A 46-year-old man comes to the emergency department for evaluation of left ankle pain. The patient was walking down a flight of stairs when he missed a step and landed on the lateral aspect of his foot. He immediately experienced pain in the ankle that has progressively worsened over the past 4 hours despite ibuprofen and application of ice. The patient's medical conditions include chronic hypertension and hyperlipidemia. Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, and pulse is 76/min. BMI is 29 kg/m². Examination of the left ankle shows significant bruising over the lateral aspect. Range of motion is limited on external rotation of the foot due to pain. There is no tenderness to palpation over bony prominences of the ankle and sensation is normal. The patient can walk to the examination room but has a significant limp. Which of the following is the best next step in management of this patient?

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11ec25c8_d857_4f4a_bc81_d363a17a421b_MD0003_00 This patient has a lateral ankle sprain. Lateral ankle sprains are typically caused by forceful inversion of the foot during running, walking on uneven surfaces (eg, descending stairs), or a fall from height. The anterior talofibular ligament is most commonly injured, but the calcaneofibular ligament can also be injured in more severe sprains. anterior talofibular ligament Examination in a lateral ankle sprain shows swelling about the lateral ankle and tenderness over the ligaments. If the ligaments are intact (grade I sprain), the ankle will be stable and weightbearing is only minimally affected. However, partial (grade II) or complete (grade III) ligament tears may be associated with ecchymosis, anterior or inversion laxity, and impaired weightbearing. If the patient has tenderness only over the ligaments distal to the lateral malleoli and can bear weight, conservative management (eg, compression bandage or brace, ice packs, crutches to reduce weightbearing) without imaging is appropriate. However, if there is tenderness over the posterior edge or tip of the malleolus or the patient cannot bear weight, x-ray of the ankle is indicated to rule out a distal fibular fracture. (Choice B) Surgical intervention for ankle sprains is rarely indicated. It is primarily considered for patients with severe (grade III) sprains who have occupations (eg, professional athlete) or other factors that increase the risk of repeat injury. It is not clear whether immediate surgery is superior to delayed surgery. (Choice C) Intraarticular corticosteroid injections are primarily performed for inflammatory arthritides (eg, gout, rheumatoid arthritis) and are not indicated for acute trauma. (Choices D and E) This patient can bear weight and has no malleolar tenderness; x-ray is not indicated for acute management. MRI is rarely needed for ankle sprains, although it may be considered to rule out a concomitant talar fracture in patients who do not improve as expected in 6-8 weeks. Educational objective: Lateral ankle sprains are typically caused by forceful inversion of the foot. The anterior talofibular ligament is most commonly injured. If there is tenderness only over the ligaments distal to the lateral malleoli and the patient can bear weight, conservative management (eg, compression bandage or brace, ice packs, crutches to reduce weightbearing) without imaging is appropriate. References: Update on acute ankle sprains. (http://www.ncbi.nlm.nih.gov/pubmed/22962897)

A 46-Year-Old Man Comes to the Emergency Department for Evaluation