Peripheral Oedema and Ankle Swelling History
Author – Dr Ramya Sriskandarajah Editor – Dr James Mackintosh
Last updated 09/07/2024
Table of Contents
Introduction
Swollen ankles are a common presenting complaint. They occur when excess fluid leaks from the intravascular space into surrounding tissues – the so-called third space, resulting in swelling in the extremities. This can be secondary to local or systemic disease. Unilateral ankle swelling is usually due to local factors, such as infection or trauma. Bilateral swelling is more likely in systemic diseases such as heart failure. When taking a history, try to characterise whether there is unilateral or bilateral swelling early on and this can help narrow down your differentials.
Presenting Complaint
Site
Unilateral or Bilateral?
- Unilateral – trauma, cellulitis, septic arthritis, Charcot joint
- Bilateral – systemic disease e.g. heart failure, hypoalbuminemia, drugs – amlodipine
Character
Heavy, clothing might feel tight – DVT, lymphoedema, chronic venous insufficiency
Painful – DVT, trauma, septic arthritis
Burning – cellulitis
Painless – heart failure, liver cirrhosis, renal disease, drug-induced, charcot joint
Timing
Is the swelling constant or intermittent?
Did it come on suddenly or gradually?
- Can suggest an acute or chronic cause
Has the swelling changed at all?
- Worsening throughout the day may suggest chronic venous insufficiency or lymphoedema
| Acute | Subacute | Chronic |
|---|---|---|
Fracture | DVT | Heart Failure |
Ligament sprain | Cellulitis | Liver Cirrhosis |
Compartment syndrome | Drug-induced | Lymphoedema |
Septic Arthritis | Nephrotic syndrome | Charcot joint |
Associated Symptoms
Shortness of breath – acute: pulmonary embolism (secondary to DVT); chronic: heart failure
Erythema – acute: DVT, trauma, cellulitis; chronic: venous insufficiency
Ankle pain – may suggest preceding trauma leading to fracture, ligament injury
Frothy urine – nephrotic syndrome
FLAWS (fever, lethargy, anorexia, weight loss, night sweats) – malignancy, infection – cellulitis, septic arthritis, filariasis
Polyuria, polydipsia, peripheral neuropathy, blurred vision, fatigue – symptoms of poorly controlled diabetes may be suggestive of a charcot joint.
Aggravating/Alleviating Factors
Alleviating – does swelling improve on elevation? No improvement – there may be a lymph drainage problem
Aggravating – movement? If they cannot weight bear be suspicious of an ankle fracture – refer to Ottawa ankle rules – https://www.mdcalc.com/calc/1670/ottawa-ankle-rule OR consider septic arthritis
Precipitating Event
Trauma
Recent immobility – surgery, long-haul flights
Insect bites/skin injuries – can lead to skin break precipitating cellulitis, septic arthritis
Change in medication -reduction in diuretics or starting new medicine
Differentials
You can break down differentials for ankle swelling into unilateral and bilateral. You can never go wrong with using a surgical sieve. Thinking about infection, inflammation and malignancy as broader categories can help provide structure.
| Differential | Image | Features |
|---|---|---|
DVT |
| Unilateral calf swelling, pain, erythema, warmth.Risk factors: previous DVT, coagulopathies, history of malignancy or immobility |
Cellulitis |
| Spreading erythema, well demarcated, warmth, fever, skin breaks - insect bite/skin injury |
Trauma |
| Acute onset pain, swelling, bruising, deformity, type of injury may be suggested by the mechanism |
Achilles rupture/tear |
| Acute onset pain, swelling, may have heard a popping sensation, history of running/jumping,
previous history of tendon injury e.g. achilles tendonitis/tendinopathy, recent fluoroquinolone use e.g. ciprofloxacin |
Heart failure |
| Acute or chronic bilateral ankle swelling, associated with dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, reduced exercise tolerance.
Risk factors: previous myocardial infarction, hypertension, cardiac valve dysfunction, poor lifestyle factors |
Venous insufficiency |
| Bilateral chronic pain and swelling, associated with standing, improves with leg elevation, associated varicose veins, hyperpigmentation, venous ulcers |
Medication change |
| Bilateral, non-painful, usual culprits are amlodipine, diuretics e.g. furosemide |
Liver cirrhosis |
| Bilateral chronic painless swelling, associated jaundice, pruritus, weight loss, pale stool, dark urine, abdominal swelling (ascites), dilated abdominal veins (caput medusae) |
Lymphoedema |
| Bilateral pitting oedema, typically affects whole leg
Risk factors: previous lymph node dissection, limb surgery, radiotherapy, previous DVT
-> Usually a diagnosis of exclusion |
Nephrotic syndrome |
| Bilateral painless swelling, associated frothy urine, swollen eyelids
-> Increases risk of DVT |
You can also consider sorting causes into unilateral and bilateral symptoms.
