What is the standard of care for an ankle sprain?

Standard of Care for Ankle Sprains

The standard of care for ankle sprains should include functional treatment with early mobilization and supervised exercise therapy, as this approach leads to better outcomes in terms of pain reduction, swelling control, and return to normal activities compared to immobilization or RICE alone. 1

Diagnosis

Initial Assessment

• Apply the Ottawa Ankle and Foot Rules to determine need for radiography:
  • Bone tenderness at posterior edge/tip of lateral malleolus
  • Bone tenderness at posterior edge/tip of medial malleolus
  • Inability to bear weight for four steps immediately after injury and in emergency department
• These rules have high sensitivity (99.7%) for detecting fractures, potentially avoiding unnecessary radiographs 1

Optimal Timing for Examination

• Reexamination 4-5 days after injury provides optimal assessment of ligament damage 1
• Excessive swelling and pain can limit examination accuracy in first 48 hours 1

Key Physical Findings for Severe Sprains

• Four findings associated with grade III (complete ligament rupture):
  • Swelling
  • Hematoma
  • Pain on palpation
  • Positive anterior drawer test
• 96% of patients with all four findings have lateral ligament rupture 1

Treatment Approach

Acute Phase (0-72 hours)

• Functional treatment is superior to immobilization 1
• Apply a semirigid brace (preferred over tape or elastic bandages) for 4-6 weeks 1
• NSAIDs (oral or topical) are effective for pain control in the short term (<14 days) 1
• Cryotherapy (ice) is beneficial when combined with exercise therapy but has limited value alone 1
• Avoid RICE (Rest, Ice, Compression, Elevation) as a standalone treatment, as there is no evidence it positively influences pain, swelling, or function 1

Rehabilitation Phase

• Begin supervised exercise therapy as soon as possible 1, 2
• Focus on:
  • Proprioception training
  • Strength exercises
  • Coordination exercises
  • Functional activities 1
• Supervised exercises produce better outcomes than non-supervised training 1, 2
• An accelerated exercise protocol during the first week improves ankle function and activity levels 3

Common Pitfalls and Considerations

Avoid These Common Mistakes

1. Relying solely on RICE therapy - insufficient evidence supports its effectiveness 1, 4
2. Prolonged immobilization - leads to poorer outcomes than functional treatment 1
3. Delaying rehabilitation exercises - early intervention improves recovery 1, 3
4. Using elastic bandages instead of semirigid braces - braces provide superior support and cost-effectiveness 1

Special Considerations

• Delayed physical examination (4-5 days post-injury) has better diagnostic accuracy for ligament damage (sensitivity 84%, specificity 96%) 1
• Patients with previous ankle sprains have higher risk of recurrence and may benefit from more intensive proprioceptive training 1
• Consider referral if symptoms persist beyond 4-6 weeks despite appropriate treatment 1

Prevention of Recurrence

• Both neuromuscular training and ankle braces are effective for preventing recurrent sprains 1
• Bracing appears superior to taping and neuromuscular training for prevention 1
• For patients with history of recurrent sprains, continued use of ankle support during high-risk activities is recommended 1

Return to Work/Sport

• Functional treatment with bracing and a return-to-work schedule speeds up return to work 1
• Supervised exercises focusing on proprioception, strength, coordination, and function lead to faster return to sport 1
• Monitor for signs of chronic ankle instability (recurrent sprains, persistent instability) 1

By following this evidence-based approach focusing on early functional treatment and supervised rehabilitation exercises rather than traditional RICE therapy, patients with ankle sprains can expect better outcomes in terms of pain control, return to normal activities, and prevention of chronic instability.