Demystifying Ankle Swelling: Uncovering the Causes Behind It!

Is your ankle swollen (with or without associated pain) and wondering the cause and what you can do?

Thousands of people face this problem every day. Sometimes without any specific reason, sometimes following surgery, an injury, a fall, or circulatory issues.

This situation raises numerous questions and sometimes causes worry.

As a physiotherapist, I will address the most frequently asked questions from my patients who complain about swelling around the ankle’s malleolus. I hope that this information will help you feel more at ease and provide you with simple and practical actions to address edema and its consequences.

At the end of the article, you will find references to international scientific publications that support my professional experience.

Still have questions after reading this article? Feel free to leave a comment below 🙂!

What Are the Symptoms of a Swollen Ankle?

Understanding the symptoms can provide some clarity. Here is a list of symptoms that may be experienced when one or both ankles are swollen:

• Swelling: This refers to an increase in size of the ankle, also known as edema. It can sometimes extend up the leg, affecting the knee or even the thigh. It can affect either the right or left ankle, or both.
• Redness and warmth in the affected area. These two phenomena are often associated with a swollen ankle.
• Pain or stiffness during ankle movement, or even at rest. Let’s delve a bit more into the pain in this article.
• Feeling of tearing or cracking during movement.
• Instability or weakness in the ankle: You may feel like it gives way or twists when walking or going down stairs, or it may actually give way.
• Difficulty in flexing (dorsiflexion) or extending (extension) the ankle. The fluid restricts proper joint movement. It’s purely mechanical; the fluid is incompressible. There’s no need to force it, as flexibility will return once the edema subsides.

Swollen Ankle Without Pain?

It often comes as a surprise, but an ankle can be swollen and warm without experiencing any pain!

Pain is a highly complex phenomenon, considered to be multifactorial. It is not solely triggered by physical or biological issues, but also influenced by cognitive and environmental factors.

Here are a few situations in which it is entirely possible to have swollen ankles or malleoli without pain:

• Osteoarthritis: 20 to 60% of individuals with knee osteoarthritis experience no pain.
• Infection
• Allergic reaction
• Muscle injury or strain without immediate pain
• Circulation problems, lymphedema

This is an important factor to consider when trying to identify the underlying cause of pain.

Swollen and Painful Ankle

Let’s delve a bit further into the pain that is sometimes associated with a swollen ankle.The pain can be localized in various areas:

• On the side of the ankle, at the inner or outer malleolus.
• In the front of the foot.
• Anywhere around the ankle.
• Behind the ankle, near the Achilles tendon.
• Radiating up the calf.
• And more.

Here are the types of pain you may experience:

1. Inflammatory-type pain: This is often associated with a red and warm ankle. Symptoms may worsen in the latter part of the night and decrease with movement.
2. Mechanical-type pain: The pain will be more intense during activities such as walking, exercising, or flexing and extending the ankle. It tends to subside at rest.
3. Of course, it is possible to experience both mechanical and inflammatory pain simultaneously.

Having pain does not necessarily indicate a serious condition!

Swollen Ankle: One or Both?

The fact that only one ankle is swollen while the other shows no swelling at all is an important consideration for diagnosis.

For instance, it is more likely to be due to trauma or arthritis rather than a cardiac issue.

However, this isolated sign is not sufficient for making a diagnosis!

Swollen Ankles in the Evening

Regardless of the cause of ankle edema, it is common for ankles to swell more in the evening.

Here are two possible explanations:

1. Standing or sitting position (compared to lying down): During the day, we spend time in a standing or sitting position, which can lead to fluid accumulation in the feet and ankles. Fluid tends to accumulate in the lower parts of our body due to gravity. Therefore, by the end of the day, the feet and ankles may appear more swollen.
2. Venous insufficiency: If you have venous insufficiency (when your veins struggle to pump blood back to the heart), swelling is often more pronounced in the evening. Blood pools in the veins, leading to fluid accumulation in the surrounding tissues, causing them to swell.