Vascular – DVT
Infection – cellulitis, septic arthritis, filariasis
Inflammation – red, hot, swollen joint: gout/pseudogout/rheumatoid arthritis,
Malignancy – pelvic/abdominal mass compressing inferior vena cava
Trauma – acute onset, may suggest fracture or ligament injury
- Remember these causes could also be bilateral – although this is not so common!
With bilateral causes, think about where the problem could be. Remember, this is usually caused by a more systemic issue.
Right sided heart failure – CHF, pulmonary HTN
Low albumin states – Liver cirrhosis, nephrotic syndrome, gastrointestinal losses e.g Crohn’s disease , malnutrition
Poor venous return – Chronic venous insufficiency, pregnancy – gravid uterus can compress the inferior vena cava, abdominal mass causing a bilateral DVT
Drugs – Calcium channel blockers, alpha blockers
Impaired lymphatic drainage – Primary lymphoedema, secondary lymphedema from lymph node dissection, radiotherapy, previous DVT
Red Flags
After getting an idea about what could be causing the ankle swelling, it is important to ask about red flag symptoms to rule out more sinister causes that may require more urgent treatment.
- Preceding trauma and not weight bearing –> fracture
- High fever – cellulitis/septic arthritis that may have caused systemic infection leading to sepsis
- Anorexia, weight loss, night sweats -> malignancy – either predisposing to DVT or causing venous compression by mass effect
- Any DVT symptoms – risk factors: previous DVT, coagulopathies, history of malignancy, immobility. PE screen – pleuritic chest pain, haemoptysis, palpitations, SOB
Background
There are some specific questions you can ask in past medical history/drug history/family history and social history that can help build a picture as to what’s causing the ankle swelling. By asking about these specific features you demonstrate to OSCE examiners your additional knowledge.
Past Medical History
IHD, chronic respiratory disease -> cor pulmonale, MI -> HF
Previous DVT and varicose veins can increase the risk of chronic venous insufficiency
Malignancy, radiation, surgery -> secondary lymphoedema
Liver disease, renal disease, malnutrition -> hypoalbuminemia
Diabetes/immunosuppression -> increased risk of infection -> cellulitis/septic arthritis
Drug History
Antihypertensives:
- Calcium channel blockers: amlodipine
- Diuretics: furosemide, indapamide
- Alpha blocker: doxazosin
All of these medications can cause swollen ankles as a side effect
Anti-inflammatory:
- NSAIDs – ibuprofen
- Corticosteroids – prednisolone
Swollen ankles are a side effect of these medications
Hormones:
- COCP
- HRT – oestrogen, testosterone
- Androgens
- Aromatase inhibitors
Swollen ankles can be a side effect of hormonal therapies but they can increase the risk of VTE, so very important to ask about
Antidiabetic:
- Insulin
- Thiazolidinediones: pioglitazone
Swollen ankles are a side effect of these medications. However, multiple anti-diabetic drugs should also ring alarm bells as they could indicate an important risk factor. Remember, diabetes can increase the risk of infection (cellulitis, septic arthritis), cardiovascular disease including heart failure, peripheral vascular disease and charcot joint, all possible causes of swollen ankles
Family History
Primary lymphoedema, coagulopathies, varicose veins and chronic venous insufficiency often have a hereditary element.
Social History
Smoking -> increased risk of DVT, CVD, chronic venous insufficiency, malignancy
Alcohol -> liver cirrhosis -> hypoalbuminemia
IVDU -> DVT
Sports/exercise -> bone/muscle/tendon/ligament injury
Travel -> filariasis
MLA Tip 💡
There are lots of different causes of ankle swelling. However, if you break it down to acute vs chronic and bilateral vs unilateral this can really help tailor your differentials to what your patient has come in with.
- BMJ Best practice – https://bestpractice.bmj.com/topics/en-gb/609
- Oxford Handbook of Clinical Diagnosis – https://academic.oup.com/book/31795/chapter/266175029?searchresult=1#266175122
- GP notebook – https://gpnotebook.com/en-GB/pages/cardiovascular-medicine/history-ankle-swelling