Think of this under several headings:
  • which structure(s) seem to be the problem?
  • what kind of pain is the problem?
  • does the patient have any other complaints?
  • could this be caused by a systemic or remote problem?

Which structure(s) seem to be the problem?

Most pain around the ankle is coming from a defined structure or structures. Ask the patient to show you the most painful area and use your anatomical knowledge to localise it to a particular structure if possible.
Sometimes related structures all hurt: the lateral ligaments and lateral gutter of the ankle joint and the syndesmosis in a non-resolving ankle sprain, or the posterior tibial tendon and deltoid ligament in adult acquired flatfoot, for example.
This page gives an overview of the sorts of pain patients complain of, and how to begin to interpret them in terms of what might be wrong pathologically. There are separate pages for the four quadrants of the ankle - anterior, lateral, posterior and medial - to make it easier to read. But first...

Pain all over

Some patients complain of pain everywhere. Even then, it's worth trying to pin them down to an area where the pain is worst. Sometimes gentle palpation of the ankle helps. For some people, that's just how they describe pain, and it's your job to interpret!
Pain that really is all over tends to suggest:
  • arthritis in multiple joints
  • infection
  • Charcot neuroarthropathy
  • complex regional pain syndrome or other kinds of neuropathic pain

What kind of pain?

Arthritic pain is usually aching or throbbing. It increases with activity although in severe arthritis may be present all the time. It can usually be improved to some extent by analgesics. The patient can usually show you where the pain is worst, and this is usually related to a particular joint or joints. It may be accompanied by swelling around the joint which also varies with activity. Patients with inflammatory arthritis usually have several joints involved and are stiff for a long period in the morning or after rest.

Pain after injury is usually related mainly to the injured structure - for example, the lateral ankle ligaments. It is usually aching and may throb when severe or re-injury occurs. Again, there may be swelling. It is mainly differentiated from arthritic pain by the history of injury and localisation to an injured structure, but you can see there is plenty of overlap.

The pain of tendonopathy is usually worst shortly after activity, or after a period of rest, when the tendon also feels stiff. The pain is improved by activity or stretching. There may be swelling along the affected tendon. Pain from the insertion of tendons, or from plantar fasciitis, is similar.

Other complaints

"Giving way"

There is a section on assessing this as a central symptom, although this overlaps with the material here. Clarify exactly what the patient means. Often they are describing episodes of instability when the ankle seems to buckle beneath them. Find out how often these occur, whether the ankle actually buckles or just feels as though it is going to, and whether the episodes are related to running, rough ground, stairs or wearing heels. Ask which way the ankle goes: usually it twists into varus and the lateral side appears weak, but a few patients complain of valgus twisting and the medial side feels weak. Particularly in older patients, the patient may not be describing acute episodes of instability but gradual tilting of the hindfoot die to posterior tibial tendon and deltoid/spring ligament insufficiency.


Swelling is often related to an injury, but may be caused by arthritis, tendonpathy or oedema. Ask whether the swelling is in a particular place, and consider what structures it may be related to. Alternatively, the patient may say it is all over the ankle, which may represent generalised oedema or diffuse synovitis.


Patients occasionally say their ankle "locks" or "sticks", but this is less common than in the knee. It should make you con side whether the patient has a loose body in the joint, particularly after injury. However, it is often just a way of describing acute sudden pain - so it's important to clarify exactly what the patient means by "locking".

Neuropathic complaints

Patients may complain of severe, lancinating pain, burning, tingling or a sensation of heat or cold. It may be unpleasant to have clothes or bedclothes touch the limb. These suggest a neuropathic cause for pain. Frequent colour changes in the foot or limb, or profuse sweating, suggest a sympathetic nerve component, which occurs in complex regional pain syndromes

Systemic and remote disease

It's important to consider whether the ankle problem may be part of a more general condition. Examples include:
  • generalised arthritis - ask about
  • other joints involved
  • early morning stiffness
  • psoriasis
  • iritis
  • urethritis
  • colitis - although you may have to work out whether the patient's bowel symptoms are likely to be dues to inflammatory colitis
  • inflammatory low back pain
  • rheumatoid nodules or gouty tophi
  • generalised joint laxity with foot/ankle deformity - ask about other lax joints, and whether any of them dislocate
  • peripheral neuropathy causing foot or ankle symptoms - ask about weakness or altered sensation elsewhere, about likely cause such as diabetes or alcohol abuse, and about family history. Do the current symptoms fit a peripheral nerve distribution better than any localised ankle or foot structure?
  • referred or radicular pain from the spine or other joints - ask about back pain and typical sciatic radiation. Do the current symptoms fit a dermatome better than any foot or ankle structure?