Many injuries and other musculoskeletal conditions can follow daily patterns, meaning symptoms peak or subside at predictable times of day. For example, we recently published an article about ankle sprains and discussed how throbbing pain can often occur at night.

So what about those who experience stiff ankles or ankle pain in the morning? What causes stiff ankles and ankle pain in the morning, and what would be the next steps to figuring out further investigation or treatment for this ankle pain?

To help provide insight into these questions, this article will discuss instances when someone may experience ankle pain in the morning. While this article is not a substitute for an in-person consultation with a physiotherapist, which would be your best option to ensure an accurate diagnosis and optimal treatment moving forwards, we hope this information may serve as peace of mind and assist in identifying what the cause may be and what possible treatment options could look like.

Inflammatory Joint Conditions

Background

Inflammatory conditions can cause ankle pain in the morning, especially if there is no associated injury. These inflammatory conditions tend to be more systemic, meaning they involve general processes throughout the entire body, but can lead to pain in specific joints as a consequence.

For example, rheumatoid arthritis (RA) is an inflammatory condition that can cause ankle stiffness, sweling, and pain. Unlike pain and swelling that occurs in damaged tissue after an ankle sprain, rheumatoid arthritis is technically considered an auto-immune disease, whereby the body’s immune system attacks the healthy joint tissue.

While the exact cause of rheumatoid arthritis is unknown and likely varies across individuals, there appears to be a strong genetic component, which is why a family history of this condition is one of the primary risk factors.

Evidence suggests that a genetic component is involved in many inflammatory conditions like rheumatoid arthritis, but having a genetic predisposition doesn’t necessarily mean you will get rheumatoid arthritis.

In many cases, it seems like an environmental trigger is required to bring forth symptoms, such as infection from different viruses or bacteria. In fact, we are now seeing evidence that the highly prevalent COVID-19 virus may also be a trigger for the disease process of inflammatory arthritis (Mukarram et al, 2021).

Other inflammatory conditions can include juvenile idiopathic arthritis (JIA), psoriatic arthritis, ankylosing spondylitis, gout, and systemic lupus erythematosus. All of these conditions have their own nuances in terms of symptoms and treatment, but a common theme across the board is that their is an inflammatory process occurring throughout the body that does not require acute injury and can affect a number of joints, including the ankle joints.

Signs, Symptoms, and Diagnosis

The primary symptoms of inflammatory joint disease causing ankle pain in the morning includes ankle stiffness and swelling usually that can include pain with movement or to the touch. The joint may also feel quite warm, especially when ankle swelling is present, and may also look a little more red in some cases.

In most cases, many joints are affected. For example, with rheumatoid arthritis, smaller joints in the hands, fingers, and toes are most often affected, and in more progressive or severe cases, bigger joints like the ankles, knees, shoulders, and hips can also become affected. Gout may be an exception to this, as many people may only experience pain and swelling in one joint, with the big toes and the ankle joints being the more common sites for gout.

Given that the immune system can oversee more structures in the body (not just ankles and other joints), people with these inflammatory conditions may also experience symptoms involving other body parts, including the heart, lungs, kidneys, skin, eyes, etc.

One very important symptom that helps distinguish these inflammatory conditions is joint stiffness that spikes in the morning or after prolonged rest. This joint stiffness may last quite a long time and is not quickly relieved by “getting started” in the morning. This can help differentiate from other joint conditions, for example osteoarthritis, which can cause some ankle stiffness in the morning but can be easily improved in a short time (e.g. less than 30 minutes) by general movement like walking.

Overall, the diagnosis of inflammatory joint disease will require a combination of subjective history, physical exam findings, blood tests, and occasionally diagnostic imaging (Houghton, 2008).

Subjective history is what the patient reports, and the healthcare practitioner may ask detailed questions about family history, medical history, and symptoms in the joints or other body parts.

Physical exam findings will focus on careful examination of affected and unaffected joints, but may also include other work-ups like blood pressure measurements.

Blood tests can be used to identify biomarkers associated with a genetic predisposition, which can help strengthen the suspicion for an inflammatory joint disease (Farheen and Agarwal, 2011).

Diagnostic imaging like x-rays and MRIs can also be used to examine bone health, structural changes to the joint shape, and changes to cartilage lining the joints.

Treatment

I wish I could say that physiotherapy is a one-stop-shop for curing inflammatory joint disease, but that simply isn’t the case. While physio is definitely an effective way to facilitate the management of these inflammatory conditions, including the reduction of frequency and intensity of symptoms and slowing the progression of these diseases, pharmaceutical treatments are usually necessary to really make a difference and buy a window to include things like physical therapy into treatment.

