Raiyyan Tahsan

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TC(1048).(05).Orthopedics Case No 126:- Ankle Sprain

Ankle Sprain — গোড়ালির লিগামেন্ট মচকানো

ক্লিনিক্যাল নোট: নিচের ড্রাগ ডোজগুলো সাধারণত প্রাপ্তবয়স্ক রোগীর জন্য। Pregnancy, CKD, peptic ulcer, anticoagulant use, uncontrolled HTN/CVD, asthma/NSAID allergy, liver disease, elderly, child—এসব ক্ষেত্রে ডোজ/ড্রাগ বদলাতে হবে। X-ray লাগবে কি না তা Ottawa Ankle Rules দিয়ে সিদ্ধান্ত নেওয়া উচিত।

1. Definition — সংজ্ঞা

Ankle sprain হলো গোড়ালির joint-এর আশেপাশের ligament অতিরিক্ত stretch বা tear হওয়া—সাধারণত inversion injury-তে lateral ligament complex, বিশেষ করে anterior talofibular ligament বা ATFL, সবচেয়ে বেশি affected হয়। 2021 JOSPT clinical practice guideline lateral ankle ligament sprain-এর diagnosis, treatment ও prevention-এ functional assessment, early mobilisation, external support এবং exercise rehabilitation-কে গুরুত্ব দিয়েছে।

2. Cause / Etiology — কারণগুলো

A. Common mechanism

  • Inversion injury — পা ভেতরের দিকে বেঁকে যাওয়া
    • সবচেয়ে common।
    • সাধারণত lateral ankle ligament injured হয়।
    • ATFL প্রথমে, severe হলে CFL, তারপর PTFL involve হতে পারে।
  • Plantar flexion + inversion
    • দৌড়, jump landing, uneven ground-এ পা পড়া, stairs থেকে নামার সময় বেশি হয়।
    • ATFL injury-এর classic mechanism।
  • Eversion injury — পা বাইরের দিকে বেঁকে যাওয়া
    • Medial/deltoid ligament sprain হতে পারে।
    • Deltoid ligament শক্তিশালী হওয়ায় isolated medial sprain তুলনামূলক কম; fracture/syndesmotic injury exclude করতে হয়।
  • External rotation / dorsiflexion injury
    • High ankle sprain বা syndesmotic sprain হতে পারে।
    • Pain ankle joint-এর একটু উপরে, recovery ধীরে, athlete-দের ক্ষেত্রে গুরুত্বপূর্ণ।

B. Risk factors — ঝুঁকির কারণ

  • আগে ankle sprain হওয়া — সবচেয়ে গুরুত্বপূর্ণ risk factor।
  • Poor balance/proprioception।
  • Weak peroneal muscles।
  • High-heeled shoe বা unstable footwear।
  • Uneven surface, wet floor, sports court।
  • Obesity।
  • Ligament laxity / hypermobility।
  • Inadequate warm-up।
  • Returning to sport before full rehab।

3. Pathophysiology — কীভাবে ক্ষতি হয়

  • অতিরিক্ত stretch হলে ligament fibre microscopic tear → pain ও swelling।
  • Partial tear হলে joint movement painful হয়, কিন্তু instability কম।
  • Complete rupture হলে joint laxity/instability হয়।
  • Tissue injury → prostaglandin-mediated inflammation → pain, swelling, warmth।
  • Recurrent sprain হলে mechanoreceptor damage → proprioception কমে → chronic ankle instability হতে পারে।

4. Symptoms — লক্ষণগুলো

  • Pain
    • Injury-এর সাথে সাথেই lateral ankle-এ sharp pain।
    • Walking, stair climbing, weight-bearing-এ pain বাড়ে।
  • Swelling
    • সাধারণত ৩০ মিনিট থেকে কয়েক ঘণ্টার মধ্যে ফুলে যায়।
    • Severe swelling হলে fracture/major ligament tear ভাবতে হবে।
  • Bruising / ecchymosis
    • ২৪–৪৮ ঘণ্টার মধ্যে নীলচে দাগ দেখা যায়।
    • Extensive bruising = Grade II/III sprain বা fracture সন্দেহ।
  • Tenderness
    • ATFL area: lateral malleolus-এর anterior-inferior part।
    • CFL area: lateral malleolus-এর নিচে।
    • Syndesmosis হলে ankle joint-এর উপরের anterior tibiofibular area painful।
  • Difficulty walking
    • ৪ steps হাঁটতে না পারলে X-ray indication হতে পারে—Ottawa Ankle Rules অনুযায়ী।
  • Instability / giving way
    • Severe tear বা recurrent sprain-এ বেশি দেখা যায়।
  • Reduced range of motion
    • Pain, swelling ও muscle guarding-এর কারণে dorsiflexion/plantar flexion কমে যায়।

