What is the appropriate management for a patient presenting with pain on the left ankle?

Management of Left Ankle Pain

Begin with plain radiographs of the ankle (AP, lateral, and mortise views) as the initial imaging study, regardless of whether the pain is acute or chronic. 1

Initial Clinical Assessment

Determine Acuteness vs. Chronicity

• Acute pain (<3 weeks): Apply Ottawa Ankle Rules to determine if imaging is needed 1
• Chronic pain (>6 weeks): Radiographs are indicated as the starting point for diagnostic workup 1, 2

Ottawa Ankle Rules for Acute Trauma

Obtain radiographs if ANY of the following are present: 1

• Inability to bear weight immediately after injury
• Point tenderness over the medial malleolus, posterior edge or inferior tip of lateral malleolus, talus, or calcaneus
• Inability to ambulate 4 steps in the emergency department

If the patient can walk AND has no point tenderness over bony structures, imaging is usually not appropriate. 1

Critical Red Flags Requiring Urgent Evaluation

• Acute inability to bear weight with significant deformity or swelling 3, 2
• Neurovascular compromise: coldness, absent pulses, numbness in foot 2
• Fever or systemic symptoms suggesting infection 2

Diagnostic Algorithm After Initial Radiographs

If Radiographs Show Fracture or Osteochondral Injury

• Order CT ankle without IV contrast for detailed fracture evaluation 1
• Order MRI ankle without IV contrast if osteochondral injury is suspected 1
• CT is superior to radiography for fracture detection 1

If Radiographs Are Normal but Pain Persists

For Suspected Ligamentous Injury or Instability

• Order MRI ankle without IV contrast OR MR arthrography (equivalent alternatives) 1
• MRI is better than CT for soft-tissue evaluation, including syndesmotic injuries 1

For Suspected Tendon Abnormality

• Order either MRI ankle without IV contrast OR ultrasound of the ankle 1
• Ultrasound has higher resolution for peripheral nerve-related symptoms 1
• Ultrasound with dynamic evaluation should be used when symptoms occur only during specific movements 1

For Suspected Ankle Impingement Syndrome

• Order MRI ankle without IV contrast 1
• MRI shows sensitivity of 75-83% and specificity of 75-100% for anterolateral impingement 1

For Pain of Unknown Etiology with Normal Radiographs

• Order MRI ankle without IV contrast as the next study 1
• MRI globally evaluates all anatomic structures including bone marrow and is effective for detecting occult stress injuries 1

Special Considerations for Focal Pathology

• For focal soft-tissue abnormality: Consider ultrasound or MRI 1
• For peripheral nerve symptoms: Ultrasound has higher resolution than MRI 1
• For suspected occult fracture: CT or MRI can detect initially missed fractures 1
• For diagnostic nerve blocks: US-guided anesthetic injection can help plan surgical intervention 1

Important Clinical Pitfalls to Avoid

Do Not Overlook Neurologic Causes

• L5 nerve root compression causes dorsal foot and big toe pain with sensory loss 4
• L5-S1 disc lesions are the most common cause, affecting >90% of symptomatic lumbar disc herniations 4
• Weakness of foot dorsiflexion and great toe extension confirms L5 involvement 4
• Order MRI of the lumbosacral plexus if radicular symptoms are present 4

Do Not Dismiss Bilateral Ankle Pain

• Bilateral presentation suggests systemic or developmental causes rather than trauma 3
• Consider inflammatory arthritis, vascular disease, or metabolic conditions 2

Do Not Assume All Diabetic Ankle Pain Is Neuropathic

• Diabetic patients may have occult fractures despite minimal symptoms 2
• These patients require imaging even without typical pain patterns due to peripheral neuropathy 1, 2

Do Not Order Imaging for Minimally Symptomatic Clicking

• Asymptomatic or minimally symptomatic clicking does not warrant imaging 3
• This leads to unnecessary radiation exposure and potential overdiagnosis of incidental findings 3

Conservative Management

Initial Treatment for Acute Sprains (Grade I-II)

• Functional treatment is equally effective as immobilization for most acute lateral ligament injuries 5, 6
• Most ankle sprains involve multiple structures beyond just lateral ligaments, including joint capsule, extensor digitorum brevis, sinus tarsi, and peroneal tendons 7

Pain Management

• Ibuprofen 400 mg every 4-6 hours as needed for pain relief 8
• Use the lowest effective dose for the shortest duration 8
• Doses greater than 400 mg every 4-6 hours are no more effective 8