Ankle sprains are the most common types of ankle injuries sustained in both the general population and athletes alike. Additionally, ankle fractures, muscle strains, and contusions are also very common occurrences.
These injuries are usually associated with some event or mechanism that can be reported by the patient, such as rolling the ankle or being on the receiving end of a slide tackle in soccer.
That said, many people who seek physical therapy for the ankle pain won’t have any obvious injury, instead citing random ankle pain, often reporting something along the lines of “My ankle hurts for no reason”.
In this case, while the patient is experiencing sudden ankle pain without an injury, this doesn’t mean there isn’t an irritated or damaged structure, which is why a structured examination is so important to determine the underlying cause of the pain.
This article will discuss some of the more common sources of ankle pain without injury with the hope that this can help guide you to seek the proper care and put you on a path to safe and effective recovery.
Sudden Outer Ankle Pain Without Injury
Chronic ankle instability is one of the most common reasons to experiences generalized ankle pain without injury, especially on the outside of the ankle.
Chronic Ankle Instability – Overview
Chronic ankle instability can occur for various reasons, but two overarching themes typically stand out. First, a person with ankle instability may have generalized hypermobility in all their joints. Some people call this being “double jointed”, although that’s not exactly an accurate medical term.
People with generalized joint hypermobility will often have a high Beighton score, which is common way to obtain an objective measure of global joint hypermobility. While being flexible is typically a good thing, being too flexible can make a person vulnerable to various joint injuries and conditions that will make the ankle hurt.
Second, ankle instability can also result from a history of ankle sprains. This can result from a history of frequent minor ankle sprains, or from less frequent but more severe ankle sprain, and will often lead to chronic lateral ankle pain.
Even if these injuries occurred a long time ago, if dynamic ankle stability is not improve and maintained over the course of time, one can be more vulnerable to developing injuries or random occurrences of pain in the ankle (Hertel and Corbett, 2019).
Chronic Ankle Instability – Case Example
A real-life case example I have recently seen involved a person who had both generalized hypermobility and a history of bilateral ankle sprains.
This patient’s ankle had not bothered them since their last sprain years ago, but after going on vacation that involved prolonged walking and more hiking than usual, they sought care from physiotherapy for sudden onset ankle pain without injury.
Based on examination findings, which included high than normal ankle range of motion, generalized ligamentous laxity, reduced strength on the affected side, and significantly reduced balance on the affected side, they were diagnosed with both medial and lateral ankle instability.
Ultimately, a high level of activity combined with chronic ankle instability ended up being the source of their ankle pain that occurred while on vacation.
Chronic Ankle Instability – Treatment
Treatment for chronic ankle stability is very similar to treatment for an ankle sprain; however, in the absence of an acute ankle injury, the patient may be able to start with more advanced ankle stability and proprioception exercises.
For example, balance training on unstable surfaces like a bosu ball and dynamic lower body strengthening like single leg squats can be very effective tools to improve ankle strength and stability.
If the patient’s ankle pain is in a flared up state, treatment may start more conservatively with ankle resistance band exercises with an emphasis on strengthening the muscles around the ankle while the pain settles down.
The patient may also be advised to wear an ankle brace during activity to prevent pain or another sprained ankle while they work on improving their ankle stability over time.
In order to optimize your treatment and ensure that anything you are doing is both safe and effective, its highly recommended to seek in-person consultation from a physiotherapist.
Otherwise, playing it safe with strengthening exercises that do not cause an increase in symptoms is likely the way to go, but only direct care will ensure maximum safety and effectiveness.
Sudden Inner Ankle Pain Without Injury
Tarsal tunnel syndrome is one of the most common reasons to experience sudden inner ankle pain without injury.
Tarsal Tunnel Syndrome – Overview
This condition is often related to trauma, such as a medial ankle sprain, but and can often be overlooked as a source of sudden ankle pain without injury as well (Kiel and Kaiser, 2018). The tarsal tunnel is located on the medial (inside) aspect of the ankle and contains numerous structures.
