San Francisco Podiatry Video

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Saturday, April 27, 2013

Popping, Clicking Ankle Pain. What, Why and How!


Hi My Running Doc!

My daughter has sprained her ankles a number of times. She keeps turning her ankles and they swell up. She also seems to have this popping and clicking sound from the ankle when she walks and it's really bothering her.
     Questions:
          Why does that happen?
          How do we fix it?
          What's the surgery that she needs 
          to cure the snapping and pain?
Thanks!
S.B., Berkeley, CA


Answer: Ankle sprains are the most common musculoskeletal injury. In fact, there is no sports injury that shows up in the emergency department more often in a twisted ankle. Fortunately ankle sprains heal just fine most of the time. But in some cases there can be a significant injury to the ankle that prevents them from healing properly and causes problems down the road.

There are 3 primary potential causes of popping and clicking in the ankle that might be associated with persistent ankle sprains and chronic ankle instability.
1. Torn Peroneal Retinaculum
2. Lateral Process Fracture of the Talus Bone
3. Osteochondral Lesion of the Talar Dome

One common cause of popping and clicking in the ankle is from dislocating or subluxing peroneal tendons. The peroneal tendons run down the back to leg behind the fibula. They turn around the end of the fibula as they curve down toward the outside of the foot. 

There is a thin band of tissue called the peroneal retinaculum that holds the peroneal tendons in place behind the fibula. In some cases involving ankle sprains, the peroneal tendons actually fire so hard to try to keep the foot under the leg when you roll the ankle that the perineal retinaculum actually gets torn off of the fibula bone. Because it is torn, the peroneal tendons are not held firmly in place behind the fibula.

When this occurs, the peroneal tendons are free to slide forward over the leading edge of the fibula bone. As the tendons snap back and forth across the fibula, they cause a popping and clicking sound and/or sensation as you walk. When this occurs it is not always painful but it certainly can be painful. It is more worrisome if it is painful simply because this might signify a tear or a split in one of the peroneal tendons.

If one of the peroneal tendons is torn or split it might need a platelet rich plasma injection (also known as a PRP injection) to help stimulate healing. If the torn peroneal tendon cannot heal on its own, it might require surgery to sew it back together. In any event pain in this area should not be ignored.

Another cause of popping and clicking in the ankle can be a misdiagnosed or undiagnosed lateral process fracture of the talus bone. The talus bone is the bone that connects the top of the foot to the bottom of the ankle. Lateral process fractures are sometimes referred to as snowboarders fractures.

We used to think that lateral process fractures were a rare occurrence. However Dr. Segler led a team of investigators through the largest study ever completed on lateral process fractures of the talus. He and his team won an award from the American College of Foot and Ankle Surgeons for this research. What his team found was that these fractures are about 10 times more common than previously thought. They just get missed all the time.Is

Lateral process fractures are frequently misdiagnosed as ankle sprains. Yet a broken bone does not generally heal the same way as a torn ligament. If not treated correctly, the broken bone can develop into a nonunion where the bone actually never heals. When this occurs, there can be continued pain and swelling in the ankle. Sometimes there can be a popping and clicking sensation as well.

The third potential cause of popping and clicking in the ankle after an ankle sprain is an osteochondral lesion of the talus. An osteochondral fracture is a crack in the bone underneath the cartilage. Basically what happens is the ankle rolls and the talus bone can tilt so far that the corner of the talar dome smacks into the tibia bone or fibular bone. If the talus has a hard enough impact as it twists, it can crack the bone and damage the cartilage. 

Sometimes the cartilage and the fractured piece of bone (known as an osteochondral fragment) can become loose. If not treated correctly this may not heal. If the cartilage is loose and has a flap of tissue that flips back and forth it can cause a clicking or popping sensation. This is often associated with swelling and pain in the ankle.

If there is popping and clicking from the ankle, but no history of a serious ankle sprain, the shape of the fibula can potentially lead to subluxing peroneal tendons. The retinaculum might actually still be intact but because there is not a very deep groove in the back of the fibula the peroneal tendon still slide back and forth causing a popping and clicking sensation at the side of the ankle. This can cause peroneal tendinitis.

