Give me possible diagnosis for swelling and pain over ankle
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I now have comprehensive data from Rosen's Emergency Medicine and Miller's Orthopaedics. Here is a thorough differential diagnosis organized by category:
Differential Diagnosis: Ankle Swelling and Pain
Ankle swelling and pain have a broad differential spanning traumatic, arthritic, infectious, vascular, and tendinous causes. The key diagnostic boxes from Rosen's Emergency Medicine (Boxes 49.1 & 49.2) are reproduced below, supplemented by other textbook sources.
🦴 Traumatic / Bony Causes
| Condition | Key Features |
|---|---|
| Ankle sprain (lateral > medial) | Most common; tenderness over lateral ligaments (ATFL, CFL); mechanism usually inversion |
| Lateral malleolus fracture | Pain + swelling over distal fibula; Ottawa Rules guide X-ray need |
| Medial malleolus fracture | Medial ankle swelling + tenderness |
| Bimalleolar / trimalleolar fracture | Significant swelling; often unstable; requires surgical fixation |
| Maisonneuve fracture | Medial ankle disruption + proximal fibula fracture; examine full fibula |
| Osteochondral lesion of the talar dome | Chronic or post-sprain ankle pain; confirmed on MRI |
| Lateral process fracture of the talus (snowboarder's fracture) | Missed in ~40% of cases, mistaken for ankle sprain |
| Posterior process fracture of the talus | Forced plantar flexion; pain + swelling posteriorly |
| Anterior process fracture of calcaneus | Lateral ankle pain; missed on plain films |
| Fracture of base of 5th metatarsal | Avulsion (zone 1) vs. Jones fracture (zones 2–3); lateral foot pain |
| Stress fracture | Gradual onset; no acute trauma; positive bone scan/MRI before X-ray changes |
| Ankle dislocation | Obvious deformity; neurovascular compromise possible |
| Lisfranc injury | Midfoot/tarsometatarsal instability; associated with 2nd metatarsal base fracture |
| Midtarsal joint (Chopart) injury | Frequently mistaken for ankle sprain |
🔗 Ligament / Syndesmotic Injuries
| Condition | Key Features |
|---|---|
| Lateral collateral ligament sprain (ATFL, CFL) | Anterior drawer test positive; inversion stress test positive |
| Deltoid ligament sprain (medial) | Medial swelling; often associated with bony injury |
| Syndesmosis (high ankle) sprain | External rotation stress test positive; pain above ankle; more disabling than lateral sprain |
| Retinaculum rupture | Superior peroneal retinaculum disruption; "fleck sign" on X-ray |
🧵 Tendon Injuries
| Condition | Key Features |
|---|---|
| Achilles tendon rupture | Sudden pop, posterior ankle; positive Thompson test; palpable defect |
| Peroneal tendon dislocation/rupture | Snapping sensation on eversion; lateral/retrofibular pain |
| Peroneal tendinopathy/tenosynovitis | Chronic lateral ankle pain; common after ankle sprains or with cavovarus deformity |
| Tibialis posterior tendon rupture | Medial ankle pain; inability to perform single-leg heel raise; pes planus deformity |
| Tibialis anterior tendon rupture | Anterior mass/retraction; foot drop; difficulty with dorsiflexion |
| Flexor hallucis longus tendinopathy | Posterior medial ankle; "trigger toe" in dancers |
🔴 Inflammatory / Arthritic Causes
| Condition | Key Features |
|---|---|
| Gout | Sudden, severe; hot, red, swollen; uric acid crystals; first MTP often involved but ankle common |
| Pseudogout (CPPD) | Similar to gout; calcium pyrophosphate crystals |
| Septic arthritis | Fever, warmth, severe pain; joint fluid analysis mandatory; emergency |
| Reactive arthritis (Reiter's syndrome) | Asymmetric oligoarthritis (knee, ankle, hip); associated urethritis + conjunctivitis; post-infection (Chlamydia, Shigella, Yersinia) |
| Rheumatoid arthritis | Symmetric; morning stiffness; other joint involvement |
| Psoriatic arthritis | Asymmetric; dactylitis; skin/nail changes |
| Osteoarthritis (ankle) | Chronic; prior trauma or overuse; joint space narrowing on X-ray |
| Charcot joint (neuropathic arthropathy) | Diabetics or neuropathic patients; painless destruction; severely swollen, warm ankle with minimal pain relative to severity |
🦠 Infectious Causes
| Condition | Key Features |
|---|---|
| Septic arthritis | Red, hot, swollen joint; fever; WBC elevated; requires aspiration |
| Cellulitis / abscess | Skin erythema, warmth, induration; may not involve the joint itself |
| Osteomyelitis | Deep bone pain; may follow trauma or hematogenous spread |
| Lyme arthritis | Endemic area; history of tick bite; monoarticular large joint swelling |
🩸 Vascular / Systemic Causes
| Condition | Key Features |
|---|---|
| Deep vein thrombosis (DVT) | Calf/ankle swelling; risk factors (immobility, post-op, malignancy); Homan sign (unreliable); confirm with Doppler US |
| Postthrombotic syndrome | Chronic swelling + aching after DVT; venous stasis changes |
| Peripheral edema | Bilateral; cardiac, renal, hepatic, or venous insufficiency |
| Compartment syndrome | After trauma or cast; severe pain out of proportion; tight compartment; emergency fasciotomy |
🧠 Key Clinical Pearls
- Ottawa Ankle Rules: X-ray indicated if bony tenderness at posterior edge of distal 6 cm of fibula/tibia, tip of either malleolus, navicular, or base of 5th metatarsal — OR inability to bear weight for 4 steps.
- Missed diagnoses: Lateral process talar fracture, anterior calcaneal process fracture, and osteochondral lesions are commonly attributed to "ankle sprain."
- Thompson test: Squeeze the calf — absence of plantar flexion = Achilles rupture.
- Always examine the full fibula if a medial malleolar fracture is found (rule out Maisonneuve fracture).
- Septic arthritis is a time-sensitive emergency — joint aspiration cannot wait.
- Charcot joint in a diabetic patient: dramatic swelling with relatively little pain is a red flag.
Sources: Rosen's Emergency Medicine, 10th ed. (Boxes 49.1 & 49.2); Miller's Review of Orthopaedics, 9th ed.; Tintinalli's Emergency Medicine; Goldman-Cecil Medicine.
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