Chronic ankle pain

Chronic ankle pain following an injury is a common malady of athletes. The most common cause for a persistently painful ankle is incomplete healing of the joint after an ankle sprain. Chronic pain may also be related to repeated ankle injuries. Once an athlete has suffered an ankle injury, he/she is at increased risk for recurrent injuries, due to either incomplete healing with premature resumption of activity, or residual weakening of the support structures from the original injury. The most common causes of chronic ankle pain following injury are:

1. Ankle sprain with instability
2. Tendonitis or tendon tear
3. Neuritis (inflammation of the nerve that traverses the ankle joint)
4. Synovitis (inflammation of the lining of the joint).

Ankle sprain with instability

Ankle instability refers to a painful “looseness” of the ankle joint which generally follows a severe sprain. The term ankle sprain, although generally used for any non-bone ankle injury, specifically refers to an injury of the supporting ligaments, usually as a result of either inversion (twisting inward) or eversion (twisting outward) of the foot. Instability usually occurs after a severe sprain, with a tear of either the medial (inner) or lateral (outer) ligaments. Instability, in turn, leads to pain, and early onset of degenerative arthritis.

Tendonitis

Tendonitis is inflammation of a tendon, the structure that attaches muscle to bone. In the ankle, tendonitis most commonly affects either the medial (inner) tendons (tibialis tendonitis), the lateral (outer) tendons, or the Achilles tendon. Ankle tendonitis is the result of overuse (such as from sports or exercise), injury, or arthritis. Symptoms include pain, swelling, ankle weakness, and tenderness over the affected tendon. Tendonitis is usually diagnosed based on the patient’s history and symptoms, as well as physical examination. Rarely, x-rays or an MRI scan may be ordered in difficult cases. Treatment includes rest, immobilization, and anti-inflammatory medication.

Neuritis

Neuritis is defined as irritation or inflammation of a nerve, resulting in pain, impairment of muscle function or both. In the ankle area, there are several nerves that course along the inner and outer portion of the joint. In the case of ankle injury, the nerves can be directly affected, resulting in neuritis. Alternatively, conditions resulting in ankle instability may indirectly result in neuritis. Finally, injuries may cause scar tissue, which may then compress or “entrap” a nerve. Neuritis, like tendonitis, is usually diagnosed on the basis of medical history and physical examination. Imaging by MRI may be helpful to identify scar tissue that may be compressing a nerve.

Synovitis

Synovitis refers to inflammation of the synovium, or lining, of the ankle joint. Most joints have a synovial lining that provides cushioning for smooth joint movement. Injury of the ankle can cause inflammation of the synovial lining, resulting in pain, “heat” and swelling of the ankle. The risk of synovitis increases with repeat ankle injuries and poor muscle conditioning (which increases the risk of injury). The diagnosis is usually made on the basis of history and physical examination. X-rays may be ordered to rule out fractures. Treatment includes rest, immobilization and anti-inflammatory medications. In severe cases, cortisone injection into the joint may be performed.