Sprained Ankle - 5

Important The Ottowa Ankle Rules can save time, money and radiation - learn them.   

The Ottowa Ankle Rules in action

Unfortunately many patients come to the emergency department with the expectation of having an X-ray. This can be due to their previous experience of having X-rays for every minor trauma.

This can mean that it is easier to just give in and do the X-ray.

To do so is poor medicine, and reinforces the patients' belief of the neccessity of the X-ray.

Reducing the number of X-rays has benefits in safety, time, convenience and cost. Therefore if you have decided not to do an X-ray, you need to sell the idea of not having the X-ray to the patient.

Remember though, that 0.5% of both groups in the Ottowa trial had a missed fracture.     

How not to convince the patient about they do not an X-ray

'You do not need an X-ray. Get Out of My Emergency Room.'
[The origin of the word 'GOMER']    

How to convince a patient that the do not need an X-ray

Acknowledge that they have pain.
Explain that the function of the ligaments - that they hold the foot onto the ankle, and that inversion injury can rupture the ligaments.
Explain that when they have injured the ankle once, they are more likely to do so again.
Suggest RICE
- Rest,
- Ice (during the first 24 Hrs),
- Compression (N.B. there is no evidence to support the use of compression bandages)
- Elevation - tell the patient to keep the leg elevated to at least the level of the pelvis when they are sitting down.    


Physiotherapy does little to help in the acute healing stages, but may help the rehabilitation. This may be by increasing muscle or ligament strength, or by increasing proprioception awareness, or a combination of these.
Exercises using a wobble board are often most useful.    


The sprained ankle will be painful. Non-steroidal anti-inflammatory drugs are generally the most effective. Side effects are minimised by only taking for short courses.

Indometacin is powerful and cheap, Ibuprofen is safe and can be purchased over the counter in most countries.

COX2 inhibitors have not been shown to have a better side effect profile than ibuprofen, and are expensive.

Aspirin is cheap and effective, but current advice is to avoid in all patients below 16 years, due to the risk of Reye's syndrome.

Paracetamol/ compound analgesics
Regular paracetamol is sometimes enough in children. The NSAIDs mentioned above seem to be more effective for this sort of musculoskeletal pain, and do not have the side effects (brain/bowel) of codeine or similar products.