What’s the right call when your ankle is big, fat & sore?
Evidence-based advice for the first week following a big ankle injury.
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When you have a Big, Fat, Sore Ankle (BFSA…who doesn’t like an unnecessary acronym) it can be difficult to know what to do or who to see or when. Obviously if there is a bony looking thing sticking out a hole in your skin, ‘don’t be a hero, dial triple zero’* or head to your nearest ED/A&E.
*or dial ‘112’ — the international emergency number that reroutes you to your local emergency services
For ‘first-time-ankle-injurers’….it can be quite worrying as the ankle can blow up quite a bit (i.e. swell), there may also be quite a bit of bruising, some of which can take a week to fully come out before it become apparent.
Sometimes the BFSA’s look really bad and turn out to be a mild injury, and sometimes the NSFAs (not-so-fat-ankles) turn into the long-term problems, so it’s very difficult in that early period to know what’s going on until the swelling settles down.
Here’s some tips for dealing with a ‘Cankle’ (another scientific term for a BFSA) in that first week:
Stay off it, compress it, elevate it
If it’s sore to weight-bear, stay off it. Pushing through the pain and limping on it may cause further swelling making it bigger and fatter and possibly turning into a RBFSA (really big, fat, sore ankle). Stay off it.
Put some firm compression on it, a tubular compression sock such as ‘tubigrip’ or a bandage from your home first aid kit. Compression is best done in layers so cover the ankle at least twice, but not so firm that it aches from the tightness.
If your BFSA is turning into a RBFSA, elevate it above the level of the groin to help with swelling drainage.
Take analgesics, but not oral anti-inflammatories (in first 3 days)
Pop some paracetamol or over-the-counter analgesics, but avoid using anti-inflammatories in those first few days as we don’t want to dampen the natural inflammation healing response from the body.
“Should I ice it?” — funny you ask…. Icing is good for numbing the area if it’s really achy as an analgesic however the evidence that it helps “reduce swelling” is very debatable, if done incorrectly it may actually increase swelling. So just save the old ice pack for extra pain-relief if the analgesics aren’t giving you relief.
Someone else said it better:
Icing is primarily an analgesic — a pain-reliever — and not an actual treatment. That is, it doesn’t “fix” anything. Use it like you use ibuprofen. It may help to resolve chronic problems (much more about this below), but it’s mostly intended to simply numb painfully inflamed or other hurting tissues. — Paul Ingraham at https://www.painscience.com/articles/icing.php
If you do go to ED/A&E…
The job of ED/A&E for acute injuries is
- To determine if you’re about to die, then
- Determine if there’s an immediate need to operate and repair a big fracture, based on the results of an Xray.
After that they are no further assistance to you, ignore the following advice that past patients have reported from their ED/A&E experiences:
- “it’s just a sprain, you’ll be right”
- “there’s no need for Physio, just rest”
- “the Xray is clear so you’ll be fine”
Xrays rule out big fractures but miss a butt-tonne (slang for ‘a lot’) of other significant injuries such as smaller fractures, avulsion fractures, ligament ruptures, cartilage damage and much more. So if ED/A&E says “Xray is clear, nothing there, off you go” just keep all of the above in mind, be polite, say thanks then get out of there and organise your own ‘tertiary’ care (Physio, GP, Sports Doctor etc.).
Please, if you felt a sudden pain in your HEEL, or felt like someone kicked you, shot you, threw something at you, and you felt a pop and now you have HEEL (back of ankle) pain, please make sure ED/A&E rule out an Achilles Tendon injury (rupture/tear), and if you have done it they should boot you with wedges under your heel to lift your heel up then send you off for a orthopaedic review.
To Boot or Not To Boot? That is the question…
A moonboot/camboot/offload boot can be very useful to allow you to weight-bear in comfort without causing further injury to the ankle and reduce pain/swelling. A moonboot is there to offload your ankle for the necessary steps you need to in life, avoid going walking around the mall or hiking with your friends in it if you have a RBFSA or BFSA. Once you can weight-bear without pain out of the boot, if your BFSA has settled down to a SLFA (slightly-less-fat-ankle), you can start walking the necessary steps you need to in life out of the boot.
Only if there is a fracture(s), ligament rupture(s) or another reason to be immobilised will you be told to be in a boot for long periods of time >4 weeks. If you are told by a GP or ED to be in the boot for >4 weeks without knowing why, please see a Physio for a second opinion and ongoing management, as the longer you’re in the boot unnecessarily the harder it is to restore range of motion in ankle joints coming out of it.
Xray (XR) or no Xray?
If something looks out of place or you’re pretty confident you’ve done something bad, see a local GP or Physio and organise an XR referral. Generally if you can’t weight-bear on Day 3 and have pain in any of the areas on the below pic at day 2–3, we’ll send you off for an XR anyway. These are called the ‘Ankle Ottawa Rules’.
Although your XR might come back NAD (no abnormality detected) it does not mean you don't have a fracture, it just means the XR can’t see a BIG fracture, but at least it’s enough to rule out the immediate need for surgery.
MRI vs no MRI?
An MRI can be useful towards the end of the first week following an ankle injury resulting in a BFSA. However only if there’s strong possibility of intra-articular (inside the joint) injuries or if the injuries sustained could be affecting your return to sports/exercise and need the MRI to hold you back from making not-so-smart return to sports/exercise decisions (for example, if you ruptured (completely torn) your stabilising ligaments) you will need to be in a boot for at least 4–6 weeks. The MRI will allow you to plan ahead and prepare for that as well as rule out other nasties that will take longer to get better or may require a surgery vs no-surgery decision.
If an MRI doesn’t change management however, it won’t be recommended.
When should I see a Physio?
If you have a RBFSA or BFSA it’s best to see the Physio around day 4–5 which allow you to get all of the above sorted out and hopefully the BFSA will be a SLFA (slightly less fat ankle), at that time we can do a better assessment and get clearer idea of what injury you have done and if a MRI is recommended at that time there will be less “noise” on MRI and we can more clearly see injured areas.
When in doubt, pop into your nearest Registered and Regulated Musculoskeletal Healthcare Professional (Physiotherapist) and they will help you out and can also fit you with a moonboot if needed.
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