What is the appropriate treatment for an ankle sprain?

Ankle Sprain Treatment Protocol

The appropriate treatment for an ankle sprain should follow the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) initially, followed by early functional treatment with semi-rigid or lace-up supports and a progressive rehabilitation program including proprioceptive and strengthening exercises. 1

Initial Management (First 48-72 Hours)

1. PRICE Protocol:

   • Protection: Avoid activities that cause pain
   • Rest: Limit weight-bearing as needed
   • Ice: Apply cold therapy for 20-30 minutes, 3-4 times daily
   • Compression: Consider compression wrap for comfort (not primarily for swelling reduction)
   • Elevation: Keep the ankle elevated to reduce swelling

2. Pain Management:

   • NSAIDs (e.g., naproxen, celecoxib) to reduce pain and inflammation
   • Diclofenac shows superior results compared to ibuprofen for pain during motion 1
   • Alternative: Acetaminophen 1000mg every 6 hours (max 4000mg daily) 1
   • Topical diclofenac gel can provide localized pain relief with fewer systemic side effects 1

3. Support and Weight-Bearing:

   • Use semi-rigid or lace-up supports rather than elastic bandages 1
   • Begin with partial weight-bearing using crutches as needed 1
   • Progress to full weight-bearing as pain and swelling decrease (typically within 5-10 days) 1

Functional Rehabilitation (Begin within 48-72 hours)

1. Early Mobilization:

   • Begin functional treatment within 48-72 hours of injury 1
   • Functional treatment is superior to immobilization (patients return to work 7.1 days sooner) 1

2. Progressive Exercise Program:

   • Start with gentle range of motion exercises:

     • Ankle circles
     • Alphabet drawing with toes
     • Towel stretches for dorsiflexion 1

   • Progress to strengthening exercises:

     • Resistance band exercises in all directions
     • Heel raises (progressing from bilateral to unilateral) 1
     • Balance and proprioception exercises 1

3. Advanced Rehabilitation:

   • Sport-specific exercises as recovery progresses 2
   • Continue proprioceptive and strengthening exercises long-term to prevent recurrence 1

Imaging Considerations

• Use Ottawa Ankle Rules to determine if radiographs are necessary (sensitivity 96%, specificity 98%) 1:

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

• If symptoms persist despite normal radiographs, consider MRI to evaluate:

  • Ligament integrity
  • Cartilage damage
  • Synovitis or impingement lesions
  • Osteochondral lesions not visible on radiographs 1

Prevention of Recurrence

• Use semi-rigid ankle support for sports activities for at least 6 weeks 1
• Implement long-term proprioceptive training (reduces relative risk of recurrence by 38%) 1
• Continue strengthening exercises even after return to full activity 1

Common Pitfalls to Avoid

1. Overreliance on elastic bandages: Semi-rigid or lace-up supports are more effective 1
2. Prolonged immobilization: This delays recovery compared to early functional treatment 1
3. Inadequate rehabilitation: Comprehensive rehabilitation is essential to prevent recurrence 2
4. Discontinuing crutches too early: Continue until walking without significant pain or limping 1
5. Neglecting proprioceptive training: Critical for preventing recurrent sprains 1

Special Considerations

• For persistent symptoms despite conservative treatment for 4-6 months, consider surgical options including anatomic repair and reconstructions 1
• Arthroscopic intervention may be considered for refractory cases or professional athletes requiring rapid recovery 1
• Manual therapy combined with supervised exercise may lead to better recovery than home exercises alone 3