5. Severity Grading — ক্লিনিক্যাল গ্রেড

Grade I — mild sprain

  • Ligament stretch / microscopic tear।
  • Mild pain, mild swelling।
  • Walking possible।
  • Instability নেই।
  • Recovery সাধারণত ১–২ সপ্তাহ।

Grade II — moderate sprain

  • Partial ligament tear।
  • Moderate pain, swelling, bruising।
  • Walking painful।
  • Mild–moderate instability থাকতে পারে।
  • Recovery সাধারণত ৩–৬ সপ্তাহ।

Grade III — severe sprain

  • Complete ligament rupture।
  • Severe swelling, bruising, marked tenderness।
  • Weight-bearing difficult/impossible।
  • Instability prominent।
  • Recovery ৬–১২ সপ্তাহ বা বেশি; orthopedic/physio follow-up দরকার।

6. Clinical Diagnosis — ক্লিনিক্যাল ডায়াগনোসিস

A. History-taking — কী জিজ্ঞেস করবেন

  • Injury mechanism: inversion, eversion, twisting, fall, sports injury।
  • Immediate swelling হয়েছে কি না।
  • Pop/snap sound হয়েছিল কি না।
  • Weight-bearing ability: injury-এর পর ও clinic-এ ৪ steps হাঁটতে পারে কি না।
  • Previous ankle sprain।
  • Pain location: lateral, medial, posterior, midfoot, syndesmotic area।
  • Neurovascular symptoms: numbness, cold foot, weakness।
  • Comorbidities: diabetes, neuropathy, anticoagulant, CKD, PUD।

B. Inspection

  • Swelling location।
  • Bruising।
  • Deformity আছে কি না—deformity থাকলে fracture/dislocation until proven otherwise।
  • Skin wound/open injury।

C. Palpation — specific points

  • Posterior edge/tip of lateral malleolus।
  • Posterior edge/tip of medial malleolus।
  • Base of 5th metatarsal।
  • Navicular bone।
  • ATFL, CFL, PTFL tenderness।
  • Syndesmosis/AITFL tenderness।
  • Achilles tendon gap/tenderness।

D. Functional test

  • Patient ৪ steps হাঁটতে পারে কি না।
  • Single-leg stance, heel raise—acute severe pain থাকলে avoid।

E. Special tests

  • Anterior drawer test
    • ATFL tear/instability detect করতে।
    • Acute pain বেশি হলে প্রথম দিন reliable নাও হতে পারে; ৪–৭ দিন পরে repeat করলে ভালো।
  • Talar tilt test
    • CFL injury assess করতে।
  • Squeeze test / external rotation stress test
    • Syndesmotic বা high ankle sprain সন্দেহে।
  • Thompson test
    • Achilles tendon rupture exclude করতে।

7. Investigations — কোন পরীক্ষা কখন করবেন

A. X-ray — কখন করবেন

Ottawa Ankle Rules positive হলে ankle X-ray করতে হবে। ACR guideline-এ acute ankle trauma-তে Ottawa positive হলে ankle radiographs usually appropriate বলা হয়েছে।

Ankle X-ray indication:

  • Malleolar zone pain + নিচের যেকোনো একটিঃ
    • Posterior edge/tip of lateral malleolus tenderness
    • Posterior edge/tip of medial malleolus tenderness
    • Injury-এর পর বা clinic-এ ৪ steps হাঁটতে অক্ষম

Foot X-ray indication:

  • Midfoot pain + নিচের যেকোনো একটিঃ
    • Base of 5th metatarsal tenderness
    • Navicular tenderness
    • ৪ steps হাঁটতে অক্ষম

