Review Question - QID 216840

This patient sustained an acute ankle sprain. Early functional rehabilitation allows for the quickest return to physical activity following an acute ankle sprain.

Ankle sprains are very common twisting injuries to the ankle that are the most common reason for missed athletic participation. Diagnosis can be made clinically with swelling and ecchymosis of the ankle and pain with range of motion. Radiographs are only indicated when clinical examination meets criteria (Ottawa ankle rules). Treatment usually includes a brief period of immobilization followed by early functional physical therapy. Operative management should be considered in grade I-III injuries that continue to have pain and instability despite extensive nonoperative management.

Tropp et al. compared coordination training and orthosis use for the prevention of ankle joint injuries in soccer. They report that both techniques reduced the frequency of ankle sprains in soccer players with previous ankle problems. They concluded that the orthosis is an alternative to taping, and can be used during the rehabilitation period after injury or when playing on uneven ground, while coordination training ought to be included in the rehabilitation of ankle injuries to prevent functional instability.

Stiell et al. prospectively compared original (first stage) and refined (second stage) clinical decision rules regarding the use of radiography in acute ankle injuries. They reported that the potential reduction in radiography is estimated to be 34% for the ankle series and 30% for the foot series using the refined rules. They concluded that refinement and validation have shown the Ottawa ankle rules to be 100% sensitive for fractures, to be reliable, and to have the potential to allow physicians to safely reduce the number of radiographs ordered in patients with ankle injuries by one third.

Osborne et al. reviewed ankle sprains and prevention. They report that critical evaluation of the effectiveness of ankle braces supports their use for at least 6 months following injury in athletes who have sustained a moderate or severe sprain; however, their role in primary prevention of ankle sprain is less evident. They concluded that functional ankle rehabilitation is the mainstay of acute ankle sprain treatment and in recent reviews has been deemed preferable to immobilization or early surgery for the initial treatment of acutely injured ankles.

Figures A&B are the AP and lateral radiographs of an ankle without osseous injury. Figure C demonstrates the anterior drawer test; ankle instability typically has >3mm of translation. Figure D demonstrates the syndesmosis squeeze test to diagnosis high ankle sprains. Illustration A depicts the Ottowa ankle rules.

Incorrect Answers:
Answers 1&2: Advanced imaging is not need in this acute injury. If the pain and swelling persistent, advanced imaging should be considered
Answer 3: Anatomic reconstruction or tendon transfer with tenodesis should be considered in grade I-III injuries that continue to have pain and instability despite extensive nonoperative management
Answer 5: Six weeks of immobilization should be avoided in an acute ankle sprain and early functional rehabilitation is encouraged