Ankle Injury in a School Basketball Game
During a school basketball game in the school hall on a wooden floor, a 15-year-old player lands from a rebound on an opponent's foot. Her right ankle rolls inward. She immediately has pain over the outside of the ankle, rated 7/10, and swelling appears within minutes. She cannot put weight on it and cannot hop four times. On the sideline, the teacher finds tenderness over the anterior talofibular ligament but no tenderness over the posterior edge of the lateral malleolus, the medial malleolus, the navicular or the base of the fifth metatarsal. The skin is intact and the foot is warm and pink. The teacher wants to tape the ankle tightly and send her back into the fourth quarter because the team has only five players. The player is tearful and says she does not want to let the team down.
1. Using the Ottawa ankle rules and clinical reasoning, decide whether she needs an X-ray and whether she should return to play. Explain your answer.
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The Ottawa ankle rules indicate an ankle X-ray when there is pain in the malleolar zone plus either bone tenderness at the posterior edge or tip of the lateral malleolus, bone tenderness at the posterior edge or tip of the medial malleolus, or inability to bear weight for four steps both immediately and in the emergency department. She cannot bear weight for four steps, so an X-ray is indicated even though specific bone tenderness is absent.
She should not return to play. She cannot bear weight, has rapid swelling and significant ligament tenderness. Taping and sending her back risks worsening a ligament injury or moving a fracture. The correct decision is to remove her from the game, protect the ankle and arrange assessment. The team being short does not override safety.
2. Describe your immediate sideline management for the first 10 minutes and the first 48 hours. Justify each action.
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First 10 minutes: stop play, help her off the court without letting her walk on it, and assess circulation, sensation and movement in the foot. Apply a splint or support, elevate the ankle above heart level if possible, and apply a cold pack with a cloth barrier for up to 15–20 minutes for pain. Do not ask her to 'walk it off' or test her by making her hop.
First 48 hours: protect the ankle from further injury, rest from sport, elevate regularly, and use compression if it does not cause numbness. Avoid heat, alcohol, massage and running in the first 48 hours because they can increase swelling. Ice is for pain relief, not a cure. Refer for assessment because she cannot bear weight. Explain that return will be criteria-based, not time-based.
3. Design a criteria-based return-to-play plan for school basketball. Do not use a fixed number of days.
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Return should progress only when each criterion is met:
- Pain and swelling: no significant swelling, pain-free walking and stairs.
- Range and strength: full ankle range and calf strength within about 90% of the other side.
- Basic function: pain-free hopping, lateral shuffles and single-leg balance.
- Sport-specific work: jogging, cutting, jumping and landing without pain or giving way.
- Practice: non-contact drills, then controlled contact, then full game play.
If swelling returns or she lacks confidence, go back one step. Medical clearance is needed if a fracture is found. The reasoning is that time alone does not show tissue readiness; function and load tolerance do.