What is the best approach for ankle sprain care?

Best Approach for Ankle Sprain Care

Functional rehabilitation with early therapeutic exercise is superior to immobilization or RICE alone for ankle sprain treatment, and should be the primary approach to ankle sprain care. 1

Initial Assessment

• Apply 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
  • Bone tenderness at the base of the fifth metatarsal or navicular bone 1

• Delay definitive clinical assessment of ligament damage by 4-5 days post-injury for optimal accuracy (sensitivity 84%, specificity 96%) 1

• Key physical findings for severe (grade III) sprains include:

  • Swelling
  • Hematoma
  • Pain on palpation
  • Positive anterior drawer test 1

Treatment Protocol

Pain and Inflammation Management

1. NSAIDs (Oral or Topical):

   • Provide superior pain control, improved function, decreased swelling, and faster return to activity compared to placebo 1
   • Options include diclofenac, celecoxib (200mg twice daily), naproxen, or ibuprofen 1
   • Caution: Studies primarily included young, healthy participants less prone to side effects 1

2. Cryotherapy:

   • Apply ice for 20-30 minutes, 3-4 times daily
   • Most effective when combined with exercise therapy rather than used alone 1
   • Avoid direct ice contact with skin to prevent cold injury

Functional Rehabilitation

1. Early Mobilization:

   • Begin functional treatment within 48-72 hours of injury 1
   • Functional treatment is superior to immobilization:
     • Patients return to sports 4.6 days sooner
     • Patients return to work 7.1 days sooner 1

2. Support Devices:

   • Use lace-up or semirigid ankle supports rather than elastic bandages or tape 1
   • Semirigid supports result in:
     • Shorter time to return to sports and work
     • Less ankle instability 1

3. Progressive Exercise Program:

   • Phase 1 (Days 1-3): PRICE protocol to minimize pain and swelling
   • Phase 2 (Days 3-7): Begin range of motion and strengthening exercises
   • Phase 3 (Week 2+): Endurance training, sport-specific drills, and balance training 1
   • An accelerated exercise protocol during the first week improves ankle function and activity levels 2

Common Pitfalls to Avoid

1. Relying solely on RICE:

   • There is no evidence that RICE alone, cryotherapy alone, or compression therapy alone positively influences pain, swelling, or function 1
   • RICE should be combined with functional rehabilitation for optimal outcomes

2. Prolonged immobilization:

   • Immobilization shows no benefits over functional treatment 1
   • Delays return to work and sports activities

3. Inadequate follow-up:

   • Without proper rehabilitation, up to 70% of patients continue to have problems and up to 80% experience recurrent sprains 3
   • Manual therapy combined with supervised exercise leads to better recovery than home exercises alone 3

4. Neglecting proprioceptive training:

   • Balance and proprioceptive training helps prevent recurrent sprains, particularly in those with history of previous sprains 1

Special Considerations

• Severe (Grade III) sprains: The superiority of surgical repair versus functional rehabilitation remains controversial 1

• Recurrent sprains: Support devices provide protection against future ankle sprains, particularly in persons with a history of recurrent sprains 1

• Chronic instability: Consider ankle disk or proprioceptive neuromuscular facilitation exercise regimens 1

By implementing this evidence-based approach focusing on early functional rehabilitation rather than traditional RICE alone, patients can expect faster recovery, earlier return to activities, and reduced risk of chronic problems or recurrent sprains.