The nerve that passes through this area is the posterior tibial nerve, and any sort of compression, irritation, or inflammation to this nerve can cause symptoms ranging from numbness, tingling, and pain on the inside of the ankle that may radiate down to the sole of the foot or elsewhere in the ankle.
Other structures that pass through this tunnel include tibialis posterior, flexor digitorum longus, and flexor hallucis longus.
For students learning anatomy of this region, these tendons are often referred to as Tom, Dick, and Harry, which is just a way to remember the tendons of the tarsal tunnel. The posterior tibial artery and vein are also included in the tarsal tunnel.
Tarsal Tunnel Syndrome – Case Example
The most recent real-life case example of tarsal tunnel syndrome I have seen in clinic involved a young man who was seeking care for numbness and tingling on the inside of his foot and ankle that intermittently turned into a pain he described as burning.
His pain was aggravated with activity, especially running, and would linger for a few hours after activity before settling back into more mild symptoms.
Some things that stood out during the physical examination included the patient’s foot and ankle positioning in standing and while walking/running.
For example, this patient exhibited significant rearfoot valgus, which is when the ankle appears to be positioned in an everted position while in standing (medial aspect of ankle appears stretched out, lateral aspect of ankle appears compressed), and excessive pronation during stance phase of walking.
This type of positioning can place quite a bit of stress on the inside of the ankle, and the tarsal tunnel is in an unfortunate position to take the brunt of this stress.
This patient also had diabetes, which is considered a risk factor for developing tarsal tunnel syndrome, and he also had a history of Achilles tendinopathy.
While Achilles tendinopathy is not necessarily a causative factor for tarsal tunnel syndrome, it suggests a general history of ankle dysfunction, and if his tibialis posterior tendon was at all affected, this could be an intrinsic contributing factor to the development of his pain.
Lastly, provoking the nerve by physically tapping on its tarsal tunnel portion led to his familiar symptoms that radiated into the sole of his foot. Clinically, this is referred to as a positive Tinel’s sign.
Anything that stressed the tarsal tunnel, for example, passive eversion overpressure held for 30s, also elicited his familiar symptoms.
Tarsal Tunnel Syndrome – Treatment
Physiotherapy treatment for tarsal tunnel syndrome will vary depending on the contributing factors to the patient’s ankle pain, but will likely involve some component of mobility exercises, such as calf stretching, and may also include more specific neural mobility exercises, such as tibial nerve flossing.
There will also be a component of strengthening exercises, such as tibialis posterior and the smaller instrinsic muscle of the foot, which may progress to more functional strength and stability exercises to redistribute the forces that were previously concentrated on the tarsal tunnel.
Some items in the clinic may be used as adjuncts to therapy to assist with symptom reduction or tactile cuing during exercise, such as applying kinesiology tape to help with medial arch support.
Lastly, education about load management and activity modification will be important, especially in the early stages of recovery when symptoms are easily provoked.
If conservative treatment fails, surgery may be another option, but this is left as a last resort scenario. This is usually more indicated if there is a clear space-occupying lesion identified that is physically encroaching on the structures within the tarsal tunnel.
Sudden Posterior Ankle Pain Without Injury
Achilles tendinopathy is one of the most common sources of posterior ankle pain without injury.
Achilles tendinopathy refers to pain in the Achilles tendon due to degeneration and disorganization of its collagen fibers, which is a main protein that gives the tendon its strength.
Achilles Tendinopathy – Overview
Many people have heard the term “Achilles tendonitis”, which refers to inflammation of a tendon. Achilles tendinopathy is a bit different from Achilles tendonitis, as it rarely involves a significant component of inflammation, and this is actually much more common than a pure form of tendonitis.
Given that tendinopathy develops over time, it can be difficult to detect until symptoms arise, which is why it can result in sudden ankle pain without injury. Sometimes it may start with the sensation of increased stiffness in the tendon.
This may feel like generalized calf stiffness at first, or there may be some soreness with high levels of activity. Pain from tendinopathy can gradually increase over time, or there may be a seemingly innocent inciting event.