If this is the case, it is possible to perform surgery to deepen the groove at the back of the fibula in order to help the peroneal tendons stay in place. This will stop the popping and clicking and prevent chronic irritation of the tendon that can lead to tears in the peroneal tendons.

Another related issue with chronic ankle instability and persistently weak ankles is that the ankles can get sprained over and over. If you often find yourself rolling your ankles when walking on uneven surfaces or running on trails, the first step would be physical therapy or a home rehabilitation self-treatment program to try to strengthen the ankles and restore stability.

In some cases of chronic ankle instability the ankles are so weak that the ligaments on the outside of the ankle need to be surgically repaired or rebuilt. 

In any case, if you have popping and clicking, especially associated with pain and swelling of the ankle, it shouldn't be ignored. Get it checked out right away.

Dr. Christopher Segler, D.P.M. is board certified, American Board of Podiatric Medicine. His practice is limited to  runners, triathletes and active young adults who want to stay active. He travels often to accommodate patients with complicated injuries in San Francisco, Houston, and Hawaii. He also provides remote consultations via Skype for injured expat patients living abroad who need expert advice, but cannot readily access a true foot and ankle expert while overseas. If you have a question about a complicated foot or ankle injury that just isn't getting better, you can reach him directly at 415-308-0833

39 comments:

  1. Thank you so much for this article. I fractured my ankle and I've been going to a specialist and have been doing xrays every 2 weeks. The bone is now healed and I'm now doing exercises and slowly walking on the foot again. The specialist has not mentioned anything about my ligaments or additional fractures. I've been off that foot for about a month and a half. Now that I'm walking on it, is it normal that I feel popping near the ankle when I take a step forward? It's not painful when it pops but my ankle's range of motion is still limited... so I'm hoping its not serious and somewhat common during the physical therapy stage. Thanks and I hope to hear from you soon :)

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  2. I had OCD and ligament repair surgery last May. I can run up to 9 miles pain free. Haven't tried anything farther since 2013.

    My surgeon said that continuing to run long distances could lead to ankle fusion surgery later in life.

    Is that true or am I okay to run a marathon or two a year?

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  3. It is great to hear that you are running again after OCD repair and ankle ligament repair surgery.
    It is true that there is a high incidence of post traumatic arthritis after any type of ankle injury, including surgery. Without evaluating your ankle, x-rays, MRI , and operative report, I couldn't comment on whether or not running a marathon will be okay for you. But as a general rule, the more use the ankle gets, the more risk of wearing the surgically repaired cartilage out, and the more risk of ankle fusion surgery down the road.

    it is a common recommendation among surgeons that you should avoid excessive activity after any surgery on a joint.

    Over 20 years ago, I had two surgeries on my knee. After my reconstructive knee surgery I was told by my orthopedic surgeon that I should never run. I was told that the cartilage would wear out in 10 years.

    Given that has now run many marathons and 14 Ironman triathlons since then, that recommendation was obviously wrong.

    Because I am a runner myself, and my practice centers on the treatment of runners, I believe the goal is always to get a runner back to running. I think it is most important to discuss the importance of running to you as an individual when you have these discussions with your surgeon. You can then figure out the best strategies to get back with running without damaging your ankle.

    Best of luck!
    Dr.Segler
    www.DocOnTheRun.com

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  4. Hi Dr. Segler — I stumbled upon this article while searching for causes of ankle pain and clicking when walking. I fractured my ankle almost 10 years ago (missed a step going downstairs and landed on the side of my foot. Small piece of bone fractured off the ankle). Went through physical therapy and it ended up being stronger than my other non-injured ankle... Or so I thought. I recently started running but had to stop after only a few runs because the pain in my ankle was so bad. The pain actually got worse a week after I stopped and it started to swell. I've noticed that when I walk, the ankle makes cracking sounds every few steps. I'm not sure if it's something that I just need to power through and it'll ease up on its own, or if I need to see a doctor. Any advice?

