Special Operations Forces Medical Handbook

3-76

Prevention and Hygiene: Overuse injuries and recurrences can be prevented with proper stretching, rest
and conditioning. Review sexual history and provide appropriate treatment for sexual contacts of patients
with gonococcal arthritis.
No Improvement/Deterioration: Return to clinic if symptoms persist for 3-4 weeks.

Follow-up Actions
Return evaluation: Repeat exam. Refer for recurrent, persistent or occult injuries.
Evacuation/Consultation Criteria: Evacuate those unable to complete the mission or keep up with the team.
Aspiration of the joint may be indicated in instances of delayed evacuation. Consult Orthopedics for cases of
severe knee pain or recurrent, persistent or occult injuries. Knee dislocations (tears of ACL, PCL and one or
both of the collateral ligaments) need referral for evaluation of the popliteal artery.

Symptom: Joint Pain: Ankle Pain

CDR Scott Flinn, MC, USN

Introduction: Ankle pain may be due to nerve injury in back, gout, or trauma. Risk factors are previous injury,
parachute landings, or walking in rough terrain.

Subjective: Symptoms
Acute pain (immediate onset to a few hours) is usually due to trauma, or more rarely infection or severe
inammation. Subacute pain occurs with inammation. Chronic pain is usually due to old recurrent trauma
causing degenerative joint disease. It may also be due to other arthritides. Constitutional: Acute constitutional
symptoms of infection could include fever, malaise, chills, and nausea. Other joints may be involved if there
is a chronic arthritic component. Location: Ankle trauma will cause sprains, fractures and rarely, dislocations.
Other joints that may be involved include the midfoot (Lisranc’s joint), metatarsals (especially the fth), the
tarsal navicular, and bular head.
Focused History: How did you hurt your ankle? (twisting injury - think sprain versus fracture; no trauma
suspect infection or inammation) Did you hear a “pop” or feel a tearing sensation? Can you walk? (tells extent
of injury) Have you had this before? (for example, gouty arthritis in a patient known to have gout)

Objective: Signs
Using Basic Tools: Inspection: Examine the ankle and document swelling, deformity, erythema, ecchymosis,
and range of motion.
Palpation: Palpate for a sensation of warmth (suggesting infection or inammation) and edema (suggesting
trauma). Palpate the posterior aspect of the medial and lateral malleolus, palpate any area of tenderness, but
especially, the base of the fth metatarsal
Using Advanced Tools: X-rays (when if available), Lab: Gram stain of aspirated joint uid if infection or
gout is suspected.
Ottawa Ankle Rules - Always obtain x-rays to rule out fracture when any of the following are present:

1. Pain/tenderness on posterior aspect or tip of medial malleolus


2. Pain/tenderness on posterior aspect or tip of lateral malleolus


3. Unable to walk immediately after injury and when evaluated

Assessment:
Differential Diagnosis
The history and physical will almost always lead to an accurate diagnosis. Joint infections are very rare
without pre-existing trauma and the patient will not want to move their ankle at all.
Sprain, fracture/dislocation, infection, inammatory joint disease such as gout or pseudogout, degenerative
joint disease, other arthritis.

Plan:
Treatment

1. If patient is ambulatory, encourage ambulation. Keeping boot on may help reduce swelling and provide