What treatment should be given to a 14-year-old female with a tender ankle due to a cleat injury, with negative X-rays (radiographs)?

From the Guidelines

For this 14-year-old female with a cleat injury to the ankle and negative X-rays but tenderness on palpation, I recommend providing RICE therapy instructions (Rest, Ice, Compression, Elevation) along with appropriate pain management, as this approach is supported by the most recent and highest quality study 1. The patient should be given acetaminophen (Tylenol) 650 mg every 6 hours as needed for pain, not to exceed 3,000 mg in 24 hours, or ibuprofen (Motrin/Advil) 400 mg every 6 hours with food, not to exceed 1,200 mg in 24 hours. Some key points to consider in the treatment of ankle sprains include:

• The use of a semirigid brace for protection, as it is suggested to be the most cost-effective option compared with taping 1
• The application of ice for 15-20 minutes every 2-3 hours while awake for the first 48-72 hours
• Elevation of the ankle above heart level when possible
• The use of crutches for 24-48 hours if weight-bearing is painful
• Follow-up with the primary care provider in 5-7 days if symptoms persist or worsen, and return to the emergency department if severe pain develops or the patient is unable to bear weight after 48 hours. The goal of these measures is to reduce inflammation, control pain, and promote healing in what is likely a mild ankle sprain, as supported by previous studies 1.

From the Research

Ankle Injury Treatment

The patient, a 14-year-old female, has suffered an ankle injury from a cleat and presents with a tender ankle to palpation, but negative X-rays. Considering the treatment options, the following points are relevant:

• The RICE therapy (rest, ice, compression, and elevation) is often recommended for ankle sprains, but there is insufficient evidence from randomized controlled trials to determine its effectiveness in adults 2.
• For pain management, acetaminophen extended release and ibuprofen have been compared in a randomized controlled noninferiority trial, showing that acetaminophen extended release is noninferior to ibuprofen for the treatment of grade I or II lateral ankle sprains in adults 3.
• A narrative review discusses the evaluation, rehabilitation, and prevention of ankle sprains, highlighting the importance of a thorough clinical evaluation and individualized treatment plans 4.

Medication Options

Based on the available evidence, the following medication options could be considered:

• Acetaminophen extended release, which has been shown to be noninferior to ibuprofen for the treatment of ankle sprains in adults 3.
• Ibuprofen, which is commonly used for pain management in ankle sprains.

Clinical Decision Rules

The Ottawa ankle rules, which are clinical decision rules for the use of radiography in acute ankle injuries, have been refined and validated to be 100% sensitive for fractures and reliable 5. However, these rules do not directly address treatment options prior to discharge.

Treatment Prior to Discharge

Given the negative X-rays and tender ankle, treatment prior to discharge could include:

• Pain management with acetaminophen or ibuprofen, as supported by the study comparing these medications 3.
• RICE therapy, although the evidence for its effectiveness is limited 2.
• Individualized treatment plans based on a thorough clinical evaluation, as recommended in the narrative review 4.