Ankle Pain

Evaluation: Important items to consider in the history:

• Etiology/onset (trauma, gradual)

• Functional loss?

• Previous injury

Differential Diagnosis: Think of acute vs. chronic

• Acute

  • Ankle sprain

  • Ankle fracture/dislocation

  • Infected joint (rare)

  • Capsulitis (irritation of joint capsule of the ankle)

• Chronic

  • Degenerative joint disease (DJD)

  • Other arthritidies

Physical exam: Look for signs of infection and fracture.  

• Dislocation should be obvious on exam.  

  • All may require Medical Evacuation if possible.  

• Infection is a surgical emergency.  

• Fractured and/or dislocated ankles will obviously limit the functional capabilities of the service member.  

• Dislocation may compromise vascular supply.  

Signs to look for include:

• Infection

  • Very painful range of motion, both active and passive – helps to differentiate between overlying cellulitis and joint infection

  • edema

  • erythema

  • warmth

  • fever

• Fracture vs. Sprain

  • Use the Ottawa rules - palpate the posterior aspect lateral malleolus, posterior aspect medial malleolus. If no tenderness and able to ambulate, very unlikely to have ankle fracture.  Need to look for foot fracture also – palpate navicular and base of 5th metatarsal.

• Dislocation:

  • Check for pulses after relocating 

Labs:

• If suspect ankle infection (rare) need to tap joint to confirm, crystal induced arthritis may mimic such as gout.

• Ankle/foot x-rays for positive Ottawa criteria

Treatment

Trauma: Sprains – usually inversion, if eversion, suspect fracture

• PRICEMM for acute soft tissue injuries:

• Protection – against reinjury – bracing if needed with ACE, Air cast, etc.

• Rest-  relative rest - duty restrictions as necessary

• Ice – 20 minutes t.i.d.

• Compression – especially initially – prevents excess edema and speeds healing

• Elevate – above heart to also prevent excess edema

• Medications - anti-inflammatory medications for pain

• Modalities – if available – electrical stimulation, then begin range of motion and Proprioception (spatial sensation- where is my ankle positioned?) exercises – for example have patient spell out the alphabet

• If need to keep service member functioning, the combat boot makes a good functional brace

Trauma: Fracture

• Splint with posterior splint

• Crutches

• Ankle fractures require excellent anatomic realignment to prevent long-term problems.  

• Difficult fractures to diagnose and manage include talar dome fractures and Osteochondral defects (may require MRI for diagnosis)

Infection: If unable to tap and/or Medevac:

• Begin antibiotics

• Crutches

• Anti-inflammatories.  

• In young (<40) consider GC as cause and Rx with Ceftriaxone

• Superficial cellulitis - oral antibiotics with/without IM/IV antibiotics

Mechanical/Overuse such as DJD, capsulitis

• Activity modification

• Anti-inflammatories

• Physical Therapy – ROM, strength, proprioception

Christopher Kardohely, DPM and Scott D. Flinn, MD

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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