Sprains are common, and women's ankles aren't weakerMixed evidence
Pooled across 181 studies of different sports, ankle sprains were more common per exposure in girls and women (13.6 against 6.94 per 1,000). But in one US emergency department registry (2002 to 2006), sprains were no more common in women than men overall: young men had more at 15 to 24, and women more after 30, about twice the men's rate. A 2010 to 2024 update found women slightly higher overall. In the West Midlands, A&E sprain rates were highest in girls aged 10 to 14.
When men and women play the same sport, a review found no consistent difference, and a previous sprain was the main shared risk; differences in ligament size and shape haven't been linked with sprains. Laboratory studies show small changes in balance and arch height across the menstrual cycle, but no study links them to sprains.
Sources 1, 2, 3, 4, 5, 6
The tendon along the inner ankle: mostly women from their 40s, and often missedEmerging evidence
Tibialis posterior tendon problems affected 3.3% of women over 40 at one English practice, and none had been diagnosed. "Middle aged women are most commonly affected", a review says, and most people are first told they have a sprain or arthritis. Flat feet, high blood pressure, diabetes, a steroid injection near the tendon, past ankle injuries, a sudden rise in activity, less supportive shoes and a higher body weight make it more likely.
It starts with "vague pain" and "swelling behind the medial malleolus" (the inner ankle bone). As it goes on, the arch flattens on one side, more toes show from behind, and you are "unable (or barely able) to perform a single unsupported heel rise". Experts now call the later stage progressive collapsing foot deformity.
Sources 7, 8, 9, 10, 11
Flat feet that don't hurt are normalStrong evidence
Flat feet "do not usually cause any problems", "should not stop you doing any activities, including sports" and "are rarely a sign of anything serious", the NHS says. "You do not need to do anything" if they're not causing problems, and insoles "will not change the shape of your feet". A flat foot that is new, painful, stiff or on one side only needs a GP.
Source 12
The Achilles: not clearly a women's problem, and ruptures are mostly in menEmerging evidence
Achilles tendinopathy affected about 2 in 1,000 people a year in Dutch general practice, a third linked to sport, and lower limb tendon problems weren't more common in women in another Dutch practice. Ruptures were about 3 times more common in men in Denmark, with an average age of 44 in women. One small study found thinner Achilles tendons in active women on HRT after the menopause, with no symptoms measured, so it shows nothing about protection.
Sources 13, 14, 15, 16
Heels: an injury risk, mostly in your 20s and 30sEmerging evidence
In US emergency departments, high-heel injuries affected about 7 in 100,000 women a year, most often at 20 to 29 and 30 to 39, mostly ankle and foot sprains and strains, and nearly doubled over 11 years. A review found heels linked with injuries such as sprains, falls and fractures in 7 of 8 studies, and with pain in 3 of 5, but not with arthritis.
In 11 women who wore heels every day, the calf muscle fibres were shorter and the Achilles stiffer, "reducing the ankle's active range of motion", and walking in heels made the calf work harder. These are small laboratory studies.
Sources 17, 18, 19, 20
Hypermobility: diagnosed more in women, but not doom for the ankleMixed evidence
In Wales, 70% of the 6,021 people diagnosed with Ehlers-Danlos syndrome or joint hypermobility syndrome were women, and women were diagnosed about 8.5 years later than men. But across 46 studies of about 23,000 adults, generalised hypermobility on the Beighton score didn't differ between women and men, and across 18 studies hypermobile sports players had no extra ankle injuries.
The NHS lists "keep getting sprains and strains" among the symptoms of joint hypermobility syndrome, which "often gets better as you get older", and says "The main treatment is improving muscle strength and fitness".
