What is the treatment for ankle pain with radiating pain?

Treatment of Ankle Pain with Radiating Pain

Begin with plain ankle radiographs (AP, lateral, and mortise views), followed by MRI ankle without IV contrast if radiographs are normal, while simultaneously initiating conservative management with activity modification, NSAIDs, and functional bracing. 1

Initial Diagnostic Workup

First-Line Imaging

• Plain radiography is the most appropriate initial imaging study for all patients with ankle pain, regardless of whether radiating pain is present 1, 2, 3
• Standard views include anteroposterior, lateral, and mortise (foot internally rotated 15-20 degrees) projections 1
• Radiographs can identify fractures, osteoarthritis, osteochondral lesions, ossific fragments, and soft-tissue abnormalities 4

Advanced Imaging When Radiographs Are Normal

• MRI ankle without IV contrast should be ordered as the next study when there is pain of uncertain etiology and ankle radiographs are normal 1, 2, 3
• MRI provides comprehensive evaluation with high diagnostic accuracy: 77-92% for ligament tears, 93-96% sensitivity for osteochondral lesions 4
• Ultrasound is an alternative option with 91% accuracy for ligament injuries and superior resolution for peroneal tendon pathology and peripheral nerve evaluation 3, 4

Conservative Management (Initiate Immediately)

Activity Modification and Bracing

• Reduce or temporarily cease activities that provoke symptoms, particularly repetitive loading or high-impact exercises 3, 5
• Semirigid or lace-up ankle supports provide functional treatment and should be used rather than full immobilization 3, 5
• Early functional bracing is preferred over immobilization for most ankle conditions 5

Pharmacologic Management

• NSAIDs reduce swelling and pain and may decrease time to return to activities 3
• Daily pain medications are rarely necessary for most patients with chronic ankle pain 5

Physical Therapy

• Graded exercise regimens with proprioceptive elements (such as ankle disk training) reduce risk of recurrent injury 3
• Eccentric strengthening exercises are the primary treatment for Achilles tendinopathy if this is the source of radiating pain 6
• Stretching of the plantar fascia is first-line therapy if plantar fasciitis contributes to symptoms 6

Differential Diagnoses to Consider with Radiating Pain

Nerve-Related Pathology

• Superficial peroneal nerve injury can cause radiating pain from the ankle to the dorsomedial aspect of the foot, particularly after trauma or arthroscopy 7
• Morton neuroma causes burning pain in the ball of the foot with numbness or burning that radiates to the toes (commonly third and fourth toes) 6
• US-guided nerve blocks can be helpful for diagnostic purposes and surgical planning 1

Common Structural Causes

• Chronic lateral ligament injury affects up to 40% of patients after ankle sprains, with persistent pain in 5-46% at 1-4 years 4
• Osteochondral lesions frequently cause persistent pain and are often missed on plain radiographs (41% missed) 1, 4
• Peroneal tendon pathology (tendinopathy, tears, subluxation) can cause lateral ankle pain with potential radiation 4, 5
• Sinus tarsi syndrome and lateral ankle impingement are additional causes of chronic pain 4, 5

Interventional Options for Refractory Cases

Diagnostic and Therapeutic Injections

• Image-guided anesthetic injections (fluoroscopy, CT, or US-guided) identify pain sources and aid surgical planning when multiple sites of pathology are present 1
• Interdigital corticosteroid injection is first-line for Morton neuroma, though 30% may not respond 6
• Avoid corticosteroid injections near the Achilles tendon due to increased rupture risk 3

Advanced Interventions

• Extracorporeal shockwave therapy can be used for plantar fasciitis or Achilles tendinopathy after first-line therapies fail 6
• Radiofrequency treatment can be used safely for chronic foot and ankle pain management, though optimal technique parameters require further study 8
• Platelet-rich plasma injection is an option for refractory plantar fasciitis 6

Red Flags Requiring Urgent Evaluation

• Acute inability to bear weight 2, 3
• Significant swelling or deformity 2, 3
• Point tenderness over specific osseous structures 2, 3
• Neurovascular compromise (coldness, numbness in the foot) 3

Critical Pitfalls to Avoid

• Do not order imaging for asymptomatic or minimally symptomatic findings, as this leads to unnecessary radiation exposure and overdiagnosis of incidental findings 2, 3
• Do not use full immobilization devices routinely, as early functional bracing is superior 5
• Avoid corticosteroid injections near the Achilles tendon 3
• Remember that up to 34% of asymptomatic patients have peroneus brevis tears, making clinical correlation essential before attributing symptoms to imaging findings 4