Posterior Ankle Pain: Causes, Symptoms and Treatments

Posterior Ankle Impingement Syndrome (PAIS)

Symptoms of PAIS depend on the cause but typically involve pain and problems in moving the foot normally, with activities such as walking being affected. In PAIS, the pain is felt deep in the back of the ankle and is brought on by pointing the foot down or standing on tiptoe. Doing activities such as sport or dancing often make it worse and the back of the foot is often stiff and painful when ‘pushing off’ the foot (such as when sprinting).

Sever’s Disease

In Sever’s disease, the heel pain comes and goes, being worse when running or jumping and on waking. It also causes limping or walking on the toes (to avoid putting pressure on the heel) and the back of the heel is painful if squeezeed. With heel spurs, standing can be painful and the pain is felt at the bottom of the heel bone. There may also be swelling in that area and the spurs can cause limping or difficulty with walking.

Achilles tendinopathy

Achilles tendinopathy typically causes pain and stiffness around the tendon that is worse on waking and usually develops gradually over a few weeks. It is often worse after exercise although it may temporarily feel a little easier when exercising. You may also notice some thickening or swelling of the Achilles tendon itself. With an Achilles tendon rupture the symptoms are usually sudden with people often hearing a loud ‘crack’ or ‘snap’ sound along with sudden pain at the back of the heel as if being hit there. There may be an immediate inability to walk normally or point the toes. (Although it can occur at any age it is most common in people aged between 30 and 50 who play sport occasionally rather than regularly).

How is posterior ankle pain diagnosed?

Your doctor or healthcare professional will take a detailed history about your symptoms including how long you have had them, whether any activities make them better or worse and whether you have any other medical problems that could affect your joints. They will examine your ankle, check whether moving your foot downwards makes your pain worse (such as occurs in PAIS), and look to see if your Achilles tendon is inflamed, swollen or ruptured. If it felt that diagnostic imaging of your ankle may help determine the cause of your pain, X-rays can show any bone abnormalities or heel spurs and CT or MRI scans can show up any abnormalities in the soft tissue at the back of the ankle and whether there is any pinching of your ligaments, muscles or other tissues in that area.

If they are needed there are a number of possible medical treatments available but these depend on the cause of the posterior ankle pain.

These include braces or splints to help stabilise the ankle, painkillers that reduce ankle inflammation and discomfort, orthotic inserts that fit into your shoes and which help align your feet in the correct anatomical position, and physiotherapy.

More intensive medical treatments include joint aspiration using a needle to remove any excess fluid from the ankle, steroid injections to reduce pain and inflammation, and occasionally surgery to repair torn tendons or ligaments.

Always ask your doctor whether you need medical treatment or if self-care will treat your symptoms first.

What self-care measures can I do to relieve posterior ankle pain?

Fortunately, many cases of posterior ankle pain get better with time, rest and simple painkillers. If you find that your ankle is still painful after trying self-care measures then speak with your doctor. The initial advice is usually the ‘RICE’ approach which is a simple self-care technique that helps to reduce ankle swelling and pain, and speed up healing:

• Rest your ankle. Try to stay off your feet as much as possible for 24-48 hours, avoid exercising and don’t try to ‘run off’ the discomfort as this may end up making things worse.

• Ice your ankle. This helps to reduce swelling and pain but don’t put ice directly onto your skin. Use an ice pack wrapped in a towel and apply this to your ankle for 10-15 minutes every few hours. (If you don’t have an ice pack then a bag of frozen peas in a towel works just as well!)

• Compress your ankle with an elastic medical bandage to help support the joint and reduce swelling. Be careful though not to wrap the ankle too tightly here - if you do, the blood flow to it can be affected. Loosen the bandage if the skin goes cold or numb, or turns blue.

• Elevate your foot. This means keeping your ankle propped up in front of you when you are sitting and keeping it elevated at night when you are asleep. This helps reduce swelling and discomfort.

As well as following this RICE advice, using non-steroidal anti-inflammatory painkillers (NSAIDs) such as ibuprofen, diclofenac or naproxen help to reduce pain and inflammation in the ankle, and these can be taken as tablets or rubbed into the ankle as an ointment or gel. (Check with your GP first that it is safe for you to use these as some people with asthma, high blood pressure, kidney failure and heart failure may not be able to use them.) Always make sure that you are wearing supportive and comfortable footwear. Avoid shoes that are too loose - including sandals and flip-flops - and consider using heel inserts in your shoes to help reduce your symptoms.

Exercises to help treat posterior ankle pain

It is important to have strong ankle muscles and joints to help both prevent posterior ankle pain and increase your chances of recovery if you have it, and exercises can help you achieve this. Remember that you should never do any exercise that makes your pain worse. There are 5 main groups of exercise that can help here - ankle stretches, ankle flexion, ankle rotation, heel raises and heel slides.

• Ankle stretches. Sit on the floor with your legs out in front of you and wrap a towel or resistance band around your toes on both feet. Pull back slightly until you start to feel a stretch in the soles of your feet and the back of your calves. Hold for 30 seconds and repeat 3 times.

• Ankle flexion. Sit on a chair with your left leg extended in front of you. Flex the top of your toes backward, and hold for 20 seconds. Relax, and repeat 10 times before doing the same with your right leg.

• Ankle rotation. Lying on the floor, raise your right foot about 20 inches then rotate it to the left and then back to the right. Hold for 10 seconds then return to the starting position. Repeat 20 times then do the same with your left foot.

• Heel raises. Stand near a wall or chair that you can balance against then slowly raise your left foot backward until your lower leg is at a 90 degree angle. Hold for 5 seconds, return to the starting position. Repeat 10 times then do the same with your right leg.

• Heel slides. Lie comfortably on your back and slide your right heel up towards your buttocks as far as comfortable, then slide it back down. Repeat 10 times then do the same with your left leg. with each leg.

You may not always be able to prevent posterior ankle pain but you can help to reduce the risk of it occurring by keeping your bones, ligaments and tendons strong.

To help achieve this, keep your weight at a healthy level to prevent putting undue strain on your ankles. If you are overweight, try to lose weight by exercising regularly and eating a healthy diet.

Aim to keep your other muscles - such as your hamstrings, back and gluteal muscles - strong and flexible to help reduce the risk of injury, and never ignore ankle pain if it occurs.

If you find a particular ankle movement is painful, always rest it or take a break and see your doctor if it does not settle.

Always make sure you warm up properly before doing any exercise, including stretching, as ankle ligaments and tendons are less likely to be injured when they are warmed up.

If you have chronic posterior ankle pain, always make sure that you have seen your doctor so that an accurate diagnosis can be made and the correct treatment given.

Understanding the cause of your ankle pain can allow you to adapt your lifestyle so that it is not aggravated by certain activities but you should always aim to live as active a life as possible, including exercising in ways that do not put strain on the ankle (such as swimming).

Avoiding being overweight is important, and taking occasional painkillers if required is fine provided you are taking them in the recommended dose. If you find that your pain is significantly affecting your daily activities then your doctor can refer you to an ankle specialist for more detailed investigations.

If you have posterior ankle pain, don’t let it get you down. Here at Healthwords we want to keep you up to date with everything we are doing to give you the latest up to date information about a wide range of health conditions including joint pain so make sure you subscribe to our newsletter as well as looking at the products we have available that can help with joint pain.