eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Ankle Injury, Soft Tissue: Differential Diagnoses & Workup

Author: Mircea Muresanu, MD,, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Sep 25, 2009

Differential Diagnoses

Fractures, Ankle
Fractures, Foot
Tendonitis
Tenosynovitis

Other Problems to Be Considered

Achilles tendon rupture
Peroneal tendon subluxation
Septic joint

Workup

Imaging Studies

  • Radiographic studies of the ankle should include the following films:
    • 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)
  • The Ottawa foot and ankle rules are a prospectively validated clinical decision tree for radiograph ordering in adults.16,17,18 By following these rules, emergency physicians can eliminate up to 30% of radiographs that are routinely ordered without missing clinically significant fractures.
  • A recent meta-analysis of 12 studies showed the Ottawa foot and ankle rules can be reliably used at excluding fractures in children older than 5 years. Twelve studies included 3,130 patients and identified 671 fractures resulting in a prevalence of 21.4%. With a pooled sensitivity of 98.5% and a missed fracture rate of 1.2%, the Ottawa foot and ankle rules are useful (level 2 evidence) at excluding fractures in children older than 5 years.25  
  • Criteria for foregoing radiography are as follows:
    • Ottawa ankle rules: Ankle radiographs are indicated if there is pain in the malleolar area and any of the following:
      • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
      • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
      • An inability to bear weight, both immediately and in the emergency department for 4 steps
    • Ottawa foot rules: Foot radiographs are indicated if there is bony pain in the midfoot and any of the following :
      • Bone tenderness at the base of the fifth metatarsal (for foot injuries)
      • Bone tenderness at the navicular bone (for foot injuries)
      • An inability to bear weight, both immediately and in the emergency department for 4 steps

Other Tests

  • Stress radiographs or arthrographies are not mandatory in the ED, but they may be requested by an orthopedic consultant.
  • Careful evaluation of the foot, particularly the base of the fifth metatarsal, may reveal tenderness, which would prompt radiographs of the foot to rule out a Jones fracture.

More on Ankle Injury, Soft Tissue

Overview: Ankle Injury, Soft Tissue
Differential Diagnoses & Workup: Ankle Injury, Soft Tissue
Treatment & Medication: Ankle Injury, Soft Tissue
Follow-up: Ankle Injury, Soft Tissue
Multimedia: Ankle Injury, Soft Tissue
References
[ CLOSE WINDOW ]

References

  1. Fong DT, Man CY, Yung PS, Cheung SY, Chan KM. Sport-related ankle injuries attending an accident and emergency department. Injury. Oct 2008;39(10):1222-7. [Medline].

  2. Beynnon BD, Vacek PM, Murphy D, Alosa D, Paller D. First-time inversion ankle ligament trauma: the effects of sex, level of competition, and sport on the incidence of injury. Am J Sports Med. Oct 2005;33(10):1485-91. [Medline].

  3. Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med. Jul 2007;14(7):641-5. [Medline].

  4. Nelson AJ, Collins CL, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train. Jul-Sep 2007;42(3):381-7. [Medline].

  5. Wexler RK. The injured ankle. Am Fam Physician. Feb 1 1998;57(3):474-80. [Medline].

  6. Ivins D. Acute ankle sprain: an update. Am Fam Physician. Nov 15 2006;74(10):1714-20. [Medline].

  7. Dias LS. The lateral ankle sprain: an experimental study. J Trauma. Apr 1979;19(4):266-9. [Medline].

  8. Jones MH, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop Relat Res. Feb 2007;455:173-5. [Medline].

  9. Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. Jul 2007;35(7):1197-207. [Medline].

  10. McKeon PO, Mattacola CG. Interventions for the prevention of first time and recurrent ankle sprains. Clin Sports Med. Jul 2008;27(3):371-82, viii. [Medline].

  11. Praemer A, Furner S, Rice D. Musculoskeletal conditions in the Unites States. American Academy of Orthopedic Surgeons. 1999;173-5.

  12. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. Apr 2008;121(4):324-331.e6. [Medline].

  13. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. Nov-Dec 2006;20(10):739-44. [Medline].

  14. Linde F, Hvass I, Jurgensen U, Madsen F. Early mobilizing treatment in lateral ankle sprains. Course and risk factors for chronic painful or function-limiting ankle. Scand J Rehabil Med. 1986;18(1):17-21. [Medline].

  15. Refshauge KM, Kilbreath SL, Raymond J. Deficits in detection of inversion and eversion movements among subjects with recurrent ankle sprains. J Orthop Sports Phys Ther. Apr 2003;33(4):166-73; discussion 173-6. [Medline].

  16. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. Mar 3 1993;269(9):1127-32. [Medline].

  17. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. Feb 22 2003;326(7386):417. [Medline].

  18. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. Apr 1992;21(4):384-90. [Medline].

  19. Wester JU, Jespersen SM, Nielsen KD, Neumann L. Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study. J Orthop Sports Phys Ther. May 1996;23(5):332-6. [Medline].

  20. Aiken AB, Pelland L, Brison R, Pickett W, Brouwer B. Short-term natural recovery of ankle sprains following discharge from emergency departments. J Orthop Sports Phys Ther. Sep 2008;38(9):566-71. [Medline].

  21. Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med. Nov-Dec 1999;27(6):753-60. [Medline].

  22. Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018. [Medline].

  23. Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. Am J Sports Med. Sep 2004;32(6):1385-93. [Medline].

  24. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg. 1995;114(2):92-6. [Medline].

  25. Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. Apr 2009;16(4):277-87. [Medline].

  26. Lamb SE, Marsh J, Hutton J, Nakash R, Cooke MW, on behalf of the Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet. 2008;373:575-81.

  27. Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. Oct 2008;16(10):608-15. [Medline].

  28. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. Apr 18 2007;CD000380. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

ankle injury, soft tissue ankle injury, soft-tissue ankle injury, ankle sprain, sprained ligament, twisted ankle, Ottawa ankle rules, sports-related ankle injury, ankle injuries, anterior talofibular ligament rupture, ATFL rupture, recurrent ankle sprain, calcaneofibular ligament rupture, CFL rupture, posterior talofibular ligament rupture, PTFL rupture, distal tibiofibular syndesmotic rupture, superior peroneal retinaculum rupture, ankle ligaments, inversion ankle injury   

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

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.

Coauthor(s)

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.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, 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 and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

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.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.