What are the red flags for ankle & foot injury in urgent care?

Neurovascular compromise or tented skin → Reduce/splint and refer to ED/ortho now; Open wound over fracture → Open fracture pathway — antibiotics, ortho; Proximal fibula tenderness → Maisonneuve injury — X-ray full fibula; Positive Simmonds test / palpable gap → Achilles rupture — equinus backslab, ortho/fracture clinic; Hot swollen joint without clear injury → Septic arthritis / gout — not a sprain; Unable to weight-bear and diabetic neuropathy → Charcot foot — specialist foot team

Which decision rule is used for ankle & foot injury?

Ottawa ankle & foot rules: Bone tenderness at posterior edge or tip of lateral malleolus (distal 6 cm); Bone tenderness at posterior edge or tip of medial malleolus (distal 6 cm); Bone tenderness at base of 5th metatarsal (foot X-ray); Bone tenderness at navicular (foot X-ray); Unable to weight-bear 4 steps both immediately and in clinic. Any one positive → X-ray (ankle and/or foot). All negative → no X-ray needed. Less reliable if intoxicated, reduced sensation, or under 5.

What should I prescribe for ankle & foot injury?

Paracetamol: 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) (As needed); Ibuprofen 5% gel (topical NSAID): Apply thinly up to 3 times a day (Up to 1–2 weeks); Ibuprofen: 400 mg three times a day with food (3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy)

● Urgent care clinic · 30-minute consult

Ankle & foot injury

Q: What safety-netting advice should I give for ankle & foot injury?

Advise the patient to return or seek help if: Calf pain or swelling, or breathlessness (DVT/PE); Foot becomes cold, pale, numb or very swollen; Pain getting worse rather than better, or can’t walk after a few days; No improvement in 2–3 weeks.

Twisted ankle or foot — Ottawa rules decide the X-ray.

Typical consult⏱ 15 min

Investigations🔬 X-ray only if Ottawa positive

Usual outcome💊 Analgesia + RICE + walking

0–5Red flags + history5–12Examine12–17Decide17–24Treat + explain24–30Safety-net + document

1Rule out first — red flags

If you find…	…then
Neurovascular compromise or tented skin	Reduce/splint and refer to ED/ortho now
Open wound over fracture	Open fracture pathway — antibiotics, ortho
Proximal fibula tenderness	Maisonneuve injury — X-ray full fibula
Positive Simmonds test / palpable gap	Achilles rupture — equinus backslab, ortho/fracture clinic
Hot swollen joint without clear injury	Septic arthritis / gout — not a sprain
Unable to weight-bear and diabetic neuropathy	Charcot foot — specialist foot team

4Decide — investigate only if it changes the plan

Ottawa ankle & foot rules

Bone tenderness at posterior edge or tip of lateral malleolus (distal 6 cm)
Bone tenderness at posterior edge or tip of medial malleolus (distal 6 cm)
Bone tenderness at base of 5th metatarsal (foot X-ray)
Bone tenderness at navicular (foot X-ray)
Unable to weight-bear 4 steps both immediately and in clinic

Any one positive → X-ray (ankle and/or foot). All negative → no X-ray needed. Less reliable if intoxicated, reduced sensation, or under 5.

Investigation	Only if…
Ankle X-ray (AP + mortise + lateral)	Only if Ottawa ankle rule positive
Foot X-ray	Only if Ottawa foot rule positive

5Treat & send home

Management & advice

PRICE for 48–72 h: protect, rest, ice 15–20 min every 2–3 h while awake (not directly on skin), compression only if comfortable, elevate
Avoid HARM for 72 h: heat, alcohol, running, massage
Early weight-bearing as pain allows; crutches if needed
Simple sprain: expect 2–6 weeks to improve; return to sport gradually
Fracture: follow local fracture pathway (e.g. stable Weber A / 5th MT base avulsion → walking boot + virtual fracture clinic)

Refer / follow-up

Fracture → local fracture clinic / virtual fracture clinic
Achilles rupture → same-day ortho or fracture clinic in equinus
Not improving after 2–3 weeks → GP/physiotherapy (self-referral where available)

℞

Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.

Drug	Dose	Duration / notes
Paracetamol	1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk)	As needed
Ibuprofen 5% gel (topical NSAID)	Apply thinly up to 3 times a day	Up to 1–2 weeks
Ibuprofen	400 mg three times a day with food	3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy

6Safety-net

Say it like this

This looks like a sprain — no sign of a broken bone using the checks we do. Keep walking on it as much as you can, ice and raise it, and use the painkillers. Most ankles feel much better in 2 to 6 weeks. Come back or call 111 if your foot goes cold, numb or very swollen, if you get calf pain or feel breathless, or if you still can’t walk on it after a few days.

Come back / call 111 — or 999 if severe — if:

Calf pain or swelling, or breathlessness (DVT/PE)
Foot becomes cold, pale, numb or very swollen
Pain getting worse rather than better, or can’t walk after a few days
No improvement in 2–3 weeks

7Patient leaflets — scan & go

Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.

Sprains and strainsnhs.uk/conditions/sprains-and-strains

Broken anklenhs.uk/conditions/broken-ankle

8Document

Ankle & foot injury — clinic note

A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.

URGENT CARE — ANKLE & FOOT INJURY PRESENTING COMPLAINT: HISTORY Mechanism: inversion / eversion / direct blow / fall from height: Able to weight-bear immediately and now (4 steps)?: Heard a pop or crack? Immediate swelling?: Previous injuries or instability: Occupation, sport, driving, who is at home: PMH: diabetes, osteoporosis, anticoagulants; analgesia taken: RED FLAGS (record present / absent) [ ] Neurovascular compromise or tented skin [ ] Open wound over fracture [ ] Proximal fibula tenderness [ ] Positive Simmonds test / palpable gap [ ] Hot swollen joint without clear injury [ ] Unable to weight-bear and diabetic neuropathy PMH: DRUG HISTORY: ALLERGIES: SOCIAL (job / who is at home / driving): OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 ) EXAMINATION Look: swelling, bruising, deformity, skin integrity: Feel: posterior edge/tip of both malleoli (distal 6 cm), base of 5th metatarsal, navicular, proximal fibula: Squeeze test (syndesmosis) and Simmonds test (Achilles): Distal pulses, capillary refill, sensation: Watch them walk 4 steps: DECISION RULE — Ottawa ankle & foot rules: result ______ INVESTIGATIONS: none required / Ankle X-ray (AP + mortise + lateral), Foot X-ray — result: IMPRESSION: PLAN Treatment / TTO (drug, dose, duration): Advice given: Leaflet given (QR / printed): Sprains and strains, Broken ankle Follow-up / referral: SAFETY-NETTING (told to return / call 111 / 999 if): - Calf pain or swelling, or breathlessness (DVT/PE) - Foot becomes cold, pale, numb or very swollen - Pain getting worse rather than better, or can’t walk after a few days - No improvement in 2–3 weeks Patient understands and agrees with the plan: Y / N Seen by: Grade: Date/Time:

✓Guidelines

Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.

More injuries & musculoskeletal

Knee injuryTwisting or direct knee injury — Ottawa knee rule, spot the ACL and locked knee.Wrist injury & scaphoidFall on the outstretched hand — distal radius vs scaphoid.Hand & finger injuryBoxer’s fracture, mallet finger, crush injuries and the hand you must not miss.Shoulder & collarbone injuryCollarbone fractures, ACJ injuries and the dislocated shoulder.