Ankle sprain

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Updated by: Allison Duey-Holtz, APP
Updated on: 8/2/17

Diagnosis

Mechanism of Injury

• Rotational/twisting mechanism (ie. inversion, eversion)
• "High ankle sprain” (syndesmosis injury) - Forced dorsiflexion + eversion

Signs and symptoms

• Pain
• Swelling
• Bruising
• Limping or difficulty bearing weight
• Instability

Differential Diagnosis

• Ankle fracture
  • Salter Harris injury in skeletally immature patients
  • Posterior malleolus fracture
  • Medial malleolus fracture
  • Juvenile Tilleaux fracture
  • Triplane fracture
    • Syndesmosis injury
    • Maisonneuve fracture
    • Foot fracture

Referring provider's initial evaluation and management:

Physical Exam

• Inspection, palpation, ROM, strength
• Special tests:
  • Anterior drawer, Talar tilt tests for lateral ankle laxity
  • Syndesmotic squeeze test to assess for syndesmotic injury

Diagnostic Tests

Radiographs indicated if the following are present per the Ottawa ankle and foot rules:

• Ankle:
  • Bony tenderness over the medial or lateral malleolus
  • Inability to bear weight (4 steps) immediately after injury, in ED or physician's office
• Foot:
  • Bony tenderness of the base of the 5th metatarsal
  • Bony tenderness of the navicular
  • Inability to bear weight (4 steps) immediately after injury, in ED or physician's office

Recommended views

• Ankle - AP/lateral/mortise (weightbearing if possible)
• Foot – AP/lateral/oblique (weightbearing if possible)
• If clinically indicated:
  • Tibia/fibula – AP/lateral

Management:

• If no fracture:
  • Rest, Ice, Compression, Elevation
  • Ibuprofen/acetaminophen as needed for pain
  • ACE bandage wrap or lace-up ankle brace for compression/support
  • Crutches for protected weightbearing if limping/difficulty weightbearing. Wean off as tolerated.
  • For severe sprains, consider walking boot if available and able to be applied and fitted appropriately
• If fracture present:
  • Apply splint
  • Crutches – no bearing weight
  • Refer to Orthopedics/Sports Medicine
• Return to activity after ankle sprain:
  • Physically ready to return:
    • Able to ambulate and perform sport-specific activities (i.e. running, jumping and cutting) pain-free and with normal mechanics
  • Psychologically ready to return
  • Should perform ankle exercises for ROM, strength and neuromuscular control prior to return
  • Recommend lace-up ankle brace with PE/sports to decrease risk of re-injury

When to initiate referral to Sports Medicine/ Orthopedic Clinic:

• Confirmed fracture
• Severe sprain
• Injury to syndesmosis
• Uncertainty regarding diagnosis, treatment or and/or return to activity
• Worsening symptoms or no/minimal improvement in 7-10 days

What can referring provider send to Sports Medicine/ Orthopedic Clinic?

1. Using Epic

• Please complete the external referral order

In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:

• Urgency of the referral
• What is the key question you would like answered?

Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

• In order to help triage our patients maximize the visit time, please fax the above information to (414) 607-5288
• It would also be helpful to include:
• Chief complaint, onset, frequency
• Recent progress notes
• Labs and imaging results
• Other Diagnoses
• Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.

Specialist's workup will likely include:

If no fracture initially diagnosed:

• History and physical exam
• Potentially repeat x-rays
• Potentially advanced imaging (CT or MRI)
• Boot or brace
• Plan for rehabilitation, including possible PT referral, and return to play

If confirmed fracture:

• History and physical exam
• Potentially repeat x-rays
• Potentially advanced imaging (CT or MRI)
• Immobilization in boot vs cast +/- crutches depending on type of injury

References:

Wolfe MW, UHL TL, and McCluskey LC. Management of ankle sprains. Am Fam Physician. 2001; 63(1):93-104.

Tiemstra JD. Update on acute ankle sprains. Am Fam Physician. 2012; 85(12):1170-11-75.

Steill IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993; 269(9):1127-1132.

Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009; 16(4):277-287.