Operational Medicine 2001
Ankle Pain

Evaluation: Important items to consider in the history:

• Etiology/onset (trauma, gradual)

• Functional loss?

• Previous injury

Differential Diagnosis: Think of acute vs. chronic

• Acute

  • Ankle sprain

  • Ankle fracture/dislocation

  • Infected joint (rare)

  • Capsulitis (irritation of joint capsule of the ankle)

• Chronic

  • Degenerative joint disease (DJD)

  • Other arthritidies

Physical exam: Look for signs of infection and fracture.  

• Dislocation should be obvious on exam.  

  • All may require Medical Evacuation if possible.  

• Infection is a surgical emergency.  

• Fractured and/or dislocated ankles will obviously limit the functional capabilities of the service member.  

• Dislocation may compromise vascular supply.  

Signs to look for include:

• Infection

  • Very painful range of motion, both active and passive – helps to differentiate between overlying cellulitis and joint infection

  • edema

  • erythema

  • warmth

  • fever

• Fracture vs. Sprain

  • Use the Ottawa rules - palpate the posterior aspect lateral malleolus, posterior aspect medial malleolus. If no tenderness and able to ambulate, very unlikely to have ankle fracture.  Need to look for foot fracture also – palpate navicular and base of 5th metatarsal.

• Dislocation:

  • Check for pulses after relocating 

Labs:

• If suspect ankle infection (rare) need to tap joint to confirm, crystal induced arthritis may mimic such as gout.

• Ankle/foot x-rays for positive Ottawa criteria

Treatment

Trauma: Sprains – usually inversion, if eversion, suspect fracture

• PRICEMM for acute soft tissue injuries:

• Protection – against reinjury – bracing if needed with ACE, Air cast, etc.

• Rest-  relative rest - duty restrictions as necessary

• Ice – 20 minutes t.i.d.

• Compression – especially initially – prevents excess edema and speeds healing

• Elevate – above heart to also prevent excess edema

• Medications - anti-inflammatory medications for pain

• Modalities – if available – electrical stimulation, then begin range of motion and Proprioception (spatial sensation- where is my ankle positioned?) exercises – for example have patient spell out the alphabet

• If need to keep service member functioning, the combat boot makes a good functional brace

Trauma: Fracture

• Splint with posterior splint

• Crutches

• Ankle fractures require excellent anatomic realignment to prevent long-term problems.  

• Difficult fractures to diagnose and manage include talar dome fractures and Osteochondral defects (may require MRI for diagnosis)

Infection: If unable to tap and/or Medevac:

• Begin antibiotics

• Crutches

• Anti-inflammatories.  

• In young (<40) consider GC as cause and Rx with Ceftriaxone

• Superficial cellulitis - oral antibiotics with/without IM/IV antibiotics

Mechanical/Overuse such as DJD, capsulitis

• Activity modification

• Anti-inflammatories

• Physical Therapy – ROM, strength, proprioception

Christopher Kardohely, DPM and Scott D. Flinn, MD

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Operational Medicine 2001
Health Care in Military Settings

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