Swollen Ankles

Differential Diagnosis

Common Diagnoses

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

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