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  5. Hello Krysten,

    I'm sorry to hear that you're having trouble with your ankle. It can be tough to return to running after the type of injury that you had. Without evaluating you I could not offer any advice, as I don't really know your condition. So I cannot comment specifically on your injury or current condition.

    In general, it is never a good idea to try to simply power through swelling, cracking sounds and pain in the ankle. This could be an indication of a serious problem in the ankle that could lead to rapid degeneration of the ankle cartilage.

    With any episodes of pain, swelling and abnormal sensations in the ankle it would be important to have an evaluation by a qualified foot and ankle specialist immediately to make sure that you don't do any damage to the ankle.

    Best of luck...and heal fast!
    Dr. Christopher Segler
    "Doc On The Run"

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  6. iam having snapping and clicking sound problem from eight months but doctor suggest me to do some ankle physics exercise.I don't have any swelling in my ankle but i have little pain when snapping in my ankle .please suggest me, how can be treat this problem?

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  7. Hi,Dr.Segler,

    I am having snapping and Clicking problem in my ankle but i don't have any swelling in my ankle but when snapping happens in my ankle ,there is a little bit pain and can't run and walk very fast.I am taking treatment from orthopedist from 8 months but he suggested some ankle physical exercise and ultra sound therapy,still iam doing those exercise still iam having little bit pain when snapping in my ankle,please suggest me,how can do treatment for my snapping problem in my ankle?

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  8. I fractured my 5th metatarsal in my left foot back in January. My doctor sent me for x-rays and the x-ray doctor told me I needed surgery and didn't explain anything else. When I saw my pre-surgery doctor, he said I didn't need surgery and sent me to an orthopedic doctor. This doctor took x-rays and said I didn't need surgery and gave me a stocking. My follow-up appointment a month later showed my fracture was healing and the doctor said there was no need for me to come back. I have been doing well despite my ankle still being slightly swollen. A few weeks ago I wore flat shoes and now I feel like I can feel the fracture again. It doesn't hurt and I can walk normal, I can just feel it. Or maybe it's my mind making me think that way. My ankle has also started to click again although not as bad when the accident first happened. My ankle is still slightly swollen too. I cannot afford another doctor's visit right now as I am still paying off this last one and I don't want to go through that whole runaround again. Can anybody give me any advice? Or how long does it take a non-surgical fracture to heal? I can't seem to get any answers on-line.

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  9. Hello. I love to run and still can but my anckle has never fully healed from this summer when i twisted it dancing a a party. I jumped from a meter high platform fell on my anckle side ways. Went to the doctors in spain they said you've just sprained it. But was working at a fair ground and could never rest.
    Now some days it inflates and when i move it about in a circular motion it pops slightly but not very loud. Have done 12km on it but it feels worn the next day and inflates. I can't kick a football with the same confidence (soccer) and when i swim with it hurts. What should i do it's been 6 months?

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    Replies
    1. Hello Harry,

      Sorry to hear about the persistent trouble...sound incredibly frustrating! (sorry for also just now responding). Hopefully you have worked the kinks out and are back to running. If not there are a couple of possibilities to consdier:

      1) you have have had a lateral process fracture, and not just a sprain
      2) you have developed chronic ankle instability and laxity from all the walking you had to do after you sprained it.

      Even so, you should still be able to get better. It is imperative that you rule out any big trouble before increasing activity or simply trying to increase your running distance. But you can do it...just make sure you get a thorough second opinion from a sports medicine podiatris who specializes in the treatment of runners.

      Heal fast....get back to running!

      Dr Christopher Segler

      Delete
  10. I broke my fibula and dislocated ankle after fall on ice. 15 days later, I had surgery w/ screws and band. 8 weeks of healing and 12 weeks of rehab followed and even tho 2 years have passed. I click all over the leg especially at ankle. I have significant pain at shin and ankle. 800 mg Ibuprofen TID helps somewhat. I cannot bear weight on tip toe and climbing stairs is painful.Tolerance to standing seems to be decreasing. AM I just a wimp? Do I try a cane? Keep pushing thru? What do I do next? I'm 65 yo and this has changed my life! Is it just normal for rlderly people to suffer after a fall? I am frustrated.

