Outside Ankle Pain? What Could Be Wrong?

by Chris Centeno, MD /

Outside ankle pain is common. So what’s here that could be causing your pain? How should this be diagnosed? Let’s dive in.

What’s Here?

There are few things that can cause outside ankle pain. First, this is where the peroneus brevis and longus tendons live, so small tears in those ligaments or degeneration (tendinopathy) can cause pain. Next, nerves live here, so an irritated nerve in your back can mimic ankle pain. Finally, strong ligaments are here that stabilize the ankle. This last bit is where we’ll focus today, as if these are stretched, the ankle joints may get trashed.

What Is Stress Ultrasound Imaging?

If we want to see if ligaments are strong, that can be a challenge with static imaging like MRI. This imaging type will show big tears in ligaments, but smaller tears causing laxity usually won’t show up. So how can we diagnose those? We need to stress the ligaments while we’re looking at them. There’s only one type of imaging that can do that: stress ultrasound.

You might most be familiar with ultrasound as an imaging machine used during pregnancy to see babies in the womb. We can use the same technology, though tweaked a bit, as a diagnostic tool for many things besides just pregnancy, and one of those things is to visualize ligaments and diagnose instability. As you can see in my video above, for an ankle, I can place the ultrasound probe on the ankle and as the ankle is stressed, I can visualize how the ankle ligament responds.

When a loose ligament is challenged with stressed movement, I will see it give way and stretch too much, allowing ankle instability. If the ligament doesn’t give way or stretches very little, I can rule out ankle instability. Most patients who have loose ankle ligaments will have negative MRIs, and a critical diagnosis will be missed, and as with most things, the sooner loose ankle ligaments are addressed, the better, as leaving them untreated can create worse problems down the road.

Outside Ankle Pain: One Patient’s Ligament Issues

Recently, a patient came to see me for his outside ankle pain, centered just above the ankle. He’d had no known injury that he could recall; he just knew that the ankle pain came on suddenly about two or three months prior. He is a very active athlete who plays hockey and Lacrosse, so it is possible he had injuries, such as twisted ankles or sprains, throughout the years that may have contributed to his outside ankle pain over time.

Using stress ultrasound imaging (watch my video above to see this patient’s stress ultrasound), I was able to determine that his outside ankle pain was due to subtle issues with some of the ligaments in his ankle. This is not something the average family doctor, podiatrist, or orthopedic surgeon would have found as it would require stressing of the ankle ligaments while observing them under ultrasound to properly diagnose.

What was wrong with this patient’s ligaments that caused outside ankle pain? They were too loose, and there were multiple partial tears. Five of his ankle ligaments, in total, were damaged. These ligament issues caused instability in his ankle joint, between the fibula (the smaller lower-leg bone) and tibia (larger lower-leg bone), as due to the loose ligaments, the joint was now moving way too much. This created pain because the ankle was moving in ways it wasn’t supposed to. Why wouldn’t the average doctor catch this issue? Because the typical diagnostic tool, an MRI scan (which, as already mentioned, can only provide a still image), often misses this diagnosis.

Treating Outside Ankle Pain with PRP, Not Surgery

Even if a family doctor or orthopedic physician had discovered these ligament issues, in my experience, neither of this patient’s ligament issues would have required surgery to repair. Ligament surgery, in fact, has been shown to be unable to restore normal ankle and foot motion, which can lead to more problems in the ankles and even with alignment issues up the kinetic chain, into the knees, hips, and so on.

In interventional orthopedics, we would provide a precise injection of high-dose PRP under ultrasound guidance into the patient’s ligaments and do another stress ultrasound in two months to check on the patient’s progress. Most of these patients require anywhere from one to three treatments.

So if you’ve been struggling with outside ankle pain and your doctor just can’t seem to find a solution, it’s possible he or she is simply using the wrong diagnostic imaging tool, so find a doctor who knows how to diagnose and nonsurgically treat ankle instability.

