This is a UKMLA-centred history guide about peripheral oedema and ankle swelling.

Introduction

Swollen ankles are a common presenting complaint. They occur when excess fluid leaks from the intravascular space into surrounding tissues – the so-called third space – causing swelling in the extremities. This can be secondary to local or systemic disease. Unilateral ankle swelling is usually due to local factors, such as infection or trauma. Bilateral swelling is more likely in systemic diseases such as heart failure. When taking a history, try to characterise whether there is unilateral or bilateral swelling early on, as this can help narrow down your differentials. 

Presenting Complaint

Site

Unilateral or Bilateral?  

• Unilateral – trauma, cellulitis, septic arthritis, Charcot joint 
• Bilateral – systemic disease, e.g. heart failure, hypoalbuminaemia, drugs (e.g. amlodipine) 

Character

Heavy, clothing might feel tight – DVT, lymphoedema, chronic venous insufficiency 

Painful – DVT, trauma, septic arthritis 

Burning – cellulitis  

Painless – heart failure, liver cirrhosis, renal disease, drug-induced, Charcot joint 

Timing

Is the swelling constant or intermittent? 

Did it come on suddenly or gradually? 

• Can suggest an acute or chronic cause 

Has the swelling changed over time? 

• Worsening throughout the day may suggest chronic venous insufficiency or lymphoedema

Associated Symptoms

Shortness of breath – acute: pulmonary embolism (secondary to DVT); chronic: heart failure 

Erythema – acute: DVT, trauma, cellulitis; chronic: venous insufficiency

Ankle pain – may suggest preceding trauma leading to fracture, ligament injury 

Frothy urine – nephrotic syndrome  

FLAWS (fever, lethargy, anorexia, weight loss, night sweats) – malignancy, infection – cellulitis, septic arthritis, filariasis  

Polyuria, polydipsia, peripheral neuropathy, blurred vision, fatigue – symptoms of poorly controlled diabetes may be suggestive of a Charcot joint. 

Aggravating/Alleviating Factors

Alleviating – does swelling improve on elevation? If no improvement, there may be a problem with lymphatic drainage  

Aggravating – worse on movement? If they cannot weight bear, this should raise suspicion of an ankle fracture if there is a history of trauma – refer to Ottawa ankle rules (https://www.mdcalc.com/calc/1670/ottawa-ankle-rule). Consider septic arthritis.

Precipitating Event

Trauma 

Recent immobility – surgery, long-haul flights 

Insect bites/skin injuries – can lead to skin break, precipitating cellulitis or septic arthritis

Change in medication – reduction in diuretics or starting a new medicine

Differentials

You can break down differentials for ankle swelling into unilateral and bilateral. You can never go wrong with using a surgical sieve. Thinking broadly about infection, inflammation and malignancy can help provide structure.

You can also consider sorting causes into unilateral and bilateral symptoms.

Unilateral

Vascular – DVT 
Infection – cellulitis; septic arthritis; filariasis  
Inflammation – red, hot, swollen joint: gout/pseudogout/rheumatoid arthritis 
Malignancy – pelvic/abdominal mass compressing the inferior vena cava  
Trauma – acute onset, may suggest fracture or ligament injury  
– Remember these causes could also be bilateral – although this is not so common! 

Bilateral
 
With bilateral causes, think about where the problem could be. Remember, this is usually caused by a more systemic issue.
Right-sided heart failure – CHF, pulmonary HTN
Low albumin states – Liver cirrhosis; nephrotic syndrome; gastrointestinal losses, e.g Crohn’s disease; malnutrition 
Poor venous return – Chronic venous insufficiency; pregnancy – a gravid uterus can compress the inferior vena cava; abdominal mass, causing a bilateral DVT
Drugs – Calcium channel blockers; alpha blockers
Impaired lymphatic drainage – Primary lymphoedema; secondary lymphoedema from lymph node dissection; radiotherapy; previous DVT

Red Flags

After considering the differentials for ankle swelling, it is important to ask about red flag symptoms to rule out more sinister causes that may require more urgent treatment.  

• Preceding trauma and not weight bearing –> fracture  
• High fever – cellulitis/septic arthritis that may have caused systemic infection leading to sepsis 
• Anorexia, weight loss, night sweats -> malignancy – either predisposing to DVT or causing venous compression by mass effect
• Any DVT symptoms – risk factors: previous DVT; coagulopathies; history of malignancy; immobility. PE screen – pleuritic chest pain, haemoptysis, palpitations, SOB 

Background

There are often details in the past medical history/drug history/family history, and social history that can help you formulate a differential. By interrogating these, you can demonstrate your knowledge to OSCE examiners.

Past Medical History

IHD, chronic respiratory disease -> cor pulmonale, MI -> HF 

Previous DVT and varicose veins can increase the risk of chronic venous insufficiency  

Malignancy, radiation, surgery -> secondary lymphoedema  

Liver disease, renal disease, malnutrition -> hypoalbuminemia  

Diabetes/immunosuppression -> increased risk of infection -> cellulitis/septic arthritis

Drug History

Antihypertensives:

• Calcium channel blockers: amlodipine
• Diuretics: furosemide, indapamide
• Alpha blocker: doxazosin
  
  All of these medications can cause swollen ankles as a side effect

Anti-inflammatory:

• NSAIDs – ibuprofen
• Corticosteroids – prednisolone
  
  Swollen ankles are a side effect of these medications

Hormones:

• COCP
• HRT – oestrogen, testosterone
• Androgens
• Aromatase inhibitors
  
  Swollen ankles can be a side effect of hormonal therapies but they can also increase the risk of VTE, so is very important to ask about

Antidiabetic:

• Insulin
• Thiazolidinediones: pioglitazone

Swollen ankles are a side effect of these medications. However, multiple anti-diabetic drugs should also ring alarm bells as they could indicate an important risk factor. Remember, diabetes can increase the risk of infection (cellulitis, septic arthritis), cardiovascular disease including heart failure, peripheral vascular disease and charcot joint, all possible causes of swollen ankles

Family History

Primary lymphoedema, coagulopathies, varicose veins and chronic venous insufficiency often have a hereditary element.

Social History

Smoking -> increased risk of DVT, CVD, chronic venous insufficiency, malignancy 

Alcohol -> liver cirrhosis -> hypoalbuminemia  

IVDU -> DVT  

Sports/exercise -> bone/muscle/tendon/ligament injury  

Travel -> filariasis 

References
 
1. BMJ Best practice – https://bestpractice.bmj.com/topics/en-gb/609  

2. Oxford Handbook of Clinical Diagnosis – https://academic.oup.com/book/31795/chapter/266175029?searchresult=1#266175122

3. GP notebook – https://gpnotebook.com/en-GB/pages/cardiovascular-medicine/history-ankle-swelling 

Author – Dr Ramya Sriskandarajah  

Editor – Dr James Mackintosh

Last updated 27/01/2026