What is the initial management and treatment for an ankle sprain?

Initial Management and Treatment for Ankle Sprain

Functional support and early exercise therapy should be the primary treatment for ankle sprains, as there is no evidence that RICE (Rest, Ice, Compression, Elevation) alone has any positive influence on pain, swelling, or patient function. 1

Diagnostic Assessment

When evaluating an ankle sprain:

1. Apply Ottawa Ankle and Foot Rules to determine if X-rays are needed 1

   • These rules have high sensitivity (99.7%) for detecting fractures, correctly ruling out fractures in 299 out of 300 patients without radiography 1

2. Delayed physical examination (4-5 days post-injury) provides optimal assessment of ligament damage 1

   • Anterior drawer test has 84% sensitivity and 96% specificity when performed 4-5 days after injury
   • Key findings suggesting severe (grade III) sprains: swelling, hematoma, pain on palpation, and positive anterior drawer test 1

Treatment Algorithm

Immediate Phase (0-72 hours)

1. Functional support

   • Apply an ankle brace (preferred over elastic bandages or immobilization) 1
   • Use for 4-6 weeks for optimal outcomes 1

2. Pain management

   • NSAIDs (oral or topical) for short-term pain relief (<14 days) 1
   • NSAIDs improve pain control, decrease swelling, and allow quicker return to activity 1

3. Early weight-bearing

   • Begin as soon as pain allows 1
   • Avoid immobilization as it leads to less optimal outcomes 1

4. Note on RICE protocol

   • Despite traditional recommendations, there is no evidence that RICE alone positively influences outcomes 1
   • Individual components (rest, ice, compression, elevation) lack scientific support for efficacy 1
   • If immobilization is used for pain/swelling, limit to maximum of 10 days 1

Rehabilitation Phase (after 72 hours)

1. Exercise therapy

   • Begin as soon as possible to restore joint function 1
   • Include neuromuscular and proprioceptive exercises 1
   • Exercise therapy reduces recurrent injuries and functional ankle instability 1

2. Functional rehabilitation progression

   • Range of motion exercises
   • Strengthening exercises
   • Proprioceptive training
   • Sport-specific exercises (if applicable)

Grading and Treatment Based on Severity

Grade	Description	Treatment Approach
I	Minimal structural damage, mild pain/swelling	Functional support, early weight-bearing, exercise therapy
II	Partial ligament tear, moderate pain/swelling	Functional support (brace preferred), NSAIDs, early exercise therapy
III	Complete ligament rupture, severe pain/swelling	Functional support (brace), consider short period (<10 days) of immobilization if pain severe, then functional rehabilitation

Common Pitfalls to Avoid

1. Overreliance on RICE protocol - Evidence does not support its efficacy 1
2. Prolonged immobilization - Leads to poorer outcomes than functional treatment 1
3. Delayed rehabilitation - Early exercise therapy is crucial for optimal recovery 1
4. Using elastic bandages - Semirigid supports (braces) are superior 1
5. Unnecessary radiography - Follow Ottawa Rules to determine need for imaging 1

Long-term Considerations

• Support devices provide protection against future sprains, particularly for those with recurrent sprains 1
• Exercise therapy reduces the prevalence of recurrent injuries and functional ankle instability 1
• Inadequate treatment can lead to chronic problems including decreased range of motion, pain, and joint instability 1

The evidence clearly shows that functional treatment with early mobilization and exercise therapy provides better outcomes than immobilization or RICE alone. Using an ankle brace for support during the healing process, along with appropriate pain management and progressive exercise therapy, offers the best approach to recovery from ankle sprains.