What is the appropriate workup and management for a 14-year-old with a rolled ankle and persistent pain one week later?

Workup and Management for 14-Year-Old with Persistent Ankle Pain One Week Post-Injury

For a 14-year-old with persistent ankle pain one week after a rolled ankle, obtain radiographs if Ottawa Ankle Rules (OAR) criteria are met, and if initial radiographs are negative but pain persists, proceed with MRI or CT to evaluate for occult fractures, osteochondral injuries, or ligamentous damage. 1

Initial Assessment at One Week Post-Injury

Apply Ottawa Ankle Rules to Determine Need for Radiographs

Obtain ankle radiographs if any of the following are present: 1

• Inability to bear weight immediately after injury OR currently unable to take 4 steps
• Point tenderness over the posterior edge or inferior tip of the lateral malleolus
• Point tenderness over the posterior edge or inferior tip of the medial malleolus
• Point tenderness over the navicular bone
• Point tenderness over the base of the fifth metatarsal

The OAR have 96.7% sensitivity for detecting fractures, correctly ruling out fracture without radiography in 299 out of 300 patients. 1

Physical Examination Findings to Document

Perform delayed physical examination (4-5 days post-injury optimal) to assess ligament injury severity: 1

• Anterior drawer test - has 84% sensitivity and 96% specificity when performed 4-5 days post-injury for detecting anterior talofibular ligament rupture 1
• Assess for swelling, hematoma, and pain on palpation around the distal fibula 1
• Crossed-leg test - apply pressure to medial knee; pain in syndesmosis area suggests high ankle sprain 1
• Document ability to bear weight and ambulate 1

Advanced Imaging for Persistent Pain with Negative Initial Radiographs

If radiographs were obtained initially and were negative, but pain persists at one week, MRI without IV contrast or CT without IV contrast are both appropriate next steps. 1

MRI Ankle Without IV Contrast (Preferred for Soft Tissue)

• Most sensitive for occult fractures with bone marrow edema patterns 1
• Excellent for ligamentous injuries: 93-96% sensitivity and 100% specificity 1
• Best for detecting osteochondral lesions, which may cause persistent pain 1, 2, 3
• Superior for evaluating soft tissue impingement and peroneal tendon injuries 1, 2

CT Ankle Without IV Contrast (Alternative, Better for Bone Detail)

• Useful for radiographically occult fractures, particularly talar and calcaneal fractures 1
• Demonstrates fractures in one-third of cases with joint effusion but no visible fracture on radiographs 1
• Better for evaluating syndesmotic injuries and subtle fracture patterns 1

These are equivalent alternatives per ACR guidelines - choose based on clinical suspicion (MRI for ligament/cartilage concerns, CT for occult fracture concerns). 1

Management Based on Findings

If No Fracture Identified

Implement functional rehabilitation with the following components: 1

• NSAIDs to reduce swelling and pain, may decrease time to return to activities 1
• Semirigid or lace-up ankle supports (NOT elastic bandages) for functional treatment 1
• Graded exercise regimen with proprioceptive training (ankle disk training) to reduce risk of recurrent sprain 1
• Short period of protected weight-bearing followed by progressive functional rehabilitation 4

If Occult Fracture or Osteochondral Lesion Found

• Small avulsion fractures (<15mm): conservative management with immobilization and radiographic follow-up 5
• Large fragments (>15mm) or displaced fractures: orthopedic referral for potential surgical fixation 5
• Osteochondral lesions: may require arthroscopic excision or repair if symptomatic 2, 3

If Severe Ligament Injury (Grade III) Confirmed

• Functional rehabilitation remains first-line for most cases 4, 6
• 80% of acute ankle sprains recover fully with conservative management 4
• Reserve surgical consideration for cases with persistent instability after adequate rehabilitation trial 4, 6

Critical Pitfalls to Avoid

Do not rely on clinical examination alone in the first 48 hours - excessive swelling and pain limit accurate assessment of ligament integrity 1

Do not miss syndesmotic (high ankle) injuries - these require different management and have longer recovery times; test with crossed-leg maneuver 1

Do not overlook associated injuries in persistent pain cases: 2, 3

• Anterior impingement from fibrous scar tissue (common cause of pain >6 weeks post-sprain)
• Peroneal tendon tears or subluxation
• Osteochondral lesions of the talus
• Subtalar joint involvement

Ensure adequate follow-up - reexamine at 3-5 days post-injury for optimal ligament assessment, and again if symptoms persist beyond expected recovery timeline 1