How should I evaluate and manage a patient presenting with ankle pain?

Evaluation and Management of Ankle Pain

For acute ankle pain, immediately apply the Ottawa Ankle Rules to determine if radiography is needed, then initiate PRICE protocol with functional support using a lace-up ankle brace or removable boot, NSAIDs for pain control, and schedule reassessment at 3-5 days to distinguish partial from complete ligament tears. 1

Initial Clinical Assessment

History Elements to Obtain

• Mechanism of injury: Determine if inversion injury occurred in plantar-flexed position (typical lateral ankle sprain) versus dorsiflexion with eversion and internal tibial rotation (high ankle/syndesmotic sprain) 1
• Timing of injury and rapidity of swelling onset: Rapid swelling suggests more severe injury 1
• History of recurrent ankle sprains: Increases risk of chronic ankle instability 1
• Ability to bear weight immediately after injury: Critical for determining need for imaging 1
• Current pain level, sports participation level, and workload: These negatively influence recovery and increase recurrence risk 1

Physical Examination Findings

Four key findings predict grade III lateral ligament rupture with 96% accuracy when all present (versus 14% when absent): 1

• Swelling
• Hematoma
• Pain on palpation of lateral ligaments
• Positive anterior drawer test

Perform these specific tests: 1

• Anterior drawer test: Detects excessive anterior displacement of talus onto tibia; positive if talus subluxates anteriorly compared to unaffected ankle
• Crossed-leg test: Apply pressure to medial knee; pain in syndesmosis area indicates high ankle sprain
• Palpation: Assess anterior talofibular, calcaneofibular, and posterior talofibular ligaments, as well as both malleoli and base of 5th metatarsal

Imaging Decision-Making

Ottawa Ankle Rules (Primary Tool)

Obtain ankle radiographs only if: 1

• Pain in malleolar zone AND either:
  • Bone tenderness at posterior edge or tip of lateral malleolus (6 cm)
  • Bone tenderness at posterior edge or tip of medial malleolus (6 cm)
  • Inability to bear weight both immediately and in emergency department (4 steps)

Obtain foot radiographs only if: 1

• Pain in midfoot zone AND either:
  • Bone tenderness at base of 5th metatarsal
  • Bone tenderness at navicular bone
  • Inability to bear weight both immediately and in emergency department (4 steps)

The Ottawa Ankle Rules correctly rule out fracture in 299 out of 300 patients (99.7% sensitivity), avoiding unnecessary radiography in the vast majority of cases. 1

Immediate Management (First 48-72 Hours)

PRICE Protocol

Initiate immediately for all ankle sprains: 1, 2

• Protection: Apply lace-up ankle support or semirigid ankle brace (NOT elastic bandage alone) 1
• Rest: Avoid activities requiring active dorsiflexion for 48-72 hours 2
• Ice: Apply to reduce swelling and pain 1, 2
• Compression: Use compressive wrapping to control hematoma expansion 2
• Elevation: Elevate leg to minimize swelling 2

Pharmacologic Management

Prescribe NSAIDs on a scheduled basis (not as-needed) to reduce swelling and pain, which decreases time to return to usual activities. 1

Functional Support

Use semirigid or lace-up ankle supports rather than immobilization - these provide superior functional outcomes compared to elastic bandages or rigid immobilization. 1

Critical Reassessment at 3-5 Days

Reexamination at 3-5 days is essential to distinguish partial tears from complete ligament ruptures, as excessive swelling and pain limit accurate examination in the first 48 hours. 1

At this visit, determine: 1

• Whether symptoms are improving with conservative management
• If physical examination findings suggest grade III injury (all four key findings present)
• Whether patient can bear weight and perform activities of daily living

Advanced Imaging Indications

When to Order MRI

Obtain MRI without contrast if: 1, 2

• No improvement or worsening symptoms at 2-3 weeks despite appropriate conservative management 2
• Suspicion of complete ligament tear based on clinical examination 1
• Chronic ankle pain with suspected ligament instability (MRI shows 97% diagnostic accuracy for anterior talofibular ligament injury and 77-92% accuracy for chronic lateral ligament tears) 1
• Suspected tendon pathology (MRI has >90% sensitivity for ankle tendon tears) 1
• Suspected osteochondral lesion 1

MRI advantages: Evaluates associated injuries that may mimic or accompany instability including tenosynovitis, tendon injury, and osteochondral lesions. 1

Rehabilitation Protocol

Graded Exercise Regimen

Implement proprioceptive training to reduce risk of recurrent ankle sprain: 1, 2

• Progressive strengthening of ankle dorsiflexors and everters
• Ankle disk training (proprioceptive exercises)
• Gradual return to activity based on pain-free range of motion and strength

Continue use of semirigid or lace-up ankle supports during sports participation, especially in patients with history of recurrent sprains, to decrease risk of reinjury. 1

Common Pitfalls to Avoid

Do not rely solely on initial examination within 48 hours of injury - swelling and pain obscure accurate assessment of ligament integrity; mandatory reassessment at 3-5 days is required. 1

Do not use elastic bandages as sole support - semirigid or lace-up supports provide superior functional outcomes. 1

Do not prescribe analgesics "as needed" - scheduled dosing provides better pain control and faster return to function. 1

Do not delay MRI beyond 2-3 weeks if symptoms persist - this suggests occult fracture, complete ligament tear, or other significant pathology requiring different management. 2

Be aware that up to 34% of asymptomatic patients may have peroneus brevis tendon tears on MRI - correlate imaging findings with clinical examination. 1

Special Populations

Diabetic patients with neuropathy: Consider more protective immobilization and closer follow-up due to increased risk of complications. 1

High-level athletes: May require early MRI to determine exact injury grade and expedite return-to-sport planning. 1

Patients with recurrent sprains: Require more aggressive proprioceptive rehabilitation and consideration of prolonged bracing during sports activities. 1