What a fluke. Stepped on a piece of wood I guess on the edge and it flipped up and my ankle rolled with it. Instantly swelled up.

The first image is about an hour after the injury and I was in the way to the urgent care. They took an xray and said most likely a grade 2 sprain but they couldn't tell if there was a fracture. They said it looked like a shadow on my xray but couldn't be sure so they referred me to an orthopedic.

Second picture is about 18 hours after injury. Swelling has gone down but I'm now feeling a pain in the inside of my ankle as well. That is the part that is causing some extra stress.

Based on this description, any thoughts or recommendations? I'm a 32 year old male with a 3 year old and an 8 month old. Needless to say my wife is thrilled.

We're going to use this as a trial to see if she can handle 3 kids on her own! Ha.

Did you go to an urgent care? Hard to say without seeing x-rays (assuming they're good quality x-rays), and laying hands on the ankle.

But if you're walking on it, I would think likely a sprain. However there is always the possibility of a minor avulsion fracture with the mechanism you describe. These are unlikely to be clinically significant, as it is a non-surgical fracture.

That being said, you probably do need a repeat exam in a week or two to evaluate for join laxity. If you get repeat x-rays in about 10-14 days, any potential fracture will likely be easier to see.

If it was me, I'd just RICE it. At night time, write the alphabet with your toes to keep some mobility. Discomfort is ok, pain isn't. I, personally, would not think an orthopedic surgeon would add much value, unless I felt I needed surgery. If anything, I would see physical therapy to help you rehab it.

Looks like a distal fibula fracture to me. Boot for 6 weeks

Bummer. i got things to do!

Any thoughts on why the pain is on the inside of my ankle mostly even though my ankle rolled out?

aggiebrad16 said:

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Bummer. i got things to do!

Any thoughts on why the pain is on the inside of my ankle mostly even though my ankle rolled out?

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Good question so I asked OpenEvidence:

Medial ankle pain following an eversion injury has a broad differential, with the leading diagnosis being deltoid ligament sprain, though several important alternative and concomitant diagnoses must be considered.

Most Likely: Deltoid Ligament Sprain

The deltoid ligament complex (superficial and deep components) is the primary medial stabilizer, providing restraint to eversion and external rotation of the talus.[1] Eversion/dorsiflexion is the classic mechanism for medial ankle sprain.[2] Injury ranges from grade I (stretch) to grade III (complete rupture). Key exam findings include tenderness over the medial malleolus and deltoid ligament, medial ecchymosis, and pain with passive eversion. Isolated deltoid sprains are less common than lateral sprains and should prompt evaluation for associated injuries, particularly syndesmotic disruption and fibular fracture (Maisonneuve pattern).[1][2]

Other Diagnoses to Consider

- Medial malleolar fracture or occult fracture Point tenderness at the tip or posterior edge of the medial malleolus, inability to bear weight, or positive Ottawa Ankle Rules should prompt radiographs. Occult fractures not visible on initial radiographs can be detected by MRI or CT.[2][3]

- Syndesmotic (high ankle) sprain Eversion with an external rotational component is the most common mechanism. Tenderness over the anterior tibiofibular ligament, positive squeeze test, and pain with passive external rotation in dorsiflexion distinguish this from isolated deltoid injury.[2][4]

- Posterior tibial tendon strain or tear Rare acutely (~1% of ankle sprains presenting to clinic) but frequently missed. Persistent medial pain, weakness with single-leg heel rise, and tenderness along the tendon course posterior to the medial malleolus are key findings. MRI findings can be subtle, and radiologist interpretation missed pathology in the majority of cases in one series. Risk factors include increasing age, female sex, and excessive pronation.[5][6][7]

- Osteochondral lesion of the talar dome Medial talar dome lesions are more common than lateral (67% vs 33%) and are strongly associated with prior ankle trauma. Persistent deep ankle pain, clicking, or locking after the acute injury resolves should raise suspicion. MRI is the study of choice.[8][9][3]

- Tarsal tunnel syndrome (acute traction neuropathy) Eversion can stretch the posterior tibial nerve within the tarsal tunnel. Distinguishing features include burning, tingling, or numbness radiating to the plantar surface and toes, positive Tinel sign posterior to the medial malleolus, and a positive dorsiflexion-eversion test. Incidence after ankle sprain is approximately 0.6% within 2 years, with higher risk in older patients, females, and those with metabolic syndrome.[10][11][12]

- Medial ankle joint capsular sprain Often coexists with deltoid injury and presents with diffuse medial swelling and pain with range of motion.

