Ankle Injury: Diagnosis, treatment, rehabilitation and management for the patient and practitioner

Ankle injury can be debilitating and exhausting, affecting a patients mobility, quality of life and ability to work and partake in sports and exercise. Whether traumatic or insidious in nature, this page looks at the most likely cause of your ankle pain as well as what you can do about it. Whether you're a patient or a therapist looking for ankle injury diagnosis, orthopedic tests, treatment, rehabilitation or wishing to find out how modern medicine, and manual therapy can help, it's all here.

Ankle Injury Diagnosis

Depending on how you have injured your ankle there are a few very common causes of ankle pain and the chances are your, or your patient's complaint can be attributed to one of the following conditions.

  • Anterior Talo-fibular ligament sprain
  • Deltoid ligament injury
  • Plantar fasciitis 
  • Achilles tendinitis
  • Tarsal tunnel syndrome
  • Osteoarthritis
  • Syndesmosis sprain (high ankle sprain)
  • Fracture

A few things to rule when diagnosing an ankle injury is refereed, systemic or neuropathic pain, either from a nerve root irritation or other osteopathic pain for example diabetic neuropathy. Gout, rheumatoid arthritis and other types arthropathies also need to be ruled out before continuing.

Determining the onset of the injury is key to forming a diagnosis along with certain other aspects such as:

  • Mechanism of injury
  • Any snapping? 
  • Transient or fixed deformity at time of injury? Transitory locking? ( loose body, mm spasm, fracture)
  • Any swelling? Could you walk after the injury?
  • Sensory/motor changes?
  • Pain after activity? (suggest overuse)
  • What type of shoes do you wear

Pain on the inside of the ankle

Inside ankle pain can be completely debilitating but is most likely, if it is not due to direct trauma, to be caused by an overexercise or overuse injury. A manual therapist will know exactly what to look for and exactly how such an injury can be treated and what to do to prevent it from returning.

By looking at the biomechanics of the pelvis, hip, knee and ankle excessive strain can be eased from the offending tissue so that normal function and use can be restored usually fairly quickly, depending on how long it has been there.

With a small amount of lower extremity (leg) rehabilitation and reconditioning in the form of strengthening and stretching, inner, or medial, ankle pain can be easily fixed. Follow this link to read more about inside ankle pain and how you can help yourself and your patients.

Sharp ankle pain

If you have particularly sharp ankle pain then you need to rule out either a fracture or a stress fracture as well other more systemic conditions such as rheumatoid arthritis. The chances are however that you are most likely suffering from a sprain, tendinopathy or arthritis - all of which can be simply and effectively diagnosed and in most case well treated or at least well managed. For more information follow this guide for more in depth information about sharp ankle pain.

Things to look out for: observation

Osteopaths like Louise and I will look out for certain things when we're examining a patient. This include fairly obvious things (for example if a toes is missing, or the even the foot) but also more subtle things like the shape and symmetry of the arches and even uneven wear on the soles of the shoes. Here's a list of things to look out for when examining your or your patients foot and ankle.

  • Check shoes for signs of abnormal wear
  • Standing foot and ankle alignment from behind
  • Arches and alignment of achilles tendon
  • Deformities, bunion, callus, frostbite, gangrene etc
  • Hair loss, pallor (diabetes)
  • Musculature atrophy especially in gastrocnemius (likely neuropathic cause)
  • Gait analysis

We'd also look out for movement in the foot and ankle and oftentimes the knee and hip too. Specifically we're looking for any abnormalities in range of movement and quality of movement but also looking for any clicking, weakness, hyper-mobility and restrictions. For the ankle we need to examine its specific vectors of movement, which are:

  • Dorsiflexion
  • Plantarflexion
  • Eversion
  • Inversion
  • Circumduction (look for clicking of peroneal tendon or retinaculum)
  • Toe flexion and extension

Palpation and things to feel

A good manual therapist will feel and palpate every aspect of the foot, ankle and calf to help form a diagnosis. What we're feeling for is any abnormalities between the good and bad ankles, this might include any swelling, heat, obvious tendon or ligament rupture, muscle spasm and callus formation.

Checking the pulses are also important so check the dorsalis pedis pulse which is on the top of the foot and the posterior tibial pulse, behind the medial malleolus. Check all tendons entering through the ankle and check the plantar fascia for pain and thickening especially around  the medial tubercle of the calcaneus.

Nerve impingement and irritation

The ankle is a very common site of neurological symptoms, and with any ankle injury you need to rule out nervous tissue damage as a cause and also as a consequence. Blow are the most commonly affected nerves either due to, or responsible for ankle pain.

