Ankle pain
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This page is for adult patients. For pediatric patients, see: Ankle pain (peds).
Background
Clinical Features
- Ankle pain
Differential Diagnosis
Other Ankle Injuries
Distal Leg Fracture Types
- Tibial plateau fracture
- Tibial shaft fracture
- Pilon fracture
- Maisonneuve fracture
- Tibia fracture (peds)
- Ankle fracture
- Foot and toe fractures
Foot and Toe Fracture Types
Hindfoot
Midfoot
Forefoot
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[1]
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
- ↑ Shah K, Spear J, Nathanson LA, Mccauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis?. J Emerg Med. 2007;32(1):23-6.