Views: AP, lateral, mortise view ankle X-ray।

B. MRI — কখন করবেন

  • Pain/swelling ৬ সপ্তাহের বেশি persist করলে।
  • Suspected osteochondral lesion of talus।
  • Syndesmotic injury।
  • Peroneal tendon tear।
  • Occult fracture।
  • Recurrent instability।
  • Elite athlete / surgical planning।

C. Ultrasound

  • Dynamic ligament/tendon assessment করা যায়।
  • Experienced operator থাকলে ATFL/CFL tear, tendon injury দেখা যায়।
  • Fracture exclude করার primary test নয়।

D. CT scan

  • Complex fracture, occult fracture, intra-articular fracture suspected হলে।
  • X-ray abnormal/unclear হলে।

E. Lab test

  • Routine ankle sprain-এ lab লাগে না।
  • Fever, cellulitis, septic arthritis, gout, inflammatory arthritis সন্দেহ হলে CBC, ESR/CRP, uric acid, joint aspiration দরকার হতে পারে।

8. Differential Diagnosis — যেগুলো বাদ দিতে হবে

  • Lateral malleolus fracture।
  • Medial malleolus fracture।
  • Base of 5th metatarsal fracture।
  • Navicular fracture।
  • Osteochondral lesion of talus।
  • Syndesmotic / high ankle sprain।
  • Peroneal tendon tear/subluxation।
  • Achilles tendon rupture।
  • Ankle dislocation।
  • Septic arthritis।
  • Acute gout।
  • Cellulitis।
  • DVT — calf swelling/pain থাকলে।

9. Complications — রোগের জটিলতা

  • Chronic ankle instability
    • বারবার ankle মচকায়, হাঁটার সময় “giving way” লাগে।
    • কারণ: ligament laxity + proprioception loss।
  • Recurrent ankle sprain
    • প্রথম sprain-এর পর rehab না করলে recurrence বেশি হয়।
    • Exercise-based rehabilitation recurrent sprain কমাতে সাহায্য করে।
  • Persistent pain and swelling
    • Inadequate rest, occult fracture, osteochondral lesion, tendon injury থাকলে pain দীর্ঘস্থায়ী হয়।
  • Stiffness
    • অতিরিক্ত immobilization করলে joint stiff হয়ে যায়।
  • Osteochondral lesion of talus
    • Deep ankle pain, locking/catching sensation হতে পারে।
  • Peroneal tendon injury
    • Lateral ankle pain persist করে; eversion weakness থাকতে পারে।
  • Complex regional pain syndrome
    • Pain disproportionate, skin colour/temperature change, hypersensitivity।
  • Early osteoarthritis
    • repeated instability ও cartilage injury হলে long-term OA risk বাড়ে।

10. Treatment Management — চিকিৎসা ব্যবস্থাপনা

A. Immediate management: first 48–72 hours

POLICE principle

  • Protection
    • Brace/elastic bandage/ankle support।
    • Severe pain হলে crutch।
  • Optimal Loading
    • সম্পূর্ণ bed rest নয়; pain-tolerated protected weight-bearing।
    • Early controlled movement recovery ভালো করে।
  • Ice
    • ১৫–২০ মিনিট, দিনে ৩–৫ বার, প্রথম ২–৩ দিন।
    • Ice directly skin-এ দেবেন না।
  • Compression
    • Crepe bandage/ankle sleeve।
    • Toes numb/cold/blue হলে bandage ঢিলা করতে হবে।
  • Elevation
    • Heart level-এর উপরে পা তুলে রাখা।

Avoid first 48–72 hours

  • Heat massage।
  • Alcohol rub।
  • Aggressive exercise।
  • Running/jumping।
  • Forceful manipulation।

B. Grade-wise management

Grade I

  • Elastic compression/ankle brace ১–২ সপ্তাহ।
  • Pain-tolerated walking।
  • ROM exercise ২৪–৪৮ ঘণ্টা পর।
  • Return to normal activity: pain-free walking + full ROM হলে।

