Ankle Sprain Workup

  • Author: Craig C Young, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Sep 22, 2011
 

Approach Considerations

Plain radiographs may be clinically indicated to diagnose a fracture of the ankle or foot. Ankle stress radiographs contribute little to the management of acute ankle sprains because surgical treatment of the acute sprain is rarely indicated. Abnormal swelling or clinical ankle instability in an acute sprain may be documented with bilateral stress radiographs of the ankle.

MRI is not indicated unless unusual features are present, such as extensive swelling, ecchymosis, or pain, that suggest an osteochondral lesion not observed on plain radiographs. Even if MRI scans demonstrate bone bruising or actual articular cartilage damage, conservative ankle sprain treatment is indicated initially.

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Plain Radiographic Imaging

The use of radiographs in patients with ankle injuries is guided by the Ottawa Ankle Rules. These rules state that an ankle radiographic series is required only if the patient has pain in the malleolar zone and any of the following 3 findings[36, 37, 38] :

  • Bone tenderness at the posterior edge or tip of the lateral malleolus (ie, the lower 6 cm of the fibula)
  • Bone tenderness at the posterior edge or tip of the medial malleolus (ie, the lower 6 cm of the tibia)
  • Inability to bear weight immediately after the injury and in the emergency department

The Ottawa Ankle Rules state that a foot radiographic series is required only if the patient has any pain in the midfoot zone and any of the following 3 findings:

  • Bone tenderness at the base of the fifth metatarsal
  • Bone tenderness at the navicular bone
  • Inability to bear weight immediately after the injury and in the emergency department

The Ottawa Ankle Rules are contingent upon the patient presenting within 10 days of the injury. Although they were not originally intended for patients younger than age 18 years, a meta-analysis of 12 studies showed that the Ottawa foot and ankle rules can be reliably used to exclude fractures in children older than age 5 years. The studies included a total of 3,130 patients and identified 671 fractures, resulting in a prevalence of 21.4%. Demonstrating a pooled sensitivity of 98.5% and a missed fracture rate of 1.2%, the report indicated that the Ottawa foot and ankle rules are useful (level 2 evidence) for excluding fractures in children.[2] Another study suggests they may be useful for children as young as 2 years.[3]

Radiographic studies of the ankle should include the following views:

  • An anteroposterior (AP) film with the ankle in 5-15° of adduction
  • A true lateral film
  • A 45° oblique film with the ankle in dorsiflexion (ie, Mortise view)
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Stress-View Radiographic Imaging

Stress radiographic films may provide further assessment for ankle stability; however, patient cooperation may be limited, depending on the severity of the injury. Stress-view exams include the talar tilt and anterior drawer tests. Because of muscular guarding due to patient pain, the accuracy of these tests is dramatically increased with the use of local anesthesia. Compare the stress views with those of the uninvolved ankle in both tests. Other variables in determining the reliability of these tests include the degree of patient relaxation and cooperation, the amount of force used, the angle of ankle flexion, and the amount of laxity in the uninvolved side. (See Clinical Presentation.)

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Computed Tomography Scanning

Computed tomography (CT) scanning may be indicated if imaging of soft tissues is warranted or if bone imaging beyond radiography is indicated. CT scanning is useful for evaluating osteochondritis dissecans and stress fractures. In complex injuries, 3-dimensional CT scanning may be useful.

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MRI

MRI may be useful when osteochondrosis or meniscoid injury is suspected in patients with a history of recurrent ankle sprains and chronic pain.[35]

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Arthrographic Imaging

Ankle arthrograms may be useful for determining capsular damage and the number of ankle ligaments damaged; however, arthrography is indicated only if surgery is needed, and the criteria for surgery to repair double lateral ligament complete tears are still under debate. Staples found that arthrograms provide the most preoperative information.[39, 40]

Ankle arthrograms are not indicated in every patient considered for surgical treatment. Marked clinical instability in a young individual with great physical demands being considered for surgery requires an ankle arthrogram.

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Bone Scanning

A bone scan can detect subtle bone abnormalities (e.g., stress fracture, osteochondral defects). A bone scan can also detect syndesmotic disruption.

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Contributor Information and Disclosures
Author

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Michael T Andary, MD, MS  Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

David T Bernhardt, MD  Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joseph R Bozzelle, Jr, MD  Director, Rehabilitation Services, Crowley Rehabilitation Hospital, Doctors Hospital of Opelousas, Southwest Medical Center

Joseph R Bozzelle, Jr, MD is a member of the following medical societies: Louisiana State Medical Society

Disclosure: Nothing to disclose.

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

James K DeOrio, MD  Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology

Disclosure: Nothing to disclose.

John S Early, MD  Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, and Texas Medical Association

Disclosure: AO North America Honoraria Speaking and teaching; Osteotech Consulting fee Consulting; Stryker Consulting fee Consulting; Biomet Consulting fee Consulting; AO North America Grant/research funds fellowship funding; MMI inc Honoraria Speaking and teaching

Ray Foster, MD, FACS  Medical Staff Physician, Black Hills Health and Education Center

Ray Foster, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

Lars Grimm, MD, MHS  House Staff, Department of Diagnostic Radiology, Duke University Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Stephen Kishner, MD, MHA  Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

James Monroe Laborde, MD, MS  Clinical Assistant Professor, Department of Orthopedics, Louisiana State University Health Sciences Center and Tulane Medical School; Adjunct Assistant Professor, Department of Biomedical Engineering, Tulane University; Adjunct Assistant Professor, Department of Physical Medicine and Rehabilitation, Louisiana State University Medical School

James Monroe Laborde, MD, MS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Lynne McCullough, MD, FACEP  Associate Professor of Medicine and Emergency Medicine, Geffen School of Medicine at UCLA; Medical Director, Westwood Emergency Department

Disclosure: Nothing to disclose.

Mircea Muresanu, MD  Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn

Mircea Muresanu, MD, is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Antonia Quinn, DO  Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate Medical Center/Kings County Hospital Center; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Antonia Quinn, DO is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Douglas A Reeves Jr, MD  Team Physician, Clemson University, Clemson, South Carolina

Douglas A Reeves Jr, MD is a member of the following medical societies: American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Marlon P Rimando, MD  Assistant Clinical Professor, Department of Medicine, University of Hawaii

Marlon P Rimando, MD is a member of the following medical societies: National Strength and Conditioning Association

Disclosure: Nothing to disclose.

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM  President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David T Bernhardt, MD  Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Consuelo T Lorenzo, MD  Physiatrist, Department of Physical Medicine and Rehabilitation, Alegent Health, Immanuel Rehabilitation Center

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Kenneth R Chuang, MD and Christopher F Richards, MD, to the development and writing of source articles.

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Anterior drawer test.
Talar tilt test.
Tilt board.
strengthening using an elastic band.
Ankle brace
Example of a lace-up ankle support. Courtesy of Swede-O, Inc.
Example of a brace for immobilization or functional purposes. Courtesy of Swede-O, Inc.
Example of a brace that can be used for functional purposes. Courtesy of Swede-O, Inc.
Example of a brace secured with Velcro straps. Courtesy of Swede-O, Inc.
Example of a lace-up ankle support brace with figure-8 straps. Courtesy of Swede-O, Inc.
 
 
 
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