Ankles (swollen)

Swollen Ankles (Ankle Edema)

Introduction

Ankle swelling (edema) is the accumulation of excess fluid in the tissues around the ankles and feet.

• May affect one or both ankles.

• Can be painless or painful.

• Often worse after standing or sitting for long periods.

• May indicate benign or life-threatening conditions, so careful evaluation is essential.

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Mechanisms of Edema

• Increased hydrostatic pressure: e.g., heart failure, venous insufficiency.

• Reduced oncotic pressure: e.g., low albumin in liver disease, nephrotic syndrome.

• Increased capillary permeability: e.g., inflammation, infection.

• Lymphatic obstruction: e.g., lymphedema, tumors.

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Causes of Swollen Ankles

1. Local / Musculoskeletal Causes

• Sprains, fractures, or trauma.

• Infections: cellulitis, septic arthritis.

• Venous insufficiency / varicose veins.

• Deep vein thrombosis (DVT): usually one-sided, red, painful, warm.

2. Cardiovascular Causes

• Congestive heart failure (CHF): bilateral ankle swelling, worse at night.

• Pulmonary hypertension.

• Constrictive pericarditis.

3. Renal Causes

• Nephrotic syndrome.

• Chronic kidney disease.

• Acute glomerulonephritis.

4. Liver Causes

• Cirrhosis with hypoalbuminemia.

• Portal hypertension.

5. Endocrine / Metabolic Causes

• Hypothyroidism (myxedema).

• Diabetes (leading to kidney disease).

6. Medications

• Calcium channel blockers (Amlodipine, Nifedipine).

• NSAIDs (Ibuprofen, Naproxen).

• Steroids.

• Hormonal therapy (estrogen, progesterone).

7. Other Causes

• Pregnancy.

• Obesity.

• Lymphedema (post-surgery, tumor, congenital).

• Allergic reactions (angioedema).

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Clinical Features

• Swelling: pitting vs non-pitting.

  • Pitting edema → heart, kidney, liver causes.

  • Non-pitting edema → lymphedema, hypothyroidism.

• Unilateral vs bilateral:

  • Unilateral → trauma, DVT, infection.

  • Bilateral → systemic disease (heart, liver, kidney).

• Associated symptoms:

  • Shortness of breath, fatigue → heart failure.

  • Frothy urine, facial puffiness → nephrotic syndrome.

  • Jaundice, ascites → cirrhosis.

  • Pain, redness → cellulitis, DVT.

  • Cold, dry skin → hypothyroidism.

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Diagnostic Approach

1. History

• Onset, duration, progression.

• Relation to standing, time of day.

• Past medical history: heart, kidney, liver disease, thyroid disorders.

• Medications.

• Recent trauma or surgery.

2. Examination

• Inspect ankles (pitting vs non-pitting edema).

• Measure blood pressure, heart rate, JVP (for heart failure).

• Abdominal exam (ascites, liver disease).

• Chest exam (crackles in CHF).

• Leg exam (tenderness, redness in DVT).

3. Investigations

• Blood tests: CBC, renal function, liver function, thyroid function, electrolytes, albumin.

• Urine tests: proteinuria (nephrotic syndrome).

• ECG, Echocardiogram: evaluate cardiac function.

• Chest X-ray: heart size, pulmonary edema.

• Venous Doppler ultrasound: rule out DVT.

• Liver ultrasound: cirrhosis, portal hypertension.

• Lymphoscintigraphy: for lymphedema if unclear.

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Management and Treatment

Treatment depends on cause.

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A. General Measures

• Elevate legs when resting.

• Avoid prolonged standing/sitting.

• Wear compression stockings (unless contraindicated in arterial disease or acute DVT).

• Reduce salt intake.

• Weight reduction if obese.

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B. Pharmacological Treatment

1. Heart Failure

• Diuretics:

  • Furosemide 20–40 mg orally daily (adjust as needed).

  • Spironolactone 25–50 mg orally daily (especially if reduced EF).

• ACE inhibitors: Enalapril 5–20 mg orally daily.

• Beta-blockers: Carvedilol 12.5–25 mg orally twice daily.

2. Kidney Disease

• Loop diuretics (Furosemide).

• ACE inhibitors/ARBs (e.g., Losartan 50–100 mg daily) for proteinuria.

• Dialysis if advanced.

3. Liver Disease (Cirrhosis with Ascites and Edema)

• Spironolactone 100 mg daily, titrate up.

• Add Furosemide 40 mg daily if needed.

• Salt restriction, fluid restriction.

• Liver transplant if end-stage.

4. Hypothyroidism

• Levothyroxine 50–100 mcg orally daily, titrate according to TSH.

5. DVT

• Anticoagulation:

  • Enoxaparin 1 mg/kg SC every 12 h.

  • Then switch to Warfarin (INR 2–3) or DOAC (Apixaban, Rivaroxaban).

6. Infection (Cellulitis)

• Flucloxacillin 500 mg orally four times daily × 7 days.

• If penicillin allergy: Clarithromycin 500 mg orally twice daily.

7. Drug-Induced Edema

• Stop or switch medication (e.g., calcium channel blocker).

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C. Procedural / Surgical Treatment

• Endovenous ablation or vein stripping for varicose veins.

• Lymphatic drainage or surgery for lymphedema.

• Cardiac surgery, liver transplant, or dialysis in severe cases.

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Complications

• Skin changes: eczema, ulcers (chronic venous insufficiency).

• Infection (cellulitis).

• Functional impairment.

• Missed diagnosis of life-threatening conditions (MI-related CHF, DVT, cirrhosis).

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Prognosis

• Benign edema (standing, mild venous insufficiency): good prognosis.

• Heart, kidney, liver disease: prognosis depends on underlying condition.

• DVT: risk of pulmonary embolism if untreated.

• Lymphedema: chronic, but manageable with therapy.

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Patient Education

• Swollen ankles are common, but persistent or severe swelling needs evaluation.

• Elevate legs and wear compression stockings if advised.

• Reduce salt intake and maintain a healthy weight.

• Take medications as prescribed.

• Seek urgent care if:

• Sudden painful swelling (possible DVT).

• Associated chest pain or breathlessness (possible heart failure or pulmonary embolism).

• Jaundice, abdominal swelling, or frothy urine.