Ankle sprains are one of the most common injuries both in athletes and the general population. This injury involves damage to the ligaments that help support the ankle joint, with the ligaments on the outside of the ankle being injured far more frequently than the ligaments on the inside of the ankle.

When it comes to recovering from an ankle sprain, there’s a little more to it than most people think. Unfortunately, simply resting the ankle until it feels better often doesn’t work, or at the very least will lead to a more vulnerable ankle at further risk of injury, which is why exercise-based treatment for ankle sprains is highly recommended.

Additionally, it is very common to feels different sensations in the foot and ankle throughout the rehab process, and even occasionally after full recovery has been achieved. One of the more commonly reported sensations after an ankle sprain is heel pain.

There can be many different reasons for developing this heel pain after an ankle sprain, and in this article we will discuss the most common causes of this heel pain.

Swelling and Inflammation

With an acute ankle sprain, the inflammatory phase of healing is a necessary process in order to provide a clean slate for further recovery, but if the associated inflammation is excessive or prolonged, it can be quite painful.

Swelling that occurs in the inflammatory phase of healing can also be painful, particularly if there is severe swelling creating pressure on the tissue around the ankle.

So if the inflammatory process is necessary, can anything be done to reduce heel pain associated with this inflammation after an ankle sprain? The short answer is yes, but it the pain may not be completely eliminated without the use of targeted medications, which we will not discuss in this article.

The main strategy during the inflammatory phase of healing is to provide an optimal environment for healing while preventing excessive or prolonged inflammation. This can be achieved by following the R.I.C.E. principle, which stands for rest, ice, compression, and elevation. Some clinicians will use the term P.R.I.C.E. as well, which is the same thing, just with a ‘P’ that stand for protection.

While the evidence for using ice to reduce swelling after an acute ankle sprain is mixed, it can certainly help decrease pain and reduce the risk of secondary tissue damage that can be caused by lots of swelling. There are many different ways to ice a sprained ankle, with the most common being gel ice packs, crushed ice, and ice cryo-cuffs.

Compression, for example, graded compression socks, can also be used to reduce and prevent excessive swelling during any stage of recovery. There are many different types of compression socks that vary in terms of how much pressure they actually apply to the area.

Compression socks that offer 20-30 mmHg of pressure are the most common and can be a good starting point, and if necessary, you can go up or down from there the comfort and results are not optimal.

Elevation is a great way to reduce swelling in the ankle. Elevating the ankle will reduce blood pressure in the local area and will also facilitate lymphatic return. Given that blood and swelling can pool in the ankle when it is down all day, and weight bearing may stress some tissues, elevating the ankle is often both effective in terms of reducing the amount of swelling, but can also help reduce heel pain after an ankle sprain.

Bruising

This may seem fairly obvious, but the calcaneus, which is the formal name for the heel bone, can become bruised if there is impact associated with a traumatic ankle sprain. The torn ligaments and associated ankle pain may garner much of the patient’s attention at first, but then as those symptoms settle, a dull aching pain may reveal itself in the heel, especially if a tiny hairline fracture is present.

If a heel bruise is present following an ankle sprain, it is important to ensure that the heel is adequately protected in order to allow for proper healing. Depending on the severity of injury, this could range from ensuring you are wearing proper footwear with good support, all the way to temporarily wearing an air cast or non-weight bearing altogether.

Plantar Fasciitis

Plantar fasciitis is the most common cause of heel pain in general, and can occur after an ankle sprain, especially in cases where there is a sudden increase in activity and excessive load is placed on the fascia that supports the arch of the foot, or if heel spurs are also present.

In fact, a recent study has shown that the plantar fascia is actually thinner in those with lateral ankle sprains compared to their non-injured counterparts (Romero-Morales et al, 2020). The muscles and tendons that support the plantar fascia may have become weaker or less resilient after an ankle sprain, especially if range of motion and weight bearing was substantially reduced in the early stages of rehab.

