• Age
  • Acute or chronic pain
  • Duration/Frequency
  • Mechanism
  • Sport/position
  • Pop/Tear
  • Swelling (Rapid?)
  • ROM deficit
  • Instability
  • Weight-bearing immediately
  • Location of pain
  • Mechanical symptoms
  • Attempted treatment (RICE?)

Physical Exam


  • Joint Effusion, ecchymosis
  • Skin integrity- abrasion/laceration etc
  • Gait
  • Ability to bear weight (Walking, running, squatting, etc)


  • Dorsiflexion/Plantar Flexion
  • Inversion/Eversion
  • Subtalar Motion


  • Effusion vs extra-articular soft tissue swelling
  • Anterior-Physis-tibia, capsule/joint line, anterior tibialis
  • Medial-Medial Malleolus/Tibia, posterior tibialis, deltoid ligament
  • Lateral-Lateral Malleolus/Fibula, lateral ligaments, peroneal tendon
  • Posterior – Achilles Tendon, Os Trigonum Syndrome

Special Maneuvers

  • Drawer/Talar Tilt

Neurovascular exam

Adjacent Joints


Radiographs Indications

  • Deformity, acute effusion, not weight bearing, instability, bone/ physis tender, chronic pain not improving
  • Standard trauma- AP, lateral, mortise

MRI Indications

  • Radiographs fail to clarify the problem
  • To confirm your clinical suspicion (To answer a specific clinical question Is there a cartilage tear? Is there an OCD in the ankle?)
  • Pain failing conservative care
  • To plan for surgery

Differential Diagnosis by Anatomic Location

Diffuse/Global Pain

  • Fracture, acute trauma, immediate dec ROM

Anterior Ankle Pain

  • Tibia fracture
  • Anterior Impingement
  • Tibialis Anterior Tendinopathy
  • OCD Talus

Medial Ankle Pain

  • Posterior Tibialis Tendonitis/Overuse
  • Medial sprain-isolated medial ankle sprain rare, screen for fracture
  • Tibia Fracture/stress fx
  • Medial Tibial Stress Syndrome/Shin splints

Lateral Ankle Pain

  • Lateral ankle sprain/syndesmosis injury
  • Fibula fracture/stress fx
  • Peroneal tendonitis/overuse
  • Chronic ankle instability

Posterior Ankle Pain

  • Achilles tendonitis/overuse
  • Os Trigonum Syndrome



  • Pain Control
  • Crutches
  • Splint/Brace
  • Limit use to < 1 week to avoid stiffness
  • Rehabilitation Early ROM

When to Refer

  • Failure to improve with conservative care
  • Potential surgical conditions (intraarticular/displaced fx, dislocation, OCD, physis injury)
  • Parental Concern
  • Growth concerns
  • Return to play concerns