What is the management approach for an ankle sprain?

Ankle Sprain Management

For optimal ankle sprain management, implement the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) combined with early functional treatment within 48-72 hours, use of semirigid or lace-up supports, and NSAIDs for pain and inflammation. 1

Initial Assessment and Management

Assessment

• Apply the 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

Immediate Treatment (First 24-48 hours)

1. PRICE Protocol 1

   • Protection: Avoid activities that cause pain
   • Rest: Limit weight-bearing initially
   • Ice: Apply cold therapy for 20-30 minutes, 3-4 times daily
   • Compression: Apply wrap for comfort (not to restrict circulation)
   • Elevation: Keep foot elevated to reduce swelling

2. Pain Management

   • NSAIDs: First-line medication for reducing pain and inflammation 1
     • Diclofenac shows superior results compared to ibuprofen for pain during motion
     • Consider topical diclofenac gel for localized pain with fewer systemic side effects
   • Alternative: Acetaminophen 1000mg every 6 hours (max 4000mg daily) if NSAIDs are contraindicated 1

Functional Treatment (48-72 hours post-injury)

Support and Weight-bearing

• Begin partial weight-bearing with crutches, progressing to full weight-bearing as pain and swelling decrease 1
• Use semirigid or lace-up ankle supports rather than elastic bandages alone 1
• Continue crutch use for 5-10 days, discontinuing when patient can walk without significant pain or limping 1

Rehabilitation Exercises (Start within 48-72 hours)

1. Early Mobilization Exercises 1

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

2. Progressive Strengthening 1

   • Resistance band exercises in all directions
   • Heel raises (progress from bilateral to unilateral)

3. Proprioceptive Training 1

   • Balance exercises
   • Single-leg standing (progress to unstable surfaces)
   • This reduces recurrence risk by 38% (RR 0.62,95% CI 0.51-0.76)

Long-term Management

Ongoing Support

• Use semi-rigid ankle support for sports activities for at least 6 weeks to prevent recurrence 1
• Continue proprioceptive and strengthening exercises long-term 1, 2

Follow-up Considerations

• If symptoms persist despite appropriate management, consider advanced imaging:
  • MRI to evaluate ligament integrity and detect osteochondral lesions 1
  • Ultrasound can detect occult fractures not visible on X-ray 1

Surgical Considerations

• Consider surgical options if conservative treatment fails after 4-6 months 1
• Arthroscopic intervention reserved for refractory cases or professional athletes requiring rapid recovery 1

Common Pitfalls to Avoid

• Overreliance on elastic bandages instead of proper semirigid or lace-up supports 1
• Prolonged immobilization instead of early functional treatment (patients return to work 7.1 days sooner with functional treatment) 1
• Neglecting proprioceptive training, which is crucial for preventing recurrent sprains 1
• Discontinuing rehabilitation too early before adequate strength and proprioception are restored 1, 3, 4

The evidence strongly supports a functional approach to ankle sprain management rather than immobilization, with early progressive loading and appropriate support devices being key to optimal recovery 1, 3.