Grade II

  • Semi-rigid brace/aircast/taping ২–৪ সপ্তাহ।
  • Crutch ২–৫ দিন, pain অনুযায়ী।
  • Physiotherapy: ROM → strengthening → balance/proprioception।
  • Sports return: functional test pass করলে।

Grade III

  • Short immobilization ৭–১০ দিন পর্যন্ত লাগতে পারে।
  • এরপর functional brace + supervised rehab।
  • Orthopedic referral যদি:
    • gross instability,
    • syndesmotic injury,
    • fracture,
    • persistent pain > ৬ weeks,
    • elite athlete,
    • recurrent sprain।

11. Pharmacological Treatment — বাংলাদেশে প্রেসক্রিপশনে ব্যবহৃত ওষুধ

মূলনীতি: একসাথে একাধিক oral NSAID দেবেন না—যেমন ibuprofen + naproxen + diclofenac একসাথে নয়। NSAID short course, lowest effective dose। JOSPT guideline ও systematic review-গুলো acute ankle sprain-এ pain/swelling কমাতে NSAID ব্যবহার সমর্থন করে, তবে rehab অপরিহার্য।

1) Generic name: Paracetamol / Acetaminophen

  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative; non-opioid analgesic
  • Bangladesh available brand name:
    • Napa 500 mg tablet — Paracetamol
    • Ace 500 mg tablet — Paracetamol
    • Fast 500 mg tablet — Paracetamol
    • Xpa 500 mg tablet — Paracetamol
      MedEx lists paracetamol brands such as Ace, Fast, Napa and others; Napa/Ace pages also list sprains among indications.
  • Dose: 500–1000 mg orally every 6–8 hours PRN
  • Maximum: 3 g/day safer routine; selected healthy adultে 4 g/day পর্যন্ত, তবে liver risk বিবেচনা করতে হবে।
  • Duration: 3–5 days PRN
  • কেন used হয়: mild–moderate pain control; NSAID contraindicated হলে first choice।
  • Drug description: central prostaglandin synthesis inhibition; anti-inflammatory effect কম, কিন্তু pain control ভালো।
  • Side effects: nausea, rash, rare liver toxicity; overdose → acute liver failure।
  • Drug interaction: alcohol, warfarin with prolonged high dose, enzyme inducer drugs; multiple cold/flu productsে paracetamol থাকলে overdose risk।
  • Avoid/caution: severe liver disease, chronic alcohol use।

2) Generic name: Ibuprofen

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; non-selective COX inhibitor
  • Bangladesh available brand name:
    • Profen 400 mg tablet — Ibuprofen
    • Flamex 400 mg tablet — Ibuprofen
    • Neurofen 400 mg tablet — Ibuprofen
    • Advel 400 mg tablet — Ibuprofen
      MedEx lists adult ibuprofen dose as 200–400 mg up to 3–4 times daily, maximum 1200 mg/day; Profen/Flamex/Neurofen are listed 400 mg brands.
  • Dose: 200–400 mg orally every 6–8 hours after food PRN
  • Maximum: 1200 mg/day without specialist supervision
  • Duration: 3–5 days
  • কেন used হয়: pain + swelling + inflammation কমাতে।
  • Drug description: COX-1/COX-2 inhibition → prostaglandin synthesis কমে → pain/inflammation কমে।
  • Side effects: dyspepsia, gastritis, ulcer/bleeding, renal impairment, fluid retention, BP increase, bronchospasm, rash।
  • Drug interaction: anticoagulant/antiplatelet, aspirin, steroid, SSRI/SNRI, ACEi/ARB + diuretic, lithium, methotrexate।
  • Avoid/caution: PUD/GI bleeding, CKD, uncontrolled HTN, heart failure, ischemic heart disease, NSAID-induced asthma, pregnancy third trimester।