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  11. It seems hard to imagine that anyone (even you) should label you a "whimp" after all you have been through. There is always a solution and a way to improve, but it all depends upon what was done in the surgery to repair the damage, and what has happened though physical therapy and the rest of your recovery. Without knowing all of the details, it would not be possible to determine what you should do next, but you have a couple of very reasonable options: 1) see you surgeon and find out what he/she suggests as the next step. 2) gather all of your records (X-rays, MRI, CT scan, operative report, physical therapy progress notes, etc.) and see another sports medicine podiatrist for an in-depth second opinion. If you aren't getting better, something is being overlooked.

    Heal fast, and best of luck in your recovery!
    Dr Christopher Segler

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  12. I had a sprain in my right ankle 2 years ago while playing football,but i kept on playing football and didnt pay much attention. It got swollen up so instead of iceing I used hot water for its treatment.
    I had a plaster and also took physio therapy treatment but after such a long time popping sound come from my ankle , although it donot pain much but worried about it
    Please give your suggestion how can i come up with this problem and make my ankle strong so that I can again play and run

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  13. Hello Aanchal,

    I am sorry to hear you are still having ankle pain after an injury. Unfortunately many patients develop chronic pain and ankle swelling after these types of sprains. In my experience most patients can still recover and return to activity. The bets approach would be to determine what exactly what happened, what structure has been injured and what you need to do to continue to improve and return to running and playing football without pain. We could likely figure that out during a remote consultation during which we discuss your entire history and come up with solutions. You can learn more about booking a remote consultation for an ankle sprain second opinion at http://www.docontherun.com/talk-to-the-expert/

    I look forward to helping you get back to activity as quickly as possible!

    Sincerely,
    Dr. Christopher Segler
    www.DocOnTheRun.com

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  14. Hello,

    I am now 19 weeks post lateral ligament reconstruction. The ankle now feels a lot more stable (no sensation of rolling ankle), however it is still painful (5/10) swollen and very stiff. My ankle now always seems to click when I walk or do specific rehab exercises, should I be concerned by this? The clicks are loud and feels like it is clicking in something (rubbing on another bone?). My rehab is going well, I now am cycling, rowing, wall squats, lunges, propriception on even and uneven surfaces with either eyes open or eyes shut, single and double standing. Can you recommend any other exercises which will be beneficial to strengthen my ankles? From the pain, clicks shall I go see my doctor/surgeon?

    Thanks,

    Alex

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  15. Hi I sprained my ankle over 11 years ago. It took a long time to get better but still bothers me every now and then. I've noticed that sometimes when I stretch my feet, I will hear a popping sound and then it starts to hurt when I walk. It doesn't stop until it pops back. Do you know why this might be happening?

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  16. I twisted my ankle and now its popping what's the deal

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  17. My 15 year old son has constant snapping and popping from both ankles when he walks. It is especially bad going up stairs. Never broke or sprained either ankle. His pediatrician has told me it's fine and not to worry. I didn't for many years but it seems that the popping and snapping is getting worse. He has hyper mobility in many joints but no true Ehler danlos diagnosis. Could this be the cause of the snapping and popping? There is no pain, swelling or prior injury. He wants to run track but it worries me with the snapping. Second opinion time? Thanks

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    Replies
    1. Hello Courtney,

      Thank you for your inquiry. If your pediatrician has said that there is no concern with the popping and snapping in the ankles when your son walks then I'm sure that an evaluation has been provided and that your doctor believes that to be the case. But if you are still concerned that there may be a pending problem and you're not confident in the diagnosis and treatment recommendation, it is always best to seek a second opinion to make sure that your son doesn't end up with any persistent problems in the ankle resulting from the popping and snapping when he walks.

      Thank you for reading!

