EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis for James’ presentation?

• Prompt: Based on his history and examination, what are the most likely causes of his symptoms?
• Prompt: How would you differentiate between an ankle sprain, strain, and fracture?

Q2. What is the most appropriate initial management for James?

• Prompt: What treatment strategies should be implemented in the acute phase?
• Prompt: When should imaging be considered?

Q3. James is concerned about returning to work and soccer. How would you advise him?

• Prompt: How long should he avoid sports and heavy activity?
• Prompt: What rehabilitation strategies should he follow to optimise recovery?

Q4. What are the red flags that would prompt further investigation or specialist referral?

• Prompt: What clinical features might indicate a more serious injury such as a fracture or ligament rupture?
• Prompt: When should an orthopaedic or physiotherapy referral be considered?

Q5. What preventive strategies can help reduce the risk of future ankle injuries?

• Prompt: What advice would you give regarding strengthening, footwear, and warm-ups?
• Prompt: How can he modify his activities to reduce re-injury risk?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your differential diagnosis for James’ presentation?

Answer:

James presents with ankle pain, swelling, and difficulty weight-bearing following an inversion injury while playing soccer. The most likely differential diagnoses include:

1. Ankle Sprain (Most Likely Diagnosis)

• Most commonly involves lateral ligament complex, particularly the anterior talofibular ligament (ATFL).
• Key findings: lateral swelling, tenderness over ATFL, and pain on inversion.
• No bony tenderness or significant laxity suggests a Grade 1 or 2 sprain rather than rupture.

2. Ankle Strain

• Involves injury to musculotendinous structures rather than ligaments.
• Would present with pain on resisted movement and muscle belly tenderness, which is absent in James’ case.

3. Ankle Fracture

• Ottawa Ankle Rules guide the need for imaging:
  • Bony tenderness at posterior edge of malleoli or 5th metatarsal.
  • Inability to bear weight immediately or in clinic.
• James can bear weight and has no malleolar tenderness, making a fracture less likely.

4. Syndesmotic Injury (“High Ankle Sprain”)

• Occurs with external rotation injuries, affecting anterior tibiofibular ligament.
• Presents with pain above the ankle joint, positive squeeze test.
• James’ injury mechanism (inversion) makes this unlikely.

5. Peroneal Tendon Injury

• Considered if there is pain behind the lateral malleolus, subluxation sensation, or tenderness over the peroneal tendons, which are not present in this case.

Given James’ mechanism of injury, physical exam findings, and ability to bear weight, a Grade 1-2 lateral ankle sprain is the most likely diagnosis. Imaging is not immediately required, but follow-up should ensure no delayed presentation of significant injury.

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Q2: What is the most appropriate initial management for James?

Answer:

The acute management of a lateral ankle sprain follows the RICE principles and focuses on reducing pain, minimising swelling, and promoting functional recovery.

1. RICE Protocol (First 48 Hours)

• Rest: Avoid excessive weight-bearing. Use crutches if pain prevents normal gait.
• Ice: Apply 15–20 minutes every 2 hours to reduce inflammation.
• Compression: Use an elastic bandage or ankle brace to limit swelling.
• Elevation: Keep the ankle above heart level when resting.

2. Pain Management

• Paracetamol or NSAIDs (e.g., ibuprofen) for pain relief.
• NSAIDs can be used after 48 hours, as early use may delay ligament healing.

3. Functional Support

• Use ankle taping or a semi-rigid brace for support.
• Avoid prolonged immobilisation to prevent stiffness and muscle atrophy.

4. Indications for Imaging (Ottawa Ankle Rules)

• Bony tenderness over posterior malleolus, 5th metatarsal, or navicular.
• Inability to bear weight for 4 steps at injury or in the clinic.
• If these are present, X-ray should be arranged.

5. Follow-up Plan

• Review in 1 week to assess swelling, pain, and function.
• If symptoms persist beyond 2 weeks, consider physiotherapy.

