What is the appropriate assessment and treatment for a patient with a suspected ankle sprain after rolling her ankle?

Assessment and Treatment of Ankle Sprain

For a patient with a suspected ankle sprain after rolling her ankle, the appropriate assessment should follow the Ottawa Ankle Rules to rule out fracture, followed by a thorough examination of ligamentous structures and implementation of the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for initial management. 1

Initial Assessment

• Determine the mechanism of injury - typically an inversion injury that occurs in the plantar-flexed position for lateral ankle sprains 1
• Assess timing of injury and history of previous ankle sprains, which is a common risk factor for new injuries 1
• Evaluate for urgent signs requiring immediate attention: high level of pain, rapid onset of swelling, coldness/numbness in the injured foot, inability to bear weight, or complicating conditions (e.g., diabetes) 1

Ottawa Ankle and Foot Rules

Apply these rules to determine if radiography is necessary:

• An ankle X-ray is required only if there is pain in the malleolar zone and:

  • Bone tenderness at the posterior edge or tip of the lateral malleolus, OR
  • Bone tenderness at the posterior edge or tip of the medial malleolus, OR
  • Inability to bear weight for four steps both immediately after injury and in the emergency department 1

• If the Ottawa Rules are negative (no point tenderness over malleoli, talus, or calcaneus, and patient able to walk), radiography is not indicated 1

Physical Examination

• Look for key findings associated with more severe (grade III) sprains: swelling, hematoma, pain on palpation, and positive anterior drawer test 1
• Perform the anterior drawer test to detect excessive anterior displacement of the talus, indicating anterior talofibular ligament tear 1
• Conduct a crossed-leg test to detect high ankle (syndesmotic) sprains - pain in the syndesmosis area when pressure is applied to the medial side of the knee 1
• Reexamine the patient 3-5 days after injury when pain and swelling have improved to better distinguish partial tears from complete ligament ruptures 1

Grading of Ankle Sprains

Classify the sprain based on severity:

• Grade I (mild): Minimal swelling, tenderness, no instability
• Grade II (moderate): Moderate swelling, tenderness, some instability
• Grade III (severe): Severe swelling, tenderness, instability with complete ligament tear 1

Treatment Approach

Immediate Management

• Implement PRICE protocol:

  • Protection: Use appropriate support/brace
  • Rest: Limit weight-bearing initially
  • Ice: Apply for 15-20 minutes every 2-3 hours
  • Compression: Use elastic bandage or wrap
  • Elevation: Keep ankle above heart level 1

• Use nonsteroidal anti-inflammatory drugs to reduce swelling and pain and potentially decrease recovery time 1

Functional Treatment

• Functional rehabilitation is preferred over immobilization 1
• Use semirigid or lace-up ankle supports rather than elastic bandages for better outcomes 1
• Begin early range of motion, weight-bearing, and neuromuscular training exercises as tolerated 1
• Implement proprioceptive training (e.g., ankle disk exercises) after 3-4 weeks to improve balance and neuromuscular control 1

Prevention of Recurrence

• Continue using semirigid or lace-up ankle supports, especially for patients with history of recurrent sprains 1
• Implement graded exercise regimens with proprioceptive elements like ankle disk training to reduce risk of future sprains 1

Special Considerations

• For severe (Grade III) sprains, controversy exists regarding surgical versus conservative treatment, but functional treatment has been shown to provide the fastest recovery without affecting long-term stability 1
• If radiographs demonstrate fracture or potential osteochondral injury, CT or MRI without IV contrast may be appropriate for further evaluation 1
• For suspected syndesmotic injuries, MRI is recommended for verification 1

Common Pitfalls to Avoid

• Excessive imaging when not indicated by Ottawa Rules 1
• Unwarranted non-weight-bearing and prolonged immobilization 1
• Delay in implementing functional movements and rehabilitation 1
• Inadequate assessment for syndesmotic injuries, which require different management 1