Intended for healthcare professionals

Endgames Case Review

Management of ankle injuries

BMJ 2015; 351 doi: (Published 15 December 2015) Cite this as: BMJ 2015;351:h6698
  1. Matthew Welck, senior fellow in foot and ankle surgery1,
  2. Michael Rafferty, orthopaedic specialist registrar1,
  3. Stephanie Eltz, orthopaedic specialist registrar1,
  4. Shafic Said Al-Nammari, specialist registrar2,
  5. Kelechi Chika Eseonu, trauma and orthopaedic registrar 3
  1. 1Department of Orthopaedics, Wexham Park Hospital, Slough, UK
  2. 2Department of Trauma and Orthopaedics, Barts and the London NHS Trust, London, UK
  3. 3Department of Orthopaedic Surgery, John Radcliffe Hospital, Oxford, UK
  1. Correspondence to: M Welck

A 26 year old woman presented to the emergency department after injuring her left ankle. While walking on an uneven pavement in the rain she lost her footing and described a sudden “buckling” of her ankle (plantar flexion and inversion injury). She could not bear weight so an ambulance was called.

She was previously fit and well and was on no regular drugs. Six months earlier she had twisted the same ankle while playing hockey. Radiographs taken at the emergency department had been normal, and she was discharged with crutches and a compression bandage. She returned to work after two weeks but had not returned to sport because she did not trust her ankle.

Clinical examination identified tenderness, swelling, and ecchymosis over the anterior talofibular and calcaneofibular ligaments, with some bony tenderness on the posterior edge of the lateral malleolus. She had no medial tenderness. Ankle ligament stress testing was not performed owing to pain.


  • 1. What is the most likely diagnosis?

  • 2. What are the other possible diagnoses after this mechanism of injury?

  • 3. What relevant history and examination are needed?

  • 4. How should she be investigated?

  • 5. How should she be managed?

  • 6. What features warrant specialist referral in patients with ankle sprain presenting to general practice?

  • 7. How should she be followed up?


1. What is the most likely diagnosis?

Short answer

Lateral ankle ligamentous injury.


The most common injury sustained during an ankle plantar flexion and inversion injury is a lateral ankle ligamentous injury. The bony architecture of the ankle joint is most stable in dorsiflexion. Ankle sprains are therefore more likely to occur with the ankle in plantar flexion because ligamentous support is more important.

A 2014 meta-analysis found a higher incidence of ankle sprain in females than in males, in children than in adolescents, and in adolescents than in adults. Indoor and court …

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