ankle pain approch
TRANSCRIPT
Background
• Age• Sex• Occupation: athlete• Pre-existing chronic conditions: DM, RA, AS,
psoriasis, hematological disorders• Other pre-existing chronic symptoms• Drugs the pt is taking: fluoroquinolones,
thiazides
Pain Characteristics
• Exact site• Duration• Severity• Onset and course• Effect of activity (including specific) and rest
Associated Symptoms
• Pain at other joints• Pain at other sites of body including back• H/O preceding diarrhea, dysentery, abdominal
pain, urethral discharge, sore-throat• Cough, conjunctivitis, fever, skin rash• Anorexia, weight loss
Past History
• Past HO joint or back pain– Recurrent acute mono-, oligo
• Other serious illnesses• Painful red eye
Family History
• Rheumatic diseases
• Painful red eye
• Psoriasis
• IBD
General Examination
• Nutritional state• Anemia, polycythemia• Parotid enlargement• Skin rashes, incl. erythema nodosum• Lymphadenopathy
Systemic Examination
• Precordium: changes in sounds, murmurs
• Lungs: asthma, apical creps, effusion
• Abdomen: organomegaly, lumps
• NS: Mononeuritis
Locomotor System
• Tenderness in hand joints
• SI joint tenderness
• Restriction of movement of spine
Ankle: Inspection
• Ascertain exact site of pain• Joint position• Swelling: capsular or local• Erythema of skin• Ecchymoses• Range of active movement
Ankle: Palpation• Tenderness: joint line vs. localized• Warmth• Pain on movement:– Uniform throughout– Stress pain• Universal• Selective
• Palpation during movement: crepitus
Classifying Info
• Systemic features including PH• H/O trauma• Onset & course• Site of pain– Articular vs. periarticular– Posterior, heel, medial, lateral, anterior
Syndromes: Articular
• Articular, Acute– recurrent– Acute 1st episode
• Articular, chronic– Without systemic features– With systemic features• Musculoskeletal• Extra-skeletal
Syndromes: Peri-articular
• HO Trauma• Without HO trauma
Articular
• Acute articular– Recurrent: crystal, palindromic, ReA, hemarthrosis– 1st episode: above + septic, traumatic
• Chronic– Tuberculosis– SpAs– RA
• Ankle sprain: local swelling, tenderness– Lateral– Medial– Syndesmotic
Posterior Ankle Pain• Achilles tendinitis• Haglund's Syndrome • Stress fracture
– Calcaneal – Tibial
• Sever's lesion (calcaneal apophysitis in adolescents)
• Retro-calcaneal and retro-Achilles bursitis
• Vascular claudication
• Deep venous thrombosis
• Cellulitis
• Abscess
• Osteomyelitis
• Bone cyst
• Malignancy
• Hematoma
Findings on Examination• Swelling & localized tenderness 2 to 6 cm
above insertion of Achilles: Achilles tendinitis
• tender swelling behind upper pole of calcaneum: retrocalcaneal bursitis
• A 2 to 3 mm bony extrusion visible and palpable above the site of attachment of Achilles tendon: Haglund's Syndrome
Heel Pain….• Plantar fasciitis
• Calcaneal apophysitis
• Calcaneal Periostitis
• Painful calcaneal spur
• Entrapment of the posterior tibial nerve as it courses beneath the medial malleolus
Heel Pain• Neoplasm or infection is typically constant or
characterized by nocturnal worsening
• Stress fractures
• Painful heel pad syndrome
• Atrophy of the heel pad
• Rupture of the plantar fascia
Findings on Examination…• Discrete tenderness near origin of the fascia at
medial tuberosity of calcaneum: plantar fasciitis
• CALCANEAL APOPHYSITIS (Sever’s Disease)
– pain reproduced by digital palpation over apophysis
– calcaneal compression test: hold heel in palm with the
fingers enveloping upper portion of heel, squeeze to
compress heel in transverse plane
History & Examination
• Calcaneal Periostitis: – Worst in morning– Diffuse tenderness along plantar aspect and
lateral border of the heels
• Painful heel pad syndrome:– Plantar fascia is not tender– Pain is not accentuated when examiner
dorsiflexes the toes
Medial Ankle Pain
• Tibialis posterior tenosynovitis
• Flexor hallucis longus injuries
• Flexor digitorum longus tendinitis
• Os tibiale externum
• Medial ankle sprain
History & Examination
• Tibialis posterior tenosynovitis:– gradually increasing pain over the medial ankle
– Sign: swelling in above mentioned sites
• Os tibiale externum (os navicularis syndrome): – hockey players, figure skaters, soccer players, and skiers – palpation over the navicular tuberosity causes pain
• exacerbated by resisted inversion
– Confirmed radiographically
Lateral Ankle Pain
• Peroneus Tenosynovitis
• Lateral ankle sprain
• Os peroneum
• Sinus tarsi syndrome
History & Examination
• Peroneus Tenosynovitis– Symptom: pain in the region of the peroneal
tendons• The pain is worsened by passive inversion with
plantarflexion or active eversion with dorsiflexion of the foot
– Sign: swelling and warmth
Anterior Ankle Pain
• Tibialis anterior tendinitis
• Syndesmotic ankle sprain
• Navicular stress fracture
Tibialis anterior tendinitis• History: pain along the course of the tendon– along anteromedial ankle
– precipitated by activity and improves with rest
– Recent change in the amount and type of activity, activity level, activity surface, and footwear
• Physical examination: pain with either passive plantarflexion or active dorsiflexion– tenderness and swelling along the tibialis anterior muscle,
best appreciated with the foot actively dorsiflexed
Lab Testing…
• Often not necessary• Acute and recurrent acute articular: CBC,
serum uric acid, synovial fluid study• Chronic articular: CBC routine– Depends on presence or absence of systemic
features– Selection depends on the systemic feature– CXR, RF, ACCP, X-ray pelvis AP view, MT, synovial
biopsy
• Periarticular with HO trauma: severe pain: X-ray ankle, AP, lateral and mortise views
• USG: suspected bursitis, tenosynovitis