What is the initial treatment for an acute ankle sprain?

Initial Treatment for Acute Ankle Sprain

The initial treatment for an acute ankle sprain should follow the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for the first 72 hours, followed by early functional rehabilitation with appropriate ankle support. 1, 2

Immediate Management (First 72 Hours)

PRICE Protocol Components

• Protection: Protect the ankle from further injury using appropriate support
• Rest: Limit weight-bearing activities for up to 72 hours
• Ice (Cryotherapy): Apply ice to reduce swelling and pain
  • Apply directly to the injured area for 15-20 minutes
  • Repeat several times daily during the first 72 hours
  • Both the American Academy of Family Physicians and American Academy of Orthopedic Surgeons recommend cryotherapy 2
• Compression: Use a compressive device or bandage to limit swelling
  • Semi-rigid or lace-up supports are more effective than elastic bandages 2
• Elevation: Keep the ankle elevated above heart level to reduce swelling

Pain Management

• NSAIDs (e.g., naproxen, celecoxib) are recommended to:
  • Reduce pain and inflammation
  • Improve function
  • Decrease swelling
  • Allow quicker return to activity 2, 1
  • Studies show NSAIDs are superior to placebo for pain control, function, and return to duty 2

Early Functional Treatment (After 48-72 Hours)

Ankle Support

• Use semi-rigid or lace-up supports rather than tape or elastic bandages 1
  • These supports result in shorter time to return to sports and activities 2
  • Functional treatment with appropriate support is superior to immobilization 2

Exercise Therapy

• Begin exercises to restore motion and strength within 48-72 hours of injury 2
• Include:
  • Ankle circles
  • Alphabet drawing with toes
  • Towel stretches for dorsiflexion
  • Resistance band exercises in all directions
  • Heel raises (progressing from bilateral to unilateral) 1

Progression of Treatment

1. Initial Phase (0-72 hours): PRICE protocol to minimize pain and swelling
2. Rehabilitation Phase (begins at 48-72 hours): Exercises to restore motion and strength
3. Advanced Phase: Endurance training, sport-specific drills, and balance training 2

Common Pitfalls to Avoid

• Excessive immobilization: Functional treatment is superior to immobilization 2
  • Patients with functional treatment return to sports sooner (4.6 days earlier)
  • Patients return to work 7.1 days sooner with functional treatment compared to immobilization
• Delayed mobilization: Begin exercises within 48-72 hours to promote healing
• Inadequate support: Choose semi-rigid or lace-up supports over elastic bandages
• Overlooking proprioception: Include balance exercises to prevent recurrence
• Using heat: Heat is not recommended for acute ankle injuries 2

Evidence Strength and Considerations

The recommendations are based on guidelines from the American Academy of Family Physicians and other authoritative sources 2, 1. While some studies have explored alternative treatments like hydrogen-rich water hydrotherapy 3, the evidence for these approaches is limited to case reports and should not replace established PRICE protocol and functional rehabilitation.

A systematic review of RICE therapy noted insufficient evidence from randomized controlled trials to determine the relative effectiveness of individual components 4, but the combined approach remains the standard of care based on clinical experience and guideline consensus.