What are the other causes of ankle pain in adults aged 65 years and older?

Other Causes of Ankle Pain in Adults ≥65 Years

In older adults with ankle pain, the differential diagnosis extends well beyond osteoarthritis to include tendon abnormalities, ligament injuries, osteochondral lesions, impingement syndromes, inflammatory arthropathies (especially pseudogout and gout), and—critically—referred pain from the hip or lumbar spine. 1

Common Non-Osteoarthritic Causes

Soft-Tissue Pathology

• Tendon abnormalities (including tears and tenosynovitis) are a frequent cause of chronic ankle pain in older adults and require MRI for definitive diagnosis 1
• Ligament injuries and ankle instability often present with chronic pain; periostitis adjacent to the ankle may indicate underlying tenosynovitis 1
• Impingement syndromes (both anterior and posterior) cause pain with specific movements and are better visualized on CT than conventional bone scintigraphy 1

Intra-Articular Pathology

• Osteochondral lesions are common and may present with mechanical symptoms; MRI is highly accurate for detection 1
• Synovial osteochondromatosis can be identified on plain radiographs as calcified or ossified intra-articular bodies 1
• Ankle effusions are detected on radiography with 53–74% accuracy and often indicate ligamentous injury or occult fracture 1

Crystal Arthropathies

• Pseudogout commonly affects the ankle joint in older adults and should be suspected with acute-onset pain and swelling 2
• Gout may involve the ankle, though the first metatarsophalangeal joint is more typical; serum uric acid and joint aspiration guide diagnosis 2

Inflammatory Conditions

• Elderly-onset rheumatoid arthritis presents differently than younger-onset disease, with more acute onset, systemic features, and frequent shoulder girdle involvement; bilateral symmetrical small joint involvement suggests this diagnosis 2
• Chronic synovitis from inflammatory arthritis causes erosions visible on radiography and is best assessed with MRI for disease activity 1

Referred Pain (Critical Not to Miss)

Hip and Spine Pathology

• The American College of Radiology specifically advises evaluating the hip when ankle/knee imaging is normal but pain persists, as hip osteoarthritis commonly refers pain distally 3
• Lumbar spine pathology must be considered in patients with chronic ankle pain and unremarkable ankle radiographs 3

Diagnostic Algorithm

Initial Imaging

• Plain radiography (anteroposterior, lateral, and mortise views) is the mandatory first study for all patients with chronic ankle pain 1
• Radiographs identify osteoarthritis, osteochondral abnormalities, stress fractures, calcified bodies, and evidence of prior trauma 1

Advanced Imaging Indications

• MRI without contrast is indicated when radiographs are normal or show only effusion but pain persists, as it globally evaluates ligaments, tendons, cartilage, and bone 1, 4
• CT is reserved for specific scenarios: evaluating subchondral cysts in known degenerative disease or when impingement syndrome is suspected 1
• Image-guided anesthetic injection (fluoroscopy, CT, or ultrasound-guided) helps localize the pain source when multiple degenerative sites are present, aiding surgical planning 1

Key Clinical Pitfalls

Pattern Recognition

• Bilateral symmetrical involvement suggests rheumatoid arthritis rather than osteoarthritis 2
• Morning stiffness lasting ≥60 minutes indicates inflammatory arthritis, not osteoarthritis 4
• Soft tissue swelling, erythema, or warmth mandate urgent evaluation for septic arthritis or crystal disease 4

Age-Specific Considerations

• Ankle symptoms in older adults are typically insidious in onset from chronic processes, unlike acute injuries in younger patients 5
• Acute injuries in the elderly require different management approaches than in younger individuals 5
• Toenail disorders (75%), lesser toe deformities (60%), and corns/calluses (58%) are extremely common and may contribute to altered gait mechanics that stress the ankle 6

Diagnostic Errors to Avoid

• Never attribute persistent ankle pain solely to ankle pathology without imaging the hip, especially when ankle radiographs are unremarkable 3
• Do not overlook systemic features (fever, weight loss, elevated inflammatory markers) that suggest inflammatory or infectious etiologies 2
• Avoid assuming all ankle pain in older adults is "just arthritis"—septic arthritis, inflammatory disease, and referred pain must be excluded 2