Kategoria: Injuries and Sports Medicine (EN)

After a limb injury, assessment should not stop at the painful bone or joint: circulation and nerve function below the injury also need to be checked. A fracture, dislocation, large haematoma or overly tight immobilisation can compress a blood vessel or nerve. Detecting that problem early may be more urgent than assigning a precise fracture label.

Polish version · For Patients

What does an orthopaedic surgeon check during the examination?

A neurovascular examination combines several observations. The clinician compares colour and temperature between limbs, checks capillary refill after pressure on a nail bed, feels for pulses at appropriate sites, tests sensation in the territories of individual nerves and asks the patient to perform selected movements of the fingers, toes, hand or foot.

Each part answers a different question. A palpable pulse is reassuring, but it does not exclude every clinically important circulatory problem. Likewise, normal skin colour does not rule out injury to a specific nerve. The overall pattern and comparison with the opposite side matter.

Why is the examination repeated?

The condition of a limb can change after reduction of a fracture or dislocation, application of a cast, increasing swelling or secondary displacement. Neurovascular findings should therefore be documented before an intervention and checked again afterwards. This helps establish whether an abnormality was present from the outset or developed later.

This is also why patients are told to watch their fingers or toes after immobilisation. Swelling often increases during the first few days and a cast or splint that was initially comfortable may become too tight.

What can an abnormal finding mean?

• a cold, pale or blue limb may indicate impaired blood flow;
• delayed capillary refill has to be interpreted together with temperature and pulses;
• new numbness may reflect nerve compression or injury;
• inability to perform a movement can result from pain, tendon or muscle injury, or nerve dysfunction;
• pain that seems disproportionate to the injury and worsens with passive movement of the digits can be one warning sign of acute compartment syndrome.

Why is an X-ray not enough?

X-rays show bone position well, but they do not directly assess nerve function or blood flow. Good fracture alignment therefore does not automatically mean that all soft tissues are safe. Conversely, numbness does not necessarily mean that a nerve has been divided; swelling or pressure can cause temporary symptoms. Distribution, progression and the complete examination determine how concerning a finding is.

Which symptoms after injury or casting need urgent reassessment?

• increasing numbness or reduced ability to move the fingers or toes;
• digits that become clearly colder, pale or blue;
• severe and increasing pain despite elevation and prescribed analgesia;
• a rapidly increasing sense of pressure or tightness under a cast;
• marked swelling that makes finger or toe movement difficult.

In that situation, do not cut or alter the immobilisation yourself. Prompt reassessment is needed. Trying to check a pulse at home is not an adequate substitute: it may be difficult to locate reliably, and the presence of a pulse does not rule out every complication.

Sources

1. National Institute for Health and Care Excellence. Fractures (complex): assessment and management. NICE guideline NG37.
2. National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NICE guideline NG38.

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Return to sport after an ankle sprain is safest when the joint tolerates loading, has sufficient range of motion, strength and balance, and the athlete can perform sport-specific movements without substantial pain, giving way or a clear increase in symptoms the following day. The number of days since injury—or the disappearance of swelling alone—is not enough.

Progression should be gradual: from normal walking and simple exercises to running, changes of direction and finally full training. A more severe injury, suspected syndesmotic injury, fracture or osteochondral lesion requires a different plan.

First establish what was injured

A typical lateral ankle sprain involves the ligaments on the outer side of the ankle. Similar symptoms, however, can occur with a fracture, syndesmotic injury, peroneal tendon injury or an osteochondral lesion. If the diagnosis is uncertain, an early return to sport can delay appropriate treatment.

Imaging should be selected to answer a clinical question rather than ordered automatically. See the English overview of diagnostic tests for the roles of X-ray, ultrasound, MRI and CT.

There is no single safe number of days

Two injuries both described as an “ankle sprain” can differ greatly in severity, stability and sporting demands. A runner returning after a minor sprain faces different requirements from a footballer, basketball player or tennis player who needs to brake, land and change direction rapidly.

The calendar is therefore only one part of the decision. More important is how the ankle responds to progressively harder loading and how it feels over the following 24 hours.

