How to treat an ankle sprain or strain?

Treatment of Ankle Sprains

Functional rehabilitation with early mobilization is superior to immobilization for treating ankle sprains, with NSAIDs providing effective pain relief and semirigid supports offering better outcomes than elastic bandages. 1

Initial Assessment and Diagnosis

• Use the Ottawa Ankle and Foot Rules to determine if radiography is needed:

  • Inability to bear weight immediately and for four steps
  • Bone tenderness at the posterior edge or tip of the lateral or medial malleolus
  • These rules have high sensitivity (99.7%) for detecting fractures 1

• Optimal clinical assessment of ligament damage:

  • Delay examination for 4-5 days post-injury when pain and swelling have decreased
  • Anterior drawer test to assess anterior talofibular ligament damage (84% sensitivity, 96% specificity when performed 4-5 days after injury) 1

Treatment Algorithm

Phase 1: Acute Management (First 72 Hours)

1. Pain Management:

   • NSAIDs (oral or topical) are recommended for short-term pain relief
   • Evidence shows NSAIDs improve pain control, decrease swelling, and allow faster return to activity 1
   • Options include piroxicam, celecoxib, naproxen, or diclofenac 1

2. Support and Protection:

   • Use semirigid ankle supports or lace-up braces rather than elastic bandages
   • Semirigid supports result in shorter time to return to sports/work and less ankle instability 1

3. Ice/Cryotherapy:

   • Important note: While traditionally recommended, recent evidence questions RICE protocol effectiveness
   • The 2018 British Journal of Sports Medicine guideline states: "There is no evidence that RICE alone, or cryotherapy alone has any positive influence on pain, swelling or patient function" 1
   • If using ice, intermittent application may be more effective than continuous application 2
   • Apply for 20 minutes, 3-4 times daily, using ice wrapped in a damp cloth 3

4. Early Mobilization:

   • Begin gentle range of motion exercises within 48-72 hours of injury
   • Avoid complete immobilization as it delays recovery 1

Phase 2: Functional Rehabilitation (Days 3-14)

1. Progressive Exercise Program:

   • Begin exercises to restore motion and strength within 48-72 hours 1
   • Include range of motion, stretching, and progressive strengthening exercises
   • Focus on:
     • Ankle dorsiflexion and plantarflexion
     • Ankle inversion and eversion with resistance bands
     • Calf raises and toe raises

2. Weight-Bearing Progression:

   • Encourage early weight-bearing as tolerated with appropriate support
   • Patients using functional treatment return to work 7.1 days sooner than those with immobilization 1

Phase 3: Advanced Rehabilitation (Week 2 onward)

1. Proprioception and Balance Training:

   • Single-leg balance exercises
   • Progress to unstable surfaces (balance pad, BOSU ball) 3
   • These exercises help reduce the risk of recurrent sprains

2. Sport-Specific Training:

   • Endurance training
   • Sport-specific drills
   • Functional movement patterns 1

Return to Activity Criteria

• Pain-free movement
• Normal strength and flexibility
• Functional testing showing adequate performance 3
• Patients with functional treatment return to sports 4.6 days sooner than those with immobilization 1

Common Pitfalls to Avoid

1. Overreliance on RICE protocol alone:

   • Current evidence does not support RICE as a standalone treatment 1, 4
   • A 2012 review found insufficient evidence from randomized controlled trials to determine the effectiveness of RICE therapy 4

2. Prolonged immobilization:

   • Leads to muscle atrophy and delayed recovery
   • Functional treatment is superior to immobilization 1

3. Inadequate rehabilitation:

   • Incomplete rehabilitation increases risk of chronic ankle instability and recurrent sprains
   • Comprehensive exercise program is essential 5

4. Unnecessary imaging:

   • Follow Ottawa Ankle Rules to determine need for radiography
   • Excessive imaging is wasteful and unnecessary 5

Special Considerations

• For severe lateral ligament ruptures, surgical repair may be considered, though evidence comparing surgery to functional rehabilitation remains controversial 1
• Persistent symptoms beyond 2-3 weeks of appropriate treatment warrant further evaluation 3

By following this evidence-based approach to ankle sprain management, you can optimize recovery time, minimize complications, and reduce the risk of chronic ankle instability.