Swollen and Red Ankle

Some people may also experience both swelling and redness in their ankles.

This can manifest as either generalized redness throughout the skin or specific red patches.

In cases of redness, there may also be associated warmth present.

What Are the Common Causes of Swollen Ankles?

Swelling in the ankle, whether it affects the entire joint or only a specific part, is typically due to an accumulation of fluid in the ankle joint. This fluid can be of two types:

1. Blood: In this case, it is referred to as hemarthrosis. It often occurs as a result of an accident or injury. Sometimes, it can be caused by inflammation alone.
2. Synovial fluid: This is known as synovitis or synovial effusion. Synovial fluid is naturally present in all joints, providing lubrication and facilitating movement. However, there are instances where it is produced in excessive amounts, leading to swelling as it accumulates within the joint.

When an injury or inflammation occurs, the blood vessel walls can become more permeable, allowing more fluid to pass into the joint from the vessels. This accumulation of fluid can cause swelling.

Swollen Ankle Following a Trauma, Hurt, Fall, or Accident?

Have you experienced an impact on your ankle? Did you twist your ankle while playing sports, slipping, or falling?

Here are the most common causes of ankle swelling in such cases:

1. Bruising or hematoma: This occurs when certain blood vessels rupture.
2. Sprain or torn: One or more ligaments (such as the lateral collateral ligament or deltoid ligament) or tendon (like a torn Achilles) become stretched or torn. The lateral collateral ligament (LCL) is often the most affected, including its individual components: the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. Refer to my article on swelling after an ankle sprain for more information.
3. Cartilage injury.
4. Fracture of one or more malleoli.

A simple interview and examination may sometimes suffice to diagnose the problem. In some cases, additional tests such as an X-ray may be required.

Swollen Ankle Following Surgery

Any surgery performed under local or general anesthesia can cause swelling in the ankle, even if it does not directly involve the lower limb. This includes:

• Arthroscopy (even a simple injection, which is not considered surgery)
• Ankle ligament reconstruction
• Ankle replacement
• Ankle arthrodesis (joint fusion)
• Ankle osteotomy

Swollen Ankles Due to Heat

A team of Canadian general practitioners made the following observation: every summer, many patients consult them due to concerns about swelling in their ankles, while there are fewer cases during other seasons.

These patients often do not have any underlying cardiac issues that could explain the swelling.

The doctors decided to further investigate this phenomenon. They looked at the frequency of searches on Google for terms such as “ankle swelling,” “ankle edema,” “ankle swelling causes,” “swollen ankles”, according to the seasons.

These summer peaks could be explained by:

• An increased number of ankle sprains during the summer, which is a common cause of swelling. However, the search patterns for “ankle sprain” do not follow the same seasonal trends.
• More health-related searches by students. However, searches should decrease during the summer vacation period, which is not the case.
• People wearing shorter clothing during the summer, making them more aware of ankle edema.

The most likely hypothesis proposed by the research team is that fluid retention is more significant during the summer. Fluid retention during the hottest months of the year may also have been an evolutionary advantage, ensuring sufficient hydration when water resources are limited.

With more fluid than usual in the joint and surrounding tissues, swelling occurs!

If you are reading this blog post in the spring or summer, have not experienced any ankle injuries, and do not have any known medical conditions, this may provide an explanation for your edema🙂!

Swollen Ankles and Water Retention

Is water retention always associated with an underlying medical condition? Not necessarily.

In fact, when we talk about water retention in the ankle, we simply refer to swelling or edema.

Water retention in the ankle = ankle edema = ankle swelling

Exploring the possible causes of water retention in the ankle is essentially the same as investigating the causes of ankle swelling.

The following table summarizes the most common causes of water retention and leg swelling.

Swollen Ankles Without an Apparent Cause

Ankle swelling can sometimes occur “without an apparent cause.”

By this, I mean it is not related to a specific event such as an accident, fall, or surgery.

