Diagnosis and Treatment of Sudden Anterolateral Ankle Pain
Most Likely Diagnosis
The sudden onset of stabbing, spasmodic pain in the anterolateral aspect of the ankle above the joint line most likely represents anterolateral ankle impingement syndrome, particularly if there is a history of prior ankle inversion injury, or alternatively, acute tendinopathy of the peroneal tendons or extensor digitorum longus. 1, 2
Diagnostic Approach
Key Clinical Features to Identify
Anterolateral impingement syndrome presents with sharp, stabbing pain localized to the anterolateral gutter between the talus and lateral malleolus, typically triggered by activity or dorsiflexion movements 3, 1
Perform the lateral synovial impingement test: With the patient seated and knee flexed to 90 degrees, forcefully dorsiflex and evert the ankle while applying pressure over the anterolateral joint line—reproduction of the patient's pain indicates impingement with 94.8% sensitivity and 88% specificity 2
Pain on palpation at the anterolateral joint line, often with some swelling or limitation in dorsiflexion, strongly supports the diagnosis 3
The condition typically follows inadequate rehabilitation after an inversion sprain, leading to chronic inflammation, scar tissue formation, and entrapment of hypertrophic soft tissue in the lateral gutter 1
Imaging Strategy
Start with plain radiographs (anteroposterior, lateral, and mortise views) to exclude bony impingement from osteophytes, loose bodies, or fractures 3
If plain radiographs are negative but clinical suspicion remains high, consider MRI to visualize soft tissue impingement, synovitis, or associated ligamentous pathology 4
An oblique anteromedial impingement view may be needed if anteromedial rather than anterolateral pathology is suspected, as standard radiographs can be falsely negative 3
Treatment Algorithm
Initial Conservative Management (First 6-8 Weeks)
NSAIDs for short-term pain relief (effective for acute symptoms but no effect on long-term outcomes) 5, 1
Physical therapy modalities including ice, ultrasound, and progressive strengthening exercises 5, 1
Relative rest with activity modification to reduce repetitive loading of the affected area 5
Avoid movements that reproduce symptoms, particularly forced dorsiflexion and eversion 3
If Conservative Treatment Fails
Arthroscopic debridement is the definitive treatment for anterolateral impingement refractory to conservative management 1, 4
Arthroscopic removal of hypertrophic synovial tissue and scar tissue provides good to excellent long-term results (5-8 years) in 83% of patients with grade 0 and grade I lesions 3
The procedure has high safety, low complication rates, and allows most patients to return to previous levels of work and sports 1, 4
Important Caveats
Exclude other causes of chronic anterolateral ankle pain including peroneal tendinopathy, lateral ligament instability, osteochondral lesions, and nerve entrapment (branches of the deep peroneal nerve innervating the sinus tarsi) 1, 6
If there is associated chronic ankle instability from ligamentous laxity, this must be addressed surgically in addition to impingement debridement 1
Do not inject corticosteroids into the anterolateral gutter as this may provide temporary relief but does not address the mechanical impingement and has no effect on long-term outcomes 5
Results of arthroscopic treatment decline significantly in patients with grade II lesions (osteophytes secondary to arthritis with joint space narrowing), where only 50% achieve good/excellent outcomes 3