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There are many reasons why you may experience outside of ankle pain. These reasons include peroneal tendonitis, lateral ankle sprains, sinus tarsi syndrome, OCD lesions, and fractures.
In this article, you’ll learn the causes of outer ankle pain and how to treat it.
What Causes Outer Ankle Pain?
1) Peroneal Tendonitis
The peroneal muscles originate in the leg and become tendons as they are coarse further down the ankle. The peroneal tendons help with the eversion motion of the foot and ankle, as well as plantarflexion (foot and toes pointing in a downward direction).
What Causes the Peroneal Tendons to Become Inflamed?
Overuse of the peroneal tendon can cause tendonitis. For instance, if you are fairly active and participate in a lot of sports that could be causing you to overuse the peroneal tendons, you may develop peroneal tendonitis.
Swift cutting motions of the ankle required during certain sports like basketball can cause the peroneal tendons to become strained.
Peroneal tendonitis can also occur after participating in prolonged activities without appropriate warm-up training. It can occur during repetitive activities such as jumping and running.
Also, certain foot structures, like individuals who have high-arched feet, are more likely to have issues with peroneal tendonitis due to excess stress on the outside of the foot and ankle associated with their foot structure.
Symptoms of Peroneal Tendonitis
- Pain and swelling along the outside portion of your ankle along the peroneal tendons
- Warmth in the ankle
- Pain with eversion and inversion of the ankle
- Bruising of the ankle
- Inability to bear weight due to pain
- Weakness of the ankle
How Do You Diagnose Peroneal Tendonitis?
If you suspect you have peroneal tendonitis, you should be evaluated by a foot doctor.
Your doctor will obtain a history and perform a physical exam. Your doctor will palpate your tendons and check where exactly the tendon may be inflamed.
Your doctor will then order an x-ray of your foot and ankle. Although soft tissue structures cannot be visualized on an x-ray, the x-ray allows your doctor to rule out any anatomical abnormalities like bone spurs and abnormalities in the shape of your ankle bone that could be causing your peroneal tendons to have issues during activities.
Not only that, x-rays allow visualization of your foot structure. It can help your doctor understand if your foot structure is causing these injuries.
Your doctor may order a Magnetic Resonance Imaging scan (MRI) to confirm peroneal tendonitis. An MRI allows visualization of the peroneal tendons in detail and can help identify the presence of tendonitis and tendon injury.
In some cases, the peroneal tendon may tear or dislocate. An MRI can help identify this.
How Are Peroneal Tendon Injuries Treated?
Peroneal tendonitis can often be treated conservatively. RICE therapy can help reduce pain and discomfort in the peroneal tendons.
Your doctor may suggest you wear an ankle brace for a month or longer to help improve the stability of the ankle when you are walking.
The Zenith ankle brace is effective for peroneal tendonitis. You can buy it on Amazon. It is a supportive ankle brace and will provide your ankle with appropriate stability. You can wear it with your shoes.
Peroneal tendonitis can take 6-8 weeks to resolve, and your doctor will suggest you limit your activities to prevent further damage to the tendon.
Your doctor will suggest physical therapy to help improve ankle range of motion, decrease pain, and improve balance.
Here’s an article that demonstrates how to properly perform stretching exercises for peroneal tendonitis.
After the tendonitis symptoms improve, your doctor may suggest you wear custom orthotics to help alleviate strain along the outer ankle. You can request a script for a pair of custom orthotics at your foot doctor’s office.
A custom orthotic is an orthotic that is designed for your unique foot structure. Although they can be pricey (ranging from $300-$800) a pair, they usually will last for several years (5-7 years).
2) Lateral Ankle Sprains
Ankle sprains are more commonly seen in athletes, but can occur in anyone. A lateral ankle sprain occurs when you twist your foot and ankle in an inwards direction.
This can cause the 3 ligaments mentioned previously (ATFL, CFL, and PTFL) to become stretched out and weak.
The anterior talofibular ligament is the weakest and is the first one to become injured, followed by the calcaneofibular ligament, and lastly the posterior talofibular ligament.
Occasionally, tears of the ligaments can occur. If there is an injury to all three ligaments, complete instability of the ankle joint may occur.
What Are the Symptoms of an Ankle Sprain/Tear?
- Pain with swelling on the outside of the ankle
- Bruising on the outside of the ankle
- Inability to bear weight on the ankle
- Feeling like the ankle is going to give away when trying to walk
- Restricted range of motion when trying to move the ankle up and down
- Hearing a “snap” or “pop” notice during injury
How Are Ankle Sprains Diagnosed?
