What is the initial management for ankle sprains in urgent care?

Initial Management of Ankle Sprains in Urgent Care

The initial management for ankle sprains in urgent care should follow the PRICE protocol (Protection, Rest, Ice, Compression, and Elevation) with cold application for 20-30 minutes, 3-4 times daily, and functional rehabilitation rather than immobilization. 1

Assessment and Diagnosis

1. Initial evaluation:

   • Determine timing and mechanism of injury
   • Apply Ottawa Ankle and Foot Rules to determine need for radiography
   • Assess ability to bear weight immediately after injury
   • Check for point tenderness over the malleoli, talus, or calcaneus

2. When to order X-rays:

   • Inability to bear weight immediately after injury
   • Point tenderness over bony structures
   • Follow Ottawa Ankle Rules (high sensitivity of 96% for fracture detection) 2

Immediate Management (PRICE Protocol)

1. Protection:

   • Avoid activities that cause pain 1
   • A person with a painful extremity injury that limits use should avoid activities that cause pain and seek medical attention 1

2. Rest:

   • Functional rest rather than complete immobilization
   • Limit use of the injured extremity to avoid worsening the injury 1

3. Ice (Cold Application):

   • Apply cold therapy for 20-30 minutes, 3-4 times daily 1
   • Most effective method: ice and water mixture in a bag surrounded by a damp cloth
   • Avoid direct ice-to-skin contact to prevent cold injury
   • Cold application decreases pain and swelling but has not been demonstrated to improve function or recovery time 1

4. Compression:

   • Apply a compression wrap for comfort after an acute ankle sprain 1
   • Ensure compression does not compromise circulation
   • Note: Evidence suggests compression wraps may not reduce swelling or improve recovery time 1

5. Elevation:

   • Keep the injured ankle elevated to reduce swelling

Pharmacological Management

• NSAIDs may be used for short-term pain relief
• Consider topical NSAIDs for localized relief with fewer systemic side effects

Functional Rehabilitation

• Preferred over immobilization 1
• Begin early motion restoration and strengthening exercises
• Use semirigid supports rather than elastic bandages 1
• Consider supervised exercise program focusing on:
  • Proprioception
  • Strength
  • Coordination

Follow-up Care

• Reexamination 3-5 days after injury when pain and swelling have improved may help with definitive diagnosis 1
• Support devices provide protection against future ankle sprains, particularly for those with recurrent sprains 1
• Consider ankle disk or proprioceptive exercises to prevent recurrence 1

Common Pitfalls and Caveats

1. Avoid these mistakes:

   • Complete immobilization (leads to muscle atrophy)
   • Prolonged ice application (>30 minutes can cause tissue damage)
   • Overtightening compression wraps (can compromise circulation)
   • Premature return to full activity (increases risk of reinjury)

2. Special considerations:

   • More than 70% of people who sprain their ankles continue to have problems 3
   • Up to 80% will sprain their ankles again without proper rehabilitation 3
   • Inadequate treatment can lead to chronic problems such as decreased range of motion, pain, and joint instability 1

3. When to refer:

   • Signs of severe injury (inability to bear weight, significant swelling/bruising)
   • Suspected fracture
   • No improvement after 1-2 weeks of conservative management
   • History of recurrent sprains

The evidence strongly supports functional treatment over immobilization for quicker recovery and earlier return to normal activities 4. Recent guidelines emphasize that early functional rehabilitation with appropriate support is the cornerstone of effective ankle sprain management 1.