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Ankle sprain
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
- Physically ready to return:
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.