Sunday, March 03, 2024
Ankle Pain FOOT PAIN

Front of Ankle Pain (Anterior): Causes, Symptoms, Diagnosis & Treatment

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For individuals leading an active lifestyle, experiencing pain in the front of the ankle can be a common occurrence.

Front (anterior) ankle pain can be the result of various conditions: anterior ankle impingement, extensor tendonitis, anterior tibial tendonitis, deep peroneal nerve entrapment, arthritis, and ankle sprains.

This article discusses in detail the causes and treatments of front of ankle pain. 

athlete ankle kicking soccer ball

What Are the Causes of Front Ankle Pain?

1) Anterior Ankle Impingement Could Be Causing the Front Ankle Pain

The anatomy of the ankle consists of the tibia (shin bone), the fibula, and the talus. Overextension in the upward (dorsiflexion) or downward (plantarflexion) movement of the ankle may result in the impingement of bones and related soft tissues.

Anterior ankle impingement,  referred to as “Footballer’s ankle”, is commonly seen in athletes but is not exclusive to them.

For instance, soccer players often engage in repetitive ankle motions when kicking the ball, leading to chronic discomfort and potential impingement over time. 

This condition also affects other active individuals, such as runners and dancers.

This impingement might stimulate the formation of bone spurs on the front of the tibia and talus. This causes pain during ankle movement. 

Symptoms

  • Dull, achy pain in the front of the ankle
  • Inability to effectively dorsiflex (move upwards) the ankle due to pain
  • Difficulty walking upstairs, downstairs, and uphill
  • Pain that occurs when walking, but is relieved with rest
  • Swelling in the front of the ankle
  • Pain when squatting

Diagnosis

Your doctor will obtain a history and perform a physical exam. Your doctor will check the ankle range of motion to determine whether there is pain in the ankle joint when it is pushed upwards (dorsiflexed).

Your doctor will order an x-ray to evaluate your ankle joint. This can be done at your foot doctor’s office. X-rays will show swelling of the ankle as well as bone spurs.

Occasionally the lining of the joints (synovial tissue) and the ankle capsule may be pinched. If your doctor believes this is the case, he/she may order an MRI of the ankle.

A Magnetic Resonance Imaging Scan (MRI) provides detailed images of soft tissue structures in the foot. An MRI will confirm the impingement of the soft tissue structures. 

Treatment

For the most part, anterior impingement syndrome can be treated conservatively.

Resting the ankle, icing, and limiting activities can help reduce ankle pain and discomfort. Anti-inflammatory medications such as Ibuprofen can be beneficial to help alleviate pain in the ankle.

However, in some cases, due to spurring in the front of the ankle, surgery may be warranted.

The surgery will need to be done in the operating room under anesthesia. Arthroscopic surgery can be done using small incisions in the ankle. The bone spurs can be removed this way.

The surgeon may opt to make a larger open incision to remove a large bone spur and scar tissue. 

You will need to be partial weight-bearing in a cast boot or splint after surgery for 3 to 4 weeks. 

Physical therapy will be needed after surgery to reduce pain and improve range of motion. 

Activities can usually be resumed fully in 3 to 6 months.

What Happens if You Don’t Treat Ankle Impingement?

Untreated anterior ankle impingement syndrome could  lead to the formation of larger, more debilitating bone spurs at the front of the ankle. This condition results from recurrent straining of the ankle joint. 

Chronic pain, accompanied by progressive arthritis within the joint, could be another undesirable outcome. 

This can impair the range of motion in the ankle, restricting one’s ability to engage in normal activities.

Can Shoes Cause Anterior Ankle Impingement?

Shoes can cause anterior ankle impingement syndrome. This includes shoes that are excessively worn or overly flexible. Ill-fitting footwear can increase ankle movement during ambulation and worsen symptoms. 

Similarly, shoes that are too tight in the front portion of the ankle may trigger pain and contribute to the impingement of the ankle joint.

Read more about how bad shoes can cause foot pain in this supplemental post

extensor tendons

2) Extensor Tendonitis Could Be Causing Ankle Pain

Pain at the front of one’s ankle could be due to extensor tendonitis. 

Originating in the leg, the extensor muscle extends down the front of the ankle, turning into tendons that ultimately insert into the toes. These tendons play an important role in lifting the foot during walking.

The use of overly tight shoes, which place pressure on the top of the feet, can lead to pain along the extensor tendons. 

Extensor tendonitis may result from the excessive strain of the extensor tendons during prolonged walking or uphill walking/running.

Symptoms

  • Pain in the front of the ankle and foot
  • Swelling in the front of the ankle and foot
  • Bruising in the front of the ankle
  • Pain while walking that is relieved with rest
  • Pain while walking uphill
  • Top of foot pain when wearing tight shoes

Diagnosis

Extensor Tendonitis is diagnosed via a physical exam at a foot doctor’s office. To rule out other potential causes of ankle pain, such as stress fractures, an x-ray of the ankle will be ordered. 

