Ankle sprainMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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381 items

☷ Legend

01Approach to the Critical Patient/attcp31

Immediate threats

›Immediate threats

›Airway compromise from associated trauma

›Hemodynamic instability from associated trauma

›Open injury

›Gross deformity suggesting fracture or dislocation

›Neurovascular compromise

›Absent dorsalis pedis pulse

›Absent posterior tibial pulse

›Delayed capillary refill

›Progressive numbness

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive toe motion

›Tense compartments

›Septic joint concern

›Fever

›Atraumatic severe pain

›Inability to bear weight without trauma

Initial priorities

›Initial priorities

›Escalate to resuscitation bay for shock or major trauma

›If open fracture suspected, immediate antibiotics and ortho consult

›If dislocation suspected, urgent reduction pathway

›If neurovascular deficit, urgent reduction or immobilization and consult

›Pain control and protected weight bearing

Key decision points

›Key decision points

›Ottawa ankle rules eligibility

›Imaging need for fracture exclusion

›Syndesmotic injury concern

›Peroneal tendon injury concern

›Achilles rupture screen

›Discharge safety and mobility

02History/hx36

Injury context

›Injury context

›Mechanism inversion

›Lateral ligament injury pattern

›Mechanism eversion

›Deltoid injury pattern

›Mechanism external rotation

›Syndesmotic injury pattern

›Sound or sensation of pop

›Immediate swelling timing

›Swelling within minutes suggesting hemarthrosis

›Ability to bear weight immediately after injury

›Current ability to bear weight 4 steps

›Location of maximal pain

›Lateral malleolus region

›Medial malleolus region

›Base of fifth metatarsal region

›Navicular region

›Proximal fibula region

Red flags and associated injury

›Red flags and associated injury

›Proximal fibula pain

›Midfoot pain and plantar ecchymosis

›Achilles pain and weakness

›Numbness or tingling

›Cold foot sensation

›Wound or puncture

›Fever or rigors

Prior function and risk

›Prior function and risk

›Prior ankle sprains

›Prior fractures or surgery

›Chronic ankle instability symptoms

›Athletic participation level

›Anticoagulant use

›Bleeding disorder

›Diabetes

›Peripheral neuropathy

›Pregnancy status

03Physical Exam/exam39

Inspection and palpation

›Inspection and palpation

›Gait and weight bearing ability

›Swelling distribution

›Ecchymosis distribution

›Skin integrity

›Point tenderness lateral malleolus posterior edge and tip

›Point tenderness medial malleolus posterior edge and tip

›Point tenderness base of fifth metatarsal

›Point tenderness navicular

›Point tenderness proximal fibula

›Tenderness anterior talofibular ligament

›Tenderness calcaneofibular ligament

›Tenderness deltoid ligament

›Tenderness syndesmosis anterior inferior tibiofibular ligament

Range of motion and stability

›Range of motion and stability

›Active dorsiflexion limitation

›Active plantarflexion limitation

›Pain with passive inversion

›Pain with passive eversion

›Anterior drawer test

›Increased translation compared with contralateral

›Soft end point

›Talar tilt test

›Increased tilt compared with contralateral

›External rotation stress test for syndesmosis

›Pain at syndesmosis

›Squeeze test for syndesmosis

›Pain at syndesmosis

Neurovascular and tendon screening

›Neurovascular and tendon screening

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill time

›Sensation superficial peroneal distribution

›Sensation deep peroneal distribution

›Sensation tibial distribution

›Toe flexion strength

›Toe extension strength

›Thompson test

›Absent plantarflexion suggesting Achilles rupture

04Differential Diagnosis/ddx18

Traumatic mimics and co-injuries

›Traumatic mimics and co-injuries

›Ankle fracture ICD-10 S82 series

›Talar dome osteochondral lesion

›Base of fifth metatarsal fracture ICD-10 S92.35

›Navicular fracture ICD-10 S92.25

›Lisfranc injury ICD-10 S93.32

›Syndesmotic injury high ankle sprain ICD-10 S93.43

›Maisonneuve fracture

›Peroneal tendon subluxation or tear

›Achilles tendon rupture ICD-10 S86.01

›Ankle dislocation ICD-10 S93.0

Non-traumatic mimics

›Non-traumatic mimics

›Gout flare

›Septic arthritis

›Cellulitis

›Inflammatory arthritis flare

›Deep vein thrombosis

›Charcot neuroarthropathy

05Laboratory Tests/lt18

Routine testing

›Routine testing

›No routine labs for isolated uncomplicated ankle sprain

›Pregnancy test when imaging planned and pregnancy status uncertain

›Urine hCG

If alternate diagnosis suspected

›If alternate diagnosis suspected

›Infection concern

›White blood cell count for systemic infection

›C reactive protein for inflammatory burden

›Blood cultures if sepsis criteria

›Crystal arthritis concern

›Arthrocentesis fluid analysis

›Gram stain

›Culture

›Cell count

›Crystal analysis

›Anticoagulant associated hemarthrosis concern

›INR for warfarin use

›Hemoglobin for significant bleeding concern

06Diagnostic Tests/dt50

Scoring Systems

›Scoring systems

›Ottawa ankle rules

›Pain in malleolar zone

›Bone tenderness posterior edge or tip of lateral malleolus

›Bone tenderness posterior edge or tip of medial malleolus

›Inability to bear weight 4 steps immediately and in ED

›Ottawa foot rules

›Pain in midfoot zone

›Bone tenderness at base of fifth metatarsal

›Bone tenderness at navicular

›Inability to bear weight 4 steps immediately and in ED

›Reported sensitivity range 92 percent to 100 percent for fracture exclusion

›Specificity range 16 percent to 51 percent

›Not validated for gross intoxication or unreliable exam

›Use caution in neuropathy and reduced pain perception

MRI

›MRI

›MRI indications

›Persistent pain and swelling beyond expected recovery

›Suspected osteochondral lesion

›Suspected syndesmotic injury with normal radiographs

›Suspected tendon tear

›Suspected occult fracture

›MRI limitations

›Limited acute ED availability

›Incidental findings not correlating with symptoms

›MRI interpretation pearls

›ATFL and CFL disruption grading

›Bone marrow edema for occult fracture

›Cartilage defect for talar dome lesion

›CT

›CT indications

›Complex fracture characterization

›Suspected occult fracture with high clinical suspicion and equivocal radiographs