Sources 21, 22, 23, 24
Swollen ankles: usually harmless, but the pattern mattersStrong evidence
"Swelling in the ankles, feet or legs often goes away on its own", the NHS says. Its list of usual causes includes standing or sitting still for long, salty food, being overweight, pregnancy, some medicines ("some blood pressure medicines, contraceptive pills, hormone therapy, antidepressants or steroids"), varicose veins and thyroid problems. Amlodipine commonly swells the ankles. The NHS combined pill side effects page doesn't list swelling, and the NHS premenstrual syndrome page lists "bloating" rather than swollen ankles, so the pill and periods are possible causes, not proven ones.
The NHS says varicose veins are more likely in women, but in 1,566 Edinburgh adults they were found in 40% of men and 32% of women, so the sources disagree. Lipoedema "is more common in women" and usually spares the feet, unlike fluid. One swollen, throbbing leg can be a clot, which the combined pill, HRT, pregnancy and long journeys make more likely; with the pill, the risk "affects up to 1 in 1,000 people".
Sources 25, 26, 27, 28, 29, 30, 31, 32
Stress fractures and low energyStrong evidence
Women had more stress fractures across 11 military and 10 athletic studies: about 9.2% against 3% in recruits, and 9.7% against 6.5% in athletes. But women recruits and athletes of normal weight and bone health were less likely to get them, so fitness and bone health matter more than sex. In 259 active girls and young women, combined risks (12 hours or more of exercise a week, a sport that rewards leanness and restricted eating) raised the rate to 46%.
Low energy availability, from eating too little for the training you do, harms the bones of women and men alike, the International Olympic Committee (IOC) says. Around the ankle, stress fractures can affect the fibula, the talus, the navicular and the heel. Missing 3 periods in a row, or irregular periods, is a reason to see a GP.
Sources 33, 34, 35, 36, 37
Rheumatoid arthritis and goutStrong evidence
Rheumatoid arthritis affects about 1.2% of UK women and 0.4% of men. In 1,000 people with it, the hindfoot or ankle was affected at the start in 17%. The National Institute for Health and Care Excellence (NICE) asks for urgent referral when more than one joint is swollen, even with normal blood tests. Psoriatic arthritis can affect the ankle too.
Gout is about a quarter as common in women as in men (1.05% against 3.97% in the UK), but the gap narrows with age, and the NHS lists having been through the menopause as a risk.
Sources 38, 39, 40, 41, 42, 43
Later life and old injuriesEmerging evidence
In one UK study of people aged 50 and over, 14.1% of women had ankle pain in the past month, against 9.2% of men; the authors suggest women may report pain more readily. Ankle arthritis mostly follows an old injury (78% in one specialist series), and in Denmark broken ankles were more common in women, whose rates peaked at 55. Our ankle pain in older adults guide covers later life.
Sources 44, 45, 46
When a scan or test helpsStrong evidence
After a twist, clinicians use the Ottawa ankle rules (being unable to take four steps, or tenderness at the back edge or tip of either ankle bone) to decide who needs an X-ray: across 27 studies they missed almost no breaks and saved 30% to 40% of X-rays. Ligament damage is judged best by an examination 4 to 5 days after the injury. The inner ankle tendon is diagnosed by examination: "Scans are not usually needed".
A suspected stress fracture may need a magnetic resonance imaging (MRI) or bone scan, as the first X-ray is often normal. One swollen leg needs an ultrasound scan within 24 hours if a clot is suspected, and suspected rheumatoid arthritis needs blood tests and X-rays, which shouldn't delay referral. Scans find things that don't hurt: MRI showed changes in 49% of symptom-free college athletes.
Sources 47, 48, 9, 36, 32, 40, 49
How it usually goesEmerging evidence
"In many cases, new pain or a flare-up of long-standing ankle problems should begin to settle within 6 weeks", NHS inform says. "After 2 weeks, most sprains and strains will feel better", though "Severe sprains and strains can take months", and without balance training a third of athletes sprained again within a year. A broken ankle "usually takes 6 to 8 weeks to heal, but it can take longer". The inner ankle tendon is easier to treat early. No one can promise a timescale.
Sources 50, 51, 52, 53, 9, 24