An MRI may be considered to thoroughly assess the extensor tendons. The imaging from an MRI can confirm tendon inflammation and effectively rule out tendon tears.

Treatment

The RICE (Rest, Ice, Compression, Elevation) protocol serves as an effective initial treatment strategy to alleviate pain associated with extensor tendonitis. 

Restricting walking and resting the foot for several weeks will reduce discomfort. In most cases, extensor tendonitis will resolve with adequate rest.

Proper footwear and the use of orthotics will redistribute pressure within the foot and decrease the tension on the extensor tendons. 

For over-the-counter orthotic solutions, Powerstep Pinnacle Orthotic is recommended, owing to its substantial arch support and a deep heel cup. It is particularly beneficial for individuals with mild to moderate flat feet.

For severe flat feet, Powerstep Pinnacle Maxx Orthotic is suggested. Its design is similar to that of the Powerstep Protech orthotic, with an additional heel post to prevent overpronation in severely flat-footed individuals.

The Powerstep Pinnacle High Arch Orthotic is ideal for those with high-arched feet. This orthotic offers an effective foot stabilization by perfectly contouring to the arch.

Physical therapy, extending over a month, can also offer significant relief from pain associated with extensor tendonitis. It improves the range of motion in the ankle and aids in pain reduction.

3) Anterior Tibial Tendonitis  

The anterior tibial tendon is a very strong tendon that is responsible for the upwards motion of the ankle and foot. 

Repetitive activities that cause forceful upwards motion of the ankle can cause pain along the anterior tibial tendon and result in tibialis anterior tendonitis. This is commonly seen in runners and even soccer players. 

Symptoms

  • Pain in the front inside portion of the ankle and foot
  • Swelling in the front of the ankle and foot
  • Bruising in the front of the ankle
  • Ankle weakness
  • Difficulty walking or running uphill and downhill
  • Stiffness in the ankle

Diagnosis

A physical examination is usually sufficient to diagnose anterior tibial tendonitis. Symptoms such as pain and swelling are typically observed along the ankle and the inner side of the foot, where the tendon inserts. X-rays might be ordered to exclude the possibility of fractures.

However, if a tear or complete rupture of the anterior tibial tendon is suspected, the healthcare provider may recommend an MRI for a more detailed visualization of the tendon.

Treatment

Anti-inflammatory medications and RICE therapy help alleviate pain associated with anterior tibial tendonitis. If there is significant inflammation of the tendon, limiting activities can help reduce painful symptoms. 

Physical Therapy can also be beneficial to reduce pain and improve strength.

If the anterior tibial tendon becomes torn or ruptured after an injury, surgery would be needed to prevent foot drop. 

How Long Does Anterior Tibialis Tendonitis Take To Heal?

Anterior tibial tendonitis can take anywhere from two to three months to heal depending on the severity of symptoms and inflammation of the tendon. 

Healing may occur faster in some people if they rest and undergo physical therapy to help improve pain and tendon function.

woman with injury ankle

4) A High Ankle Sprain Injury From Sports Could Be Causing Pain

A high ankle sprain (or syndesmotic sprain) could be causing pain in the front of the ankle. The syndesmotic ligaments exist in the syndesmotic space between the tibia and the fibula bone above the ankle joint. 

The syndesmotic ligaments prevent the tibia and fibula from spreading apart and also aid with shock absorption during activities. 

Syndesmotic injuries occur from twisting and rotational trauma to the ankle. These injuries can be seen in athletes who participate in high-impact sports like football and basketball. 

This can also be seen in runners. High ankle sprains may also occur due to falls. 

Symptoms

  • Pain and swelling in the front of the ankle
  • Bruising in the front of the ankle
  • A “popping” sound in the front of the ankle during injury
  • Difficulty walking due to pain
  • Inability to flex the ankle upwards and outwards
  • Stiffness in the ankle

Treatment

Conservative treatment methods like RICE (Rest, Ice, Compression, Elevation) therapy are typically effective for high ankle sprains. 

Applying ice to the ankle helps constrict blood flow, thereby reducing pain. Elevating the ankle will help decrease swelling and throbbing pain. 

The healthcare provider will recommend rest and may recommend wearing an ankle splint for about 3-4 weeks.

Physical therapy will be necessary to enhance strength and range of motion. Healing from high ankle sprains often takes at least 6 weeks.

In case of severe damage to the ankle ligaments, coupled with associated fractures, surgical intervention may be recommended. 

If surgery is necessary, the patient will need to stay off their feet and use a cast or splint for post-operative care for about 6-8 weeks.

5) Deep Peroneal Nerve Entrapment 

If an individual experiences burning and tingling sensations in the front of their ankle, it could indicate the entrapment of the deep peroneal nerve. This nerve travels along the front of the ankle and extends into the first webspace of the foot.

In certain people who have bony prominences at the front of their ankles, or those who wear tight footwear, the deep peroneal nerve can become irritated and compressed. 