Therefore, if weight bearing activity is increased too suddenly, the plantar fascia may be exposed to a larger demand than it can handle, ultimately resulting in heel pain.

We have published a comprehensive article about plantar fasciitis which discusses various ways this condition is treated, so please feel free to refer to that article for more detailed information.

Generally speaking, stretches for the sole of the foot and the calf muscles, intrinsic foot muscle strengthening, and calf muscle strengthening are all common ways to provide relief and build support for the plantar fascia.

In addition to exercise-based therapy, modalities like shockwave therapy, soft tissue release, dry needling, and electrical stimulation can all help with recovery, either in terms of manipulating the tissue itself, or providing temporary pain relief.

Feel free to check out our article on plantar fasciitis after an ankle sprain for more comprehensive information about that condition specifically, especially as it relates to activity-based prevention and treatment.

Fat Pad Atrophy

Fat pad atrophy is another common cause of heel pain, both in terms of acute pain and chronic pain, and can reveal itself after an ankle sprain, especially in those with historically unstable ankles. This fat pad is located directly under the heel bone and helps to disperse forces sustained during any sort of activity on your feet.

Fat pad atrophy refers to the thinning of this fat pad, or a change in its elasticity, which in most cases is due to excessive wear and tear as a result of a long history of impact activities.

Chronic ankle instability as a result of a longstanding history of ankle fractures and ankle sprains can also facilitate the development of fat pad atrophy.

Those with diabetes, or with inflammatory conditions such as rheumatoid arthritis, are also more likely to develop fat pad atrophy.

So how does fat pad atrophy cause heel pain after an ankle sprain? Similar to plantar fasciitis, fat pad atrophy may have been an ongoing process prior to the ankle sprain, but not to the point where symptoms have interfered with activity.

When resuming weight bearing activity after an ankle sprain, especially if the heel and ankle were inflamed for a quite a while, a patient may find this condition has now become more symptomatic.

Similarly, if risk factors are present, such as obesity, diabetes, systemic inflammatory conditions, or even residual inflammation from the injury, an uptick in weight bearing activity without enough recovery time may facilitate the development of fat pad atrophy, thus causing heel pain after an ankle sprain.

The pain caused by fat pad atrophy often feels like a bruise, but you may not see any visible bruising. This pain is often described as being in the middle of the heel when walking, running, or standing for a long time, whereas the pain associated with plantar fasciitis is often located a little more towards the inside of the heel and foot.

Barefoot walking on hard surfaces, or pressing on the heel with a lot of pressure, will both increase pain caused by fat pad atrophy (Balius et al, 2021).

Treatment for fat pad atrophy often involves load management, meaning reducing the volume of impact activity that may be causing the symptoms.

Joint mobilizations and soft tissue release can also aid in recovery, especially when focused on releasing or stretching the calf muscles.

Improving strength and control of the foot and ankle is also imperative, as this can help evenly distribute the stress on the foot and heel during weight bearing activities.

Taping and/or custom insoles can also help alleviate pain caused by fat pad atrophy. The tape is applied to squeeze the fat tissue in a way that increases its thickness under the heel bone, thus reducing pain felt during walking on hard surfaces.

Custom insoles work in a similar manner, as they are usually cup shaped, again offering more support under the heel. Furthermore, specialized rocker shoes can also help redistribute stress on the heel, ultimately providing pain relief (Choo et al, 2020).

Tendinopathy

Various forms of tendinopathy can also cause heel pain after an ankle sprain. Achilles tendinopathy is by far the most common ankle tendinopathy, and given the Achilles tendon connects the calf muscles to the back of the heel bone, this can absolutely be an area of pain, which is more specifically termed “insertional Achilles tendinopathy” (Gaston and Daniel, 2021).

We have published a comprehensive article about repetitive injuries of the Achilles tendon, including treating Achilles tendonitis and tendinopathy, so please refer to that for more detailed information about pathology and treatment methods.

