What is the treatment for left ankle pain over the Anterior Talofibular Ligament (ATFL), with pain radiating to the lateral malleolus and fibula, in the absence of any detectable abnormalities on ultrasound and X-ray?

From the Guidelines

For left ankle pain over the anterior talofibular ligament (ATFL) without injury and normal imaging, I strongly recommend initiating a comprehensive conservative management approach, prioritizing functional treatment with exercise and functional support, as outlined in the most recent and highest quality study 1. This approach should begin with the RICE protocol, including rest, ice application for 15-20 minutes several times daily, compression with an elastic bandage, and elevation of the ankle above heart level.

• Over-the-counter NSAIDs like ibuprofen (400-600mg three times daily with food) or naproxen (220-440mg twice daily) can be taken for 7-10 days to reduce pain and inflammation, as suggested by 1 and further supported by the discussion on treatment modalities in 1.
• Physical therapy focusing on ankle strengthening and proprioception exercises is crucial, starting with ankle circles, alphabet tracing with the foot, and calf stretches, progressing to resistance band exercises and balance training.
• A supportive ankle brace during activities may help stabilize the joint, in line with the recommendations for functional support in 1. Key considerations include:
• The pain radiating up the fibula suggests possible nerve irritation or referred pain along the peroneal muscle group, which responds well to targeted stretching and strengthening exercises.
• If pain persists beyond 2-3 weeks despite these measures, it is essential to consult a specialist for further evaluation, as this could represent peroneal tendonitis, sinus tarsi syndrome, or other soft tissue pathologies that don't appear on basic imaging, highlighting the importance of a thorough assessment as indicated in 1.

From the Research

Treatment Options for Left Ankle Pain

• The patient is experiencing left ankle pain over the ATFL, with no injury, and the pain radiates up the fibula to the lateral malleolus. Ultrasound and X-ray results show no abnormalities.
• Considering the lack of abnormalities in the ultrasound and X-ray results, the treatment options may focus on managing the pain and inflammation.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• NSAIDs are commonly used to treat tendinopathy and other soft tissue injuries, but their effectiveness is still debated 2, 3.
• A study on the effects of NSAID treatment on human tendinopathic tissue found that short-term ibuprofen treatment had no effect on gene expression in human chronic tendinopathic tendon 2.
• However, another study suggested that topical NSAIDs can be effective in treating acute, localized soft tissue injuries or painful conditions 4.
• A systematic review and meta-analysis found that NSAID use can reduce strength loss, soreness, and blood creatine kinase level after an acute muscle injury, at least in the short term 5.

Topical NSAIDs

• Topical NSAIDs have been shown to be effective in treating certain types of acute pain, with minimal systemic absorption and risk of related adverse events 4.
• They can provide a therapeutic option for treatment of acute, localized soft tissue injuries or painful conditions in areas of the body that can be readily treated using the topical route of administration.

Other Considerations

• The use of NSAIDs in the management of soft-tissue injuries such as ankle sprains is well established, but there is debate over whether NSAIDs delay healing and contribute to long-term joint instability 3.
• It is essential to weigh the potential benefits and risks of NSAID use in the treatment of left ankle pain, considering the individual patient's needs and medical history.