M71.07 Abscess of bursa, ankle and foot

Name of the Condition

• Abscess of bursa, ankle and foot

Summary

An abscess of the bursa, ankle and foot is a localized collection of pus within a bursa in the ankle or foot region. This condition causes pain, swelling, and functional impairment at the affected site. Bursae are small fluid-filled sacs that reduce friction between tissues, and when infected, they can become inflamed and filled with purulent material.

Causes

Abscesses of the bursa typically result from bacterial infection, often introduced through direct trauma, skin breakdown, or spread from adjacent tissues. Staphylococcus aureus is a common causative organism. Non-infectious causes, such as chronic inflammation or foreign body reaction, may also lead to bursal abscess formation.

Risk Factors

• Recent injury or surgery near a bursa in the ankle or foot
• Skin infections or open wounds in the vicinity
• Immunocompromised states (e.g., diabetes, HIV)
• Chronic inflammatory conditions (e.g., rheumatoid arthritis)
• Repetitive motion or pressure on the bursa

Symptoms

• Localized pain, swelling, and warmth over the bursa
• Redness or erythema at the site
• Fever or systemic signs of infection
• Limited range of motion in adjacent joints
• Pus drainage if the abscess ruptures

Diagnosis

Diagnosis involves a physical examination to assess bursal characteristics, including tenderness, fluctuance, and warmth. Imaging (e.g., ultrasound) may confirm fluid collection. Aspiration of the bursa may be performed to identify the causative organism and guide treatment.

Treatment Options

Treatment typically includes antibiotic therapy to address the infection. Drainage of the abscess may be necessary if it does not resolve with antibiotics alone. Rest, elevation, and pain management are also recommended to reduce symptoms and promote healing.

Prognosis and Follow-Up

With appropriate treatment, most bursal abscesses resolve without long-term complications. Follow-up care may involve monitoring for recurrence or signs of spreading infection. Physical therapy may be recommended to restore function if mobility is affected.

Complications

Untreated abscesses can lead to the spread of infection to surrounding tissues or bones. Chronic inflammation or persistent pain may occur if the abscess is not fully drained or if the underlying cause is not addressed.

Lifestyle & Prevention

Avoiding repetitive pressure or trauma to the ankle and foot can reduce risk. Maintaining good skin hygiene and promptly treating wounds or infections in the area may help prevent bursal abscesses.

When to Seek Professional Help

Seek medical attention if symptoms worsen, fever develops, or pus drainage occurs. Prompt evaluation is important if pain or swelling persists despite home care or if mobility is significantly impaired.

Tips for Medical Coders

Document the specific location (ankle or foot) and any associated factors, such as trauma or infection, to support accurate coding. Ensure clinical documentation aligns with the ICD-10-CM code M71.07 for proper classification.