Achilles Tendinopathy – Case Example
A real-life case example I have seen recently in the clinic involved a nordic skier. This gentleman is a highly active individual, and near the end of the skiing season, he was involved in a long distance race with significant elevation changes.
He sought care from the clinic for severe pain in his left Achilles tendon in the days following the race. While there was likely a component of Achilles tendonitis in the sense that there was some reactive inflammation, his inflammatory symptoms subsided to reveal tendinopathy characteristics.
Upon examination, the mid-portion of his affected tendon was significantly thicker than his unaffected tendon. This thickening of the tendon is a hallmark sign of tendinopathy.
This also suggests his tendinopathy had been developing for some time, and without any worrying symptoms, the patient was understandably unaware the condition was developing.
The race he participated in was just enough to provoke the tendon to the point of pain that he had difficulty settling, particularly since the pain is with activity and the tendon is frequently stressed with day-to-day activity, such as walking.
For instance, this patient was able to identify that the toe-off phase of walking aggravated his pain, and this pain was also increased with any form of impact activity, such as running and jumping, which is one of the most common symptoms.
So while there was no specific injury in the acute sense, an activity that was completely normal and familiar for this patient was enough to bring on his symptoms to a point where he needed help.
Achilles Tendinopathy – Treatment
As with any other injury or condition, treatment will vary across individuals and should be optimized with in-person consultation with a physiotherapist.
That said, the common theme to all tendinopathy treatment is loading the tendon, which is often performed through specific strengthening exercises, especially eccentric strengthening exercises (Maffulli et al, 2020).
In the case of Achilles tendinopathy, a heel drop program consisting of strategically progressive calf raise exercises can help improve function and reduce symptoms over time.
For any other tendons, the program will look similar, but will be more targeted to the muscles associated with that particular tendon. General ankle stability and strengthening can also go a long way to assist in providing additional support to the tendon.
These tendinopathy rehab programs usually require a high level of commitment, as exercises will be performed most days of the week, sometimes every day. Additionally, a mild to moderate level of pain can be expected, which is often a barrier for many patients.
While the experience may not be overly pleasant, most patients are happy with the long term outcomes, as their function has improved and symptoms are reduced, and this is something they can continue to self-manage on their own.
Sudden Bottom of Foot and Ankle Pain Without Injury
Plantar fasciitis is a very common condition affecting the bottom of the foot close to the ankle and can be brought on by ankle dysfunction without an acute injury, such as reduced joint movement, strength, and stability.
Plantar Fasciitis – Overview
The plantar fascia is the thick dense connective tissue spanning the bottom of the foot. This is a passive tissue, meaning it cannot be actively contracted, so it’s at the mercy of the forces applied to it.
The plantar fascia is one of the main supports for the sole of the foot, particularly the medial arch of the foot. It runs from the calcaneus (heel bone) to the toes.
During walking, when the foot is on the ground and progresses from heel strike to toe-off, the plantar fascia is stressed, which is normal, and provides structural support to the bottom of the foot.
While it’s normal for the plantar fascia to experience some level of stress and strain, excessive or repetitive stress and strain can cause degeneration of the collagen fibers, much like a tendinopathy, which can result in foot pain during simple activities like walking.
The fascia can also become inflamed, especially if acutely irritated. If the stress and strain on the plantar fascia continues to be quite excessive and there is also a lack of additional support to the fascia, there may be some physical tearing of the fascia itself, which can be quite painful.
The most common location of pain for plantar fasciitis is the anteromedial aspect of the calcaneus, or in other words, the front and inside portion of the bottom of the heel. It is also entirely possible to feel the pain elsewhere, such as the entirety of the bottom of the foot.
Plantar fasciitis pain may be worse first thing in the morning. Patients will often complain of substantial difficulty with the first few steps in the morning, getting up to use the bathroom in the middle of the night, or standing up and walking after sitting at their office desk for too long. Pain may also be increased with faster walking, running, and jumping.
