What could be causing sudden loss of balance and foot ankle pain?

Sudden Loss of Balance with Foot Ankle Pain: Acute Lateral Ankle Sprain

This presentation is most consistent with an acute lateral ankle sprain, specifically an inversion injury affecting the lateral stabilizing ligaments (anterior talofibular and calcaneofibular ligaments), which accounts for approximately 2 million injuries annually in the United States. 1, 2

Immediate Diagnostic Approach

Rule Out Fracture First

• Apply the Ottawa Ankle Rules immediately to determine if radiographs are needed 1, 2:
  • Pain on the dorsal side of one or both malleoli
  • Palpation pain at the base of the fifth metatarsal bone
  • Palpation pain of the navicular bone
  • Inability to walk at least four steps immediately after injury or in the emergency department 1
• The Ottawa Ankle Rules have 97-99% negative predictive value, correctly ruling out fracture without radiography in 299 out of 300 patients 1
• Only 15% of patients with lateral ankle sprains who undergo radiography actually have a fracture 1

Physical Examination Timing Matters

• Reexamine the patient 4-5 days post-injury for optimal assessment of ligament injury severity 1
• Excessive swelling and pain can limit examination accuracy within the first 48 hours 1, 3
• The anterior drawer test has 84% sensitivity and 96% specificity when performed 4-5 days after injury 1

Key Examination Findings

• If all four of these findings are present, there is a 96% likelihood of lateral ligament rupture 1:
  • Swelling
  • Hematoma
  • Pain on palpation over the lateral ligaments
  • Positive anterior drawer test
• Only 14% of patients without all four findings have a lateral ligament rupture 1

Immediate Treatment Protocol

PRICE Protocol (First 48-72 Hours)

Initiate the PRICE protocol immediately 2:

• Protection: Use semirigid or lace-up ankle supports (NOT elastic bandages) 1, 2
• Rest: Activity modification, but avoid complete immobilization 2
• Ice: Apply through a wet towel for 10-minute periods 4
• Compression: Use appropriate ankle support devices 2
• Elevation: Reduce swelling 2

Medication

• Start NSAIDs immediately - they have evidence for improving healing, reducing edema and pain, and decreasing time to return to usual activities 1, 2

Functional Treatment Over Immobilization

• Semirigid or lace-up ankle supports are superior to elastic bandages and are the recommended functional treatment 1, 2
• Functional rehabilitation is preferable to complete immobilization to prevent muscular atrophy and deconditioning 2, 4

Addressing the Balance Component

Why Balance is Affected

• Loss of balance with ankle injury reflects proprioceptive deficits that occur immediately with lateral ligament injury 5
• Athletes with chronic ankle sprains show statistically significant deficits in foot proprioception, static balance, and dynamic balance even one year after injury 5

Early Intervention for Balance

• Begin proprioceptive exercises early in the treatment process, including ankle disk training and neuromuscular facilitation 1, 2
• Graded exercise regimens with proprioceptive elements help reduce the risk of recurrent ankle sprain 1

Risk Factors for Poor Recovery

Address these factors early to prevent chronic ankle instability 1:

• Current level of pain
• Patient's workload
• Level of sports participation
• All of these negatively influence recovery and increase risk of future injury recurrence 1

When to Obtain Advanced Imaging

• If pain persists beyond 1 week despite negative radiographs, MRI without contrast or CT without contrast are equivalent alternatives 3
• MRI has 93-96% sensitivity and 100% specificity for visualizing high-grade ligament injuries, osteochondral defects, syndesmotic injuries, and occult fractures 1

Red Flags Requiring Urgent Evaluation

Seek immediate evaluation if any of these are present 1, 4:

• High level of pain
• Rapid onset of swelling
• Coldness or numbness in the injured foot
• Inability to bear weight
• Complicating conditions (e.g., diabetes)
• Pain becomes constant at rest 4

When to Refer

Refer to a podiatric foot and ankle surgeon if 2, 3:

• No improvement after 6-8 weeks of appropriate conservative treatment
• Need for advanced imaging studies
• Consideration of surgical intervention

Common Pitfalls to Avoid

• Do not examine only once - the initial examination within 48 hours may be limited by swelling and pain; always reexamine at 4-5 days 1, 3
• Do not use elastic bandages for functional treatment - semirigid or lace-up supports are superior 1, 2
• Do not completely immobilize unless absolutely necessary - functional rehabilitation prevents deconditioning 2, 4
• Do not ignore the balance component - proprioceptive deficits must be addressed to prevent chronic instability 5