This is one of the commonest presenting complaints in the elderly and, in this age group, may be linked to recurrent falls. As a result, it is frequently the reason for a home visit request. In younger age groups, it is much rarer, but much more likely to signify serious pathology.
- Congestive Cardiac Failure (CCF)
- Drug Reaction: Especially Calcium Antagonists
- Gravitational (Venous Insufficiency, Often with Poor Mobility)
- Pelvic Mass (Including Pregnancy)
- Premenstrual Syndrome
- Renal: Acute or Chronic Nephritis, Nephrotic Syndrome
- Protein-Losing Enteropathy (e.g. Coeliac Disease, Inflammatory Bowel Disease)
- Inferior Vena Cava Thrombosis
- Milroy’s Disease (Hereditary Lymphoedema)
- Ancylostomiasis (Hookworm)
Key distinguishing features of the most common diagnoses
|CCF||Drug Reaction||Gravitational||Obesity||Pelvic Mass|
|Shortness of Breath on Exertion||Yes||No||No||Possible||Possible|
|Altered Breath Sounds||Yes||No||No||No||No|
|Less Swollen in the Morning||Possible||Possible||Yes||Possible||Possible|
|Taking Oedema-Genic Drug||Possible||Yes||No||No||No|
|Other Symptoms or Signs||Yes||No||No||No||Yes|
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).
- 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.
- 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.