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Ankle Pain

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Ankle Pain

Ankle Pain
Brett M. Cascio MD
Basics
Description
  • Ankle pain can result from a variety of
    underlying causes, including trauma, arthritis, sports-related
    conditions, infection, systemic disorders, and neoplastic processes.
  • Successful treatment requires a full
    understanding of ankle anatomy, a proper history, and a thorough
    physical examination to yield an appropriate differential diagnosis.
  • Ankle anatomy:
    • Bones: The ankle joint is comprised of the talus, distal tibia, and distal fibula.
    • Ligaments:
      • Lateral: ATFL, CFL, PTFL
      • Syndesmotic: Anterioinferior tibiofibular ligament, posteroinferior tibiofibular ligament
Epidemiology
Incidence
  • Extremely common
  • More common with increasing age
Etiology
  • Trauma
  • Arthritis: Degenerative, inflammatory
  • Stress fracture, overuse
  • OATS of talus
  • Tendinitis or tendon tear
  • Acute ligament sprain or chronic instability
  • Infection: Septic arthritis, osteomyelitis
  • Neoplasm
Geriatric Considerations
Common causes of ankle pain include degenerative or inflammatory arthritis, PTT dysfunction, chronic tendinosis, and gout.
Pediatric Considerations
Ankle pain commonly is secondary to trauma, occult tarsal coalition, or bone or soft-tissue tumor.
Pregnancy Considerations
Pregnant patients may experience transient ankle pain
secondary to lower extremity edema or altered lower extremity mechanics
in addition to other adult causes.
Associated Conditions
  • Rheumatoid or inflammatory arthritis
  • Gout
  • Lyme disease
  • Tarsal coalition
Diagnosis
Signs and Symptoms
  • Ankle pain that is well localized after a traumatic episode may represent an ankle sprain, fracture, or tendon injury.
  • Pain without a history of trauma but with
    substantial joint swelling, warmth, and extreme pain with passive ROM
    could indicate a septic joint or an acute gouty attack.
  • Chronic symptoms related to activity in
    adult patients may indicate degenerative arthritis of the ankle,
    whereas morning pain and stiffness may indicate an inflammatory
    condition.
  • Ankle pain, swelling, and a skin rash after a tick bite may represent Lyme disease.
History
  • Elicit a careful history of factors that caused or exacerbate the pain.
    • History of trauma
    • Activities that exacerbate symptoms
    • Presence of morning pain and stiffness
    • History of gouty involvement of hallux
    • Constitutional symptoms, such as fever, night sweats, weight loss, night or rest pain
    • History of tick bite
    • Athletic history
Physical Exam
  • Localize area of maximum tenderness:
    • Medial and lateral malleoli
    • Tendons: Posterior tibialis, peroneals, Achilles, extensor tendons
    • Ligaments: Deltoid ligament, lateral ligaments, and syndesmotic ligaments
    • Anterior joint line/capsule
  • Assess active and passive ROM of the affected ankle and compare with that of the contralateral ankle.
  • Assess ligament stability and manual muscle strength.
  • Examine the skin about the ankle and assess for focal swelling, warmth, or joint effusion.
  • Assess the neurovascular status of the foot.
  • Assess the patient’s gait.
Tests
Lab
  • Order serum laboratory tests based on the level of suspicion for specific clinical entities:
    • Septic arthritis: Complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein
    • Rheumatoid arthritis or other inflammatory arthritis: Rheumatoid screen, rheumatoid factor, antinuclear antibody
    • Gout: Serum uric acid level
    • Lyme disease: Lyme antibody screen
Imaging
  • Radiography:
    • Standing AP, lateral, and mortise views of the ankle are necessary.
    • An oblique radiograph of the foot may be indicated to rule out calcaneonavicular coalition.
  • MRI:
    • May be necessary to detect occult processes such as stress fractures, OATS, tendon abnormality, or neoplasm
    • Also can evaluate traumatic injuries and identify OCDs, occult fractures, and tendon tears
  • CT:
    • Can help define fracture fragments and intra-articular involvement
    • Can help identify neoplastic processes such as cysts or osteoid osteoma
    • May be indicated to identify tarsal coalition
Diagnostic Procedures/Surgery
  • Arthrocentesis is a useful method for diagnosing septic arthritis or gout.
    • In septic arthritis, findings include positive Gram stain and/or culture, most commonly Staphy lococcus aureus.
    • In gout and pseudogout, findings include urate or calcium pyrophosphate crystals, respectively.
Differential Diagnosis (1)
  • Ankle sprain
  • Ankle fracture
  • Tendon strain or rupture
  • Stress fracture
  • Tendinitis or degenerative tendinosis
  • Osteoarthritis or degenerative arthritis
  • Rheumatoid or inflammatory arthritis
  • Septic arthritis (2)
  • Lyme disease
  • Acute gout
  • Osteochondritis dissecans of the talar dome
  • Bone tumor
  • Soft-tissue neoplasm
  • Tarsal coalition

