If It’s Not in the Differential, It Won’t be in the Diagnosis: Ankle Pain

If It's Not in the Differential, It Won’t be in the Diagnosis: Ankle Pain

Matt Baird, MD, and Mike Weinstock, MD

• Start with stable vs unstable
• Stable: sprains, strains, isolated Weber type A lateral malleolus fractures, tiny avulsion fractures (medial and lateral malleoli, talus, dorsum of navicular)
• Unstable: Maisonneuve injuries, Achilles ruptures, all other fractures

The following points pertain to stable injuries

What works? 

• Ottawa Ankle and Foot Rules
• NSAIDs and acetaminophen for short-term pain relief (<2 weeks) [3]
• Exercise (physical therapy)
  • Early mobilization and weight-bearing
  • Range of motion, stretching, strengthening, proprioceptive and neuromuscular training, sport-specific exercise
• Bracing 
  • Bracing for earlier return to activity
  • Bracing for primary and secondary prevention

What doesn’t work?

• Unnecessary imaging
• Unnecessary immobilization
• Non-weight-bearing status
• Delayed mobilization
• Inadequate rehabilitation

What can fool us?

• Commonly missed fractures
  • Proximal fibula (Maisonneuve injuries)
  • Posterior malleolus
  • Talus
  • Calcaneus
  • Body and anterior process
• Soft tissue injuries
  • Osteochondritis dissecans lesions
  • Syndesmotic injuries
  • Achilles rupture
  • Lisfranc injuries (brief!!)

REFERENCES:

Diagnostic accuracy of clinical decision rules to exclude fractures in acute ankle injuries: systematic review and meta-analysis
Barelds I, Krijnen WP, van de Leur JP, van der Schans CP, Goddard RJ. J Emerg Med. 2017;53(3):353-368. doi:10.1016/j.jemermed.2017.04.035

Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis
Dowling S, Spooner CH, Liang Y, et al. Acad Emerg Med. 2009;16(4):277-287. doi:10.1111/j.1553-2712.2008.00333.x

Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline
Vuurberg G, Hoorntje A, Wink LM, et al. Br J Sports Med. 2018;52(15):956. doi:10.1136/bjsports-2017-098106

Acute ankle sprain in athletes: clinical aspects and algorithmic approach
Halabchi F, Hassabi M. World J Orthop. 2020;11(12):534-558. doi:10.5312/wjo.v11.i12.534

Treatment of complete rupture of the lateral ligaments of the ankle: a randomized clinical trial comparing cast immobilization with functional treatment
Ardèvol J, Bolíbar I, Belda V, Argilaga S. Knee Surg Sports Traumatol Arthrosc. 2002;10(6):371-377. doi:10.1007/s00167-002-0308-9

Ankle bracing is effective for primary and secondary prevention of acute ankle injuries in athletes: a systematic review and meta-analyses
Barelds I, van den Broek AG, Huisstede BMA. Sports Med. 2018;48(12):2775-2784. doi:10.1007/s40279-018-0993-2

RELATED CONTENT:

CorePendium: Ankle Fractures

CorePendium: Maisonneuve Fracture

Orthopedic Fundamentals