One of the most common (and frustrating) niggles from running is front ankle pain.
It can creep up over a number of runs, starting with an uncomfortable tightness in the ankle and building to a stabbing pain or constant ache in the front of the ankle.
The secret to treating front ankle pain effectively is to understand the loading pattern that’s lead to the pain, then address that issue.
Why does the top of my ankle hurt?
The front of the ankle can become painful during running due to a number of different pathologies (ie. different injuries).
Each of these pathologies causes pain in a slightly different area so it’s worth identifying exactly where the pain is centred.
Based on the location and behaviour of the front ankle pain, you should be able to determine the type of injury and likely reason for the issue.
From there, you can trial different approaches to treating the front ankle pain. As a healthcare professional, we recommend only trialling one treatment approach at a time and wait until you can determine its effect before adding or trialling a different treatment.
This is to make it easier to figure out the effect of each treatment. This slower approach will actually help resolve the front ankle pain faster with less confusion.
As a quick example, let’s say you try stretching the ankle. Within 3 days, you realise it’s making it worse. So you stop that and try some lower drop shoes, which helps. After a week, you add some gentle strengthening exercises which gradually solve the problem.
Plan B for the impatient runner: try it all at once. You stretch, change shoes and strengthen. After a week, it’s no different – is it not working or is the stretching offsetting the benefit of the other approaches?
What do you call the front part of your ankle?
The front of the ankle is divided up into three regions for ease of categorisation: the centre of the front (anterior), the front part closest to the other ankle (anteromedial) and front part furthest from the other ankle (anterolateral).
Each area is home to a different collection of structures and loading demands, so each has their own unique injuries that can cause front ankle pain.
Anteromedial ankle pain
Pain at the front inside aspect of the ankle is commonly caused by a bony impingement or by a reaction of the Tibialis Anterior tendon (or “Anterior Tibialis” for our American readers).
A bony impingement (a form of Talocrural Impingement) occurs when the sensitive tissue surrounding the joint gets aggravated and inflamed. It may have been squashed as the ankle moves forward or over-stretched as the foot was forced down. Once it reacts, it will become irritated by stretch or compression of the area.
Anterolateral ankle pain
Front ankle pain towards the outside is more commonly found after ankle ligament damage. It can be due to ongoing ligament stress, a joint capsule reaction (known as synovitis), a reaction in the Peroneal tendons or a soft tissue impingement.
As the ankle rolls, the ligaments can get torn from rapid overstretch. The same roll can also overstretch the Peroneal tendons and the joint capsule. This can lead to a Peroneal Tendinopathy and a Talocrural Impingement respectively.
Anterior ankle pain
Front ankle pain in the middle of the area is found with joint capsule reactions (synovitis) and cartilage injuries inside the joint.
The joint capsule reaction, called “Synovitis“, occurs with the joint is significantly overstretched. This area can react if the foot is forced down into a “pointed toe” position.
Cartilage injuries are a lot more variable in their presentation. They often have swelling evident inside the ankle and can create pain in whichever position causes pressure on that part of the cartilage. These are referred to as a “Talar Dome Injury“.
What causes pain at the front of the ankle?
In most cases, the ankle reacts to excessive compression or stretch and becomes painful as we’ve detailed above.
For runners, excessive stretch can occur with faster running or steep downhill running (specially faster downhill running).
Excessive compression can happen with fatigued running, uphill running (particularly longer hills) or very loose or technical trails.
Overworked muscles and tendons can occur with hillier runs, fatigued running, loose or slippery ground and poorly selected or old footwear.
Can you sprain the front of your ankle?
If there was an incident where the front of the joint was stretched, it’s possible to sprain the front of your ankle. However, it’s not like a classic ankle sprain.
In a normal inwards rolling ankle sprain, the injury is due to ligament damage.
For a front ankle pain causes by a sudden stretch, the injury would be to the joint capsule and tendons in the area.
While it’s still a sprain, it behaves very differently to a typical lateral ankle sprain.
What can cause ankle pain without injury?
Compression injuries and tendon reactions can come on slowly over a number of weeks.
This is due to mild but continuous irritation of the area which gradually causes an inflammatory reaction.
It can occur with a sudden change in training load or type, such as a switch to speed work or hills, or due to in old or inappropriate running shoes.
How do you treat front ankle pain?
Without knowing the exact cause, it’s a bit of trial-and-error. But there is always a fix out there that will work.
There are specific fixes for tendinopathies, impingements and cartilage injuries, but the fix for each of those conditions would worsen the other conditions so the diagnosis is critical before embarking on those approaches.
For a more generic approach that should help treat 90% of front ankle pain issues, here’s the plan.
The first step is to back off your high intensity sessions such as speed work or hills. Don’t stop running altogether as this makes the injury harder to treat (see our explanation of why rest is a BIG problem).
Then look at using a topical or oral anti-inflammatory for a few days (after discussing it with your Pharmacist or Doctor).
After that, upgrade your footwear to a fresher and more supportive pair. If in doubt, or if you think you may need orthotics, speak to a Physiotherapist or Podiatrist first.
Lastly, test out different forms of supportive taping around the ankle and foot. This can help to minimise the forces going through the front of the ankle when you’re running.