Where the ankle hurts points at the cause. Outside after a roll is a lateral sprain. Behind the outer bone on push-off is the peroneal tendons. A pinch at the front when squatting is anterior impingement. An ache on the inside with a dropping arch is the tibialis posterior tendon. Giving way on uneven ground is the subtalar joint. All five need balance work, and only one needs a scan.
Where the ache sits on the inside of the ankle and the arch is flattening with it, the three exercises for that specific tendon are set out in PhysioHub’s guide to tib post exercises.
The ankle divides neatly into four regions plus the joint underneath it, and each produces a distinct pattern. Start with which part you would point at.
| Where it hurts | Usual cause | Telltale sign | Rehab focus |
|---|---|---|---|
| Outside, below the bone | Lateral ankle sprain | History of rolling it, swelling within hours | Early movement, then balance and strength |
| Outside, behind the bone | Peroneal tendinopathy | Aches on push-off and on cambered ground | Progressive loading in eversion and calf work |
| Front of the joint | Anterior impingement | Sharp pinch when squatting or lunging | Ankle range work and squat modification |
| Inside, along the arch | Tibialis posterior dysfunction | Arch flattening, cannot do a single heel raise | Heel raises with a ball squeezed between the heels |
| Just below the outer bone | Sinus tarsi syndrome | Giving way on uneven ground | Balance and proprioceptive work |
Four of the five improve substantially with the same balance and calf strengthening. The fifth, the inside tendon, needs its own programme and is the one worth identifying early.
This is a documentary review of published evidence and clinical practice rather than a diagnosis of your ankle. The five here cover the large majority of non-fracture ankle pain in adults. Others considered and left out because they are less common include Achilles tendinopathy, osteochondral lesions of the talus, syndesmosis injuries, tarsal tunnel syndrome, stress fractures, and inflammatory arthritis.
The order reflects how often each explains ankle pain, weighed against how clearly it can be recognised without imaging.
The sources read were the systematic review and meta-analysis of the Ottawa Ankle Rules, which pooled 27 studies covering 15,581 patients, and the wider literature on balance training after ankle sprain. Evidence checked in August 2026.
What could not be checked: no study has ranked these five by frequency in a UK population, so the order rests on presentation patterns. The Ottawa rules apply to acute injuries and do not help with gradual-onset pain. An ankle that cannot take four steps, one with bone tenderness at the back edge or tip of either ankle bone, or one that is hot and swollen with a fever needs seeing rather than exercising.
Start with whether it needs an X-ray at all. The Ottawa rules take ten seconds and reliably rule fractures out. Press the back edge and tip of both ankle bones, then try four steps.
Ask whether there was a moment. A roll, a landing or a step off a kerb points at a sprain. Pain that built over weeks points at a tendon.
Try a single-leg heel raise. Being unable to lift the heel off the floor on one leg, with an arch that flattens, is the single most important finding on this page, because it points at the tibialis posterior tendon.
Notice the surface. Cambered pavements and side slopes irritate the outer tendons. Uneven and root-crossed ground provokes the giving-way of instability. Squatting and lunging provoke the front of the joint.
What it is
Stretching or tearing of the ligaments on the outside of the ankle, usually as the foot rolls inwards under you.
Who it affects
Everyone, and it is the most common musculoskeletal injury there is. Sport, kerbs, stairs and uneven ground account for most of them.
How it presents
Immediate pain on the outside of the ankle, swelling within hours, bruising over the following days, and difficulty weight-bearing at first. The version that persists is the one where the ankle keeps giving way months later.
What the evidence supports
Rule out a fracture first with the Ottawa Ankle Rules, which pooled across 27 studies and 15,581 patients pick up around 97.6 per cent of fractures and cut unnecessary X-rays by 30 to 40 per cent. Then early controlled movement rather than prolonged immobilisation, followed by balance training, which is the part that reduces the chance of it happening again.
The rehab
Protect and elevate for a day or two, then move within comfort. Add resisted turning of the foot outwards against a band. Then single-leg balance, progressed to eyes closed, then to a cushion, then to reaching and hopping. Eight to twelve weeks to do properly.
Limits and cautions
Stopping when it stops hurting is what produces the repeat sprains, because strength and balance recover more slowly than pain does.
Why it ranks first
It is by far the most common, and it is the one where good rehabilitation changes the next five years rather than the next fortnight.
What it is
Overload of the two tendons that run behind and below the outer ankle bone and turn the foot outwards.
Who it affects
Runners who have increased mileage or moved to cambered roads and trails, people who have had repeated ankle sprains, and anyone with a high-arched foot.