Just like tendinopathy, there does not have to be a specific acute injury to bring on symptoms. Sometimes patients will just notice random onset of pain, also called insidious onset pain.
In most cases, there is something that contributes to increased pain, such as flat feet or excessively high arches, prolonged walking while on vacation, or a sudden change in activity.
Plantar Fasciitis – Case Example
The most recent case of plantar fasciitis that I have seen in the clinic involved someone who recently injured their hip and were off their feet for a while. Once they recovered from their injury, they resumed their normal fitness program which included running and also went on vacation which involved lots of walking in flip flops.
They came into the clinic seeking care for pain on the bottom of their foot and heel, and it was determined they had the beginning of plantar fasciitis.
In this case, the patient’s symptoms included pain on the bottom of the heel which was worse than the pain in the middle of the sole of their foot, significant pain with the first few steps in their morning, and increased pain walking up hill.
Their pain would subside a little after a few minutes of walking, but would eventually start to increase again as they walked longer, especially in unsupportive footwear like flip flops.
Plantar Fasciitis – Treatment
Treatment for plantar fasciitis is usually a combination of short-term symptoms reduction and long term management.
Things that can help relieve pain from plantar fasciitis include rolling the bottom of the foot on a frozen water bottle, massage, specialized compression sleeves or socks for the foot, stretching, and wearing shoes with good support.
Approaches for a more permanent solution usually involve a combination of stretching and strengthening. Stretching will often combine ankle dorsiflexion, like a calf stretch, possibly combining big toe extension at the same time, which is sometimes referred to as a Windlass stretch (Latt et al, 2020).
Strengthening will involve the small intrinsic muscles of the foot to provide additional support, as well as other larger muscles like tibialis posterior, which also helps support the bottom of the foot, which is especially important in those with flat feet. Calf stretching and strengthening will also be a large component.
To know how to properly organize and progress your exercises, it’s highly recommended to consult with a physiotherapist in person.
Gradual and General Ankle Pain Without Injury
Ankle osteoarthritis can also be a cause of gradually increasing generalized ankle pain without injury, and this is usually seen in individuals who are older in age with a history of substantial activity involving the ankle, or a history of trauma.
Ankle Osteoarthritis – Overview
Ankle osteoarthritis is a non-inflammatory form of ankle arthritis that commonly affects the hips, knees, and hands, but can affect many other joints as well, including the ankle.
This occurs when the cartilage in the ankle joints degrades over time and is no longer providing a uniform surface for the appropriate distribution of forces sustained during functional activity.
Altered cartilage structure can lead to increased concentration of stress in different areas of the joint as well as the development of osteophytes, which are bony growths in and around the joint.
If these osteophytes impinge on the joint during movement, or if the ankle bones themselves begin contacting each other in the absence of cartilage, the person will experience ankle joint pain with functional movements in weight bearing positions.
Given that osteoarthritis develops over a long period of time, people usually notice stiffness occurring before pain, and the stiffness may be so gradual that they don’t detect it, and as such, don’t address the issue at hand.
Eventually, progressive post-activity soreness may begin to creep in, and over time, this will get increasingly worse.
People usually seek care for ankle osteoarthritis once they begin to notice that they don’t recover well from their daily activities, or even more demanding activities that they once enjoyed, such as playing a sport. They will usually cite either gradual or sudden ankle pain without injury during or after activity that may get better with rest, but will return again with activity.
Ankle Osteoarthritis – Case Example
The most recent real-life case example of ankle osteoarthritis I have seen in clinic was actually a post-surgical case, whereby the 60 year-old patient had an ankle replacement surgery of the talocrural joint (the main ankle joint allowing plantarflexion and dorsiflexion) and a subtalar joint fusion (the lower ankle joint that allows ankle inversion and eversion).
This person originally sought care for their progressively increasing ankle pain that eventually limited both their professional and leisure activities, both of which included substantial time walking on uneven terrain.