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Treatment
General Measures
  • Ankle sprains or low-grade trauma can be treated with the RICE protocol and gradual weightbearing as tolerated.
  • Patients with ankle fractures should be
    splinted, instructed to remain nonweightbearing, and referred to an
    orthopaedist for definitive care.
  • Hot, swollen, erythematous ankles may warrant arthrocentesis to rule out a gouty attack or septic arthritis.
Activity
  • Patients with ankle sprains and low-grade trauma should begin to bear weight gradually as tolerated.
  • Nonweightbearing activity is appropriate in a patient with an ankle fracture, pending evaluation by an orthopaedist.
  • Protected weightbearing in a cast or boot
    brace often is useful for patients with conditions such as tendon
    strain, tendinitis/tendinosis, stress fracture, OCD of the talus, or
    symptomatic tarsal coalition.
Special Therapy
Physical Therapy
May be indicated in certain cases once diagnosis and specific treatments are performed
Medication (Drugs)
First Line
  • NSAIDs are used for tendon injuries, sprains, stress fractures, and arthritis.
  • Narcotics are used for fracture pain.
  • Gouty attacks may require NSAIDs and colchicine, whereas allopurinol may be needed for suppression of chronic attacks.
  • Septic joints require antibiotics and either aspiration or surgical debridement (2).
  • Corticosteroid injection is used for arthritis pain.
Surgery
  • Unstable fractures typically require surgical reduction and fixation.
  • Pain from ligament instability, tendon tear, or OCD of the talus may ultimately require surgical treatment.
  • Septic arthritis is treated with surgical
    irrigation and debridement rather than serial aspirations in patients
    with chronic, Gram-negative or Staphylococcus infection; patients who are immunocompromised; or patients for whom antibiotics and aspirations have failed (2).
  • Arthritis pain that does not respond to
    appropriate nonsurgical means may necessitate ankle arthrodesis
    (fusion) or arthroplasty.
  • Bony or soft-tissue neoplasm typically
    requires appropriate staging workup and biopsy, followed by definitive
    surgical treatment (e.g., bone grafting of benign cyst, wide resection
    with limb-sparing surgery, or even amputation).
Follow-up
Disposition
Issues for Referral
  • Acute fracture should prompt referral to an orthopaedist for definitive management.
  • Chronic conditions unresponsive to rest,
    activity and sports restriction, medications, and immobilization should
    lead to referral to an orthopaedist for additional evaluation and
    management.
  • Bone or soft-tissue neoplasm should be referred to musculoskeletal oncologist for staging workup and biopsy.
Prognosis
Depends on underlying cause
Complications
Many of the causes of ankle pain can lead to progressive pain and stiffness.
Patient Monitoring
Careful short-term follow-up is necessary to monitor ROM and prevent contractures.
References
1. Renstrom PAFH. Persistently painful sprained ankle. J Am Acad Orthop Surg 1994;2:270–280.
2. Ross JJ. Septic arthritis. Infect Dis Clin North Am 2005;19:799–817.
Additional Reading
Pfeffer GB (ed). Chronic Ankle Pain in the Athlete. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2000.
Richardson EG (ed). Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2004.
Miscellaneous
Codes
ICD9-CM
719.47 Ankle joint pain
Patient Teaching
Activity
Activity depends on abnormality.
Prevention
Maintenance of strength and flexibility
FAQ
Q: What are 7 possible causes of ankle pain?
A: Fracture, sprain, tendon injury, tendinitis, arthritis, infection, or neoplasm.

Q: What structures comprise the medial and lateral ankle ligaments?
A: Superficial and deep deltoid, ATFL, PTFL, and CFL.

Q: What type of condition is suggested by morning stiffness and ankle pain?
A: Rheumatoid or inflammatory arthritis.
Q: What conditions likely require referral to an orthopaedist?
A: Acute fracture, neoplasm, and a chronic condition unresponsive to initial nonsurgical treatment attempts.

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