Bored Review – Sprains, Strains, and Ottawa Rules

A 40 year-old man presents to your ED with ankle pain. He rolled his ankle while engaged in various slapstick shenanigans involving snow storms, public transportation, and an overweight man who at first seemed oafish and ignorant, but in the end showed himself to be emotionally intelligent, leading our patient to realize that it was not his portly traveling partner, but he himself who had some personal issues to work on.


How do you determine if this patient needs an X-ray?

Ottawa Ankle Rules 

If patient has any of the following, they will need X-ray:

  1. Bony tenderness at posterior aspect of medial malleolus
  2. Bony tenderness at posterior aspect of lateral malleolus
  3. Bony tenderness at base of 5th metatarsal
  4. Bony tenderness at navicular bone
  5. Inability to bear weight immediately after incident AND in the ED (have them take 4 steps)

The Ottawa Ankle Rules were developed in a 1992 study and included all patients presenting to Ottawa Civic and General Hospitals with a new ankle injury. They have been validated and refined through several studies over the years. Most recently, a systematic review found the Ottawa Ankle Rules have 96-99% sensitivity and 10-80% sensitivity for excluding ankle fractures in adults. A meta-analysis in children found a pooled sensitivity of 98.5%.  


X-rays are negative. You determine that the patient has a ligament sprain.


What are the 3 grades of ankle sprain?

Grade 1: No ligament tear, minimal swelling and tolerable weight bearing

Grade 2: Partial ligament tear, more swelling, difficulty bearing weight, some loss of function

Grade 3: Complete ligament tear, cannot bear weight, loss of function

In reality, it is difficult to distinguish between Grade 1 and 2 in the ED immediately after injury. Grade 3 sprains will almost always be unable to bear weight and will be unstable with certain physical exam maneuvers (see below).


What are some other important physical exam maneuvers?

The anterior drawer test can be used to determine anterior talofibular ligament (ATFL) tear. This is the most commonly damaged ligament in ankle sprains.


The cross-leg test is when you squeeze together the fibula and tibia at about mid-calf. If there is pain at the ankle with this maneuver, this indicates damage to the tibiofibular syndesmosis.



Our patient does not appear to have an unstable or Grade 3 ankle sprain, so he will not need immediate orthopedics evaluation.


How do you treat a stable (Grade 1 or 2) ankle sprain?

Studies have shown that patients have earlier return to mobility with functional treatment rather than immobilization.

Within first 24 hours: RICE

  • Rest – up to 72 hours
  • Ice – only 20 minutes or less at a time
  • Compression – Elastic wrap for patient’s who are weight bearing; Aircast or soft, lace-up ankle brace for non-weight bearing
  • Elevation

Within first 72 hours: Early mobilization with motion and strength exercises, then return to activity as early as tolerated.


Who needs ortho follow up?

Follow up with orthopedics or sports medicine for those initially unable to bear weight or any suspected medial ligament or syndesmotic ligament sprains.


Bonus question: What is the name of John Candy's character in Planes, Trains, and Automobiles?

Don’t know, never saw it.

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e

Maughan, Karen. (2017). Ankle Sprain. UpToDate. 

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