The main tests used by practitioners include Tinnels sign, which involves gently and repeatedly tapping the nerve at various locations (for example the tarsal tunnel) to elicit a response (which usually arises in the form of dysthesia or parasthesia, along the course of the nerve or most commonly in it's sensory distribution).

Nerve stretch tests are also used but are more difficult to perform in the ankle due to the limited range of movement of the knee and ankle compared to say the arm. The straight leg raise (SLR), as well as eliciting pain caused by nerve root compression, can also sometimes highlight peripheral neurological impingement in or around the foot and ankle.

Deep peroneal nerve 

Check the Deep peroneal nerve which get its innervation from L4- S2 and can be irritated or compressed due to anterior compartment syndrome and also under the extensor retinaculum (Anterior Tarsal tunnel syndrome).

Symptoms are most likely to appear between the 1st and 2nd toes on the top of the foot but in severe case peroneal nerve entrapment will cause drop foot, an inability to lift or dorsiflex the foot.

Superficial peroneal nerve

Superficial peroneal is innervated by l4 - s2 and can be caused by a lateral, or outward ankle sprain (the most common type) as well as becoming trapped by fascial tissue at the lateral malleolus. Patients will present with an inability to evert the foot as well as having sensory changes such and paresthesia (pins and needles), numbness and dysesthesia (abnormal sensation) around the outside of the ankle and across the top foot to the toes.

Tibial nerve

The tibial nerve (L4 - S3)is a fairly common nerve to get impinged and itg does so most predominantly in the tarsal tunnel (behind the medial malleolus on the inner ankle) leading to a well known ankle injury called tarsal tunnel syndrome. Other less common sites include the popliteal fossa and below/behind the soleus muscle.

This injury is largely due to either swelling from a traumatic ankle injury such as a strain, knee dislocation or para-tendinitis of the tibialis posterior tendon. Patients are most likely to lose the ability to actively plantar flex and invert their foot at the ankle but also flex their toes. There will be some sensory disturbance at the sole of the foot

Medial and lateral plantar nerves

A rare cause of foot pain is compression or injury to the medial and lateral plantar nerves (L4 - S3) which can lead to burning heel pain and in some case over-pronation of the foot.

Orthopedic tests for determining the cause of ankle pain and injury

While modern imaging technology is effective at determining the tissue causing pain and the exact cause of various conditions, when it comes to the ankle, sound anatomical, biomechanical and orthopaedic knowledge are usually more then effective. When it comes to testing the ankle for injury professional use the following tests.

Anterior drawer test – The examiner pushes the tibia (and fibula) posteriorly observing the amount of posterior translation (sensitivity 86% and specificity 74%). If the anterior talofibular ligament is torn, the talus will sublux anteriorly compared with the unaffected ankle

Anterior Talofibular & Calcaneofibular Ligaments - To test instability of lateral aspect of ankle  Patient is seated with their legs dangling from the examination couch. The practitioner then applies an inversion stress on the calcaneus. Localised pain and joint instability would be suggestive of ligamentous instability or injury.

The Posterior Talofibular Ligament  - For the posterior talofibular ligament to be involved a massive trauma such as a dislocation must be sustained. It is therefore not practical to assess this ligament as referral would be you course of action.  This ligament can be torn/sprained only in conjunction with the other lateral ligaments 

The Deltoid Ligament - Stabilise leg by contacting the tibia and calcaneus applying an eversion stress. Localised pain and gapping indicative of ligamentous instability.   

Inversion Talar tilt test - Have the patient in the seated position, with their knee bent and foot in a neutral or slightly dorsiflexed position. Stabilize the distal tibia with one hand while applying an inversion force to the foot. Positive findings include any pain in the ankle or increased joint laxity.  Talus tilts or gaps excessively; pain 

Eversion Talar Tilt Test - Have the patient in the seated position, with their knee bent and foot in a neutral or slightly dorsiflexed position. Stabilize the distal tibia with one hand while applying an inversion force to the foot Talus tilts or gaps excessively; pain 

External Rotation or Kleiger’s Test - Patient seated with their knee bent on the exam table. Stabilize the distal tibia while externally rotating the foot. External rotation of the talus applies pressure to the lateral malleolus, causing a widening of the tibiofibular joint. Positive findings: Increased external rotation of the foot when compared bilaterally, or any pain in the anterolateral ankle joint is considered to be a positive finding. 

