Case Report: Acute Ankle Inversion Injury with Significant Edema

Case at a Glance

A 28-year-old female presented with acute left ankle pain, significant swelling, and inability to bear weight following an inversion injury sustained two days prior. Examination and imaging confirmed a severe ankle sprain without an associated fracture.

Patient's Story

The patient, a 28-year-old female with no significant past medical history, presented for evaluation of an injury to her left ankle. Two days prior to presentation, while walking, she inadvertently stepped into a small depression in the ground, causing her left ankle to 'roll' or twist inward. She reported immediate onset of pain and has since experienced progressive swelling and difficulty ambulating.

Initial Assessment

On physical examination, the patient was in mild distress due to pain. The left ankle exhibited significant, diffuse edema, most prominent over the lateral aspect. There was marked tenderness to palpation over the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) regions. The patient was unable to bear full weight on the affected limb. Range of motion (dorsiflexion, plantar flexion, inversion, and eversion) was severely limited by pain and swelling. There was no gross deformity, and distal pulses and sensation were intact.

The Diagnostic Journey

Given the mechanism of injury and the patient's inability to bear weight immediately after the incident and during the examination, the Ottawa Ankle Rules were applied and were positive, indicating the need for radiographic evaluation to rule out a malleolar fracture. Anteroposterior (AP), lateral, and mortise view X-rays of the left ankle were obtained. The radiographs revealed significant soft tissue swelling but no evidence of an acute fracture, dislocation, or syndesmotic widening.

Final Diagnosis

Based on the clinical findings of an inversion mechanism, localized lateral ligamentous tenderness, significant edema, and negative radiographic findings, the patient was diagnosed with an acute Grade II or III lateral ankle sprain.

Treatment Plan

An initial conservative management plan was initiated, focusing on the PRICE protocol:

• Protection: The patient was fitted for a walking boot and provided with crutches, with instructions for non-weight-bearing to partial weight-bearing as tolerated.
• Rest: Advised to limit activity and avoid movements that provoke pain.
• Ice: Application of cold packs to the affected area for 15-20 minutes every 2-3 hours.
• Compression: Use of an elastic compression wrap to help manage swelling when not icing.
• Elevation: Instructed to keep the ankle elevated above the level of the heart as often as possible.

Over-the-counter NSAIDs (e.g., ibuprofen) were recommended for pain and inflammation management.

Outcome and Follow-up

The patient was scheduled for a follow-up appointment in 7-10 days to re-evaluate her progress. She was advised that once the acute pain and swelling subside, she should begin gentle range-of-motion exercises. A referral to physical therapy was planned to commence after the follow-up visit, focusing on a structured rehabilitation program to restore strength, flexibility, and proprioception, thereby reducing the risk of chronic ankle instability.