Ankle Pain/Swelling

Ankle pain is a common problem that generally occurs secondary to acute or chronic injury or degenerative joint disease. Ankle sprains, most commonly due to traumatic inversion injury, are the most common cause of ankle pain. In cases of trauma, the Ottawa rules are used to decide whether X-rays are indicated and have been shown to improve the cost effectiveness of radiologic evaluation without compromising quality of care. Bilateral ankle swelling suggests cardiac or vascular etiologies (e.g., CHF) rather than intrinsic foot/ankle disease.

Differential Diagnosis

• Inversion sprain (85% of ankle sprains)
  –Results in pain, swelling, and ecchymosis of the lateral malleolar area
  –Damage occurs to the three ligaments of inferior fibula (anterior and posterior talofibular and calcaneofibular ligaments) and peroneal muscle

• Degenerative joint disease
  –Pain is present upon waking in the
  morning; relieved by mild activity
  –Grinding/popping occurs with motion

• Inversion/eversion injury of subtalar joint
  –Results in pain while walking on uneven ground
• Syndesmosis injury (“high ankle sprain”)
  –Stretching of the interosseous membrane
  –Results in pain at the lower leg
• Avulsion fracture of the distal fibula
  –Results in persisting lateral malleolar pain
  –Difficult to differentiate from the
  epiphyseal line on X-ray
• Repetitive injury with disruption of the ankle retinaculum
  –Results in chronic pain of the posterior aspect of the ankle
• Poor shoe alignment
• Bimalleolar fracture
• Trimalleolar fracture: Bimalleolar fracture plus a fracture of the lateral aspect of the distal tibia
• Neoplasm
• Peroneal nerve entrapment
• Diabetic (Charcot's) arthropathy

Workup and Diagnosis

• History and physical examination
  –Ankle, foot, and lower leg examination
  –Always evaluate neurovascular status, including pulses, color, and capillary refill
  –Observation of bones and soft tissues, color, swelling
  –Anterior/posterior drawer test: Ankle is held in one hand and the lower tibia is pushed and pulled to evaluate for instability
  –Range of motion should be evaluate both actively and passively (grinding or popping suggests DJD)
• Ottawa ankle rules are used to determine whether an X-ray of
  the ankle is necessary following trauma
  –Tenderness of the distal 6 cm of the fibula or tibia
  –Tender navicular area
  –Tender proximal fifth metatarsal
  –Cannot bear weight (at least four steps)
• Standard three-view ankle X-rays, stress views (inversion or eversion), and consider foot series or lower leg series
• Lateral X-rays in plantar- or dorsiflexion may help evaluate for anterior or posterior impingement
• CT or MRI may be indicated to clarify findings on plain films and to evaluate cartilage, nerves, tendons, ligaments
• Muscle strength and range of motion testing

Treatment

• PRICE
  –Protection from additional strain/injury
  –Relative rest (stretching is okay) ±crutches
  –Ice for initial 24–48 hours after trauma
  –Compression (elastic wrap or ankle support)
  –Elevation of foot (higher than the pelvis)
• Casting is often indicated for fractures and significant ankle sprains
• Short-term bracing may reduce risk of reinjury
• Surgery may be indicated (e.g., bimalleolar fracture, trimalleolar fracture)
• Physical therapy referral to improve strength, range of motion, and proprioception
• NSAIDs or other analgesic

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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