What is the best way to treat an ankle sprain?

Management of Ankle Sprains

The best treatment for an ankle sprain involves immediate application of the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for the first 72 hours, followed by early functional rehabilitation with appropriate ankle support. 1

Acute Management (First 72 Hours)

PRICE Protocol

• Protection: Limit weight-bearing using crutches
• Rest: Avoid activities that cause pain
• Ice: Apply for 15-20 minutes, 3-4 times daily (wrap in damp cloth to prevent cold injury)
• Compression: Use compression wraps or semi-rigid supports (ensure they don't compromise circulation)
• Elevation: Keep the ankle elevated above heart level when possible

Weight-bearing Status

• Begin with partial weight-bearing using crutches
• Progress to full weight-bearing as pain and swelling decrease
• Typically continue crutch use for 5-10 days depending on symptom improvement
• Discontinue crutches when:
  • Walking without significant pain or limping
  • Swelling has significantly decreased
  • Adequate balance and proprioception are demonstrated
  • Usually within 7-14 days for moderate sprains 1

Pain Management

• NSAIDs (e.g., naproxen, celecoxib) to reduce pain and inflammation
• Alternative: acetaminophen 1000mg every 6 hours (not exceeding 4000mg daily)
• Diclofenac shows superior results compared to ibuprofen for pain during motion
• Topical diclofenac gel can be considered for localized pain relief with fewer systemic side effects 1

Diagnosis and Assessment

Ottawa Ankle Rules

Use to determine if radiographs are necessary (sensitivity 96%, specificity 98%):

• Inability to bear weight immediately after injury
• Point tenderness over the malleoli, talus, or calcaneus 1

Imaging Recommendations

• Begin with radiography to evaluate for fractures
• Consider MRI if radiographs are normal but symptoms persist
• Ultrasound can detect occult fractures not visible on X-ray 1

Rehabilitation Phase (After 72 Hours)

Begin Progressive Exercises (48-72 hours post-injury)

• Ankle circles
• Alphabet drawing with toes
• Towel stretches for dorsiflexion
• Resistance band exercises in all directions
• Heel raises (progressing from bilateral to unilateral) 1

Balance and Proprioception Training

• Single-leg stance exercises (progress from stable to unstable surfaces)
• Balance board training
• Proprioceptive exercises are crucial to prevent recurrence (relative risk reduction of 38%) 1

Prevention of Recurrence

• Use semi-rigid ankle support for sports activities for at least 6 weeks
• Continue proprioceptive and strengthening exercises long-term
• Consider taping for additional support during high-risk activities 1

Warning Signs for Referral

• Persistent pain lasting more than 6 weeks may indicate:

  • Inadequate rehabilitation
  • Impingement
  • Occult osteochondral lesions
  • Peroneal tendon injury
  • Syndesmosis injury 1, 2

• Consider surgical options if conservative treatment fails after 4-6 months 1

Important Considerations

• Traditional RICE protocol alone may not be optimal for healing as it limits blood flow 3
• Despite being widely recommended, complete RICE treatment is rarely applied correctly in clinical settings 4
• Combination of manual therapy and supervised exercises leads to better recovery than home exercises alone 5
• The most effective form of compression remains unclear, though compression has been shown to reduce swelling 6

Pitfalls to Avoid

• Returning to full activity too soon (increases risk of re-injury)
• Neglecting proprioceptive training (critical for preventing recurrence)
• Overuse of NSAIDs (may suppress natural healing process)
• Failing to progress from protection to functional rehabilitation
• Ignoring persistent symptoms (could indicate more serious injury)