3) Generic name: Naproxen Sodium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • Bangladesh available brand name:
    • Naprosyn 500 mg tablet — Naproxen sodium
    • Naxin 500 mg tablet — Naproxen sodium
    • Naproxen 500 mg tablet — Naproxen sodium
    • Naprox Plus 500 mg + Esomeprazole 20 mg — combination
      MedEx lists Naprosyn/Naxin/Naproxen 500 mg brands and Naproxen sodium + Esomeprazole 500 mg+20 mg combinations.
  • Dose: 250–500 mg orally twice daily after food
  • Duration: 3–5 days; severe inflammationে 7 days পর্যন্ত physician review সহ
  • কেন used হয়: longer acting NSAID; swelling/pain বেশি হলে useful।
  • Drug description: prostaglandin synthesis inhibition; analgesic + anti-inflammatory।
  • Side effects: gastritis, GI bleed, renal impairment, dizziness, edema, BP rise।
  • Drug interaction: anticoagulants, aspirin, clopidogrel, steroid, SSRI, ACEi/ARB/diuretic, lithium, methotrexate।
  • Avoid/caution: same as NSAIDs; high GI risk হলে PPI বা combination product consider।

4) Generic name: Diclofenac Sodium / Diclofenac Potassium

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; acetic acid derivative; non-selective COX inhibitor
  • Bangladesh available brand name:
    • Diclofen 50 mg tablet — Diclofenac sodium
    • Clofenac 50 mg tablet — Diclofenac sodium
    • A-Fenac 50 mg tablet — Diclofenac sodium
    • A-Fenac K 50 mg tablet — Diclofenac potassium
      MedEx lists diclofenac sodium 50 mg brands including Diclofen/Clofenac/A-Fenac; diclofenac potassium is specifically indicated for post-traumatic pain, inflammation and swelling due to sprains.
  • Dose: 50 mg orally 2–3 times daily after food
  • Maximum: 150 mg/day
  • Duration: 3–5 days
  • কেন used হয়: acute post-traumatic pain, inflammation, swelling কমাতে।
  • Drug description: COX inhibition → prostaglandin কমে → pain/inflammation কমে।
  • Side effects: gastritis, ulcer, GI bleed, renal injury, edema, BP rise, liver enzyme rise, cardiovascular risk।
  • Drug interaction: anticoagulants, antiplatelets, steroids, SSRIs, ACEi/ARB/diuretics, methotrexate, lithium।
  • Avoid/caution: IHD/stroke risk, uncontrolled HTN, CKD, PUD, asthma with NSAID sensitivity।

5) Generic name: Diclofenac Sodium topical gel

  • Therapeutic category: Topical analgesic, anti-inflammatory
  • Pharmacological class: Topical NSAID
  • Bangladesh available brand name:
    • Diclofen 1% w/w gel — Diclofenac sodium
    • Fastfit 1% w/w gel — Diclofenac sodium
    • Fengel 1% w/w gel — Diclofenac sodium
    • VOLINAC 1% w/w gel — Diclofenac sodium + methyl salicylate + linseed oil + menthol combination
      MedEx lists diclofenac 1% gel brands and states diclofenac gel is applied 2–4 g to the affected area 3–4 times daily.
  • Dose: affected area-তে 2–4 g gel, দিনে 3–4 বার
  • Duration: 5–7 days
  • কেন used হয়: localized pain/swelling; oral NSAID contraindicated বা mild sprain হলে useful।
  • Drug description: local COX inhibition; systemic absorption কম।
  • Side effects: local rash, itching, burning, photosensitivity; systemic NSAID side effect rare but possible।
  • Drug interaction: oral NSAID/anticoagulant-এর সাথে combined use করলে bleeding/GI risk theoretical বাড়তে পারে।
  • Avoid/caution: broken skin, eczema, open wound; gel লাগিয়ে tight occlusive dressing নয়।

6) Generic name: Aceclofenac

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID
  • Bangladesh available brand name:
    • Avenac 100 mg tablet — Aceclofenac
    • Reservix 100 mg tablet — Aceclofenac
    • Paino 100 mg tablet — Aceclofenac
    • Ceclofen 100 mg tablet — Aceclofenac
      MedEx states aceclofenac is indicated for pain/inflammation including trauma and lists multiple 100 mg brands.
  • Dose: 100 mg orally twice daily after food
  • Duration: 3–5 days
  • কেন used হয়: pain + inflammation control; অনেক physician acute musculoskeletal trauma-তে ব্যবহার করেন।
  • Drug description: COX inhibition → prostaglandin synthesis কমায়।
  • Side effects: dyspepsia, gastritis, ulcer, renal impairment, dizziness, edema, BP rise।
  • Drug interaction: same NSAID interactions—anticoagulant, steroid, SSRI, ACEi/ARB/diuretic, methotrexate, lithium।
  • Avoid/caution: PUD, CKD, CVD risk, pregnancy third trimester।