Occasionally, soft tissue masses often seen in the ankle, such as ganglion cysts, can also result in nerve impingement.

Symptoms

  • Burning and tingling pain in the front of the ankle
  • Numbness in the front of the ankle
  • Pain with plantarflexion and inversion of the ankle
  • Pain when the nerve is tapped on

Diagnosis

The diagnosis of deep peroneal nerve entrapment often relies on a thorough history and physical exam. The doctor will perform a ‘Tinel’s test,’ tapping on the skin over the nerve to check if the individual experiences a burning and tingling sensation.

The healthcare provider will order x-rays of the ankle to rule out any bone prominences potentially impinging on the nerve. 

If a soft tissue mass is suspected to be pressing on the nerve, an MRI may be ordered to identify it.

Treatment

Most cases of deep peroneal neuritis can be treated conservatively. Avoiding tight, constrictive footwear that may exert direct pressure on the nerve is advisable. 

RICE (Rest, Ice, Compression, Elevation) therapy can help reduce pain and discomfort.

Corticosteroid injections can provide relief from nerve pain. If the ankle is swollen, wearing compression stockings can help reduce the swelling. Reduced swelling will alleviate nerve pain.

The Jobst 15-20mmHg compression stockings are recommended to reduce swelling. They  can be worn during the day and removed at night. They can be purchased on Amazon.

In rare instances, surgery may be needed for deep peroneal nerve entrapment. The procedure would involve decompressing the nerve and removing any masses or bone prominences present in the ankle. 

Post-operatively, the doctor will generally recommend weight-bearing as tolerated in a splint for four weeks or longer.

arthritis

6) Arthritis in the Ankle Joint

Different forms of arthritis, including osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis, could be the underlying causes of pain in the front of one’s ankle.

Osteoarthritis, often referred to as “wear and tear” arthritis, commonly develops with age. The gradual erosion of cartilage leads to the bones in the ankle rubbing against each other, causing pain and swelling.

Rheumatoid arthritis is an autoimmune disease capable of causing arthritis in the ankle. In this condition, the body’s immune system attacks its own tissues, resulting in cartilage damage and synovitis, both of which can cause discomfort.

Post-traumatic arthritis can emerge following an ankle injury, such as a fracture. This can cause damage on the ankle joint and cause painful symptoms years after the initial injury.

Symptoms

  • Pain and swelling in the front of the ankle
  • Stiffness in the ankle (especially in the morning)
  • Pain with walking
  • The warmth of the ankle
  • Cracking sound in the ankle joint

Diagnosis

The diagnosis of ankle arthritis typically involves x-rays, which may reveal a diminished joint space in the ankle and potential bone spurs. 

Doctors may also order blood tests to look for inflammatory markers indicating an autoimmune disease.

Treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as topical Voltaren 1% gel or oral medications like Motrin can be used to manage ankle arthritis. Physical therapy can also be beneficial in alleviating pain.

To stabilize the ankle joint and prevent excessive movement, doctors might recommend wearing an ankle brace. The Zenith ankle brace is an effective option that provides appropriate stability and can be worn comfortably in shoes.

In severe cases of ankle arthritis, surgery might be suggested. Bone spurs in the ankle can be removed arthroscopically. 

If there is extensive damage to the ankle joint due to post-traumatic arthritis, an ankle arthrodesis may be recommended, in which the ankle would be fused using plates, screws, or an intramedullary nail. 

Following surgery, the patient may need to stay off the foot for a minimum of 6-12 weeks. Full recovery could take up to a year.

To read more about arthritis and how it affects the foot, check out this post.
doctor and patient

When Should You Go to the Doctor for Ankle Bone Pain?

Recognizing the appropriate time to seek medical attention by a health care provider in the clinic for ankle bone pain is important in preventing further ankle joint injury and ensuring optimal healing. 

Although discomfort may resolve on its own, there are certain signs that warrant immediate consultation with a healthcare provider. 

Consider scheduling a visit with your doctor under the following circumstances listed below.

  • The presence of persistent ankle pain that has continued for several weeks.
  • An ligament injury or tendon injury that might suggest a sprain or strain
  • Observing redness in the area surrounding your ankle.
  • Experiencing difficulty while walking.
  • The sensation of numbness or a burning type of pain in your ankle.
  • Struggling with balance issues related to ankle discomfort.

Conclusion

In conclusion, it’s evident that numerous conditions could be triggering discomfort at the front of an individual’s ankle. Recognizing the root cause of this pain is important to receive the most effective treatment. In the event of an injury anterior to the ankle joint, it’s crucial to reach out to a foot specialist quickly for an accurate diagnosis and comprehensive care.

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Vaishnavi Bawa
Dr. Vaishnavi Bawa is a Podiatrist who specializes in treating foot and ankle pathology. LifesLittleSteps mission is to educate the public about foot health in an easy-to-understand manner using evidence-based medicine.
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