In such cases, it could be related to your overall health, the environment you are in, a medical condition, or a specific physical condition that may not necessarily be a disease.

Here is a non-exhaustive list of potential causes of ankle edema without trauma:

• Chronic venous insufficiency
• Inflammatory rheumatic disease such as rheumatoid arthritis
• Ankle osteoarthritis (although less common than knee osteoarthritis)
• Stress fracture of the tibia (and/or fibula)
• Tendinopathy or tendonitis: Inflammation of one or more tendons that attach to the ankle joint. This is often associated with repeated or intense movements, overuse, or excessive strain. The most common ankle tendinopathies include:
  • Achilles tendonitis
  • Posterior tibial tendonitis
  • Peroneal (fibular) tendonitis
  • Flexor hallucis longus tendonitis
• Cardiac-related ankle swelling, linked to heart problems such as heart failure. The heart is no longer able to efficiently pump blood throughout the body, leading to fluid accumulation in tissues. Ankles are often the first to swell as they are located in the lower part of the body and are more prone to fluid retention.
• Liver problem: Liver cirrhosis
• Pregnancy
• Obesity
• Air travel
• Kidney problem: Renal insufficiency
• Complex regional pain syndrome: Ankle CRPS
• Side effects of certain medications: The list is extensive and includes antihypertensives, hormones, chemotherapy drugs, NSAIDs, etc.
• Bursitis
• Infection (including tuberculosis)
• Gout
• Allergy
• Hormonal changes
• Thyroid issues
• Rare conditions: Rare genetic disorders such as neurofibromatosis type 1, Rosai-Dorfman disease, primary intestinal lymphangiectasia
• Synovitis
• Rare cases: Tumors, pseudotumors, foreign body reactions

How to Determine the Cause of Swollen Ankles?

Here are the findings from a research team in the United States that aimed to identify the most probable causes of lower limb edema without a history of trauma:

Fluid retention can result from various causes, including different local or systemic disorders such as superficial and deep infra-inguinal venous reflux, supra- and infra-inguinal deep venous obstruction, and primary and secondary lymphatic diseases.

While the most likely cause of unilateral lower limb edema in individuals over 50 years old is venous disease, the etiology is often multifactorial.

Gasparis 2020

These statements illustrate the difficulty, even for a healthcare professional, of determining the precise causes of ankle swelling.

The most important factor is not to overlook anything “serious” that would require specific treatment for a condition other than just the edema. However, in such cases, there are often other associated signs, known as red flags, such as fever, weight loss, etc.

Here is a list of questions to help you better determine the possible origin of the swelling.

Of course, it is advisable to seek the opinion of a healthcare professional who is accustomed to dealing with such problems on a daily basis to ensure a more accurate diagnosis.

• When did the swelling (and other symptoms) first appear?
• Did it occur following anything specific? A fall, impact, sports activity, change of footwear, increased training load, etc.
• If there is pain, does it occur mainly during certain activities or at rest? Is it worse at night?
• What other symptoms do you have?
• Is the edema localized only to the ankle or does it affect the entire leg? Is it on one side or both sides?
• Have you experienced this problem before or a similar issue, and in what context?
• Do you feel that the ankle swelling is increasing, stable, or decreasing?
• Do you have any medical conditions (osteoarthritis, rheumatic disease, etc.) or physical conditions (overweight, muscle weakness) that could partially explain this swelling?

After answering these questions, review the section dedicated to common causes of ankle swelling. This may provide further insights.

What to Do About Swollen Ankles, With or Without Pain?

At this point, you should have a better understanding of the underlying cause of the swelling. Now let’s discuss practical steps you can take if the swelling is bothering you.

When to Consult a Doctor or Physical Therapist?

Have you not consulted a healthcare professional yet for this issue? Have the information in this article or others you found on the internet not been sufficient to reassure you?

In that case, you can schedule an appointment with your primary care physician. This will provide you with a more personalized assessment of the problem you’re experiencing.

Have you already consulted a healthcare professional who reassured you about the cause of your ankle edema?

