Management of Continued Ankle Pain with Normal X-ray and No Swelling

Diagnostic Approach

For patients with continued ankle pain, normal X-rays, and no swelling, MRI without IV contrast is the most appropriate next imaging study to evaluate for occult injuries such as ligamentous tears or osteochondral lesions, as recommended by the American College of Radiology 1, 2
If the patient meets any Ottawa Ankle Rules criteria, radiographs should have already been performed, according to the American College of Radiology 3, 4
Normal radiographs rule out most fractures but not soft tissue injuries or occult bone injuries, as noted by the American College of Radiology 4, 5
Persistent pain beyond 1-3 weeks with normal radiographs requires further evaluation, as suggested by the American College of Radiology 1, 2

MRI without IV contrast is the preferred next imaging study for patients with persistent ankle pain (>1 week but <3 weeks) with negative initial radiographs, as recommended by the American College of Radiology 1, 2
CT ankle without IV contrast is an alternative but less sensitive for soft tissue injuries, according to the American College of Radiology 1, 2

Activity modification and avoidance of aggravating activities, as well as NSAIDs for pain control and weight loss if indicated, are recommended by the American Academy of Family Physicians 6

Obtain MRI without IV contrast to evaluate for occult injuries, as suggested by the American College of Radiology 1, 2
Consider referral to a podiatric foot and ankle surgeon or orthopedist, and additional treatments may include customized orthotic devices, immobilization, or limited corticosteroid injections, as recommended by the American Academy of Family Physicians 6