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Ankle Injury and Pain: Causes, Symptoms, Diagnosis, and Treatment


The ankle joint is a very complex structure. It can easily be injured from trauma, or there can be pain from other causes. After a physician takes a history and performs a physical examination, laboratory tests and imaging studies are needed. The immediate ankle injury treatment is immobilization, ice, elevation, light compression, and medications.

What structures make up the ankle joint?

The ankle joint is formed when the tibial and fibula bones of the lower leg meet with the bones of the foot, including the calcaneus and the talus (see diagram). Intertwined between these bones are numerous tendons that connect muscles to bones and ligaments that connect bones to bones, enabling the ankle to function correctly.

The fibula attaches to the foot on the outer side of the ankle joint, called the lateral malleolus. In contrast, the area on the inside where the tibia attaches is called the medial malleolus. These are the "bumps" you feel on the outside and inside of the ankle.

ankle-fracture

What causes an ankle injury or pain?

Any injury to these bones, ligaments, or tendons can lead to ankle pain. Traditionally, a "sprain" involved a stretching of the ligaments, while a "strain" involved a stretching of the tendons. However, nowadays, many physicians use the terms interchangeably, mainly because it's hard for the physician to determine the exact cause until a magnetic resonance imaging (MRI) test can be done (discussed below).

Besides injury, other conditions cause ankle pain, including osteoarthritis, rheumatoid arthritis (an auto-inflammatory disease), aging, tight muscles/tendons from inactivity, gout, flat feet (pes planus), high arch (pes cavus), or systemic lupus erythematosus, also known as SLE or lupus.

What are the symptoms associated with an ankle injury?

The symptoms of an ankle injury are most commonly pain and swelling that vary depending on the injured structures and the severity of the damage.

The most painful ankle injuries involve a fracture, usually at the distal fibula (lateral malleolus) or distal tibia (medial malleolus); fractures are generally the result of some sort of trauma or fall. However, osteoporosis, a condition where the bones are thinned, causes ankle fractures easier than expected.

What is the diagnostic workup of a person with ankle injury and pain?

The history is essential to see if there was some mild or moderate trauma, a history of arthritis, or other chronic conditions, like gout, arthritis, lupus, etc.

The physical exam is essential to check for areas of tenderness and swelling. In addition, the ankle should be checked for redness and warmth, seen with gout.

Laboratory tests can rule out some serious conditions and assist with the diagnosis.

  • A complete blood count (CBC) can reveal increased white blood cells (WBC), indicating inflammation or infection. If gout is suspected, a serum uric acid level is needed.
  • An erythrocyte sedimentation rate (ESR) is a general inflammatory marker that is elevated in rheumatoid arthritis, gout, and infection.
  • A rheumatoid factor (RF) is a marker of autoimmune diseases and can be positive in rheumatoid arthritis and lupus.

Diagnostic imaging studies:

A: Plain x-rays are needed to rule out a fracture while also checking for an underlying bony abnormality that could be present in rheumatoid arthritis, osteoarthritis, osteoporosis, or gout. They should immediately be performed in all cases of ankle injury and pain.

B: A Computed tomography (CT or CAT) scan or magnetic resonance imaging (MRI) scan is needed to evaluate the bones and soft tissues, such as the ligaments and tendons. However, an MRI is currently the "gold standard" for soft tissue evaluation in cases of ankle injury and pain. At the same time, a CT scan is used to evaluate the fractured bones, prior to surgery.

What are the treatments for ankle injury and pain?

The first thing to do for any ankle injury, either a fracture or sprain, is to immobilize the joint, preferably with a splint. In addition, the application of ice is critical in the first 24 hours since the immediate ice application can eliminate a significant amount of future swelling.

Elevation of the affected ankle is important since blood is affected by gravity; therefore, elevating the ankle to the heart level will decrease the swelling and pain.

Light compression, such as from an ace bandage, is recommended to decrease swelling. In addition, your physician can supply crutches to avoid placing pressure on the ankle.

What kinds of medication can be used for ankle injury and pain?

For pain, there are over-the-counter pain medicines like aspirin and acetaminophen (Tylenol).

Non-steroidal anti-inflammatory drugs (NSAIDs) not only help with pain but, like the name implies, help with inflammation (swelling); they can be taken over the counter or by prescription. However, caution must be used with all NSAIDs since there is a risk of gastrointestinal (GI) irritation, leading to stomach ulcers and bleeding.

What are the long-term treatments if no fracture is present?

Once a fracture has been ruled out, physical therapy (PT) can use modality treatments, such as electrical stimulation and ultrasound, to decrease pain and swelling, in addition to crutch use training.

How should an ankle fracture be treated?

A chip fracture can usually be treated by conservative treatment, but a more serious fracture requires referral to an orthopedist or a foot surgeon such as a podiatrist.

Key takeaways

The ankle joint is very complex, made up of bones, ligaments, and tendons, any of which can be injured.

Ankle injuries present with pain and swelling.

Any ankle injury requires immediate x-rays to rule out a fracture or any underlying bony abnormality.

The treatments for an ankle injury include immobilization, ice, elevation, light compression, and medications.

References

Rao, Smita, Jody Riskowski, and Marian T. Hannan, ‘Musculoskeletal Conditions of the Foot and Ankle: Assessments and Treatment Options’, Best Practice & Research. Clinical Rheumatology, 26.3 (2012), 345–68 <https://doi.org/10.1016/j.berh.2012.05.009>

Wire, Jessica, Shady Hermena, and Valori H. Slane, ‘Ankle Fractures’, in StatPearls (Treasure Island (FL): StatPearls Publishing, 2022) <http://www.ncbi.nlm.nih.gov/books/NBK542324/> [accessed 2 September 2022]

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