      Sincerely,
      Dr. Segler
      www.DocOnTheRun.com

      Delete
  18. Hello,

    I am currently 21 weeks post surgery. I had lateral ligambet reconstruction surgery. I had this surgery due to chronic ankle instability, I play semi proffessional football so am In need of fixing my ankle. I am progressing though my rehab well (propriception work and weight bearing fully) however my ankle now clicks a lot (when I walk or walk up/down stairs and when I do plantar/dorsi flexion and eversion and inversion exercises. Is this normal? I am worried from reading the above statements regarding snapping ankle. Also, are there any other specific rehab exercises you can recommend? Thanks, A

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    Replies
    1. Hello "Anonymous,"

      If you have had surgery, it is always best to discuss any postoperative concerns with your surgeon, as he/she will have the most information about what was done during your surgery, which could cause any symptoms postoperatively and what you should do to proceed without persistent difficulty.

      Wishing you a safe and rapid return to football.

      Sincerely,
      Dr. Segler
      www.DocOnTheRun.com

      Delete
  19. I av an ankle pain and swelling, I don't rembr falling or spraining my ankle.it just started all of a sudden.and av done xray,physiotherapy, and taken different kind of drugs,I was given methyl prednisolone in my angle joint and it relieved for some while and back again.pls what can I do.it crack when I try to squeeze it.its over 4yrs now and d pain is unbearable.

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  20. Good Evening. I currently have an avulsion fracture of the distal fibula. I fractured this same bone three years ago and my orthopedic believes that it may not have healed correctly and that is why it fractured more easily this time. I should also note that I have noticed ever since I had my first fracture my ankle would pop and click when I would rotate it in a circular motion. My question is that I was getting ready this morning and put leggings on without my boot and moved my ankle and heard and felt a loud pop. My ankle doesn't hurt anymore than it has since I fractured it a week and a half ago. I can't tell if it's unstable or not as I have kept the boot on it. Is this something that should be concerning or a typical occurrence of healing? Thank you.

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  21. Hello Rebecca,

    Thank you for reading and for your inquiry. I am sorry to hear that you have had another fracture. Given that you heard a loud pop, and that you have had more than one injury, you should certainly have your local orthopedic surgery evaluate your ankle in person right away.

    Wishing you a speedy recovery!

    Dr Christopher Segler
    www.DocOnTheRun.com

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  22. Hello Dr.
    6 weeks ago I had landed on my ankle and it felt like it dislocated and went back in right after impact as I grabbed my ankle. There has been a lot of clicking and popping happening for the last 3 weeks and I was wondering if that is a sign of torn ligament or particular tendon? Or if it could be from being in a boot for 2 weeks? I have an MRI scheduled so I will know eventually if anything was torn, but I was curious about the clicking.
    Thank you for your time.
    Yasmine

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    Replies
    1. Hello Yasmine,

      Sorry to hear about your injury. Popping and clicking in the ankle is never normal. That can be a sign of a number of different injuries including toward ligaments, dislocating tendons or even subtle fracture patterns in the foot or ankle. Popping and clicking ion the ankle is almost never directly caused by wearing a fracture walking boot.

      It is good that you're being evaluated and have an MRI scheduled so that you can figure out exactly what is going on.

      Best of luck!

      Sincerely,
      Dr. Segler
      www.DocOnThe Run.com

      Delete
  23. Hello,

    I've been running on an elliptical and doing T25. with that workout there's stop and go and sprinting. Last week the back of my ankle (a little above my heel) started to bother me. I'm not in pain, but it's a little sore. it cracks when i walk (doesn't hurt). I stopped running last week and I haven't exercised. I've been icing it. it hasn't gotten worse but I don't feel like it's gotten any better. Not sure if I should give it more time or go see the doctor. I don't know if it's ankle related or if it's my achilles. thoughts? thanks so much!

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    Replies
    1. Hello VT,

      Is hard to say based on the description. But in general, pain is less significant than cracking sensations. However one of the many things to consider in that area would be an os trigonum irritation. You can find more info at www.anklecenter.com , specifically at this url: http://www.anklecenter.com/index.php?option=com_content&view=category&layout=blog&id=120&Itemid=202

      I hope that helps!

      Sincerely,
      Dr. Segler
      www.DocOnThe Run.com

      Delete
  24. This comment has been removed by a blog administrator.

