What is the appropriate management for a patient presenting with a sprain?

Management of Sprains

For patients presenting with a sprain, first aid providers should apply cold therapy (ice and water surrounded by a damp cloth) for 20-30 minutes, 3-4 times daily, avoid activities that cause pain, and consider applying a compression wrap for comfort while ensuring circulation is not compromised. 1

Initial Assessment and Management

Immediate Care (First 72 Hours)

• Avoid activities that cause pain and seek medical attention 1
• Apply cold therapy (ice and water in a damp cloth) for 20-30 minutes, 3-4 times daily 1, 2
  • Do not place ice directly on skin to prevent cold injury
  • Cold therapy has been shown to decrease pain and swelling in joint sprains 1
• Consider compression wrap application for comfort, especially for ankle sprains 1, 2
  • Ensure the wrap doesn't compromise circulation
  • While compression may provide comfort, evidence suggests it does not significantly reduce swelling or improve recovery time 1
• Elevate the injured area to reduce swelling 2

Pain Management

• NSAIDs (e.g., naproxen, celecoxib) can reduce pain, inflammation, and improve function 2
  • Caution: NSAIDs may potentially suppress the natural healing process
• Alternative: Acetaminophen 1000mg every 6 hours (not exceeding 4000mg daily) 2
• Topical diclofenac gel can provide localized pain relief with fewer systemic side effects 2

Rehabilitation Phase

Early Rehabilitation (48-72 Hours Post-Injury)

• Begin progressive strengthening exercises within 48-72 hours 2
• Start with:
  • Ankle circles
  • Alphabet drawing with toes
  • Towel stretches for dorsiflexion
  • Resistance band exercises in all directions
  • Heel raises (progressing from bilateral to unilateral) 2

Weight-Bearing Progression

• Begin with partial weight-bearing using crutches if needed 2
• Progress to full weight-bearing as pain and swelling decrease 2
• Discontinue crutches when:
  • Patient can walk without significant pain or limping
  • Swelling has significantly decreased
  • Patient demonstrates adequate balance and proprioception 2

Prevention of Recurrence

• Proprioceptive exercises are crucial to prevent recurrence of sprains 2
• Consider semi-rigid ankle support for sports activities for at least 6 weeks 2
• Continue proprioceptive and strengthening exercises long-term 2

When to Seek Further Medical Attention

• Persistent pain lasting more than 6 weeks may indicate:
  • Inadequate rehabilitation
  • Impingement
  • Other complications requiring medical evaluation 2
• Consider imaging if symptoms persist:
  • Begin with radiography to evaluate for fractures or other abnormalities 2
  • Consider MRI if radiographs are normal but symptoms persist 2

Evidence Quality and Considerations

The recommendations are primarily based on the 2024 American Heart Association and American Red Cross Guidelines for First Aid 1 and comprehensive ankle sprain management guidelines 2. These guidelines represent the most recent and authoritative evidence.

While some research suggests alternative approaches like hydrogen-rich water hydrotherapy 3, these lack sufficient evidence compared to established protocols. Similarly, studies comparing different compression methods 4 and icing protocols 5 provide supplementary information but don't override the core recommendations from major guidelines.

A key caveat is that despite the widespread recommendation of RICE (Rest, Ice, Compression, Elevation), implementation in clinical practice has historically been inconsistent 6, highlighting the importance of proper patient education and adherence to treatment protocols.