A 17-year-old soccer player presents with a history of twisting his ankle during a match. The young man describes the injury as occurring when his foot was planted, and he rolled his ankle inward while attempting to change direction. He immediately experienced pain on the outer side of his ankle and had difficulty bearing weight.
On examination, there is swelling and tenderness over the lateral ligaments of the ankle, particularly the anterior talofibular ligament (ATFL). The anterior drawer test is mildly positive and there is minimal tenderness over the medial ligaments and syndesmosis. X-rays show no fracture or widening of the tibiofibular clear space. What is the most likely diagnosis?
- Grade II lateral sprain
- Grade II posterior tibial tendinitis
- Lateral malleolar fracture with deltoid ligament injury
- Lateral ankle sprain
Click to see the answer
Answer: d. Lateral ankle sprains typically occur due to a combination of ankle inversion and plantar flexion, leading to damage to the ATFL and calcaneofibular ligament. It is crucial to distinguish between lateral/medial sprains and high ankle sprains due to variations in treatment approaches. Standard plain radiographs of the ankle are recommended due to the association of joint instability with this injury.
What is the best next step in management for this athlete?hat is the most likely diagnosis?
- Immobilization with a short leg cast and referral to a specialist
- Immediate return to play with an ankle brace for support
- Protection, rest, ice, compression, elevation, and medication (PRICE-M) with early physical therapy
- MRI to assess the extent of ligament damage and associated injuries
Click to see the answer
Answer: c. The PRICE-M protocol (protection, rest, ice, compression, elevation, and medication, typically nonsteroidal anti-inflammatory drugs [NSAIDs] and/or acetaminophen) is the common treatment plan for lateral ankle sprains. Immobilization and bracing strategies vary depending on the severity of the sprain, determined by the grade. Since your patient had significant swelling, tenderness, and was unable to bear weight, you classified his sprain as Grade III. Thus, in addition to recommending acetaminophen 500 mg every 4 to 6 hours as needed for pain, not to exceed 6 doses per day, you wrapped his ankle in an elastic wrap and prescribed a 10-day period of immobilization in a non–weight-bearing cast with crutches. You told your patient that unfortunately he would not be able to return to soccer for at least 8 weeks and provided a referral for physical therapy to begin as soon as he was out of the boot and off crutches.
For an in-depth review of this topic, access the full course.
Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