Medications like non-steroidal anti inflammatory drugs (e.g. Advil) can be helpful in managing joint inflammation, these conditions will often require more specific medications known as “disease modifying anti-rheumatic drugs”, or DMARDs for short, of which there are many classes.

Methotrexate is the most common DMARD, but can also be combined with other types of DMARDs for optimal results. For more information about these medications, it is highly suggested to speak with a doctor or pharmacist, as they are specifically trained in medications.

In terms of physical therapy, this will really depend on the exact condition; however, some common themes across the board include education regarding activity modification, maintaining and improving range of motion for stiff ankles, and strategic strength training to help provide support to joints that may be compromised.

Additionally, adjuncts to therapeutic exercise, such as electrotherapeutic modalities (e.g. TENS and IFC), ultrasound, and manual therapy (e.g. soft tissue release, careful joint mobilizations, hands-on stretching and strengthening, etc) may be used to reduce stiffness and pain and assist in the overall management of symptoms so the patient can find relief as well.

Achilles Tendinopathy and Other Ankle Tendinopathies

Background

We recently wrote a comprehensive article about Achilles tendonitis and tendinopathy, so we will be fairly brief in our description of this condition here, but it is worth mentioning, as Achilles tendinopathy can also lead to increased ankle pain in the morning.

Achilles tendonitis refers to inflammation of the Achilles tendon, and while this inflammation can occur in isolation, it’s much more common to experience Achilles tendinopathy, which refers to the degeneration and disorganization of collagen fibers within the tendon with or without associated inflammation.

Achilles tendinopathy is more common in people participating in long distance running, sprinting, and jumping sports like volleyball and basketball. Placing a high demand on the Achilles tendon in a very repetitive fashion can lead to pain behind the ankle joint if the Achilles tendon doesn’t experience enough recovery between bouts of activity, if there is a sudden increase in activity, or if the calf muscle complex and other ankle muscles aren’t strong enough to appropriately distribute the forces on the ankle.

Signs, Symptoms, and Diagnosis

People with Achilles tendinopathy typically report ankle pain with activities that really stress the tendon, such as running and jumping. However, many people with Achilles tendinopathy also report increased ankle pain and and stiff ankles in the morning, especially when first getting out of bed. As the tendon “warms up” with general movement from starting the day, symptoms may subside until being provoked again by prolonged activity.

It’s also possible to have other tendinopathies in the ankles, include those specific to the tendons of tibialis posterior which is quite intimate with the Achilles tendon, tibialis anterior which is on the front and inside of the ankle, and the peroneal tendons which are located on the outside or lateral aspect of the ankle joint. In this case, aggravating factors will include activities that specifically stress those tendons.

For tibialis anterior, this may be something like resisted ankle dorsiflexion, for example, peeling up on the pedals of a stationary bike.

For tibialis posterior, these will be many of the same activities that provoke the Achilles tendon, e.g. running and jumping, but the pain may feel a little more medial in the ankle and/or local to the inside arch of the foot.

For peroneal tendinpathy, any rapid loading like running or jumping will also provoke ankle pain, as well as rapid change of direction movements that commonly occur in sports like soccer, but the pain will likely be felt more on the outside of the foot and ankle.

All of these tendinopathies may lead to increase ankle pain in the morning.

Diagnosis will require a thorough subjective history asking about symptoms, when they occur, when they feel better, and activities that you typically participate in. Physical examination may focus on range of motion and strength testing, gait analysis, and palpation.

In terms of palpation, the healthcare professional may even be able to see noticeable thickening of the affected tendon, especially if it’s Achilles tendinopathy. Other tests like blood work and diagnostic imaging usually aren’t required for an accurate diagnosis, but may be useful in ruling out other conditions that could also be suspected.

Treatment

Treatment for tendinopathy is largely activity-based, which is the bread and butter of physiotherapy treatment. While people may experience short-term pain relief with gentle stretching of the tendon and ankle joint in general, it is generally advised to avoid excessively stretching the tendon, as this may just irritate it further.

Achieving a long term reduction in tendinopathy symptoms will require specific loading of the tendon, which will resemble a targeted strengthening program. In the case of Achilles tendinopathy, heel drop programs are crucial for treatment, and this should be guided by a physical therapist who can advise on the exact therapeutic exercises to perform, the specific dose (e.g. sets and reps), and when to progress the program.

Other forms of treatment that can really help reduce symptoms while still engaging in exercise-based rehab include shockwave therapy, which has shown good results for treating numerous tendinopathies, but especially Achilles tendinopathy (Fridman et al, 2008).

If these conservative measures to care are taking too long or simply aren’t having the desired affect for symptoms reduction, slightly more invasive measures may be considered, such as percutaneous microelectrolysis, which involves running an electrical current through the skin with acupuncture needles. This technique has shown to be effective in reducing ankle pain and stiffness in the morning that occurs with Achilles tendinopathy, particularly in those who report stiff ankles (Ronzio et al, 2017).