James should be reassured that most Grade 1-2 ankle sprains resolve within 2-4 weeks, but adherence to rehabilitation is essential for full recovery.

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Q3: James is concerned about returning to work and soccer. How would you advise him?

Answer:

James’ return to work and sport should be gradual and structured to prevent re-injury.

1. Returning to Work (Warehouse Assistant – Standing & Lifting)

• Modified duties (e.g., avoiding prolonged standing, reducing heavy lifting) for 1–2 weeks.
• Ankle brace or taping can provide support.
• Consider a medical certificate for light duties if needed.

2. Returning to Soccer (Sporting Activity)

• Mild sprains: Return in 2-3 weeks if pain-free.
• Moderate sprains: May take 4-6 weeks.
• Gradual re-introduction:
  • Phase 1: Strength and proprioception exercises.
  • Phase 2: Non-contact drills (e.g., jogging, agility).
  • Phase 3: Full training, then match play.

3. Rehabilitation Exercises

• Balance exercises (single-leg stand) to improve proprioception.
• Strengthening (calf raises, resistance band exercises).
• Stretching (gentle dorsiflexion and eversion stretches).

James should avoid rushing back too soon, as early return without full recovery increases re-injury risk.

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Q4: What are the red flags that would prompt further investigation or specialist referral?

Answer:

James requires further assessment or referral if the following red flags are present:

1. Signs of Fracture (Indicating Urgent Imaging)

• Inability to bear weight for 4 steps.
• Bony tenderness at the posterior malleolus, navicular, or 5th metatarsal.
• Gross deformity or open wounds.

2. Signs of Severe Ligament Injury

• Significant joint laxity on anterior drawer test (suggesting Grade 3 sprain or rupture).
• Persistent instability or recurrent giving-way episodes beyond 6 weeks.

3. Syndesmotic Injury (High Ankle Sprain)

• Pain above the ankle joint.
• Positive squeeze test or external rotation test.
• Requires MRI and orthopaedic referral if suspected.

4. Persistent Symptoms Beyond 6 Weeks

• Ongoing pain, swelling, or stiffness despite rehabilitation.
• Consider MRI to assess for ligament rupture or cartilage damage.

Referral to orthopaedics or sports physiotherapy may be needed for advanced rehabilitation or surgical evaluation if conservative management fails.

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Q5: What preventive strategies can help reduce the risk of future ankle injuries?

Answer:

Preventing ankle sprains is crucial, especially for active individuals like James. Key strategies include:

1. Strength & Proprioception Training

• Balance exercises (e.g., wobble board, single-leg stance) to improve stability.
• Strengthening exercises (calf raises, resistance band drills).

2. Proper Footwear & Equipment

• Supportive shoes with good lateral stability.
• Consider ankle braces or taping for high-risk activities (e.g., soccer).

3. Warm-Up & Stretching

• Dynamic warm-up (e.g., leg swings, jogging) before sport.
• Post-exercise stretching to maintain flexibility.

4. Avoid Playing on Unstable Surfaces

• Uneven ground increases injury risk.
• Consider using ankle braces on risky surfaces.

Following these strategies reduces re-injury risk by up to 50% and helps James safely return to his activities.

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SUMMARY OF A COMPETENT ANSWER

• Applies evidence-based criteria (Ottawa Ankle Rules) for imaging decisions.
• Provides clear, structured management using RICE principles.
• Gives practical return-to-work and sport advice.
• Identifies red flags for further investigation.
• Discusses preventive strategies based on physiotherapy best practices.

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PITFALLS

• Failing to consider high ankle sprain or syndesmotic injury.
• Not applying Ottawa Ankle Rules correctly, leading to unnecessary imaging.
• Neglecting functional rehabilitation, increasing risk of chronic instability.
• Providing vague return-to-play advice without a structured plan.

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REFERENCES

• RACGP – RACGP Musculoskeletal Guidelines
• GP Exams – Sprain/Strain

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MARKING

Each competency area is assessed on a scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD