A 17 year old male presents to the Emergency Department one day after sustaining a "twisting" injury to his left ankle while playing soccer. The patient claims to have sustained a "twisted ankle" while he was running towards the goal. He does not recall exactly in which direction his ankle twisted. He did not feel or hear any "snaps," "pops," or "clicks." Although he was able to bear some weight on the ankle immediately after the injury, today he has much more pain and swelling bout the anterior and lateral aspect of the affected ankle. Overnight he did not elevate the ankle nor did he apply any ice to the injured ankle. He denies sustaining any other injuries and has not sustained any previous injury to his left ankle. This morning he is unable to walk on the ankle secondary to increased pain and swelling. On examination, he is barely able to bear any weight on the affected ankle secondary to pain. There is obvious swelling (without ecchymosis) to the anterior and lateral aspect of the ankle joint. Distally, his toes are pink, with brisk capillary refill and intact sensation to light touch. Tenderness can be elicited by palpation over the anterior aspect of the ankle joint (Refer to photo).

The black arrow points to the region of maximum tenderness. There is no tenderness along the inferior tip of the lateral malleolus or over the bony prominence of the lateral malleolus. There is no tenderness along the medial aspect of the ankle or along the proximal aspects of both the tibial and fibular shafts. The squeeze test over the distal tibia-fibula region does not produce any pain. Both the anterior drawer and talar tilt maneuvers are within normal limits when compared to the nonaffected ankle.

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Discussion & Teaching Points:

Ankle injuries are one of the most common sports-related orthopedic injuries seen in the Emergency Department. These types of injuries are most commonly sustained in patients between 15 - 35 years of age. The majority of ankle sprains (up to 85%) are due to inversion injuries while only 15% are due to eversion-related injuries. There are 3 lateral ankle ligaments and one broad, fan-shaped medial ligament.