If you twist your ankle, you should stop your activities and start RICE therapy to help control ankle pain and swelling.
If your pain is severe and you cannot bear weight on your ankle, it’s a good idea to contact a foot doctor.
Your doctor will obtain a history and perform a physical exam by checking which ankle ligament may be injured.
Your doctor will order x-rays of your foot and ankle to check for fractures in the ankle joint.
Your doctor may order an MRI to evaluate the ankle ligaments more clearly. The MRI will show whether the ankle ligaments are sprained or torn.
How Are Ankle Ligament Injuries Treated?
The majority of ankle sprains can be treated conservatively without surgery. If you have a mild to a moderate ankle sprain or partial tear of one of your ankle ligaments, your doctor may suggest you walk in a lace-up ankle brace for a month.
You should continue RICE therapy to reduce pain and swelling in your ankle.
You will need physical therapy (approximately 4 weeks) to improve ankle stability. This is because when you sprain your ankle, you become more likely to sprain the same ankle due to damage to proprioception receptors in your ankle.
Proprioception receptors send signals to your brain about the position and movement of your ankle.
If you have a severe ankle ligament injury that is unresponsive to conservative therapy, your doctor may suggest surgery.
Surgery would be done in the operating room under general anesthesia. Your doctor will repair your ankle ligaments.
After the surgery, your doctor will suggest you stay off of your foot in a splint or walking boot for 6 weeks, followed by gradual weight bearing and physical therapy.
Recovery may take anywhere from 3-6 months depending on the individual and the injury.
3) An Osteochondral Lesion of the Talus Could Be Causing Outer Ankle Pain
An osteochondral lesion (OCD) lesion of the talus is when there is damaged cartilage present in the talus bone. An OCD lesion can occur after a twisting injury.
Osteochondral lesions can occur on the inside or outside of the ankle. Outer OCD lesions will cause pain along the outer ankle.
What Are the Symptoms of Anterior Lateral OCD Lesions?
- Catching or locking of the ankle joint
- Swelling in the ankle
- Dull, achy pain in the outer ankle
- Pain when walking on the ankle
- Bruising of the outer ankle
How Are OCD Lesions Diagnosed?
If you have sprained your ankle in the past and feel a constant, dull achy pain in your outer ankle, you should see your doctor.
Your doctor will obtain x-rays of your ankle. OCD lesions can be visualized on x-ray, however, it is a subtle finding and is often missed.
Your doctor may choose to order an MRI to visualize the talus as well as assess for any ligament and tendon damage in your ankle.
Your doctor may want to order a Computed Tomography scan (CT scan) to evaluate the talus in more detail. A CT scan allows visualization of the outer cortex and bone more clearly.
How Are Anterior Lateral Talar OCD Lesions Treated?
If the OCD lesion shows minimal damage to the ankle, your doctor may suggest immobilization in a cast boot for 4 to 6 weeks. Alleviating pressure in your ankle can help reduce ankle pain and help the OCD lesion heal.
However, if the OCD lesion is large and there is significant displacement (shifting) of the fragment, your doctor may suggest surgery. Surgery would be done in the operating room under anesthesia.
Your doctor will clean out the joint. If the defect is large, he/she may insert a bone graft in the ankle bone to allow for the area to heal.
After surgery, your doctor will instruct you to remain off of your foot in a cast/splint for up to 6 weeks, followed by gradual weight bearing and physical therapy. Recovery could take 3-6 months.
4) Sinus Tarsi Syndrome Could Be Causing Outer Ankle Pain
The sinus tarsi is the tunnel of space between the talus and calcaneus bone. Inside the sinus tarsi, there are connective tissue, fat, and nerve endings.
Impingement, injury, and instability of the sinus tarsi are known as “sinus tarsi syndrome”. This can occur due to a severe ankle sprain which causes the tissues in the sinus tarsi to become pinched and strained.
However, it can also occur due to chronic impingement of the sinus tarsi in a flat-footed person who overpronates (foot rolls inwards).
Symptoms of Sinus Tarsi Syndrome
- Pain and swelling in the ankle
- Constant, dull throbbing pain in the outer ankle when standing and walking
- Pain with inversion and eversion motion of the ankle
- Pain when walking on uneven surfaces
- Bruising of the ankle
How Do You Diagnose Sinus Tarsi Syndrome?
Your foot doctor will perform a history and physical exam by palpating the sinus tarsi. If you have tenderness in the sinus tarsi with a history of ankle sprain, you may likely have inflammation in the area.
