When is referral to orthopaedics indicated for an ankle sprain presenting to urgent care?

Orthopaedic Referral Indications for Ankle Sprains from Urgent Care

Refer to orthopaedics when radiographs demonstrate fracture, when there is clinical suspicion of syndesmotic injury (positive crossed-leg test), when osteochondral lesions are suspected, or when the patient fails to improve with 1-3 weeks of appropriate functional treatment despite supervised physiotherapy. 1, 2, 3

Immediate Orthopaedic Referral Required

Fractures Identified on Imaging

• Any fracture detected on ankle radiographs (AP, lateral, mortise views) mandates orthopaedic consultation, as these require specialist evaluation for potential operative management 1, 2
• High-energy trauma with complex fracture patterns (posterior malleolar fractures, pilon-variant fractures) requires immediate orthopaedic referral 2

Syndesmotic (High Ankle) Sprains

• Positive crossed-leg test—where pressure applied to the medial knee produces pain in the syndesmosis area—indicates a high ankle sprain requiring orthopaedic evaluation 2, 3
• Syndesmotic injuries typically require more intensive rehabilitation and longer recovery time than lateral ankle sprains, and may require surgical fixation 2
• MRI confirmation of syndesmotic injury warrants orthopaedic referral 3

Suspected Osteochondral Lesions

• When radiographs suggest osteochondral injury or when clinical suspicion exists (persistent pain, mechanical symptoms, effusion), obtain MRI without contrast and refer to orthopaedics 1, 2, 3
• Osteochondral lesions often require arthroscopic excision or repair 4

Delayed Orthopaedic Referral (After Conservative Trial)

Failed Conservative Management

• Persistent pain beyond 1-3 weeks despite appropriate functional treatment (semi-rigid brace for 4-6 weeks plus supervised exercise therapy within 48-72 hours) warrants MRI and orthopaedic referral 1, 2
• Pain lasting 6 or more weeks after injury may indicate inadequate rehabilitation, impingement syndrome, occult osteochondral lesions, peroneal tendon injury, or lateral instability—all requiring specialist evaluation 4

Chronic Ankle Instability

• Recurrent sprains or functional instability developing after initial injury despite completing supervised rehabilitation program should be referred for consideration of surgical reconstruction 1, 5, 6
• Up to 40% of patients develop chronic ankle instability despite initial treatment, and 3-34% experience recurrent sprains 2

Grade III Sprains in Elite Athletes

• High-level or professional athletes with complete ligament ruptures may benefit from early orthopaedic consultation, as they may require surgical intervention for rapid return to play 2
• However, most grade III sprains in non-elite athletes should still be managed conservatively first, as functional treatment provides fastest recovery without affecting long-term stability 3

Red Flags Requiring Urgent Evaluation (Not Necessarily Orthopaedics)

Neurovascular Compromise

• Coldness, numbness, severe pain, or absent pulses indicate potential neurovascular injury requiring immediate evaluation—this may necessitate vascular surgery consultation rather than orthopaedics 2, 3

Alignment Abnormalities or Dislocation

• Physical examination or radiographs demonstrating alignment abnormality, dislocation, or gross instability require immediate orthopaedic consultation 1

What Should NOT Be Referred

Uncomplicated Lateral Ankle Sprains (Grades I-II)

• Simple lateral ankle sprains without fracture, with negative Ottawa Ankle Rules, and without syndesmotic involvement should be managed in urgent care with functional treatment 1, 2, 3
• Apply semi-rigid or lace-up brace for 4-6 weeks, prescribe NSAIDs, arrange supervised physiotherapy within 48-72 hours, and schedule follow-up at 3-5 days 1, 2, 3

Grade III Lateral Sprains (Initial Management)

• Even complete lateral ligament ruptures should receive a trial of conservative functional treatment first, as surgery shows limited evidence, longer recovery, higher rates of ankle stiffness, and more complications compared to functional rehabilitation 2
• Reserve surgical referral for those who fail adequate conservative management 2

Common Pitfalls to Avoid

• Do not refer all grade III sprains immediately—the vast majority respond to functional treatment, and surgery should be reserved for failed conservative management or elite athletes with specific demands 2, 3, 5
• Do not delay MRI in patients with persistent pain beyond 1-3 weeks—occult osteochondral lesions, syndesmotic injuries, and peroneal tendon pathology require advanced imaging for diagnosis 1, 2, 4
• Do not miss syndesmotic injuries—always perform the crossed-leg test, as these injuries require different management and have longer recovery times 2, 3
• Do not refer without first ensuring appropriate conservative treatment was attempted—this includes semi-rigid bracing for 4-6 weeks AND supervised exercise therapy within 48-72 hours, not just bracing alone 1, 2