Similar to plantar fasciitis, a sudden uptick in activity, with or without the presence of inflammation, may facilitate the development of tendinopathy, especially in those who already have a history of these repetitive use conditions. This is one of the reasons why its important to steadily progress therapeutic exercises, as opposed to going from a protective mode right back into high impact activities.

Aside from the Achilles tendon, other tendons that pass over the heel can also be affected, such as tibialis posterior and the peroneal tendons.

Regardless of the exact tendon involved, the main course of treatment for tendinopathies is loading. This means specific targeted strengthening of the muscles and tendons affected, which helps build resiliency in the tendon and provides a long term solution for pain relief.

Stretching may briefly alleviate some of the pain, but it is typically not advised to focus on stretching when rehabbing a tendinopathy. Instead, active range of motion is suggested, as the tendon will experience the movement but won’t be placed under excessive passive stretch.

Other forms of treatment such as shockwave and dry needling can also assist in treating tendinopathy, but again, the meat and potatoes of the program will be specific and progressive loading of the affected tendon.

For optimal results, it is highly recommended to seek physical therapy, as the physical therapist can advise on acceptable levels of pain during the rehab exercises, and when it is appropriate to progress those exercises.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome has been shown to be a very common cause of ankle pain and heel pain in those with a history of ankle sprains (Inthasan et al, 2019). In reality, this isn’t pain of the heel itself, but rather, pain in a space located on the medial ankle over top of the heel bone.

The tarsal tunnel provides passage for three tendons: tibialis posterior, flexor digitorum longus, and flexor hallucis longus. It also includes the posterior tibial artery and vein, and the posterior tibial nerve.

Given the nerve can be affected, the area it supplies downstream may experience symptoms, namely numbness/tingling/burning pain on the inside of the foot and sole of the foot, as well as medial ankle pain over the tarsal tunnel itself.

If the ankle joint is relatively unstable (particularly following medial ankle sprains), the foot and ankle complex experiences a high degree of pronation during stance, or there is inflammation present in the area, pain may develop on the inside of the ankle and heel. All of these things can happen after an ankle sprain, especially untreated sprained ankles, which is why tarsal tunnel can be a culprit of medial heel pain after an ankle sprain.

Treatment will focus on pinning down the source of symptoms and will likely involved a combination of range of motion/stretching exercises, as well as exercises that improve foot and ankle control in order to prevent excessive stress being placed on the inside of the ankle and heel, and may also include nerve mobility exercises if the posterior tibial nerve is particularly affected.

A physical therapist will be well equipped to find the source of the problem and provide the appropriate guidance from there.

Summary

There are many possible causes of heel pain after an ankle sprain, and while the treatment for many of these causes includes a combination of load management and therapeutic exercise, having a physiotherapist perform a physical examination can help provide insight into the cause of the heel pain and provide the confidence you need to safely and effectively manage these conditions.

References

Balius, R., Bossy, M., Pedret, C., Porcar, C., Valle, X., & Corominas, H. (2021). Heel fat pad syndrome beyond acute plantar fascitis. The Foot, 48, 101829.

Choo, Y. J., Park, C. H., & Chang, M. C. (2020). Rearfoot disorders and conservative treatment: a narrative review. Ann Palliat Med, 9(5), 3546-52.

Gaston, T. E., & Daniel, J. N. (2021). Achilles Insertional Tendinopathy-Is There a Gold Standard?. Archives of Bone and Joint Surgery, 9(1), 5.

Inthasan, C., & Mahakkanukrauh, P. (2019). Tarsal tunnel syndrome: Anatomical facts and clinical implications. Journal of the Anatomical Society of India, 68(3), 236-241.

Romero-Morales, C., López-López, S., Bravo-Aguilar, M., Cerezo-Téllez, E., Benito-de Pedro, M., López, D. L., & Lobo, C. C. (2020). Ultrasonography comparison of the plantar fascia and tibialis anterior in people with and without lateral ankle sprain: a case-control study. Journal of Manipulative and Physiological Therapeutics, 43(8), 799-805.

Disclaimer:

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