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Sprained Your Ankle - Now What?

Trey Larant

Ankle sprains are the most common athletic injury, accounting for up to 40% of all sports injuries. Currently, the standard of care in this country is extremely inefficient in treating ankle sprains. I hope this information can help you make a more informed decision as to what to do after an ankle sprain, so you can get back to your activities faster and help prevent re-injury in the future.


Foot and ankle anatomy diagram from a lateral view.
Foot and ankle anatomy containing various ligaments and tendons that can be injured during an ankle sprain. Obtained from cosg.net


Canada came out with a very useful tool to better equip their emergency room staff in triaging patients who need an XRAY. Since healthcare is a government-funded service in Canada, they wanted the most efficient and cost-effective way to address this common injury. They came out with the “Ottawa Ankle Rules,” a list of guidelines to help determine which patients actually need an XRAY, and therefore reduce unnecessary imaging.



Ottawa Ankle Rules:

  • Bony tenderness along bottom 6 cm of fibula (outer leg bone/ankle)

  • Bony tenderness along bottom 6 cm of tibia (main leg bone/inner ankle)

  • Bony tenderness at base of 5th metatarsal (base of pinky toe)

  • Bony tenderness of navicular (bone on inner foot/arch)

  • Inability to stand on the leg immediately after injury or walk 4 steps during examination

If any of these are positive, then the patient is appropriate for an X-ray. Studies show this is 97.6% sensitive in ruling in a fracture, and that there is less than 1.73% probability there is a fracture if all of these rules are negative.


This is something we learned right away in physical therapy school, so that when we see a patient, we know when it is appropriate to send for an X-ray. Yet with all the research surrounding these guidelines, our emergency rooms here in the States don’t use them.


Typical healthcare timeline after an ankle sprain:

  1. Sprain your ankle

  2. Go to urgent care/emergency room and get an X-ray

  3. Majority of the time the X-ray is negative or there was too much swelling to see properly

  4. Told to follow up with your primary care doctor, possibly given crutches/boot/anti-inflammatories

  5. Wait a few weeks to get into primary care doctor, all while missing out on sporting activities, using crutches/walking with a limp, told to rest/ice/elevate/take ibuprofen

  6. Get into primary care doctor, who has one semester of musculoskeletal training, and refers you out to an orthopedic doctor who specializes in the foot/ankle

  7. Wait another few weeks to months to see the specialist, who orders an MRI to see the muscles/ligaments/tendons

  8. Wait another week or two to get the MRI, wait another week after that to have the results read

  9. Have a follow up appointment with the orthopedic doctor who tells you nothing is broken, sends you to physical therapy

  10. You come to physical therapy often weeks to months after your ankle sprain, now extremely weak, painful, still limping, and have missed half of your sports season. Likely to re-injure if you are not treated

This infuriates me as a physical therapist, because an otherwise straight-forward injury which heals in approximately 4-6 weeks for a low-grade sprain, turns into a multi-month treatment due to system inefficiencies. Now we also have to undo all of the limping and movement compensations you have made while awaiting treatment. This is why I created a cash-pay practice in the first place. So you don’t have to wait for treatment. So you don’t have to get stuck in this inefficient system and wait weeks-months for real help. I can get you seen often the same day as your injury and get you on the road to recovery immediately. I know these ankle rules and what to look for if an X-ray is truly needed. You won’t have to wait and pay for multiple doctor’s office visits and unnecessary imaging. Instead, you get back to your activities faster.


How the timeline SHOULD look in healthcare after an ankle sprain (i.e. cash-pay PT):

  1. Sprain your ankle

  2. Go see a physical therapist

  3. PT determines if you need an X-ray, most often you do not and can get started on treatment right away. If you do need an X-ray, they know what to look for and will send you to do so

  4. Rehab the injury, including re-strengthening the muscles, balance training, proper walking/running mechanics, and instruction in activity adjustments so you know what to do while you are recovering

  5. Return to your activities! Less likely to re-injure in the future since you properly rehabbed the injury in the first place



References

  1. Halabchi F, Hassabi M. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal of Orthopedics. 2020;11(12):534-558. doi:https://doi.org/10.5312/wjo.v11.i12.534

  2. Physiopedia. Ottawa Ankle Rules. Physiopedia. Published 2014. https://www.physio-pedia.com/Ottawa_Ankle_Rules




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