Enthesitis

Background

We would also like to briefly mention enthesitis, which refers to inflammation of the areas where tendons and ligaments attach to bone (entheses). While tendinopathies can sometimes be classified as insertional tendinopathy, meaning the symptoms are localized to where the tendon inserts on the bone, enthesitis can also occur without repetitive use and therefore without associated tendinopathy, such as in cases of ankylosing spondylitis and juvenile idiopathic arthritis.

Signs, Symptoms, and Diagnosis

In may cases, enthesitis can be diagnosed with careful palpation of tendon and ligament attachment points. This information may be used in diagnosis broader conditions like ankylosing spondylitis, or simply to understand where symptoms may be most intense.

Pain on palpation is the most common symptoms on enthesitis, but anything involving the tendons or ligaments pulling on the bone can also elicit symptoms, which may lead to pain with general activity. In the case of inflammatory conditions like ankylosing spondylitis or juvenile idiopathic arthritis, enthesitis pain will be usually be higher in the morning (Houghton, 2008).

Treatment

Treatment for enthesitis will vary depending on the cause. If this is a consequence of a systemic inflammatory condition, pharmaceutical treatment with specific medications may help provide a long term management solution and provide the ability to continue improving strength, stability, and mobility around the area via physiotherapy.

A physical therapist can also provide education on activity modification which can help provide the patient with more control over their condition, and in addition to education and exercise-based treatments, may also be able to incorporate adjuncts to treatment like electrical stimulation, dry needling, or manual therapy techniques to address stiff ankles.

A physician may also recommend anti-inflammatories, such as a topical ani inflammatory that can be applied directly over the inflamed enthesis, and can also provide referrals to more specialized physicians if they suspect there is a unique condition or disease causing the enthesitis.

Plantar Fasciitis

Background

We also wrote an in-depth article on plantar fasciitis, also known as policeman’s heel, so we will be fairly brief on this condition as well. Plantar fasciitis refers to inflammation of the fascia on the sole of the foot, which provides a huge amount of support for the arch of the foot.

Given this is passive tissue, meaning it cannot be actively contracted, it’s at the mercy of the forces placed upon it and relies heavily on muscular support of the foot and ankle, and those with a history of ankle problems are more likely to develop this condition.

Signs, Symptoms, and Diagnosis

A hallmark symptom of plantar fasciitis is heel pain, or pain in the sole of the foot, with the first few steps in the morning. The most common location for pain is the bottom of the heel towards its inside and front portion (anteromedial portion of the bottom of the calcaneus).

While foot, heel, and/or ankle pain in the morning is common, it’s also common to experience it with excessive walking, especially if in poor footwear like flip flops that do not provide adequate arch support. People may feel pain with the first few steps, then feel a bit better as they keep walking, and eventually the pain gradually returns after too much walking.

Treatment

Given the plantar fascia is loaded with every step and cannot be actively controlled, it’s a fairly tricky condition to treat, especially if it’s been hanging around for a while.

Physiotherapy is highly recommended for plantar fasciitis treatment, and will likely begin with specific stretching of the plantar fascia and strengthening of the small intrinsic muscles of the foot, as well as bigger muscles of the foot and ankle complex.

Adjuncts to exercise-based treatment may include shockwave therapy, soft tissue release, electrotherapeutic modalities like electrical stimulation, and dry needling (Latt et al, 2020).

Other helpful strategies to reduce foot and ankle pain in the morning caused by plantar fasciitis include rolling the sole of the foot out on a frozen water bottle, wearing plantar fasciitis compression socks while sleeping and/or during the day, wearing Strassburg socks at night, performing self massage on the sole of the foot, wearing shoes with proper arch support, and/or buying insoles or orthotics for good foot arch support.

Ankle Osteoarthritis

Background

Ankle osteoarthritis can certainly lead to increased ankle pain and stiffness in the morning that is quickly improved with movement. This type of arthritis is often called “wear-and-tear” arthritis and is more likely to occur in those with a history of ankle issues.

Ankle osteoarthritis is caused by mechanical degradation of the cartilage within a joint, which can lead to areas of concentrated stress on the joints, ultimately altering joint mechanics and causing pain in the area. At it’s most severe, a total reduction in cartilage may lead to bone-on-bone contact, which is highly painful.

Signs, Symptoms, and Diagnosis

A classic sign of osteoarthritis is joint stiffness in the morning, also known as “gelling stiffness”. This specific form of stiffness occurs after long periods of rest, such as sleeping, and is though to be caused by a temporary thickening of the fluids inside the joint.

