What is the appropriate assessment and management of a teenager presenting with ankle pain?

Assessment and Management of Ankle Pain in Teenagers

Begin with plain radiographs (anteroposterior, lateral, and mortise views) as the initial imaging study for any teenager presenting with ankle pain, as this is the most appropriate first-line diagnostic approach to identify fractures, osteochondral injuries, and other osseous abnormalities. 1

Initial Clinical Assessment

History and Physical Examination Priorities:

• Mechanism of injury: Determine if there was inversion trauma (suggests lateral ligament injury), forced plantar flexion (suggests anterior talofibular ligament injury), or a fall from height (suggests calcaneal fracture) 2, 3, 4

• Timing of symptoms: Acute onset (<6 weeks) versus chronic pain (>6 weeks) fundamentally changes the differential diagnosis and imaging approach 1

• Activity level: Progressive worsening pain following increased activity or change to harder walking surface suggests stress fracture 2

• Location of pain: Lateral ankle pain suggests ligament injury or lateral process fracture; posterior heel pain indicates Achilles tendonitis or Haglund's deformity; diffuse heel pain suggests stress fracture 2

Critical Physical Examination Maneuvers:

• Point tenderness localization: Palpate the lateral malleolus, medial malleolus, base of fifth metatarsal, navicular bone, Achilles insertion, lateral calcaneal wall, and calcaneofibular ligament course 2, 5, 4

• Calcaneal compression test: Squeeze the calcaneus from medial to lateral—pain suggests stress fracture 2

• Weight-bearing assessment: Document ability to bear weight immediately after injury and take four steps 2, 4

• Swelling pattern: Rapid onset swelling suggests acute ligamentous injury or fracture; lateral gutter swelling indicates lateral ligament involvement 2

Imaging Algorithm

Step 1: Apply Ottawa Ankle Rules to Determine Need for Radiographs

Obtain radiographs if ANY of the following are present 2, 4:

• Inability to bear weight immediately after injury
• Point tenderness over malleoli, talus, or calcaneus
• Inability to ambulate 4 steps in the emergency department or office

Step 2: Initial Radiographic Evaluation

• Standard views: Anteroposterior, lateral, and mortise (obtained by internally rotating foot 15-20 degrees) 1

• Diagnostic yield: Radiographs can identify osteoarthritis, osteochondral abnormalities, stress fractures, calcified intra-articular bodies, ossific fragments indicating ligamentous injury, and ankle effusions with 53-74% accuracy 1

Step 3: Advanced Imaging for Persistent Pain with Negative Radiographs

If pain persists >1 week with negative radiographs 2:

• MRI without contrast OR CT without contrast are equivalent alternatives for further evaluation
• Technetium bone scanning is specifically indicated for suspected stress fracture, as symptoms often precede radiographic findings 2

Important Caveat: Do NOT routinely order MRI, CT, ultrasound, or bone scan as the first imaging study—radiography must come first 1

Common Diagnoses in Teenagers

Lateral Ankle Ligament Injuries:

• Most common ankle injury in adolescents, involving anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) 3, 4
• 80% recover fully with conservative management; 20% develop chronic instability 3

Sever's Disease (Calcaneal Apophysitis):

• Most common cause of heel pain in adolescents and children 2
• Presents with posterior heel pain at Achilles insertion 2, 5

Stress Fractures:

• Symptoms precede radiographic findings—requires bone scan or MRI for early diagnosis 2
• Pain on calcaneal compression test is highly suspicious 2

Osteochondral Lesions:

• Involve talar dome most commonly 1
• Radiographs often fail to show full extent—MRI needed if suspected with normal radiographs 1

Lateral Process Fracture of Talus ("Snowboarder's Fracture"):

• Causes lateral and posterior ankle pain with antalgic gait following inversion trauma 2

Management Approach

Acute Ankle Sprains (<6 weeks):

• Cryotherapy for first 3-7 days to reduce pain and improve recovery 4
• Lace-up ankle support or air stirrup brace combined with elastic compression wrap 4
• Early mobilization speeds healing more effectively than prolonged rest 4
• Pain control: NSAIDs, acetaminophen, or mild opioids 4

Stress Fractures:

• Protect and immobilize the foot with non-weight bearing or protected weight bearing 2, 5
• Advanced imaging for early diagnosis when radiographs negative 2, 5

Sever's Disease:

• Activity modification and rest 5
• NSAIDs for pain control 5
• Heel lifts or orthoses 5
• Stretching exercises for gastrosoleus complex 5

Critical Timing Considerations

Reexamination Window:

• Always reexamine 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 2

Referral Indications:

• No improvement after 6-8 weeks of appropriate conservative treatment 2, 5
• Need for advanced imaging or diagnostic testing 2, 5
• Suspicion of infection, tumor, or inflammatory arthritis 5
• Consideration of surgical intervention 2, 5

Common Pitfalls to Avoid

• Missing stress fractures: Patients often report increased walking activity before symptom onset, and radiographs may initially be negative—maintain high index of suspicion and use bone scan or MRI 2

• Ordering MRI first: This violates established imaging guidelines—always start with plain radiographs 1

• Inadequate initial examination: Swelling within first 48 hours can obscure findings—schedule follow-up examination at 3-5 days 2

• Overlooking bilateral symptoms: Consider arthritides in patients with bilateral heel pain or pain in other joints 2