Potential differential diagnoses for ankle pain:

Achilles tendon rupture, Achilles tendon strain, lateral ligament sprain, fracture, gout, dislocation.

Various types of ankle pain:

Ankle pain may be acute or chronic. Pain may be attributed to various differential diagnoses.

The treatment for ankle pain is largely the same. Patient should be encouraged to “protect” the joint. This may be encouraged by wearing a brace around the affected joint. “Rest” the joint by non-weight bearing, using crutches during ambulation. Applying ice to the affected area. Compressing the surrounding tissues with an ace wrap. Elevating the joint to reduce inflammation. Lastly, using oral NSAIDs for pain control.

Ankle Sprain:

Lateral ligament injuries are the most commonly reported injury to the ankle (Van Rijn et al, 2011). Lateral ligament injuries are the most common injury due to the anatomy of the ankle. The lateral ligament is the most vulnerable ligament.

Sprains are treated in phases.

1 – Protection, Rest, Ice, Compression, Elevation & NSAIDs.

2 – Introduce gentle weight bearing

Various types of treatment

Ice, compression, and elevation.

Depending on the severity of injury immobilization or surgical repair may be indicated.

Diagnostics

The mechanism of injury leading to the ankle pain is important to formulating an accurate differential diagnosis. Imaging may be required to narrow down a diagnosis. Imaging such as CT, MRI, and x-ray may be helpful.

Ankle Fractures

Risk factors which predispose patients to a higher risk of ankle fractures include: osteoporosis, diabetes, and obesity (Strauss et al, 2011).

Generally, patients with ankle fractures present with pain, swelling, deformity, and an inability to bear weight on the affected joint (Strauss et al, 2011).  Supination-external rotation fractures are the most common type of ankle fracture (Strauss et al, 2011).

Unimalleolar – involving one side of the ankle

Bimalleolar – involving medial and lateral malleolus

Trimalleolar – Involving three areas of the malleolous.

Treatment:

Treatment of an ankle fracture is contingent upon several factors “A patient is treated nonoperatively if he/she sustains a nondisplaced, stable fracture with an intact syndesmosis or if stable anatomic reduction is achieved after a displaced fracture. ORIF is indicated in open and/or unstable fractures, and when closed reduction fails. Unstable fractures may cause widening of the mortise or displacement of the talus. The method of stabilization utilized during ORIF depends on the anatomical location of the ankle fracture and associated soft tissue injury” (Urruela et al, 2011)

Strauss, E. J., M.D., & Egol, K. A., M.D. (2011). Identifying and managing ankle fractures in older patients. The Journal of Musculoskeletal Medicine, 28(4), 137-140,145-147. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/863651469?accountid=167104

Urruela, A., & Egol, K. (2011). Foot and ankle fractures in the elderly patient. Aging Health, 7(4), 591-605. doi:http://dx.doi.org/10.2217/ahe.11.45

van Rijn, R.,M., Willemsen, S. P., Verhagen, A. P., Koes, B. W., Bierma-Zeinstra, S., & Hush, J. M. (2011). Explanatory variables for adult patients’ self-reported recovery after acute lateral ankle Sprain/Invited commentary. Physical Therapy, 91(1), 77-84. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/846755272?accountid=167104 (Links to an external site.)Links to an external site.

Reply to Dee

 

Patients can have ankle pain for a variety of reasons. To formulate an accurate diagnosis and differentials, providers must be able to accurately assess physically and with assessment questions. Assessing when the pain started, exacerbating and alleviating factors, and any possible precipitating injuries. An ankle sprain, for example, is caused by sudden stress on one or more of the ligaments of the ankle (Uphold & Graham, 2013). Assessing if the patient twisted the ankle and experienced pain immediately or within the hour of the insult, an inversion injury should be suspected (Uphold & Graham, 2013). Asking the patient exactly how the injury occurred, the positioning of the foot when the injury occurred, if there was any swelling, to describe the type of pain, if ADL’s are affected, if there is any limping or night pain can aid in formulating an accurate diagnosis and treatment plan (Dains, Baumann, & Scheibel, 2016).

Physical assessment should include observing the patient’s gait for any limp, assessing for any deformities, inspection of the skin and nails (for inflammation or the possibility of ingrown toenails causing gait abnormality) (Dains, Baumann, & Scheibel, 2016); measuring limb circumference and length to assess for atrophy and to ascertain if this is a chronic or acute problem; palpation of the joints and performing range of motion is also important in formulation of the diagnosis and treatment.

Performing the anterior drawer test, to assess the anterior talofibular ligaments of the lateral side of the ankle; the talar tilt test to assess the stability of the calcaneofibular ligament; and the squeeze test to assess if medial or lateral damage has occurred (Uphold & Graham, 2013). Differentials include muscle strain, tendonitis, peroneal tendon dislocation, tendon rupture, fracture, gout or arthritis (Uphold & Graham, 2013). Diagnostics that should be included are xray, if there is pain near the malleoli, inability to bear weight, bone tenderness, according to Ottawa rules (Uphold & Graham, 2013). CBC can be obtained to rule out infection, uric acid to rule out gout, RA, ANA and CRP to rule out rheumatoid arthritis, arthritis, and infection, respectively (Dains, Baumann, & Scheibel, 2016).

Treatment is dependent upon diagnosis. If patient has a strain/sprain, rest, ice, compression, and elevation is the appropriate treatment. Patient can also be treated with short term NSAID’s for pain relief. If there is no improvement within 2-3 weeks, or if symptoms worsen, patient may need to be referred to an orthopedist (Uphold & Graham, 2013).

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced Health Assessment and Clinical Diagnosis in Primary Care (5th ed.). St. Louis, MO: Elsevier.

Uphold, C. R., & Graham, M. V. (2013). Clinical Guidelines in Family Practice (5th ed.). Gainesville, FL: Barmarrae

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