7) Generic name: Etoricoxib

  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • Bangladesh available brand name:
    • Etorix 60/90 mg tablet — Etoricoxib
    • Cox-E 60/90/120 mg tablet — Etoricoxib
    • Torimon 90/120 mg tablet — Etoricoxib
    • Recox 60/90/120 mg tablet — Etoricoxib
      MedEx lists etoricoxib brands and doses including 60, 90 and 120 mg strengths.
  • Dose: 60 mg once daily; severe acute inflammatory painে selected patientে 90 mg once daily
  • Duration: 3–5 days; shortest possible course
  • কেন used হয়: NSAID প্রয়োজন কিন্তু GI intolerance তুলনামূলক বেশি হলে selected use; তবে CVD/BP risk evaluate করতে হবে।
  • Drug description: COX-2 selective inhibition → pain/inflammation কমায়; platelet effect তুলনামূলক কম।
  • Side effects: dyspepsia, edema, hypertension, renal impairment, cardiovascular thrombotic risk, headache।
  • Drug interaction: warfarin/anticoagulant, ACEi/ARB/diuretic, lithium, methotrexate।
  • Avoid/caution: ischemic heart disease, stroke/TIA, heart failure, uncontrolled HTN, CKD, pregnancy।

8) Generic name: Pantoprazole / Esomeprazole

  • Therapeutic category: Anti-ulcerant, gastroprotective
  • Pharmacological class: Proton pump inhibitor — PPI
  • Bangladesh available brand name:
    • Pantoprazole: Pantoprazole 20/40 mg, PC-20 20 mg, Pantogut 20/40 mg
    • Esomeprazole: Nexum MUPS 20/40 mg, Esotid 20/40 mg, Maxpro MUPS 20 mg
      MedEx lists pantoprazole 20 mg brands and esomeprazole 20/40 mg brands; PPIs reduce gastric acid and are used for GERD/ulcer/NSAID-induced ulcer risk.
  • Dose:
    • Pantoprazole 20–40 mg once daily before breakfast
    • Esomeprazole 20 mg once daily before breakfast
  • Duration: only during NSAID course, usually 3–7 days; high GI risk হলে longer physician review সহ।
  • কেন used হয়: NSAID-induced gastritis/ulcer risk কমাতে; sprain নিজে treat করে না।
  • Drug description: gastric parietal cell H+/K+ ATPase inhibit করে acid secretion কমায়।
  • Side effects: headache, nausea, diarrhea/constipation; long-term useে hypomagnesemia, B12 deficiency, infection risk।
  • Drug interaction: clopidogrel interaction concern especially omeprazole/esomeprazole; warfarin monitoring; antifungal absorption কমতে পারে।
  • Avoid/caution: unnecessary long-term use।

9) Generic name: Paracetamol + Tramadol Hydrochloride

  • Therapeutic category: Analgesic combination
  • Pharmacological class: Non-opioid analgesic + weak opioid analgesic
  • Bangladesh available brand name:
    • NapaDol 325 mg + 37.5 mg tablet
    • P-Dol 325 mg + 37.5 mg tablet
    • Pangesic 325 mg + 37.5 mg tablet
    • Resadol 325 mg + 37.5 mg tablet
      MedEx lists multiple paracetamol + tramadol 325 mg+37.5 mg brands in Bangladesh.
  • Dose: 1 tablet every 6–8 hours PRN severe pain
  • Maximum: generally 8 tablets/day; paracetamol total daily dose হিসাব করতে হবে
  • Duration: 1–3 days only, if simple analgesic/NSAID inadequate
  • কেন used হয়: severe pain short-term control; routine Grade I sprain-এ দরকার নেই।
  • Drug description: tramadol μ-opioid receptor agonist + serotonin/noradrenaline reuptake inhibition; paracetamol central analgesic।
  • Side effects: dizziness, drowsiness, nausea, vomiting, constipation, dependence, respiratory depression rare, seizure risk।
  • Drug interaction: alcohol, benzodiazepine, sedatives, SSRI/SNRI/TCA/MAOI, antiepileptic drugs; serotonin syndrome/seizure risk।
  • Avoid/caution: epilepsy, substance misuse, severe respiratory disease, pregnancy/lactation, driving/machinery।

