eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Ankle Injury, Soft Tissue: Follow-up

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

Follow-up

Further Outpatient Care

  • Patients with grade I or mild grade II lateral sprains should have a follow-up visit with their primary care physician in 1-2 weeks.
  • Consult an orthopedist or a sports medicine specialist for all other injuries.
  • Consider physical therapy referral for rehabilitation and strengthening to prevent recurrent injuries.
  • Some orthopedic surgeons suggest an operative course for competitive athletes who have failed conservative treatments and whose ankle function did not improve with appropriate rehabilitation.27 Recently, however, a Cochrane Database of Systematic Reviews article of 20 trials concluded that there is insufficient evidence to determine the relative effectiveness of surgical versus conservative management of lateral ligament ankle sprains.28

Deterrence/Prevention

  • Ankle sprains are prevalent sports injuries and are associated with a high cost both in medical expenses as well as in forced lifestyle modifications. Therefore, prevention of first time as well as recurrent sprains is a common sense approach to addressing this problem. Over the years, numerous strategies for preventing ankle sprains have been described.10 They range from balance and coordination training using a wobble board19,23 to external support (taping/bracing), foot orthotics, specialized footwear, and strengthening and stretching.10 Most evidence points to the use of the wobble board and external support such bracing and taping as the most effective ways of preventing first-time and recurrent ankle sprains.10,19,21,22

Complications

  • Functional, mechanical instability, or both20
  • Impaired proprioception of the affected ankle, leading to further ankle instability15
  • Chronic pain, stiffness, swelling, osteoarthritis12,13
  • Failure to return to previous levels of competitiveness, impaired activities of daily living

Prognosis

  • With appropriate initial treatment, referral, and physical therapy, most patients have a rapid and favorable outcome.
  • In a systematic literature review 36-85% of the patients reported full recovery at 2 weeks to 36 months, independent of the initial grade of sprain,12 with most recovery within the first 6 months.24 After 12 months, the risk of recurrent ankle sprain returns to preinjury levels.23 However, 3-34% of patients reported re-sprains at 2 weeks to 96 months after the initial injury.12 Furthermore, after 3 years, some patients still had residual pain and instability. One risk factor for residual symptoms seems to be participation in competitive sports.12
  • Posttraumatic osteoarthritis is common in patients with repetitive ankle injuries. A recent study estimates that approximately 12% of the overall prevalence of osteoarthritis (OA) is in fact posttraumatic OA of the hip, knee, or ankle.13 The financial burden is significant, costing an estimated $3.06 billion dollars annually.13

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose
    • Failure to obtain a radiograph
    • Misinterpretation of a radiograph
    • Failure to recognize ankle instability
  • Failure to treat injury appropriately
    • Failure to immobilize unstable injuries
    • Failure to refer significant injuries to the appropriate specialist
  • Unmet expectations - Failure to warn the patient of the potential for prolonged recovery or chronic symptoms or instability

Special Concerns

  • Elderly patients may require home health visits to assess mobility and ability to perform activities of daily living (ADL).
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Christopher F Richards, MD, to the development and writing of this article.
 



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References
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References

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  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].

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

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

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  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].

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  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].

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Further Reading

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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   

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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

 
 
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