Five areas an orthopaedic surgeon and physiotherapist assess

The international PAASS consensus organises return-to-sport assessment into five domains. It is not a single test or an automatic clearance certificate, but a practical framework that helps ensure important elements are not overlooked.

1. Pain

Pain should be assessed during sport and over the previous 24 hours. Mild discomfort does not always mean activity must stop, but pain that increases during training, changes movement technique or is clearly worse the next day suggests that the load was too high.

2. Range of motion, strength and power

The ankle should regain the range of motion required for the sport. Strength of the peroneal muscles and calf matters, but so do endurance and the ability to produce force quickly. Calf raises, single-leg squats and side-to-side comparison tasks can be useful in practice.

3. Confidence and perceived stability

The athlete should trust the ankle during landing, cutting and contact. Fear of movement can alter loading even when simple tests look satisfactory. A persistent feeling that the ankle “gives way” deserves reassessment.

4. Balance and neuromuscular control

The ankle must respond to loss of balance and uneven ground. Single-leg stance and dynamic tasks help assess limb control. It is useful to observe not only time or distance but also landing quality, knee and trunk position, and the number of errors.

5. Sport-specific tasks and full training

Jumping, landing, acceleration, deceleration, cutting and ball drills should reflect the demands of the individual sport. One of the most useful tests is the ability to complete a full training session without loss of control and without a meaningful increase in symptoms afterwards.

How should return be progressed?

1. Daily loading: walking without a marked limp, stairs and basic exercises.
2. Straight-line movement: brisk walking, jogging and easy running.
3. Dynamic loading: hops, landings and acceleration.
4. Change of direction: cutting, braking and tasks on less predictable surfaces.
5. Sport training: controlled drills first, followed by full training.
6. Competition: only after the athlete tolerates the full demands of training.

Each stage should be performed with good movement quality. If pain, swelling or a sense of instability clearly increases during activity or the next day, the load should be reduced and the situation reassessed.

What should rehabilitation include?

Current guidance supports progressive restoration of weight-bearing, range of motion, strength and neuromuscular control. Rehabilitation commonly includes mobility work, strengthening, balance training, single-leg tasks and gradual progression toward sport-specific movement.

Prolonged complete immobilisation is not standard for every ankle sprain. A short period of immobilisation can be appropriate after a severe injury, but subsequent care should usually include early, safe mobilisation. The details depend on ankle stability and associated injuries.

Can a brace or taping reduce the risk of another sprain?

For athletes returning after a sprain, bracing or taping can be one component of recurrence-risk reduction, particularly in sports involving jumps and rapid changes of direction. They do not replace rehabilitation. External support by itself does not restore strength, balance or confidence in movement.

When do symptoms not fit a simple ankle sprain?

Reassessment is appropriate when pain is higher above the ankle, deep within the joint, accompanied by locking, tendon snapping, repeated giving way or a lack of expected improvement. Pain behind the lateral malleolus may also arise from the peroneal tendons rather than from the ankle ligaments themselves.

Warning signs

• visible deformity or suspected dislocation;
• inability to bear weight with marked focal bony tenderness;
• a cold, pale or blue foot, increasing numbness or weakness;
• very severe or rapidly increasing pain;
• an open wound;
• increasing calf swelling, shortness of breath or chest pain;
• lack of expected improvement or deterioration after initial improvement.

The key point

Safe return to sport after an ankle sprain is a function-based decision. Pain, movement, strength, balance, confidence in the joint and sport-specific performance all matter. Completing full training without a subsequent symptom flare is a much more useful test than the date of injury alone.

Polish version · Sports Medicine and Reconstructive Surgery

References

• Smith MD et al. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. Br J Sports Med. 2021;55:1270–1276. DOI: 10.1136/bjsports-2021-104087.
• Martin RL et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1–CPG80. DOI: 10.2519/jospt.2021.0302.

This material is educational. Rehabilitation pace and return-to-sport decisions should be tailored to the injury, clinical examination and demands of the sport.

Content prepared by: Tomasz Poboży - orthopaedic surgeon.