How it presents
Ache behind or below the outer ankle bone, worse on push-off, on cambered surfaces and on side slopes. Often a gradual onset over weeks rather than a single moment. Sometimes swelling that tracks along the tendon rather than sitting in a lump.
What the evidence supports
Progressive loading, in line with how tendon problems elsewhere are managed. Trial evidence specific to these tendons is limited, so the programme is built by extension from the better-studied Achilles and patellar tendons.
The rehab
Reduce cambered running and side slopes for a few weeks. Isometric holds turning the foot outwards against a fixed resistance. Then banded eversion, three sets of 15, three days a week, and calf raises with the foot slightly turned in. Our peroneal tendon exercise guide covers the stretches that go with it.
Limits and cautions
A tendon that clicks or snaps over the bone as the foot moves may be subluxing, which is a different problem and worth assessing.
Why it ranks second
It is common in runners, it is regularly mistaken for a sprain that never settled, and it needs loading rather than resting.
What it is
Compression of soft tissue, or a small bony spur, at the front of the ankle joint as the shin travels forward over the foot.
Who it affects
Footballers, dancers and anyone with a history of repeated ankle sprains. It is common enough in football to have been nicknamed footballer’s ankle.
How it presents
A sharp pinch at the front crease of the ankle when squatting deeply, lunging, or walking uphill. Not usually painful at rest. Ankle range is often visibly reduced compared with the other side.
What the evidence supports
Restoring ankle range and modifying the positions that pinch. Where a bony block is present, range work has a ceiling, and that is worth knowing before spending three months on mobility drills.
The rehab
Ankle mobilisation with a band pulling the joint forward while you lunge over the foot, done daily. Squatting with the heels slightly raised so training continues. Calf and ankle strengthening through the available range.
Limits and cautions
Forcing the ankle into the pinching position repeatedly tends to inflame it. A hard, bony end feel that does not change over six to eight weeks of consistent work usually means a structural block rather than stiffness.
Why it ranks third
It is common in specific groups, it has a clear provoking movement, and it is easily worked around while it is treated.
What it is
Failure of the tendon that runs behind the inner ankle bone and supports the arch of the foot.
Who it affects
Most often women over 40, and more often in people with higher body weight, diabetes or high blood pressure. It is far less common than the four above and considerably more consequential.
How it presents
Ache and sometimes swelling along the inside of the ankle and into the arch, worse with standing and walking. Over time the arch flattens and the heel drifts outwards. The key sign is being unable to perform a single-leg heel raise on that side.
What the evidence supports
Early identification and loading. Left alone, the tendon progressively lengthens and the foot shape changes in ways that exercise cannot reverse, so this is the one on the page where waiting has a real cost.
The rehab
Heel raises with a ball squeezed between the heels to bias the work towards this tendon, progressing from seated to standing to single leg. Arch support in the shoe while capacity is rebuilt. Our guide to tib post exercises sets out the three moves and the progression.
Limits and cautions
An arch that is visibly collapsing, a heel that has drifted outwards, or an inability to do a single heel raise all mean this should be assessed rather than self-managed.
Why it ranks fourth
It ranks fourth on frequency and first on consequence. It is the ankle problem most worth catching early.
What it is
Pain in the small channel between the heel bone and the bone above it, just in front of and below the outer ankle bone.
Who it affects
People who have had repeated ankle sprains, and those with a flat or highly mobile foot.
How it presents
A deep ache just below the outer ankle bone, worse on uneven ground, with a strong sense of the ankle being about to give way. Often described as an ankle that never quite recovered from a sprain.
What the evidence supports
Balance and proprioceptive training, the same core work as for chronic ankle instability. Evidence specific to this diagnosis is thin, and it is often managed as part of the instability picture rather than separately.
The rehab
Single-leg balance progressions on increasingly unstable surfaces, resisted foot turning in both directions, and calf strengthening. Taping or a supportive shoe helps some people through the early weeks.
Limits and cautions
An ankle that genuinely gives way repeatedly, rather than feeling as though it might, is worth assessing for ligament laxity that rehabilitation alone may not resolve.
Why it ranks fifth
It is the least clearly defined of the five, it overlaps heavily with chronic instability, and it responds to the same programme.
| Cause | Onset | Where | Single-leg heel raise | Balance work helps | Typical timescale |
|---|---|---|---|---|---|
| Lateral sprain | Sudden | Outside, below the bone | Usually fine once settled | Yes, essential | 2–12 weeks |
| Peroneal tendinopathy | Gradual | Outside, behind the bone | Fine | Helpful | 8–12 weeks |
| Anterior impingement | Gradual or post-sprain | Front crease | Fine | Secondary | 6–12 weeks |
| Tibialis posterior dysfunction | Gradual | Inside, into the arch | Cannot do it, the key sign | Secondary | 3–6 months |
| Sinus tarsi syndrome | After sprains | Just below the outer bone | Fine | Yes, the main treatment | 6–12 weeks |
The single-leg heel raise column is the one worth testing tonight. It is the fastest way to separate the one problem here that gets structurally worse from the four that do not.
