What is the recommended assessment and treatment for a 9-year-old female with an ankle injury presenting with bruising, intact range of motion, and minimal pain one week after injury?

Assessment and Treatment for Pediatric Ankle Injury

For a 9-year-old female with an ankle injury one week post-injury presenting with bruising, intact range of motion, and minimal pain with manipulation, functional treatment with appropriate ankle support and early rehabilitation exercises is strongly recommended over immobilization. 1

Assessment

Physical Examination

• Evaluate for:
  • Bruising pattern and extent
  • Range of motion (already noted to be intact)
  • Pain with weight-bearing
  • Point tenderness over:
    • Medial malleolus
    • Lateral malleolus (posterior edge or inferior tip)
    • Talus
    • Calcaneus
  • Ability to bear weight and walk

Imaging Considerations

• Based on Ottawa Ankle Rules, imaging is likely not necessary in this case since:
  • Patient has minimal pain with manipulation
  • Range of motion is intact
  • Injury occurred one week ago and patient is ambulatory 1
• If the patient meets any of the following criteria, radiographs would be indicated:
  • Inability to bear weight immediately after injury
  • Point tenderness over the malleoli, talus, or calcaneus
  • Inability to take 4 steps in the examination room 1

Treatment Plan

Immediate Management

1. Functional treatment with appropriate ankle support

   • Use a lace-up or semi-rigid ankle support rather than elastic bandage or tape 1
   • Semi-rigid ankle supports result in shorter time to return to sports and work compared to elastic bandages 1

2. PRICE protocol for symptom management

   • Protection: Appropriate ankle support
   • Rest: Relative rest (avoid activities that cause pain)
   • Ice: Apply cold therapy (ice with water in a damp cloth) for 20-30 minutes, 3-4 times daily 1
   • Compression: Apply compression wrap for comfort (ensure it's not too tight) 1
   • Elevation: Elevate the ankle when resting

Rehabilitation Protocol

1. Early Phase (Days 1-7)

   • Begin gentle range of motion exercises:
     • Ankle circles
     • Alphabet drawing with toes
   • Avoid activities that cause pain 1

2. Progressive Phase (Weeks 1-3)

   • Advance to strengthening exercises:
     • Resistance band exercises in all directions
     • Towel stretches for dorsiflexion
     • Heel raises (progress from bilateral to unilateral) 2

3. Return to Activity Phase (Weeks 3-6)

   • Balance and proprioception training:
     • Single-leg stance (eyes open, then closed)
     • Balance board exercises 2
   • Sport-specific exercises as tolerated

Return to Activity Guidelines

• For mild ankle sprains (which this appears to be based on presentation):
  • Return to light activities: 2 weeks
  • Full return to former activities: 3-4 weeks 1
• Criteria for full return:
  • Pain-free walking
  • Full range of motion
  • Restored strength
  • Ability to perform activity-specific movements without pain 2

Common Pitfalls to Avoid

1. Excessive immobilization

   • Functional treatment is superior to immobilization, with patients returning to work 7.1 days sooner 1
   • Longer periods of immobilization (>4 weeks) are less effective than functional treatments 1

2. Inadequate support

   • Elastic bandages are less effective than lace-up or semi-rigid supports 1
   • Proper support reduces risk of recurrent sprains 2

3. Delayed mobilization

   • Begin exercises within 48-72 hours to promote healing 1
   • Exercise therapy helps prevent recurrence of ankle injuries 1

4. Inappropriate modalities

   • Ultrasound, laser therapy, and electrotherapy have no proven benefit in ankle injuries 1
   • Manual mobilization has limited added value 1

This approach prioritizes functional recovery while minimizing pain and preventing recurrence, which will optimize the child's morbidity, mortality, and quality of life outcomes.