What is the treatment and management for a deep bone contusion in the ankle?

Management of Deep Bone Contusion in the Ankle

Deep bone contusions in the ankle should be treated with the PRICE protocol (Protection, Rest, Ice, Compression, and Elevation) initially, followed by functional rehabilitation with early mobilization rather than immobilization. 1

Understanding Bone Contusions

A bone contusion is a bruise or microfracture within the bone that doesn't appear on regular X-rays but is visible on MRI as an area of bone marrow edema. These injuries commonly occur with ankle trauma and can cause significant pain and disability.

Initial Assessment and Diagnosis

• MRI is the gold standard for diagnosing bone contusions, as they are not visible on standard radiographs 1
• CT scans may help identify associated fractures but are less sensitive for bone contusions
• Persistent ankle pain for more than 1 week after initial negative radiographs warrants further imaging, particularly MRI 1

Treatment Protocol

Acute Phase (0-72 hours)

1. Protection: Use appropriate supportive devices

   • Semirigid supports are superior to elastic bandages 1
   • Consider walking boots or braces depending on severity

2. Rest: Limit weight-bearing as needed

   • Avoid activities that cause pain
   • Use crutches if necessary for severe pain

3. Ice: Apply for 20 minutes every 2-3 hours

   • Use a thin barrier between ice and skin
   • Continue for first 48-72 hours

4. Compression: Use compression bandages

   • Apply from toes to mid-calf
   • Ensure not too tight to avoid circulation problems

5. Elevation: Keep the ankle above heart level

   • Especially important during the first 48 hours
   • Continue when resting throughout recovery

Pain Management

• Topical NSAIDs are first-line treatment with favorable benefit-risk ratio 1
• Oral NSAIDs (ibuprofen, naproxen) can help reduce pain and inflammation
• Acetaminophen can be used as an alternative if NSAIDs are contraindicated

Rehabilitation Phase (After 72 hours)

1. Early Mobilization:

   • Begin gentle range-of-motion exercises as soon as pain allows
   • Functional rehabilitation is preferred over immobilization 1
   • Gradually increase weight-bearing as tolerated

2. Progressive Strengthening:

   • Start with isometric exercises
   • Progress to resistance exercises as pain allows
   • Focus on peroneal muscles and ankle stabilizers

3. Proprioceptive Training:

   • Balance exercises on stable surfaces, progressing to unstable surfaces
   • Ankle disk exercises may help prevent future injuries 1

Recovery Timeline and Return to Activity

• Mild contusions: 2-4 weeks for resolution of symptoms
• Moderate to severe contusions: 6-12 weeks for full recovery
• Return to sports/activities should be gradual and pain-free
• Monitor for increased pain during activity progression, which indicates overloading 1

When to Refer

Consider referral to orthopedic specialist if:

• Pain persists beyond 6-8 weeks despite appropriate treatment
• Significant functional limitation continues
• Suspicion of associated injuries (osteochondral lesions, ligament tears)

Potential Complications

• Chronic pain (affects approximately 20% of patients) 1
• Post-traumatic arthritis
• Delayed healing
• Osteonecrosis (rare but serious)

Prevention of Recurrence

• Proper rehabilitation before returning to full activity
• Use of appropriate supportive devices for high-risk activities
• Proprioceptive training has shown benefit in preventing recurrent ankle injuries 1
• Address any biomechanical issues that may contribute to injury

Early functional rehabilitation with progressive loading is the cornerstone of effective treatment for deep bone contusions in the ankle, with most patients experiencing good outcomes when managed appropriately.