What is the recommended initial treatment for a patient with a suspected ankle sprain, specifically regarding the use of a post-shoe, splint, or cam boot?

Management of Suspected Ankle Sprains: Functional Support vs. Immobilization

For suspected ankle sprains, an ankle brace is the recommended initial treatment as it provides the best functional support while allowing early mobilization and faster recovery compared to immobilization options like casts or splints. 1

Initial Assessment and Treatment Decision

Assessment:

• Use Ottawa Ankle Rules to rule out fractures (sensitivity >99%) 1
• Reassess 3-5 days after injury to better distinguish partial tears from complete ligament ruptures 1
• Look for key findings of severe sprains: swelling, hematoma, pain on palpation, and positive anterior drawer test 1

Treatment Selection Algorithm:

1. First-line: Ankle Brace

   • Provides optimal functional support while allowing controlled movement 1
   • Results in less pain at 3 weeks compared to immobilization 2
   • Allows earlier return to work (54% vs 13% at 10 days) 2
   • Use for 4-6 weeks for optimal outcomes 1

2. Alternative: Functional Taping

   • Can be used if brace unavailable or not tolerated 1
   • Less effective than bracing but superior to compression bandages 1

3. Limited Role for Immobilization

   • Short-term immobilization (<10 days) may help with severe pain/swelling 1
   • Prolonged immobilization (>10 days) leads to poorer outcomes 1, 3
   • A below-knee cast may be considered for severe sprains but only for a short period 4

Supporting Treatment Measures

Exercise Therapy

• Begin as soon as possible after injury 1
• Focus on proprioception, strength, coordination and function 1
• Reduces risk of recurrent sprains by 38% 1

Pain Management

• NSAIDs can reduce pain and swelling 1
• Short-term use recommended (avoid prolonged use as it may delay healing) 1, 5

Return to Work/Activity Timeline

• 2 weeks: Mostly sedentary work with limited lifting (<10kg) 1
• 3-4 weeks: Return to full work for minor sprains 1
• 6-8 weeks: Return to full work for more severe sprains 1

Important Considerations

Benefits of Functional Treatment vs. Immobilization

• Functional treatment (brace/tape + exercise) is superior to immobilization 1, 2
• Early mobilization with support prevents chronic symptoms and instability 2
• Allows faster return to work and daily activities 1, 2

Common Pitfalls to Avoid

• Prolonged immobilization (>10 days) delays recovery and may lead to stiffness 1, 3
• Delaying physical therapy/exercise can result in poorer outcomes 3
• Using compression bandages alone provides inadequate support 1, 4
• Neglecting exercise therapy increases risk of recurrent sprains 1

Special Considerations

• For severe sprains (grade III), a short period (<10 days) of immobilization may help manage initial pain and swelling before transitioning to functional support 1
• Professional athletes may benefit from more aggressive early functional rehabilitation 1

The evidence strongly supports functional treatment with an ankle brace as the optimal initial approach for suspected ankle sprains, providing better outcomes in terms of pain control, return to function, and prevention of chronic instability compared to immobilization options.