Musculoskeletal System 1 out of 408
A 33-year-old woman comes to the physician because of left ankle pain and swelling for the last 4 days after she missed a step and fell down the stairs. She has been able to move around slowly but is worried because the pain has not subsided despite taking acetaminophen. She is otherwise healthy. Her only medication is an oral contraceptive. She is 173 cm (5 ft 8 in) tall and weighs 74 kg (163 lb); BMI is 25 kg/m2. Vital signs are within normal limits. Physical examination shows moderate swelling of the left ankle and tenderness along the anterior edge of the lateral malleolus. Range of motion at the left ankle joint is limited due to pain. Left dorsalis pedis pulse is 2+. She walks without a limp. Which of the following is the most appropriate next step in management?
Protected weight bearing, cooling, and compressionAnkle sprains are most commonly caused by injury of the anterior talofibular ligament due to excessive inversion of the foot. Conservative treatment for acute ankle sprains consists of protection, optimal loading, ice, compression, and elevation (POLICE principle), along with NSAIDs for analgesia. Immediately after the injury, patients should undergo a brief period of relative rest followed by mobilization exercises within a pain-free range and protected weight bearing. Conservative treatment is indicated in patients with normal x-rays and in those who do not require imaging according to the Ottawa ankle rules. Accordingly, because this patient is able to bear weight on the ankle and does not have point tenderness at the posterior edge or tip of the lateral or medial malleolus, x-rays are not required.
If ankle instability or severe pain is present, a cast boot or short leg cast can be used for a few days. Surgery may be indicated if there is ligament rupture, especially in patients who are likely to experience continuous stress on the ankle joint, such as professional athletes. Surgical reconstruction of ankle ligamentsSurgical reconstruction of ankle ligaments may be considered in patients with chronic ankle instability, as evidenced by recurrent ankle sprains, or in patients with a complete tear of the ligament who are likely to experience continuous stress at the ankle joint (e.g., professional athletes). This patient does not experience recurrent ankle sprains and has no signs of a ruptured ligament (e.g., ecchymosis, ankle instability, inability to bear weight). Leg cast to immobilize the ankleA leg cast is used to immobilize the ankle in patients who have an ankle fracture or an ankle sprain with severe pain and ankle instability (grade III sprain). Usually, these patients cannot bear weight on the affected ankle. This patient, however, has been able to bear weight for the past 4 days. Moreover, an ankle fracture or grade III sprain manifests with severe pain, swelling, ecchymosis, ankle instability, and tenderness along the malleolus, whereas this patient only has moderate swelling, no ecchymosis, and a stable ankle joint. X-ray of the ankleThe Ottawa ankle rules are used to determine whether a patient with foot pain requires an x-ray. Imaging is indicated for patients who are unable to bear weight on the affected foot or have tenderness at the posterior edge of the medial or lateral malleolus. As this patient is able to bear weight and pain is localized to the anterior edge of the malleolus, x-rays are not indicated. MRI of the ankleAn MRI of the ankle is used to assess ankle sprains that do not respond to conservative therapy (i.e., pain persists after 6–8 weeks). This patient is only 4 days post-injury and in the acute setting, an MRI has no advantage over x-rays.
Back Next