If you rolled it and it swelled within hours, check the Ottawa rules, then start moving it early and commit to eight weeks of balance work rather than stopping when the pain goes.
If it aches behind the outer bone on runs and cambered pavements, that is the peroneal tendons. Cut the camber, then load them progressively.
If squatting produces a sharp pinch at the front, raise the heels to keep training and work on ankle range daily.
If you cannot do a single-leg heel raise and the arch is flattening, get that assessed. This is the one where months of waiting change the foot.
If the ankle feels like it is about to give way on uneven ground, balance training is the treatment, progressed properly rather than repeated at the same level.
If you cannot take four steps, or the bone is tender at the back edge or tip, get an X-ray before doing any of the above.
What has changed in the Uckfield clinic over the last couple of seasons is where ankle injuries are coming from. Autumn used to bring a wave of sprains from the first weeks of football and rugby, and it still does once the pitches go soft and rutted through October. What has been added is a steady flow from trail running and off-road walking, which has grown a great deal locally, and those injuries behave differently: fewer dramatic single rolls, more ankles that have been quietly rolling slightly for months on root-crossed ground and have never rebuilt their balance.
The clinical point is that both groups need the same thing and only one group tends to get it. A dramatic sprain gets rehabilitated because it hurt enough to take seriously. The gradual instability gets stretched, taped and tolerated, and the deficit that keeps it going is a delayed reaction time rather than tightness. Balance training fixes that, and it has to be progressed to be worth doing: 30 seconds on one leg becomes eyes closed, becomes a cushion, becomes a reach or a hop. Standing on one leg at the same easy level for six weeks builds nothing.
Where an ankle keeps letting you down on uneven ground or has not recovered from a sprain months later, our sports injury and performance service is built around exactly that rebuild.
How do I know if my ankle is sprained or broken?
Clinicians use the Ottawa Ankle Rules. An X-ray is needed if there is bone tenderness along the back edge or tip of either ankle bone, or if you could not put weight on it and take four steps both immediately after the injury and when seen. A systematic review of 27 studies covering 15,581 patients found a pooled sensitivity of about 97.6 per cent, with only 0.3 per cent false negatives, and applying the rules reduces unnecessary X-rays by 30 to 40 per cent.
Why does my ankle keep rolling after a sprain?
Because the sprain damages the nerve endings in the ligaments that tell your brain where the foot is, as well as the ligaments themselves. Without deliberate balance retraining, the reaction time stays slow and the ankle rolls again. Around a third to a half of people go on to have ongoing instability after a first sprain, and balance work is the part of rehabilitation that reduces it.
What is the best exercise for ankle stability at home?
Single-leg balance, progressed properly. Start with 30 seconds on a firm floor. Then close your eyes. Then stand on a folded towel or cushion. Then add a movement, such as reaching the other foot out in different directions or catching a ball. Each step is genuinely harder than the last, and the progression is what makes it work rather than the exercise itself.
Should I use ice or keep moving after an ankle sprain?
Both, in that order. Protect and elevate for the first day or two, then start moving within comfort as soon as you can. Early controlled movement and weight-bearing produce better outcomes than prolonged immobilisation for most ordinary sprains, which is why walking boots and long periods on crutches have fallen out of favour for anything other than fractures and severe injuries.
Why does the front of my ankle pinch when I squat?
That is anterior ankle impingement, where soft tissue or a small bony spur at the front of the joint is compressed as the shin travels forward over the foot. It is common after repeated sprains and in footballers. Squatting with the heels slightly raised removes the pinch and lets you keep training while the ankle range is worked on.
How long does an ankle sprain take to heal?
Most ordinary sprains are comfortable within two to six weeks, and full return to sport usually takes longer than the pain suggests. The strength and balance deficits persist well after the swelling settles, which is exactly why re-injury rates are high in people who stop rehabilitation when it stops hurting.
When should ankle pain be checked?
If you cannot take four steps on it, if there is tenderness on the bone at the back edge or tip of either ankle bone, if the ankle looks deformed, if it is hot and swollen with a fever, or if pain and swelling on the inside are accompanied by a visibly flattening arch. That last pattern is the tibialis posterior tendon, and it does badly if it is left.
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