Objective To investigate whether retrograde tibial intramedullary nail (RTN) fixation can cause postoperative anterior ankle pain in the treatment of distal tibial extra-articular fracture. MethodsA retrospective analysis was performed for 29 patients with distal tibial extra-articular fractures caused by trauma, who received RTN treatment between January 2021 and December 2023. There were 19 males and 10 females, with an average age of 47.3 years. There were 18 cases of closed fractures and 11 cases of open fractures. The time from injury to hospital admission was 1-5 days, with an average of 3.7 days. The operation time, intraoperative blood loss, bone healing time, time to full weight-bearing, visual analogue scale (VAS) score, Olerud-Molander ankle score (OMAS), and occurrence of anterior ankle pain were recorded. Results The operation time was 43-75 minutes (mean, 60.7 minutes); intraoperative blood loss was 50-120 mL (mean, 88.3 mL). All patients were followed up 14-32 months (mean, 24.0 months). All patients achieved fracture healing and the healing time was 3-6 months (mean, 4.5 months). The postoperative full weight-bearing time was 40-63 days (mean, 53.3 days). The VAS scores were 0-5 (mean, 2.0) at 3 months after operation and 0-3 (mean, 1.5) at last follow-up. The OMAS scores were 60-95 (mean, 80.3) at last follow-up and the ankle functions were rated as excellent in 3 cases, good in 24, and fair in 2, with a excellent and good rate of 93.1%. The postoperative anterior ankle pain occurred in 2 patients (6.9%) and relieved after removal of RTN. Conclusion RTN treatment for distal tibial extra-articular fractures provides firm fixation, which is beneficial for early postoperative functional exercise and weight-bearing in patients, and has a lower incidence of anterior ankle pain.