›Preoperative planning request

›CT limitations

›Ionizing radiation

›CT interpretation pearls

›Subtle talar fractures

›Posterior malleolus involvement

Ultrasound

›Ultrasound

›POCUS applications

›Joint effusion identification

›Tendon integrity assessment

›Achilles tendon discontinuity

›Peroneal tendon subluxation dynamic exam

›Ultrasound limitations

›Operator dependence

›Limited ability to exclude fracture

›Ultrasound adjunct role

›Supportive evidence when radiographs negative and tendon injury suspected

07Disposition/dispo18

Discharge criteria

›Discharge criteria

›Pain controlled with oral medications

›No open injury

›No neurovascular compromise

›No fracture or dislocation on imaging when obtained

›Safe ambulation plan

›Crutches or walker training

›Clear follow up plan

Admission or urgent specialty evaluation

›Admission or urgent specialty evaluation

›Open fracture or open joint concern

›Neurovascular deficit

›Suspected compartment syndrome

›Suspected septic arthritis

›Unstable fracture pattern

›Ankle dislocation

›Suspected syndesmotic injury with instability

›Suspected Achilles rupture

›Inability to mobilize safely at home

08Treatment/t77

Immobilization and functional support

›Immobilization and functional support

›Early phase goals

›Pain reduction

›Swelling control

›Protection of injured ligament

›Support selection by severity

›Mild sprain

›Lace up brace or elastic support

›Moderate sprain

›Air stirrup brace or walking boot

›Severe sprain

›Short period immobilization in boot or cast

›Weight bearing

›Early weight bearing as tolerated when stable

›Crutches for pain limited gait

›Elevation and compression

›Compression wrap for swelling reduction

›Elevation above heart level for swelling

Analgesia and anti-inflammatory therapy

›Analgesia and anti-inflammatory therapy

›Acetaminophen

›Adult dosing

›1000 mg orally every 6 to 8 hours as needed

›Maximum 4000 mg per day

›Liver disease or heavy alcohol use

›Maximum 2000 mg per day

›Ibuprofen

›Adult dosing

›400 mg orally every 6 to 8 hours as needed

›Maximum 2400 mg per day

›Avoid or use caution

›Chronic kidney disease

›Peptic ulcer disease

›Anticoagulant use

›Third trimester pregnancy

›Naproxen

›Adult dosing

›500 mg orally once then 250 mg orally every 6 to 8 hours as needed

›Maximum 1250 mg per day on day 1

›Maximum 1000 mg per day after day 1

›Topical NSAID

›Diclofenac gel

›Apply to painful area up to 4 times daily

›Avoid broken skin

›Evidence summary

›NSAIDs and acetaminophen similar short term pain relief in acute ankle sprain

›Opioids not superior for pain relief

Rehabilitation and return to activity

›Rehabilitation and return to activity

›Early motion

›Pain limited range of motion exercises

›Ankle alphabet

›Dorsiflexion stretching

›Strengthening progression

›Peroneal strengthening

›Resistance band eversion

›Calf strengthening

›Heel raises progression

›Proprioception and balance

›Single leg stance progression

›Eyes open

›Eyes closed

›Unstable surface

›Return to sport criteria

›Pain free full range of motion

›Near symmetric strength

›Functional hop or agility testing without pain

›Recurrence prevention

›Ankle brace during high risk sport participation

›Consider 6 to 12 months for recurrent sprain risk reduction

Procedures and escalation

›Procedures and escalation

›If suspected septic arthritis

›Arthrocentesis prior to antibiotics when feasible

›If dislocation

›Immediate reduction pathway

›If suspected fracture with skin tenting

›Urgent reduction or splinting and consult

›If suspected syndesmotic instability

›Ortho consultation for stress imaging or advanced imaging

09Special Populations/sp32

Pregnancy

›Pregnancy

›Pregnancy considerations

