Ankle and foot injuries are extremely common presentations in emergency departments, sports medicine clinics, and primary care. They occur across all age groups—from young athletes to elderly patients with falls—and range from simple ligament sprains to complex fractures and neurovascular emergencies.
For learners, these injuries are important because they demand structured assessment. Missing a fracture, compartment syndrome, or unstable injury can lead to chronic pain, deformity, or long-term disability. At the same time, unnecessary imaging increases cost and radiation exposure.
The goal is simple: identify serious injuries early while safely managing minor ones.
Functional Anatomy of the Ankle and Foot
Understanding anatomy makes clinical reasoning easier.
The ankle joint is formed by:
- Tibia
- Fibula
- Talus
This joint primarily allows dorsiflexion and plantarflexion.
The foot consists of:
- Hindfoot (talus, calcaneus)
- Midfoot (navicular, cuboid, cuneiforms)
- Forefoot (metatarsals and phalanges)
Ligaments, tendons (notably the Achilles tendon), and neurovascular structures provide stability and movement.
Mechanisms of Injury
Most ankle and foot injuries occur due to:
- Twisting or inversion injuries
- Falls from height
- Sports-related trauma
- Direct blows or crush injuries
The mechanism of injury often predicts the type of damage. For example, inversion injuries commonly cause lateral ankle sprains, while axial loading may result in calcaneal fractures.
Red Flags in Ankle and Foot Injuries
Certain features suggest serious pathology and require urgent attention.
Important red flags include:
- Inability to bear weight
- Severe swelling or deformity
- Open wounds or exposed bone
- Neurovascular compromise (numbness, pallor, weak pulses)
- Disproportionate pain suggesting compartment syndrome
- High-energy trauma
Presence of red flags should prompt immediate imaging and specialist referral.
Common Ankle Injuries
Ankle Sprains
Ankle sprains are the most common ankle injury and usually involve ligament damage.
They are commonly classified as:
- Grade I: ligament stretch, mild pain and swelling
- Grade II: partial tear, moderate swelling and instability
- Grade III: complete tear, severe swelling and instability
Most sprains involve the lateral ligament complex following inversion injury.
Ankle Fractures
Ankle fractures range from stable to highly unstable injuries.
Clues suggesting fracture include:
- Point tenderness over malleoli
- Significant swelling and bruising
- Inability to bear weight
Unstable fractures require urgent orthopedic assessment.
Achilles Tendon Injury
Often occurs during sudden acceleration or jumping.
Classic features include:
- Sudden “pop” sensation
- Posterior ankle pain
- Inability to plantarflex effectively
A positive Thompson test supports the diagnosis.
Common Foot Injuries
Metatarsal Fractures
These fractures commonly result from direct trauma or twisting injuries.
The fifth metatarsal deserves special attention due to:
- Avulsion fractures
- Jones fractures (higher risk of non-union)
Pain localized to the midfoot or forefoot should never be ignored.
Calcaneal Fractures
Typically occur after falls from height.
Key points:
- Severe heel pain and swelling
- Often associated with spinal injuries
- Require CT imaging for assessment
Always examine the spine in these patients.
Lisfranc Injury
A frequently missed but serious midfoot injury.
Clues include:
- Midfoot pain and swelling
- Pain with forefoot stress
- Plantar bruising
Missed Lisfranc injuries can cause long-term disability.
History Taking in Ankle and Foot Injuries
A focused history should include:
- Mechanism of injury
- Ability to bear weight immediately and after injury
- Location of pain
- Previous injuries
- Associated numbness or weakness
The history often narrows the diagnosis before imaging.
Physical Examination
A systematic examination is essential.
Key components include:
- Inspection for swelling, deformity, bruising
- Palpation of bony landmarks and ligaments
- Assessment of range of motion
- Neurovascular examination
- Gait assessment if possible
Never forget to check distal pulses and sensation.
Ottawa Ankle Rules: When to Order X-rays
The Ottawa Ankle Rules help reduce unnecessary imaging.
An ankle X-ray is indicated if:
- Pain in malleolar zone AND
- Bone tenderness at medial or lateral malleolus OR
- Inability to bear weight
A foot X-ray is indicated if:
- Pain in midfoot AND
- Tenderness at navicular or base of 5th metatarsal OR
- Inability to bear weight
These rules are highly sensitive for fractures.
Diagnostic Investigations
Imaging
- X-rays are first-line for suspected fractures
- CT scan is useful for complex fractures
- MRI is reserved for ligament, tendon, or occult injuries
Imaging should be guided by clinical findings, not routine.
Management of Ankle and Foot Injuries
Conservative Management
Appropriate for most sprains and stable injuries.
Includes:
- Rest, ice, compression, elevation (RICE)
- Analgesics and NSAIDs
- Early mobilization and physiotherapy
- Functional bracing
Prolonged immobilization should be avoided when possible.
Surgical and Specialist Management
Required for:
- Unstable fractures
- Open injuries
- Neurovascular compromise
- Complete tendon ruptures
- Lisfranc injuries
Early referral improves outcomes.
Complications to Watch For
Potential complications include:
- Chronic ankle instability
- Non-union of fractures
- Post-traumatic arthritis
- Compartment syndrome
- Missed Lisfranc injuries
Early recognition prevents long-term morbidity.
Common Pitfalls in Assessment
Mistakes learners often make include:
- Skipping weight-bearing assessment
- Ignoring midfoot pain
- Missing Achilles tendon rupture
- Overusing X-rays without applying Ottawa rules
- Failing to document neurovascular status
Careful examination prevents most errors.
Key Learning Pearls
Most ankle and foot injuries are minor, but serious injuries must be ruled out. Ottawa ankle rules guide imaging decisions. Midfoot injuries are commonly missed. Always assess neurovascular status. Early mobilization improves recovery in stable injuries.
FAQs
Are X-rays required for every ankle injury?
No. Ottawa ankle rules help decide when imaging is necessary.
Which ankle sprains take the longest to heal?
High ankle (syndesmotic) sprains often take longer than lateral sprains.
Can patients walk with a fracture?
Yes. Ability to walk does not completely rule out a fracture.
Why are Lisfranc injuries dangerous?
They are easily missed and can cause chronic pain and disability if untreated.
Is immobilization always needed?
No. Early controlled movement is beneficial in most stable injuries.
