Swollen Ankles

Differential Diagnosis

Common Diagnoses

  • Congestive Cardiac Failure (CCF)
  • Drug Reaction: Especially Calcium Antagonists
  • Gravitational (Venous Insufficiency, Often with Poor Mobility)
  • Obesity
  • Pelvic Mass (Including Pregnancy)

Occasional Diagnoses

  • Cirrhosis
  • Premenstrual Syndrome
  • Anaemia
  • Renal: Acute or Chronic Nephritis, Nephrotic Syndrome
  • Protein-Losing Enteropathy (e.g. Coeliac Disease, Inflammatory Bowel Disease)

Rare Diagnoses

  • Malnutrition
  • Inferior Vena Cava Thrombosis
  • Filariasis
  • Milroy’s Disease (Hereditary Lymphoedema)
  • Ancylostomiasis (Hookworm)

Ready Reckoner

Key distinguishing features of the most common diagnoses

CCFDrug ReactionGravitationalObesityPelvic Mass
Shortness of Breath on ExertionYesNoNoPossiblePossible
Altered Breath SoundsYesNoNoNoNo
Less Swollen in the MorningPossiblePossibleYesPossiblePossible
Taking Oedema-Genic DrugPossibleYesNoNoNo
Other Symptoms or SignsYesNoNoNoYes

Possible Investigations

Likely:Urinalysis, FBC, U&E, LFT, BNP.

Possible:ECG, TFT, echocardiography.

Small Print:CXR, pelvic ultrasound, further investigation of underlying cause.

  • Urinalysis: For proteinuria.
  • FBC: Look for anaemia of chronic disorder, raised MCV (alcohol abuse).
  • U&E: Will reveal underlying renal failure; sodium low in CCF and cirrhosis.
  • LFT: May reveal hypoproteinaemia (e.g. in cirrhosis, protein-losing enteropathy and nephrotic syndrome).
  • BNP: Likely to be elevated in heart failure.
  • ECG: In heart failure, may show signs of left ventricular hypertrophy, ischaemia or arrhythmia.
  • Echocardiography: To confirm suspected heart failure.
  • CXR: Pulmonary oedema and pleural effusion in CCF.
  • Pelvic ultrasound: For pelvic mass.
  • Further investigation of underlying cause: This might involve CT scan (pelvic mass), renal biopsy (nephritis) and bowel investigations (enteropathy).

Top Tips

  • In the elderly, the cause is often multifactorial, with immobility playing a major role.
  • Proper assessment can take time – consider spreading the work over a couple of consultations, using the intervening time to arrange and assess investigations.
  • Ankle swelling is usually symmetrical, though venous insufficiency in particular can affect one side much more than the other. But if only one ankle is swollen, consider deep vein thrombosis, a ruptured Baker’s cyst or cellulitis.
  • Don’t forget that many drugs (such as calcium antagonists and NSAIDs) can cause marked ankle swelling.

Red Flags

  • If no cause is obvious in an elderly person, examine the abdomen and also consider a rectal examination.
  • The younger the patient, the greater the chance of significant pathology – especially renal.
  • Marked swelling of recent and sudden onset is likely to be significant regardless of age.

Published: 2nd August 2022 Updated: 10th April 2024

Report errors, or incorrect content by clicking here.

What is Nursing in Practice Reference?

Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

Learn More

Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.