Recommended Next Steps

Assuming initial history and focused exam (including Ottawa Ankle Rules, squeeze test, single-leg heel rise, and neurovascular assessment) have been performed:

- Imaging: Radiographs (AP, lateral, mortise views) are the appropriate initial study if Ottawa Ankle Rules are positive. Full-length fibular views should be obtained if a Maisonneuve fracture is suspected. If radiographs are negative but pain persists beyond 1 week, MRI without contrast is the reference standard for evaluating deltoid integrity, occult fracture, osteochondral lesion, tendon pathology, and syndesmotic injury. Ultrasound is a reasonable alternative for targeted deltoid or tendon assessment, with sensitivity up to 100% for deltoid rupture.[2][3][13][14][15]

- Red flags for escalation: Inability to bear weight, gross instability on exam, widened mortise on radiographs, or suspected Maisonneuve fracture warrant urgent orthopedic evaluation.[1][4]

Is there additional clinical context such as the patient's age, activity level, ability to bear weight, or whether initial radiographs have already been obtained that would help narrow the differential further?

References

Deltoid Ligament Rupture in Ankle Fracture: Diagnosis and Management. Lee S, Lin J, Hamid KS, Bohl DD. The Journal of the American Academy of Orthopaedic Surgeons. 2019;27(14):e648-e658. doi:10.5435/JAAOS-D-18-00198.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. Herring SA, Kibler WB, Putukian M, et al. Medicine and Science in Sports and Exercise. 2024;56(3):385-401. doi:10.1249/MSS.0000000000003324.

ACR Appropriateness Criteria Acute Trauma to the Ankle. Smith SE, Chang EY, Ha AS, et al. Journal of the American College of Radiology : JACR. 2020;17(11S):S355-S366. doi:10.1016/j.jacr.2020.09.014.

Management of Acute Ankle Sprains: Common Questions and Answers. Wu V, Padilla CA, Smith NA. American Family Physician. 2025;112(6):609-617.

Acute Tears of the Tibialis Posterior Tendon Following Ankle Sprain. Jackson LT, Dunaway LJ, Lundeen GA. Foot & Ankle International. 2017;38(7):752-759. doi:10.1177/1071100717701686.

The Difficult Diagnosis of Posterior Tibialis Tendon Rupture in Sports Injuries. Marcus RE, Goodfellow DB, Pfister ME. Orthopedics. 1995;18(8):715-21. doi:10.3928/0147-7447-19950801-05.

Tendinopathies of the Foot and Ankle. Deu RS, Coslick AM, Dreher G. American Family Physician. 2022;105(5):479-486.

Surgical Treatment for Osteochondral Lesions of the Talus. Powers RT, Dowd TC, Giza E. Arthroscopy : The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2021;37(12):3393-3396. doi:10.1016/j.arthro.2021.10.002.

National Athletic Trainers' Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes. Kaminski TW, Hertel J, Amendola N, et al. Journal of Athletic Training. 2013 Jul-Aug;48(4):528-45. doi:10.4085/1062-6050-48.4.02.

Heel Pain: Diagnosis and Management. Morancie NA, Irvin L, Rayala BZ. American Family Physician. 2025;112(6):648-656.

Heel Pain: Diagnosis and Management. Tu P. American Family Physician. 2018;97(2):86-93.

How Common Is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury?. Foster KS, Greenlee TA, Young JL, Janney CF, Rhon DI. The Journal of Knee Surgery. 2022;35(11):1181-1191. doi:10.1055/s-0042-1751246.

ACR Appropriateness Criteria Chronic Ankle Pain: Update 2025. Expert Panel on Musculoskeletal Imaging, Schonberger A, Bartolotta RJ, et al. Journal of the American College of Radiology : JACR. 2026;:S1546-1440(26)00066-9. doi:10.1016/j.jacr.2026.02.006.

Diagnostic Tools to Evaluate Ankle Instability Caused by a Deltoid Ligament Rupture in Patients With Supination-External Rotation Ankle Fractures: A Systematic Review and Meta-Analysis. de Krom MA, Kalmet PH, Jagtenberg EM, et al. Injury. 2022;53(2):724-731. doi:10.1016/j.injury.2021.09.034.

The Value of Radiologic Diagnostics in Evaluating Deltoid Integrity in Isolated Type B Ankle Fractures: A Systematic Review of the Literature. van Leeuwen CAT, Krijnen P, Hoogendoorn JM, Schipper IB. Archives of Orthopaedic and Trauma Surgery. 2022;142(7):1523-1530. doi:10.1007/s00402-021-03850-y.

Sorry for you! Ankle sprains suck!

Defer to the docs. But have an unfortunate amount of experience with rolling my right ankle outward. It often was accompanied by a pop. Hurt like hell swelled and bruised. Became a chronic reinjury thing for a a bunch of years.

Saw an ortho a number time. Always just a severe sprain and all that went with it.

Actually finally doing pretty well.

'93, dunked on a 9' goal. Rolled my left ankle, badly.
Crutches for 3 weeks. No running/bouncing, etc. for six weeks. Lots of ice.