Ankle pain: where it hurts, what helps, and when to get it checked

Do I need an X-ray? The Ottawa ankle rulesStrong evidence

After a twisted ankle, clinicians use the Ottawa ankle rules to decide who needs an X-ray. An ankle X-ray is needed if the back edge or tip of either ankle bone is tender to press, or you couldn't take four steps straight after the injury or when you are examined. A foot X-ray is needed if the navicular (the bony bump on the inner midfoot) or the base of the fifth metatarsal (the bump halfway along the outer edge of the foot) is tender, or the same four-step test fails.

The rules are very good at ruling fractures out. In the study that refined them, they picked up every fracture and could cut ankle X-rays by about a third; a review of 27 studies (15,581 people) found they missed almost no ankle or midfoot fractures, in children too, and could cut X-rays by 30 to 40%.

They are a guide for clinicians, not a self-test. If you can't walk four steps, if pressing on one of those bony points hurts, if the foot looks out of shape, or if you're unsure, get it checked the same day. Ligament damage is best judged 4 to 5 days after the injury, once the swelling has gone down.

Sources 20, 21, 19, 2

Ankle pain is common, and sprains often come backStrong evidence

About 15% of adults aged 45 and over report frequent ankle pain. Sprains are commoner in women and girls than in men and boys, in children than adults, and in indoor and court sports. Pain falls fast in the first 2 weeks after a sprain, but in a review of 31 studies 5% to 33% still had some pain a year later and 3% to 34% sprained the ankle again. That is why the sprain guide keeps going after the pain has gone.

Sources 22, 23, 24

Outer ankle tendon pain (the peroneal tendons)Mixed evidence

The peroneal tendons run behind the bony bump on the outside of the ankle. Tendon irritation, tears and tendons slipping out of their groove cause outer ankle pain that can be hard to tell from a ligament injury, and it can come with an unstable ankle or a high-arched foot. Treatment advice rests on case series and expert opinion: anti-inflammatories, rest, changing activity and orthoses first, then a boot or cast for 6 weeks in stubborn cases.

A sensible home plan borrows the tendon-loading approach (editorial): press the outside of the foot into a wall without moving (8 to 12 holds of about 6 seconds), then band eversion (3 sets of 10, as in a chronic ankle instability trial), single-leg calf raises, single-leg balance and side hops, keeping pain to about 5 out of 10 and settled by the next morning. Clicking, or a tendon you can feel slipping over the ankle bone, needs assessing.

Sources 38, 32, 39

Gout and a hot, swollen ankleStrong evidence

A sudden hot, red, swollen joint without an injury may be gout, which most often affects the big toe, or a joint infection (septic arthritis), which is urgent. See a GP for a first attack of gout, and get help the same day with a high temperature, shivering or being unable to put weight on it. There is no exercise plan for a hot, swollen joint: in a gout attack, the NHS advises rest, raising it and an ice pack for up to 20 minutes, and NICE says ice alongside medicine may help.

Sources 4, 5, 10

Diabetes and your ankles and feet

With diabetes, check your feet every day, especially after exercise. NICE asks for an ulcer, an infection, or an unexplained hot, swollen foot with a change in colour to reach a specialist foot service within 1 working day, and a suspected Charcot foot is kept off weight until it has been checked. Exercise is still recommended: a 2023 international guideline suggests a foot and ankle exercise programme for people at low to moderate risk, with suitable foot protection. The foot pain guide has more.

Sources 8, 13

Myths worth dropping

Many popular beliefs about ankles are weaker than they sound.

• "If I can walk on it, it isn't broken." The X-ray rules also check for tenderness over the bones, because you can have a fracture and still walk. If a bony point is tender, or you're unsure, get it checked.
• "Rest a sprain until it stops hurting." Early, protected weight-bearing and exercise beat immobilisation, and exercise in the first week improved function in a trial.
• "Once it stops hurting, the sprain is fixed." Up to a third of people sprain the same ankle again, and in one cohort 40% had chronic instability a year later. Balance training cut repeat sprains in a large trial.
• "Ice is the treatment." There isn't enough trial evidence to judge rest, ice, compression and elevation; ice may help comfort alongside exercise.
• "Flat feet need fixing." Most cause no problems and need no treatment, and a flat foot is not a general injury risk.
• "You need running shoes for your foot type." Choosing running shoes by foot type did not prevent injuries in a Cochrane review.

Sources 20, 2, 19, 26, 24, 27, 42, 7, 43, 44, 45

Sprains: early, protected movement beats restStrong evidence

A brace or tape with gradually more weight through the foot, plus exercise, beats immobilisation, and for a severe sprain up to 10 days in a below-knee cast or brace can speed early recovery. Starting exercise in the first week improved function in a trial of 101 people. The sprain guide has the full plan.

Sources 19, 25, 26

Balance training and a brace cut repeat sprainsStrong evidence

Exercise-based rehab after a sprain lowered the odds of another one over the next year (odds ratio 0.60 across 14 trials). In a trial of 522 athletes, an 8-week home balance programme cut repeat sprains from 33% to 22%. A brace worn for sport cuts them too, and lace-up braces cut ankle injuries in a trial of 1,460 school basketball players.

Sources 28, 27, 29, 30, 19

An ankle that keeps giving way: balance and strength training firstStrong evidence

The clinical guideline's top grade goes to balance and neuromuscular exercise for chronic ankle instability, and balance training gave the most consistent gains in a systematic review. In one trial, 6 weeks of balance training, or of band and heel-raise training, three times a week improved strength, balance and side-hopping.

Sources 19, 31, 32

Inner ankle tendon pain: strengthening helps, on thin evidenceEmerging evidence

In tibialis posterior tendon dysfunction, adding resistance exercise (a slow, lowering phase did best) to insoles and stretching improved pain and function in a small trial; a review of 3 trials (93 people) called the research thin. The flat feet guide has the plan.

Sources 35, 36

Ankle arthritis: ankle trials are thin, general arthritis advice appliesMixed evidence

Most ankle arthritis follows an injury: 78% in one series of 406 ankles. There are no completed ankle-arthritis exercise trials beyond a feasibility study, so NICE's general advice for osteoarthritis (tailored exercise, and weight loss if you need it) is the best guide.

Sources 40, 33, 34, 9

Calf stretching adds only a few degrees of ankle bendStrong evidence

In a systematic review, calf stretching increased ankle bend (dorsiflexion) by about 2 to 3 degrees. Whether that matters for pain or function is unclear, so the plans here use stretching alongside strength and balance, not instead.

Source 37

Insoles and shoe changes don't prevent repeat sprainsEmerging evidence

Foot orthoses and footwear changes haven't been shown to prevent repeat sprains, and a brace or tape on its own doesn't improve balance in an unstable ankle. For arthritis, NICE says not to routinely offer insoles, braces or supports unless the joint is unstable or loaded abnormally and exercise alone won't do.

Sources 19, 9