10) Generic name: Ketorolac Tromethamine

  • Therapeutic category: Strong short-term analgesic
  • Pharmacological class: NSAID
  • Bangladesh available brand name:
    • Toradolin 10 mg tablet — Ketorolac
    • Ketoact 10 mg tablet — Ketorolac
    • Minolac 10 mg tablet — Ketorolac
    • Maxdol 10 mg tablet — Ketorolac
      MedEx lists ketorolac 10 mg brands and states oral ketorolac 10 mg every 4–6 hours, maximum 40 mg/day, short-term only; MedEx indication is mainly moderate–severe acute post-operative pain, so ankle sprain-এ routine first-line নয়।
  • Dose: 10 mg orally every 6 hours PRN
  • Maximum: 40 mg/day
  • Duration: maximum 5 days; preferably shorter
  • কেন used হয়: severe acute pain, when other options insufficient; uncomplicated ankle sprain-এ routine নয়।
  • Drug description: potent COX inhibitor; strong analgesic, relatively less anti-inflammatory at analgesic dose।
  • Side effects: high GI bleed risk, renal injury, dizziness, edema, bronchospasm।
  • Drug interaction: any NSAID, aspirin, anticoagulant, steroid, SSRI, ACEi/ARB/diuretic, lithium, methotrexate।
  • Avoid/caution: PUD/GI bleed, CKD, bleeding risk, anticoagulant use, elderly, pregnancy, asthma/NSAID allergy।

12. Bangladesh doctors usually prescribe — practical list

Uncomplicated ankle sprain-এ বাংলাদেশে সাধারণত প্রেসক্রিপশনে দেখা যায়:

  • Paracetamol 500 mg
    • mild pain, safer analgesic হিসেবে।
  • One oral NSAID only
    • Ibuprofen 400 mg / Naproxen 500 mg / Diclofenac 50 mg / Aceclofenac 100 mg / Etoricoxib 60–90 mg
    • pain + inflammation + swelling কমানোর জন্য।
  • Topical NSAID gel
    • Diclofenac gel 1%
    • localized pain ও swelling কমাতে; systemic side effect কম।
  • PPI
    • Pantoprazole 20/40 mg বা Esomeprazole 20 mg
    • NSAID দিলে gastric protection-এর জন্য, বিশেষ করে gastritis/PUD risk থাকলে।
  • Tramadol combination বা ketorolac
    • শুধু severe pain বা selected case-এ short duration; routine Grade I/II sprain-এ নয়।
  • Antibiotic / steroid
    • simple closed ankle sprain-এ দরকার নেই।
    • open wound, cellulitis, septic arthritis suspicion থাকলে আলাদা assessment দরকার।

13. Rehabilitation exercises — কখন কী করবেন

Phase 1: 0–3 days

  • Pain-free ankle pump।
  • Toe movement।
  • Ice/compression/elevation।
  • Protected walking।

Phase 2: 3–7 days

  • Alphabet exercise with ankle।
  • Gentle dorsiflexion/plantar flexion।
  • Isometric eversion/inversion।
  • Calf stretching pain-free range-এ।

Phase 3: 1–3 weeks

  • Resistance band strengthening।
  • Heel raise।
  • Balance board / single-leg stance।
  • Proprioception training।

Phase 4: return to sport

  • Jogging → running → cutting/pivoting।
  • Hop test, figure-of-8 running।
  • Brace/taping during sport for 3–6 months if recurrent risk।

14. Prevention — কীভাবে প্রতিরোধ করবেন

  • Previous sprain থাকলে sport/activity-তে ankle brace বা taping ব্যবহার।
  • Balance/proprioception training: single-leg stance, wobble board।
  • Peroneal muscle strengthening।
  • Proper shoe: stable heel counter, good grip।
  • Uneven surface-এ সতর্ক হাঁটা।
  • Warm-up before sports।
  • Fatigue অবস্থায় খেলাধুলা avoid।
  • Full pain-free ROM, strength, balance না ফিরলে sport-এ return নয়।
  • Obesity থাকলে weight management।
  • Recurrent sprain হলে physiotherapy + orthopedic evaluation।

