What are the management options for ankle pain?

Management Options for Ankle Pain

Functional treatment with early mobilization, NSAIDs, and external support is superior to immobilization for ankle pain management, particularly for ankle sprains. 1

Diagnostic Approach

• Apply the Ottawa Ankle Rules to determine need for radiography
  • Bone tenderness at posterior edge or tip of lateral/medial malleolus
  • Inability to bear weight immediately after injury and in emergency department
• Physical examination findings for severe sprains include:
  • Swelling, hematoma, pain on palpation, positive anterior drawer test
  • Delayed examination (4-5 days post-injury) improves diagnostic accuracy 1

Initial Treatment

Medications

• NSAIDs are first-line treatment for acute ankle pain
  • Provide superior pain control, improved function, decreased swelling, and quicker return to activity compared to placebo 1
  • Both oral and topical NSAIDs are effective for short-term pain relief (<14 days) 1
  • Selective NSAIDs (celecoxib) are non-inferior to non-selective NSAIDs (ibuprofen, naproxen, diclofenac) 1
  • Paracetamol (acetaminophen) is equally effective as NSAIDs for pain, swelling and range of motion 1
• Caution: NSAIDs may delay natural healing by suppressing necessary inflammation 1

RICE Protocol (Rest, Ice, Compression, Elevation)

• RICE alone has limited evidence supporting its effectiveness 1, 2
• Individual components:
  • Ice (cryotherapy): Limited evidence for reducing swelling when used alone 1
  • Compression: Inconclusive evidence for effectiveness 1, 3
  • Rest and elevation: No evidence available on individual effects 1
• Cryotherapy combined with exercise therapy may help reduce swelling 1
• Heat is not recommended for acute ankle injuries 1

Functional Treatment

External Support

• Use functional support for 4-6 weeks 1
• Lace-up or semi-rigid ankle supports are more effective than tape or elastic bandages 1
• Semi-rigid ankle supports result in:
  • Shorter time to return to sports and work
  • Less ankle instability compared to elastic bandages 1
• Tubular elastic bandage (Tubigrip) may not improve functional recovery and might increase need for pain medication 3

Exercise Therapy

• Implement a three-phase approach:

  1. Initial phase (first 24-72 hours): Protect ankle, minimize pain and swelling
  2. Intermediate phase (48-72 hours post-injury): Begin exercises to restore motion and strength
  3. Advanced phase: Progress to endurance training, sport-specific drills, and balance training 1

• Functional treatment allows patients to:

  • Return to sports 4.6 days sooner than immobilization
  • Return to work 7.1 days sooner than immobilization 1

Common Pitfalls to Avoid

• Excessive imaging when not indicated by Ottawa Ankle Rules
• Unwarranted non-weight bearing and immobilization
• Delay in initiating functional movements
• Inadequate rehabilitation 4
• Relying solely on RICE protocol without incorporating exercise and functional support 1, 2

Special Considerations

• High ankle sprains (syndesmosis injuries) require specific diagnosis and may need different management
• Persistent symptoms despite 2-3 weeks of conservative treatment warrant further evaluation
• Surgery is rarely indicated for acute ankle sprains and should be considered only in selected refractory cases 4

Emerging Treatments

• Hydrotherapy with hydrogen-rich water shows promise in case reports for reducing pain and swelling 5
• Heel kicking exercise based on traditional Chinese medicine principles may provide rapid pain relief and functional improvement 6