What are the treatment considerations and management options for ankle injuries?

Management of Ankle Injuries: Assessment, Treatment, and Education

The PRICE protocol (Protection, Rest, Ice, Compression, and Elevation) combined with functional rehabilitation using semirigid supports and proprioceptive exercises is the most effective approach for treating ankle injuries and preventing recurrence. 1

Initial Assessment Questions

When evaluating ankle injuries, ask the following key questions:

• What was the mechanism of injury? (inversion, eversion, plantar flexion)
• When did the injury occur?
• Is there a history of previous ankle sprains?
• What is the pain level and location?
• Was there rapid swelling or a "popping" sensation?
• Can the patient bear weight on the injured foot?
• Are there any complicating conditions (diabetes, peripheral vascular disease)?

Physical Examination

Key examination findings to assess:

• Weight-bearing ability
• Location and extent of swelling and bruising
• Point tenderness over specific ligaments
• Anterior drawer test for anterior talofibular ligament integrity
• Crossed-leg test for high ankle (syndesmotic) sprains
• Range of motion assessment

Ottawa Ankle and Foot Rules

Use these rules to determine need for radiography:

• Ankle X-rays if pain near malleoli and:
  • Inability to bear weight for four steps
  • Bone tenderness at posterior edge or tip of either malleolus
• Foot X-rays if pain in midfoot and:
  • Inability to bear weight for four steps
  • Bone tenderness at base of fifth metatarsal or navicular

Classification of Ankle Sprains

• Grade I: Mild stretching of ligaments with minimal pain, swelling, and joint instability
• Grade II: Partial tearing with moderate pain, swelling, and some joint instability
• Grade III: Complete ligament rupture with severe pain, swelling, and joint instability

Treatment Protocol

Immediate Management (First 48-72 hours)

1. PRICE Protocol 1:

   • Protection: Prevent further injury using appropriate support
   • Rest: Limit weight-bearing as needed
   • Ice: Apply for 15-20 minutes every 2-3 hours
   • Compression: Use elastic bandage or compression wrap
   • Elevation: Keep foot above heart level when possible

2. Pain Management:

   • NSAIDs help reduce swelling and pain and may decrease recovery time 1
   • Consider acetaminophen if NSAIDs are contraindicated

Functional Support

• Semirigid or lace-up ankle supports are superior to elastic bandages for treatment 1, 2
• For moderate to severe sprains, use a semirigid orthosis for at least 6 months following injury 2
• Avoid simple elastic tubular bandages (like Tubigrip) as they may increase the need for analgesia and don't improve functional recovery 3

Rehabilitation Protocol (Begin after acute phase)

1. Early Phase (Days 3-7):

   • Range of motion exercises
   • Gentle stretching
   • Progressive weight bearing as tolerated

2. Intermediate Phase (Weeks 1-3):

   • Strengthening exercises for ankle evertors and invertors
   • Balance exercises on stable surfaces

3. Advanced Phase (Weeks 3-6):

   • Proprioceptive training using ankle disk exercises 1
   • Sport-specific exercises
   • Progressive return to activities

Prevention of Recurrence

• Continued use of ankle supports: Semirigid or lace-up supports for 6+ months, especially for those with history of recurrent sprains 1, 2
• Proprioceptive training: Regular ankle disk exercises reduce risk of future sprains 1
• Strengthening program: Focus on peroneal muscles to improve lateral stability

Patient Education Points

1. Explain the nature of the injury and expected recovery timeline
2. Demonstrate proper PRICE technique
3. Teach proper use of support devices
4. Emphasize importance of completing the full rehabilitation program
5. Warn about potential complications of inadequate treatment:
   • Chronic ankle instability
   • Decreased range of motion
   • Persistent pain
   • Joint instability 1

Common Pitfalls to Avoid

• Inadequate initial assessment: Missed fractures or high ankle sprains can lead to prolonged recovery
• Premature return to activity: Complete the full 6-week rehabilitation program
• Neglecting proprioceptive training: Critical for preventing recurrence
• Overreliance on simple elastic bandages: Use semirigid supports for better outcomes
• Failure to reexamine: Reassess 3-5 days after injury when swelling has decreased to better evaluate ligament integrity 1

Special Considerations

• High ankle (syndesmotic) sprains: Require longer immobilization and recovery time
• Athletes: May benefit from sport-specific rehabilitation protocols
• Recurrent sprains: Consider longer use of ankle supports and more intensive proprioceptive training
• Persistent symptoms: Consider second-line investigations (MRI, CT) and specialist referral if symptoms persist beyond expected recovery time 2