›Lower maximum with liver disease or heavy alcohol use
›Ibuprofen PO 400 mg every 6 to 8 hours as needed
›Avoid with GI bleed history
›Avoid with advanced CKD
›Avoid with decompensated heart failure
›Topical diclofenac gel local protocol dependent
›Prefer for older adults with NSAID risk
›Avoid on broken skin
Immobilization and functional support
›Support
›Compression wrap if mild sprain
›Air stirrup brace for lateral sprain
›Walking boot for severe sprain or occult fracture concern
›Crutches with protected weight bearing as tolerated
Diagnostic sequencing
›Diagnostic plan
›Radiographs if Ottawa rules positive or clinical concern
›CT if radiographs show complex fracture or high suspicion occult fracture
›MRI if persistent pain with negative radiographs and concern for osteochondral or ligament injury
›Arthrocentesis before antibiotics if septic arthritis suspected and patient stable
Condition specific treatment pathways
›Pathway selection
›Suspected sprain
›Early protected mobilization when stable
›Physical therapy referral for proprioception and strength
›Suspected fracture
›Immobilize and keep non weight bearing until stability confirmed
›Orthopedics consult if unstable or displaced fracture
›Suspected septic arthritis
›Immediate orthopedic consultation
›IV antibiotics after cultures and aspiration when feasible
›Suspected gout
›NSAID if low risk
›Colchicine PO 1.2 mg once then 0.6 mg 1 hour later
›Then 0.6 mg once or twice daily as tolerated
›Avoid or reduce dose in CKD and with interacting drugs
Reassessment loop
›Reassessment
›Repeat neurovascular exam after splinting
›Repeat pain score within 30 to 60 minutes after analgesia
›Recheck swelling progression before discharge
›Escalate if increasing pain out of proportion or new neurologic deficit
17Disposition/dispo20
ICU and high acuity criteria
›High acuity disposition
›Septic shock or sepsis criteria
›Limb ischemia signs
›Suspected compartment syndrome
›Open fracture with hemodynamic instability
Inpatient admission criteria
›Admission indications
›Septic arthritis requiring operative management
›Unstable fracture requiring urgent surgery
›Inability to ambulate with unsafe home situation
›Uncontrolled pain despite ED therapy
Observation pathway criteria
›Observation
›Severe sprain with need for mobility training
›Possible occult fracture needing serial exam and follow up imaging plan
›Atraumatic monoarthritis awaiting synovial results and clinical trend
Discharge criteria and follow up
›Discharge
›Neurovascularly intact
›Pain controlled on oral regimen
›Safe ambulation plan with brace or crutches
›Clear follow up plan within 3 to 7 days for fracture concern
›Sports medicine or physiotherapy follow up within 1 to 2 weeks for sprain rehab
18Discharge Instructions/di14
Copy discharge instructions
›Patient facing instructions
›Your ankle pain is most consistent with a sprain or soft tissue injury unless imaging showed a fracture
›Use the brace or boot as instructed and use crutches if needed to limit pain with walking
›Elevate the ankle when resting and use compression if advised
›Use acetaminophen and or ibuprofen as directed unless you were told to avoid them
›Do not take ibuprofen or other NSAIDs if you have kidney disease severe stomach ulcer bleeding or are on blood thinners unless your clinician said it is safe
›Return to the emergency department urgently if
›Your foot becomes cold pale blue or numb
›You cannot move your toes
›Pain rapidly worsens or pain is severe with gentle toe movement
›You develop fever or the ankle becomes hot very red and more swollen
›You notice new drainage from a wound
›Follow up with your clinician or a fracture clinic within the recommended time window
›Do not drive if you cannot safely brake or if you are taking sedating pain medication
19References/r6
Guidelines and decision tools
›Key sources
›Stiell IG et al Decision rules for the use of radiography in acute ankle injuries 1993
›Martin RL et al JOSPT Clinical Practice Guideline Lateral Ankle Ligament Sprains Revision 2021
›Ravn C et al Guideline for management of septic arthritis in native joints SANJO 2023
›IDSA and PIDS Clinical Practice Guideline Acute Bacterial Arthritis in Pediatrics 2023
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.