What is the appropriate management for ankle swelling in an adolescent?

Management of Ankle Swelling in a 14-Year-Old

Apply the Ottawa Ankle Rules immediately to determine if radiographs are needed—if the adolescent can bear weight for 4 steps and has no point tenderness over the malleoli, talus, or calcaneus, skip imaging and proceed directly to functional treatment with bracing and supervised exercise therapy. 1, 2

Initial Assessment and Imaging Decision

The Ottawa Ankle Rules (OAR) are validated for children ≥5 years of age and should guide your imaging decision with 92-100% sensitivity for detecting fractures 1, 2:

Obtain ankle radiographs (AP, lateral, and mortise views) if ANY of the following are present:

• Inability to bear weight immediately after injury OR inability to walk 4 steps in the clinic 1
• Point tenderness over the posterior edge or inferior tip of the medial malleolus 1
• Point tenderness over the posterior edge or inferior tip of the lateral malleolus 1
• Point tenderness over the talus or calcaneus 1

Do NOT obtain radiographs if OAR criteria are negative—this avoids unnecessary radiation exposure and costs without missing clinically significant fractures 1, 2

If Radiographs Are Negative or Not Indicated

Immediate Treatment Protocol

Start functional treatment immediately rather than immobilization, as this reduces time to return to activity by approximately 4.6 days 2:

1. Bracing (not immobilization): Use a semi-rigid or lace-up ankle support, which is superior to elastic bandages or tape 2

2. Supervised exercise therapy starting immediately: 2

   • Proprioceptive exercises
   • Strength training
   • Coordination drills
   • Functional exercises specific to the patient's activities

3. Cold therapy: Apply for 20-30 minutes per application without direct skin contact for pain and swelling relief 2

4. NSAIDs (use cautiously): May be used short-term for pain and swelling, but use judiciously as they may suppress natural healing 2

Critical Timing for Clinical Assessment

Wait 4-5 days post-injury before performing detailed ligamentous examination, as this timing provides optimal sensitivity (84%) and specificity (96%) for detecting ligament ruptures using the anterior drawer test 2

If Pain Persists Beyond 1 Week with Negative Initial Radiographs

Order MRI without IV contrast as the next study if pain persists for more than 1 week but less than 3 weeks, as MRI is most sensitive for detecting 1:

• Occult fractures with bone marrow edema
• Ligamentous injuries (particularly in inversion injuries)
• Osteochondral injuries
• Soft-tissue abnormalities

CT without IV contrast is an alternative if MRI is unavailable, particularly useful for detecting radiographically occult talar fractures, calcaneal fractures, and posterior malleolar fractures 1

Red Flags Requiring Different Evaluation

Do NOT apply OAR if the patient has: 1

• Peripheral neuropathy or neurological compromise
• Diabetes with neuropathy (these patients may walk without pain despite fracture)
• Suspected foreign body
• High-energy trauma or polytrauma

In these cases, obtain radiographs regardless of clinical findings 1

Special Consideration for Non-Traumatic Bilateral Swelling

If the 14-year-old presents with bilateral, chronic, non-pitting edema without trauma history, consider non-musculoskeletal etiologies such as lymphedema, as this presentation is atypical for ankle sprain 3. This requires different diagnostic workup including comprehensive blood tests and specialist referral 3.

Follow-Up Protocol

Monitor regularly for: 2

• Swelling reduction
• Pain improvement
• Functional progress with return to activities
• Continue proprioception, strength, and functional exercises until full recovery 2

Address early: 2

• Pain levels
• School/sports participation restrictions
• Workload modifications These factors negatively influence recovery and increase recurrence risk if not managed 2

Common Pitfalls to Avoid

• Never immobilize when functional treatment is appropriate—this significantly delays recovery 2, 4
• Never obtain radiographs when OAR criteria are negative—this wastes resources and exposes the patient to unnecessary radiation 2
• Never examine for ligamentous injury in the first 3 days—wait until days 4-5 for accurate assessment 2
• Never use RICE protocol alone—there is no evidence supporting its effectiveness as monotherapy 4