In such a situation, some individuals are tempted to seek additional opinions until they find a professional who identifies a specific cause and treatment. This is known as “medical wandering” or “diagnostic wandering,” which is an extensively researched phenomenon.

Another approach in this situation is to trust the initial opinion you received. Personally, this is often the option I choose.

Whether the discomfort is significant or not, you can decide to wait a few weeks before seeking another opinion to see how things progress.

Seeking another opinion is not trivial, as it can consume time, cause anxiety, and incur expenses, without guaranteeing a different or more satisfactory opinion.

Furthermore, the professionals you consult for another opinion may be inclined to propose a “solution” or “treatment” at any cost to address your distress, even if they are not entirely convinced of its efficacy. It is sometimes easier and quicker to “offer something” rather than reassure and advise patience.

As a physiotherapist, I observe this phenomenon on a daily basis, particularly in cases of lower limb edema, whether related to surgery or a medical condition.

Seeking the opinions of one or more healthcare professionals for diagnosis and treatment is possible, but seeking multiple opinions may not always be relevant.

What to Do to Reduce Swelling in the Ankle?

In some cases (such as rheumatic diseases like rheumatoid arthritis or venous insufficiency), specific treatments may be prescribed and can effectively reduce or eliminate the swelling.

However, regardless of the underlying cause, the available means to treat swelling in the ankle remain the same.

There are countless treatments or home remedies suggested to combat ankle edema. Some of these have been evaluated in clinical studies involving healthy adults or individuals with specific conditions, while others have not.

List of Possible Treatments

Here is an overview of commonly suggested treatments by professionals:

• Wearing compression stockings, which have been shown to reduce lower limb volume in some healthy individuals (Sugahara 2018). However, certain conditions may contraindicate their use. See examples of compression stockings stade II on Amazon
• Applying cold therapy or cryotherapy.
• Undergoing pressotherapy sessions.
• Receiving manual lymphatic drainage or other manual massages, either manually or using a device.
• Using shockwave therapy.
• Utilizing ultrasound treatment.
• Wearing an ankle brace/orthosis, applying strapping, or using other compressive bandages.
• Elevating the leg with the ankle higher than the heart.
• Avoiding prolonged static standing and walking as much as possible.
• Taking anti-inflammatory medications.
• Adopting an anti-inflammatory and antioxidant-rich diet.
• Regularly performing ankle movements, especially in dorsiflexion and plantarflexion.
• Undergoing joint aspiration (arthrocentesis).
• Receiving injections (corticosteroids, hyaluronic acid, etc.).
• Considering surgical intervention.
• Applying essential oils or ointments.
• Reducing salt intake.

How to choose from this (incomplete) list? Should one try each treatment individually or experiment with multiple treatments simultaneously?

What I recommend doing against swollen ankle

Here’s how I usually approach these situations where there are many possible treatments but few that seem to stand out significantly.

I choose based on these 4 criteria:
☑️ Maximum effectiveness (theoretical/empirical)
☑️ Minimum side effects
☑️ Minimum cost (time, energy, money)
☑️ Minimum dependence on a third party or equipment

For example, this automatically rules out surgical procedures like aspiration: no long-term guarantee that the fluid won’t return to the joint, costly to perform, and risk of side effects such as infection.

I also eliminate shockwave therapy because the theoretical mechanism of action on edema is inconsistent, and it requires visiting a professionally equipped practitioner or investing in expensive equipment. Additionally, there is often a surcharge for shockwave therapy sessions.

You may be surprised by my recommendations, especially if you have been advised to pursue other treatments. Often:

• Physiotherapists may recommend exercises, shockwave therapy, or pneumatic compression.
• Rheumatologists may suggest medications or injections.
• Surgeons may consider aspiration if other approaches fail.
• Osteopaths may recommend osteopathic sessions.

What’s the common theme? Each healthcare professional tends to recommend what they specialize in! This is an important factor to consider when seeking advice from different professionals.