Name of the Condition

• Common Name: Ankle sprain
• Medical Term: Sprain of unspecified ligament of right ankle, initial encounter

Summary

An ankle sprain is an injury where one or more ligaments of the ankle are stretched, torn, or otherwise damaged. It commonly occurs due to a sudden twist or roll of the foot, causing pain and instability.

Causes

Ankle sprains often result from activities that require sudden changes in direction, such as sports, or from uneven surfaces which may cause the ankle to turn awkwardly.

Risk Factors

• Participation in sports, especially those involving running, jumping, or sharp movements
• Walking or running on uneven surfaces
• Previous ankle injuries, which can weaken ligaments
• Wearing inappropriate or unsupportive footwear

Symptoms

• Swelling and bruising around the ankle
• Pain or tenderness when touching or moving the ankle
• Limited range of motion
• Instability and difficulty bearing weight

Diagnosis

• Physical examination to assess pain, swelling, range of motion, and stability
• Imaging tests such as X-rays to rule out fractures, and MRI to assess ligament damage

Treatment Options

• R.I.C.E. method: Rest, Ice, Compression, and Elevation to reduce swelling and pain
• Physical therapy: Exercises to restore strength, flexibility, and balance
• Medication: NSAIDs to alleviate pain and inflammation
• Brace or Splint: To support and stabilize the ankle
• Surgery: In rare cases, to repair severe ligament tears

Prognosis and Follow-Up

With appropriate treatment, most ankle sprains improve within a few weeks. Follow-up care may include physical therapy to prevent future sprains. It is crucial to allow the ligament to fully heal to prevent chronic instability.

Complications

• Chronic ankle pain
• Persistent instability or repeated sprains
• Joint arthritis in the long term

Lifestyle & Prevention

• Strengthening exercises for the foot and ankle
• Wearing appropriate footwear, especially in sports
• Being cautious when walking on uneven surfaces
• Using ankle braces if advised after a previous injury

When to Seek Professional Help

• Severe pain or swelling
• Inability to bear weight on the ankle
• Ankle appears deformed
• No improvement after a few days of self-care

Additional Resources

• American Orthopaedic Foot & Ankle Society (AOFAS): aofas.org
• National Institute of Arthritis and Musculoskeletal and Skin Diseases: niams.nih.gov

Tips for Medical Coders

• Confirm the encounter is initial (indicated by 'A' in the code).
• Ensure laterality is correct – this relates to the right ankle.
• Avoid misclassification with similar conditions like strains or fractures.