Inside Ankle Pain

author : AMSSM

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Pain on the inside of the ankle is a frustrating issue to deal with, here are many structures present on the inside of the ankle, which can also make the diagnosis difficult for health care providers.

Member Question

I've only recently started running and I've noticed a funny pain on the inside of my right ankle for a few days. It didn't start hurting while running, it was sometime later. Pushing on the bony knob to about 2" directly above it is painful. When I start walking or running in the morning it's actively painful but goes away in a few minutes, although pushing on the spots still hurts a bit. I thought I'd be able to identify the offending tendon by looking at a pic of foot anatomy / researching but I'm lost. All the photos of posterior tibial tendon stress seem to be behind the bony knob on the ankle, closer to the heel. My arch, top of foot, Achilles, front and back of leg don't hurt at all. I got shin splints years ago but those were right on the front of my shin. I tried hopping on the foot and I'm able to do that easily (whew).  I also tried the dorsiflexing in the BT article about soleus pain and I can do that just fine. 

Health insurance for feet issues stinks in BC and I won't have the $ to see a podiatrist for about six weeks. Any help for me? My shoes are pretty new so I may be able to talk to the Running Room and work something out if changing shoes is my best bet. 

Answer by Kyle Goerl, MD
Member AMSSM

Pain on the inside of the ankle is a frustrating issue to deal with, especially in runners and endurance athletes.   There are many structures present on the inside of the ankle, which can also make the diagnosis difficult for health care providers. The “bony knob” most likely referred to in the question above is called the medial malleolus. It is the end of the tibia, also known as the “shin bone.” There are many other bones making up the ankle joint and foot, so it is difficult to determine without a thorough exam which prominent structure may be the site of pain. The most concerning source of bone pain would be a stress fracture. Stress fractures are overuse injuries, and not uncommon in runners, but the location of the pain above would be odd for a stress fracture.

Structures other than bone in the same area include ligaments, tendons, and the tibial nerve. The primary purpose of a ligament is to hold bone to bone. The most prominent ligament on the inside of the ankle is the deltoid ligament, and it does attach to the medial malleolus. Prior ankle injuries could have caused damage to this ligament leading to scar tissue formation, which may now be painful after a period of time away from running. Tendons in the area that run behind the medial malleolus include the posterior tibial tendon (responsible for helping to point the foot down), the flexor hallucis longus tendon (responsible for pointing the big toe down), and the flexor digitorum tendon (responsible for pointing the rest of the toes down). Tendons can become irritated and inflamed with either acute injuries or overuse injuries. Finally, the tibial nerve can become irritated where it runs behind the medial malleolus causing a rare condition known as tarsal tunnel syndrome.

Often times it is worth thinking on a more simple level. In the case above, it sounds like you may have returned to running after a period of time away. When one returns to endurance activities after a period of rest, it is important to do so in a gradual and systematic manner. Ramping up distance or intensity too quickly can lead to overuse injuries just as quickly. The other interesting part about the story above is the fact that the athlete was training in new shoes. If the shoe does not fit correctly, or it is not built for the athlete’s gate, then that shoe can also cause problems. The simplest thing to do is to return to the store where you bought the shoes. Most good running shoe stores will work with athletes to get them in the best shoe possible for their foot shape and running gate. In fact, really great running stores can do a gait analysis to further help characterize your gait in order to find the best shoe.

Finally, the standard treatments apply. Ice after exercise to help reduce swelling, and ibuprofen or acetaminophen for pain can be helpful. Activity modification is also important, meaning a likely reduction in the mileage, alternative training modalities, and again, a gradual and systematic increase in running once pain free. If these strategies do not improve your pain, then it is important to see a health care provider with expertise in sports injuries.

Kyle Goerl, MD
Primary Care Sports Medicine Fellow
Madsen Health Center
555 S. Foothill Blvd., Suite 301
Salt Lake City, UT 84112

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date: July 2, 2014