The upshot? Your outside ankle pain may be due to loose ligaments. Oftentimes, the only way to get that accurately diagnosed is by using an ultrasound machine and a doctor who knows what to look for. If you have this problem, you almost certainly don’t need surgery, just some ultra-precise injections of PRP or bone marrow stem cells.

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13 thoughts on “Outside Ankle Pain? What Could Be Wrong?

  1. DavefromLA

    Can the above also be diagnosed as peroneal tendonitis (or tendinopathy, tendonosis etc.), for pain near the base of the 5th metatarsal and the little “golf ball” size muscle that’s slightly above that area on top of the foot near the base of the ankle? I know runners who sometimes have issues in this area from overuse and who may have a high arch and also may not be “pushing through” their big toe, thus putting more stress on the peroneal muscles. I assume this causes degeneration and hadn’t thought that PRP could help — so thank you for this blog and any further info you can provide would be appreciated!

    1. Chris Centeno Post author

      Yes, PRP under ultrasound guidance can help. Please find a physician who is experienced in this area. Either our list of providers or those certified by IOF, as this is not something the average orthopedic surgeon or podiatrist knows how to do.

  2. Sarala Johnson MD

    How would do you treat spinal issues eg. herniated or subluxed vertebrae that cause the inability to walk because of the pain.
    This is a question ,not a commen.t Thank you.

    1. Regenexx Team

      Dr. Johnson,
      Please see: https://youtu.be/nJys-Zguu38

  3. Dr Arshad / orthopedic surgeon

    it is really and interesting finding , i have seen many of these undiagnosed pain above the ankle joint ( In spite of MRI and static U/S )
    thanks you have opened a door for me to look differently
    will be waiting from you to the number of patients and result
    best wishes

  4. liz northrop

    I live in Seattle, WA.
    How do I find a doctor experienced with PRP?
    Thanks.

  5. Marsha K

    I have inside ankle pain, and as I write I am being in week two after being treated with ultrasound guided PRP for tibial tendon tears as well as an Achilles’ tendon tear. Two months ago, I treated for biceps tendon and hamstring tendon tears with PRP, and these
    tendons are fully

    1. Regenexx Team

      Marsha,
      This will explain what to expect at the different phases of healing ligaments and tendons go through after regenerative treatment. Please see: https://regenexx.com/blog/understanding-ligaments-repair-regen-med-treatments/

  6. CHAD FREEMAN

    Chris, how can I get this kind of exam. I go to regenexx Pittsburgh. Do you ever come there?
    Ever since I injured my ankle it “pops” on eversion. It has since my surgery. MRI suggested deep deltoid ligament.

    I had platelets done on my low back because of a tight calf nerve problem which exacerbated the ankle problems. Just trying to get my sinus tarsai to quit hurting. I have pretty flat feet. But a decent arch when sitting. I rebuilt it by walking in barefoot shoes for 2 months, but the sinus tarsi hurt so bad I had to stop.

    I am trying to coach my sons U5 Soccer team but after running for a bit coaching I have to ice the outer side of my ankle.

    1. Regenexx Team

      CHAD,
      I don’t, but the Pittsburgh clinic should have no issue doing this type of ultrasound stress exam.

  7. Steven bennett

    I have had a bit of tendon put across the outside of my ankle. Been numb under hot under foot ever since. Been 10 weeks of agony with swelling Sweeting pins and needles under foot. Lower shin numb. What is wrong. Also had trouble with lower ankle healing. Open hole for eight weeks and burning on the upper outside of the ankle often. I feel lots of pain from different areas. Old ankle injury pains from the past. have had shin mustle damage from accident 30 years ago. So I rely on the big toe to dig in to stop ankle from rolling. I feel the I need to get this operation reversed. I had no pain before operation but now are in pain all the time.

    1. Regenexx Team

      Hi Steven,
      Sorry to hear about the situation you’re your surgery left you in. What was the surgery was done to address?

Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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