Thompson’s Test - Have the patient lying prone on a table with their foot extended off the edge. Squeeze the calf muscle at position slightly distal to the place of widest girth. Examine the movement at the foot. A positive test occurs when the calf is squeezed and no plantar movement occurs at the foot.  

Hyperdorsiflexion sign - with the patient prone and knees flexed to 90°, maximal passive dorsiflexion of both feet may reveal excessive dorsiflexion of the affected leg Excessive dorsiflexion Compression Test - Patient sitting with their foot on the table. Grasp the mid-calf and squeeze the tibia and fibula together. Gradually move distally to ankle. Any pain in the lower leg may be indicative of a fracture or syndesmotic sprain. 

Side to side test – Sitting/supine. Stabilises the lower leg with one hand. Grasps the rear-foot and slides the talus/calcaneus laterally and medially. A positive test will create pain and a noticeable "clunk"

External rotation stress test - externally rotate and then passively dorsiflex the ankle.  Pain at the syndesmosis is a positive test. 

Morton’s Neuroma - Morton’s neuroma is a common finding in the feet. Direct compression is applied between the metatarsal heads. Compression through all metatarsal heads. Localised pain.  A Morton’s neuroma is usually found between the 3rd and 4th metatarsal heads. 

Tinnel’s Sign - For detecting Nerve irritation. Lightly tap the deep peroneal nerve, a positive result will cause tingling or pins and needles in foot.

Ankle Injury treatment and rehabilitation

Osteopaths such as Louise and I take a very holistic view to ankle injury and believe that for proper function to be restored and for pain to be removed, every aspect of the body from the foot and ankle to the head and neck needs to be addressed and restrictions removed where appropriate.

In the following video Louise demonstrates an example of how an osteopathic examination and treatment is carried out, as well as demonstrating some techniques for the treatment of ankle injury. Some of the techniques which are specifically effective for treatment of ankle injury are outlined below with information on the mechanism of action and physiology.

Soft tissue work

Soft tissue work, sports massage and myofascial work constitute an important part of ankle treatment. Removing tension from tight or spasmodic muscles, restrictions and tightness in fascia as well as improving the blood supply to muscles and aiding in waste removal and the reduction of swelling.

Overuse, trauma, inactivity and stress causes increased tension in muscles leading to reduced blood flow and local ischaemia. This  leads to pain but also a build up of waste products in the area which cause further irritation, inflammation and pain (substance P, prostaglandins, cytokines, histamine and bradykinin). Over a long period of time the situation becomes chronic leading to tissue fibrosity and shortening or tightening of the muscle. Soft tissue work essentially increases circulation to and drainage from the area to diminish the inflammation and improve lymphatic circulation. 

There are 4 main types of soft tissue work and several sub sections discussed elsewhere. The main types include inhibition, effleurage, neuromuscular technique (NMT) and trigger point release. In the case of ankle injury effleurage is of utmost importance, as is neuro-muscular technique. Follow this link for how to treat swollen ankles.


Articulation of joints is a fundamental part of treating it. With articulation we move the ankle and foot joint through their natural range of motion and extending it to its full physiological range. We do this to to increase mobility, blood supply and help with venous/lymphatic drainage.

The benefits of this extend to the hyaline cartilage covering the inside surface of the joints, the movement of joint pushes synovial fluid into the cartilage providing it with important nutrients and waste removal - essential for the health of the joint.

Articulation can also be effective in restoring proper position of anatomical structures, structures which may have been misaligned due to ankle injury. For example in an eversion ankle strain the talus bone can be shifted forwards, altering the mechanic of the foot and ankle ultimately leading to poor function, increased pain and a higher chance of reinjury.

Balance ligamentous tension (BLT)

When it comes to treating an ankle injury, especially a very traumatic one, BLT is an extremely valuable tool in a manual therapist tool kit. In a healthy joint the articular mechanism is held by ligamentous tissues which are in balanced and even tension. In trauma, if not torn the ligaments will still attempt a relative state of balance. By taking the tissues to a point of balance in which all the forces are at zero or neutral, the involuntary forces within the body can be utilized to correct the problem.

Ankle injury rehabilitation

As previously mentioned, to maintain and aid in recovery of ankle issues, stretching and strengthening are absolutely crucial. It is recommended to get proper, informed advice from an expert but if you can't, here are some well established exercises for your ankle. The following guide is expanded for more information on how to stretch your ankle and ankle weight exercises.

I hope you enjoyed this guide on ankle injury diagnosis, treatment and rehabilitation. For more information follow our channel on youtube and keep up to date with all the goings on at the Osteo Fitness Collective.