›Avoid NSAIDs in third trimester

›Prefer acetaminophen for pain control

›Imaging considerations

›Radiographs acceptable when clinically indicated

›Shielding when feasible

›VTE risk context

›Immobilization increases VTE risk

›Early mobilization when safe

Geriatric

›Geriatric

›Higher fracture risk

›Lower threshold for radiographs

›Osteoporosis considerations

›Occult fracture risk with low energy mechanism

›Mobility and falls risk

›Assistive device needs assessment

›Home safety planning

›Medication risk

›NSAID renal and GI risk increased

›Prefer topical NSAID when appropriate

Pediatrics

›Pediatrics

›Growth plate considerations

›Salter Harris injury mimic sprain

›Ottawa ankle rules age considerations

›Use caution in younger children

›Lower threshold for imaging when exam unreliable

›Weight based analgesia

›Acetaminophen 15 mg per kg per dose orally every 6 hours as needed

›Maximum 60 mg per kg per day

›Ibuprofen 10 mg per kg per dose orally every 6 to 8 hours as needed

›Maximum 40 mg per kg per day

10Background/b21

Epidemiology

›Epidemiology

›Common sports related injury

›Lateral ligament complex most frequently injured

›High recurrence risk after first sprain

›Chronic ankle instability subset

Pathophysiology

›Pathophysiology

›Lateral ligament complex injury sequence

›ATFL most commonly injured

›CFL next most commonly injured

›PTFL less commonly injured

›Injury mechanisms

›Inversion with plantarflexion stressing ATFL

›Inversion with dorsiflexion stressing CFL

›Syndesmotic injury mechanism

›External rotation and dorsiflexion

Therapeutic Considerations

›Therapeutic considerations

›Functional support preferred over prolonged immobilization for most sprains

›Early progressive loading supports recovery

›Balance and proprioception training reduces recurrence

›NSAID benefit similar to acetaminophen for short term pain in many studies

›Persistent pain triggers evaluation for occult fracture or osteochondral lesion

11Patient Discharge Instructions/pdi31

copy discharge instructions

›copy discharge instructions

›Diagnosis ankle sprain

›Brace or boot use as directed

›Remove for hygiene and exercises if allowed

›Weight bearing as tolerated

›Crutches until able to walk without limping

›Swelling control

›Elevation above heart level

›Compression wrap snug not tight

›Ice 10 to 15 minutes up to 3 to 5 times daily for pain

›Pain medications

›Use acetaminophen or NSAID as directed

›Avoid NSAIDs if pregnant in third trimester or kidney disease

›Exercises start within 24 to 72 hours if pain allows

›Gentle range of motion

›Balance drills when walking comfortable

›Follow up

›Primary care or sports medicine within 5 to 10 days

›Physiotherapy referral if ongoing pain or instability

›Return to ED now

›Increasing pain not controlled with medications

›New numbness or weakness

›Foot becomes cold or pale

›Inability to bear weight worsening

›Fever

›Spreading redness

›Wound drainage

›Urgent ortho or sports medicine

›Persistent pain or swelling beyond 2 weeks

›Recurrent giving way

›Suspected Achilles rupture signs

12References/r10

Clinical guidelines and evidence

›Clinical guidelines and evidence

›JOSPT clinical practice guideline for lateral ankle ligament sprains revision 2021

›Functional support and therapeutic exercise emphasis

›AAOS OrthoInfo sprained ankle overview

›Early weight bearing as tolerated

›Short period immobilization for higher grade injuries

›Umbrella review of acute ankle sprain management 2022

›NSAIDs and acetaminophen similar short term pain relief

›Meta analyses on Ottawa ankle rules diagnostic accuracy

›High sensitivity for fracture exclusion

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.