The Ottawa Ankle Rules (OAR) were developed at the University of Ottawa in 1992 and have a sensitivity of 98–100% for ankle and midfoot fractures — their use eliminates unnecessary X-rays in 30–40% of ankle injury presentations. The rules apply only to acute ankle injuries in adults — they are less validated in children (growth plates complicate interpretation), pregnant women, and patients with multiple injuries. Critically, the inability to weight-bear immediately after injury is as important a criterion as bony tenderness — a patient who hobbles 4 steps but cannot stand on the injured ankle still meets the weight-bearing criterion for X-ray. Achilles tendon rupture is the most commonly missed significant ankle injury — the Simmonds squeeze test takes 5 seconds and should be performed in every case of acute Achilles/posterior heel pain. A palpable gap in the tendon is present in 70% of complete ruptures.

The distinction between an acute lateral ligament sprain and a chronic ankle instability syndrome is clinically important. A single significant sprain that is inadequately rehabilitated leads to persistent proprioceptive deficit and mechanical laxity — the patient describes the ankle "giving way" on uneven ground. This is not a new injury each time but ongoing instability from the original inadequately healed ligament. The treatment is proprioceptive rehabilitation via physiotherapy, not repeated rest and RICE. Patients who present with recurrent "ankle sprains" without adequate rehabilitation should be referred to physiotherapy for a structured proprioceptive and strengthening programme. Persistent instability despite 6 months of physiotherapy may indicate a ligament reconstruction referral to orthopaedics.

Peroneal tendon pathology is the most commonly missed diagnosis after an ankle sprain — studies show that 25% of patients with "chronic lateral ankle pain after sprain" have a peroneal tendon tear as the primary pathology rather than residual ligament injury. The peroneal tendons run posterior to the lateral malleolus in a shared fibrous tunnel — they stabilise the ankle in eversion and are stressed during inversion injuries. A peroneal tendon tear presents with persistent lateral ankle pain, swelling along the peroneal tendons (not at the ligament), and pain with resisted eversion. If lateral ankle pain persists beyond 6–8 weeks without improvement despite appropriate management, USS or MRI of the peroneal tendons should be arranged before referral to orthopaedics or physiotherapy. Fluoroquinolone antibiotics (ciprofloxacin, ofloxacin) are a significant risk factor for tendon rupture — both Achilles and peroneal tendons — via an unclear mechanism. This is a black box FDA warning and is documented in the MHRA SPC. Avoid in patients with current tendinopathy.

Serum urate during an acute gout attack may be paradoxically normal or low — the acute inflammatory response redistributes urate from serum into the joint and tissues. A normal urate during an acute attack does not exclude gout. Urate should be re-measured 4–6 weeks after the acute attack resolves to establish the true baseline level for urate-lowering therapy (ULT) decisions. Target urate for ULT is <360 μmol/L (<300 μmol/L for tophaceous gout). The mortise view (15–20° internal rotation) is the most important X-ray for ankle assessment — it shows the tibiotalar joint space and the integrity of the ankle mortise. A widened lateral clear space (>5 mm) indicates syndesmotic disruption — a high ankle sprain that requires orthopaedic assessment and may need screw fixation.

The management of acute Achilles tendon rupture (conservative vs surgical) remains debated — the UKSTAR trial (UK) demonstrated equivalent functional outcomes with functional rehabilitation in a controlled ankle motion (CAM) boot versus surgical repair, with significantly fewer complications (wound infection, sural nerve injury, deep vein thrombosis) in the conservative group. Most UK orthopaedic centres now offer functional conservative management (immediate weight-bearing in equinus CAM boot) as the primary approach, reserving surgery for young athletes with high performance demands. The GP's role is to diagnose the rupture, immobilise immediately (backslab if available, or immediate orthopaedic referral), and arrange same-day review — not to decide on surgical vs conservative management.

The Alfredson eccentric loading protocol for Achilles tendinopathy was developed in 1998 and remains the best-evidenced single treatment — in Alfredson's original study, 100% of patients returned to pre-injury level of activity at 12 weeks. Eccentric (lengthening) contractions specifically stimulate neovascularisation and collagen remodelling in the tendon. The programme requires compliance with twice daily exercises for 12 weeks — explaining the mechanism and time commitment to patients significantly improves adherence. Corticosteroid injection for Achilles tendinopathy should be avoided — multiple studies show a short-term improvement in pain followed by a significantly increased risk of complete Achilles rupture. This is in contrast to plantar fasciitis (where steroid injection has a clear role). Starting allopurinol during an acute gout attack prolongs and worsens the attack — NICE and ACR guidelines both state that ULT should be initiated only after the acute attack has fully resolved, with prophylactic colchicine or NSAID cover for the first 3–6 months.

VTE prophylaxis in lower limb immobilisation is a frequently neglected clinical duty in primary care. The NICE guideline NG89 (VTE prevention) specifies that patients immobilised in a plaster cast or functional brace following a lower limb injury should have a VTE risk assessment performed and LMWH considered. The risk is highest for above-knee immobilisation (thigh and knee injuries) but ankle fractures in plaster also carry a 2–4-fold increased DVT risk. LMWH is prescribed for the duration of immobilisation plus 7 days. GPs who prescribe plaster or arrange immobilisation must document VTE risk assessment — this is a medicolegal obligation. The specific LMWH dose for VTE prophylaxis (not treatment) is weight-based: tinzaparin 3500 units OD subcutaneously or enoxaparin 40 mg OD subcutaneously.

Proprioceptive rehabilitation is the most important component of ankle sprain management for preventing recurrence — yet it is rarely prescribed in primary care, where PRICE (Protection, Rest, Ice, Compression, Elevation) is often the only advice given. Studies show that ankle sprain recurrence rates are 40–70% without proprioceptive rehabilitation, falling to 20% with a structured balance training programme. The mechanism is restoration of ankle proprioceptive afferent signalling — ligament injury disrupts the mechanoreceptors in the ligament, impairing balance and increasing the risk of re-injury. Balance board training retrains the central nervous system to compensate. This takes 12 weeks of consistent daily practice. Gout medication review is often the most impactful intervention — thiazide diuretics (bendroflumethiazide, hydrochlorothiazide) significantly raise serum urate and are a major treatable contributor to recurrent gout. Switching to an alternative antihypertensive (amlodipine, losartan — the latter is mildly uricosuric) can reduce gout frequency dramatically without ULT.

Extracorporeal shockwave therapy (ESWT) for chronic refractory Achilles tendinopathy is supported by NICE IPG571 — it delivers acoustic shockwaves through the skin to stimulate neovascularisation and collagen remodelling in the tendon. It is performed as an outpatient procedure over 3 sessions. NICE evidence supports its use when conservative treatment (including eccentric loading) has failed for a minimum of 3 months. It is not available in all areas but can be accessed via physiotherapy MSK services or private. PRP (platelet-rich plasma) injection for tendinopathy shows promising early results in trials but is not currently funded by NHS for most indications — it may be available privately. The key principle: if 12 weeks of compliant Alfredson protocol fails, referral to a specialist MSK service is warranted rather than simply continuing the same management.