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  25. I fell in March and twisted my ankle. I didn't go to the doctor because I've had many sprains in my lifetime and figured it would heal fine with a little rest. Everything was fine other than being sore until about 4 weeks later. I started hearing clicking and feeling it on the outside ankle bone. I still waited but finally went to the doctor. I saw a PA who took X-rays with me laying down and watch me walk once about 4 feet. The radiologist diagnosed degenerative arthritis in the ankle joint. My concern is, I read several articles it and most said many doctors misdiagnose because they take the obvious solution. I never had any clicking or noticed anything unusual until after my fall. I'm suppose to see a podiatrist for some orthopedic support. I don't feel very confident about this diagnosis because the PA barely spent 5 minutes check g it out. Just would like another opinion about who I should go see about it.
    Thank you for any feedback.

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  26. Hello Dolllynda,

    I'm sorry to hear about the trouble with your ankle. Given that you're still having trouble you should certainly seak a second opinion.

    Thank you,
    Dr Segler

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  27. At the end of November I had a talus fracture without need of surgery, the bone had healed over 8weeks in a cast and 4 weeks in a walking boot and then I got back to training (I'm an elite trampoline gymnast) in my first week I rolled my ankle causing excrutiating pain up through my leg. Since then every other step and if I do rotations with my ankle it clicks very loudly and isn't comfortable - is there anything I can do to prevent this? Also when I fractured my talus I had an avulsion fracture in my left foot, however as they didn't cast it I was putting all my weight through this foot while on crutches, now if I point my foot down to the floor it feels as if it locks before it makes a large crack, which is quite worrying. Is there anything I can do help either of my feet to stop the cracking noises?
    Thanks
    Izzy

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  28. I rolled my ankle a couple days ago during a tempo run. It's the same one I sprained 9 months ago and I thought it was healed. It didn't swell this time and I can walk with only a little pain and stiffness, but it makes a cracking noise when I walk or move or stretch it. Should I be concerned or do I just need to give it more time? I haven't seen my doctor because with no swelling or bruising I'm assuming it's a very minor sprain.

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  29. Hello Angela,

    Sorry hear about your ankle! Pain, stiffness, and especially a cracking noise are worrisome. Even if only perceived as "rolled ankle" or sprain, the symptoms you describe could be a much more serious (albeit subtle) fracture in the ankle itself. Seeking an evaluation with your own doctor, (or a remote consultation with an ankle expert: http://www.docontherun.com/talk-to-the-expert/ ) should be the first order of business.

    Heal fast...and get back to running!

    Dr. Segler
    www.docontherun.com

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  30. I'm 11 and my left ankle click so it's good to know why .

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  31. Hi doctor,
    I had an ankle sprain 2 or 3 years ago while I was playing football. My foot is fine but ever since that day I just have the popping noise whenever I rotate my foot. I don't get any swelling or pain. Do you think this will be a problem in the future?

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  32. I don't know why but my ankle keeps cracking and it hurts, even when I'm just walking it hurts and cracks.

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  33. Hello Hillary,

    Thank your for your comment. Any time a runner has popping, clicking, cracking WITH PAIN it is worrisome. In some cases it is a dislocating perennial tendon, a small fracture under the cartilage in the ankle or a lateral process fracture. It is also best to get it checked out.

    You can also learn more at ankle center.com

    Thanks!
    Dr. Christopher Segler
    Doc On the Run
    www.docontherun.com
    https://www.docontherun.com/ankle-sprains/

    ReplyDelete
  34. I came here because I have recently found only my left ankle popping excessively simply by lying in bed and moving my foot up & down.
    Background is that 3 weeks ago I was bitten by a Red Back Spider on my left ankle. Emergency put me on antibiotics for 10 days. Now that the wound has nearly healed (swelling and discharge has stopped) I have discovered that the popping has started.
    Also my calf muscle feels a bit tight and stiff (a bit like a cramp when not enough blood circulating),
    Just started walking again without clutches and hoping the ankle popping will go away soon ?

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