Ankle pain

This page is for adult patients. For pediatric patients, see: Ankle pain (peds).

Background

Ankle anatomy: left ankle, anterior-lateral view.

Ankle anatomy: left ankle, anterior-medial view.

Ankle anatomy

Clinical Features

• Ankle pain

Differential Diagnosis

Other Ankle Injuries

• Ankle sprain
• Ankle dislocation
• Ankle syndesmosis injury
• Radiograph-negative ankle injury (peds)

Distal Leg Fracture Types

• Tibial plateau fracture
• Tibial shaft fracture
• Pilon fracture
• Maisonneuve fracture
• Tibia fracture (peds)
• Ankle fracture
  • Ankle fracture (peds)
    • Tillaux fracture
• Foot and toe fractures

Foot and Toe Fracture Types

Hindfoot

• Talus fracture
• Calcaneus fracture

Midfoot

• Lisfranc injury
• Navicular fracture
• Cuboid fracture
• Cuneiform fracture

Forefoot

• Fifth metatarsal fracture
• Non-fifth metatarsal fracture
• Toe fracture

Foot diagnoses

Acute

• Foot and toe fractures
• Subtalar dislocation
• Metatarsophalangeal joint sprain (turf toe)
• Acute arterial ischemia
• Calcaneal bursitis

Subacute/Chronic

• Diabetic foot infection
• Peripheral artery disease
• Plantar fasciitis
• Trench foot
• Ingrown toenail
• Paronychia
• Tinea pedis
• Morton's neuroma
• Diabetic neuropathy

Evaluation

Workup

Acute traumatic

• Consider x-rays
  • Use Ottawa Ankle Rules for acute ankle injuries to determine need for x-rays

Atraumatic / Subacute

• Consider x-rays
• Consider labs for infectious workup (i.e. septic joint)
  • CBC
  • Chemistry
  • Coags
  • ESR/CRP
• Consider arthrocentesis

Diagnosis

Acute traumatic

• Typically determined by imaging

Atraumatic / Subacute

• See following for analysis of synovial fluid, if indicated

Arthrocentesis of synoval fluid

Synovium	Normal	Noninflammatory	Inflammatory	Septic
Clarity	Transparent	Transparent	Cloudy	Cloudy
Color	Clear	Yellow	Yellow	Yellow
WBC	<200	<200-2000	200-50,000	>1,100 (prosthetic joint) >25,000; LR=2.9 >50,000; LR=7.7 >100,000; LR=28
PMN	<25%	<25%	>50%	>64% (prosthetic joint) >90%
Culture	Neg	Neg	Neg	>50% positive
Lactate	<5.6 mmol/L	<5.6 mmol/L	<5.6 mmol/L	>5.6 mmol/L
LDH	<250	<250	<250	>250
Crystals	None	None	Multiple or none	None

• Viscosity of synovial fluid may actually be decreased in inflammatory or infectious etiologies, as hyaluronic acid concentrations decrease
• The presence of crystals does not rule out septic arthritis; however, the diagnosis is highly unlikely with synovial WBC < 50,000

Management

• Depends on individual diagnosis
• Traumatic injuries may require a posterior ankle splint and/or crutches

Disposition

• Depends on specific diagnosis
  • Most closed and distally neurovascularly intact traumatic injuries are treated as an outpatient
  • Ortho referral for significant fractures/dislocations
  • Septic joint should be admitted

See Also

• Diagnoses by Body Part (Main)