant swelling is present; reexamine at 3-5 days post-onset as swelling can obscure findings 6
• Avoid corticosteroid injections near the Achilles tendon, as this increases rupture risk 6
• Do not order imaging for asymptomatic or minimally symptomatic findings, as this leads to unnecessary radiation exposure and potential overdiagnosis of incidental findings 2
• Recognize that bilateral presentation suggests systemic or developmental phenomenon rather than traumatic pathology 2

Specific Diagnoses to Consider in Weightlifters

Stress Fracture

• Repetitive load to the heel can lead to calcaneal stress fracture 1
• Pain on calcaneal compression is highly suspicious 1
• Treatment involves protecting and immobilizing the foot 1

Anterior Impingement Syndrome

• Pain with hyperdorsiflexion is characteristic 4
• Arthroscopic excision is effective for refractory cases 5, 4

Peroneal Tendinopathy

• Lateral ankle pain is common in chronic cases 3
• Conservative treatment should precede surgical consideration 5