Swollen Ankles

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.

Published: 2nd August 2022 | Updated: 15th August 2022

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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.