Twist and Shout! Does Your Ankle Injury Need an X-ray?

I see A LOT of ankle injuries.

It hit me yesterday, after having written over 120 blogs so far, that none of them is about ankle injuries. Can you believe that?  Out of all the musculoskeletal trauma that I see in my practice, probably ankle injuries are the most common. They occur in all ages, in both boys and girls, in athletes and in those doing nothing at all related to sports. Even in general pediatric practice, ankle injuries account for about 5% of all visits, so they’re a fairly common event. Ankle sprains are the most common diagnosis. They hurt, can be incredibly swollen and dramatic in appearance, can be tricky to manage, and sometimes take a longer than you might think to heal.

Twist and shout!

The ankle joint is reasonably complicated because it’s a joint that can move in all directions, which means there are many ways to injure it. People often describe “twisting” their ankle, but usually they mean that their foot turned either too far “in” or “out,” which is described in medical terms as “inversion” or “eversion.” There are many ligaments in the ankle and foot which can get pulled and even torn during an exaggerated movement. Once that occurs, the swelling results from all the inflammatory cells that rush to the site of the injury to help with repair. Once an ankle is swollen due to inflammation, pain occurs along with decreased range of motion and sometimes inability to bear weight or walk. Summing up, it’s a drag.

To x-ray or not to x-ray?

So once an injury occurs, what then? Does every injured ankle need an x-ray? This, friends, is the million dollar question. The answer is NO, of course; otherwise this blog entry would be fairly concise and straightforward.

The Clinical Decision Rule.

Back in the 1990’s, some smart researchers in Canada came up with what we call a “clinical decision rule” whereby they studied a few variables in many patients and came up with an algorithm for what clinical findings predicted the need for a certain test. This was done for ankle injuries in adults and has become known as the “Ottawa Ankle Rules.” Summarized in the picture below, the OAR state that ankle x-rays are necessary only if there is pain near the malleoli (the pointy bones on both sides of the ankle) and one of the following: 1) inability to bear weight immediately after the injury and at the medical evaluation (four steps); or 2) bone tenderness at the posterior edge or tip of either ankle bone.

Initially, this clinical decision rule was created for adults but the research has been subsequently repeated and validated for the pediatric population over age 2 years, so now there’s a pediatric version as well. These rules predict quite well who is likely to need an x-ray because they have a fracture, and who doesn’t need one because they likely don’t. When used accurately, the application of these rules reduce the need for ankle x-rays, thereby decreasing radiation exposure in children (which is a good thing!) and lowering healthcare costs (any little bit helps). I bring this research and clinical decision rule up so that if you are ever in the position of dealing with an ankle injury and your healthcare professional suggests that you don’t need an x-ray, he/she may be right.

There are different types of ankle sprains.

In an ankle sprain, damage to the ligament varies from simply stretched or slightly torn to completely torn. I like this description from the University of Michigan:

• Grade I is stretching or slight tearing of the ligament with mild tenderness, swelling, and stiffness. The ankle feels stable, and it is usually possible to walk with minimal pain.
• Grade II is a larger but incomplete tear with moderate pain, swelling, and bruising. Although the ankle sometimes feels stable, the damaged areas are tender to the touch, and walking is painful. See a picture of a grade II ankle sprain.
• Grade III is a complete tear of the affected ligament or ligaments with severe swelling and bruising. The ankle is unstable and may feel “wobbly.” Walking is usually not possible because the ankle gives out and there is intense pain, although initial pain may quickly subside.

Managing an ankle sprain.

If the working diagnosis is an ankle sprain, a few interventions can be made to aid the healing process.

First, the ankle needs to be immobilized so the injured tendons can heal. Protecting the injured area with a firm brace or splint means that re-injury (by bumping it against something or twisting it again) is less likely to occur.Also, don’t walk on it! This  helps move along the healing process as the joint is permitted to REST.
This brings up that mnemonic that everyone seems to know, and for good reason: it works. RICE. Rest, Ice, Compression, and Elevation. 
REST- We’ve talked about rest, but I’ll say it again:  don’t walk on it!
ICE – Icing the injury can help too. This is most helpful for the first few days after the injury as it helps decrease pain and swelling. Ice should NOT be applied constantly without any breaks, so aim for about 20 minutes 3-4 times a day.
COMPRESSION – Compressing with an elastic bandage works well to reduce swelling of the ankle
ELEVATION – elevating the entire leg can also decrease the amount of fluid that settles in the tissues around the ankle. This can be achieved by stacking a couple of pillows and propping your leg on top.

All of this helps the ankle heal faster. And of course, ibuprofen is an effective pain reducer in this setting.

People often ask if and when they should take their child to see a pediatric orthopedic specialist.

Most of the time ankle sprains heal slowly but steadily on their own over several weeks by simply following the above guidelines, and primary care clinicians are well versed in monitoring the healing process. That being said, if the pain and swelling are still significant after about a week, it may be worth talking to your healthcare professional about whether or not specialty care is indicated. In some cases, physical therapy can help build range of motion and strength, executed in a safe, controlled manner.

If you take anything away from this document, I hope it’s the fact that some ankle injuries can be managed conservatively, supportively, and successfully simply by following R I C E after an appropriate medical evaluation. You/your child may not need an x-ray in certain situations to make the diagnosis of an ankle sprain, and I hope after reading this you’ll be ok with that.