Your doctor will order x-rays to assess your foot structure and see if it is contributing to the impingement of the structures in the sinus tarsi.
An MRI may be ordered to confirm the presence of inflammation and soft tissue in the sinus tarsi. Not only that, an MRI can help rule out the presence of an adjacent ankle ligament sprain/tear.
How Is Sinus Tarsi Syndrome Treated?
In most cases, sinus tarsi syndrome pain can be treated conservatively with immobilization. Your doctor may suggest you wear an ankle brace to help reduce ankle motion.
Steroid injections can be beneficial in reducing pain.
If you have severely flat feet, your doctor may suggest custom orthotics to help elevate the arch of the foot and alleviate pressure along the sinus tarsi.
You should start RICE therapy and reduce activities for a few weeks. Your doctor will recommend physical therapy to help reduce pain and improve balance.
In rare cases, surgery may be needed for sinus tarsi syndrome. Surgery would be done in the operating room under anesthesia.
Your doctor would remove inflammatory tissue that is present in the sinus tarsi that is causing your pain.
You will need to be immobilized in a cast boot after surgery for 4-6 weeks with minimal weight bearing, followed by physical therapy for a month.
5) Fracture of the Lateral Malleolus Could Cause Outside of Ankle Pain
An ankle fracture occurs when one or more bones in the ankle joint break due to trauma. The most common type of ankle fracture involves the lateral malleolus, which is the bony prominence on the outside of the ankle.
This is known as the “fibula”. Fibular fractures occur due to injury, and can cause outer ankle pain.
Symptoms of an Ankle Fracture
- Swelling and bruising in the ankle
- Difficulty bearing weight on the affected leg
- Visible deformity
- Limited range of motion in the ankle joint
- Numbness/tingling in the ankle
- A “popping” sound at the time of injury
Diagnosis
Fibular fractures can be diagnosed through a combination of a physical examination and imaging tests. During the physical examination, your doctor will assess your symptoms and perform a physical exam.
Imaging tests, such as X-rays or a CT scan, can provide a detailed view of the fracture and help determine the severity and location of the injury.
In some cases, a MRI (magnetic resonance imaging) may also be used to evaluate the soft tissue structures around the fracture.
Treatment
The treatment for fibular fractures depends on several factors: severity and location of the fracture, the age and overall health of the patient, and the patient’s activity level.
In many cases, the initial treatment for a fibular fracture involves immobilization of the affected leg with a cast for 6-8 weeks.
For more severe or complicated fractures, surgery may be required to realign the bones and stabilize the fracture with pins, screws, or plates.
After surgery, the patient may need to wear a cast or brace for several weeks and undergo physical therapy to regain strength and mobility in the affected leg.
Conclusion
As you can see, there are multiple reasons why the outside of your ankle may hurt. It’s important to seek help if you experience constant outer ankle pain. By identifying what the issue is that is causing your ankle to hurt, you can appropriately treat it and speed up your recovery.
Make sure to contact your local foot doctor if you experience outer ankle pain.
Related article: Front of Ankle Pain (Anterior): Causes, Symptoms, Diagnosis & Treatment
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References
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3. Simpson MR, Howard TM. Tendinopathies of the foot and ankle. Am Fam Physician. 2009 Nov 15;80(10):1107-14. https://pubmed.ncbi.nlm.nih.gov/19904895/
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6. Grandberg, C., de Oliveira, D.P. & Gali, J.C. Superior peroneal retinaculum reattachment for an atraumatic peroneus brevis tendon subluxation: a case report. J Med Case Reports 16, 239 (2022).https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-022-03455-y#citeas
7. Bruns J, Habermann C, Werner M. Osteochondral Lesions of the Talus: A Review on Talus Osteochondral Injuries, Including Osteochondritis Dissecans. CARTILAGE. 2021;13(1_suppl):1380S-1401S.https://journals.sagepub.com/doi/full/10.1177/1947603520985182
8. Hannon CP, Smyth NA, Murawski CD, Savage-Elliott I, Deyer TW, Calder JD, Kennedy JG. Osteochondral lesions of the talus: aspects of current management. Bone Joint J. 2014 Feb;96-B(2):164-71. https://pubmed.ncbi.nlm.nih.gov/24493179/9. McGovern RP, Martin RL. Managing ankle ligament sprains and tears: current opinion. Open Access J Sports Med. 2016 Mar 2;7:33-42.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780668/
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