Conservative treatment through physiotherapy, which involved improving ankle range of motion and functional strength/stability, was very helpful in allowing the patient to manage her condition for approximately 10 years, but eventually her symptoms continued to progress and further treatment, surgery in this case, was warranted.
Ankle Osteoarthritis Treatment
Physiotherapy is a mainstay treatment for any form of osteoarthritis. In the case of ankle osteoarthritis, physiotherapy will focus on improving joint range of motion and improving strength and stability of the foot and ankle.
Given that the degradation of the cartilage is pretty well irreversible, improving the joint’s motion and allowing the surrounding muscles to take more of the load can really help reduce symptoms and improve function (Herrera-Perez et al, 2022).
Other adjuncts to exercise-based treatment include manual therapy, for example, joint mobilization techniques, soft tissue release, or dry needling. These techniques may improve the ease at which someone can perform their exercises, and may also help in temporarily reducing symptoms.
If improvements are made in the clinic with manual therapy, it’s very important to follow that up with specific exercises to maintain those improvements long term.
If the damage to the joint progresses to a point where conservative therapy has minimal success, joint injections, such as Duralane or cortisone injections, may assist in symptom reduction and buy a window for the patient to comfortably participate in activity-based rehab.
Surgery is usually considered a last resort, as it is primarily for pain relief, and there may be associated functional limitations that come as a trade-off. The initial recovery also requires the patient to confidently live their life without weight-bearing on the surgical ankle for weeks to months.
Other Inflammatory Conditions
An autoimmune disease or inflammatory arthritis, such as rheumatoid arthritis, can also affect the joints of the ankles (Simonsen et al, 2021).
While physical therapy can play a role in the management of inflammatory and/or autoimmune disease, there is usually a heavier focus on medical management, which may come in the form of targeted pain medications, nonsteroidal anti inflammatory drugs (NSAIDs), or other medical interventions.
Systemic inflammatory conditions can also make someone more prone to injury, for example, by altering the mobility of the joints throughout the body (hypermobility or hypomobility), and may exacerbate the inflammatory process of seemingly innocent and mild injuries.
Treatment for these types of conditions will likely be more multidisciplinary and will vary depending on the exact nature of the disorder and how the ankle is subsequently affected.
The family physician, or specialized physician (e.g. a rheumatologist) may take the lead on care, and can advise how to navigate the healthcare system for your particular needs. Other professionals, such as physical therapists, or foot and ankle surgeons, may also be consulted.
Summary
There can be many causes of sudden ankle pain without injury, and while this can be frustrating for people who experience sudden ankle pain, it’s worth knowing that the cause and associated treatment options can usually be identified with a visit to your local physiotherapist.
This article described different causes of insidious onset ankle pain and associated treatment options, but keep in mind it’s never a one-size-fits-all approach.
Treatment may require the inclusion of more than one healthcare professional for long terms management, or it can be as simple as receiving some advise from your doctor or physiotherapist and self-managing with a simple exercise program aimed to treat and prevent ankle pain.
References
Herrera-Pérez, M., Valderrabano, V., Godoy-Santos, A. L., de César Netto, C., González-Martín, D., & Tejero, S. (2022). Ankle osteoarthritis: comprehensive review and treatment algorithm proposal. EFORT Open Reviews, 7(7), 448.
Hertel, J., & Corbett, R. O. (2019). An updated model of chronic ankle instability. Journal of athletic training, 54(6), 572-588.
Kiel, J., & Kaiser, K. (2018). Tarsal tunnel syndrome. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2022. PMID: 30020645.
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.
Maffulli, N., Longo, U. G., Kadakia, A., & Spiezia, F. (2020). Achilles tendinopathy. Foot and Ankle Surgery, 26(3), 240-249.
Simonsen, M. B., Hørslev‐Petersen, K., Cöster, M. C., Jensen, C., & Bremander, A. (2021). Foot and ankle problems in Patients with Rheumatoid Arthritis in 2019: Still an Important Issue. ACR Open Rheumatology, 3(6), 396-402.
Disclaimer:
The content here is designed for information & education purposes only and is not intended for medical advice.