To distinguish from ankle stiffness caused by inflammatory conditions like rheumatoid arthritis, gelling stiffness is usually relieved within 30 mins of gentle activity, which can be as simple as getting out of bed and starting your day. Conversely, stiffness associated with inflammatory conditions like rheumatoid arthritis or gout can stick around for much longer periods of time and the associated joint may be visibly inflamed.

Osteoarthritis can be highly suspected based on subjective history, for example, a history of frequent high-impact activities, history of trauma, presence of gelling stiffness, older age, and absence of other auto-immune or inflammatory conditions.

X-rays can also be helpful in diagnosing osteoarthritis, and while this type of imaging is not effective at seeing the actual cartilage, the joint space between the bones can be assessed for areas of narrowing, which is indicative of cartilage degradation.

Treatment

The primary form of treatment for ankle osteoarthritis is physical therapy, as improving range of motion can help with symptoms and overall function, and improving joint strength and stability will go a long way for supporting the joint and ultimately reducing the stress on the joint itself.

Another reason physical therapy is recommended, rather than just exercise in general, is because physical therapists will be able to identify muscular imbalances and other biomechanical factors that may be facilitating force and stress applied on the joint at the initial appointment. From there, the physical therapists will then be able to prescribe specific exercises that will be most successful in addressing the impairments noted, ultimately providing an optimal exercise program for both rehab and fitness.

A doctor may also prescribe non steroidal anti-inflammatories. While osteoarthritis technically isn’t considered an inflammatory condition, a damaged joint is more susceptible to inflammation from trauma or excessive activity, so these types of medications may assist in symptoms reduction, particularly ankle pain in the morning or after excessive activity. All that said, it’s best to consult with a doctor or pharmacist about medications rather than a physiotherapist.

The last resort for treatment of advanced osteoarthritis is a joint replacement. An ankle joint replacement may involve one or more joints, or occasionally, can involve a replacing one joint (e.g. the talocrural joint) and fusing another joint (e.g. the subtalar joint).

This type of treatment is intended to decrease pain in the ankle caused by osteoarthritis, and can actually be quite effective (Yeowell et al, 2021). However, given that pain reduction is the primary goal, returning to full function is not always expected. Rehab via physical therapy will help improve function as much as possible, but realistically, pain reduction is the goal.

Therefore, an ankle joint replacement is considered a last resort option for ankle osteoarthritis, especially considering the general risks associated with surgery. It also requires a substantial period of non-weight bearing after the surgery, so the patient would need to be physically and cognitively capable of accommodating these types of restrictions while recovering.

Summary

Many different conditions and injuries can cause ankle pain in the morning. Inflammation is a common culprit in ankle pain and stiffness in the morning, but these symptoms can also be brought on by repetitive use injuries, as well as other joint conditions caused by osteoarthritis.

Physiotherapy can have a role in the rehab of all of these conditions, but is more highly emphasized in repetitive use injuries like tendinopathies and osteoarthritis. People with inflammatory conditions will still benefit from physiotherapy, but in these cases, pharmaceutical interventions like specific disease-modifying medications may play a more primary role in treatment.

References

Farheen, K., & Agarwal, S. K. (2011). Assessment of disease activity and treatment outcomes in rheumatoid arthritis. Journal of Managed Care Pharmacy, 17(9 Supp B), S09-S13.

Fridman, R., Cain, J. D., & Weil, L. (2008). Extracorporeal shockwave therapy for the treatment of Achilles tendinopathies: a prospective study. Journal of the American Podiatric Medical Association, 98(6), 466-468.

Houghton, K. M. (2008). Review for the generalist: evaluation of pediatric foot and ankle pain. Pediatric Rheumatology, 6(1), 1-10.

Latt, L. D., Jaffe, D. E., Tang, Y., & Taljanovic, M. S. (2020). Evaluation and treatment of chronic plantar fasciitis. Foot & Ankle Orthopaedics, 5(1), 2473011419896763.

Mukarram, M. S., Ishaq Ghauri, M., Sethar, S., Afsar, N., Riaz, A., & Ishaq, K. (2021). COVID-19: an emerging culprit of inflammatory arthritis. Case reports in rheumatology, 2021.

Ronzio, O. A., da Silva Coldibeli, E., Soares Fernandes, M. D. R., Froes Meyer, P., & da Silva, R. M. V. (2017). Effects of percutaneous microelectrolysis (MEP®) on pain, rom and morning stiffness in patients with achilles tendinopathy. European Journal of Physiotherapy, 19(sup1), 62-63.

Yeowell, G., Samarji, R. A., & Callaghan, M. J. (2021). An exploration of the experiences of people living with painful ankle osteoarthritis and the non-surgical management of this condition. Physiotherapy, 110, 70-76.

Disclaimer:

The content here is designed for information & education purposes only and is not intended for medical advice.