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The content focuses on triaging orthopaedic injuries and conditions and was reviewed by site owner, Canadian Physiotherapist Terry Kane. If you have any comments or suggestions to improve the content, please contact Terry at terry@terrykane.ca.
Triaging Ankle Injuries
Introduction
Ankle injuries are among the most common musculoskeletal injuries, affecting athletes, active individuals, and the general population. Whether the injury occurs from a sports-related incident, a simple misstep, or a high-impact trauma, proper triage is crucial for determining the severity and necessary course of action. This guide outlines how to effectively assess and manage ankle injuries using established protocols and best practices.
Understanding Ankle Anatomy
The ankle is a complex joint composed of bones, ligaments, tendons, and muscles that work together to provide mobility and stability. The primary structures involved in ankle injuries include:
- Bones: Tibia, fibula, and talus
- Ligaments: Medial (deltoid) ligament, lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular), and syndesmosis (tibiofibular ligaments)
- Tendons: Achilles tendon, peroneal tendons, and tibialis posterior tendon
Common Types of Ankle Injuries
- Sprains: Stretching or tearing of ligaments, classified into three grades:
- Grade I: Mild stretching and microscopic tears
- Grade II: Partial tearing of ligaments with moderate swelling and instability
- Grade III: Complete tear with significant instability
- Fractures: Breaks in one or more ankle bones
- Dislocations: The talus bone is forced out of its normal position
- Tendon Injuries: Achilles tendon ruptures or peroneal tendon subluxation
- Soft Tissue Injuries: Contusions and hematomas
Initial Assessment and Triage
Proper assessment is crucial to determine whether an ankle injury requires urgent medical attention or conservative management. The following steps guide triage decisions.
1. Evaluate the Mechanism of Injury
Understanding how the injury occurred helps predict the severity and structures involved. Key questions include:
- Was it a twisting motion, direct impact, or a fall?
- Did the individual hear a popping or cracking sound?
- Was weight-bearing possible immediately after the injury?
2. Perform a Physical Examination
A thorough physical assessment includes:
- Inspection: Look for swelling, deformity, bruising, or open wounds.
- Palpation: Gently press on different areas of the ankle to identify pain points and swelling.
- Range of Motion (ROM) Testing: Assess dorsiflexion, plantarflexion, inversion, and eversion.
- Weight-Bearing Test: Determine whether the individual can stand or walk without severe pain.
- Neurovascular Assessment: Check for adequate blood flow, sensation, and motor function in the foot and toes.
3. Use the Ottawa Ankle Rules
The Ottawa Ankle Rules (OAR) help identify the need for X-rays in cases of acute ankle trauma. X-rays are recommended if the patient has:
- Pain in the malleolar zone and any of the following:
- Tenderness over the posterior edge or tip of the lateral or medial malleolus (6 cm above the ankle)
- Inability to bear weight immediately and after four steps in the emergency room
- Pain in the midfoot zone and any of the following:
- Tenderness over the base of the fifth metatarsal
- Tenderness over the navicular bone
- Inability to bear weight immediately and after four steps
If none of these criteria are met, a fracture is unlikely, and conservative management can be considered.
Emergency vs. Non-Emergency Cases
Red Flags Requiring Immediate Medical Attention
- Obvious deformity suggesting dislocation or severe fracture
- Severe swelling and bruising with inability to move the ankle
- Open wounds with bone protrusion (open fractures)
- Loss of sensation or poor circulation (cold, pale foot)
- Pain that worsens despite rest and elevation
Non-Emergency Cases for Conservative Management
- Mild to moderate sprains (Grade I or II)
- No signs of fracture based on OAR
- Ability to bear weight with minimal pain
- No neurovascular compromise
Management of Ankle Injuries
Treatment depends on the severity and type of injury. Common approaches include:
Acute Management: RICE Protocol
- Rest: Avoid weight-bearing to prevent further damage.
- Ice: Apply ice packs (15-20 minutes every 2-3 hours) to reduce swelling and pain.
- Compression: Use an elastic bandage or brace to minimize swelling.
- Elevation: Keep the foot elevated above heart level to reduce fluid accumulation.
Pharmacological Treatment
- Over-the-counter NSAIDs (e.g., ibuprofen, naproxen) to manage pain and inflammation
- Acetaminophen for pain relief if NSAIDs are contraindicated
Immobilization and Support
- Mild Sprains: Functional support with an ankle brace or taping
- Moderate Sprains: Walking boot or splint for additional support
- Severe Sprains and Fractures: Cast or splint with possible surgical intervention
Rehabilitation and Recovery
Once acute symptoms subside, rehabilitation aims to restore strength, flexibility, and proprioception:
- Early Motion Exercises: Gentle ROM exercises to prevent stiffness
- Strengthening Exercises: Resistance bands, calf raises, and toe curls
- Balance and Proprioception Training: Single-leg stands and wobble board exercises
- Gradual Return to Activity: Progressive loading with sport-specific drills
Prevention of Ankle Injuries
- Proper Footwear: Supportive shoes with good ankle stability
- Strength Training: Strengthen ankle stabilizers and lower leg muscles
- Warm-Up and Stretching: Enhance flexibility before physical activity
- Balance Training: Improve coordination to prevent missteps
- Taping or Bracing: Additional support for individuals with previous ankle injuries
Conclusion
Triaging ankle injuries requires a systematic approach to determine the severity and appropriate intervention.
By assessing the mechanism of injury, applying clinical guidelines such as the Ottawa Ankle Rules, and recognizing red flags, healthcare professionals and first responders can make informed decisions about treatment.
Early management with the RICE protocol, appropriate immobilization, and structured rehabilitation helps facilitate recovery and prevent long-term complications.
Proper prevention strategies further reduce the risk of recurrent ankle injuries, ensuring better outcomes for active individuals and athletes alike.