What is the best course of treatment for a 55-year-old female with a history of acquired hypothyroidism, mixed anxiety and depressive disorder, vitamin D deficiency, and osteoarthritis of both knees, who presents with severe right ankle pain and swelling after a fall, with difficulty bearing weight and tenderness to palpation along the lateral aspect of the right foot?

Immediate Imaging and Diagnosis Required

This patient requires immediate radiographic evaluation of the right ankle and foot to rule out fracture, followed by functional treatment with bracing, NSAIDs, and early supervised rehabilitation if no fracture is identified.

Urgent Diagnostic Workup

Apply Ottawa Ankle Rules Immediately

• Radiographs are mandatory because this patient cannot bear weight (difficulty bearing weight reported) and has severe pain (10/10) with lateral foot tenderness—both meeting Ottawa Ankle Rules criteria for imaging 1, 2
• The Ottawa Ankle Rules have 96.7% sensitivity for detecting fractures, correctly ruling out fracture in 299 of 300 patients without radiography 2
• Order AP, lateral, and mortise views of the right ankle, plus foot series given the lateral foot tenderness 2

Critical Diagnostic Consideration

• The mechanism is concerning: her left knee gave out causing a fall, but the right ankle is injured—this suggests she twisted or landed awkwardly on the right ankle during the fall, raising concern for significant ligamentous injury or occult fracture 2
• The lateral foot tenderness specifically requires foot radiographs in addition to ankle views 2

If Radiographs Are Negative

Delayed Physical Examination is Essential

• Re-examine in 4-5 days when swelling subsides to accurately assess ligament integrity—initial examination within 48 hours cannot distinguish between simple distortion and complete ligament rupture 1, 2, 3
• Perform anterior drawer test (84% sensitivity, 96% specificity) and crossed-leg test to evaluate for high ankle sprain at the delayed examination 1, 2

Consider Advanced Imaging if Pain Persists

• If severe pain continues despite negative radiographs, obtain MRI without contrast to evaluate for occult fractures, osteochondral lesions, or severe ligamentous damage 2
• MRI is most sensitive for occult fractures and excellent for ligamentous injuries 2

Immediate Treatment Protocol (Assuming No Fracture)

Functional Bracing—Not Immobilization

• Apply a lace-up or semi-rigid ankle brace within 48 hours and continue for 4-6 weeks—this is superior to immobilization and leads to return to sports 4.6 days sooner and return to work 7.1 days sooner 1
• Avoid immobilization beyond what's needed for initial pain control (3-5 days maximum), as prolonged immobilization causes decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1

PRICE Protocol Components

• Protection: Use the ankle brace as described above 1, 4
• Rest: Avoid only activities that cause pain; begin weight-bearing as tolerated immediately 1
• Ice: Apply cold (ice and water surrounded by damp cloth) for 20-30 minutes per application, avoiding direct skin contact 1
• Compression: The ankle brace provides this; ensure circulation is not compromised 1
• Elevation: Elevate the leg when possible 1, 3

Optimize Pain Management

• Increase ibuprofen to therapeutic dosing: She's currently taking only two tablets daily (likely 400mg total), which is subtherapeutic 5
• For acute ankle injury pain, prescribe ibuprofen 400mg every 4-6 hours as needed (maximum 3200mg daily), which has Level 1 evidence for reducing pain and swelling while accelerating return to activity 1, 5
• NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) are effective for short-term use (<14 days) 1
• Avoid opioids—they cause significantly more side effects without superior pain relief 1
• Take with food or milk to minimize GI complaints 5

Supervised Rehabilitation Protocol

Begin Within 48-72 Hours

• Start supervised exercise therapy within 48-72 hours after injury—this has Level 1 evidence for effectiveness and is superior to home exercises alone 1
• Supervised exercises are critical; patients working with a physical therapist have better outcomes than those performing home exercises independently 1

Specific Exercise Components

• Range of motion exercises: Begin immediately to prevent stiffness 1
• Proprioception training: Critical to prevent recurrent sprains, especially given her history of knee osteoarthritis which may affect balance 1
• Strengthening exercises: Focus on ankle stabilizers 1
• Coordination and functional exercises: Progress as tolerated 1

Manual Therapy Adjunct

• Manual mobilization can be added to enhance treatment effects but should never be used alone 1

Return to Activity Timeline

For Moderate to Severe Sprains (Likely in This Case)

• Return to sedentary work: 3-4 weeks 1
• Full return to work and normal activities: 6-8 weeks depending on physiotherapy results 1

Address Underlying Risk Factors

Comorbidity Management

• Her vitamin D deficiency may impair bone health and healing—ensure adequate supplementation 6
• Her knee osteoarthritis likely contributed to the fall mechanism (knee giving out) and may affect rehabilitation—consider physical therapy addressing both lower extremities 6
• Hypothyroidism should be optimized as it can affect healing and muscle function 6

Fall Prevention

• The fact that her knee "gave out" while sitting suggests significant knee instability requiring evaluation 6
• Consider referral for comprehensive lower extremity strengthening and balance training to prevent future falls 6, 1

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 2
• Do not skip the delayed physical examination at 4-5 days—this is when accurate ligament assessment becomes possible 1, 2
• Do not immobilize beyond 3-5 days—this delays recovery without improving outcomes 1
• Do not miss a high ankle sprain (syndesmotic injury)—these require different management and longer recovery times; test with crossed-leg maneuver at delayed examination 1, 2
• Do not prescribe subtherapeutic NSAID doses—her current regimen is inadequate for acute injury 5

If Fracture Is Identified

• Management depends on fracture type and displacement 2
• Simple, minimally displaced, non-articular fractures may be treated with immobilization 6
• Displaced or articular fractures require orthopedic referral for potential surgical fixation 2

Long-Term Prevention

• Continue ankle bracing during high-risk activities even after recovery to prevent recurrence 1
• Incorporate ongoing ankle exercises into regular activities—this has high cost-benefit ratios due to reduced recurrence rates 1
• Address the underlying knee instability that precipitated this fall 6