approach toanklepain prof atiq 24 09 11

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