Ankle Sprain

Diagnosis/Definition

Traumatic ankle injury with negative radiological findings.  Graded I-III with Grade I being ligamentous trauma without laxity, mild pain and swelling, Grade II being ligamentous trauma, considerable signs of swelling, pain, loss of motion and Grade III being ligamentous laxity and joint instability.

Initial Diagnosis and managemen

• History
• Mechanism of injury
• Location of pain and swelling
• Ability to walk or bear weight
• History of prior inversion sprains and prior treatment
• When did the injury occur
• Age of the patient
• Complicating illness
• Medications
• Presence of pain elsewhere in the legs
• Physical Examination
• Observe for obvious deformity
• Determine location of swelling and ecchymosis
• Palpate for local tenderness
• Squeeze and rotatory tests
• A squeeze test is performed by squeezing the tibia and fibula together at the mid calf. Pain distally at ankle joint indicates syndesmotic sprain.
• The external rotation test is performed by having the patient sit with the knee flexed 90 degrees. The foot is externally rotated while the examiner holds the tibia in a fixed position. Pain at the ankle joint indicates injury to the syndesmotic ligaments.
• Evaluation of peroneal tendons
• Observation of patient walking
• Neurovascular status
• Test range of motion
• Plain films if indicated.
• X rays are required if bone tenderness is present as well as the patient inability to bear weight at the time of evaluation.
• NSAIDs.
• Adults - 200 to 400 milligrams (mg) every four to six hours as needed for up to 2 weeks. Example: Ibuprofen
• Take tablet or capsule forms of these medicines with a full glass (8 ounces) of water.
• Do not lie down for about 15 to 30 minutes after taking the medicine. This helps to prevent irritation that may lead to trouble in swallowing.
• To lessen stomach upset, these medicines should be taken with food or an antacid.
• Elastic wrap or gel cast for compression.
• "Weight bearing as tolerated" and crutch walking if limp present.
• Do not prescribe posterior splint or recommend non-weight bearing as these result in increased swelling, pain and risk of Reflex Sympathetic Dystrophy.
• Ice and elevation for 20 min every 2 hours for 72 hours.
• Encourage active range of motion.
• See attached example
• Move the foot up and down as tolerated as though pressing on a gas pedal.
• Make circles with the foot, both clockwise and counterclockwise.
• As tolerated, begin bearing weight on the foot. In either a sitting or a standing position, shift weight from front to back and from the inside to the outside of the foot.
• Begin non weight-bearing Achilles stretch.
• Appropriate restrictions of activity.
• See attached profile example
• No running until walking is pain free
• Use crutch if weight bearing on injured ankle is to painful

Ongoing Management and Objectives

• Same day visits should be scheduled for patients experiencing sudden, intense pain with rapid onset of swelling, cold or numbness in the foot, presence of gross deformity, complicating conditions (ex. Diabetes), the fact that it is a work related injury and/or the inability to bear any weight.

• Return to full activities is expected for Grade I sprains in 3-4 weeks and for Grade II sprains in 6-8 weeks.  The time to return to full activities for Grade III varies and is dependent on orthopedic management choice.

• Flexibility and strength testing

• See attached example

• Move the foot up and down as tolerated as though pressing on a gas pedal.

• Make circles with the foot, both clockwise and counterclockwise.

• As tolerated, begin bearing weight on the foot. In either a sitting or a standing position, shift weight from front to back and from the inside to the outside of the foot.

• Begin non weight-bearing Achilles stretch.

• The patient should also begin balancing exercises as tolerated. Instruct the patient: when he/she can do this comfortable for 30 seconds, he/she should challenge the affected leg. Try 5-10 repetitions for 30 seconds each, two or three times a day. Alternatively a balance board may be used.

• Patient will require period of functional rehabilitation between the return of normal strength and motion and return to normal activity.  This is normally determined by Physical Therapy.

• Follow up visits should be scheduled for two weeks after injury. However, patient should be informed if inability to bear weight and pain persists after 3 days he/she should contact provider for same day appointment.

Indication a profile is needed

• Any limitations that affect strength range of movement, and efficiency of legs and feet.
• Limitations that produce slightly limited mobility of joints, muscular weakness, or other musculo-skeletal defects.
• Defects or impairments that require significant restriction of use.