15. Red flags — urgent referral

  • Deformity / suspected dislocation।
  • Open wound।
  • Neurovascular compromise: cold foot, absent pulse, numbness।
  • Unable to bear weight + bony tenderness।
  • Severe swelling/bruising।
  • Pain out of proportion।
  • Suspected Achilles rupture।
  • Suspected syndesmotic injury।
  • Persistent pain/swelling > 1–2 weeks despite treatment।
  • Recurrent giving way।

Overview / Summary

  • Ankle sprain হলো ankle ligament stretch/tear; সবচেয়ে common হলো lateral ankle sprain, usually inversion injury।
  • Diagnosis মূলত clinical; fracture exclude করতে Ottawa Ankle Rules ব্যবহার করতে হবে।
  • X-ray সব রোগীর দরকার নেই; Ottawa positive হলে AP/lateral/mortise ankle X-ray।
  • Treatment-এর core হলো POLICE + functional brace + early mobilisation + rehab।
  • ওষুধ: paracetamol, one NSAID, topical diclofenac; PPI শুধু NSAID-related gastric risk কমাতে।
  • Tramadol/ketorolac routine নয়—selected severe pain only।

Actionable Plan / Steps

  1. First visit: Ottawa Ankle Rules apply করুন; positive হলে X-ray।
  2. First 72 hours: protection, compression, elevation, ice, protected weight-bearing।
  3. Pain control: Paracetamol ± one NSAID; topical diclofenac add করা যায়।
  4. Avoid: multiple NSAID, routine steroid/antibiotic, aggressive massage।
  5. Follow-up: 5–7 days পরে pain, swelling, walking ability, instability reassess।
  6. Rehab: ROM → strengthening → balance/proprioception → sport-specific drill।
  7. Refer: Grade III, syndesmotic injury, fracture suspicion, persistent pain > 6 weeks, recurrent instability।

Reference List

Textbook

  1. Campbell’s Operative Orthopaedics, 14th ed. Chapter: Sports-related foot and ankle injuries / ligament injuries.
  2. Apley & Solomon’s System of Orthopaedics and Trauma, 10th ed. Chapter: Injuries of the ankle and foot.
  3. Harrison’s Principles of Internal Medicine, 21st ed. Section: Approach to musculoskeletal pain and soft-tissue injury.
  4. Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed. Chapter: NSAIDs, acetaminophen, opioids.
  5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Chapter: Analgesic-antipyretic and anti-inflammatory agents.

Guidelines / Clinical criteria

  1. Martin RL, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1–CPG80. DOI: 10.2519/jospt.2021.0302.
  2. American College of Radiology. ACR Appropriateness Criteria: Acute Trauma to the Ankle.
  3. NICE CKS. Sprains and strains — Assessment; Ottawa ankle and foot rules.
  4. AAOS OrthoInfo. Sprained Ankle — Home treatments and RICE.

Peer-reviewed articles with DOI

  1. van den Bekerom MPJ, et al. NSAIDs for treating acute ankle sprains in adults: benefits outweigh adverse events. Knee Surg Sports Traumatol Arthrosc. 2015;23:2390–2399. DOI: 10.1007/s00167-014-2851-6.
  2. Bleakley CM, et al. Rehabilitation Exercises Reduce Reinjury Post Ankle Sprain. Arch Phys Med Rehabil. 2019;100(7):1367–1375. DOI: 10.1016/j.apmr.2018.10.005.
  3. Bachmann LM, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326:417. DOI: 10.1136/bmj.326.7386.417.

4.Gaddi D, et al. Acute Ankle Sprain Management: An Umbrella Review of Systematic Reviews. Front Med. 2022;9:868474. DOI: 10.3389/fmed.2022.868474.

Md.Rafiqul Islam Lipu,Date:-17-06-2026 Wednesday,Time:-09-49-12 Pm

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