From the Guidelines
The next step in managing chronic ankle instability with persistent swelling in an 11-year-old patient with a 5-year history of injury should be a comprehensive orthopedic evaluation, including imaging studies such as MRI to assess ligament integrity, cartilage damage, and potential growth plate involvement. This approach is supported by the high diagnostic accuracy of MRI for evaluating ligamentous integrity, with studies demonstrating accuracy of 97% for MRI compared with arthroscopic findings 1.
Key Considerations
- Physical therapy focusing on proprioception, balance training, and strengthening of the peroneal muscles should be initiated, with sessions 2-3 times weekly for 6-8 weeks.
- A pediatric ankle brace or semi-rigid orthosis may be recommended during physical activities to provide support while allowing for normal development.
- Anti-inflammatory medications like ibuprofen (10mg/kg every 6-8 hours as needed) can help manage acute swelling episodes, but should not be used long-term.
- Elevation of the affected limb above heart level for 20 minutes several times daily and compression with an appropriate-sized elastic bandage can help control swelling.
Rationale
The persistent nature of symptoms five years post-injury suggests possible chronic ligamentous laxity or growth-related complications that require specialized pediatric orthopedic assessment before considering more invasive interventions like surgery, which is generally reserved for cases that fail conservative management 1. The use of functional support devices such as tape or brace has been shown to be effective in preventing recurrent ankle sprains, with no reported complications 1.
Additional Recommendations
- Surgery should be reserved for patients with lateral ligament ruptures to avoid unnecessary invasive treatment and risk of complications 1.
- Exercise therapy has been shown to have a significant preventive effect for recurrent ankle sprains, and may be beneficial in the rehabilitation of chronic ankle instability 1.
From the Research
Diagnosis and Assessment
- The patient's history of chronic ankle instability with persistent swelling following an injury 5 years ago suggests the need for a comprehensive assessment to determine the underlying cause of the instability 2, 3.
- A thorough physical examination, including assessment of the talocrural and subtalar joints, is essential to evaluate the patient's ankle instability 4.
- Diagnostic tools such as stress radiographs, magnetic resonance imaging, and ankle arthroscopy may be used to identify associated intraarticular lesions and ligamentous instability 2, 3.
Treatment Options
- Nonoperative treatment, including physical therapy and functional bracing, may be considered as the initial treatment approach for chronic ankle instability 2, 5.
- Surgical treatment, such as anatomic ligament repair and inferior extensor retinaculum augmentation, may be considered if nonoperative treatment fails to improve symptoms 2.
- Ankle arthroscopy may be used to treat associated intraarticular lesions, but all-arthroscopic ligament repair is associated with a high complication rate 2.
Rehabilitation and Prevention
- A functional rehabilitation program that progresses from basic to advanced exercises can help improve ankle range of motion, strength, and proprioception 6.
- Proprioceptive training, preventive equipment (bracing/taping), and closed kinetic chain strengthening can help prevent recurrent ankle instability 5, 6.
- Early functional rehabilitation and a structured progression of exercises can help minimize the risk of developing long-term, recurrent ankle instability 6, 4.