What is the best course of treatment for a 70-year-old woman with a history of hyperlipidemia, GERD, arthritis, cancer, and osteoporosis risk, who presents with left ankle and right hip pain after twisting her ankle, and has limited range of motion and tenderness in both areas?

Management of Lateral Ankle Sprain with Secondary Hip Pain

This patient requires immediate ankle X-rays to exclude fracture, followed by functional treatment with a semi-rigid ankle brace for 4-6 weeks combined with supervised exercise therapy starting within 48-72 hours, while the hip pain warrants urgent imaging to rule out occult hip fracture given her age and osteoporosis risk.

Immediate Diagnostic Evaluation

Ankle Assessment

• Apply Ottawa Ankle Rules to determine need for radiography: X-rays are indicated because she has lateral malleolar tenderness on palpation and initially could not walk without a cane 1, 2, 3
• The mechanism (missed step with ankle twist), lateral malleolar ecchymosis, significant pain with talar tilt, and limited dorsiflexion (10 degrees) and plantarflexion (20 degrees) suggest at least a Grade II lateral ligament sprain 1, 2
• Negative anterior/posterior drawer and talar tilt tests are reassuring against complete rupture, but delayed physical examination at 4-5 days post-injury is critical for accurate ligament assessment when swelling subsides 1, 2, 4

Hip Evaluation - Critical Priority

• New-onset right hip pain with trochanteric tenderness and painful internal rotation in a 70-year-old woman is highly suspicious for hip fracture and requires immediate AP pelvis and lateral hip radiographs 5, 6
• Her altered gait pattern (limping, favoring left ankle) creates abnormal loading on the contralateral hip, but hip fracture must be excluded urgently as initial radiographs can be falsely negative in up to 10% of cases 5
• If initial hip X-rays are negative but clinical suspicion remains (persistent pain, inability to bear weight normally), MRI of the right hip must be obtained within 2-3 days to identify occult fracture 5, 6
• This is a medical emergency: Hip fractures in elderly patients require surgical planning within 24-48 hours to reduce mortality and complications 5, 6

Ankle Treatment Protocol

Immediate Management (First 48 Hours)

• Apply PRICE protocol: Protection, Rest, Ice (20-30 minutes per application avoiding direct skin contact), Compression wrap (ensuring circulation not compromised), and Elevation 1, 2
• Initiate NSAIDs immediately (ibuprofen, naproxen, diclofenac, or celecoxib) to reduce pain and swelling, which accelerates return to activity 1, 2
• Apply a lace-up or semi-rigid ankle brace within 48 hours and continue for 4-6 weeks - this is superior to elastic bandages or immobilization and leads to faster return to function (4.6 days sooner return to sports, 7.1 days sooner return to work) 1, 2

Functional Rehabilitation (Starting 48-72 Hours Post-Injury)

• Begin supervised exercise therapy within 48-72 hours - this has Level 1 evidence for effectiveness and is superior to home exercises alone 1, 2
• Rehabilitation must include:
  • Range of motion exercises to restore dorsiflexion/plantarflexion 1, 2
  • Proprioception training (critical to prevent recurrent sprains, especially given her arthritis) 1, 2
  • Progressive strengthening exercises 1, 2
  • Coordination and functional exercises 2
• Weight-bearing as tolerated immediately, avoiding only activities that cause pain 2

Critical Pitfalls to Avoid

• Do not immobilize beyond 3-5 days: Prolonged immobilization leads to decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1, 2
• Do not rely on RICE protocol alone - individual components are useful, but functional bracing and supervised exercise are essential 2
• Inadequate treatment leads to chronic problems in 5-46% of patients at 1-4 years, including persistent pain and ankle instability 2

Hip Management Algorithm

If Hip Fracture is Confirmed

• Immediate orthopedic surgical consultation and hospital admission for operative management within 24-48 hours 5, 6
• Activate interdisciplinary care with orthogeriatric/hospitalist consultation to optimize comorbidities and coordinate surgical timing (strong recommendation, decreases complications and improves outcomes) 5, 6
• Implement multimodal analgesia: peripheral nerve block plus IV acetaminophen to reduce opioid requirements and avoid delirium risk in elderly patients 5
• Surgical approach depends on fracture pattern: arthroplasty for displaced femoral neck fractures (with cemented femoral stem), cephalomedullary nail for intertrochanteric/subtrochanteric fractures 5, 6

If Hip Imaging is Negative

• The trochanteric tenderness with painful internal rotation suggests trochanteric bursitis secondary to altered gait mechanics from ankle injury 1
• Treatment includes: activity modification, NSAIDs (already initiated for ankle), physical therapy focusing on hip strengthening and gait normalization once ankle permits 1
• Re-evaluate hip symptoms after ankle rehabilitation progresses - many compensatory hip symptoms resolve with normalized gait pattern 2

Follow-Up and Prevention

Ankle Re-Assessment

• Schedule re-examination at 3-5 days post-injury when swelling has decreased to accurately assess ligament integrity and adjust treatment plan 1, 2
• Continue semi-rigid brace for full 4-6 weeks even as symptoms improve 2
• Incorporate ongoing ankle exercises into regular activities after recovery to prevent recurrence (high cost-benefit ratio) 2

Return to Activity Timeline

• For this Grade II sprain: expect return to sedentary activities at 2-3 weeks, full return to normal function at 4-6 weeks depending on rehabilitation progress 2
• Continue ankle bracing during high-risk activities even after recovery, especially given her arthritis and fall risk 2

Osteoporosis Evaluation - Essential

• Given her age (70), history suggesting osteoporosis risk, and potential hip fracture concern, refer to Bone Health Clinic for DXA scan and secondary fracture prevention 5
• Initiate vitamin D supplementation (800 IU/day) with adequate calcium intake (1000-1200 mg/day) 5

Key Clinical Pearls

• The ability to walk does not exclude serious injury: She ambulated with a cane initially, but this does not rule out significant ligament injury or occult hip fracture 6
• Address both injuries simultaneously: The ankle sprain is creating abnormal biomechanics that may be contributing to hip pain, but hip fracture must be excluded first 2, 5
• Supervised rehabilitation is non-negotiable: Self-directed home exercises have inferior outcomes compared to supervised physical therapy for ankle sprains 2
• Her history of arthritis increases risk for chronic ankle instability if rehabilitation is inadequate 1, 2