Ankle pain

Written by Daan Lansdorp, physiotherapist and owner of FysioGrow.

Does your ankle bother you after a sprain, during sport, on the stairs or after a long day on your feet? Do you feel your ankle has become unreliable or keeps giving way? Is it holding you back at work, in sport or in the things you love doing most? Imagine being able to move again without thinking about your ankle all the time.

I’d like to tell you where ankle pain can come from and what you can do about it. Read on to find out more!

Symptoms of ankle pain

Ankle pain can show up in different ways. You’ll read more about that below. Besides the pain itself, you may have these symptoms:

• Pain on the outside or inside of the ankle, sometimes into the foot
• Swelling around the ankle joint or on top of the foot
• Difficulty pulling your toes up or pointing your ankle
• An unstable or unsafe feeling, as if your ankle could give way
• Pain when you put weight on it, especially on uneven ground or when turning
• Stiffness in the morning or after sitting still for a long time
• A clicking, popping or grinding feeling in the joint
• Loss of strength when pushing off while walking or running

Causes of ankle pain

Ankle pain can have different causes. Think of an acute sprain, a fall or misstep, long-term overload from sport or work, an earlier injury that didn’t heal properly, or osteoarthritis of the ankle joint. All of these send a pain signal to the central nervous system.

When the nervous system thinks it sees a problem or damage in the body, it will try to stop the problem from getting bigger. It does this by giving a pain signal. So this pain signal actually has a very good reason!

Instead of ‘numbing’ the signal with a painkiller, we can also look for the cause of the problem. Because if you tackle that, there’s a good chance the pain goes away for good. Without having to depend on pain medication.

The most common causes of ankle pain:

• Acute ankle sprain (inversion injury). A sprain where the ankle rolls inwards, overstretching or (partly) tearing the outer ankle ligaments. One of the most common sports injuries.
• Chronic ankle instability. In a large share of people with a severe sprain, the joint keeps feeling unreliable, often because the muscle reflexes and stability haven’t recovered enough.
• Ankle osteoarthritis. Wear of the cartilage in the upper or lower ankle joint, often after several past injuries.
• Achilles tendinopathy. Irritation or a (partial) tear of the Achilles tendon, often in runners and after a sudden increase in load.
• Heel spur and plantar fasciitis. Pain on the inside of the heel or the sole of the foot, often worst with the first steps in the morning.
• Peroneal tendon problems. Irritation of the tendons that run along the outside of the ankle, with pain behind and below the outer ankle bone.
• Anterior impingement (footballer’s ankle). Pinching at the front of the ankle joint when you pull the foot up as far as it goes, often in footballers and dancers.
• Compensation from the knee, hip or walking pattern. A changed foot roll-off because of knee or hip pain can overload the ankle again and again.

There are more possible causes, and we’ll find out during the assessment. If you have more general pain elsewhere in your body, you can read more about it there.

Sometimes the pain stays, even though the body seems to have healed the acute cause. There can be different reasons for this. The body may have developed ways to compensate, so you can keep moving anyway. In the longer term, that compensating can actually overload other parts of the body, often the knee, the hip or the other ankle. After an ankle injury the nervous system can also be set to be more “careful”, so the muscle reflexes react more slowly and the joint feels unreliable for longer than it really needs to.

Fear of movement and the urge to spare the ankle can play a part in this. The longer you avoid loading the ankle normally again, the longer recovery takes. During the assessment we also look at these patterns, so we can build up confidence and load as part of the treatment plan.

Treatment of ankle pain

Once we’ve found out what’s causing your pain, we draw up a treatment plan. First we try to get all the muscle tissue, connective tissue and joints working properly again on their own.

Sometimes there’s still too much tension in the calf, the shin muscles or the connective tissue around the ankle, and that has to be treated first. We do this on the treatment table. Once the tissue has been treated, you can produce more strength straight away and the ankle moves more freely.

Then we teach the body to get all the tissues working well together again. With ankle problems, balance and proprioception training is an important part: the nervous system has to learn again to react quickly and automatically to small disturbances, so you don’t roll your ankle on every uneven step. For example, with every step you take, your foot, calf and hip have to catch your body weight together. If your hip stability isn’t in order, your lower leg turns slightly too far inwards as you put your foot down. Per step that seems harmless, but over thousands of steps a day it becomes a constant overload of the outer ankle ligaments and peroneal tendons. You feel the pain in the ankle, while the cause sits higher up in the chain.

Because the exercise programme teaches the body to spread strength and stability fairly through the whole chain again, we tackle the cause of the pain!

The number of treatments depends on the problem. With good guidance, an ankle sprain usually heals within four to twelve weeks, depending on how bad it is. With chronic instability or Achilles tendinopathy it takes longer, often three to six months, because building up strength and tendon load takes time. With ankle osteoarthritis we work towards managing the pain better, with changes in load, footwear and the surrounding muscles.

Want to get rid of your pain? Have a proper assessment of where it comes from? Move better, longer and more easily again? Book an appointment now and come and see us at FysioGrow in Rijswijk, near The Hague! If you’d like more information first, click the WhatsApp icon. I’m happy to answer your questions.

Frequently asked questions about ankle pain

When should I see a physiotherapist for ankle pain?

When a sprain hasn’t clearly improved after a week, when your ankle keeps giving way, when you have chronic pain after an earlier injury, or when the pain limits your sport or work. If you can’t walk on the ankle straight after an injury, see a visible deformity, or have heavy swelling that won’t go down with bruising, go to your GP or the emergency department first to rule out a fracture.

How long does a sprained ankle take to heal?

A mild sprain often heals within two to three weeks, a moderate one within four to six weeks, and a severe sprain with ligament damage can take up to three months. Good guidance makes a big difference: starting early with gradual loading and balance training keeps the ankle from feeling unreliable for good.

Does physiotherapy help with chronic ankle instability?

Yes. If your ankle keeps giving way, targeted balance and strength training is the most effective treatment. The nervous system learns to react quickly to small disturbances again, and the stabilising muscles get stronger. Because of this, many people can play sport fully again without surgery. Surgery is only considered if six months of good exercise therapy doesn’t bring enough results.

What can I do myself after a sprain?

The first 48 hours: cool it calmly, raise the leg when you can and use a compression bandage if there’s a lot of swelling. After that, don’t stay in bed: short, careful loading within what the pain allows speeds up recovery. Don’t rely on rest and painkillers alone, because the nervous system has to actively learn to stabilise the ankle again.

When can I play sport again after an ankle injury?

When you can walk, run and stand on one leg with your eyes closed without pain, and when you can do sport-specific movements (hopping, short sprints, turning) without problems. Going back on the field too early is the main cause of a new injury or chronic instability. With a final test we can judge whether you’re ready to return in every respect.

Do I need an X-ray after a sprain?

Not always. According to the Ottawa Ankle Rules, an X-ray is only needed with specific warning signs: pain on specific bony points around the ankle, not being able to walk straight after the injury, or being over 55 combined with those pain points. In other cases we can judge well during the assessment whether a fracture is suspected, and refer you on if needed.

If your ankle pain lasts longer than expected, the nervous system may play a part in keeping the pain going. Read more about this on our page about tailbone pain.