46 Ankle Pain

Ankle Pain

There are a number of different things to take into consideration when assessing a patient with ankle pain.

  • One cause of ankle pain can be peroneal tendinopathy, which is described as persistent peroneal tendon pain and loss of function related to mechanical loading (Scott et al., 2020).
  • Another causes of ankle pain is a sprained ankle, there are three different types of ankle sprain all with varying severity:
    • Inversion (lateral) ankle sprain – The most common type of ankle sprain involving tearing of the ligaments on the outside of the ankle (anterior talofibular ligament).
    • Eversion (medial) ankle sprain – Involving a tear of the deltoid ligaments, on the inside of the ankle.
    • High (syndesmotic) ankle sprain – Injury to the tibiofibular ligament above the ankle.


The structure of the foot consists of 26 bones, 33 joints (20 of which are actively articulated), 4 layers of arch muscles, and 100+ muscles, tendons, and ligaments. Following an initial ankle injury there is a risk of re-injury dependent on a combination of factors including, but not limited to: sensorimotor deficits and changes in ankle biomechanics.


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Outcomes Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • Lower Extremity Functional Scale (LEFS)
  • Foot and Ankle Ability Measure
  • Foot and Ankle Disability Index

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Talar Tilt Test
  • Anterior Drawer of the Ankle
  • Calcaneocuboid Stress Test
  • Calcaneofibular Stress Test
  • Talofibular Ligament Stress Test (Anterior & Posterior)
  • Deltoid Ligament Stress Test
  • Dorsiflexion External Rotation Stress Test (Kleiger’s Test)
  • The Syndesmosis Squeeze Test
  • Tinel’s Sign



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

Massage therapists are uniquely suited to incorporate a number sensory-targeted rehabilitation strategies for patients with chronic ankle instability (Mckeon et al., 2016). This may include superficial peroneal nerve mobilization – the superficial peroneal nerve passes between peroneal muscles and the extensor digitorum longus. It then pierces the deep fascia and is divided in cutaneous nerves that enter the foot to innervate the dorsal surface (Plaza-Manzano et al., 2016). The specific movement to mobilize the superficial peroneal nerve involves plantar flexion with inversion combined with straight leg raise. Branches of the saphenous nerve also innervate the talocrural capsule.

Structures to be Aware of When Treating Ankle Sprains

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from ankle pain may include neurovascular structures and investing fascia of:

  • Plantar Fascia
  • Lumbricals
  • Adductor Hallucis
  • Flexor Hallucis Brevis
  • Metatarsals & Interossei
  • Peroneals (peroneus longus, peroneus brevis)
  • Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius)
  • Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)
  • Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior, popliteus)
  • Ankle Joint (talocrural joint, subtalar joint and the inferior tibiofibular joint)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as stretching, strengthening and proprioceptive exercises may be useful for people with ankle pain.


Prognosis is favorable, a multi-modal rehabilitation approach utilizing exercise (proprioceptive and strengthening) and manual therapy (plantar massage, joint mobilizations and nerve mobilization) can be used to enhance motor control in patients (Doherty et al., 2017; Plaza-Manzano et al., 2016).

Massage Sloth: Massage Tutorial – Ankle Pain Techniques and Strategy

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for ankle pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

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Albin, S. R., Koppenhaver, S. L., Marcus, R., Dibble, L., Cornwall, M., & Fritz, J. M. (2019). Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. The Journal of orthopaedic and sports physical therapy, 49(5), 310–319. doi:10.2519/jospt.2019.8864

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Cox, T., Sneed, T., & Hamann, H. (2018). Neurodynamic mobilization in a collegiate long jumper with exercise-induced lateral leg and ankle pain: A case report. Physiotherapy theory and practice, 34(3), 241–249. https://doi.org/10.1080/09593985.2017.1377793

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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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